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Department of Veterans Affairs OIG

Comprehensive Healthcare Inspection Summary Report: Evaluation of Breast Cancer Surveillance in Veterans Health Administration Facilities

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report evaluates notification and surveillance for patients with mammogram results requiring action during the COVID-19 pandemic. The inspections involved interviews with key staff and evaluations of clinical processes. The OIG reviewed providers’ notification of mammogram results requiring action to patients within VHA’s defined time frame and patients’ completion of the recommended actions.The OIG issued no recommendations for improvement.
Department of Veterans Affairs OIG

Review of Personnel Shortages in Federal Health Care Programs During the COVID-19 Pandemic

The COVID-19 pandemic put an unprecedented strain on the nation’s federal healthcare systems. The Pandemic Response Accountability Committee (PRAC) Health Care Subgroup surveyed more than 300 facilities across four federal healthcare programs to determine if the facilities had sufficient medical staff during the pandemic. The VA Office of Inspector General (OIG) reviewed staffing at Veterans Health Administration facilities, the Department of Justice OIG reviewed Federal Bureau of Prisons facilities, the Department of Defense OIG reviewed medical treatment facilities, and the Health and Human...
Department of Veterans Affairs OIG

VHA Can Improve Controls Over Its Use of Supplemental Funds

The Coronavirus Aid, Relief, and Economic Security (CARES) Act appropriated about $17.2 billion in supplemental funds to the Veterans Health Administration (VHA) to support VA’s efforts to prevent, prepare for, and respond to the COVID-19 pandemic. The OIG conducted this audit to assess the effectiveness of VA’s controls over VHA’s use of these funds.Because VA’s financial management system does not support the direct obligation of supplemental funds for all expenses, staff used expenditure transfers to shift funds between appropriation accounts. Expenditure transfers are documented using...
Department of Veterans Affairs OIG

Audie L. Murphy Memorial Veterans’ Hospital Missed Opportunities to Distribute Excess Ventilators during the COVID-19 Pandemic

The COVID-19 pandemic caused a surge in demand for ventilators and provoked concerns about potential supply shortages across VA medical facilities. During the course of a previous broader review, the VA Office of Inspector General (OIG) uncovered a potential issue with the number of ventilators procured and stored at the Audie L. Murphy Memorial Veterans’ Hospital in San Antonio, Texas, and sought to determine whether they had been properly requested, acquired, received, and accounted for.The OIG found the facility acquired more ventilators from March 1, 2020, through November 30, 2021, than...
Department of Veterans Affairs OIG

Insights on Telehealth Use and Program Integrity Risks Across Selected Health Care Programs During the Pandemic

The Pandemic Response Accountability Committee’s (PRAC) Health Care Subgroup developed this report to share insights about the expansion—and the emerging risks—of telehealth in selected programs across six federal agencies during the first year of the COVID-19 pandemic. The selected programs, which provided telehealth services to about 37 million people in 2020 (up from just three million in 2019), included the Veterans Health Administration, Medicare, TRICARE, Federal Employees Health Benefits Program, Office of Workers’ Compensation Programs, and Department of Justice prisoner healthcare...
Department of Veterans Affairs OIG

VHA Progressed in the Follow-Up of Canceled Appointments during the Pandemic but Could Use Additional Oversight Metrics

The OIG reviewed the Veterans Health Administration’s (VHA) progress in monitoring their follow-up of canceled appointments during the COVID-19 pandemic.In 2020, the OIG reported that VHA had not followed up on about 32 percent of canceled appointments. VHA then implemented the Cancelled Appointments and Consult Management Initiative and created a cancellation report to track follow-up conducted for appointments originally scheduled to occur after July 21, 2020. The report allowed tracking by types of care, by month, and cumulatively, but VHA did not use all the reporting features. VHA...
U.S. Postal Service OIG

COVID-19 Test Kit Distribution

The Biden administration purchased rapid COVID-19 test kits to give to Americans free of charge for home use and partnered with the U.S. Postal Service to package and deliver the kits. Within a short period, the Postal Service established a test kit program, which facilitated ordering, fulfillment, and delivery of kits to 125 million residential addresses. The Postal Service designed and developed a website for customers to order test kits for delivery to their homes.Our objective was to assess the accounting treatment and selected technology support associated with the distribution of the...
Department of Veterans Affairs OIG

Comprehensive Healthcare Inspection Summary Report: Evaluation of Medication Management in Veterans Health Administration Facilities, Fiscal Year 2021

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP) report highlights the results of a focused evaluation of Veterans Health Administration (VHA) facilities’ medication management related to remdesivir use. The report describes medication management-related findings from healthcare inspections performed at 34 VHA medical facilities during fiscal year 2021. Each inspection involved interviews with key staff and reviews of clinical and administrative processes.The OIG found that VHA met many elements of expected performance, including the availability of...
U.S. Postal Service OIG

Coronavirus Aid, Relief, and Economic Security (CARES) Act Funding

Our objective was to assess the Postal Service’s justification for and use of funds received under the CARES Act, as amended by the Consolidated Appropriations Act of 2021, and associated disclosure requirements.
Department of Veterans Affairs OIG

The Veterans Health Administration Needs to Do More to Promote Emotional Well-Being Supports Amid the COVID-19 Pandemic

The Veterans Health Administration (VHA) Office of Emergency Management issued the initial COVID-19 Response Plan on March 23, 2020, and then an updated version on August 7, 2020. The National Center for Organization Development created a COVID-19 rapid response consultation process for VHA leaders in a supervisory role. The Organizational Health Council developed a team that coordinated with multiple VHA program offices to create a COVID-19 Employee Support Toolkit and other resources. Additionally, several program offices independently created and disseminated employee well-being resources...
Department of Veterans Affairs OIG

Purchases of Smartphones and Tablets for Veterans’ Use during the COVID-19 Pandemic

The COVID-19 pandemic accelerated efforts by the Veterans Health Administration (VHA) to expand veteran access to telehealth. Accordingly, VHA’s Connected Care Office created a new digital divide consult to issue iPhones to veterans experiencing homelessness who were enrolled in the Department of Housing and Urban Development VA Supportive Housing (HUD-VASH) Program. VHA was already loaning iPads to other veterans who lacked telehealth capable devices through the digital divide consult process. The VA Office of Inspector General (OIG) initiated this review to evaluate whether purchases of...
Department of Veterans Affairs OIG

Comprehensive Healthcare Inspection of Facilities’ COVID-19 Pandemic Readiness and Response in Veterans Integrated Service Networks 2, 5, and 6

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP) report provides a focused evaluation of Veterans Integrated Service Networks (VISNs) 2, 5, and 6 facilities’ COVID-19 pandemic readiness and response. This evaluation focused on emergency preparedness; supplies, equipment, and infrastructure; staffing; access to care; community living center patient care and operations; facility staff feedback; and VA and VISNs 2, 5, and 6 vaccination efforts.The OIG has aggregated findings on COVID-19 preparedness and responsiveness from routine inspections to ensure...
Department of Veterans Affairs OIG

VA’s Compliance with the VA Transparency & Trust Act of 2021

In November 2021, Congress passed the VA Transparency & Trust Act of 2021 to oversee VA’s spending of emergency relief funding related to the COVID-19 pandemic. The law requires VA to report to Congress how it will spend the funding and provide biweekly updates thereafter.The law also requires the VA OIG to report within 120 days on whether VA is spending the funds according to its plan and must address waste, fraud, and abuse. This inaugural report focuses on whether the spend plans VA provided to Congress on December 22, 2021, satisfy the requirements of the Transparency Act.VA’s spend plans...
Department of Veterans Affairs OIG

Care in the Community Consult Management During the COVID-19 Pandemic at the Martinsburg VA Medical Center in West Virginia

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Martinsburg VA Medical Center (facility) in West Virginia to assess allegations of failure to schedule a Care in the Community (CITC) COVID Priority 1 cardiology consult within Veterans Health Administration requirements, and delays in CITC consult scheduling caused by inadequate CITC staffing.The OIG substantiated that a COVID Priority 1 CITC cardiology consult was not scheduled within 30 days of the clinically indicated date. The OIG determined that the consult was amongst a backlog of approximately 5,000...
Department of Veterans Affairs OIG

Audit of Community Care Consults during COVID-19

During COVID-19, VHA’s Office of Community Care (OCC) took steps to ensure veterans continued to have expanded access to health care in the community, as required by the VA MISSION Act of 2018. OCC issued policies to VA facilities to postpone nonurgent appointments and offer alternatives to in-person care, such as telehealth. The VA Office of Inspector General (OIG) conducted this audit to determine whether VHA effectively managed community care consults for routine appointments during the pandemic.The OIG found that routine community care consults were unscheduled for an average of 42 days...
Department of Veterans Affairs OIG

Systems and Tools Implemented to Track COVID-19 Vaccine Data

The VA Office of Inspector General (OIG) examined whether the Veterans Health Administration (VHA) implemented data collection and reporting systems to report on the supply of COVID-19 vaccines to VA medical facilities and doses administered to VA employees and veterans enrolled in VA’s healthcare system (approximately 9.5 million individuals). Although essential for national reporting, tracking VA vaccine data is difficult because VA does not have a centralized national pharmacy inventory management system to track vaccine supply at facilities.Although VHA staff swiftly developed data...
Department of Veterans Affairs OIG

Comprehensive Healthcare Inspection of Facilities' COVID-19 Pandemic Readiness and Response in Veterans Integrated Service Networks 1 and 8

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP) report provides a focused evaluation of Veterans Integrated Service Network (VISN) 1 and 8 facilities’ COVID-19 pandemic readiness and response. This evaluation focused on emergency preparedness; supplies, equipment, and infrastructure; staffing; access to care; community living center patient care and operations; facility staff feedback; and VA and VISN 1 and 8 vaccination efforts.The OIG has aggregated findings on COVID-19 preparedness and responsiveness from routine inspections to ensure prompt...
Department of Veterans Affairs OIG

Deficiencies in Select Community Care Consult (Stat) Processes During the COVID-19 Pandemic

The VA Office of Inspector General (OIG) conducted a national review of stat community care consults generated during the outset of the COVID-19 pandemic to evaluate consult processes. Patient involvement in care urgency disagreements and reporting of adverse events in community care were also reviewed. When the OIG identified deficiencies in processes, electronic health records (EHRs) of the patients at issue were further examined for potential negative outcomes. The OIG did not identify any negative care outcomes.For the 2,236 stat community care consults generated from March 20, 2020...
Department of Veterans Affairs OIG

Failure to Mitigate Risk of and Manage a COVID-19 Outbreak at a Community Living Center at VA Illiana Health Care System in Danville, Illinois

The VA Office of Inspector General (OIG) conducted an inspection at the VA Illiana Health Care System in Danville, Illinois, to determine the validity of allegations, specific to COVID-19 and the Community Living Center (CLC), of failure to observe infection control practices, failure to minimize risk of exposure to COVID-19, inconsistent ongoing testing, and failure to notify residents, families, and staff of positive test results. During the inspection, the OIG identified concerns related to leaders’ post-outbreak actions.The OIG substantiated a failure to observe general infection control...
Department of Veterans Affairs OIG

Care Concerns and the Impact of COVID-19 on a Patient at the Fayetteville VA Coastal Health Care System in North Carolina

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Fayetteville VA Coastal Health Care System in North Carolina to assess concerns related to the quality, coordination, and timeliness of care, and the impact of COVID-19 on a patient with unintentional weight loss who was later diagnosed with oral cancer and died at another VA medical center.The OIG substantiated that the primary care provider and dietitians did not provide quality care to the patient. The primary care provider’s failure to follow-up on an earlier finding and not place an order for a medical test...
U.S. Postal Service OIG

U.S. Postal Service Protection Against External Cyberattacks

Our objective was to determine if the Postal Service has an effective security posture to protect its Information Technology (IT) infrastructure from external cyberattacks and prevent unauthorized access to restricted data.
Department of Veterans Affairs OIG

Deficiencies in COVID-19 Screening and Facility Response for a Patient Who Died at the Michael E. DeBakey VA Medical Center in Houston, Texas

The VA Office of Inspector General (OIG) conducted a healthcare inspection regarding allegations of incompletely screening for COVID-19 and treatment of a patient with serious mental illness who presented for same-day care at the Michael E. DeBakey VA Medical Center (facility).The OIG substantiated that facility staff did not complete the patient’s COVID-19 temperature screening.The OIG substantiated that facility staff failed to medically manage the patient with COVID-19 symptoms, sent the patient to the drive-through testing area without medical evaluation, and did not isolate the patient...
Department of Veterans Affairs OIG

Review of VHA’s Telehealth Billing Practices for Community Care during the COVID-19 Pandemic

Management advisory memorandum detailing the growth of community telehealth claims and the associated risks.

Department of Veterans Affairs OIG

Comprehensive Healthcare Inspection of Facilities' COVID-19 Pandemic Readiness and Response in Veterans Integrated Service Network 19

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP) report provides a focused evaluation of Veterans Integrated Service Network (VISN) 19 facilities’ COVID-19 pandemic readiness and response. This evaluation focused on emergency preparedness; supplies, equipment, and infrastructure; staffing; access to care; community living center patient care and operations; facility staff feedback; and VA and VISN 19 vaccination efforts.The OIG has aggregated findings on COVID-19 preparedness and responsiveness from routine inspections to ensure prompt dissemination of...
U.S. Postal Service OIG

COVID-19 Leave Administration

Our objective was to assess the Postal Service’s management of its employees’ use of novel coronavirus disease (COVID-19) leave under the Families First Coronavirus Response Act (FFCRA). Although the FFCRA expired on December 31, 2020, the Postal Service continued to allow liberal leave usage for employees who had a sickness related to COVID‑19. On March 11, 2021, the American Rescue Plan Act was signed into law. This Act is similar to the FFCRA in that it created a new type of leave. Effective March 12, 2021, and continuing through September 30, 2021, the American Rescue Plan Act provides...
Department of Veterans Affairs OIG

Medical/Surgical Prime Vendor Contract Emergency Supply Strategies Available Before the COVID-19 Pandemic

VA medical facilities’ demand for personal protective equipment (PPE) increased dramatically during the COVID-19 pandemic. The VA Office of Inspector General (OIG) reviewed how the Veterans Health Administration (VHA) ensured the Medical/Surgical Prime Vendor-Next Generation (MSPV-NG) program and its prime vendors met contract requirements by offering medical facilities a no-cost option to develop advance-order supply lists tailored to catastrophic events and contingency plans. The OIG also assessed whether facilities took advantage of those options and strategies and relied on the contracts...
Department of Veterans Affairs OIG

Review of VHA’s Financial Oversight of COVID-19 Supplemental Funds

In response to the Coronavirus Aid, Relief, and Economic Security (CARES) Act, the VA Office of Inspector General (OIG) reviewed the Veterans Health Administration’s (VHA) tracking and reporting of COVID-19 supplemental funding from legislation for pandemic relief.VA met monthly reporting requirements to OMB and Congress on supplemental fund obligations and expenditures. VA also submitted required weekly obligations and expenditures from supplemental funding to OMB by program activity. Of approximately $17.3 billion in medical care supplemental funds, VA reported it had obligated about $7.11...
Department of Veterans Affairs OIG

Use and Oversight of the Emergency Caches Were Limited during the First Wave of the COVID-19 Pandemic

The OIG assessed how effectively VA managed its emergency caches during the first wave of the COVID-19 pandemic in early 2020. These caches contain a standard supply of drugs and medical supplies, including some personal protective equipment, for use during a public health emergency.The review team found that use and oversight of the emergency caches were limited. Only nine of 144 medical facilities activated their emergency caches during the review period (February through June 2020). Among the reasons they were not used included medical facility directors reporting supplies were not needed...
U.S. Postal Service OIG

U.S. Postal Inspection Service Pandemic Response to Mail Fraud and Mail Theft

Our objective was to assess the Postal Inspection Service’s response to mail fraud and mail theft during the COVID-19 pandemic. After we began the audit, we received a congressional request from seven members of Congress asking us to identify what actions, if any, the Postal Inspection Service had taken to address the increase in mail theft during the COVID-19 pandemic.
Department of Veterans Affairs OIG

Inadequate Resident Supervision and Documentation of an Ophthalmology Procedure at the Oklahoma City VA Health Care System in Oklahoma

The VA Office of Inspector General (OIG) conducted an inspection in response to allegations related to ophthalmology resident supervision and quality of care by an attending ophthalmologist (subject ophthalmologist) at the Oklahoma City VA Health Care System in Oklahoma.The OIG substantiated that the subject ophthalmologist failed to provide adequate resident supervision and entered inaccurate documentation related to supervision for a single patient case. The ophthalmology residents were unable to reach the subject ophthalmologist when the patient experienced a complication during an eye...
Department of Veterans Affairs OIG

Comprehensive Healthcare Inspection Program (virtual reviews) Reports VISN 6 & 2

This report will provide (1) a descriptive evaluation of Veterans Integrated Service Network facilities’ pandemic readiness and response as determined by recent Comprehensive Healthcare Inspection Program inspections.
 

Department of Veterans Affairs OIG

Inconsistent Documentation and Management of COVID-19 Vaccinations for Community Living Center Residents

While reviewing the Veterans Health Administration’s (VHA) plans to document receipt and distribution of the COVID-19 vaccine, the VA Office of Inspector General (OIG) determined that VHA facilities did not consistently document the COVID-19 vaccination status of veterans living in VA’s Community Living Centers (CLCs).The OIG determined that VHA could not know at a national level whether the vaccine was offered to some CLC residents, and if so, what their status was. Because CLC residents are in the highest COVID-19 vaccine priority group, they should be offered the vaccine, when possible...
U.S. Postal Service OIG

Customer Perceptions of the U.S. Postal Service During the COVID-19 Pandemic

The OIG conducted a nationally representative survey to understand the ways the COVID-19 pandemic may have altered customer perceptions of the Postal Service and their habits around mail and other postal-related activities. The OIG found that Americans continued to hold favorable views of the Postal Service during the pandemic, underscoring the important role USPS plays for the nation. During the pandemic, the core ways customers interacted with the Postal Service were through mail receipt, post office visits, and delivery of online orders. Nearly 70 percent of survey respondents reported...
Department of Veterans Affairs OIG

Review of Community-Based Outpatient Clinics Closed Due to the COVID-19 Pandemic

The VA Office of Inspector General (OIG) reviewed community-based outpatient clinic (CBOC) closures that occurred due to the COVID-19 pandemic to evaluate the impact on patient care. The OIG virtually interviewed Veterans Health Administration (VHA) staff at 140 facilities that oversaw the 1,031 CBOCs that were operational prior to the World Health Organization’s pandemic declaration.Of these CBOCs, 173 were closed to face-to-face visits on or after February 1, 2020. Reasons for closure fell into four categories including (a) safety of patients and staff, (b) need for consolidation of...
U.S. Postal Service OIG

Impact of Pandemic on Postal Service Finances

From March through September 2020, the Postal Service separated pandemic-related expenses from daily operating expenses to determine the financial impact. These pandemic-related expenses included supplies, services, transportation expenses, and sick and annual leave expenses, among others. Some expenses, such as supplies and services, were directly tracked while others, like transportation expenses, were estimated. Our objective was to assess the impact of the pandemic on Postal Service finances.
Department of Veterans Affairs OIG

Comprehensive Healthcare Inspection of Facilities' COVID-19 Pandemic Readiness and Response in Veterans Integrated Service Networks 10 and 20

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP) report provides a focused evaluation of Veterans Integrated Service Network (VISN) 10 and 20 facilities’ COVID-19 pandemic readiness and response. This evaluation focused on emergency preparedness; supplies, equipment, and infrastructure; staffing; access to care; community living center patient care and operations; and facility staff feedback.The OIG has aggregated findings on COVID-19 preparedness and responsiveness from routine inspections to ensure prompt dissemination of information given the quickly...
Department of Veterans Affairs OIG

Potential Risks Associated with Expedited Hiring in Response to COVID-19

This management advisory memo identifies potential risks associated with the Veterans Health Administration’s (VHA) efforts to expedite adding new staff to meet increased demand caused by the COVID-19 pandemic. The VA Office of Inspector General (OIG) recognizes the tremendous pressure to quickly hire staff to meet unprecedented needs. To achieve VHA’s goal of bringing all new employees on duty within three days of making a tentative offer, VHA has modified or deferred tasks such as fingerprinting, background investigations, drug testing, credentialing, and preplacement physicals.The potential...
Department of Veterans Affairs OIG

Review of Veterans Health Administration’s Virtual Primary Care Response to the COVID-19 Pandemic

The VA Office of Inspector General (OIG) conducted a review to assess Veterans Health Administration’s (VHA) virtual primary care response to the COVID-19 pandemic, as well as the use of virtual care by primary care providers and their perceptions of VA Video Connect (VVC) between February 7 and June 16, 2020.The COVID-19 pandemic presented significant challenges to health care delivery worldwide. One strategy initiated by VHA, in accordance with the Centers for Disease Control and Prevention recommendation to social distance, included expanding the delivery of primary care via virtual care...
U.S. Postal Service OIG

Service Performance of Election and Political Mail During the November 2020 General Election

Our objective was to evaluate the U.S. Postal Service’s service performance of Election and Political Mail during the November 2020 general election. We also evaluated the handling of mail for the Georgia Senate runoff election held on January 5, 2021.The Postal Service prioritized processing of Election Mail during the 2020 general election, significantly improving timeliness over the 2018 mid-term election even with significantly increased volumes of Election Mail in the mailstream. Although timeliness was slightly below goals, proper handling and timely delivery of all Election Mail...
Department of Veterans Affairs OIG

Reporting and Monitoring Personal Protective Equipment Inventory during the Pandemic

The spread of COVID-19 drastically increased the demand for personal protective equipment (PPE) such as masks, gloves, and gowns, and significantly disrupted the global supply chain. As the nation’s largest integrated healthcare system, the Veterans Health Administration (VHA) had to compete for PPE for its personnel and patients. The VA Office of Inspector General (OIG) received hotline allegations that VHA medical facilities could not acquire and maintain enough PPE to keep pace with escalating needs. The OIG assessed how VHA reported and monitored PPE supply levels during the pandemic. The...
U.S. Postal Service OIG

Pandemic Volume and Revenue Projected Scenarios

The Postal Service develops a range of financial projections as part of its financial planning. A financial projection is an estimate or forecast of a future situation or trend based on a study of present and historical trends. The main projection the Postal Service completes is the annual financial plan, which estimates revenue, volume, and expenses for each fiscal year. The fiscal year (FY) 2020 plan was approved by the U.S. Postal Service Board of Governors in February 2020. On March 13, 2020, the President of the United States issued the national emergency declaration concerning the COVID...
Department of Veterans Affairs OIG

Medication Delivery Delays Prior to and During the COVID-19 Pandemic at the Manila Outpatient Clinic in Pasay City, Philippines

The VA Office of Inspector General (OIG) conducted an inspection to assess allegations related to delayed medication delivery from the VA Manila Outpatient Clinic (clinic) pharmacy in Pasay City, Philippines, prior to and during the COVID-19 pandemic.The OIG substantiated a patient experienced medication delivery delays and did not timely receive morphine from the clinic pharmacy in October and November 2019. While the patient requested a renewal in a timely manner, pharmacists could not fill the medication because there was no available stock from the Veterans Health Administration’s (VHA)...
U.S. Postal Service OIG

Mail Service During the Early Stages of the COVID-19 Pandemic

During the COVID-19 pandemic, the Postal Service provided vital service, including the delivery of critical items such as medications, stimulus payments, and Social Security checks. Further, the Postal Service is the leading delivery service provider for online purchases. A May 2020 Harris Poll survey on America’s 100 essential companies’ responses to the COVID-19 pandemic, ranked the Postal Service as number one, based on its resolve, integrity, responsiveness, and permanence. Our objective was to evaluate mail service during the early stages of the novel coronavirus (COVID-19) disease...
Department of Veterans Affairs OIG

VHA’s COVID-19 Vaccine Planning and Implementation

This review will assess VHA’s response, readiness, implementation, and outcomes with the administration of the COVID-19 vaccines to employees and veterans. 
 

Department of Veterans Affairs OIG

Added Measures Could Reduce Veterans’ Risk of COVID-19 Exposure in Transitional Housing

The VA Office of Inspector General (OIG) reviewed the measures taken by the Veterans Health Administration’s (VHA) Homeless Program Office, medical facilities, and community service providers to mitigate COVID-19 risks in transitional housing programs for veterans experiencing homelessness.The OIG found that while transitional housing service providers successfully implemented four of six specific Centers for Disease Control and Prevention (CDC) COVID-19 risk mitigation measures, the providers could have strengthened implementation of two others.VHA and service provider staff said the Homeless...
Department of Veterans Affairs OIG

Review of Veterans Health Administration’s Emergency Department and Urgent Care Center Operations During the COVID-19 Pandemic

The VA Office of Inspector General (OIG) conducted a review of the Veterans Health Administration’s response to anticipated demand and use of emergency department and urgent care center services when faced with the possibility of an influx of patients needing evaluation during the COVID-19 pandemic. A survey was deployed and 63 emergency department and urgent care center directors were interviewed.The OIG learned there was a decreased number of patient visits to the emergency departments (19.8 percent decline) and to the urgent care centers (28.6 percent decline) for January–June 2020 when...
U.S. Postal Service OIG

Employee Safety – Postal Service COVID-19 Response

To lead its pandemic response, the Postal Service created the COVID-19 Command Response Team at headquarters to ensure the agency followed directives and guidance from the CDC. The Postal Service implemented changes to slow the spread of the virus, manage and support affected employees, and ensure that recovered employees returned to work safely. Our objective was to assess the Postal Service’s response to the novel coronavirus disease (COVID-19) outbreak regarding the safety of its employees.
Department of Veterans Affairs OIG

Enhanced Strategy Needed to Reduce Disability Exam Inventory Due to the Pandemic and Errors Related to Canceled Exams

The COVID-19 pandemic has affected how the Veterans Benefits Administration (VBA) provides disability benefits to veterans. On April 3, 2020, VBA discontinued all in-person disability exams that help determine the severity of medical conditions and the amount of benefits paid. The OIG conducted this review to assess how VBA scheduled and conducted exams during the pandemic to limit veterans’ exposure, minimize processing delays, and ensure claims were not prematurely denied due to missed or canceled in-person exams. The OIG also evaluated VBA’s strategy for addressing the inventory of delayed...
Department of Veterans Affairs OIG

Veterans Crisis Line Challenges, Contingency Plans, and Successes During the COVID-19 Pandemic

The Office of Inspector General (OIG) reviewed Veterans Crisis Line (VCL) operations ranging from contingency planning to quality metrics and lessons learned during the COVID-19 pandemic. The OIG completed remote interviews, document reviews, and surveyed VCL employees and Suicide Prevention staff. VCL staff had historically worked from communal call centers with shared space and equipment, a model that posed a safety risk to staff during the pandemic. To continue operations, VCL’s primary challenge was to equip and transition nearly 800 employees to telework-based operations. Over the course...
U.S. Postal Service OIG

Military, Diplomatic, and Other International Election Mail

The Postal Service processes international election and political mail for eligible U.S. citizens throughout the world. Military and diplomatic members and their families or other U.S. citizens located in foreign countries can use or receive these types of mail. Election mail is any item mailed to, or from, authorized election officials that enables citizens to participate in the voting process. For example, local election offices in the U.S. send ballots or other election materials to international recipients and the international voters mail their completed election ballots back. Political...
Department of Veterans Affairs OIG

Date of Receipt of Claims and Mail Processing During the COVID-19 National State of Emergency

The OIG reviewed the Veterans Benefits Administration’s (VBA) processing of mail and benefit claims during the COVID-19 pandemic. Specifically, the review team examined whether VBA staff documented the date of receipt for benefits-related correspondence as required by new guidance during the national state of emergency and continued mail operations at VA facilities to ensure benefit claims were processed. Based on its sample analysis, the OIG found VBA staff did not properly apply date of receipt documentation guidance for an estimated 98 percent of 3,200 claims established from April 7...
U.S. Postal Service OIG

Package Delivery in Rural and Dense Urban Areas

In 2019, carriers delivered nearly 6 billion packages to every corner of America—more than 19 million every day. This represents an 87 percent increase in the U.S. Postal Service’s package volume since 2013, driven by booming ecommerce sales.
U.S. Postal Service OIG

The U.S. Postal Service and Emergency Response: A History of Delivering for the American Public

The U.S. Postal Service has a formal role in the federal National Response Framework, which guides the country’s response to disasters and emergencies like hurricanes, bioterrorism, pandemics and other incidents. The OIG examined how the Postal Service continues to support the American public during the ongoing COVID-19 pandemic, even as the outbreak affects postal operations. The Postal Service has delivered essential items like prescriptions, unemployment benefit and stimulus payments, personal protective equipment, and coronavirus test kits. The Postal Service also has provided a backbone...
Department of Veterans Affairs OIG

Appointment Management During the COVID-19 Pandemic

The Veterans Health Administration (VHA) took measures to protect patients and employees from COVID-19 by canceling face-to-face appointments that were not urgent and converting some of them to virtual appointments. The VA Office of Inspector General (OIG) assessed VHA’s appointment management strategies and the status of canceled appointments. The review team found that about five million appointments (68 percent) canceled from March 15 through May 1, 2020, had evidence of follow up or other tracking. Patients completed appointments predominantly by telephone and some by video. Other...
U.S. Postal Service OIG

Processing Readiness of Election and Political Mail During the 2020 General Elections

The Postal Service plays a vital role in the American democratic process and this role continues to grow as the volume of Election and Political Mail increases. In addition to the next general election, which will be held November 3, 2020, there will be federal elections for all 435 seats in the U.S. House of Representatives and 35 of the 100 seats in the U.S. Senate. There will also be 13 state and territorial elections for governor and numerous other state and local elections. Due to the COVID-19 pandemic, there is an expected increase in the number of Americans who will choose to vote by...
Department of Veterans Affairs OIG

Alleged Deficiencies in the Management of Staff Exposure to a Patient with COVID-19 at the VA Portland Health Care System in Oregon

The VA Office of Inspector General (OIG) conducted a healthcare inspection to determine the validity of allegations related to the management of staff exposure to a patient diagnosed with COVID-19 at the VA Portland Medical Center (facility) in Oregon. The events under review involved the facility’s first patient diagnosed with COVID-19. The OIG did not substantiate that emergency department staff failed to notify imaging department staff that a patient was suspected to have COVID-19 before sending the patient to the imaging department. At the time of the patient’s transport to the imaging...
Department of Veterans Affairs OIG

Review of Veterans Health Administration’s COVID-19 Response and Continued Pandemic Readiness

On March 26, 2020, the VA Office of Inspector General (OIG) published its first COVID-19-focused report, OIG Inspection of Veterans Health Administration’s COVID-19 Screening and Pandemic Readiness. In that report, the OIG evaluated how the Veterans Health Administration (VHA) was preparing facilities to meet anticipated rising demands. This report outlines VHA’s continued response to the pandemic and provides VHA leaders’ descriptions of the evolving challenges they faced in caring for veterans and potentially nonveteran patients as well. The OIG engaged leaders from 70 selected facilities in...
Department of Veterans Affairs OIG

Review of Highly Rural Community-Based Outpatient Clinics Limited Access to Select Specialty Care

The VA Office of Inspector General (OIG) reviewed the accessibility of dermatology, orthopedics, and urology specialty care for patients in the 17 Veterans Health Administration (VHA) community-based outpatient clinics (CBOCs) classified as highly rural. The OIG also reviewed accessibility, barriers, and the availability and utilization of resources for the time frame March 1, 2018 (or from the date the CBOC became highly rural), through February 28, 2019. VHA utilized clinical consults, electronic consults (eConsults), telehealth, and community care to provide specialty care at the highly...
U.S. Postal Service OIG

Management Alert – Timeliness of Ballot Mail in the Milwaukee Processing & Distribution Center Service Area

On April 9 and April 16, 2020, we received requests from U.S. Senators Tammy Baldwin and Ron Johnson and U.S. Representatives Gwen Moore and Bryan Steil to investigate reports of absentee ballots not delivered in a timely manner for the Wisconsin primary election held Tuesday, April 7, 2020. This management alert responds to the congressional requests and presents our results and recommendations to address the issues identified in this report.
Department of Veterans Affairs OIG

OIG Inspection of Veterans Health Administration’s COVID-19 Screening Processes and Pandemic Readiness

The VA Office of Inspector General (OIG) conducted an inspection to evaluate novel coronavirus disease (COVID-19) screening processes at 237 VA facilities (medical centers, community-based outpatient clinics, and community living centers) and to collect data on pandemic preparations. Screening processes at 71 percent of visited medical centers were adequate, while 28 percent had opportunities for improvement. The vast majority of community-based outpatient clinics had screening procedures in place. Although VA announced a no visitors policy for community living centers on March 10, 2020, OIG...