Reports
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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 Labor OIG
Audit of COVID-19 Impact on MSHA’s Mandatory Inspections
The Mine Safety and Health Administration (MSHA) works to prevent death, illness, and injury from mining and promote safe and healthful workplaces for US miners. The Federal Mine Safety and Health Act of 1977 requires MSHA to inspect each underground mine in its entirety four times a year and each surface mine in its entirety two times a year. These are called regular mandatory health and safety inspections. In 2021, MSHA’s data showed approximately 12,500 mines requiring an inspection while MSHA's inspection data showed it conducted around 18,500 inspections per year. This project will audit how the COVID-19 pandemic impacted MSHA's ability to complete mandatory safety and health inspections.
Department of Justice OIG
Staff Perceptions of the Federal Bureau of Prisons' Management of the Coronavirus Disease 2019 Pandemic: A Follow-Up Survey of BOP Staff
Results from this survey are available at the following link: https://experience.arcgis.com/experience/582f32f0127c4c86870b2e129c05b9…
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...
Environmental Protection Agency OIG
Pandemic Highlights Need for Additional Tribal Drinking Water Assistance and Oversight in EPA Regions 9 and 10
The coronavirus pandemic negatively impacted the oversight and assistance that Regions 9 and 10 provide to the tribal drinking water systems under their purview, as well as the capacity of these systems to provide safe drinking water. The pandemic also underscored the limitations of both EPA resources and tribal drinking water system resiliency. As a result, tribal drinking water systems may be unable to operate safely and comply with drinking water regulations. Access to safe and clean water is critical at all times, but even more so during pandemic situations.
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...
Department of Homeland Security OIG
Lessons Learned from FEMA’s Initial Response to COVID-19
The objective was to determine how effectively FEMA supported and coordinated Federal efforts to distribute personal protective equipment (PPE) and ventilators in response to the COVID-19 outbreak. We determined that FEMA did not have reliable data to inform allocation decisions and ensure accurate adjudication of resource requests, it did not have a process to allocate the limited supply of PPE, and FEMA’s strategic documents did not clearly outline roles and responsibilities to lead the Federal response. We made three recommendations that FEMA improve the reliability of WebEOC, formally...
Department of Homeland Security OIG
DHS Needs to Enhance Its COVID-19 Response at the Southwest Border
The objective of this review was to determine to what extent the Department of Homeland Security has implemented COVID-19 measures for migrants at the southwest border. We reported that U.S. Customs and Border Protection (CBP) does not conduct COVID-19 testing for migrants who enter CBP custody and is not required to do so. Instead, CBP relies on local public health systems to test symptomatic individuals. According to CBP officials, as a frontline law enforcement agency, it does not have the necessary resources to conduct such testing. For migrants that are transferred or released from CBP...
Department of Homeland Security OIG
Violations of ICE Detention Standards at Otay Mesa Detention Center
During our unannounced inspection of Otay Mesa in San Diego, California, we identified violations of ICE detention standards that compromised the health, safety, and rights of detainees. Otay Mesa complied with standards for classification and generally provided sufficient medical care to detainees. In addressing COVID-19, Otay Mesa did not consistently enforce precautions including use of facial coverings and social distancing. Overall, we found that Otay Mesa did not meet standards for grievances, segregation, or staff-detainee communications. Specifically, Otay Mesa did not respond timely...
Department of Homeland Security OIG
ICE’s Management of COVID-19 in Its Detention Facilities Provides Lessons Learned for Future Pandemic Responses
ICE has taken various actions to prevent the pandemic’s spread among detainees and staff at their detention facilities. At the nine facilities we remotely inspected, these measures included maintaining adequate supplies of PPE such as face masks, enhanced cleaning, and proper screening for new detainees and staff. However, we found other areas in which detention facilities struggled to properly manage the health and safety of detainees. For example, we observed instances where staff and detainees did not consistently wear face masks or socially distance. In addition, we noted that some...