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Deficiencies in Reporting Reliable Physical Infrastructure Cost Estimates for the Electronic Health Record Modernization Program
From the Introduction: "In this report, the VA [Department of Veterans Affairs] Office of Inspector General (OIG) examines VA's reporting of cost estimates for physical infrastructure upgrades related to the 10-year Electronic Health Record Modernization (EHRM) effort. This effort will replace VA's aging electronic health record system (the Veterans Health Information Systems and Technology Architecture) with a system based on the one used by the Department of Defense. By doing so, VA expects to establish a single common system that will provide a comprehensive, lifetime health record for military service members. Significant physical infrastructure upgrades must occur at facilities nationwide to support successful system deployment, such as electrical work, cabling, and heating, ventilation, and cooling. [...] The OIG initiated this audit to determine whether VA developed and reported reliable life cycle cost estimates (LCCE) for physical infrastructure upgrades needed to support the new electronic health record system. Specifically, the OIG team examined whether the Veterans Health Administration (VHA) developed estimates that were comprehensive, well documented, accurate, and credible, in accordance with VA standards, and whether the Office of Electronic Health Record Modernization (OEHRM) reported reliable estimates to Congress."
United States. Department of Veterans Affairs. Office of Inspector General
2021-05-25
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Comprehensive Healthcare Inspection of Facilities' COVID-19 Pandemic Readiness and Response in Veterans Integrated Service Networks 2, 5, and 6
From the Report Overview: "This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP) report examines key clinical and administrative processes that are associated with promoting quality care. Comprehensive healthcare inspections are one element of the OIG's overall efforts to ensure that the nation's veterans receive high-quality and timely VA [Veterans Affairs] healthcare services. The inspections are performed approximately every three years for each medical facility. The OIG selects and evaluates specific areas of focus each year. Starting in July 2020, the OIG added pandemic readiness and response as an issue for examination. CHIP staff have aggregated findings that relate to COVID-19 [coronavirus disease 2019] readiness and response from these routine inspections to ensure that the information is provided in a comprehensive manner, given the constantly changing landscape as infection rates and demands on facilities continually shift. To promote this objective, CHIP staff have combined the findings of inspected medical facilities by Veterans Integrated Service Networks (VISNs), which are regional systems that provide oversight of medical centers in their area.1 This report is the fourth in a series. It provides a descriptive evaluation of VISN 2, 5, and 6 facility responses to the COVID-19 pandemic. This examination is based on findings from healthcare inspections performed during the third and fourth quarters of fiscal year 2021 (April 1 through September 30, 2021). The report also provides a more recent snapshot of the pandemic's demands on facility operations based on data compiled as of September 2021. Additionally, it includes information on COVID-19 vaccination efforts, based on a review of VA's vaccination statistics as of September 29, 2021."
United States. Department of Veterans Affairs. Office of Inspector General
2022-04-07
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VA's Compliance with the VA Transparency & Trust Act of 2021
From the Introduction: "In response to the coronavirus pandemic, Congress passed legislation to provide VA [Department of Veterans Affairs] with funding to support uninterrupted care and benefits to veterans: the Families First Coronavirus Response Act (FFCRA); the Coronavirus Aid, Relief, and Economic Security (CARES) Act; and the American Rescue Plan (ARP) of 2021 Act. To provide oversight of VA's spending of this emergency relief funding, Congress passed the VA Transparency & Trust Act of 2021 (the Transparency Act). The Transparency Act requires VA to provide a detailed plan to Congress outlining its intent for obligating and expending funds covered by the act, to include a justification for each type of obligation. Additionally, the act requires VA to submit reports to Congress every 14 calendar days (biweekly) detailing its obligations, expenditures, and planned uses of the funds, as well as justification for any deviation from the plan. [...] This inaugural report focuses on whether the spend plans VA provided to Congress on December 22, 2021, satisfy the requirements of the act. In subsequent reports, the OIG [Office of Inspector General] will assess VA's reported obligation and expenditure of funds as detailed in its biweekly reports."
United States. Department of Veterans Affairs. Office of Inspector General
2022-03-22
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Deficiencies in Select Community Care Consult (Stat) Processes During the COVID-19 Pandemic
From the Executive Summary: "The VA [Department of Veterans Affairs] Office of the Inspector General (OIG) conducted a national review of select community care consults (stat community care consults) that were generated during a 103-day period at the outset of the COVID-19 [coronavirus disease 2019] 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. [...] In this report, the OIG addressed two components of the stat community care consult process-- the clinical aspect and the administrative aspect. To review the clinical aspect, the OIG evaluated whether care was rendered within 24 hours. For the administrative aspect, the OIG evaluated whether the status of stat community care consults was changed to complete within 24 hours. Facility processes were assessed through EHR reviews and survey responses."
United States. Department of Veterans Affairs. Office of Inspector General
2021-11-10
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Veterans Health Administration Needs to Do More to Promote Emotional Well-Being Supports Amid the COVID-19 Pandemic
From the Executive Summary: "The VA [Department of Veterans Affairs] Office of Inspector General (OIG) conducted a review to assess how the Veterans Health Administration (VHA) addressed the emotional well-being of employees during the novel coronavirus disease (COVID-19) pandemic. The OIG also conducted an overview of VHA programs, including what specialized programs, if any, were developed and deployed in response to the unique psychological challenges created by the COVID-19 pandemic for VHA's staff. Mental health needs generally surge during and after disasters, including pandemics. In March 2020, after declaring COVID-19 a pandemic, the World Health Organization highlighted the importance of maintaining the mental health and emotional well-being of healthcare workers caring for COVID-19 patients. On March 23, 2020, the VHA Office of Emergency Management issued the initial COVID-19 Response Plan with its four-phase approach and a second, updated version on August 7, 2020. The August 2020 response plan update included language allowing VHA to delegate responsibility to program offices to develop resources for response plan strategies. With that delegated authority, the National Center for Organization Development created and maintained resources for leaders and the VHA Organizational Health Council created and maintained across multiple program offices. The OIG initiated the review on November 30, 2020, and conducted virtual interviews with VA and VHA leaders in multiple offices. The OIG developed a series of survey questions about VHA guidance regarding employees' emotional well-being during the pandemic, available resources, monitoring of available support programs, and employee engagement with available support programs."
United States. Department of Veterans Affairs. Office of Inspector General
2022-05-10
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Department of Veterans Affairs, Office of Inspector General: Audit of VA's Response to Hurricane Katrina
"On August 29, 2005, Hurricane Katrina struck areas of the Gulf Coast, causing widespread damage over 90,000 square miles located in Alabama, Louisiana, and Mississippi with Category 3 winds and torrential rains. [...]. The hurricane directly impacted the VA Southeast Louisiana Veterans Health Care System in New Orleans, LA; the VA Gulf Coast Veterans Health Care System in Gulfport, MS; five community-based outpatient clinics (CBOCs) along the Gulf Coast; the New Orleans Regional Office; and the Biloxi VA National Cemetery. [...]. Our oversight responsibilities included determining whether actions taken by VA in response to Hurricane Katrina fulfilled its requirements as outlined in the National Response Plan (NRP) and VA's emergency preparedness plans. The NRP establishes a single, comprehensive framework for managing domestic incidents across all levels of government. [...]. The Acting Assistant Secretary for OSP [Operations, Security, and Preparedness]agreed with the recommendations in the report and provided acceptable implementation plans. [...]. He reported the Office of OSP is in the process of developing: (1) a definition of habitable housing; (2) timeliness criteria and mechanisms to periodically test whether making transitional housing available to victims is effective, expedited, and efficient; (3) mechanisms to continuously maintain a list of habitable housing; (4) criteria to determine which properties VA makes available during disasters and when the properties are to be placed back on the market; and (5) oversight mechanisms to ensure housing support is provided in the event of disasters."
United States. Department of Veterans Affairs. Office of Inspector General
2007-09-28
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Veterans Health Administration: Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System
From the Executive Summary: "The VA [Veterans Affairs] Office of Inspector General (OIG) reviewed allegations at the Phoenix VA Health Care System (PVAHCS) that included gross mismanagement of VA resources, criminal misconduct by VA senior hospital leadership, systemic patient safety issues, and possible wrongful deaths. We initiated this review in response to allegations first reported to the VA OIG Hotline. We expanded our work at the request of the former VA Secretary and the Chairman of the House Committee on Veterans' Affairs (HVAC) following an HVAC hearing on April 9, 2014, on delays in VA medical care and preventable veteran deaths. Since receiving those requests, we have received other Congressional requests including those submitted by the Chair and Ranking Members of the following Committees and Subcommittees. […] On May 28, 2014, we published a preliminary report, Review of Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths at the Phoenix Health Care System -- Interim Report, to ensure all veterans received appropriate care and to provide VA leadership with recommendations for immediate implementation. This report updates the information previously provided in the Interim Report to reflect the final results of our review. We focused this report on the following five questions and identified serious conditions at the PVAHCS and throughout the Veterans Health Administration (VHA). 1) Were there clinically significant delays in care?; 2) Did PVAHCS omit the names of veterans waiting for care from its Electronic Wait List (EWL)?; 3) Were PVAHCS personnel following established scheduling procedures?; 4) Did the PVAHCS culture emphasize goals at the expense of patient care?; and 5) Are scheduling deficiencies systemic throughout VHA?"
United States. Department of Veterans Affairs. Office of Inspector General
2014-08-26
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Veterans Health Administration - Interim Report: Review of Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths at the Phoenix Health Care System
"This interim report provides an overview of our ongoing review at the Phoenix Health Care System (HCS), identifies the allegations we have substantiated to date, and provides recommendations that VA [Department of Veterans Affairs] should implement immediately. Allegations at the Phoenix HCS include gross mismanagement of VA resources and criminal misconduct by VA senior hospital leadership, creating systemic patient safety issues and possible wrongful deaths. While our work is not complete, we have substantiated that significant delays in access to care negatively impacted the quality of care at this medical facility. The issues identified in current allegations are not new. Since 2005, the VA Office of Inspector General (OIG) has issued 18 reports that identified, at both the national and local levels, deficiencies in scheduling resulting in lengthy waiting times and the negative impact on patient care. As required by the Inspector General Act of 1978, each of the reports listed was issued to the VA Secretary and the Congress and is publicly available on the VA OIG website. These reports are identified in Appendix D."
United States. Department of Veterans Affairs. Office of Inspector General
2014-05-28
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Emergency Preparedness in Veterans Health Administration Facilities
"The VA Office of Inspector General (OIG) conducted a review of the Veterans Health Administration's (VHA) Emergency Preparedness program to determine whether VHA facilities had comprehensive, effective emergency preparedness programs; employees had appropriate emergency preparedness training; and VHA buildings' heating, ventilation, and air conditioning (HVAC) systems complied with National Institute for Occupational Safety and Health (NIOSH) guidelines. After the events of September 11, 2001, leaders in government acknowledged the need for a unified approach to managing potential terrorist threats. Public Law 107-188, Public Health Security and Bioterrorism Preparedness and Response Act of 2002, is 'an Act to improve the ability of the United States to prevent, prepare for, and respond to bio-terrorism and other public health emergencies.' This law mandated that the Department of Veterans Affairs Central Office (VA) and VHA medical facilities participate in the National Disaster Medical System (NDMS); work in collaboration with the States and other public or private entities to provide health services and health-related social services; and respond to the needs of victims of a public health emergency."
United States. Department of Veterans Affairs. Office of Inspector General
2006-01-06
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Improvements Needed to Ensure Final Disposition of Unclaimed Veterans' Remains
From the Executive Summary: "The VA [Department of Veterans Affairs] Office of Inspector General (OIG) initiated this review in response to a news report about 28 deceased veterans' unclaimed remains kept in storage for up to 44 years at a funeral home in Roseburg, Oregon. In 2018, VA estimated the remains of between 11,500 and 52,600 veterans may be unclaimed at funeral homes nationwide. This review examined whether VA has an effective governance structure that provides reasonable assurance that deceased veterans whose remains are unclaimed receive a dignified burial--that is, when veterans' remains are interred in a final resting place such as burial in a national cemetery. The OIG's assessment included administration and oversight actions of department-level program offices with VA-wide responsibilities, administration-level program offices in each of VA's three administrations, and facilities such as VA medical centers. The review team also assessed VA's compliance with applicable statutory and regulatory requirements, such as compliance with federal internal control and enterprise risk management standards, standards for documenting payments, and general obligations to perform outreach on behalf of potential beneficiaries."
United States. Department of Veterans Affairs. Office of Inspector General
2021-12-15
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Comprehensive Healthcare Inspection Summary Report: Evaluation of Leadership and Organizational Risks in Veterans Health Administration Facilities, Fiscal Year 2020
From the Overview: "The Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of randomly selected Veterans Health Administration (VHA) facilities. Comprehensive healthcare inspections are one element of the OIG's overall efforts to ensure that the nation's veterans receive high-quality and timely VA [Department of Veterans Affairs] healthcare services. The OIG inspects each facility approximately every three years. The OIG selects and evaluates specific areas of focus each year. The purpose of this report is to provide a descriptive evaluation of VHA facility leadership performance and effectiveness as evidenced by quality care, organizational risks, patient outcomes and experiences, and employee engagement and satisfaction. The OIG initiated unannounced inspections at 36 VHA medical facilities from November 4, 2019, through September 21, 2020. Each inspection involved interviews with facility leaders and staff, and reviews of clinical and administrative processes. The results in this report are a snapshot of VHA leaders' performance at the time of the fiscal year 2020 OIG reviews. They should be considered when improving operations and healthcare quality and mitigating organizational risks."
United States. Department of Veterans Affairs. Office of Inspector General
2021-12-14
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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
From the Executive Summary: "The VA [Department of Veterans Affairs] Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations that facility leaders failed to mitigate risk of and manage a community living center (CLC) COVID-19 [coronavirus disease 2019] outbreak (CLC outbreak) at the VA Illiana Health Care System (facility) in Danville, Illinois. In the fall of 2020, 11 residents died of COVID-19, and 239 patients and 92 staff were diagnosed with the virus. The allegations stated that a COVID-19 outbreak occurred in two CLC neighborhoods--Unity and Victory--and there was a failure to observe general infection control practices specifically related to respiratory personal protective equipment (PPE) use, issuance, and training; failure to minimize risk of exposure to COVID-19 for CLC residents and staff; and inconsistent ongoing testing and failure to notify residents, their families, and staff of positive COVID-19 test results. The OIG [Office of the Inspector General] identified concerns related to facility and CLC leaders' actions following the CLC outbreak."
United States. Department of Veterans Affairs. Office of Inspector General
2021-09-28
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Systems and Tools Implemented to Track COVID-19 Vaccine Data
From the Executive Summary: "As a federal agency administering COVID-19 [coronavirus disease 2019] vaccines, VA [U.S. Department of Veterans Affairs] is required to report directly to the Centers for Disease Control and Prevention (CDC) on its COVID-19 vaccine supply and on all administered doses. The VA Office of Inspector General (OIG) conducted this review to determine if the Veterans Health Administration (VHA) implemented the data collection and reporting systems needed to fulfill this role--specifically, to report on the supply of vaccines to VA medical facilities and clinics, and doses administered to veterans enrolled in VA's healthcare system and to VA employees. Developing systems to track and report on the supply and administration of the COVID-19 vaccines presented distinct challenges for VHA. One challenge was that VHA does not have a centralized pharmacy inventory management system to track vaccine supply at facilities. Another was the scale of the effort: the two populations that were the immediate focus--veterans enrolled in VA's healthcare system and VHA employees--numbered some 9.5 million. To vaccinate these populations, VA had to quickly modify separate tracking systems. VA also had to be able to track vaccinations for unenrolled veterans (around 10 million as of June 2021), veterans' spouses and caregivers, and other federal agency employees to prepare for providing vaccinations to these or others as needed."
United States. Department of Veterans Affairs. Office of Inspector General
2021-12-07
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Care in the Community Consult Management During the COVID-19 Pandemic at the Martinsburg VA Medical Center in West Virginia
From the Introduction: "The VA [Department of Veterans Affairs] Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations related to the timeliness of scheduling Care in the Community (CITC) consults at the Martinsburg VA Medical Center (facility) in West Virginia. The OIG identified additional concerns related to a backlog of active, unscheduled consults, and the consult management process during the COVID-19 [coronavirus disease 2019] pandemic."
United States. Department of Veterans Affairs. Office of Inspector General
2022-02-16
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Combined Assessment Program Summary Report: Management of Disruptive and Violent Behavior in Veterans Health Administration Facilities
"The VA [Veterans Affairs] Office of Inspector General completed a healthcare inspection of the management of disruptive and violent behavior in Veterans Health Administration (VHA) facilities. The purpose of the inspection was to evaluate facility compliance with selected VHA requirements. VHA's leaders have stated that they are committed to reducing and preventing disruptive and violent behaviors through the development of policies aimed at patient, visitor, and employee safety."
United States. Department of Veterans Affairs. Office of Inspector General
2018-01-30
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OIG Inspection of Veterans Health Administration's COVID-19 Screening Processes and Pandemic Readiness, March 19-24, 2020
From the Document: "On March 11, 2020, due to the 'alarming levels of spread and severity' of the novel coronavirus disease (COVID-19), the World Health Organization declared a pandemic. Within two days, screening processes were implemented to assess veterans' and visitors' infection status at all Veterans Health Administration (VHA) facilities. [...] Approximately one week after screening was initiated at all VHA facilities, the Office of Inspector General (OIG) conducted an inspection to evaluate expeditiously the process (including access to community living centers) and to meet with VHA medical facility leaders to collect data on preparations for an expected dramatic increase in patients with illnesses related to COVID-19. The unannounced visits to facilities were planned to minimize exposure and potential transmission of the novel coronavirus for both VA and OIG personnel as well as patients and visitors. Every effort was made to ensure that the visits were not disruptive to facility activities or distracting from COVID-19 responses. The goal was to complete unobtrusive but effective oversight of screening and pandemic preparedness to glean critical information of immediate use to VA leaders at every level as they respond to the needs of veterans, their families, and other stakeholders."
United States. Department of Veterans Affairs. Office of Inspector General
2020-03-26
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Veterans Crisis Line Challenges, Contingency Plans, and Successes During the COVID-19 Pandemic
From the Executive Summary: "The Office of Inspector General (OIG) is conducting a series of reviews focusing on the Veterans Health Administration's (VHA) management of key clinical areas during the COVID-19 [coronavirus disease 2019] pandemic that are crucial to the well-being of veterans. This review focused on select Veterans Crisis Line (VCL) operations ranging from contingency planning to quality metrics and lessons learned. The VCL is organizationally aligned under the VHA Office of Mental Health and Suicide Prevention and operates 24 hours per day and 7 days per week, with call centers in Canandaigua, New York; Atlanta, Georgia; and Topeka, Kansas. [...] As COVID-19 evolved, many Americans, including veterans, experienced a range of negative effects from fear and social isolation to unemployment and financial insolvency. Because of these and other stressors associated with the pandemic, an increase in the volume of incoming VCL calls, chats, and texts was expected. [...] Overall, VCL leaders repeatedly expressed that although initially reluctant, the transition to telework had improved staff morale and decreased unplanned leave usage, as well as positioned the VCL to recruit additional staff and enhance future services operations. The OIG was impressed with VCL leaders' and employees' efforts to promote employee health safety and ensure that the VCL met its mission to provide immediate access to crisis intervention services during the COVID-19 pandemic."
United States. Department of Veterans Affairs. Office of Inspector General
2020-10-28
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Comprehensive Healthcare Inspection of Facilities' COVID-19 Pandemic Readiness and Response in Veterans Integrated Service Network 19
From the Report Overview: "This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP) report examines key clinical and administrative processes that are associated with promoting quality care. Comprehensive healthcare inspections are one element of the OIG's overall efforts to ensure that the nation's veterans receive high-quality and timely VA [Department of Veteran Affairs] healthcare services. The inspections are performed approximately every three years for each medical facility. The OIG selects and evaluates specific areas of focus each year. Starting in July 2020, pandemic readiness and response was added as an issue for examination. [...] This report is the second in a series. It provides a descriptive evaluation of VISN [Veterans Integrated Service Network] 19 facilities' responses to COVID-19 [coronavirus disease 2019]. This examination is based on findings from healthcare inspections performed during the first quarter of fiscal year 2021 (October 1 through December 31, 2020). The report also provides a more recent snapshot of the pandemic's demands on these facilities' operations based on data compiled as of April 2021. Additionally, it includes information on VISN 19's COVID-19 vaccination efforts, based on data collected by an OIG survey of vaccination coordinators in February 2021 and a review of VA's vaccination statistics as of March 29, 2021. Interviews and survey results provide additional context on lessons learned and perceptions of readiness and responses."
United States. Department of Veterans Affairs. Office of Inspector General
2021-07-07
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Deficiencies in Emergency Preparedness for Veterans Health Administration Telemental Health Care at VA Clinic Locations Prior to the Pandemic
From the Executive Summary: "The VA [Department of Veterans Affairs] Office of Inspector General (OIG) conducted a review of emergency preparedness, as of November 1, 2019, for Veterans Health Administration (VHA) outpatient telemental health care in a VA patient-clinic location as a response to steadily expanding telehealth care over the last decade in an increasingly virtual and technology-driven environment. Telehealth is a technology-based, virtual mode of health care used 'to provide clinical care in circumstances where distance separates those receiving services and those providing services.' Telehealth delivery of mental health care is referred to as telemental health. This review included telemental health care in VA clinics, excluding home and non-VA locations. [...] After the World Health Organization's declaration of the COVID-19 [coronavirus disease 2019] pandemic in March 2020, VHA planned to leverage telehealth services in lieu of certain face to-face care to ensure safety of veterans and staff. Patient visits shifted away from in-person clinic care as often as possible to telehealth including 'in-home virtual care visits.' This report discusses emergency procedures specific to the provision of telemental health care to patients located within a VA setting."
United States. Department of Veterans Affairs. Office of Inspector General
2021-06-24
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Inspection of Information Technology Security at the VA Outpatient Clinic in Austin, Texas
From the Executive Summary: "Information technology (IT) controls protect VA [Department of Veterans Affairs] systems and data from unauthorized access, use, modification, or destruction. To determine compliance with the Federal Information Security Modernization Act of 2014 (FISMA), the VA Office of Inspector General (OIG) contracts with an independent public accounting firm that conducts an annual audit of VA's information security program and practices. The FISMA audit is conducted in accordance with guidelines issued by the Office of Management and Budget and applicable National Institute of Standards and Technology (NIST) information security guidelines. [...] [I]n 2020, the OIG [Office of the Inspector General] started an IT security inspection program. IT inspections help identify whether VA facilities are meeting federal security requirements related to configuration management, physical security, security management, and access controls. They are typically conducted at selected facilities that have not been assessed under the annual audit required by FISMA (each audit focuses on a sample) or at facilities that previously performed poorly. The VA Outpatient Clinic in Austin, Texas, was selected because it was not evaluated during prior OIG-contracted FISMA audits. The OIG conducted this inspection to determine whether the clinic was meeting federal security guidance."
United States. Department of Veterans Affairs. Office of Inspector General
Bowman, Michael; Tate, Al; Alicea, Luis . . .
2021-06-22
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Use and Oversight of the Emergency Caches Were Limited During the First Wave of the COVID-19 Pandemic
From the Executive Summary: "The COVID-19 [coronavirus disease 2019] pandemic has had a major impact on VA's [Department of Veterans Affairs] ability to carry out its missions of providing health care for veterans through the Veterans Health Administration (VHA), and for nonveterans from local communities when needed. The pandemic has increased veterans' need for healthcare services while disrupting the national supply of personal protective equipment that healthcare workers require when treating veterans. To cope with the challenges, VA created and has followed a COVID-19 response plan, which includes drawing on emergency caches (stored reserves) at medical facilities nationwide to address shortages of drugs and medical supplies. [...] The VA Office of Inspector General (OIG) conducted this review to determine how effectively VA managed its emergency caches during the first wave of the COVID-19 pandemic, which emerged in the United States in early 2020. Specifically, the team examined to what degree VA used cache contents and whether the caches were ready to activate. This is an area of particular concern given a 2018 OIG audit of VA's management of the emergency cache program that as part of its findings determined that not all caches were ready to activate if needed because expired or missing drugs hindered the mission readiness of the caches."
United States. Department of Veterans Affairs. Office of Inspector General
2021-06-09
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Review of VHA's Financial Oversight of COVID-19 Supplemental Funds
From the Executive Summary: "[T]he VA [Department of Veterans Affairs] Office of Inspector General (OIG) initiated this review to report on efforts by the Veterans Health Administration (VHA) to establish financial oversight mechanisms for tracking and reporting COVID-19 [coronavirus disease 2019] supplemental funding. This review focused on VHA because it received most of the supplemental funding. Of the $19.57 billion in CARES [Coronavirus Aid, Relief, and Economic Security] Act funding provided to VA, VHA received approximately $17.24 billion for medical care supplemental funds, as well as $60 million from the FFCRA [Families First Coronavirus Response Act], for a total of approximately $17.3 billion. The OIG team reviewed VHA's efforts to establish financial oversight for tracking and reporting on COVID-19 supplemental funding. The team did not assess the effectiveness of VA's or VHA's internal controls for individual obligations and expenditures, nor the reasonableness of each one."
United States. Department of Veterans Affairs. Office of Inspector General
2021-06-10
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Medical/Surgical Prime Vendor Contract Emergency Supply Strategies Available Before the COVID-19 Pandemic
From the Executive Summary: "When COVID-19 [coronavirus disease 2019] struck, VA [Department of Veterans Affairs] medical facilities' demand for personal protective supplies increased dramatically. VA facilities pressed their usual suppliers for greater quantities of these supplies, as did many medical facilities everywhere, especially for personal protective equipment (PPE). In VA's case, the usual suppliers were four primary contractors participating in the Medical/Surgical Prime Vendor (MSPV) Program. Primary contractors, known as prime vendors, provide just-in-time distribution of medical, surgical, dental, and laboratory supplies. The prime vendors were also required to provide VA medical facilities, based on their designation as Federal Emergency Medical Facilities, with plans and strategies to ensure emergency and continuous supply support to prepare for major catastrophic events. In addition, VA has the All-Hazards Emergency Cache Program and its Pandemic Influenza Plan to help keep its facilities operational during a catastrophe. The VA Office of Inspector General (OIG) conducted this review of the contracts and program to determine whether the Veterans Health Administration (VHA) ensured the prime vendors met requirements by offering VA medical facilities a no-cost option to develop supply lists tailored to catastrophic events (emergency plans) and providing contingency plans and strategies for continuing service to each VA medical facility they support. In addition, the OIG assessed whether facilities took advantage of the options and strategies offered in the plans and the extent to which VHA relied on the contracts to obtain PPE during the pandemic."
United States. Department of Veterans Affairs. Office of Inspector General
2021-06-14
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Inadequate Oversight of Contractors' Personal Identity Verification Cards Puts Veterans' Sensitive Information and Facility Security at Risk
From the Executive Summary: "The VA [Department of Veterans Affairs] Office of Inspector General (OIG) conducted this review to determine whether Veterans Health Administration (VHA) contracting officers complied with mandates to ensure contractors account for and return their personnel's personal identity verification (PIV) cards as required, such as at the end of a contract or employment. A PIV card is a federally issued credential that is used by authorized individuals to gain access to federal facilities and information systems commensurate with the cardholder's security level and allows for multifactor authentication. The Federal Acquisition Regulation (FAR) establishes that it is the contracting officer's responsibility to ensure that all identification issued to contractor employees, including PIV cards, is returned. The VHA procurement manual embraces this principle by establishing that contracting officers shall ensure the contractor provides a list of PIV cards issued and returns all PIV cards to the issuing office. Unreturned PIV cards increase risks for unauthorized access to VA facilities and information systems. This poses a threat to property and to veterans, visitors, VA staff, and contractors. It also creates opportunities for individuals to compromise veterans' personal data, which could result in identity theft for personal profit and medical identity theft to access treatment, medications, or other gains."
United States. Department of Veterans Affairs. Office of Inspector General
2021-06-29
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Traumatic Brain Injury Services and Leaders' Oversight at the Southeast Louisiana Veterans Health Care System in New Orleans
From the Executive Summary: "The VA [Department of Veterans Affairs] Office of Inspector General (OIG) conducted a healthcare inspection at the request of Chairman Mark Takano, House Committee on Veterans' Affairs, to assess patient evaluation and treatment of traumatic brain injury (TBI) at the Southeast Louisiana Health Care System (facility) in New Orleans. The purpose of the inspection was to assess allegations that facility staff failed to adequately evaluate and treat TBI for patients who served in Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND). "
United States. Department of Veterans Affairs. Office of Inspector General
2021-06-30
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Review of Community-Based Outpatient Clinics Closed Due to the COVID-19 Pandemic
From the Executive Summary: "On March 11, 2020, due to the 'alarming levels of spread and severity,' the World Health Organization declared COVID-19 [coronavirus disease 2019] a pandemic. The VA [Department of Veterans Affairs] Office of Inspector General (OIG) conducted a review of community-based outpatient clinic (CBOC) closures due to COVID-19 to evaluate the impact on the provision of patient care related to the pandemic. Based on survey responses and interviews with facility leaders, the OIG concluded that, generally, patient care needs were not interrupted. Clinicians triaged patients and offered other care delivery options including virtual care."
United States. Department of Veterans Affairs. Office of Inspector General
2021-04-06
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Inconsistent Documentation and Management of COVID-19 Vaccinations for Community Living Center Residents
From the Document: "While reviewing the Veterans Health Administration's (VHA) plans to document receipt and distribution of the COVID-19 [coronavirus disease 2019] vaccine, the Office of Inspector General (OIG) determined that VHA facilities did not consistently document the COVID-19 vaccination status of veterans living in VA's [Department of Veterans Affairs] community living centers (CLCs). This management advisory memorandum is meant to provide information to help VHA leaders determine if there is a need for additional national guidance or other remedial action before the OIG releases its full report on vaccine distribution."
United States. Department of Veterans Affairs. Office of Inspector General
2021-04-14
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Reporting and Monitoring Personal Protective Equipment Inventory During the Pandemic
From the Executive Summary: "The spread of COVID-19 [coronavirus disease 2019] drastically increased the demand for personal protective equipment (PPE) and significantly disrupted the global supply chain for items such as face coverings, gloves, and gowns. VA [Department of Veterans Affairs], which has the largest integrated healthcare system in the nation, was faced with competing for PPE both in its service to millions of veterans and as part of its fourth mission. The VA Office of Inspector General (OIG) received allegations from its hotline that Veterans Health Administration (VHA) medical facilities could not acquire and maintain adequate inventory to keep pace with escalating needs. The OIG assessed how VHA reported and monitored its PPE supply levels during the pandemic and solicited information about whether facilities ran out of PPE or experienced significant shortages, as well as lessons learned. Without reliable information on its PPE inventory, VHA cannot effectively assess demand, monitor stock levels, or identify supply shortages at facilities. Shortages can jeopardize the health of frontline personnel, patients, their families or caregivers, and the general public."
United States. Department of Veterans Affairs. Office of Inspector General
Morris, Daniel; Claiborne, Cherelle; Clay, Katherine . . .
2021-02-24
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Potential Risks Associated with Expedited Hiring in Response to COVID-19
From the Document: "The OIG [Office of Inspector General] recognizes the tremendous pressure VA [Department of Veterans Affairs] faced in meeting the unprecedented and significant challenges posed by the pandemic, which required swift hiring and reallocation of staff. In any such actions to expedite hiring processes, there are inevitable tensions with ensuring security and quality measures are attained. The purpose of this management advisory memorandum is to identify potential risks involved in the expedited hiring process. Although VHA [Veterans Health Administration] may be aware of some or all of these concerns, this memorandum shares the OIG's observations made during its review to help VHA determine if additional actions are appropriate."
United States. Department of Veterans Affairs. Office of Inspector General
Steele, Shawn; Albee, Andrew; Derick, Michael . . .
2021-03-11
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Comprehensive Healthcare Inspection of Facilities' COVID-19 Pandemic Readiness and Response in Veterans Integrated Service Networks 10 and 20
From the Report Overview: "This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP) report examines key clinical and administrative processes that are associated with promoting quality care. Comprehensive healthcare inspections are one element of the OIG's overall efforts to ensure that the nation's veterans receive high-quality and timely VA [Veteran Affairs] healthcare services. The inspections are performed approximately every three years for each medical facility. The OIG selects and evaluates specific areas of focus each year. Starting in July 2020, pandemic readiness and response was added as an issue for examination. [...] This report is the first in a series. It provides a descriptive evaluation of facilities' responses to COVID-19 [coronavirus disease 2019] within VISNs [Veterans Integrated Service Networks] 10 and 20. This examination is based on findings from healthcare inspections performed during the fourth quarter of fiscal year 2020 (July 1 through September 30, 2020). It also provides a more recent snapshot of the pandemic's demands on these facilities' operations based on data compiled as of December 31, 2020. Interviews and survey results provide additional context on lessons learned and perceptions of both preparedness and responses."
United States. Department of Veterans Affairs. Office of Inspector General
Ross, Jr., Larry; Arugay, Daisy; Barnes, Lisa . . .
2021-03-16
