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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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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
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Review of Veterans Health Administration's Emergency Department and Urgent Care Center Operations During the COVID-19 Pandemic
From the Executive Summary: "The VA [Department of Veterans Affairs] Office of Inspector General (OIG) conducted a review of the Veterans Health Administration's (VHA) response to anticipated demand and use of emergency department and urgent care center services when faced with an influx of patients needing evaluation during the COVID-19 [coronavirus disease 2019] pandemic. A survey questionnaire was deployed to selected emergency department and urgent care center directors to learn what steps VHA emergency medicine leaders took from March to July 2020, as well as plans they intend to take should a future need arise. COVID-19 is a multifaceted infectious disease that can cause a wide spectrum of presentations ranging from asymptomatic (without symptoms) to displaying severe multisystem illness. Beyond the flu-like symptoms that may characterize early presentation with COVID-19, patients can develop serious systemic problems. Making a diagnosis of COVID-19 in the emergency department or urgent care center setting may provide critical information to practitioners on the management of patient symptoms. OIG staff conducted virtual interviews with 63 directors from 49 emergency departments and 14 urgent care centers from July 13 through July 28, 2020, to collect the directors' survey responses on various COVID-19-related topics."
United States. Department of Veterans Affairs. Office of Inspector General
2020-12-18
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Added Measures Could Reduce Veterans' Risk of COVID-19 Exposure in Transitional Housing
From the Executive Summary: "Individuals experiencing or at risk for homelessness are particularly vulnerable to the transmission of COVID-19 [coronavirus disease 2019] because of limited access to health care and to facilities that help them maintain hygiene and basic sanitation. People living in settings such as homeless shelters and other communal living spaces can experience rapid spread of the virus. Therefore, it is critical that VA [Department of Veterans Affairs] and its transitional housing service providers implement measures to reduce veterans' risk of exposure to COVID-19. The VA Office of Inspector General (OIG) conducted this review to assess the measures taken by the Veterans Health Administration's (VHA) Homeless Program Office, medical facilities, and service providers to mitigate veterans' risks of COVID-19 exposure while in transitional housing. This review focused on two transitional housing service programs administered by the Homeless Program Office--the Health Care for Homeless Veterans (HCHV) and Grant and Per Diem (GPD) programs."
United States. Department of Veterans Affairs. Office of Inspector General
2020-12-18
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Enhanced Strategy Needed to Reduce Disability Exam Inventory Due to the Pandemic and Errors Related to Canceled Exams
From the Executive Summary: "The COVID-19 [coronavirus disease 2019] pandemic has affected how the Veterans Benefits Administration (VBA) fulfills its mission of 'providing benefits and services to Veterans, their families, and survivors in a responsive, timely, and compassionate manner in recognition of their service to the Nation.' Due to the pandemic, VBA discontinued all in-person disability exams on April 3, 2020. The exams allow VBA to determine the severity of veterans' service-related illnesses or injuries, which in turn determines the monthly benefits VBA pays disabled veterans. To continue providing some exams, VBA relied on telemental health and reviews of acceptable clinical evidence (ACE). ACE exams are based on a review of medical records and history without an in-person clinical exam or testing but may include a telephone or video interview. The VA [Department of Veterans Affairs] Office of Inspector General (OIG) conducted this review to assess 1. how VBA scheduled and conducted exams during the COVID-19 pandemic to limit veterans' exposure, minimize claims-processing delays, and ensure claims are not prematurely denied due to missed or canceled in-person exams; and 2. VBA's strategy for addressing the inventory of disability exams delayed due to the COVID-19 pandemic."
United States. Department of Veterans Affairs. Office of Inspector General
2020-11-19
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Medication Delivery Delays Prior to and During the COVID-19 Pandemic at the VA Manila Outpatient Clinic in Pasay City, Philippines
From the Document: "The VA [Department of Veterans Affairs] Office of Inspector General (OIG) conducted a healthcare 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 [coronavirus disease 2019] pandemic. The OIG substantiated that prior to the pandemic, a patient experienced medication delivery delays and did not timely receive morphine [hyperlink] from the clinic pharmacy in October and November 2019. The OIG found that while the patient requested a renewal in a timely manner, pharmacists could not fill the medication because there was no available stock. This was due to the Veterans Health Administration's (VHA) prime vendor, McKesson Corporation (McKesson), experiencing stock shortages that resulted in medications being unavailable to the clinic pharmacy in October and November 2019. Additionally, the Clinic Manager told the OIG there was a general shortage of morphine, not specific to the clinic, that resolved in late September 2019. The OIG did not substantiate that a second patient experienced medication delivery delays for five new order medications, one medication renewal, and a glucometer [hyperlink] for diabetic [hyperlink] testing in November 2019. The OIG was unable to substantiate if this patient experienced delivery delays of three medication refills [hyperlink] because the OIG could not determine when the patient requested the refills."
United States. Department of Veterans Affairs. Office of Inspector General
2021-01-28
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Review of Veterans Health Administration's Virtual Primary Care Response to the COVID-19 Pandemic
From the Executive Summary: "The VA [Department of Veterans Affairs] Office of Inspector General (OIG) conducted a review to assess the Veterans Health Administration's (VHA) virtual primary care response to the COVID-19 [coronavirus disease 2019] 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. [...] To review VHA's COVID-19 response as it related to the provision of outpatient care, the OIG focused on the use of virtual modalities in primary care, including primary care providers' use and perceptions of VVC. The OIG reviewed primary care encounter data, conducted interviews with VHA leaders, and distributed a questionnaire to primary care providers at selected sites to collect information and perceptions related to the use of virtual care modalities."
United States. Department of Veterans Affairs. Office of Inspector General
2021-03-11
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VHA Needs More Reliable Data to Better Monitor the Timeliness of Emergency Care
From the Executive Summary: "The VA [Department of Veterans Affairs] Office of Inspector General (OIG) conducted this audit to determine whether Veterans Health Administration (VHA) oversight of emergency departments ensured patients received emergency care services in a timely manner and whether facilities made any needed improvements to the patient flow process. Emergency departments measure timeliness using software that records patient flow--the movement of patients through a facility from arrival to discharge or admission. The accurate recording of emergency data is critical to monitoring the timeliness of emergency medical care to the approximately 2.3 million patients who visit VHA's 110 emergency departments each year, including those with life-threatening conditions. The OIG recognizes that emergency departments are, by their nature, responding to unpredictable numbers of patients with a wide range of health conditions."
United States. Department of Veterans Affairs. Office of Inspector General
Morris, Daniel; Anello, Kalli; Caturia, Jordan . . .
2021-06-23
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Care Concerns and the Impact of COVID-19 on a Patient at the Fayetteville VA Coastal Health Care System in North Carolina
From the Executive Summary: "The VA [Department of Veterans Affairs] Office of Inspector General (OIG) conducted a healthcare inspection at the Fayetteville VA Coastal Health Care System (facility) in North Carolina to assess concerns related to quality, coordination, and timeliness of a patient's care in 2020. The impact of the coronavirus (COVID-19) on the care of the patient was also evaluated. The patient later died at another Veterans Health Administration (VHA) facility."
United States. Department of Veterans Affairs. Office of Inspector General
2021-09-27
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Deficiencies in COVID-19 Screening and Facility Response for a Patient Who Died at the Michael E. Debakey VA Medical Center in Houston, Texas
From the Executive Summary: "The VA [Veterans Affairs] Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations related to the screening for COVID-19 [coronavirus disease 2019] [hyperlink] and subsequent treatment of a patient with serious mental illness who presented for same-day care at the Michael E. DeBakey VA Medical Center (facility) in Houston, Texas. During the course of the inspection, the OIG identified additional concerns related to the facility's deficiencies in educating Mental Health Intensive Case Management (MHICM) patients and families on COVID-19 screening processes, noncompliance with the facility's missing patient policy, and facility leaders' failures related to adverse events [hyperlink] reporting and institutional disclosure [hyperlink]. Aside from serious quality of care issues, this inspection also involves a vulnerable patient disappearing for four days after being put in the care of the facility. The patient's family contacted the facility and informed them that the patient was missing, but the facility was not able to locate the patient. The patient was ultimately found off-site four days later in the midst of a medical emergency, taken to the facility for care, and passed away the following day."
United States. Department of Veterans Affairs. Office of Inspector General
2021-08-18
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Appointment Management During 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] mission of providing health care for veterans through the Veterans Health Administration (VHA). The VA Office of Inspector General (OIG) conducted this review to assess VHA's appointment management strategies during the pandemic and the state of VA medical facilities' canceled appointments. The review team assessed the data on about 7.3 million appointments canceled from March 15, 2020, through May 1, 2020, to help clarify for VA the processes and places that may need attention to address the needs of patients who had appointments at VA facilities canceled. VA operates the largest integrated healthcare system in the United States, with over 1,200 medical facilities serving more than 9.2 million enrolled veterans. Providing access to timely care at VA facilities continues to be a challenge for VHA, despite increased facility staffing, internal process improvements, and expanded community care and telehealth options."
United States. Department of Veterans Affairs. Office of Inspector General
2020-09-01
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Review of Veterans Health Administration's COVID-19 Response and Continued Pandemic Readiness
From the Introduction: "The VA [Department of Veterans Affairs] Office of Inspector General (OIG) conducted a review of Veterans Health Administration (VHA) facility leaders' assessments of healthcare operations affected by COVID-19 [coronavirus disease 2019] from March 11, 2020, through June 15, 2020. The OIG engaged leaders from 70 selected facilities in discussions about patient-care services provided in three clinical settings: (1) inpatient (acute care) and outpatient care, (2) community care, and (3) community living centers (CLCs). Facility leaders also commented on lessons learned and plans to manage anticipated COVID-19 surges."
United States. Department of Veterans Affairs. Office of Inspector General
2020-07-16
