Reports

Department of Veterans Affairs OIG

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

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

Full Details: Oversight.gov Report Page

Inspection / Evaluation | 2/16/2022

1 - Closed

The Veterans Integrated Service Network Director confirms that weekly calls with facility and Veterans Integrated Service Network leaders are held to discuss active Improvement Action Plans, progress made, timelines, and next steps.

2 - Closed

The Martinsburg VA Medical Center Director verifies that Improvement Action Plans, identifying areas of improvement and outlining recommendations, are in place for unmet national Care in the Community performance metrics.

3 - Closed

The Martinsburg VA Medical Center Director ensures COVID Priority 1 consults are run and reviewed by Care in the Community managers and staff daily.

4 - Closed

The Martinsburg VA Medical Center Director confirms that clinical reviews of COVID Priority 1 active consults are completed and documented, monitors compliance, and takes action as warranted.

5 - Closed

The Martinsburg VA Medical Center Director ensures a process is in place to review and address consults for patients who died prior to being scheduled or seen by a community care provider to determine if an adverse event occurred as a result of a delay in processing a patient’s consult.

6 - Closed

The Martinsburg VA Medical Center Director evaluates the effectiveness of strategies to manage the backlog of active consults and the use of urgent and emergent to prioritize consults for scheduling, determines if changes in practice are warranted, and documents the agreed upon process.

7 - Closed

The Martinsburg VA Medical Center Director conducts a review to determine who, outside Care in the Community staff, is facilitating appointment scheduling and evaluates if the scheduling assistance of other services is an effective use of resources, and establishes a standardized process to align practices.

8 - Closed

The Martinsburg VA Medical Center Director ensures Care in the Community staffing levels are adequate to support the processing of consults according to time frames set by the Veterans Health Administration.

Pandemic Response Accountability Committee

Small Business Administration Paycheck Protection Program Phase III Fraud Controls

The PRAC examined whether the Small Business Administration (SBA) Phase III fraud controls, which were applied to process Paycheck Protection Program (PPP) loans in 2021, would have likely detected the earlier fraud found in PPP criminal cases. SBA designed the PPP Phase III controls to address significant fraud identified in the earlier phases of the program and some were later used by the SBA in its Restaurant Revitalization Fund (RRF) program.

Full Details: Oversight.gov Report Page

Department of Education OIG

The Department’s Implementation of CARES Act Flexibilities to TEACH Grant Service Obligations

The objective of our review was to evaluate the Department of Education’s plans and processes to ensure Teacher Education Assistance for College and Higher Education (TEACH) grantees receive full-time credit toward their service obligations for part-time and temporarily interrupted service due to Coronavirus Disease 2019 (COVID-19). We found weaknesses in FSA’s development and implementation of plans and processes to ensure TEACH grantees receive full-time credit towards their service obligations for part-time or temporarily interrupted service due to COVID-19. Additionally, we found that FSA...

Full Details: Oversight.gov Report Page

Inspection / Evaluation | 1/20/2022

Department of the Interior OIG

Fulfillment of Purchase Card Orders

Our inspection identified $155,575 in CARES Act and pandemic-related purchase card transactions with insufficient documentation.

Full Details: Oversight.gov Report Page

Small Business Administration OIG

SBA’s Oversight of the Grant Recipient’s Implementation of the CARES Act Resource Partners Training Portal

We evaluated the SBA’s handling of the grant to train small businesses on federal resources available in the wake of the Coronavirus Disease 2019 (COVID-19) pandemic. The Coronavirus Aid Relief and Economic Security (CARES) Act authorized funds up to $25 million for SBA to administer a grant to an association or associations representing resource partner centers to establish a single centralized hub for COVID-19 information.We found SBA did not ensure the grant recipient developed and implemented an effective marketing and outreach strategy to ensure the hub successfully achieved the...

Full Details: Oversight.gov Report Page

Inspection / Evaluation | 1/18/2022

Department of Homeland Security OIG

Medical Processes and Communication Protocols Need Improvement at Irwin County Detention Center

The objective was to determine whether Irwin County Detention Center (ICDC), in Ocilla, Georgia provided Immigration and Customs Enforcement detainees adequate medical care and adhered to COVID-19 protections.

Full Details: Oversight.gov Report Page

Inspection / Evaluation | 1/06/2022

Department of Health & Human Services OIG

COVID-19 Tests Drove an Increase in Total Medicare Part B Spending on Lab Tests in 2020, While Use of Non-COVID-19 Tests Decreased Significantly

Full Details: Oversight.gov Report Page

Pandemic Response Accountability Committee

Semiannual Report to Congress: April 1, 2021 - September 30, 2021

The Pandemic Response Accountability Committee's (PRAC) Semiannual Report to Congress covering the period April 1, 2021 through September 30, 2021

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...

Full Details: Oversight.gov Report Page

Inspection / Evaluation | 11/10/2021

01 - Closed

The Under Secretary for Health evaluates community care resources, facility practices, and Veterans Health Administration requirements related to stat community care consult processes and takes action as warranted to ensure that patients receive clinically indicated care in the appropriate time frame

02 - Closed

The Under Secretary for Health clarifies guidance to VA medical facilities for stat community care consults including the timeliness of clinical review and approval, retrieval of medical records, and administrative closure.

03 - Closed

The Under Secretary for Health issues guidance to VA medical facilities regarding the override process for stat community care consults to include collaboration expected between the referring provider and the designee.

04 - Closed

The Under Secretary for Health evaluates patient involvement in decision-making regarding clinical reviewers’ modification of the urgency status of stat community care consults to determine if the process is in alignment with Veterans Health Administration patient-centered care goals and takes action as warranted.

05 - Closed

The Under Secretary for Health evaluates the time frame for adjudicating and communicating clinical appeals, determines applicability to the 24-hour requirement for completing stat community care consults, and takes action as warranted.

06 - Closed

The Under Secretary for Health evaluates adverse event reporting processes in community care, including a review of guidance provided in the VHA National Patient Safety Improvement Handbook, 1050.01 and the VHA Patient Safety Events in Community Care: Reporting, Investigation and Improvement Guidebook for inconsistencies and takes action as warranted.

1 - Closed

2 - Closed

3 - Closed

4 - Closed

5 - Closed

6 - Closed

Department of the Interior OIG

Pandemic Purchase Card Use

Our inspection identified several issues with CARES Act and pandemic-related purchase card transactions made through September 30, 2020.

Full Details: Oversight.gov Report Page

Date Range

Report Type

Report Category

Submitting Agency

State (State and Local Reports)

Fraud Type

Agency Reviewed

Related Organizations

Management Challenges

Any Recommendations

Any Open Recommendations

Reports

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

Small Business Administration Paycheck Protection Program Phase III Fraud Controls

The Department’s Implementation of CARES Act Flexibilities to TEACH Grant Service Obligations

Fulfillment of Purchase Card Orders

SBA’s Oversight of the Grant Recipient’s Implementation of the CARES Act Resource Partners Training Portal

Medical Processes and Communication Protocols Need Improvement at Irwin County Detention Center

COVID-19 Tests Drove an Increase in Total Medicare Part B Spending on Lab Tests in 2020, While Use of Non-COVID-19 Tests Decreased Significantly

Semiannual Report to Congress: April 1, 2021 - September 30, 2021

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

Pandemic Purchase Card Use

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