Federal Reports

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 various specialty CITC consults that were unscheduled. Additionally, facility CITC staff failed to create action plans to improve failed metrics; maximize use of available reports to manage consults; conduct clinical reviews of unscheduled consults; and develop a process to review potential adverse events occurring because of delayed consults. The OIG also learned that confusion surrounding priority and urgency status categories resulted in workarounds by other departments to avoid further delays in patient care.The OIG substantiated that inadequate staffing within the facility’s CITC Service caused delays in the scheduling of CITC consults. Contributing factors included reports of frequent staff turnover, outdated local CITC processes and lack of training, staff absences, and lack of alternative work options during the COVID-19 pandemic.The OIG made one recommendation to the Veterans Integrated Service Network Director related to monitoring the facility’s CITC Improvement Action Plans, progress, timelines, and next steps.The OIG made seven recommendations to the Facility Director related to CITC Improvement Action Plans, COVID Priority 1 report reviews, implementation of a clinical review process for unscheduled COVID Priority 1 consults and consults in which the patient died prior to being scheduled, evaluation of backlog management strategies, review of appointment scheduling occurring in departments outside CITC, and ensuring adequate CITC staffing levels.

As of December 31st, 2021, there are 67 open recommendations, 8 of which were reported as “implemented” by management; and none of the remaining 59 categorized as “Overdue.” Since the date of the OIG’s last recommendation status report, dated September 30th, 2021, 16 new recommendations were added, and 9 recommendations were closed.

The Pandemic Response Accountability Committee (PRAC) is charged with conducting oversight of pandemic-related spending to prevent and detect fraud, waste, abuse, and mismanagement. In May 2021, we engaged MITRE, a not-for-profit federally funded research and development center, to conduct an independent study of lessons learned from the administration of pandemic-related emergency funding for unemployment insurance (UI) benefit programs in a sample of states. The objective of this study was to increase understanding of how states implemented pandemic UI benefit programs and how their different implementation approaches may have reduced the fraud risk, including identity theft-related fraud. MITRE, in coordination with the U.S. Department of Labor (DOL), contacted all 54 state and territory workforce agencies (SWAs) and 12 responded. This report summarizes the responses of those 12 SWAs except where otherwise indicated.