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Report File
Date Issued
Submitting OIG
Department of Veterans Affairs OIG
Agencies Reviewed/Investigated
Department of Veterans Affairs
Components
Veterans Health Administration
Report Number
24-01598-43
Report Description

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess confidential complaints alleging a veteran was going to be discharged from the Housing and Urban Development VA Supportive Housing (HUD-VASH) program and “should not have been,” and that other veterans were discharged from HUD-VASH “for no reason.” The OIG also evaluated access to primary care for veterans enrolled in HUD-VASH who remain unhoused.

The OIG did not substantiate that the veteran, nor other veterans, were discharged from the HUD-VASH program “for no reason.” However, deficiencies existed with the veteran’s case management, including treatment plan and discharge documentation. The OIG determined similar deficiencies occurred in the case management of other veterans discharged from HUD-VASH. Additionally, the electronic health records of many unhoused HUD-VASH veterans, who did not have scheduled primary care appointments, demonstrated the absence of treatment plans and assignments to primary care teams.

Deficiencies in case management and failures in supervisory oversight resulted in missed opportunities for improved case management for HUD-VASH veterans. The OIG is concerned that the absence of treatment plans, as well as primary care assignments, could affect HUD-VASH case management staff’s ability to coordinate veteran-centered care and may contribute to deficient facilitation of clinical services for this vulnerable population.

The OIG made five recommendations to the Facility Director related to completion and oversight of HUD-VASH documentation, HUD-VASH discharges, and assignment to primary care teams for unhoused HUD-VASH veterans.

Report Type
Inspection / Evaluation
Location

CA
United States

Number of Recommendations
5
Questioned Costs
$0
Funds for Better Use
$0
Report updated under NDAA 5274
No

Open Recommendations

This report has 5 open recommendations.
Recommendation Number Significant Recommendation Recommended Questioned Costs Recommended Funds for Better Use Additional Details
01 No $0 $0

The Greater Los Angeles Healthcare System Director ensures veterans enrolled in the Housing and Urban Development Veterans Affairs Supportive Housing program have documented treatment plans consistent with Veterans Health Administration and facility policy.

02 No $0 $0

The Greater Los Angeles Healthcare System Director reviews and assesses the Housing and Urban Development Veterans Affairs Supportive Housing program supervisors electronic health record review process to assess Housing and Urban Development Veterans Affairs Supportive Housing-related documentation, including treatment plan deficiencies, and takes action as warranted.

03 No $0 $0

The Greater Los Angeles Healthcare System Director ensures facility Housing and Urban Development Veterans Affairs Supportive Housing program discharge policy is in alignment with Veterans Health Administration policy.

04 No $0 $0

The Greater Los Angeles Healthcare System Director reviews and assesses the Housing and Urban Development Veterans Affairs Supportive Housing program supervisors process to identify incongruencies between electronic health records and Homeless Operations Management and Evaluation System documentation, and takes action as warranted.

05 No $0 $0

The Greater Los Angeles Healthcare System Director reviews patient aligned care team assignments for unhoused Housing and Urban Development Veterans Affairs Supportive Housing veterans, and takes action as warranted.

Department of Veterans Affairs OIG

United States