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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
22-03076-65
Report Description

The Veterans Health Administration (VHA) Grant and Per Diem (GPD) program funds community-based transitional housing for veterans experiencing homelessness. An OIG administrative investigation examined VHA’s oversight of the Veterans Village of San Diego (VVSD), a GPD program grantee providing drug treatment and other services. 

The OIG found that staff at the VA San Diego Healthcare System (the VA facility) responsible for local oversight of VVSD were aware that in 2021 and through most of 2022, issues with drug sales by non-VA residents, drug use, and insufficient staffing increased risks to veterans co-located there. However, VA facility staff did not take timely or effective action to ensure VVSD remediated these issues. Local facility staff lacked important information related to residents at VVSD who were funded by non-VA entities. Also, a regional official responsible for GPD oversight did not provide adequate support. Finally, the OIG found that the GPD National Program Office could have provided clearer guidance on key issues, such as when certain grantee enforcement measures should be used and how to redress recurrent grant noncompliance issues.

The OIG followed up the initial investigation with a limited review of VHA oversight of VVSD through September 2024, prompted in part by reports that improvements may not have taken hold. The investigation revealed that issues related to veteran care and safety, and a lack of information about co-located non-VA residents, recurred or persisted at VVSD. 

VHA concurred with the OIG’s finding and five recommendations to improve governing policies, training, or other guidance, and appropriate follow-up for GPD-funded residents at VVSD who lost access to drug treatment services there. VHA provided acceptable action plans and completion timelines. The OIG will monitor VA’s progress until sufficient documentation has been received to close the recommendations as implemented.

Report Type
Investigation
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

Clarify policies, guidance, and/or training on when admissions holds, removal of veterans from grantee facilities, and the withholding or suspension of per diem payments are appropriate and required.

02 No $0 $0

Clarify policies, guidance, and/or training on how facility staff determine whether corrective actions for an identified problem related to a grantee should be required or suggested, including what factors to consider, who makes the final determination, and whether and how the determination is reviewed by others.

03 No $0 $0

Implement a mechanism designed to reasonably ensure that VA oversight staff take appropriate enforcement measures to address persistent or recurring deficiencies by a Grant and Per Diem grantee that pose risks to veteran care and safety.

04 No $0 $0

Ensure grant agreements require the grantee to promptly disclose to VA any adverse health or safety conditions occurring at any facility where VA-funded participants are receiving service, including the occurrence of sentinel events affecting non-VA-funded participants on the grantees premises and any adverse health or safety inspection results or similar findings made concerning the grantees premises or operations by any non-VA oversight entity, such as a federal, state, county, or local regulator.

05 No $0 $0

Ensure Grant and Per Diem participants residing at the Veterans Village of San Diego (VVSD) who are eligible for clinical drug treatment receive appropriate support to obtain those services despite the closure of VVSDs clinical treatment housing model.

Department of Veterans Affairs OIG

United States