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Brought to you by the Council of the Inspectors General on Integrity and Efficiency
Federal Reports
Report Date
Agency Reviewed / Investigated
Report Title
Type
Location
U.S. Agency for International Development
Financial Audit of USAID Resources Managed by Children in Distress Network in South Africa Under Cooperative Agreement 72067418CA00030, April 1, 2023, to March 31, 2024
Financial Audit of USAID Resources Managed by Institut Pasteur de Madagascar Under Cooperative Agreement 72068719CA00001, January 1 to December 31, 2024
PEPFAR in Ukraine: USAID/Ukraine Achieved Mixed Results When Implementing Programs Due to Wartime Challenges and Did Not Conduct Independent Performance Monitoring
The OIG’s Mental Health Inspection Program (MHIP) evaluates Veterans Health Administration’s (VHA’s) continuum of mental healthcare services. This inspection focused on inpatient care delivered at the VA Philadelphia Healthcare System (facility) in Pennsylvania.
The facility met some VHA requirements for the inpatient mental health unit, such as completion of twice-yearly environment of care inspections, and had some aspects of a recovery-oriented environment. However, not all areas met VHA standards for a safe, hopeful, and healing setting. Facility leaders did not establish written processes for staff to accompany veterans on outdoor breaks.
The facility did not have an established mental health executive committee for local oversight or a plan for continued transformation to recovery-oriented services. Additionally, inpatient staff did not offer the required daily hours of interdisciplinary programming. Facility leaders did not have formal written guidance to monitor and ensure compliance with state involuntary commitment laws.
Not all electronic health records (EHRs) reviewed included documentation of a treatment plan. Most EHRs did not have evidence of required discussions with veterans on the risks and benefits of prescribed medications. Some EHRs did not have evidence of timely suicide risk screenings. Most reviewed safety plans did not address ways to make the environment safer from potentially lethal means beyond access to firearms and opioids.
Inpatient unit clinical staff were compliant with suicide prevention trainings, but nonclinical staff did not consistently complete the required training.
The Interdisciplinary Safety Inspection Team did not adhere to VHA requirements, including staff’s completion of annual environmental safety hazards training, and did not address safety hazards, including ligature risks.
The OIG issued 20 recommendations to the Facility Director, Chief of Staff, and Associate Chief of Staff for Behavioral Health. These recommendations, once addressed, may improve the quality and delivery of veteran-centered, recovery-oriented care on the inpatient mental health.
We audited the U.S. Department of Housing and Urban Development (HUD) to determine whether HUD had adequate oversight of the physical condition of the public housing units that converted to non-Federal Housing Administration (FHA)-insured project-based vouchers (PBV) under RAD.
We found HUD needs to improve its oversight of the physical condition of converted projects. Before the implementation of its PBV monitoring pilot program, HUD performed limited monitoring of RAD PBV projects. HUD also did not have a standardized process for monitoring the projects for compliance with its requirements. Additionally, for converted units that were PHA owned, HUD did not consistently receive required housing quality standards (HQS) inspection reports.
These conditions occurred because HUD did not specifically target converted projects for review. It also did not have a system to collect and maintain information about the physical and financial condition of RAD PBV projects. Instead, HUD relied on the contract administrators (PHAs) to oversee the converted projects. Additionally, HUD did not have a protocol or procedures for its field offices to ensure that HQS inspection reports for PHA-owned projects had been received and reviewed, as applicable, before HUD eliminated the requirement in June 2024.
As a result of HUD’s limited monitoring and lack of a system to collect and maintain data, HUD did not have information to assess whether the contract administrators effectively performed their oversight responsibilities of ensuring that (1) families resided in units that were decent, safe, and sanitary; (2) the converted projects’ reserve for replacement accounts were sufficiently funded to address extraordinary maintenance, repair, and replacement of capital items; and (3) project owners’ withdrawals from reserve accounts were appropriate. When we inspected a sample of RAD PBV units from 28 converted projects associated with three PHAs, we found that more than 74 percent of the units failed to meet HQS. Further, based on our calculations, the reserve for replacement accounts for 12 of the 28 projects were underfunded. Therefore, unless HUD specifically selects projects for review, it is unable to adequately monitor the long-term sustainability of these projects.
We made several recommendations to HUD to improve its oversight of projects converted under RAD. Specifically, we made recommendations related to (1) targeting projects for review and developing policies and procedures for monitoring, (2) reviewing reserve for replacement accounts to ensure sufficient account balances and compliance with applicable HUD requirements, (3) implementing a process to ensure reserve for replacement requirements in HUD’s business documents are consistent for converted projects, and (4) collecting data on projects’ reserve for replacement accounts to support the Office of Field Operations’ monitoring activities. We also made a recommendation for HUD to provide inspection reports showing that units meet HUD’s current physical condition standards.