Federal Reports

With a requested fiscal year 2026 budget of about $3.5 billion for homelessness programs, the Veterans Health Administration (VHA) is committed to preventing and ending veteran homelessness. VHA’s Homeless Programs Office uses a required screening process to identify veterans who are experiencing or at risk of homelessness and need assistance. Medical facilities must complete screenings for veterans under their care, have a process for positive screenings, and ensure staff respond to requests for services within seven business days. Follow-up action must occur within 30 days.

From January through June 2024, VHA screened over 2.4 million veterans and identified 31,149 who reported either experiencing or being at risk of homelessness. About 59 percent (18,250) requested to be referred to social work or homelessness program staff for further assistance. At 42 of 140 facilities, 25 to about 71 percent of veterans (depending on the facility) who wanted to be referred for additional assistance during the screening did not receive follow-up action within 30 days.

The audit team evaluated screening reminder processes at four medical facilities and found weaknesses in the referral and follow-up processes that put veterans at risk of not receiving assistance after they indicated they were experiencing or at risk of homelessness. Deficiencies in the process occurred, in part, because facilities did not establish written local policies and procedures in accordance with federal internal control standards and VHA policy. In addition, the Homeless Programs Office did not ensure facilities had an effective mechanism to monitor follow-up action. The VA Office of Inspector General made four recommendations to improve controls over referral, follow-up, and monitoring processes to ensure veterans’ needs are addressed after positive homelessness screenings. VHA’s under secretary concurred with three recommendations and concurred in principle with one recommendation.

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the John D. Dingell VA Medical Center (facility) to evaluate allegations of inaccurate complete blood count (CBC) with differential results and reporting, and a laboratory supervisor not passing a proficiency test. The OIG identified concerns regarding quality assurance processes and laboratory leaders’ response, which were not in compliance with VHA Directive 1106, Pathology and Laboratory Medicine Service and VHA Directive 1050.01(1), VHA Quality and Patient Safety Programs. 

The OIG substantiated eight medical technologists (technologists) missed or under reported blast cells, leading to inaccurate CBC with differential results for a patient. The OIG did not identify adverse clinical outcomes. 

Laboratory leaders did not implement a quality assurance process to ensure the accuracy of CBC with differential results. Further, none of the technologists were informed of the inaccurate readings, precluding mitigation of errors. Pathologists completed the OIG-requested retrospective review of readings, but the OIG remains concerned that misreads may continue without sustained oversight.

Laboratory leaders, including the quality management technologist, and patient safety managers, did not ensure corrective actions were timely implemented or tracked. Factors contributing to delayed completion of corrective actions and unresolved patient safety risks included conflicting interpretations of the quality management technologist’s responsibilities and laboratory leaders not following a reporting policy. 

The OIG substantiated a supervisor did not pass a blood bank proficiency test in summer 2024, leading to the suspension of blood bank crossmatch testing services. However, laboratory leaders constructed a contingency plan and completed requirements to resume services within a week.

The Facility Director concurred with the OIG’s five recommendations related to communicating errors to technologists, patient safety staff’s monitoring of action plans, clarification of the quality management technologist’s role, oversight of accuracy for CBC results, and laboratory leaders not following a reporting policy.