Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection to review allegations regarding the heart transplant program and the performance and behavior of the cardiothoracic section chief (section chief). The OIG also reviewed the temporary inactivation of the heart transplant program and factors associated with reactivation, and Veterans Integrated Service Network (VISN) and facility leaders’ responses to staff concerns about the heart transplant program.

The OIG did not substantiate that the section chief’s surgical patient outcomes, including morbidity and mortality rates, and the facility’s readmission rates statistically varied from national averages to warrant further assessment by the National Surgery Office.

The OIG was unable to determine whether the section chief had “incredibly long” cardiopulmonary bypass times and was not able to draw a conclusion regarding current versus historical cardiopulmonary bypass times for the section chief. The OIG noted facility staff performed a low volume of transplants, which may contribute to variations in outcomes.

The OIG substantiated the section chief repeatedly exhibited unprofessional conduct toward staff, and determined facility and surgical leaders failed to create a culture of safety to ensure staff felt comfortable reporting concerns.

The OIG found VISN leaders failed to ensure a timely quality of care review of cardiothoracic cases; however, the VISN Chief Medical Officer identified further concerns in the heart transplant program that were addressed promptly.

The OIG made two recommendations to the Under Secretary for Health related to a comprehensive review of the transplant program and oversight of quality measures; one recommendation to the VISN Director regarding completion of facility leaders’ requests for clinical care reviews; and three recommendations to the Facility Director including a clinical care review, a review of the section chief’s conduct, and a review of staff’s concerns and development of a culture of safety.

The audit objectives were to determine whether program funds were managed in accordance with the ARC and Federal grant requirements.

Our Objective(s)To assess the controls BTS has in place to ensure the completeness and accuracy of data for on-time performance and reported causes of delays and cancellations.Why This AuditFlight disruptions, including both flight delays and cancellations, are a part of many passengers’ experiences. Air carriers are required to submit to BTS on-time performance data—such as departure and arrival times, elapsed flight times, and minutes of delay—as well as the reported causes of any delayed or canceled flights. Accurate reporting of these data is important for the Department of Transportation (DOT) to understand the causes of delays and cancellations and take actions to protect consumers.What We FoundBTS relies on informal procedures to verify the accuracy of on-time performance data and lacks procedures to verify the data’s completeness.BTS has established informal quality control procedures to identify inaccuracies in on-time performance data submitted by reporting carriers. For example, BTS developed an automated process that performs 117automated checks of the data to identify any errors or inconsistencies.However, BTS has not yet formally adopted these procedures nor established a plan to ensure their continued execution.Although BTS requires reporting carriers to certify that the on-time performance information they submit is correct and complete, the Agency does not have a method for verifying that carriers are reporting data for all flights, raising concerns about the data’s reliability.BTS lacks effective guidance and procedures for verifying reported causes data.BTS’ technical directives, which provide guidance to carriers on reporting the causes of flight delays and cancellations, lack clarity, leading air carriers to interpret the guidance and report their data inconsistently.BTS lacks procedures to identify and address inconsistencies in reported causes data. Instead, the Agency relies on methods the air carriers are using to ensure their submitted data is accurate.We found a high rate of disagreement between data from FAA on reported causes versus the data that carriers report to BTS. BTS has not taken steps to understand and address the causes of these discrepancies.RecommendationsWe made 7 recommendations to improve the completeness and consistency of on-time performance and reported causes data.

The purpose of this memorandum is to alert the U.S. Department of Housing and Urban Development (HUD) to an issue that the Office of the Inspector General (OIG), has identified that affects the timeliness with which public housing agencies (PHA) with units that have lead-based paint are performing required lead-based paint visual assessments.

HUD OIG audited, among other issues, whether three of the nation’s largest PHAs conducted timely lead-based paint visual assessments as required by the Lead Safe Housing Rule (LSHR).  In each of these audits, we discovered that the PHAs did not always meet the requirement to conduct lead-based paint visual assessments within 12 months as required by the LSHR.  A common issue HUD OIG found was that the PHAs incorrectly interpreted the LSHR timing requirement that lead-based paint visual assessments must occur every 12 months to be consistent with HUD’s timing requirement that physical unit inspections occur annually.  PHAs either combined the visual assessments with the annual physical condition inspections required by 42 U.S.C. (United States Code) 1437d(f), or improperly relied on the “annual” requirement instead of the LSHR 12-month requirement for the timing of lead-based paint visual assessments.

We recommend that HUD Issue guidance to PHAs clarifying the timing of unit inspections and lead-based paint visual assessments to address the misinterpretation caused by the terms “annual” and “every 12 months.”

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Recommendations

Public and Indian Housing

•   2025-CH-0801-001-A

   

  Issue guidance to PHAs clarifying the timing of unit inspections and lead-based paint visual assessments to address the misinterpretation caused by the terms “annual” and “every 12 months.”