Federal Reports

The VA Office of Inspector General (OIG) conducted a follow-up healthcare inspection at the Tuscaloosa VA Medical Center (facility) in Alabama to evaluate the status of patient safety program deficiencies identified in a 2023 OIG report and Veterans Integrated Service Network (VISN) 7’s oversight of the facility’s patient safety program. Additionally, the inspection evaluated actions taken to address deficiencies in the community living center (CLC) regarding residents at risk for elopement identified in a 2022 OIG report.
In contrast to previous findings, the OIG found that the facility’s patient safety program complied with VA-mandated standards. The OIG’s analysis of facility patient safety data showed the patient safety manager appropriately accepted or rejected event reports; considered significant safety events for root cause analysis; and completed eight annually required patient safety analyses for fiscal year 2023.
While the VISN patient safety officer’s oversight of patient safety programs improved, the OIG identified the need for qualitative analysis of patient safety data, which is essential to assess the impact and effectiveness of VISN patient safety programs and develop effective actions plans.
Facility leaders addressed the deficiencies identified in the 2023 and 2022 OIG reports and determined actions taken by the facility leaders resulted in a facility culture where patient safety has become paramount. The OIG concluded that a commitment to continue to administer a high-quality patient safety program was evident in facility leaders’ actions.
The OIG determined that the facility resolved previous concerns regarding the safety and security of the residents in the CLC as well as implemented a review process to ensure electronic health record documentation for residents at risk for elopement was consistent with facility policy.
The OIG made three recommendations to the VISN Director related to the patient safety officer’s qualitative reviews of patient safety data.

HUD’s Office of Housing contracts with performance-based contract administrators to administer the housing assistance payments (HAP) contract with owners. Through RAD, HUD oversees the HAP contracts for converted properties and monitors owners for compliance with HUD’s requirements, which include maintaining (1) units in decent, safe, and sanitary condition and (2) reserve for replacement accounts to help defray the cost of replacing properties’ capital items.

We found HUD needs to improve its oversight of the physical condition of public housing units that converted to PBRA and FHA-insured PBV under the RAD program. Of the 242 units we observed, 65 percent contained 576 deficiencies, 63 of which were life-threatening deficiencies. Converted properties are required to maintain reserve for replacement accounts to fund extraordinary maintenance, repair, and replacement of capital items. However, owners’ reserve for replacement accounts’ balances were not supported for 13 of the 14 properties reviewed. Further, HUD did not ensure that initial inspections of converted properties occurred in a timely manner.

The unit deficiencies occurred because the properties’ (1) management officials did not ensure that staff or contractors inspected the physical condition of RAD units annually and (2) maintenance departments were understaffed, resulting in delayed inspections and repairs. Further, HUD did not ensure that its staff consistently performed management and occupancy reviews (MOR) to monitor the operation of the properties for compliance with HUD’s requirements for the physical condition of RAD units and reserve for replacement accounts. Specifically, for the properties that we reviewed, HUD’s staff had not conducted (1) initial MORs for 50 percent of the properties even though they had been converted under RAD between 3 to 10 years ago and (2) timely initial MORs for nearly 48 percent of the properties. HUD also did not have a (1) process for monitoring the timeliness of properties’ initial inspections and (2) clear guidance specifying the timing of initial inspections for non-FHA-insured PBRA properties.

As a result, families resided in units that were not decent, safe, and sanitary. Further, there is an increased risk of (1) additional families’ residing in units that are not decent, safe, and sanitary and (2) properties’ reserve for replacement accounts being insufficiently maintained to address extraordinary maintenance, repair, and replacement of capital items. Further, HUD did not have necessary information to determine the (1) initial physical of condition of the units, including identifying deficiencies that require timely corrective actions, and (2) timing of properties’ next inspection, which is based on each property’s previous inspection score.

We made several recommendations to HUD to improve its oversight of properties converted under RAD. Specifically, we made recommendations related to determining the timing and completion of initial and subsequent MORs, including issuing updated guidance that includes a system to track the timeliness of initial MORs. We also made recommendations to provide training to staff members to ensure that they have the skills necessary to complete MORs of converted properties and to review the reserve for replacement account balances for all properties to ensure the accuracy of the account balances. Lastly, we made recommendations for HUD to implement adequate procedures and controls to ensure that servicing lenders comply with HUD time requirements in initial inspections of converted properties and determine an appropriate timeframe for when noninsured PBRA converted properties should be initially inspected and work with the Real Estate Assessment Center to ensure that inspections are ordered and completed within that timeframe.

In accordance with the Government Performance and Results Modernization Act of 2010, this report presents the results of the OIG's work over fiscal year 2024 in meeting its performance goals.