Federal Reports

We audited the U.S. Department of Housing and Urban Development’s (HUD) oversight of lead in the water of multifamily housing units based on our goal of strengthening the soundness of multifamily housing. The audit was part of the activities in our fiscal year 2019 audit plan. Our objective was to determine whether HUD’s Office of Multifamily Housing Programs had sufficient policies, procedures, and controls to ensure that households living in multifamily housing units had a sufficient supply of safe drinking water.HUD’s Office of Multifamily Housing Programs did not have sufficient policies, procedures, and controls to ensure that households living in multifamily housing units had a sufficient supply of safe drinking water. Multifamily housing properties were served by public water systems that reported levels of lead above the Environmental Protection Agency’s lead action level. However, HUD had limited requirements concerning lead in the drinking water of multifamily housing units and did not require multifamily property owners or management agents to take action regarding the potential for lead in the drinking water. These weaknesses occurred because HUD relied on the Agency to ensure that public water systems provided water that was safe to drink. As a result, HUD lacked assurance that households lived in multifamily housing units that had a sufficient supply of safe drinking water.We recommend that the Director of Multifamily Asset Management and Portfolio Oversight develop and implement an action plan that includes sufficient policies, procedures, and controls that address households living in multifamily housing units having a sufficient supply of safe drinking water.

The Office of the Inspector General audited TVA's management of Mac® desktops and laptops to determine if Mac® desktop and laptop patching and configuration management followed TVA policy. In summary, we found (1) TVA is at potential risk for compromise of Mac® desktops and laptops due to inaccurate inventory, (2) TVA was not patching Mac® systems in the designated time frames in TVA policy, and (3) TVA did not have a Mac® baseline as required by TVA policy. TVA management agreed with our findings and recommendations.

The VA Office of Inspector General (OIG) investigated allegations that the chief of staff at a VA medical center engaged in a conflict of interest by performing work for a private company that provides education services and misused his official position by recruiting VA physicians to work for that same company in 2017 and 2018. The OIG did not substantiate either alleged violation. The OIG did, however, identify a related misuse of government resources. After the OIG investigation began, the chief of staff sought advice from the VA Office of General Counsel regarding whether the work for the company presented a conflict of interest. The chief of staff was advised that there was no conflict of interest. In seeking this advice, the chief of staff disclosed that he had previously asked two VA physicians to do work for the company. The OGC ethics team advised that the VA physicians could continue working for the company; however, the chief of staff should not participate in any employment arrangements between the VA physicians and the company. The chief of staff confirmed that he would follow the advice. The OIG identified email threads exchanged between the chief of staff and the VA physicians in support of the outside business activities associated with the education company. When presented with these emails, the chief of staff apologized and expressed surprise. The two VA physicians indicated they believed (incorrectly) that the use of VA resources to conduct activities related to the company was permissible if it was done outside working hours. The OIG makes no recommendations. However, nothing in this report shall prevent the medical center director from taking appropriate administrative action with respect to the improper use of VA email resources by the chief of staff and the physicians.

The VA Office of Inspector General (OIG) conducted an inspection to evaluate a complaint regarding staffing, length of stay, and medical assessments on inpatient mental health units at the facility. Senator Elizabeth Warren referred similar concerns to the OIG regarding the inpatient mental health units. An allegation of inappropriate prescribing practices and identified concerns regarding nurse staffing methodology, recovery-oriented programming, and inpatient mental health levels of care were also reviewed. The OIG substantiated that from October 1, 2017, through September 30, 2019, inpatient psychiatry staffing was below expected staffing levels but was unable to determine if medical provider staffing was inadequate because the Veterans Health Administration (VHA) does not provide guidelines for medical staffing. The OIG did not substantiate patients had increased lengths of stay due to insufficient psychiatry staffing. From October 1, 2017, through September 30, 2019, staff did not complete the VHA-required number of utilization management reviews. The OIG did not substantiate patients remained on the acute inpatient mental health unit after psychiatric stabilization to treat medical issues that were overlooked during the admission process. The OIG did not substantiate that inpatient psychiatrists inappropriately prescribed antidepressant medications and vitamin B12 injections. From 2017 through 2019, facility leaders failed to complete VHA-required nurse staffing methodology. In January 2020, facility leaders approved the nurse staffing methodology. Inpatient mental health unit managers did not ensure the required recovery-oriented programming on Sundays, and programming did not consistently occur when scheduled. Facility leaders failed to convert sustained treatment and rehabilitation and specialized inpatient posttraumatic stress disorder beds to acute or residential beds, which resulted in staff’s failure to complete required utilization reviews. The OIG made seven recommendations related to inpatient mental health staffing, utilization management reviews, medical assessments, nurse staffing methodology, recovery-oriented programming, and inpatient mental health levels of care.