Federal Reports

The VA Office of Inspector General (OIG) initiated a healthcare inspection following inquiries from several members of Congress regarding the death of a patient (patient 1) perpetrated by another patient (patient 2) on the inpatient mental health unit at the West Palm Beach VA Healthcare System (facility). One of the inquiries was related to whether facility leaders sustained corrective measures recommended after a 2019 OIG inspection prompted by a patient’s suicide on the same unit. 

The OIG found that inpatient mental health unit staff did not follow Veterans Health Administration (VHA) Mental Health Environment of Care (EOC) Checklist requirements associated with patients using wheelchairs, specifically regarding patient 1’s room assignment and assigned patient safety observation level. During the inspection, facility leaders revised the room assignment screening process to align with VHA requirements.

The OIG identified findings similar to the 2019 OIG inspection, including inconsistent patient safety observation practices and inaccurate documentation, inappropriate assignment of additional staff duties, and facility policy that did not align with VHA requirements. Although leaders became aware that staff were not performing patient safety observations correctly and identified strategies for improvement, changes were not implemented.

As a result of the inspection, facility leaders updated facility policy to require provider orders before discontinuing a patient safety observation level and adding a direct line of sight observation level. Updated policy prohibits staff from performing patient safety observations while completing other duties. The OIG issued six recommendations to the Facility Director addressing mental health environment of care checklist requirements, observation practices, training, oversight processes, and documentation discrepancies.

The Veterans Integrated Network and Facility Directors concurred with the recommendations. The Facility Director provided action plans that included staff education on the mental health EOC checklist and patient safety observation requirements, and auditing patient safety observation practices to ensure staff compliance.

We performed an audit of the Tennessee Valley Authority’s (TVA) Contract No. 15387 with a company to provide a broad range of engineering, design, and construction management support when and as requested by TVA.  The objective of our audit was to determine if the costs billed to TVA were in accordance with the contract’s terms.  Our audit scope included approximately $33.2 million in costs billed to TVA between January 1, 2024, and March 31, 2025. 

In summary, we determined the company overbilled TVA an estimated $33,595, including (1) 14,079 in unsupported and overbilled travel and temporary living allowance costs, (2) $13,764 in invoice and payment errors, (3) a net $3,632 in performance fee credits, and (4) $2,120 in labor costs.  In addition, we identified opportunities for TVA to improve the administration of the contract.  Specifically, (1) the contract was unclear on how the company was to bill temporary employees it received from staffing agencies and (2) TVA did not evaluate fee for all tasks greater than $50,000, as required by the contract.   

During our unannounced inspection of Winn Correctional Center (Winn) in Winnfield, Louisiana, we found it complied with Performance-Based National Detention Standards 2011, as revised in December 2016, for the Special Management Units (SMU), general hygiene, and the grievance system.  However, the facility did not fully comply with reviewed standards for environmental health and safety, food service, use of force, medical care, classification, voluntary work program, legal access and materials, staff-detainee communication, and outdoor recreation in the SMU. 

We assessed public housing agencies’ (PHA) management of the occupancy of public housing units.  Our audit objective was to (1) assess the occupancy of public housing units, and (2) determine whether HUD had adequate oversight of PHAs’ occupancy, particularly PHAs’ management of vacant units.
 

We found PHAs had occupancy rates below HUD’s optimal level or a high number of long-term vacant units.  Further, although HUD monitors PHAs’ occupancy rates, it does not require very small PHAs or all PHAs with a high number of long-term vacant units take action to address vacancies.

These conditions occurred because PHAs experienced delays in turning over vacant units, especially units that required extensive repairs, due to (1) a lack of financial and staffing resources, including contractors, (2) inadequate processes or management oversight, and (3) holding vacant units offline to relocate tenants from units or buildings that were being repaired, renovated, demolished, or converted under HUD’s Rental Assistance Demonstration Program (RAD).  Additionally, some PHAs’ units were vacant because they were uninhabitable due to fires, natural disasters, or deterioration.  Further, HUD’s current risk mitigation action plan requires HUD staff to execute occupancy action plans for only PHAs with occupancy rates below 90 percent and 50 or more vacant units.  

As a result, PHAs were not consistently maximizing occupancy, resulting in fewer eligible families benefiting from affordable housing.  In addition, the PHAs that we reviewed lost the opportunity to receive operating subsidies and earn rental revenue for vacant units, totaling nearly $80 million in 2024 and more than $106 million in 2025.
 

We recommend that HUD’s Deputy Assistant Secretary for Field Operations (1) revise its Risk Mitigation Action Plan to include risk indicators to target PHAs with long-term vacant units and assess PHAs’ unit turnover timeliness; and (2) include a review of the physical condition of PHAs’ vacant units and turnovers as part of its field office staff’s monitoring activities.  We also recommend that HUD require PHAs to implement adequate procedures and controls over vacant units to help ensure that potential rent revenue and operating subsidies are not lost on vacant units and evaluate the physical condition of long-term vacant units and develop a plan to address the units, as appropriate.