Federal Reports

We audited the New York City Department of Housing Preservation and Development’s (HPD) Housing Choice Voucher Program. We selected HPD for review based on its size and because we had not conducted an audit of its Housing Choice Voucher Program. The objective of the audit was to determine whether HPD ensured that its program units met HUD’s housing quality standards and whether it abated housing assistance payments when required.HPD did not always ensure that its program units met housing quality standards and its quality control inspections met sample requirements, but it generally abated housing assistance payments when required. Of the 58 sample units inspected, 52 units had housing quality standards violations. While each of the 52 units had at least 1 violation, only 6 of the units materially failed to meet HUD’s standards. In addition, although HPD generally abated the correct amount of payments, we identified several areas in which it could improve its controls. These conditions occurred because HPD did not always thoroughly conduct inspections and used an inspection order form that did not identify the key aspects of housing quality standards performance; included non-program units in its quality control sample and conducted quality control inspections concurrently with unit inspections; and did not have adequate controls over abatements and inspection documentation. As a result, HPD disbursed $26,044 in housing assistance payments and received approximately $2,259 in administrative fees for units that materially failed to meet HUD’s housing quality standards. Further, HUD did not have assurance that HPD’s quality control process was fully effective and that it consistently carried out the abatement process, including maintaining records that were accurate and complete. By improving its inspection process, HPD could better ensure that $760,363 in future program funds is spent on units that meet HUD’s housing quality standards.We recommend that HUD require HPD to (1) certify, along with the owners of the 52 units cited in the finding, that the applicable housing quality standards violations have been corrected; (2) reimburse its program from non-Federal funds $28,303 for the 6 units that materially failed to meet standards; (3) improve controls over its inspection process to ensure that units meet housing quality standards and that the results are used to enhance the effectiveness of its inspections; and (4) improve controls over its quality control sampling process and its abatement process.

Pennsylvania did not ensure that its managed-care organizations complied with Federal and State requirements prohibiting Medicaid payments to providers for inpatient hospital services related to treating certain provider-preventable conditions. For our audit period, we identified that managed-care organizations paid providers approximately $43.5 million for 576 claims that contained provider-preventable conditions.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate care of a patient who died in a behavioral health unit at the Gulf Coast Veterans Health Care System, Biloxi, Mississippi. The specific concern was the unit staff’s failure to initiate full resuscitation efforts when the patient was found unresponsive (event). Behavioral health unit registered nurses (RNs) did not fulfill the position responsibilities or ensure accurate documentation for the patient. Unit staff did not initiate appropriate resuscitation efforts after finding the patient unresponsive. The OIG was unable to determine whether initiating full resuscitation efforts would have been successful if employed at the time the patient was found unresponsive. An RN inappropriately determined the patient’s death; staff did not consistently track documentation of the behavioral health unit RNs’ basic life support competency and training; and emergency department providers did not document a discussion with the admitting behavioral health provider. The behavioral health unit’s emergency cart was unlocked and contained an expired tubing package. The OIG identified deficiencies in the facility’s response to the event that included the reporting requirements to the State Licensing Board and consideration of an institutional disclosure. Despite the claim that staff initiated resuscitation for the patient, the OIG did not find documentation of therapeutic measures on required forms and the designated committee did not review the event. The OIG made nine recommendations related to emergency/code blue procedures, pronouncement of death, health record documentation, and review processes.