Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate factors that may have impacted or contributed to the unexpected death of a ventilator-dependent patient on the Spinal Cord Injury (SCI) unit at the VA San Diego Healthcare System and to follow-up on the facility’s response. The OIG could not determine what the ventilator settings were at the time of the patient’s death, because facility staff who inspected the ventilator immediately thereafter changed the settings to check whether alarms were functional and then reportedly returned the settings to the previous levels. The OIG determined the facility did not implement risk mitigation strategies for the use of the in-line Passy-Muir® Valve (PMV) on ventilated patients. The facility did not have a back-up monitoring plan when the ventilator alarms were off, patient criteria to determine when the valve should be removed, policies for facility staff and patient/family education on the use of the PMV, policies or procedures for monitoring and documenting ventilator and alarm settings while using the PMV, or a policy to use anti-disconnect devices. At the time of the patient’s death, the SCI unit used an outdated nurse call system that required the use of a splitter to connect the ventilator to the call system, none of the respiratory therapy staff had training or competency assessments related to PMV use, staff failed to report the patient’s ventilator tubing disconnections through the Patient Safety reporting system, and SCI leaders failed to follow the standard operating procedure for the management of clinical alarms. The OIG made five recommendations related to policy and training for use of the PMV on the SCI unit and the anti-disconnect device, potential issuance of a National Patient Safety Advisory, training for reporting patient safety issues, and reviewing clinical alarms according to facility policies.

Medicare spending is expected to exceed $1.5 trillion by 2028, more than double the $708 billion in spending in 2017. To help control Medicare spending, while promoting high-quality healthcare, CMS has been implementing alternative payment models that reward providers for the quality and value of services. This is part of the transition away from fee-for-service to value-based care.

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We audited the Housing Authority of the City of Easton, PA’s Housing Choice Voucher Program because (1) we received a complaint alleging that the Authority made improper payments to program participants and a consultant to the Authority inappropriately placed herself on the program waiting list and (2) we had never audited the Authority. Our audit objective was to determine whether the Authority administered its program in accordance with U.S. Department of Housing and Urban Development (HUD) requirements. We focused the audit on evaluating the allegations in the complaint and reviewing (1) participant eligibility and selection from the waiting list and (2) the accuracy of and support for housing assistance payments. The two allegations in the complaint did not have merit. However, the Authority did not (1) properly administer its waiting list and select tenants from it and (2) perform quarterly interim recertifications for families reporting zero income. These conditions occurred because the Authority was unaware of some waiting list requirements, lacked procedures to collect and maintain documentation to show that it properly selected applicants from the waiting list, and lacked procedures for performing quarterly interim recertifications for families reporting zero income. As a result, HUD lacked assurance that applicants were (1) properly placed on the waiting list, (2) fairly awarded preference points, and (3) properly selected from the waiting list. The Authority also made ineligible housing assistance payments totaling $2,463. We recommend that HUD direct the Authority to (1) update its administrative plan to clearly define the weights and rankings in its preference system and ensure compliance with residency preference regulations; (2) develop and implement policies and procedures to ensure that it administers its waiting list according to the requirements in its administrative plan, including maintaining documentation to show that it properly selected applicants from the waiting list; (3) develop and implement procedures for recertifying families reporting zero income; and (4) provide documentation to show that the family that received the benefit of the $2,463 overpayment in housing assistance reimbursed the program or repay its program from non-Federal funds for any amount not reimbursed by the family.