Federal Reports

The VA Office of Inspector General (OIG) reviewed a complainant’s allegations and substantiated that the facility’s providers, at the time of a patient’s most recent hospital admission, failed to complete thorough evaluations including reconciliation of medications. The incomplete evaluation may have contributed to the patient’s declining health and likely hindered the provision of additional needed treatment. Providers failed to appropriately treat the patient’s underlying condition or recognize potential signs of illness such as an elevated white blood cell count. The OIG would have expected the providers to identify and remove the source of infection. The OIG was unable to determine whether the providers’ failures contributed to the patient’s death. The OIG was unable to determine whether system providers discharged the patient without a discussion with the family of the patient’s medical condition. However, the patient was competent and was included in care discussions; including family members in the discussions was not required. The OIG substantiated that providers did not communicate care options to mitigate the patient’s suffering. In addition, podiatry clinic staff did not consistently follow system policy for scheduling appointments and wound care clinic consults were not performed as required. Coordination of care expected for a geriatric patient with chronic illnesses, multiple wounds, and who was “at risk” for foot ulcers was lacking and care was fragmented. Deficiencies in the patient’s care coordination likely contributed to the patient’s worsening wounds. The podiatry attending physician did not document resident supervision in accordance with system policy. The OIG made eight recommendations related to medication reconciliation, provider education, infection source, care transitions, discharge planning, podiatry clinic scheduling, wound care clinic consults and practices, and resident supervision.

The U.S. Department of Housing and Urban Development (HUD), Office of Inspector General audited the Federal Housing Administration (FHA) based on the results of another audit, which found that the lender improperly filed for partial claims before completing the loan modifications and reinstating the loans. Our audit objective was to determine whether FHA improperly paid partial claims that did not reinstate the delinquent loans.We found that FHA improperly paid partial claims that did not reinstate their related delinquent loans. From a sample of 87 partial claims reviewed, FHA paid 47 partial claims totaling more than $2.7 million that did not cure the loan delinquency. By using a statistical projection, we estimated that the FHA insurance fund was unnecessarily depleted by $27.1 million in partial claims. We recommend that the Deputy Assistant Secretary for Single Family Housing (1) take corrective action against lenders for the improper partial claims that did not reinstate the delinquent loans and have not been repaid, (2) design controls to protect the insurance fund from improper partial claims that did not reinstate the loans to put $27.1 million to better use, and (3) update program guidance, clarifying that upon application of the partial claim funds, the mortgage must be fully reinstated with no unpaid amounts.

This report provides the results of our review of the circumstances surrounding the death of Peace Corps Volunteer Bernice Heiderman on January 9, 2018, in Comoros. Our review identified several vulnerabilities associated with the Peace Corps’ failure to provide an early diagnosis and prompt treatment for PCV Heiderman’s malaria. This report makes 7 recommendations to the Peace Corps to address the vulnerabilities we identified and make it more likely that medical officers will provide timely diagnosis and prompt, effective treatment for malaria so that future Volunteer deaths from the disease can be prevented.