Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations that staff at the San Diego VA Healthcare System, California, failed to provide mental health care to a patient who subsequently died by suicide. The OIG did not substantiate that the system failed to provide mental health care when the patient sought help. The OIG found that the suicide risk assessment of the patient was adequate. The system complied with both Veterans Health Administration (VHA) and system requirements related to the risk assessment and resident supervision, supervision documentation, and monitoring of resident supervision documentation. The OIG identified deficits in the decision-making process to deactivate the patient’s High Risk for Suicide Patient Record Flag. The assigned Suicide Prevention Coordinator deactivated the High Risk for Suicide Patient Record Flag without contacting the patient, consulting the patient’s treatment team, the patient having scheduled future appointments, and despite the patient having not been engaged in mental health services for more than two months. VHA does not have clearly delineated requirements for the decision-making process to deactivate the High Risk for Suicide Patient Record Flag; however, the Executive Director, Suicide Prevention Program, told the OIG that the suicide prevention coordinator is expected to consult with the patient’s treatment team, provide evidence of decreased risk and reduced suicide risk factors, and document rationale for clinical judgment about mental health conditions and behaviors. Further, the OIG identified deficits in the medication reconciliation process and documentation. The OIG made one recommendation to the Under Secretary for Health related to management of High Risk for Suicide Patient Record Flags and one recommendation to the System Director related to the medication reconciliation process and documentation.

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.