Federal Reports

We audited the Detroit Housing Commission’s Moderate Rehabilitation program based on concerns regarding the conditions of the housing units and the results of our prior audit of the Commission’s former projects. The audit was part of the activities in our fiscal year 2018 annual audit plan. Our audit objective was to determine whether the Commission administered its program in accordance with the U.S. Department of Housing and Urban Development’s (HUD) and its own requirements.The Commission did not always administer its program in accordance with HUD’s and its own requirements. Specifically, it did not (1) correctly calculate and pay housing assistance for its program households, (2) obtain and maintain required eligibility documentation, (3) appropriately update contract rents, and (4) always enforce HUD’s housing quality standards. As a result, the Commission overpaid more than $47,000 and underpaid nearly $25,000 in housing assistance and utility allowance reimbursements. In addition, it paid more than $85,000 in unsupported housing assistance.We recommend that the Director of HUD’s Detroit Office of Public Housing require the Commission to (1) reimburse its program more than $23,000 from non-Federal funds; (2) reimburse the households or projects nearly $25,000 from non-Federal funds for the underpayment of housing assistance and utility allowances; (3) support or reimburse its program, households, or projects more than $85,000 for unsupported housing assistance payments; (4) pursue collection or reimburse its program nearly $24,000 from non-Federal funds for the overpayment of housing assistance; and (5) implement adequate quality control procedures to correct the findings cited in this audit report.

Prior OIG reviews identified significant Medicare Part B overpayments, including those to ambulance suppliers, for services they provided to Medicare beneficiaries during skilled nursing facility (SNF) stays covered under Medicare Part A. The Centers for Medicare & Medicaid Services (CMS) generally concurred with recommendations in these reports and implemented them. However, our analysis of recent claim data indicated that overpayments for ambulance transportation might still be occurring.

An Amtrak Foreman was formally reprimanded and disqualified from his current position on January 22, 2019, for one year after he admitted to violating the company’s Standards of Excellence and Acceptable Use policies for computer and network systems. The employee inappropriately viewed movies while on duty after they were uploaded to his Amtrak computer. A Locomotive Technician was counseled for his part in bringing the movies to work and providing them to the foreman.

The VA Office of Inspector General (OIG) conducted a healthcare inspection in response to a request from the OIG Office of Investigations to review the care of a patient at the Perry Point VA Medical Center, Maryland. The patient died in the hospice unit after receiving a potential overdose of a pain medication solution (oxycodone). Pharmacy Service staff dispensed oxycodone solution in one bulk bottle for multiple patients, including the identified patient, rather than in unit doses, which contributed to processes that increased risks in all phases of medication management. Additionally, pharmacists inconsistently processed medication orders. The facility’s established process for administering oxycodone solution contributed to additional risk as nurses did not have tools to accurately measure the solution. Facility leaders and patient safety program staff failed to recognize the inherent risks in medication administration and did not evaluate the patient’s death after receiving a potential medication overdose to determine the causes, system issues, and associated risks. Facility staff did not disclose the potential overdose to the patient’s family, conduct a root cause analysis or a peer review, or report it as an Adverse Drug Event to gain further understanding of the reasons and identify possible actions that could be taken to mitigate further risk. Facility staff did not follow requirements for ensuring recent acute care experience when hiring the nurse who administered the potential overdose and did not ensure the nurse’s competency related to the administration of this high-alert medication. Due to the identified medication management issues, the OIG was unable to determine whether the potential overdose contributed to the patient’s death. The OIG made eight recommendations related to evaluating and addressing the inaccuracies and risks involved with use of bulk bottles of oxycodone solution, quality review of the patient’s death, nurse hiring, and competencies processes.

The OIG investigated allegations that Smith & Marrs, Inc., an oil and gas production company, failed to report mineral production and sales from Federal leases located in New Mexico, which resulted in a loss of royalties owed to the U.S. Department of the Interior (DOI). We conducted the investigation jointly with the Bureau of Land Management’s (BLM) Special Investigations Group. We found that Smith & Marrs, Inc., failed to properly report oil and gas production and sales from Federal leases, which resulted in an underpayment of royalties and late payment interest. We then coordinated with ONRR officials to determine the total loss of royalties and interest, and ONRR sent Smith & Marrs payment requests for royalties due and late payment interest, which amounted to approximately $158,000. ONRR subsequently confirmed they had received full payment from Smith & Marrs.We referred our investigative findings to the U.S. Attorney’s Office for the District of Colorado, which declined prosecution.