Federal Reports

Departments are required by law to develop and maintain governance structures, controls, and processes to safeguard resources and assets. A robust fraud risk framework helps to ensure that programs fulfill their intended purpose and that funds are spent effectively. HUD relies on public housing authorities (PHAs) to detect and prevent fraud, waste, and abuse in its housing programs.  Therefore, we audited the New York City Housing Authority’s (NYCHA) fraud risk management maturity with the objective of assessing its fraud risk management practices for preventing, detecting, and responding to fraud when administering HUD‐funded programs. We chose NYCHA because it is HUD’s largest PHA, administering billions of dollars in HUD funding and because its programs receive over 25 percent of HUD’s rental assistance funding nationwide.

We found that NYCHA has established several antifraud controls, but its processes to mitigate fraud risks are largely reactive. NYCHA is actively taking steps to formalize a more proactive fraud risk management approach and is progressing toward a more mature antifraud program.  We assessed NYCHA’s antifraud efforts against established best practices to determine the maturity of its fraud risk management practices, and found it to be at an “initial” maturity level. We found NYCHA does not have a comprehensive strategy or framework for identifying and responding to fraud risks. Specifically, it did not (1) assess fraud risks across NYCHA or develop a process to regularly conduct assessments to identify and rank fraud risks, (2) develop a response plan for fraud risks based on a fraud risk assessment, and (3) implement a process to monitor and evaluate the effectiveness of fraud risk management activities.

Due to the size and complexity of NYCHA, as well as its high fraud risk exposure, it should aim for a higher fraud risk maturity level. Without a comprehensive fraud risk management framework or antifraud strategy, HUD funding will continue to be at an increased risk of fraud, and NYCHA will not be positioned to understand how it can best improve its programs to detect fraud or potential fraud.  Further, since HUD has not issued formal guidance to PHAs regarding its expectation of PHAs in assisting HUD with its responsibility to implement fraud risk management activities over HUD programs, it is likely that many PHAs have not implemented formal fraud risk management programs. As a result, HUD is missing a critical control using leading practices that could detect and prevent fraud and minimize fraud risk at the PHA level in the Office of Public and Indian Housing programs that spend approximately $38.5 billion annually on voucher and public housing programs, representing over 50 percent of HUD’s budget.

This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the VA Dublin Healthcare System in Georgia. 

This evaluation focused on five key content domains:
   •    Culture
   •    Environment of care
   •    Patient safety
   •    Primary care
   •    Veteran-centered safety net

The OIG issued eight recommendations for improvement in three domains:
 1.    Environment of care
   •    Navigational signage
   •    Toxic exposure program oversight and screening navigator roles and responsibilities
   •    Clean and safe patient care areas
   •    Biohazard storage area contents, signage, and hand-washing supplies and equipment
   •    Environment of care trends, performance improvement plans, and outcome measures
 2.    Patient safety
   •    Ordering providers communicate and document test results
   •    Facility-level policies and standard operating procedures comply with VHA requirements
 3.    Veteran-centered safety net
   •    Homeless program staff have appropriate vehicles

The VA Office of Inspector General (OIG) conducted a healthcare inspection to determine how surgical instruments that were not suitable for service (nonconforming instruments) were used during a patient procedure at the Carl Vinson VA Medical Center (facility) in Dublin, Georgia. The OIG identified Sterile Processing Service (SPS)-related deficiencies as well as a continuation of previously identified deficiencies.

The OIG determined that SPS and operating room staff failed to remove nonconforming surgical instruments from a rectal tray that was used during a patient procedure. Moreover, the OIG found additional surgical instruments in nonconforming condition and that, contrary to policy, the reprocessing and use of nonconforming instruments was a permitted practice at the facility.

Additionally, facility leaders failed to establish a preventative maintenance program for the sharpening, repair, or replacement of surgical instruments prior to May 30, 2024.

The OIG also identified a continuation of previously identified deficiencies that included: the failure of facility leaders to fully implement an electronic surgical instrument tracking system known as CensiTrac, address concerns of the CensiTrac coordinator’s performance, and resolve concerns related to the intended use of an SPS conference and training room. Frequent changes in staff assigned to leadership positions, along with leaders’ failures identified above, likely contributed to the continued SPS deficiencies.

The OIG made two recommendations to the Facility Director related to ensuring staff’s compliance with identification and disposition of nonconforming surgical instruments and training operating room staff to recognize nonconforming surgical instruments. The OIG made three recommendations to the Veterans Integrated Service Network Director related to reviewing patients potentially affected by nonconforming instruments, evaluating whether administrative action is warranted for individuals regarding SPS deficiencies at the facility, and performing oversight of the facility’s implementation of facility-level action plans and sustainability of identified outcomes.