VA Long-Term Care:

Oversight of Community Nursing Homes Needs Strengthening

GAO-01-768: Published: Jul 27, 2001. Publicly Released: Sep 7, 2001.

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The Department of Veterans Affairs (VA) spent about $1.9 billion--or about 10 percent of its health care budget--to provide nursing home care to veterans in fiscal year 2000. VA will likely see increasing demand for nursing home care during the next decade. The number of veterans age 85 and older is expected to triple--from 422,000 veterans in 2000 to nearly 1.3 million in 2010. Among the very old, the prevalence of chronic health conditions and disabilities increases markedly. In addition, VA is required to provide long-term care to some veterans, which may further increase veterans' demand for nursing home care. Almost 73 percent of VA's nursing home care in fiscal year 2000 went to VA's 134 nursing homes; the rest went to state-owned and operated veterans' nursing homes (15 percent) or to community nursing homes under local or national contract to VA (12 percent). VA generally requires its medical center staff to conduct annual inspections of state veterans' homes and community nursing homes; it also requires monthly staff visits to veterans in community nursing homes. However, VA plans to change its oversight of community nursing homes, eliminating the requirement for annual VA inspections and instead relying on Medicare and Medicaid certification inspections done by state agencies under contract to the Centers for Medicare and Medicaid Services (CMS). This report reviews (1) VA's policies for overseeing state veterans' homes and community nursing homes, including the mechanisms available to VA to ensure that nursing homes correct problems, and the extent to which VA has followed these policies and (2) planned changes in VA's oversight policies and the strategies to implement them. GAO found that VA's adherence to its oversight policies for state veterans' homes and community nursing homes has been mixed because of a lack of VA monitoring and oversight. VA medical staff are required to inspect each state veterans' home annually, and of the 86 inspections reviewed by GAO, about 85 percent were done within the time frame or shortly thereafter. VA lacks a departmentwide approach to monitoring medical centers' community nursing home oversight activities and enforcing VA's oversight policies--particularly regarding locally contracted homes, which make up about 75 percent of the community nursing homes under contract to VA--and individual medical centers vary in how well they have overseen community nursing homes. Under its planned policy change, VA would eliminate the requirement for annual inspections of community nursing homes and instead would rely on Medicare and Medicaid certification inspections. Local VA medical centers' staff will review state inspection reports and CMS data to evaluate community nursing homes. However, the quality of state inspections of nursing homes varies, and CMS is unable to accurately assess state inspection results in all cases.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: VA has established a policy for overseeing all community nursing homes (CNH) that relies on using data from state inspections as well as the experience of VA review teams when they make monthly site visits to all CNH facilities under contract. This policy also outlines a plan for VA to conduct comparative reviews to assess the sufficiency of state inspections.

    Recommendation: To strengthen its oversight of community nursing homes and better ensure that veterans receive acceptable quality of care, the Secretary of Veterans Affairs should direct the Under Secretary for Health to develop a single structured, comprehensive, and uniformly applied policy for overseeing all community nursing homes under local or national contract to VA. Such a policy may require annual VA inspections of all such homes or rely on state inspections and other data, including information on substantiated complaints, to provide information on nursing home quality. However, if VA chooses the second option, it should monitor the reliability of state inspection data by conducting its own inspections of a portion of all community nursing homes under contract, or contract with CMS to do so, and use the results of these comparative inspections to make judgments about the quality of state data. In those states where nursing home inspections appear inadequate, VA should conduct its own inspections of all community nursing homes under contract to VA.

    Agency Affected: Department of Veterans Affairs

  2. Status: Closed - Implemented

    Comments: VA has implemented the use of an inspection protocol for community nursing homes, making it easier for VA to compare the results of site visit reports across facilities. VA previously developed training for staff expected to conduct community nursing home inspections and VA issued guidance on the objectives of monthly visits by issuing an oversight handbook in June 2000. VA also previously provided guidance on interpreting On-Line Survey, Certification, and Reporting and MDS quality indicator data by conducting monthly telephone conferences and by issuing the oversight handbook.

    Recommendation: To strengthen its oversight of community nursing homes and better ensure that veterans receive acceptable quality of care, the Secretary of Veterans Affairs should direct the Under Secretary for Health to ensure consistent and comprehensive VA medical oversight activities by (1) developing and implementing an inspection protocol and conducting inspection training for all VA staff expected to conduct community nursing home inspections, (2) providing guidance and direction on the objectives of VA's monthly visits and the methodology to be used during visits, and (3) providing guidance on how to obtain, interpret, and use the On-Line Survey, Certification, and Reporting, quality indicator, and other data in assessing community nursing home quality of care when VA implements its planned policy.

    Agency Affected: Department of Veterans Affairs

  3. Status: Closed - Implemented

    Comments: VA's new policy for community nursing home oversight includes a system to monitor facilities' compliance with its oversight policy. The policy now requires that each VA facility provide documentation to VA's Geriatrics and Extended Care Strategic Healthcare Group (GEC SHG), showing that all contract nursing homes are in compliance with VA standards. This documentation must include the date each nursing home was reviewed, how the reviews were conducted (including whether an on-site review by VA staff was conducted), whether consultation with the state survey agency was obtained, and "any other pertinent comments or recommendations." Each VA facility must provide this information to GEC SHG by February 1 of each year.

    Recommendation: To strengthen its oversight of community nursing homes and better ensure that veterans receive acceptable quality of care, the Secretary of Veterans Affairs should direct the Under Secretary for Health to ensure that VA medical centers follow VA's community nursing home oversight policies by (1) developing and implementing a system through which headquarters can determine which VA medical centers have conducted oversight as required and (2) establishing a mechanism for ensuring that VA medical centers adhere to these policies. For example, VA could require medical center directors to certify annually that they have inspected or otherwise assessed the quality of care in community nursing homes as required, similar to what is required of medical center directors under the state veterans' home program.

    Agency Affected: Department of Veterans Affairs

 

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