VA Health Care:

Efforts to Assure Quality of Care in State Homes

HRD-90-40: Published: Nov 27, 1989. Publicly Released: Nov 27, 1989.

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Pursuant to a congressional request, GAO determined whether the Department of Veterans Affairs (VA): (1) inspected state homes frequently enough to evaluate the care veterans received; and (2) used adequate procedures to assess the quality of care provided in state homes. GAO also determined whether VA had implemented three GAO recommendations made in 1981 to: (1) revise its state home inspection standards to provide more specificity and guidance; (2) review VA inspection reports on state homes to ensure standards compliance; and (3) develop standards in surgical care and related services for state home hospital units.

GAO found that: (1) VA requirements for annual inspections were consistent with the general inspection practices of other health care organizations; (2) VA inspection guidelines were adequate, but it did not consistently follow them; and (3) one of the six VA medical centers GAO reviewed did not perform annual inspections properly, and five of the six did not consistently follow up on noted deficiencies to ensure that state homes corrected them. GAO also found that VA: (1) revised its inspection guidelines to provide more specificity and guidance; (2) reviewed all inspection reports to determine whether reports were complete and whether state homes addressed all standards; and (3) did not develop standards on surgical care and related services for state homes' hospital units because it believed that such standards would duplicate those used by the Joint Commission on Accreditation of Healthcare Organizations, which inspected state homes providing surgical care.

Recommendation for Executive Action

  1. Status: Closed - Implemented

    Comments: VA has implemented a mechanism for regional director staff to use to monitor the state home inspection activities. The mechanism requires that VAMC provide VA Central Office with status reports and action plans for the correction of any deficiencies cited in inspection reports. These reports and plans are due 6 months after the inspections are done.

    Recommendation: The Secretary of Veterans Affairs should direct the Chief Medical Director to require VA regional offices to ensure that medical centers adhere fully to current VA inspection requirements, particularly the requirements to follow up on corrective action agreed to be taken by the state homes.

    Agency Affected: Department of Veterans Affairs


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