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VA Nursing Home Care: VA Has Opportunities to Enhance Its Oversight and Provide More Comprehensive Information on Its Website

GAO-19-428 Published: Jul 03, 2019. Publicly Released: Aug 02, 2019.
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Fast Facts

VA spent $5.7 billion in 2017 on nursing home care for about 39,000 veterans. VA provides or pays for this care in 3 settings—VA-owned centers, veterans homes that states own and operate, and community nursing homes in which VA contracts for care.

To help veterans choose where to receive nursing home care, VA developed a website that provides information on the homes' quality. However, VA does not provide any information on state veterans homes—which is where more than half of the veterans receive care.

We recommended that VA provide information about state homes on its website.

Actual and projected daily average census of veterans by setting, FY’s 2012, 2027, and 2022

Bar chart showing the various populations over time.

Bar chart showing the various populations over time.

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What GAO Found

According to the Department of Veterans Affairs (VA), veterans' use of nursing home care increased 3 percent, from an average daily census of 37,687 to 38,880 veterans, from fiscal years 2012 to 2017. VA projects that use will increase 16 percent from fiscal years 2017 to 2022 with the aging of Vietnam War veterans. VA's nursing home expenditures increased 17 percent (8 percent adjusted for inflation), from $4.9 billion to $5.7 billion, from fiscal years 2012 to 2017.

VA's Actual and Projected Average Daily Census of Veterans in Nursing Homes, by Setting, Fiscal Years 2012, 2017, and 2022

VA's Actual and Projected Average Daily Census of Veterans in Nursing Homes, by Setting, Fiscal Years 2012, 2017, and 2022

During the contract year completed in 2018, VA contractors conducted required inspections of community living centers (CLC) (VA-owned and -operated) and state veterans homes (SVH) (state-owned and -operated) to ensure they complied with quality standards. Selected VA medical centers also completed required annual reviews of Centers for Medicare & Medicaid Services data and conducted optional onsite reviews for community nursing homes (CNH), with which VA contracts. However, VA has opportunities to enhance its oversight. For example, VA did not conduct the quarterly monitoring of contractor performance as stipulated in its contract for CLC inspections from April 2017 to April 2018. VA officials also said they intended to regularly observe contractors conducting inspections to ensure they effectively determine compliance with standards, but have not done so due to competing demands. Officials also said they had performed these observational assessments in the past but were unable to provide documentation of them occurring. Conducting and documenting the quarterly observational assessments would allow VA to identify areas for improvements and to take any needed corrective actions.

VA's Access to Care website provides publicly available information about the quality of CLCs and CNHs based on inspections. Veterans and their families can use the website to help inform their decisions on nursing home placement. However, the website does not include any SVH information. Although VA has access to SVH quality information, according to VA officials, they are not required to publicly report it. For some SVHs, VA is the only source for quality care information. Some of the quality information is available locally, but the VA website is an important tool for veterans and their families. Providing SVH information on its website could enhance veterans and their families' ability to evaluate all nursing home options.

Why GAO Did This Study

VA provides nursing home care for veterans whose health needs are extensive enough to require skilled nursing and personal care in an institutional setting. VA provides or pays for the cost of nursing home care for eligible veterans.

GAO was asked to examine VA nursing home care. In this report, GAO 1) describes utilization of and expenditures for VA-funded nursing home care, 2) examines VA's use of inspections to assess the quality of nursing home care and its oversight of the process, and 3) examines the information VA publicly provides through its website on the quality of nursing home care.

To perform this work, GAO reviewed VA policies and information on inspections and interviewed VA officials. GAO also selected six VA medical centers based on factors such as their participation with CLCs, SVHs, and CNHs and location. For each, GAO interviewed medical center officials and officials from corresponding VA regional offices, CLCs, SVHs, and CNHs.


GAO is making four recommendations, including recommendations for VA to enhance its oversight of the quality of care provided to veterans in CLCs, SVHs, and CNHs and include on its website information on the quality of care for SVHs that is comparable to what it provides on CLCs and CNHs. VA concurred with two recommendations and concurred in principle with two recommendations.

Recommendations for Executive Action

Agency Affected Recommendation Status
Veterans Health Administration The Under Secretary of Health should develop a strategy to regularly monitor the contractors' performance in conducting CLC and SVH inspections, ensure performance results are documented and any needed corrective actions are taken. (Recommendation 1)
Closed – Implemented
VA concurred with this recommendation and provided information to address it in July 2020. Specifically, VA developed and implemented standard operating procedures to regularly monitor the CLC and SVH contractors' performance in conducting inspections through observational assessments, to document these assessments, and to track corrective actions.
Veterans Health Administration The Under Secretary of Health should require that all failures to meet quality standards are cited as deficiencies on SVH inspections. (Recommendation 2)
Closed – Implemented
VA concurred with this recommendation. In February 2021, VA updated its guidance on survey requirements for state veterans homes. According to VHA Directive 1145.01, all failures to meet the quality standards identified by the VA team performing the inspections will be cited as deficiencies.
Veterans Health Administration The Under Secretary of Health should develop guidance for Veterans Affairs Medical Center staff conducting optional onsite CNH reviews. (Recommendation 3)
Closed – Implemented
VA concurred in principle with this recommendation. In August 2021, VA provided documentation on the guidance clarifications the agency made. Specifically, VA provided documentation of VHA guidance issued in October 2020 that replaced optional onsite reviews with information already available through the Center for Medicare and Medicaid Services' Nursing Home Compare. VHA also provided a Community Nursing Home Field Guidebook and training to VA medical center staff that outlined a specific waiver process for homes which are underperforming on Nursing Home Compare. This waiver process directs VA medical center staff to focus on the specific experience of the veteran. Since VA clarified their guidance, we are closing this recommendation as implemented.
Veterans Health Administration The Under Secretary of Health should provide information on the quality of all SVHs that is comparable to the information provided on the other nursing home settings on its Access to Care website. (Recommendation 4)
Closed – Implemented
VA concurred in principle with this recommendation. As of July 2021, the department had added information about SVHs on its Access to Care website, including information for the two-thirds of SVHs that are on Nursing Home Compare. VA stated they would continue to improve the SVH information, but that the actions would take time. In February 2023, VA indicated that it had completed adding the SVH information it was able to and we see improvements on its website that can help consumers. For example, users of VA's website can now determine which SVHs, not just CMS-certified Community Nursing Homes and VA Community Living Centers, are located in their geographic area. Additionally, users can view quality measures-such as falls with major injury-for all three types of facilities. Finally, for the SVHs that are CMS-certified, VA's website provides a link to Nursing Home Compare, so users can review CMS' assessment of the SVH. For the remaining SVHs, VA's website informs users that the SVH has not been certified by CMS.

Full Report

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Access to health careCompliance oversightContractor performanceFederal spendingGeriatricsHealth careInternal controlsNursing homesQuality standardsQuality of lifeVeterans affairsQuality of care