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VA Nursing Home Care: Opportunities Exist to Enhance Oversight of State Veterans Homes

GAO-23-105167 Published: Nov 14, 2022. Publicly Released: Nov 14, 2022.
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Fast Facts

The Department of Veterans Affairs pays for about 14,500 veterans to live in 153 state-run nursing homes as of FY2021. VA oversees these homes by inspecting them to ensure that they meet the agency's quality standards. But VA could improve its oversight.

VA inspections in 2019 and 2021 showed an increase in the number and the severity of deficiencies cited. VA's only enforcement action is to withhold payments to force these state veterans homes to comply, but VA considers this too severe for most situations. VA officials are considering asking Congress for more enforcement authorities.

Our 4 recommendations address this issue, and more.

A senior citizen who uses a walker next to a medical staff member in a hallway.

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Highlights

What GAO Found

The Department of Veterans Affairs (VA) is the only federal entity that oversees all 153 state veterans homes, which provide nursing home care to roughly 14,500 veterans. While these homes are owned and operated by states, VA helps pay for care for eligible veterans and is required to ensure the homes meet VA's quality standards. To do this, VA conducts regular inspections, and homes that do not meet standards can be cited for deficiencies. The Centers for Medicare & Medicaid Services (CMS) also conducts inspections in the nearly 76 percent of state veterans homes that receive Medicare or Medicaid payments and, like VA, can cite deficiencies. In response to GAO's national survey of state agencies that operate state veterans homes, 43 states reported also inspecting homes for compliance with state-specific regulations or on a for-cause basis.

GAO's analysis of VA's available annual inspection data for 2019 and 2021 found increases in both the number and the severity of deficiencies cited. For example, the total number of deficiencies increased from 424 in 2019 to 766 in 2021. A majority of the increase was in the quality of care and infection control categories, which cover accidents and staff hand hygiene. Additionally, GAO found that, for those homes with annual inspection data available in both 2019 and 2021, many were cited for deficiencies in the same standard.

GAO found that VA could enhance oversight by, among other things, an expansion of the tools it has to bring these homes into compliance with quality standards. According to VA officials, compared to CMS, VA lacks a range of enforcement actions to use to bring state veterans homes into compliance (see figure). Specifically, VA's only enforcement action is to withhold payment to compel homes to come into compliance. VA considers this action too severe for most situations. VA officials said they are considering seeking legislative authority to take additional enforcement actions to ensure compliance with quality standards. Having such tools would strengthen VA's ability to better ensure that veterans receive quality care in these homes.

Available Enforcement Actions for Department of Veterans Affairs and Centers for Medicare & Medicaid Services

Available Enforcement Actions for Department of Veterans Affairs and Centers for Medicare & Medicaid Services

Why GAO Did This Study

Many aging veterans rely on nursing home care to meet their daily needs. In fiscal year 2021, VA paid about $1.5 billion for veteran nursing home care provided in state veterans homes.

GAO was asked to provide information on VA's oversight of state veterans homes, and the joint explanatory statement accompanying the Consolidated Appropriations Act, 2021, contained a provision for GAO to review the relationship between VA and these homes. This report (1) describes the oversight of state veterans homes to ensure compliance with quality standards; (2) examines available data about deficiencies cited during inspections; and (3) examines how VA could enhance its oversight of state veterans homes.

GAO conducted a nationwide survey to collect information on the 153 state veterans homes providing nursing home care. GAO analyzed data from VA's annual inspections for 2019 and 2021. (Data were not available for 2020 because inspections were suspended due to the COVID-19 pandemic.) GAO also reviewed relevant statutes, regulations, and VA documents, and interviewed federal and state officials and organizations involved with veteran care.

Recommendations

GAO is making four recommendations to VA, including that it identify additional enforcement tools to ensure state veterans home compliance with quality standards, and seek legislative authority for them, as appropriate. VA agreed with the recommendations.

Recommendations for Executive Action

Agency Affected Recommendation Status
Department of Veterans Affairs The Under Secretary of Health should develop a plan to ensure the data system it is currently developing has the capabilities to aggregate and analyze state veterans home data by multiple units of measurement, including by state and home, and across survey years. (Recommendation 1)
Closed – Implemented
In September 2023, VA provided evidence that the agency has a plan for developing a system for state veterans home data. The plan includes steps to ensure the data system will enable users to aggregate and analyze data by state and home and across survey years, among other units of measurement.
Department of Veterans Affairs The Under Secretary of Health should implement a process for consistently following up with state veterans homes that have not implemented their corrective active plans by the agreed upon dates. (Recommendation 2)
Closed – Implemented
In September 2023, VA provided evidence that the agency developed and implemented a process to follow up with state veterans homes about corrective action plans (CAP). Specifically, in March 2023, VA released an updated standard operating procedure for the management of CAPs that requires VA to follow up with state veterans homes that have not submitted evidence of CAP implementation. VA also shared documentation that shows VA staff have been trained on the new process and that VA tracks that status of each CAP.
Department of Veterans Affairs The Under Secretary of Health should identify additional enforcement actions that would help ensure state veterans home compliance with quality standards and seek legislative authority to implement those actions, as appropriate. (Recommendation 3)
Open
VA concurred with this recommendation. GEC indicated it would develop a process to notify key stakeholder's (both state and VA) based on the level/severity of noncompliance with quality standards. The level of noncompliance will determine the enforcement action. GEC will create a legislative proposal for submission. GEC will operationalize these enforcement actions through changes to the Federal Regulations. In March 2023, GEC indicated it would develop a standard operating procedure to outline the process for withholding per diem from state veterans homes. Regulatory review will also be done to determine if any changes are necessary to Federal Regulations. We will continue to monitor VA's actions and update the recommendation accordingly.
Department of Veterans Affairs The Under Secretary of Health should ensure GEC's centralization efforts align with VA's policies for national policy management, such as by issuing an interim notice to communicate the oversight changes to all stakeholders and pursuing the expeditious formalization of the new oversight in official directives and regulations. (Recommendation 4)
Open
VA concurred with this recommendation. In response to this recommendation, GEC indicated that it would issue an interim notice to stakeholders about the state veterans homes modernization efforts, to include forthcoming oversight changes. GEC will revise the Veterans Health Administration Directive to align with State Veterans Homes modernization and ensuing oversight changes once formal rulemaking has been implemented. GEC will operationalize these changes in oversight processes through amendments to Federal Regulations. In March 2023, GEC indicated officials met with VHA National Policy Operations leadership to discuss necessary steps to ensure that GEC's centralization efforts align with VA's policies for national policy management, specifically VHA Directive 0999 VHA Policy Management. GEC has drafted an interim notice, VHA Notice Oversight Requirements for State Veterans Homes, and has initiated revision of VHA Directive . The VHA Notice will be submitted to initiate the VHA concurrence process while the directive is being reviewed. The initial efforts are focused on VHA notice issuance and VHA policy revisions. We will continue to monitor VA's actions and update the recommendation accordingly.

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Topics

Nursing homesCompliance oversightQuality of careMedicareQuality standardsMedicaid servicesVeteransVeterans oversightVeterans affairsRegulatory noncompliance