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

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.

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.

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.

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.

The Department of Veterans Affairs (VA) operates one of the largest  health care delivery systems in the nation. In fiscal year 2017, more than  9 million veterans were enrolled in the VA health care system, at a total  cost of nearly $72.9 billion. VA provides nursing home care for eligible  veterans whose health care needs are extensive enough to require skilled  nursing and personal care in an institutional setting.

VA provides or pays for nursing home care in three settings. Specifically:

VA provides nursing home care in VA-owned homes known as  community living centers (CLC).

VA also pays for all or part of the cost of nursing home care for  veterans in state veterans homes (SVH), which are owned and  operated by states.

Finally, VA pays for care provided to veterans in public or privately  owned community nursing homes (CNH), with which VA contracts to  provide care to veterans.

A primary means through which VA oversees the quality of care provided  to veterans at these facilities is through periodic inspections. VA then  reports some information on nursing home quality on a department-run  website (called Access to Care) to help veterans and their families make  decisions about where to receive nursing home care.

Recent news stories have raised concerns about the quality of care  veterans have received at some individual nursing homes. Amid these  reports, you raised concerns about VA’s oversight of the quality of nursing  home care and the extent to which veterans and their families have  access to information on the quality of individual nursing homes. In light of  these concerns, you requested that we review VA’s nursing home care. In  this report, we  1.  describe utilization of and expenditures for VA nursing home care;  2.  examine VA’s use of inspections to assess the quality of nursing  home care and its oversight of the process; and  3.  examine the information VA publicly provides on the quality of VA  nursing home care.

To describe utilization of and expenditures for VA nursing home care, we  analyzed VA data for fiscal years 2012 through 2017 reported in VA’s  congressional budget submissions and used in its Enrollee Health Care  Projection Model. We interviewed VA central office officials, including  those from the Office of Enrollment and Forecasting responsible for  enrollee projections and the Office of Community Care, which oversees  community spending. We assessed the reliability of the information that  VA uses to develop budgets by interviewing knowledgeable VA officials,  reviewing VA and GAO reports related to this information, and performing  data reliability checks. Based on our assessment, we determined that the  data were sufficiently reliable for the purposes of this report.

To examine VA’s use of inspections to assess the quality of nursing home  care provided to veterans and its oversight of the process, we reviewed  VA policy and guidance on VA’s nursing home inspections and their  implementation, including policy and guidance for how the inspections are  used to determine whether nursing homes meet applicable quality  standards. We interviewed VA officials responsible for VA’s oversight of  nursing home quality—including the Office of Geriatrics and Extended  Care, which is responsible for strategic nursing home planning and policy  development for all three settings—and the VA contractors that conduct  CLC and SVH inspections. We interviewed officials from a  nongeneralizable sample of six VA Medical Centers (VAMC) to learn  more about their use of inspections. We selected these six because they  have jurisdiction over nursing home care in all three types of settings and  by considering factors such as geographic variation, level of hospital  complexity at the VAMC, and whether the SVH associated with the VAMC  accepted Medicare or Medicaid payment and was, as a result, subjected  to additional federal oversight by Centers for Medicare & Medicaid  Services (CMS), an agency within the Department of Health and Human  Services. We also interviewed officials from a CLC, an SVH, and a CNH  under each of the six VAMCs’ jurisdiction and officials from the  associated Veterans Integrated Services Network (VISN). We reviewed  relevant documentation from VA and its contractors, such as nursing  home inspection reports for our selected sites and associated corrective  action plans, VA summary reports on CLC and SVH inspections for the  contract year ending in 2018, and spreadsheets that VA uses to monitor inspections for all CLCs and SVHs. We examined the information  collected using criteria from VA policies and federal internal control  standards related to performing monitoring activities.

To examine the information that VA publicly provides on the quality of VA  nursing home care, we reviewed the information VA provides to veterans  through its website. We interviewed officials at the National Association  for State Veterans Homes and six SVHs to collect information on how  veterans receive information on SVH quality. We also interviewed VA  officials responsible for providing this information to veterans, including  those from the Office of Geriatrics and Extended Care and officials from  the six selected VAMCs, about the information they provide. We  examined the information collected using criteria from federal internal  control standards about communicating important information externally.  We also examined the information using criteria developed during our  prior work on transparency tools.

We conducted this performance audit from February 2018 to July 2019 in  accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.

VA provides or pays for nursing home care through three separate  programs, one for each of the nursing home settings in which VA  provides or pays for care. In general, the three settings provide similar  nursing home care, in which veterans receive skilled nursing care,  recreational activities, and other services. However, some of the nursing  homes may provide care to veterans on a short-term basis, such as  rehabilitation after a hospitalization for a period of 90 days or less (“short  stay”), or on a long-term basis, which is a period of 91 days or more  (“long stay”). Further, officials told us that some of these homes may also  provide certain special needs care for a limited number of residents, such  as dementia or rehabilitative care, which may require additional  specialized equipment or trained staff. Federal oversight of care provided  to veterans within the three settings is conducted by VA only or a  combination of VA and CMS. See table 1 for key characteristics on the  three nursing home settings.

Depending on a veteran’s eligibility status, VA pays the full or partial cost  of nursing home care in each setting. For example, VA is required by law  to provide the full cost of nursing home care for veterans who need  nursing home care for a service-connected disability—which is an injury  or disease that was incurred or aggravated while on active duty—and for  veterans with service-connected disabilities rated at 70 percent or more.  For all other veterans, VA provided nursing home care is based on  available resources.

Veterans and their families are responsible for making decisions about  nursing home care that will best meet their needs. At the national level,  VA provides information about nursing homes on its Access to Care  website; according to VA, the website is intended to help inform veterans  and their families’ about the quality of care in nursing homes. According  to VA central office officials, the responsibility for helping veterans make  decisions about nursing home care is decentralized to local VAMCs. In  consultation with veterans and their families, VAMC social workers and  clinical care providers can discuss factors such as the veteran’s eligibility  for care in each setting, health needs, the type of care provided at  different homes, space availability, and the veteran’s geographic  preference. VAMC staff may also encourage veterans to take a tour of the  prospective home.

VA models its oversight of nursing home services provided to veterans on  the methods used by CMS. CMS defines the quality standards that  approximately 15,600 nursing homes nationwide must meet in order to  participate in the Medicare and Medicaid programs. To monitor  compliance with these standards, CMS contracts with state survey  agencies to conduct inspections of each home not less than once every  15 months. During these inspections the state survey agency might  identify deficiencies—or instances in which the nursing home does not  meet an applicable quality standard. To address identified deficiencies,  CMS generally requires nursing homes to implement corrective action  plans. CMS also monitors—by conducting observational assessments of  state agencies during inspections or conducting its own comparison  inspections on a sample of homes each year—the state agencies that  inspect CNHs to ensure that these inspections accurately identify whether  the homes meet quality standards. In addition, CMS collects data on  various clinical quality measures and calculates nursing home staffing  ratios. CMS assigns each nursing home ratings in three components— inspections, quality measures, and staffing ratios—and an overall quality  rating. CMS places the greatest weight on inspections in its calculations  of each home’s overall quality rating. CMS publicly reports a summary of  the information it collects on the quality of nursing homes on its Nursing  Home Compare website, which uses a five-star quality rating system.  As we previously reported, this website facilitates public comparison of  nursing home quality.

Within VA central office, the Office of Geriatrics and Extended Care is  responsible for overseeing the quality of nursing home care provided to  veterans in each of the three settings—CLCs, SVHs, and CNHs. The key  mechanism VA uses to assess quality in each of these settings is regular  inspections—generally occurring annually—that determine the extent to  which homes meet relevant quality standards. VA’s use of inspections  and other methods to ensure the quality of care in each of the three  nursing home settings differs:

CLCs. VA owns, operates, and oversees the quality of CLCs, and  conducts regular unannounced inspections to determine the extent to  which CLCs meet quality standards. VA central office contracts with  the Long Term Care Institute to conduct these inspections, and VA  central office reviews the results of all inspections. CLCs receive an  initial inspection when they open and then periodic, unannounced  inspections thereafter. The frequency of these inspections depends  on the number and severity of deficiencies identified during the prior  year’s inspection, but they generally occur every 11 to 13 months.  CLCs are required to develop and implement corrective action plans  for each deficiency identified that detail how it will be addressed. VA  central office approves these plans, and the VISN and VA central  office monitor the CLC’s actions until each deficiency is addressed.  Per VA’s contract, VA monitors the Long Term Care Institute to  ensure that inspections are conducted within required timeframes and  to conduct quarterly assessments of the contractor’s performance,  among other things. In addition, for each CLC, VA also collects  information on quality measures and staffing ratios and uses this  information, along with the inspection results, to assign a star rating  from 1 to 5 stars. In June 2018, VA central office consolidated the  ratings for all of the individual CLCs—modeled after CMS’s Nursing  Home Compare—into its Access to Care website.

SVHs. States own and operate SVHs and, as a result, in most cases  SVHs are inspected by state agencies to determine the extent of their  compliance with state requirements. About two-thirds of SVHs are  inspected by CMS; however, VA is the only entity that conducts  annual inspections for all SVHs. Although, VA does not exercise any  supervision or control over the administration, personnel,  maintenance, or operation of any state home, VA conducts these  annual reviews for all SVHs and is prohibited from making payments  to SVHs until it determines that they meet applicable quality  standards. VA central office contracts with Ascellon to conduct these  inspections and reviews the results of the inspections. The  inspections first occur when an SVH initially seeks to become eligible  for VA payments, and, once the SVH is eligible, unannounced  inspections occur on an annual basis to verify that an SVH is eligible  to continue to receive VA payments. For these annual inspections, the  contractor generally cites deficiencies when SVHs are not in  compliance with applicable quality standards. SVHs develop and  implement corrective action plans for each deficiency identified, and  the VAMC director approves the plan. VA should monitor the  contractor’s performance annually, for example, to ensure that  inspections are conducted within certain timeframes. VA’s Office of  Geriatrics and Extended Care maintains a database of all corrective  action plans, and VISN and VAMC staff monitor the SVHs’ actions  until each deficiency is addressed. VA also collects VA prescribed  quality measure and staffing data from SVHs as part of its survey  process. However, VA does not currently assign a quality rating to  SVHs.

CNHs. CNHs can be publicly or privately owned and operated, and,  CMS provides federal oversight for all CNHs that receive Medicare or  Medicaid payments. VA requires CNHs under contract to be certified  by CMS, and, unlike the other two settings, VA is not required to  conduct regular inspections of CNHs. Instead, VA requires VAMC  staff to conduct veteran care assessments on a monthly basis and  annually review information CMS collects on the homes’ quality,  including CMS inspection results, to evaluate whether to initiate or  continue a contract with a CNH.  The annual reviews use seven  criteria established by VA’s Office of Geriatrics and Extended Care,  including whether the CNH’s total number of health deficiencies from  the most recent CMS inspection is twice the average of the state in  which it is located. According to VA officials, CNHs that fail to meet  four out of VA’s seven criteria during the annual reviews of CMS data  are excluded from participation in its CNH program unless the VAMC  seeks a waiver from VA central office to allow the home to participate.  If VAMC staff are considering seeking a waiver to allow a CNH to  continue participating in the CNH program, or have any other  concerns about a home, they have the option of conducting their own  onsite reviews of the home to assess care quality.

Utilization of and Expenditures for VA Nursing Home Care Increased from Fiscal Year 2012 through 2017, with Larger Increases Expected in Future Years

Our analysis of VA data shows that veterans’ utilization of VA nursing  home care—across CLCs, SVHs, and CNHs—increased 3 percent from  fiscal year 2012 through 2017, from an average daily census of 37,687 to  38,880 veterans. VA projects that nursing home utilization will increase  another 16 percent, to an average of 45,279 per day by fiscal year 2022,  with varying increases projected for each of the nursing home settings.  (See fig. 1.) Moreover, VA projects that overall demand for VA nursing  home care will continue to increase through 2034, driven by the aging of  the cohort of Vietnam War veterans. VA projects that Vietnam veterans  will increasingly rely on VA’s health care system for care and will use  more health care services, including nursing home care.

As figure 1 shows, SVHs accounted for the largest percentage (53  percent) of the average number of veterans who received nursing home  care each day in fiscal year 2017. However, the number of veterans in  CNHs has increased and is projected to continue to increase. For  example, the average number of veterans receiving nursing home care in  CNHs increased 35 percent from fiscal year 2012 to 2017, from an  average of 6,875 to 9,251 per day. Over the same period, the number of  veterans in CLCs fell 9 percent, and in SVHs it fell 1 percent. VA officials  told us that they are prioritizing the use of CLCs for short-term care, and  that CNHs have the greatest capacity to meet the future long-term needs  of veterans. VA projects that by 2034 the number of veterans receiving  nursing care in these homes will exceed 17,000. In addition, VA projects  that demand for nursing home care in CLCs and CNHs will decrease after  2034, and VA has not projected care in SVHs beyond 2022. VA officials  also said that VA has limited flexibility to expand the number of beds in  CLCs and SVHs to accommodate the projected number of veterans  needing care.

While VA expects to continue placing more of the veterans needing  nursing home care into CNHs, officials noted some challenges  contracting with these homes. Specifically, VA central office officials said  that about 600 CNHs had decided to end their contracts with VA over the  last few years for a variety of reasons. For example, officials from four of  the VAMCs we interviewed told us about CNH concerns that contract  approvals can take 2 years, homes have difficulties meeting VA staff  requirements, and VA’s payment rates were very low. Officials said  provisions in the VA MISSION Act of 2018 may alleviate some of these  difficulties. Specifically, the Act consolidates various VA community care  programs into the Veterans Community Care Program and authorizes VA  to enter into veterans care agreements with certain providers, including  nursing homes. In contrast to contracts, such agreements may not  require providers to meet certain wage and benefit requirements. Officials  told us that they are in the process of replacing CNH contracts with  veterans care agreements, which may alleviate some of those  challenges.

In addition, VA officials told us that most nursing homes—including  homes in each of the three settings—have limited capacity to serve  veterans with special needs, such as those needing dementia, ventilator,  or behavioral care. For example, they said that homes may not have any  of the necessary specialized equipment or trained staff, or may not have  as many of these beds as needed, to meet certain veterans’ special care  needs. VA officials told us that they are working to expand the availability  of special needs care in each of the three settings.

Our analysis of VA data also shows that VA nursing home care  expenditures have increased in recent years, reflecting increases in the  number of veterans receiving such care. Specifically, VA’s nursing home  expenditures across all three settings increased 17 percent from fiscal  years 2012 through 2017, from $4.9 billion to $5.7 billion. These  expenditures are expected to increase to $7.3 billion in fiscal year 2022  as utilization is projected to increase. VA officials told us that  expenditures for nursing home care are projected to increase due to the  rising costs of care as well as higher utilization of services. (See fig. 2.)

Of the three settings, CLCs accounted for the largest share of VA nursing  home expenditures; however, this reflects differences in the costs of care  and the extent to which VA pays for these costs in each of these settings:

For CLCs, VA pays the full cost of care for veterans in these homes  and, according to VA officials, VA expenditures for care provided in  CLCs are greater compared to the other settings, because CLCs are  able to provide acute care that requires higher staffing levels and  more specialized equipment. In addition, VA officials indicated that  CLC expenditures also include the overhead costs of being  associated with VAMC hospitals.

For SVHs, 80 percent of veterans receive VA’s partial daily rate that  covers only about a quarter of their care costs. For example, in fiscal  year 2017, VA’s average SVH per diem was $106 for veterans without  eligible service connected disabilities. VA also pays the full cost of  care for the remaining 20 percent of veterans with service-connected  disabilities. In fiscal year 2017, the full rate for these veterans was  $397 per day.

For CNHs, VA pays the full cost of care for veterans; however, more  of these veterans receive long-term care, at a lower cost per day, than  the short-term care that many veterans receive in CLCs, such as for  rehabilitation after surgery, at a higher cost per day.

As a result of these differences, in fiscal year 2017, VA paid, on average,  $1,074 per day per veteran for care in CLCs, $268 for CNHs, and $166  for SVHs.

VA Contractors Completed Required Nursing Home Inspections, but VA Has Opportunities to Enhance Its Oversight of the Process

During the contract year completed in 2018, VA’s two contractors  conducted the required annual inspections of CLCs and SVHs to  determine the extent to which the homes met quality standards. However,  VA has opportunities to enhance its oversight of the contractors’  inspections by regularly monitoring both contractors’ performance  inspecting CLCs and SVHs through observational assessments and by  citing all SVH deficiencies. Although VA’s plans call for quarterly  observational assessments, they have not been consistently conducted  and documented. Similarly, VA has not provided guidance for the optional  onsite reviews of CNHs that VAMCs may perform thus limiting their  potential impact.

VA’s CLC Contractor Conducted Required Annual Inspections, but VA Did Not Conduct Quarterly Monitoring of Contractor Performance

Our review found that during the contract year completed in 2018, VA’s  CLC contractor performed the required annual inspections for 126  CLCs. (See table 2.) Through these inspections, VA’s contractor  determined the extent to which each CLC met applicable quality  standards and issued deficiencies when standards were not met. The  most common areas of deficiencies were those in which 1) the facility did  not provide quality care for its residents, for example, in its treatment and  prevention of pressure ulcers or managing its residents’ pain; 2) the  facility did not adequately prevent and control infections, for example, by  providing residents influenza and pneumococcal immunizations; and 3)  the facility did not provide adequate care and services to sustain the  highest possible quality of life for its residents, for example, by providing  residents unable to carry out activities of daily living with adequate  assistance to maintain good nutrition, grooming, and personal and oral  hygiene. (See appendix I for more information on the types of deficiencies  identified.)

To address deficiencies, VA required CLCs to produce corrective action  plans and tracked the CLCs’ progress until the deficiencies were  resolved. In addition, for some of the most common deficiencies among  CLCs, VA officials said VA took steps such as developing additional  VAMC policies to facilitate improvement. For example, to reduce the  number of CLC deficiencies related to pain management and improve  CLCs’ performance in this area, VA officials said they developed specific  guidelines for CLCs to use to assess pain in patients with dementia who  were unable to provide numeric pain scores.

While VA has monitored and determined that CLC inspections occurred  as stipulated in its contract and tracked the results of the inspections, it  has an opportunity to enhance its oversight. According to its contract, VA  will monitor contractor performance on a quarterly basis, and VA central  office officials told us their intention has been to meet this stipulation by  observing the contractor as it conducts some inspections—an approach  consistent with CMS’s inspection oversight process. However, VA  officials told us that they have not been completing these observations  quarterly and did not conduct any observations for the April 2017 to April  2018 contract year. VA officials said they had not performed this  quarterly observation due to competing demands. For example, the three- person team at VA central office responsible for CLC oversight has  overseen a number of recent initiatives, including the rollout of CLC  quality ratings in 2018. Officials also told us they conducted one  observation for the current contract year in December 2018 (during the  course of our review). However, we were not able to confirm the  December 2018 observation or any other observations of the CLC  inspections because VA has not documented the results. A VA official  said that developing an approach for documenting the quarterly  observations is something VA needs to work on.

VA’s failure to monitor the CLC contractor’s performance through  observational assessments is inconsistent with its own goals of assessing  the contractor’s performance quarterly and modeling its oversight after  CMS’s approach to its own contractors’ inspections. It is also inconsistent  with federal internal control standards that state that management should  establish and operate monitoring activities to monitor the internal control  system and evaluate the results. By not conducting these quarterly  observations for more than a year, VA does not know whether, or to what  extent, the contractor is effectively assessing CLC compliance with quality  standards and is unable to hold the contractor accountable for its  inspections. Without effective monitoring of the contractor’s  performance inspecting CLCs, VA risks that quality concerns in some  CLCs could go overlooked, placing veterans at risk.

VA’s SVH Contractor Conducted Required Annual Inspections of SVHs; VA Has Opportunities to Enhance This Oversight

Our review found that during the contract year completed in 2018, VA’s  SVH contractor performed required annual inspections for all 148 SVHs.  (See table 3.) As with CLCs, VA’s SVH contractor determined through  these inspections the extent to which each SVH met applicable quality  standards and cited deficiencies when they were not met. The most  common areas of deficiencies were those in which 1) the facility’s  physical environment did not adequately protect the health and safety of  its residents, for example, by ensuring their safety from fires; 2) the facility  did not provide quality care for its residents, for example, by adequately  managing their pain; and 3) the facility did not assess residents’ health  sufficiently, for example, within 14 days of residents’ admission and on an  annual basis thereafter. (See appendix II for more information on the  types of deficiencies identified.)

To address deficiencies, VA required SVHs to produce corrective action  plans and tracked the SVH’s progress until they were resolved. In  addition, VA officials said they took steps to address deficiencies common  among SVHs. For example, to reduce SVH deficiencies related to  physical environment standards for fire safety and improve SVH  performance in this area, VA central office staff told us they held SVH  town halls with a fire safety engineer and created reference guides for  SVH administrators about regulatory changes in fire safety codes.

However, while VA has monitored that its contractor conducted the  required SVH inspections and tracked the results of these inspections, VA  has not monitored the SVH contractor’s performance of these inspections  through regular observational assessments to ensure that contractor staff  effectively determine whether SVHs are meeting required standards.  Specifically, VA officials told us they intended to observe the SVH  contractor’s inspections on a quarterly basis, which would be consistent  with VA’s approach to CLCs and its goal of modeling its oversight on  CMS’s. VA officials told us that although they have a goal of performing  this monitoring on a quarterly basis; they could not recall when VA last  observed the SVH contractor’s inspections. When asked, VA officials  did not provide specific reasons why they had not performed the  observational assessments; in prior discussions, these officials noted that  VA’s oversight of SVHs is less involved than its oversight of CLCs  because VA does not exercise any supervision or control over the  administration, personnel, maintenance, or operation of any state home.

However, VA pays for veterans to receive care in SVHs, and states that  oversee these homes may or may not conduct their own oversight.  Furthermore, as CMS conducts oversight of only those SVHs that receive  Medicare or Medicaid payments (about two-thirds of all SVHs), for some  SVHs, VA is the only federal agency with oversight over the quality of  those homes care. For example, VA is the only entity that conducts  regular inspections of SVHs in Missouri and New Hampshire.

VA is missing another opportunity to enhance its oversight of SVHs by not  requiring the SVH contractor to identify all failures to meet quality  standards as deficiencies during its inspections. While CMS requires its  inspectors to cite all deficiencies, VA directed its contractor to cite low- level deficiencies—deficiencies considered by the contractor to pose no  actual harm but with potential for minimal harm—as “recommendations”  rather than deficiencies. For example, during one SVH inspection, the  contractor recommended that “to ensure nutritional adequacy, the facility  should follow the menus, which are planned in advance.” VA officials told  us that unlike deficiencies, they do not track or monitor the nature of the  recommendations or whether the recommendations have been  implemented. In contrast, state survey agencies under contract with  CMS are required to cite all failures to meet quality standards as  deficiencies. In addition to not citing recommendations as deficiencies,  according to the VA contractor’s 2016-2017 annual summary report,  SVHs can fix issues identified by the SVH contractor while the inspectors  are still onsite to avoid being cited on the inspection. As a result, these  issues are also not documented as deficiencies. Officials at four of the six  SVHs we interviewed specifically reported being able to make on-site  corrections to avoid being cited for deficiencies—for instance, officials at  one SVH told us that the SVH was able to relocate handwashing stations  before the end of the inspection in order to avoid being cited for a  deficiency by the VA inspectors.

According to VA, VA does not require its SVH contractor to identify all  failures to meet quality standards as deficiencies in its inspections, VA  officials said this practice reflects policy and a negotiated position with  SVHs. VA officials reiterated that because SVHs are owned and operated  by the states, VA is less involved with their oversight than CLCs. Our  review of the VA contractor’s annual summary report showed that almost  50 percent of SVHs inspected between August 2017 and July 2018 (the  contract year completed in 2018), zero deficiencies were identified  through inspections. VA officials cited VA’s ‘collegial approach’ and  willingness to make onsite corrections as factors contributing to the  decline in recent years. Furthermore, while VA and CMS subject SVHs to  slightly different standards, our review of VA and CMS inspection reports  from a sample of five SVH inspection reports shows that VA identified a  total of seven deficiencies and made four recommendations from these  homes. In contrast, CMS identified a total of 33 deficiencies for these  homes for approximately the same time period.

By not performing observational assessments of SVH inspections, VA  does not know whether, or to what extent, VA’s contractor needs to  improve its ability to identify SVHs’ compliance with quality standards,  which increases the possibility that quality concerns in some SVHs could  go overlooked, potentially placing veterans at risk. Further, by not  requiring the contractor to cite all failures to meet quality standards as  deficiencies on its inspections, VA does not have complete information on  deficiencies identified at SVHs and therefore cannot track this information  to help identify trends in quality across these homes. Further, it is  inconsistent with federal internal control standards that state that  management should establish and operate monitoring activities to monitor  the internal control system and evaluate the results.

Selected VAMCs Completed Required Annual Reviews, but Conducted Optional CNH Onsite Reviews without the Benefit of Guidance

We found that in 2017 the six selected VAMCs annually reviewed CMS  data on the quality of all the CNHs with which they contract, which is a VA  requirement. Specifically, the VAMCs reviewed the CMS data to  determine whether the CNHs met VA criteria for contract renewal. (See  table 4.) The top three criteria from the annual reviews that VAMCs failed  to meet were 1) whether total registered nursing staff ratios per resident  day fell below the state average, 2) whether total nursing staff ratios per  resident day fell below the state average; and 3) whether six or more of  selected CMS quality measures fell above the state average.

In addition, we found that all six of our selected VAMCs conducted their  own onsite CNH reviews—which, according to VA policy, VAMC officials  have the option of performing if they have quality concerns about CNHs  with which they contract or are determining whether to seek a waiver. The  CNH onsite reviews conducted by these VAMCs focused on many of the  categories for quality standards, such as food and nutrition services,  quality of care, quality of life, and physical environment. While conducting  onsite reviews of CNHs is optional under VA policy, officials at many of  the VAMCs we interviewed told us that these onsite reviews—which the  VAMCs we interviewed referred to as CNH inspections—are valuable in  conducting CNH oversight as they provide important information about a  home’s quality that VAMC staff would not have known otherwise. For  example, officials from one VAMC shared with us results from an onsite  review in which they found moldy and expired food in a CNH’s kitchen— food storage had been identified as an issue during a previous state  survey for CMS and was purported to have been corrected 5 months  prior. Furthermore, some VAMC staff said that they would suspend  placement of veterans in certain CNHs and may not renew a CNH  contract based on their findings from these onsite reviews.

However, VA could strengthen its support for the optional onsite reviews  by providing guidance to VAMC staff conducting these reviews. Officials  at some VAMCs expressed concerns that VA did not provide the  guidance they needed to conduct the optional onsite reviews, and that  they would like to have more information from VA’s central office. As one  VAMC official said, “without training or guidance from VA , it  is difficult for VAMC staff, especially new staff, to know how to conduct  these inspections.” VAMC officials at the six selected VAMCs told us that  in the absence of guidance from VA, they had each independently  developed their own tools and processes. Furthermore, officials at these  VAMCs had differing understandings of the steps they can take if they  identify quality concerns during onsite reviews. For example, staff at  some VAMCs required CNHs to write corrective action plans and  monitored the CNHs’ implementation until the deficiencies were  addressed; in contrast, staff at other VAMCs did not monitor  implementation, because they did not think they had the authority to hold  CNHs accountable to correct deficiencies they identified.

VA central office officials who oversee the CNH program told us that they  do not provide training or guidance because CMS and the states, not VA,  are responsible for regulating the quality of care in these nursing homes.  However, in the absence of guidance from VA central office on the  optional CNH onsite reviews—guidance that could be developed, for  example, by collecting and disseminating best practices—VA has missed  an opportunity to leverage efficiencies across VA’s network of VAMCs  and empower VAMC officials with knowledge about the steps they can  take to hold CNHs accountable for correcting problems. Furthermore, it is  inconsistent with federal internal control standards that state that  management should design control activities to achieve its objectives—in  this case, to ensure that VAMCs contract with CNHs that provide high  quality care.

VA Publicly Provides Information on Care Quality for Only Two of Its Three Nursing Home Settings

As part of its efforts to help veterans find placement into a nursing home,  VA publicly provides information on care quality for CLCs and CNHs  through its Access to Care website, but VA does not provide information  on the quality of SVHs. Specifically, the website allows users to enter a  location—such as a city and a surrounding distance—to produce a map  with a list of CLCs and VA-contracted CNHs in their preferred area (see  fig. 3). For each of the homes on the list, VA reports quality information it  collects through its own inspections for CLCs and information CMS  collects for CNHs. As previously noted, veterans and their families are  responsible for making decisions about the nursing home care that will  best meet their needs. Their decision-making can be aided by  discussions with VAMC staff and information provided on VA’s Access to  Care website, among other sources. The ability for veterans and their  families to access information on nursing home quality through the  Access to Care website—such as the currently available quality  information on CLCs and CNHs—is particularly critical as VAMC officials  do not always discuss quality information in their consultations with  veterans and their families.

As figure 3 shows, VA’s Access to Care website does not provide any  information to the public about the quality of the 148 SVHs that provide  nursing home care. Specifically, VA does not currently provide any  information on SVHs on its Access to Care website—including  information on the location of SVHs or CMS information on care quality  that VA could easily provide on SVHs using information obtained from  CMS’s website, Nursing Home Compare, as VA does now for CNHs.

VA has explored activities that could provide veterans and their families  with information about SVHs. For example, as stated in VA’s SVH  strategic plan for fiscal years 2017 to 2022, VA considered an initiative to  create a five-star program for SVHs. Additionally, VA has collaborated  with SVHs to produce some data on quality measures. For example,  during the course of this review, VA provided to us a quality measures  report for SVHs by state that they developed in partnership with the  National Association of State Veterans Homes. VA is able to develop this  information because it has access to information on SVH quality—in fact,  as the only entity that conducts regular inspections, it is the only source  for quality information on all SVHs. Specifically, VA collects VA prescribed  inspection, quality measure, and staffing data as part of its survey  process that could be used to develop and distribute quality information  for each home. Some of this information is available to the public at the  local level, but it is not currently provided by VA. For example, SVHs are  required to make the results of the most recent VA inspection of the home  available for examination in a place accessible to residents.

According to VA officials, there is no requirement to provide information  on SVH quality on the Access to Care website, as SVHs are owned and  operated by the states. However, the website is an important tool for  veterans and their families to help inform their decision making on nursing  home placement. VA has stated goals to provide useful and  understandable information to veterans. The VA website could be the  only readily accessible source of quality care information publicly  available to veterans and their families for certain SVHs. As the SVH  strategic plan indicates, VA sees the value in developing SVH ratings that  could be used to provide quality information to veterans and their families.  Furthermore, officials from three of the SVHs we spoke with told us that  they supported having quality information available about their homes that  would allow comparisons between SVHs or between SVHs and other  homes, such as information contained in Nursing Home Compare.

Without information about SVHs on VA’s Access to Care website,  veterans and their families are limited in their ability to effectively evaluate  all of their options when selecting a nursing home. Our prior work has  shown that effective transparency tools—such as websites that allow  consumers to compare the quality of different providers—provide highly relevant information to consumers. However, the limited information VA  provides on its Access to Care website is inconsistent with VA’s  articulated commitment to veteran-centric care, a component of which is  ensuring that veterans are well informed about their options for care.  The website’s limited information is also inconsistent with federal internal  control standards, which state that management should externally  communicate the necessary quality information to achieve an entity’s  objective—in this case, providing important information to veterans on the  quality of nursing homes. Action to inform veterans about the quality of  SVHs would better enable veterans and their families to compare the  quality of their nursing home care options across all three settings.

In the coming years, VA projects an increase in the number of veterans  receiving nursing home care. This makes it particularly important that VA  ensure veterans receive quality care, regardless of the setting—CLC,  SVH, or CNH—in which this care is provided. Inspections are a key  oversight tool used to ensure veterans receive quality care. VA relies  primarily on annual inspections to oversee the quality of nursing home  care at CLCs and SVHs, and our review shows that VA’s two contractors  conducted these required inspections during the period we reviewed.  However, our review also shows that VA has opportunities to enhance  this oversight. First, VA has not regularly monitored the contractors’  performance conducting these inspections by conducting observational  assessments as intended and therefore does not know whether the  contractors need to improve their ability to determine the homes’  compliance with quality standards. Second, VA does not require  inspectors of SVHs to identify all failures to meet quality standards as  deficiencies, which limits VA’s ability to track all deficiencies identified at  SVHs and identify trends in quality across homes. Third, VA has not  provided guidance for VAMC staff for instances in which they may  conduct onsite reviews of CNHs directly. As a result, VA has missed an  opportunity to leverage efficiencies across VA’s network of VAMCs and  empower VAMC officials with knowledge about the steps they can take to  hold CNHs accountable for correcting problems. By making  enhancements to its oversight of inspections across all three settings, VA  would have greater assurance that the inspections are effective in  ensuring the quality of care within each setting.

VA also seeks to ensure that each veteran chooses a nursing home  placement that best meets his or her preferences and needs. To enable  veterans to evaluate their care options, VA uses its Access to Care  website. However, this website provides no information about SVHs,  which is where most veterans are currently receiving VA-funded nursing  home care. Since VA is the only entity that inspects and collects quality  information on all SVHs, VA possesses quality information that is not  available elsewhere. However, because VA’s website lacks information  on the quality of SVHs, veterans and their families are limited in their  ability to compare the quality of the available nursing home care options.

We are making the following four recommendations to the 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)

The Under Secretary of Health should require that all failures to meet  quality standards are cited as deficiencies on SVH inspections.  (Recommendation 2)

The Under Secretary of Health should develop guidance for VAMC staff  conducting optional onsite CNH reviews. (Recommendation 3)

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)

VA provided written comments on a draft of this report, which are  reprinted in appendix III. In its written comments, VA generally concurred  with all four recommendations. With respect to our recommendation on  regularly monitoring contractor performance in conducting CLC and SVH  inspections, VA concurred and stated they would develop a procedure for  observational inspections. VA also concurred with our recommendation  requiring all failures to meet quality standards to be cited as deficiencies  on SVH inspections and that “any regulation assessed to be incompliant  at the time of the survey will be rated as either provisional or not met,  which requires a corrective action plan from the SVH.”

VA concurred in principle with our other two recommendations and  described actions it plans to take to address them. Specifically, regarding  our recommendation to develop guidance for VAMC staff conducting  optional CNH onsite reviews, VA stated that it will issue a memo to clarify  and provide guidance related to CNHs. VA also noted that, although we  found the VAMC staff we interviewed discussed and considered these  onsite reviews “inspections,” VA does not. Based on these technical  comments, we adjusted our terminology. Further, we reiterate the value  that VAMC officials placed on these reviews for assessing the quality of  care veterans receive in the report. Accordingly, we believe that VA has  the opportunity when developing the memo to clarify and provide  guidance related to these optional CNH onsite reviews.

With respect to our recommendation that VA provide information on the  quality of all SVHs that is comparable to the information provided on the  other nursing home settings, VA stated it plans to evaluate the feasibility  of providing SVH data. VA noted challenges with developing their own  five star ratings for SVHs since VA does not have all the required data for  SVHs that is needed. We acknowledge that developing comparable  information will take time and have adjusted some language in our report  to reflect that VA had considered developing an SVH five-star program.  VA also stated that we inaccurately portrayed VA’s oversight authority,  because each state oversees its own SVH and VA does not have the  authority to regulate the business or clinical practices of the SVH. Both  our draft and final reports stated that “VA does not exercise supervision or  control over the administration, personnel, maintenance, or operation of  any state home.” However, as stated in the report, federal law prohibits  payments to SVHs that do not meet standards the VA prescribes and  authorizes VA to inspect any SVH at such times as VA deems necessary  to ensure that such facility meets those standards. Further, we reiterate  that as VA is the only entity to conduct inspections for all SVHs—it  uniquely possesses information that is not available elsewhere.  Accordingly, we believe that VA has the opportunity to help veterans and  their families by providing quality information for SVHs as it does for the  other nursing home settings.

As agreed with your offices, unless you publicly announce the contents of  this report earlier, we plan no further distribution until 30 days from the  report date. At that time, we will send copies of this report to the  appropriate congressional committees, the Secretary of the Department  of Veterans Affairs, and other interested parties. In addition, the report will  be available at no charge on GAO’s website at http://www.gao.gov.

If you or your staffs have any questions about this report, please contact  me at (202) 512-7114 or silass@gao.gov. Contact points for our Offices  of Congressional Relations and Public Affairs may be found on the last  page of this report. GAO staff who made key contributions to this report  are listed in appendix IV.

Appendix I: Types of Deficiencies Identified from Community Living Center (CLC) Inspections, 2017 to 2018

Appendix II: Types of Deficiencies Identified from State Veterans Home (SVH) Inspections, 2017 to 2018

Resident Behavior and Facility Practices  10 (5)  3 (2)  0 (0)  192  The total number of deficiencies may include deficiencies from one SVH that VA does not consider a  skilled nursing facility.

Appendix III: Comments from the Department of Veterans Affairs

Appendix IV: GAO Contact and Staff Acknowledgments

In addition to the contact named above, Karin Wallestad (Assistant  Director), Jim Melton (Analyst-in-Charge), Kye Briesath, Krister Friday,  and Mandy Pusey made key contributions to this report. Also contributing  were Vikki Porter and Jennifer Whitworth.

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.