Report to Congressional Requesters

United States General Accounting Office

GAO

July 2001 VA LONG-TERM

CARE

Oversight of

Community Nursing

Homes Needs

Strengthening

GAO-01-768
Page i GAO-01-768 VA Nursing Home Oversight

Letter 1

Results in Brief 3

Background 4

VA Oversight Has Been Mixed and Headquarters’ Involvement

Insufficient 7

VA’s Plan to Rely on Community Nursing Home Inspections

Conducted by States Appears Reasonable, but Implementation Is

Uncertain 16

Conclusions 21

Recommendations for Executive Action 22

Agency Comments 23

Appendix I Scope and Methodology 25

Appendix II Instances in Which VA Has Withheld State Veterans’

Home Per Diem Payments 28

Appendix III Comments From the Department of Veterans Affairs 30

Related GAO Products 32

Tables

Table 1: 10 VA Medical Centers’ Reported Annual Inspection

Activities for Locally Contracted Community Nursing

Homes 12

Table 2: 10 VA Medical Centers’ Adherence to VA’s Veteran Visit

Policy 14

Table 3: State Veterans’ Homes We Contacted During Our Review,

and the Associated VA Medical Centers Performing

Inspections 27

Contents
Page ii GAO-01-768 VA Nursing Home Oversight

Figures

Figure 1: Fiscal Year 2000 Program Expenditures and Average

Daily Census for VA’s Nursing Home Programs 5

Figure 2: Two Ways in Which VA Contracts with Community

Nursing Homes 6

Figure 3: Location of VA Medical Centers Included in Our Review 25

Abbreviations

CMS Centers for Medicare and Medicaid Services

HCFA Health Care Financing Administration

JCAHO Joint Commission on Accreditation of Healthcare

 Organizations

OSCAR On-Line Survey, Certification, and Reporting

QI quality indicator

VA Department of Veterans Affairs
Page 1 GAO-01-768 VA Nursing Home Oversight

July 27, 2001

The Honorable Lane Evans

Ranking Democratic Member

Committee on Veterans’ Affairs

House of Representatives

The Honorable Christopher Bond

Ranking Minority Member

Subcommittee on VA, HUD, and Independent Agencies

Committee on Appropriations

United States Senate

In fiscal year 2000, 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. VA is likely to see an increase in demand

for nursing home care over the next decade because 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—and the prevalence of chronic health

conditions and disabilities increases markedly at advanced age. In

addition, as a result of the Veterans Millennium Health Care and Benefits

Act (P.L. 106-117, Nov. 30, 1999) VA is required to provide long-term care

to certain veterans, which may further increase veterans’ demand for

nursing home care.1

About 73 percent of VA’s fiscal year 2000 nursing home care spending was

for care in VA’s 134 nursing homes; the remainder was for veterans’ care in

the 94 state-owned and operated veterans’ nursing homes (15 percent) or

in approximately 3,400 community nursing homes under local or national

contract to VA (12 percent). In the past, we have reported on problems

concerning the quality of care provided in community nursing homes. For

example, in 2000 we reported that nearly 30 percent of nursing homes

 1

Prior to the Veterans Millennium Health Care and Benefits Act, long-term care was

generally provided on a first-come, first-served basis within VA budget constraints. The act

requires that VA provide nursing home care to (1) any veteran needing such care for a

disability connected to his or her military service and (2) any veteran who is at least 70

percent disabled by a service-connected condition and who needs nursing home care,

regardless of whether the care is required specifically for the disabling condition. The act

contains a provision that requires VA to evaluate and report on its long-term care

experience under this statute to assist the Congress in deciding whether these benefits

should be modified or extended beyond December 31, 2003, the current expiration date.

United States General Accounting Office

Washington, DC 20548
Page 2 GAO-01-768 VA Nursing Home Oversight

inspected by state agencies under contract to the Health Care Financing

Administration (HCFA)2

 had problems serious enough to cause actual

harm to their residents.3

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 mechanism for community

nursing homes, eliminating the requirement for annual VA inspections and

instead relying on Medicare and Medicaid certification inspections

conducted by state agencies under contract to the Centers for Medicare

and Medicaid Services (CMS). Concerned about VA’s ability to monitor the

care provided in non-VA settings, you asked us to (1) review 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) evaluate planned changes in VA’s oversight policies and the

strategies to implement them.

To address these issues, we met with officials of VA’s Geriatrics and

Extended Care Strategic Healthcare Group at VA headquarters and

officials at 10 VA medical centers, and obtained and reviewed written

policies and regulations governing the frequency of state veterans’ home

inspections and the frequency of, and staff participating in, community

nursing home inspections and visits. To determine whether state veterans’

homes have been inspected as frequently as required, we reviewed VA

inspection reports from state veterans’ home inspections conducted

during calendar years 1997 through 2000. To determine whether the

medical centers we visited inspected community nursing homes and

visited veterans as frequently as required and with the required staff, we

(1) interviewed staff and reviewed community nursing home inspection

reports at each medical center we visited and (2) reviewed the patient

records of about 800 veterans placed in community nursing homes by

these medical centers. We also interviewed officials at 10 state veterans’

 2

On June 14, 2001, the Secretary of Health and Human Services announced that HCFA’s

name had been changed to the Centers for Medicare and Medicaid Services. In this report,

we will continue to refer to HCFA where our findings apply to the organizational structure

and operations associated with that name.

3

Nursing Homes: Sustained Efforts Are Essential to Realize Potential of the Quality

Initiatives (GAO/HEHS-00-197, Sept. 28, 2000).
Page 3 GAO-01-768 VA Nursing Home Oversight

homes across the country. (See app. I for a more detailed description of

our scope and methodology.) Our work was conducted from August 2000

through May 2001, in accordance with generally accepted government

auditing standards.

VA’s adherence to its oversight policies for state veterans’ homes and

community nursing homes has been mixed, reflecting a lack of VA

headquarters’ monitoring and oversight. VA medical center staff are

required to inspect each state veterans’ home annually, and of the 1997

through 2000 state veterans’ home inspections we analyzed, VA completed

about 86 percent within the required time frame—12 months of the prior

inspection—or shortly thereafter. If VA finds serious problems in a state

veterans’ home, VA may withhold per diem payments to the home until the

problems are corrected. VA has withheld payments from three state

veterans’ homes; two of the three homes have corrected their problems to

VA’s satisfaction and VA has reinstated per diem payments, but VA

continues to withhold payments from the remaining home. VA

headquarters appears to be appropriately monitoring VA medical centers’

oversight of state veterans’ homes, but its monitoring of community

nursing home oversight is less diligent. 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. VA medical center staff are required to conduct annual inspections

of all community nursing homes with which they have local contracts and

to visit veterans in those homes monthly, but only 4 of the 10 VA medical

centers we reviewed reported conducting the required annual inspections,

and only 4 of 10 generally made required visits to veterans. The remaining

centers we reviewed exhibited varying levels of adherence to these

policies. If VA finds problems in a community nursing home, it may take

one of four actions: stop placing veterans in the home, withdraw veterans

from the home, terminate the home’s contract, or allow the contract to

expire without renewal. However, the number and type of actions taken by

VA nationwide to ensure that community nursing homes correct problems

are unknown because neither VA headquarters nor the VA medical centers

we visited maintain data on these actions.

Under its planned policy change, VA would eliminate the requirement for

annual inspections of community nursing homes and instead rely on

Medicare and Medicaid certification inspections. Local VA medical

Results in Brief
Page 4 GAO-01-768 VA Nursing Home Oversight

centers’ staff will review state inspection reports and CMS data to evaluate

community nursing homes. However, relying on this information may be

problematic for VA because the quality of state inspections of nursing

homes varies, and CMS is unable to accurately assess state inspection

performance. As a result, VA may not be able to rely on state inspection

results in all cases. Moreover, without additional information VA will be

unable to discern which states provide reliable data and which do not. In

addition, many VA field staff told us that they did not know how to obtain

or interpret all of the information they will be expected to review under

VA’s planned policy, yet VA has not decided how, or if, it will assist

medical centers in obtaining or using this information. To improve VA’s

oversight of community nursing homes, we are recommending that VA (1)

develop a structured, comprehensive, and uniformly applied policy for

overseeing all community nursing homes under contract to VA, including a

mechanism to monitor the reliability of state inspections of nursing

homes, (2) provide guidance on implementing its policy, and (3) develop a

means to ensure that medical centers follow the policy. In commenting on

a draft of our report, VA agreed with our conclusions and

recommendations.

In addition to providing nursing home care in its own facilities,4

 VA

contracts with community nursing homes and pays state veterans’ homes

part of the cost to care for veterans.5

 Figure 1 below shows the fiscal year

2000 program expenditures for each of VA’s three nursing home programs

as well as the average number of veterans cared for on any given day

(known as the average daily census) in each setting.

 4

Because VA nursing home care units were not within the scope of our review, this report

does not assess the oversight of, or care provided in, these facilities.

5

These VA programs encompass only a portion of the veterans needing nursing home care.

VA has estimated that it meets about 16 percent of veterans’ demand for nursing home

care; most veterans’ nursing home care is financed through Medicare or Medicaid, private

insurance, or personal assets.

Background
Page 5 GAO-01-768 VA Nursing Home Oversight

Figure 1: Fiscal Year 2000 Program Expenditures and Average Daily Census for

VA’s Nursing Home Programs

Source: VA data.

State veterans’ homes are nursing homes owned and operated by

individual states.6

 These homes originated in the post-Civil War era, when

the federal government was unable to meet Civil War veterans’ demands

for care. In response, states established and began operating homes for the

care of soldiers at state expense; in fiscal year 2000, there were 94 state

veterans’ homes operating in 43 states.7

 VA subsidizes a portion of the

daily cost of care of veterans residing in these homes, paying a flat daily

rate ($51.38 in fiscal year 2001) for each eligible veteran. VA also pays a

portion of the construction costs for some homes. However, VA does not

directly place patients in state veterans’ homes as it does in community

nursing homes. Rather, veterans must apply to the homes for admission,

and eligibility and admission requirements vary by each state. For

 6

Some state veterans’ homes include—or consist solely of—domiciliaries, which are

facilities for the care of veterans who do not require hospital or nursing home care but are

unable to live independently because of medical or psychiatric disabilities. Some state

veterans’ homes also offer hospital care or adult day health care. In this report, references

to state veterans’ homes refer only to nursing homes’ portions of these facilities.

7

VA expects the number of state veterans’ homes to increase markedly in the next several

years. At the time of our review, VA had received applications requesting assistance to help

fund the construction of another 24 homes.

$1,352,880,000

$227,817,000

$279,834,000 11,812

3,685

15,258

Program expenditures Average daily census

VA nursing homes State veterans’ homes Community nursing homes
Page 6 GAO-01-768 VA Nursing Home Oversight

example, certain states admit only veterans who served during wartime,

while other states admit all honorably discharged veterans.

There are about 17,000 community nursing homes in the nation, providing

care to about 1.6 million Americans, including veterans receiving care at

VA’s expense. Several factors influence whether veterans are placed in

community nursing homes. For example, about one-fourth of VA medical

centers have no in-house nursing homes, and thus rely on community

nursing homes to provide such care. Also, some veterans may prefer

placement in community nursing homes—to be closer to family, for

example.

VA purchases care from community nursing homes in one of two ways

(see fig. 2). Most nursing homes under contract to VA have a contract with

a local VA medical center. VA also contracts with community nursing

homes under its Regional Community Nursing Home initiative, in which

nursing home chains in single or multiple states contract directly with VA

headquarters for services at their nursing homes. In 2000, VA contracted

with about 2,500 nursing homes on a local basis and with about 900 more

nursing homes under its Regional Community Nursing Home program.

Figure 2: Two Ways in Which VA Contracts with Community Nursing Homes

VA

headquarters

Local VA

medical center

CONTRACT

CONTRACT

Nursing home chain

Individual nursing homes
Page 7 GAO-01-768 VA Nursing Home Oversight

All Medicare- or Medicaid-certified nursing homes, whether state veterans’

homes or community nursing homes, are required to undergo periodic

inspections by state agencies under contract to CMS. (Virtually all of the

approximately 17,000 community nursing homes across the country are

Medicare- or Medicaid-certified; at the time of our review, 43 state

veterans’ homes were so certified.) CMS contracts with states and requires

that they inspect each nursing home annually, with the time between

inspections not to exceed 15 months. These inspections are conducted by

teams of state surveyors who spend several days on site conducting a

broad review of whether the care and services delivered meet CMS quality

standards and seeking to ensure that inadequate resident care is identified

and corrected. The results of each inspection are recorded in a report

detailing the nature of any identified problems, and are also entered into

CMS’ On-Line Survey, Certification, and Reporting (OSCAR) database,

which contains the results of state inspections as well as information

about the homes’ residents. OSCAR also contains information on

complaints, which states are required to investigate.

VA has established written oversight policies to help ensure that state

veterans’ homes and community nursing homes provide care of acceptable

quality. However, VA medical centers’ adherence to these policies has

been incomplete. VA records show that VA medical centers across the

country have generally inspected state veterans’ homes as often as

required, and VA headquarters has taken several recent steps to increase

its own monitoring of medical centers’ performance. On the other hand,

fewer than half of the 10 VA medical centers we visited followed VA’s

community nursing homes oversight policies, and VA headquarters has

neither effectively monitored VA medical centers’ oversight of these

homes nor provided sufficient guidance on how these oversight activities

should be conducted.

VA Oversight Has

Been Mixed and

Headquarters’

Involvement

Insufficient
Page 8 GAO-01-768 VA Nursing Home Oversight

VA policy requires that VA medical center staff inspect state nursing

homes before they can be certified as state veterans’ homes, and annually

thereafter. In January 2000, VA issued regulations detailing standards to be

used when inspecting state veterans’ homes.8

 These standards are

considerably more detailed and lengthy than those they replaced, and

cover such issues as resident rights, quality of life, quality of care, and

physical environment.

Based on our review of VA documentation for 250 inspections conducted

from calendar years 1997 through 2000, about 58 percent of inspections

were conducted within 12 months of the prior inspection, as required by

VA policy. An additional 28 percent were conducted within 15 months, the

maximum time CMS allows between Medicare or Medicaid certification

inspections. Time lapses between other inspections varied, up to a

maximum of 48 months; VA records show that one state veterans’ home

has not been inspected by VA since January 1997.

VA facility officials gave varying reasons for not making inspections on

time. One VA facility, for example, did not inspect the state veterans’ home

for which it has oversight in 1997, 1998, or 1999 because the home was

accredited by the Joint Commission on Accreditation of Healthcare

Organizations (JCAHO), and VA medical center officials accepted JCAHO

accreditation as proof that the home met VA standards.9

 Another facility

gave the same reason for not inspecting a state veterans’ home in 2000.

Other officials stated that they believed VA’s policy had been changed to

allow VA medical centers to accept Medicare or Medicaid certification as

evidence that state veterans’ homes meet VA standards, and as a result

stopped making inspections. The chief of VA’s state veterans’ home

program told us, however, that these were not acceptable reasons for

discontinuing annual inspections and that all state veterans’ homes must

be inspected annually.

On the other hand, some state veterans’ homes have been inspected more

than once every 12 months. For example, one home received six VA

inspections from May 1998 through May 2000 because of VA concerns

about the home’s quality. Another home has been inspected twice each

 8

See 65 FR 962, at 971, Jan. 6, 2000; 38 C.F.R. Part 51.

9

JCAHO is an accrediting organization that certifies homes that request inspections and

meet its standards.

Most State Veterans’

Homes Are Inspected as

Often as Required, and VA

Headquarters Has

Increased Its Monitoring of

VA Medical Centers’

Performance
Page 9 GAO-01-768 VA Nursing Home Oversight

calendar year since 1997 to ensure that identified problems were

corrected.

If VA finds deficiencies in a state veterans’ home it can provisionally

certify the home, meaning that VA will continue to pay per diem to the

home while allowing time to correct the deficiencies. However, if the

inspection team finds serious uncorrected deficiencies at the home, VA

can withdraw its recognition of the home and stop per diem payments. VA

does not have the authority to withdraw veterans from a state veterans’

home even if the home fails to meet VA standards, although VA requires

that all state veterans’ homes make the results of their most recent VA

inspections available. According to VA officials, VA has withheld per diem

payments to three state veterans’ homes. VA withheld one home’s

payments beginning in 1999, and withheld the other homes’ payments

beginning in 2000. A VA official attributed one home’s problems to the lack

of funds allocated to it by the state; another’s to its remote location, which

made attracting staff difficult; and the third home’s to its antiquated

building, which has been unable to meet VA’s life safety requirements. One

of the three homes had per diem payments reinstated within 4 months, and

another within about 10 months, but the remaining home has not had per

diem payments reinstated. In each case, according to the VA field staff, the

state operating the home made up the resulting shortfall; veterans were

not required to pay the difference. (See app. II for a more detailed

description of each home’s problems and VA’s actions.)

VA has taken several recent steps to increase its monitoring of, and

improve VA medical centers’ performance of, state veterans’ home

inspections. In the past, not all VA medical centers provided copies of

their annual state veterans’ home inspection reports to VA headquarters,

although VA policy calls for medical centers to submit copies of these

reports within 30 days of the inspections, and VA headquarters officials

told us that they had no way of knowing whether a missing report meant

that the inspection was not conducted or that the report was simply not

sent. Additionally, those reports that were submitted to headquarters were

often not sent until several months after the inspections. VA headquarters

was also concerned that VA medical centers were not performing

inspections with the necessary thoroughness or consistency to ensure

adequate, uniform oversight of all state veterans’ homes.

To increase its involvement in the state veterans’ home program, VA

headquarters has made several program changes. First, in 2000, VA

emphasized in a policy memorandum that VA medical centers were to

submit inspection reports to headquarters within 30 days of the
Page 10 GAO-01-768 VA Nursing Home Oversight

completion of the inspections. To track the results of these inspections,

VA headquarters officials have entered the results of all state inspections

conducted since 1998 into a database and plan to enter the results of all

future inspections.10 Program officials told us that they will use this

database to analyze inspection results and trends, including the extent to

which identified problems recur in subsequent inspections, and to

determine which state veterans’ homes are due for an annual inspection.

Using this information, the program officials can contact the inspecting

facilities to remind them of upcoming inspections. VA is also developing

an electronic inspection form to be used by VA field staff to enter the

results of inspections; the electronic form is expected to speed submission

of the report and eliminate the need for headquarters to enter the

information manually into the database. Finally, program officials

established an e-mail discussion group and initiated quarterly telephone

conference calls to all field locations responsible for state veterans’ home

oversight; both of these activities are intended to facilitate communication

between VA program officials and VA field staff charged with carrying out

inspections.

To improve the conduct and consistency of inspections around the

country, VA program officials also developed a 3-day training course,

which has been delivered to inspection personnel in about half of VA’s 22

networks.11 (Another eight networks currently are scheduled to receive

training in calendar year 2001. Training for the remaining networks has not

yet been scheduled.) The training course is designed to familiarize

inspectors with VA’s standards for state veterans’ homes and provide

guidance on planning, conducting, and documenting inspections. The

training is delivered by a program official from headquarters, who is

accompanied by field personnel familiar with VA standards and inspection

procedures who provide insight based on their own inspection

experiences.

 10We developed this database to facilitate our analysis of VA data. VA officials requested the

results of our analysis for their own use, and began using the database to help oversee the

state veterans’ home program.

11In 1995, VA created 22 Veterans Integrated Service Networks, a new management

structure to coordinate the activities of and allocate funds to VA hospitals, outpatient

clinics, nursing homes, and other facilities in each region.
Page 11 GAO-01-768 VA Nursing Home Oversight

In contrast to VA’s oversight of state veterans’ homes, VA oversight of

community nursing homes, both locally and centrally contracted, has been

inadequate. Most VA medical centers we visited have not inspected homes

or visited veterans with required frequency, and VA headquarters has

similarly failed to review centrally contracted homes as often as required.

VA headquarters has not centrally monitored and enforced its community

nursing home oversight policies, nor has it provided sufficient guidance on

conducting oversight activities.

VA’s oversight policy differs between community nursing homes under

local contract to individual VA medical centers and those homes under

central contract to VA headquarters. VA policy requires that VA medical

centers contracting with community nursing homes send at least a nurse

and a social worker, and other staff as needed (such as dietitians or

pharmacists), to inspect each home annually after reviewing the most

recent state inspection report for the home.12 VA’s standards for evaluating

community nursing homes are those CMS uses for Medicare and Medicaid

certification. However, VA has exempted centrally contracted homes—

those in its Regional Community Nursing Home program—from annual

inspections. VA officials told us they believed that exempting such homes

from annual inspections would serve as an incentive for nursing home

chains to participate in the program. They also believed that VA did not

want to add to the oversight burden on local VA medical centers by

requiring them to inspect additional homes. VA policy calls for VA

headquarters staff to review available CMS data on these homes in order

to determine whether the homes provide acceptable care.

VA policies also require VA medical center staff to visit each veteran

receiving community nursing home care at VA’s expense every 30 days,

regardless of whether the veteran is in a locally contracted or a centrally

contracted home. Every 60 days the visits must be made by registered

nurses. Through these visits, VA staff are expected to monitor quality of

care and review individual patients’ care plans, assist patients and families

with the social and emotional aspects of the transition to long-term care,

and observe the homes’ conditions. VA does not have a standard checklist

for use by VA staff visiting veterans in community nursing homes, instead

noting in its written policy that “it is important to emphasize the individual

 12VA’s written policies governing community nursing home oversight are contained in

Veterans’ Health Administration Manual M-5, Part II, Chapter 3.

VA Medical Centers’

Adherence to Community

Nursing Home Oversight

Policies Has Been

Incomplete, and VA

Headquarters’ Monitoring

Insufficient
Page 12 GAO-01-768 VA Nursing Home Oversight

basis of [the visits]. When visits become routine, there is a danger that the

focus will be lost and that quality will suffer.”

If VA staff detect problems in a community nursing home, whether

through annual inspections or monthly visits, the medical center may take

one of four disciplinary actions: discontinue placing additional veterans in

the home, remove veterans receiving VA-funded care in the home,

terminate the home’s contract, or decline to renew the contract upon

expiration. Although staff at the VA medical centers we visited told us they

had used these actions rarely, the number and type of disciplinary actions

taken by VA nationwide are unknown because neither VA headquarters

nor the medical centers we visited maintain data on such actions.

Only 4 of the 10 VA medical centers we visited reported following VA

policy by having at least a nurse and a social worker inspect each locally

contracted community nursing home, and review the state inspection

report for each home. (See table 1.) One additional VA medical center

reviewed the state inspection report, but the inspection was conducted by

a nurse only. Among the five remaining VA medical centers, four reviewed

the state inspection report but did not conduct annual inspections, while

one neither reviewed the report nor conducted annual inspections.

Table 1: 10 VA Medical Centers’ Reported Annual Inspection Activities for Locally Contracted Community Nursing Homes

VA medical center

Conducted inspection with at least

a nurse and social worker Reviewed state inspection report

Birmingham, AL X X

Loma Linda, CA X

Gainesville, FL X

New Orleans, LA X X

Minneapolis, MN X

Cleveland, OH X X

Muskogee, OK X X

Pittsburgh, PA a X

Providence, RI

Seattle, WA X

Note: These are the practices that the medical centers reported using at the time of our visits, which

we conducted from November 2000 through February 2001.

a

Pittsburgh conducted inspections using a nurse only.

Staff at facilities that did not conduct the required annual inspections told

us that they did not have sufficient resources to conduct inspections or did

not see any value in duplicating state inspections. An official at one VA

VA Has Not Inspected

Community Nursing Homes as

Required
Page 13 GAO-01-768 VA Nursing Home Oversight

medical center told us that because VA policy did not require inspections

of centrally contracted homes, staff at that medical center were no longer

required to inspect locally contracted homes. According to the chief of

VA’s community nursing home program, staff at several VA medical

centers told him (in response to our visits) they did not know that the

policies requiring annual inspections were still in effect.

Homes in the Regional Community Nursing Home initiative have also not

been overseen as required. The VA headquarters official responsible for

reviewing CMS data on centrally contracted community nursing homes

told us that he has reviewed such data on only about 60 percent of

centrally contracted homes each year. According to this official, the large

number of centrally contracted homes (currently about 900) and the lack

of sufficient staff to review data on these homes has prevented VA from

reviewing these data promptly.

This lack of oversight may have serious implications because, according to

our analysis of HCFA data from calendar years 1999 and 2000, about 30

percent of homes in the Regional Community Nursing Home initiative

were cited in their most recent state inspections for deficiencies serious

enough to cause harm to residents. For example, one home participating

in the program was cited in its last state inspection for 4 deficiencies

causing actual harm to residents in addition to another 31 lesser

deficiencies, for a total of 35 deficiencies—the most of any nursing home

in that state. Overall, however, the 30 percent of homes with serious

deficiencies in the regional program is identical to the portion of all HCFAcertified homes nationwide—30 percent—that were cited for such

deficiencies by state inspectors from January 1999 through July 2000.13

Veterans receiving community nursing home care at VA’s expense must,

according to VA policy, receive visits from VA staff every 30 days; every 60

days, these visits must be made by VA nurses. However, the 10 VA medical

centers we visited varied in their adherence to this policy. (See table 2.)

During calendar years 1999 through 2000, only 4 of these 10 VA medical

centers generally sent both a staff member to visit each veteran every 30

days and a nurse to visit each veteran every 60 days. In a few cases even

these four medical centers allowed longer than 30 days between visits, or

longer than 60 days between nurse visits. Another VA medical center

began making visits as required in August 2000, about the time we began

 13GAO/HEHS-00-197.

VA Has Not Visited Veterans in

Community Nursing Homes as

Often as Required
Page 14 GAO-01-768 VA Nursing Home Oversight

our review. Before then, records show that medical center staff made

visits only sporadically; staff from this medical center made only 40

percent of the required visits to veterans in our sample who were

discharged prior to August 2000.

Of the remaining five VA medical centers in our study, two generally sent

staff to visit veterans every 30 days as required, but nearly all visits were

made by social workers—few nurse visits occurred, and those that did

were often spaced much further apart than 60 days. Conversely, one VA

medical center generally made nurse visits as required, approximately

every 60 days, but few other visits were made to veterans. Finally, staff

from two VA medical centers made few visits to veterans; in one location,

of the 73 veterans whose records we reviewed, only 3 had received visits

from January 1, 1999, through December 2000. Several veterans at this

location had been in community nursing homes continually since January

1, 1999, without receiving visits from VA medical center staff .

Table 2: 10 VA Medical Centers’ Adherence to VA’s Veteran Visit Policy

VA medical center

Visited veterans every

30 daysa

A nurse visited

veterans every 60 daysa

Birmingham, AL

Loma Linda, CA X

Gainesville, FL X X

New Orleans, LA X X

Minneapolis, MN

Cleveland, OH X X

Muskogee, OK X

Pittsburgh, PA X

Providence, RI

Seattle, WA X X

Note: At each selected VA medical center, we reviewed the staff’s visiting activities from January 1,

1999, through the date of our site visit to that medical center. Our site visits began in November 2000

and were completed in February 2001.

a

At no locations were all veterans visited exactly within the 30- or 60-day time frames required by VA

policy. However, the facilities indicated in each column made nearly all visits within these time

frames.

In explaining their lack of adherence to VA policies, several staff told us

that their medical centers did not have sufficient personnel both to make

visits and complete their other duties. Staff at the two facilities making

very few visits told us that in addition to having insufficient staff to make
Page 15 GAO-01-768 VA Nursing Home Oversight

visits, they did not believe the visits provided them information that they

could use to oversee care.

VA headquarters has had little involvement in VA’s community nursing

home oversight program. Although VA policy requires medical centers to

inspect locally contracted community nursing homes annually and to visit

veterans in locally and centrally contracted homes, they are not required

to report the results of these inspections or visits to VA headquarters—or

even to report whether they performed them. Because it has little or no

knowledge of the extent to which medical centers have followed its

inspection requirements, VA has not implemented any mechanism to

ensure that VA medical centers conduct oversight as specified—primarily,

according to a VA official, because VA’s community nursing home program

office has not had sufficient resources to monitor VA medical centers’

oversight of community nursing homes under contract to VA. In contrast

to its handling of the community nursing home program, VA monitors and

ensures adherence to its state veterans’ home oversight policies by

requiring each medical center director to certify annually that the state

veterans’ home(s) under that medical center’s jurisdiction meet VA

standards.

In addition to poorly monitoring VA medical centers’ inspection activities,

VA headquarters has not provided guidance to medical centers on how to

implement VA’s oversight policies. For instance, although VA policy states

that VA medical centers are to use CMS’ nursing home standards when

evaluating community nursing homes, no structured process or format has

been developed for conducting either annual inspections or monthly visits,

and individual VA medical centers have made determinations about what

elements of community nursing home care they will examine during these

inspections and visits. Thus, even when annual inspections and monthly

visits are made, VA has no assurance that the nursing home processes and

care indicators examined by one VA medical center will be the same as

those examined by other VA medical centers. Indeed, at the 10 VA medical

centers we visited, documentation of nursing home inspections and visits

to veterans showed that medical centers differed in the processes and

indicators they examined.

VA Headquarters Has Neither

Monitored VA Medical Centers

nor Provided Adequate

Guidance
Page 16 GAO-01-768 VA Nursing Home Oversight

From the beginning of our review, VA has been planning to eliminate its

requirement for annual inspections of locally contracted community

nursing homes by VA medical center staff because these homes are

already inspected by CMS-sponsored state surveyors. However, state

veterans’ homes would continue to undergo annual inspections by VA.

Under the planned policy, VA medical center staff would be allowed to

rely on the results of the state inspections and on other available

information about locally contracted community nursing homes to

determine whether the homes meet VA standards. While, in general, state

inspections appear to be more thorough than VA inspections, some state

inspection agencies find considerably more nursing home problems than

others do, and CMS does not know whether this variation results from

differences in nursing home quality or differences in inspector practices

and abilities. In addition, VA has not yet decided how medical centers

should use CMS and other information in assessing nursing home quality

or what assistance headquarters will provide. Without effective guidance

from VA headquarters on the use of these data, VA facilities may not be

able to accurately and consistently interpret the data and make judgments

about nursing home quality nationwide.

VA’s planned oversight policy for locally contracted community nursing

homes would eliminate the requirement for a physical VA inspection of

each locally contracted home and instead would allow local VA facilities

to base annual contract renewal decisions about homes on available

documentation. The VA official responsible for developing this policy told

us that, while its implementation is imminent, VA has not set a date for its

new policy implementation. Under the planned policy, local facilities

would review CMS and other data to assess the quality of care provided in

these locally contracted homes. The data include the following.

• CMS’ OSCAR data. VA’s planned policy requires a review of data from

CMS’ OSCAR database. For all Medicare- or Medicaid-certified nursing

homes, OSCAR contains the results of the three most recent state

inspections as well as information about the homes’ residents and

complaints against the homes.

• Quality indicators. VA’s planned policy also requires VA facilities to

review nursing home resident data known as the Facility Quality Indicator

(QI) Profile. QIs serve as numeric warning signs of care problems, such as

greater-than-expected instances of weight loss, dehydration, or pressure

VA’s Plan to Rely on

Community Nursing

Home Inspections

Conducted by States

Appears Reasonable,

but Implementation Is

Uncertain

New Oversight Policy

Relies Heavily on CMS

Data, but Incorporates

Other Information
Page 17 GAO-01-768 VA Nursing Home Oversight

sores. QI profiles are derived by CMS from nursing homes’ assessments of

residents and are used to rank a facility in 24 areas compared with other

nursing homes in a state.14 In using this tool, staff at a VA medical center

could, for example, compare the percentage of residents experiencing

weight loss in a particular community nursing home with the average for

all nursing homes in that state to determine whether the home’s

prevalence of weight loss is above or below the state average.

• Veteran visit results. VA’s planned policy also states that the results of

staff visits to veterans in community nursing homes—which would

continue to be required under the planned policy—can provide

information about the quality of care in these homes. Moreover, VA

officials told us that they expect that visits would take on more

importance as an oversight tool if annual inspections were no longer

required. According to the planned policy, the results of VA’s visits to

veterans in community nursing homes, in conjunction with CMS and state

data, can be used to make judgments about the quality of care in these

homes.

In using these sources of information, VA’s planned policy directs VA

medical centers to obtain and analyze OSCAR and QI profile data on

locally contracted community nursing homes,15 if the homes are Medicareor Medicaid-certified, along with other necessary state inspection reports

and information. No VA inspection would be required for Medicare- or

Medicaid-certified homes. Instead, an “informational” visit would be made

to each home by a VA representative to meet the home’s leadership, learn

about any special programs in the home, and determine how the home can

best meet veterans’ needs. If the home is not Medicare- or Medicaidcertified, the VA medical center would instead send, at a minimum, a

social worker, nurse, dietician, fire safety officer, and contracting officer

to inspect the home. Other VA staff, such as physicians or clinical

pharmacists, may be included in the inspection if the VA inspection team

deems it necessary. Regardless of whether an inspection is conducted,

information gained by visiting veterans is expected to be incorporated into

the quality assessment process.

 14QIs were the result of a HCFA-funded project at the University of Wisconsin. The

developers based their work on nursing home resident assessment information known as

the minimum data set—data that all Medicare- or Medicaid-certified homes are required to

report. See Center for Health Systems Research and Analysis, Facility Guide for the

Nursing Home Quality Indicators (University of Wisconsin-Madison: Sept. 1999).

15Centrally contracted homes will continue to be reviewed by VA headquarters staff.
Page 18 GAO-01-768 VA Nursing Home Oversight

Because state inspections of community nursing homes generally appear

to be more lengthy and thorough than those performed by VA, and

because the states use trained, professional inspectors while VA does not,

VA’s planned policy seems reasonable. However, states vary in the extent

to which they report nursing home problems and, as a result, VA may not

be able to rely on state data in all cases. Further, VA will have difficulty

discerning which states provide reliable information and which do not

because CMS has not determined the reason for the variation in states’

inspection results.

Many VA medical center staff told us that their inspections did not match

the duration of state inspections. Based on our discussions with staff who

perform the required inspections at the VA medical centers we visited, VA

inspections consumed an average of about 14 hours of staff time per

inspection. One medical center reported spending only about 6 hours on

each of its inspections (three staff spending 2 hours at each home), while

another reported spending about 18 hours on each of its inspections. In

contrast, the state inspection agencies in the four states we examined in

our September 2000 report averaged at least 94 hours per inspection,

including one state that averaged 162 hours per inspection.16

State inspections may be superior to VA inspections in other areas as well.

For example, CMS requires that each state inspector receive training

within his or her first year of employment. A VA official told us that VA has

provided no such training to its community nursing home inspectors. State

inspectors also are employed solely to conduct inspections, while VA

inspectors perform inspections in addition to their normal duties at VA

medical centers. CMS is required by statute to evaluate the performance of

state survey agencies by evaluating 5 percent of state inspections

performed annually. CMS most often complies with this requirement by

accompanying state officials on nursing home inspections (known as

observational surveys) and at other times by independently inspecting

nursing homes already inspected by states and then comparing the results

 16The difference in duration between VA inspections and state inspections may significantly

affect the quality of oversight, given a 1998 study by the University of Wisconsin’s Center

for Health Systems Research and Analysis that showed a correlation between the average

survey time and the number of deficiencies identified. See Center for Health Systems

Research and Analysis: Analysis of LTC Survey Time and Workload Factors (University of

Wisconsin-Madison: May 1998).

VA’s Planned Policy

Appears Reasonable, but

Concerns Remain About

Variations in State

Inspections
Page 19 GAO-01-768 VA Nursing Home Oversight

of the inspections (known as comparative surveys).17 VA performs no such

oversight or evaluation of VA medical centers’ inspections.

While state inspections appear to be more thorough than VA’s, they may

not be sufficiently reliable to fully disclose the quality of care in a home.

For example, we noted in our July 1998 report that state inspection results

could be understated because nursing homes could often predict when

their reviews would occur and take steps to mask problems.18 Problems

were also missed because sampling methods were not used that could

enhance the identification of potential problems and help determine their

prevalence. We also noted in our September 2000 report that in 70 percent

of HCFA comparative surveys conducted from October 1998 through May

2000, HCFA inspectors found deficiencies that were more serious than

those found by the state inspectors, suggesting that the state inspectors

did not detect all existing problems in the homes. HCFA also found

serious, substantiated complaints in homes that state inspectors reported

as deficiency-free.

Some VA medical center staff we visited during this review reached similar

conclusions through their own inspections. At 2 of the 10 sites we visited,

VA staff told us that they do not believe state inspection reports in their

states contain information on all the problems that may exist at the homes.

At one facility, VA staff responsible for conducting inspections stated that

they frequently found nursing home problems that were not reported by

the state inspection team; in some cases, the state certified that a home

had corrected identified problems when, according to the VA inspection

team, the problems were clearly not corrected. Similarly, staff at a VA

medical center in another state told us that they did not believe that state

inspection reports reflected all deficiencies in the nursing homes

inspected.

However, VA will likely find it difficult to identify all the states whose

inspections provide inadequate information because neither VA nor CMS

has sufficient information to do so. Notwithstanding the knowledge of

selected VA staff we spoke with, local knowledge at each VA medical

center may be insufficient to give VA adequate information about which

 17In fiscal year 2000, HCFA performed 782 observational surveys and 111 comparative

surveys.

18California Nursing Homes: Care Problems Persist Despite Federal and State Oversight

(GAO/HEHS-98-202, July 27, 1998), p. 4.
Page 20 GAO-01-768 VA Nursing Home Oversight

states provide reliable data on community nursing home performance.

Further, CMS does not have such information; as noted in our prior work,

its oversight of state efforts has serious limitations that prevent it from

developing accurate and reliable assessments of state inspection

performance. Although data show a wide range in the number of times

states cite nursing homes for deficiencies (for example, in 1999 the

average number of deficiencies cited by state inspectors ranged from 2

deficiencies per home in New Jersey to 11.4 deficiencies per home in

Nevada), CMS cannot accurately determine whether this variation stems

from differences in the quality of care in the home or in the quality of state

inspections. This is partly because there have been too few comparative

surveys in each state to assess whether the state appropriately identifies

serious deficiencies. HCFA conducted only one to three comparative

surveys per state annually, providing little information on how

representative these surveys are of overall state performance.19

Our discussions with VA field staff revealed considerable unfamiliarity

with the information they will be expected to use to evaluate community

nursing home quality under VA’s planned policy. However, VA has not

determined what guidance, if any, to provide to its medical centers in

implementing the new policy. Although it is important that any guidance

leave room for local knowledge and understanding when using the

information, without such guidance, VA risks having different standards

applied by different VA medical centers in assessing whether community

nursing homes are suitable for veteran placement.

Nearly all of the medical centers we visited use the results of state

inspections, which are public documents, as part of their required efforts

to evaluate locally contracted community nursing homes. However,

according to a VA headquarters program official, no VA medical centers

have access to OSCAR data, although VA is negotiating with CMS to allow

access at all VA medical centers. Further, the same VA headquarters

official told us that VA has no plans to provide criteria for VA medical

centers to apply when using state inspection reports or OSCAR data to

evaluate community nursing homes. Without such criteria, or even

minimal guidelines, VA headquarters will have no assurance that staff at

 19A CMS official stated that CMS intends to increase the number of comparative inspections

it conducts, from 111 comparative surveys in 2000 to 162 in 2001.

VA Has Developed No

Guidance to Help Medical

Center Staff Who Are

Unfamiliar With Planned

Oversight Tools
Page 21 GAO-01-768 VA Nursing Home Oversight

each VA medical center are using such data consistently and

appropriately.

VA field staff we visited were generally unfamiliar with the facility QI

profile. Staff at two facilities were not aware that patient assessments are

aggregated by CMS into a profile of each nursing home, and staff we spoke

with at most facilities did not know how to obtain QI profiles for nursing

homes or how to interpret the information. However, VA’s planned policy

has no provisions for guidance on the use of the QI profile, including

guidance on how, in combination with other information, the QI profile

can be used to make preliminary assessments of nursing home quality.

Without guidance on how to use the QI profile, the staff at each VA

medical center will need to determine where to obtain facility QI profiles,

how to decide which indicators are most important in evaluating quality,

and what scores might suggest nursing home problems.

Although VA has generally overseen state veterans’ homes with the

frequency required by its policies, the community nursing home program

has problems that require attention. Serious gaps exist in VA’s knowledge

about the quality of care provided to veterans in community nursing

homes because, although some VA medical centers are conducting the

required inspections and visits, other medical centers have decided not to

follow VA’s oversight policy. Further, because headquarters has not

participated sufficiently in VA’s community nursing home oversight

program and has not monitored medical centers’ performance, it has

remained unaware of these centers’ decisions. The result is that VA cannot

be assured that all of its veterans receive care in nursing homes that meet

VA standards.

VA’s recent plan to eliminate its requirement for inspections of locally

contracted community nursing homes in favor of state inspection reports

and other data has merit, in principle, because it may reduce unnecessary

duplication and allow VA to better use its resources. Such a policy would

also eliminate the disparity between oversight of locally contracted homes,

for which VA currently requires annual inspections, and oversight of

centrally contracted homes, for which VA requires a review of CMS data.

However, sufficient information about the reliability of individual state

inspections does not exist, and without such information VA will be

unable to determine whether in all cases state data provide credible

information about nursing home quality. VA could determine which states

provide adequate information by conducting its own inspections in a

portion of community nursing homes under contract and comparing its

Conclusions
Page 22 GAO-01-768 VA Nursing Home Oversight

own findings to those of the states, or by contracting with CMS to do so

and comparing CMS’ findings to those of the states. Currently, however,

VA has plans to do neither.

VA field staff also lack sufficient guidance to ensure that oversight

activities are regularly and consistently carried out. VA field staff who

might (under the new plan) review OSCAR, QI, and other data to

determine whether community nursing homes meet VA standards

generally do not know how to obtain the data and what elements of these

data are most critical to evaluating home quality. Similarly, although VA

has provided an inspection protocol and inspection training to staff who

inspect state veterans’ homes, it has provided no such protocol or training

for staff who inspect community nursing homes, and currently these

inspections do not appear to provide comprehensive or comparable data

on nursing home performance.

Finally, the inconsistency between the ongoing requirement for an annual

inspection of all state veterans’ homes and the plan to eliminate such

inspections of community nursing homes is confusing and needs to be

resolved. If VA believes that CMS-sponsored state inspections of nursing

homes, combined with other available data, will provide adequate

assurance of acceptable quality in community nursing homes, this logic

could reasonably apply to Medicare- or Medicaid-certified state veterans’

homes where CMS-sponsored state inspections already occur. Such a

decision, however, would still require VA to evaluate the reliability of state

inspection reports, as we believe VA will need to do under the planned

oversight policy for its community nursing home program.

To strengthen its oversight of community nursing homes and better ensure

that veterans receive acceptable quality of care, we recommend that the

Secretary of Veterans Affairs direct the Under Secretary for Health to take

the following actions.

• 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

Recommendations for

Executive Action
Page 23 GAO-01-768 VA Nursing Home Oversight

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.

• Ensure consistent and comprehensive VA medical center 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 the visits, and (3) providing guidance on how to obtain,

interpret, and use OSCAR, QI, and other data in assessing community

nursing home quality of care when VA implements its planned policy.

• 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.

We provided VA a draft copy of our report for its review and comment. VA

agreed with our conclusions and recommendations and noted that it is

developing a comprehensive draft directive on community nursing home

evaluation and monitoring that will address our concerns about VA

oversight. It also noted that it has plans underway to establish annual

review protocols and follow-up training for VA staff who conduct

community nursing home inspections. VA’s comments are reprinted in

appendix III.

As agreed with your offices, unless you announce the report’s contents

earlier, we plan no further distribution until 30 days after its issue date. We

will then send copies to the Secretary of Veterans Affairs, appropriate

congressional committees, and other interested parties. We will make

copies available to others upon request.

Agency Comments
Page 24 GAO-01-768 VA Nursing Home Oversight

Please contact me at (202) 512-7101 or Ronald J. Guthrie at (303) 572-7332

if you or your staffs have any questions. Joe Buschy, Steve Gaty, and Alan

Wernz also made key contributions to this report.

Stephen P. Backhus

Director, Health Care—Veterans’

 and Military Health Care Issues
Appendix I: Scope and Methodology

Page 25 GAO-01-768 VA Nursing Home Oversight

To identify VA’s policies for overseeing community nursing homes and

state veterans’ homes, we met with officials of VA’s Geriatrics and

Extended Care Strategic Healthcare Group and reviewed applicable laws,

regulations, and directives. We then evaluated adherence to these policies

by reviewing documents and interviewing staff at a judgmentally selected

sample of 10 VA medical centers. We selected our sample as follows. First,

we limited our selection pool to those medical centers having oversight

over at least one state veterans’ home, because we wished to review VA

medical centers’ oversight procedures for state veterans’ homes. Out of

VA’s 172 medical centers, we identified 65 having such oversight. We then

used VA data to determine the average daily census of veterans placed in

community nursing homes by each of these 65 medical centers. We used

these data to further limit our selection pool to those medical centers for

which the average daily census was above or near the median average

daily census for all VA medical centers nationwide. Finally, we selected VA

medical centers from various geographic regions of the country. The

information we obtained from the 10 medical centers is not necessarily

representative of VA medical centers in total. Figure 2 shows the VA

medical centers we visited.

Figure 3: Location of VA Medical Centers Included in Our Review

To determine the extent to which VA has followed its policies governing

the frequency of community nursing home inspections and the type of

staff (for example, nurses and social workers) making those inspections,

we interviewed staff and reviewed community nursing home inspection

reports (if available) and other documentation at the 10 medical centers

Appendix I: Scope and Methodology

 Seattle 

 Loma Linda 

 Minneapolis 

 Muskogee 

New Orleans 

 Providence 

 Pittsburgh 

 Gainesville 

 Birmingham 

Cleveland 
Appendix I: Scope and Methodology

Page 26 GAO-01-768 VA Nursing Home Oversight

we visited. To determine the extent to which VA has followed its policies

governing the frequency of visits to veterans in community nursing homes

and the type of staff making those visits, we reviewed the VA records of

veterans placed in community nursing homes by these 10 medical centers.

We limited our evaluation to veterans who had spent at least 30

consecutive days in community nursing homes from January 1, 1999,

through the dates of our visits. At centers where the number of such

veterans substantially exceeded 100, we reviewed the records of about 100

veterans selected at random. At the remaining centers, we reviewed the

records of all such veterans. In total, we reviewed the records of 832

veterans.

To determine the extent to which VA followed its policies governing the

frequency of state veterans’ home inspections, we requested from VA

headquarters and each VA facility with state veterans’ home oversight the

reports of each inspection conducted since January 1, 1997. We then

entered the results of each inspection into a database to track (1) the date

of each inspection, (2) the results of each inspection, including the number

and type of problems identified, and (3) the date each inspection report

was received by VA headquarters, if available. During our site visits we

reviewed additional documentation related to the inspections, particularly

the plans of correction submitted by the state homes in response to VA

reports of deficiencies. We also attended a 3-day state veterans’ home

inspection training course delivered to one of VA’s networks.

To evaluate VA’s mechanisms for implementing its planned community

nursing home policies, we interviewed the chief of VA’s contract

community-based care programs and reviewed the planned policy

directive in headquarters. We also interviewed staff at the 10 VA medical

centers we visited to determine their familiarity with the information that

VA headquarters plans to use in lieu of annual VA inspections.

To describe the mechanisms VA uses to ensure that nursing homes correct

identified problems, we discussed VA’s options and actions with officials

at VA headquarters and at the 10 medical centers we visited, and reviewed

VA policies governing the use of these mechanisms. In addition, we either

visited or telephoned officials in 10 state veterans’ homes that were

inspected by one of the 10 VA medical centers, and attended the 2001

national meeting of the National Association of State Veterans’ Homes, in

order to obtain state veterans’ home officials’ views of the impacts of VA’s

oversight efforts. Table 3 shows the state veterans’ homes we contacted.
Appendix I: Scope and Methodology

Page 27 GAO-01-768 VA Nursing Home Oversight

Table 3: State Veterans’ Homes We Contacted During Our Review, and the

Associated VA Medical Centers Performing Inspections

Location of state veterans’ homes contacted VA medical center

Alexander City, AL Birmingham, AL

Barstow, CA Loma Linda, CA

Daytona Beach, FL Gainesville, FL

Jackson, LA New Orleans, LA

Minneapolis, MN Minneapolis, MN

Sandusky, OH Cleveland, OH

Claremore, OK Muskogee, OK

Pittsburgh, PA Pittsburgh, PA

Bristol, RI Providence, RI

Orting, WA Seattle, WA
Appendix II: Instances in Which VA Has

Withheld State Veterans’ Home Per Diem

Payments

Page 28 GAO-01-768 VA Nursing Home Oversight

According to VA officials, VA has withheld per diem to three state

veterans’ homes. In each case, according to the VA field staff, the state

operating the home made up the resulting shortfall; veterans were not

required to pay the difference. A synopsis of each case follows, based on

VA documents and comments by VA officials.

The first home to have payments withheld was cited for problems in mid1998, even before it began accepting residents. VA subsequently approved

the home’s plan to correct the problems and recognized the facility as a

state veterans’ home. However, VA inspectors continued to find problems

and after a June 1999 inspection revealed instances of patient abuse and

infection problems, the VA medical center recommended that the per diem

be withheld. On September 15, 1999, VA notified the home that per diem

payments would be withheld until VA could certify that the home

complied with VA standards. The home corrected the problems and about

3 months later, on December 28, 1999, VA notified the home that payments

would be reinstated retroactive to November 5, 1999, the date on which a

VA inspection certified that all VA standards were met. An official in VA’s

state veterans’ home program office attributed this home’s problems to the

lack of operating funds provided by the state in which the home operated.

VA medical center staff inspected the home again in May 2000 and found

that it met VA standards.

The second home to have payments withheld opened in 1996 and

subsequently was cited for numerous problems, including medication

errors and staffing shortages, during all VA inspections. Inspections in

both February and November 1999 found compliance with only 67 percent

of VA standards, and VA officials informed the home that they would

recommend that payments be withheld unless significant changes were

made. In April 2000, VA received the home’s plan to correct the problems

found during the most recent inspection. VA rejected the plan and

recommended that per diem be withheld. On May 31, 2000, VA notified the

home that per diem payments would be withheld as of that date, and as of

July 17, 2001, those payments have not been reinstated.1

 VA officials told

us that the home’s remote location makes it difficult for the home to hire

and retain sufficient staff to provide adequate patient care.

 1

Per diem payments to the domiciliary at the home were also withheld beginning May 31,

2000, but have since been reinstated.

Appendix II: Instances in Which VA Has

Withheld State Veterans’ Home Per Diem

Payments
Appendix II: Instances in Which VA Has

Withheld State Veterans’ Home Per Diem

Payments

Page 29 GAO-01-768 VA Nursing Home Oversight

The third home from which VA has withheld per diem payment began

operating as a state veteran’s home in 1993. The state veterans’ home was

one wing of a facility that also houses a community nursing home with

which the local VA medical center contracted for patient care. During a

January 1997 inspection of the home, a small fire occurred, and VA

inspectors found evidence suggesting that records related to the home’s

fire safety operations had been falsified. After the home refused to take

any corrective action, VA withdrew its patients from the community

nursing home portion of the facility and recommended that per diem

payments be withheld from the state veterans’ home portion. However, the

home then agreed to correct its problems and per diem was not withheld.

Subsequent inspections found continuing life safety problems, including a

June 2000 inspection that found that the home was in compliance with

only 71 percent of VA’s life safety standards. Accordingly, VA medical

center staff recommended that per diem payments be withheld, and on

August 29, 2000, VA notified the home that per diem payments were being

withheld until VA could determine that its standards were being met. The

home subsequently corrected its problems and on July 2, 2001, VA notified

the home that payments would be reinstated retroactive to April 1, 2001,

the date on which VA certified that all VA standards were met. VA officials

told us that the home is an old structure, which has made it difficult for the

home to meet VA’s life safety standards.
Appendix III: Comments From the Department of Veterans

Affairs

Page 30 GAO-01-768 VA Nursing Home Oversight

Appendix III: Comments From the

Department of Veterans Affairs
Appendix III: Comments From the Department of Veterans

Affairs

Page 31 GAO-01-768 VA Nursing Home Oversight
Related GAO Products

Page 32 GAO-01-768 VA Nursing Home Oversight

Nursing Homes: Sustained Efforts Are Essential to Realize Potential of the

Quality Initiatives (GAO/HEHS-00-197, Sept. 28, 2000).

Nursing Homes: HCFA Should Strengthen Its Oversight of State Agencies

to Better Ensure Quality Care (GAO/T-HEHS-00-27, Nov. 4, 1999).

Nursing Home Care: Enhanced HCFA Oversight of State Programs Would

Better Ensure Quality (GAO/HEHS-00-6, Nov. 4, 1999).

Nursing Homes: Proposal to Enhance Oversight of Poorly Performing

Homes Has Merit (GAO/HEHS-99-157, June 30, 1999).

Nursing Homes: HCFA Initiatives to Improve Care Are Under Way but Will

Require Continued Commitment (GAO/T-HEHS-99-155, June 30, 1999).

Veterans’ Affairs: Observations on Selected Features of the Proposed

Veterans’ Millennium Health Care Act (GAO/T-HEHS-99-125, May 19,

1999).

Nursing Homes: Complaint Investigation Processes Often Inadequate to

Protect Residents (GAO/HEHS-99-80, March 22, 1999).

Nursing Homes: Additional Steps Needed to Strengthen Enforcement of

Federal Quality Standards (GAO/HEHS-99-46, Mar. 18, 1999).

California Nursing Homes: Care Problems Persist Despite Federal and

State Oversight (GAO/HEHS-98-202, July 27, 1998).

VA Health Care: Better Data Needed to Effectively Use Limited Nursing

Home Resources (GAO/HEHS-97-27, Dec. 20, 1996).

Related GAO Products

(406189)
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