VA Community Living Centers: Actions Needed to Better Manage Risks to Veterans' Quality of Life and Care
Published: 2011-10-19T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The Department of Veterans Affairs (VA) annually provides care to more than 46,000 elderly and disabled veterans in 132 VA-operated nursing homes, called community living centers (CLC). After media reports of problems with the care delivered to veterans in CLCs, VA contracted with the Long Term Care Institute, Inc. (LTCI), a nonprofit organization that surveys nursing homes, to conduct in-depth reviews of CLCs in 2007-2008 and again in 2010-2011. GAO was asked to evaluate VA's approach to managing veterans' quality of care and quality of life in CLCs. This report examines (1) VA's response to and resolution of LTCI-identified deficiencies and (2) information VA collects about the quality of care and quality of life in CLCs and how VA uses it to identify and manage risks. To do this work, GAO interviewed officials from VA headquarters, examined all 116 2007-2008 and 67 2010-2011 LTCI reviews, and analyzed 50 CLCs' corrective action plans for 2007-2008 and 23 such plans for 2010-2011.
section_title: What GAO Found
paragraphs: VA headquarters established a process for responding to deficiencies identified at CLCs during the 2007 and 2008 LTCI reviews. VA is using the process, which requires CLCs to submit corrective action plans addressing LTCI-identified deficiencies--such as how CLCs will address a lack of competent nursing staff and a failure to provide a sanitary and safe living environment--during the 2010 and 2011 LTCI reviews. On the basis of its analysis of the deficiencies identified in 2007 and 2008, VA headquarters also developed a national training and education initiative. VA headquarters officials told GAO that they plan to analyze the deficiencies identified during the 2010 and 2011 reviews and identify national areas for improvement. However, GAO found weaknesses in VA's process for responding to and resolving LTCI-identified deficiencies. First, VA headquarters does not maintain clear and complete documentation of the feedback it provides to CLCs regarding their corrective action plans. Second, VA headquarters does not require VA's networks, which oversee the operations of VA medical facilities, including CLCs, to report on the status of CLCs' implementation of corrective action plans or to verify CLCs' self-reported compliance with the requirements of the national training and education initiative. Because of these weaknesses, VA headquarters cannot provide reasonable assurance that LTCI-identified deficiencies are resolved. For example, without requiring networks to report on the status of CLCs' implementation of their corrective action plans, VA headquarters cannot determine whether CLCs' corrective action plans are fully implemented. Unaddressed, weaknesses in VA headquarters' process for responding to LTCI-identified deficiencies may compromise the quality of care and quality of life of veterans in CLCs. VA headquarters' current approach to identifying risks associated with the quality of care and quality of life of CLC residents does not comprehensively analyze information from all available sources, and for the sources VA does analyze, it does not compare findings across sources. VA's approach relies significantly on the analysis of findings from LTCI reviews of CLCs. However, in addition to LTCI reviews, VA headquarters obtains information about CLCs from a variety of other sources, such as VA's Office of Inspector General (OIG), but does not analyze the information from all these other sources. Further, for the sources it does analyze, VA headquarters evaluates each source in isolation and does not compare the findings from one source with findings from the other sources. Therefore, VA headquarters' current approach to identifying risks in CLCs may result in missed opportunities to detect patterns and trends in information about the quality of care and quality of life within a CLC or across many CLCs. For example, in comparing findings from VA's Office of the Medical Inspector, OIG, LTCI, and VA's quality indicator and quality measure data for one CLC, GAO found a pattern of deficiencies related to pain management. Without considering information from all available sources and comparing it across sources, VA headquarters cannot fully identify risks in CLCs, estimate the significance of the risks, or take actions to mitigate them.
section_title: What GAO Recommends
paragraphs: GAO recommends that VA document feedback to CLCs and require periodic status reports about corrective action plan implementation, and implement a process to comprehensively identify and manage risks to residents in CLCs by analyzing and comparing information about residents' quality of care and quality of life. In its comments on a draft of this report, VA concurred with these recommendations.

section_title: Letter
paragraphs: The Department of Veterans Affairs (VA) spent more than $4.5 billion on  nursing home care in fiscal year 2010, over $3.3 billion of which was for  care in 132 VA-operated nursing homes, called community living centers  (CLC). CLCs offer a range of services that include short-term postacute  rehabilitation for conditions such as a stroke; long-term care for veterans  who cannot be cared for at home because of severe and chronic physical  or mental limitations; and end-of-life care for terminal illnesses. More than  46,000 elderly and disabled veterans annually receive care in CLCs. This  vulnerable population relies on VA to ensure they receive quality care and  maintain their quality of life while residing in a CLC.
In 2004, problems related to the care and conditions in one CLC surfaced  in the media, raising concerns about the effectiveness of VA’s efforts to  manage the quality of care and quality of life in its CLCs. In response, VA  headquarters had in-depth unannounced reviews conducted at selected  CLCs between August 2004 and November 2006, and contracted with the  Long Term Care Institute, Inc. (LTCI), in March 2007 to conduct in-depth  reviews of 116 CLCs. LTCI conducted its reviews between June 2007  and September 2008. In late 2009, a series of newspaper articles  reported the details of deficiencies that LTCI had identified at another  CLC in September 2008. Specifically, the articles reported a lack of  competent skilled nursing in the CLC as well as failure to provide a  sanitary and safe living environment, promote and protect veterans’ rights  to autonomy, and treat veterans with respect and dignity.
Recognizing the value of the information obtained from the in-depth  reviews of CLCs, VA headquarters awarded a second contract in July  2010 to LTCI to begin reviewing all 132 CLCs in September 2010. In light  of this contract and the 2009 newspaper articles, you raised questions  about VA’s process for responding to the deficiencies identified during the  LTCI reviews, as well as the agency’s overall approach to managing the  quality of care and quality of life in its CLCs. These questions included  how VA headquarters uses available information regarding the quality of  care and quality of life in its CLCs, such as the deficiencies cited by LTCI,  to identify patterns and associated risks and take appropriate actions to  address those risks. This report examines (1) actions VA headquarters  has taken to respond to and resolve LTCI-identified deficiencies and   (2) what information VA headquarters collects regarding the quality of  care and quality of life in CLCs and the extent to which VA headquarters  uses the information to identify and manage risks.
To examine actions VA headquarters has taken to respond to and resolve  deficiencies LTCI identified during its 2007 and 2008, and 2010 and 2011,  reviews of CLCs, we obtained and analyzed copies of the 116 LTCI  reviews performed during 2007 and 2008; VA headquarters’ subsequent  analyses of those reviews; copies of 50 CLCs’ corrective action plans and  related documentation from the 2007 and 2008 reviews; copies of the   67 LTCI reviews performed between September 1, 2010, and March 31,  2011; and copies of 23 CLCs’ corrective action plans from the 2010 and  2011 reviews. We also reviewed relevant VA policy documents, including  Veterans Health Administration Directive 2009-43, Quality Management  System. We interviewed officials from VA headquarters offices involved in  responding to LTCI-identified deficiencies, including the Office of  Geriatrics and Extended Care and the Office of the Deputy Under  Secretary for Health for Operations and Management. In addition, we  reviewed Executive Career Field Plans of VA network directors and  interviewed officials from 2 of VA’s 21 networks, which oversee the  operations of the various medical facilities within their assigned  geographic area. These two networks were the VA Mid-Atlantic Health  Care Network (Durham, North Carolina) and the VA Northwest Health  Network (Vancouver, Washington). To select the networks, we  considered the average number of deficiencies per CLC reviewed by  LTCI in 2007 and 2008. We assessed VA headquarters’ response to the  identified deficiencies in the context of federal standards for internal  control for monitoring, control activities, and information and  communications. The internal control for monitoring refers to an agency’s  ability to provide reasonable assurance that actions are taken in response  to the findings from reviews and the deficiencies identified are promptly  resolved, while the internal control for control activities refers to an  agency’s ability to provide reasonable assurance that management’s  directives are carried out, which includes appropriately documenting  transactions and internal controls. The internal control for information and  communications refers to an agency’s ability to provide reasonable  assurance of the relevance and reliability of information necessary to  achieve an agency’s objectives, including verifying the accuracy of its  data.
To determine what information VA headquarters collects regarding the  quality of care and quality of life in CLCs and the extent to which VA  headquarters uses the information to identify and manage risks, we  reviewed reports from reviews and investigations performed at CLCs  between June 2007 and June 2011. We also reviewed VA analyses of  information contained in these reports and VA policy documents. We  interviewed officials from Geriatrics and Extended Care; the Office of the  Deputy Under Secretary for Health for Operations and Management; the  Office of the Assistant Deputy Under Secretary for Health for Informatics  and Analytics; the Office of the Assistant Deputy Under Secretary for  Health for Quality, Safety, and Value; and the Office of Inspector General  (OIG). We assessed VA headquarters’ use of information regarding the  quality of care and quality of life in CLCs in the context of federal  standards for internal control for risk assessment. The internal control for  risk assessment refers to an agency’s ability to identify and analyze  relevant risks associated with achieving its objectives.
We conducted this performance audit from August 2010 through  September 2011 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.
subsections: section_title: Background
paragraphs: VA provides nursing home care for some veterans, as required, and  makes these services available to other veterans on a discretionary basis,  as resources permit. Specifically, VA is required by law to provide  nursing home care to any veteran who needs it for a service-connected  disability and to any veteran who needs it and has a service-connected  disability rated at 70 percent or greater. However, VA provides most of  its nursing home care to veterans on a discretionary basis, as resources  permit. VA’s policy on nursing home eligibility requires that VA networks  provide nursing home care to veterans with 60 percent service-connected  disability ratings who are either unemployable or who have been  determined by VA to be permanently and totally disabled. For all other  veterans, VA’s policy is to provide nursing home care on a discretionary  basis, with certain veterans having higher priority, including veterans who  require care following a hospitalization.
CLCs provide both short-stay (90 days or less) and long-stay (more than  90 days) services. According to VA data, almost 94 percent of the  residents admitted to CLCs in fiscal year 2010 were short-stay. Short-stay  care in CLCs includes skilled nursing care, rehabilitation, restorative care,  maintenance care for those awaiting alternative placement, hospice, and  respite care. The remaining admissions, about 6 percent, were long-stay.  Long-stay care includes dementia care, maintenance care, and care for  those with spinal cord injury and disorders.
Responsibility for VA’s medical facilities, including CLCs, rests with both  VA’s networks and VA headquarters. Almost all of VA’s 132 CLCs,  located throughout VA’s 21 networks, are colocated with or in close  proximity to a VA medical center (VAMC). While networks are charged  with the day-to-day management of the VAMCs within their network, VA  headquarters maintains responsibility for establishing national policy and  overseeing both networks and VAMC operations. Within VA  headquarters, Geriatrics and Extended Care is responsible for developing  VA’s policies and other national actions related to the quality of care and  quality of life in VA’s CLCs. The Office of the Deputy Under Secretary for  Health for Operations and Management, through each network, ensures  that VAMCs, including CLCs, comply with VA’s policies and implement  other national actions.
The LTCI contract, which began in September 2010, is for 1 year, and  provides for LTCI to conduct reviews between September 2010 and  August 2011. VA may exercise an option to renew for each of 4 additional  years through August 2015. Officials from both Geriatrics and Extended  Care and the Office of the Deputy Under Secretary for Health for  Operations and Management share responsibility for administering VA’s  contract with LTCI.
LTCI uses the Centers for Medicare & Medicaid Services’ scope and  severity scale for classifying nursing home deficiencies. There are four  severity classifications, with the least serious deficiencies rated as having  the potential for minimal harm and the most serious deficiencies rated as  immediate jeopardy situations—in which residents are potentially or  actually at risk of dying or being seriously injured. The remaining two  severity classifications are actual harm and potential for more than  minimal harm. The scope of deficiencies—or the number of residents  potentially or actually affected by the deficient care—may be rated as  isolated, pattern, or widespread.
VA policy requires that all VAMCs be accredited by The Joint  Commission. As part of the accreditation process for a VAMC, which  occurs on average every 3 years, The Joint Commission surveys and  accredits any CLC associated with the VAMC. VA requires CLCs to  meet The Joint Commission long-term care standards. CLCs are also  subject to periodic reviews by VA’s OIG.
section_title: VA Headquarters Established a Process for Responding to LTCI-Identified Deficiencies, but Cannot Provide Reasonable Assurance That Deficiencies Have Been Resolved
paragraphs: VA headquarters established a process for responding to deficiencies  identified at CLCs during the 2007 and 2008 reviews. This process, which  requires CLCs to submit corrective action plans addressing LTCI- identified deficiencies—such as how CLCs will address a lack of  competent nursing staff and a failure to provide a sanitary and safe living  environment—is also being used during the 2010 and 2011 LTCI reviews.  However, because of weaknesses in the process, VA headquarters  cannot provide reasonable assurance that deficiencies that could  potentially affect the quality of care and quality of life of residents are  resolved.
subsections: section_title: VA Headquarters’ Process Requires Corrective Action Plans and, for 2007 and 2008, National Training and Education
paragraphs: VA headquarters established a process for responding to LTCI-identified  deficiencies that requires each CLC to develop a corrective action plan  addressing all deficiencies identified and submit it to VA headquarters  within 30 days of receiving an LTCI report. The plans may include actions  such as training CLC staff on clinical policies and procedures or  implementing nursing and interdisciplinary rounds to monitor the clinical  issues related to the deficiencies. VA headquarters officials review each  corrective action plan to determine whether the actions can be expected  to correct all identified deficiencies and whether the time frames for  completing the actions are reasonable. The officials then provide each  CLC feedback by telephone, discussing any revisions to the corrective  action plans that may be necessary. The officials document these  discussions using hand-written notes on hard copies of CLCs’ corrective  action plans, which are not shared with VA networks and CLCs. VA  headquarters officials told us they may schedule additional telephone  calls with CLCs when significant revision of a corrective action plan is  necessary or if the officials want an update on the implementation of the  plan. For deficiencies identified in the 2007 and 2008 LTCI reviews, the  documentation showed that officials had at least two telephone calls with  29 of the 116 CLCs reviewed. Three of these 29 CLCs received more  than two follow-up calls. When additional calls were made, VA  headquarters required the CLCs to submit an updated corrective action  plan.
While VA’s process requires that all deficiencies identified be addressed,  it gives priority to deficiencies at the immediate jeopardy or actual harm  levels. When LTCI review teams identify such deficiencies during a  survey, they are required to notify VA headquarters and the relevant  VAMC. LTCI identified immediate jeopardy or actual harm deficiencies  at 25 of the 116 CLCs (about 22 percent) reviewed in 2007 and 2008, and  at 10 of the 67 CLCs (about 15 percent of the CLCs) reviewed in 2010  and 2011 as of March 31, 2011.
After the 2007 and 2008 LTCI reviews, VA headquarters officials  analyzed the deficiencies from the 116 reviews and from the analysis  developed eight clinical high-risk categories. According to these officials,  the eight categories, which included medication management, infection  control, and peripherally inserted central catheter (PICC) lines, posed the  greatest risk to residents’ health and safety. (See table 1.) The officials  then implemented a national training and education initiative to address  the eight categories.
VA headquarters convened a workgroup that developed national training  guidelines and checklists for evaluating CLC staff competencies in each  of the eight categories. The workgroup included representatives from  Geriatrics and Extended Care, the Office of Nursing Services, Nutrition   and Food Services, and the Infectious Diseases Program Office. A VA  headquarters official told us that the workgroup included the last three  offices because the majority of LTCI-identified deficiencies were related to  nursing, nutrition, and infection control issues. VA headquarters provided  the VA networks and CLCs with the national guidelines and checklists  and required CLCs to incorporate them into their training and education  policies. VA headquarters required CLCs to report whether they had met  the following four requirements for each of the eight clinical high-risk  categories: (1) establish CLC policies, (2) adopt procedures for  implementing the policies, (3) design an assessment to observe staff  proficiency in providing care matching the established procedure, and   (4) establish a plan for ongoing training and assessment of staff, including  new staff. In addition, CLCs were required to directly observe staff  providing care to CLC residents and report the percentage of staff that  had been observed as being proficient in the procedures necessary to  comply with CLCs’ policies for each of the eight clinical high-risk  categories. If CLCs did not meet all four requirements for each category  or had observed less than 90 percent of their staff as proficient in  providing care in any one of the clinical high-risk categories, they were to  develop and submit corrective action plans to VA headquarters.  According to the documentation we reviewed, in most categories, the  majority of CLCs indicated that they had met the requirements of the  national training and education initiative. However, in every category  there were CLCs that did not meet these requirements and had to submit  a corrective action plan. For example, for the medication management  clinical high-risk category, 14 of the 132 CLCs submitted a corrective  action plan because they either were not in compliance with the four  requirements or had not observed at least 90 percent of their staff as  being proficient in providing care.
After LTCI’s 2010 and 2011 reviews of VA’s CLCs are complete, VA  headquarters plans to analyze the deficiencies identified by LTCI. To  facilitate the analysis, VA headquarters is working with LTCI to track and  note trends with regard to deficiencies on a quarterly basis. LTCI provides  quarterly reports to VA headquarters, which include data on which  deficiencies are the most frequently identified nationally. For each CLC,  these reports include data on the total number of deficiencies identified  and the categories in which the identified deficiencies fall. VA  headquarters officials expect that these quarterly reports will facilitate the  identification of national areas for improvement as well as help them  review CLCs’ performance on the LTCI reviews over time.
section_title: VA Headquarters Cannot Provide Reasonable Assurance That All Deficiencies Are Resolved Because of Weaknesses in Its Process for Responding to Deficiencies
paragraphs: When responding to LTCI-identified deficiencies, VA headquarters does  not always maintain clear and complete documentation of the feedback it  provides to CLCs regarding their corrective action plans. In addition, VA  headquarters does not require VA networks to report on the status of  CLCs’ implementation of their corrective action plans or to verify CLCs’  self-reported compliance with the requirements of the national training  and education initiative. Without the ability to determine whether CLCs  appropriately responded to feedback, fully implemented their corrective  action plans from the 2007 and 2008 LTCI reviews, or fully complied with  requirements of the national training and education initiative, and without  the ability to determine the status of corrective action plans that CLCs are  implementing during LTCI’s 2010 and 2011 reviews, VA headquarters  does not have reasonable assurance that LTCI-identified deficiencies are  resolved.
Lack of clear and complete documentation of feedback. VA headquarters  does not always maintain clear and complete documentation of the  feedback it provides CLCs about their corrective action plans, which is not  consistent with good management practices as outlined in federal internal  control standards. According to these standards, internal control activities,  such as VA headquarters’ feedback, should be clearly and completely  documented in a manner that is accurate, timely, and helps provide  reasonable assurance that program objectives are being achieved. VA  headquarters uses an unsystematic approach for documenting the  feedback it provides to CLCs regarding their corrective action plans. The  approach relies solely on hard copies of CLCs’ action plans that have  hand-written notes on them, which are not shared with the VA networks  and CLCs, to document the feedback provided during VA headquarters’  telephone calls with CLCs. We found that this approach did not always  result in clear—that is, understandable to anyone not involved in the  telephone feedback calls—and complete documentation. In particular, the  documentation we reviewed did not always clearly and completely  indicate the specific feedback provided to CLCs, including actions VA  headquarters advised CLCs to take to address weaknesses with their  corrective action plans. For example, for one CLC we obtained two  corrective action plans from VA headquarters. One was an older action  plan and the other was a revised action plan. The older action plan  contained no notes or any indication of the content of VA headquarters’  feedback that resulted in the revised action plan, so we were unable to  independently determine whether the revised action plan addressed VA  headquarters’ feedback. In addition, we found that the plans for 19 of the  50 2007 and 2008 CLC corrective action plans that we reviewed—or  about 38 percent of the plans—lacked any notes documenting the  feedback that VA headquarters gave CLCs on the telephone calls.
Lack of reporting requirement for VA networks. VA headquarters does not  require its networks to report on the status of CLCs’ implementation of  their corrective action plans, and VA headquarters does not routinely  schedule additional telephone calls with CLCs following the submission of  initial corrective action plans and VA’s initial telephone calls. For example,  VA headquarters held additional telephone calls with only 25 percent of  CLCs following the 2007 and 2008 LTCI reviews, and 15 percent of the  CLCs following the 2010 and 2011 LTCI reviews, as of March 31, 2011.  Therefore, VA headquarters does not know whether CLCs fully  implemented their plans and corrected all LTCI-identified deficiencies.
Federal standards for internal control state that the findings of reviews  should be promptly resolved and that information on the status of the  findings should be communicated to management so that management  can provide reasonable assurance that a program is achieving its  objectives—in this case, that CLCs are providing quality care and  maintaining veterans’ quality of life. VA headquarters officials told us  that beyond the initial telephone calls with CLCs, VA headquarters does  not receive any additional information from CLCs regarding the  implementation status of their corrective action plans. Rather, VA  headquarters officials expect the findings of the 2010 and 2011 LTCI  reviews will help them determine whether CLCs resolved all deficiencies  identified by LTCI in 2007 and 2008—2 or 3 years after the deficiencies  were first identified.
Lack of verification requirement for national initiative. We found that VA  headquarters relied on self-reported information from CLCs regarding   (1) compliance with all four requirements for each of the eight clinical  high-risk categories and (2) the percentage of staff that were observed to  be proficient in treatments and procedures associated with the categories.  VA headquarters did not specify to its networks that they should verify the  accuracy of CLCs’ self-reported information. Reliance on self-reported  information is inconsistent with federal standards for internal control  specifying that management should be able to provide reasonable  assurance about the accuracy of data—in this case, that VA networks  verify the accuracy of CLCs’ self-reported information. Although we  cannot generalize to all networks, neither of the two VA networks we  visited requested documentation to verify CLCs’ self-reported information  for the national training and education initiative. Further, the 2010 and  2011 LTCI reviews indicate that some CLCs are not in compliance with  the requirements for the eight clinical high-risk categories stemming from  the 2007 and 2008 reviews. For example, a CLC reported to VA  headquarters that by June 2009 it would have a policy in place for training  and educating its staff on PICC lines—one of the eight clinical high-risk  categories. However, when LTCI reviewed this CLC in 2010, it found that  this CLC had failed to provide proper care and treatment when  administering medication to a resident through a PICC line. When LTCI  asked to see the CLC’s policy related to PICC lines, the CLC’s staff  stated that the CLC did not have one.
section_title: VA Headquarters Receives Information about CLCs from Multiple Sources, but Does Not Analyze It to Assess and Manage Risks
paragraphs: In addition to LTCI reviews, VA headquarters obtains information about  CLCs from a variety of other sources that could be used to more  comprehensively identify risks associated with the care and quality of life  of CLC residents. VA headquarters does not analyze all of these sources,  and for those sources it does analyze, VA evaluates each source in  isolation without comparing the information it receives across all available  sources to identify major or commonly cited risks and trends. As a result,  VA headquarters’ current approach to identifying risks in CLCs may result  in missed opportunities to detect patterns and trends in information about  the quality of care and quality of life within a CLC or across many CLCs.  Without considering information from all available sources and comparing  it across different sources, VA headquarters cannot adequately identify  and manage risks in CLCs.
subsections: section_title: VA Headquarters Receives Useful Information about CLCs from Multiple Sources
paragraphs: We found that VA headquarters receives information about the quality of  care and quality of life in CLCs from at least nine different sources. The  type of information VA headquarters receives from each of these sources,  and how often the agency receives it, varies. The nine sources of  information about CLCs are the following:    LTCI. Conducts annual unannounced reviews that assess the extent  to which CLCs follow 176 federal long-term care standards. LTCI  review teams observe the delivery of care for a sample of residents in  order to examine such areas as medication management, infection  control practices, and respect for residents’ rights and dignity. LTCI  provides VA headquarters a report of all deficiencies identified. VA  headquarters then shares the report with the network and the  reviewed CLC. The CLC is expected to correct identified deficiencies.    The Joint Commission. Performs accreditation surveys every 3 years,  on average, assessing CLCs’ compliance with 227 long-term care  standards, such as infection control practices and resident  assessments. When The Joint Commission surveyors find  noncompliance, they determine whether a systemic problem exists by  assessing the CLC’s established policies and processes. This  determination is the basis for whether CLCs are found deficient in a  long-term care standard. VA networks and CLCs receive survey  reports from The Joint Commission, which identify specific  deficiencies. CLCs are required to resolve the deficiencies within  certain time frames in order to maintain accreditation.    OIG. Performs its Combined Assessment Program reviews at  VAMCs, including CLCs, about every 3 years. Under this program,  OIG reviews selected VAMC activities, including CLC activities, to  assess the effectiveness of patient care administration (the process of  planning and delivering patient care) and quality management (the  process of monitoring quality of care to identify and correct harmful  and potentially harmful practices and conditions). CLCs typically are  part of each Combined Assessment Program review. Upon  completion of each review, OIG issues a report to VA headquarters,  the network, and the VAMC, which identifies the VAMC’s deficiencies,  including any deficiencies identified in the CLC. VA requires VAMCs,  including CLCs, to fully resolve deficiencies within a year of the  completion of a Combined Assessment Program review.    VA Office of the Medical Inspector (OMI). Conducts investigations to  determine the validity of allegations made by complainants regarding  the care provided to veterans, including residents of CLCs. If an  allegation is validated, the VAMC, including the CLC, is required to  address any recommendations made by OMI.    System-wide Ongoing Assessment and Review Strategy (SOARS).
Performs reviews of VAMCs, including CLCs, every 3 years to  evaluate readiness for some external and internal reviews, such as  those by The Joint Commission and OIG. It is a consultative  program within VA designed to identify programmatic weaknesses in  VAMCs, including CLCs. SOARS teams issue reports to VA networks  and VAMCs, including CLCs, with recommendations based on  identified deficiencies, and VAMCs and CLCs are expected to  implement the recommendations.    Quality Measures and Quality Indicators. Report the percentage of  residents in a CLC who have certain conditions, such as a pressure  ulcer, or residents who are at risk for developing certain conditions,  such as CLC residents who have limited mobility and are at risk of  developing a pressure ulcer. CLCs periodically assess residents and  enter information about their conditions into a database, which  automatically calculates percentage scores for 24 categories of quality  measures and quality indicators. Data are available on an ongoing  basis.    Artifacts of Culture Change Tool. Reports the extent to which CLCs  provided resident-centered care. Using a standard self-assessment  tool, CLCs score their own performance in certain areas, such as  allowing residents to choose when they eat meals, bathe, and sleep.  CLCs report their scores to VA headquarters every 6 months.
Issue Briefs. Provide specific information to VA headquarters officials  regarding unusual incidents, such as deaths, disasters, or anything  else that happens at a VAMC, including a CLC, that might generate  media interest or affect care.    Complaints. Provide information from veterans or their representatives  about the quality of care or the quality of life in VAMCs, including  CLCs.
section_title: VA Headquarters Does Not Consider the Potential Usefulness of All Available Information to Assess and Manage Risks in CLCs
paragraphs: VA headquarters’ approach for identifying risks associated with the quality  of care and quality of life of CLC residents is deficient in two respects—it  does not comprehensively analyze information from all available sources,  and it does not compare findings across these sources. Without analyzing  information from all available sources and comparing the results, VA  headquarters’ assessments of risks in CLCs are incomplete. According to  federal internal control standards, management should assess the risks  the agency may face from both external and internal sources. The  standards state that a risk management process includes   (1) comprehensively identifying risks associated with achieving an  agency’s goals (for example, providing quality of care and quality of life in  CLCs); (2) estimating the significance of the risks; and (3) determining  actions to mitigate the risks, such as developing or clarifying policies or  targeting reviews of noncompliant CLCs.
VA headquarters’ current approach relies significantly on the analysis of  findings from LTCI reviews of CLCs. VA headquarters also relies on  analysis of the findings from The Joint Commission accreditation surveys  and the Artifacts of Culture Change tool. (See app. I for a detailed  description of these analyses.) While these three separate analyses  enable VA headquarters to identify trends in each source of information,  such as the most frequently cited deficiencies across all CLCs or the  average number of deficiencies per CLC, they do not provide a complete  assessment of the risks that would be identified by evaluating all nine  sources. Information VA headquarters receives about the quality of care  and the quality of life in CLCs from the remaining six sources—OIG, OMI,  SOARS, quality measures and quality indicators, issue briefs, and  complaints—could also be valuable in identifying patterns in CLC-related  findings. VA headquarters officials we interviewed said they do not  typically analyze information they receive about CLCs from these six  sources because they do not always believe that doing so would be  valuable for identifying trends and patterns regarding the quality of care  and quality of life in CLCs. For example, VA headquarters officials said  that they do not extract CLC-related findings from OIG Combined  Assessment Program reviews because the reviews typically do not  include enough CLC-related findings to warrant analysis. However, when  we analyzed findings from the 77 OIG Combined Assessment Program  reviews that were completed at VAMCs that have CLCs between   October 1, 2009, and June 20, 2011, we found that 49 of the reviews—or  about 64 percent—included at least one finding related to the quality of  care or quality of life in a CLC. Without analyzing information from all  available sources about the quality of care and quality of life in CLCs, VA  headquarters’ assessments of risks in CLCs are incomplete.
VA headquarters does not compare information across all sources to  identify patterns of findings for an individual CLC, CLCs within a network,  or all CLCs nationwide. Rather, VA headquarters analyzes the findings  from three sources separately to identify trends in the findings. However,  it does not compare the findings from one source to the findings from the  other sources. One source’s findings, in isolation, may not present the  significance of certain risks, especially those that may suggest immediate  risks for residents within a given CLC or across all CLCs. However, if  related information that VA headquarters receives was compared across  different sources concurrently, VA headquarters officials would be better  positioned to recognize the risks to CLC residents.
One example we identified of the benefit from considering the usefulness  of multiple information sources is in the area of pain management. In this  regard, we found that in fiscal years 2009 and 2010, VA headquarters’  quality indicator and quality measure data showed that about 25 percent  of all long-stay CLC residents and 40 percent of all short-stay CLC  residents experienced moderate to severe pain. In June 2007, OMI  investigated allegations about the quality of care for a resident at one  CLC and found, among other things, that the CLC had failed to  adequately manage the resident’s pain. Three months later, in September  2007, LTCI conducted a review of the same CLC and found that staff  were not performing assessments after administering pain medications to  determine whether the medication had been effective. In November 2009,  the OIG visited the same CLC as part of a Combined Assessment  Program review and found that staff had not documented pain medication  effectiveness within the required time frames nearly two-thirds of the time  that pain medications were administered. If VA had comprehensively  analyzed OMI information—which it does not analyze—along with LTCI  information that was available in 2007 and compared this information with  the information from the 2009 OIG review and quality indicator and quality  measure data, VA headquarters would have been better informed about  the significance of the risks and what actions might have helped to  mitigate the risks of pain medication management problems at this CLC.
section_title: Conclusions
paragraphs: The 46,000 elderly and disabled veterans annually who are residents in  VA’s CLCs depend on VA to provide them with quality care and maintain  their quality of life. The weaknesses in VA headquarters’ process for  resolving LTCI-identified deficiencies put veterans at risk of persistent  deficiencies that could become more serious over time. VA headquarters  officials told us that they intend to use the findings of the 2010 and 2011  LTCI reviews to determine whether deficiencies that were first identified  by LTCI 2 to 3 years earlier have been resolved. However, VA  headquarters cannot provide reasonable assurance of resolution of  deficiencies because it does not (1) clearly document the feedback that it  provides to CLCs about corrective action plans for LTCI-identified  deficiencies, (2) require VA networks to report on the status of CLCs’  implementation of action plans, and (3) verify CLCs’ self-reported  information about their implementation of the requirements of the national  training and education initiative. Unaddressed, these weaknesses in VA  headquarters’ process for responding to LTCI-identified deficiencies may  compromise the quality of care and quality of life of veterans in CLCs.
Even though VA headquarters receives information about the quality of  care and quality of life in CLCs from LTCI and a variety of other sources,  the agency does not comprehensively analyze all available information to  identify and manage risks in CLCs. Because VA headquarters does not  analyze information from all available sources, it may be missing  opportunities to detect trends and patterns in findings from different  information sources for a CLC, CLCs within a network, or all CLCs.  Without comprehensively analyzing information from all available  sources, VA headquarters cannot fully identify risks in CLCs, estimate the  significance of the risks, or take actions to mitigate them.
section_title: Recommendations for Executive Action
paragraphs: To provide reasonable assurance that LTCI-identified deficiencies are  resolved and that veterans receive quality care and maintain their quality  of life in VA CLCs, we recommend that the Secretary of Veterans Affairs  direct the Under Secretary for Health to take the following two actions:    For reviews conducted by LTCI under the current contract and any  similar future contracts, (1) clearly and completely document the  feedback provided to CLCs about their corrective action plans,   (2) require VA networks to provide periodic reports on the status of  CLCs’ implementation of their corrective action plans, and (3) develop  and implement a process for verifying any information reported  directly to VA headquarters by CLCs.    Develop and implement a process to comprehensively identify,  estimate, and mitigate risks in CLCs by analyzing and comparing all  available information regarding the quality of care and quality of life in  CLCs.
section_title: Agency Comments and Our Evaluation
paragraphs: In its comments on a draft of this report, VA concurred with our  recommendations and described the department’s planned actions to  implement them. VA did not provide technical comments on the draft  report. VA’s comments are included in appendix II.
To address our recommendation that, for reviews conducted by LTCI, VA  headquarters should document the feedback provided to CLCs about  their corrective action plans, require VA networks to report periodically on  the status of CLCs’ implementation of corrective action plans, and  implement a process for verifying information CLCs report directly to VA  headquarters, VA stated that it plans to develop and implement a national  feedback process by the end of the second quarter of fiscal year 2012 as  part of its response to results from the LTCI reviews. VA stated that the  process will include having VA networks work with VAMC leadership to  develop a comprehensive action plan to address areas of concern  highlighted in the LTCI reviews, using a standardized template for CLCs’  corrective action plans, and requiring VAMCs to post corrective action  plans on a secure database and provide updated corrective action plans  at least monthly. VA indicated that the process will provide access to the  status of action plans at any time and that officials from VA headquarters  will provide oversight to ensure completion of action plans, including  requiring VA networks to validate completion of all action items. VA,  however, did not specify in its comments whether its process would  include a step to document the feedback provided to CLCs about their  corrective actions plans. We believe it is important for VA to document  feedback provided to CLCs as part of its process  To address our recommendation that VA headquarters develop and  implement a process to comprehensively identify, estimate, and mitigate  risks in CLCs by analyzing and comparing all available information  regarding quality of care and quality of life, VA stated that it plans to  design a process that will use all available information about the quality of  care and quality of life in CLCs. VA indicated that this process would  allow officials to analyze and compare information for individual CLCs, for  CLCs within a VA network, and across all CLCs nationwide. VA intends to  design this process during the first quarter of fiscal year 2012 and plans  to use the process to analyze and compare CLC information and begin  reporting it during the second quarter of fiscal year 2012. We commend  this effort and encourage VA to proceed with these plans.
As agreed with your office, 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 to the Secretary of Veterans  Affairs, appropriate congressional committees, and other interested  parties. In addition, the report will be available at no charge on the GAO  website at http://www.gao.gov.
If you or your staff have any questions about this report, please contact  me at (202) 512-7114 or williamsonr@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs are on the last page  of this report. GAO staff who made major contributions to this report are  listed in appendix III.
section_title: Appendix I: VA Headquarters’ Analysis of Information about the Quality of Life and Care in Community Living Centers
subsections: section_title: Frequency of analysis
paragraphs: Description of VA headquarters analysis  Identify the most frequently cited deficiencies nationally.  Identify the total number of deficiencies per community living center  (CLC).    Classify deficiencies identified in each CLC into 1 of 17 different  groups (e.g., activities, environment, infection control, medication,  etc.). Use these groups to track trends in deficiencies by VA network  and by CLC.    Determine whether each CLC was substantially compliant with federal  long-term care standards.  Identify most frequently cited findings for two areas:  1.  Direct impact: includes findings that are likely to present an  2. immediate risk to residents’ safety or quality of care; for example,  resident assessment and pain management.  Indirect impact: includes findings that pose less immediate risk to  residents’ safety or quality of life, but could become more serious  over time; for example, care planning and ensuring that corridors,  hallways, and doors remain free from obstructions that would  prevent exit in the event of a fire.    Calculate average number of findings per CLC.    Calculate average performance on 30 measures and indicators, by VA  network and nationally; for example, percentage of long-stay residents  who have experienced moderate to severe pain.    Calculate average scores, by VA network and nationally, for areas  such as care practices (e.g., allowing residents to choose when they  eat, bathe, and sleep) and leadership (e.g., holding regular community  meetings that encourage the participation of staff, residents, and  families).
section_title: Appendix II: Comments from the Department of Veterans Affairs
section_title: Appendix III: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Mary Ann Curran, Assistant  Director; Stella Chiang; Julie Flowers; Alison Goetsch; Aaron Holling;  Alexis MacDonald; Elizabeth Morrison; and Lisa Motley were major  contributors to this report.
section_title: Related GAO Products
paragraphs: VA Long-Term Care: Trends and Planning Challenges in Providing  Nursing Home Care to Veterans. GAO-06-333T. Washington, D.C.:  January 9, 2006.
VA Long-Term Care: Oversight of Nursing Home Program Impeded by  Data Gaps. GAO-05-65. Washington, D.C.: November 10, 2004.