VA provides or pays for nursing home care through three separate programs, one for each of the nursing home settings in which VA provides or pays for care. In general, the three settings provide similar nursing home care, in which veterans receive skilled nursing care, recreational activities, and other services. However, some of the nursing homes may provide care to veterans on a short-term basis, such as rehabilitation after a hospitalization for a period of 90 days or less (“short stay”), or on a long-term basis, which is a period of 91 days or more (“long stay”). Further, officials told us that some of these homes may also provide certain special needs care for a limited number of residents, such as dementia or rehabilitative care, which may require additional specialized equipment or trained staff. Federal oversight of care provided to veterans within the three settings is conducted by VA only or a combination of VA and CMS. See table 1 for key characteristics on the three nursing home settings. Depending on a veteran’s eligibility status, VA pays the full or partial cost of nursing home care in each setting. For example, VA is required by law to provide the full cost of nursing home care for veterans who need nursing home care for a service-connected disability—which is an injury or disease that was incurred or aggravated while on active duty—and for veterans with service-connected disabilities rated at 70 percent or more. For all other veterans, VA provided nursing home care is based on available resources. Veterans and their families are responsible for making decisions about nursing home care that will best meet their needs. At the national level, VA provides information about nursing homes on its Access to Care website; according to VA, the website is intended to help inform veterans and their families’ about the quality of care in nursing homes. According to VA central office officials, the responsibility for helping veterans make decisions about nursing home care is decentralized to local VAMCs. In consultation with veterans and their families, VAMC social workers and clinical care providers can discuss factors such as the veteran’s eligibility for care in each setting, health needs, the type of care provided at different homes, space availability, and the veteran’s geographic preference. VAMC staff may also encourage veterans to take a tour of the prospective home. VA models its oversight of nursing home services provided to veterans on the methods used by CMS. CMS defines the quality standards that approximately 15,600 nursing homes nationwide must meet in order to participate in the Medicare and Medicaid programs. To monitor compliance with these standards, CMS contracts with state survey agencies to conduct inspections of each home not less than once every 15 months. During these inspections the state survey agency might identify deficiencies—or instances in which the nursing home does not meet an applicable quality standard. To address identified deficiencies, CMS generally requires nursing homes to implement corrective action plans. CMS also monitors—by conducting observational assessments of state agencies during inspections or conducting its own comparison inspections on a sample of homes each year—the state agencies that inspect CNHs to ensure that these inspections accurately identify whether the homes meet quality standards. In addition, CMS collects data on various clinical quality measures and calculates nursing home staffing ratios. CMS assigns each nursing home ratings in three components— inspections, quality measures, and staffing ratios—and an overall quality rating. CMS places the greatest weight on inspections in its calculations of each home’s overall quality rating. CMS publicly reports a summary of the information it collects on the quality of nursing homes on its Nursing Home Compare website, which uses a five-star quality rating system. As we previously reported, this website facilitates public comparison of nursing home quality. Within VA central office, the Office of Geriatrics and Extended Care is responsible for overseeing the quality of nursing home care provided to veterans in each of the three settings—CLCs, SVHs, and CNHs. The key mechanism VA uses to assess quality in each of these settings is regular inspections—generally occurring annually—that determine the extent to which homes meet relevant quality standards. VA’s use of inspections and other methods to ensure the quality of care in each of the three nursing home settings differs: CLCs. VA owns, operates, and oversees the quality of CLCs, and conducts regular unannounced inspections to determine the extent to which CLCs meet quality standards. VA central office contracts with the Long Term Care Institute to conduct these inspections, and VA central office reviews the results of all inspections. CLCs receive an initial inspection when they open and then periodic, unannounced inspections thereafter. The frequency of these inspections depends on the number and severity of deficiencies identified during the prior year’s inspection, but they generally occur every 11 to 13 months. CLCs are required to develop and implement corrective action plans for each deficiency identified that detail how it will be addressed. VA central office approves these plans, and the VISN and VA central office monitor the CLC’s actions until each deficiency is addressed. Per VA’s contract, VA monitors the Long Term Care Institute to ensure that inspections are conducted within required timeframes and to conduct quarterly assessments of the contractor’s performance, among other things. In addition, for each CLC, VA also collects information on quality measures and staffing ratios and uses this information, along with the inspection results, to assign a star rating from 1 to 5 stars. In June 2018, VA central office consolidated the ratings for all of the individual CLCs—modeled after CMS’s Nursing Home Compare—into its Access to Care website. SVHs. States own and operate SVHs and, as a result, in most cases SVHs are inspected by state agencies to determine the extent of their compliance with state requirements. About two-thirds of SVHs are inspected by CMS; however, VA is the only entity that conducts annual inspections for all SVHs. Although, VA does not exercise any supervision or control over the administration, personnel, maintenance, or operation of any state home, VA conducts these annual reviews for all SVHs and is prohibited from making payments to SVHs until it determines that they meet applicable quality standards. VA central office contracts with Ascellon to conduct these inspections and reviews the results of the inspections. The inspections first occur when an SVH initially seeks to become eligible for VA payments, and, once the SVH is eligible, unannounced inspections occur on an annual basis to verify that an SVH is eligible to continue to receive VA payments. For these annual inspections, the contractor generally cites deficiencies when SVHs are not in compliance with applicable quality standards. SVHs develop and implement corrective action plans for each deficiency identified, and the VAMC director approves the plan. VA should monitor the contractor’s performance annually, for example, to ensure that inspections are conducted within certain timeframes. VA’s Office of Geriatrics and Extended Care maintains a database of all corrective action plans, and VISN and VAMC staff monitor the SVHs’ actions until each deficiency is addressed. VA also collects VA prescribed quality measure and staffing data from SVHs as part of its survey process. However, VA does not currently assign a quality rating to SVHs. CNHs. CNHs can be publicly or privately owned and operated, and, CMS provides federal oversight for all CNHs that receive Medicare or Medicaid payments. VA requires CNHs under contract to be certified by CMS, and, unlike the other two settings, VA is not required to conduct regular inspections of CNHs. Instead, VA requires VAMC staff to conduct veteran care assessments on a monthly basis and annually review information CMS collects on the homes’ quality, including CMS inspection results, to evaluate whether to initiate or continue a contract with a CNH. The annual reviews use seven criteria established by VA’s Office of Geriatrics and Extended Care, including whether the CNH’s total number of health deficiencies from the most recent CMS inspection is twice the average of the state in which it is located. According to VA officials, CNHs that fail to meet four out of VA’s seven criteria during the annual reviews of CMS data are excluded from participation in its CNH program unless the VAMC seeks a waiver from VA central office to allow the home to participate. If VAMC staff are considering seeking a waiver to allow a CNH to continue participating in the CNH program, or have any other concerns about a home, they have the option of conducting their own onsite reviews of the home to assess care quality. Our analysis of VA data shows that veterans’ utilization of VA nursing home care—across CLCs, SVHs, and CNHs—increased 3 percent from fiscal year 2012 through 2017, from an average daily census of 37,687 to 38,880 veterans. VA projects that nursing home utilization will increase another 16 percent, to an average of 45,279 per day by fiscal year 2022, with varying increases projected for each of the nursing home settings. (See fig. 1.) Moreover, VA projects that overall demand for VA nursing home care will continue to increase through 2034, driven by the aging of the cohort of Vietnam War veterans. VA projects that Vietnam veterans will increasingly rely on VA’s health care system for care and will use more health care services, including nursing home care. As figure 1 shows, SVHs accounted for the largest percentage (53 percent) of the average number of veterans who received nursing home care each day in fiscal year 2017. However, the number of veterans in CNHs has increased and is projected to continue to increase. For example, the average number of veterans receiving nursing home care in CNHs increased 35 percent from fiscal year 2012 to 2017, from an average of 6,875 to 9,251 per day. Over the same period, the number of veterans in CLCs fell 9 percent, and in SVHs it fell 1 percent. VA officials told us that they are prioritizing the use of CLCs for short-term care, and that CNHs have the greatest capacity to meet the future long-term needs of veterans. VA projects that by 2034 the number of veterans receiving nursing care in these homes will exceed 17,000. In addition, VA projects that demand for nursing home care in CLCs and CNHs will decrease after 2034, and VA has not projected care in SVHs beyond 2022. VA officials also said that VA has limited flexibility to expand the number of beds in CLCs and SVHs to accommodate the projected number of veterans needing care. While VA expects to continue placing more of the veterans needing nursing home care into CNHs, officials noted some challenges contracting with these homes. Specifically, VA central office officials said that about 600 CNHs had decided to end their contracts with VA over the last few years for a variety of reasons. For example, officials from four of the VAMCs we interviewed told us about CNH concerns that contract approvals can take 2 years, homes have difficulties meeting VA staff requirements, and VA’s payment rates were very low. Officials said provisions in the VA MISSION Act of 2018 may alleviate some of these difficulties. Specifically, the Act consolidates various VA community care programs into the Veterans Community Care Program and authorizes VA to enter into veterans care agreements with certain providers, including nursing homes. In contrast to contracts, such agreements may not require providers to meet certain wage and benefit requirements. Officials told us that they are in the process of replacing CNH contracts with veterans care agreements, which may alleviate some of those challenges. In addition, VA officials told us that most nursing homes—including homes in each of the three settings—have limited capacity to serve veterans with special needs, such as those needing dementia, ventilator, or behavioral care. For example, they said that homes may not have any of the necessary specialized equipment or trained staff, or may not have as many of these beds as needed, to meet certain veterans’ special care needs. VA officials told us that they are working to expand the availability of special needs care in each of the three settings. Our analysis of VA data also shows that VA nursing home care expenditures have increased in recent years, reflecting increases in the number of veterans receiving such care. Specifically, VA’s nursing home expenditures across all three settings increased 17 percent from fiscal years 2012 through 2017, from $4.9 billion to $5.7 billion. These expenditures are expected to increase to $7.3 billion in fiscal year 2022 as utilization is projected to increase. VA officials told us that expenditures for nursing home care are projected to increase due to the rising costs of care as well as higher utilization of services. (See fig. 2.) Of the three settings, CLCs accounted for the largest share of VA nursing home expenditures; however, this reflects differences in the costs of care and the extent to which VA pays for these costs in each of these settings: For CLCs, VA pays the full cost of care for veterans in these homes and, according to VA officials, VA expenditures for care provided in CLCs are greater compared to the other settings, because CLCs are able to provide acute care that requires higher staffing levels and more specialized equipment. In addition, VA officials indicated that CLC expenditures also include the overhead costs of being associated with VAMC hospitals. For SVHs, 80 percent of veterans receive VA’s partial daily rate that covers only about a quarter of their care costs. For example, in fiscal year 2017, VA’s average SVH per diem was $106 for veterans without eligible service connected disabilities. VA also pays the full cost of care for the remaining 20 percent of veterans with service-connected disabilities. In fiscal year 2017, the full rate for these veterans was $397 per day. For CNHs, VA pays the full cost of care for veterans; however, more of these veterans receive long-term care, at a lower cost per day, than the short-term care that many veterans receive in CLCs, such as for rehabilitation after surgery, at a higher cost per day. As a result of these differences, in fiscal year 2017, VA paid, on average, $1,074 per day per veteran for care in CLCs, $268 for CNHs, and $166 for SVHs. During the contract year completed in 2018, VA’s two contractors conducted the required annual inspections of CLCs and SVHs to determine the extent to which the homes met quality standards. However, VA has opportunities to enhance its oversight of the contractors’ inspections by regularly monitoring both contractors’ performance inspecting CLCs and SVHs through observational assessments and by citing all SVH deficiencies. Although VA’s plans call for quarterly observational assessments, they have not been consistently conducted and documented. Similarly, VA has not provided guidance for the optional onsite reviews of CNHs that VAMCs may perform thus limiting their potential impact. Our review found that during the contract year completed in 2018, VA’s CLC contractor performed the required annual inspections for 126 CLCs. (See table 2.) Through these inspections, VA’s contractor determined the extent to which each CLC met applicable quality standards and issued deficiencies when standards were not met. The most common areas of deficiencies were those in which 1) the facility did not provide quality care for its residents, for example, in its treatment and prevention of pressure ulcers or managing its residents’ pain; 2) the facility did not adequately prevent and control infections, for example, by providing residents influenza and pneumococcal immunizations; and 3) the facility did not provide adequate care and services to sustain the highest possible quality of life for its residents, for example, by providing residents unable to carry out activities of daily living with adequate assistance to maintain good nutrition, grooming, and personal and oral hygiene. (See appendix I for more information on the types of deficiencies identified.) To address deficiencies, VA required CLCs to produce corrective action plans and tracked the CLCs’ progress until the deficiencies were resolved. In addition, for some of the most common deficiencies among CLCs, VA officials said VA took steps such as developing additional VAMC policies to facilitate improvement. For example, to reduce the number of CLC deficiencies related to pain management and improve CLCs’ performance in this area, VA officials said they developed specific guidelines for CLCs to use to assess pain in patients with dementia who were unable to provide numeric pain scores. While VA has monitored and determined that CLC inspections occurred as stipulated in its contract and tracked the results of the inspections, it has an opportunity to enhance its oversight. According to its contract, VA will monitor contractor performance on a quarterly basis, and VA central office officials told us their intention has been to meet this stipulation by observing the contractor as it conducts some inspections—an approach consistent with CMS’s inspection oversight process. However, VA officials told us that they have not been completing these observations quarterly and did not conduct any observations for the April 2017 to April 2018 contract year. VA officials said they had not performed this quarterly observation due to competing demands. For example, the three- person team at VA central office responsible for CLC oversight has overseen a number of recent initiatives, including the rollout of CLC quality ratings in 2018. Officials also told us they conducted one observation for the current contract year in December 2018 (during the course of our review). However, we were not able to confirm the December 2018 observation or any other observations of the CLC inspections because VA has not documented the results. A VA official said that developing an approach for documenting the quarterly observations is something VA needs to work on. VA’s failure to monitor the CLC contractor’s performance through observational assessments is inconsistent with its own goals of assessing the contractor’s performance quarterly and modeling its oversight after CMS’s approach to its own contractors’ inspections. It is also inconsistent with federal internal control standards that state that management should establish and operate monitoring activities to monitor the internal control system and evaluate the results. By not conducting these quarterly observations for more than a year, VA does not know whether, or to what extent, the contractor is effectively assessing CLC compliance with quality standards and is unable to hold the contractor accountable for its inspections. Without effective monitoring of the contractor’s performance inspecting CLCs, VA risks that quality concerns in some CLCs could go overlooked, placing veterans at risk. Our review found that during the contract year completed in 2018, VA’s SVH contractor performed required annual inspections for all 148 SVHs. (See table 3.) As with CLCs, VA’s SVH contractor determined through these inspections the extent to which each SVH met applicable quality standards and cited deficiencies when they were not met. The most common areas of deficiencies were those in which 1) the facility’s physical environment did not adequately protect the health and safety of its residents, for example, by ensuring their safety from fires; 2) the facility did not provide quality care for its residents, for example, by adequately managing their pain; and 3) the facility did not assess residents’ health sufficiently, for example, within 14 days of residents’ admission and on an annual basis thereafter. (See appendix II for more information on the types of deficiencies identified.) To address deficiencies, VA required SVHs to produce corrective action plans and tracked the SVH’s progress until they were resolved. In addition, VA officials said they took steps to address deficiencies common among SVHs. For example, to reduce SVH deficiencies related to physical environment standards for fire safety and improve SVH performance in this area, VA central office staff told us they held SVH town halls with a fire safety engineer and created reference guides for SVH administrators about regulatory changes in fire safety codes. However, while VA has monitored that its contractor conducted the required SVH inspections and tracked the results of these inspections, VA has not monitored the SVH contractor’s performance of these inspections through regular observational assessments to ensure that contractor staff effectively determine whether SVHs are meeting required standards. Specifically, VA officials told us they intended to observe the SVH contractor’s inspections on a quarterly basis, which would be consistent with VA’s approach to CLCs and its goal of modeling its oversight on CMS’s. VA officials told us that although they have a goal of performing this monitoring on a quarterly basis; they could not recall when VA last observed the SVH contractor’s inspections. When asked, VA officials did not provide specific reasons why they had not performed the observational assessments; in prior discussions, these officials noted that VA’s oversight of SVHs is less involved than its oversight of CLCs because VA does not exercise any supervision or control over the administration, personnel, maintenance, or operation of any state home. However, VA pays for veterans to receive care in SVHs, and states that oversee these homes may or may not conduct their own oversight. Furthermore, as CMS conducts oversight of only those SVHs that receive Medicare or Medicaid payments (about two-thirds of all SVHs), for some SVHs, VA is the only federal agency with oversight over the quality of those homes care. For example, VA is the only entity that conducts regular inspections of SVHs in Missouri and New Hampshire. VA is missing another opportunity to enhance its oversight of SVHs by not requiring the SVH contractor to identify all failures to meet quality standards as deficiencies during its inspections. While CMS requires its inspectors to cite all deficiencies, VA directed its contractor to cite low- level deficiencies—deficiencies considered by the contractor to pose no actual harm but with potential for minimal harm—as “recommendations” rather than deficiencies. For example, during one SVH inspection, the contractor recommended that “to ensure nutritional adequacy, the facility should follow the menus, which are planned in advance.” VA officials told us that unlike deficiencies, they do not track or monitor the nature of the recommendations or whether the recommendations have been implemented. In contrast, state survey agencies under contract with CMS are required to cite all failures to meet quality standards as deficiencies. In addition to not citing recommendations as deficiencies, according to the VA contractor’s 2016-2017 annual summary report, SVHs can fix issues identified by the SVH contractor while the inspectors are still onsite to avoid being cited on the inspection. As a result, these issues are also not documented as deficiencies. Officials at four of the six SVHs we interviewed specifically reported being able to make on-site corrections to avoid being cited for deficiencies—for instance, officials at one SVH told us that the SVH was able to relocate handwashing stations before the end of the inspection in order to avoid being cited for a deficiency by the VA inspectors. According to VA, VA does not require its SVH contractor to identify all failures to meet quality standards as deficiencies in its inspections, VA officials said this practice reflects policy and a negotiated position with SVHs. VA officials reiterated that because SVHs are owned and operated by the states, VA is less involved with their oversight than CLCs. Our review of the VA contractor’s annual summary report showed that almost 50 percent of SVHs inspected between August 2017 and July 2018 (the contract year completed in 2018), zero deficiencies were identified through inspections. VA officials cited VA’s ‘collegial approach’ and willingness to make onsite corrections as factors contributing to the decline in recent years. Furthermore, while VA and CMS subject SVHs to slightly different standards, our review of VA and CMS inspection reports from a sample of five SVH inspection reports shows that VA identified a total of seven deficiencies and made four recommendations from these homes. In contrast, CMS identified a total of 33 deficiencies for these homes for approximately the same time period. By not performing observational assessments of SVH inspections, VA does not know whether, or to what extent, VA’s contractor needs to improve its ability to identify SVHs’ compliance with quality standards, which increases the possibility that quality concerns in some SVHs could go overlooked, potentially placing veterans at risk. Further, by not requiring the contractor to cite all failures to meet quality standards as deficiencies on its inspections, VA does not have complete information on deficiencies identified at SVHs and therefore cannot track this information to help identify trends in quality across these homes. Further, it is inconsistent with federal internal control standards that state that management should establish and operate monitoring activities to monitor the internal control system and evaluate the results. We found that in 2017 the six selected VAMCs annually reviewed CMS data on the quality of all the CNHs with which they contract, which is a VA requirement. Specifically, the VAMCs reviewed the CMS data to determine whether the CNHs met VA criteria for contract renewal. (See table 4.) The top three criteria from the annual reviews that VAMCs failed to meet were 1) whether total registered nursing staff ratios per resident day fell below the state average, 2) whether total nursing staff ratios per resident day fell below the state average; and 3) whether six or more of selected CMS quality measures fell above the state average. In addition, we found that all six of our selected VAMCs conducted their own onsite CNH reviews—which, according to VA policy, VAMC officials have the option of performing if they have quality concerns about CNHs with which they contract or are determining whether to seek a waiver. The CNH onsite reviews conducted by these VAMCs focused on many of the categories for quality standards, such as food and nutrition services, quality of care, quality of life, and physical environment. While conducting onsite reviews of CNHs is optional under VA policy, officials at many of the VAMCs we interviewed told us that these onsite reviews—which the VAMCs we interviewed referred to as CNH inspections—are valuable in conducting CNH oversight as they provide important information about a home’s quality that VAMC staff would not have known otherwise. For example, officials from one VAMC shared with us results from an onsite review in which they found moldy and expired food in a CNH’s kitchen— food storage had been identified as an issue during a previous state survey for CMS and was purported to have been corrected 5 months prior. Furthermore, some VAMC staff said that they would suspend placement of veterans in certain CNHs and may not renew a CNH contract based on their findings from these onsite reviews. However, VA could strengthen its support for the optional onsite reviews by providing guidance to VAMC staff conducting these reviews. Officials at some VAMCs expressed concerns that VA did not provide the guidance they needed to conduct the optional onsite reviews, and that they would like to have more information from VA’s central office. As one VAMC official said, “without training or guidance from VA , it is difficult for VAMC staff, especially new staff, to know how to conduct these inspections.” VAMC officials at the six selected VAMCs told us that in the absence of guidance from VA, they had each independently developed their own tools and processes. Furthermore, officials at these VAMCs had differing understandings of the steps they can take if they identify quality concerns during onsite reviews. For example, staff at some VAMCs required CNHs to write corrective action plans and monitored the CNHs’ implementation until the deficiencies were addressed; in contrast, staff at other VAMCs did not monitor implementation, because they did not think they had the authority to hold CNHs accountable to correct deficiencies they identified. VA central office officials who oversee the CNH program told us that they do not provide training or guidance because CMS and the states, not VA, are responsible for regulating the quality of care in these nursing homes. However, in the absence of guidance from VA central office on the optional CNH onsite reviews—guidance that could be developed, for example, by collecting and disseminating best practices—VA has missed an opportunity to leverage efficiencies across VA’s network of VAMCs and empower VAMC officials with knowledge about the steps they can take to hold CNHs accountable for correcting problems. Furthermore, it is inconsistent with federal internal control standards that state that management should design control activities to achieve its objectives—in this case, to ensure that VAMCs contract with CNHs that provide high quality care. As part of its efforts to help veterans find placement into a nursing home, VA publicly provides information on care quality for CLCs and CNHs through its Access to Care website, but VA does not provide information on the quality of SVHs. Specifically, the website allows users to enter a location—such as a city and a surrounding distance—to produce a map with a list of CLCs and VA-contracted CNHs in their preferred area (see fig. 3). For each of the homes on the list, VA reports quality information it collects through its own inspections for CLCs and information CMS collects for CNHs. As previously noted, veterans and their families are responsible for making decisions about the nursing home care that will best meet their needs. Their decision-making can be aided by discussions with VAMC staff and information provided on VA’s Access to Care website, among other sources. The ability for veterans and their families to access information on nursing home quality through the Access to Care website—such as the currently available quality information on CLCs and CNHs—is particularly critical as VAMC officials do not always discuss quality information in their consultations with veterans and their families. As figure 3 shows, VA’s Access to Care website does not provide any information to the public about the quality of the 148 SVHs that provide nursing home care. Specifically, VA does not currently provide any information on SVHs on its Access to Care website—including information on the location of SVHs or CMS information on care quality that VA could easily provide on SVHs using information obtained from CMS’s website, Nursing Home Compare, as VA does now for CNHs. VA has explored activities that could provide veterans and their families with information about SVHs. For example, as stated in VA’s SVH strategic plan for fiscal years 2017 to 2022, VA considered an initiative to create a five-star program for SVHs. Additionally, VA has collaborated with SVHs to produce some data on quality measures. For example, during the course of this review, VA provided to us a quality measures report for SVHs by state that they developed in partnership with the National Association of State Veterans Homes. VA is able to develop this information because it has access to information on SVH quality—in fact, as the only entity that conducts regular inspections, it is the only source for quality information on all SVHs. Specifically, VA collects VA prescribed inspection, quality measure, and staffing data as part of its survey process that could be used to develop and distribute quality information for each home. Some of this information is available to the public at the local level, but it is not currently provided by VA. For example, SVHs are required to make the results of the most recent VA inspection of the home available for examination in a place accessible to residents. According to VA officials, there is no requirement to provide information on SVH quality on the Access to Care website, as SVHs are owned and operated by the states. However, the website is an important tool for veterans and their families to help inform their decision making on nursing home placement. VA has stated goals to provide useful and understandable information to veterans. The VA website could be the only readily accessible source of quality care information publicly available to veterans and their families for certain SVHs. As the SVH strategic plan indicates, VA sees the value in developing SVH ratings that could be used to provide quality information to veterans and their families. Furthermore, officials from three of the SVHs we spoke with told us that they supported having quality information available about their homes that would allow comparisons between SVHs or between SVHs and other homes, such as information contained in Nursing Home Compare. Without information about SVHs on VA’s Access to Care website, veterans and their families are limited in their ability to effectively evaluate all of their options when selecting a nursing home. Our prior work has shown that effective transparency tools—such as websites that allow consumers to compare the quality of different providers—provide highly relevant information to consumers. However, the limited information VA provides on its Access to Care website is inconsistent with VA’s articulated commitment to veteran-centric care, a component of which is ensuring that veterans are well informed about their options for care. The website’s limited information is also inconsistent with federal internal control standards, which state that management should externally communicate the necessary quality information to achieve an entity’s objective—in this case, providing important information to veterans on the quality of nursing homes. Action to inform veterans about the quality of SVHs would better enable veterans and their families to compare the quality of their nursing home care options across all three settings. In the coming years, VA projects an increase in the number of veterans receiving nursing home care. This makes it particularly important that VA ensure veterans receive quality care, regardless of the setting—CLC, SVH, or CNH—in which this care is provided. Inspections are a key oversight tool used to ensure veterans receive quality care. VA relies primarily on annual inspections to oversee the quality of nursing home care at CLCs and SVHs, and our review shows that VA’s two contractors conducted these required inspections during the period we reviewed. However, our review also shows that VA has opportunities to enhance this oversight. First, VA has not regularly monitored the contractors’ performance conducting these inspections by conducting observational assessments as intended and therefore does not know whether the contractors need to improve their ability to determine the homes’ compliance with quality standards. Second, VA does not require inspectors of SVHs to identify all failures to meet quality standards as deficiencies, which limits VA’s ability to track all deficiencies identified at SVHs and identify trends in quality across homes. Third, VA has not provided guidance for VAMC staff for instances in which they may conduct onsite reviews of CNHs directly. As a result, VA has missed an opportunity to leverage efficiencies across VA’s network of VAMCs and empower VAMC officials with knowledge about the steps they can take to hold CNHs accountable for correcting problems. By making enhancements to its oversight of inspections across all three settings, VA would have greater assurance that the inspections are effective in ensuring the quality of care within each setting. VA also seeks to ensure that each veteran chooses a nursing home placement that best meets his or her preferences and needs. To enable veterans to evaluate their care options, VA uses its Access to Care website. However, this website provides no information about SVHs, which is where most veterans are currently receiving VA-funded nursing home care. Since VA is the only entity that inspects and collects quality information on all SVHs, VA possesses quality information that is not available elsewhere. However, because VA’s website lacks information on the quality of SVHs, veterans and their families are limited in their ability to compare the quality of the available nursing home care options. We are making the following four recommendations to the Veterans Health Administration: The Under Secretary of Health should develop a strategy to regularly monitor the contractors’ performance in conducting CLC and SVH inspections, ensure performance results are documented and any needed corrective actions are taken. (Recommendation 1) The Under Secretary of Health should require that all failures to meet quality standards are cited as deficiencies on SVH inspections. (Recommendation 2) The Under Secretary of Health should develop guidance for VAMC staff conducting optional onsite CNH reviews. (Recommendation 3) The Under Secretary of Health should provide information on the quality of all SVHs that is comparable to the information provided on the other nursing home settings on its Access to Care website. (Recommendation 4) VA provided written comments on a draft of this report, which are reprinted in appendix III. In its written comments, VA generally concurred with all four recommendations. With respect to our recommendation on regularly monitoring contractor performance in conducting CLC and SVH inspections, VA concurred and stated they would develop a procedure for observational inspections. VA also concurred with our recommendation requiring all failures to meet quality standards to be cited as deficiencies on SVH inspections and that “any regulation assessed to be incompliant at the time of the survey will be rated as either provisional or not met, which requires a corrective action plan from the SVH.” VA concurred in principle with our other two recommendations and described actions it plans to take to address them. Specifically, regarding our recommendation to develop guidance for VAMC staff conducting optional CNH onsite reviews, VA stated that it will issue a memo to clarify and provide guidance related to CNHs. VA also noted that, although we found the VAMC staff we interviewed discussed and considered these onsite reviews “inspections,” VA does not. Based on these technical comments, we adjusted our terminology. Further, we reiterate the value that VAMC officials placed on these reviews for assessing the quality of care veterans receive in the report. Accordingly, we believe that VA has the opportunity when developing the memo to clarify and provide guidance related to these optional CNH onsite reviews. With respect to our recommendation that VA provide information on the quality of all SVHs that is comparable to the information provided on the other nursing home settings, VA stated it plans to evaluate the feasibility of providing SVH data. VA noted challenges with developing their own five star ratings for SVHs since VA does not have all the required data for SVHs that is needed. We acknowledge that developing comparable information will take time and have adjusted some language in our report to reflect that VA had considered developing an SVH five-star program. VA also stated that we inaccurately portrayed VA’s oversight authority, because each state oversees its own SVH and VA does not have the authority to regulate the business or clinical practices of the SVH. Both our draft and final reports stated that “VA does not exercise supervision or control over the administration, personnel, maintenance, or operation of any state home.” However, as stated in the report, federal law prohibits payments to SVHs that do not meet standards the VA prescribes and authorizes VA to inspect any SVH at such times as VA deems necessary to ensure that such facility meets those standards. Further, we reiterate that as VA is the only entity to conduct inspections for all SVHs—it uniquely possesses information that is not available elsewhere. Accordingly, we believe that VA has the opportunity to help veterans and their families by providing quality information for SVHs as it does for the other nursing home settings. As agreed with your offices, unless you publicly announce the contents of this report earlier, we plan no further distribution until 30 days from the report date. At that time, we will send copies of this report to the appropriate congressional committees, the Secretary of the Department of Veterans Affairs, and other interested parties. In addition, the report will be available at no charge on GAO’s website at http://www.gao.gov. If you or your staffs have any questions about this report, please contact me at (202) 512-7114 or silass@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made key contributions to this report are listed in appendix IV. Number of deficiencies (percent) 1 (0) Admission, Transfer, and Discharge Rights 0 (0) 1 (0) 19 (3) 87 (15) 1 (0) 14 (2) 3 (1) 1 (0) 279 (48) 67 (12) 51 (9) Number of deficiencies (percent) 6 (3) 4 (2) 0 (0) 2 (1) 93 (48) 1 (1) 36 (19) 4 (2) 33 (17) Resident Behavior and Facility Practices 10 (5) 3 (2) 0 (0) 192 The total number of deficiencies may include deficiencies from one SVH that VA does not consider a skilled nursing facility. In addition to the contact named above, Karin Wallestad (Assistant Director), Jim Melton (Analyst-in-Charge), Kye Briesath, Krister Friday, and Mandy Pusey made key contributions to this report. Also contributing were Vikki Porter and Jennifer Whitworth.

Summary: VA provides nursing home care for veterans whose health needs are extensive enough to require skilled nursing and personal care in an institutional setting. VA provides or pays for the cost of nursing home care for eligible veterans. GAO was asked to examine VA nursing home care. In this report, GAO 1) describes utilization of and expenditures for VA-funded nursing home care, 2) examines VA's use of inspections to assess the quality of nursing home care and its oversight of the process, and 3) examines the information VA publicly provides through its website on the quality of nursing home care. To perform this work, GAO reviewed VA policies and information on inspections and interviewed VA officials. GAO also selected six VA medical centers based on factors such as their participation with CLCs, SVHs, and CNHs and location. For each, GAO interviewed medical center officials and officials from corresponding VA regional offices, CLCs, SVHs, and CNHs. According to the Department of Veterans Affairs (VA), veterans' use of nursing home care increased 3 percent, from an average daily census of 37,687 to 38,880 veterans, from fiscal years 2012 to 2017. VA projects that use will increase 16 percent from fiscal years 2017 to 2022 with the aging of Vietnam War veterans. VA's nursing home expenditures increased 17 percent (8 percent adjusted for inflation), from $4.9 billion to $5.7 billion, from fiscal years 2012 to 2017. During the contract year completed in 2018, VA contractors conducted required inspections of community living centers (CLC) (VA-owned and -operated) and state veterans homes (SVH) (state-owned and -operated) to ensure they complied with quality standards. Selected VA medical centers also completed required annual reviews of Centers for Medicare & Medicaid Services data and conducted optional onsite reviews for community nursing homes (CNH), with which VA contracts. However, VA has opportunities to enhance its oversight. For example, VA did not conduct the quarterly monitoring of contractor performance as stipulated in its contract for CLC inspections from April 2017 to April 2018. VA officials also said they intended to regularly observe contractors conducting inspections to ensure they effectively determine compliance with standards, but have not done so due to competing demands. Officials also said they had performed these observational assessments in the past but were unable to provide documentation of them occurring. Conducting and documenting the quarterly observational assessments would allow VA to identify areas for improvements and to take any needed corrective actions. VA's Access to Care website provides publicly available information about the quality of CLCs and CNHs based on inspections. Veterans and their families can use the website to help inform their decisions on nursing home placement. However, the website does not include any SVH information. Although VA has access to SVH quality information, according to VA officials, they are not required to publicly report it. For some SVHs, VA is the only source for quality care information. Some of the quality information is available locally, but the VA website is an important tool for veterans and their families. Providing SVH information on its website could enhance veterans and their families' ability to evaluate all nursing home options. GAO is making four recommendations, including recommendations for VA to enhance its oversight of the quality of care provided to veterans in CLCs, SVHs, and CNHs and include on its website information on the quality of care for SVHs that is comparable to what it provides on CLCs and CNHs. VA concurred with two recommendations and concurred in principle with two recommendations.