GAO United States Government Accountability Office Report to Congressional Addressees November 2022 VA NURSING HOME CARE Opportunities Exist to Enhance Oversight of State Veterans Homes GAO-23-105167 GAO Highlights Highlights of GAO-23-105167, a report to congressional addressees Why GAO Did This Study Many aging veterans rely on nursing home care to meet their daily needs. In fiscal year 2021, VA paid about $1.5 billion for veteran nursing home care provided in state veterans homes. GAO was asked to provide information on VA's oversight of state veterans homes, and the joint explanatory statement accompanying the Consolidated Appropriations Act, 2021, contained a provision for GAO to review the relationship between VA and these homes. This report (1) describes the oversight of state veterans homes to ensure compliance with quality standards; (2) examines available data about deficiencies cited during inspections; and (3) examines how VA could enhance its oversight of state veterans homes. GAO conducted a nationwide survey to collect information on the 153 state veterans homes providing nursing home care. GAO analyzed data from VA's annual inspections for 2019 and 2021. (Data were not available for 2020 because inspections were suspended due to the COVID-19 pandemic.) GAO also reviewed relevant statutes, regulations, and VA documents, and interviewed federal and state officials and organizations involved with veteran care. What GAO Recommends GAO is making four recommendations to VA, including that it identify additional enforcement tools to ensure state veterans home compliance with quality standards, and seek legislative authority for them, as appropriate. VA agreed with the recommendations. View GAO-23-105167. For more information, contact Sharon M. Silas at (202) 512-7114 or silass@gao.gov. VA NURSING HOME CARE Opportunities Exist to Enhance Oversight of State Veterans Homes What GAO Found The Department of Veterans Affairs (VA) is the only federal entity that oversees all 153 state veterans homes, which provide nursing home care to roughly 14,500 veterans. While these homes are owned and operated by states, VA helps pay for care for eligible veterans and is required to ensure the homes meet VA's quality standards. To do this, VA conducts regular inspections, and homes that do not meet standards can be cited for deficiencies. The Centers for Medicare & Medicaid Services (CMS) also conducts inspections in the nearly 76 percent of state veterans homes that receive Medicare or Medicaid payments and, like VA, can cite deficiencies. In response to GAO's national survey of state agencies that operate state veterans homes, 43 states reported also inspecting homes for compliance with state-specific regulations or on a for-cause basis. GAO's analysis of VA's available annual inspection data for 2019 and 2021 found increases in both the number and the severity of deficiencies cited. For example, the total number of deficiencies increased from 424 in 2019 to 766 in 2021.A majority of the increase was in the quality of care and infection control categories, which cover accidents and staff hand hygiene. Additionally, GAO found that, for those homes with annual inspection data available in both 2019 and 2021, many were cited for deficiencies in the same standard. GAO found that VA could enhance oversight by, among other things, an expansion of the tools it has to bring these homes into compliance with quality standards. According to VA officials, compared to CMS, VA lacks a range of enforcement actions to use to bring state veterans homes into compliance (see figure). Specifically, VA's only enforcement action is to withhold payment to compel homes to come into compliance. VA considers this action too severe for most situations. VA officials said they are considering seeking legislative authority to take additional enforcement actions to ensure compliance with quality standards. Having such tools would strengthen VA's ability to better ensure that veterans receive quality care in these homes. Available Enforcement Actions for Department of Veterans Affairs and Centers for Medicare & Medicaid Services VA ENFORCEMENT ACTIONS SELECTED CMS ENFORCEMENT ACTIONS ¢ Civil monetary penalties (fines for each day or instance of noncompliance) ¢ Withhold payment for daily veteran care ¢ Denial of payment for all newly admitted eligible residents ¢ State monitoring (on-site monitor to achieve and maintain compliance) ¢ Termination from the Medicare and Medicaid programs Source: GAO analysis of VA information and 42 U.S.C. §§ 1395i-3(h), 1396r(h); 42 C.F.R. § 488.406 (2021). | GAO-23-105167 United States Government Accountability Office Contents Letter Background 4 VA, CMS, and Most States Conduct Inspections to Oversee State Veterans Homes' Compliance with Relevant Quality Standards 8 VA Data Show an Increase in Deficiencies Cited on State Veteran Home Inspections 15 VA Could Enhance Its Oversight of State Veterans Homes by Improving Data Analytic Capabilities and Expanding Enforcement Options 22 Conclusions 30 Recommendations for Executive Action 30 Agency Comments and Our Evaluation 31 Appendix | Federal Oversight of State Veterans Homes 34 Appendix II State Veterans Homes That Provide Nursing Home Care In All 50 States and Puerto Rico 37 Appendix III State Policies for State Veterans Home Oversight and Summary of These Homes in Each State 45 Appendix IV Categories of Standards Assessed during VA's Annual Inspection of State Veterans Homes 50 Appendix V How CMS Calculates a Nursing Home's Overall Star Rating 51 Appendix VI Comments from the Department of Veterans Affairs 52 Appendix VII GAO Contact and Staff Acknowledgments 55 Page i GAO-23-105167 VA Oversight of State Veterans Homes Tables Table 1: Federal State Veterans Home Oversight Methods Used by the Department of Veterans Affairs (VA) and the Centers for Medicare & Medicaid Services (CMS) 34 Table 2: States' Responses to GAO Survey Questions on Information About State Veterans Homes Providing Nursing Home Care in Each State, as of March-April 2022 37 Table 3: States' Responses to GAO Survey Questions on State Policies for State Veterans Home Oversight and Summary of State Veterans Homes in Each State 45 Table 4: Survey Responses on Enforcement Actions Available to the States for Conducting Oversight of State Veterans Homes 47 Table 5: Categories of Standards Assessed during VA's Annual Inspection of State Veterans Homes 50 Table 6: Performance of State Veterans Homes in 2021 on CMS's Star Measures for Overall Quality, Health Inspections, Staffing, and Quality Measures Compared to Other Nursing Homes in Their Respective State 51 Figures Figure 1: Federal Oversight of State Veterans Homes by the Department of Veterans Affairs (VA) and the Centers for Medicare and Medicaid Services (CMS), as of January 2022 9 Figure 2: Map of Certain State-Specific Oversight Activities for State Veterans Homes 13 Figure 3: Count of Deficiencies in 2019 and 2021, by Deficiency Severity and Scope 18 Figure 4: Count of Deficiencies in 2019 and 2021, by Category of Deficiency 20 Figure 5: Enforcement Actions Available for Department of Veterans Affairs (VA) and Centers for Medicare & Medicaid Services (CMS) for Noncompliance with Quality Standards 27 Page ii GAO-23-105167 VA Oversight of State Veterans Homes Abbreviations COVID-19 CMS GEC VA VAMC VISN Coronavirus Disease 2019 Centers for Medicare & Medicaid Services Office of Geriatrics and Extended Care Department of Veterans Affairs VA Medical Center Veterans Integrated Service Network This is a work of the U.S. government and is not subject to copyright protection in the United States. The published product may be reproduced and distributed in its entirety without further permission from GAO. However, because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately. Page iii GAO-23-105167 VA Oversight of State Veterans Homes GAO U.S. GOVERNMENT ACCOUNTABILITY OFFICE 441 G St. N.W. Washington, DC 20548 November 14, 2022 Congressional Addressees Like many older Americans, aging veterans may rely on nursing home care to meet their daily needs. The Department of Veterans Affairs (VA) provides or pays for nursing home care for eligible veterans. In fiscal year 2021, this care cost almost $7.3 billion for approximately 33,000 veterans whose health care needs were extensive enough to require skilled nursing and personal care in an institutional setting. Almost half of these veterans-about 14,500-received this nursing home care in state owned and operated facilities known as state veterans homes. In fiscal year 2021, VA provided funding for nursing home care for veterans in 153 state veterans homes across the country at a cost of about $1.5 billion.' To receive VA payments, state veterans homes must meet VA quality standards related to quality of care, quality of life, infection control, and resident rights, among other areas. Homes that fail to meet the standards can be cited for deficiencies by VA. Some of these homes also receive Medicare or Medicaid payments from the Centers for Medicare & Medicaid Services (CMS). These homes must also meet CMS quality standards and can be cited for deficiencies by CMS. In recent years, we have examined the quality of care at state veterans homes and VA's oversight of this care. For example, in November 2020, we reported that VA had paused inspections during the COVID-19 pandemic.2 VA resumed inspections in January 2021. VA's overall efforts to provide timely, cost-effective, and quality care to veterans have been a focus of our work for many years. In 2015, VA health care was added to 1As of January 2022, 160 state veterans homes were officially recognized by VA. Of those, 153 provide nursing home care. The remaining 7 are domiciliaries only. 2See GAO, COVID-19: Urgent Actions Needed to Better Ensure an Effective Federal Response, GAQ-21-191 (Washington, D.C.: Nov. 30, 2020). Page 1 GAO-23-105167 VA Oversight of State Veterans Homes our High Risk List, due to challenges we identified in VA's provision of services. We were asked to provide information on VA's oversight of state veterans homes, and the joint explanatory statement accompanying the Consolidated Appropriations Act, 2021, contained a provision for us to review the relationship between VA and these homes.? This report 1. describes the oversight being conducted to ensure state veterans homes' compliance with nursing home quality standards; 2. examines what available data show about deficiencies cited during recent state veterans home inspections; and 3. examines how VA could enhance its oversight of state veterans home to ensure compliance with quality standards. To describe the oversight of state veterans homes to ensure compliance with nursing home quality standards, we reviewed federal documents, conducted a national survey, and interviewed officials from VA and other organizations. We reviewed VA and CMS documents about state veterans home inspection policies and processes.* We also reviewed prior GAO work about how VA conducts inspections of these homes. Additionally, we surveyed officials from the state agencies that operate state veterans homes in each of the 50 states and Puerto Rico. We conducted the survey from March 16 through April 14, 2022; we received 51 responses for a response rate of 100 percent. We reviewed the survey 3GAO's high-risk program identifies government operations with vulnerabilities to fraud, waste, abuse, and mismanagement, or in need of transformation to address economy, efficiency, or effectiveness challenges. See GAO, High-Risk Series: Dedicated Leadership Needed to Address Limited Progress in Most High-Risk Areas, GAO-21-119SP (Washington, D.C.: Mar. 2, 2021). 4See 166. Cong. Rec. H8742 (daily ed. Dec, 21, 2020) (statement of Rep. Lowey regarding Consolidated Appropriations Act, 2021, Pub. L. No. 116-260). 5Assessing VA and CMS processes for duplicative goals and activities was outside the scope of our review. While GAO annually identifies federal programs and agencies with duplicative goals and activities across government, we recognize that there could be instances where some degree of program fragmentation, overlap, or duplication may be warranted because of the nature or magnitude of the federal effort. See GAO, Additional Opportunities to Reduce Fragmentation, Overlap, and Duplication and Achieve Billions of Dollars in Financial Benefits: Annual Report GAO-22-105301 (Washington, D.C.: May 11, 2022). SWashington, D.C., does not have any state veterans homes. To help develop the survey, we pretested the survey instrument with state officials from the respondent population from three different states. Page 2 GAO-23-105167 VA Oversight of State Veterans Homes responses for any internal inconsistencies, and for discrepancies from VA documentation for certain information collected in the survey. We conducted follow-up with states to resolve discrepancies as needed. Additionally, we interviewed officials from VA, the National Association of State Veterans Homes, and the National Association of State Directors of Veterans Affairs. To examine what available data show about the deficiencies cited at state veterans homes, we reviewed data from VA's annual inspections of state veterans homes that were completed in 2019 or 2021. While VA refers to these annual inspections as "surveys," for the purposes of our reporting, we refer to them as inspections. We discuss relevant information from these inspections, such as the number and types of deficiencies cited, severity of these deficiencies as classified by VA, and state veterans home plans to correct deficiencies cited in each inspection. We did not include 2020 in our analysis because, as mentioned, VA suspended all annual inspections in March 2020 in response to the COVID-19 pandemic; inspections resumed in January 2021. We determined VA's annual inspections data were reliable for our reporting objective after reviewing VA's directive for inspecting state veterans homes and interviewing knowledgeable VA officials to better understand the data. We identified weaknesses in the data, as discussed in this report. In addition to VA data, we reviewed the publicly available CMS Five-Star Quality Rating data for the state veterans homes that also receive CMS oversight." We reviewed CMS's technical manual for its rating data and compared the performance of these state veterans homes against other types of nursing homes in their respective state. We determined the CMS data were sufficiently reliable for the purpose of our objective. To examine how VA can enhance its state veterans home oversight to ensure compliance with quality standards, we reviewed VA documents on the oversight process for state veterans homes. These documents included VA directives on requirements for annual inspections and on the payments to state veterans homes for care provided to veterans; contracts with agencies hired by VA to inspect the homes; presentations outlining changes to VA's oversight structure; and an enterprise data 7We provided CMS officials with an opportunity to review key facts presented in this report and incorporated their relevant technical comments. Page 3 GAO-23-105167 VA Oversight of State Veterans Homes strategy, among other things. We also reviewed applicable statutes and regulations pertaining to VA's oversight authorities. We interviewed knowledgeable VA officials, as well as representatives from the National Association of State Veterans Homes and National Association of State Directors of Veterans Affairs to understand state veterans home and state government perspectives.® Further, we interviewed officials from five state veterans homes to better understand VA's oversight in individual homes. We selected the five homes to capture variation across characteristics including management type, oversight entity, bed size, and geographic location. The findings from the five selected homes in our sample are not generalizable to all state veterans homes. We assessed whether VA's oversight efforts were consistent with its oversight policies and planning documents and with relevant federal internal control standards related to information and communication.? We conducted this performance audit from April 2021 to November 2022 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. Background VA provides or pays for nursing home care in three nursing home settings: VA-owned and -operated community living centers, publicly or privately owned community nursing homes, and state-owned and -operated state veterans homes. In general, the three settings provide similar nursing home care, in which veterans receive skilled nursing care, 8We also reached out to representatives from six veteran service organizations. We received responses from three of these organizations. 8See GAO, Standards for Internal Control in the Federal Government, GAO-14-704G (Washington, D.C.: September 2014). Internal control comprises the plans, methods, policies, and procedures used to fulfill the mission, strategic plan, goals, and objectives of the entity. Page 4 GAO-23-105167 VA Oversight of State Veterans Homes recreational activities, and other services.1° While the cost of care varies across the three settings, in fiscal year 2021, the average daily cost for veterans receiving VA- supported nursing home services was lowest in state veterans homes, where the largest share of veterans get their care." Support of State Veterans Homes VA supports state veterans homes by providing per diem payments for each day that each eligible veteran is receiving care and has an overnight stay, with certain exceptions.'2 VA also provides grants to construct, acquire, remodel, or modify state veterans homes, and payments to states for the hiring and retention of nurses.13 State veterans homes are owned and operated by states. Federal statute prohibits VA from having authority over the management of or control of any state home. 4 Depending on the veteran, VA pays the full or partial cost of state veterans home care.15 States have different methods of funding the remaining balance, including private out-of-pocket payments from the 19Some 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 ona long-term basis, which is a period of 91 days or more ("long stay"). Further, officials previously told GAO 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. 11The average daily costs per veteran per day at state veterans homes was $285 in fiscal year 2021, according to VA's fiscal year 2023 budget submission. In that same year, the average daily cost for the 6,684 veterans in VA's community living centers was $1,850.39, and for the 9,928 veterans in community nursing homes, the average daily cost was $347.12. These numbers do not include care veterans received at other types of state veterans homes, such as those providing only domiciliary care. 12See 38 U.S.C. §§ 1741, 1745. In certain circumstances, VA also pays per diem when there is no overnight stay (i.e., the veteran is temporarily absent from the facility) if the facility has a 90 percent or greater occupancy rate. 13§ee 38 U.S.C. §§ 8131-8138 and § 1744. 1438 U.S.C. § 1742(b). 15According to VA policy, its payments are equal to the lesser of the annual basic per diem rate-determined annually on a fiscal year basis-or one-half of the daily cost of nursing home care provided to eligible veterans in the state veterans home. 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. Unless reauthorized by Congress, this statutory requirement will terminate on September 30, 2022. See 38 U.S.C. § 1710A(a). For these veterans, VA makes prevailing rate per diem payments. See 38 C.F.R. § 51.41 (2021). Page 5 GAO-23-105167 VA Oversight of State Veterans Homes veteran or state general funds. States might also obtain payment from CMS for services furnished to eligible individuals in state veterans homes certified to participate in Medicare or Medicaid. Oversight of Quality of Care in State Veterans Homes Federal law and VA policy prevent VA from making payments to state veterans homes until it determines that they meet applicable quality of care and other standards. '® Within VA, the Office of Geriatrics and Extended Care (GEC) is responsible for overseeing the quality of care provided to veterans at state veterans homes. Each home is affiliated with a VA medical center (VAMC). The VAMC of jurisdiction-usually the VAMC located closest to the home-is responsible for helping veterans make decisions about nursing home care, responding to inquiries from state veterans home management, referring management to the appropriate VA office for assistance, and serving as an educational resource for state veterans home employees, among other things.1" Each VANC resides within a Veterans Integrated Services Network (VISN), and GEC works with liaisons within each VISN to address state veterans home quality issues, as needed. '8 VA conducts inspections that determine the extent to which state veterans homes meet relevant nursing home quality of care standards. '9 VA contracts with a third party to conduct these inspections and is responsible for monitoring the contractor's performance. The contract stipulates that such monitoring includes directly observing 10 percent of the inspections, sampling 50 percent of the contractor's inspection reports and reviewing them for any needed corrections, and validating 90 percent of the reports for timely submission. 1638 U,S.C. § 1742(a); Department of Veterans Affairs, Veterans Health Administration (VHA), Survey Requirements for State Veterans Homes, VHA Directive 1145.01 (Washington, D.C.: Feb. 18, 2021). 17Before January 2022, VAMCs of jurisdiction for each state veterans home managed most of VA's oversight of the homes. In January 2022, GEC officials said they began to centralize many of the inspection oversight tasks previously conducted by VAMC representatives. 18V/A provides healthcare services through 18 geographically divided VISNs. Each VISN is responsible for coordination and oversight of all administrative and clinical activities within its specified geographic region. 18VA will inspect the home in accordance with 38 C.F.R. § 51.31 to determine whether the home and program of care meet the applicable requirements of 38 C.F.R. Part 51, Subpart C, and the applicable standards in Subparts D, E or F. Page 6 GAO-23-105167 VA Oversight of State Veterans Homes The first inspection a home receives after it applies to receive VA's per diem payments is to recognize the home as a state veterans home. VA reviews policies, procedures, staffing patterns, and all other requirements appropriate to the facility's level of care, and issues a pass or fail decision for the facility. For those that pass, subsequent inspections are generally unannounced and typically occur annually or in response to a specific incident or complaint. Subsequent inspections are intended to ensure the home continues to meet applicable standards. Those that meet all standards are certified by VA and continue to receive per-diem payments. Any applicable standard that VA's inspectors find to be "not met" during an inspection triggers a deficiency citation to the state veterans home. Each deficiency is classified using a system that CMS developed for its investigations. VA rates each deficiency for its scope-which indicates whether the deficiency is isolated to one patient, a pattern, or widespread; and its severity-which indicates whether the deficiency can cause harm or poses immediate jeopardy to resident health or safety. State veterans homes must submit a corrective action plan for each deficiency cited during a VA inspection; included in these plans are specific steps that must be taken to correct the deficiency. Homes with an accepted corrective action plan in place are provisionally certified and are eligible for per-diem payments. While VA is the only federal agency that oversees all state veterans homes, CMS also oversees many of them due to their participation in Medicare or Medicaid as part of CMS' oversight of over 15,000 certified nursing homes nationwide.2° CMS enters into agreements with state agencies to inspect these homes, as it does for all nursing homes it inspects. Prior GAO Work on State Veterans Homes We have previously reported on VA's oversight in state veterans homes and identified opportunities for improved oversight. For example, in 2019 we found that VA did not require that all failures to meet standards be documented as cited deficiencies, unlike CMS; nor did VA monitor the contractor's performance to ensure that contractor staff effectively determine whether state veterans homes are meeting required 20Some state veterans homes may also receive inspections from the Joint Commission, a nonprofit organization that provides voluntary health care accreditation for hospitals. Page 7 GAO-23-105167 VA Oversight of State Veterans Homes VA, CMS, and Most States Conduct Inspections to Oversee State Veterans Homes' Compliance with Relevant Quality Standards standards.?' VA has since addressed these issues. We have also found that, even though VA is the only source of information about the quality of state veterans homes, it does not make such information publicly available. We recommended that VA do so. VA concurred in principle but has not fully addressed this recommendation as of August 2022.22 It is particularly important that VA ensure veterans receive quality care because, as we have previously reported, veterans' use of long-term care services has increased in recent years and VA projects the trend to continue.23 Furthermore, ensuring the quality of care provided at state veterans homes has become even more critical since the emergence of COVID-19. Nursing home residents are often in frail health and living in close proximity to one another-and therefore at higher risk of being infected with and dying from COVID-19. In 2021, VA addressed a previous recommendation we made to include timely data on COVID-19 cases and deaths among staff and residents at state veterans homes on its website, which is useful for overseeing whether the homes effectively took steps to prevent and mitigate the spread of COVID-19.24 VA conducts annual inspections of all state veterans homes, and CMS conducts its own inspections in nearly 76 percent of these homes. In response to our national survey of officials from state agencies that operate state veterans homes that provide nursing home care, 43 states reported conducting their own inspections in addition to the oversight conducted by VA and CMS. 21See GAO, VA Nursing Home Care: VA Has Opportunities to Enhance Its Oversight and Provide More Comprehensive Information on Its Website, GAO-19-428 (Washington, D.C.: July 3, 2019). 22See GAO-19-428. 23See GAO, VA Health Care: Veterans' Use of Long-Term Care Is Increasing, and VA Faces Challenges in Meeting Demand, GAO-20-284 (Washington, D.C.: Feb. 19, 2020). 24See GAO-21-191. Page 8 GAO-23-105167 VA Oversight of State Veterans Homes VA and CMS Inspections To help ensure state veterans homes are meeting VA's quality standards, the department is responsible for conducting regular inspections of all of these homes, the only federal entity to do so.25 As shown in figure 1, nearly 76 percent of state veterans homes that provide nursing home care (116 of 153 as of January 2022) are also inspected by CMS to ensure they meet the federal quality standards required to receive Medicare or Medicaid payments. ee Figure 1: Federal Oversight of State Veterans Homes by the Department of Veterans Affairs (VA) and the Centers for Medicare and Medicaid Services (CMS), as of January 2022 --_ 153 STATE VETERANS HOMES THAT PROVIDE NURSING HOME CARE (100%) "1 116 state veterans homes 37 state veterans have federal VA and CMS inspections ed are subject to VA and CMS corrective 2 4% ¢ have federal VA action plans inspections only are subject to CMS civil monetary penalties and * are subject to other CMS enforcement actions VA corrective action plans Source: GAO analysis of data from Department of Veterans Affairs (VA) and Centers for Medicare & Medicaid Services (CMS). | GAO-23-105167 Note: CMS has the ability to take a variety of enforcement actions, including imposing civil monetary penalties of varying amounts. VA documentation shows that VA's inspection program is modeled upon CMS inspection methods. VA policy calls for inspections of state veterans homes on a regular schedule, approximately yearly, to assess compliance with 189 standards across 16 categories.26 CMS policy calls for CMS to inspect nursing homes, including state veterans homes, every 15 months or less. CMS assesses compliance with standards that are grouped into 22 categories.2" Both agencies examine the extent to which the homes are meeting applicable quality of care standards, among other 25While state veterans homes are owned and operated by the states, federal law stipulates that VA may inspect any state veterans home at such times as the Secretary deems necessary. 38 U.S.C. § 1742(a). 26V/A inspections check for 16 categories of standards-15 in 38 C.F.R. Part 51, Subpart D, and other standards in Subpart C of this part, which VA has previously counted under a single category. 27See 42 U.S.C. §§ 1395i-3(f)(1),1396r(F)(1); 42 C.F.R. Part 483, Subpart B (2021). Page 9 GAO-23-105167 VA Oversight of State Veterans Homes issues.28 Additionally, both VA and CMS conduct for-cause inspections- which are typically unannounced-that may arise from complaints or facility reported incidents. During inspections, if VA's contractor identifies any standard that is "not met," it cites the home for a deficiency. The deficiency is rated for its scope and severity.2° The contractor is required to provide a written description of the deficiency and its rating to VA. Then VA is to send a signed letter of the inspection results, including reasons for any deficiency, to the home's management within 20 business days from the last day of the inspection. Both VA and CMS require state veterans homes to develop a corrective action plan for each deficiency in a routine or for-cause inspection.2° VA requires the plans to state specific interventions with target dates for remediation; identify trends and patterns; consider core causes; and include a plan to monitor effectiveness over time. According to VA policy, VA will review the plan and either approve it or find it not acceptable because it does not address the deficiency or cannot be completed in a reasonable time period. If not approved, the home must submit a revised plan. CMS similarly requires the home to detail its planned corrective actions and the anticipated date of correction. Depending on the scope and severity of the deficiency, the CMS state agency may re-visit the home to ensure it implemented the plan and corrected the deficiency. CMS has the authority to impose monetary penalties on state veterans homes with deficiencies, while VA officials noted they cannot.31 CMS penalties vary based on factors including whether a deficiency is classified as causing immediate jeopardy to residents' health or safety. For example, in 2022, CMS policy requires civil monetary penalties up to $23,989 per day for deficiencies where there is immediate jeopardy, and up to $7,195 per day when there is no immediate jeopardy. VA officials 28CMS and VA assess compliance with similar categories of standards, such as quality of care and quality of life, while only VA inspections include a fiscal component. 29VA uses a matrix adapted from CMS for deficiency ratings. "Scope" generally refers to whether the deficiency is isolated to one patient or widespread, and "severity" generally refers to whether the deficiency can cause injury, harm, impairment, or death. 30The CMS form is named Statement of Deficiencies and Plan of Correction (Form CMS- 2567), but we use the term "corrective action plan." 31See 42 U.S.C. §§ 1395i-3(h)(2)(B)(ii), 1396r(h)(3)(C)(ii); 42 C.F.R. § 488.438 (2021). See 45 C.F.R. § 102.3 (2021) for annually adjusted civil monetary penalty amounts. Page 10 GAO-23-105167 VA Oversight of State Veterans Homes said the department can, upon approval of the VA Secretary, withhold its per diem payments to state veterans homes if the home has a deficiency that VA determines is egregious, makes no attempt to fix it, and has a history of well-documented non-compliance. See appendix | for additional detail on federal state veterans home oversight by VA and CMS. State Oversight Activities Through our national survey of officials from state agencies, 43 states reported conducting some kind of oversight on their state veterans homes separate from federal oversight.22 States own and operate state veterans homes and, as a result, states may conduct their own oversight activities of the homes. (See appendix II for the survey responses with information reported about each state veterans home, and appendix III for the survey responses about state-specific oversight policies and a summary of state veterans homes in each state.) States that reported conducting some kind of oversight reported doing so through either routine inspections based on state-specific nursing home quality regulations, for-cause inspections, or both. Of the 43 states that reported conducting their own oversight, e 33 reported having state-specific nursing home quality regulations; e 39 reported conducting for-cause inspections that are separate from federal (i.e., VA or CMS) for-cause inspections; and e 29 reported both types of oversight.%% In contrast, 7 states reported they do not have either state-specific nursing home quality regulations or for-cause inspections. Like all states, these states' homes are subject to VA inspections and some also receive CMS inspections. Among the 25 state veterans homes that provide nursing home care in these states, 8 of them-those in New Hampshire 32We deployed the survey in all 50 states and Puerto Rico (Washington, D.C., does not have any state veterans homes), but Wyoming is excluded from this analysis because it reported not having any state veterans homes that provide nursing home care. The survey also asked for background information about all state veterans homes. 33Additionally, all of the states except California and Massachusetts reported that they require state veterans home administrators to hold a nursing home administrator license. Page 11 GAO-23-105167 VA Oversight of State Veterans Homes and Missouri-are not inspected by CMS because they are not Medicare- or Medicaid-certified, and only receive oversight from VA. See figure 2 for a map that indicates which states reported having state- specific nursing home quality regulations, for-cause inspection, both, or neither. Page 12 GAO-23-105167 VA Oversight of State Veterans Homes Figure 2: Map of Certain State-Specific Oversight Activities for State Veterans Homes : 20 4 a Be, Puerto Rico Hawaii ony pean Has only state-specific for-cause inspections (10 states) Has both state-specific nursing home quality regulations and for-cause inspections (29 states) Does not have state-specific nursing home quality regulations or for-cause inspections (7 states) 2 Z Has only state-specific nursing home quality regulations (4 states) Does not have any state veterans homes that provide nursing home care (1 state) Source: GAO; Map Resources (map). | GAO-23-105167 Note: Information for each state in figure 2 is current as of the date of each state's survey completion, which varied by state from March to April 2022. Page 13 GAO-23-105167 VA Oversight of State Veterans Homes The states that reported having state-specific nursing home quality regulations varied in when and how they assessed compliance with these regulations. These states reported assessing compliance with the regulations in either a routine state inspection (13 states); during a routine CMS inspection, because the homes are also CMS-certified (15 states); or in both a routine state inspection and during routine CMS inspections (5 states). According to the survey responses, there are a number of different state agencies that conduct the separate state inspections, including departments and offices of health, long-term care, health care administration, community health, healthcare assurance, and human services. Of the 43 states that reported assessing compliance with state-specific nursing home quality regulations or conducting their own for-cause inspections, 41 reported requiring state veterans homes to use a corrective action plan, separate from any federal plan to bring deficiencies into compliance. Additionally, 37 states reported they have the option to take one or more enforcement actions if a home does not meet state standards. Survey respondents reported various types of enforcement actions their states can take, including issuing monetary penalties or fines (30 states), closing the home (28 states), and suspending admissions to the home (27 states).34 See appendix III for a state-by-state list of available enforcement actions as reported by state officials in the survey responses. 34Other types of enforcement actions that states reported they can take include withholding state payments or funds (21 states), having a different state agency temporarily take over management of the home (16 states), revoking the home's license (4 states), and imposing fines or imprisonment for operating a facility without a license (1 state). Page 14 GAO-23-105167 VA Oversight of State Veterans Homes VA Data Show an Increase in Deficiencies Cited on State Veteran Home Inspections Our analysis of VA's annual inspection data for 2019 and 2021 found increases in both the number of deficiencies and the number of deficiencies that were classified as causing actual harm, including immediate jeopardy.%5 (As previously noted, we did not include 2020 in our analysis because VA halted annual inspections in March 2020 in response to the COVID-19 pandemic; inspections resumed in January 2021.) Specifically, we found that the number of deficiencies increased from 424 in 2019 to 766 in 2021.36 Similarly, the average number of deficiencies cited per inspection increased from 2.8 in 2019 to 6.2 in 2021.37 Further, 36 state veterans homes had no deficiencies in 2019; in 2021 all homes had at least one deficiency that caused no actual harm 35Data for 2019 is from 150 annual inspections of state veterans homes; data for 2021 is from 123 inspections. As a result, the number of deficiencies reported in 2021 is fewer than what would have been found had all the homes been inspected in that year, as they were in 2019. That means that comparisons in the number of deficiencies between 2019 and 2021 underestimate the magnitude of the difference where the reported numbers are higher for 2021. In addition, when the numbers of reported deficiencies are higher in 2019, the number of deficiencies in 2021 might actually have been higher had inspection results for the missing homes been included. Similarly, any percentages reported for 2021 are either higher or lower than what they would have been had the full population of homes been inspected. There were fewer inspections in 2021 because 28 homes received an interim records review from VA's GEC in January 20271 in lieu of an annual inspection. We did not include the results of these record reviews in our analysis due to the limited number of standards they reviewed. Specifically, interim records reviews checked compliance with 22 standards, while annual inspections in 2021 checked more than 180. VA officials told us they completed these reviews because these 28 homes were about to have their certification lapse. Homes must be certified every 600 calendar days in order to receive per diem payments. 36Our analysis of VA inspection data found that about 22 percent of the increase in overall deficiencies may be attributable to a change in how VA cited deficiencies in 2019 and 2021. Specifically, in 2019, VA allowed non-compliance that received a severity rating of causing no actual harm but with the potential for minimum harm to be cited as "recommendations" rather than deficiencies. In GAO-19-428, we recommended that VA require all non-compliance with standards be cited as deficiencies. VA has since implemented this recommendation. 37According to VA summary data the average number of deficiencies per survey ranged from 1.8 to 2.6 between 2015 and 2018. Page 15 GAO-23-105167 VA Oversight of State Veterans Homes but had the potential for more than minimal harm. VA officials identified several factors that may have contributed to the increase in deficiencies.38 For example, social isolation of residents in response to COVID-19 may have contributed to more falls in 2021. 38V/A officials told us differences in how inspections were conducted in 2019 and 2021 could have affected state veteran home performance on VA's inspections, but that potential effects are unknown. Specifically, prior to halting inspections in March 2020, all annual inspections were conducted in person by a contractor on behalf of VA; there was no option for virtual inspections. In response to the COVID-19 pandemic, VA awarded a new contract with an option for virtual inspections beginning in January 2021. VA officials told us they use several criteria when determining if an inspection should be done virtually or in-person, such as the prevalence of COVID-19 in the community and the availability of Wi-Fi at the nursing home. According to VA data, most annual inspections between January 2021 and March 2022 were completed virtually. Since then, VA has begun completing a majority of its inspections in-person. For example, between July and September 2022, VA completed 69 percent of its inspections in-person, and 31 percent virtually. Page 16 GAO-23-105167 VA Oversight of State Veterans Homes Severity and Scope of Deficiencies Deficiencies are rated for severity (effect of noncompliance) and scope (number of residents, employees, or locations affected). Severity Immediate jeopardy: caused, or is likely to cause, serious injury, harm, impairment, or death Actual harm that is not immediate jeopardy: results in actual harm that is not immediate jeopardy No actual harm with potential for more than minimal harm: results in the potential for no more than minimal physical, mental, or psychosocial harm, or in minimal discomfort, but has the potential to result in more than minimal harm that is not immediate jeopardy No actual harm with potential for no more than minimal harm: has the potential for causing no more than minor negative impact Scope Widespread: pervasive through the facility or represented systemic failure that affected or had the potential to affect a large portion or all of the facility's residents Pattern: affected more than limited number of residents, or employees involved, or the situation occurred in several locations but the locations are not dispersed through the facility Isolated: affected one or a limited number of residents or a limited number of employees involved, or the situation occurred only occasionally or in a limited number of locations Source: GAO analysis of Centers for Medicare & Medicaid Services (CMS) information. | GAO-23-105167 Our analysis found the most common scope and severity ratings for deficiencies in 2019 and 2021 were the lower level ratings-isolated in scope and no actual harm (see fig. 3). However, we found that deficiencies that caused actual harm or immediate jeopardy-the most severe ratings-increased as a share of total deficiencies from 8 percent in 2019 to 20 percent in 2021. Further, the percent of state veterans homes with at least one deficiency that caused actual harm increased from 9 percent in 2019 to 63 percent in 2021.29 About 79 percent of all deficiencies in 2021 with a severity rating of actual harm resulted from non-compliance with standards associated with preventing accidents; preventing and treating pressure sores (i.e., bedsores); and providing the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.4° 39For example, a resident suffered fractured ribs after four falls over a 4-month period. The inspector found that the home's documentation did not address causal and contributing factors to the resident's falls, such as the condition of the environment and what the resident was attempting to do. The home was cited for a deficiency that caused actual harm because the home failed to ensure that residents received adequate supervision to prevent accidents and that the environment remained as free of accident hazards as possible. 40For example, a facility was cited for not providing the necessary care because it failed to adequately assess a resident's knee and shoulder pain. Specifically, the facility did not assess the type of pain, what aggravated and alleviated the pain, interventions that previously worked or did not work, and the resident's acceptable level of pain. Page 17 GAO-23-105167 VA Oversight of State Veterans Homes Figure 3: Count of Deficiencies in 2019 and 2021, by Deficiency Severity and Scope 2019 (data from 150 inspections) Immediate jeopardy to resident health or safety (0 total) Actual harm (33 total) No actual harm with potential for more than minimal harm (330 total) No actual harm with potential for minimal harm (1 total) SEVERITY OF DEFICIENCY Lacks a scope and severity rating? (60 total) 2021 (data from 123 inspections) Immediate jeopardy to resident health or safety (12 total) Actual harm (142 total) No actual harm with potential for more than minimal harm (535 total) No actual harm with potential for minimal harm (77 total) SEVERITY OF DEFICIENCY Lacks a scope and severity rating? (0 total) e Pattern (p) @ Widespread (w) [2] Unknown scope (u)? Scope of deficiencies: O Isolated (i) 0 (i) 0 (p) 0 (w) H---0 27 (i) -® 6 (p) 0 (w) © 157 (i) +8 67 (p) a 106 Cw) 101 (i) 0 (p) 0 (w) 0 50 100 150 200 250 300 350 Number of deficiencies +0 8 (i) + 3 (p) fo! (w) 0133 (i) -® 9 (p) 0 (w) © 337 (i) ® 124 (p) |}H_______@) 74 (w) +--0 20 (i) 8: 29:(p) +---@ 28 (w) 0 (u) 0 50 100 150 200 250 300 350 Number of deficiencies Source: GAO analysis of Department of Veterans Affairs (VA) data. | GAO-23-105167 Note: Data for 2019 is from 150 annual inspections of state veterans homes; data for 2021 is from 123 inspections. As a result, the number of deficiencies reported for 2021 is fewer than what would have been found had all homes been inspected in that year. There were fewer in 2021 because 28 Page 18 GAO-23-105167 VA Oversight of State Veterans Homes homes received an interim records review from VA's office of Geriatrics and Extended Care in January 2021 in lieu of an annual inspection. We were not able to include 2020 in our analysis because VA suspended all annual inspections in March 2020 in response to the COVID-19 pandemic; inspections resumed in January 2021. Isolated deficiencies affect one or a limited number of residents or a limited number of staff involved, or the situation occurred only occasionally or ina limited number of locations. Pattern deficiencies affect more than limited number of residents, or more than limited number of staff involved, or the situation occurred in several locations but the locations are not dispersed through the facility. Widespread deficiencies are pervasive (affect many locations) throughout the facility or represented systemic failure that affected or had the potential to affect a large portion or all of the facility's residents. "Our review of VA's data found that some deficiencies from 2019 lacked a scope and severity rating. We labeled these deficiencies as having an "unknown severity" and "unknown scope." In examining the types of deficiencies cited in 2019 and 2021, we found that a majority (77 percent) of the increase in deficiencies was because of increases in non-compliance with standards associated with two of the 16 categories. Specifically, quality of care-such as accidents and pressure sores-and infection control-such as hand hygiene-categories. (See appendix IV for a list of all 16 categories.) Non-compliance with quality of care standards was the fourth most common category of deficiencies in 2019 and the most common in 2021.41 Non-compliance with infection control standards represented a small percentage of deficiencies in both years, but increased as a share of total deficiencies from 2 percent in 2019 to 8 percent in 2021 (see fig. 4).42 State veterans homes were cited for infection control deficiencies for several reasons, including staff non- compliance with a home's hand hygiene or personal protective equipment policies. 41 Administration, physical environment, and resident assessments were the three categories with the most deficiencies in 2019. Our review of VA data also found that 41 homes (27 percent of homes for which we had data) were cited for at least one quality of care deficiency in 2019, while 111 homes (90 percent) were cited in 2021. 42Qur review of VA data also found that 7 homes (5 percent) were cited for one infection control deficiency in 2019, while 65 homes (53 percent) were cited in 2021. Page 19 GAO-23-105167 VA Oversight of State Veterans Homes Figure 4: Count of Deficiencies in 2019 and 2021, by Category of Deficiency 7 22 (2%) (5%) 29 (4%) 0 100 200 300 400 500 600 700 800 Number (and percentage) of deficiencies ia Administration [| Resident assessment [FT Infection control [ Resident rights a Physical environment a Specialized rehabilitative services || Quality of care Other Source: GAO analysis of Department of Veteran Affairs (VA) data. | GAO-23-105167 Note: Data for 2019 is from 150 annual inspections of state veterans homes; data for 2021 is from 123 inspections. As a result, the number of deficiencies reported for 2021 is fewer than what would have been found had all the homes been inspected in that year. There were fewer inspections in 2021 because 28 homes received an interim records review from VA's office of Geriatrics and Extended Care in January 2021 in lieu of an annual inspection. We were not able to include 2020 in our analysis because VA suspended all annual inspections in March 2020 in response to the COVID- 19 pandemic; inspections resumed in January 2021. VA checks for compliance with 189 standards across 16 different categories. VA inspections check for 16 categories of standards-15 in 38 C.F.R. Part 51, Subpart D, and other standards in Subpart C, which VA has previously counted under a single category. Categories included in "other" are fiscal, admission transfer and discharge, resident behavior and facility practices, quality of life, nursing services, dietary services, physician services, dental services, and pharmacy services. In contrast, available VA data indicated that there were fewer deficiencies in 2021 for non-compliance with certain standards, including those associated with resident assessment-such as requirements for homes to develop comprehensive care plans to meet each resident's physical, mental, and psychosocial needs-and to offer specialized rehabilitation services-such physical therapy and mental health services. For example, 29 percent of state veterans homes were cited for at least one resident assessment deficiency in 2019, while 21 percent were cited in 2021. Page 20 GAO-23-105167 VA Oversight of State Veterans Homes COVID-19 Pandemic COVID-19 has inflicted a devastating toll on residents and staff at state veterans homes. According to VA data, 1,714 home residents and 62 home staff infected with COVID-19 have died as of July 2022. VA Officials told us that COVID-19 has had an ongoing effect on inspections and deficiencies cited, though the effect of the pandemic has not been thoroughly analyzed. According to VA officials, some measures taken by officials at state veterans homes to mitigate the effect of COVID-19 may have affected the quality of care and physical environment. For example, residents spent more time in their rooms and less time at social gatherings and dining rooms. VA officials told us the increased social isolation may have led to more falls and pressure ulcers, potentially contributing to the increase in deficiencies between 2019 and 2021. Source: GAO analysis of Department of Veteran Affairs (VA) information. | GAO-23-105167 We also found that 54 of the 122 state veterans homes for which we had annual inspection data for both 2019 and 2021 were cited for the same deficiency, meaning they failed to meet the same standard in both years. From this group of homes with repeat deficiencies, 18 had two or more repeat deficiencies. The most common categories for repeat deficiencies were physical environment and quality of care. For example, 39 homes were cited in both years for non-compliance with applicable codes to ensure life safety from fire.43 In addition, 9 homes were cited in both years for non-compliance with taking sufficient steps to prevent accidents, which is a standard of quality care.44 In addition to VA inspection data, we also reviewed CMS's Five-Star Rating System data to understand what it may reveal about state veteran home quality. CMS's quality rating system is intended to help consumers compare nursing home quality. The Five-Star Rating System assigns each nursing home participating in the Medicare or Medicaid programs an overall rating ranging from one star (much below average quality) to five stars (much above average quality). In our review of the CMS data, we found that, of the 116 state veterans homes participating in Medicare or Medicaid in 2021, a majority had higher overall star ratings than other types of nursing homes in their state.45 Specifically, 77 of 111 state veterans homes with star ratings scored above the median rating for other nursing homes in their state for overall quality in 2021. A nursing home's overall star rating is based on CMS data and has three components: health inspections, staffing, and quality measures. State veteran homes' performance on the staffing component-94 scored above their state's median-generally increased the number of stars these homes received for overall quality.4¢ 43Standard 51.200(a) checks multiple systems in the facility for compliance with life fire safety codes, such as sprinklers, fire alarms, and doors. A deficiency cited may involve different codes or chapters, despite being part of the same standard. 44Standard 51.120(i) requires that facility management ensure the resident environment remain as free of accident hazards as possible, and that each resident receives adequate supervision and assistance devices to prevent accidents. 45As previously mentioned, CMS oversees more than 15,000 certified nursing homes nationwide that participate in Medicare or Medicaid. 46GAO and others have reported on the link between staffing levels and quality outcomes for residents. For example, GAO, Medicare: Additional Reporting on Key Staffing Information and Stronger Payment Incentives Needed for Skilled Nursing Facilities, GAO-21-408 (Washington, D.C.: July 9, 2021). Page 21 GAO-23-105167 VA Oversight of State Veterans Homes VA Could Enhance Its Oversight of State Veterans Homes by Improving Data Analytic Capabilities and Expanding Enforcement Options See appendix V for additional information about how CMS star ratings are calculated. We found that while VA captures important data on state veterans home quality through annual inspections, its ability to oversee homes' compliance with quality standards could be enhanced by improving its data analysis capabilities. We also found that VA could improve the effectiveness of corrective action plans by developing a process for following up on plans that lack evidence of timely implementation. Further, expanding its range of enforcement actions could help VA ensure state veterans home compliance with quality standards. Finally, VA is in the process of making substantial changes to how it oversees these homes by centralizing its oversight processes; VA could help ensure this effort is successful by bringing it into alignment with VA policy. Improving Data Analytic Capabilities Could Strengthen Ability to Oversee State Veterans Home Performance on Inspections VA officials said that they are limited in their ability to efficiently analyze state veterans home oversight data collected and stored in a legacy data system and that current plans for the replacement data system do not ensure that the new system will have the necessary analytic capabilities to make VA's work more efficient. VA officials said they have relied on the State Home Online Survey Tool data system to store inspection related documents since 2001. According to VA officials, the data system holds copies of inspection documents, as well as corrective action plans. To analyze data from this system, VA officials told us they download individual documents and copy information into Excel spreadsheets. Once VA officials copy data into Excel-a time-consuming process-VA officials said they are then able to analyze oversight data to review the state veterans homes' performance on VA inspections, such as identifying the most common categories of deficiencies. VA officials acknowledged that the State Home Online Survey Tool they have used since 2001 is an antiquated and inefficient system, and that the agency needs to improve its data analytic capabilities. As such, GEC is in the process of replacing the tool with a new data system, which officials expect to be implemented by the end of 2022. However, according to VA officials, the new data system will not have some key analytic capabilities, such as the ability to aggregate deficiency data by facility, state, region, or survey year and track trends over time. When asked, VA officials involved in the process of implementing the new data system said they hoped to include some capabilities in future iterations of the system. However, VA officials said they did not know the extent of the analysis possibilities in the future, and officials did not provide a plan Page 22 GAO-23-105167 VA Oversight of State Veterans Homes detailing the analytic capabilities VA needs to oversee state veterans homes. Having a data system with key analytic capabilities would be consistent with VA's directive on state veterans home inspection requirements. 47 According to the directive, the relevant data system should be used to analyze all inspection data to improve efficiency of oversight and make data available in a timely manner. Further, adding these capabilities would be consistent with VA's data enterprise strategy that calls for data analysis to be used to develop, justify, and support decision making to facilitate program evaluation and promote positive results for veterans. Until VA has a data system with necessary analytical capabilities, VA officials will not be able to efficiently perform their oversight of quality at state veterans homes. Developing a Process for Monitoring Implementation of Corrective Action Plans Could Improve Oversight Effectiveness We found that VA could improve the effectiveness of its oversight of corrective action plans by developing a process for following up on those that lack evidence of timely implementation. According to VA's policies, in order to receive per diem payments from VA, state veterans homes must meet all standards (full certification) or have an accepted corrective action plan for each deficiency cited during a VA inspection (provisional certification). Before VA officials accept a home's corrective action plan as being sufficient for addressing a deficiency, officials are responsible for verifying that corrective action plan documentation identifies specific steps to correct the deficiency and a proposed date for completing these steps. To move from provisional to full certification, a state veterans home must submit evidence to VA that is has implemented its corrective action plan. Our review of documentation for inspections completed in 2019 and 2021 found issues with VA's documentation around the implementation of these corrective action plans. Specifically, our review of 2019 inspections found that 22 percent (93) of these accepted plans remained in 47V/HA Directive 1145.01. Page 23 GAO-23-105167 VA Oversight of State Veterans Homes provisional status because they lacked evidence that the state veteran home had implemented them by the agreed upon completion date.48 Our review of 2021 inspections found that 48 percent (228 of the 476 deficiencies with accepted corrective action plans) remained in provisional status because there was no evidence that the state veterans home had implemented steps outlined in the corrective action plan by the agreed upon completion date. Over 21 percent of these deficiencies (49 of the 228) were rated as causing actual harm, and 5 more were rated as immediate jeopardy.49 For these 5 immediate jeopardy deficiencies- where noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident-the corrective action plans lacked evidence that they had been implemented by the agreed upon completion date and the associated state veterans homes remained in provisional status.5° VA officials told us they might not have information on implementation of corrective action plans for a number of reasons, including that the local VANC staff did not enter implementation information into VA's data system, despite the state veterans home completing the steps, or that, simply, the home had not implemented the corrective action plan by the proposed completion date. VA officials said they do not currently have a process for following up with state veterans homes about accepted 48Of these 93 corrective action plans, 41 were meant to correct deficiencies that affected more than a limited number of residents or that were pervasive through the facility-and had a severity rating of no actual harm but with the potential for more than minimum harm. Of the 52 remaining deficiencies, two caused actual harm; 15 lacked a scope and severity rating; and 35 were isolated in scope with a severity of causing no actual harm but with the potential for more than minimum harm. 48The remaining 287 deficiencies did not have a corrective action plan in place at the time of our review. There are several reasons this information was unavailable, including that deficiencies were within the 55 business days for a state to submit a corrective action plan and for VA to accept it. 50State veterans homes are required to implement an acceptable abatement plan to remove the immediate threat posed by the immediate jeopardy deficiency before the survey team leaves the facility. After implementing the abatement plan, homes follow the normal process for submitting corrective action plans that will sustain improvement. Of the remaining seven immediate jeopardy deficiencies in 2021, one had evidence that a corrective action plan had been implemented and six lacked any corrective action plan information and were near or past the maximum amount of time it takes a state veterans homes to submit a corrective action plan and VA to review and accept. In its agency comments, VA officials indicated that all 2021 inspections needing a corrective action plan have been received and approved since our analysis was completed. Page 24 GAO-23-105167 VA Oversight of State Veterans Homes corrective action plans that lack evidence after the state's agreed upon completion date. According to VA's directive, per diem payments to state veteran homes are contingent upon them meeting VA quality standards. Further, federal internal control standards state that organizations should have quality information to achieve their objectives.5' If VA had a process for following up with state veterans homes about corrective action plans that lack evidence past the state's agreed upon completion date, it would have the information needed to better oversee quality issues in these homes. Such a process, for example, could include contacting management at state veterans homes every 30 days once the state's agreed upon completion date has passed to ask why the corrective action plan lacks evidence that it has been implemented and require this information to be recorded in its data systems. Developing a Range of Enforcement Options Could Help Ensure Compliance with Quality Standards VA could better ensure compliance with quality standards by developing a range of enforcement options to ensure that the deficiencies identified during VA inspections are corrected. Specifically, while VA's corrective action plan process provides a framework for state veterans homes to address issues of noncompliance, homes have long-standing deficiencies that have not been corrected. According to VA, it has only one enforcement action-withholding of per diem payments-to compel state veterans homes to make necessary corrections. VA considers this action too severe for most situations. We found that state veterans homes had long-standing deficiencies that had not been corrected and, as such, were out of compliance and remained "provisionally certified" by VA. Provisional certification allows homes to receive per-diem payments while they address deficiencies cited in an inspection through the corrective action plan process. Under the terms of a corrective action plan, state veterans homes should be taking steps to address deficiencies cited during an inspection in order to receive full certification. However, as previously described, homes are not required to provide evidence that deficiencies have been addressed. In the event no evidence is provided, a home remains provisionally certified, 51GAO-14-704G. Page 25 GAO-23-105167 VA Oversight of State Veterans Homes and continues to receive payments from VA, despite not fully meeting the quality standards outlined by the department.®2 Currently, VA's only enforcement action to get state veterans homes to correct deficiencies is to withhold per diem payments if a home is out of compliance. According to VA officials, VA has never used this enforcement action because it is considered too severe for most circumstances. VA would have to withhold the complete per-diem payment-partial withholding is not an option-and this could result in residents being transferred out of the home. Officials told us withholding the per diem would only be considered if the deficiency is egregious, the home makes no attempt to fix the deficiency, and the home has a history of well-documented non-compliance.53 According to VA officials, it has been over a decade since the agency considered withholding a noncompliant home's per diem. In contrast, CMS and some states have the ability to take a variety of enforcement actions, including imposing fines of varying amounts. CMS has a range-from mild to severe-of enforcement actions, or remedies, available to help get nursing homes in compliance (see fig. 5). These remedies are based on the scope and severity of the deficiencies, ratings that VA also uses in its inspection process. The administrator at one state veterans home illustrated the difference between VA and CMS enforcement powers, noting they were more concerned about deficiencies cited by CMS, given the monetary penalties associated with them. Additionally, according to our survey, 37 states have the ability to take enforcement actions-including issuing fines or other monetary penalties, withholding state payments of funds, and suspending admissions-against state veterans homes out of compliance with their state standards. 52State veterans homes are not inspected again until their next annual inspection, unless a for-cause inspection is warranted. Between 2011 and 2019, VA completed between one and three for-cause inspections per year. VA completed nine for-cause inspections in 2020. As previously noted, VA stopped all annual inspections in March 2020 in response to the COVID-19 pandemic. According to VA officials, in 2020, for-cause inspections were scheduled instead of annual inspections due to specific requests made by VA Medical Center Directors who felt an onsite inspection was necessary. VA completed two for- cause inspections in 2021 and zero in 2022 as of July 7, 2022. 53The Secretary of VA would have to approve the withholding of per diem payments, according to VA officials. Page 26 GAO-23-105167 VA Oversight of State Veterans Homes Figure 5: Enforcement Actions Available for Department of Veterans Affairs (VA) and Centers for Medicare & Medicaid Services (CMS) for Noncompliance with Quality Standards DEPARTMENT OF CENTERS FOR MEDICARE & VETERANS AFFAIRS (VA) MEDICAID SERVICES (CMS) ¢ Withhold complete per diem payment ¢ Civil monetary penalties (fines for each day or instance of noncompliance) ¢ Denial of payment for all newly admitted eligible residents? ¢ Directed in-service training (training to staff on a specific issue identified as a problem) ¢ Directed plan of correction (home has to implement specific actions according to plan developed by CMS, the state, or a temporary manager) ¢ State monitoring (on-site monitor in the home to achieve and maintain compliance) ¢ Temporary management (substitute manager appointed by the state with the authority to hire, terminate, and reassign staff; obligate funds; and alter the nursing home's procedures, as appropriate) ¢ Termination from the Medicare and Medicaid programs Source: GAO analysis of VA information and 42 U.S.C. §§ 1395i-3(h), 1396r(h); 42 C.F.R. § 488.406 (2021). | GAO-23-105167 "CMS may also deny payment for all Medicare- or Medicaid-covered residents, but this remedy is seldom used. According to CMS, it is mindful of the potential consequences of such actions when assessing whether to impose or continue a payment suspension. VA officials acknowledged the agency's limited options for enforcing quality standards at state veterans homes once they are provisionally certified.*4 Officials in the GEC program office told us they are considering a legislative proposal that would request from Congress authority allowing the department to impose fines or withhold a percentage of the per diem for noncompliance. However, officials did not provide any specifics about the proposal, such as other enforcement options it could entail and the quality triggers that would be used. Seeking such authority would be consistent with one of VA's goals for the state veteran home program: that VA have tools and a process that can help assure compliance and fiscal integrity. It would also align VA's 54V/A officials told us they are considering developing an "escalation process" for poor performing state veterans homes, which would be based on three factors: 1) severity of deficiencies cited; 2) the number of deficiencies cited, including if there was an increase in the number of deficiencies year over year; and 3) the number of repeat deficiencies year over year. However, VA did not have a timeline for implementing this process. Page 27 GAO-23-105167 VA Oversight of State Veterans Homes practices with those used by CMS in overseeing nursing homes. For example, CMS's statutory framework and accompanying regulations acknowledge that a range of options is important, as different factors- including the scope and severity of a deficiency-should be considered when selecting a remedy that will ensure compliance with standards. For CMS, the range of options includes monetary penalties, directed training, and temporary management of the home.55 With a range of remedies, VA would be better positioned to compel state veterans homes to address issues of noncompliance and ensure the program meets it goals. Following VA Policy Could Help Ensure Successful Implementation of Oversight Centralization Efforts While GEC's efforts to centralize state veterans home oversight are promising, GEC could help ensure the successful implementation of its efforts as it moves forward by following VA's directive outlining the processes program offices must follow when developing policy or making policy changes. In January 2022, GEC began centralizing oversight of state veterans homes by shifting responsibilities for many tasks previously conducted by the 105 representatives at the VAMC of jurisdiction to four new national program managers in its own office. For example, the national program managers are now responsible for reviewing corrective action plans and managing information in VA's data system. VA officials said that centralizing state veterans home oversight at the national level in GEC would help improve data consistency, communication, and planning. Further, all responsibilities for state veterans home oversight at VA- which also include managing the contractors, making per diem payments, and administering state veterans home construction grants-would be aligned within the same national office. The new oversight process represents a significant shift in GEC's oversight policies and affects both VA stakeholders at the VAMC-level and state veterans home stakeholders who have previously worked closely with their VAMCs of jurisdiction on VA oversight issues. However, we found that GEC has not followed VA's directive for national policy development, which requires policy owners to take certain steps for VA policy development, distribution, communication, and management. VA developed the directive for national policy development in response to being placed on our High Risk List in February 2015 for having "ambiguous policies and inconsistent processes," among other things. 55See 42 U.S.C. §§ 1395i-3(h)(2)(B), 1396r(h)(3)(C); 42 C.F.R. § 488.406 (2021). Page 28 GAO-23-105167 VA Oversight of State Veterans Homes Specifically, VA issued a policy management directive outlining the processes program offices, such as GEC, must follow when developing policy or making policy changes.§*¢ In particular, VA policy development efforts should include a formal review and concurrence process when directives, such as GEC's state veterans home oversight directive, are being updated or changed. Further, if policy needs to be communicated to stakeholders quickly, a VA notice may be published as an interim policy document. When GEC began implementing this oversight change in January 2022, it used what officials described as "operating procedures" that were agreed upon in conversations with and shared in PowerPoint presentations to communicate the change with VAMC and selected stakeholders. GEC Officials said they plan to make changes to directives and regulations, which are formal documents available to all stakeholders, but making these changes can be a multi-year process. For example, GEC officials indicated that they would update the VA directive with the significant changes in state veterans home oversight in the first quarter of fiscal year 2023 (9 months after the changes were operationalized) and that they anticipate submitting draft regulations to the VA Office of Regulatory Affairs by end of fiscal year 2023. Neither the PowerPoint presentations nor the conversations with VAMC and state veterans home officials meet VA's requirements for communicating national policy, designed to avoid ambiguous and inconsistent processes. VA's requirements for national policy can help ensure necessary communication between VA and stakeholders. For example, if VA issued an interim notice describing the oversight changes (per the directive, a notice can be considered an interim policy document while directives are being completed), that notice would be posted internally and externally for all stakeholders to view.5" However, as of September 2022, an interim notice has not been issued. As a result, the old directive outlining state veterans home oversight is still publicly available and the policy of record, even though it describes many processes that have since been replaced 56Department of Veterans Affairs, Veterans Health Administration (VHA), VHA Policy Management, VHA Directive 0999 (Washington, D.C.: Mar. 29, 2022). This directive integrates policies that were in place prior to GEC's efforts to centralize its oversight of state veterans homes. 57According to VA, it worked with the National Association of State Veterans Homes as it began to implement changes and shared information at national conferences. However, without formal documentation, communication with individual state veterans homes may have been inconsistent and outside of VA's control. Page 29 GAO-23-105167 VA Oversight of State Veterans Homes Conclusions Recommendations for Executive Action such as the roles of VAMCs, GEC, and data management. Because of this, there is a risk that state veterans home stakeholders-particularly stakeholders within the 153 homes-have inconsistent, incorrect, or incomplete information on the new oversight procedures. When asked in September 2022 whether they were using the directive to guide the centralization efforts, VA officials said they had not been but that they would use the policy to guide their centralization efforts moving forward. Using VA policy to guide efforts moving forward-including following its requirement to issue an interim notice that would publicly communicate changes to stakeholders and then pursuing in earnest the formalization of the oversight in official directives and regulations-could help ensure successful implementation of this effort to centralize state veterans home oversight. VA conducts important oversight of state veterans homes through its inspection processes. This oversight is designed to ensure that the 14,500 veterans for whom VA pays for care live in homes that meet VA's quality standards. However, the department could enhance its oversight of state veterans homes, and VA has taken some steps to do so. VA plans to replace its antiquated data system, but it is important that the new system has the capabilities to allow for efficient analysis of state veterans home compliance with quality standards. Additionally, VA needs a process to monitor the implementation of corrective action plans so it has information on the steps homes are taking to address issues of noncompliance. VA recognizes some of its limitations in ensuring state veterans homes comply with its quality standards and is considering making legislative requests for additional enforcement authorities. As CMS has, VA may find that a range of enforcement actions allow for remedies to be tailored to the scope and severity of cited deficiencies. Finally, VA has taken important steps to centralize its oversight of state veterans homes for improved consistency in the process. Appropriately documenting and communicating the changes to stakeholders, as required by VA policy, would help to ensure successful implementation of these changes. We are making the following four recommendations to VA: The Under Secretary of Health should develop a plan to ensure the data system it is currently developing has the capabilities to aggregate and analyze state veterans home data by multiple units of measurement, including by state and home, and across survey years. (Recommendation 1) Page 30 GAO-23-105167 VA Oversight of State Veterans Homes Agency Comments and Our Evaluation The Under Secretary of Health should implement a process for consistently following up with state veterans homes that have not implemented their corrective active plans by the agreed upon dates. (Recommendation 2) The Under Secretary of Health should identify additional enforcement actions that would help ensure state veterans home compliance with quality standards and seek legislative authority to implement those actions, as appropriate. (Recommendation 3) The Under Secretary of Health should ensure GEC's centralization efforts align with VA's policies for national policy management, such as by issuing an interim notice to communicate the oversight changes to all stakeholders and pursuing the expeditious formalization of the new oversight in official directives and regulations. (Recommendation 4) We provided a draft of this report to VA for review and comment. In written comments provided by VA (reproduced in appendix VI), VA generally agreed with our findings and concurred with our recommendations. Specifically, VA concurred in principle with our recommendation that it develop a plan to ensure its data systems has the capabilities to aggregate and analyze state veterans homes inspection data. VA noted that it may need to request funding if the newly developed integrated operational platform does not have this technical capability. VA concurred with the remaining three recommendations. VA officials said they would update the standard operating procedures to outline a process to ensure follow up with state veterans homes that have not implemented their corrective action plans and update its internal tracking documents to include this information so VA's national program managers will be alerted if evidence is not submitted. To address our recommendation that VA identify additional enforcement actions that would help ensure state veterans homes' compliance with quality standards and seek legislative authority to implement those actions, VA indicated that it planned to create a legislative proposal to include enforcement actions that would be based on the level and severity of noncompliance. VA would also make any necessary updates to its regulations. Page 31 GAO-23-105167 VA Oversight of State Veterans Homes Finally, VA indicated that it would issue an interim notice on its oversight changes to address our recommendation. Once formal rulemaking has been implemented, VA will make changes to its directive and regulations. VA also provided technical comments, which we incorporated as appropriate. We are sending copies of this report to the appropriate congressional committees, the Secretary 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 staff have any questions about this report, please contact me at (202) 512-7114 or at SilasS@gao.gov. Contact points for our Office of Congressional Relations and Office of Public Affairs can be found on the last page of this report. Other major contributors to this report are listed in appendix VII. Bho Sx Sharon M. Silas Director, Health Care Page 32 GAO-23-105167 VA Oversight of State Veterans Homes List of Addressees The Honorable Jon Tester Chairman Committee on Veterans' Affairs United States Senate The Honorable Martin T. Heinrich Chairman The Honorable John Boozman Ranking Member Subcommittee on Military Construction, Veterans Affairs, and Related Agencies Committee on Appropriations United States Senate The Honorable Debbie Wasserman Schultz Chairwoman The Honorable John R. Carter Ranking Member Subcommittee on Military Construction, Veterans Affairs, and Related Agencies Committee on Appropriations House of Representatives The Honorable Chris Pappas Chairman Subcommittee on Oversight and Investigations Committee on Veterans' Affairs House of Representatives The Honorable Robert P. Casey, Jr. United States Senate The Honorable Edward J. Markey United States Senate The Honorable Pat Toomey United States Senate The Honorable Elizabeth Warren United States Senate Page 33 GAO-23-105167 VA Oversight of State Veterans Homes Appendix |: Federal Oversight of State Veterans Homes The Department of Veterans Affairs (VA) is the only federal entity to conduct oversight of all state veterans homes. The Centers for Medicare & Medicaid Services (CMS) conducts additional oversight in the nearly 76 percent of state veterans homes that provide nursing home care and receive Medicare or Medicaid payments. In general, VA used the CMS model for developing its inspection methods according to VA documents, but the two agencies' oversight methods have some differences. See table 1 below for a description of the methods VA and CMS use in their oversight of state veterans homes. Applicable terms, where they differ, appear in bold in the table below. Cs Table 1: Federal State Veterans Home Oversight Methods Used by the Department of Veterans Affairs (VA) and the Centers for Medicare & Medicaid Services (CMS) Oversight method VA description CMS description Initial certification -« Recognition Survey is a home's first VA inspection Required to be eligible to receive payments from VA Review requirements related to the appropriate level of care standards Reviews compliance with federal, state, and local laws and relevant professional standards Certification Survey is a home's first CMS inspection Required to be eligible to receive payments from CMS Focuses on residents and the structural requirements that relate to qualification standards Recurring ° inspection Annual Survey occurs on a regular schedule, approximately yearly Verifies state veterans homes' eligibility to continue to receive VA payments Checks compliance with 189 standards across 16 categories, such as quality of care and a fiscal component The Standard Survey occurs every 15 months or less Checks compliance with standards that are grouped into 22 categories, such as resident rights, quality of life, resident assessment, quality of care, and administration; no fiscal component? Inspections on ° particular area(s) of concern For-Cause Surveys are a full inspection, but focus on specific events that prompted the inspection Typically reviews a significant concern, or a series of incidents, complaints, deficiencies, or events that may jeopardize the health or safety of residents Abbreviated Standard Surveys do not include all aspects of the Standard Survey Focus on particular tasks that relate to, for example, complaints received or a change of ownership, management, or director of nursing. Consequences of » not meeting standards State veterans homes receive a deficiency for any standard that is "not met" during any inspection Deficiency is rated for its scope and severity using a matrix adapted from CMS® Home is notified of any deficiencies within 20 business days of the end of the inspection Extended Survey conducted within 14 days after completing the Standard Survey if substandard quality of care was found during the Standard Survey Partial Extended Survey conducted if substandard quality of care was found during an Abbreviated Standard Survey or revisit (see below) that was not previously identified Page 34 GAO-23-105167 VA Oversight of State Veterans Homes Appendix |: Federal Oversight of State Veterans Homes Oversight method VA description CMS description Tracking of « VA medical facility of jurisdiction requests the +« CMS issues Statement of Deficiencies and Plan of deficiencies and state veterans home to submit a Corrective Correction (Form CMS-2567) to the state veterans home outcomes Action Plan to address any identified that includes summary of deficiencies cited (For deficiencies deficiencies, no later than 20 business days =, Home uses the same form to submit plan to correct the that do not pose upon receipt of the letter deficiency immediate * VA reviews and approves the plans foreach. pogt-Survey Revisit verifies correction of deficiencies jeopardy to deficiency cited in a prior inspection resident health or safety) If the plan is not acceptable-because it does not address the deficiency or cannot be completed in a reasonable time period-then the home submits a revised plan Provisional certification granted when VA has approved the plan Full certification granted when VA receives evidence from the home that the plan was implemented Enforcement actions for continued noncompliance include: Continued noncompliance after 3 months from the date of the inspection that first determined noncompliance must result in denial of payments for new admissions Continued noncompliance after 6 months from the date of the inspection that first determined noncompliance results in termination of provider agreements Tracking of deficiencies that pose immediate Findings shared with VA's Office of Geriatrics and Extended Care, which will determine if the findings indicate an immediate jeopardy May be identified during standard, abbreviated standard, extended, or partial extended surveys If immediate jeopardy is not removed, termination and/or jeopardy situation within an hour of receiving the temporary management will be imposed in as few as 2 information calendar days after the inspection which determined e After determination, the VA inspection team is immediate jeopardy and provider agreement must be not allowed to leave the home until the home terminated no later than 23 calendar days from the last submits an acceptable corrective action plan day of the inspection to abate it » The home submits an allegation that the immediate jeopardy has been removed and describes how the immediate jeopardy has been addressed so that removal of the immediate jeopardy can be verified onsite e (See "penalties/enforcement actions" below for more about CMS' immediate jeopardy actions) Penalties/ e According to VA officials: e Penalties imposed for deficiencies vary based on factors enforcement e - Withhold per-diem payments if including whether a deficiency is classified as causing actions immediate jeopardy to resident health or safety deficiency is egregious, the home makes no attempt to fix the deficiency, and the home has a history of well- documented non-compliance VA Secretary must approve such an action Daily or per instance penalties for deficiencies imposed Higher daily penalties for deficiencies with immediate jeopardy Payments may be denied for new admissions for continued noncompliance Public reporting Information on the quality of all state veterans homes not publicly available® Each nursing home has a five-star quality rating which is publicly reported on Nursing Home Care Compare website, among other information Ratings have three components-inspections, quality measures, and staffing measuring (staffing levels and staffing turnover}-and an overall quality rating Page 35 GAO-23-105167 VA Oversight of State Veterans Homes Appendix |: Federal Oversight of State Veterans Homes Oversight method VA description CMS description Oversight of e« Among other things, VA's contract stipulates + Conducts comparative inspections of some nursing contractors (VA) that: homes to compare its results to the state agency's results and state « 10 percent of inspections have VA direct »« May accompany state inspectors to directly observe them inspection observations, during inspections-to evaluate the performance and agencies (CMS) | a samples 50 percent of inspection reports ability to document inspection deficiencies and reviews for any needed corrections; « VA validates 90 percent of inspection reports for timely submission; « VA reviews monthly status reports and quarterly reports from the contractor to assure they include all needed elements; and e VAreviews any feedback that homes provide on the inspection process Source: GAO analysis of VA and CMS information. | GAO-23-105167 *See 42 C.F.R. Part 483, Subpart B (2021). 'Completed VA inspections, and all supporting documentation, are stored in a database, the State Home Online Survey Tool. "Scope" generally refers to whether the deficiency is isolated to one patient or widespread, and "severity" generally refers to whether the deficiency can cause injury, harm, impairment, or death. °GAO previously recommended that VA should provide publicly available information on all state veterans homes-information that it has available for other nursing home settings. See GAO-19-428. 4See Centers for Medicare & Medicaid Services, Nursing Home Care Compare website, accessed July 27, 2022, https:/Avwww.medicare.gov/care-compare/. Additionally, the state agency must make Form CMS-2567 available with noted deficiencies and corrective action plans, as well as separate listings of any notice of isolated deficiencies, within 14 days of a request for the information. Page 36 GAO-23-105167 VA Oversight of State Veterans Homes Appendix II: State Veterans Homes That Provide Nursing Home Care In All 50 States and Puerto Rico To obtain information about state veterans homes that provide nursing home care in each state, we conducted a national survey (March through April 2022) to officials from state agencies that operate state veterans homes in all 50 states and Puerto Rico (Washington, D.C., does not have any of these homes). Table 2 lists information respondents provided in the survey about all 153 state veterans homes that provide nursing home care and were recognized by the Department of Veterans Affairs as of the date of survey completion, including their location, number of nursing home beds, whether they are certified by the Centers for Medicare & Medicaid Services (CMS), and whether they are managed directly by the state or by a contractor. Table 2: States' Responses to GAO Survey Questions on Information About State Veterans Homes Providing Nursing Home Care in Each State, as of March-April 2022 State State veterans home State veterans Certified Managed by Accredited by Number of name home location by CMS state agency Joint nursing or Commission? home beds contractor Alabama Bill Nichols State Alexander City No Contractor No 150 Veterans Home Colonel Robert L. Howard Pell City No Contractor No 174 State Veterans Home Floyd E. "Tut" Fann State Huntsville No Contractor No 150 Veterans Home William F. Green State Bay Minette No Contractor No 150 Veterans Home Alaska Alaska Veterans' & Palmer No State No 14 Pioneers' Home Arizona Phoenix State Veteran Phoenix Yes State No 200 Home Tucson State Veteran Tucson Yes State Yes 120 Home Arkansas Arkansas State Veterans Fayetteville Yes State No 90 Home at Fayetteville Arkansas State Veterans Little Rock Yes State No 96 Home at Little Rock California Veterans Home of Barstow Yes State No 100 California - Barstow The table is accurate for each state as of the date they completed their survey in March- April 2022. We excluded state veterans homes states reported that either do not provide nursing home care (i.e., state veterans homes that provide domiciliary care only) or that were not operational and recognized by the Department of Veterans Affairs as of the date of survey completion. Page 37 GAO-23-105167 VA Oversight of State Veterans Homes Appendix Il: State Veterans Homes That Provide Nursing Home Care In All 50 States and Puerto Rico State State veterans home State veterans Certified Managed by Accredited by Number of name home location by CMS state agency Joint nursing or Commission? home beds contractor Veterans Home of Chula Vista Yes State No 180 California - Chula Vista Veterans Home of Fresno Yes State No 120 California - Fresno Veterans Home of Redding Yes State No 60 California - Redding Veterans Home of Los Angeles Yes State No 312 California - West Los Angeles Veterans Home of Yountville Yes State No 336 California - Yountville Colorado Bruce McCandless VCLC Florence Yes State No 105 Spanish Peaks VCLC Walsenburg Yes Contractor No 120 VCLC at Fitzsimons Aurora Yes State No 180 VCLC at Homelake Monte Vista Yes State No 60 VCLC at Rifle Rifle Yes State No 89 Connecticut Department of Veterans Rocky Hill Yes State No 125 Affairs Delaware Delaware Veteran's Milford Yes State No 144 Home Florida Baldomero Lopez State | Land O' Lakes Yes State No 120 Veterans' Nursing Home Chester Sims State Panama City Yes State No 120 Veterans' Nursing Home Clyde E. Lassen State St. Augustine Yes State No 120 Veterans' Nursing Home Douglas Jacobson State Port Charlotte Yes State No 120 Veterans' Nursing Home Emory Bennett State Daytona Beach Yes State No 120 Veterans' Nursing Home Sandy Nininger State Pembroke Pines Yes State No 120 Veterans' Nursing Home Georgia Georgia War Veterans Milledgeville No Contractor Yes 375 Home Georgia War Veterans Augusta No State Yes 192 Nursing Home Hawaii Yukio Okutsu State Hilo Yes Contractor No 95 Veterans Home Idaho Idaho State Veterans Boise Yes State No 122 Home - Boise Page 38 GAO-23-105167 VA Oversight of State Veterans Homes Appendix Il: State Veterans Homes That Provide Nursing Home Care In All 50 States and Puerto Rico State State veterans home State veterans Certified Managed by Accredited by Number of name home location by CMS state agency Joint nursing or Commission? home beds contractor Idaho State Veterans Lewiston Yes State No 66 Home - Lewiston Idaho State Veterans Pocatello Yes State No 66 Home - Pocatello Illinois Illinois Veterans' Home at Anna No State No 49 Anna Illinois Veterans' Home at LaSalle No State No 190 LaSalle Illinois Veterans' Home at Manteno No State No 294 Manteno Illinois Veterans' Home at Quincy No State No 382 Quincy Indiana Indiana Veterans Home West Lafayette Yes State No 212 lowa lowa Veterans Home Marshalltown Yes State No 387 Kansas Kansas Soldiers Home Fort Dodge Yes State No 56 Kansas Veterans Home _- Winfield Yes State No 97 Kentucky Carl M Brashear Radcliff Radcliff Yes State No 120 Veterans Center Joseph E. Ballard Hanson Yes State No 156 Western Kentucky Veterans Center Paul E Patton Eastern Hazard Yes State No 120 Kentucky Veterans Center Thomson-Hood Veterans Wilmore Yes State No 285 Center Louisiana Louisiana Veterans Home Jackson Yes State No 129 Northeast LA Veterans Monroe Yes State No 156 Home Northwest LA Veterans Bossier City Yes State No 156 Home Southeast LA Veterans Reserve Yes State No 156 Home Southwest LA Veterans Jennings Yes State No 156 Home Maine Maine Veterans' Home- Augusta Yes State No 108 Augusta Maine Veterans' Home- Bangor Yes State No 120 Bangor Maine Veterans' Home - Caribou Yes State No 40 Caribou Page 39 GAO-23-105167 VA Oversight of State Veterans Homes Appendix Il: State Veterans Homes That Provide Nursing Home Care In All 50 States and Puerto Rico State State veterans home State veterans Certified Managed by Accredited by Number of name home location by CMS state agency Joint nursing or Commission? home beds contractor Maine Veterans' Home - Scarborough Yes State No 120 Scarborough Maine Veterans' Home - South Paris Yes State No 62 South Paris Maryland Charlotte Hall Veterans = Charlotte Hall Yes Contractor No 318 Home Massachusetts Soldiers Home in Chelsea Yes State Yes 189 Chelsea Soldiers Home in Holyoke Holyoke No State Yes 234 Michigan Michigan Veteran Homes Marquette Yes State No 184 - D.J. Jacobetti Michigan Veteran Homes Grand Rapids Yes State No 128 at Grand Rapids Michigan Veteran Homes_ Chesterfield Yes State No 128 at Chesterfield Township Township Minnesota MN State Veterans Home Minneapolis Yes State No 350 - Minneapolis MN State Veterans Home Fergus Falls Yes State No 106 - Fergus Falls MN State Veterans Home Luverne Yes State No 85 - Luverne MN State Veterans Home _ Silver Bay Yes State No 83 - Silver Bay Mississippi Mississippi Veterans Collins No State No 150 Home at Collins Mississippi Veterans Jackson No State No 150 Home at Jackson Mississippi Veterans Kosciusko No State No 150 Home at Kosciusko Mississippi Veterans Oxford No State No 150 Home at Oxford Missouri Missouri Veterans Home Cameron No State No 200 - Cameron Missouri Veterans Home Cape Girardeau No State No 150 - Cape Girardeau Missouri Veterans Home Mexico No State No 150 - Mexico Missouri Veterans Home Mt Vernon No State No 200 - Mt. Vernon Page 40 GAO-23-105167 VA Oversight of State Veterans Homes Appendix Il: State Veterans Homes That Provide Nursing Home Care In All 50 States and Puerto Rico State State veterans home State veterans Certified Managed by Accredited by Number of name home location by CMS state agency Joint nursing or Commission? home beds contractor Missouri Veterans Home St James No State No 150 - St. James Missouri Veterans Home _ St Louis No State No 188 - St. Louis Missouri Veterans Home Warrensburg No State No 200 - Warrensburg Montana Eastern Montana Glendive Yes Contractor No 80 Veterans Home Montana Veteran's Home Columbia Falls Yes State No 105 Southwest Montana Butte Yes Contractor No 60 Veterans Home Nebraska Central Nebraska Kearney No State No 225 Veterans Home Eastern Nebraska Bellevue No State No 120 Veterans Home Norfolk Veterans Home Norfolk No State No 159 Western Nebraska Scottsbluff No State No 62 Veterans Home Nevada Northern Nevada State Sparks Yes Contractor No 96 Veterans Home Southern Nevada State Boulder City Yes State No 180 Veterans Home New New Hampshire Veterans _ Tilton No State No 250 Hampshire Home New Jersey Menlo Park Veterans Edison Yes State No 328 Home Paramus Veterans Home Paramus Yes State No 336 Vineland Veterans Home Vineland Yes State No 330 New Mexico Fort Bayard State Silver City Yes State No 40 Veterans' Home New Mexico State Truth or Yes State No 135 Veterans' Home Consequences New York Long Island State Stony Brook Yes State No 350 Veterans Home NYS Veterans Home at Batavia Yes State No 126 Batavia NYS Veterans Home at Montrose Yes State No 252 Montrose NYS Veterans Home at Oxford Yes State No 242 Oxford Page 41 GAO-23-105167 VA Oversight of State Veterans Homes Appendix Il: State Veterans Homes That Provide Nursing Home Care In All 50 States and Puerto Rico State State veterans home State veterans Certified Managed by Accredited by Number of name home location by CMS state agency Joint or Commission? home beds contractor NYS Veterans Home, St. Jamaica Yes State No 250 Albans North Carolina Black Mountain State Black Mountain Yes Contractor Yes 100 Veterans Home Fayetteville State Fayetteville Yes Contractor Yes 150 Veterans Home Kinston State Veterans Kinston Yes Contractor Yes 100 Home Salisbury State Veterans Salisbury Yes Contractor Yes 99 Home North Dakota ND Veterans Home Lisbon Yes State No 52 Ohio Ohio Veterans Home Georgetown Yes State No 168 Ohio Veterans Home Sandusky Yes State No 427 Oklahoma Ardmore Veterans Center Ardmore No State No 175 Claremore Veterans Claremore No State No 302 Center Clinton Veterans Center Clinton No State No 148 Lawton/Fort Sill Veterans Lawton No State No 200 Center Norman Veterans Center Norman No State No 301 Sulphur Veterans Center Sulphur No State No 122 Talihina Veterans Center Talihina No State No 175 Oregon Oregon Veterans' Home -__ Lebanon Yes Contractor No 154 Lebanon Oregon Veterans' Home _ The Dalles Yes Contractor No 151 The Dalles Pennsylvania Delaware Valley Veterans Philadelphia Yes State No 130 Home Gino Merli Veterans Scranton Yes State No 196 Center Hollidaysburg Veterans Hollidaysburg Yes State No 257 Home Pennsylvania Soldiers & Erie Yes State No 107 Sailors Home Southeastern Veterans Spring City Yes State No 238 Center Southwestern Veterans _' Pittsburgh Yes State No 236 Center Puerto Rico La Casa Del Veterano Juana Diaz No Contractor No 120 Rhode Island RI Veterans Home Bristol No State No 192 Page 42 GAO-23-105167 VA Oversight of State Veterans Homes Appendix Il: State Veterans Homes That Provide Nursing Home Care In All 50 States and Puerto Rico State State veterans home State veterans Certified Managed by Accredited by Number of name home location by CMS state agency Joint nursing or Commission? home beds contractor South Carolina CM Tucker Jr Nursing Columbia Yes State No 90 Care Center E. Roy Stone Pavilion Richard M Campbell Anderson Yes Contractor No 220 Veterans Nursing Home Veterans' Victory House Walterboro Yes Contractor No 220 South Dakota Michael J Fitzmaurice Hot Springs Yes State No 78 State Veterans Home Tennessee Ben Atchley State Knoxville Yes State No 140 Veterans Home Brigadier General Clarksville Yes State No 108 Wendell H. Gilbert Tennessee State Veterans Home Tennessee State Murfreesboro Yes State No 140 Veterans Home - Murfreesboro William D. Manning Humboldt Yes State No 140 Tennessee State Veterans Home Texas Alfredo Gonzalez Texas McAllen Yes Contractor No 160 State Veterans Home Ambrosio Guillen Texas El Paso Yes Contractor No 160 State Veterans Home Clyde W. Cosper Texas Bonham Yes Contractor No 160 State Veterans Home Frank M. Tejeda Texas Floresville Yes Contractor No 160 State Veterans Home Lamen-Lusk-Sanchez Big Spring Yes Contractor No 160 Texas State Veterans Home Richard A. Anderson Houston Yes Contractor No 120 Texas State Veterans Home Ussery-Roan Texas State Amarillo Yes Contractor No 120 Veterans Home Watkins-Logan Texas Tyler Yes Contractor No 100 State Veterans Home William R. Courtney Temple Yes Contractor No 160 Texas State Veterans Home Utah George E. Wahlen Ogden Ogden Yes Contractor No 120 Veterans Home Page 43 GAO-23-105167 VA Oversight of State Veterans Homes Appendix Il: State Veterans Homes That Provide Nursing Home Care In All 50 States and Puerto Rico State State veterans home State veterans Certified Managed by Accredited by Number of name home location by CMS state agency Joint nursing or Commission? home beds contractor Mervyn Sharp Bennion Payson Yes Contractor No 108 Veterans Home Southern Utah Veterans _ Ivins Yes Contractor No 108 Home William E. Christoffersen Salt Lake City Yes Contractor No 81 Veterans Home Vermont Vermont Veterans Home Bennington Yes State No 130 Virginia Sitter & Barfoot Veterans Richmond Yes State No 200 Care Center Virginia Veterans Care Roanoke Yes State No 196 Center Washington Spokane Veterans Home Spokane Yes State No 100 Walla Walla Veterans Walla Walla Yes State No 80 Home Washington Soldiers Orting Yes State No 97 Home Washington Veterans Port Orchard Yes State No 240 Home West Virginia WV Veterans Nursing Clarksburg No State No 120 Facility Wisconsin Wisconsin Veterans Chippewa Falls Yes Contractor No 72 Home Chippewa Falls Wisconsin Veterans King Yes State No 521 Home King Wisconsin Veterans Union Grove Yes State No 158 Home Union Grove Source: GAO. | GAO-23-105167 Note: We excluded state veterans homes states reported that either do not provide nursing home care (i.e., state veterans homes that provide domiciliary care only) or that were not operational and recognized by the Department of Veterans Affairs as of the date of survey completion. Additionally, Wyoming is excluded from this table because the state reported not having any state veterans homes that provide nursing home care. ®The Joint Commission is a nonprofit organization that provides voluntary health care accreditation for hospitals using standards that address a facility's level of performance in areas such as patient rights, patient treatment, and infection control. Page 44 GAO-23-105167 VA Oversight of State Veterans Homes Appendix III: State Policies for State Veterans Home Oversight and Summary of These Homes in Each State To obtain information that included state-specific policies for state veterans home oversight, we conducted a national survey (March through April 2022) of officials from state agencies that operate state veterans homes in all 50 states and Puerto Rico. Table 3 shows policies that officials in each state reported their state has for oversight of their state veterans homes that provide nursing home care, and it has summary information about all state veterans homes in each state. Table 3: States' Responses to GAO Survey Questions on State Policies for State Veterans Home Oversight and Summary of State Veterans Homes in Each State State oversight policies State veterans homes State Requires Has state- Conducts Requires Has abilityto Number Number Number license for specific state- state-specific take at least providing managedby certified by state veterans regulations specific for- corrective one type of nursing contractor' Centers for home for nursing cause action plans enforcement home care Medicare & administrators home quality inspections action? Medicaid Services AK Yes No Yes Yes No 1 0 0 AL Yes Yes Yes Yes Yes 4 4 0 AR Yes Yes Yes Yes Yes 2 0 2 AZ Yes Yes No Yes No 2 0 2 CA No Yes Yes Yes Yes 6 0 6 CO Yes Yes Yes Yes Yes 5 1 5 CT Yes Yes Yes Yes Yes 1 0 1 DE Yes Yes Yes Yes Yes 1 0 1 FL Yes Yes Yes Yes Yes 6 0 6 GA Yes Yes Yes Yes Yes 2 1 0 HI Yes Yes Yes Yes Yes 1 1 1 IA Yes No Yes Yes Yes 1 0 1 ID Yes Yes No No Yes 3 0 3 IL Yes No Yes Yes Yes 4 0 0 IN Yes Yes Yes Yes Yes 1 0 1 KS Yes No Yes Yes No 2 0 2 KY Yes No Yes Yes Yes 4 0 4 LA Yes No No N/AS N/A 5 0 5 MA No Yes Yes Yes Yes 2 0 1 MD Yes Yes Yes Yes Yes 1 1 1 ME Yes Yes Yes Yes Yes 5 0 5 MI Yes Yes No Yes Yes 3 0 3 MN Yes No No N/A N/A 4 0 4 Page 45 GAO-23-105167 VA Oversight of State Veterans Homes Appendix Ill: State Policies for State Veterans Home Oversight and Summary of These Homes in Each State State oversight policies State veterans homes State Requires Has state- Conducts Requires Has ability to Number Number Number license for specific state- state-specific take at least providing managedby certified by state veterans regulations specific for- corrective one type of nursing contractor' Centers for home for nursing cause action plans enforcement home care Medicare & administrators home quality inspections action? Medicaid Services MO Yes No No N/A N/A 7 0 0 MS Yes Yes Yes Yes Yes 4 0 0 MT Yes No Yes Yes Yes 3 2 3 NC Yes No Yes Yes Yes 4 4 4 ND Yes Yes Yes Yes Yes 1 0 1 NE Yes Yes Yes Yes Yes 4 0 0 NH Yes No No N/A N/A 1 0 0 NJ Yes Yes Yes Yes Yes 3 0 3 NM _ Yes No No N/A N/A 2 0 2 NV Yes No No N/A N/A 2 1 2 NY Yes Yes Yes Yes Yes 5 0 5 OH Yes Yes Yes Yes Yes 2 0 2 OK Yes No Yes Yes No 7 0 0 OR Yes Yes No Yes Yes 2 2 2 PA Yes Yes Yes Yes Yes 6 0 6 PR Yes Yes Yes Yes Yes 1 1 0 RI Yes No Yes Yes Yes 1 0 0 SC Yes Yes Yes Yes Yes 3 2 3 SD Yes Yes Yes Yes Yes 1 0 1 TN Yes Yes Yes Yes Yes 4 0 4 TX Yes Yes Yes Yes Yes 9 9 9 UT Yes No No N/A N/A 4 4 4 VA Yes Yes Yes Yes No 2 0 2 VT Yes Yes Yes No Yes 1 0 1 WA Yes Yes Yes Yes Yes 4 0 4 wi Yes No Yes Yes No 3 1 3 WV Yes Yes Yes Yes Yes 1 0 0 WY N/AS N/A N/A N/A N/A 0 0 0 Legend: N/A = not applicable Source: GAO, | GAO-23-105167 ®See Table 4 for more information about enforcement actions available to the states as reported in the survey. >The state veterans homes not reported as contractor-managed were reported to be managed by a state agency. Page 46 GAO-23-105167 VA Oversight of State Veterans Homes Appendix Ill: State Policies for State Veterans Home Oversight and Summary of These Homes in Each State °State-specific corrective action plans and enforcement actions do not apply to the seven states that reported they do not have state-specific nursing home quality regulations or for-cause surveys- Louisiana, Minnesota, Missouri, Nevada, New Hampshire, New Mexico, and Utah. 'The state oversight questions do not apply to Wyoming because it reported not having any state veterans homes that provide nursing home care. Of the 43 states that reported assessing state-specific nursing home quality regulations and/or conducting their own for-cause inspections, 37 states reported they have the option to take one or more enforcement actions if a state veterans home does not meet state standards. Table 4 shows each state's response to which enforcement actions, if any, are available to their state. Table 4: Survey Responses on Enforcement Actions Available to the States for Conducting Oversight of State Veterans Homes State None Issue fines Withhold state Suspend Managed Close the Other and/or payments/fund admissions - temporarily by home monetary s a different penalties state agency AK Vv _- _- _- _- - - Probational license or termination of AL _ _ _ _ _ Vv license. AR _- Vv _- _- _- _- - AZ Vv _- _- _- _- - - CA _- Vv Vv Vv _- Vv _- co _- _- _- _- Vv Vv _- CT - v - Vv - Vv - DE - Vv Vv Vv Vv Vv - FL _- Vv Vv Vv _- Vv _- GA _- Vv Vv Vv Vv Vv _- HI _- Vv Vv Vv _- Vv _- IA _- Vv v Vv v Vv _- Revoke license. Also issue fine and/or imprisonment for operating a facility without a ID _- _- _- _- _- _- license IL _- Vv v Vv _- _- _- Page 47 GAO-23-105167 VA Oversight of State Veterans Homes Appendix Ill: State Policies for State Veterans Home Oversight and Summary of These Homes in Each State State None Issue fines | Withhold state Suspend Managed Close the Other and/or payments/fund admissions temporarily by home monetary s a different penalties state agency IN - Vv v v - - - KS v - - - - - - KY - Vv - - - Vv - MA - - - Vv - v - MD _- v v v Vv Vv - Take away ME - - - - v Vv license Revoke license to operate as a skilled nursing MI - facility MS _- | | < | < MT - v - - - - NC _- ND _ NE _- NJ _- NY _- NS || | 4114/6 S/S 41 <1) 6 OH _- OK Vv Managed temporarily by a contractor; and applying other restrictions such as total number of OR _- residents Sq PA - q KS PR - RI _ sc _ SD _- TN _- 414114) 416) 416 4] <1) 6) < 4141.) 1616) 476 <1) <) 1 | q1 S114) 61) 606 | TX _- VA < | | | | | | VT _ < < < < < | WA _- < < < < | | Page 48 GAO-23-105167 VA Oversight of State Veterans Homes Appendix Ill: State Policies for State Veterans Home Oversight and Summary of These Homes in Each State State None Issue fines | Withhold state Suspend Managed Close the Other and/or payments/fund admissions temporarily by home monetary s a different penalties state agency WI Vv - - - - - - WV - v - v - v - Totals 6 30 21 27 16 28 - Legend: v = The state indicated having the ability to take the enforcement action. - = The state indicated not having the ability to take the enforcement action, or it indicates "not applicable." Source: GAO | GAO-23-105167 Note: The seven states that reported having neither state-specific nursing home quality regulations nor for-cause inspections are excluded from this table-Louisiana, Minnesota, Missouri, Nevada, New Hampshire, New Mexico, and Utah. Wyoming is also excluded since the state reported not having any state veterans homes that provide nursing home care. Page 49 GAO-23-105167 VA Oversight of State Veterans Homes Appendix IV: Categories of Standards Assessed during VA's Annual Inspection of State Veterans Homes Table 5: Categories of Standards Assessed during VA's Annual Inspection of State Veterans Homes Category Number of standards Example Fiscal 23 Submitting the correct form to VA each month to receive per diem payments Resident rights 23 Putting the results of VA's inspection in a place that is readily accessible to residents Admission, transfer, and discharge 11 Notifying the resident and, if known, a family member or legal representative prior to transferring or discharging a resident Resident behavior and facility 6 The inappropriate use of a sedating psychotropic drug to manage practices or control behavior Quality of life 19 Establishing a council of residents that meet at least quarterly Resident assessment 11 Comprehensive assessments that include describing the resident's capability to perform daily life functions, strengths, performances, needs as well as significant impairments in functional capacity Quality of care 20 Preventing and treating pressure sores Nursing services 5 Providing registered nurses 24 hours per day, 7 days per week Dietary services 8 Employing a qualified dietician on a full-time, part-time, or on a consultant basis Physician services 6 Providing or arranging for the provision of physician services 24 hours a day, 7 days per week, in case of an emergency Specialized rehabilitative services 2 Providing specialized rehabilitative services such as but not limited to physical therapy, speech therapy, occupational therapy, and mental health services for mental illness are required in the resident's comprehensive plan of care Dental services 1 Arranging for transportation to and from dental services Pharmacy services 6 Licensed pharmacist reviews each resident's drug regiment at least once a month Infection control 3 Establishing and maintaining an infection control program Physical environment 12 Maintaining an effective pest control program Administration 33 Having detailed written plans and procedures to meet all potential emergencies and disasters, such as fire, severe weather, and missing residents Source: GAO analysis of Department of Veteran Affairs (VA) data. | GAO-22-105167 Note: VA inspections check for 16 categories of standards-15 in 38 C.F.R. Part 51, Subpart D, and other standards in Subpart C, which VA has previously counted under a single category. Page 50 GAO-23-105167 VA Oversight of State Veterans Homes Appendix V: How CMS Calculates a Nursing Home's Overall Star Rating A nursing home's overall star rating is based on Centers for Medicare & Medicaid (CMS) data and has three components: health inspections, staffing, and quality measures. Specifically, a home's overall star rating is calculated by taking the home's performance (star rating) on the health inspection and adding or subtracting stars depending on the home's performance on staffing and quality measures.1 As table 6 shows, most (87 percent) state veterans homes performed above the median in their state on staffing measures, indicating state veterans homes generally had higher staffing levels per resident compared to other nursing homes. 2 As a result, state veterans home performance on staffing generally increased the number of stars they received for overall quality. Table 6: Performance of State Veterans Homes on CMS's Star Measures for Overall Quality, Health Inspections, Staffing, and Quality Measures Compared to Other Nursing Homes in Their Respective State, as of January 2022 Category Above median Equal to median Below median Overall quality 77 18 16 Health inspections 55 18 38 Staffing 94 7 5 Quality measures 42 29 36 Source: GAO analysis of Centers for Medicare & Medicaid Services (CMS) data. | GAO-22-105167 Note: We chose to base our analysis on how state veteran homes performed relative to the median score of other nursing home in their state because the median splits performance into three groups. For example, if the median score in a state is 3 stars, then homes fall below the median (rated 1-2 stars), at the median (3 stars), or above the median (4-5 stars). 1For additional information about how a home's overall and component star ratings are calculated, see CMS, Design for Care Compare Nursing Home Five-Star Quality Rating System: Technical Users' Guide (Baltimore, Md.: July 2022). 2The source for reported staffing hours is the Payroll-Based Journal system. These data are submitted quarterly and are due 45 days after the end of each reporting period. Only data submitted and accepted by the deadline are used by CMS for staffing calculations and in the Five-Star Rating System. Homes then receive scores across several measures, such as the number of registered nurse hours per resident per day. An individual home's performance on these measures is then assessed against the national distribution of the measures. Page 51 GAO-23-105167 VA Oversight of State Veterans Homes Appendix VI: Comments from the Department of Veterans Affairs DEPARTMENT OF VETERANS AFFAIRS WASHINGTON October 31, 2022 Ms. Sharon M. Silas Director Health Care U.S. Government Accountability Office 441 G Street, NW Washington, DC 20548 Dear Ms. Silas: The Department of Veterans Affairs (VA) has reviewed the Government Accountability Office (GAO) draft report: VA NURSING HOME CARE: Opportunities Exist to Enhance Oversight of State Veterans Homes (GAQ-23-105167). The enclosure contains technical and general comments and the action plan to address the draft report recommendations. VA appreciates the opportunity to comment on the draft report. Sincerely, -- Ta Bodh Tanya J. Bradsher Chief of Staff Enclosure Page 52 GAO-23-105167 VA Oversight of State Veterans Homes Appendix VI: Comments from the Department of Veterans Affairs Enclosure Department of Veterans Affairs (VA) Response to the Government Accountability Office (GAO) Draft Report VA NURSING HOME CARE: Opportunities Exist to Enhance Oversight of States Veteran Home (GAO-23-105167) Recommendation 1: The Under Secretary for Health should develop a plan to ensure the data system it is currently developing has the capabilities to aggregate and analyze state veterans home data by multiple units of measurement, including by state and home, and across survey years. VA Response: Concur in Principle. The Office of Geriatrics & Extended Care, Facility Based Care (GEC-FBC), will explore whether the newly developed Integrated Operational Platform (IOP) has the capabilities to aggregate and analyze State Veterans Homes (SVH) survey data by multiple units of measurement, including by state and home, and across survey years. If the IOP lacks this technical capability, GEC will explore with the Veterans Health Administration's (VHA) Office of Information and Technology what data system options are currently available. If no data system options are currently available, GEC will request the necessary funds through the business forum process for an off-the-shelf product or creation of a custom product for use. Target Completion Date: September 2025 Recommendation 2: The Under Secretary of Health should implement a process for consistently following up with State Veterans Home that have not implemented their corrective action plans by the agreed upon dates. VA Response: Concur. GEC-FBC will implement a process to ensure follow up with SVHs that have not implemented their corrective action plans (CAP) by the agreed upon dates. GEC will update the SVH CAP Process Standard Operating Procedure (SOP) to outline this process. GEC will provide this updated SOP to all SVHs through an educational town hall. Additionally, GEC will provide the updated SOP to all Veterans Integrated Service Networks (VISN) and VA medical centers (VAMC). GEC will update its internal survey process tracker to include the latest proposed completion date in the submitted CAP that was approved by the SVH Program Manager. This tracker will then alert SVH Managers to follow up with SVHs that have not submitted evidence of CAP implementation within 1 month of that identified date. Target Completion Date: March 2023 Page 53 GAO-23-105167 VA Oversight of State Veterans Homes Appendix VI: Comments from the Department of Veterans Affairs Enclosure Department of Veterans Affairs (VA) Response to the Government Accountability Office (GAO) Draft Report VA NURSING HOME CARE: Opportunities Exist to Enhance Oversight of States Veteran Home (GAO-23-105167) Recommendation 3: The Under Secretary of Health should identify additional enforcement actions that would help ensure State Veterans Home compliance with quality standards and seek legislative authority to implement those actions, as appropriate. VA Response: Concur. GEC-FBC will develop a process to notify key stakeholders (both state and VA) based on the level/severity of noncompliance with quality standards. The level of noncompliance will determine the enforcement action. GEC will create a legislative proposal for submission. GEC will operationalize these enforcement actions through changes to 38 C.F.R. Part 51 Federal Regulations. Target Completion Date: December 2025 Recommendation 4: The Under Secretary of Health should ensure GEC's centralization efforts align with VA's policies for national policy management, such as by issuing an interim notice to communicate the oversight changes to all stakeholders and pursuing the expeditious formalization of the new oversight in official directives and regulations. VA Response: Concur. GEC-FBC will issue an interim notice to VISN Network Directors, VAMC Directors and external stakeholders (to include SVHs) on SVH's modernization efforts, to include forthcoming oversight changes. GEC will revise VHA Directive 1145.01, Survey Requirements for State Veterans Homes, to align with SVHs modernization and ensuing oversight changes once formal rulemaking has been implemented. GEC will operationalize these changes in oversight processes through amendments to 38 C.F.R. Part 51 Federal Regulations. Target Completion Date: December 2025 Page 54 GAO-23-105167 VA Oversight of State Veterans Homes Appendix VII: GAO Contact and Staff Acknowledgments GAO Contact Sharon M. Silas, (202) 512-7114 or silass@gao.gov Staff In addition to the contact named above, Karin Wallestad (Assistant Director), Erin C. Henderson (Analyst-in-Charge), Rob Dougherty, Topher Acknowledgments Hoffmann, Eric Peterson, and Jeffrey Tamburello made key contributions to this report. Also contributing were Vikki Porter, Atiya Siddiqi, Amber Sinclair, Karen Vasquez-Romero, Cathy Hamann Whitmore, Jennifer Whitworth, and Kiley Wilson. 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