As More Veterans Turn to Nursing Homes for Care, VA Needs to Improve Oversight

At a time when veterans are increasingly seeking nursing home care, the Veterans Affairs Department needs to improve its inspection practices at the facilities and provide more information on its website about state-run homes for veterans, the Government Accountability Office found. 

As the population of Vietnam veterans ages, VA projects that veterans’ use of nursing home care will grow 16% between 2017 and 2022, the watchdog noted, while veterans’ use of nursing home care grew just 3% from 2012 through 2017.

From February 2018 to July 2019, auditors reviewed department policies and inspections information, and interviewed VA officials for the three types of facilities the department uses to provide care: VA-owned and operated community living centers, state-run veterans homes, and community nursing homes with which VA contracts. GAO made a number of recommendations for how the department, which has one of the country’s largest healthcare delivery systems, can enhance its oversight and provide better information online. 

For a number of reasons, community living centers, which the VA owns, operates and oversees, account for the largest share of the department’s nursing home costs. The facilities, which are associated with VA medical center hospitals, can provide acute care, which is more staff intensive and can require specialized equipment. The auditors found that VA did not consistently perform the required quarterly assessments of contractor performance at the facilities, which risks the quality of care veterans receive. 

While state veterans homes are owned, operated and, in most cases, inspected by the state, VA conducts annual inspections of them. GAO reported that the department is missing a chance to improve oversight by not mandating that state veterans home contractors “identify all failures to meet quality standards as deficiencies during its inspections.” Currently, VA directs contractors to cite minor issues that pose no actual harm to veterans as “recommendations” rather than “deficiencies.” 

Lastly, there are community nursing homes, which can be publicly or privately owned and operated. The Centers for Medicare and Medicaid Services oversees those that receive Medicare or Medicaid funding, and VA requires its medical centers to conduct at least annual reviews of the nursing homes with which they contract. Of the six medical centers GAO auditors visited to review their nursing home oversight practices, all of them conducted additional onsite nursing home inspections. But GAO found that department-level officials had not provided sufficient guidance for medical center staff conducting the onsite reviews. “In the absence of guidance from VA, they had each independently developed their own tools and processes,” GAO found. 

To help veterans and their families understand their nursing home care options, VA provides information on the community living centers and community nursing homes on its Access to Care website, however, the department does not include anything on state veterans homes. Without such information, “veterans and their families are limited in their ability to effectively evaluate all of their options when selecting a nursing home,” the auditors wrote. “Our prior work has shown that effective transparency tools—such as websites that allow consumers to compare the quality of different providers—provide highly relevant information to consumers.”

GAO made four recommendations. The first is to create a plan to monitor contractors’ performance at community living centers and state veterans homes. Next, auditors recommend VA require state veterans home inspectors to denote all “failures to meet quality standards” as “deficiencies,” not “recommendations,” as is currently the practice. Third, auditors said VA should develop guidelines for medical center staff for their onsite inspections of community nursing homes. Lastly, VA should provide information about state-run veterans homes on its website, GAO said. 

The VA generally concurred with the recommendations and described a plan to address the later two. It will issue a memo to clarify and outline guidance for community nursing home inspections. Also, it will look into providing data about state veterans homes on the Access to Care website.