VA Health Care

Efforts to Assure Quality of Care in State Homes Gao ID: HRD-90-40 November 27, 1989

Pursuant to a congressional request, GAO determined whether the Department of Veterans Affairs (VA): (1) inspected state homes frequently enough to evaluate the care veterans received; and (2) used adequate procedures to assess the quality of care provided in state homes. GAO also determined whether VA had implemented three GAO recommendations made in 1981 to: (1) revise its state home inspection standards to provide more specificity and guidance; (2) review VA inspection reports on state homes to ensure standards compliance; and (3) develop standards in surgical care and related services for state home hospital units.

GAO found that: (1) VA requirements for annual inspections were consistent with the general inspection practices of other health care organizations; (2) VA inspection guidelines were adequate, but it did not consistently follow them; and (3) one of the six VA medical centers GAO reviewed did not perform annual inspections properly, and five of the six did not consistently follow up on noted deficiencies to ensure that state homes corrected them. GAO also found that VA: (1) revised its inspection guidelines to provide more specificity and guidance; (2) reviewed all inspection reports to determine whether reports were complete and whether state homes addressed all standards; and (3) did not develop standards on surgical care and related services for state homes' hospital units because it believed that such standards would duplicate those used by the Joint Commission on Accreditation of Healthcare Organizations, which inspected state homes providing surgical care.


Our recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.

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