VA Community Living Centers
Actions Needed to Better Manage Risks to Veterans' Quality of Life and Care Gao ID: GAO-12-11 October 19, 2011The Department of Veterans Affairs (VA) annually provides care to more than 46,000 elderly and disabled veterans in 132 VA-operated nursing homes, called community living centers (CLC). After media reports of problems with the care delivered to veterans in CLCs, VA contracted with the Long Term Care Institute, Inc. (LTCI), a nonprofit organization that surveys nursing homes, to conduct in-depth reviews of CLCs in 2007-2008 and again in 2010-2011. GAO was asked to evaluate VA's approach to managing veterans' quality of care and quality of life in CLCs. This report examines (1) VA's response to and resolution of LTCI-identified deficiencies and (2) information VA collects about the quality of care and quality of life in CLCs and how VA uses it to identify and manage risks. To do this work, GAO interviewed officials from VA headquarters, examined all 116 2007-2008 and 67 2010-2011 LTCI reviews, and analyzed 50 CLCs' corrective action plans for 2007-2008 and 23 such plans for 2010-2011.
VA headquarters established a process for responding to deficiencies identified at CLCs during the 2007 and 2008 LTCI reviews. VA is using the process, which requires CLCs to submit corrective action plans addressing LTCI-identified deficiencies--such as how CLCs will address a lack of competent nursing staff and a failure to provide a sanitary and safe living environment--during the 2010 and 2011 LTCI reviews. On the basis of its analysis of the deficiencies identified in 2007 and 2008, VA headquarters also developed a national training and education initiative. VA headquarters officials told GAO that they plan to analyze the deficiencies identified during the 2010 and 2011 reviews and identify national areas for improvement. However, GAO found weaknesses in VA's process for responding to and resolving LTCI-identified deficiencies. First, VA headquarters does not maintain clear and complete documentation of the feedback it provides to CLCs regarding their corrective action plans. Second, VA headquarters does not require VA's networks, which oversee the operations of VA medical facilities, including CLCs, to report on the status of CLCs' implementation of corrective action plans or to verify CLCs' self-reported compliance with the requirements of the national training and education initiative. Because of these weaknesses, VA headquarters cannot provide reasonable assurance that LTCI-identified deficiencies are resolved. For example, without requiring networks to report on the status of CLCs' implementation of their corrective action plans, VA headquarters cannot determine whether CLCs' corrective action plans are fully implemented. Unaddressed, weaknesses in VA headquarters' process for responding to LTCI-identified deficiencies may compromise the quality of care and quality of life of veterans in CLCs. VA headquarters' current approach to identifying risks associated with the quality of care and quality of life of CLC residents does not comprehensively analyze information from all available sources, and for the sources VA does analyze, it does not compare findings across sources. VA's approach relies significantly on the analysis of findings from LTCI reviews of CLCs. However, in addition to LTCI reviews, VA headquarters obtains information about CLCs from a variety of other sources, such as VA's Office of Inspector General (OIG), but does not analyze the information from all these other sources. Further, for the sources it does analyze, VA headquarters evaluates each source in isolation and does not compare the findings from one source with findings from the other sources. Therefore, VA headquarters' current approach to identifying risks in CLCs may result in missed opportunities to detect patterns and trends in information about the quality of care and quality of life within a CLC or across many CLCs. For example, in comparing findings from VA's Office of the Medical Inspector, OIG, LTCI, and VA's quality indicator and quality measure data for one CLC, GAO found a pattern of deficiencies related to pain management. Without considering information from all available sources and comparing it across sources, VA headquarters cannot fully identify risks in CLCs, estimate the significance of the risks, or take actions to mitigate them. GAO recommends that VA document feedback to CLCs and require periodic status reports about corrective action plan implementation, and implement a process to comprehensively identify and manage risks to residents in CLCs by analyzing and comparing information about residents' quality of care and quality of life. In its comments on a draft of this report, VA concurred with these recommendations.
RecommendationsOur 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.
Director: Randall B. Williamson Team: Government Accountability Office: Health Care Phone: (206) 287-4860GAO-12-11, VA Community Living Centers: Actions Needed to Better Manage Risks to Veterans' Quality of Life and Care
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United States Government Accountability Office:
GAO:
Report to the Ranking Member, Committee on Veterans' Affairs, U.S.
Senate:
October 2011:
VA Community Living Centers:
Actions Needed to Better Manage Risks to Veterans' Quality of Life and
Care:
GAO-12-11:
GAO Highlights:
Highlights of GAO-12-11, a report to the Ranking Member, Committee on
Veterans‘ Affairs, U.S. Senate.
Why GAO Did This Study:
The Department of Veterans Affairs (VA) annually provides care to more
than 46,000 elderly and disabled veterans in 132 VA-operated nursing
homes, called community living centers (CLC). After media reports of
problems with the care delivered to veterans in CLCs, VA contracted
with the Long Term Care Institute, Inc. (LTCI), a nonprofit
organization that surveys nursing homes, to conduct in-depth reviews
of CLCs in 2007-2008 and again in 2010-2011. GAO was asked to evaluate
VA‘s approach to managing veterans‘ quality of care and quality of
life in CLCs. This report examines (1) VA‘s response to and resolution
of LTCI-identified deficiencies and (2) information VA collects about
the quality of care and quality of life in CLCs and how VA uses it to
identify and manage risks. To do this work, GAO interviewed officials
from VA headquarters, examined all 116 2007-2008 and 67 2010-2011 LTCI
reviews, and analyzed 50 CLCs‘ corrective action plans for 2007-2008
and 23 such plans for 2010-2011.
What GAO Found:
VA headquarters established a process for responding to deficiencies
identified at CLCs during the 2007 and 2008 LTCI reviews. VA is using
the process, which requires CLCs to submit corrective action plans
addressing LTCI-identified deficiencies”-such as how CLCs will address
a lack of competent nursing staff and a failure to provide a sanitary
and safe living environment”-during the 2010 and 2011 LTCI reviews. On
the basis of its analysis of the deficiencies identified in 2007 and
2008, VA headquarters also developed a national training and education
initiative. VA headquarters officials told GAO that they plan to
analyze the deficiencies identified during the 2010 and 2011 reviews
and identify national areas for improvement. However, GAO found
weaknesses in VA‘s process for responding to and resolving LTCI-
identified deficiencies. First, VA headquarters does not maintain
clear and complete documentation of the feedback it provides to CLCs
regarding their corrective action plans. Second, VA headquarters does
not require VA‘s networks, which oversee the operations of VA medical
facilities, including CLCs, to report on the status of CLCs‘
implementation of corrective action plans or to verify CLCs‘ self-
reported compliance with the requirements of the national training and
education initiative. Because of these weaknesses, VA headquarters
cannot provide reasonable assurance that LTCI-identified deficiencies
are resolved. For example, without requiring networks to report on the
status of CLCs‘ implementation of their corrective action plans, VA
headquarters cannot determine whether CLCs‘ corrective action plans
are fully implemented. Unaddressed, weaknesses in VA headquarters‘
process for responding to LTCI-identified deficiencies may compromise
the quality of care and quality of life of veterans in CLCs.
VA headquarters‘ current approach to identifying risks associated with
the quality of care and quality of life of CLC residents does not
comprehensively analyze information from all available sources, and
for the sources VA does analyze, it does not compare findings across
sources. VA‘s approach relies significantly on the analysis of
findings from LTCI reviews of CLCs. However, in addition to LTCI
reviews, VA headquarters obtains information about CLCs from a variety
of other sources, such as VA‘s Office of Inspector General (OIG), but
does not analyze the information from all these other sources.
Further, for the sources it does analyze, VA headquarters evaluates
each source in isolation and does not compare the findings from one
source with findings from the other sources. Therefore, VA headquarters‘
current approach to identifying risks in CLCs may result in missed
opportunities to detect patterns and trends in information about the
quality of care and quality of life within a CLC or across many CLCs.
For example, in comparing findings from VA‘s Office of the Medical
Inspector, OIG, LTCI, and VA‘s quality indicator and quality measure
data for one CLC, GAO found a pattern of deficiencies related to pain
management. Without considering information from all available sources
and comparing it across sources, VA headquarters cannot fully identify
risks in CLCs, estimate the significance of the risks, or take actions
to mitigate them.
What GAO Recommends:
GAO recommends that VA document feedback to CLCs and require periodic
status reports about corrective action plan implementation, and
implement a process to comprehensively identify and manage risks to
residents in CLCs by analyzing and comparing information about
residents‘ quality of care and quality of life. In its comments on a
draft of this report, VA concurred with these recommendations.
View [hyperlink, http://www.gao.gov/products/GAO-12-11]. For more
information, contact Randall Williamson at (202) 512-7114 or
williamsonr@gao.gov.
[End of section]
Contents:
Letter:
Background:
VA Headquarters Established a Process for Responding to LTCI-
Identified Deficiencies, but Cannot Provide Reasonable Assurance That
Deficiencies Have Been Resolved:
VA Headquarters Receives Information about CLCs from Multiple Sources,
but Does Not Analyze It to Assess and Manage Risks:
Conclusions:
Recommendations for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: VA Headquarters' Analysis of Information about the Quality
of Life and Care in Community Living Centers:
Appendix II: Comments from the Department of Veterans Affairs:
Appendix III: GAO Contact and Staff Acknowledgments:
Related GAO Products:
Table:
Table 1: Clinical High-Risk Categories Defined by VA Headquarters'
Analysis of Deficiencies Identified in 2007 and 2008 Long Term Care
Institute, Inc., Reviews:
Abbreviations:
CLC: community living center:
LTCI: Long Term Care Institute, Inc.
OIG: Office of Inspector General:
OMI: Office of the Medical Inspector:
PICC: peripherally inserted central catheter:
SOARS: System-wide Ongoing Assessment and Review Strategy:
VA: Department of Veterans Affairs:
VAMC: VA medical center:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
October 19, 2011:
The Honorable Richard Burr:
Ranking Member:
Committee on Veterans' Affairs:
United States Senate:
Dear Senator Burr:
The Department of Veterans Affairs (VA) spent more than $4.5 billion
on nursing home care in fiscal year 2010, over $3.3 billion of which
was for care in 132 VA-operated nursing homes, called community living
centers (CLC).[Footnote 1] CLCs offer a range of services that include
short-term postacute rehabilitation for conditions such as a stroke;
long-term care for veterans who cannot be cared for at home because of
severe and chronic physical or mental limitations; and end-of-life
care for terminal illnesses. More than 46,000 elderly and disabled
veterans annually receive care in CLCs. This vulnerable population
relies on VA to ensure they receive quality care and maintain their
quality of life while residing in a CLC.[Footnote 2]
In 2004, problems related to the care and conditions in one CLC
surfaced in the media, raising concerns about the effectiveness of
VA's efforts to manage the quality of care and quality of life in its
CLCs. In response, VA headquarters had in-depth unannounced reviews
conducted at selected CLCs between August 2004 and November 2006, and
contracted with the Long Term Care Institute, Inc. (LTCI), in March
2007 to conduct in-depth reviews of 116 CLCs.[Footnote 3] LTCI
conducted its reviews between June 2007 and September 2008.[Footnote
4] In late 2009, a series of newspaper articles reported the details
of deficiencies that LTCI had identified at another CLC in September
2008. Specifically, the articles reported a lack of competent skilled
nursing in the CLC as well as failure to provide a sanitary and safe
living environment, promote and protect veterans' rights to autonomy,
and treat veterans with respect and dignity.
Recognizing the value of the information obtained from the in-depth
reviews of CLCs, VA headquarters awarded a second contract in July
2010 to LTCI to begin reviewing all 132 CLCs in September 2010. In
light of this contract and the 2009 newspaper articles, you raised
questions about VA's process for responding to the deficiencies
identified during the LTCI reviews, as well as the agency's overall
approach to managing the quality of care and quality of life in its
CLCs. These questions included how VA headquarters uses available
information regarding the quality of care and quality of life in its
CLCs, such as the deficiencies cited by LTCI, to identify patterns and
associated risks and take appropriate actions to address those risks.
This report examines (1) actions VA headquarters has taken to respond
to and resolve LTCI-identified deficiencies and (2) what information
VA headquarters collects regarding the quality of care and quality of
life in CLCs and the extent to which VA headquarters uses the
information to identify and manage risks.
To examine actions VA headquarters has taken to respond to and resolve
deficiencies LTCI identified during its 2007 and 2008, and 2010 and
2011, reviews of CLCs, we obtained and analyzed copies of the 116 LTCI
reviews performed during 2007 and 2008; VA headquarters' subsequent
analyses of those reviews; copies of 50 CLCs' corrective action plans
and related documentation from the 2007 and 2008 reviews;[Footnote 5]
copies of the 67 LTCI reviews performed between September 1, 2010, and
March 31, 2011; and copies of 23 CLCs' corrective action plans from
the 2010 and 2011 reviews.[Footnote 6] We also reviewed relevant VA
policy documents, including Veterans Health Administration Directive
2009-43, Quality Management System. We interviewed officials from VA
headquarters offices involved in responding to LTCI-identified
deficiencies, including the Office of Geriatrics and Extended Care and
the Office of the Deputy Under Secretary for Health for Operations and
Management.[Footnote 7] In addition, we reviewed Executive Career
Field Plans of VA network directors and interviewed officials from 2
of VA's 21 networks, which oversee the operations of the various
medical facilities within their assigned geographic area. These two
networks were the VA Mid-Atlantic Health Care Network (Durham, North
Carolina) and the VA Northwest Health Network (Vancouver, Washington).
To select the networks, we considered the average number of
deficiencies per CLC reviewed by LTCI in 2007 and 2008.[Footnote 8] We
assessed VA headquarters' response to the identified deficiencies in
the context of federal standards for internal control for monitoring,
control activities, and information and communications.[Footnote 9]
The internal control for monitoring refers to an agency's ability to
provide reasonable assurance that actions are taken in response to the
findings from reviews and the deficiencies identified are promptly
resolved, while the internal control for control activities refers to
an agency's ability to provide reasonable assurance that management's
directives are carried out, which includes appropriately documenting
transactions and internal controls. The internal control for
information and communications refers to an agency's ability to
provide reasonable assurance of the relevance and reliability of
information necessary to achieve an agency's objectives, including
verifying the accuracy of its data.
To determine what information VA headquarters collects regarding the
quality of care and quality of life in CLCs and the extent to which VA
headquarters uses the information to identify and manage risks, we
reviewed reports from reviews and investigations performed at CLCs
between June 2007 and June 2011. We also reviewed VA analyses of
information contained in these reports and VA policy documents. We
interviewed officials from Geriatrics and Extended Care; the Office of
the Deputy Under Secretary for Health for Operations and Management;
the Office of the Assistant Deputy Under Secretary for Health for
Informatics and Analytics; the Office of the Assistant Deputy Under
Secretary for Health for Quality, Safety, and Value; and the Office of
Inspector General (OIG). We assessed VA headquarters' use of
information regarding the quality of care and quality of life in CLCs
in the context of federal standards for internal control for risk
assessment. The internal control for risk assessment refers to an
agency's ability to identify and analyze relevant risks associated
with achieving its objectives.
We conducted this performance audit from August 2010 through September
2011 in accordance with generally accepted government auditing
standards. Those standards require that we plan and perform the audit
to obtain sufficient, appropriate evidence to provide a reasonable
basis for our findings and conclusions based on our audit objectives.
We believe that the evidence obtained provides a reasonable basis for
our findings and conclusions based on our audit objectives.
Background:
VA provides nursing home care for some veterans, as required, and
makes these services available to other veterans on a discretionary
basis, as resources permit.[Footnote 10] Specifically, VA is required
by law to provide nursing home care to any veteran who needs it for a
service-connected disability and to any veteran who needs it and has a
service-connected disability rated at 70 percent or greater.[Footnote
11] However, VA provides most of its nursing home care to veterans on
a discretionary basis, as resources permit.[Footnote 12] VA's policy
on nursing home eligibility requires that VA networks provide nursing
home care to veterans with 60 percent service-connected disability
ratings who are either unemployable or who have been determined by VA
to be permanently and totally disabled. For all other veterans, VA's
policy is to provide nursing home care on a discretionary basis, with
certain veterans having higher priority, including veterans who
require care following a hospitalization.
CLCs provide both short-stay (90 days or less) and long-stay (more
than 90 days) services. According to VA data, almost 94 percent of the
residents admitted to CLCs in fiscal year 2010 were short-stay. Short-
stay care in CLCs includes skilled nursing care, rehabilitation,
restorative care, maintenance care for those awaiting alternative
placement, hospice, and respite care. The remaining admissions, about
6 percent, were long-stay. Long-stay care includes dementia care,
maintenance care, and care for those with spinal cord injury and
disorders.
Responsibility for VA's medical facilities, including CLCs, rests with
both VA's networks and VA headquarters. Almost all of VA's 132 CLCs,
located throughout VA's 21 networks, are colocated with or in close
proximity to a VA medical center (VAMC). While networks are charged
with the day-to-day management of the VAMCs within their network, VA
headquarters maintains responsibility for establishing national policy
and overseeing both networks and VAMC operations. Within VA
headquarters, Geriatrics and Extended Care is responsible for
developing VA's policies and other national actions related to the
quality of care and quality of life in VA's CLCs. The Office of the
Deputy Under Secretary for Health for Operations and Management,
through each network, ensures that VAMCs, including CLCs, comply with
VA's policies and implement other national actions.
The LTCI contract, which began in September 2010, is for 1 year, and
provides for LTCI to conduct reviews between September 2010 and August
2011. VA may exercise an option to renew for each of 4 additional
years through August 2015.[Footnote 13] Officials from both Geriatrics
and Extended Care and the Office of the Deputy Under Secretary for
Health for Operations and Management share responsibility for
administering VA's contract with LTCI.
LTCI uses the Centers for Medicare & Medicaid Services' scope and
severity scale for classifying nursing home deficiencies. There are
four severity classifications, with the least serious deficiencies
rated as having the potential for minimal harm and the most serious
deficiencies rated as immediate jeopardy situations--in which
residents are potentially or actually at risk of dying or being
seriously injured. The remaining two severity classifications are
actual harm and potential for more than minimal harm. The scope of
deficiencies--or the number of residents potentially or actually
affected by the deficient care--may be rated as isolated, pattern, or
widespread.
VA policy requires that all VAMCs be accredited by The Joint
Commission.[Footnote 14] As part of the accreditation process for a
VAMC, which occurs on average every 3 years, The Joint Commission
surveys and accredits any CLC associated with the VAMC.[Footnote 15]
VA requires CLCs to meet The Joint Commission long-term care
standards.[Footnote 16] CLCs are also subject to periodic reviews by
VA's OIG.
VA Headquarters Established a Process for Responding to LTCI-
Identified Deficiencies, but Cannot Provide Reasonable Assurance That
Deficiencies Have Been Resolved:
VA headquarters established a process for responding to deficiencies
identified at CLCs during the 2007 and 2008 reviews. This process,
which requires CLCs to submit corrective action plans addressing LTCI-
identified deficiencies--such as how CLCs will address a lack of
competent nursing staff and a failure to provide a sanitary and safe
living environment--is also being used during the 2010 and 2011 LTCI
reviews. However, because of weaknesses in the process, VA
headquarters cannot provide reasonable assurance that deficiencies
that could potentially affect the quality of care and quality of life
of residents are resolved.
VA Headquarters' Process Requires Corrective Action Plans and, for
2007 and 2008, National Training and Education:
VA headquarters established a process for responding to LTCI-
identified deficiencies that requires each CLC to develop a corrective
action plan addressing all deficiencies identified and submit it to VA
headquarters within 30 days of receiving an LTCI report. The plans may
include actions such as training CLC staff on clinical policies and
procedures or implementing nursing and interdisciplinary rounds to
monitor the clinical issues related to the deficiencies. VA
headquarters officials review each corrective action plan to determine
whether the actions can be expected to correct all identified
deficiencies and whether the time frames for completing the actions
are reasonable. The officials then provide each CLC feedback by
telephone, discussing any revisions to the corrective action plans
that may be necessary. The officials document these discussions using
hand-written notes on hard copies of CLCs' corrective action plans,
which are not shared with VA networks and CLCs. VA headquarters
officials told us they may schedule additional telephone calls with
CLCs when significant revision of a corrective action plan is
necessary or if the officials want an update on the implementation of
the plan. For deficiencies identified in the 2007 and 2008 LTCI
reviews, the documentation showed that officials had at least two
telephone calls with 29 of the 116 CLCs reviewed.[Footnote 17] Three
of these 29 CLCs received more than two follow-up calls. When
additional calls were made, VA headquarters required the CLCs to
submit an updated corrective action plan.
While VA's process requires that all deficiencies identified be
addressed, it gives priority to deficiencies at the immediate jeopardy
or actual harm levels. When LTCI review teams identify such
deficiencies during a survey, they are required to notify VA
headquarters and the relevant VAMC.[Footnote 18] LTCI identified
immediate jeopardy or actual harm deficiencies at 25 of the 116 CLCs
(about 22 percent) reviewed in 2007 and 2008, and at 10 of the 67 CLCs
(about 15 percent of the CLCs) reviewed in 2010 and 2011 as of March
31, 2011.[Footnote 19]
After the 2007 and 2008 LTCI reviews, VA headquarters officials
analyzed the deficiencies from the 116 reviews and from the analysis
developed eight clinical high-risk categories. According to these
officials, the eight categories, which included medication management,
infection control, and peripherally inserted central catheter (PICC)
lines, posed the greatest risk to residents' health and
safety.[Footnote 20] (See table 1.) The officials then implemented a
national training and education initiative to address the eight
categories.
Table 1: Clinical High-Risk Categories Defined by VA Headquarters'
Analysis of Deficiencies Identified in 2007 and 2008 Long Term Care
Institute, Inc., Reviews:
Category: Dignity;
Percentage of 116 CLCs with related deficiencies[A]: 90;
[Empty];
Examples of deficiencies:
* Residents lacked privacy, including exposure during care;
provision of care in public areas, such as applying ointment to a
resident's upper body in the dining room in front of other residents;
and uncovered catheter bags attached to residents' wheelchairs;
* Residents had poor hygiene, including having dirty fingernails, not
being shaven or bathed, and generally looking unkempt.
Category: Medication management;
Percentage of 116 CLCs with related deficiencies[A]: 78;
[Empty];
Examples of deficiencies:
* Residents were not assessed prior to administering medication (e.g.,
blood pressure not taken before administering hypertension medication
or blood sugar testing not completed before administering insulin);
* Medication was not administered according to policy and procedures.
For example, staff did not document insulin injection sites or check
documentation for prior insulin injection sites to ensure that insulin
would not be injected routinely into the same site. Not rotating
insulin injection sites can lead to hardening of the skin or weakening
of fatty tissue under the skin. These can change the way insulin is
absorbed, making it difficult to manage blood glucose levels.
Category: Infection control;
Percentage of 116 CLCs with related deficiencies[A]: 59;
Examples of deficiencies:
* Staff did not adhere to proper isolation procedures (e.g., entering
and exiting rooms of residents with infectious diseases without
wearing or removing protective gowns and gloves);
* Staff did not follow handwashing policies and procedures.
Category: Psychotropic medications[B];
Percentage of 116 CLCs with related deficiencies[A]: 47;
Examples of deficiencies:
* Staff administered psychotropic medications as a restraint and
beyond the scope of the physician's original order (e.g., using
psychotropic medications to calm residents before trying other
nonpharmacological interventions to manage behavior);
* Staff did not track and review residents' behavior to help ensure
that use of a psychotropic medication was appropriate.
Category: Percutaneous endoscopic gastrostomy tubes[C];
Percentage of 116 CLCs with related deficiencies[A]: 30;
Examples of deficiencies:
* Staff did not ensure full doses of medications were administered;
* Residents experiencing significant weight loss were not assessed by
a practitioner.
Category: Restraints;
Percentage of 116 CLCs with related deficiencies[A]: 28;
Examples of deficiencies:
* Staff were not trained to know which devices were classified as
restraints and therefore used restraints without physician
authorization (e.g., staff used bed rails, seat belts, and tables to
restrict resident mobility, all of which are classified as restraints).
Category: Pressure ulcers[D];
Percentage of 116 CLCs with related deficiencies[A]: 24;
Examples of deficiencies:
* Residents were not regularly assessed for having or being at risk
for pressure ulcers;
* Residents with pressure ulcers did not receive proper care,
including wound care.
Category: Peripherally inserted central catheter (PICC) lines[E];
Percentage of 116 CLCs with related deficiencies[A]: 21;
Examples of deficiencies:
* Staff did not properly prepare lines (e.g., did not flush lines)
before and after administering medications, when required;
* Staff did not follow procedures for dressing changes of PICC lines,
which could increase the risk of local or systemic infection.
Source: Long Term Care Institute, Inc. (LTCI), and VA data.
Notes: GAO analyzed data contained in the 2007 and 2008 LTCI reviews
and data provided by VA headquarters based on its analysis of the 2007
and 2008 LTCI reviews.
[A] Represents the percentage of 116 community living centers (CLC)
where LTCI identified at least one deficiency related to that category
in 2007 or 2008.
[B] A psychotropic medication is any medication whose intended purpose
is to alter perception, mental status, or behavior. Examples of drug
classes include antipsychotic, antidepressant, and antianxiety
medications.
[C] A percutaneous endoscopic gastrostomy tube is a flexible feeding
tube that is placed through the abdominal wall and into the stomach to
allow nutrition, fluids, and medications to be put directly into the
stomach.
[D] Pressure ulcers are areas of damaged skin caused by staying in one
position for too long. They commonly form where bones are close to the
skin, such as ankles, back, elbows, heels, and hips. Residents are at
risk if they are bedridden, use a wheelchair, or are unable to change
position. Pressure ulcers can lead to serious infections, some of
which are life-threatening.
[E] A central line is a small tube that is placed in a large vein in
the neck, chest, groin, or arm to give fluids, blood, or medications
or to do medical tests quickly. A central line can remain for weeks or
months, and some patients receive treatment through the line several
times a day. A PICC line is a specific type of central line that is
placed into a vein in the arm.
[End of table]
VA headquarters convened a workgroup that developed national training
guidelines and checklists for evaluating CLC staff competencies in
each of the eight categories. The workgroup included representatives
from Geriatrics and Extended Care, the Office of Nursing Services,
[Footnote 21] Nutrition and Food Services,[Footnote 22] and the
Infectious Diseases Program Office.[Footnote 23] A VA headquarters
official told us that the workgroup included the last three offices
because the majority of LTCI-identified deficiencies were related to
nursing, nutrition, and infection control issues. VA headquarters
provided the VA networks and CLCs with the national guidelines and
checklists and required CLCs to incorporate them into their training
and education policies. VA headquarters required CLCs to report
whether they had met the following four requirements for each of the
eight clinical high-risk categories: (1) establish CLC policies, (2)
adopt procedures for implementing the policies,[Footnote 24] (3)
design an assessment to observe staff proficiency in providing care
matching the established procedure, and (4) establish a plan for
ongoing training and assessment of staff, including new staff.
[Footnote 25] In addition, CLCs were required to directly observe
staff providing care to CLC residents and report the percentage of
staff that had been observed as being proficient in the procedures
necessary to comply with CLCs' policies for each of the eight clinical
high-risk categories.[Footnote 26] If CLCs did not meet all four
requirements for each category or had observed less than 90 percent of
their staff as proficient in providing care in any one of the clinical
high-risk categories, they were to develop and submit corrective
action plans to VA headquarters. According to the documentation we
reviewed, in most categories, the majority of CLCs indicated that they
had met the requirements of the national training and education
initiative. However, in every category there were CLCs that did not
meet these requirements and had to submit a corrective action plan.
For example, for the medication management clinical high-risk
category, 14 of the 132 CLCs submitted a corrective action plan
because they either were not in compliance with the four requirements
or had not observed at least 90 percent of their staff as being
proficient in providing care.[Footnote 27]
After LTCI's 2010 and 2011 reviews of VA's CLCs are complete, VA
headquarters plans to analyze the deficiencies identified by LTCI. To
facilitate the analysis, VA headquarters is working with LTCI to track
and note trends with regard to deficiencies on a quarterly basis. LTCI
provides quarterly reports to VA headquarters, which include data on
which deficiencies are the most frequently identified nationally. For
each CLC, these reports include data on the total number of
deficiencies identified and the categories in which the identified
deficiencies fall. VA headquarters officials expect that these
quarterly reports will facilitate the identification of national areas
for improvement as well as help them review CLCs' performance on the
LTCI reviews over time.
VA Headquarters Cannot Provide Reasonable Assurance That All
Deficiencies Are Resolved Because of Weaknesses in Its Process for
Responding to Deficiencies:
When responding to LTCI-identified deficiencies, VA headquarters does
not always maintain clear and complete documentation of the feedback
it provides to CLCs regarding their corrective action plans. In
addition, VA headquarters does not require VA networks to report on
the status of CLCs' implementation of their corrective action plans or
to verify CLCs' self-reported compliance with the requirements of the
national training and education initiative. Without the ability to
determine whether CLCs appropriately responded to feedback, fully
implemented their corrective action plans from the 2007 and 2008 LTCI
reviews, or fully complied with requirements of the national training
and education initiative, and without the ability to determine the
status of corrective action plans that CLCs are implementing during
LTCI's 2010 and 2011 reviews, VA headquarters does not have reasonable
assurance that LTCI-identified deficiencies are resolved.
Lack of clear and complete documentation of feedback. VA headquarters
does not always maintain clear and complete documentation of the
feedback it provides CLCs about their corrective action plans, which
is not consistent with good management practices as outlined in
federal internal control standards. According to these standards,
internal control activities, such as VA headquarters' feedback, should
be clearly and completely documented in a manner that is accurate,
timely, and helps provide reasonable assurance that program objectives
are being achieved.[Footnote 28] VA headquarters uses an unsystematic
approach for documenting the feedback it provides to CLCs regarding
their corrective action plans. The approach relies solely on hard
copies of CLCs' action plans that have hand-written notes on them,
which are not shared with the VA networks and CLCs, to document the
feedback provided during VA headquarters' telephone calls with CLCs.
We found that this approach did not always result in clear--that is,
understandable to anyone not involved in the telephone feedback calls-
-and complete documentation. In particular, the documentation we
reviewed did not always clearly and completely indicate the specific
feedback provided to CLCs, including actions VA headquarters advised
CLCs to take to address weaknesses with their corrective action plans.
For example, for one CLC we obtained two corrective action plans from
VA headquarters. One was an older action plan and the other was a
revised action plan. The older action plan contained no notes or any
indication of the content of VA headquarters' feedback that resulted
in the revised action plan, so we were unable to independently
determine whether the revised action plan addressed VA headquarters'
feedback. In addition, we found that the plans for 19 of the 50 2007
and 2008 CLC corrective action plans that we reviewed--or about 38
percent of the plans--lacked any notes documenting the feedback that
VA headquarters gave CLCs on the telephone calls.
Lack of reporting requirement for VA networks. VA headquarters does
not require its networks to report on the status of CLCs'
implementation of their corrective action plans, and VA headquarters
does not routinely schedule additional telephone calls with CLCs
following the submission of initial corrective action plans and VA's
initial telephone calls. For example, VA headquarters held additional
telephone calls with only 25 percent of CLCs following the 2007 and
2008 LTCI reviews, and 15 percent of the CLCs following the 2010 and
2011 LTCI reviews, as of March 31, 2011. Therefore, VA headquarters
does not know whether CLCs fully implemented their plans and corrected
all LTCI-identified deficiencies. Federal standards for internal
control state that the findings of reviews should be promptly resolved
and that information on the status of the findings should be
communicated to management so that management can provide reasonable
assurance that a program is achieving its objectives--in this case,
that CLCs are providing quality care and maintaining veterans' quality
of life.[Footnote 29] VA headquarters officials told us that beyond
the initial telephone calls with CLCs, VA headquarters does not
receive any additional information from CLCs regarding the
implementation status of their corrective action plans. Rather, VA
headquarters officials expect the findings of the 2010 and 2011 LTCI
reviews will help them determine whether CLCs resolved all
deficiencies identified by LTCI in 2007 and 2008--2 or 3 years after
the deficiencies were first identified.
Lack of verification requirement for national initiative. We found
that VA headquarters relied on self-reported information from CLCs
regarding (1) compliance with all four requirements for each of the
eight clinical high-risk categories and (2) the percentage of staff
that were observed to be proficient in treatments and procedures
associated with the categories. VA headquarters did not specify to its
networks that they should verify the accuracy of CLCs' self-reported
information. Reliance on self-reported information is inconsistent
with federal standards for internal control specifying that management
should be able to provide reasonable assurance about the accuracy of
data--in this case, that VA networks verify the accuracy of CLCs' self-
reported information.[Footnote 30] Although we cannot generalize to
all networks, neither of the two VA networks we visited requested
documentation to verify CLCs' self-reported information for the
national training and education initiative. Further, the 2010 and 2011
LTCI reviews indicate that some CLCs are not in compliance with the
requirements for the eight clinical high-risk categories stemming from
the 2007 and 2008 reviews. For example, a CLC reported to VA
headquarters that by June 2009 it would have a policy in place for
training and educating its staff on PICC lines--one of the eight
clinical high-risk categories. However, when LTCI reviewed this CLC in
2010, it found that this CLC had failed to provide proper care and
treatment when administering medication to a resident through a PICC
line. When LTCI asked to see the CLC's policy related to PICC lines,
the CLC's staff stated that the CLC did not have one.
VA Headquarters Receives Information about CLCs from Multiple Sources,
but Does Not Analyze It to Assess and Manage Risks:
In addition to LTCI reviews, VA headquarters obtains information about
CLCs from a variety of other sources that could be used to more
comprehensively identify risks associated with the care and quality of
life of CLC residents. VA headquarters does not analyze all of these
sources, and for those sources it does analyze, VA evaluates each
source in isolation without comparing the information it receives
across all available sources to identify major or commonly cited risks
and trends. As a result, VA headquarters' current approach to
identifying risks in CLCs may result in missed opportunities to detect
patterns and trends in information about the quality of care and
quality of life within a CLC or across many CLCs. Without considering
information from all available sources and comparing it across
different sources, VA headquarters cannot adequately identify and
manage risks in CLCs.
VA Headquarters Receives Useful Information about CLCs from Multiple
Sources:
We found that VA headquarters receives information about the quality
of care and quality of life in CLCs from at least nine different
sources. The type of information VA headquarters receives from each of
these sources, and how often the agency receives it, varies. The nine
sources of information about CLCs are the following:
* LTCI. Conducts annual unannounced reviews that assess the extent to
which CLCs follow 176 federal long-term care standards.[Footnote 31]
LTCI review teams observe the delivery of care for a sample of
residents in order to examine such areas as medication management,
infection control practices, and respect for residents' rights and
dignity. LTCI provides VA headquarters a report of all deficiencies
identified. VA headquarters then shares the report with the network
and the reviewed CLC. The CLC is expected to correct identified
deficiencies.
* The Joint Commission. Performs accreditation surveys every 3 years,
on average, assessing CLCs' compliance with 227 long-term care
standards, such as infection control practices and resident
assessments. When The Joint Commission surveyors find noncompliance,
they determine whether a systemic problem exists by assessing the
CLC's established policies and processes. This determination is the
basis for whether CLCs are found deficient in a long-term care
standard. VA networks and CLCs receive survey reports from The Joint
Commission, which identify specific deficiencies. CLCs are required to
resolve the deficiencies within certain time frames in order to
maintain accreditation.[Footnote 32]
* OIG. Performs its Combined Assessment Program reviews at VAMCs,
including CLCs, about every 3 years. Under this program, OIG reviews
selected VAMC activities, including CLC activities, to assess the
effectiveness of patient care administration (the process of planning
and delivering patient care) and quality management (the process of
monitoring quality of care to identify and correct harmful and
potentially harmful practices and conditions).[Footnote 33] CLCs
typically are part of each Combined Assessment Program review. Upon
completion of each review, OIG issues a report to VA headquarters, the
network, and the VAMC, which identifies the VAMC's deficiencies,
including any deficiencies identified in the CLC. VA requires VAMCs,
including CLCs, to fully resolve deficiencies within a year of the
completion of a Combined Assessment Program review.
* VA Office of the Medical Inspector (OMI). Conducts investigations to
determine the validity of allegations made by complainants regarding
the care provided to veterans, including residents of CLCs.[Footnote
34] If an allegation is validated, the VAMC, including the CLC, is
required to address any recommendations made by OMI.[Footnote 35]
* System-wide Ongoing Assessment and Review Strategy (SOARS). Performs
reviews of VAMCs, including CLCs, every 3 years to evaluate readiness
for some external and internal reviews, such as those by The Joint
Commission and OIG.[Footnote 36] It is a consultative program within
VA designed to identify programmatic weaknesses in VAMCs, including
CLCs. SOARS teams issue reports to VA networks and VAMCs, including
CLCs, with recommendations based on identified deficiencies, and VAMCs
and CLCs are expected to implement the recommendations.
* Quality Measures and Quality Indicators. Report the percentage of
residents in a CLC who have certain conditions, such as a pressure
ulcer, or residents who are at risk for developing certain conditions,
such as CLC residents who have limited mobility and are at risk of
developing a pressure ulcer. CLCs periodically assess residents and
enter information about their conditions into a database, which
automatically calculates percentage scores for 24 categories of
quality measures and quality indicators. Data are available on an
ongoing basis.
* Artifacts of Culture Change Tool.[Footnote 37] Reports the extent to
which CLCs provided resident-centered care. Using a standard self-
assessment tool, CLCs score their own performance in certain areas,
such as allowing residents to choose when they eat meals, bathe, and
sleep. CLCs report their scores to VA headquarters every 6 months.
* Issue Briefs. Provide specific information to VA headquarters
officials regarding unusual incidents, such as deaths, disasters, or
anything else that happens at a VAMC, including a CLC, that might
generate media interest or affect care.[Footnote 38]
* Complaints. Provide information from veterans or their
representatives about the quality of care or the quality of life in
VAMCs, including CLCs.[Footnote 39]
VA Headquarters Does Not Consider the Potential Usefulness of All
Available Information to Assess and Manage Risks in CLCs:
VA headquarters' approach for identifying risks associated with the
quality of care and quality of life of CLC residents is deficient in
two respects--it does not comprehensively analyze information from all
available sources, and it does not compare findings across these
sources. Without analyzing information from all available sources and
comparing the results, VA headquarters' assessments of risks in CLCs
are incomplete. According to federal internal control standards,
management should assess the risks the agency may face from both
external and internal sources. The standards state that a risk
management process includes (1) comprehensively identifying risks
associated with achieving an agency's goals (for example, providing
quality of care and quality of life in CLCs); (2) estimating the
significance of the risks; and (3) determining actions to mitigate the
risks, such as developing or clarifying policies or targeting reviews
of noncompliant CLCs.[Footnote 40]
VA Headquarters Does Not Analyze Information from All Available
Sources:
VA headquarters' current approach relies significantly on the analysis
of findings from LTCI reviews of CLCs. VA headquarters also relies on
analysis of the findings from The Joint Commission accreditation
surveys and the Artifacts of Culture Change tool. (See app. I for a
detailed description of these analyses.) While these three separate
analyses enable VA headquarters to identify trends in each source of
information, such as the most frequently cited deficiencies across all
CLCs or the average number of deficiencies per CLC, they do not
provide a complete assessment of the risks that would be identified by
evaluating all nine sources. Information VA headquarters receives
about the quality of care and the quality of life in CLCs from the
remaining six sources--OIG, OMI, SOARS, quality measures and quality
indicators, issue briefs, and complaints--could also be valuable in
identifying patterns in CLC-related findings. VA headquarters
officials we interviewed said they do not typically analyze
information they receive about CLCs from these six sources because
they do not always believe that doing so would be valuable for
identifying trends and patterns regarding the quality of care and
quality of life in CLCs. For example, VA headquarters officials said
that they do not extract CLC-related findings from OIG Combined
Assessment Program reviews because the reviews typically do not
include enough CLC-related findings to warrant analysis. However, when
we analyzed findings from the 77 OIG Combined Assessment Program
reviews that were completed at VAMCs that have CLCs between October 1,
2009, and June 20, 2011, we found that 49 of the reviews--or about 64
percent--included at least one finding related to the quality of care
or quality of life in a CLC. Without analyzing information from all
available sources about the quality of care and quality of life in
CLCs, VA headquarters' assessments of risks in CLCs are incomplete.
VA Headquarters Does Not Compare Information across All Available
Sources:
VA headquarters does not compare information across all sources to
identify patterns of findings for an individual CLC, CLCs within a
network, or all CLCs nationwide. Rather, VA headquarters analyzes the
findings from three sources separately to identify trends in the
findings. However, it does not compare the findings from one source to
the findings from the other sources. One source's findings, in
isolation, may not present the significance of certain risks,
especially those that may suggest immediate risks for residents within
a given CLC or across all CLCs. However, if related information that
VA headquarters receives was compared across different sources
concurrently, VA headquarters officials would be better positioned to
recognize the risks to CLC residents.
One example we identified of the benefit from considering the
usefulness of multiple information sources is in the area of pain
management. In this regard, we found that in fiscal years 2009 and
2010, VA headquarters' quality indicator and quality measure data
showed that about 25 percent of all long-stay CLC residents and 40
percent of all short-stay CLC residents experienced moderate to severe
pain. In June 2007, OMI investigated allegations about the quality of
care for a resident at one CLC and found, among other things, that the
CLC had failed to adequately manage the resident's pain. Three months
later, in September 2007, LTCI conducted a review of the same CLC and
found that staff were not performing assessments after administering
pain medications to determine whether the medication had been
effective. In November 2009, the OIG visited the same CLC as part of a
Combined Assessment Program review and found that staff had not
documented pain medication effectiveness within the required time
frames nearly two-thirds of the time that pain medications were
administered. If VA had comprehensively analyzed OMI information--
which it does not analyze--along with LTCI information that was
available in 2007 and compared this information with the information
from the 2009 OIG review and quality indicator and quality measure
data, VA headquarters would have been better informed about the
significance of the risks and what actions might have helped to
mitigate the risks of pain medication management problems at this CLC.
Conclusions:
The 46,000 elderly and disabled veterans annually who are residents in
VA's CLCs depend on VA to provide them with quality care and maintain
their quality of life. The weaknesses in VA headquarters' process for
resolving LTCI-identified deficiencies put veterans at risk of
persistent deficiencies that could become more serious over time. VA
headquarters officials told us that they intend to use the findings of
the 2010 and 2011 LTCI reviews to determine whether deficiencies that
were first identified by LTCI 2 to 3 years earlier have been resolved.
However, VA headquarters cannot provide reasonable assurance of
resolution of deficiencies because it does not (1) clearly document
the feedback that it provides to CLCs about corrective action plans
for LTCI-identified deficiencies, (2) require VA networks to report on
the status of CLCs' implementation of action plans, and (3) verify
CLCs' self-reported information about their implementation of the
requirements of the national training and education initiative.
Unaddressed, these weaknesses in VA headquarters' process for
responding to LTCI-identified deficiencies may compromise the quality
of care and quality of life of veterans in CLCs.
Even though VA headquarters receives information about the quality of
care and quality of life in CLCs from LTCI and a variety of other
sources, the agency does not comprehensively analyze all available
information to identify and manage risks in CLCs. Because VA
headquarters does not analyze information from all available sources,
it may be missing opportunities to detect trends and patterns in
findings from different information sources for a CLC, CLCs within a
network, or all CLCs. Without comprehensively analyzing information
from all available sources, VA headquarters cannot fully identify
risks in CLCs, estimate the significance of the risks, or take actions
to mitigate them.
Recommendations for Executive Action:
To provide reasonable assurance that LTCI-identified deficiencies are
resolved and that veterans receive quality care and maintain their
quality of life in VA CLCs, we recommend that the Secretary of
Veterans Affairs direct the Under Secretary for Health to take the
following two actions:
* For reviews conducted by LTCI under the current contract and any
similar future contracts, (1) clearly and completely document the
feedback provided to CLCs about their corrective action plans, (2)
require VA networks to provide periodic reports on the status of CLCs'
implementation of their corrective action plans, and (3) develop and
implement a process for verifying any information reported directly to
VA headquarters by CLCs.
* Develop and implement a process to comprehensively identify,
estimate, and mitigate risks in CLCs by analyzing and comparing all
available information regarding the quality of care and quality of
life in CLCs.
Agency Comments and Our Evaluation:
In its comments on a draft of this report, VA concurred with our
recommendations and described the department's planned actions to
implement them. VA did not provide technical comments on the draft
report. VA's comments are included in appendix II.
To address our recommendation that, for reviews conducted by LTCI, VA
headquarters should document the feedback provided to CLCs about their
corrective action plans, require VA networks to report periodically on
the status of CLCs' implementation of corrective action plans, and
implement a process for verifying information CLCs report directly to
VA headquarters, VA stated that it plans to develop and implement a
national feedback process by the end of the second quarter of fiscal
year 2012 as part of its response to results from the LTCI reviews. VA
stated that the process will include having VA networks work with VAMC
leadership to develop a comprehensive action plan to address areas of
concern highlighted in the LTCI reviews, using a standardized template
for CLCs' corrective action plans, and requiring VAMCs to post
corrective action plans on a secure database and provide updated
corrective action plans at least monthly. VA indicated that the
process will provide access to the status of action plans at any time
and that officials from VA headquarters will provide oversight to
ensure completion of action plans, including requiring VA networks to
validate completion of all action items. VA, however, did not specify
in its comments whether its process would include a step to document
the feedback provided to CLCs about their corrective actions plans. We
believe it is important for VA to document feedback provided to CLCs
as part of its process:
To address our recommendation that VA headquarters develop and
implement a process to comprehensively identify, estimate, and
mitigate risks in CLCs by analyzing and comparing all available
information regarding quality of care and quality of life, VA stated
that it plans to design a process that will use all available
information about the quality of care and quality of life in CLCs. VA
indicated that this process would allow officials to analyze and
compare information for individual CLCs, for CLCs within a VA network,
and across all CLCs nationwide. VA intends to design this process
during the first quarter of fiscal year 2012 and plans to use the
process to analyze and compare CLC information and begin reporting it
during the second quarter of fiscal year 2012. We commend this effort
and encourage VA to proceed with these plans.
As agreed with your office, unless you publicly announce the contents
of this report earlier, we plan no further distribution until 30 days
from the report date. At that time, we will send copies to the
Secretary of Veterans Affairs, appropriate congressional committees,
and other interested parties. In addition, the report will be
available at no charge on the GAO website at [hyperlink,
http://www.gao.gov].
If you or your staff have any questions about this report, please
contact me at (202) 512-7114 or williamsonr@gao.gov. Contact points
for our Offices of Congressional Relations and Public Affairs are on
the last page of this report. GAO staff who made major contributions
to this report are listed in appendix III.
Sincerely yours,
Signed by:
Randall B. Williamson:
Director, Health Care:
[End of section]
Appendix I: VA Headquarters' Analysis of Information about the Quality
of Life and Care in Community Living Centers:
Source of information: Long Term Care Institute, Inc;
Frequency of analysis: Quarterly, annually;
Description of VA headquarters analysis:
* Identify the most frequently cited deficiencies nationally;
* Identify the total number of deficiencies per community living
center (CLC);
* Classify deficiencies identified in each CLC into 1 of 17 different
groups (e.g., activities, environment, infection control, medication,
etc.). Use these groups to track trends in deficiencies by VA network
and by CLC;
* Determine whether each CLC was substantially compliant with federal
long-term care standards.
Source of information: The Joint Commission;
Frequency of analysis: Annually;
Description of VA headquarters analysis:
* Identify most frequently cited findings for two areas:[A];
1. Direct impact: includes findings that are likely to present an
immediate risk to residents' safety or quality of care; for example,
resident assessment and pain management;
2. Indirect impact: includes findings that pose less immediate risk to
residents' safety or quality of life, but could become more serious
over time; for example, care planning and ensuring that corridors,
hallways, and doors remain free from obstructions that would prevent
exit in the event of a fire;
* Calculate average number of findings per CLC.
Source of information: Quality measures and quality indicators;
Frequency of analysis: Quarterly, annually;
Description of VA headquarters analysis:
* Calculate average performance on 30 measures and indicators, by VA
network and nationally;
for example, percentage of long-stay residents who have experienced
moderate to severe pain.
Source of information: Artifacts of culture change tool;
Frequency of analysis: Every 6 months;
Description of VA headquarters analysis:
* Calculate average scores, by VA network and nationally, for areas
such as care practices (e.g., allowing residents to choose when they
eat, bathe, and sleep) and leadership (e.g., holding regular community
meetings that encourage the participation of staff, residents, and
families).
Source: GAO analysis of VA data.
[A] In its surveys, The Joint Commission determines whether findings
have a direct or an indirect impact on resident care.
[End of table]
[End of section]
Appendix II: Comments from the Department of Veterans Affairs:
Department Of Veterans Affairs:
Washington DC 20420:
October 11, 2011:
Mr. Randall Williamson:
Director, Health Care:
U.S. Government Accountability Office:
441 G Street, NW:
Washington, DC 20548:
Dear Mr. Williamson:
The Department of Veterans Affairs (VA) has reviewed the Government
Accountability Office's (GAO) draft report, "VA Community Living
Centers: Actions Needed to Better Manage Risks to Veterans' Quality of
Care and Quality of Life," (GAO-12-11) and is providing comments in
the enclosure.
VA appreciates the opportunity to comment on your draft report.
Sincerely,
Signed by:
John R. Gingrich:
Chief of Staff:
Enclosure:
[End of letter]
Enclosure:
Department of Veterans Affairs (VA) Comments to Government
Accountability Office (GAO) Draft Report: VA Community Living Centers:
Actions Needed to Better Manage Risks to Veterans' Quality of Care and
Quality of Life (GAO-12-11):
GAO Recommendation: To provide reasonable assurance that LTCI-identified
deficiencies are resolved and that veterans receive quality care and
maintain quality of life in VA CLCs, we recommend that the Secretary
of Veterans Affairs direct the Under Secretary for Health to take the
following two actions:
Recommendation 1: For reviews conducted by LTCI under the current
contract and any similar future contracts, (1) clearly and completely
document the feedback provided to CLCs about their corrective action
plans, (2) require VA networks to provide periodic reports on the
status of CLCs' implementation of their corrective action plans, and
(3) develop and implement a process for verifying any information
reported directly to VA headquarters by CLCs.
VA Comment: Concur. The Veterans Health Administration, Deputy Under
Secretary for Operations and Management (DUSHOM) in collaboration with
the Deputy Under Secretary for Policy and Services (DUSH/PS) will
provide leadership and oversight for the development and execution of
a process designed to provide continuous national feedback in response
to Long Term Care Institute (LTCI) community living centers (CLC)
review results. This process will be fully operational by the end of
2nd quarter fiscal year (FY) 2012. The process will include, but not
be limited to:
1) Veterans Integrated Service Network (VISN) Chief Medical
Officers/Quality Management Officers working with VA medical center
(VAMC) leadership to develop a comprehensive action plan to address
areas of concern obtained in the feedback from a LTCI review;
2) Using a standardized action plan template to outline corrective
action plans;
3) VAMCs placing final action plans on a secured Sharepoint site that
will automatically notify the Offices of Geriatrics and Extended Care
(GEC) in the Offices of the DUSHOM and DUSH/PS;
4) Requiring VAMCs to update action plans at least monthly;
5) The GEC operations and policy offices briefing the Assistant Deputy
Under Secretary for Health for Policy and Services (ADUSH/PS) and the
ADUSH for Clinical Operations quarterly on the status of all action
plans;
6) The ADUSH offices providing oversight to ensure completion of plans
of action.
This process provides access to status of actions plans at any point
in time for review and action, as well as planned quarterly reviews
and briefings with yearly surveys to determine overall effectiveness
of process and national outcomes. VISNs will validate the completion
of all action items. The findings of the contract CLC Yearly Survey
outcomes will serve to validate the success of action plans.
Recommendation 2: Develop and implement a process to comprehensively
identify, estimate, and mitigate risks in CLCs by analyzing and
comparing all available information regarding the quality of care and
quality of life in CLCs.
VA Comment: Concur. The GEC Offices in the Offices of the DUSHOM and
DUSH/PS will collaborate with the Office of the Assistant Deputy Under
Secretary for Informatics and Analytics to design a process to
comprehensively identify, estimate, and mitigate risks in CLCs by
analyzing and comparing all available information regarding the
quality of care and quality of life in CLCs.
The process will support continuous data collection and quarterly
analysis, including the ability to identify trends at the VAMC, VISN
and national levels. The target for completion of the process is the
end of FY 2012, quarter 1, with the first report generation planned
for FY 2012, quarter 2. The GEC offices will brief the DUSH/PS and
DUSHOM about the analysis of information about outcomes of care and
quality of life for residents in CLCs on a quarterly basis.
[End of section]
Appendix III: GAO Contact and Staff Acknowledgments:
GAO Contact:
Randall B. Williamson, (202) 512-7114 or williamsonr@gao.gov:
Staff Acknowledgments:
In addition to the contact named above, Mary Ann Curran, Assistant
Director; Stella Chiang; Julie Flowers; Alison Goetsch; Aaron Holling;
Alexis MacDonald; Elizabeth Morrison; and Lisa Motley were major
contributors to this report.
[End of section]
Related GAO Products:
VA Long-Term Care: Trends and Planning Challenges in Providing Nursing
Home Care to Veterans. [hyperlink,
http://www.gao.gov/products/GAO-06-333T]. Washington, D.C.: January 9,
2006.
VA Long-Term Care: Oversight of Nursing Home Program Impeded by Data
Gaps. [hyperlink, http://www.gao.gov/products/GAO-05-65]. Washington,
D.C.: November 10, 2004.
[End of section]
Footnotes:
[1] The remaining $1.2 billion spent for nursing home care was for
care provided to veterans in state veterans homes ($652 million) and
community nursing homes ($550 million).
[2] VA's model of care for CLC residents emphasizes the delivery of
quality health care and the maintenance of a quality of life for CLC
residents. Practices that contribute to residents' quality of life
include the extent to which CLC staff treat residents with respect and
dignity and the extent to which residents are permitted to exercise
personal preferences in areas such as the activities they choose to
engage in and the food they choose to eat. See Veterans Health
Administration Handbook 1142.01, Criteria and Standards for VA
Community Living Centers (Aug. 13, 2008).
[3] LTCI is a not-for-profit organization that surveys nursing homes
and other residential settings to improve care for residents.
[4] VA had no in-depth reviews of CLCs conducted between October 2008
and September 2010.
[5] The 50 corrective action plans we reviewed were submitted by CLCs
that were reviewed by LTCI in 2007 or 2008 and again between September
1, 2010, and March 31, 2011. We chose March 31, 2011, as the final
date for inclusion in our sample of 2010 and 2011 LTCI reviews and
corrective action plans because VA headquarters requires that LTCI
provide a final report 10 days after the completion of an LTCI review.
VA headquarters then transmits the review to the CLC, which has up to
30 days to submit its corrective action plan to VA headquarters. Given
the time frames within which we could reasonably expect to receive
copies of the 2010 and 2011 LTCI reviews and action plans from VA
headquarters, we chose to limit the scope of our sample to LTCI
reviews that were completed before March 31, 2011.
[6] The corrective action plans and related documentation of the 23
CLCs represent all of the 2010 and 2011 action plans that were
available as of March 22, 2011. These 23 CLCs represent about 34
percent of the CLCs included in our sample of LTCI reviews that were
completed, as of March 31, 2011. Findings from our review of the
sample of 2007 and 2008 corrective action plans, along with findings
from our review of the sample of 2010 and 2011 LTCI reviews and
corrective action plans, cannot be generalized to all CLCs.
[7] In this report, we use Geriatrics and Extended Care when referring
to the Office of Geriatrics and Extended Care.
[8] We selected the VA Mid-Atlantic Health Care Network because it had
a high average number of deficiencies per CLC. We selected the VA
Northwest Health Network because it had a medium average number of
deficiencies per CLC.
[9] GAO, Standards for Internal Control in the Federal Government,
[hyperlink, http://www.gao.gov/products/GAO/AIMD-00-21.3.1]
(Washington, D.C.: November 1999).
[10] VA nursing home care is provided in three settings: VA-operated
CLCs, community nursing homes, and state veterans homes.
[11] 38 U.S.C. § 1710A(a). These requirements will terminate on
December 31, 2013. 38 U.S.C. § 1710A(d). The statute states that these
requirements may not be construed as authorizing or requiring that a
veteran who was receiving nursing home care in a department nursing
home on November 30, 1999, be displaced, transferred, or discharged
from the facility. 38 U.S.C. § 1710A(b)(2). Requirements for the
provision of nursing home care, like those related to hospital and
medical care, are effective in any fiscal year only to the extent and
in the amount provided in advance in appropriations acts for such
purposes. 38 U.S.C. § 1710(a)(4).
[12] 38 U.S.C. § 1710(a)(2), (3).
[13] In August 2011, VA exercised its option for a second year for
reviews to be conducted from September 2011 through August 2012. The
cost of the contract for the base year was $3.5 million. If VA
exercises all of the options through 2015, the total cost of the
contract for 5 years will be $18.3 million.
[14] See Veterans Health Administration Handbook 1100.16,
Accreditation of Veterans Health Administration Medical Facility and
Ambulatory Programs (Sept. 22, 2009). The Joint Commission is an
independent organization that accredits and certifies health care
organizations and programs in the United States.
[15] Community nursing homes that receive Medicare or Medicaid
payments must be inspected by state agencies that contract with the
Centers for Medicare & Medicaid Services not later than 15 months
after the date of the previous inspection, and the statewide average
for inspection of nursing homes must not exceed 12 months. See 42
U.S.C. §§ 1395i-3(g)(2)(A)(iii), 1396r(g)(2)(A)(iii). Community
nursing homes are evaluated on compliance with federal long-term care
standards, which are codified at 42 C.F.R. Part 483, Subpart B.
Community nursing homes may separately contract with The Joint
Commission to receive accreditation, although this is not a
requirement for receiving Medicare or Medicaid payment.
[16] See Veterans Health Administration Handbook 1142.01, Criteria and
Standards for VA Community Living Centers (Aug. 13, 2008).
[17] The 29 CLCs that participated in more than one telephone call
with VA headquarters after their 2007 or 2008 review were located in
16 of VA's 21 networks.
[18] For immediate jeopardy level findings, LTCI surveyors are
required to remain at the CLC until the deficiencies are abated.
[19] To be consistent with criteria used by VA in requiring
notification of immediate jeopardy and actual harm deficiencies, our
analysis did not include deficiencies classified as isolated actual
harm. According to a VA headquarters official, deficiencies classified
as isolated actual harm were not included in the criteria due to their
limited scope.
[20] A central line is a small tube that is placed in a large vein in
the neck, chest, groin, or arm to give fluids, blood, or medications
or to do medical tests quickly. A central line can remain for weeks or
months, and some patients receive treatment through the line several
times a day. A PICC line is a specific type of central line that is
placed into a vein in the arm.
[21] The Office of Nursing Services is responsible for devising
policies on all issues related to nursing practice and nursing
workforce for VA's clinical programs, including nurses in CLCs.
[22] Nutrition and Food Services is responsible for providing overall
policy, guidelines, and program development relevant to each health
care system and medical center's nutrition and food services.
[23] The Infectious Diseases Program Office is responsible for
assisting and developing policy, guidelines, and program development
for infectious diseases clinical programs, infection prevention and
control, and the infectious diseases health science policy and
epidemiology program.
[24] For example, the procedures adopted could include those in the
Lippincott Manual of Nursing Practice, which is a manual that outlines
clinical guidelines and procedures for nursing practice.
[25] In 2009, VA headquarters specified these requirements in three
memorandums from VA's Deputy Under Secretary for Health for Operations
and Management. The memorandums were dated January 28, 2009; April 23,
2009; and October 15, 2009. VA required CLCs to submit these eight
checklists during calendar years 2009 and 2010.
[26] The requirements for the national training and education
initiative were applicable to all 132 CLCs, including the 16 CLCs that
LTCI did not review in 2007 and 2008.
[27] The corrective action plans for the clinical high-risk categories
were separate from the corrective action plans that all CLCs had to
submit directly in response to the LTCI-identified deficiencies.
[28] Control activities are the policies, procedures, techniques, and
mechanisms that help ensure that an agency's directives are carried
out and that the agency accomplishes its objectives. See [hyperlink,
http://www.gao.gov/products/GAO/AIMD-00-21.3.1].
[29] See [hyperlink, http://www.gao.gov/products/GAO/AIMD-00-21.3.1].
[30] See [hyperlink, http://www.gao.gov/products/GAO/AIMD-00-21.3.1].
[31] These are the same long-term care standards used by the Centers
for Medicare & Medicaid Services for certifying community nursing
homes for participation in the Medicare and Medicaid programs. See 42
C.F.R. Part 483, Subpart B (2010). Every nursing home receiving
Medicare or Medicaid payment must be evaluated on these long-term care
standards not later than 15 months after the date of the previous
evaluation, and the statewide average for these evaluations must not
exceed 12 months. See 42 U.S.C. §§ 1395i-3(g)(2)(A)(iii),
1396r(g)(2)(A)(iii).
[32] The Joint Commission has established timelines based on whether a
deficiency is considered directly or indirectly related to patient
care. Deficiencies directly related to patient care must be resolved
within 45 days. Deficiencies indirectly related to patient care must
be resolved within 60 days.
[33] The activities selected as topics of the Combined Assessment
Program reviews change every 6 to 12 months. According to OIG
officials, the selection of activities is based on various internal
and external factors: (1) past experience of Combined Assessment
Program review team members, (2) trends identified from the OIG
complaint system, and (3) problems identified in the private sector
(e.g., past concerns regarding the availability of flu vaccines).
[34] Between November 2007 and June 2011, OMI conducted a total of
five investigations concerning incidents in CLCs.
[35] Officials from VA networks and VA headquarters are responsible
for ensuring that VAMCs, including CLCs, have adequately addressed
recommendations made by OMI.
[36] SOARS identifies 28 areas in which a VAMC may be reviewed based
on 100 different VA-defined criteria.
[37] Culture change refers to efforts to transform the culture of
nursing home care from a medical model, where care is driven by a
medical diagnosis, to a person-centered model, where care is driven by
the needs of the individual, as affected by medical conditions. The
goals of care are achieved in an environment where the resident is
respected, treated with dignity, and invited to be an active
participant in the resident's own care. See Veterans Health
Administration Handbook 1142.01, Criteria and Standards for VA
Community Living Centers (Aug. 13, 2008).
[38] Instances that may trigger an issue brief include a homicide or
suicide on VA property, significant clinical incidents or outcomes
negatively affecting a veteran or group of veterans, or a breach of
information security.
[39] These complaints are separate from allegations submitted to OMI.
[40] See [hyperlink, http://www.gao.gov/products/GAO/AIMD-00-21.3.1].
[End of section]
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