Responsibility for VA’s medical facilities, including CLCs, rests with both  VA’s networks and VA headquarters. 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. After LTCI’s 2010 and 2011 reviews of VA’s CLCs are complete, VA  headquarters plans to analyze the deficiencies identified by LTCI. 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. 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. 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.   OIG.   VA Office of the Medical Inspector (OMI).   Quality Measures and Quality Indicators. 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. VA headquarters’ current approach relies significantly on the analysis of  findings from LTCI reviews of CLCs. However,  it does not compare the findings from one source to the findings from the  other sources. 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. 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. 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. 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. Identify the total number of deficiencies per community living center  (CLC). Related GAO Products

VA Long-Term Care: Trends and Planning Challenges in Providing  Nursing Home Care to Veterans.
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.