March 11, 2022

The United States Government Accountability Office (“GAO”) report entitled “VA Community Living Centers: Opportunities Exist to Strengthen Oversight of Quality of Care” that was publicly released on December 30, 2021 stated, in part: “VA provides care to about 9,000 veterans in 134 VA-operated nursing homes, called “community living centers.” For oversight, VA conducts unannounced inspections and tracks quality measures (such as the percentage of residents with a fall) and nurse staffing levels. Performance generally improved from FY 2015-FY 2019. For example, inspections found fewer practices that caused actual harm. But deficiencies didn’t consistently trend downward and individual centers showed mixed results.”

CLCs are nursing homes that are associated with—and often co-located within—VAMCs. VA models its oversight of CLC services on the methods used by CMS, which includes evaluating CLCs against CMS-defined quality standards. VA also collects information on clinical quality measures and nurse staffing levels and uses this information to inform its oversight of CLCs. The VA, VISNs, and CLCs each have certain responsibilities for ensuring veterans receive high quality of care at CLCs, which include identifying opportunities for quality improvement.

How The Study Was Done

GAO reviewed VA policies, analyzed the most recent 5 years of complete data on CLC quality at the time of its review, and interviewed VA officials. GAO also selected six VA CLCs based on factors such as CLC performance on VA’s quality ratings website and location. For each, GAO interviewed CLC officials and officials from corresponding VA regional offices.

GAO reported that VA data on quality from three sources—results of unannounced inspections, performance on clinical quality measures, and nurse staffing levels—found that nationally, CLCs improved from fiscal years 2015 through 2019. However, individually, CLCs showed mixed results in performance for each data source GAO analyzed and variation in performance across the years GAO reviewed.

During the period GAO reviewed, the five most frequently cited deficiencies accounted for approximately 47 percent of all citations from fiscal years 2015 through 2019. These citations were: (1) infection prevention and control, (2) providing quality care, (3) maintaining an environment free of accidents and hazards, (4) providing treatment and services to prevent and heal pressure ulcers, and (5) services provided meet professional standards. Individual CLCs frequently had these deficiencies cited in multiple fiscal years, often in consecutive fiscal years, which may further indicate that CLCs have persistent challenges in addressing these deficiencies. For example, 108 CLCs had multiple deficiencies for infection prevention and control practices from fiscal years 2015 through 2019, with 83 of them having received citations in consecutive years.

The GAO concluded: “there are opportunities for VA to continue to strengthen its oversight of CLCs by improving agency guidance to them and using additional information on quality to inform its oversight. VA has not provided CLCs with guidance regarding when CMS quality standards are superseded by VA policy, leaving the burden on CLC officials and its contracted inspector to know when these cases arise. VA’s existing CLC-related policies are outdated and its training documentation on quality standards does not specify instances when VA policy supersedes CMS quality standards. By clarifying this guidance, VA will increase the likelihood that CLC providers and staff will follow–and inspectors will assess performance against—the appropriate standards. While VA has plans to update its CLC policies, it is important that VA provide CLCs with a clear understanding of what standards they are required to meet and how those reflect quality of care for this unique veteran population. In addition, VA could also use other key data on CLC quality to strengthen its oversight. VA’s focus on three sources of data on quality—the results of unannounced inspections, performance on clinical quality measures, and nurse staffing levels—limits the agency’s oversight and its ability to identify negative performance trends and areas of concern for CLC residents. Reliable data on adverse events from patient safety reports and resident experiences through surveys could give VA a better picture of care provided within its CLCs and help the agency meet its strategic goals regarding increased transparency. These opportunities would enable VA to more effectively oversee its CLCs and ensure that CLCs are providing high quality care to veterans.”


If you or a loved one suffered injuries (or worse) while a resident of a VA nursing home due to nursing home neglect, nursing home negligence, nursing home abuse, a nursing home fall, or the nursing home failing to properly care for a vulnerable adult, you should promptly find a VA nursing home claim lawyer in your state who may investigate your nursing home claim for you and file a VA nursing home claim on your behalf or behalf of your loved one, if appropriate.

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