What GAO found

The Department of Veterans Affairs (VA) provides care to nearly 9,000 veterans per day in 134 VA-operated nursing homes called Community Living Centers (CLCs), which are associated with VA Medical Centers (VAMC). CLC residents and their representatives can voice concerns about the quality of care in the CLC by filing a complaint with CLC staff or patient advocates at VAMCs. The GAO found that VA had insufficient policies, limited oversight, and unclear guidelines for dealing with complaints about care in its CLCs, among other issues. Specifically:

• VA only requires staff to document complaints made to VAMC officials, which means that most complaints about CLC care are likely not documented. According to VA officials, most complaints are resolved at the CTC level and are not high. As a result, VA cannot be assured that complaints are resolved for the vulnerable population of the CLC.
• GAO’s review of complaint documentation from four CLCs found that some staff did not properly implement VA’s complaints policies. For example, GAO found that staff did not always deal with complaints in a timely manner, such as waiting 1 month to start processing a complaint about unsanitary conditions. This reflects VA’s limited oversight of adherence to its policies. With more robust monitoring, VA may be able to identify and correct errors in handling complaints about care in CLCs.
• VA did not clearly specify which serious complaints should be brought to VA management through alerts called briefing notes, resulting in underreporting. Specifically, the GAO found that most of the abuse-related complaints it examined did not result in a case.

These policy, monitoring and referral issues are incompatible with VA’s strategic goals of providing high quality care and taking responsibility for its actions. Until these issues are resolved, VA cannot guarantee that all complaints about CLC care are followed up and resolved as part of its oversight of quality improvement efforts for the vulnerable CLC population.

Additionally, GAO has found that residents of the CLC and their representatives are not provided with accurate and complete information on how to file complaints. For example, VA rights and responsibilities documents for residents and their representatives require them to complain to entities that do not receive complaints about CLC care. This misinformation is incompatible with VA’s strategic goals of keeping veterans informed and for VA to be transparent and openly accountable for its actions. Without providing accurate and complete information about the options for filing complaints about CLC care, VA cannot guarantee that concerns of residents and their representatives about CLC care are heard and resolved.

Why GAO did this study

VA is responsible for overseeing the quality of care provided in its CLCs. However, several reports have raised concerns about substandard care in some CLCs. Complaints are a valuable source of information about the quality of care in nursing homes, as investigations into these complaints can quickly identify and resolve issues for this vulnerable population.

GAO was asked to review the quality of care in CLCs. In this report, GAO examined, among other objectives, the VA’s approach to handling complaints about care in CLCs and VA’s communications about how to file complaints.

For this report, GAO examined VA policies and interviewed VA officials. The GAO also selected six VA CLCs to obtain variations on factors such as the performance of the CLCs on quality metrics and geographic location. For each, GAO interviewed CTC officials and corresponding regional office officials and reviewed complaints information and policies.