VA Health Care: VA Needs to Continue to Strengthen Its Oversight of Quality of State Veterans Homes

What GAO Found

The Department of Veterans Affairs (VA) pays over $1 billion a year to state veterans homes (SVH)—homes owned and operated by the states—to provide nursing home care to approximately 20,000 veterans. In fiscal year 2019, VA paid SVHs $1.17 billion for an average daily census of 20,072 veterans (51 percent of the total veterans receiving nursing home care through VA). Further, VA projects its payments to SVHs will continue to increase; VA projects it will pay $1.7 billion to SVHs to provide care to veterans in fiscal year 2022.

VA oversees the quality of care veterans receive at SVHs mainly through annual inspections that VA hires a contractor to perform. In its July 2019 report, GAO found that VA’s SVH contractor performed the required annual inspections for all SVHs in 2018, but VA needed to take action to enhance its oversight of SVHs and to ensure that information on quality of care provided in this setting is publicly available to veterans. Specifically, GAO found the following:

  • VA does not require its SVH contractor to identify all failures to meet quality standards during its inspections as deficiencies . For example, GAO found that VA allows its SVH contractor to cite some failures to meet quality standards as “recommendations,” rather than as deficiencies. VA officials said they do not track or monitor the nature of the recommendations or whether they have been addressed. As a result, VA does not have complete information on all failures to meet quality standards at SVHs and cannot track this information to identify trends in quality across these homes.
  • VA is not conducting all monitoring of its SVH contractor. GAO found that, at the time of its review, VA had not monitored the SVH contractor’s performance of inspections through regular observational assessments to ensure that contractor staff effectively determine whether SVHs are meeting required standards. Specifically, VA officials said they intended to observe the SVH contractor’s inspections on a quarterly basis; however, at the time of GAO’s review, VA officials could not recall when VA last observed the SVH contractor’s inspections. In July 2020, VA provided information indicating that they will regularly monitor the SVH contractor’s performance in conducting inspections through observational assessments.
  • VA does not share information on the quality of SVHs on its website. GAO found that, while VA provides information on the quality of other nursing home care settings on its website, it does not do so for SVHs. According to VA officials, there is no requirement to provide information on SVH quality on its website, as SVHs are owned and operated by the states. VA is the only federal agency that conducts regular oversight inspection on the quality of care of all SVHs and, as a result, is the only agency that could share such quality information on its website.

Why GAO Did This Study

Veterans—like over a million other Americans—rely on nursing home care to help meet their health needs. For eligible veterans whose health needs require skilled nursing and personal care, VA provides or pays for nursing home care in three nursing home settings: the VA-owned and -operated community living centers, public- or privately owned community nursing homes, and state-owned and -operated SVHs. In fiscal year 2019, VA provided or paid for nursing home care for over 39,000 veterans. The majority of these veterans received care at SVHs.

This statement summarizes the GAO’s July 2019 report, GAO-19-428 , with a focus on issues related to SVHs. Specifically, it describes the: (1) use of and expenditures for SVHs, (2) inspections used by VA to assess the quality of SVH care and VA’s oversight of the inspection process, and (3) information VA provides publicly on the quality of SVH care. As part of that work GAO analyzed VA data on expenditures for SVHs and interviewed VA officials. For this statement GAO reviewed expenditure and utilization data for fiscal year 2019.

What GAO Recommends

In its July 2019 report, GAO made three recommendations related to SVHs, including that VA require that all failures to meet quality standards are cited as deficiencies on SVH inspections. VA concurred with two recommendations and concurred in principle with the third. VA has addressed one recommendation and continued attention is needed to address the two remaining recommendations.

For more information, contact Sharon M. Silas at (202) 512-7114 or silass@gao.gov.

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    The four efforts within the Next Generation Combat Vehicles (NGCV) portfolio all prioritize rapid development, while using different acquisition approaches and contracting strategies. Some of the efforts use the new middle-tier acquisition approach, which enables rapid development by exempting programs from many existing DOD acquisition processes and policies. Similarly, the efforts use contracting strategies that include both traditional contract types as well as more flexible approaches to enable rapid development of technology and designs. Vehicles of the Next Generation Combat Vehicles Portfolio The two programs within the portfolio that recently initiated acquisitions—Mobile Protected Firepower and Optionally Manned Fighting Vehicle—have taken some steps to mitigate risks in cost and technology consistent with GAO's leading practices. The Army's use of the middle-tier approach for these efforts may facilitate rapid development, but the programs could benefit from additional application of GAO's leading practices. For example, the programs identified some risks in their cost estimates, but because each presented a single estimate of the total cost—referred to as a point estimate—these estimates do not fully reflect how uncertainty could affect costs. Similarly, the programs took some steps to mitigate technical risk by limiting development to 6 years or less and incrementally introducing new technologies, steps consistent with GAO's leading practices. However, by delaying key systems engineering reviews, the programs took some steps not consistent with leading practices, which could increase technical risk. While trade-offs may be necessary to facilitate rapid development, more consistent application of GAO's leading practices for providing cost estimates that reflect uncertainty and conducting timely systems engineering reviews could improve Army's ability to provide insight to decision makers and deliver capability to the warfighter on time and at or near expected costs. The Army has taken actions to enhance communication, both within the Army and with Department of Defense stakeholders, to mitigate risks. Within the Army, these actions included implementing a cross-functional team structure to collaboratively develop program requirements with input from acquisition, contracting, and technology development staff. Program officials also coordinated with other Army and Department of Defense stakeholders responsible for cost and test assessment, even where not required by policy, to mitigate risk. The Army views the NGCV portfolio as one of its most critical and urgent modernization priorities, as many current Army ground combat vehicles were developed in the 1980s or earlier. Past efforts to replace some of these systems failed at a cost of roughly $23 billion. In November 2017, the Army began new efforts to modernize this portfolio. GAO was asked to review the Army's plans for modernizing its fleet of ground combat vehicles. This report examines (1) the acquisition approaches and contracting strategies the Army is considering for the NGCV portfolio, (2) the extent to which the Army's efforts to balance schedule, cost, and technology are reducing acquisition risks for that portfolio, and (3) how the Army is communicating internally and externally to reduce acquisition risks. GAO reviewed the acquisition and contracting plans for each of the vehicles in the portfolio to determine their approaches; assessed schedule, cost, and technology information—where available—against GAO's leading practice guides on these issues as well as other leading practices for acquisition; and interviewed Army and DOD officials. GAO is making three recommendations, including that the Army follow leading practices on cost estimation and systems engineering to mitigate program risk. In its response, the Army concurred with these recommendations and plans to take action to address them. For more information, contact Jon Ludwigson at (202) 512-4841 or ludwigsonj@gao.gov.
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  • DHS Annual Assessment: Most Acquisition Programs Are Meeting Goals but Data Provided to Congress Lacks Context Needed For Effective Oversight
    In U.S GAO News
    As of September 2020, 19 of the 24 Department of Homeland Security (DHS) programs GAO assessed that had DHS approved acquisition program baselines were meeting their currently established goals. However, of the 24 programs, ten had been in breach of their cost or schedule goals, or both, at some point during fiscal year 2020. A few programs experienced breaches related to external factors, such as the COVID-19 pandemic, while others breached their baseline goals because of acquisition management issues. Five of these programs rebaselined to increase costs or delay schedules, but the remaining five were still in breach status as of September 2020 (see table). Further, GAO found that some of the 19 programs that were meeting their currently established goals—including the U.S. Coast Guard's Offshore Patrol Cutter program—are at risk of future cost growth or schedule slips. DHS Major Acquisition Programs In Breach of Approved Cost or Schedule Goals (or Both) As of September 2020. Program (estimated life-cycle cost) Breach Type National Cybersecurity Protection System ($5,908 million) Schedule Homeland Advanced Recognition Technology ($3,923 million) Cost and Schedule Grants Management Modernization ($289 million) Cost and Schedule National Bio Agro-Defense Facility ($1,298 million) Schedule Medium Range Surveillance Aircraft ($15,187 million) Schedule Source: GAO analysis of Department of Homeland Security (DHS) data. | GAO-21-175 Note: The life-cycle cost information is the current acquisition program baseline cost goal as of September 2020. Programs may revise cost goals, if necessary, when the new baseline is approved. GAO found that supplemental guidance for the development of acquisition documents generally aligned with requirements in DHS's acquisition management policy. However, guidance for developing acquisition documentation in DHS's Systems Engineering Life Cycle Instruction and accompanying Guidebook does not reflect current requirements in DHS's acquisition management policy. DHS officials stated that the information related to development of acquisition documents—including the systems engineering life cycle tailoring plan—should be consistent across all of DHS's policies, instructions, and guidebooks. Inconsistent agency-wide guidance can lead to a lack of clarity on when programs should submit their program documentation. The Joint Explanatory Statement accompanying a bill to the DHS Appropriations Act, 2019, directed DHS to provide quarterly briefings on summary ratings for all major acquisition programs. While DHS is meeting this direction with summary ratings, the ratings do not include contextual information, such as programs' cost, schedule, or performance risks. This type of information would help Congress understand how the ratings relate to potential program outcomes. Determining what additional risk information is needed for DHS's major acquisition programs along with the reporting timeframes and the appropriate mechanism to provide the information, would help ensure that decision makers have needed context. DHS plans to spend more than $7 billion on its portfolio of major acquisition programs—with life-cycle costs over $300 million— in fiscal year 2021 to help execute its many critical missions. The Explanatory Statement accompanying the DHS Appropriations Act, 2015, included a provision for GAO to review DHS's major acquisitions on an ongoing basis. This report, GAO's sixth review, assesses the extent to which (1) DHS's major acquisition programs are meeting baseline goals, (2) DHS's guidance for developing acquisition documentation is consistent with DHS acquisition policy, and (3) DHS is reporting relevant information to Congress on its portfolio of major acquisition programs. GAO assessed 24 acquisition programs, including DHS's largest programs that were in the process of obtaining new capabilities as of April 2018, and programs GAO or DHS identified as at risk of poor outcomes. GAO assessed cost and schedule progress against baselines; assessed DHS's congressional reporting requirements; and interviewed DHS officials and congressional appropriations committee staff. GAO is making one recommendation for DHS to align acquisition guidance with policy, and one matter for Congress to consider determining what additional information it needs to perform oversight. DHS concurred with our recommendation. For more information, contact Marie A. Mak at (202) 512-4841 or makm@gao.gov.
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