Auditors Identify 80% Increase in Deficiencies Nationwide; Identify Dozens That Cause Harm to Residents or Place Them in “Immediate Jeopardy”

Chelsea, Holyoke Facilities in Massachusetts Had 25 Deficiencies – Including Five Causing Harm to Residents

Washington (December 22, 2022) - Senator Edward J. Markey (D-Mass.) joined Senator Elizabeth Warren (D-Mass.), a member of the Senate Armed Services Committee (SASC), in requesting the Government Accountability Office (GAO) to produce a completed report of the increases in both the number and severity of care deficiencies at State Veterans Homes (SVHs) across the nation, citing an increase “from 424 in 2019 to 766 in 2021.”

SVHs are state-managed facilities that provide nursing home, home, or adult day care to veterans through funding from the Department of Veterans Affairs (VA) and Centers for Medicare & Medicaid Services (CMS). Facilities receive regular inspections from the VA to ensure the best care for veterans and can, in turn, cite facilities for deficiencies when quality of care standards are not met. 

“GAO’s analysis of VA’s available annual inspection data for 2019 and 2021 found increases in both the number and the severity of deficiencies cited,” said the report. “A majority of the increase was in the quality of care and infection control categories, which cover accidents and staff hand hygiene. GAO found that, for those homes with annual inspection data available in both 2019 and 2021, many were cited for deficiencies in the same standard.”

VA inspections of the two State Veterans Homes in Massachusetts identified similar patterns. In 2019, VA inspection identified four deficiencies at Holyoke, none of which caused actual harm. But in 2021, VA identified 15 deficiencies, including three that caused actual harm. Similarly, in 2019, VA inspection identified four deficiencies at Chelsea, two of which caused actual harm. But in 2021, VA identified 11 deficiencies, including two that caused actual harm. 

For example, in 2021, Chelsea “did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection." Holyoke likewise failed to do so, with the surveyor observing multiple instances where staff treated residents while not wearing personal protective equipment (PPE).

“After putting their lives on the line, veterans deserve nothing less than outstanding care and a peaceful retirement,” said Senator Warren. “The VA has tools at its disposal to ensure that our State Veterans Homes are running effectively and efficiently and I will continue to push for oversight of these facilities.” 

“We have an obligation to protect those who have protected us,” said Senator Markey. “The GAO’s report reveals far too many failures in the care our veterans are receiving at state-run facilities, and I will continue to advocate on their behalf until we have transparency and high-quality care for our veterans.”

The GAO report showed that the VA could “enhance oversight by…, an expansion of the tools it has to bring these homes into compliance with quality standards.” The report included four recommendations for the Under Secretary of Health to increase compliance with quality of care standards:

  1. The Under Secretary of Health should develop a plan to ensure the data system it is currently developing has the capabilities to aggregate and analyze state veterans home data by multiple units of measurement, including by state and home, and across survey years. 
  2. The Under Secretary of Health should implement a process for consistently following up with state veterans homes that have not implemented their corrective active plans by the agreed upon dates. 
  3. The Under Secretary of Health should identify additional enforcement actions that would help ensure state veterans home compliance with quality standards and seek legislative authority to implement those actions, as appropriate.
  4. The Under Secretary of Health should ensure the Office of Geriatrics and Extended Care’s (GEC) centralization efforts align with VA's policies for national policy management, such as by issuing an interim notice to communicate the oversight changes to all stakeholders and pursuing the expeditious formalization of the new oversight in official directives and regulations. 

“I will be continuing my oversight and watching the VA carefully to make sure they implement these recommendations,” said Senator Warren.

In May 2020, Senators Markey and Warren requested this audit amid a concerning spike in veteran deaths and other reported care deficiencies at SVHs across the nation during the coronavirus disease 2019 (COVID-19) pandemic. In April 2020, Senators Markey and Warren led Massachusetts lawmakers in writing to the VA New England Health Care System asking what steps it was taking to assist Massachusetts State Veterans Homes in coronavirus mitigation.