VVA Reports on COVID-19 Deaths at State Veterans Homes

BY MICHAEL KEATING

Reacting to reports of patient deaths in the nation’s State Veterans Homes from COVID-19, in early March VVA President John Rowan charged the Veterans Health Care Committee with looking into the matter. The VVA Subcommittee on the Aging Veteran Experience (SAVE) was formed and on August 6 submitted its final report—“Leave No Veteran Behind…the Mission Continues: America’s Aging Veteran Population and the COVID-19 Pandemic”—which confirmed 1,011 coronavirus-related deaths in the state facilities (See full report here).

While a seemingly straightforward pursuit, the report explains that actual numbers were surprisingly difficult to come by. Some veterans homes, for example, didn’t release figures. What’s more, testing was not universal at the SVHs, so cause of death was not always clear, and some states reported COVID deaths without clinical confirmation. So SAVE members included other reporting sources, including State Departments of Health and Veterans Affairs and reputable news sources. The subcommittee also turned to VVA state council presidents and asked them to report COVID-19 deaths.

The subcommittee noted in its report that it “adopted the concepts of ‘Provisional Numbers,’ ” which acknowledged the imprecision of its numbers while underscoring the significance of the findings. Deaths were tracked for the period April 29 to July 17 in 47 of the 162 state veterans homes. No data were collected on age of death or pre-existing conditions. Nor were the death rates compared with those in non-veteran nursing homes.

In its report, SAVE outlined the history of the State Veterans Homes. The first Soldiers Home was established in Darien, Conn., in 1864 to care for displaced, indigent, and disabled veterans of the Civil War. Other northern states followed—each funded, developed, and regulated by the individual state.

“As America continued to send troops into harm’s way,” SAVE reports, “the quality of care, mounting costs, and increasing numbers of veterans eligible for admission became a burden on the states.”

Congress passed the State Home Construction Grant Program in 1964, which mandated that VA provide up to 65 percent funding for the renovation, acquisition, or construction of facilities. In 1988 Congress authorized federal cost-sharing at SVHs of about 30 cents per patient per day. In addition, the SVHs received inflation-adjusted per diem payments. The FY2020 VA per diem payments, the SAVE report notes, are $89.52 for adult day care, $48.50 for domiciliary care, and $112.36 for nursing home care.

But with funding came regulation, as legislators sought to ensure that the money was well spent and veterans received proper care. These mandated requirements are set forth in the Code of Federal Regulations 38: Part 51, Subpart D, which covers the standards applicable to the payment of per diem to VHCs. Non-adherence results in non-payment. The threat of non-payment gives the VA considerable clout, as those per diem payments form a significant part of each home’s budget. It’s a balancing act, however: Withholding funds results in reduced services for veterans.

Federal regulations cover a broad range of concerns, including resident rights, quality of care, reporting of sentinel events, unnecessary drugs, notification of changes, staffing, and infection control.

The regulations are enforced through annual unannounced inspections, usually by a VA contractor. In addition, about two-thirds of the SVHs are inspected annually by the Center for Medicare and Medicaid Services. But only the VA conducts annual inspections at every SVH.

“During these annual inspections,” SAVE reports, “the contractor generally cites deficiencies when SVHs are not in compliance with applicable quality standards. SVHs develop and implement corrective-action plans, and the VAMC director of jurisdiction approves the plan.”

The SAVE report criticized the VA for not enough regulation and not enough oversight. VA Secy. Robert Wilkie, in particular, was cited for his hands-off policy regarding state-owned homes.

“We realized that veterans in State Veterans Homes are often overlooked, disenfranchised, or without family. They have little or no voice in determining their care. VVA refuses to leave these veterans behind,” VVA President John Rowan said.

“We were disturbed that VA officials, including Secretary Wilkie, have denied having any authority or responsibility for veterans in the homes,” he said. “In truth, VA’s Geriatric and Extended Care Programs offer a continuum of services and programs that includes the State Veterans Homes. We were dismayed that VA leadership had chosen to view this group of veterans as part of VA’s Fourth Mission: to assist civilians in times of emergency.”

Noting that 55 percent of America’s veterans are over 65 years old, the report stressed the importance of strategic planning and oversight for the care of this aged demographic. The subcommittee made nine recommendations, all but one directed to the VA:

VA Oversight: Appoint a VA staff member from the local VAMC for oversight of the State Veterans Homes who will be present during inspections and help ensure that corrections are made.

Compliance: Ensure timely correction of deficiencies.

Spend Per Diem on the Veteran: An accounting by the VA is essential as some states deposit per diem funds into the state general fund rather than applying them directly to the needs of the SVHs and their veteran-patients.

Train All Staff: The local VAMC must conduct “regular and frequent” training of SVH staff, especially in new protocols and procedures.

Communicate: The VA website must provide information on State Veterans Home and rate the quality of care at each one so that veterans and their families are better able to make informed decisions about elder care.

Investigate Failures: A full investigation of the pandemic failings of the Pennsylvania SVH in Spring Hill should be undertaken immediately, and the results delivered to the responsible state and federal agencies.

Review Per Diem Rates: Because the present per diem does not cover the cost of care at SVHs under VA regulations, and because it is actually based on the per diem provided to care for homeless veterans, the rate needs to be reevaluated.

Continuum of Care: “These findings and recommendations” SAVE reports, “underscore a lack of involvement by the VA in the inspection process, the mitigation of deficiencies, and the corrective actions which safeguard the care and support of over 33,000 veterans living in State Homes.”

Addressing state responsibilities, SAVE recommends that the National Association of State Directors of Veterans Affairs and the National Association of State Veterans Homes should meet to discuss challenges in facing the coronavirus pandemic. Discussions should include lessons learned, unmet needs, and critical omissions.

In conclusion, the subcommittee—composed of Veterans Health Care Committee Chair Chuck Byers, VVA Special Adviser Linda Schwartz, former VVA Vice President Marsha Four, and Women Veterans Committee Chair Kate O’Hare-Palmer (all registered nurses), as well as PTSD and Substance Abuse Committee Chair Tom Hall, Communications Director Mokie Porter, and Deputy Director for Policy and Government Affairs Sharon Hodge—urged that the VA become more actively involved in addressing the challenges and deficiencies of the State Veterans Homes, especially in light of the crisis brought on by COVID-19.

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