COVID-19: VA Should Assess Its Oversight of Infection Prevention and Control in CLCs (GAO-21-559)
Summary
GAO-21-559, a July 2021 report from the United States Government Accountability Office to congressional addressees on COVID-19 and Department of Veterans Affairs (VA) Community Living Centers (CLC), which are described as VA-owned and -operated nursing homes. GAO reports that VA issued guidance and trainings to support the pandemic response, but conducted limited oversight of infection prevention and control from March 2020 through February 2021. It states that VA suspended annual in-person inspections before resuming them virtually in February 2021. GAO recommends that VA conduct a retrospective assessment of its oversight; VA concurred in principle.
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United States Government Accountability Office
Report to Congressional Addressees
COVID-19
July 2021
VA Should Assess Its
Oversight of Infection
Prevention and
Control in Community
Living Centers
GAO-21-559
July 2021
COVID-19
VA Should Assess Its Oversight of Infection
Prevention and Control in Community Living Centers
Highlights of GAO-21-559, a report to
congressional addressees
Why GAO Did This Study What GAO Found
Close to 8,000 veterans per day The Department of Veterans Affairs (VA) took steps—such as issuing guidance
received nursing home care provided and trainings—to support the response to the COVID-19 pandemic in Community
by VA in CLCs in fiscal year 2020. Living Centers (CLC), which are VA-owned and -operated nursing homes. This
COVID-19 has posed significant risks guidance focused on, for example, limiting CLC entry and testing residents and
to nursing home residents and staff, as staff for COVID-19, while the trainings were intended to prepare staff for, among
residents are often in frail health, and other things, a surge in cases.
residents and staff have close daily
contact with each other. However, the agency conducted limited oversight of infection prevention and
control in these facilities during the first year of the pandemic, from March 2020
The CARES Act includes a provision
through February 2021. In particular, the agency suspended annual in-person
that GAO monitor the federal response
inspections of CLCs before resuming them virtually in February 2021. The
to the pandemic. This report describes,
among other objectives, guidance and
agency also required that CLCs conduct a one-time self-assessment of their
training VA has issued to help CLCs infection prevention and control practices but did not review the results in a timely
respond to the pandemic and manner to make more immediate improvements.
examines VA’s oversight of infection
prevention and control in CLCs during
the pandemic.
GAO analyzed documents, including
guidance, training-related materials,
and CLC self-assessments of their
infection prevention and control
practices. GAO also interviewed VA
officials and CLC staff, the latter from
five facilities selected based on factors
such as having been cited for infection
prevention and control deficiencies
prior to the pandemic.
What GAO Recommends
VA should conduct a retrospective
assessment of its oversight of infection
prevention and control in CLCs during
the COVID-19 pandemic to identify
lessons learned and be better
prepared for future infectious disease
outbreaks. VA concurred with GAO’s
recommendation in principle. VA plans
to review the results of CLCs’
assessments of their infection VA officials acknowledged these shortcomings as the agency responded in real
prevention and control practices and time to the rapidly evolving pandemic. As VA has described this time as a
require CLCs to take any needed “learning period,” it could benefit from assessing its decisions and actions related
corrective actions. to oversight of infection prevention and control during the pandemic to identify
any lessons learned. Such an assessment would align with VA’s plans to assess
and report on the agency’s overall response to the pandemic as well as its
strategic goal to promote continuous quality improvement in CLCs. Results from
View GAO-21-559. For more information, such an assessment—which could look at both successes and missed
contact Sharon Silas at (202) 512-7114 or
silass@gao.gov. opportunities—could help VA better prepare for future infectious disease
outbreaks in CLCs.
United States Government Accountability Office
Contents
Letter 1
Background 5
VA Disseminated Evolving Guidance and Training on a Range of
Topics to Help CLCs Respond to the COVID-19 Pandemic 7
Selected CLCs Described Common Experiences Responding to
the Pandemic Related to Issues Such as Evolving Guidance,
Obtaining Supplies, and Staffing 11
VA Conducted Limited Oversight of Infection Prevention and
Control in CLCs during the First Year of the Pandemic 15
Conclusions 19
Recommendation for Executive Action 19
Agency Comments 20
Appendix I Examples of Changes to VA Guidance for Selected CLC Services and
Procedures during COVID-19, March 2020 to March 2021 24
Appendix II VA Stages for Resuming Certain CLC Services Based on the
Prevalence of COVID-19 27
Appendix III Comments from the Department of Veterans Affairs 28
Appendix IV GAO Contact and Staff Acknowledgments 31
Tables
Table 1: Common Experiences Responding to the COVID-19
Pandemic among Five Selected VA Community Living
Centers (CLC) 12
Table 2: Examples of Changes to VA Guidance for Selected CLC
Services and Procedures during COVID-19, March 2020
to March 2021 24
Table 3: VA Stages for Resuming Certain CLC Services Based on
the Prevalence of COVID-19 27
Page i GAO-21-559 VA Nursing Homes and COVID-19
Figure
Figure 1: Examples of Evolving VA Guidance on Selected Topics
Related to CLCs’ Response to the COVID-19 Pandemic,
March 2020 through March 2021 9
Abbreviations
CDC Centers for Disease Control and Prevention
CLC community living center
CMS Centers for Medicare & Medicaid Services
COVID-19 Coronavirus Disease 2019
PPE personal protective equipment
VA Department of Veterans Affairs
VAMC VA medical center
VISN Veterans Integrated Service Network
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Page ii GAO-21-559 VA Nursing Homes and COVID-19
Letter
441 G St. N.W.
Washington, DC 20548
July 28, 2021
Congressional Addressees
Thousands of veterans rely on nursing home care provided or paid for by
the Department of Veterans Affairs (VA) to help them meet their skilled
nursing and personal care needs. 1 Many of these veterans—around
8,000 per day in fiscal year 2020—receive this care in one of 134
community living centers (CLC). 2 In contrast to the other nursing home
settings in which veterans may receive nursing home care, CLCs are
owned and operated by VA and are associated with, and may be located
in, on the campuses of, or near VA medical centers (VAMC). 3 CLCs
provide nursing home care that includes short-term rehabilitation, respite
care, hospice care, long-term skilled nursing, mental health recovery,
dementia care, and care for spinal cord injuries and disorders to veterans
in this setting.
VA’s management of the response to the Coronavirus Disease 2019
(COVID-19) pandemic for CLCs is of critical importance. COVID-19 is a
new and highly contagious respiratory disease causing severe illness and
death, particularly among the elderly. 4 COVID-19 has posed significant
risk to the health and safety of the nation’s nursing home residents, who
are often in frail health and live in close proximity to one another. One of
1VA is required to provide nursing home care for two categories of veterans, known as
mandatory veterans: (1) veterans who require nursing home care because of a service-
connected disability, and (2) veterans who require nursing home care and who also have
a service-connected disability rated at 70 percent or greater. A service-connected
disability is an injury or disease that was incurred or aggravated while on active duty.
Additionally, VA may provide nursing home care to other veterans, on a discretionary
basis, as capacity and resources permit. See 38 U.S.C. §§ 1710, 1710A.
2U.S. Department of Veterans Affairs, FY 2022 Budget Submission: Medical Programs
and Information Technology Programs, vol. 2 of 4 (June 2021).
3In addition to providing nursing home care to veterans in CLCs, VA pays for such care for
veterans in two other settings: public or privately owned community nursing homes and
state-owned and -operated veterans homes.
VAMCs provide two or more categories of care to veterans, such as inpatient, outpatient,
residential rehabilitation, or institutional extended—that is, nursing home—care.
4A. Patel and D.B. Jernigan, “Initial Public Health Response and Interim Clinical Guidance
for the 2019 Novel Coronavirus Outbreak—United States, December 31, 2019–February
4, 2020,” Centers for Disease Control and Prevention, Morbidity and Mortality Weekly
Report, vol. 69: 140–146 (2020).
Page 1 GAO-21-559 VA Nursing Homes and COVID-19
the first major outbreaks of COVID-19 reported in the United States
occurred in a Washington State nursing home in February 2020. Since
then, there has been a rapid increase in the number of COVID-19 cases
in U.S. nursing homes, with more than 132,000 nursing home resident
deaths reported as of May 2021—which may be an undercount. 5 Nursing
home staff, who have close and personal day-to-day contact with at-risk
residents, may also be at elevated risk for either contracting COVID-19
while working in these facilities or transmitting the virus to residents. 6
Given the risk COVID-19 poses in nursing homes, VA issued guidance
specific to its CLCs on COVID-19 mitigation—or infection prevention and
control—and criteria for making operational decisions to protect residents
and staff. 7 A primary means through which VA oversees infection
prevention and control in CLCs is through periodic inspections.
5Centers for Medicare & Medicaid Services, COVID-19 Nursing Home Data (Submitted
Data as of Week Ending 5/2/2021), accessed May 13, 2021,
https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data/bkwz-xpvg/.
We reported in September 2020 that the Centers for Medicare & Medicaid Services’
(CMS) data on COVID-19 cases and deaths among residents and staff in nursing homes
may be an undercount because it does not capture the early months of the pandemic. We
recommended that the U.S. Department of Health and Human Services, in consultation
with CMS and the Centers for Disease Control and Prevention, develop a strategy to
capture more complete data on COVID-19 cases and deaths in nursing homes retroactive
to January 1, 2020. See GAO, COVID-19: Federal Efforts Could Be Strengthened by
Timely and Concerted Actions, GAO-20-701, (Washington, D.C.: Sept. 21, 2020).
6See, for example, Kaiser Family Foundation, COVID-19 and Workers at Risk: Examining
the Long-Term Care Workforce, accessed January 6, 2021,
https://www.kff.org/coronavirus-covid-19/issue-brief/covid-19-and-workers-at-risk-examinin
g-the-long-term-care-workforce/, and M. Keith Chen, J.A. Chevalier, and E.F. Long,
“Nursing Home Staff Networks and COVID-19,” Proceedings of the National Academy of
Sciences of the United States of America, vol. 118 (1): 1-7 (2021). We also reported in
May 2021 that over half of the COVID-19 outbreaks that occurred among community
nursing homes from May 2020 through January 2021 began with a staff member. See
GAO, COVID-19 in Nursing Homes: Most Homes Had Multiple Outbreaks and Weeks of
Sustained Transmission from May 2020 through January 2021, GAO-21-367,
(Washington, D.C.: May 19, 2021).
7See, for example, U.S. Department of Veterans Affairs Memorandum, Coronavirus
(COVID-19) Community Living Centers – Revised 03/17/20 (March 17, 2020), and U.S.
Department of Veterans Affairs, Community Living Center (CLC) Moving Forward Plan
(July 27, 2020).
Page 2 GAO-21-559 VA Nursing Homes and COVID-19
In August 2020, we began work reviewing VA’s response to the COVID-
19 pandemic in CLCs under the CARES Act provision that GAO monitor
the federal response to the pandemic. 8 In this report, we
1. describe guidance and training that VA has provided to CLCs to help
guide their response to the COVID-19 pandemic;
2. describe selected CLCs’ experiences responding to the COVID-19
pandemic; and
3. examine VA’s oversight of infection prevention and control in CLCs
during the COVID-19 pandemic.
To describe the guidance and training VA provided to help guide CLCs’
response to the COVID-19 pandemic, we reviewed guidance that VA
developed and disseminated between March 2020 and March 2021 on
the response and related CLC operational changes. 9 We also reviewed
documentation related to the COVID-19-specific trainings and tools that
VA made available to CLC staff. We interviewed VA officials from the
Office of Geriatrics and Extended Care, who are responsible for CLC
strategic planning and policy development, regarding this guidance and
training. We also spoke with officials from three VA research centers
focused on infection prevention and control that have developed related
resources for CLCs.
To describe CLCs’ experiences responding to the pandemic, we
interviewed staff from five CLCs and their associated VAMCs and
Veterans Integrated Service Networks (VISN). 10 Specifically, we
interviewed staff involved in infection prevention as well as nursing staff,
among others, to understand their experiences responding to the COVID-
8Pub. L. No. 116-136, § 19010(b), 134 Stat. 281, 580 (2020). We regularly issue
government-wide reports on the federal response to COVID-19. For the latest report, see
GAO, COVID-19: Continued Attention Needed to Enhance Federal Preparedness,
Response, Service Delivery, and Program Integrity, GAO-21-551 (Washington, D.C.: July
19, 2021). Our next government-wide report will be issued in October 2021 and will be
available on GAO’s website at https://www.gao.gov/coronavirus.
9We categorized the guidance based on topic and selected those related to CLC access
and admissions; use of personal protective equipment; resident experiences pertaining to,
for example, restrictions on group activities; COVID-19 screening and testing; staffing; and
strategies related to handling suspected and positive COVID-19 cases to summarize for
this report. This guidance may pertain to CLCs specifically or to VAMCs and Veterans
Integrated Service Networks (VISNs), inclusive of CLCs.
10VISNs are regional health care networks that manage the day-to-day functions of
VAMCs within their networks through, for example, administrative and clinical oversight.
Page 3 GAO-21-559 VA Nursing Homes and COVID-19
19 pandemic, including their perspectives on the actions the CLCs took
and the support they received from VA. We selected the five CLCs for
variation in (1) their quality rating, (2) the number of cited infection
prevention and control deficiencies prior to the pandemic, (3) their
maximum bed capacities, (4) the complexity level of the associated
VAMC, and (5) their geographic location. 11 We identified experiences
reported by staff from a majority of (at least four) of the five CLCs, but
included additional examples or exceptions from fewer CLCs for
illustrative purposes. The information obtained from these interviews
cannot be generalized to other CLCs or associated VAMCs and VISNs.
To examine VA’s oversight of infection prevention and control in CLCs
during the pandemic, we interviewed VA officials from the Office of
Geriatrics and Extended Care regarding any modifications they made to
the CLC oversight process in light of the pandemic as well as any
additional ways they monitored CLC infection prevention and control
practices in response to COVID-19. We also spoke to staff from the five
selected CLCs who were responsible for quality oversight regarding these
changes. We obtained and reviewed copies of self-assessments VA
required CLCs to complete regarding their infection prevention and
control practices. These assessments were completed by 129 of the 134
11The five selected CLCs were located in Bedford, MA; Milwaukee, WI; Menlo Park, CA;
Orlando, FL; and San Antonio, TX.
VA assigns CLCs a quality rating of one to five stars, where five stars indicates the highest
quality and one star indicates the lowest quality. The ratings are based on data related to
nurse staffing levels, quality of resident care measures, and the results of inspections. We
selected two CLCs with five-star ratings and one CLC with a four-star, three-star, and two-
star rating as of September 2019, the end of the most current rating period at the time of
our selection, noting that there were no one-star rated CLCs as of that date.
We also identified whether CLCs were cited for an infection prevention and control
deficiency during inspections VA conducted in the two fiscal years prior to the pandemic—
fiscal year 2018 and fiscal year 2019. We selected two CLCs that were cited for such a
deficiency in both fiscal years, one CLC that was cited for such a deficiency in one of
these two fiscal years, and two CLCs that were not cited for such a deficiency in either of
these two fiscal years.
Further, we divided identified CLCs’ maximum bed capacity range and divided this range
into thirds. We selected two CLCs in the upper third of this range, two CLCs in the middle
third of this range, and one CLC in the bottom third of this range.
VA categorized VAMCs according to complexity level, which is determined on the basis of
the characteristics of the patient populations served, clinical services offered, educational
and research missions, and administrative complexity. As such, we selected CLCs to
approximate the percentage of VAMCs of each complexity level across the country. We
also selected CLCs to ensure variation in geographic location as identified by the location
of the associated VISNs.
Page 4 GAO-21-559 VA Nursing Homes and COVID-19
CLCs as of July 2020. 12 We analyzed CLCs’ responses to identify any
self-reported gaps in these practices. We evaluated VA’s oversight in the
context of the agency’s strategic goals for geriatrics and extended care
programs, which includes CLCs, as well as federal internal control
standards related to evaluating internal control issues and remediating
deficiencies. 13
We conducted this performance audit from August 2020 through July
2021 in accordance with generally accepted government auditing
standards. Those standards require that we plan and perform the audit to
obtain sufficient, appropriate evidence to provide a reasonable basis for
our findings and conclusions based on our audit objectives. We believe
that the evidence obtained provides a reasonable basis for our findings
and conclusions based on our audit objectives.
Within VA, the Office of Geriatrics and Extended Care is responsible for
Background overseeing the quality of nursing home care provided to veterans residing
in CLCs. VA models its oversight of CLCs on the methods used by the
Centers for Medicare & Medicaid Services (CMS). 14 CMS defines the
quality standards that approximately 15,600 nursing homes nationwide
must meet in order to participate in the Medicare and Medicaid
programs. 15 These include quality standards related to infection
prevention and control—a critical component of preventing the spread of
COVID-19 within nursing homes—as well as other matters such as
delivery of care, resident outcomes, and facility conditions. The infection
prevention and control standards pertain to, for example, hand hygiene,
appropriate use of personal protective equipment (PPE), and other
12U.S. Department of Veterans Affairs, Unannounced Surveys for State Veterans Homes
and Community Living Centers (July 6, 2020). According to VA officials, five of the CLCs
that were closed at the time that the self-assessment was administered did not complete
it. Thus, we reviewed self-assessments for 129 of the 134 CLCs.
13U.S. Department of Veterans Affairs, Geriatrics and Extended Care, GEC Mission,
Vision, Goals, (Updated April 8, 2016), accessed April 30, 2021,
https://www.va.gov/GERIATRICS/GEC_Mission_Vision_Goals.asp, and GAO, Standards
for Internal Control in the Federal Government, GAO-14-704G (Washington, D.C.: Sept.
2014). Internal control is a process effected by an entity’s management, oversight body,
and other personnel that provides reasonable assurance that the objectives of an entity
will be achieved.
14A VA 2016 memorandum specifies that VA will implement an unannounced inspection
program modeled on the nursing home oversight conducted by CMS.
15See 42 U.S.C. §§ 1395i-3(f)(1),1396r(f)(1); 42 C.F.R. Part 483, Subpart B (2020).
Page 5 GAO-21-559 VA Nursing Homes and COVID-19
infectious disease transmission-based precautions. 16 The Centers for
Disease Control and Prevention’s (CDC) guidance on preventing the
spread of COVID-19 in nursing homes identified the need to reinforce and
monitor resident and staff adherence to hand hygiene and the use of PPE
during the pandemic. 17
To monitor compliance with these standards, CMS enters into
agreements with state survey agencies to conduct inspections of each
nursing home. During these inspections, a state survey agency might
identify deficiencies—or instances in which the nursing home does not
meet an applicable quality standard. 18 Similarly, VA enters into an
agreement with a contractor to conduct regular unannounced
inspections—generally occurring annually—that determine the extent to
which CLCs meet quality standards. 19 VA reviews the results of all
inspections and requires that CLCs develop and implement corrective
action plans for each deficiency identified that detail how it will be
addressed. VA approves these plans and monitors CLCs’ actions until
each deficiency is addressed.
16CMS requires that nursing homes establish and maintain infection prevention and
control programs that include (1) a system to prevent, identify, report, investigate, and
control infections and communicable diseases for all residents, staff, volunteers, visitors,
and others providing services in the home; (2) written standards, policies, and procedures
for their infection prevention and control program; (3) antibiotic use protocols and a
system to monitor antibiotic use; and (4) a system for recording incidents identified under
the home’s infection prevention and control program and any corrective actions taken.
See 42 C.F.R. § 483.80(a)(1)-(4) (2020).
17Centers for Disease Control and Prevention, Interim Infection Prevention and Control
Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes (Updated March
29, 2021), accessed May 19, 2021,
https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html
18Surveyors classify cited deficiencies into categories according to scope (the number of
residents potentially affected) and severity (the potential for or occurrence of harm to
residents).
19CLCs receive an initial inspection when they open and then periodic, unannounced
inspections thereafter. The frequency of these inspections depends on the number and
severity of deficiencies identified during the prior year’s inspection, but they generally
occur every 11 to 13 months.
Page 6 GAO-21-559 VA Nursing Homes and COVID-19
VA disseminated numerous guidance documents, trainings, and other
VA Disseminated resources to CLCs to help staff manage the response to the COVID-19
Evolving Guidance pandemic. Throughout the first year of the pandemic, VA frequently
shared new and updated guidance with CLC staff to help mitigate the
and Training on a spread of COVID-19. VA also made trainings and other resources
Range of Topics to available to help CLC staff manage their duties and help improve their
knowledge of COVID-19.
Help CLCs Respond
to the COVID-19 Guidance on COVID-19. During the first year of the pandemic, from
March 2020 through March 2021, VA developed and disseminated over
Pandemic 70 pieces of guidance that evolved along with information about COVID-
19 to help CLCs respond to the pandemic. 20 VA’s early guidance outlined
safeguards designed to mitigate the introduction and spread of COVID-19
within CLCs, such as guidance on assigning dedicated staff to CLCs,
limiting the number of staff entering the facility, and the use and
conservation of PPE. 21 This guidance also suspended certain regular
operations, such as visitor entry and new veteran admissions. 22 VA
distributed this guidance frequently, in some cases sharing multiple
pieces of guidance on a single day early in the response.
VA continued to issue new and updated guidance throughout the
pandemic as new information became available about how COVID-19
spreads and as access to supplies increased. (See fig. 1 and app. I.) For
example, VA revised its isolation guidance for infectious residents from a
test-based strategy to a symptom-based strategy in response to changing
information from CDC. 23 VA guidance also evolved as access to supplies
20This includes guidance for CLCs specifically as well as VAMCs and VISNs, inclusive of
CLCs. VA shared approximately 45 percent of this guidance with CLC staff during the first
two months of the pandemic.
21See, for example, U.S. Department of Veterans Affairs, Coronavirus (COVID-19)
Community Living Centers – Revised 03/17/20 and U.S. Department of Veterans Affairs,
Coronavirus (COVID-19) Personal Protective Equipment (PPE) Use (March 15, 2020).
22See, for example, U.S. Department of Veterans Affairs, Coronavirus (COVID-19)
Community Living Centers – Revised 03/17/20.
23U.S. Department of Veterans Affairs, Discontinuation of Transmission-Based
Precautions for Patients with Confirmed COVID-19 in Healthcare Settings (May 29, 2020),
and U.S. Department of Veterans Affairs, Update to 052920 Discontinuation of
Transmission-Based Precautions for Patients with Confirmed COVID-19 in Healthcare
Settings (September 14, 2020). Since the beginning of the COVID-19 pandemic, CDC has
focused on improving its knowledge of COVID-19; updating and sharing related guidance
accordingly; and coordinating with agencies, such as VA, on the pandemic response. VA
regularly revised guidance throughout the pandemic to align with updated CDC
information.
Page 7 GAO-21-559 VA Nursing Homes and COVID-19
increased. For example, in March 2020, VA guidance indicated that the
agency could not meet the demand for PPE, and its use should be limited
to procedures likely to increase aerosols. 24 Subsequently, in April 2020,
VA released guidance stating the agency had received adequate PPE to
remove some restrictions on PPE use. 25
24U.S. Department of Veterans Affairs, Coronavirus (COVID-19) Personal Protective
Equipment (PPE) Use.
25U.S. Department of Veterans Affairs, Update: Coronavirus (COVID-19) Return to a
Contingency Strategy for Facemask and N95 Respirator Use (April 16, 2020). Specifically,
this guidance states the amount of PPE available was adequate for CDC PPE
contingency strategies. CDC PPE contingency strategies include temporary measures
during periods of anticipated supply shortages where current supply may meet the current
or anticipated utilization rate, but where there may be uncertainty about adequacy of
future PPE supply. Strategies include extended use of facemasks for staff encounters with
multiple patients.
Page 8 GAO-21-559 VA Nursing Homes and COVID-19
Figure 1: Examples of Evolving VA Guidance on Selected Topics Related to CLCs’ Response to the COVID-19 Pandemic,
March 2020 through March 2021
Note: We categorized VA guidance based on topic and selected those related to Community Living
Centers (CLC) access and admissions; resident experiences pertaining to, for example, restrictions
on group activities; staffing; use of personal protective equipment; Coronavirus Disease 2019
(COVID-19) screening, testing, and vaccinations; and strategies related to handling suspected and
positive COVID-19 cases as examples. This guidance may pertain to CLCs specifically or to VA
medical centers and Veterans Integrated Service Networks, inclusive of CLCs.
While VA initially standardized its guidance across all CLCs, over time VA
issued guidance that allowed CLCs to adapt their response to the
pandemic based on the local spread of COVID-19. For example, VA
released guidance in July 2020 permitting leadership at individual CLCs,
as well as the associated VAMCs and VISNs, to resume certain CLC
services in three stages based on the prevalence of COVID-19 within the
individual CLC. 26 (See app. II.) Specifically, individual CLCs are allowed
to transition from one stage to another after meeting certain criteria and
26U.S. Department of Veterans Affairs, Community Living Center (CLC) Moving Forward
Plan.
Page 9 GAO-21-559 VA Nursing Homes and COVID-19
must revert to a prior stage should a resident or staff member be
diagnosed with COVID-19.
VA primarily relied upon national phone calls and emails with CLC and
VISN staff to share new and updated guidance and clarify information
during the pandemic. 27 For instance, VA officials told us they set up
monthly national phone calls with CLCs to discuss the COVID-19
response and compiled CLC frequently asked questions collected from
phone calls and emails to clarify guidance.
Trainings and other resources. Since March 2020, VA has compiled
numerous trainings and other resources related to COVID-19, which they
circulated to CLC staff to help them manage the pandemic. 28 (See
sidebar for one example of these resources.) VA provided skills-based
training for CLC staff on a variety of topics, including the following:
• Training on infection prevention and control, such as the proper
donning and doffing of PPE to mitigate the spread of COVID-19. One
such training used an interactive avatar to demonstrate the
appropriate order to remove jewelry, perform hand hygiene, and don
protective gown, N95 respirator, face shield, and gloves prior to a
healthcare provider entering the room of suspected or confirmed
COVID-19 cases. 29
• Training on certain clinical care or services that CLC staff may not
typically perform. For example, VA provided online trainings for CLC
nursing staff on how to perform an electrocardiogram. 30 As CLC
access was limited to essential staff during the pandemic, CLC
27According to VA officials, these national phone calls served as a forum to share
information related to the COVID-19 response broadly, including discussing guidance,
sharing challenges and leading practices, and offering opportunity for feedback.
28VA shared over 250 trainings, tools, and other resources to help staff manage their
response to the pandemic. See, for example, U.S. Department of Veterans Affairs, Clinical
Crisis Skills Training for Community Living Centers, (Updated April 9, 2020), accessed
April 5, 2021, https://www.va.gov/covidtraining/clc.html. Some of these trainings were
developed by VA, while others were developed by CDC or other healthcare organizations.
29U.S. Department of Veterans Affairs, Donning and Doffing: Interactive Training,
accessed April 26, 2021, https://emergencytraining.azureedge.net.
30An electrocardiogram is a test that detects and records the heart’s activity, including
heart beat rhythm and strength.
Page 10 GAO-21-559 VA Nursing Homes and COVID-19
nursing staff told us they were trained to perform procedures, such as
electrocardiograms, which are typically performed by specialists. 31
• Training to help CLC staff prepare for a potential surge in cases. For
VA Temperature Dashboard Tool for
COVID-19 example, VA officials told us they conducted a series of field trainings
In addition to guidance and training, VA on acute care and post-acute care for COVID-19 cases for CLC
officials told us they developed and shared nursing staff and staff temporarily reassigned to CLCs from other
tools with Community Living Center (CLC)
staff to support their response to the
departments of the associated VAMC who typically did not work in
pandemic. For example, VA officials involved acute-care settings.
in research on infection prevention and
control told us they developed a Temperature VA officials told us that they shared these trainings with CLCs by posting
Dashboard Tool that allowed CLC staff to them on VA’s website, incorporating information on, and links to, certain
track residents’ daily temperatures over time.
According to officials, collecting and trainings in guidance documents and discussing them on national phone
comparing data on a resident’s daily calls with CLC staff. Officials also told us that staff were encouraged to
temperature can predict the probability that a
resident has Coronavirus Disease 2019 take these trainings, but that they were not mandatory.
(COVID-19) one week before testing positive
for the virus that causes the disease. A higher
body temperature--even one defined by
smaller deviations from a resident’s baseline
than a typical fever--can be a leading indicator
of COVID-19 among the elderly, according to
officials. VA officials told us that they
introduced the dashboard in CLCs nationwide
in March 2020 after piloting it in three
Veterans Integrated Service Networks.
Source: GAO interviews with Department of Veterans Affairs
(VA) officials. | GAO-21-559
Staff from the five selected CLCs described common experiences
Selected CLCs responding to the COVID-19 pandemic, such as experiences with
Described Common evolving guidance, obtaining supplies, and staffing issues. (See table 1.)
For example, as described earlier, staff from all five selected CLCs told us
Experiences that VA provided them with frequent, rapidly evolving guidance to inform
Responding to the their response to the pandemic, which at times necessitated
implementation on very short notice. Many of the experiences described
Pandemic Related to
Issues Such as
Evolving Guidance,
Obtaining Supplies,
and Staffing
31See, for example, U.S. Department of Veterans Affairs, Coronavirus (COVID-19)
Community Living Centers – Revised 03/17/20 regarding limitations on CLC access.
Page 11 GAO-21-559 VA Nursing Homes and COVID-19
by CLC staff are experiences that we and others have reported that other
nursing homes also experienced during the pandemic. 32
Table 1: Common Experiences Responding to the COVID-19 Pandemic among Five Selected VA Community Living Centers
(CLC)
Common
experience Description Examples
Evolving Implementing rapidly- • Staff at the five CLCs told us it was difficult to keep up with VA’s frequent and evolving
guidance evolving guidance, at guidance on Coronavirus Disease 2019 (COVID-19).
times on very short • Some staff explained that because some guidance was effective immediately, they had
notice to, for example, determine related responsibilities or ensure that staff were trained and
ready to implement the changes very quickly.
Obtaining Obtaining necessary • Staff at four CLCs told us that, early in the pandemic, they had difficulty obtaining some
supplies supplies, such as necessary supplies, such as COVID-19 testing kits or appropriate masks to protect
personal protective both CLC staff and residents from transmitting COVID-19.
equipment (PPE) • For example, some staff described limited amounts of COVID-19 testing kits early in
the pandemic that may have made it difficult to track such transmissions.
Staffing Addressing issues • Staff at the five CLCs reported taking on additional responsibilities, such as feeding
issues related to staff on sick residents, conducting lab draws, or taking residents to medical appointments, in part
leave or under because family caregivers or auxiliary staff who typically perform these tasks were not
quarantine and allowed in the CLC.
additional staff • In addition, staff at some of the CLCs described increased demand for staff—
responsibilities particularly during surges of COVID-19 cases—such as when nurses and other staff
became ill or were required to quarantine.
• However, staff at one CLC told us that their staff-to-resident ratio had improved since
the beginning of the pandemic because the CLC significantly reduced the capacity of
the CLC by limiting the number of residents, in part so residents could each have their
own room, while the number of staff remained the same.
32For example, GAO previously reported that community nursing homes and State
Veterans Homes faced similar experiences related to supplies, staffing, resident isolation,
or vaccinations. See GAO, COVID-19 In Nursing Homes: HHS Has Taken Steps In
Response To Pandemic, but Several GAO Recommendations Have Not Been
Implemented, GAO-21-402T (Washington, D.C: March 17, 2021), and GAO, COVID-19:
Urgent Actions Needed to Better Ensure an Effective Federal Response, GAO-21-191
(Washington, D.C.: Nov. 30, 2020).
A CMS Commission on COVID-19 in nursing homes made similar observations on
guidance, staffing, building changes and resident isolation; see MITRE, Coronavirus
Commission on Safety and Quality in Nursing Homes: Commission Final Report, PRS
Release Number 20-2382 (McLean, Va: September 2020).
VA’s Office of Inspector General also reported similar experiences among CLC staff
related to guidance, supplies, moving residents, and resident isolation. See Department of
Veterans Affairs, Office of Inspector General, Comprehensive Healthcare Inspection of
Facilities’ COVID-19 Pandemic Readiness and Response in Veterans Integrated Service
Networks 10 and 20, Report #21-01116-98 (March 16, 2021).
Page 12 GAO-21-559 VA Nursing Homes and COVID-19
Common
experience Description Examples
Moving Moving residents to and • Staff at four of the CLCs described moving residents between facilities, such as
residents from other facilities to between CLCs or between the CLC and its associated VA medical center (VAMC), to
accommodate infection accommodate infection surges or because the CLC did not provide care for residents
surges with COVID-19.
• Staff at one CLC described residents’ challenges with these moves as an upheaval
being in a new and unfamiliar environment, particularly for those with dementia who
rely on the familiarity of their surroundings.
• Some staff also described their own challenges related to moving residents, including
managing much longer commutes or the inability to work in the new location due to
family obligations.
Building Building limitations • Staff at the five CLCs described building limitations that necessitated adjustments,
changes necessitated such as the need for more single occupancy rooms or air circulation improvements in
adjustments to prevent building ventilation systems, to prevent the airborne transmission of COVID-19 within
the transmission of enclosed spaces.
COVID-19 • Some staff also described challenges with providing access to adequate space for
residents who needed physical therapy or for residents with dementia.
Staff stress Staff stress caring for • Staff at the five CLCs described the stress they experienced related to caring for
residents during the residents, especially those at the end of life, or fears of bringing the virus home to their
pandemic, and fears of families during the pandemic.
infecting their families • For example, some staff described the burden of supporting residents near death
whose families were unable to be there due to the visitor restrictions and the grief they
experienced related to residents’ deaths.
• Further, staff at one CLC told us about fears of transmitting the virus to their family
members, including their children or elderly parents.
Resident Residents isolated from • Staff at the five CLCs told us that, over time, prohibitions on resident gatherings and
isolation family and friends due to restrictions on in-person visits with family and friends caused residents to feel isolated.
visitation restrictions • Some staff described how the lack of visitors was difficult for residents, and how they
also missed opportunities to socialize with each other or participate in activities outside
the CLC.
• Some staff also told us that it could be difficult to tell when residents were close to
dying as their health could change very quickly—especially among residents near the
end of life during the pandemic—so the residents may have missed opportunities for
families to say goodbye to their loved ones.
Vaccine Vaccinating CLC • Staff at five of the CLCs described having sufficient vaccines for all the staff or
rollout residents and staff as residents who chose to receive them and did not indicate any problems with their
VA’s highest priority administration.
• Some staff also described vaccine reluctance among staff but stated that some of the
staff who initially declined subsequently agreed to be vaccinated.
Source: GAO analysis of interviews with staff at five selected Department of Veterans Affairs (VA) CLCs. | GAO-21-559
Note: We selected the five CLCs to provide variation in their quality ratings, the number of cited
infection prevention and control deficiencies they received in the 2 years prior to the pandemic, their
maximum bed capacities, the complexity level of the associated VAMCs, and their geographic
locations.
Page 13 GAO-21-559 VA Nursing Homes and COVID-19
Staff from the CLCs described how they or VA responded to each of
these experiences; these responses ranged from receiving training from
VA to shifting staff resources. For example:
• CLC staff told us that the training they received from VA, as well as
the CLCs’ associated VAMCs or VISNs, helped them implement the
rapidly evolving COVID-19 guidance.
• CLC staff also said that they communicated regularly with officials
from the associated VAMCs and VISNs about supplies and staffing
needs. For example, staff at four CLCs explained that the VAMCs or
VISNs reassigned staff to their CLCs during the pandemic, including
moving nurses from outpatient clinics because of the lower demand
for those services and hiring additional staff to meet increased
demand at CLCs. 33
• CLC staff also noted that VA’s efforts to vaccinate CLC residents and
staff had been going well. VA officials told us that, as of June 6, 2021,
87 percent of CLC residents had received at least one dose of
vaccine, and 84 percent had been fully vaccinated. 34
33For example, VA activated its Disaster Emergency Medical Personnel System to
respond to the pandemic, which was developed to deploy existing clinical and non-clinical
staff to reinforce existing staff levels where needed due to an emergency or disaster. VA
reported in April 2021 that it also continued to recruit and orient new personnel.
34VA officials stated that the percentage of residents who have been vaccinated may
change, primarily due to resident movement and also indicated that there may be CLC
residents for whom vaccinations are not clinically appropriate or who decline vaccinations.
VA guidance indicates that visitors may be allowed in CLCs under certain conditions,
including if more than 70 percent of residents are vaccinated for COVID-19 and the most
recent positive COVID-19 case was more than 14 days prior, which will help to end
residents’ extended isolation. See U.S. Department of Veterans Affairs, COVID-19:
Visitations to Veterans Health Administration (VHA) Community Living Centers (CLC) and
Spinal Cord Injury & Disorder (SCID) Neighborhoods (March 16, 2021).
Page 14 GAO-21-559 VA Nursing Homes and COVID-19
CLC staff also explained how they shared practices with each other, so
that CLCs that faced later outbreaks of COVID-19 were able to learn from
those who had experienced earlier waves of the pandemic.
VA conducted limited oversight of infection prevention and control in
VA Conducted Limited CLCs during the first year of the pandemic, suspending its annual
Oversight of Infection inspections of CLCs and taking limited, alternative actions to ensure that
CLCs were best able to prevent the spread of COVID-19. VA officials
Prevention and acknowledged these shortcomings. 35 VA described this year as a
Control in CLCs “learning period,” as the agency took important steps to limit the number
of individuals entering CLCs and helped CLCs respond to a rapidly
during the First Year evolving pandemic in real time.
of the Pandemic
Specifically, to oversee infection prevention and control in CLCs between
March 2020 and February 2021, VA did the following:
• Suspended annual inspections of CLCs until the agency was
able to conduct them virtually. In March 2020, VA suspended its
annual inspections of CLCs, periodically reevaluating the state of the
VA’s Office of Inspector General found that VA facilities had not consistently documented
or managed the COVID-19 vaccinations of CLC residents, based on its analysis of
national data on vaccinations from December 14, 2020, when vaccinations began, through
January 19, 2021. For example, the Inspector General found that some CLCs had used a
locally developed tracking system to document why residents had not been vaccinated,
such as those who refused or for whom it was medically inappropriate, and had not
entered this information into the national data system. The Inspector General also found
that some CLCs were unclear about whether to vaccinate certain residents, such as
residents staying less than 21 days who may had not have been given a first dose of the
vaccine because the CLC had not yet determined how to schedule the second dose after
these residents had left the CLC. VA agreed to identify and evaluate these gaps and
develop a corrective action plan to resolve the concerns. See VA Office of Inspector
General, Veterans Health Administration: Inconsistent Documentation and Management of
COVID-19 Vaccinations for Community Living Center Residents, Report #21-00913-91
(April 14, 2021).
35CMS experienced similar limitations related to its oversight of community nursing homes
during the pandemic. In March 2020, the agency suspended comprehensive in-person
inspections of such nursing homes. Instead, CMS required state survey agencies to
conduct targeted infection prevention and control inspections and high-priority complaint
investigations as long as surveyors had access to adequate PPE. Subsequently, in
August 2020, CMS authorized comprehensive in-person inspections to resume as soon as
state agencies had adequate resources, such as staff and PPE. See GAO, COVID-19:
Urgent Actions Needed to Better Ensure an Effective Federal Response, GAO-21-191
(Washington, D.C.: Nov. 30, 2020).
Page 15 GAO-21-559 VA Nursing Homes and COVID-19
pandemic to determine whether this suspension should continue. 36
These inspections are VA’s primary means of CLC oversight, which
the agency uses to evaluate CLCs on a broad range of quality
standards, including those relevant to COVID-19 mitigation. VA
suspended these inspections, which the agency’s contractor typically
conducts in person, because of the risk of contracting or transmitting
COVID-19 to CLC residents and staff as well as to inspectors. 37
According to VA officials, they considered conducting virtual
inspections early in the pandemic, but the agency first had to modify
its contract with the organization that conducts the inspections to
allow for this. Once this modification was complete, VA resumed
inspections virtually in February 2021. 38
• Required CLCs to assess their own infection prevention and
control practices related to the pandemic but did not review them
in a timely manner. In July 2020, VA required that CLCs complete a
one-time self-assessment specific to their practices to prevent the
transmission of COVID-19, such as hand hygiene, the appropriate use
of PPE, and restrictions on visitor entry. 39 Many of the practices
assessed align with those described in VA’s guidance to help CLCs
respond to the pandemic. In our review of the self-assessments, we
found that CLCs identified gaps in their infection prevention and
36See, for example, U.S. Department of Veterans Affairs, Postponement of Long-Term
Care Surveys (March 6, 2020), and U.S. Department of Veterans Affairs, Unannounced
Surveys for State Veterans Homes and Community Living Centers.
37According to VA guidance, while these inspections are essential for continued oversight
and monitoring of CLCs, a temporary suspension to mitigate the potential spread of
COVID-19 was considered to be in the best interest of residents, staff, and inspectors.
See U.S. Department of Veterans Affairs, Postponement of Long-Term Care Surveys.
38U.S. Department of Veterans Affairs, Virtual Survey Process for Department of Veterans
Affairs (VA) Community Living Centers (CLC) and Spinal Cord Injury/Disorders (SCI/D)
Long Term Care Unites (VIEWS 4420960) (February 2, 2021).
39U.S. Department of Veterans Affairs, Unannounced Surveys for State Veterans Homes
and Community Living Centers. CMS developed the self-assessment tool for use by
community nursing homes, and VA adapted it for its own use. The self-assessment
includes questions related to standard and transmission-based precautions, including
hand hygiene and PPE; resident care; infection prevention and control standards, policies,
and procedures; infection surveillance; visitor entry; education, monitoring, and screening
of staff; and staffing in emergencies.
Page 16 GAO-21-559 VA Nursing Homes and COVID-19
control practices. 40 For example, one CLC reported that staff were
observed not conducting hand hygiene after patient care and that
non-critical reusable medical equipment was observed to be visibly
dirty between uses. Another CLC reported that the facility had not
conducted the appropriate screening, restriction, and education for
visitors entering the CLC. According to VA officials, although they
reviewed the results of the self-assessments with CLCs, they did not
do so in a timely manner, which would have allowed CLCs to make
more immediate improvements. Specifically, CLCs were required to
complete the self-assessment in July 2020; in September of that year,
VA officials told us they had not reviewed the results, but indicated
they had done so by December. VA officials told us they do not have
plans to require that CLCs complete the self-assessment again now
that annual inspections have resumed.
• Relied on informal communications not designed to assess
infection prevention and control. VA officials told us they relied on
informal communications with CLC staff to discuss their COVID-19
status as well as infection prevention and control practices—including
monthly phone calls established in response to the pandemic and pre-
established quarterly phone calls that included VISN leadership.
During these phone calls, which officials said have continued beyond
VA’s resumption of annual inspections, CLC staff can ask questions
and obtain real-time information about the pandemic response
broadly, including but not limited to infection prevention and control.
Given the informal nature of these calls, they were not designed to
allow VA to assess CLC infection prevention and control practices in a
standardized and comprehensive manner.
VA could benefit from assessing the decisions and actions related to its
oversight of infection prevention and control in CLCs during the first year
of the pandemic. When asked in May 2021 whether the agency had plans
for assessing its oversight of infection prevention and control in CLCs
during the pandemic, VA officials told us that they had discussed
40GAO previously found that 95 percent of CLCs were cited for infection control
deficiencies prior to the pandemic, with some CLCs cited in consecutive years. These
deficiencies often pertained to the same gaps we identified in our review of the self-
assessments—such as hand hygiene and appropriate use of PPE. See GAO, VA Health
Care: Community Living Centers Were Commonly Cited for Infection Control Deficiencies
Prior to the COVID-19 Pandemic, GAO-21-195R (Washington, D.C.: Jan. 6, 2021). In
addition, GAO previously found that prior to COVID-19 most nursing homes that
participate in Medicare and Medicaid had infection control deficiencies, with more than
half of the nursing homes having persistent problems. See GAO, Infection Control
Deficiencies Were Widespread and Persistent in Nursing Homes Prior to COVID-19
Pandemic, GAO-20-576R (Washington, D.C.: May 20, 2020).
Page 17 GAO-21-559 VA Nursing Homes and COVID-19
conducting such an assessment in the future, including some ideas of
what an assessment could include. Officials indicated they would develop
a plan for conducting such an assessment by August 2021. Such an
assessment would align with VA’s plans to assess and report on the
agency’s overall response to the pandemic, which the agency stated is
essential as a learning organization. 41 In addition, it would be consistent
with the agency’s strategic goal to promote continuous quality
improvement among its geriatrics and extended care programs, which
include CLCs, as well as federal standards for internal control, which
require that agencies evaluate internal controls issues and address
identified deficiencies. 42
By conducting a retrospective assessment of its oversight of infection
prevention and control in CLCs during the pandemic, VA could better
prepare to help CLCs mitigate future infectious disease outbreaks among
this vulnerable population, rather than having to react in real time as it
often did during the pandemic. VA’s first two reports on the agency’s
overall response to the pandemic, covering the period January 2020
through December 2020, describe the COVID-19-specific actions the
agency took to protect CLC residents and staff by, for example, restricting
access and admissions, suspending group activities, and testing and
vaccinating residents and staff, as outlined in VA guidance. 43 However,
these reports do not indicate whether the agency oversaw CLCs’
implementation of these actions or how officials determined their
effectiveness, and do not include an assessment of VA’s oversight of
infection prevention and control broadly in the absence of annual
41In October 2020, VA issued an initial report evaluating the agency’s response between
January 2020 and June 2020, covering a period prior to, as well as approximately the first
four months of, the pandemic. See U.S. Department of Veterans Affairs, Veterans Health
Administration (VHA) Coronavirus Disease 2019 (COVID-19) Response Report (October
27, 2020). The report states that these types of assessments are essential to VA as a
learning organization and that the agency plans to continue them and consider strategic
follow-up actions informed by the agency’s experiences.
42U.S. Department of Veterans Affairs, Geriatrics and Extended Care, GEC Mission,
Vision, Goals, accessed April 30, 2021,
https://www.va.gov/GERIATRICS/GEC_Mission_Vision_Goals.asp, and GAO-14-704G.
43U.S. Department of Veterans Affairs, Veterans Health Administration (VHA) Coronavirus
Disease 2019 (COVID-19) Response Report, and U.S. Department of Veterans Affairs,
Veterans Health Administration (VHA) Coronavirus Disease 2019 (COVID-19) Response
Report – Annex A (May 10, 2021).
Page 18 GAO-21-559 VA Nursing Homes and COVID-19
inspections. 44 The results of a more comprehensive and retrospective
assessment of VA oversight of infection prevention and control in CLCs
could help the agency identify any lessons learned and needed changes.
Further, it could also help VA identify successful decisions and actions
taken to protect CLC residents and staff.
VA’s management of the COVID-19 pandemic for CLCs is of critical
Conclusions importance, given that veterans who receive care and staff who work in
this nursing home setting are at increased risk of contracting or
transmitting the disease. Although VA was active in generating guidance,
training, and other support for CLCs, the agency conducted limited
oversight of infection prevention and control in CLCs during the first year
of the pandemic. Between March 2020 and February 2021, VA
suspended annual, in-person CLC inspections—which the agency uses to
determine whether CLCs meet infection prevention and control quality
standards and have since resumed virtually—and implemented
alternative means of oversight that were limited in different ways.
It is understandable that VA faced challenges that affected its ability to
oversee nursing homes during the pandemic, as information about
COVID-19 and its mitigation rapidly evolved, and the agency had to
respond in real time. Assessing its decisions and actions related to its
oversight during this period—looking at both successful decisions and
actions as well as missed opportunities to protect this vulnerable
population—would align with VA’s plans to review the agency’s overall
response to the pandemic and better prepare the agency to help CLCs
mitigate future infectious disease outbreaks.
The Department of Veterans Affairs Under Secretary for Health should
Recommendation for conduct a retrospective assessment of VA’s oversight of infection
Executive Action prevention and control in CLCs during the COVID-19 pandemic to identify
lessons learned and be better prepared for future infectious disease
outbreaks. (Recommendation 1)
44VA found that the agency effectively participated in monitoring and dissemination of
evolving guidelines to prevent, diagnose, and treat COVID-19 to protect CLC residents,
but the report did not define or otherwise indicate a standard for evaluating this statement.
See U.S. Department of Veterans Affairs, Veterans Health Administration (VHA)
Coronavirus Disease 2019 (COVID-19) Response Report – Annex A.
Page 19 GAO-21-559 VA Nursing Homes and COVID-19
We provided a draft of this report to VA for review and comment. In its
Agency Comments written comments, reproduced in Appendix III, VA concurred with our
recommendation in principle. VA stated that by January 2022, it will
review the results of CLCs’ July 2020 assessments of their infection
prevention and control practices to identify any trends and require that
CLCs develop related corrective action plans. We agree this may help
CLCs improve their infection prevention and control practices and be
better prepared for future infectious disease outbreaks. Our
recommendation intended that VA conduct a broader assessment of its
decisions and actions related to its oversight of infection prevention and
control in CLCS during the COVID-19 pandemic; that this assessment
potentially include, but not be limited to, decisions that affected the
timeliness of the agency’s review of CLCs’ assessments; and that VA’s
broader assessment identify lessons learned for the future. We
encourage VA to conduct such an assessment as well.
We are sending copies of this report to the appropriate congressional
committees, the Secretary of Veterans Affairs, and other interested
parties. In addition, the report is available at no charge on the GAO
website at http://www.gao.gov.
If you or your staff have any questions about this report, please contact
me at (202) 512-7114 or at SilasS@gao.gov. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on
the last page of this report. GAO staff who made key contributions to this
report are listed in appendix IV.
Sharon M. Silas
Director, Health Care
Page 20 GAO-21-559 VA Nursing Homes and COVID-19
List of Addressees
The Honorable Patrick Leahy
Chairman
The Honorable Richard Shelby
Vice Chairman
Committee on Appropriations
United States Senate
The Honorable Ron Wyden
Chairman
The Honorable Mike Crapo
Ranking Member
Committee on Finance
United States Senate
The Honorable Patty Murray
Chair
The Honorable Richard Burr
Ranking Member
Committee on Health, Education, Labor, and Pensions
United States Senate
The Honorable Gary C. Peters
Chairman
The Honorable Rob Portman
Ranking Member
Committee on Homeland Security and Governmental Affairs
United States Senate
The Honorable Jon Tester
Chairman
Committee on Veterans’ Affairs
United States Senate
The Honorable Rosa L. DeLauro
Chairwoman
The Honorable Kay Granger
Ranking Member
Committee on Appropriations
House of Representatives
Page 21 GAO-21-559 VA Nursing Homes and COVID-19
The Honorable Frank Pallone, Jr.
Chairman
The Honorable Cathy McMorris Rodgers
Republican Leader
Committee on Energy and Commerce
House of Representatives
The Honorable Bennie G. Thompson
Chairman
The Honorable John Katko
Ranking Member
Committee on Homeland Security
House of Representatives
The Honorable Carolyn B. Maloney
Chairwoman
The Honorable James Comer
Ranking Member
Committee on Oversight and Reform
House of Representatives
The Honorable Mark Takano
Chairman
Committee on Veterans’ Affairs
House of Representatives
The Honorable Richard E. Neal
Chairman
The Honorable Kevin Brady
Republican Leader
Committee on Ways and Means
House of Representatives
The Honorable Julia Brownley
Chairwoman
Subcommittee on Health
Committee on Veterans’ Affairs
House of Representatives
The Honorable Edward J. Markey
United States Senate
Page 22 GAO-21-559 VA Nursing Homes and COVID-19
The Honorable Elizabeth Warren
United States Senate
Page 23 GAO-21-559 VA Nursing Homes and COVID-19
Appendix I: Examples of Changes to VA Appendix I: Examples of Changes to VA
Guidance for Selected CLC Services and
Guidance for Selected CLC Services and
Procedures during COVID-19, March 2020 to
March 2021
Procedures during COVID-19, March 2020
to March 2021
Table 2: Examples of Changes to VA Guidance for Selected CLC Services and Procedures during COVID-19, March 2020 to
March 2021
Guidance topic Summary of guidance and date issued
Facility access and March 6, 2020
admissions • New admissions to CLCs will be based on priority system and will be placed under quarantine and
observation for COVID-19 symptoms for 14 days.
• CLCs should limit entry of visitors and staff, who should be screened prior to entry.
March 10, 2020
• New admissions to CLCs will be suspended except for those already in another VA facility.
• No visitors allowed entry except at the end of a resident’s life.
July 27, 2020
• Based on the prevalence of COVID-19, CLCs may permit entry to community admissions and limited
visitors.
October 1, 2020
• While visitors should remain limited, CLCs should regularly reassess their visitation plans to balance
resident welfare with infection control risks.
March 16, 2021
• Visitors allowed in CLCs under certain conditions, including if more than 70 percent of residents are
vaccinated for COVID-19, and the most recent positive COVID-19 case was more than 14 days prior.
Resident experiences March 6, 2020
• CLCs should limit social activities, such as meals and field trips.
• Medical visits outside the CLC should be rare and telehealth should be used instead.
March 19, 2020
• Residents with necessary medical appointments outside the CLC should be placed under COVID-19
observation for 14 days after returning to the CLC.
July 27, 2020
• Based on the prevalence of COVID-19, residents are allowed to attend in-person activities with certain
precautions.
• Based on the prevalence of COVID-19, residents may attend medical appointments in VA Medical
Center under certain precautions and without 14-day observation.
February 4, 2021
• To mitigate COVID-19 social isolation, CLCs can request VA funding to enhance safe, small-group
activities.
Staffing March 6, 2020
• Where possible, the number of staff entering the CLC should be limited and dedicated CLC staff
should be used.
March 15, 2020
• Asymptomatic staff who are exposed to COVID-19-positive patients can continue to work.
April 18, 2020
• Staff suspected or confirmed to have COVID-19 should either be tested or wait until symptoms
resolve—at least seven days after symptoms appeared—before returning to work.
Page 24 GAO-21-559 VA Nursing Homes and COVID-19
Appendix I: Examples of Changes to VA
Guidance for Selected CLC Services and
Procedures during COVID-19, March 2020 to
March 2021
Guidance topic Summary of guidance and date issued
Personal Protective March 15, 2020
Equipment (PPE) • When PPE supplies cannot meet demand, PPE should be prioritized for high-risk procedures likely to
produce aerosols.
April 16, 2020
• VA recently received a large supply of N95 respirators. Staff caring for COVID-19-positive residents
should use N95 respirators.
• VA should have plans for extended use or decontamination of masks in the event of disrupted supply
chains.
Screening, testing, and March 6, 2020
vaccinations • Residents should be screened daily for COVID-19 symptoms.
March 10, 2020
• Staff should be screened for COVID-19 symptoms.
March 17, 2020
• Residents should be screened for temperatures higher than 100.4 degrees.
April 14, 2020
• With recent increases in testing kits, staff and residents should undergo baseline COVID-19 testing.
June 11, 2020
• CLC residents should be tested upon admission to a CLC.
• Residents who leave the CLC for outside medical appointments should be tested weekly.
• Residents and staff should be tested as soon as a new case is identified at the facility. Those who
initially test negative should continue to be tested weekly until 14 days have passed since the most
recent positive case in the facility.
July 7, 2020
• Residents should be screened for temperatures higher than 99 degrees.
November 25, 2020
• Staff should be tested based on risk.
• Residents who leave the CLC for outside medical appointments should be tested based on risk rather
than weekly.
• Residents and staff should be tested as soon as a new case is identified at the facility. Those who
initially test negative should be tested twice weekly until 14 days have passed since the most recent
positive case in the facility.
December 10, 2020
• Residents and staff will be among the first vaccinated by VA.
February 7, 2021
• CLCs must continue prevention activities against COVID-19, including testing and screening
procedures, regardless of the vaccination status of residents.
Page 25 GAO-21-559 VA Nursing Homes and COVID-19
Appendix I: Examples of Changes to VA
Guidance for Selected CLC Services and
Procedures during COVID-19, March 2020 to
March 2021
Guidance topic Summary of guidance and date issued
Suspected and positive March 6, 2020
COVID-19 cases • CLC residents with suspected cases of COVID-19 should be isolated.
March 15, 2020
• Staff with COVID-19 symptoms should cease patient care and leave work.
May 29, 2020
• It is recommended that certain COVID-19-positive patients be tested before discontinuing isolation.a
September 14, 2020
• Using the time since symptoms first appeared and resolved is the preferred way to determine the
infectiousness of certain patients.b
Source: GAO review of select Department of Veterans Affairs (VA) guidance. | GAO-21-559
Note: We categorized VA guidance based on topic and selected those related to Community Living
Center (CLC) access and admissions; resident experiences pertaining to, for example, restrictions on
group activities; staffing; use of personal protective equipment; Coronavirus Disease 2019 (COVID-
19) screening, testing, and vaccinations; and strategies related to handling suspected and positive
COVID-19 cases as examples. This guidance may pertain to CLCs specifically or to Veterans Affairs
Medical Centers or Veterans Integrated Service Networks, inclusive of CLCs.
a
This guidance aligns with Centers for Disease Control (CDC) recommendations and pertains to
symptomatic patients for whom testing should be considered if the timing of symptom onset is
unclear, as well as to symptomatic and asymptomatic patients who are severely
immunocompromised. Otherwise, using a time-based or symptom-based strategy is preferred.
b
This guidance aligns with CDC recommendations and pertains to patients with mild to moderate
illness who are not severely immunocompromised, and patients with severe or critical illness who are
severely immunocompromised. A test-based strategy is no longer recommended, with some
exceptions, because in the majority of cases it results in prolonged isolation of patients who continue
to shed detectable virus but are no longer infectious.
Page 26 GAO-21-559 VA Nursing Homes and COVID-19
Appendix II: VA Stages for Resuming Certain Appendix II: VA Stages for Resuming Certain
CLC Services Based on the Prevalence of
CLC Services Based on the Prevalence of
COVID-19
COVID-19
Table 3: VA Stages for Resuming Certain CLC Services Based on the Prevalence of COVID-19
CLC service Stage 1 (most restrictive)a Stage 2b Stage 3 (least restrictive)c
Admissions and No community admissions except No community admissions except Admission from community allowed
Screening in rare circumstances for veterans needing hospice care with a negative COVID-19 test
14-day observation upon admission 14-day observation upon admission 14-day observation upon admission
to CLC to CLC to CLC
Visitors No visitors unless resident is One adult visitor allowed at a time, Visitation allowed indoors; no more
actively dying per resident, in an outdoor area than two visitors per resident
Activities and Dining COVID-19 positive residents must Less than 10 COVID-19 negative More than 10 residents can attend
stay in their room residents can join activities with group activities
COVID-19 negative residents can social distancing and the use of
join activities with social distancing face masks
and the use of face masks Communal dining limited by social
distancing
Appointments All appointments outside the CLC Necessary appointments in VA No restrictions
should be conducted virtually as medical center (VAMC) can be
able scheduled
14-day observation upon re-entry to 14-day observation not needed if
CLC certain precautions are followed
Necessary appointments off
campus still require 14-day
observation upon return to CLC
Source: U.S. Department of Veterans Affairs (VA), Community Living Center (CLC) Moving Forward Plan (July 27, 2020). | GAO-21-559
a
VA guidance requires that VAMCs follow a separate phased approach to resume normal operations,
with phase 1 having the most restrictions and phase 3 having the least restrictions. CLCs must
remain in stage 1 while the associated VAMC is in phase 1 or phase 2. During this stage, CLCs
should minimize movement within the facility regardless of Coronavirus Disease 2019 (COVID-19)
transmission within the local community.
b
CLCs may transition to this stage after no new cases of COVID-19 among residents or staff have
occurred for 21 days while operating under stage 1, and if the associated VAMC is also operating
under the lowest level of restrictions. However, the CLC must return to stage 1 if a new confirmed or
suspected case of COVID-19 is identified among residents or staff.
c
CLC may transition to this stage after no new cases of COVID-19 among residents or staff have
occurred for 21 days while operating under stage 2. However, the CLC must return to stage 1 if a new
confirmed or suspected case of COVID-19 is identified among residents or staff.
Page 27 GAO-21-559 VA Nursing Homes and COVID-19
Appendix III: Comments from the
Appendix III: Comments from the Department
of Veterans Affairs
Department of Veterans Affairs
Page 28 GAO-21-559 VA Nursing Homes and COVID-19
Appendix III: Comments from the Department
of Veterans Affairs
Page 29 GAO-21-559 VA Nursing Homes and COVID-19
Appendix III: Comments from the Department
of Veterans Affairs
Page 30 GAO-21-559 VA Nursing Homes and COVID-19
Appendix IV: GAO Contact and Staff
Appendix IV: GAO Contact and Staff
Acknowledgments
Acknowledgments
Sharon M. Silas, (202) 512-7114 or silass@gao.gov
GAO Contact
In addition to the contact named above, Karin Wallestad (Assistant
Staff Director), Karen Belli (Analyst-in-Charge), Kye Briesath, and Naomi
Acknowledgments Joswiak made key contributions to this report. Also contributing were
Laurie Pachter, Jeffrey Tamburello, and Jennifer Whitworth.
(104464)
Page 31 GAO-21-559 VA Nursing Homes and COVID-19
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