Community Living Centers Were Commonly Cited for Infection Control Deficiencies Prior to the COVID-19 Pandemic (GAO-21-195R)
Summary
A GAO report, GAO-21-195R, dated January 6, 2021, addressed to Edward J. Markey, Jon Tester and Elizabeth Warren of the United States Senate, on VA health care. It concerns the 134 community living centers (CLC) owned and operated by the Department of Veterans Affairs, where around 9,000 veterans per day received nursing home care in fiscal year 2019. CLCs provide short-stay (90 days or less) and long-stay services, including rehabilitation, hospice care, long-term skilled nursing and dementia care. Its title states that CLCs were commonly cited for infection control deficiencies before the COVID-19 pandemic.
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Full text
441 G St. N.W.
Washington, DC 20548
January 6, 2021
The Honorable Edward J. Markey
United States Senate
The Honorable Jon Tester
United States Senate
The Honorable Elizabeth Warren
United States Senate
VA Health Care: Community Living Centers Were Commonly Cited for Infection Control
Deficiencies Prior to the COVID-19 Pandemic
Thousands of veterans rely on nursing home care provided or paid for by the Department
of Veterans Affairs (VA) to help meet their skilled nursing and personal care needs each
day. 1 Many of these veterans—around 9,000 per day in fiscal year 2019—receive this care
in the 134 community living centers (CLC) owned and operated by VA. 2 CLCs provide both
short-stay (90 days or less) and long-stay services to veterans. These services include
short-term rehabilitation, respite, hospice care, long-term skilled nursing, mental health
recovery, dementia care, and care for spinal cord injuries and disorders.
Ensuring the quality of nursing home care provided to veterans residing in CLCs—and in all
nursing homes—has become even more critical with the emergence of Coronavirus
Disease 2019 (COVID-19). COVID-19 is a new and highly contagious respiratory disease
causing severe illness and death, particularly among the elderly. 3 Because of this, the
health and safety of the nation’s nursing home residents—who are often in frail health and
living in close proximity to one another—has been a concern, in particular for the disabled
and elderly veterans living in CLCs who are vulnerable to infection. One of 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 59,000 nursing home resident
deaths reported as of October 2020—which is likely an undercount. 4
1A veteran’s eligibility for nursing home care that is fully or partially covered by VA is determined by the veteran’s
priority for care, which is generally based on the veteran’s service-connected disability status. A service-connected
disability is an injury or disease that was incurred or aggravated while on active duty.
2Department of Veterans Affairs, FY 2021 Budget Submission: Medical Programs and Information Technology
Programs, vol. 2 of 4 (February 2020). VA reported that in fiscal year 2019, CLCs provided short-stay services to
2,256 residents per day and long-stay services to 6,561 residents per day, on average.
VA pays for nursing home care in two other settings: public or privately owned community nursing homes and state-
owned and -operated veteran homes.
3A. 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).
4Centers for Medicare & Medicaid Services (CMS), COVID-19 Nursing Home Data (Submitted Data as of Week
1 GAO-21-195R, VA Infection Control
Several news stories have prompted questions about the quality of care at individual CLCs. 5 In
January 2020, we began work reviewing CLC quality at your request and related to your
concerns about these stories. As part of that review, we obtained data from VA and the
contractor it uses to conduct inspections of CLCs. These inspections assess CLCs against
quality standards, including standards for patient care and facility condition. We reviewed data
on deficiencies cited at CLCs—instances in which an inspector determined that the CLC did not
meet quality standards—during regular inspections conducted prior to the COVID-19 pandemic.
Specifically, this report describes the prevalence of deficiencies related to CLCs’ infection
prevention and control practices prior to the COVID-19 pandemic. In addition to this report, we
have ongoing work in this area. Future GAO reports will address CLC quality more broadly, and
VA’s response to COVID-19 in the three nursing home settings for which VA provides or pays
for care.
For this report, we analyzed VA data on CLC inspection deficiencies from fiscal years 2015
through 2019. 6 Using these data, we analyzed the deficiency code used by VA’s contractor
when a CLC fails to meet infection prevention and control quality standards. 7 Using VA’s data,
we determined the most common type of deficiency among CLCs, the number of CLCs that had
infection prevention and control deficiencies, as well as the number of CLCs with repeated
infection prevention and control deficiencies over this 5-year period.
To determine the percentage of total CLCs with an infection control deficiency cited in any year
from fiscal years 2015 through 2019, we included all CLCs that had an inspection conducted at
any point during our review period for a total of 135 CLCs inspected. This count includes CLCs
that may have closed or opened during the review period. To determine the percentage of CLCs
Ending 10/04/2020), accessed October 16, 2020, https://data.cms.gov/stories/s/COVID-19-Nursing-Home-
Data/bkwz-xpvg/. We reported in September 2020 that CMS data on COVID-19 cases and deaths among residents
and staff in nursing homes does not capture the early months of the pandemic. Specifically, CMS began requiring
nursing homes to report COVID-19 data in May 2020 and made reporting prior to May optional. We recommended
that the 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
retroactively back 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).
For example, a recent news report estimates deaths among nursing home staff and residents to have exceeded
77,000. See Matthew Conlen, et al., “More than 40% of U.S. Coronavirus Deaths are Linked to Nursing Homes,” The
New York Times, updated September 16, 2020.
5For example, see “Secret VA Nursing-home Ratings Hid Poor Quality Care from Public,” Boston Globe, June 17,
2018 and “’They Feasted on Him’: Ants at VA Nursing Home Bit Veteran 100 Times before His Death, Daughter
Says,” Washington Post, September 17, 2019.
6We reviewed data provided by VA and its contractor for our ongoing review of CLC quality. For the purposes of this
report, we refer to the data provided by VA and its contractor as VA data.
7CMS’s State Operations Manual provides guidance to state surveyors of nursing homes to determine compliance
with federal quality standards and the deficiency codes associated with each standard, including those related to
infection prevention and control program requirements. VA has adopted these CMS standards in its oversight of
CLCs. We reviewed CMS documentation and a November 2018 national VA training for CLCs about infection
prevention and control when determining which deficiency codes to analyze for this report. The June 2016 version of
the State Operations Manual was the most recent version in use by VA’s contractor during our period of review. While
CMS restructured its deficiency code system beginning on November 28, 2017, VA did not implement these coding
changes until the start of fiscal year 2020, which is after our review period.
2 GAO-21-195R, VA Infection Control
with an infection control deficiency in individual fiscal years, we counted the total number of
CLCs inspected in each fiscal year, rather than the total number of inspections in that fiscal
year.
To provide illustrative examples of the nature of these deficiencies, we reviewed reports
resulting from inspections conducted by VA’s contractor at CLCs in fiscal year 2018 and fiscal
year 2019 that we collected for our ongoing work on CLC quality or that were publicly available
online. These reports include narratives written by VA’s contracted inspectors describing the
deficiencies they identified. Additionally, we reviewed and described the corresponding
corrective action plans the CLCs developed to address the identified infection prevention and
control deficiencies that we collected for our ongoing work on CLC quality. The examples of
deficiencies and corrective action plans are illustrative and are not generalizable.
We conducted this performance audit from July 2020 through December 2020 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.
Background
VA is responsible for overseeing the quality of nursing home care provided to veterans residing
in CLCs. The key mechanism VA uses to assess CLC quality is regular inspections, which VA
models on the methods used by the Centers for Medicare & Medicaid Services (CMS) to
oversee nursing homes participating in the Medicare and Medicaid programs. 8 CLCs receive an
initial inspection when they open and then unannounced inspections, which generally occur
annually thereafter. 9 VA uses a contractor to conduct these inspections, and VA reviews the
results of all inspections.
During these inspections, the contractor determines whether CLCs meet quality standards,
which focus on the delivery of care, resident outcomes, and facility conditions. These standards
require, for example, that CLCs establish and maintain infection prevention and control
programs. When the contractor identifies instances in which the CLC does not meet quality
standards, it can cite the CLC for deficiencies. The contractor classifies cited deficiencies
according to the scope (number of residents potentially affected) and severity (the potential
effect on residents, such as occurrence of harm). 10 CLCs are required to develop and
8CMS defines the quality standards that approximately 15,600 nursing home nationwide must meet. See 42 U.S.C.
§§ 1395i-3(f)(1),1396r(f)(1); 42 C.F.R. Part 483, Subpart B (2019). CMS oversight includes regular inspections or
surveys to monitor compliance with quality standards through direct observations.
A VA 2016 memorandum specifies that VA will implement an unannounced inspection program modeled on the
nursing home oversight conducted by CMS. VA oversees all CLCs; CMS has no oversight responsibility in CLCs.
9CLCs that have no repeat deficiencies from the previous year and no deficiencies that pose actual harm to residents
are inspected every 18 months. Until 2017, CLCs with repeat deficiencies from the previous year or deficiencies
above a certain severity level were inspected every 6 months. According to VA officials, the frequency of inspections
was changed to every year to allow CLCs time to implement corrective actions.
10VA’s contractor categorizes deficiencies into one of four severity categories based on whether the deficiency
constitutes: (1) a potential for minimal impact; (2) no actual harm with a potential for harm; (3) actual harm that is not
immediate jeopardy; or (4) immediate jeopardy to resident health or safety.
3 GAO-21-195R, VA Infection Control
implement corrective action plans for each deficiency the contractor identifies and must detail
how the deficiency will be addressed. VA approves these plans and monitors the CLC’s actions
until each deficiency is addressed.
Ninety-Five Percent of Inspected CLCs Were Cited for Infection Control Deficiencies Prior
to the COVID-19 Pandemic, Sometimes in Consecutive Years
Our analysis of VA data shows that infection prevention and control deficiencies were the most
common type of deficiency cited in inspected CLCs from fiscal year 2015 through 2019, with
128 of the 135 CLCs inspected (95 percent) having an infection prevention and control
deficiency cited in 1 or more years. 11 Over the period from 2015 through 2019, a total of 365
infection prevention and control deficiencies were cited at the inspected CLCs. The percentage
of inspected CLCs with an infection prevention and control deficiency cited each fiscal year
ranged from 46 percent to 70 percent. Deficiencies related to infection prevention and control
included situations where CLC staff did not regularly use proper hand hygiene or wear personal
protective equipment—such as gowns and gloves—to prevent the spread of infection or failed to
clean reusable medical items. Many of these practices can be critical to preventing the spread
of infectious diseases, including COVID-19.
VA data show that CLCs frequently had infection prevention and control deficiencies cited in
consecutive fiscal years, which may indicate persistent problems. 12
• Specifically, 84 of the 135 CLCs (62 percent) inspected in fiscal years 2015 through
2019 had infection prevention and control deficiencies cited in consecutive fiscal years.
• An additional 25 of the 135 CLCs (19 percent) inspected had an infection prevention and
control deficiency cited in multiple, nonconsecutive fiscal years. (See fig. 1.)
11After infection prevention and control deficiencies, the next most common deficiencies cited in CLCs from fiscal
years 2015 through 2019 were related to ensuring that the environment is free from accidents (about 52 percent of
inspected CLCs in each year) and quality of care (about 37 percent of CLCs per year). In our May 2020 report, we
similarly found that most nursing homes that participate in the Medicare and Medicaid programs were cited with
infection prevention and control deficiencies in 1 or more years prior to the COVID-19 pandemic (82 percent of all
nursing homes inspected from 2013 through 2017). GAO, Infection Control Deficiencies Were Widespread and
Persistent in Nursing Homes Prior to the COVID-19 Pandemic, GAO-20-576R, (Washington, D.C.: May 20, 2020).
We included all CLCs that had an inspection conducted at any point during our review period, from fiscal years 2015
through 2019, for a total of 135 CLCs. This count includes CLCs that may have closed or opened during the review
period.
12We reviewed infection prevention and control deficiencies by CLC by fiscal year. Due to the timing of repeat
inspections or the timing of the annual, unannounced inspections and the contract year, some CLCs were inspected
more than once in a fiscal year, and not all CLCs had an inspection in each fiscal year. As a result, CLCs with
infection prevention and control deficiencies cited in consecutive inspections that occurred in the same fiscal year
would not be included in our count. From fiscal year 2015 through 2019, 22 CLCs had infection prevention and
control deficiencies cited on consecutive inspections that occurred within the same fiscal year. Similarly, CLCs with
infection prevention and control deficiencies in consecutive fiscal years would be included in our count, even if they
did not have such deficiencies cited on consecutive inspections due to multiple inspections in a single fiscal year.
In our analysis, CLCs with infection prevention and control deficiencies cited in multiple years were categorized as
having deficiencies cited in either consecutive years or multiple nonconsecutive years, not both. CLCs with
deficiencies cited in any consecutive years during the review period are included in the consecutive years count only,
even if they had an additional deficiency cited in an inspection in a nonconsecutive year.
4 GAO-21-195R, VA Infection Control
• Furthermore, 40 of the 135 CLCs (30 percent) had these deficiencies cited in at least 3
consecutive fiscal years, 13 of these 40 CLCs (10 percent of the 135 inspected) had
these deficiencies cited in at least 4 consecutive fiscal years, and five of these 40 CLCs
(4 percent of the 135 inspected) had these deficiencies cited in all 5 fiscal years.
Figure 1: VA Community Living Centers (CLC) with Infection Prevention and Control
Deficiencies Cited in Multiple Years, Fiscal Years 2015 through 2019
Note: We reviewed infection prevention and control deficiencies by CLC by fiscal year. We included all CLCs inspected at any point
from fiscal years 2015 through 2019, a total of 135 CLCs. Due to repeat inspections or the timing of the annual unannounced
inspections, some CLCs were inspected more than once, and not all were inspected, in a fiscal year. Thus, the count of deficiencies
reflects citations in consecutive fiscal years but does not reflect deficiencies cited on consecutive inspections that occurred in the
same fiscal year (22 CLCs had infection and prevention control deficiencies cited on consecutive inspections in the same fiscal
year). Each inspected CLC was placed in only one category. That is, CLCs with deficiencies cited in any consecutive years during
the review period are included in the consecutive years count only, even if they had an additional deficiency cited in an inspection in
a nonconsecutive year.
For additional information on specific CLCs, see enclosure I.
When we reviewed example inspection records, we identified some repeat instances of
problems with infection prevention and control deficiencies. For example, in fiscal years 2018
and 2019, inspectors identified nine situations at one CLC where CLC staff did not use proper
precautions—such as appropriately wearing personal protective equipment or performing hand
hygiene—when working with residents who were documented as being at high risk of
transmitting infection. To address these deficiencies, as part of its corrective action plan, the
CLC developed new policies related to infection transmission precautions and provided training
to staff on these new policies, among other actions. For examples of the types of infection
control deficiencies cited in CLCs and the steps taken to address them, see table 1.
5 GAO-21-195R, VA Infection Control
Table 1: Illustrative Examples of Infection Prevention and Control Deficiency Narratives and Related
Corrective Actions in Community Living Centers (CLC) in Fiscal Years 2018 and 2019
Summary of inspection narrative CLC corrective actiona
At one CLC, inspectors observed a total of nine situations across fiscal In fiscal year 2018, the CLC
years 2018 and 2019 where CLC staff did not take proper precautions • developed new policies and
when they interacted with residents for whom enhanced infection signage related to infection
transmission precautions were to be followed. These proper transmission precautions;
precautions include appropriately wearing personal protective • educated staff on these policies
equipment (PPE)—gowns or gloves—or performing hand hygiene. through daily rounds and
In fiscal year 2018, seven residents were affected, five of whom were educational materials;
positive for methicillin-resistant Staphylococcus aureus (MRSA).b • installed over-the-door PPE
Across both years these situations involved, for example, nursing staff equipment holders; and
administering medications to residents without appropriately wearing
• collected real-time data on hand
such PPE.
hygiene compliance.
In fiscal year 2019, the CLC
• identified infection control
champions from each
neighborhood, or unit; and
• reviewed infection transmission
precaution policies with staff.
At a second CLC, inspectors observed a situation in both fiscal years In fiscal year 2018, the CLC
2018 and 2019 where nursing staff administered medications without • educated nurses on medication
appropriately wearing PPE to a MRSA-positive resident for whom cart use and infection
enhanced infection transmission precautions were to be followed. transmission precautions, hand
In fiscal year 2018, maintenance staff also entered the same resident’s hygiene, and PPE requirements;
room without performing hand hygiene or wearing PPE. In fiscal year and
2019, nursing staff also failed to clean a vital sign machine or discard a • trained engineering staff on
disposable cuff after taking the resident’s blood pressure. infection transmission
precautions and hand hygiene.
In fiscal year 2019, the CLC
• cleaned all vital sign machines
and replaced all blood pressure
cuffs in the neighborhood, or unit.
A resident at a third CLC with a diagnosis of Clostridium difficile was • The OT supervisor conducted in-
observed by surveyors using a deck of playing cards to perform service training with OT staff on
exercises during an occupational therapy (OT) session in fiscal year the policies on cleaning reusable
2018.c Afterwards, an OT assistant placed the cards in the box without medical equipment and hand
cleaning or sanitizing the cards—despite the fact that enhanced hygiene; and
infection transmission precautions were to be followed given the • the OT supervisor conducted
resident’s diagnosis—and did not appropriately perform hand hygiene weekly monitoring of a random
while cleaning other therapy equipment. sample of OT staff to ensure
compliance.
Inspectors observed three situations at a fourth CLC where nursing staff • The CLC educated staff on
did not appropriately wear PPE or perform hand hygiene while providing maintaining infection control
care to residents in fiscal year 2019. This included a nursing assistant while assisting residents with
who was helping a resident with hygiene care, which included changing activities of daily living,
the resident’s adult brief; one registered nurse who was administering administering intravenous
intravenous therapy to a resident with chronic obstructive pulmonary therapy, and providing wound
disease (COPD); and one registered nurse who was providing wound care and conducted audits to
care to another resident with COPD and pneumonia.d ensure compliance.
Source: GAO analysis of CLC inspection reports and corrective action plans. | GAO-21-195R
6 GAO-21-195R, VA Infection Control
a
VA requires that CLCs develop and implement corrective action plans to address cited deficiencies and tracks CLCs’ progress in
resolving each deficiency.
b
MRSA is a bacteria that is difficult to treat because of resistance to several antibiotics. In healthcare settings, such as nursing
homes, MRSA is usually spread by direct contact with an infected wound or from contaminated hands, usually those of healthcare
providers, and can cause severe problems such as bloodstream infections or pneumonia. It can also be spread through shared
equipment and supplies.
c
Clostridium difficile, also known as Clostridioides difficile or C. diff, is a bacteria that causes diarrhea and inflammation of the colon.
More than 80 percent of deaths caused by C. diff occur in people age 65 and older. C. diff is spread, for example, when individuals
touch contaminated surfaces or do not perform hand hygiene. Extended stays in healthcare settings, including nursing homes,
increase the risk of infection.
d
COPD refers to a group of diseases that cause airflow blockage and breathing-related problems. It includes emphysema and
chronic bronchitis.
Finally, our analysis of VA data shows that that inspectors classified all 365 infection prevention
and control deficiencies cited at CLCs as “not severe”—meaning the inspector determined that
residents were not harmed—in fiscal years 2015 through 2019. 13 Infection prevention and
control deficiencies were also categorized by scope—whether the incident was an isolated
occurrence, part of a pattern of behavior, or a widespread behavior—with 58 percent
categorized as isolated, 41 percent categorized as a pattern of behavior, and 1 percent
categorized as widespread in fiscal years 2015 through 2019.
• Pattern. One CLC was cited with an infection prevention and control deficiency of this
scope when inspectors found that there was no information on transmission-based
precautions in care plans or other care documentation for several residents with MRSA
colonization. 14 Inspectors also observed nursing staff failing to properly conduct hand
hygiene as required to prevent spread of infection during medication administration for
three residents with active infections.
• Widespread. One CLC was cited with an infection prevention and control deficiency of
widespread scope after inspectors observed nursing, food and nutrition, or
environmental management services staff fail to properly use personal protective
equipment or perform hand hygiene in a way that would prevent the transmission of
disease and infection from nine residents with active infections. Further, according to the
inspection report, staff were inconsistent in describing to inspectors the CLC’s policy
related to required precautions to take with these residents.
13For the purposes of this report, a classification of “not severe” means that surveyors determined that the deficiency
posed either 1) no actual harm with a potential for minimal harm or 2) no actual harm with a potential for more than
minimal harm but not immediate jeopardy.
In our May 2020 report, we similarly found that nearly all infection control deficiencies (99 percent in each year from
2013 through 2017) identified in nursing homes that participate in the Medicare and Medicaid programs were
classified as “not severe.” GAO, Infection Control Deficiencies Were Widespread and Persistent in Nursing Homes
Prior to the COVID-19 Pandemic, GAO-20-576R, (Washington, D.C.: May 20, 2020).
14MRSA or methicillin-resistant Staphylococcus aureus is a bacteria that is difficult to treat because of resistance to
several antibiotics. In healthcare settings, such as nursing homes, MRSA is usually spread by direct contact with an
infected wound or from contaminated hands, usually those of healthcare providers, and can cause severe problems
such as bloodstream infections or pneumonia. It can also be spread through shared equipment and supplies.
7 GAO-21-195R, VA Infection Control
Agency Comments
We provided a draft of this report to VA for review and comment. In the agency’s comments,
reproduced in enclosure II, VA noted that the term “widespread” in our draft title could be
interpreted according to the technical definition of a deficiency categorization of the scope. To
eliminate potential confusion, we revised our title.
____________________________________________________________________________
As agreed with your offices, unless you publicly announce the contents of this report, we plan
no further distribution until 30 days from the report date. At that time, we will send copies to the
Secretary of VA and other interested parties. In addition the report will be 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. Major contributors to this report were Karin
Wallestad (Assistant Director), Summar C. Corley (Analyst-in-Charge), and Karen Belli. Also
contributing were Laurie Pachter, Ethiene Salgado-Rodriguez, and Jennifer Whitworth.
Sharon M. Silas
Director, Health Care
Enclosures - 2
8 GAO-21-195R, VA Infection Control
Enclosure I: Inspections Conducted and Infection Prevention and Control Deficiencies
Cited at Department of Veterans Affairs’ Community Living Centers, Fiscal Years 2015
through 2019
Table 2: Inspections Performed and Infection Prevention and Control Deficiencies (IPC) Cited, by
Community Living Center (CLC), Fiscal Years (FY) 2015 through 2019
Legend: = inspection conducted, ■ = infection prevention and control deficiencies (IPC) cited during inspection,
□ = no IPC cited during inspection, - = no inspection occurred, no opportunity for an IPC to be cited.
CLC location FY 2015 FY 2016 FY 2017 FY 2018 FY 2019
Inspection IPC Inspection IPC Inspection IPC Inspection IPC Inspection IPC
conducted cited conducted cited conducted cited conducted cited conducted cited
Albany, NY □ □ - - ■ ■
Albuquerque, NM ■ ■ □ ■ - -
Altoona, PA □ ■ □ ■ ■□
Amarillo, TX ■ ■ □ ■ □
Ann Arbor, MI ■ □ □ □ ■
Asheville, NC ■ ■□ □ - - □
Augusta, GA ■ - - ■□ ■ □
Augusta, ME □ ■ ■ ■■ □
Baltimore, MD □ □ ■ ■ ■
Batavia, NY ■ - - □ □ □
Bath, NY ■ □ □ ■ ■
Battle Creek, MI □ - - ■ ■□ ■
Bay Pines, FL □ □■ □ ■ - -
Beckley, WV - - □ □ □ ■□
Bedford, MA ■ ■ ■ ■ ■
Big Spring, TX □ ■ □ □ □
Biloxi, MS ■ ■ □ □■ - -
Boise, ID □ □ ■ ■ □
9 GAO-21-195R, VA Infection Control
CLC location FY 2015 FY 2016 FY 2017 FY 2018 FY 2019
Inspection IPC Inspection IPC Inspection IPC Inspection IPC Inspection IPC
conducted cited conducted cited conducted cited conducted cited conducted cited
Bonham, TX ■ - - ■□ ■ ■
Brockton, MA ■ □ ■ ■ □
Bronx, NY ■ - - ■□ - - □
Buffalo, NY ■ □ ■ □ ■
Butler, PA ■ - - ■ □■ - -
Canandaigua, NY □ ■ ■■ ■ ■
Carrollton, GA □ □ ■ - - □
Castle Point, NY ■ - - ■■ □ ■
Charleston, SC ■ □ ■ ■ □
Cheyenne, WY ■ - - □ ■ ■
Chicago, IL □ □ ■ ■ ■
Chilicothe, OH ■ □ □ □■ □
Cincinnati, OH ■ - - ■ □ ■■
Clarksburg, WV ■ ■ ■ ■ ■
Cleveland, OH ■ □ □ ■ □
Coatesville, PA □ □ - - □ □
Columbia, MO ■ □ - - ■ □■
Columbia, SC ■ ■ □□ ■ □
Dallas, TX ■ ■ ■ □ ■
Danville, IL ■ □ □ ■■ □
Dayton, OH ■ □ □■ ■ ■
10 GAO-21-195R, VA Infection Control
CLC location FY 2015 FY 2016 FY 2017 FY 2018 FY 2019
Inspection IPC Inspection IPC Inspection IPC Inspection IPC Inspection IPC
conducted cited conducted cited conducted cited conducted cited conducted cited
Decatur, GA □ □ ■ □ ■
Denver, CO - - ■ ■ - - - -
Des Moines, IA ■ □ ■ ■ ■
Detroit, MI ■ □ ■ ■■ □
Dublin, GA ■ ■ ■ □ □
Durham, NC - - ■ □■ - - □
Erie, PA ■ ■ - - □ ■
Fargo, ND □ □ □ - - □
Fayetteville, NC □ □ □ ■ □
Fort Meade, SD □ □ - - ■□ ■
Fresno, CA ■ ■ □ ■ □
Gainesville, FL ■ □ ■ ■ ■
Grand Island, NE □ □ □ ■ ■
Grand Junction, □ ■ □ ■ ■
CO
Hampton, VA □ - - ■ ■ ■
Hines, IL ■ - - □ ■■ □
Honolulu, HI - - ■ □ □ ■
Hot Springs, SD ■ ■ - - □■ □
Houston, TX ■ ■ □ ■ □
Iron Mountain, MI □ - - ■ ■ □
Jackson, MS ■ □ ■ ■■ ■
11 GAO-21-195R, VA Infection Control
CLC location FY 2015 FY 2016 FY 2017 FY 2018 FY 2019
Inspection IPC Inspection IPC Inspection IPC Inspection IPC Inspection IPC
conducted cited conducted cited conducted cited conducted cited conducted cited
Kerrville, TX ■ - - ■ □■ ■
Lake City, FL ■■ - - ■ ■ ■
Leavenworth, KS ■ □□ □ □ □
Lebanon, PA □ □ □ - - ■
Leeds, MA □ □ - - ■ ■
Lexington, KY ■ ■ □ ■ ■
Livermore, CA □ □ □ ■ ■
Loma Linda, CA □ ■ □ ■ ■
Long Beach, CA ■ □ ■ ■ ■
Los Angeles, CA □ □ ■ ■ □
Lyons, NJ ■■ □ □ ■□ - -
Madison, WI □ - - □ ■ □
Manchester, NH ■ ■ □ □ □
Marion, IL □ ■ □ ■ ■
Marion, IN □ □ □ □ ■
Martinez, CA □ ■■ ■ ■ ■
Martinsburg, WV □ □ - - □■ ■
Menlo Park, CA ■ □ ■ ■ ■■
Miami, FL □ □ ■ ■ □
Miles City, MT □ □ □ □ - -
Milwaukee, WI □ - - ■ □ ■
Minneapolis, MN - - □ ■ - - ■
Montrose, NY - - □ □ □ □
12 GAO-21-195R, VA Infection Control
CLC location FY 2015 FY 2016 FY 2017 FY 2018 FY 2019
Inspection IPC Inspection IPC Inspection IPC Inspection IPC Inspection IPC
conducted cited conducted cited conducted cited conducted cited conducted cited
Mountain Home, ■ ■ □ □ ■
TN
Murfreesboro, TN □□ - - □■ ■ ■
New Orleans, LA - - - - - - □ - -
North Chicago, IL ■ □ ■ ■ □
North Little Rock, - - □ □ ■ ■
AR
Northport, NY ■ □ □ □ - -
Oklahoma City, □ □ □■ - - ■
OK
Orlando, FL ■ ■ ■ □ □
Palo Alto, CA ■ □ ■ - - □
Perry Point, MD ■ ■■ ■ □ ■
Philadelphia, PA ■ □ ■ □ □
Phoenix, AZ □ - - □ □ □
Pineville, LA □ ■ □ ■ □
Pittsburgh, PA □□ - - □ ■■ □
Poplar Bluff, MO □ ■ ■ ■ ■
Prescott, AZ ■ - - ■ ■ ■
Pueblo, CO □ □ ■ ■ ■■
Reno, NV ■ ■ ■ □■ □
Richmond, VA □ - - □ ■ ■
Roseburg, OR ■ ■ ■□ - - □
Saginaw, MI ■ □ ■ □ ■
13 GAO-21-195R, VA Infection Control
CLC location FY 2015 FY 2016 FY 2017 FY 2018 FY 2019
Inspection IPC Inspection IPC Inspection IPC Inspection IPC Inspection IPC
conducted cited conducted cited conducted cited conducted cited conducted cited
Salem, VA ■ ■ ■ ■ ■■
Salisbury, NC ■ □ □ □ □
San Antonio, TX □ - - ■ □ □
San Diego, CA □ ■ ■ ■ ■
San Francisco, ■ - - ■□ ■ ■
CA
San Juan, PR ■ ■ ■ ■ □
Seattle, WA ■ ■ ■ □ ■
Sepulveda, CA ■■ □ □ ■ □
Sheridan, WY □ - - □■ □ - -
Sioux Falls, SD ■ ■ □ ■ □
Spokane, WA - - □ □ ■ □
St. Albans, NY □ ■ ■ ■ ■
St. Cloud, MN ■ □ ■ - - □
St. Louis, MO ■□ ■ - - ■■ ■
Syracuse, NY □ ■ □ ■ □
Tacoma, WA □ □■ - - ■ □
Tampa, FL □■ ■ ■ ■ ■
Temple, TX □ - - □ ■ □
Tomah, WI □ ■ □ - - □
Topeka, KS - - □ ■ □ - -
Tucson, AZ □ - - ■ ■□ ■
Tuscaloosa, AL □ □ □ □ □
14 GAO-21-195R, VA Infection Control
CLC location FY 2015 FY 2016 FY 2017 FY 2018 FY 2019
Inspection IPC Inspection IPC Inspection IPC Inspection IPC Inspection IPC
conducted cited conducted cited conducted cited conducted cited conducted cited
Tuskegee, AL □ □ ■ ■■ □
Vancouver, WA - - □ □ □ ■
Waco, TX ■□ - - ■■ ■ ■
Washington, DC ■ ■ ■ ■ □
West Haven, CT □ - - ■ ■ □
West Palm ■ ■ ■ ■ ■
Beach, FL
Wichita, KS ■ ■■ ■ □ ■
Wilkes-Barre, PA ■ □ ■ □ □
Wilmington, DE - - ■□ - - ■ ■■
Legend: = inspection conducted, ■ = infection prevention and control deficiencies (IPC) cited during inspection, □ = no IPC cited
during inspection, - = no inspection occurred, no opportunity for an IPC to be cited.
Source: GAO analysis of Department of Veterans Affairs data. | GAO-21-195R
15 GAO-21-195R, VA Infection Control
Enclosure II: Comments from the Department of Veterans Affairs
16 GAO-21-195R, VA Infection Control
17 GAO-21-195R, VA Infection Control
(104561)
18 GAO-21-195R, VA Infection Control
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