Louisiana Department of Veterans Affairs Lacks Oversight of Quality of Care in War Veterans Homes, According to Audit

Oversight of the quality of care in Louisiana’s five veteran homes is lacking, according to an audit released Monday by Legislative Auditor Daryl Purpera.

Auditors evaluated the Department of Veterans Affairs’ (LDVA) oversight in all five of its veteran homes, which are located in Bossier City, Jackson, Jennings, Monroe and Reserve. The report from the state auditor concluded that staff in these homes did not always examine high-risk areas on quality assurance reviews, address deficiencies identified during internal quality assurance reviews, resolve grievances in a timely manner and consistently update care plans when incidents occurred. In addition, LDVA did not monitor whether contract providers provided quality services.

A review of nearly 2,000 quality assurance reviews completed between 2012 and 2014 showed that nearly a third identified areas of noncompliance, and 54 percent of all noncompliant reviews lacked a corrective action plan. Staff also did not always resolve grievances in a timely manner.

Additionally, all five homes were cited for deficiencies by the U.S. Department of Veterans Affairs. Deficiencies ranged from failure to dispose of garbage properly to resident injuries due to failure to update care plans. For example, a deficiency reported at the Southeast Louisiana War Veterans Home (Reserve) was the result of the facility failing to follow the care plan for a resident with a risk of wandering. The resident fell into a pond and drowned.

In calendar year 2014, 3,874 total incidents were reported between the five veteran homes. However, auditors found that LDVA does not routinely analyze incident data and consistently update care plans based on this information. More than half of all incidents reported in 2014 were related to falls.

The report also said veteran home staff did not monitor whether or not medical, pharmaceutical, radiology and physical therapy contract providers provided quality services. The homes entered into 87 contracts worth $7.7 million between 2012 and 2014.

Auditors made several recommendations for LDVA to oversee the quality of care of residents in its veteran homes, from developing new policies and procedures to making the best use of all information provided to them. In its response to the audit, the state Department of Veterans Affairs partially agreed with LLA’s recommendations.