oversight

Operational and Planning Improvements Needed in the Veterans Administration 'Domiciliary' Program for the Needy and Disabled

Published by the Government Accountability Office on 1977-09-21.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                                                                     L
                                                         v----

REPORT TO THE CONGRESS                                           ’

BY THE COMPTROLLER GENERAL
OF THE UNITED STATES
                      ~~~~~~~l~l~~l~l~ll~~~l~
                         LMQmgg


Operational And Planning
Improvements Needed In The
Veterans Ad,m inistration
“Dam Mary”     Program For
The Needy And Disabled
In this report, GAO reviews the Veterans
Administration’s  little known “domiciliary”
program to determine     how it was operating
and whether improvements     were needed. The
report discusses the characteristics of domi-
ciled   veterans,   their   living   conditions,   the
need for better program management, and the
need for better analyses of projected veteran
demand and domiciliary      and alternative care
resources before the agency proceeds further
with a multimillion   dollar construction    and
renovation prgram.

The Congress should explore with the Vet-
erans Administration     the feasibility   of pro-
viding greater incentives    for domiciled     vet-
erans having restoration    potential    to return
to community     living.




H R D-77-69
                       COMPTROLLER     GENERAL       OF      THE   UNITED   STATES
                                     WASHINGTON,      D.C.     20548




B-133044

To the President of the Senate and the                                                       o"d~
Speaker of the House of Representatives
                                                                                     PLC
       This report        reviews     the operations     of the Veterans
Administration's          domiciliary     program,    one of the least               known
and least      publicized       programs    for disabled    veterans.
        The report       discusses      the characteristics           of domiciled
veterans,        their   living     conditions,      the need for better           pro-
gram management,           and the need for better             analyses     of projected
veteran      demand and domiciliary              and alternative        care resources
before     the agency proceeds            further    with its multimillion
dollar     facility      construction         and renovation       program.      It also
discusses        the need for the Congress             to explore      with the
Veterans      Administration         the feasibility         of providing      greater
incentives         for domiciled       veterans     having restoration         poten-
tial    to return      to community         living,    such as by retaining           part
of their      income.
        We reviewed      this program and are reporting        our results
to the Congress because the agency had not taken prompt,
effective     action     on the numerous recommendations        for improve-
ments contained        in earlier    internal  studies of the program
and because the agency was embarking            on a costly     facility
construction       and renovation      program without adequately        assess-
ing veterans'       need and demand for domiciliary         care.
     We made our review pursuant     to the Budget and Accounting
Act, 1921 (31 U.S.C.    53), and the Accounting   and Auditing-Act
of 1950 (31 U.S.C.   67).
       Copies of this  report are being sent to the Director,
Office   of Management and Budget,   and the Administrator    of
Veterans    Affairs.                                     A




                                                   -Comptroller   General
                                                    of the United   States
COMPTROLLER GENERAL'S                                           OPERATIONAL AND PLANNING
REPORT TO THE CONGRESS                                          IMPROVEMENTS NEEDED IN THE
                                                                VETERANS ADMINISTRATION
                                                                "DOMICILIARY"  PROGRAM FOR
                                                                THE NEEDY AND DISABLED

             DIGEST
             ------
              The Veterans         Administration's        domiciliary
              program,      one of its least          known and least
              publicized        programs,      provides    housing,
              medical     treatment,        food, clothing,        and re-
              lated    services       to needy, disabled        veterans.
              During fiscal          year 1976, an average of 9,090
              veterans      were housed daily           in 18 VA domi-
              ciliary     facilities        which,    combined,     spent
              approximately          $62 million--an       average daily
              cost per veteran           of $18.61.
              Problems  in operating       the domiciliaries
              are caused by insufficient          management by
              the VA central    office.       Evidence     support-
              ing this conclusion       includes
              --frequent       lack            of a VA central    office
                  organizational                position  responsible          for
                  the program;
              --varying   admission     procedures                   and practices
                 among the domiciliaries;
              --lack      of evaluations,   other  than internal
                  audits,    of the quality    of medical  care;
              --ineffective                 rehabilitation         and restoration
                  efforts;           and
              --lack      of      staffing          criteria.       (See pp.    8 to 21.)
              Some of these problems      would not have occurred
              if domiciliaries    had followed      VA instructions.
              This indicates   that the VA central        office
              does not have adequate      reporting    systems or
              other controls.
              Also, VA has not planned           its proposed       domici-
              liary   construction        and renovation      program
              adequately.        Planning    should    include    analyses


Bar She&      Upon removal.    the report
cover date *should be noted    hereon.                   i                           HRD-77-69
of veteran     demand, matched with available
and projected      VA resources.       VA's projec-
tion of demand based on population           data is
not adequate     to support      its planned   multi-
million   dollar    investment.
As VA has indicated,             further       studies     of the
population        are planned.          Their planning         for
domiciliary        construction         can proceed        in an
orderly     manner if these studies                 are timely
and if they include             analyses       of factors      which
might change the size of the current                       popula-
tion,     such as improved           rehabilitation          and
restoration        programs or the characteristics
of potentially         eligible       veterans.         Wi,thout
such essential         data and analyses,              VA could
overbuild       or find itself          faced with long
waiting     lists     of eligible         veterans      seeking
domiciliary        care.
The domiciliary   program was established       by
VA in 1930 when VA took over "old soldiers
homes" which date back to 1865; however,         it
was not until   1970 that VA formally     estab-
lished the program's    mission of providing                           I
--preventive      medicine,      public    health    serv-
    ices,   and rehabilitation         measures for
   veterans    who require       continued     treatment
    in a protective       environment;
--special    behavioral and medical    rehabilita-
   tion for those who require    short-term
   services;   and
--restoration        services    for those who can be
    helped to return        to the community.    ( See
    PP.   2  and 3.)
RECOMMENDATIONS
---I_---
To correct      management problems      and improve
services      in the domiciliary    program,    the
Administrator       of Veterans  Affairs    should
--provide       improved     central     office   program
   management,       including       coordinating     domi-
   ciliary     operations      and developing        staff-
    ing criteria;


                                 ii
             --require        domiciliaries       to properly     apply the
                 admission      criteria,     including     considering
                 alternatives         to domiciliary     admission      for
                 those who do not need such care;
             --instruct      domiciliaries         to improve the medi-
                 cal care provided         domiciled    veterans,    espe-
                 cially  those with psychiatric            problems,   and
                 require   increased       surveillance     of medical
                 care quality;
             --require      domiciliaries to periodically evalu-
                 ate the success and adequacy of therapeutic
                 recreation    programs;
             --require     domiciliaries      to (1) identify       those
                 domiciled    veterans    with potential      for return
                 to community      living  and (2) develop       individ-
                 ualized   restoration     goals and plans requir-
                 ing greater     use of community      and other re-
                 sources;    and
             --implement      a reporting           system to provide       in-
                 formation    for,managers           to keep abreast      of
                 and evaluate      program        results.
             To.improve      planning   for new domiciliary         fa-
             cilities,     the Administrator,      before    proceed-
             ing further       with VA's long-range      construction
             plans,    should require      that
             --consideration     be given to the results    of
                the study currently     underway to determine
                the extent    to which existing  facilities    can
                be modernized,
             --current    domiciliary            demand be better       defined,
             --an adequate      projection  of future   demand for
                domiciliary     care be developed,    and
             --staffing       and operating    guidelines      for new
                 facilities     be defined   to assure that they
                 receive    the required    services      from nearby
                 VA hospitals.       (See pp. 34 and 35.)
             VA concurred    with       most of GAO's recommenda-
             tions  and outlined         its corrective    actions.
             VA disagreed    with       GAO's recommendations


Jear Sheet                                 iii
regarding      use of available        community
alternatives        to domiciliary       admission,
periodic      evaluations      of the therapeutic
recreation      .programs,     and a reevaluation
of its long-range         domiciliary       construction
plans.       GAO continues       to believe     that its
recommended actions         are needed and, if im-
plemented,      would improve both services              to
veterans      and the domiciliary         program.
(See pp. 35 to 40.)
Because domiciliary                care has been provided
free,      full     retention        of income from work
assignments           and most other         sources may be
both an incentive              for veterans       to remain
domiciled         and a block to their            timely     re-
habilitation           and restoration          to the com-
munity.         Therefore,         the Congress should
explore        with VA the feasibility              of pro-
viding       greater       incentives      for veterans
having restoration               potential      to return      to
community         living,      such as by VA's retention
of a portion           of domiciled        veterans'      income.
(See pp. 20 and 40.)




                                 iV
                             Contents
                             --a-----
                                                                      --Page
DIGEST                                                                   i

CHAPTER
   1       INTRODUCTION                                                  1
               Program evolution        and mission                      2
               Characteristics        of domiciled    veterans           3
               Life   in domiciliaries                                   4
               Scope of review                                           6

   2       IMPROVEMENTS NEEDED IN DOMICILIARY OPERA-
             TIONS                                                       8
                Improved medical         care needed                     9
                Recreational       programs       need to be
                  evaluated                                             12
                More effective        rehabilitation      and
                   restoration       programs      needed               15
                Staff    inconsistencies                                21
       3   IMPROVED PLANNING NEEDED FOR DOMICILIARY
             CONSTRUCTION AND RENOVATION                                22
               Physical    accommodations                               22
               Studies    and plans                                     30
               Demand for domiciliary          care and upgrad-
                  ing of existing     facilities     not fully
                  considered                                            32
   4       CONCLUSIONS, RECOMMENDATIONS TO VA, VA
             COMMENTS AND OUR EVALUATION, AND
             RECOMMENDATION TO THE CONGRESS                             34
               Conclusions                                              34
               Recommendations       to the Administrator        of
                 Veterans   Affairs                                     34
               VA comments and our evaluation                           35
               Recommendation      to the Congress                      40
APPENDIX
       I   VA domiciliaries--general    statistics         for
             fiscal    years 1975 and 1976                              41
  II       Characteristics       of domiciled   veterans                42
                                                                   Page
                                                                   --
APPENDIX
 III       Domiciliary        living       facilities               47
     IV    Letter    of June       30, 1977, from the
              Administrator         of Veterans  Affairs            48

       V   Principal      VA officals        responsible     for
              administering       activities       discussed
              in this     report                                    54

                                 ABBREVIATIONS
                                 P---B
GAO        General       Accounting        Office
VA         Veterans       Administration
                                         CHAPTER
                                         ---I_-  1
                                       INTRODUCTION
                                       --I_----
         The Veterans      Administration's            (VA's)    Department        of
Medicine       and Surgery      operates        a domiciliary        program--one       of
the least        known and least         publicized       veterans      programs--which
provides       housing,    medical       treatment,       food, clothing,          and other
services       to disabled,       but ambulatory          veterans      residing      in VA
facilities        called    "domiciliaries."            At the time of our review,
VA was operating         18 such facilities.                It now has 16.           Most of
the domiciliaries           are colocated          with VA general         hospitals      at
VA health        care centers.        l/     At June 30, 1976, VA's domicili-
aries      were operating       lO,i52       beds.     During fiscal         year 1976,
an average of 9,090 veterans                  received      domiciliary        care each
day (see app. I) and a total                  of 18,408 veterans           received     care
during      the year.
            Domiciliary    care   is    available    to:
            --A veteran     if he has a disability          which was received   or
               aggravated     while   serving     in the line of duty or if he
               is receiving     disability       compensation    while suffering
               from a permanent       disability     and cannot earn a living
               and does not have adequate means of support.
            --A veteran      who is in need of domiciliary     care if such
               veteran     is unable to defray  the expenses of necessary
               domiciliary     care. 2/   (See 38 U.S.C.   610(b).)
         Direct      management responsibility             for the program at VA's
central      office      was divided      between managers for about 2 years
until     August 1975.           At that time,       the Office    of Assistant
Chief Medical           Director     for Extended Care was established.
This office          is responsible       for all VA programs concerned
with the health            needs of the aging veteran.             Its responsi-
bilities        include     domiciliary      care;     nursing   home care;    com-
munity      nursing      home care;      hospital-based        and personal    home
-----P-M-




&/A VA health   care center,   as used in this report,                       consists
   of one or more VA hospitals    and a VA domiciliary                       which are
   colocated  and under one overall   management.
&/Prior       to enactment    of the Veterans      Omnibus Health   Care Act
   of 1976 (Public         Law 94-581)    on October    21, 1976, this eli-
   gibility       requirement    for domiciliary     care was more restric-
   tive     in that the veteran       had to have served in the military
   during       any war or after     January    31, 1955.


                                               1
care;    geriatric     day care centers;   and participation       with
States      in the   costs of constructing   and operating      State-owned
domiciliaries,        nursing  homes, and hospitals      for veterans.
     For fiscal   years 1975 and 1976, the domiciliary       program
cost $53 million   and $61.9 million,    respectively.    Based on
the average population    census,   the daily   cost per veteran
was $15.82 in fiscal    year 1975 and $18.61 in fiscal      year 1976.
PROGRAM EVOLUTION AND MISSION
I---Iv------------     --
       Domiciliaries         evolved      from "old soldiers            homes" which
were instituted         by legislation          in 1865 for soldiers           with
service-connected          disabilities.          When VA was created           in 1930,
it received       control     of the old soldiers            homes and established
the domiciliary         program.         Through legislation            and VA policy
changes,     the military-like            environment       of these homes has
been reduced,        and the eligibility           criteria        has been expanded
to veterans       with nonservice-connected               disabilities.
        Until    1960, VA defined         domiciliaries           as institutions
which provided         a home--bed,       board,      and incidental          medical
care-- for veterans           who could not care for themselves.                      How-
ever,     VA  believed      that   many   temporarily         disabled      veterans
admitted      after    World War I remained            institutionalized           because
of a lack of professional              rehabilitation           programs.        Antici-
pating     this could also occur with veterans                     of World War II,
VA planned        in 1960 to convert         the program to a concept                 of re-
storation      centers      to return     veterans       to the community.              Under
the plan,      all but 6 of 18 domiciliaries                  were to be gradually
phased out and replaced             by 40 restoration             centers     with 7,250
beds.      Nine restoration         centers      were eventually          established,
but the concept         was never fully          carried      out because,        around
1960-61,      VA hospitals        became overcrowded            and VA needed to
use the restoration            centers    for extended          care facilities.
While two domiciliaries             were closed        in 1965, two others              were
established         in early     1972 to replace         unsafe structures            in
Los Angeles.
        By 1965, the domiciliary            program was being defined               as
providing      shelter,     food, and continued           medical     care    to ambula-
tory    veterans     while    seeking    to emphasize       rehabilitation.            In
1970, VA issued its first             formal    directive      to revise        the
domiciliary      objectives       to reflect      a comprehensive          mission     of
providing
        --preventive         medicine,   public    health    services,  and re-
           habilitation        measures for veterans        who require   con-
           tinued      treatment     in a protective      environment;


                                             2
      --special    behavioral      and medical     rehabilitation        for those
         who require    intermittent,      short-term        services;     and
      --restoration      services    for       those who can be helped suffi-
          ciently   to return     to the       community,    usually within
          1 year after    admission.                      '4

In 1972, the restoration     centers  which VA had begun to estab-
lish in 1960 were closed because VA central      office  officials
did not believe   the centers    were successful and because of a
lack of funds.
CHARACTERISTICS-- OF
i?%ii~i~i!i~-%??%ANS
-------a----         -l/
       Appendix  II provides    an indepth    view        of VA's    domiciled
population.     The following      is an expanded         synopsis    of that
population's    major characteristics.
      --Demographic:         Ninety-two percent  are males;    the average
         z-60,           with a range in age of 28 to 90; 35 percent
         are under age 55; 30 percent        are age 65 or older;     and
         58 percent      came from VA hospitals.     (See tables   I and
         II,   app. II.)
         Many transferred          from VA institutions    and had long
         histories        of VA dependence.       Those who came from other
         sources        could not care for or support      themselves.   ( See
         table     III,     app. II.)
      --Disabling
         ----        conditions:      Only 21 percent      had service-
         connected   disabilitres.       Among the primary     conditions,
         50 percent   were either     neuropsychiatric      or alcoholic,
         13 percent   were circulatory,       and 6 percent    were tespir-
         atory.    Over 80 percent      of the veterans     had at least
         one secondary     diagnosis.      (See table   IV, app. II.)
      --Military
         ------    service:     Service   periods   ranged from 7 days
         to 27 years;    12 percent    had 6 months or less and
         5 percent   had over 10 years.        (See table  V, app. II.)
      --Income:
          --         Excluding     nominal    wages for work assignments,
          the approximate      average    income was $200 monthly.
          (See table VI, app. II.)

&/This   section     is based on a random          sample of 380 veterans
   at 5 domiciliaries       and, therefore,         may not be representative
   of all domiciliaries.

                                           3
       --Period     of domiciliary      dependence:     Many veterans     trans-
          Terred-in      and out of domiciliarZes       and records    were not
          adequate     to compute the exact periods         veterans   had been
          in domiciliaries.          Based on records    available,    the
          average timespan        between the date the veteran        entered
          a domiciliary       and the date of our review was 7 years;
          9 percent      had been in domiciliaries       for 6 months,
          20 percent      for over 10 years.        (See table VII,
          app. II.)
LIFE IN DOMICILIARIES
--------w--s
        Upon admission,           veterans      are assigned‘to       a temporary
living      section      until     they have received         medical     examinations,
social     evaluations,          and orientation         to the domiciliary.          The
orientation         includes       information      on services      available,      what
will    be required         of the veterans,          and how they are to conduct
themselves.           After    this     initial    period   of about 1 week, the
veterans      are assigned           to a bed in another        section     which is
normally      on a ward-type            arrangement.
       The daily   routine    begins about 6:15 a.m. and ends when
lights   are turned     off around 10:00 p.m.          At that time bed
checks are made by domiciliary          assistants.       These assistants
oversee   the living     areas,   assure that veterans         abide by rules,
and stay alert     for veterans     needing    special    attention.
        Depending    on the domiciliary,            veterans       in the morning
either    stand in line or go by ward to the cafeteria.                           (Either
before    or soon after       breakfast     they are expected             to clean up
the living      area around their        beds.)        After     breakfast,      those
desiring     medical   attention      or drug prescriptions               are given
passes for sick call.            (See p. 5.)         post domiciliaries            have
clinics    and separate      medical     facilities         to handle sick call
and preventive       medicine     services.         These facilities          are usual-
ly open at any time except nights,                  weekends,        and holidays.
Medical    needs and specialized           care during         these periods         are
handled     by nearby VA hospitals.              The independent         domiciliary
at White City,       Oregon, which is not near a VA hospital,                        has
a 25-bed infirmary        and has arrangements              with local       community
hospitals     for emergency and specialized                 care.
        veterans    with work or activity     assignments    are expected
to report      to their  duty stations    at designated    times.     Most
domiciliaries       also have available     a wide variety    of recrea-
tional     and other activities.
VETERANS ON SICK CALL WAITING TO BE SEEN BY A PHYSlClAN AT HAMPTON,
VIRGINIA VA DOMICILIARY                                SOURCE: GAO STAFF




                                    5
       Weekly,    biweekly,      or monthly    inspections       are made of the
veterans'    personal       appearance   and living      areas.      In addition,
"lay-out"     inspections      are made monthly       or quarterly.          For
these inspections         the veterans     empty their      lockers      and display
all personal      property     on their    beds.    At certain       domiciliaries
nurses or podiatrists          accompany domiciliary          assistants      to in-
spect personal       hygiene     and look for alcoholic          beverages      and
excessive    quantities       of drugs.
       Veterans   are also subject           to disciplinary          action.       Those
charged with violating          domiciliary       rules     by such actions          as
missing     bed checks,     stealing,       being intoxicated,           fighting,
missing     work assignments,         or being insubordinate,              are brought
before    the Chief or Assistant            Chief of Domiciliary             Operations
who determines      what action        will    be taken.        Disciplinary        ac-
tions   include   reprimands,         counseling,      restriction         from leaving
the domiciliary,       fines,     or discharge       from the domiciliary.
SCOPE OF REVIEW
-1-p     ----
        We researched      the history      and purpose of the VA domicil-
iary program and analyzed            program conditions         and program man-
agement, medical        care and physical         accommodations,         recrea-
tional     and activity      programs,     and rehabilitation          efforts.       We
examined procedures          and practices      for admissions,         discipline,
discharges,      and operations        at the VA central        office      and at
domiciliaries       in Dayton,      Ohio; Hampton, Virginia;            Martinsburg,
West Virginia;        Vancouver,     Washington;      and White City,           Oregon.
We also examined internal            VA domiciliary        study reports         and
VA's plans to improve the program.
        At the five domiciliaries,        which VA officials      agreed
would be representative        of the entire     program,    we selected
a lo-percent     random sample (loo-percent         sample at Vancouver)
of the veteran      population     to develop   basic statistics.        The
domiciliary    sample sizes were:
                                         Veteran               Sample
              -Domiciliary             population               size
              Dayton                          914                 91
              Hampton                         693                 69
              Martinsburg                     567                 57
              Vancouver                        55                 55
              White City                  1,083
                                          --a                    108
                    Total                                       380
                                                                _I



                                            6
Within     the   380 sample     cases:
         --We selected    all 55 veterans at Vancouver    and 25 at
            each of the other locations   (total   of 155) for an
            expanded,  indepth  review of records.
         --We interviewed       114 of the 155 veterans       concerning
            their    residence    at the domiciliaries     and the type of
            care they were receiving.          (The remaining     41 could
            not be interviewed       because they were discharged,         in
            hospitals,      or deceased.)
         --Our staff    physician        reviewed    the medical   records    for
            56 of the 155 veterans            to evaluate   the quality    of
            medical  care provided          and the potential    for outplace-
            ment to other     facilities        or to community    living.




                                           7
                                      CHAPTER
                                      -p-m    2

           --IMPROVEMENTS NEEDED
                               ---- IN DOMICILIARY--        OPERATIONS
                                                                    -
      VA needs to provide better   management for the domiciliary
program.   At the time of our review    in late 1975 and early
1976:
       --Domiciliaries    were not properly     applying  the admission
          criteria.    Community alternatives     to domiciliary   admis-
          sion were not normally    considered.
       --Most    domiciliaries        did not have adequate procedures
          for monitoring        the   quality of medical   care,      Some
          domiciled      veterans     were not receiving   sufficient
          medical   attention.
       --Recreational    programs   were generally   not           directed     to-
          ward the individual     needs of veterans.
       --Some veterans     in domiciliaries          had potential   for re-
          turn to community      living,     but comprehensive     rehabili-
          tation  and restoration        programs were normally        not,de-
          veloped  to assist     in their      outplacement.
       --Staffing      criteria   for domiciliaries          had not been es-
          tablished.        Wide variances    existed      in staff-veteran
          ratios     among the domiciliaries.
         A 1973 internal        audit    and other 'VA studies      and workshops
identified       similar    problems      and produced      numerous recommenda-
tions     to correct     them and improve other aspects             of the domi-
ciliary     program.       However, except        for establishing       a reporting
system related         to staff     productivity,      the VA central      office
has not made substantial              changes in program operations,            and
none of the domiciliaries              have received      formal   guidance
directed      toward implementing          the internal      recommendations.
         Seventeen    of the 18 domiciliaries       are located         near VA
hospitals       in VA centers     and are under the overall          management
of the center       director.       Thus, the domiciliaries         have to com-
pete with the hospitals           for VA operating      resources.         Offi-
cials     at most domiciliaries         stated that the program's           low
priority      was related     to being near a VA hospital.              Most local
managers preferred          a free hand in operating        domiciliaries;
however,      some believed      more VA central    office     coordination
was needed.
IMPROVED MEDICAL--w----
---                CARE NEEDED
        VA needs to improve the medical              care provided     veterans
in domiciliaries.            Some veterans      were not receiving      timely
physical    examinations;         psychiatric     care was limited;       defi-
ciencies    occurred       in administering       psychotherapeutic       drugs;
and some veterans          needed more specialized         care.    These prob-
lems may exist,          in part,    because of VA's lack of criteria
for medical       staffing     of domiciliaries       and limited    internal
evaluation      of medical       care quality     there.
Annual     physical      examinations
                         --           -
       VA requires      that each veteran       in a domiciliary          receive
an annual physical         examination      as part of a preventive            medi-
cine program.        Yet, at the Hampton and Vancouver               domicili-
aries,   26 of 80 veterans          whose files    we reviewed       had waited
from 13 months to almost            3 years between examinations.               At
Hampton, this      situation       had been previously        reported      by the
VA Internal     Audit     Service,    and hospital      center    management
had taken corrective          action.     At Vancouver,       VA officials
said that they intend           to strengthen     controls      over scheduling
physical    examinations.
Psychiatric
-I__              care
        Psychiatric        problems      are predominant         among veterans      in
domiciliaries.            According      to VA's 1970 guidance,          medical
treatment        is to be provided          on the basis of need, and domi-
ciliary      clinics      are authorized         to include      mental health
coverage.          Also,    specialty      services     provided     in nearby VA
hospitals        or through      consultants        are to be used if they are
not available          in the domiciliary.             Fifty-six    percent     of the
domiciled        veterans     we sampled had a psychiatric              condition,
but in many instances               they had not received          needed psychia-
tric    consultations.
         White   _City r Oregon
       White City was the only domiciliary                 with a full-time
psychiatrist        on its staff,     but he was heading             the Physical
Medicine      and Rehabilitation        Service     and, therefore,            not prac-
ticing     psychiatry.       However, another         psychiatrist         from the
local    community     was practicing       half-time       in the domiciliary
to treat      veterans    referred    to him as problem cases or those
who voluntarily        sought help.       No psychiatric           rehabilitation
program existed        at White City until          May 1975, when the part-
time psychiatrist         began seeing all newly admitted                  veterans
with psychiatric         problems.


                                            9
       We asked this psychiatrist            to examine the medical        records
for the 25 White City veterans             in our sample selected        for an
indepth     review.       According   to medical   records,     only seven had
psychiatric       conditions.       However,   the psychiatrist      found that:
       --Four    other    veterans     probably     had psychiatric        problems.
       --At least       six veterans      had not received       needed psychia-
          tric   examinations       to determine      if their    diagnoses     were
          still    current     or to determine      whether    they needed to
          continue      taking   certain    psychotherapeutic        drugs which
          had been prescribed          for them by a general         physician.
       Martinsburg,
       ---                West Virginia
        Of the 25 veterans         whose medical      records      were selected
for detailed       review     at the Martinsburg        domiciliary,        16 had
psychiatric      conditions.        A review of their        files     showed that
only nine had received           psychiatric     consultations.           The domi-
ciliary     did not have a psychiatrist            on its staff        and used the
services      of the nearby VA hospital's           psychiatrist.           However,
according      to domiciliary       staff,   the hospital        psychiatrist
usually     only met with domiciled          veterans     whose problems        had
reached a crisis         state   and who were specifically             referred
to her.
Psychotherapeutic         drugs
        Eighty-seven        of the 155 domiciled      veterans       included       in
our records        review sample were receiving            psychotherapeutic
drugs to control          their    psychiatric  problems.         In most in-
stances,       the drugs were administered         in dosages below recom-
mended maximums, but some veterans              were obtaining          duplicate
prescriptions.           Forty-six     of the 87 veterans       had either        taken
overdoses,        had been given drugs not noted in their                 medical
records,       or were having prescriptions          refilled      too frequently.
For example:
       --A   veteran     at Martinsburg    had two active   prescriptions
          for the same drug-- one written          by the domiciliary
          physician      and one written    by a hospital   physician.
          Neither     prescription     was entered   in the medical     rec-
          ords,    but both were filled       by the VA center     pharmacy.
       --A veteran    at Vancouver    had two prescriptions--each        for
          a l-month   supply of the same drug--refilled           during a
          2-week period     in April  1975.   A notation      in the veter-
          an's medical    recordsp   dated April   12, 1975, stated
          that the "member is spending      most of her time in what


                                          10
           appears to be a drugged stupor."              Two days later,
           staff  reported   that the veteran          had apparently    been
           taking   more than the prescribed           dosage.
Veterans    needing    more
~eXiYzedZre
-----------            facilities
        Some veterans    in domiciliaries        appeared      to need more
specialized      medical   care, such as that provided            by nursing
homes or hospitals.         But, many veterans        have strongly       re-
sisted    being sent to nursing        homes.     Domiciliary      staff    said
that once veterans       are in domiciliaries,          it is difficult        to
transfer     them to more specialized         care facilities.
      As an indication        that some domiciled    veterans     needed
more specialized       care,    the medical  records   reviewed    by our
staff  physician     indicated     that 4 of 56 veterans      needed or
were nearing     the need for nursing       home care.
        As a further      indication,          at the White City domiciliary,
76 veterans     were listed          in October      1974 by the chief     medical
officer    as nursing       home candidates.            As of September    1975,
42 of the 76 were still              in the domiciliary        and were still
listed    as nursing     home candidates.             Only 7 of the 76 had
been placed      in nursing         homes.       The other   27 were in hospi-
tals,    had been discharged,             or were deceased.        The reasons
for the 42 veterans           still      being in the domiciliary        were
 (1) more rapid deterioration                in the health     of other veterans,
 (2) continued     availability           of bed space at White City,         and
 (3) veterans'     resistance          to being placed       in nursing   homes.
Internal     evaluation     of
medical
a-------    care quality
       VA requires       periodic       medical   record     reviews     at domicili-
aries.       In February      1974, VA directed         that a health       services
review organization           be established        at each domiciliary          to
systematically        review     the quality      of medical       care.    Yet, de-
spite    this directive,         most domiciliaries          have not evaluated
medical      care quality.         White City and Vancouver            have made no
evaluations.         At Martinsburg,         the VA hospital        center   had pro-
cedures      for evaluating        the quality      of medical      care for domi-
ciled    veterans     who became hospitalized             but none for evaluat-
ing medical       care within        the domiciliary.
       White City officials         said they plan to implement         a sys-
tem for monitoring         medical   care quality,      and Vancouver    offi-
cials   said they plan to take action            to improve medical      care.
Martinsburg    officials      believed    their    procedures    were ade-
quate to evaluate        the care provided      domiciled     veterans.


                                        11
RECREATIONAL PROGRAMS
---
NEED
-_I  TO BE EVALUATED
       VA has directed         that each veteran           be assigned      a daily
therapeutic     activity       schedule      related      to abilities,      interests,
and therapeutic        goals.       However, much of the veterans'                time
is idle.     We observed         veterans      lying    in bed at all times of
the day, sitting         or standing       alone,     or congregating        to talk
and pass the time.            (See pp. 13 and 14.)            This occurred          in
part because veterans            generally       had work assignments          of
4 hours or less a day and because recreation                         programs were
not directed     toward individual             needs.
        According        to a 1971 American            Hospital       Association        report
on long-term         care institutions,             effective        activity      proqrams,
correlated        with a therapeutic            goal,      must be well planned              and
scheduled       to meet individual             needs and must be periodically
evaluated.          Although       the domiciliaries             we reviewed       generally
had a wide variety              of recreational          facilities         available,      most
locations       had made no special             efforts        to direct      their    recrea-
tional     activity       programs      to meet individual              needs, did not
maintain      data on veteran           participation,            and had not made
recent     evaluations.            For example,        Martinsburg          had extensive
recreational         activities        and three personnel              responsible        for
such activities.              Yet, veteran        participation           appeared mini-
mal, information             on participation          was not maintained,             and
a formal      evaluation         of the recreational              program had not been
made in 10 years.




                                              12
I       ’   ,,,,


            ,’



    ;       y,
14
MORE EFFECTIVE REHABILITATION
~REST~~T~j%%&?AMS
-I_-              w----s- NEEEED
        VA needs to increase             its efforts        to return      domiciled
veterans       to community      living.         In 1970, when VA revised                the
domiciliary        program's     mission,         its guidance         to domiciliaries
required       that a mechanism be established                   to identify       and as-
sist    veterans      with potential          for returning          to community
living.        Although     each domiciliary            has established        a system
for outplacing         veterans,       sufficient        action      is not directed
toward      (1) developing       comprehensive           rehabilitation        and res-
toration       plans to assist        veterans        and (2) identifying             those
with potential          for outplacement.             We found some veterans               who
appeared       to have such potential,               but they were not being
helped.
        Other factors,   such as the veterans'             retention   of income
.while residing     in domiciliaries        and their      ability   to easily
 gain readmittance     to domiciliaries,        also appear to discourage
 veterans    from permanently       leaving   domiciliaries.

-IRehabilitation       resources       not
considered         on admission--
        In VA's 1970 guidance,           the return    of veterans      to the
mainstream         of society     was stressed     as a pressing     concern     for
domiciliaries.           To accomplish      this goal,   VA directed       that
each applicant         for domiciliary        care be made aware of avail-
able community         alternatives      to admission.      However, alterna-
tive    facilities       and programs      are not normally      considered
unless      the veteran       is refused    admission.     For example:         .
        --A 44-year-old     veteran    applied     for admission       to White
           City stating    he needed help to cope with being alone
           in the world,    to get back to a constructive              life,    and
           to find a job.      Admissions      personnel       said that no pro-
           gram in the domiciliary        could help him and that he
           would probably     become institutionalized.             Yet, they
           admitted   him rather    than refer       him to other available
           sources,    such as a vocational        rehabilitation         agency.
We tested     admission        practices      for 2 months in 1975 and found
that,    when veterans         were refused       admission,      in most cases it
was because the VA staff               considered     them to be unsuitable
for domiciliary         living     or incapable       of self-care.       Few
veterans    seeking       admission      were encouraged        to seek other
available     rehabilitative           sources    rather    than be admitted.




                                              15
Rehabilitation        and restoration
results
        VA needs to implement             a system to assess the results                of
its actions       to rehabilitate          and restore       veterans     to community
living.     None of the domiciliaries               routinely       compiled       and
reported     information       reflecting       rehabilitation        and restora-
tion results.         However, VA's fiscal           year 1974 report            to the
Congress stated        that 2,250 veterans            had attained        self-reliance
and rehabilitation         during       that year as a result           of the incen-
tive therapy       program     (paid work assignments).               Officials        at
the five domiciliaries            we reviewed,       however,       were unaware of
how VA arrived        at the figures         and did not know if any of their
veterans    were included.
       Discussions       with VA central          office   personnel      revealed
that this      information       was taken from a management information
system report --since           discontinued--        and was incorrectly        re-
ported     for the domiciliaries.               The 2,250 figure      was for all
VA facilities,        including       hospitals       and nursing    homes.      Only
320 should have been reported                for the domiciliary         program,
and even for these,           there was no way to identify             specific
veterans.
Veterans with       potential
for community       living
       We did not sufficiently            review the circumstances           of all
veterans     in our sample to quantify           the percentage        which could
or should be placed         in the community.          However,     some of the
sampled veterans       did have potential          for outplacement.          Our
staff    physician   identified        12 who appeared      to be able to
live   or work in a community           setting.      The following       are
examples of veterans          with such potential        who were not being
assisted     by VA for full       restoration      to community      living.
       --A veteran        entered    the Los Angeles domiciliary              in 1971
          because of a leg injury               received     as a warehouseman.
          He entered       the domiciliary           for convalescence       and
          vocational       training.        Now 45 years old, he is
          domiciled       at White City.           He applied      for vocational
          training      in typewriter         repair     before    being trans-
          ferred     from Los Angeles           to White City but never
          received      a response.         He said he has not applied            at
          White City because he has not been encouraged                       to
          pursue vocational          training        there.     His only current
          disabling       condition      is a vague complaint           about a
          problem with one of his arms.


                                           16
have remained        in the       same assignment    for   long   periods,     one
for 13 years.
        The boards assigned         veterans  to paid or nonpaid work
details     generally       geared toward operating    the VA facility.
For instance,        officials     at White City estimated     that   150
civil    service     employees     would be required   to replace     veterans
on work details.
      Assignments   are also made to keep the veterans          occupied
and to provide    money to those with little       income.     At White
City,  for example,    all veterans    receiving   monthly   incomes
of $100 or less for their       sole use from outside      sources c'an
have paid assignments.       Domiciled    veterans   with monthly    in-
comes of more than $100 but less than $150 can be paid for
their  work assignments    if they serve in key positions.
         Of the 114 veterans     we interviewed at the 5 domicili-
aries,     74 had assignments;     39 of the 74 said they had received
their     choice of assignments.
         Veterans'   activities
         not monitored
       Although     VA also requires         that domiciliaries          monitor
and evaluate       veterans'     performance       of assigned      activities,
this was not consistently              done.    Vancouver      did not begin
monitoring      veterans'      participation       until    after   our review
was initiated.          Hampton was not generally            monitoring       veterans'
attendance      and did not begin evaluating              their    performance
until    September      1975.     Yet other domiciliaries           not only moni-
tored veterans'         attendance       and evaluated      their   performance,
but also administered           disciplinary      actions      or discharged
veterans     for refusing       to work.
       According     to our observations,         most     domiciliaries       did
not make extensive         use of their     physical       therapy      and manual
arts facilities        as part of an integrated            effort     to outplace
veterans.       Rather,    these facilities       were     used primarily        at
the veterans'       desire    or at the direction          of a physician        to
enable veterans         to better  function     in the       domiciliary.
Psychology     and social
work
-     services
         Each domiciliary     has established      a psychology   service
and a social     work service.       These services,      composed of one
or more psychologists         and social    workers,   can affect    reha-
bilitation     and restoration.       Yet, only 12 of the 114 veterans


                                           19
we interviewed         said they had been counseled                    concerning
community       outplacement.             Efforts    of the psychology           service,
which is responsible               for formulating,         on the basis of
psychological         principles         and approaches,          the treatment,
rehabilitation,          and restoration            programs      at the domicilia-
ries,     were generally           limited      to attending        therapeutic
programing       board meetings            and providing        some counseling.
Our discussions          with social          workers,     who are charged with
assisting       veterans       in constructive          planning       for life     outside
the domicil iar ies , indicated                 that they were generally             doing
little      for community         outplacement.           Certain      social    workers
only participated            in a few small veterans                groups,     and most
social      workers    spent much of their              time responding          to
individual       requests        for assistance.
        Also,   because staffing       criteria    had not been estab-
lished,     wide variances     existed       in the ratio of psychologists
and social      workers  to veterans        at the five domiciliaries.
 (See p. 21.)
Other    factors
         VA personnel     at some domiciliaries        believed     that veter-
ans' retention        of income represented        a significant       incentive
for them to remain domiciled           and a substantial         block to reha-
bilitation      and restoration.       While in domiciliaries            veterans
can retain      all income from work assignments             and all other
income, except for monthly           nonservice-connected         VA pensions,
,tihich are automatically        reduced to not more than $50 after
tne second full        calendar   month following       admission.
        Forty-five      percent    of the domiciled   veterans we inter-
viewed said higher          incomes would enable them to return      to
community       living.     Fifty    percent of those with incomes were
willing     to contribute        part of it toward the cost of their
care in order to remain in the domiciliary.
       Also,   veterans       can leave for almost any length             of time
and be readmitted         upon return.         Some veterans      were absent for
up to 6 months to travel              or work.     Other veterans      discharged
on their     own initiative          or for disciplinary       reasons    find it
easy to return.          Thirty-five       percent    of the 380 veterans        in
our review     sample had been discharged              and readmitted,       some as
many as 18 times.           One veteran       at White City had been dis-
charged     14 times since 1961, including               9 times for discipline
problems.




                                             20
STAFF INCONSISTENCIES
       VA has not developed          staffing        criteria       for domiciliaries.
Each VA center     director       determines         the allocation       of staff
between the hospital          and domiciliary.              As a result,     wide
variances    exist   in domiciliary           staffing        levels.    As shown
below, for certain        staffs     at the five domiciliaries               at the
time of our review,         the number of staff               per 100 domiciled
veterans   varied    significantly.
                                                                                              Social
Domiciliary              Physicians               Psychiatrists               Nurses          workers              Psychologists

Dayton                       g/    .38                     .06                 1.20            .27                         .41
Hampton                            .61                     .Ol                  .90            .30                         .25
Martinsburg                        .21                     .03                  .75            .19                         .19
Vancouver                          .25                     (b)                  lb)           2.26                         .38
White      City              c/    .62                     .04           a/    2.13            .61                         .35
  Average                          .47                     .04                 1.60            .42                         .32

s/Includes          nursing        care    unit   with   286 patients.
k/Psychiatrists      are not assigned    to the domiciliary                             but   are available             from       the
   center.      No nurses were assigned.
c/Physicians          are also           responsible     for      handling     the     outpatient       clinic.
i/Nurses          are also        responsible      for   a 25-bed       infirmary        and a 20-bed             detoxification
   unit.

           The following    examples further                                    illustrate               the different
staffing       levels    at domiciliaries.
           --The Martinsburg     domiciliary,     with 533 domiciled     veter-
              ans, had 1 physician       on its staff   and a consulting
              physician  working   part time.       The Hampton domiciliary,
              with 663 veterans,    had 3 physicians       on its staff    and
              4 other physicians    working     part time.
           --The Dayton domiciliary,                                 with 914 veterans,    had
              11 nurses on its staff,                                while Martinsburg,    with
              533 veterans,  had only                               4 nurses on its staff.
           --The White City domiciliary,        with 1,146 veterans,      had
              7 social workers.      Hampton, with 663 veterans,        had
              only 2 social   workers   assigned    to its domiciliary.
           --Martinsburg     had 1 psychologist  on its staff for 533
              domiciled   veterans,  while White City had 4 for its
              1,146 veterans,

                                                                  21
                                       CHAPTER
                                       -__I    3
               IMPROVED PLANNING
                           -a------- NEEDED FOR DOMICILIARY
                          CONSTRUCTION
                          --          ---AND RENOVATION
       Because VA audits             and studies       showed existing         domiciliary
living    accommodations           to be outdated         and unsafe,        VA developed
proposals     to construct           new facilities        estimated        to cost
$215 million.          However, these plans were not based on an ade-
quate projection           of need for domiciliary              care or the extent
that existing        facilities        could be upgraded            to meet such need.
VA needs to further             evaluate     the demand for domiciliary                 care
and the possible           upgrading      of facilities         to meet such demand
before    proceeding         further     with construction           plans.      In addi-
tion to the impact which improvements                      in the application            of
admission     criteria         and in restoration          efforts      could have on
the domiciliary         population,         changes in eligibility             criteria
and the makeup of the veteran                  population       will    also affect
the need for domiciliary               care.
PHYSICAL ACCOMMODATIONS
--I-
         Most living      quarters     are drab, open-bay       areas with 3 to
30   veterans     to a ward.         Seventy-seven     percent    of the beds in
the domiciliaries           reviewed     are in such wards.         Buildings     are
33 to 77 years         old.      Three of the five domiciliaries             were
originally      constructed         as temporary    or semi-permanent
hospitals     during      World War II.         The others    were built      around
1900 as national          homes or asylums for disabled            veterans      and
subsequently        retained      by VA.     (See app. III.)
        Gray office-type         partitions      have been added at certain
locations      to provide      privacy.       Still,    in our opinion,          the
arrangements       often    resemble       a warehouse    setting      with each
veteran     having only a few old or poorly               maintained       furniture
items including         a bunk, double wall locker,             chair,     writing
table,    and lamp.        Walls,     if not in need of paint,            are often
painted     dull   colors.       Plus, toilets       and showers offer          little
privacy.        (See pp. 23 to 25.)




                                            22
,‘,         ’




                                      SOURCE:   GAO   STAFF


      EXAMPLE OF MODULAR LIVING ARRANGEMENTS
                PURCHASED AT HAMPTON




                       27
                                            SOURCE:   GAO   STAFF




                                            SOURCE:   GAO   STAFF

WARD LlViNG ARRANGEMENTS RENOVATED   USING WALLPAPER AND
BRIGHT COLORS AT WHITE CITY


                          28
           . -
Bap   ,_
STUDIES AND ---
-_II-       PLANS
        In response       to the June 1973 VA internal               audit    report
which severely        criticized        the quality       of living     accommoda-
tions,    VA's Chief Medical            Director      in January      1974 estab-
lished    a Special       Task Force for Domiciliary               Study.     The task
force's    April     1974 report        contained       52 recommendations        for
program-improvement            actions,     including       a proposal     that VA
adopt a 5-year plan to construct                  9,500 new domiciliary           beds
in units     of no more than 200 beds per unit.                     These units       were
to replace       all existing        units.      Construction       cost estimates
ranged from $160.6 million                to $179.4 million.
        The VA central         office      did not accept the task force's
recommendations          because of internal               disagreement        about the
specific      program changes needed.                  For this reason another
domiciliary        study group was appointed                   to propose      a solution
for improving         the program.           The "final         draft"     of the report
on this      study,     dated April        10, 1975, proposed              constructing
new domiciliaries           containing         10,000 beds over an 8-year
period     beginning       in fiscal       year 1977.            The estimated        cost
of this project          was $215 million.                The new domiciliaries
would include         200-bed facilities             in one of three designs--
motel,     high rise,       or cottage         type --and be located             throughout
the then 30 VA medical              districts.         l/      Each facility        would
contain     one-bed and two-bed units                 and could be easily              altered
to reduce or add beds as necessary.                          In addition,        the report
contained       proposed     staffing        guidelines.           The study group
also proposed         that veterans          contribute          a nominal     portion      of
their    income to help pay for the facilities.                            As before,
VA management did not accept the proposals                             in this report.
This was primarily           because of the timeframes                   involved      and
the recommendation           to use veterans'              personal      funds.
         Although    VA did not accept the proposal      to construct      all
new facilities,         VA's fiscal   year 1977 budget request      included
$22.9 million        for constructing     three 200-bed facilities.        In
justifying        the need for new facilities,      the budget justifica-
tion stated:
              "A majority        * * * are not capable    of being up-
              graded to meet current        applicable    construction
              or life      safety   codes.  Additionally,     existing
              domiciliaries        do not meet the functional        require-
              ments of modern domiciliary          care."
-----------

I/     VA now has 28 medical             districts.



                                              30
The request       further         stated:
        "It   is proposed       to implement         a phased program to
       replace      existing      domiciliaries          which cannot be
       economically         upgraded      to meet current          life      safety
       codes and modernize            existing       domiciliary          facili-
       ties which can be economically                    upgraded       to meet
       the requirements           of modern domiciliary               care.
       This program is part of an integrated                       comprehen-
       sive plan to provide            quality       care for the aging
       beneficiary.          The program also provides                  for a
       more appropriate           geographic       distribution           and bed
       capacity
       --            supported      medically        by   adlacent        hospi-
       tals."
       --           (Underscoring         supprl'~~~--
The funds      requested          were      for     the   following          facilities.
                                                                   Fiscal
                                                Total                year            Fiscal       year
                       Number               estimated                1977              1978 or
Location
-I_-                   of beds
                       I_--                       cost
                                                  --               request         future -I_-  request
                                            ------------(000                omitted)-----------

Dayton,    Ohio             200             $ 7,345            $      735                  $ 6,610
Wood,
  Wisconsin                 200                   8,401            8,401
Hampton,
  Virginia                  200              I- 7,105                 710                   ---6,395
     Total                -600          $22,851
                                         --            $9,846            $13,005
                                                                          -a-
        The request       equaled more than the first            annual increment
($10.8 million         for 600 beds) of the $215 million               proposed   by
the domiciliary          study group.          In December 1975, VA's Assistant
Chief Medical        Director        for Extended      Care said that VA's plans
were to replace          3,000 beds with new facilities,             renovate
existing    facilities         to provide        3,500 more beds, and use the
remaining     existing       facilities       with minor repairs       and upgrad-
ing.     He said that construction                and renovation   plans could
take as long as 10 years to complete.
        In March 1976, the Acting             Assistant     Chief Medical       Direc-
tor for Extended Care stated               that VA's current        construction
plans were to build          the three 200-bed facilities             as contained
in the fiscal      year 1977 budget request.                Further   new construc-
tion,     he said,   would be predicated            on availability       of funds
although     no specific       plans had been made.            In August 1976,
the Congress approved            VA's fiscal      year 1977 request         for
domiciliary      construction        funds.

                                                    31
       Subsequently,         in a November 1976 letter    to the directors
of VA health     care      facilities,   VA's Chief  Medical   Director
stated   that:
       "A modest construction                effort   has been initiated
       to counter         the inadequacies          of existing     domicili-
       aries    while       recognizing-the         need for emphasis on
       privacy      and on the psychosocial               aspects   of con-
       gregate      living.         Design criteria        have been devel-
       oped which address the multiple                    needs of the aging
       veteran      resident.         Construction      of the prototype
       for a new  -----_I200-bed domicxliaryarranged              in 4-50 bed
       -?iie        around a core support             module will     been
       inn-at               Wood, Wisconsin,         with one-at     Hampton,
       Vxiniaand               Dayton,     Ohio scheduled      in the near
       future.         Long range plans envision              one such
       domiciliary        -- in each of the 28 Medizmicts."
        (Underscoring           supplied.)
VA's latest     long-range     construction       plans,    if fully     imple-
mented, will      result   in 5,600 new domiciliary           beds.      This
represents     an increase     of 2,600 beds or about 87 percent
greater    than a figure     of 3,000 new beds, which was provided
to the Senate Appropriations            Subcommittee       on HUD-Independent
Agencies     by VA's Chief Medical         Director      in April    1976 in
response     to questions    raised     by the Subcommittee          in March
1976 during     VA's fiscal     year 1977 appropriations             hearings.
DEMAND FOR DOMICILIARY CARE
------_I
AND UPGRADING
         ---I_-    OF EXISTING
FACILITIES
         -----  NOT FULLY COGSIDERED
                               --
        The VA domiciliary             study group,        in its April        1975 final
draft     report , projected           demand for domiciliary             care in the
year 1990 to be 10,900.                  However, our examination             disclosed
this projection            was based only on historical               demand and,
therefore,        did not consider           such major factors           as (1) the
impact of an improved              rehabilitation          and restoration         program,
 (2) the universe           of veterans        needing domiciliary           care but not
currently       in domiciliaries,            and (3) potential         developments,
such as the aging World War II veteran                       population        or improved
domiciliary         living     conditions,        which will     increase       demand.
In addition,          VA's Assistant         Chief Medical       Director       for Ex-
tended Care said in December 1975 that VA had not developed
a projection.             In March 1976, this was again confirmed                     by the
Acting      Assistant       Chief Medical         Director    for Extended         Care.    He
stated,      however,       that VA did plan to evaluate                future     demand
for domiciliary            care but that this would not be done before
beginning       construction         of the new facilities.


                                           32
         Also,    before   developing     its proposal      and plans for new
facilities,        VA had not determined         the extent     to which existing
facilities        could be economically         upgraded.     In April   1976,
VA's Chief Medical           Director   advised     the Senate Appropriations
Subcommittee         on HUD-Independent       Agencies    that a study was
being conducted          to identify    the number of beds needed and
the cost for a modernization              program.     As of January     1977,
however,       the study was still        in progress     and was not expected
to be completed          before    late 1977.




                                        33
                                          CHAPTER- 4
                     CONCLUSIONS, RECOMMENDATIONS
                     -__I---                 --a TO VAp
                        VA COMMENTS AND OUR EVALUATION,
                     AND RECOMMENDATION
                     a--          -     TO THEPm-
                                               CONGRESS
CONCLUSIONS
_I_--
        The problems       in operating         VA's domiciliaries            are caused
by insufficient         management attention              at the VA central             office.
Factors      supporting      this conclusion           include     the (1) frequent
lack of a VA central             office     organizational         position       respon-
sible     for the program,           (2) varying       procedures       and practices
among the domiciliaries               on admitting        veterans      for care,
 (3) lack of internal            evaluations,        other     than internal         audits,         .
of the quality         of medical        care,    (4) ineffective          rehabilitation
and restoration         efforts,        and (5) lack of staffing              criteria.
Some of the operational               problems     noted would not have occurred
if domiciliaries         had followed          VA instructions.            This indicates
that the VA central            office     does not have adequate              reporting
systems or other controls                to assure compliance             with its
instructions.
         Also, VA has not adequately                   planned       its proposed        domi-
ciliary      construction         and renovation            program.        Ingredients
in such planning           should      include        analyses       of veteran      demand,
matched with available               and projected            resources.         VA's projec-
tion of demand, based on historical                         population        data,    is not
adequate       to support       its planned           multimillion        dollar     invest-
ment.       As VA has indicated,               further      studies      of the population
are planned.           Their planning            for domiciliary          construction         can
proceed      in an orderly          manner if such studies                are timely         and
if they include           analyses       of factors         which might change the
size of the current             population,           such as improved           rehabilita-
tion and restoration              programsp         the availability           of other VA
and Federal         programs      to serve the population,                 or the charac-
teristics        of potentially          eligible       veterans.         Without      such
essential       data and analyses,              VA could ultimately              overbuild
or find      itself     faced with long waiting                  lists    of eligible
veterans       seeking     domiciliary           care.
RECOMMENDATIONS
          ------     TO
THE     ADMINISTRATOR
---------
OF VETERANS AFFAIRS
--e--u__-
     To correct    the domiciliary   program management problems
and improve services    to veterans    in the program, we recommend
that the Administrator    of Veterans    Affairs

                                               34
      --provide     improved     central       office      program management,
          including   coordinating        domiciliary          operations and
         developing     staffing     criteria;
      --require       domiciliaries         to properly    apply the admission
          criteria,     including        considering    alternatives  to domi-
          ciliary     admission       for those who do not need such care;
      --instruct      domiciliaries         to improve the medical        care
          provided    domiciled       veterans,    especially     those with
          psychiatric    problems,         and require    increased    surveil-
          lance of medical         care quality;
      --require   domiciliaries               to periodically         evaluate     the suc-
          cess and adequacy           of    therapeutic       recreation       programs;
      --require      domiciliaries         to (1) identify         those domiciled
          veterans    with potential           for return     to community     living
          and (2) develop         individualized        restoration      goals and
          plans requiring         greater      use of community        and other
          resources:     and
      --implement    a reporting system                to provide   information
          for managers to keep abreast                 of and evaluate     program
         results,
      To improve planning     for new domiciliary       facilities,          we
recommend that the Administrator,      before     proceeding         further
with VA's long-range    construction   plans,     require       that
      --consideration          be given to the results    of the study
         currently      underway to determine      the extent   to which
         existing     facilities      can be modernized,
      --current       domiciliary          demand be better       defined,
      --an adequate         projection  of future   demand for
         domiciliary        care be developed,    and
      --staffing     and operating   guidelines for                 new facilities
          be defined    to assure that they receive                  the required
          services   from nearby VA hospitals.
VA
--_I- COMMENTS AND
OUR
--- EVALUATION
        In commenting  on our draft  report    (see app. IV), VA
generally    concurred  with most of our recommendations      and in-
dicated    a number of corrective   actions   initiated  or planned.
VA's comments and our evaluations        are summarized  below.


                                             35
Program      management
        VA said placement          of the domiciliary            program in the
Office     of Assistant        Chief Medical        Director       for Extended Care
provides     for program and operational                 direction      and coordina-
tion at the highest            departmental       level.        VA explained     that
revisions      are being made to its 1970 domiciliary                     program
guide and that a Domiciliary                 Program Coordinator          has been
appointed.        The Coordinator,           with the assistance          from a newly
appointed      Domiciliary        Program Committee,            has been designated
to develop      a comprehensive          plan for the domiciliary             program
and to establish          staffing      criteria     for domiciliaries.            The
Coordinator       is currently        reviewing      the program at various
domiciliary       locations       and plans future           regularly    scheduled
visits.
        VA stated    also that a three-part             educational       program is
being developed         to (1) upgrade the competency               of current
Chiefs     of Domiciliary       Operations,       (2) educate both adminis-
trative      and professional      domiciliary         staffs     on various     as-
pects of aging,         and (3) train       potential       Chiefs    of Domiciliary
Operations.       VA explained       that the Office          of Extended Care
will    also participate        in the Health         Service     Review Organiza-
tion's     September      1977 conference       on the impact of environment
on people      in institutions.
     We believe  these plans and actions  should have a posi-
tive impact on the overall   management and coordination of
the domiciliary  program.
Admission        criteria
        VA agreed that admission                    criteria      should be properly
applied,        but it disagreed             that more emphasis needed to be
placed on consideration                   of alternatives           to domiciliary            ad-
mission.         VA explained           that the comprehensive               domiciliary
plan being developed                will     stress       improved assessment             of
veterans        after     admission         and will       emphasize      their      early
return      to community          living.         The agency said that,               of the
three groups of domiciled                    veterans,        consideration          of alter-
natives       to their       admission         or retention        applies       only to the
first     two--(l)        veterans        in need of care for a fairly                    brief
period     of time as a transition                    from a hospital           or nursing
home care unit back to the community                           and (2) those in need
of a longer          period     of preparation             to achieve       stability         from
a health        care or economic standpoint.                      VA does not believe
that admission            or retention          alternatives          could be applied
to a third         group of domiciled              veterans--those            for whom the
domiciliary          becomes a permanent                home because of economic
or other factors.


                                                 36
        VA said that we may have misinterpreted                    the role of
domiciliaries         and viewed them as primary           diagnostic         facili-
ties.       VA pointed      out that many domiciliary            applicants         are
referred      from hospitals       or nursing     homes or apply for direct
domiciliary        admission     on their    own volition        after    leaving
another      domiciliary       and, therefore,     have already         undergone
initial      evaluations       and been determined        eligible      for domi-
ciliary      care.      VA said planned      improvements        in its manage-
ment reporting          system would provide       more accurate          identifica-
tion of these applicants             as well as the recidivism              rate,
which is also presently             an unknown factor.
         VA acknowledged        that the availability      of alternatives
to admission          must be considered,      but in the absence of
convincing         data indicating      the need for such an approach,
it did not forsee           using such alternatives       as a way to avoid
providing       domiciliary       care.    VA said its policy     states      that
domiciliary         care may be provided,        within the limits      of VA
facilities,          to any veteran     who meets the eligibility         cri-
teria       and its position       is that a veteran    who meets the eli-
gibility       criteria     is entitled     to such care.
         We believe          VA's position          on properly     applying         the domi-
ciliary        admission        criteria       and its planned         actions       to em-
phasize        the early        return      of veterans       to community        living
have merit.            However,        in our view, VA's position                on not
considering          alternatives           to domiciliary        admission        is in-
consistent          with its emphasis on the early                   return      of veterans
to community           living       and has resulted          in the unwarranted              in-
stitutionalization                of some veterans.             VA's program guidance
issued       in 1970 requires             that each applicant            for domiciliary
care be made aware of available                        community     alternatives           to
admission,          and a community            care (foster       home) program has
been available             within      VA for over 25 years.               A recent       4-year
VA study demonstrated                  the usefulness         and effectiveness             of
foster      home care for psychiatric                   patients      (the predominant
diagnosis         among domiciled             veterans)      as an alternative            to
institutionalization.                    Our review      of reported        information
on placements             to such facilities            by domiciliaries           showed
only 33 foster              home placements          from 7 of the 18 domiciliaries
during       fiscal       years 1975-76.            (Five domiciliaries            reported
no placements             in either       year;     data was not readily             available
for the other             six domiciliaries.)
       VA's position       on considering     alternatives   to domiciliary
admission     is not only contrary        to the guidance    it issued      in
1970, but more importantly,            it is not, in our opinion,       in the
best interest      of those veterans        who are suitable    for more
desirable    alternatives.        Therefore,      we believe VA should


                                               37
reexamine      its position       on considering     alternatives         to
domiciliary       admission     to insure      that veterans      suitable   for
more desirable       alternatives        are not subjected        to the environ-
ment of dependency          and institutionalization           which have been
characteristic       of VA domiciliaries.
Medical
---          care
         VA stated        that the problems         with medical      and psychiatric
care,     administering          psychotherapeutic         drugs,    and providing
more specialized             care for some veterans           are well recognized
within      VA and that program reviews,                now underway,      will    assess
these operations             and the quality        of care given domiciled
veterans.          Also,     the Office      of Extended Care, VA said,            is
cooperating         with other health          care review team visits           to the
domiciliaries           which have a similar           purpose.      VA stated     that
other actions           taken and planned         to improve medical         care are
 (1) discussions            with the Pharmacy Service             and the Mental
Health      and Behavioral          Sciences    Service     in VA's central        office
regarding       the monitoring          of medications        and (2) issuance         of
staffing       criteria        to impact on the quality            of care in all
domiciliaries.              We believe     these are steps in the right
direction       and should         improve the quality          of care provided
domiciled       veterans.
Recreation
---                 programs
       VA disagreed        with our recommendation           that the success
and adequacy of therapeutic            recreation       programs be periodi-
cally      evaluated,    with the focus on avoiding             excessive      idle
time.       VA said a wide variety         of recreational         activities       are
available,        but freedom of choice        is granted       in the amount
or degree of participation.              VA pointed      out that factors,
such as the age and health           of some domiciliary            members, the
availability         of other therapeutic        programs,      and the veterans'
personal       wishes are involved       in determining         the activities.
VA said it did not feel it was desirable                   to mandate activity
or organize        the entire   day of domiciled         veterans.
       We recognize      that other    factors     need to be considered,
and we acknowledge         VA's concern     that activities         not be man-
dated and the veterans'         entire    day not be organized.             How-
ever,   we believe      VA should address       the therapeutic         aspect
of recreational       programs and the programs'            effectiveness       in
meeting    the individual      needs of veterans.           Concern in this
area has also been expressed           in the recent        National      Academy




                                          38
of Sciences        report     to the Congress,         l/ which stated    that there
was little        or no therapeutic       value aFtributed        to the recrea-                   1
tional      services     offered     by domiciliaries.         The report    stated
also that domiciliary             staffs  are too small to work individ-
ually     with veterans         or with small groups to encourage            greater
participation         in group life      or assist        them in taking    advantage
of the social         and recreational       activities.
Community       restoration
        In addition        to VA's plans to stress                improved      assessment
of veterans       after      admission       and emphasizing           a return     to com-
munity    living      at the earliest            possible      time, VA stated          that
one facet       of the comprehensive               domiciliary       plan being devel-
oped deals with identifying                  and restoring         veterans      to commun-
ity living       and the development               of individualized          restoration
goals and plans with more extensive                        use of community         and other
resources.        VA explained          that this area will             be emphasized
in forthcoming          administrative           and educational         conferences         as
well as in program visits                 to the domiciliaries.               Also,     the
revised     domiciliary         manual and future             Extended Care Letters
to domiciliary          chiefs     will     contain     directives       emphasizing         the
area.     We believe         the actions         taken and planned          by VA will
improve      the domiciliaries'             efforts      to identify       and restore
to community        living      those veterans          having such potential.
Management       reporting       system
         VA agreed with our recommendation                     to implement         a manage-
ment reporting         system to provide           information         for managers to
keep abreast        of and evaluate         program results.               VA stated        that
a management reporting             system would be developed                 which would
identify,      on a quarterly         basis,     the number and type of admin-
istrative,      direct     care, and support             staff    assigned        to domi-
ciliaries      and would weigh that information                    against       staffing
standards      now being developed.              While we believe             this     infor-
mation     is needed as part of an effective                     management reporting
system,      we also believe        additional         information,         reflecting
the results       of program operations              as compared to established
standards,      will    be necessary         for managers to adequately                   assess
the domiciliaries'          effectiveness          in achieving          the program's
objectives      and goals.

L/"Health   Care for American   Veterans,"    a report  of the Commit-
   tee on Health-Care  Resources    in the Veterans    Administration,
   Assembly of Life Sciences,    National    Research Council,      Na-
   tional  Academy of Sciences,    submitted   to the Congress on
   June 3, 1977.


                                             39
Construction         plans
        VA disagreed           with our recommendation              that it not proceed
with long-range             construction        plans until        (1) information            is
developed        on domiciliary           demand and the extent             to which
existing       facilities         could be upgraded          and (2) staffing             and
operating       guidelines           for the new facilities            are defined.             VA
stated     that      it now has available            sufficient        information          to
justify      its initial          phase (short-range           plan)     of new domi-
ciliary      construction.              VA said that,       during     this    initial
phase, information              will     be refined     to determine          specific
needs and the extent                of additional       new construction             for the
long-range        plan.        VA said also that there is no question                         re-
garding      the need for replacement                of the domiciliary              struc-
tures nor is there any chance that VA's current                              replacement
program will           exceed demand for domiciliary                  care over the next
15 to 20 years.               Based on the rate of domiciliary                   construction
funding      for fiscal         years 1977-78,        VA stated,         it would take
until    fiscal        year 1995 to completely              upgrade the domicili-
aries,     thereby        allowing       adequate    opportunity         to adjust       plans
if needs change.
          We believe       that VA's revised          plans and provisions           for
flexibility         in its construction            program are a step toward
proper      long-range        construction       planning.       However, we believe
that before        long-range        plans are set, further            consideration
should be given to (1) the potential                       for reduction      in demand
through       improved       procedures      for restoring       domiciled      veterans
to community          living     and (2) the potential           increased     demand
due to the change in eligibility                    criteria     for domiciliary
admission       which resulted           from the October        1976 enactment          of
Public      Law 94-581.
RECOMMENDATION TO
------emI_
THE
----- CONGRESS
        Because domiciliary        care has been provided              free,   full
retention      of income from work assignments                and most other
sources may be both an incentive               for veterans         to remain
domiciled      and a block to their         timely     rehabilitation        and
restoration        to the community.        Therefore,       we recommend
that the Congress explore           with VA the feasibility               of pro-
viding     greater    incentives    for veterans         having restoration
potential      to return      to community     living,      such as by VA's
retention      of a portion      of domiciled       veterans'       income.




                                              40
                                                                               VA DOMICILIARIES--GENERAL                      STATISTICS
                                                                                     FOR'FISCAL         YEARS-1975           AND 1976


                                                                               Fiscal       year    1975                                                      Fiscal       year   1976
                                                             Total                      Average             Average     daily                    Total                 Averaqe            Average      daily
                  Domiciliary                          operating     beds                daily             cost per veteran                operating   beds             daily            cost per      veteran
                    (note     a)                       as of-6j30j75                    census                  (note-b)                   as of 6/30/76               census                (note     b)

    Bath,     New York                                          660                          633                    $17.85                       660                      629                 $11.24
    Bay Pines,          Florida                                 322                          305                     19.30                       332                       305                 21.96
    Biloxi,       Mississippi                                   681                          537                     14.98                       539                       523                 17.58
    Bonham;       Texas                                         230                          228                     14.55                       230                       225                 17.27
    Dayton,       Ohio                                      c/840                     c/789                       +5.96                          840                       784                 19.40
    Dublin,       Georgia                                       407                          401                     14.73                       407                       399                 18.85
    Hampton,        Virginia                                    750                          663                     14.27                       750                       657                 16.10
    Hot Springs,           South Dakota                         511                          449                     14.91                       511                       418                 18.19
    Leavenworth,           Kansas                              925                           719                     14.78                       925                       711                 16.32
E   Los Angeles,           California                          550                          438                      20.08                       550                       425                 23.57
    Martinsburg,           west Virginia                       550                          533                      13.81                       550                       528                 15.95
    Mountain        Home, Tennessee                            935                          898                      13.14                        917                      879                 15.47
    Prescott,        Arizona                                   232                          208                      16.11                       232                       205                 15.55
    Temple,       Texas                                        455                          403                      12.85                        549                      414                 13.84
    Tucson,       Arizona                                                                     47                     26.67                          72                       46                27.36
    Vancouver,         Washington                                  Gl                         49                     25.01                          80                       48                32.50
    White     City,      Oregon                             1,165                       1,146                        13.37                    1,165                    1,140                   15.35
    Wood, Wisconsin                                             853                         734                      15.81                        853                      755                 19.26

          Total                                                                    --c/9,180                    c/$15.82                     10,152                                           $18.61
                                                                                                                     -
    a/All    domiciliaries          are near VA general  hospitals                           except   for (1)      Los Angeles    which is near a VA
       psychiatric         hospital    and (2) White City which                         is    an independent        facility   not near any type
       of VA hospital.
    b/Figures         include      costs   allocated        from        adjacent      VA facilities.
    c/Figures   for fiscal   year 1975                  do not reflect   an additional                    155 beds           used    for domiciliary   purposes
       but not reported    as domiciliary                  beds at Dayton,   Ohio.                     The average           daily     census for these beds
       was 140.
  APPENDIX II                                                                          APPENDIX II




                               CHARACTERISTICS OF DOMICILED VETERANS l/
                                                         TABLE I
                                                 vETERAN'SGrAND
                                                 --          ----      SEX

                                          --II      Number of veterans --a
                 We
                 --                       Male           Female          Total             Percent
                                                                                           --
   Under               25
   25 -               34                     8                                  8               2
   35 -               44                    19                2                21               6
   45 -               54                    96                7              103               27
   55 -               64                  122               10               132               35
   65 -               74                    58                8                66              17
   75 -               84                    41                1                42              11
   Over               84                  a- 7              a-1              -- 8               2
                  Total                    351
                                          I_                z29              380             100
                                                                             D               E


                                                      TABLE II
                                                      --a--
                                        SOURCE
                                        ---a---- OF DOMICILIARY       ADMISSIONS
                                                                      ----
                            -Admitted      from                   Number of veterans
                                                                  --                       Percent
  VA general     hospital                                                149                   39
  VA psychiatric       hospital                                            74                  19
  Other hospitals                                                            5
  Community                                                              109                   2;
  Another   VA or State domiciliary                                        39                  10
  Other                                                                  --- 4                  1
                  Total                                                  -380              a/100
                                                                                           -m
a/Does                 not     total      due to rounding.
--------v---v-




 L/Based on a random sample of veterans        at the five domicil-
    iaries   included in this   review.    (See p. 6.)     Data may not
    be representative   of veterans     in all VA domiciliaries.




                                                          42
     % OF VETERANS                                             TABLE Ill- REASONS
                                                                                FORADYISSION~(note
                                                                                                a)
     80


     70



     60



     50



     40
I+
w

     30


     20



     10



      0
     REASON:            PHYSICAL                INSUFFICIENT                 REJECTED    PHYSICAL    OTHER   NO REASON
                                                INCOME            KZDToA     BY FAMILY   AND                 PROVIDED
                        KO~S!+tL                                  LIVE                   FINANCIAL
     l?/   BASED   ON    DOMICtLlARY   PILES.
APPENDIX II                                                                                               APPENDIX II
                                                                TABLB IV
                    VETERANS’           PRIMARY AND-SECONDARY MEDICAL                  DIAGNOSES          fnote         a)

                                                      Primary                          Secondary
                                                    diagnosis             Percent      diagnosis             Percent

Neuropsychiatric:
     Schizophrenia
     Anxiety      neurosis
     Chronic      brain    syndrome
     Manic depressive
     Other
              Subtotal                                   145                 38.2            40                 10.5

Alcoholism                                                  47               12.4            29                   7.6

Circulatory:
      Generalized
         arteriosclerosis                                                     4.5            21
      Hypertension                                                            1.3              5
      Varicose      veins                                                     1.8            10
      Heart disease                                                           4.7            11
      Other                                                                   0.8            15
                                                                                             -
              Subtotal                                                   --b/13.2            62            --b/16:3
Respiratory:
      Emphysema                                             10                2.6                                 3.7
      Bronchitis                                              6               1.6                                 1.8
      Tuberculosis                                            2               0.5                                 1.6
      Other                                                 - 2               0;5                                 1;3

              Subtotal                                      20            b/5.3
                                                                          --                 32                   8.4

Other:
      Obesity                                                 8               2.1            12                   3.2
      Hernia                                                  2               0 :5             7                  1.8
      Diabetes                                              11                2.9            10                   2.6
      Arthritis/rheumatism                                  12                3.2            17                   4.5
      Injured       limb                                      2               0.5              4                  1.1
     Nervous        system
         disorder                                           10                                 5                  1.3
      Renal failure                                           1                               1                   0.3
     Venereal         disease                                                                 2                   0.5
      Post surgical           care                          14                                9                   2.4
      Miscellaneous                                         56                               81                 21.3

              Subtotal                                   llii                            148               b/39.8
                                                                                                           a-
Diagnosis    unknown                                            2                              2                  0.5
   (note c)
No secondary     diagnosis                                                                   67                 17.6

                      Total                              388        b/100.0
                                                                   --                    g                b/100.0
                                                                                                          -I__
                                                         c
a/Third,       fourth,           and successive          diagnoses,       applicable         to    some    veter-
   ans,     were not           tabulated.

b/Does       not    total       due     to   rounding.

c/Records          not      available        for   two   veterans.


                                                                    44
      NO, OF VETERANS             TABLE V - LENGTHOF MILITARYSERVICE


      160



      140                        136



      TM



      100
rp
u-l
      80



      60



      40



      20



       0                                                7 - 10 YRS.    11-20YRS.   OVER 20 YRS.
                   % YEAR     H - 2 YRS.   3 - 6 YRS.
      LENGTH OF    _.. --__
                   OR  LESS
      SERVICE
APPENDIX II                                                       APPENDIX II
                                      TABLE VI
                          ESTIMATED
                          ---       MONTHLY INCOME (note    a)
     Amount                       Number of veterans                  Percent
Nike                                        29                            8
$1 - $50                                    50                           13
$51 - $100                                  38                           10
$101 - $265                              160                             42
$266 - $500                                 79                           21
Over $500                                -- 18                         -- 5
       Subtotal                          --374                        b/98
                                                                      --
Undeterminable                           a- 6
               Total                     --380                     x100
a/Data excludes    nominal wages for work assignments           in domi-
- ciliaries.     We attempted   to obtain     income data from several
   sources   for each veteran.    Inconsistencies       existed   between
   sources   for many veterans;   therefore,      we used the amount
   from the source which seemed to be most reliable.
b/    Does not         total   due to rounding.
                                       TABLE VII
                          ESTIMATED TIErVETERANS
                                          -------     HAVE BEEN
                        Di?j%NDENT
                        -----      ON  DOMICILIARIEs(note-a)
                                                  ---
                                  Number of
                                  ---            veterans             Percent
                                                                      --
Less than 3 months                          13                            3
3-  6 months                                23                            6
7-  12 months                               22                            6
l-  2 years                                 69                           18
3- 5 years                                  74                           19
6-  10 years                             103                             27
11 - 20 years                               59                           16
Over 20 years                            -- 17                         -- 4
       Total                             --380                       b/100
                                                                     --
a/ Records were not adequate          to compute exact periods         veterans
- had resided      in domiciliaries.        Therefore,    our calculations
   are from records        showing the first     day the veteran       entered
   any domiciliary       to audit date of respective        domiciliaries.
   Thirty-five     percent     of the veterans     were discharged       and
   .readmitted    during    this period.
b/    Does not         total   due to rounding.


                                            46
APPENDIX   III   APPENDIX   III
APPENDIX       IV                                                                    APPENDIX      IV


                                 VETERANS         ADMtNtSTRATtON
                              OFFICE OF THE ADMINISTRATOR   OF VETERANS   AFFAIRS
                                     WASHINGTON, D.C. 20420
                                        JUNE 3 0 1977


     .
         Mr. Gregory J. Ahart
         Director,  Human Resources Division
         U. S. General Accounting Office
         441 G Street, N.W.
         Washington, DC 20548

         Dear Mr. Ahart:

                   We are forwarding our comments on the General Accounting
         Office (GAO) draft report,  "Operational   and Planning Improvements
         Needed in the Veterans Administration    (VA) Domiciliary Program,"
         dated March 2, 1977.

                      This report reviews the VA's domiciliary    program in light
         of its stated mission and stresses the need for improvements in pro-
         gram management and planning for future demands. As indicated         in
         the report,    the VA has, in various internal   studies and reporte,
         recognized certain deficiencies      and the need for program changes.
         Accordingly,     a comprehensive plan is being developed and initial
         steps have been taken to strengthen the program.
                    We will comment on the report             recommendations       in the order
         of occurrence in chapter four:

                    RECOMMENDATION:

                    1.    To correct the domiciliary program management
                    problems and improve services to veterans in the
                    program, we recommend that the Administrator

                       a--provide     improved central office management
                           and direction     for the program to include co-
                           ordination    of domiciliary      operations and de-
                           velopment of staffing       criteria;

                      The establishment  of an Office of Assistant  Chief Medical
         Director    for Extended Care to be responsible  for all aspects of the
         Domiciliary     program and all related programs has placed this program
         at the highest departmental     level for program and operational  direction
         and coordination.

                      The domiciliary   manual, M2, Part XIX, is being revised and
         will be completed in Fiscal Year 1978. In October 1976, a Domiciliary
         Program Coordinator$was      appoifited and has responsibility      for the devel-
         opment of the comprehensive plan announced as a Department of Medicine
         and Surgery Objective in the Chief Medical Director's          letter,
         IL-10-76-27,    dated May 26, 1976. The Domiciliary       Program Committee,

                                                   48
APPENDIX IV                                                                 APPENDIX IV

   Mr. Gregory J. Ahart
   Director,  Human Resources Division
   U. S. General Accounting Office


   with members from both professional    and administrative     services,   was
   appointed to assist the Program Coordinator      in developing the compre-
   hensive plan and establish    staffing criteria.     The Coordinator    has
   reviewed the Domiciliary   Program at four locations      and two more re-
   views are planned in the immediate future.       Visits to the other ten
   are scheduled for completion by January 1978. Subsequent visits
   will be regularly  scheduled.

                A three-part  educational   program is being developed in
    conjunction   with the Office of Academic Affairs.        One facet deals with
    upgrading the competency of current Chiefs of Domiciliary          Operations;
    the second, for both administrative      and professional    staff members, is
    concerned with various aspects of aging; the third providea training
    for potential    Chiefs of Domiciliary   Operations.    The first   conference
    in phase one of this program, scheduled for September 1977, is to be
    followed by advanced training      six months later.

                 Following a January 1977 administrative         conference,    the
    Chiefs of Domiciliary      Operations attended a three-day educational
    conference sponsored by Mental Health and Behavioral Sciences Service
    on care of the chronic psychiatric        patient --the first     time they have
    participated     in a professional   meeting.     In addition,    the Office of
    Extended Care, which encompasses the Domiciliary            Program, will partici-
    pate in the Health Service Review Organization          September 1977 confer-
    ence on the impact of environment on people in institutions.

                l.b--require     domiciliaries     to properly apply the
                       admission criteria      including consideration
                       of available community alternatives       to domi-
                       ciliary   admission for those who do not need
                        such care;

                 While we agree that admission criteria           should be properly
    applied, we do not agree that more emphasis needs to be placed on con-
    sideration    of alternatives     to domiciliary    admission.      However, the plan
    being developed will stress improved assessment after admission and
    emphasize a return to community living at the eazt                   possible time.
    It must be kept in mind that of the three groups of veterans domiciled,
    the consideration      of alternatives      to admission/retention     only applies
    to the first      two:  (1) veterans in need of care for a fairly           brief
    period of time as a transition         from a hospital     or nursing home care
    unit back to the community, and (2) those in need of a longer period of
    preparation     to achieve stability      from a health care or economic stand-
    point; and not (3) those for whom the domiciliary              becomes a permanent
    home because of economic or other factors.




                                           49
APPENDIX IV                                                                                    APPENDIX IV
   Mr. Gregory J. Ahart
   Director,  Human Resources Division
   U. S. General Accounting   Office


                While the availability         of alternatives       to admission       must be con-
   sidered,    the example cited        in the report       section,   “Rehabilitation       Resources
   Not Considered      on Admission,”      (page 181, does not support             this  contention.
   It concerns     the admission      of an applicant        at White City,      Oregon, and does
   not take into account        the fact that the White City area has no comparable
   facilities,     except   for vocational      rehabilitation.         These have no provision
   for residential      care.

                   Certain      statements        in the report          indicate      that GAO may have mis-
   interpreted        the role of domiciliaries                  and sees them as primary              diagnostic
   facilities.          Our experience          shows that many applicants                  are referrals       from
   hospitals       (inpatient        and outpatient)          or nursing         homes, or are veterans
   who of their         own volition         check out of a domiciliary                  and apply for direct
   admission       to another        domiciliary        of their       preference,        thus circumventing
   the waiting        list.      These individuals            have already          undergone initial          eval-
   uation      and been determined            eligible       for domiciliary           care.     Additionally,
   in the group now categorized                   as “direct         admissions”       and presumed in need
   of initial        evaluation        for eligibility,            the recidivism         rate is presently
   an unknown factor.              We believe        the “direct         admissions”        group may contain
   a relatively         large number whose personal                   situation,       both social       and physi-
   cal,      is well documented           due to previous            periods     of residence       in the same
   domiciliary        and for whom extensive               initial       evaluation       is not required.
   Planned      improvements         in the management reporting                   system will     permit      more
   accurate      identification           of these applicants.

                 It would be premature            to consider      adoption     of extensive      pre-
   admissions      screening      and referral       programs until       convincing      data indicates
   the need for such an approach.                 Our policy    states      that domiciliary       care
   may be provided,        within      the limits      of VA facilities,        to any veteran      who
   meets the eligibility           criteria.        The VA does not foresee          alternatives       to
   admission     as a means of avoiding             provision   of domiciliary        care.      On the
   contrary,     it is our position          that a veteran       who meets the eligibility             cri-
   teria     is entitled     to such care.

                   l.c--instruct       domiciliaries          to improve the medical
                            care provided      domiciled        veterans,  especially
                            those with psychiatric            problems,   and require
                            increased   surveillance          of medical   care quality;

                  The situation        described     in the report       concerning      patient/members
   not receiving        timely     physical     examinations,      limited    psychiatric        care, the
   deficiencies       in administering          psychotherapeutic        drugs,   and some veterans’
   need for more specialized              care,    is already     well recognized       by the VA.        The
   program reviews         currently      underway will       assess the operations           and the
   quality      of care.       Also,   the Office      of Extended      Care is cooperating          with
   Health     Care Review Service           in the Systematic        External    Review Program visits
   which serve a similar             purpose.     Discussions      have been held with Pharmacy




                                                       50
APPENDIX IV                                                               APPENDIX IV
   Mr. Gregory J. Ahart
   Director,  Human Resources Division
   U. S. General Accounting Office


   and Mental Health and Behavioral Sciences Services regarding monitoring
   medications     in order to identify      and eliminate  instances of polypharmacy.
   Finally,    issuance of staffing     criteria    will impact on the quality of care
   provided in all domiciliaries.

               l.d--require      domiciliaries  to periodically eval-
                      uate the success and adequacy of therapeutic
                      recreation    programs with a thrust of avoiding
                      excessive idle time;

                  We do not concur with the concern expressed that members have
   too much idle time.          There is a wide variety   of recreational   activities
   available,      but freedom of choice is granted in the amount or degree of
   participation.         Numerous factors are involved in determining      activities,
   including      the age and health of some domiciliary      members, the avail-
   ability     of other programs such as incentive,       occupational,   corrective    or
   educational       therapies,   and the domiciliary   members' personal wishes.
   We do not feel it is desirable         to mandate activity    or organize the en-
   tire day of patient/members.

               l.e--require    domiciliaries   to (1) identify    those
                      domiciled veterans with potential       for return
                      to community living and (2) develop individ-
                      ualized restoration    goals and plans with more
                      extens ve use of community and other resources:

               This is one facet of the comprehensive domiciliary   program being
    developed and will be emphasized in forthcoming administrative     and educa-
    tional conferences as well as in program visits.    Written directives   will
    be in the revised Dom ciliary  Manual and in future Extended Care letters.
    Our comments on Recommendation 1.b are also applicable.

               l.f--implement       a management reporting system to
                       provide   information  for managers to keep
                       abreast   of and evaluate program results.

                 We concur; a management reporting  system which will identify--
    on a quarterly    basis-- the number and type of administrative,   direct care
    and support staff assigned to the domiciliaries      will be developed.    This
    information,    weighed against standards now being developed, will permit
    us to evaluate program results.

               RECOMMENDATION

               2.       To provide improved planning for new domiciliary
               facilities,      we recommend that the Administrator,  be
               fore proceeding further with VA's long-range con-
               struction     plans, require that




                                          51
APPENDIX IV                                                                                 APPENDIX IV
   Mr. Gregory J. Ahart
   Director,  Human Resources Division
   U. S. General Accounting   Office


                     a--consideration     be given to the result  of the
                         study currently    underway to determine   the extent
                         to which existing     facilities can be modernized,

                     b--current      domiciliary        demand be better         defined,

                     c--an adequate        projection  of future   demand for
                         domiciliary       care be developed,    and

                     d--staffing      and operating     guidelines      for the new
                          facilities    be defined    to assure that they receive
                          the required    services    from adjacent        VA hospitals
                          for successful     accomplishment        of the domiciliary
                          objectives.

                  We do not concur with the recommendation                 that the VA not proceed
   further     with long range construction            plans for new domiciliary          facilities
   nor with the conclusion            that the four requirements           have not been met.
   There are identified         critical       needs to be met at this         time.    As was point-
   ed out during        the FY 76 appropriations          hearings,    VA domiciliaries         presently
   represent       substandard   circumstances       of living      for all but 1.8 percent          of
   current     residents.      Advances have been made in providing                more privacy      for
   members and in improving             the environment      through    redecorating     some’ existing
   facilities,       but extensive        renovation   would be costly        and still   may not be
   adequate      to serve the mission.

                   Information       is available        now on (a) the extent             to which existing
   facilities        can be modernized,          (b) current        domiciliary        demands, (c) future
   demand for domiciliary              care,    and (d) staffing          and operating        guidelines.
   This information          is sufficient        to justify         the initial       phase (short       range
   plan) of new domiciliary               construction.          During     this phase, information             will
   be refined        to determine       specific      needs and for the extent               of additional       new
   construction          for the long range plan.               Our surveys indicate           that buildings
   now housing         about 950 domiciliary            patients      can be effectively           modernized
   over the next seven years to meet life                       safety,     privacy     and accessibility
   for the handicapped            standards.        In addition,         more then 8900 beds are now
   contained       in structures        which do not meet all such standards                     and are not
   susceptable         to attaining       such standards         without      large expenditures          approach-
   ing or exceeding          the cost of replacement.                 All domiciliary         buildings      are
   more than 25 years old and over one half                        of these are more than 50 years
   old.       There is no question           regarding       the need for replacement              of these
   structures        nor is there any chance that our current                       replacement       program
   will     exceed demand for domiciliary                care over the next 15 to 20 years.




                                                   52
APPENDIX IV                                                                APPENDIX IV
   Mr. Gregory J. Ahart
   Director,  Human Resources Division
   U. S. General Accounting Office


                The FY 77 appropriation included design funds only for VA
   Centers (VAC) Dayton, Hampton and Martinsburg,       and design and construction
   funds for VACs Wood and Bay Pines.      The FY 78 budget request includes con-
   struction    funding for VACs Dayton and Martinsburg    and design funds for VAC
   Bath.     At this rate of funding for construction    of only one 200-bed unit
   per year, it will take until FY 95 to completely upgrade the domiciliaries.
   This schedule allows adequate opportunity      to adjust plans if needs change.

                We would like to point out that the statement concerning dom-
   iciliary    care availability   in paragraph two of the report introduction
   is incorrect.      The requirement for service in any war or for peacetime
   service after January 31, 1955 was eliminated             by PL 94-581.    Title 38
   U.S. Code Sec. 610 (b)(2) states:             "The Administrator,   within the limits
   of Veterans' Administration       facilities,      may furnish domiciliary      care to--
    . ..a veteran who is in need of domiciliary          care if such veteran is unable
   to defray,the     expenses of necessary domiciliary          care."  This change will
   expand, to an undetermined degree, the number of veterans entitled                  to
   domiciliary     care.

               We appreciate the opportunity        to comment on this     extensive
   review   of the VA Domiciliary Program.

                                             Sincerely,




                                             Administrator




                                            53
APPENDIX V                                                  APPENDIX V




                     PRINCIPAL   VA OFFICIALS
                                       ---
                RESPONSIBLE ----
                            FOR ADMINISTERING
             ACTIVITIES
             --           DISCUSSED IN THIS REPORT

                                         --      Tenure   of office
                                                 From                 To

ADMINISTRATOR OF VETERANS AFFAIRS:
    J. M. Cleland                        Mar.      1977     Present
    H. D. Grubb (acting)                 Feb.      1977     Mar.       1977
    R. L. Roudebush                      Oct.      1974     Feb.       1977
    R. L. Roudebush (acting)             Sept.     1974     Oct.       1974
    D. E. Johnson                        June      1969     Sept.      1974
DEPUTY ADMINISTRATOR:
    R. H. Wilson                         Mar.      1977     Present
    Vacant                               Jan.      1977     Mar.       1977
    0. W. Vaughn                         Nov.      1974     Jan.       1977
    Vacant                               Oct.      1974     Nov.       1974
    R. L. Roudebush                      Jan.      1974     Oct.       1974
    F. B. Rhodes                         May       1969     Jan.       1974
CHIEF MEDICAL DIRECTOR:
    J. D. Chase, M.D.                    Apr.      1974     Present
    M. J. Musser,  M.D.                  Jan.      1970     Apr.    1974
    H. M. Engle,  M.D.                   Jan.      1966     Jan.    1970




40115


                                 54
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