Dignity Denied: The Case for Reform at State Veterans Homes

1[House Hearing, 119 Congress]2[From the U.S. Government Publishing Office]34                  DIGNITY DENIED: THE CASE FOR REFORM56                        AT STATE VETERANS HOMES78=======================================================================910                                HEARING1112                               before the1314                         SUBCOMMITTEE ON HEALTH1516                                 of the1718                     COMMITTEE ON VETERANS' AFFAIRS1920                     U.S. HOUSE OF REPRESENTATIVES2122                    ONE HUNDRED NINETEENTH CONGRESS2324                             FIRST SESSION2526                               __________2728                        TUESDAY, APRIL 29, 20252930                               __________3132                           Serial No. 119-173334                               __________3536       Printed for the use of the Committee on Veterans' Affairs37      [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]3839                    Available via http://govinfo.gov4041                  U.S. GOVERNMENT PUBLISHING OFFICE4261-150                     WASHINGTON : 20254344                     COMMITTEE ON VETERANS' AFFAIRS4546                     MIKE BOST, Illinois, Chairman4748AUMUA AMATA COLEMAN RADEWAGEN,       MARK TAKANO, California, Ranking49    American Samoa, Vice-Chairwoman      Member50JACK BERGMAN, Michigan               JULIA BROWNLEY, California51NANCY MACE, South Carolina           CHRIS PAPPAS, New Hampshire52MARIANNETTE MILLER-MEEKS, Iowa       SHEILA CHERFILUS-MCCORMICK,53GREGORY F. MURPHY, North Carolina        Florida54DERRICK VAN ORDEN, Wisconsin         MORGAN MCGARVEY, Kentucky55MORGAN LUTTRELL, Texas               DELIA RAMIREZ, Illinois56JUAN CISCOMANI, Arizona              NIKKI BUDZINSKI, Illinois57KEITH SELF, Texas                    TIMOTHY M. KENNEDY, New York58JEN KIGGANS, Virginia                MAXINE DEXTER, Oregon59ABE HAMADEH, Arizona                 HERB CONAWAY, New Jersey60KIMBERLYN KING-HINDS, Northern       KELLY MORRISON, Minnesota61    Mariana Islands62TOM BARRETT, Michigan6364                       Jon Clark, Staff Director65                  Matt Reel, Democratic Staff Director6667                         SUBCOMMITTEE ON HEALTH6869               MARIANNETTE MILLER-MEEKS, Iowa, Chairwoman7071JACK BERGMAN, Michigan               JULIA BROWNLEY, California,72GREGORY F. MURPHY, North Carolina        Ranking Member73DERRICK VAN ORDEN, Wisconsin         SHEILA CHERFILUS-MCCORMICK,74JEN KIGGANS, Virginia                    Florida75ABE HAMADEH, Arizona                 MAXINE DEXTER, Oregon76KIMBERLYN KING-HINDS, Northern       HERB CONAWAY, New Jersey77    Mariana Islands                  KELLY MORRISON, Minnesota7879Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public80hearing records of the Committee on Veterans' Affairs are also81published in electronic form. The printed hearing record remains the82official version. Because electronic submissions are used to prepare83both printed and electronic versions of the hearing record, the process84of converting between various electronic formats may introduce85unintentional errors or omissions. Such occurrences are inherent in the86current publication process and should diminish as the process is87further refined.88                         C  O  N  T  E  N  T  S8990                              ----------9192                        TUESDAY, APRIL 29, 20259394                                                                   Page9596                           OPENING STATEMENTS9798The Honorable Mariannette Miller-Meeks, Chairwoman...............     199The Honorable Julia Brownley, Ranking Member.....................     3100101                               WITNESSES102                                Panel I103104Dr. Scotte Hartronft, M.D., Executive Director, Office of105  Geriatrics & Extended Care, Veterans Health Administration,106  U.S. Department of Veterans Affairs............................     4107108Ms. Sharon Silas, Director, Health Care, U.S. Government109  Accountability Office..........................................     6110111                                Panel II112113Mr. Ed Harries, President, National Association of State Veterans114  Homes..........................................................    16115116The Honorable Charlton J. Meginley, Col. (Ret), USAF, Secretary,117  Louisiana Department of Veterans Affairs.......................    18118119                                APPENDIX120                    Prepared Statements Of Witnesses121122Dr. Scotte Hartronft, M.D. Prepared Statement....................    29123Ms. Sharon Silas Prepared Statement..............................    30124Mr. Ed Harries Prepared Statement................................    45125The Honorable Charlton J. Meginley, Col. (Ret), USAF Prepared126  Statement......................................................    57127128                       Statements For The Record129130Florida Department of Veterans Affairs Prepared Statement........    65131Veterans of Foreign Wars of the United States Prepared Statement.    66132The National Association of State Directors of Veterans Affairs,133  Inc. Prepared Statement........................................    69134The Honorable Sheri Biggs, U.S. House of Representatives, (SC-3)135  Prepared Statement.............................................    72136Questions for the Record Submitted by The Honorable Mariannette137  Miller-Meeks, U.S. House of Representatives, (IA-2)............    75138139                  DIGNITY DENIED: THE CASE FOR REFORM140141                        AT STATE VETERANS HOMES142143                              ----------144145                        TUESDAY, APRIL 29, 2025146147                    Subcommittee on Health,148                    Committee on Veterans' Affairs,149                             U.S. House of Representatives,150                                                    Washington, DC.151    The subcommittee met, pursuant to notice, at 2:17 p.m., in152room 360, Cannon House Office Building, Hon. Mariannette153Miller-Meeks [chairwoman of the subcommittee] presiding.154    Present: Representatives Miller-Meeks, Taylor, Brownley,155Cherfilus-McCormick, Conaway, and Morrison.156    Also present: Representative Taylor.157158   OPENING STATEMENT OF MARIANNETTE MILLER-MEEKS, CHAIRWOMAN159160    Ms. Miller-Meeks. Before we get started, in accordance with161committee rule 5E, I ask unanimous consent that Representative162Dave Taylor from Ohio be permitted to participate in today's163committee hearing. Without objection.164    This oversight hearing of the Subcommittee on Health will165now come to order. I would like to welcome all members and166witnesses to today's hearing. We look forward to a very167productive discussion about care for aging veterans.168    Every veteran deserves independence and dignity with age.169With age however comes challenges. The Baby Boomer generation170is getting to an age where long-term care is increasingly171needed. More and more veterans are entering a period in life172where they are physically and mentally vulnerable or do not173live near family members who can assist.174    The demands on the U.S. Department of Veterans Affairs (VA)175from long-term care will only grow due to the incoming veterans176who served during the Vietnam and cold war eras. For some, they177have trouble advocating for themselves because of their health178needs which can undermine their independence.179    This subcommittee works every day to make sure VA health180care meets veterans where they are. We know older veterans181experience social isolation, or may, chronic pain, mental182health challenges, and the VA healthcare must meet our aging183veterans' needs. Recent incidents show that there is still work184to be done.185    I am particularly troubled by veteran suicide later in186life. We have talked a lot about suicide in our younger187veterans and our veterans who transition out of the service but188not much about veterans who commit suicide late in life. Just 2189weeks ago a 77-year-old veteran tragically committed suicide at190a VA medical campus.191    Sadly, very little research exists about why veterans end192their lives at a time when they should be enjoying the fruits193of all of their labor.194    Through this subcommittee's oversight trips we have heard195that older veterans who commit suicide are an invisible196population. As a 24-year Army veteran and physician, I refuse197to let this issue live in the shadows.198    Health care programs through VA are a major contact point199where the VA can interact with older veterans. Uniquely, State200veterans' homes deal with this population almost exclusively.201They are a key means by which we can support older veterans on202a daily basis.203    State veterans' homes are long-term care facilities for204veterans and often for their spouses. They are state-run but205receives substantial amounts of funding from the VA.206    When VA supports State veterans' homes it is also207supporting a compilation of smaller programs. VA gives funds208for State veterans' homes to support programs like resident209care, domiciliary care, and adult daycare.210    In addition, VA provides grants for facility construction211through a matching program with states. The VA also provides212grants for nursing retention at State veterans' homes. These213programs help veterans flourish later in life.214    Are we sure that the VA is helping State veterans' homes215meet their full potential? This oversight hearing is meant to216answer this question. I know that most homes throughout the217country give the quality of care that veterans in need deserve218but there are notable outliers.219    In 2020, at a State veterans' home in Holyoke,220Massachusetts, over 70 veterans died with COVID-19 during an221outbreak during the pandemic. Many more suffered infections. An222independent investigation revealed that this horrific tragedy223was preventable.224    Additionally, Government Accountability Office (GAO)225reported that the total number of demerits for failing226requirements in the annual VA audit increased from 2019 to2272021.228    The good news is that these are exceptions rather than the229rule, but what can we do to make sure all homes offer the230standard of care veterans deserve? I believe the VA can help231State veterans' homes succeed.232    We know that the VA has money. We give it to them every233year. Again, the VA disburses a substantial amount of funding234to support State veterans' homes through reimbursements and235grants. We must make sure the VA allocates these funds to the236right resources.237    That is why I have introduced a bill to provide veterans238with more access to essential medications. My bill would239reimburse State veterans' homes for medication cost.240    Currently, the VA does not pay State veterans' homes for241high cost medications for severely disabled veterans, yet they242are often revolutionary cancer drugs that can help243significantly lengthen the veteran's life and quality of life.244These medications are covered outside of the facility rather245than through the State veterans' homes.246    I have said it before, I will say it again. It is critical247to expand the network veterans can use to access lifesaving248medications. I also know that construction grants come with249strings attached that may not make sense for the veteran or the250State veterans' home supporting them. I look forward to251discussing this and more with the witnesses before us today.252    Older veterans deserve quality long-term care. We owe it to253them to put them at the forefront of our conversation about254veteran healthcare.255    I now yield to Ranking Member Brownley for any opening256remarks she may have.257258      OPENING STATEMENT OF JULIA BROWNLEY, RANKING MEMBER259260    Ms. Brownley. Thank, you Madam Chair. Overall, an estimated26180 percent of veterans will need long-term services and262supports at some point during their lifetime. The overwhelming263majority of aging adults, including veterans, would prefer to264age in place in their homes rather than nursing homes.265    With the recent enactment of the Elizabeth Dole Act,266Congress bolstered VA's authority to offer home and community-267based services for aging and disabled veterans. We are eager268for VA to implement this law as soon as possible.269    However, even with this expansion of VA's non-institutional270long-term care programs, not every veteran will have enough271support from family members or other caregivers to enable them272to safely age at home. For that reason there will always be a273need for nursing homes.274    State veterans' homes, which are owned and operated by the275states with Federal investments in the form of construction276grants and per diem payments, are the largest provider of277institutional long-term care for veterans. Collectively, they278serve more than 43 percent of the veterans receiving VA-funded279nursing home care on any given day in 2023.280    VA-operated community living centers served about 20281percent and VA purchased care from community nursing homes282through the remaining third of veterans.283    Despite serving the majority of veterans for whom VA284purchases nursing home care, State veteran homes receive only285about 18 percent of VA's total payments for institutional long-286term care. VA's basic per diem for State veteran homes now287covers less than 30 percent of the actual cost of care and as288little as 20 percent in some states with higher costs of289living.290    State veteran homes make up the balance of their costs291through other funding sources including State support, Medicare292and Medicaid, and the veterans themselves who share in the293cost.294    This week and next, 11 other House committees will mark up295budget reconciliation legislation ramming through draconian296cuts to Federal programs that serve the most vulnerable among297us, all to fund tax cuts for the very wealthy.298    The House Energy and Commerce Committee has been instructed299to cut $880 billion over 10 years and nearly all of those cuts300are expected to come from Medicaid, which funds long-term care301for more than 60 percent of nursing home residents.302    With many community nursing homes already teetering on the303brink of financial insolvency, these Republican budget cuts304would put them at greater risk of closures.305    Medicaid also funds many home and community-based services306enabling aging and disabled people, including veterans, to307avoid institutional settings and care. Should these Medicaid308cuts come to pass, veterans will become more reliant on VA and309State veteran homes for long-term services and supports.310    I certainly hope both the administration and the states311will be factoring this into their budget proposals in the312coming years.313    I also must say I am perplexed by the title of today's314hearing. For many veterans the sense of community and315culturally competent care that has historically been provided316by State veteran homes allows them to retain their dignity in317their later years. State veteran homes were established by the318states and are supported by VA as a way to honor our Nation's319promises to veterans through the end of their lives.320    If anything, I would argue that cutting safety net programs321on which many veterans rely, like Medicaid, will ultimately322deny them the dignity they deserve. This subcommittee last held323an oversight hearing dedicated to State veteran homes almost 5324years ago in the early months of the COVID-19 pandemic. At the325time, heartbreaking tragedies were unfolding in nursing homes326across the country, including at several State veteran homes327where staffing shortages, outdated physical infrastructure, and328poor infection control practices led to the rapid spread of the329virus.330    The pandemic quickly exposed the critical importance of331strong oversight and ongoing monitoring of the quality of care332and patient safety at nursing homes. During the pandemic,333Congress acted to address gaps in State veteran home oversight334and provided $1 billion in funding to support grants for State335veteran homes' instruction and operational needs.336    Unlike the slash and burn budget reconciliation process337House Republicans are undertaking, we used the budget338reconciliation process in 2021 to infuse much-needed funding339for State veteran homes and other critical programs on which340Americans rely.341    We also improved VA's oversight of State veterans' homes342under the Cleland-Dole Act, which was enacted in 2022. VA is343now required to document all deficiencies identified during344State veteran home inspections, even ones that are corrected on345the spot.346    In addition, this law required VA to publish the results of347State veteran home inspections and corrective action plans on348its public-facing website so that veterans and their loved ones349can make more informed choices about where to receive nursing350home care.351    I look forward to hearing more from our witnesses today352about the progress that has been made and the challenges that353still remain in State veteran home operations and oversight.354    With that, Madam Chairman, I yield back.355    Ms. Miller-Meeks. [Audio malfunction.]356357                 STATEMENT OF SCOTTE HARTRONFT358359    Mr. Hartronft. Good afternoon, Chairwoman Miller-Meeks,360Ranking Member Brownley, and distinguished Members of the361Subcommittee. My name is Dr. Scotte Hartronft, and I am the362Executive Director of the Office of Geriatrics and Extended363Care at the Department of Veterans Affairs. I am honored to364discuss the strategic approach VA employs, which results in365high-quality health care outcomes and support for the Nation's366heroes at State Veterans Homes (SVH). SVHs are owned, operated,367and managed by the states. VA's role as it relates to SVHs is368as a support to ensure Veterans receive the high-quality care369which meets the Department's standards, through annual370certification and recognition surveys, Medical Sharing371Agreements, and grants to construct, renovate, or repair State372owned facilities. Currently, the Department supports 172 SVHs,373which administer a combined 166 Nursing Home Programs, 47374Domiciliary Care Programs, and 3 Adult Day Health Care375Programs. To participate in the SVH program and its benefits,376VA must formally recognize a care facility as an SVH through377the certification process and a recognition survey. Along with378compliance with VA standards, a recognition survey requires379adherence to all applicable Federal, State, and local laws380including the relevant professional standards for VA purposes381to recognize the home as an SVH. After formal recognition, VA382conducts at least one unannounced annual survey at each383facility to ensure compliance with VA standards. The VA surveys384cover 200 clinical standards, fire and life safety standards,385administrative standards, and fiscal standards. Page 1 of 2386Many of the standards are based on the Centers for Medicare and387Medicaid Services (CMS) nursing home standards but others are388VA and SVH unique. Any areas of non-compliance identified on389surveys are addressed through corrective action plans in390collaboration with the Veterans Health Administration (VHA)391survey team. During the corrective action plan follow-up period392an ad-hoc for cause full survey can be completed if felt393necessary. Compliance with VA regulations under 38 C.F.R. part39451 and VA's survey and certification process is required for395SVHs that provide nursing home care, domiciliary care, or adult396day health care to remain eligible to receive per diem payments397or participate in the State Home Construction Grant Program.398    The VA survey process mirrors the Centers for Medicare and399Medicaid Services for long-term services and long-term care400facilities. VA offers support to State veterans' homes by401permitting recognized State veterans' homes to enter into402medical sharing agreements with our local VA medical centers to403secure additional clinical services, more secure discounted404pharmaceutical prices.405    As of February 2025, State veterans' home nursing homes406that are CMS-certified scored on average higher on the overall407star rating for the national CMS nursing home average.408    To maintain State veterans' home recognition, VHA may also409provide funds to ensure adequate levels of nursing staffing. In410Fiscal Year 2025, VA approved $4.7 million for the 17 states411and 47 State veterans' homes that applied for Federal grants to412support programs to hire and retain nursing staff.413    The State Home Construction Program is a partnership414between VA and the states to construct, renovate, or repair415state-owned and operated nursing homes, domiciliary, and/or416adult day health care facilities.417    VA provides reimbursement up to 55 percent of allowable418costs to states for the construction and renovation of State419veterans' homes. The number of awards provided each year420depends on the number of projects, their costs, and the amount421of appropriation received for the fiscal year. VA as well is422responsible for determining the priority for the funding for423facility improvement, which may include bed replacement, mold424removal, and repairs to structural hazards to State veterans'425homes to maintain their recognized status.426    In conclusion, VA remains steadfast in its dedication to427continuous improvement in the oversight of State veterans'428home. We appreciate the oversight from the committee and look429forward to answering any questions you may have.430431    [The Prepared Statement Of Scotte Hartronft Appears In The432Appendix]433434    Ms. Miller-Meeks. Well, thank you. I would just like to435remind our witnesses to speak more directly into the436microphone. Either move it closer to them or move closer to the437microphone.438    Ms. Silas, you are now recognized for 5 minutes to present439your testimony.440441                   STATEMENT OF SHARON SILAS442443    Ms. Silas. Chairwoman Miller-Meeks, Ranking Member444Brownley, and members of the subcommittee, I am pleased to be445here today to discuss our prior work on State veterans' homes.446My testimony today describes the oversight structure of State447veterans' homes and opportunities to improve VA's oversight.448    VA projects that the demand for long-term care will449continue to increase, driven in part by growing numbers of450aging veterans and veterans with service-connected451disabilities.452    As of Fiscal Year 2023, there will be about 15,000 veterans453living and being cared for in State veterans' homes at a cost454of $1.5 billion.455    In our November 2022 report, we reported that there were456153 State veterans' homes providing nursing home care in the457United States. These homes are an important resource for458housing and care for some of our most vulnerable aging459veterans.460    State veterans' homes are owned and operated by the states,461however, VA provides per diem payments for eligible veterans to462receive care in these homes, and as of Fiscal Year 2023 the463average daily cost per veteran per day was $265.464    There are three entities that may have a role in overseeing465State veterans' homes: the VA; the Centers for Medicare and466Medicaid Services, or CMS; and the states.467    First, VA is the only Federal agency that has oversight468responsibilities for all State veterans' homes. While VA does469not exercise any supervision or control over the470administration, personnel, or maintenance of the homes, VA does471provide oversight through annual inspections.472    Through these inspections, homes are assessed against473quality standards, cited deficiencies if they do not meet these474standards, and then they are required to develop a corrective475action plan to address the deficiencies.476    CMS also provides oversight of those State veterans' homes477that has received Medicare or Medicaid. CMS certifies homes in478order for them to receive funding.479    Once certified, CMS will conduct inspections about every 15480months to determine whether the home is meeting quality481standards. We found that nearly 76 percent of the 153 homes in482our study were also inspected by CMS.483    Some states also provide state-specific oversight of State484veterans' homes. For example, these states may have state-485specific regulations for nursing home quality or they are able486to take enforcement actions at the home.487    As part of our review, we found that 43 states conducted488their own oversight in addition to oversight conducted by VA489and CMS, but the remaining seven states where there was no490State oversight, five states' State veterans' homes received491oversight from CMS and VA and two State homes only received492oversight from the VA.493    In our report we made four recommendations for VA to494improve its oversight of State veterans' homes and one495recommendation remains open. During our review we found that496VA's only enforcement action to compel homes to address497deficiencies was to withhold per diem payments for veterans, a498severe action that could ultimately impact the veteran's care.499    Officials expressed reluctance to use the enforcement tool500unless under extreme circumstances. In fact, at the time of our501review, VA officials could not recall ever withholding a State502veterans' home's per diem.503    Further, we found in our November 2022 review of 153 State504veterans' homes there were a total of 756 deficiencies. 40505percent of State veteran homes were cited for the same506deficiency in 2019 and 2021. 21 percent of the deficiencies had507corrective action plans that were past their due date.508    Moreover, in our review, we cite an example of a State509administrator that noted they were more concerned with CMS'510inspections because of the civil penalties.511    VA could benefit from having a range of enforcement actions512similar to CMS that would provide a more effective tool to513motivate State veterans' homes to comply with standards. CMS514has a range of enforcement actions, including civil penalties515that are aligned with the scope and severity of the deficiency.516Having a similar approach to help VA more effectively target517penalties and better compel State veterans' homes to come into518compliance with quality standards.519    During our review, VA told us that they were considering a520legislative proposal to Congress for authority to impose fines521or withhold a percentage of the per diem payment to address522noncompliance with quality standards. We believe this to be a523good step to creating a range of enforcement actions that would524be effective.525    Subsequently, GAO recommended VA identify additional526enforcement actions that would help ensure State veterans'527homes' compliance with quality standards and seek legislative528authority to implement those actions. Although VA concurred529with our recommendation, they have not identified additional530enforcement actions. Instead, VA has responded by developing a531new enforcement plan that strengthens internal timelines and532increases the follow up with homes that have deficiencies.533    While these are good steps to strengthen oversight of State534veterans' homes, they are not necessarily actions that will535compel the homes to comply with quality standards. Our veterans536residing and receiving care in State veterans' homes are our537most vulnerable. Having a range of enforcement options that,538for example, are scaled to the scope and severity of539deficiencies similar to CMS' range of enforcement actions would540provide VA with more effective enforcement and better ensure541that State veterans' homes are providing the high quality care542veterans and their families deserve.543    That concludes my statement and I am happy to take any544questions.545546    [The Prepared Statement Of Sharon Silas Appears In The547Appendix]548549    Ms. Miller-Meeks. Thank you very much, Ms. Silas. As is my550typical practice, I will reserve my time for questions until551all of the members have had a chance to ask their questions.552    I now recognize Ranking Member Brownley for 5 minutes for553any questions she may have.554    Ms. Brownley. Thank you, Madam Chair.555    Dr. Hartronft, it is nice to see you again. My first556question to you, and I would appreciate a brief answer, is if557these Medicaid cuts happen, if there is a significant cut to558Medicaid, have you done any kind of analysis on the extent to559which this would increase veterans' reliance on the VA for560long-term services and supports?561    Mr. Hartronft. Thank you for that question. We have not562heard of any specific amount so we have not had any563discussions, but the VA, as usual, can be flexible with any564changes in the market based on expanding our use of other565contractors in homes and other facilities.566    Ms. Brownley. You do agree that if there were significant567cuts to Medicaid it would have an impact on, you know, veteran568services and longer term care such as state-owned nursing569homes?570    Mr. Hartronft. Most of any potential impacts I would have571to defer to CMS but, obviously, we would respond if we think572that adequate changes are necessary.573    Ms. Brownley. Okay. Let me ask you in terms of the GAO's574recommendations, there are 20, 22 recommendations to seek575legislative authority for a broader range of enforcement576actions. According to the GAO as of 2025, VA is no longer577interested in pursuing additional legislative authority.578    You were the executive director of the geriatrics and579extended care program when GAO made this recommendation, so580what changed between 2022 when you concurred with it and now,581aside from the obvious change in Presidential administration,582did new leadership within the VA directives change?583    Mr. Hartronft. What I can explain is as to in 2022 we were584in the process of a modernization effort which we centralized585all the surveys within VA central office instead of each local586VA doing that. What we did was we also added what we call an587escalation plan that puts, based on the number of survey588findings and severity in the categories of one through four,589and that prescribes a frequency of oversight.590    What we have done is since February we have noticed that591the outcomes has been positive in the sense that 100 percent of592our corrective action plans are now on time and they are593meeting their compliance. We also addressed in our corrective594action escalation plan what we need to do. If we were to seek595any penalty we would work with the Veterans Integrated Service596Network (VISN), the local VA, and determine within what is in597our current Code of Federal Regulations (CFR) and regs to598propose any penalties.599    Ms. Brownley. You did not feel with this reorganization600that you are speaking of, did not feel the need for any kind of601financial as in a fine or percentage of the per diem as602something that would leverage better accountability?603    Mr. Hartronft. Well, based on external feedback we have604been able to restart discussions internally and we are, kind605of, in the discussion and concurrence phase, so we have not606ruled that out. We are just now going back to that.607    Now that we have something in place that we did not have608before and we have shown good compliance with it we now are609going back to see and discuss do we think there is any other610appropriate actions that we might need to have in place if we611would have problems.612    Ms. Brownley. Ms. Silas, do you, kind of, agree with that613assessment?614    Ms. Silas. Yes. I mean, we believe that the steps that the615VA has taken to increase their oversight was really helpful.616They strengthened their timelines. They were doing more follow617up with the homes and that is really gone a long way I think to618improve oversight.619    We still think that there needs to be some sort of tools620that have some teeth to them to make sure that they can hold621the State veterans' homes accountable. I think it is also622really important that it is a range and so that it is very623similar to CMS, as I mentioned in my statement, where it is a624range that is aligned with the scope and severity of the625deficiency and that way you can, kind of, right-size the tool626to ensure there is accountability in the home.627    Ms. Brownley. Great. Dr. Hartronft, so the next panel there628is going to be testimony from the State Veteran Home629Association expressing some concern that the VA medical centers630are not really working with the residents in the State home to631ensure that they receive specialty care, including mental632health and psychiatric care, that this has been, sort of, an633ongoing concern. Can you speak to that?634    Mr. Hartronft. Yes, ma'am. It is a continuous improvement635that we work with the association because there we are paying636part of our per diem does cover basic primary care, and in637nursing homes it does count for normal primary care-related638mental health levels working with depression, things like639anxiety. Really just us clarifying the difference between640primary care level that we are paying per diem versus specialty641care, and that is why we have local liaisons that work with the642State veterans' home to try and make sure they can afford the643medicine and specialty care that is above the ability of the644State home.645    Ms. Brownley. I yield back.646    Ms. Miller-Meeks. Thank you very much, Ranking Member647Brownley.648    The chair now recognizes Representative Cherfilus-McCormick649for 5 minutes for any questions she may have.650    Ms. Cherfilus-McCormick. Thank you so much. In typical651fashion we are hearing the same old tired playbook from our652colleagues across the aisle, identify a program that serves the653most vulnerable and put the program under a microscope, pick654out any perceived flaws, ignore the program's success, defund655that program, and push veterans into the private sector.656    Today's strategies are the State veterans' homes, which657provide almost half of all of our Federal long-term care658support services to our Nation's veterans. This critical659lifeline is one of the most lean and effective programs in all660of VA.661    Per diem payments to these homes for skilled nursing care662are one-third less than the cost of private sector nursing663homes and almost 90 percent less than the VA's community living664centers. State veterans' homes only have the capacity to serve66530,000 veterans, well short of the 8.4 million veterans who are66665 and older.667    Instead of cutting funding for these programs, we should be668actively pursuing solutions that expand the capacity of these669facilities to treat more veterans and equip VA with the staff670needed to conduct effective oversight.671    Dr. Hartronft, as the executive director of the Office of672Geriatrics and Extended Care at the VHA, you are responsible673for ensuring VA's veterans' homes are safe and provide quality,674long-term care to our veterans. In your view, does your office675currently have enough staff to fulfill this core mission?676    Mr. Hartronft. Currently we are adequately staffed.677    Ms. Cherfilus-McCormick. What is your plan to move these678deficiencies that were pointed out that have been consistent679and pervasive?680    Mr. Hartronft. Okay. Most of them have been fully addressed681with oversight. Again, what we did before was each local VA was682responsible for the surveys and the follow up, whereas now we683have centralized it where we have a consistent, assigned staff684that they go, that work and oversee the same nursing homes.685Then that way they can follow them all the way through the686survey through all the steps and the corrective action plan and687then get them from provisional to full certification.688    Ms. Cherfilus-McCormick. Now, your statement sounds the689contradictory to what Ms. Silas has stated with the consistent690deficiencies. Is that correct or is there--am I missing691something, Ms. Silas?692    Mr. Hartronft. Then I guess I must have heard the question693wrong, my apologies. Can I--could you----694    Ms. Cherfilus-McCormick. The deficiencies. When we talked695about the deficiencies, well, when Ms. Silas spoke about the696deficiencies and the consistency of those deficiencies and how697there seems to be more direction in toughening up the standards698and not really curing the deficiencies. I wanted to know if you699had enough staff and if so, if not, how are you actually700planning on meeting and reversing course on these deficiencies?701    Mr. Hartronft. Okay, thank you, ma'am. Just as an overall702industry, in the CMS whenever they survey homes the number of703survey findings in the community, as well as the State704veterans' home deficiencies over time, as well as the fair705review of those deficiencies. We are a reflection of the larger706industry.707    What has changed over the time since the last time we708really had the full review from the GAO is our centralization709of the process. They may have an increased number of710deficiencies, but our staff are working with them from the day711of the survey until the completion of the corrective action712plan and getting evidence of compliance. They are getting713evidence of closure much more and to the point where it is714higher quality and much improved over time.715    Ms. Cherfilus-McCormick. Now, I have listened and spoke to716many State homes and they have all complained about the same717issues when it comes to funding and not having enough staff,718not even being reimbursed for a certain amounts to provide719food, especially at this time when there is inflation.720    Ms. Silas, I would like to hear from you what your view is721on the deficiencies and do you feel like cutting funds would722actually help them to cure or would it actually exacerbate the723issues you are finding?724    Ms. Silas. I do not think I can speak directly to the cuts725because we have not conducted a review looking specifically at726those, but I will say that my testimony, the report that we did727that was back in 2022, we had four recommendations we made.728Some of the things that Dr. Hartronft was talking about in729terms of the centralization of the Geriatrics and Extended Care730Office and the oversight----731    Ms. Cherfilus-McCormick. Well, I do not mean to cut you off732because my time is running out----733    Ms. Silas. Sure, Okay.734    Ms. Cherfilus-McCormick [continuing]. but I just wanted to735add this fact to you, so as you are going on. They are looking736to cut 72,000. With that fact being there you can go ahead and737continue.738    Ms. Silas. Sure. I do know that the oversight for the State739veterans' homes was very decentralized to the VA medical740facilities and so there was, I guess, over 100 staff that were741trying to monitor the State veterans' homes. With the742centralization I think there is four or five staff now that are743focused on monitoring a set of homes within the region.744    They are able to, as Dr. Hartronft was saying, being able745to track the corrective action plans and make sure that there746is closure and that the deficiencies are being addressed.747    Ms. Cherfilus-McCormick. Thank you.748    I yield back.749    Ms. Miller-Meeks. Thank you very much.750    The chair now recognizes Dr. Conaway for 5 minutes for any751questions he may have.752    Mr. Conway. Thank you. I would start by just providing some753background, a New Jersey situation. Last year the former754Attorney General Merrick Garland, filed a complaint in the U.S.755District Court for New Jersey against New Jersey Veterans756Memorial Homes at Menlo Park and Paramus.757    The two veterans' homes landed in the national spotlight758for reports of a significant number of deaths that occurred759during the pandemic and called for more oversight and760investigation. Well, as a result of the action by the district761court, families of 119 residents of those facilities entered762into a settlement in which each family received an average of763$455,000 and a total settlement of $53 million. The State was764responsible for paying 60 percent of that.765    Now, as the outbreak was raging, did the VA get into766veterans' homes, not only in New Jersey but across the country,767to respond to the deaths that were occurring and the other, you768know, related illnesses that were occurring in the homes? That769is, did somebody from the VA go to these various homes to770enter--to conduct a review of operations during the pandemic in771those homes?772    Mr. Hartronft. Thank you, sir, for that question. The local773VA's were in constant contact with their State veterans' homes,774but obviously since the State owns, operates, and manages them775there was only so much we can do outside of our oversight. It776was individualized and different for each home, so if there is777any specific homes we can go back and ask and find out more778details what the local VA actually did with each facility,779whether it was in-person, whether it was a telephone consult,780or if they provided staff or resources or other things.781    Mr. Conway. There were in-person visits to the homes to try782to understand if there were attempts to separate the ill783patients from patients that were not ill or to review any784recent deaths in those homes and whether or not they had785adequate staffing in the homes to make sure that the residents786of those homes were safe in light of the pandemic?787    Mr. Hartronft. It varied from home to home based on what788the State facility was working and communicating with the local789VA, so it varied from site to site, but I do not have the790details from each specific VA, data from each specific State791home, but I can take that for the record if you would like to792know more about any specific home.793    Mr. Conway. Ms. Silas tells us that the VA, and perhaps you794mentioned it and I am sorry if I missed it, that the VA does795not have the kind of authorities that, as I heard it, they796ought to have to ensure compliance with outcome standards, with797standards of care in the home.798    Do you agree with that statement? This is to the doctor to799provide me--you made the statement, Ms. Silas, but I wonder if800the doc agrees with what you said?801    Mr. Hartronft. Yes. We are working within our current802limitations with the CMR and USC, so that is why we put the803escalation in place because that could be done more immediately804while we do have now internal discussions as to what we need to805do above that. We are in the concurrency discussion phase, but806we, again, I would point out that so far the outcome from our807new plan has been successful and there not being anybody out of808timelines for any corrective action plans not being addressed.809    Mr. Conway. Now, well, Ms. Silas, do you want to--well, let810me get to this. Do you feel that if you do not have the811appropriate authorities, if you will, or actions beyond812reviewing a corrective action plan, which are very important,813of course, what do you do without legislation? What can you do814to really improve that without legislation to give you more815authority and to ensure compliance with what one would consider816to be appropriate nursing home standards?817    Ms. Silas. Sure. Without having some of those authorities,818I mean, what we were really looking for is the ability to apply819civil penalties or to take part--do a partial per diem payment820to stop back. If you do not have the authority to take those821types of actions you are going to have to get faith in word and822do changes internally, which I think the VA has done where they823have strengthened their timeline. They have done more follow up824with the homes.825    They also have an option to pause admissions to the State826veterans' homes, even though veterans can still be admitted to827the State veterans' homes. They do not have to be referred from828the VA itself.829    They have taken some actions but they are all very internal830and they are all around the processes and what we really want831to see is to see something that has a real, again, I will say832teeth again and a real penalty so that there is more833accountability for the State veterans' homes.834    Then having some of those tools and especially providing a835range they can, kind of, right-size the accountability to the836State veterans' homes.837    Mr. Conway. Thank you.838    Thank you, Madam Chair.839    Ms. Miller-Meeks. Thank you, Dr. Conaway.840    The chair now recognizes Representative Taylor for 5841minutes for any questions he may have.842    Mr. Taylor. Thank you, Chairwoman Miller-Meeks and Ranking843Member Brownley for holding this hearing today and allowing me844to participate.845    Thank you to our witnesses also for your insight and846testimony. My home State of Ohio has two State veterans' homes847with one being located in my district in Georgetown, so I848appreciate the opportunity to engage on this important issue.849    Dr. Hartronft, I understand there is a large backlog of850State veterans' homes awaiting Federal construction grant851funding. These projects that have already secured their State852share of the funding and are ready to go as soon as they853receive their matching Federal grant. However, at current854funding levels some projects may have to wait 5 to 10 years to855receive their matching Federal dollars.856    Can you describe some of the projects and some of the857conditions that veteran residents may have to face while these858homes await Federal funding?859    Mr. Hartronft. Thank you, sir. I do not have the list of860the actual approval and projects in front of me, but what we do861is with the funds that we do have each year it is a dynamic for862anything necessary from 1 year to the next if it is not covered863in the funding zone window it is moved to the next year. They864may change in the listing order based on if there is a new865application that has a higher priority level based on necessity866or some other issues.867    We do carry them over and then we continue to construct868based on the length and----869    Mr. Taylor. As the veteran population ages and as the870backlog of State veteran home construction projects continues871to grow, how does the VA plan to alleviate the backlog?872    Mr. Hartronft. The good news is that we already have873several facilities that we know are coming online within the874next year, or the next 2 years, so there are many projects that875are going through, which really working with the states to876identify where those best locations are.877    Again, we do not determine where the states place them or878how big they or the services. We largely respond to the879applications that we receive title work for the State to see880how we can best make the situation the best possible.881    Mr. Taylor. You have new projects coming online while882these, I think there are in excess of 80 tier one projects that883have their State funding lined up waiting for Federal funding.884There is no plan to do more than what has usually been done to885chisel down that list?886    Mr. Hartronft. We received around, I think it was during887COVID, we received a larger financial appropriation and we were888able to go further down the list. We were able to also help889those facilities during that time to renovate so that they890could have better ventilation systems, largely focused toward891COVID. Many of them benefited from us having that larger thing892to where they could actually do Heating, Ventilation, and Air893Conditioning (HVAC) changes and other benefits.894    Mr. Taylor. Thank you, Doctor.895    To me it appears this is a question of priorities and I896think now is a great time for Congress to have this897conversation as we consider where our Federal Government spends898our tax dollars we must always keep veterans at the forefront899as we root out waste, fraud, and abuse from several different900programs within the Federal bureaucracy. We would recognize901State veteran homes from across the country are being left902behind. It is unacceptable to me that our government would send903tens of billions of dollars overseas while leaving veterans to904wait years for much-needed modernizations at State veterans'905homes, including the Georgetown home I represent.906    That is why I introduced the Veterans First Act, which907would take a small fraction of the identified wasteful spending908and repurpose it to clear up the existing backlog of State909veterans' home construction grants.910    For President Trump and the White House the days of911spending money on things like electric cars in Vietnam and912Diversity, Equity, and Inclusion (DEI) projects in Serbia are913over. To that end, I will keep working to get our Nation's914spending priorities straightened out and the veterans are at915the top of the list.916    Once again, I thank the committee for the opportunity to917speak today. I yield back.918    Ms. Miller-Meeks. Thank you very much, Representative919Taylor.920    I now recognize and yield myself 5 minutes to ask921questions. First and foremost, thank you very much for being922here. State veterans' homes being State run do they also get923oversight or investigations, if you will, from a state's924Department of Inspections and Appeals that oversees nursing925homes within the states that are not a veterans' home?926    Ms. Silas or Dr. Hartronft.927    Ms. Silas. Sure. As we reported in our report, there were a928total of seven homes that were not getting State oversight.929Five of them were getting oversight by CMS and then there were930two states that will have no oversight except for the oversight931from VA.932    Ms. Miller-Meeks. The majority then would have oversight at933the State, as well as the VA?934    Ms. Silas. Yes.935    Ms. Miller-Meeks. Thank you for that.936    Dr. Hartronft, our subcommittee has learned that older937veterans are considered an invisible population when it comes938to suicide prevention. What has the VA observed about older939veteran suicide and what mental health care service is940available at the VA for older veterans and help lower the941incidence of suicide deaths? I know you mentioned this in your942remarks.943    Mr. Hartronft. Thank you, ma'am. There is a lot of layers944that we do at the State veterans' homes and we really respond945to what education they request because of what they are seeing946in their population at the time. A lot of our mental health947training and education has been over disruptive and disturbing948behaviors, obviously, as well as falls, but we have been949working with the Office of Mental Health and Suicide Prevention950and they are actually in the active process of planning new951educational interventions at the State homes and others when it952comes to suicide prevention, especially in the elderly953population, which is actually psychiatry.954    Ms. Miller-Meeks. Could is also being complicated by the955incidence or, excuse me, prevalence of Alzheimer's or dementia956as one ages?957    Mr. Hartronft. Yes and no. From the geriatric perspective,958obviously, there is dementia and other aspects but also,959especially in elderly men after they become recent widows,960there is those significant changes in life when they do have961that increase across all populations, the veteran and non-962veteran based on age. That is one reason why we are working963with the Office of Mental Health to get geriatric psychiatry to964get those levels of education and recognition because they can965be very subtle in the older population.966    Ms. Miller-Meeks. I would also like to commend you on the967response by the modernization, the changing in your processes,968the going from decentralization to some centralization which969has helped to clear up a lot of the deficiencies and demerits970within the system, so I am just going to--there has been a971little bit of criticism toward you for that but let me commend972you on being able to do as much as you have by looking at the973process itself and to see how you can change behavior through974that mechanism.975    Can a State veterans' home that receives citations for976deficiency in the annual VA audit still get funding on the same977terms as a home that receives no deficiencies?978    Mr. Hartronft. In the overall nursing home industry it is979rare that no one gets no deficiencies, but just, kind of,980showing that single digits usually. Because there is over 200981standards at the VA we call it the CMS standards plus fiscal982with the administration, we do a ton of standards.983    It would be very rare that you do not have at least one, no984matter being a very good facility. There is always some policy985or something that might get you somewhere, but overall we have986seen where we work with them very closely and really just987making sure that things get cleared up and they get the support988they need.989    We have literally had some State veterans' homes where the990local VA sent staff to provide direct education just in time991and others to really make sure that we are getting--we are992really wanting the outcomes. The outcome is really to make sure993that the veteran gets better care, so the local VAs have994invested a lot in their local VA State veterans' homes.995    Ms. Miller-Meeks. Would more enforcement measures create996more opportunity for correction?997    Mr. Hartronft. At this time based on the outcomes we are998seeing with our current escalation plan, which is our outcome999is to get these compliant and we have been successful. Again,1000as I said, we have been taking some external feedback to the1001point where that we are discussing are there next steps? That1002will obviously take longer in time, but we really wanted to1003focus what could we do more immediately within our parameters,1004knowing that some of the other measures may take a little1005longer going through other processes.1006    Ms. Miller-Meeks. Again, I commend you for what you have1007been able to achieve thus far.1008    I had a question for Ms. Silas but, Ms. Silas, I will1009submit it for the record since my time is running out.1010    On behalf of the subcommittee I want to thank you all for1011your testimony and for joining us today. You are now excused1012and we will wait a moment as the second panel comes to the1013witness table. Thank you so much.1014    I would now like to introduce the panel two witnesses.1015Testifying before us today we have Mr. Ed Harries, president of1016the National Association of State Veterans' homes. Mr. Harries,1017if I have mispronounced your name please feel free to correct1018me. The Honorable Charlton J. Meginley, colonel, retired U.S.1019Air Force, secretary of the Louisiana Department of Veterans1020Affairs (LDVA).1021    Mr. Harries, you are now recognized for 5 minutes to1022deliver your opening statement.10231024                    STATEMENT OF ED HARRIES10251026    Mr. Harries. Chairwoman Miller-Meeks and Ranking Member1027Brownley, as president of National Association of State1028Veterans' Homes (NASVH) thank you for inviting me to testify1029today.1030    State homes provide about half of all VA-supported skilled1031nursing care for veterans, yet we consume only 18 percent of1032the VA's total budget for this care. According to the VA, the1033calculated institutional per diem for State homes is $2621034compared to $424 for private community homes, and $1,971 for VA1035Community Living Care (CLC).1036    According to CMS data, the veterans' homes are safer, have1037a higher quality rating, and receive fewer substantiated1038complaints and citations compared to community nursing homes.1039Approximately 70 percent of the State homes are rated as four1040or five star facilities compared to just 35 percent of the1041community homes.1042    State homes also had 70 percent fewer substantiated1043complaints and half the number of infection control citations.1044Community homes are primarily overseen by CMS while State homes1045have significant oversight from VA, CMS, and our State1046government.1047    All homes receive annual VA inspections and 75 percent are1048also inspected by CMS. 85 percent are subject to either annual1049or for cause infections by their states.1050    Madam Chairwoman, while oversight is a necessary component1051of any well-run organization, it must be balanced against the1052dangers of overregulation.1053    Nursing home administrators spend an estimated 20 percent1054to 30 percent of their time on regulatory compliance and1055reporting, diverting focus from resident care and staff1056management.1057    Overregulation creates a high pressure environment for1058staff. Studies from the Journal of Nursing Regulation linked1059high levels of regulatory burden to increased stress among1060frontline staff and administrators alike.1061    Overly burdensome regulations can also stifle innovation.1062The Rand Report noted that facilities hesitant to adopt1063telehealth, personalized dementia interventions, or adaptive1064care models often cited fear of regulatory noncompliance as a1065primary barrier.1066    While good governance of any organization must include a1067through and effective oversight, overregulation can undercut1068its efficacy.1069    Madam Chairwoman, NASVH has several recommendations to1070strengthen and expand services for aging veterans at State1071veterans' homes. We strongly support the Providing Veterans1072Essential Medications Act, and we want to thank you and1073Congressman Pappas for introducing this legislation to address1074the problem of high cost medications.1075    We were both surprised and disappointed that the VA1076testified in opposition to your bill. VA officials were aware1077of the problem and have told NASVH on multiple occasions in1078recent years that they were interested in solving it.1079    The technical concerns raised by the VA could all be easily1080overcome with clarifications and additional legislative1081language. We stand ready to work with you and your committee to1082perfect this legislation.1083    Another problems State veterans' homes must overcome is the1084VA's failure to cover the cost of specialty care. Although VA1085is required by law to pay for specialty care, in practice the1086VA is regularly refusing to do so, particularly for psychiatric1087care.1088    Madam Chairwoman, many State veterans' home face continuing1089and significant financial challenges due to the COVID pandemic.1090We are still recovering. To help address this problem, NASVH1091supports an increase in the basic per diem rates and calls on1092Congress to appropriate at least $650 million to put toward1093ending construction projects.1094    Finally, I would like to discuss how the veterans' homes1095may help improve mental health support for aging veterans.1096Public Law 117 through 28 require the VA to create a geriatric1097psychiatry pilot program in the State veterans' homes. Instead,1098the VA implemented only a limited expansion telemedicine mental1099health services.1100    NASVH believes that the homes could play a larger role in1101addressing the mental health needs of our aging veterans. We1102would like to work with you to develop a new pilot program to1103do exactly that.1104    Research has shown that many of the supports that State1105veterans' homes provide to its aging veterans require1106protective factors for veterans in crisis and at risk for1107suicide. Expanding the scope of the long-term care services1108offered by veterans' homes could play a small but meaningful1109part in the VA's suicide prevention efforts.1110    That concludes my statement, and I would be pleased to1111answer any questions you or any members may have.11121113    [The Prepared Statement Of Ed Harries Appears In The1114Appendix]11151116    Ms. Miller-Meeks. Thank you, Mr. Harries.1117    Secretary Meginley, you are now recognized for 5 minutes to1118deliver your opening statement.11191120                 STATEMENT OF CHARLTON MEGINLEY11211122    Mr. Meginley. Chairwoman Miller-Meeks, Ranking Member1123Brownley, distinguished members of the House Veterans Affairs1124Committee (HVAC), on behalf of Governor Jeff Landry thank you1125for providing us the opportunity to address the critical topic1126of long-term care for our veterans, specifically in Louisiana's1127veterans' homes, which I will give you a little bit of1128information about.1129    While I cannot speak for the operations in other states, I1130assure you that Louisiana we have the requisite leadership,1131oversight, and a highly competent and dedicated staff to ensure1132that our veterans receive high quality, safe patient care and1133are always treated with the dignity they have earned and1134deserved.1135    Our five veterans' homes in Louisiana are situated and1136placed across the State. They are sanctuaries for those who1137have sacrificed greatly for our Nation. These facilities1138provide more than shelter and medical care. They offer a1139community where veterans are honored, respected, and cared for1140with deep compassion.1141    Our staff, the nurses, administrators, aides, social1142workers, therapists, and support personnel are the heart of1143this sacred mission. They take the time to understand each1144veteran's needs, stories, and preferences and, in turn, build1145meaningful connections.1146    Whether assisting with daily activities or maybe medical1147care or simply listening, these professionals create an1148environment of dignity and respect. Their work reflects a1149profound commitment to preserving each veteran's worth through1150connection, purpose, and recognition.1151    Now, contrary to the 2022 GAO report, we believe our1152veterans' homes operate under significant oversight to ensure1153the highest standards are maintained.1154    Federal and State agencies, including the Department of1155Veterans Affairs, Centers for Medicare and Medicaid Services1156via Louisiana Department of Health, Louisiana legislative1157auditors, Louisiana Office of Risk Management, Louisiana civil1158service, along with our own DVA internal auditors and our own1159DVA compliance team conducts regular inspections to evaluate1160everything from medical care quality to facility safety.1161    Compliance with these rigorous standards is mandatory. This1162oversight is complemented by internal quality assurance1163programs and an ongoing policy revision and staff training that1164prioritize quality care and resident rights, patient safety,1165and well-being.1166    Any concerns raised by any resident or their family members1167are addressed through formal grievance processes, which ensures1168accountability at every level. Under our leadership, our1169clinical teams have driven significant improvements in care1170quality.1171    VA survey deficiencies decreased by 36 percent from 53 in11722023 to 34 in 2024, but the 34 does not really tell the whole1173story. Further breakdown of these 34 deficiencies across all1174five of our veterans' homes shows that 91 percent were minimal1175with no actual harm, essentially a level B or below.1176    In fact, one of our deficiencies was for a burned out light1177bulb. Another was for a fryer that had been cleaned and1178replaced one inch from its original position.1179    I note that our system-wide pressure ulcer rates remain at1180or below 5 percent, approximately one-third of the national1181average of 15 percent for long-term care facilities.1182    According to the CMS Nursing Home Care Compare Survey,1183three of our five facilities have earned five star ratings with1184the remaining two achieving four star ratings, all by1185prioritizing robust census growth. We are proud of the care1186that we provide our veterans in Louisiana.1187    However, Ms. Chairwoman, we recognize that there is always1188going to be improvement or room for improvement. In a written,1189excuse me, in our written statement we provided some1190information about the escalating cost of medication, which we1191have covered here today is, something that we fully support.1192    The LDVA would also like to see greater support for our1193veterans' mental health and behavioral programs. We are1194experiencing a continued rise in the prevalence and acuity1195level of mental health and behavioral issues which negatively1196impact both clinical coordination and home admissions. In1197essence, there are plenty of veterans who we have to turn away1198because we simply do not have the capability to meet their1199needs.1200    Pilot studies to identify optimal staffing, infrastructure,1201and operations of enhanced geriatric psychiatric care1202capabilities are warranted and Louisiana is ready to lead this1203effort.1204    Ms. Chairwoman, veterans in our homes are not just1205patients. They are family members. They are heroes. Our staff's1206clinical competency and dedication ensures that their dignity1207is not only preserved but celebrated while they continue to1208receive high quality and safe care.1209    Robust oversight from engaged leaders and unwavering1210commitment of staff create a foundation of trust and respect1211that honors our Nation's promise and our state's promise to our1212veterans.1213    I want to thank you for your continued support of our1214veterans and the homes that serve them. I welcome any questions1215that you may have.12161217    [The Prepared Statement Of Charlton Meginley Appears In The1218Appendix]12191220    Ms. Miller-Meeks. Thank you, Secretary Meginley. As is my1221typical practice I will reserve my time until all other members1222have had a chance to ask their questions.1223    I now recognize Ranking Member Brownley for 5 minutes for1224any questions she may have.1225    Ms. Brownley. Thank you, Madam Chair.1226    Mr. Harries, I just wanted to start off with Mr. Taylor was1227here and seemingly introduced a new bill, and my understanding1228of the bill is that he wants to take $2 billion in funds that1229were appropriated to the U.S. Agency for International1230Development, or USAID, and reallocate those funds to the VA for1231State veteran homes construction grants. Is that a bill that1232you support or have you had a chance to look it over?1233    Mr. Harries. Yes. Actually, I have. The NASVH cannot1234determine where the money is going to come from. However, there1235is a huge need for more State veterans' homes across the1236country. If you think about it, and you are well-aware, the1237bolus or bubble of veterans coming at us in the age group we1238care for, it is not stopping. It is coming at us.1239    On top of that, with respect to the high-cost medication1240mitigation, more and more of these are coming through toxic1241exposures, cancer diagnoses, Parkinson's, very, very complex1242care.1243    More veterans' homes actually allows the VA to or1244accelerates the VA to complete their mission of reaching out to1245veterans across the country. Let us provide the footprint that1246they can build on.1247    Ms. Brownley. Well, thank you for that. You know, and I1248agree with you. I think we need to provide more resources. I1249have worked very hard in my tenure in Congress to expand and1250extend long-term care. My veterans' home, my State veterans'1251home within my district, is an extraordinary place with many1252happy, happy, happy veterans and their spouses as well and so I1253agree with you.1254    I just, in terms of Mr. Harris' (sic) bill I just, kind of,1255feel as though, from my perspective anyway, that U.S. foreign1256assistance is essential, a component to our national security.1257I think veterans who serve abroad probably understand that very1258well in terms of what USAID does in fostering goodwill toward1259our Nation.1260    I think USAID literally saves lives by bringing food,1261medicine, and stability to impoverished nations, and I think1262the bill just represents a false choice between funding veteran1263programs versus global security and international cooperation.1264    Quite frankly, I think that we must fund both is my1265perspective and we can do both if we do so with rational tax1266policies that require millionaires and billionaires to pay1267their fair share rather than providing massive giveaways. I1268think that is what is happening right now as we speak under the1269dome here through reconciliation as we are working through a1270tax plan to give millionaires and billionaires great tax cuts1271at the expense of others.1272    I just wanted to State that for the record, and I will move1273on and wanted to ask you both with the question that I had1274asked Dr. Hartronft earlier when he was here. If there is a1275significant cut to Medicaid over the next 10 years, have your1276respective states analyzed the extent to which this may1277increase veterans' reliance on State veteran homes? If these1278cuts lead more veterans to turn to State veteran homes for1279long-term care services?1280    Mr. Harries. I am assuming the question is for me?1281    Ms. Brownley. Yes, either one of you.1282    Mr. Harries. Well, first, we would want all veterans to1283come to the State veterans' homes.1284    Ms. Brownley. Yes.1285    Mr. Harries. I mean literally.1286    Ms. Brownley. Understood.1287    Mr. Harries. We do serve and provide a much higher level of1288service and quality of life. We firmly believe that I have seen1289it firsthand. With those Medicaid cuts, 75 percent of the1290veterans' homes are covered by CMS so therefore they would have1291a significant Medicaid population in the mix.1292    If the cuts are applied to long-term care limit levels at1293that point. We have done those studies to accommodate for that1294at this point but would be willing to look at that and any1295studies that do come forward.1296    Ms. Brownley. Very good. I think I, you know, and this last1297week I visited several facilities in my district within our1298county hospital and, you know, they were talking about the1299devastation the hospital would undergo if these cuts were1300pursued.1301    They also were, sort of, in a wait and see mode to just,1302kind of, see what happens before they take any action,1303obviously, but they went through a quick laundry list of where1304the impacts would be. They would be pretty devastating and I1305guess my time is up and I yield back.1306    Ms. Miller-Meeks. Thank you very much. I thank your county1307hospitals for not responding to stuff that has not yet1308occurred. Thank you for that.1309    Again, I am going to apologize to the witnesses for members1310that are not here given the numbers of markups that are going1311on throughout.1312    I also appreciate that it seems that Mr. Harries and1313Secretary Meginley that you understood the point of my1314questioning to Ms. Silas regarding oversight, that oversight1315for State veterans' homes occurs far beyond just the VA or the1316HVAC Health Subcommittee or HVAC Committee here in Congress,1317that you have multiple regulatory bodies conducting oversight.1318    To your point Mr. Harries, it sometimes actually creates1319burdens and hurdles and lack of innovation or new processes.1320Again, I commend the VA and Dr. Hartronft for the progress they1321have made in clearing deficiencies, so I just wanted to1322recognize that.1323    Mr. Harries, how could VA health care be improved to1324address gaps in medication reimbursement at State veterans'1325homes?1326    Mr. Harries. How could it be improved? If the VA were to1327accommodate the State veterans' homes through as they do the1328private sector nursing homes by paying for, reimbursing for1329those high-cost medications.1330    Ms. Miller-Meeks. For medication that they cover outside--1331--1332    Mr. Harries. Correct.1333    Ms. Miller-Meeks [continuing]. of the veterans' homes?1334    Mr. Harries. Exactly. My point is we are doing it for one1335party but we are not doing it for another and we are the party1336that is not getting that reimbursement.1337    There are states, and I have stories already in my previous1338testimony, and I believe there may be some in this one where1339veterans have been turned away because they have $100,0001340medication or a $28,000 medication coming in which it is the VA1341per diem rates that are paid. That is a financial loss for the1342facility. That loss has to be made up somewhere else, which1343would probably be in resident care, probably not adding another1344admission, and just the cascading effect.1345    I think the key thing is covering those medications as they1346are coming, and as I spoke earlier, the number of residents1347that we are seeing now, the number of patients coming to us1348with high-cost medications and complex comorbidities, such as,1349well, the reimbursement has got to come, especially with all1350the toxic exposures and Agent Orange exposures and such.1351    Ms. Miller-Meeks. Last month we discussed a pilot program,1352the Communities Helping Invest through Property and1353Improvements Needed for Veterans (CHIP IN) Act, which had been1354used to instruct a VA clinic next to the VA Medical Center in1355Omaha, Nebraska, and extending the CHIP IN Act from its pilot1356program for construction for either VA hospitals and/or VA1357clinics.1358    Even though the State veterans' home are a combination of1359State funding and VA funding, is this something that a little1360bit of out-of-the-box thinking that could be applied to1361construction grants for State veterans' homes?1362    Then I have got an extension to that question.1363    Mr. Harries. I do not see why not. It sounds like a1364fantastic idea.1365    Ms. Miller-Meeks. We might need to expand our potential1366legislation. The current interpretation of Federal regulations1367does not allow a State veterans' home to apply for a1368construction grant in order to begin new adult daycare health1369program. A home may only seek a grant to expand or replace a1370facility currently being used for adult day health care. What1371complications does this pose for State veterans' homes that1372want to provide adult daycare?1373    Mr. Harries. It cannot do it unless they pay for it1374entirely on their own and it is a sizable investment in care.1375Adult daycare, and we have talked about suicide prevention and1376mental illness with our veterans that are coming in, adult1377daycare, the medical model of adult daycare, the residents are1378assessed on a daily basis to make sure that does not happen.1379    It also takes out the isolation that causes a lot of1380suicides. It would be vital for us to be able to expand that1381program and have satellite offsite clinics available under1382outpatient or adult daycare facilities so that we can monitor1383and take care of those residents. Their life would be much1384better improved if we could do that.1385    Ms. Miller-Meeks. Thank you.1386    Secretary Meginley, several of Louisiana's State veterans'1387homes are in rural areas. What are challenges and best1388practices for coordinating transportation for veterans who need1389specialized care?1390    Mr. Meginley. Yes, ma'am. One of our homes is in the rural1391area of Jennings. One of the challenges that we have, because1392it is in a rural area, is making sure that we have the1393appropriate staff. Obviously, making sure we have the Licensed1394Practical Nurses (LPNs), the Registered Nurses (RNs) to be able1395to come in.1396    We are having to pull from different metropolitan areas1397making sure that these individuals are well-funded, well-paid1398is something that we consistently work with our Louisiana civil1399service to make sure that those folks are paid at least market1400rate at a minimum and offered additional co-pays as needed.1401    As far as getting them to the facilities, luckily, Bossier1402is okay. Our home in Bossier is next to Overton Brooks in1403Shreveport so they have easy access to the hospital. Reserve is1404close to New Orleans VA. Jackson is not too far from our1405Community-Based Outpatient Clinic (CBOC) in Baton Rouge, which1406is very well equipped, I think.1407    Yes, that is a problem. Something that we have talked about1408extensively is about rural transportation for veterans to VA1409hospitals and something that we have had since the1410conversations with our administrators about making sure that we1411can facilitate those needs.1412    Ms. Miller-Meeks. Thank you. I would yield. I know. I am1413sorry. She was telling me Dr. Morrison is here. Do I know Dr.1414Morrison is here? I was just about to say I yield the remainder1415of my time.1416    The chair now recognizes Dr. Morrison for 5 minutes for any1417questions she may have.1418    Ms. Morrison. Thank you, Madam Chair.1419    Thank you to our witnesses for testifying today on the role1420of State veterans' homes play and caring for our aging1421veterans. You know, a key aspect that strikes me as fundamental1422to today's hearing is the importance of having robust data to1423review as we discuss opportunities to improve oversight and1424ultimately the quality of care in State veterans' homes.1425    I know several years have passed since the last hearing on1426this issue here in Congress with my colleagues, and I have had1427the benefit of being able to review data GAO compiled in their14282022 review, as well as data from research conducted in1429collaboration with the VA and other research entities.1430    I emphasize that we have this data as a result of1431intentional and consistent efforts to monitor the quality of1432care at State veterans' homes and conduct research in this1433area. As a result of these research and monitoring efforts, we1434are able to better understand elements such as the population1435of veterans that use State veterans' homes, how State veterans'1436homes are meeting needs in comparison to community nursing1437homes and VA's community living centers, how well State1438veterans' homes responded to the COVID-19 pandemic, and even1439what areas of operation oversight might warrant additional1440review.1441    Having spent over 2 decades of caring for patients as a1442physician myself, it is important to me that our next steps1443consider evidence-based strategies and place data and form1444responses at the forefront of our actions, so I want us to1445continue using the data available to us in hearings like the1446one we are having here today.1447    Equally and perhaps more critical in this particular1448moment, I think it is imperative that we continue to collect1449this data and not undermine the research that supports our1450collective pursuit of best practices and quality care for our1451veterans.1452    Secretary Meginley, in your testimony you discussed best1453practices for the State veterans' homes under your management.1454I appreciate that you began your statement affirming your1455state's unwavering commitment to safely and effectively1456managing State veterans' homes and conclude expressing your1457willingness to continue working closely with your VA partners1458turn to ensure clinical quality and patient safety.1459    Can you elaborate a little bit more on how this partnership1460with VA has contributed to your ability to deliver high quality1461care in State veterans' homes?1462    Mr. Meginley. Yes, ma'am. I will tell you all, I am not1463just a veteran. I am a patient of the New Orleans VA. That is1464where I go to all my healthcare. I have a phenomenal1465relationship with my administrator. I can call my administrator1466at midnight on a Friday night, which I have done, to ensure1467that a veteran who is having a mental health crisis is taken1468care of immediately.1469    My administrators both in Alexandria and Shreveport are1470very much the same. The rural health care question, recently I1471was at Monroe and the honeymoon period of my time ended very1472quickly when I got confronted about community care issues.1473    I contacted my administrator in Shreveport and gave him the1474questions that some of the veterans had had concerns about, and1475that administrator answered those questions within 72 hours and1476restored some of these processes to make sure that our rural1477veterans were getting the health care that they needed through1478the CBOC entity in Shreveport.1479    The same for Alexandria as well, so, ma'am, I think my1480relationship with my administrators is phenomenal, and I can1481call any of my VA partners in a heartbeat and the answers and1482the questions that I have will get taken care of without1483question.1484    I think that is one of the strengths. I am in Alexandria. I1485live on the north shore of Louisiana not too far from New1486Orleans. I have been to Shreveport almost a dozen times, and1487every time I go either myself or my deputy, who is behind me,1488go and visit the VA administrators and ask them what can we do1489for you as a state? We give them what our questions are as to1490how they can help us with our veterans as well.1491    To me, that is the forefront and the heart of everything1492that I do. As a State VA I cannot do my job without being1493intertwined at the hip with my VA administrators and my VA1494partners.1495    Ms. Morrison. Thank you for that response. Colonel--1496Secretary, I should say, you also mentioned rigorous oversight1497is an element that supports your delivery of compassionate,1498high quality services.1499    Mr. Harries, you specifically cited the layers of oversight1500for State veterans' homes as a reason that they offer higher1501quality. Could each of you speak just briefly to the importance1502of collecting robust data at the Federal and State levels and1503how additional research informs the administration of the care1504provided at State veterans' homes?1505    Mr. Meginley. Well, I will tell you this. My deputy and I,1506my deputy is a retired Army doc, by the way, on my staff, so I1507have an on-staff physician to be able to help me answer some of1508the questions.1509    You talk about data. We have been talking about data since1510day one, and I will tell you one of the most important pieces1511of data that has stuck with me over and over is the fact that1512we turn away 72 percent of veterans who have mental health1513issues. We do not have the capability to be able to take care1514of their needs.1515    When you start talking about those numbers--we talk about1516pressure ulcer rates. One of our homes had a very low pressure1517ulcer rate. We wanted to know why your rate was so much lower1518than the others. They were all still below the national1519average, but what were you all doing differently?1520    That data allowed us to go find the answers and take that1521best practice and put it and put it in the other four homes. We1522have also talked about, you know, other data points that would1523make our workforce stronger, our medication issues stronger,1524because as Mr. Harries talked about, prescription costs are1525extraordinary, particularly in some cases. Trying to figure out1526ways to make sure that our veterans are being taken care of,1527again, having the data is very vital to us. We live and die by1528data essentially every day so that we can make our homes1529better.1530    Ms. Miller-Meeks. Is there----1531    Ms. Morrison. Well, I was hoping that Mr. Harries might1532comment, too, in----1533    Mr. Harries. Sure.1534    Ms. Miller-Meeks. Briefly, sir.1535    Ms. Morrison [continuing]. 39 seconds left.1536    Ms. Miller-Meeks. The gentlewoman's time has expired.1537    Mr. Harries. I am a six sigma black belt, which means that1538I love data and the more data I can get the better. It is the1539way you are going to solve your problems. It is the way you are1540going to get there.1541    Before we close or you cut me off, what I do want to State1542is I have heard it once that VA has the largest compilation of1543health care data in the world. Utilize that. Let us look at1544that. Let us see what we can do to leverage that to make some1545improvements.1546    Ms. Morrison. Thank you.1547    Thank you for your indulgence, Madam Chair.1548    Ms. Miller-Meeks. Thank you for yielding.1549    Members can always submit questions for the record, which I1550have done earlier so that I would not go over time.1551    Ranking Member Brownley, would you like to make any closing1552remarks?1553    Ms. Brownley. I thank you for having the hearing. I think1554this topic is an important one. With the colonel's answer to1555Ms. Morrison's question, I wonder how we can have the1556relationship that you described between your medical center and1557your State veteran home, how that relationship, how we can have1558that everywhere across the country.1559    Mr. Meginley. Well, I will tell you, ma'am, it helps when1560you are a patient because I go in 1 day as a State secretary1561leader and the next thing I am getting my knee injected. I get1562a chance to see what they are doing.1563    Ms. Brownley. Thank you. Yield back.1564    Ms. Miller-Meeks. Thank you.1565    I will recognize you in the future, sir.1566    Mr. Meginley. I am sorry, ma'am.1567    Ms. Miller-Meeks. Sorry, chain of command. Two veterans1568ought to know.1569    Number one, again, I want to apologize. My sincere1570apologies to our witnesses, to the VA, to the secretary, to Mr.1571Harries for the lack of members who are here. I thank the1572members who came. I thank you all very much.1573    When we set up hearings we do not necessarily know that1574there are going to be markups and there are numerous markups by1575numerous committees today. I am supposed to be over in one in1576Energy and Commerce but thank you for being here.1577    Thank you for your participation and taking the time in1578today's hearing. This actually is an extremely important topic,1579both given how much regulatory burden there is and oversight1580there is in health care and also the very important work that1581you do given the population that you serve and the increasing1582numbers of that population receiving access for care.1583    The complete written statements of today's witnesses will1584be entered into the hearing record. I ask unanimous consent1585that all members have 5 legislative days to revise and extend1586their remarks and include extraneous material. Hearing no1587objection, so ordered.1588    I thank all members and their witnesses for their1589participation today. This hearing is adjourned. Thank you so1590much.1591    [Whereupon, at 3:33 p.m., the subcommittee was adjourned.]15921593?15941595=======================================================================15961597                         A  P  P  E  N  D  I  X15981599=======================================================================16001601                    Prepared Statements of Witnesses16021603                              ----------16041605                 Prepared Statement of Scotte Hartronft16061607    Good afternoon, Chairwoman Miller-Meeks, Ranking Member Brownley,1608and distinguished Members of the Subcommittee. My name is Dr. Scotte1609Hartronft, and I am the Executive Director of the Office of Geriatrics1610and Extended Care at the Department of Veterans Affairs (VA). I am1611honored to discuss the strategic approach VA employs, which results in1612high-quality health care outcomes and support for the Nation's heroes1613at State Veterans Homes (SVH). SVHs are owned, operated, and managed by1614the states. VA's role as it relates to SVHs is as a support to ensure1615Veterans receive the high-quality care which meets the Department's1616standards, through annual certification and recognition surveys,1617Medical Sharing Agreements, and grants to construct, renovate, or1618repair State owned facilities.1619    Currently, the Department supports 172 SVHs, which administer a1620combined 166 Nursing Home Programs, 47 Domiciliary Care Programs, and 31621Adult Day Health Care Programs. To participate in the SVH program and1622its benefits, VA must formally recognize a care facility as an SVH1623through the certification process and a recognition survey. Along with1624compliance with VA standards, a recognition survey requires adherence1625to all applicable Federal, State, and local laws including the relevant1626professional standards for VA purposes to recognize the home as an SVH.1627    After formal recognition, VA conducts at least one unannounced1628annual survey at each facility to ensure compliance with VA standards.1629The VA surveys cover 200 clinical standards, fire and life safety1630standards, administrative standards, and fiscal standards. Many of the1631standards are based on the CMS nursing home standards but others are VA1632and SVH unique. Any areas of non-compliance identified on surveys are1633addressed through corrective action plans in collaboration with the1634Veterans Health Administration survey team. During the corrective1635action plan follow-up period an ad-hoc for cause full survey can be1636completed if felt necessary. Compliance with VA regulations under 381637C.F.R. part 51 and VA's survey and certification process is required1638for SVHs that provide nursing home care, domiciliary care, or adult day1639health care to remain eligible to receive per diem payments or1640participate in the State Home Construction Grant Program (SHCGP). VA's1641survey process mirrors the Centers for Medicare and Medicaid Services1642(CMS) for long-term care facilities.1643    VA offers support to SVHs by permitting recognized SVHs to enter1644into Medical Sharing Agreements with their local VA Medical Centers to1645procure additional clinical services or secure discounted1646pharmaceutical prices. The SVH's that are CMS certified also on average1647outperform the US nursing home star rating on their CMS surveys. To1648maintain SVH recognition, VHA may also provide funds to ensure adequate1649levels of nursing staff. In Fiscal Year 2024, VA approved $4.7 million1650for the 17 states and 47 SVHs that applied for Federal funds to support1651programs that hire or retain nursing staff.1652    SHCGP is a partnership between VA and the states to construct,1653renovate or repair state-owned and operated nursing homes,1654domiciliaries, and/or adult day health care facilities. VA provides1655reimbursement of up to 65 percent of allowable costs to states for the1656construction and renovation of SVHs. The number of awards provided each1657year depends on the number of projects, their costs, and the amount of1658appropriation received in the fiscal year. VA is responsible for1659determining the priority for funding facility improvements, which may1660include bed replacements, mold removal, and repairs to structural1661hazards to assist SVHs in proving high-quality care for Veterans.16621663Conclusion16641665    In conclusion, VA remains steadfast in its dedication to continuous1666improvement in the oversight of SVHs. We appreciate the oversight from1667the Subcommittee and look forward to answering any questions you may1668have.16691670                   Prepared Statement of Sharon Silas16711672                    Prepared Statement of Ed Harries1673[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]16741675                Prepared Statement of Charlton Meginley1676[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]16771678                       Statements for the Record16791680                              ----------16811682      Prepared Statement of Florida Department of Veterans Affairs16831684    We operate nine State veterans' homes in Florida with a1685total of 1,102 beds. Eight are skilled nursing facilities and1686one is a domiciliary offering assisted living. Florida's State1687Veterans' Nursing Homes are among the top nursing homes in the1688State.1689    The relationship between the VA and Florida is good;1690however, the VA long-term care system has historically1691struggled to keep up with current national long-term care1692models. Highlighting home and community-based care should be1693encouraged. We recommend VA support States and Territories that1694desire to integrate a long-term care campus that allows them to1695offer additional services to Veterans to remain in their homes1696in the community.1697    We recommend changing the static model of traditional1698nursing home beds to one that provides Veterans with a more1699robust venue of long-term care services. Florida is planning a1700120-bed State Veterans' Nursing Home that includes adjoining1701Adult Health Day Care, outpatient rehabilitation services and a1702community wellness center for local Veterans. We feel the1703decades-old model for strictly long-term care beds is1704restrictive and does not reflect the needs of today's aging1705Veteran. Additionally, our proposed model will allow Veterans1706to access health care services while providing an avenue for1707camaraderie that can improve their health outcomes.1708    Previous attempts to provide these updated services in1709existing State Veterans' Home sites have been denied by the VA,1710citing 20-year moratoriums imposed on original construction1711grants designed solely for long-term care beds. The denial is1712based on VA's interpretation of 38 CFR Sec.  59.110.1713    Providing enhanced services to local Veterans in areas with1714a small VA footprint saves travel time and keeps Veterans in1715their homes, allowing much-needed respite care for their family1716members and caregivers. The added socialization combats1717isolation and conversely helps combat veteran suicide.1718    VA's State Veteran Home Construction Grant Program should1719reflect these new national models of long-term care as States1720seek to expand their services for Veterans. We also recommend1721an overall increase in funding for the State Veteran Home1722Construction Grant Program to combat a backlog of vital1723projects. Previous years funding has made only a small dent in1724expanding and enhancing long-term care services for our1725Veterans. Many needed construction and rehabilitation efforts1726are delayed by years due to inadequate funding. According to1727the VA, the State of Florida is currently short of more than17282,900 Veterans' Nursing Home beds. At the current rate of1729funding, it would take decades to fill the gap. We believe1730increased funding, coupled with access to non-institutional1731long-term care, can provide a bridge for our aging Veterans'1732long-term care needs.1733    In Florida, it costs nearly twice the reimbursement rate1734provided by VA to pay for care of Veterans in our 150-bed1735Domiciliary home. We recommend VA review their compensation1736rates for long-term care, as reimbursements to States for1737Veterans in Veterans' Domiciliary Homes vastly understate the1738true cost of healthcare.1739    We appreciate the opportunity to provide testimony and1740continue our collaborative work with the VA to enhance care for1741our Nation's Veterans.17421743  Prepared Statement of Veterans of Foreign Wars of the United States17441745    Chairwoman Miller-Meeks, Ranking Member Brownley, and members of1746the subcommittee, on behalf of the men and women of the Veterans of1747Foreign Wars of the United States (VFW) and its Auxiliary, thank you1748for the opportunity to provide our comments on this important topic.1749    As the United States veteran population ages, the demand for long-1750term care will increasingly represent a significant portion of the1751Department of Veterans Affairs (VA) health care. Long-term care1752includes various services to address a veteran's health or personal1753care needs when the individual can no longer perform daily activities1754unassisted. VA offers care through nursing homes, assisted living, home1755health care, and State Veterans Homes (SVHs). SVHs are nursing1756facilities, assisted living facilities, or domiciliary care homes1757operated by State governments specifically for veterans. They provide1758long-term care services customized to address the unique needs of1759veterans. There are many benefits to SVHs, such as subsidized care, VA1760per diem grants that lower out-of-pocket expenses, and a supportive1761environment to connect with fellow veterans and build camaraderie. VA1762provides general oversight to all 153 SVHs, which collectively care for1763approximately 14,500 veterans.17641765Background17661767    State Veterans Homes trace their origins back to the pre-Civil War1768era, designed initially to care for injured and aging soldiers. These1769facilities were commonly referred to as soldiers' homes. In 1888,1770Congress authorized Federal funding to support state-operated veterans'1771homes, establishing a partnership between State and Federal Governments1772that continues today. VA provides per diem payments for each veteran1773receiving care in these homes. It is another way to assist the veteran1774in cutting out-of-pocket costs. VA also provides construction grants1775covering up to 65 percent of building or renovation costs of SVHs.1776States are required to provide at least 35 percent in matching funds.1777To qualify for VA funding, SVHs must adhere to VA quality standards in1778areas such as quality of care, standard of living, infection control,1779and resident rights.1780    All 50 states and Puerto Rico either have at least one SVH or have1781been approved to build one, and some states have multiple homes due to1782population size or geographic distribution. Examples of State agencies1783that oversee SVHs include the California Department of Veterans Affairs1784(CalVet), the Texas Veterans Land Board, the New York State Division of1785Veterans' Services, and the Florida Department of Veterans Affairs.1786SVHs typically offer services, including skilled nursing care, assisted1787living for independent veterans needing support, memory care units, and1788short-term rehabilitation or post-acute care. Eligibility criteria for1789SVHs generally require service in the U.S. Armed Forces with an1790honorable discharge, residency in the State, and medical or personal1791care needs that align with the services provided.17921793Needs of the Aging Veteran17941795    Aging veterans are unique individuals shaped by their military1796experiences, natural aging processes, and socioeconomic circumstances.1797Many elderly veterans face multiple chronic conditions and may have1798health issues related to their service, which can lead to the need for1799assisted living or nursing care. They may encounter various challenges,1800including limited income, transportation barriers, social isolation,1801difficulty accessing benefits, and cognitive decline.1802    Essential services for aging veterans include geriatric primary1803care, mental health support, neurology and memory care, rehabilitation1804and physical therapy, and dental and vision care. For veterans who can1805no longer live independently, a skilled nursing facility may be the1806best option, particularly if they are unable to perform activities of1807daily living or require supervision due to vulnerability. Loneliness1808and a diminished sense of worth often become more pronounced as they1809age. The camaraderie once enjoyed may be a distant memory, overshadowed1810by declining health and the loss of family and friends. All of these1811factors can contribute to higher risks for suicide among aging1812veterans.1813    A coordinated, veteran-centered approach is necessary to1814effectively meet the needs of aging veterans and address their overall1815well-being. This approach should include medical and mental health1816care, housing, social connections, and the dignity that should be1817afforded to them. Delivering comprehensive care including geriatric-1818specific services, and integrated mental and behavioral health support,1819is critical for enhancing the quality of life for these individuals.18201821SVH Oversight18221823    State governments and VA collaborate to provide SVHs as an option1824for veterans. VA is responsible for providing per diem for eligible1825veterans, and construction grants for building and renovating1826facilities. Unfortunately, there is a massive $1.2 billion backlog in1827construction needs of SVHs, which potentially places some veterans in1828unsafe living conditions and others waiting for available facilities.1829    VA's Geriatrics and Extended Care program oversees the per diem1830funding and ensures compliance with VA standards. These standards1831include maintaining quality of care, adequate staffing levels, timely1832recordkeeping, and safe, sanitary living conditions. VA conducts1833regular inspections, and homes that do not meet these standards are1834cited for deficiencies. According to a November 2022 Government1835Accountability Office (GAO) report, VA Nursing Home Care: Opportunities1836Exist to Enhance Oversight of State Veterans Homes, deficiencies1837increased from 424 in 2019 to 766 in 2021. This included a 12 percent1838rise in deficiencies that resulted in actual harm or immediate1839jeopardy. Additionally, data from 2020 was missing from this report as1840VA suspended inspections during the COVID-19 pandemic, precisely when1841inspections were most critical. The report also found that an outdated1842data system led to insufficient analysis of SVH data, and current plans1843for a replacement data system would not guarantee that VA would have1844the necessary analytical capabilities to improve efficiency. GAO1845recommended that VA identify additional enforcement tools and seek1846legislative authority to strengthen its oversight capabilities.1847    VA published a policy notice in August 2024 on oversight1848requirements for SVHs that provide nursing home care, domiciliary care,1849and adult day health care. This notice detailed the administration,1850oversight, and certification processes for Recognition, Annual, and1851For-Cause Surveys of SVHs, explicitly focusing on compliance with1852Federal regulations. Key elements include the survey processes,1853corrective action plans for addressing noncompliance, and the roles of1854various VA personnel in managing and overseeing SVH operations. The1855goal is to ensure eligible veterans receive high-quality care in a safe1856environment while VA maintains proper oversight of the SVHs.18571858VFW Concerns18591860    VFW members have raised concerns about long waitlists for admission1861to SVHs due to the limited number of facilities and available beds. The1862quality of care at SVHs is generally good, though veterans have had1863issues with slow communication and responses concerning inquiries about1864patient care, billing issues, eligibility, and space availability for1865individuals waiting to be transferred from medical hospitals. These1866delays create significant stress for veterans and their families.1867    For example, one Missouri veteran had been waiting so long for1868placement in an SVH that VA moved him to a nursing home with a low1869standard of care. He also experienced poor communication from the staff1870while he waited for a bed to become available at an SVH.1871    Veterans have told the VFW they have concerns about the lack of1872clear communication and setting expectations during the eligibility,1873application, and waitlist processes. The perception exists that if a1874veteran or that person's caregiver contacts a civilian nursing home,1875the veteran could likely secure a bed within a few days. However,1876delays in access and availability are prevalent at SVHs due to the1877limited number of facilities and a lack of beds required to meet the1878current demand.1879    Veterans in Alabama have voiced concerns about obtaining1880information regarding eligibility criteria for SVHs. They are1881particularly troubled by the significant variation in eligibility1882requirements and processes, even among specific facilities within the1883same state.1884    Maryland veterans and their families have reported multiple1885concerns including the lengthy application process and waitlists for1886admission to SVHs and lack of communication during this time,1887insufficient communication with survivors regarding billing issues and1888difficulties obtaining documentation even after payment has been made,1889and challenges in processing new patients during periods of system1890upgrades and changes in contracts. When veterans and their families1891raise concerns about living conditions at SVHs, VA should be responsive1892and address these issues effectively since it funds a significant1893portion of these services.1894    It is time for VA to proactively address the concerns of the aging1895veteran population. VA can enhance compliance with quality standards by1896developing a range of enforcement options to correct deficiencies1897identified during inspections. Additionally, VA needs to establish a1898process for monitoring the implementation of corrective action plans,1899enabling it to track how care facilities address noncompliance issues.1900It is also crucial for VA to improve its ability to set and manage1901expectations for medical or care facilities that serve our veterans,1902while communicating those expectations to their families.1903    The VFW urges Congress to provide full funding for VA to address1904the backlog of pending State Home Construction Grants. This would1905address the growing need and ensure these facilities are safe for1906veterans. We also urge Congress to provide oversight of VA's surveys1907and monitoring of SVHs to ensure high-quality standards for our1908Nation's veterans.1909    Chairwoman Miller-Meeks, Ranking Member Brownley, this concludes my1910statement. Thank you for the opportunity to offer our comments on this1911important issue.19121913Information Required by Rule XI2(g)(4) of the House of Representatives19141915    Pursuant to Rule XI2(g)(4) of the House of Representatives, the VFW1916has not received any Federal grants in Fiscal Year 2025, nor has it1917received any Federal grants in the two previous Fiscal Years.19181919    The VFW has not received payments or contracts from any foreign1920governments in the current year or preceding two calendar years.19211922 Prepared Statement of The National Association of State Directors of1923                         Veterans Affairs, Inc.1924[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]19251926                   Prepared Statement of Sheri Biggs1927[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]19281929     Questions for the Record Submitted by Mariannette Miller-Meeks1930[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]