    [House Hearing, 119 Congress]
    [From the U.S. Government Publishing Office]

                      DIGNITY DENIED: THE CASE FOR REFORM

                            AT STATE VETERANS HOMES

    =======================================================================

                                    HEARING

                                   before the

                             SUBCOMMITTEE ON HEALTH

                                     of the

                         COMMITTEE ON VETERANS' AFFAIRS

                         U.S. HOUSE OF REPRESENTATIVES

                        ONE HUNDRED NINETEENTH CONGRESS

                                 FIRST SESSION

                                   __________

                            TUESDAY, APRIL 29, 2025

                                   __________

                               Serial No. 119-17

                                   __________

           Printed for the use of the Committee on Veterans' Affairs
          [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

                        Available via http://govinfo.gov

                      U.S. GOVERNMENT PUBLISHING OFFICE
    61-150                     WASHINGTON : 2025

                         COMMITTEE ON VETERANS' AFFAIRS

                         MIKE BOST, Illinois, Chairman

    AUMUA AMATA COLEMAN RADEWAGEN,       MARK TAKANO, California, Ranking
        American Samoa, Vice-Chairwoman      Member
    JACK BERGMAN, Michigan               JULIA BROWNLEY, California
    NANCY MACE, South Carolina           CHRIS PAPPAS, New Hampshire
    MARIANNETTE MILLER-MEEKS, Iowa       SHEILA CHERFILUS-MCCORMICK,
    GREGORY F. MURPHY, North Carolina        Florida
    DERRICK VAN ORDEN, Wisconsin         MORGAN MCGARVEY, Kentucky
    MORGAN LUTTRELL, Texas               DELIA RAMIREZ, Illinois
    JUAN CISCOMANI, Arizona              NIKKI BUDZINSKI, Illinois
    KEITH SELF, Texas                    TIMOTHY M. KENNEDY, New York
    JEN KIGGANS, Virginia                MAXINE DEXTER, Oregon
    ABE HAMADEH, Arizona                 HERB CONAWAY, New Jersey
    KIMBERLYN KING-HINDS, Northern       KELLY MORRISON, Minnesota
        Mariana Islands
    TOM BARRETT, Michigan

                           Jon Clark, Staff Director
                      Matt Reel, Democratic Staff Director

                             SUBCOMMITTEE ON HEALTH

                   MARIANNETTE MILLER-MEEKS, Iowa, Chairwoman

    JACK BERGMAN, Michigan               JULIA BROWNLEY, California,
    GREGORY F. MURPHY, North Carolina        Ranking Member
    DERRICK VAN ORDEN, Wisconsin         SHEILA CHERFILUS-MCCORMICK,
    JEN KIGGANS, Virginia                    Florida
    ABE HAMADEH, Arizona                 MAXINE DEXTER, Oregon
    KIMBERLYN KING-HINDS, Northern       HERB CONAWAY, New Jersey
        Mariana Islands                  KELLY MORRISON, Minnesota

    Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
    hearing records of the Committee on Veterans' Affairs are also
    published in electronic form. The printed hearing record remains the
    official version. Because electronic submissions are used to prepare
    both printed and electronic versions of the hearing record, the process
    of converting between various electronic formats may introduce
    unintentional errors or omissions. Such occurrences are inherent in the
    current publication process and should diminish as the process is
    further refined.
                             C  O  N  T  E  N  T  S

                                  ----------

                            TUESDAY, APRIL 29, 2025

                                                                       Page

                               OPENING STATEMENTS

    The Honorable Mariannette Miller-Meeks, Chairwoman...............     1
    The Honorable Julia Brownley, Ranking Member.....................     3

                                   WITNESSES
                                    Panel I

    Dr. Scotte Hartronft, M.D., Executive Director, Office of
      Geriatrics & Extended Care, Veterans Health Administration,
      U.S. Department of Veterans Affairs............................     4

    Ms. Sharon Silas, Director, Health Care, U.S. Government
      Accountability Office..........................................     6

                                    Panel II

    Mr. Ed Harries, President, National Association of State Veterans
      Homes..........................................................    16

    The Honorable Charlton J. Meginley, Col. (Ret), USAF, Secretary,
      Louisiana Department of Veterans Affairs.......................    18

                                    APPENDIX
                        Prepared Statements Of Witnesses

    Dr. Scotte Hartronft, M.D. Prepared Statement....................    29
    Ms. Sharon Silas Prepared Statement..............................    30
    Mr. Ed Harries Prepared Statement................................    45
    The Honorable Charlton J. Meginley, Col. (Ret), USAF Prepared
      Statement......................................................    57

                           Statements For The Record

    Florida Department of Veterans Affairs Prepared Statement........    65
    Veterans of Foreign Wars of the United States Prepared Statement.    66
    The National Association of State Directors of Veterans Affairs,
      Inc. Prepared Statement........................................    69
    The Honorable Sheri Biggs, U.S. House of Representatives, (SC-3)
      Prepared Statement.............................................    72
    Questions for the Record Submitted by The Honorable Mariannette
      Miller-Meeks, U.S. House of Representatives, (IA-2)............    75

                      DIGNITY DENIED: THE CASE FOR REFORM

                            AT STATE VETERANS HOMES

                                  ----------

                            TUESDAY, APRIL 29, 2025

                        Subcommittee on Health,
                        Committee on Veterans' Affairs,
                                 U.S. House of Representatives,
                                                        Washington, DC.
        The subcommittee met, pursuant to notice, at 2:17 p.m., in
    room 360, Cannon House Office Building, Hon. Mariannette
    Miller-Meeks [chairwoman of the subcommittee] presiding.
        Present: Representatives Miller-Meeks, Taylor, Brownley,
    Cherfilus-McCormick, Conaway, and Morrison.
        Also present: Representative Taylor.

       OPENING STATEMENT OF MARIANNETTE MILLER-MEEKS, CHAIRWOMAN

        Ms. Miller-Meeks. Before we get started, in accordance with
    committee rule 5E, I ask unanimous consent that Representative
    Dave Taylor from Ohio be permitted to participate in today's
    committee hearing. Without objection.
        This oversight hearing of the Subcommittee on Health will
    now come to order. I would like to welcome all members and
    witnesses to today's hearing. We look forward to a very
    productive discussion about care for aging veterans.
        Every veteran deserves independence and dignity with age.
    With age however comes challenges. The Baby Boomer generation
    is getting to an age where long-term care is increasingly
    needed. More and more veterans are entering a period in life
    where they are physically and mentally vulnerable or do not
    live near family members who can assist.
        The demands on the U.S. Department of Veterans Affairs (VA)
    from long-term care will only grow due to the incoming veterans
    who served during the Vietnam and cold war eras. For some, they
    have trouble advocating for themselves because of their health
    needs which can undermine their independence.
        This subcommittee works every day to make sure VA health
    care meets veterans where they are. We know older veterans
    experience social isolation, or may, chronic pain, mental
    health challenges, and the VA healthcare must meet our aging
    veterans' needs. Recent incidents show that there is still work
    to be done.
        I am particularly troubled by veteran suicide later in
    life. We have talked a lot about suicide in our younger
    veterans and our veterans who transition out of the service but
    not much about veterans who commit suicide late in life. Just 2
    weeks ago a 77-year-old veteran tragically committed suicide at
    a VA medical campus.
        Sadly, very little research exists about why veterans end
    their lives at a time when they should be enjoying the fruits
    of all of their labor.
        Through this subcommittee's oversight trips we have heard
    that older veterans who commit suicide are an invisible
    population. As a 24-year Army veteran and physician, I refuse
    to let this issue live in the shadows.
        Health care programs through VA are a major contact point
    where the VA can interact with older veterans. Uniquely, State
    veterans' homes deal with this population almost exclusively.
    They are a key means by which we can support older veterans on
    a daily basis.
        State veterans' homes are long-term care facilities for
    veterans and often for their spouses. They are state-run but
    receives substantial amounts of funding from the VA.
        When VA supports State veterans' homes it is also
    supporting a compilation of smaller programs. VA gives funds
    for State veterans' homes to support programs like resident
    care, domiciliary care, and adult daycare.
        In addition, VA provides grants for facility construction
    through a matching program with states. The VA also provides
    grants for nursing retention at State veterans' homes. These
    programs help veterans flourish later in life.
        Are we sure that the VA is helping State veterans' homes
    meet their full potential? This oversight hearing is meant to
    answer this question. I know that most homes throughout the
    country give the quality of care that veterans in need deserve
    but there are notable outliers.
        In 2020, at a State veterans' home in Holyoke,
    Massachusetts, over 70 veterans died with COVID-19 during an
    outbreak during the pandemic. Many more suffered infections. An
    independent investigation revealed that this horrific tragedy
    was preventable.
        Additionally, Government Accountability Office (GAO)
    reported that the total number of demerits for failing
    requirements in the annual VA audit increased from 2019 to
    2021.
        The good news is that these are exceptions rather than the
    rule, but what can we do to make sure all homes offer the
    standard of care veterans deserve? I believe the VA can help
    State veterans' homes succeed.
        We know that the VA has money. We give it to them every
    year. Again, the VA disburses a substantial amount of funding
    to support State veterans' homes through reimbursements and
    grants. We must make sure the VA allocates these funds to the
    right resources.
        That is why I have introduced a bill to provide veterans
    with more access to essential medications. My bill would
    reimburse State veterans' homes for medication cost.
        Currently, the VA does not pay State veterans' homes for
    high cost medications for severely disabled veterans, yet they
    are often revolutionary cancer drugs that can help
    significantly lengthen the veteran's life and quality of life.
    These medications are covered outside of the facility rather
    than through the State veterans' homes.
        I have said it before, I will say it again. It is critical
    to expand the network veterans can use to access lifesaving
    medications. I also know that construction grants come with
    strings attached that may not make sense for the veteran or the
    State veterans' home supporting them. I look forward to
    discussing this and more with the witnesses before us today.
        Older veterans deserve quality long-term care. We owe it to
    them to put them at the forefront of our conversation about
    veteran healthcare.
        I now yield to Ranking Member Brownley for any opening
    remarks she may have.

          OPENING STATEMENT OF JULIA BROWNLEY, RANKING MEMBER

        Ms. Brownley. Thank, you Madam Chair. Overall, an estimated
    80 percent of veterans will need long-term services and
    supports at some point during their lifetime. The overwhelming
    majority of aging adults, including veterans, would prefer to
    age in place in their homes rather than nursing homes.
        With the recent enactment of the Elizabeth Dole Act,
    Congress bolstered VA's authority to offer home and community-
    based services for aging and disabled veterans. We are eager
    for VA to implement this law as soon as possible.
        However, even with this expansion of VA's non-institutional
    long-term care programs, not every veteran will have enough
    support from family members or other caregivers to enable them
    to safely age at home. For that reason there will always be a
    need for nursing homes.
        State veterans' homes, which are owned and operated by the
    states with Federal investments in the form of construction
    grants and per diem payments, are the largest provider of
    institutional long-term care for veterans. Collectively, they
    serve more than 43 percent of the veterans receiving VA-funded
    nursing home care on any given day in 2023.
        VA-operated community living centers served about 20
    percent and VA purchased care from community nursing homes
    through the remaining third of veterans.
        Despite serving the majority of veterans for whom VA
    purchases nursing home care, State veteran homes receive only
    about 18 percent of VA's total payments for institutional long-
    term care. VA's basic per diem for State veteran homes now
    covers less than 30 percent of the actual cost of care and as
    little as 20 percent in some states with higher costs of
    living.
        State veteran homes make up the balance of their costs
    through other funding sources including State support, Medicare
    and Medicaid, and the veterans themselves who share in the
    cost.
        This week and next, 11 other House committees will mark up
    budget reconciliation legislation ramming through draconian
    cuts to Federal programs that serve the most vulnerable among
    us, all to fund tax cuts for the very wealthy.
        The House Energy and Commerce Committee has been instructed
    to cut $880 billion over 10 years and nearly all of those cuts
    are expected to come from Medicaid, which funds long-term care
    for more than 60 percent of nursing home residents.
        With many community nursing homes already teetering on the
    brink of financial insolvency, these Republican budget cuts
    would put them at greater risk of closures.
        Medicaid also funds many home and community-based services
    enabling aging and disabled people, including veterans, to
    avoid institutional settings and care. Should these Medicaid
    cuts come to pass, veterans will become more reliant on VA and
    State veteran homes for long-term services and supports.
        I certainly hope both the administration and the states
    will be factoring this into their budget proposals in the
    coming years.
        I also must say I am perplexed by the title of today's
    hearing. For many veterans the sense of community and
    culturally competent care that has historically been provided
    by State veteran homes allows them to retain their dignity in
    their later years. State veteran homes were established by the
    states and are supported by VA as a way to honor our Nation's
    promises to veterans through the end of their lives.
        If anything, I would argue that cutting safety net programs
    on which many veterans rely, like Medicaid, will ultimately
    deny them the dignity they deserve. This subcommittee last held
    an oversight hearing dedicated to State veteran homes almost 5
    years ago in the early months of the COVID-19 pandemic. At the
    time, heartbreaking tragedies were unfolding in nursing homes
    across the country, including at several State veteran homes
    where staffing shortages, outdated physical infrastructure, and
    poor infection control practices led to the rapid spread of the
    virus.
        The pandemic quickly exposed the critical importance of
    strong oversight and ongoing monitoring of the quality of care
    and patient safety at nursing homes. During the pandemic,
    Congress acted to address gaps in State veteran home oversight
    and provided $1 billion in funding to support grants for State
    veteran homes' instruction and operational needs.
        Unlike the slash and burn budget reconciliation process
    House Republicans are undertaking, we used the budget
    reconciliation process in 2021 to infuse much-needed funding
    for State veteran homes and other critical programs on which
    Americans rely.
        We also improved VA's oversight of State veterans' homes
    under the Cleland-Dole Act, which was enacted in 2022. VA is
    now required to document all deficiencies identified during
    State veteran home inspections, even ones that are corrected on
    the spot.
        In addition, this law required VA to publish the results of
    State veteran home inspections and corrective action plans on
    its public-facing website so that veterans and their loved ones
    can make more informed choices about where to receive nursing
    home care.
        I look forward to hearing more from our witnesses today
    about the progress that has been made and the challenges that
    still remain in State veteran home operations and oversight.
        With that, Madam Chairman, I yield back.
        Ms. Miller-Meeks. [Audio malfunction.]

                     STATEMENT OF SCOTTE HARTRONFT

        Mr. Hartronft. Good afternoon, Chairwoman Miller-Meeks,
    Ranking Member Brownley, and distinguished Members of the
    Subcommittee. My name is Dr. Scotte Hartronft, and I am the
    Executive Director of the Office of Geriatrics and Extended
    Care at the Department of Veterans Affairs. I am honored to
    discuss the strategic approach VA employs, which results in
    high-quality health care outcomes and support for the Nation's
    heroes at State Veterans Homes (SVH). SVHs are owned, operated,
    and managed by the states. VA's role as it relates to SVHs is
    as a support to ensure Veterans receive the high-quality care
    which meets the Department's standards, through annual
    certification and recognition surveys, Medical Sharing
    Agreements, and grants to construct, renovate, or repair State
    owned facilities. Currently, the Department supports 172 SVHs,
    which administer a combined 166 Nursing Home Programs, 47
    Domiciliary Care Programs, and 3 Adult Day Health Care
    Programs. To participate in the SVH program and its benefits,
    VA must formally recognize a care facility as an SVH through
    the certification process and a recognition survey. Along with
    compliance with VA standards, a recognition survey requires
    adherence to all applicable Federal, State, and local laws
    including the relevant professional standards for VA purposes
    to recognize the home as an SVH. After formal recognition, VA
    conducts at least one unannounced annual survey at each
    facility to ensure compliance with VA standards. The VA surveys
    cover 200 clinical standards, fire and life safety standards,
    administrative standards, and fiscal standards. Page 1 of 2
    Many of the standards are based on the Centers for Medicare and
    Medicaid Services (CMS) nursing home standards but others are
    VA and SVH unique. Any areas of non-compliance identified on
    surveys are addressed through corrective action plans in
    collaboration with the Veterans Health Administration (VHA)
    survey team. During the corrective action plan follow-up period
    an ad-hoc for cause full survey can be completed if felt
    necessary. Compliance with VA regulations under 38 C.F.R. part
    51 and VA's survey and certification process is required for
    SVHs that provide nursing home care, domiciliary care, or adult
    day health care to remain eligible to receive per diem payments
    or participate in the State Home Construction Grant Program.
        The VA survey process mirrors the Centers for Medicare and
    Medicaid Services for long-term services and long-term care
    facilities. VA offers support to State veterans' homes by
    permitting recognized State veterans' homes to enter into
    medical sharing agreements with our local VA medical centers to
    secure additional clinical services, more secure discounted
    pharmaceutical prices.
        As of February 2025, State veterans' home nursing homes
    that are CMS-certified scored on average higher on the overall
    star rating for the national CMS nursing home average.
        To maintain State veterans' home recognition, VHA may also
    provide funds to ensure adequate levels of nursing staffing. In
    Fiscal Year 2025, VA approved $4.7 million for the 17 states
    and 47 State veterans' homes that applied for Federal grants to
    support programs to hire and retain nursing staff.
        The State Home Construction Program is a partnership
    between VA and the states to construct, renovate, or repair
    state-owned and operated nursing homes, domiciliary, and/or
    adult day health care facilities.
        VA provides reimbursement up to 55 percent of allowable
    costs to states for the construction and renovation of State
    veterans' homes. The number of awards provided each year
    depends on the number of projects, their costs, and the amount
    of appropriation received for the fiscal year. VA as well is
    responsible for determining the priority for the funding for
    facility improvement, which may include bed replacement, mold
    removal, and repairs to structural hazards to State veterans'
    homes to maintain their recognized status.
        In conclusion, VA remains steadfast in its dedication to
    continuous improvement in the oversight of State veterans'
    home. We appreciate the oversight from the committee and look
    forward to answering any questions you may have.

        [The Prepared Statement Of Scotte Hartronft Appears In The
    Appendix]

        Ms. Miller-Meeks. Well, thank you. I would just like to
    remind our witnesses to speak more directly into the
    microphone. Either move it closer to them or move closer to the
    microphone.
        Ms. Silas, you are now recognized for 5 minutes to present
    your testimony.

                       STATEMENT OF SHARON SILAS

        Ms. Silas. Chairwoman Miller-Meeks, Ranking Member
    Brownley, and members of the subcommittee, I am pleased to be
    here today to discuss our prior work on State veterans' homes.
    My testimony today describes the oversight structure of State
    veterans' homes and opportunities to improve VA's oversight.
        VA projects that the demand for long-term care will
    continue to increase, driven in part by growing numbers of
    aging veterans and veterans with service-connected
    disabilities.
        As of Fiscal Year 2023, there will be about 15,000 veterans
    living and being cared for in State veterans' homes at a cost
    of $1.5 billion.
        In our November 2022 report, we reported that there were
    153 State veterans' homes providing nursing home care in the
    United States. These homes are an important resource for
    housing and care for some of our most vulnerable aging
    veterans.
        State veterans' homes are owned and operated by the states,
    however, VA provides per diem payments for eligible veterans to
    receive care in these homes, and as of Fiscal Year 2023 the
    average daily cost per veteran per day was $265.
        There are three entities that may have a role in overseeing
    State veterans' homes: the VA; the Centers for Medicare and
    Medicaid Services, or CMS; and the states.
        First, VA is the only Federal agency that has oversight
    responsibilities for all State veterans' homes. While VA does
    not exercise any supervision or control over the
    administration, personnel, or maintenance of the homes, VA does
    provide oversight through annual inspections.
        Through these inspections, homes are assessed against
    quality standards, cited deficiencies if they do not meet these
    standards, and then they are required to develop a corrective
    action plan to address the deficiencies.
        CMS also provides oversight of those State veterans' homes
    that has received Medicare or Medicaid. CMS certifies homes in
    order for them to receive funding.
        Once certified, CMS will conduct inspections about every 15
    months to determine whether the home is meeting quality
    standards. We found that nearly 76 percent of the 153 homes in
    our study were also inspected by CMS.
        Some states also provide state-specific oversight of State
    veterans' homes. For example, these states may have state-
    specific regulations for nursing home quality or they are able
    to take enforcement actions at the home.
        As part of our review, we found that 43 states conducted
    their own oversight in addition to oversight conducted by VA
    and CMS, but the remaining seven states where there was no
    State oversight, five states' State veterans' homes received
    oversight from CMS and VA and two State homes only received
    oversight from the VA.
        In our report we made four recommendations for VA to
    improve its oversight of State veterans' homes and one
    recommendation remains open. During our review we found that
    VA's only enforcement action to compel homes to address
    deficiencies was to withhold per diem payments for veterans, a
    severe action that could ultimately impact the veteran's care.
        Officials expressed reluctance to use the enforcement tool
    unless under extreme circumstances. In fact, at the time of our
    review, VA officials could not recall ever withholding a State
    veterans' home's per diem.
        Further, we found in our November 2022 review of 153 State
    veterans' homes there were a total of 756 deficiencies. 40
    percent of State veteran homes were cited for the same
    deficiency in 2019 and 2021. 21 percent of the deficiencies had
    corrective action plans that were past their due date.
        Moreover, in our review, we cite an example of a State
    administrator that noted they were more concerned with CMS'
    inspections because of the civil penalties.
        VA could benefit from having a range of enforcement actions
    similar to CMS that would provide a more effective tool to
    motivate State veterans' homes to comply with standards. CMS
    has a range of enforcement actions, including civil penalties
    that are aligned with the scope and severity of the deficiency.
    Having a similar approach to help VA more effectively target
    penalties and better compel State veterans' homes to come into
    compliance with quality standards.
        During our review, VA told us that they were considering a
    legislative proposal to Congress for authority to impose fines
    or withhold a percentage of the per diem payment to address
    noncompliance with quality standards. We believe this to be a
    good step to creating a range of enforcement actions that would
    be effective.
        Subsequently, GAO recommended VA identify additional
    enforcement actions that would help ensure State veterans'
    homes' compliance with quality standards and seek legislative
    authority to implement those actions. Although VA concurred
    with our recommendation, they have not identified additional
    enforcement actions. Instead, VA has responded by developing a
    new enforcement plan that strengthens internal timelines and
    increases the follow up with homes that have deficiencies.
        While these are good steps to strengthen oversight of State
    veterans' homes, they are not necessarily actions that will
    compel the homes to comply with quality standards. Our veterans
    residing and receiving care in State veterans' homes are our
    most vulnerable. Having a range of enforcement options that,
    for example, are scaled to the scope and severity of
    deficiencies similar to CMS' range of enforcement actions would
    provide VA with more effective enforcement and better ensure
    that State veterans' homes are providing the high quality care
    veterans and their families deserve.
        That concludes my statement and I am happy to take any
    questions.

        [The Prepared Statement Of Sharon Silas Appears In The
    Appendix]

        Ms. Miller-Meeks. Thank you very much, Ms. Silas. As is my
    typical practice, I will reserve my time for questions until
    all of the members have had a chance to ask their questions.
        I now recognize Ranking Member Brownley for 5 minutes for
    any questions she may have.
        Ms. Brownley. Thank you, Madam Chair.
        Dr. Hartronft, it is nice to see you again. My first
    question to you, and I would appreciate a brief answer, is if
    these Medicaid cuts happen, if there is a significant cut to
    Medicaid, have you done any kind of analysis on the extent to
    which this would increase veterans' reliance on the VA for
    long-term services and supports?
        Mr. Hartronft. Thank you for that question. We have not
    heard of any specific amount so we have not had any
    discussions, but the VA, as usual, can be flexible with any
    changes in the market based on expanding our use of other
    contractors in homes and other facilities.
        Ms. Brownley. You do agree that if there were significant
    cuts to Medicaid it would have an impact on, you know, veteran
    services and longer term care such as state-owned nursing
    homes?
        Mr. Hartronft. Most of any potential impacts I would have
    to defer to CMS but, obviously, we would respond if we think
    that adequate changes are necessary.
        Ms. Brownley. Okay. Let me ask you in terms of the GAO's
    recommendations, there are 20, 22 recommendations to seek
    legislative authority for a broader range of enforcement
    actions. According to the GAO as of 2025, VA is no longer
    interested in pursuing additional legislative authority.
        You were the executive director of the geriatrics and
    extended care program when GAO made this recommendation, so
    what changed between 2022 when you concurred with it and now,
    aside from the obvious change in Presidential administration,
    did new leadership within the VA directives change?
        Mr. Hartronft. What I can explain is as to in 2022 we were
    in the process of a modernization effort which we centralized
    all the surveys within VA central office instead of each local
    VA doing that. What we did was we also added what we call an
    escalation plan that puts, based on the number of survey
    findings and severity in the categories of one through four,
    and that prescribes a frequency of oversight.
        What we have done is since February we have noticed that
    the outcomes has been positive in the sense that 100 percent of
    our corrective action plans are now on time and they are
    meeting their compliance. We also addressed in our corrective
    action escalation plan what we need to do. If we were to seek
    any penalty we would work with the Veterans Integrated Service
    Network (VISN), the local VA, and determine within what is in
    our current Code of Federal Regulations (CFR) and regs to
    propose any penalties.
        Ms. Brownley. You did not feel with this reorganization
    that you are speaking of, did not feel the need for any kind of
    financial as in a fine or percentage of the per diem as
    something that would leverage better accountability?
        Mr. Hartronft. Well, based on external feedback we have
    been able to restart discussions internally and we are, kind
    of, in the discussion and concurrence phase, so we have not
    ruled that out. We are just now going back to that.
        Now that we have something in place that we did not have
    before and we have shown good compliance with it we now are
    going back to see and discuss do we think there is any other
    appropriate actions that we might need to have in place if we
    would have problems.
        Ms. Brownley. Ms. Silas, do you, kind of, agree with that
    assessment?
        Ms. Silas. Yes. I mean, we believe that the steps that the
    VA has taken to increase their oversight was really helpful.
    They strengthened their timelines. They were doing more follow
    up with the homes and that is really gone a long way I think to
    improve oversight.
        We still think that there needs to be some sort of tools
    that have some teeth to them to make sure that they can hold
    the State veterans' homes accountable. I think it is also
    really important that it is a range and so that it is very
    similar to CMS, as I mentioned in my statement, where it is a
    range that is aligned with the scope and severity of the
    deficiency and that way you can, kind of, right-size the tool
    to ensure there is accountability in the home.
        Ms. Brownley. Great. Dr. Hartronft, so the next panel there
    is going to be testimony from the State Veteran Home
    Association expressing some concern that the VA medical centers
    are not really working with the residents in the State home to
    ensure that they receive specialty care, including mental
    health and psychiatric care, that this has been, sort of, an
    ongoing concern. Can you speak to that?
        Mr. Hartronft. Yes, ma'am. It is a continuous improvement
    that we work with the association because there we are paying
    part of our per diem does cover basic primary care, and in
    nursing homes it does count for normal primary care-related
    mental health levels working with depression, things like
    anxiety. Really just us clarifying the difference between
    primary care level that we are paying per diem versus specialty
    care, and that is why we have local liaisons that work with the
    State veterans' home to try and make sure they can afford the
    medicine and specialty care that is above the ability of the
    State home.
        Ms. Brownley. I yield back.
        Ms. Miller-Meeks. Thank you very much, Ranking Member
    Brownley.
        The chair now recognizes Representative Cherfilus-McCormick
    for 5 minutes for any questions she may have.
        Ms. Cherfilus-McCormick. Thank you so much. In typical
    fashion we are hearing the same old tired playbook from our
    colleagues across the aisle, identify a program that serves the
    most vulnerable and put the program under a microscope, pick
    out any perceived flaws, ignore the program's success, defund
    that program, and push veterans into the private sector.
        Today's strategies are the State veterans' homes, which
    provide almost half of all of our Federal long-term care
    support services to our Nation's veterans. This critical
    lifeline is one of the most lean and effective programs in all
    of VA.
        Per diem payments to these homes for skilled nursing care
    are one-third less than the cost of private sector nursing
    homes and almost 90 percent less than the VA's community living
    centers. State veterans' homes only have the capacity to serve
    30,000 veterans, well short of the 8.4 million veterans who are
    65 and older.
        Instead of cutting funding for these programs, we should be
    actively pursuing solutions that expand the capacity of these
    facilities to treat more veterans and equip VA with the staff
    needed to conduct effective oversight.
        Dr. Hartronft, as the executive director of the Office of
    Geriatrics and Extended Care at the VHA, you are responsible
    for ensuring VA's veterans' homes are safe and provide quality,
    long-term care to our veterans. In your view, does your office
    currently have enough staff to fulfill this core mission?
        Mr. Hartronft. Currently we are adequately staffed.
        Ms. Cherfilus-McCormick. What is your plan to move these
    deficiencies that were pointed out that have been consistent
    and pervasive?
        Mr. Hartronft. Okay. Most of them have been fully addressed
    with oversight. Again, what we did before was each local VA was
    responsible for the surveys and the follow up, whereas now we
    have centralized it where we have a consistent, assigned staff
    that they go, that work and oversee the same nursing homes.
    Then that way they can follow them all the way through the
    survey through all the steps and the corrective action plan and
    then get them from provisional to full certification.
        Ms. Cherfilus-McCormick. Now, your statement sounds the
    contradictory to what Ms. Silas has stated with the consistent
    deficiencies. Is that correct or is there--am I missing
    something, Ms. Silas?
        Mr. Hartronft. Then I guess I must have heard the question
    wrong, my apologies. Can I--could you----
        Ms. Cherfilus-McCormick. The deficiencies. When we talked
    about the deficiencies, well, when Ms. Silas spoke about the
    deficiencies and the consistency of those deficiencies and how
    there seems to be more direction in toughening up the standards
    and not really curing the deficiencies. I wanted to know if you
    had enough staff and if so, if not, how are you actually
    planning on meeting and reversing course on these deficiencies?
        Mr. Hartronft. Okay, thank you, ma'am. Just as an overall
    industry, in the CMS whenever they survey homes the number of
    survey findings in the community, as well as the State
    veterans' home deficiencies over time, as well as the fair
    review of those deficiencies. We are a reflection of the larger
    industry.
        What has changed over the time since the last time we
    really had the full review from the GAO is our centralization
    of the process. They may have an increased number of
    deficiencies, but our staff are working with them from the day
    of the survey until the completion of the corrective action
    plan and getting evidence of compliance. They are getting
    evidence of closure much more and to the point where it is
    higher quality and much improved over time.
        Ms. Cherfilus-McCormick. Now, I have listened and spoke to
    many State homes and they have all complained about the same
    issues when it comes to funding and not having enough staff,
    not even being reimbursed for a certain amounts to provide
    food, especially at this time when there is inflation.
        Ms. Silas, I would like to hear from you what your view is
    on the deficiencies and do you feel like cutting funds would
    actually help them to cure or would it actually exacerbate the
    issues you are finding?
        Ms. Silas. I do not think I can speak directly to the cuts
    because we have not conducted a review looking specifically at
    those, but I will say that my testimony, the report that we did
    that was back in 2022, we had four recommendations we made.
    Some of the things that Dr. Hartronft was talking about in
    terms of the centralization of the Geriatrics and Extended Care
    Office and the oversight----
        Ms. Cherfilus-McCormick. Well, I do not mean to cut you off
    because my time is running out----
        Ms. Silas. Sure, Okay.
        Ms. Cherfilus-McCormick [continuing]. but I just wanted to
    add this fact to you, so as you are going on. They are looking
    to cut 72,000. With that fact being there you can go ahead and
    continue.
        Ms. Silas. Sure. I do know that the oversight for the State
    veterans' homes was very decentralized to the VA medical
    facilities and so there was, I guess, over 100 staff that were
    trying to monitor the State veterans' homes. With the
    centralization I think there is four or five staff now that are
    focused on monitoring a set of homes within the region.
        They are able to, as Dr. Hartronft was saying, being able
    to track the corrective action plans and make sure that there
    is closure and that the deficiencies are being addressed.
        Ms. Cherfilus-McCormick. Thank you.
        I yield back.
        Ms. Miller-Meeks. Thank you very much.
        The chair now recognizes Dr. Conaway for 5 minutes for any
    questions he may have.
        Mr. Conway. Thank you. I would start by just providing some
    background, a New Jersey situation. Last year the former
    Attorney General Merrick Garland, filed a complaint in the U.S.
    District Court for New Jersey against New Jersey Veterans
    Memorial Homes at Menlo Park and Paramus.
        The two veterans' homes landed in the national spotlight
    for reports of a significant number of deaths that occurred
    during the pandemic and called for more oversight and
    investigation. Well, as a result of the action by the district
    court, families of 119 residents of those facilities entered
    into a settlement in which each family received an average of
    $455,000 and a total settlement of $53 million. The State was
    responsible for paying 60 percent of that.
        Now, as the outbreak was raging, did the VA get into
    veterans' homes, not only in New Jersey but across the country,
    to respond to the deaths that were occurring and the other, you
    know, related illnesses that were occurring in the homes? That
    is, did somebody from the VA go to these various homes to
    enter--to conduct a review of operations during the pandemic in
    those homes?
        Mr. Hartronft. Thank you, sir, for that question. The local
    VA's were in constant contact with their State veterans' homes,
    but obviously since the State owns, operates, and manages them
    there was only so much we can do outside of our oversight. It
    was individualized and different for each home, so if there is
    any specific homes we can go back and ask and find out more
    details what the local VA actually did with each facility,
    whether it was in-person, whether it was a telephone consult,
    or if they provided staff or resources or other things.
        Mr. Conway. There were in-person visits to the homes to try
    to understand if there were attempts to separate the ill
    patients from patients that were not ill or to review any
    recent deaths in those homes and whether or not they had
    adequate staffing in the homes to make sure that the residents
    of those homes were safe in light of the pandemic?
        Mr. Hartronft. It varied from home to home based on what
    the State facility was working and communicating with the local
    VA, so it varied from site to site, but I do not have the
    details from each specific VA, data from each specific State
    home, but I can take that for the record if you would like to
    know more about any specific home.
        Mr. Conway. Ms. Silas tells us that the VA, and perhaps you
    mentioned it and I am sorry if I missed it, that the VA does
    not have the kind of authorities that, as I heard it, they
    ought to have to ensure compliance with outcome standards, with
    standards of care in the home.
        Do you agree with that statement? This is to the doctor to
    provide me--you made the statement, Ms. Silas, but I wonder if
    the doc agrees with what you said?
        Mr. Hartronft. Yes. We are working within our current
    limitations with the CMR and USC, so that is why we put the
    escalation in place because that could be done more immediately
    while we do have now internal discussions as to what we need to
    do above that. We are in the concurrency discussion phase, but
    we, again, I would point out that so far the outcome from our
    new plan has been successful and there not being anybody out of
    timelines for any corrective action plans not being addressed.
        Mr. Conway. Now, well, Ms. Silas, do you want to--well, let
    me get to this. Do you feel that if you do not have the
    appropriate authorities, if you will, or actions beyond
    reviewing a corrective action plan, which are very important,
    of course, what do you do without legislation? What can you do
    to really improve that without legislation to give you more
    authority and to ensure compliance with what one would consider
    to be appropriate nursing home standards?
        Ms. Silas. Sure. Without having some of those authorities,
    I mean, what we were really looking for is the ability to apply
    civil penalties or to take part--do a partial per diem payment
    to stop back. If you do not have the authority to take those
    types of actions you are going to have to get faith in word and
    do changes internally, which I think the VA has done where they
    have strengthened their timeline. They have done more follow up
    with the homes.
        They also have an option to pause admissions to the State
    veterans' homes, even though veterans can still be admitted to
    the State veterans' homes. They do not have to be referred from
    the VA itself.
        They have taken some actions but they are all very internal
    and they are all around the processes and what we really want
    to see is to see something that has a real, again, I will say
    teeth again and a real penalty so that there is more
    accountability for the State veterans' homes.
        Then having some of those tools and especially providing a
    range they can, kind of, right-size the accountability to the
    State veterans' homes.
        Mr. Conway. Thank you.
        Thank you, Madam Chair.
        Ms. Miller-Meeks. Thank you, Dr. Conaway.
        The chair now recognizes Representative Taylor for 5
    minutes for any questions he may have.
        Mr. Taylor. Thank you, Chairwoman Miller-Meeks and Ranking
    Member Brownley for holding this hearing today and allowing me
    to participate.
        Thank you to our witnesses also for your insight and
    testimony. My home State of Ohio has two State veterans' homes
    with one being located in my district in Georgetown, so I
    appreciate the opportunity to engage on this important issue.
        Dr. Hartronft, I understand there is a large backlog of
    State veterans' homes awaiting Federal construction grant
    funding. These projects that have already secured their State
    share of the funding and are ready to go as soon as they
    receive their matching Federal grant. However, at current
    funding levels some projects may have to wait 5 to 10 years to
    receive their matching Federal dollars.
        Can you describe some of the projects and some of the
    conditions that veteran residents may have to face while these
    homes await Federal funding?
        Mr. Hartronft. Thank you, sir. I do not have the list of
    the actual approval and projects in front of me, but what we do
    is with the funds that we do have each year it is a dynamic for
    anything necessary from 1 year to the next if it is not covered
    in the funding zone window it is moved to the next year. They
    may change in the listing order based on if there is a new
    application that has a higher priority level based on necessity
    or some other issues.
        We do carry them over and then we continue to construct
    based on the length and----
        Mr. Taylor. As the veteran population ages and as the
    backlog of State veteran home construction projects continues
    to grow, how does the VA plan to alleviate the backlog?
        Mr. Hartronft. The good news is that we already have
    several facilities that we know are coming online within the
    next year, or the next 2 years, so there are many projects that
    are going through, which really working with the states to
    identify where those best locations are.
        Again, we do not determine where the states place them or
    how big they or the services. We largely respond to the
    applications that we receive title work for the State to see
    how we can best make the situation the best possible.
        Mr. Taylor. You have new projects coming online while
    these, I think there are in excess of 80 tier one projects that
    have their State funding lined up waiting for Federal funding.
    There is no plan to do more than what has usually been done to
    chisel down that list?
        Mr. Hartronft. We received around, I think it was during
    COVID, we received a larger financial appropriation and we were
    able to go further down the list. We were able to also help
    those facilities during that time to renovate so that they
    could have better ventilation systems, largely focused toward
    COVID. Many of them benefited from us having that larger thing
    to where they could actually do Heating, Ventilation, and Air
    Conditioning (HVAC) changes and other benefits.
        Mr. Taylor. Thank you, Doctor.
        To me it appears this is a question of priorities and I
    think now is a great time for Congress to have this
    conversation as we consider where our Federal Government spends
    our tax dollars we must always keep veterans at the forefront
    as we root out waste, fraud, and abuse from several different
    programs within the Federal bureaucracy. We would recognize
    State veteran homes from across the country are being left
    behind. It is unacceptable to me that our government would send
    tens of billions of dollars overseas while leaving veterans to
    wait years for much-needed modernizations at State veterans'
    homes, including the Georgetown home I represent.
        That is why I introduced the Veterans First Act, which
    would take a small fraction of the identified wasteful spending
    and repurpose it to clear up the existing backlog of State
    veterans' home construction grants.
        For President Trump and the White House the days of
    spending money on things like electric cars in Vietnam and
    Diversity, Equity, and Inclusion (DEI) projects in Serbia are
    over. To that end, I will keep working to get our Nation's
    spending priorities straightened out and the veterans are at
    the top of the list.
        Once again, I thank the committee for the opportunity to
    speak today. I yield back.
        Ms. Miller-Meeks. Thank you very much, Representative
    Taylor.
        I now recognize and yield myself 5 minutes to ask
    questions. First and foremost, thank you very much for being
    here. State veterans' homes being State run do they also get
    oversight or investigations, if you will, from a state's
    Department of Inspections and Appeals that oversees nursing
    homes within the states that are not a veterans' home?
        Ms. Silas or Dr. Hartronft.
        Ms. Silas. Sure. As we reported in our report, there were a
    total of seven homes that were not getting State oversight.
    Five of them were getting oversight by CMS and then there were
    two states that will have no oversight except for the oversight
    from VA.
        Ms. Miller-Meeks. The majority then would have oversight at
    the State, as well as the VA?
        Ms. Silas. Yes.
        Ms. Miller-Meeks. Thank you for that.
        Dr. Hartronft, our subcommittee has learned that older
    veterans are considered an invisible population when it comes
    to suicide prevention. What has the VA observed about older
    veteran suicide and what mental health care service is
    available at the VA for older veterans and help lower the
    incidence of suicide deaths? I know you mentioned this in your
    remarks.
        Mr. Hartronft. Thank you, ma'am. There is a lot of layers
    that we do at the State veterans' homes and we really respond
    to what education they request because of what they are seeing
    in their population at the time. A lot of our mental health
    training and education has been over disruptive and disturbing
    behaviors, obviously, as well as falls, but we have been
    working with the Office of Mental Health and Suicide Prevention
    and they are actually in the active process of planning new
    educational interventions at the State homes and others when it
    comes to suicide prevention, especially in the elderly
    population, which is actually psychiatry.
        Ms. Miller-Meeks. Could is also being complicated by the
    incidence or, excuse me, prevalence of Alzheimer's or dementia
    as one ages?
        Mr. Hartronft. Yes and no. From the geriatric perspective,
    obviously, there is dementia and other aspects but also,
    especially in elderly men after they become recent widows,
    there is those significant changes in life when they do have
    that increase across all populations, the veteran and non-
    veteran based on age. That is one reason why we are working
    with the Office of Mental Health to get geriatric psychiatry to
    get those levels of education and recognition because they can
    be very subtle in the older population.
        Ms. Miller-Meeks. I would also like to commend you on the
    response by the modernization, the changing in your processes,
    the going from decentralization to some centralization which
    has helped to clear up a lot of the deficiencies and demerits
    within the system, so I am just going to--there has been a
    little bit of criticism toward you for that but let me commend
    you on being able to do as much as you have by looking at the
    process itself and to see how you can change behavior through
    that mechanism.
        Can a State veterans' home that receives citations for
    deficiency in the annual VA audit still get funding on the same
    terms as a home that receives no deficiencies?
        Mr. Hartronft. In the overall nursing home industry it is
    rare that no one gets no deficiencies, but just, kind of,
    showing that single digits usually. Because there is over 200
    standards at the VA we call it the CMS standards plus fiscal
    with the administration, we do a ton of standards.
        It would be very rare that you do not have at least one, no
    matter being a very good facility. There is always some policy
    or something that might get you somewhere, but overall we have
    seen where we work with them very closely and really just
    making sure that things get cleared up and they get the support
    they need.
        We have literally had some State veterans' homes where the
    local VA sent staff to provide direct education just in time
    and others to really make sure that we are getting--we are
    really wanting the outcomes. The outcome is really to make sure
    that the veteran gets better care, so the local VAs have
    invested a lot in their local VA State veterans' homes.
        Ms. Miller-Meeks. Would more enforcement measures create
    more opportunity for correction?
        Mr. Hartronft. At this time based on the outcomes we are
    seeing with our current escalation plan, which is our outcome
    is to get these compliant and we have been successful. Again,
    as I said, we have been taking some external feedback to the
    point where that we are discussing are there next steps? That
    will obviously take longer in time, but we really wanted to
    focus what could we do more immediately within our parameters,
    knowing that some of the other measures may take a little
    longer going through other processes.
        Ms. Miller-Meeks. Again, I commend you for what you have
    been able to achieve thus far.
        I had a question for Ms. Silas but, Ms. Silas, I will
    submit it for the record since my time is running out.
        On behalf of the subcommittee I want to thank you all for
    your testimony and for joining us today. You are now excused
    and we will wait a moment as the second panel comes to the
    witness table. Thank you so much.
        I would now like to introduce the panel two witnesses.
    Testifying before us today we have Mr. Ed Harries, president of
    the National Association of State Veterans' homes. Mr. Harries,
    if I have mispronounced your name please feel free to correct
    me. The Honorable Charlton J. Meginley, colonel, retired U.S.
    Air Force, secretary of the Louisiana Department of Veterans
    Affairs (LDVA).
        Mr. Harries, you are now recognized for 5 minutes to
    deliver your opening statement.

                        STATEMENT OF ED HARRIES

        Mr. Harries. Chairwoman Miller-Meeks and Ranking Member
    Brownley, as president of National Association of State
    Veterans' Homes (NASVH) thank you for inviting me to testify
    today.
        State homes provide about half of all VA-supported skilled
    nursing care for veterans, yet we consume only 18 percent of
    the VA's total budget for this care. According to the VA, the
    calculated institutional per diem for State homes is $262
    compared to $424 for private community homes, and $1,971 for VA
    Community Living Care (CLC).
        According to CMS data, the veterans' homes are safer, have
    a higher quality rating, and receive fewer substantiated
    complaints and citations compared to community nursing homes.
    Approximately 70 percent of the State homes are rated as four
    or five star facilities compared to just 35 percent of the
    community homes.
        State homes also had 70 percent fewer substantiated
    complaints and half the number of infection control citations.
    Community homes are primarily overseen by CMS while State homes
    have significant oversight from VA, CMS, and our State
    government.
        All homes receive annual VA inspections and 75 percent are
    also inspected by CMS. 85 percent are subject to either annual
    or for cause infections by their states.
        Madam Chairwoman, while oversight is a necessary component
    of any well-run organization, it must be balanced against the
    dangers of overregulation.
        Nursing home administrators spend an estimated 20 percent
    to 30 percent of their time on regulatory compliance and
    reporting, diverting focus from resident care and staff
    management.
        Overregulation creates a high pressure environment for
    staff. Studies from the Journal of Nursing Regulation linked
    high levels of regulatory burden to increased stress among
    frontline staff and administrators alike.
        Overly burdensome regulations can also stifle innovation.
    The Rand Report noted that facilities hesitant to adopt
    telehealth, personalized dementia interventions, or adaptive
    care models often cited fear of regulatory noncompliance as a
    primary barrier.
        While good governance of any organization must include a
    through and effective oversight, overregulation can undercut
    its efficacy.
        Madam Chairwoman, NASVH has several recommendations to
    strengthen and expand services for aging veterans at State
    veterans' homes. We strongly support the Providing Veterans
    Essential Medications Act, and we want to thank you and
    Congressman Pappas for introducing this legislation to address
    the problem of high cost medications.
        We were both surprised and disappointed that the VA
    testified in opposition to your bill. VA officials were aware
    of the problem and have told NASVH on multiple occasions in
    recent years that they were interested in solving it.
        The technical concerns raised by the VA could all be easily
    overcome with clarifications and additional legislative
    language. We stand ready to work with you and your committee to
    perfect this legislation.
        Another problems State veterans' homes must overcome is the
    VA's failure to cover the cost of specialty care. Although VA
    is required by law to pay for specialty care, in practice the
    VA is regularly refusing to do so, particularly for psychiatric
    care.
        Madam Chairwoman, many State veterans' home face continuing
    and significant financial challenges due to the COVID pandemic.
    We are still recovering. To help address this problem, NASVH
    supports an increase in the basic per diem rates and calls on
    Congress to appropriate at least $650 million to put toward
    ending construction projects.
        Finally, I would like to discuss how the veterans' homes
    may help improve mental health support for aging veterans.
    Public Law 117 through 28 require the VA to create a geriatric
    psychiatry pilot program in the State veterans' homes. Instead,
    the VA implemented only a limited expansion telemedicine mental
    health services.
        NASVH believes that the homes could play a larger role in
    addressing the mental health needs of our aging veterans. We
    would like to work with you to develop a new pilot program to
    do exactly that.
        Research has shown that many of the supports that State
    veterans' homes provide to its aging veterans require
    protective factors for veterans in crisis and at risk for
    suicide. Expanding the scope of the long-term care services
    offered by veterans' homes could play a small but meaningful
    part in the VA's suicide prevention efforts.
        That concludes my statement, and I would be pleased to
    answer any questions you or any members may have.

        [The Prepared Statement Of Ed Harries Appears In The
    Appendix]

        Ms. Miller-Meeks. Thank you, Mr. Harries.
        Secretary Meginley, you are now recognized for 5 minutes to
    deliver your opening statement.

                     STATEMENT OF CHARLTON MEGINLEY

        Mr. Meginley. Chairwoman Miller-Meeks, Ranking Member
    Brownley, distinguished members of the House Veterans Affairs
    Committee (HVAC), on behalf of Governor Jeff Landry thank you
    for providing us the opportunity to address the critical topic
    of long-term care for our veterans, specifically in Louisiana's
    veterans' homes, which I will give you a little bit of
    information about.
        While I cannot speak for the operations in other states, I
    assure you that Louisiana we have the requisite leadership,
    oversight, and a highly competent and dedicated staff to ensure
    that our veterans receive high quality, safe patient care and
    are always treated with the dignity they have earned and
    deserved.
        Our five veterans' homes in Louisiana are situated and
    placed across the State. They are sanctuaries for those who
    have sacrificed greatly for our Nation. These facilities
    provide more than shelter and medical care. They offer a
    community where veterans are honored, respected, and cared for
    with deep compassion.
        Our staff, the nurses, administrators, aides, social
    workers, therapists, and support personnel are the heart of
    this sacred mission. They take the time to understand each
    veteran's needs, stories, and preferences and, in turn, build
    meaningful connections.
        Whether assisting with daily activities or maybe medical
    care or simply listening, these professionals create an
    environment of dignity and respect. Their work reflects a
    profound commitment to preserving each veteran's worth through
    connection, purpose, and recognition.
        Now, contrary to the 2022 GAO report, we believe our
    veterans' homes operate under significant oversight to ensure
    the highest standards are maintained.
        Federal and State agencies, including the Department of
    Veterans Affairs, Centers for Medicare and Medicaid Services
    via Louisiana Department of Health, Louisiana legislative
    auditors, Louisiana Office of Risk Management, Louisiana civil
    service, along with our own DVA internal auditors and our own
    DVA compliance team conducts regular inspections to evaluate
    everything from medical care quality to facility safety.
        Compliance with these rigorous standards is mandatory. This
    oversight is complemented by internal quality assurance
    programs and an ongoing policy revision and staff training that
    prioritize quality care and resident rights, patient safety,
    and well-being.
        Any concerns raised by any resident or their family members
    are addressed through formal grievance processes, which ensures
    accountability at every level. Under our leadership, our
    clinical teams have driven significant improvements in care
    quality.
        VA survey deficiencies decreased by 36 percent from 53 in
    2023 to 34 in 2024, but the 34 does not really tell the whole
    story. Further breakdown of these 34 deficiencies across all
    five of our veterans' homes shows that 91 percent were minimal
    with no actual harm, essentially a level B or below.
        In fact, one of our deficiencies was for a burned out light
    bulb. Another was for a fryer that had been cleaned and
    replaced one inch from its original position.
        I note that our system-wide pressure ulcer rates remain at
    or below 5 percent, approximately one-third of the national
    average of 15 percent for long-term care facilities.
        According to the CMS Nursing Home Care Compare Survey,
    three of our five facilities have earned five star ratings with
    the remaining two achieving four star ratings, all by
    prioritizing robust census growth. We are proud of the care
    that we provide our veterans in Louisiana.
        However, Ms. Chairwoman, we recognize that there is always
    going to be improvement or room for improvement. In a written,
    excuse me, in our written statement we provided some
    information about the escalating cost of medication, which we
    have covered here today is, something that we fully support.
        The LDVA would also like to see greater support for our
    veterans' mental health and behavioral programs. We are
    experiencing a continued rise in the prevalence and acuity
    level of mental health and behavioral issues which negatively
    impact both clinical coordination and home admissions. In
    essence, there are plenty of veterans who we have to turn away
    because we simply do not have the capability to meet their
    needs.
        Pilot studies to identify optimal staffing, infrastructure,
    and operations of enhanced geriatric psychiatric care
    capabilities are warranted and Louisiana is ready to lead this
    effort.
        Ms. Chairwoman, veterans in our homes are not just
    patients. They are family members. They are heroes. Our staff's
    clinical competency and dedication ensures that their dignity
    is not only preserved but celebrated while they continue to
    receive high quality and safe care.
        Robust oversight from engaged leaders and unwavering
    commitment of staff create a foundation of trust and respect
    that honors our Nation's promise and our state's promise to our
    veterans.
        I want to thank you for your continued support of our
    veterans and the homes that serve them. I welcome any questions
    that you may have.

        [The Prepared Statement Of Charlton Meginley Appears In The
    Appendix]

        Ms. Miller-Meeks. Thank you, Secretary Meginley. As is my
    typical practice I will reserve my time until all other members
    have had a chance to ask their questions.
        I now recognize Ranking Member Brownley for 5 minutes for
    any questions she may have.
        Ms. Brownley. Thank you, Madam Chair.
        Mr. Harries, I just wanted to start off with Mr. Taylor was
    here and seemingly introduced a new bill, and my understanding
    of the bill is that he wants to take $2 billion in funds that
    were appropriated to the U.S. Agency for International
    Development, or USAID, and reallocate those funds to the VA for
    State veteran homes construction grants. Is that a bill that
    you support or have you had a chance to look it over?
        Mr. Harries. Yes. Actually, I have. The NASVH cannot
    determine where the money is going to come from. However, there
    is a huge need for more State veterans' homes across the
    country. If you think about it, and you are well-aware, the
    bolus or bubble of veterans coming at us in the age group we
    care for, it is not stopping. It is coming at us.
        On top of that, with respect to the high-cost medication
    mitigation, more and more of these are coming through toxic
    exposures, cancer diagnoses, Parkinson's, very, very complex
    care.
        More veterans' homes actually allows the VA to or
    accelerates the VA to complete their mission of reaching out to
    veterans across the country. Let us provide the footprint that
    they can build on.
        Ms. Brownley. Well, thank you for that. You know, and I
    agree with you. I think we need to provide more resources. I
    have worked very hard in my tenure in Congress to expand and
    extend long-term care. My veterans' home, my State veterans'
    home within my district, is an extraordinary place with many
    happy, happy, happy veterans and their spouses as well and so I
    agree with you.
        I just, in terms of Mr. Harris' (sic) bill I just, kind of,
    feel as though, from my perspective anyway, that U.S. foreign
    assistance is essential, a component to our national security.
    I think veterans who serve abroad probably understand that very
    well in terms of what USAID does in fostering goodwill toward
    our Nation.
        I think USAID literally saves lives by bringing food,
    medicine, and stability to impoverished nations, and I think
    the bill just represents a false choice between funding veteran
    programs versus global security and international cooperation.
        Quite frankly, I think that we must fund both is my
    perspective and we can do both if we do so with rational tax
    policies that require millionaires and billionaires to pay
    their fair share rather than providing massive giveaways. I
    think that is what is happening right now as we speak under the
    dome here through reconciliation as we are working through a
    tax plan to give millionaires and billionaires great tax cuts
    at the expense of others.
        I just wanted to State that for the record, and I will move
    on and wanted to ask you both with the question that I had
    asked Dr. Hartronft earlier when he was here. If there is a
    significant cut to Medicaid over the next 10 years, have your
    respective states analyzed the extent to which this may
    increase veterans' reliance on State veteran homes? If these
    cuts lead more veterans to turn to State veteran homes for
    long-term care services?
        Mr. Harries. I am assuming the question is for me?
        Ms. Brownley. Yes, either one of you.
        Mr. Harries. Well, first, we would want all veterans to
    come to the State veterans' homes.
        Ms. Brownley. Yes.
        Mr. Harries. I mean literally.
        Ms. Brownley. Understood.
        Mr. Harries. We do serve and provide a much higher level of
    service and quality of life. We firmly believe that I have seen
    it firsthand. With those Medicaid cuts, 75 percent of the
    veterans' homes are covered by CMS so therefore they would have
    a significant Medicaid population in the mix.
        If the cuts are applied to long-term care limit levels at
    that point. We have done those studies to accommodate for that
    at this point but would be willing to look at that and any
    studies that do come forward.
        Ms. Brownley. Very good. I think I, you know, and this last
    week I visited several facilities in my district within our
    county hospital and, you know, they were talking about the
    devastation the hospital would undergo if these cuts were
    pursued.
        They also were, sort of, in a wait and see mode to just,
    kind of, see what happens before they take any action,
    obviously, but they went through a quick laundry list of where
    the impacts would be. They would be pretty devastating and I
    guess my time is up and I yield back.
        Ms. Miller-Meeks. Thank you very much. I thank your county
    hospitals for not responding to stuff that has not yet
    occurred. Thank you for that.
        Again, I am going to apologize to the witnesses for members
    that are not here given the numbers of markups that are going
    on throughout.
        I also appreciate that it seems that Mr. Harries and
    Secretary Meginley that you understood the point of my
    questioning to Ms. Silas regarding oversight, that oversight
    for State veterans' homes occurs far beyond just the VA or the
    HVAC Health Subcommittee or HVAC Committee here in Congress,
    that you have multiple regulatory bodies conducting oversight.
        To your point Mr. Harries, it sometimes actually creates
    burdens and hurdles and lack of innovation or new processes.
    Again, I commend the VA and Dr. Hartronft for the progress they
    have made in clearing deficiencies, so I just wanted to
    recognize that.
        Mr. Harries, how could VA health care be improved to
    address gaps in medication reimbursement at State veterans'
    homes?
        Mr. Harries. How could it be improved? If the VA were to
    accommodate the State veterans' homes through as they do the
    private sector nursing homes by paying for, reimbursing for
    those high-cost medications.
        Ms. Miller-Meeks. For medication that they cover outside--
    --
        Mr. Harries. Correct.
        Ms. Miller-Meeks [continuing]. of the veterans' homes?
        Mr. Harries. Exactly. My point is we are doing it for one
    party but we are not doing it for another and we are the party
    that is not getting that reimbursement.
        There are states, and I have stories already in my previous
    testimony, and I believe there may be some in this one where
    veterans have been turned away because they have $100,000
    medication or a $28,000 medication coming in which it is the VA
    per diem rates that are paid. That is a financial loss for the
    facility. That loss has to be made up somewhere else, which
    would probably be in resident care, probably not adding another
    admission, and just the cascading effect.
        I think the key thing is covering those medications as they
    are coming, and as I spoke earlier, the number of residents
    that we are seeing now, the number of patients coming to us
    with high-cost medications and complex comorbidities, such as,
    well, the reimbursement has got to come, especially with all
    the toxic exposures and Agent Orange exposures and such.
        Ms. Miller-Meeks. Last month we discussed a pilot program,
    the Communities Helping Invest through Property and
    Improvements Needed for Veterans (CHIP IN) Act, which had been
    used to instruct a VA clinic next to the VA Medical Center in
    Omaha, Nebraska, and extending the CHIP IN Act from its pilot
    program for construction for either VA hospitals and/or VA
    clinics.
        Even though the State veterans' home are a combination of
    State funding and VA funding, is this something that a little
    bit of out-of-the-box thinking that could be applied to
    construction grants for State veterans' homes?
        Then I have got an extension to that question.
        Mr. Harries. I do not see why not. It sounds like a
    fantastic idea.
        Ms. Miller-Meeks. We might need to expand our potential
    legislation. The current interpretation of Federal regulations
    does not allow a State veterans' home to apply for a
    construction grant in order to begin new adult daycare health
    program. A home may only seek a grant to expand or replace a
    facility currently being used for adult day health care. What
    complications does this pose for State veterans' homes that
    want to provide adult daycare?
        Mr. Harries. It cannot do it unless they pay for it
    entirely on their own and it is a sizable investment in care.
    Adult daycare, and we have talked about suicide prevention and
    mental illness with our veterans that are coming in, adult
    daycare, the medical model of adult daycare, the residents are
    assessed on a daily basis to make sure that does not happen.
        It also takes out the isolation that causes a lot of
    suicides. It would be vital for us to be able to expand that
    program and have satellite offsite clinics available under
    outpatient or adult daycare facilities so that we can monitor
    and take care of those residents. Their life would be much
    better improved if we could do that.
        Ms. Miller-Meeks. Thank you.
        Secretary Meginley, several of Louisiana's State veterans'
    homes are in rural areas. What are challenges and best
    practices for coordinating transportation for veterans who need
    specialized care?
        Mr. Meginley. Yes, ma'am. One of our homes is in the rural
    area of Jennings. One of the challenges that we have, because
    it is in a rural area, is making sure that we have the
    appropriate staff. Obviously, making sure we have the Licensed
    Practical Nurses (LPNs), the Registered Nurses (RNs) to be able
    to come in.
        We are having to pull from different metropolitan areas
    making sure that these individuals are well-funded, well-paid
    is something that we consistently work with our Louisiana civil
    service to make sure that those folks are paid at least market
    rate at a minimum and offered additional co-pays as needed.
        As far as getting them to the facilities, luckily, Bossier
    is okay. Our home in Bossier is next to Overton Brooks in
    Shreveport so they have easy access to the hospital. Reserve is
    close to New Orleans VA. Jackson is not too far from our
    Community-Based Outpatient Clinic (CBOC) in Baton Rouge, which
    is very well equipped, I think.
        Yes, that is a problem. Something that we have talked about
    extensively is about rural transportation for veterans to VA
    hospitals and something that we have had since the
    conversations with our administrators about making sure that we
    can facilitate those needs.
        Ms. Miller-Meeks. Thank you. I would yield. I know. I am
    sorry. She was telling me Dr. Morrison is here. Do I know Dr.
    Morrison is here? I was just about to say I yield the remainder
    of my time.
        The chair now recognizes Dr. Morrison for 5 minutes for any
    questions she may have.
        Ms. Morrison. Thank you, Madam Chair.
        Thank you to our witnesses for testifying today on the role
    of State veterans' homes play and caring for our aging
    veterans. You know, a key aspect that strikes me as fundamental
    to today's hearing is the importance of having robust data to
    review as we discuss opportunities to improve oversight and
    ultimately the quality of care in State veterans' homes.
        I know several years have passed since the last hearing on
    this issue here in Congress with my colleagues, and I have had
    the benefit of being able to review data GAO compiled in their
    2022 review, as well as data from research conducted in
    collaboration with the VA and other research entities.
        I emphasize that we have this data as a result of
    intentional and consistent efforts to monitor the quality of
    care at State veterans' homes and conduct research in this
    area. As a result of these research and monitoring efforts, we
    are able to better understand elements such as the population
    of veterans that use State veterans' homes, how State veterans'
    homes are meeting needs in comparison to community nursing
    homes and VA's community living centers, how well State
    veterans' homes responded to the COVID-19 pandemic, and even
    what areas of operation oversight might warrant additional
    review.
        Having spent over 2 decades of caring for patients as a
    physician myself, it is important to me that our next steps
    consider evidence-based strategies and place data and form
    responses at the forefront of our actions, so I want us to
    continue using the data available to us in hearings like the
    one we are having here today.
        Equally and perhaps more critical in this particular
    moment, I think it is imperative that we continue to collect
    this data and not undermine the research that supports our
    collective pursuit of best practices and quality care for our
    veterans.
        Secretary Meginley, in your testimony you discussed best
    practices for the State veterans' homes under your management.
    I appreciate that you began your statement affirming your
    state's unwavering commitment to safely and effectively
    managing State veterans' homes and conclude expressing your
    willingness to continue working closely with your VA partners
    turn to ensure clinical quality and patient safety.
        Can you elaborate a little bit more on how this partnership
    with VA has contributed to your ability to deliver high quality
    care in State veterans' homes?
        Mr. Meginley. Yes, ma'am. I will tell you all, I am not
    just a veteran. I am a patient of the New Orleans VA. That is
    where I go to all my healthcare. I have a phenomenal
    relationship with my administrator. I can call my administrator
    at midnight on a Friday night, which I have done, to ensure
    that a veteran who is having a mental health crisis is taken
    care of immediately.
        My administrators both in Alexandria and Shreveport are
    very much the same. The rural health care question, recently I
    was at Monroe and the honeymoon period of my time ended very
    quickly when I got confronted about community care issues.
        I contacted my administrator in Shreveport and gave him the
    questions that some of the veterans had had concerns about, and
    that administrator answered those questions within 72 hours and
    restored some of these processes to make sure that our rural
    veterans were getting the health care that they needed through
    the CBOC entity in Shreveport.
        The same for Alexandria as well, so, ma'am, I think my
    relationship with my administrators is phenomenal, and I can
    call any of my VA partners in a heartbeat and the answers and
    the questions that I have will get taken care of without
    question.
        I think that is one of the strengths. I am in Alexandria. I
    live on the north shore of Louisiana not too far from New
    Orleans. I have been to Shreveport almost a dozen times, and
    every time I go either myself or my deputy, who is behind me,
    go and visit the VA administrators and ask them what can we do
    for you as a state? We give them what our questions are as to
    how they can help us with our veterans as well.
        To me, that is the forefront and the heart of everything
    that I do. As a State VA I cannot do my job without being
    intertwined at the hip with my VA administrators and my VA
    partners.
        Ms. Morrison. Thank you for that response. Colonel--
    Secretary, I should say, you also mentioned rigorous oversight
    is an element that supports your delivery of compassionate,
    high quality services.
        Mr. Harries, you specifically cited the layers of oversight
    for State veterans' homes as a reason that they offer higher
    quality. Could each of you speak just briefly to the importance
    of collecting robust data at the Federal and State levels and
    how additional research informs the administration of the care
    provided at State veterans' homes?
        Mr. Meginley. Well, I will tell you this. My deputy and I,
    my deputy is a retired Army doc, by the way, on my staff, so I
    have an on-staff physician to be able to help me answer some of
    the questions.
        You talk about data. We have been talking about data since
    day one, and I will tell you one of the most important pieces
    of data that has stuck with me over and over is the fact that
    we turn away 72 percent of veterans who have mental health
    issues. We do not have the capability to be able to take care
    of their needs.
        When you start talking about those numbers--we talk about
    pressure ulcer rates. One of our homes had a very low pressure
    ulcer rate. We wanted to know why your rate was so much lower
    than the others. They were all still below the national
    average, but what were you all doing differently?
        That data allowed us to go find the answers and take that
    best practice and put it and put it in the other four homes. We
    have also talked about, you know, other data points that would
    make our workforce stronger, our medication issues stronger,
    because as Mr. Harries talked about, prescription costs are
    extraordinary, particularly in some cases. Trying to figure out
    ways to make sure that our veterans are being taken care of,
    again, having the data is very vital to us. We live and die by
    data essentially every day so that we can make our homes
    better.
        Ms. Miller-Meeks. Is there----
        Ms. Morrison. Well, I was hoping that Mr. Harries might
    comment, too, in----
        Mr. Harries. Sure.
        Ms. Miller-Meeks. Briefly, sir.
        Ms. Morrison [continuing]. 39 seconds left.
        Ms. Miller-Meeks. The gentlewoman's time has expired.
        Mr. Harries. I am a six sigma black belt, which means that
    I love data and the more data I can get the better. It is the
    way you are going to solve your problems. It is the way you are
    going to get there.
        Before we close or you cut me off, what I do want to State
    is I have heard it once that VA has the largest compilation of
    health care data in the world. Utilize that. Let us look at
    that. Let us see what we can do to leverage that to make some
    improvements.
        Ms. Morrison. Thank you.
        Thank you for your indulgence, Madam Chair.
        Ms. Miller-Meeks. Thank you for yielding.
        Members can always submit questions for the record, which I
    have done earlier so that I would not go over time.
        Ranking Member Brownley, would you like to make any closing
    remarks?
        Ms. Brownley. I thank you for having the hearing. I think
    this topic is an important one. With the colonel's answer to
    Ms. Morrison's question, I wonder how we can have the
    relationship that you described between your medical center and
    your State veteran home, how that relationship, how we can have
    that everywhere across the country.
        Mr. Meginley. Well, I will tell you, ma'am, it helps when
    you are a patient because I go in 1 day as a State secretary
    leader and the next thing I am getting my knee injected. I get
    a chance to see what they are doing.
        Ms. Brownley. Thank you. Yield back.
        Ms. Miller-Meeks. Thank you.
        I will recognize you in the future, sir.
        Mr. Meginley. I am sorry, ma'am.
        Ms. Miller-Meeks. Sorry, chain of command. Two veterans
    ought to know.
        Number one, again, I want to apologize. My sincere
    apologies to our witnesses, to the VA, to the secretary, to Mr.
    Harries for the lack of members who are here. I thank the
    members who came. I thank you all very much.
        When we set up hearings we do not necessarily know that
    there are going to be markups and there are numerous markups by
    numerous committees today. I am supposed to be over in one in
    Energy and Commerce but thank you for being here.
        Thank you for your participation and taking the time in
    today's hearing. This actually is an extremely important topic,
    both given how much regulatory burden there is and oversight
    there is in health care and also the very important work that
    you do given the population that you serve and the increasing
    numbers of that population receiving access for care.
        The complete written statements of today's witnesses will
    be entered into the hearing record. I ask unanimous consent
    that all members have 5 legislative days to revise and extend
    their remarks and include extraneous material. Hearing no
    objection, so ordered.
        I thank all members and their witnesses for their
    participation today. This hearing is adjourned. Thank you so
    much.
        [Whereupon, at 3:33 p.m., the subcommittee was adjourned.]

    ?

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                             A  P  P  E  N  D  I  X

    =======================================================================

                        Prepared Statements of Witnesses

                                  ----------

                     Prepared Statement of Scotte Hartronft

        Good afternoon, Chairwoman Miller-Meeks, Ranking Member Brownley,
    and distinguished Members of the Subcommittee. My name is Dr. Scotte
    Hartronft, and I am the Executive Director of the Office of Geriatrics
    and Extended Care at the Department of Veterans Affairs (VA). I am
    honored to discuss the strategic approach VA employs, which results in
    high-quality health care outcomes and support for the Nation's heroes
    at State Veterans Homes (SVH). SVHs are owned, operated, and managed by
    the states. VA's role as it relates to SVHs is as a support to ensure
    Veterans receive the high-quality care which meets the Department's
    standards, through annual certification and recognition surveys,
    Medical Sharing Agreements, and grants to construct, renovate, or
    repair State owned facilities.
        Currently, the Department supports 172 SVHs, which administer a
    combined 166 Nursing Home Programs, 47 Domiciliary Care Programs, and 3
    Adult Day Health Care Programs. To participate in the SVH program and
    its benefits, VA must formally recognize a care facility as an SVH
    through the certification process and a recognition survey. Along with
    compliance with VA standards, a recognition survey requires adherence
    to all applicable Federal, State, and local laws including the relevant
    professional standards for VA purposes to recognize the home as an SVH.
        After formal recognition, VA conducts at least one unannounced
    annual survey at each facility to ensure compliance with VA standards.
    The VA surveys cover 200 clinical standards, fire and life safety
    standards, administrative standards, and fiscal standards. Many of the
    standards are based on the CMS nursing home standards but others are VA
    and SVH unique. Any areas of non-compliance identified on surveys are
    addressed through corrective action plans in collaboration with the
    Veterans Health Administration survey team. During the corrective
    action plan follow-up period an ad-hoc for cause full survey can be
    completed if felt necessary. Compliance with VA regulations under 38
    C.F.R. part 51 and VA's survey and certification process is required
    for SVHs that provide nursing home care, domiciliary care, or adult day
    health care to remain eligible to receive per diem payments or
    participate in the State Home Construction Grant Program (SHCGP). VA's
    survey process mirrors the Centers for Medicare and Medicaid Services
    (CMS) for long-term care facilities.
        VA offers support to SVHs by permitting recognized SVHs to enter
    into Medical Sharing Agreements with their local VA Medical Centers to
    procure additional clinical services or secure discounted
    pharmaceutical prices. The SVH's that are CMS certified also on average
    outperform the US nursing home star rating on their CMS surveys. To
    maintain SVH recognition, VHA may also provide funds to ensure adequate
    levels of nursing staff. In Fiscal Year 2024, VA approved $4.7 million
    for the 17 states and 47 SVHs that applied for Federal funds to support
    programs that hire or retain nursing staff.
        SHCGP is a partnership between VA and the states to construct,
    renovate or repair state-owned and operated nursing homes,
    domiciliaries, and/or adult day health care facilities. VA provides
    reimbursement of up to 65 percent of allowable costs to states for the
    construction and renovation of SVHs. The number of awards provided each
    year depends on the number of projects, their costs, and the amount of
    appropriation received in the fiscal year. VA is responsible for
    determining the priority for funding facility improvements, which may
    include bed replacements, mold removal, and repairs to structural
    hazards to assist SVHs in proving high-quality care for Veterans.

    Conclusion

        In conclusion, VA remains steadfast in its dedication to continuous
    improvement in the oversight of SVHs. We appreciate the oversight from
    the Subcommittee and look forward to answering any questions you may
    have.

                       Prepared Statement of Sharon Silas

                        Prepared Statement of Ed Harries
    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

                    Prepared Statement of Charlton Meginley
    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

                           Statements for the Record

                                  ----------

          Prepared Statement of Florida Department of Veterans Affairs

        We operate nine State veterans' homes in Florida with a
    total of 1,102 beds. Eight are skilled nursing facilities and
    one is a domiciliary offering assisted living. Florida's State
    Veterans' Nursing Homes are among the top nursing homes in the
    State.
        The relationship between the VA and Florida is good;
    however, the VA long-term care system has historically
    struggled to keep up with current national long-term care
    models. Highlighting home and community-based care should be
    encouraged. We recommend VA support States and Territories that
    desire to integrate a long-term care campus that allows them to
    offer additional services to Veterans to remain in their homes
    in the community.
        We recommend changing the static model of traditional
    nursing home beds to one that provides Veterans with a more
    robust venue of long-term care services. Florida is planning a
    120-bed State Veterans' Nursing Home that includes adjoining
    Adult Health Day Care, outpatient rehabilitation services and a
    community wellness center for local Veterans. We feel the
    decades-old model for strictly long-term care beds is
    restrictive and does not reflect the needs of today's aging
    Veteran. Additionally, our proposed model will allow Veterans
    to access health care services while providing an avenue for
    camaraderie that can improve their health outcomes.
        Previous attempts to provide these updated services in
    existing State Veterans' Home sites have been denied by the VA,
    citing 20-year moratoriums imposed on original construction
    grants designed solely for long-term care beds. The denial is
    based on VA's interpretation of 38 CFR Sec.  59.110.
        Providing enhanced services to local Veterans in areas with
    a small VA footprint saves travel time and keeps Veterans in
    their homes, allowing much-needed respite care for their family
    members and caregivers. The added socialization combats
    isolation and conversely helps combat veteran suicide.
        VA's State Veteran Home Construction Grant Program should
    reflect these new national models of long-term care as States
    seek to expand their services for Veterans. We also recommend
    an overall increase in funding for the State Veteran Home
    Construction Grant Program to combat a backlog of vital
    projects. Previous years funding has made only a small dent in
    expanding and enhancing long-term care services for our
    Veterans. Many needed construction and rehabilitation efforts
    are delayed by years due to inadequate funding. According to
    the VA, the State of Florida is currently short of more than
    2,900 Veterans' Nursing Home beds. At the current rate of
    funding, it would take decades to fill the gap. We believe
    increased funding, coupled with access to non-institutional
    long-term care, can provide a bridge for our aging Veterans'
    long-term care needs.
        In Florida, it costs nearly twice the reimbursement rate
    provided by VA to pay for care of Veterans in our 150-bed
    Domiciliary home. We recommend VA review their compensation
    rates for long-term care, as reimbursements to States for
    Veterans in Veterans' Domiciliary Homes vastly understate the
    true cost of healthcare.
        We appreciate the opportunity to provide testimony and
    continue our collaborative work with the VA to enhance care for
    our Nation's Veterans.

      Prepared Statement of Veterans of Foreign Wars of the United States

        Chairwoman Miller-Meeks, Ranking Member Brownley, and members of
    the subcommittee, on behalf of the men and women of the Veterans of
    Foreign Wars of the United States (VFW) and its Auxiliary, thank you
    for the opportunity to provide our comments on this important topic.
        As the United States veteran population ages, the demand for long-
    term care will increasingly represent a significant portion of the
    Department of Veterans Affairs (VA) health care. Long-term care
    includes various services to address a veteran's health or personal
    care needs when the individual can no longer perform daily activities
    unassisted. VA offers care through nursing homes, assisted living, home
    health care, and State Veterans Homes (SVHs). SVHs are nursing
    facilities, assisted living facilities, or domiciliary care homes
    operated by State governments specifically for veterans. They provide
    long-term care services customized to address the unique needs of
    veterans. There are many benefits to SVHs, such as subsidized care, VA
    per diem grants that lower out-of-pocket expenses, and a supportive
    environment to connect with fellow veterans and build camaraderie. VA
    provides general oversight to all 153 SVHs, which collectively care for
    approximately 14,500 veterans.

    Background

        State Veterans Homes trace their origins back to the pre-Civil War
    era, designed initially to care for injured and aging soldiers. These
    facilities were commonly referred to as soldiers' homes. In 1888,
    Congress authorized Federal funding to support state-operated veterans'
    homes, establishing a partnership between State and Federal Governments
    that continues today. VA provides per diem payments for each veteran
    receiving care in these homes. It is another way to assist the veteran
    in cutting out-of-pocket costs. VA also provides construction grants
    covering up to 65 percent of building or renovation costs of SVHs.
    States are required to provide at least 35 percent in matching funds.
    To qualify for VA funding, SVHs must adhere to VA quality standards in
    areas such as quality of care, standard of living, infection control,
    and resident rights.
        All 50 states and Puerto Rico either have at least one SVH or have
    been approved to build one, and some states have multiple homes due to
    population size or geographic distribution. Examples of State agencies
    that oversee SVHs include the California Department of Veterans Affairs
    (CalVet), the Texas Veterans Land Board, the New York State Division of
    Veterans' Services, and the Florida Department of Veterans Affairs.
    SVHs typically offer services, including skilled nursing care, assisted
    living for independent veterans needing support, memory care units, and
    short-term rehabilitation or post-acute care. Eligibility criteria for
    SVHs generally require service in the U.S. Armed Forces with an
    honorable discharge, residency in the State, and medical or personal
    care needs that align with the services provided.

    Needs of the Aging Veteran

        Aging veterans are unique individuals shaped by their military
    experiences, natural aging processes, and socioeconomic circumstances.
    Many elderly veterans face multiple chronic conditions and may have
    health issues related to their service, which can lead to the need for
    assisted living or nursing care. They may encounter various challenges,
    including limited income, transportation barriers, social isolation,
    difficulty accessing benefits, and cognitive decline.
        Essential services for aging veterans include geriatric primary
    care, mental health support, neurology and memory care, rehabilitation
    and physical therapy, and dental and vision care. For veterans who can
    no longer live independently, a skilled nursing facility may be the
    best option, particularly if they are unable to perform activities of
    daily living or require supervision due to vulnerability. Loneliness
    and a diminished sense of worth often become more pronounced as they
    age. The camaraderie once enjoyed may be a distant memory, overshadowed
    by declining health and the loss of family and friends. All of these
    factors can contribute to higher risks for suicide among aging
    veterans.
        A coordinated, veteran-centered approach is necessary to
    effectively meet the needs of aging veterans and address their overall
    well-being. This approach should include medical and mental health
    care, housing, social connections, and the dignity that should be
    afforded to them. Delivering comprehensive care including geriatric-
    specific services, and integrated mental and behavioral health support,
    is critical for enhancing the quality of life for these individuals.

    SVH Oversight

        State governments and VA collaborate to provide SVHs as an option
    for veterans. VA is responsible for providing per diem for eligible
    veterans, and construction grants for building and renovating
    facilities. Unfortunately, there is a massive $1.2 billion backlog in
    construction needs of SVHs, which potentially places some veterans in
    unsafe living conditions and others waiting for available facilities.
        VA's Geriatrics and Extended Care program oversees the per diem
    funding and ensures compliance with VA standards. These standards
    include maintaining quality of care, adequate staffing levels, timely
    recordkeeping, and safe, sanitary living conditions. VA conducts
    regular inspections, and homes that do not meet these standards are
    cited for deficiencies. According to a November 2022 Government
    Accountability Office (GAO) report, VA Nursing Home Care: Opportunities
    Exist to Enhance Oversight of State Veterans Homes, deficiencies
    increased from 424 in 2019 to 766 in 2021. This included a 12 percent
    rise in deficiencies that resulted in actual harm or immediate
    jeopardy. Additionally, data from 2020 was missing from this report as
    VA suspended inspections during the COVID-19 pandemic, precisely when
    inspections were most critical. The report also found that an outdated
    data system led to insufficient analysis of SVH data, and current plans
    for a replacement data system would not guarantee that VA would have
    the necessary analytical capabilities to improve efficiency. GAO
    recommended that VA identify additional enforcement tools and seek
    legislative authority to strengthen its oversight capabilities.
        VA published a policy notice in August 2024 on oversight
    requirements for SVHs that provide nursing home care, domiciliary care,
    and adult day health care. This notice detailed the administration,
    oversight, and certification processes for Recognition, Annual, and
    For-Cause Surveys of SVHs, explicitly focusing on compliance with
    Federal regulations. Key elements include the survey processes,
    corrective action plans for addressing noncompliance, and the roles of
    various VA personnel in managing and overseeing SVH operations. The
    goal is to ensure eligible veterans receive high-quality care in a safe
    environment while VA maintains proper oversight of the SVHs.

    VFW Concerns

        VFW members have raised concerns about long waitlists for admission
    to SVHs due to the limited number of facilities and available beds. The
    quality of care at SVHs is generally good, though veterans have had
    issues with slow communication and responses concerning inquiries about
    patient care, billing issues, eligibility, and space availability for
    individuals waiting to be transferred from medical hospitals. These
    delays create significant stress for veterans and their families.
        For example, one Missouri veteran had been waiting so long for
    placement in an SVH that VA moved him to a nursing home with a low
    standard of care. He also experienced poor communication from the staff
    while he waited for a bed to become available at an SVH.
        Veterans have told the VFW they have concerns about the lack of
    clear communication and setting expectations during the eligibility,
    application, and waitlist processes. The perception exists that if a
    veteran or that person's caregiver contacts a civilian nursing home,
    the veteran could likely secure a bed within a few days. However,
    delays in access and availability are prevalent at SVHs due to the
    limited number of facilities and a lack of beds required to meet the
    current demand.
        Veterans in Alabama have voiced concerns about obtaining
    information regarding eligibility criteria for SVHs. They are
    particularly troubled by the significant variation in eligibility
    requirements and processes, even among specific facilities within the
    same state.
        Maryland veterans and their families have reported multiple
    concerns including the lengthy application process and waitlists for
    admission to SVHs and lack of communication during this time,
    insufficient communication with survivors regarding billing issues and
    difficulties obtaining documentation even after payment has been made,
    and challenges in processing new patients during periods of system
    upgrades and changes in contracts. When veterans and their families
    raise concerns about living conditions at SVHs, VA should be responsive
    and address these issues effectively since it funds a significant
    portion of these services.
        It is time for VA to proactively address the concerns of the aging
    veteran population. VA can enhance compliance with quality standards by
    developing a range of enforcement options to correct deficiencies
    identified during inspections. Additionally, VA needs to establish a
    process for monitoring the implementation of corrective action plans,
    enabling it to track how care facilities address noncompliance issues.
    It is also crucial for VA to improve its ability to set and manage
    expectations for medical or care facilities that serve our veterans,
    while communicating those expectations to their families.
        The VFW urges Congress to provide full funding for VA to address
    the backlog of pending State Home Construction Grants. This would
    address the growing need and ensure these facilities are safe for
    veterans. We also urge Congress to provide oversight of VA's surveys
    and monitoring of SVHs to ensure high-quality standards for our
    Nation's veterans.
        Chairwoman Miller-Meeks, Ranking Member Brownley, this concludes my
    statement. Thank you for the opportunity to offer our comments on this
    important issue.

    Information Required by Rule XI2(g)(4) of the House of Representatives

        Pursuant to Rule XI2(g)(4) of the House of Representatives, the VFW
    has not received any Federal grants in Fiscal Year 2025, nor has it
    received any Federal grants in the two previous Fiscal Years.

        The VFW has not received payments or contracts from any foreign
    governments in the current year or preceding two calendar years.

     Prepared Statement of The National Association of State Directors of
                             Veterans Affairs, Inc.
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                       Prepared Statement of Sheri Biggs
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         Questions for the Record Submitted by Mariannette Miller-Meeks
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