GAO: VA oversight of state veterans homes improved but lacks enforcement tools, GAO and VA witnesses say

Chairwoman Miller Meeks opened the House Veterans' Affairs Subcommittee on Health hearing by emphasizing the committee’s oversight role for long-term care for aging veterans and the role of state veterans homes in that system. “Every veteran deserves independence and dignity with age,” she told members and witnesses.

The Government Accountability Office (GAO) told the subcommittee that state veterans homes provide important long-term care for aging veterans but that VA enforcement tools are limited. GAO witness Ms. Silas summarized the agency’s November 2022 review, noting persistent deficiencies: “In our review, we cite an example of a state administrator that noted they were more concerned with CMS's inspections because of the civil penalties.” GAO reported 766 deficiencies across a sample of 53 state homes and said 40% of homes were cited for the same deficiency in both 2019 and 2021; 21% of corrective action plans were past their due date.

GAO recommended that VA identify additional enforcement actions scaled to the scope and severity of deficiencies and seek legislative authority to implement them. Ms. Silas said VA had proposed a legislative option in the past and that GAO still considers an expanded range of penalties—such as civil fines or partial withholding of per diem payments—an appropriate complement to current tools.

Department of Veterans Affairs witnesses described changes since the GAO review. Dr. Hartreeff, the executive director for the VHA Office of Geriatrics and Extended Care, said VA centralized its survey function and added an escalation plan that prescribes oversight frequency based on the number and severity of findings. He told the committee that centralization has improved follow-up on corrective action plans and that, since February, a larger percentage of plans are on time and showing compliance. “What we did was we also added what we call an escalation plan ... and that prescribes a frequency of oversight,” he said.

Dr. Hartreeff and other VA witnesses said the department has strengthened internal timelines and increased follow-up, and they argued those process changes have begun producing better outcomes. VA also told members it is considering, but has not yet adopted, seeking additional legislative authority for penalties.

State and industry witnesses told the committee centralization helps but may not be sufficient without external enforcement options. Ed Harries, president of the National Association of State Veterans Homes (NASBA), told the subcommittee that state homes consistently score better on CMS star ratings than community nursing homes but said financial and regulatory incentives matter. Harries urged Congress to authorize reimbursement for costly medications and to consider a graduated enforcement toolbox for VA similar to CMS’s, arguing such authority would allow VA to “right size” penalties to the severity of deficiencies.

Members pressed for specifics about the consequences of limited enforcement authority. GAO said VA’s only formal enforcement lever has been withholding per diem, a severe measure GAO officials said VA rarely uses. VA officials told the committee they had not recalled using withholding in recent memory and that their internal escalation plan focuses first on remediation and assistance, not immediate financial sanctions.

Contextual figures discussed during the hearing: GAO and witnesses said there are about 153 state veterans homes nationally; VA data cited by witnesses showed roughly 15,000 veterans living in state homes at a cost of about $1.5 billion in fiscal year 2023. Witnesses said state homes provide roughly 43% of VA‑funded nursing home care on any given day, while receiving about 18% of VA’s payments for institutional long-term care. GAO and members noted that VA’s basic per diem covers less than 30% of actual cost on average and can cover as little as 20% in higher-cost states.

The hearing record included a VA description of available supports: VA conducts annual inspections, permits medical‑sharing agreements with local VA medical centers, and reimburses up to 65% of allowable construction costs under the State Home Construction Program. VA also reported $4.7 million in fiscal year 2025 awards for nursing retention across 17 states and 47 state homes.

The subcommittee did not take formal votes. GAO reiterated that a range of enforcement actions would better align penalties with deficiencies, while VA emphasized recent internal reforms and said it is reexamining whether additional authorities are necessary. The hearing closed with members and witnesses agreeing that oversight remains a priority and that Congress may need to weigh whether statutory authority should be expanded to give VA a graduated enforcement toolbox.

Ending: Committee members asked for additional follow-up and for VA to provide evidence of improved corrective action outcomes. GAO left one recommendation open in its November 2022 report, and VA said it is continuing to develop internal tools while evaluating whether legislative changes are needed.