Audit: Veterans’ homes failed to report deaths
NASHVILLE – Three of the four state-operated veterans’ homes in Tennessee received below-average scores for quality of care in a recent audit, which also found they failed to report veterans’ deaths and failed to conduct background checks on employees.
The findings were part of a 114-page report by the Tennessee Comptroller, which conducted the performance review of the homes in Humboldt, Knoxville, Clarksville and Murfreesboro during the period Jan. 1, 2015, to June 30, 2018.
There are two other veterans’ homes in Tennessee operated by the Department of Veterans Affairs in Murfreesboro and Mountain Home. They were not included in this audit. However, those two homes were under investigation as part of a national review after secret scores assigned by the VA were released in June.
In the audit, completed in October, the Murfreesboro, Humboldt and Knoxville state homes got two-star ratings during various points of the review, with Murfreesboro and Humboldt consistently performing poorer than the other two locations, the report states.
The home in Clarksville, which opened in January 2016, consistently received a five-star rating, according to monthly audit scores between September 2017 and May 2018.
According to the Tennessee State Veterans’ Homes Board that runs the homes, the differences between care at the locations is a result of the types of patients at the homes. Homes in Murfreesboro and Humbolt have a larger long-term care population, which includes older residents with more “negative triggers of the quality measures,” compared to younger and more shortterm residents in Knoxville and Clarksville.
The audit also found that management failed to notify the Comptroller’s Office of at least three instances of possible unlawful conduct regarding administrative matters in a reasonable amount of time. The report does not detail the instances, but states a “public official with knowledge,” believes that the misconduct occurred. Other audit findings include: ❚ There weren’t adequate internal controls over the resident assessment processes and monitoring of contracted direct care providers.
❚ Nurses didn’t document that they had distributed all doses of medicine to residents as prescribed.
❚ The homes didn’t ensure that their Quality Assurance Committees and subcommittees fulfilled their responsibilities and duties to help improve operations.
❚ The homes didn’t have comprehensive policies for documenting, addressing and monitoring the resolutions of complaints received from residents and employees.
❚ The management still didn’t properly monitor contractors that provide services to residents for compliance with Title VI requirements, despite findings from a prior audit.
❚ The homes lacked internal controls over volunteers.
❚ Management didn’t ensure that the wait list at each of the four veterans’ homes contained required information and that the lists were updated in accordance with established policies and procedures
However, the latest ratings of overall quality of care has shown improvement, according to Ed Harries, executive director of Tennessee State Veterans’ Homes. Centers for Medicare and Medicaid Services rated Clarksville and Knoxville homes five-stars and Murfreesboro and Humbolt homes fourstars, Harries said.
“Our focus is on the care of our residents and we do that very well,” he said.
Failure to report deaths
The veterans’ homes are required by state law to submit monthly death reports to their county health department. But the audit found that staff failed to accurately document or report 20 of the 60 veteran deaths during the review period.
Two of those deaths, which occurred at the Humboldt home, were not reported at all, the audit found. Management did not explain to the Comptroller’s Office why the deaths went unreported.
Another death at the Knoxville home was incorrectly classified, when in fact the resident was discharged from the home. Management said the mistake was a human error and that it wasn’t inaccurately reported.
The remaining deaths were not reported in the required time frame or had other misinformation, the audit found.
“When the homes do not provide accurate and timely resident death information, they are compromising a vital function of government, since the Department of Health’s Division of Vital Records uses this information as part of a reconciliation to ensure that a death certificate is issued for each death that occurs in the State of Tennessee,” the report states.
The lack of a death certificate could affect the veterans’ family and their ability to settle their estate. Also, inaccuracies within the homes’ resident records regarding whether a resident was discharged alive or dead could create difficulties with readmission or billing.
The report recommended that management establish control of the reporting process by assigning the responsibility to a specific staff member or creating a monthly checklist to remind staff of the reporting deadline and what to include in the report.
According to Harries, staff had been unaware of the deadlines to report deaths. A new policy was developed and approved, educating all administrators since Nov. 1.
‘Placing residents at risk’
The audit found that the veterans’ homes did not always obtain the criminal background and health checks for employees that are mandated by federal and state laws.
In a 25-employee sample of the 1,320 individuals hired during the review period, the homes failed to properly screen 16 percent of employees.
In the sample, the audit found the homes:
❚ Failed to obtain a criminal background check on 8 percent of employees.
❚ Failed to conduct check on national sex offender public website on 100 percent of employees.
❚ Failed to conduct check on state sex offender registry on 100 percent of employees.
❚ Failed to obtain drug screening on 4 percent of employees.
❚ Completed two reference checks instead of the required three on 8 percent of employees.
The Comptroller’s Office conducted an independent background check of the employees and found that no employee was a sex offender or had abuse violations, according to their report.
“Without using the screening techniques prescribed by federal and state laws and regulations, the homes may hire an unsuitable individual, thereby placing residents at risk for sub-par care and injury or even abuse and neglect,” the report states.
In an explanation of the problems identified, the director of risk management said she believed that human resource personnel may have not followed the background process because they were “overwhelmed by the demands of processing new hires,” due to high turnover rates.
Additionally, she said in the cases where the homes could not produce records of a completed background check, it was because the homes did not follow record-keeping procedures.
Personnel were trained in July 2018 based on the finding and management will conduct random monitoring in the future to test compliance, the report states.
Harries said in two of the reviewed cases, documentation was either lost or misplaced during the homes’ transition to a new background provider. In several other cases, the checks came back on the employee’s first day of work while they were at orientation and did not have access to residents.
Failed to document complaints
There are a few ways veterans or their families can make report complaints to the homes. The main methods are through two hotlines or making a report through the social services department.
The audit found that the homes did not have comprehensive policies in place to document, address or monitor the resolution of complaints.
Of the 62 complaints made through the hotlines during the review period:
❚ Management did not document actions taken in response to 26 percent of the calls.
❚ Management did not document the date the complaints were closed in 37 percent of the calls.
❚ Humboldt home did not adequately document steps taken to investigate complaints provided during resident council meetings.
Of the complaints received through social services, Humboldt staff didn’t maintain complaint logs for six months, and Clarksville staff didn’t document resolutions for 7 percent of complaints that involved laundry concerns, the audit found.
“Complaints are dealt with appropriately here and very rapidly as possible,” Harries said. “Resident complaints are dealt with in the moment.”