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Congress launches investigation of alleged poor care at VA nursing homes

Nick Bonanno pushed his father, Russ Bonanno, down the hallway at the VA in Bedford.Kelsey Cronin

The House Veterans Affairs Committee has launched an investigation into care at the VA’s 133 nursing homes after learning the agency had given almost half of them the lowest possible score in secret, internal rankings.

The probe follows an investigation by The Boston Globe and USA TODAY that showed 60 VA nursing homes — including one in Bedford, Mass. — rated only one out of five stars for quality last year in the agency’s own ranking system.

Internal documents obtained by the Globe and USA Today revealed that patients in more than two-thirds of VA nursing homes were more likely to suffer pain and serious bedsores than their private sector counterparts. More generally, VA nursing homes scored worse than private nursing homes on a majority of key quality indicators, including rates of anti-psychotic drug prescription and decline in daily living skills.


Massachusetts Democratic Representative Seth Moulton applauded the committee’s investigation and said he hopes the panel will hold a field hearing in his state, where the Bedford VA nursing home was rated worse than private nursing homes on 10 of 11 key quality indicators last year, including rates of pain and infection.

He also chastised the department for keeping the rankings from the nursing home residents and their families.

“Veterans deserve the best health care in the world. Period. That means having more transparency than private providers, not less,” said Moulton, a former Marine who served four tours of duty in Iraq and gets medical care at the Bedford VA hospital. “The VA is doing many things well, but this is a clear example of where they are failing.”

The VA tracked the quality of its nursing homes for years but withheld the data from the public until receiving inquiries from the news organizations. The VA then released some quality information and argued its nursing homes provide good care even though their residents are typically sicker than those at private facilities.


House VA Committee chairman Representative Phil Roe, Republican of Tennessee, ordered the investigation, saying he was “disturbed” by the news reports.

Florida Republican Representative Vern Buchanan had urged Roe in a letter last month to have his committee examine the “shocking and unacceptable conditions” and adopt “tough disclosure requirements to create greater transparency.”

“A congressional investigation should leave no stone unturned in finding out how this happened in the first place and how it can be prevented in the future,” he wrote.

A Roe spokeswoman said the committee anticipates holding a hearing in the fall, and may release more details as the investigation progresses.

VA press secretary Curt Cashour said Monday that agency officials “welcome the committee’s oversight.”

“We look forward to informing the committee about the care we provide veterans in our nursing homes and how it compares closely to care in the private sector, even though the department on average cares for sicker patients in its nursing homes than do private facilities,” he said.

The VA operates nursing homes in 46 states that serve some 46,000 veterans annually. The agency has tracked detailed information about the quality of care they provide since at least 2011 and instituted a ranking system in 2016, but kept everything secret until last month.

The VA also has contracted for more than a decade with an outside company to conduct inspections of its nursing homes and kept the resulting reports from the public.


The agency banned the public release of the reports in 2009 after the Pittsburgh Tribune-Review published the findings from one report detailing “significant issues” at the VA nursing home in Philadelphia, including poor resident grooming and pest control. In one case, a patient’s leg had to be amputated after an infection in his foot went untreated for so long his toes turned black and attracted maggots.

The VA said at the time that the reports are internal quality assurance documents protected from disclosure under federal law.

Cashour, the VA press secretary, said, after receiving inquiries from USA Today and the Globe, that the VA now would release the reports. He said Monday that the agency is working with an outside contractor to remove nursing home residents’ personal information from the inspection reports before releasing them.

Nearly a dozen lawmakers have demanded more information from the VA, and several senators cosponsored legislation to force the agency to release all of its nursing home information on an ongoing basis in the future. The Senate passed the measure last month. House lawmakers will have to pass it before it can become law.

Indiana Republican Senator Todd Young, one of the cosponsors, said Monday said it is his “strong hope” that the provision passes.

Young said agency secrecy “disserves our veterans as well as their family members and friends who assist our veterans in identifying the highest quality center of care that they aim to receive for any given service.”


Buchanan said in an interview that the VA’s claims that its facilities perform worse than private nursing homes because VA residents are typically sicker “don’t pass the smell test.”

“I don’t buy that,” said Buchanan, a veteran who served on the VA committee overseeing the agency from 2007 through 2011. “We’ve just got to do a lot better. It’s just not acceptable.”

Andrea Estes can be reached at andrea.estes@globe.com.