Auditor General DePasquale Says Audit Raises Concerns about Waiting Lists, Complaint Process at DMVA Veterans’ Homes

Encouraged that audit is leading to major changes to better serve Pennsylvania veterans
July 07 2016
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Auditor General DePasquale Says Audit Raises Concerns about Waiting Lists, Complaint Process at DMVA Veterans’ Homes

Encouraged that audit is leading to major changes to better serve Pennsylvania veterans

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Audit report


HARRISBURG (July 7, 2016) – Auditor General Eugene DePasquale said today the Department of Military and Veterans Affairs (DMVA) needs to fix problems with admissions, its waiting lists, and grievance tracking at the commonwealth’s six veterans’ homes.

“This audit exposes flaws at the DMVA that led to delayed care to Pennsylvania veterans,” DePasquale said. “We identified problems in its waiting list and admission procedures as well as deficiencies in how staff at veterans’ homes handle complaints about resident care and living situations.”

To qualify for admission to a state veterans’ home, an individual must be an eligible veteran or the spouse of an eligible veteran who is a current resident of Pennsylvania or was a resident upon entry into the Armed Forces.

The audit, which covered July 2014 through March 2016, has three findings and 13 recommendations for improvement.

Waiting Lists in Wrong Order

DePasquale said DMVA’s outdated and inflexible policy has led to state veterans homes not administering waiting lists consistently at all six homes.

“Reviewing a one-day snap shot, we found 14 veterans were in the wrong order on the waiting lists,” DePasquale said. “Because of our audit, DMVA fixed these 14 errors. However, unless DMVA improves its oversight and monitoring of waiting lists, other veterans could be affected.”

Auditors noted that 11 of those on the waiting lists should have been higher on the lists and three should have been in lower positions. 

“Our audit, and DMVA’s cooperation, eliminated unnecessary delays in admission for 11 veterans,” DePasquale said. “This is important because every day that a veteran is waiting for a state veterans’ home bed could have a financial, health and safety impact on the veteran. Bureaucratic errors should not hold veterans back from care.”

DMVA officials attributed these deficiencies to typographical errors, such as entering the wrong date, and a system error.

The audit also notes that DMVA does not adequately monitor the state veterans’ home waiting lists. DMVA said it already was taking steps to implement audit recommendations.

Illogical Admissions Procedures

In addition to errors in the waiting lists, the department found certain admissions procedures to be contrary to the best interests of veterans and their spouses.

DVMA policy states that applicants are to be removed from the list if they are not able to accept admission within 10 business days of being notified of an opening.  Thus, if they are unable to move to a home in 10 days, they automatically are removed from all waiting lists.

“The current policy is bad for veterans and needs to be revised,” DePasquale said. “Otherwise, veterans who get to the top of a waiting list could be forced to start all over if personal circumstances prevent them from going into the home immediately. Veterans deserve better.”     

Auditors also questioned policies that forced eligible Pennsylvanians to remain on a waiting list despite dozens of open beds. 

“One of the state veterans homes — Hollidaysburg — had approximately 70 or more open beds, but 12 spouses of veterans were on a waiting list to use those beds,” DePasquale said. “Meanwhile, veterans wanting to get into the Southwestern Veterans’ Home could be waiting a year or more for a spot in that home.” 

DMVA officials said the waiting list for spouses in Hollidaysburg is a result of federal limitations on reimbursement for spousal residents. 

“When we brought the issues to their attention, DMVA admitted three of the 12 veterans’ spouses,” DePasquale said. “While we understand budget constraints, using all available resources to care for veterans and their spouses must be priority one.”

DMVA officials agreed the current waiting list policy lacks flexibility and said they will revise it and provide additional staff training.

Inconsistent handling of grievances, complaints

Auditors found that the DMVA’s new grievance policy and tracking system that was instituted during the audit fails to ensure that grievances are properly addressed. Grievances can include concerns related to a resident’s care, abuse or neglect; treatment; a violation of a resident’s rights; misappropriation of personal property; or mismanagement of personal funds. 

The audit identified numerous problems with the grievance process that resulted in a lack of confidence that veterans’ concerns are being heard, including:

  • No mechanism for recording and tracking complaints;
  • Failure to adequately train staff on the new procedures; and
  • Ambiguous language, which resulted in interpretation differences among different state veterans’ homes.

For example: A complaint that is not “immediately” resolved by the staff present becomes a grievance that must be tracked.

“The DMVA policy does not define what ‘immediately’ means,” DePasquale said. “As a result, some veterans’ homes considered it to mean within 24 hours; others used 48 hours. Such inconsistencies make it difficult to ensure that veterans’ complaints and grievances are properly addressed.” 

Auditors tested 13 of 86 grievances, and nine of those 13 grievances did not comply with DMVA grievance policy, including grievances missing a commandant’s signature, no documentation showing that the grievant was contacted within two business days, and failure to resolve grievances within seven days.

“Our more significant concern is what we might not be hearing if state veterans homes are not tracking all grievances,” DePasquale said. “The Southwestern Veterans’ Home had 13 grievances while Southeastern Veterans’ Home had two grievances, yet both have approximately the same number of residents. The DMVA should review its policies to ensure that every complaint and grievance is being recorded and resolved quickly.

“We need to ensure that concerns about veterans care in the state’s care are being addressed. Without a proper tracking system, it is impossible to know that.” 

The Department of Military and Veterans Affairs audit report is available online at:

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EDITOR’S NOTE:  There are approximately 463,400 veterans age 65 and older living in Pennsylvania as of 2014, according to the U.S. Census. A breakdown of veterans 65 and older by county follows.

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