The Department of Veterans Affairs' home and community-based services were so delayed in the Washington, D.C. area that wait times lasted more than a year, for some vets, the agency's inspector general found.
One veteran died before receiving the care he requested, according to the IG report.
Related: Read the report
Sen. Barbara Mikulski, D.-Md., requested the audit, which examined the effect of the increase in the program's services, from $1.3 million for 148 patients in 2010 to $6.7 million for 573 patients in 2014. The sharp rise quickly overwhelmed staff. As the number of patients on wait lists grew significantly at the D.C. facility, the report said a "[Veterans Integrated Service Network] staff member we interviewed shared the opinion that leadership at the facilities felt pressure to work within their budgets even though they could request more money."
The VA eliminated the wait list by February 2015, after adding $2 million to the program in June 2014, the report said.
VA is also dealing with the problem on a national scale as well. As of March 31, 2015, more than 2,500 patients were on electronic wait lists to get home care.
In July 2014, Mikulski's office was alerted of a complaint that a veteran was referred to home care, but remained on a wait list until he died in April 2014. The patient, who was referred to home care in October 2013, was in his 70s and had a series of strokes beginning in August 2013.
VA policy places home care priority on veterans with service-connected disabilities. Because the patient's condition did not meet a 50 percent threshold for a service-connected disability, he was placed on an electronic wait list.
The inspector general offered three recommendations, including requiring facilities to develop action plans for further address the care needs of patients on electronic wait lists, as well as ensuring compliance and oversight.
VA officials concurred with the recommendations and said it had addressed the issues highlighted and would have action plans in place by April 2016.