It's not just Phoenix

The Department of Veterans Affairs (VA) has come under scrunity by Congress, Veteran Service Organizations, media and in the veterans’ community for its failures in leadership performance and accountability which have resulted in quality of care or patient safety issues that have affected veterans. The following list outlines specific VA issues nationally as well as at Local VA Medical Centers and Regional Offices. 

Nationally

• VA fails to release internal documents that corroborated at least 19 preventable deaths and VA officials did not respond to direct questions in a House Veterans Oversight and Investigations Hearing on April 2, 2014.

• Florida Governor Scott has convened a state inspection team to examine VA facilities in the wake of quality and patient safety issues. 

• At the conclusion of the Congressional Oversight and Investigation Hearing regarding “Correcting ‘Kerfuffles’ – Analyzing Preventable Patient Deaths at Jackson VAMC” on November 13, 2013, Chairman Coffman requested a report on how the G.V. (Sonny) VAMC is specifically addressing the concerns of understaffing, overbooked patients, lack of oversight for the medical center’s nurse practitioners, lack of patients’ access to physicians, and radiology reports being misread and unread within 30 days. On November 14, 2013, The American Legion requested a copy of the report and as of March 31, 2014, the VA has yet to provide the report. During our System Worth Saving Task Force site visit in Jackson MS on January 20-22, facility director Joe Battle was unable to give The American Legion a copy of the action plan the facility has taken to address the preventable deaths.  Director Battle stated that he could release the report because it was not cleared by VA Central Office.   Upon further requests for this information after our site visit, Veterans Health Administration staff told us that they could not release the report because Office of Congressional Legislative Affairs (OCLA) had not cleared or sent this response to Congress.   Not only is Congress waiting for this information but the delays in OCLA responding to Congress have now spilled over and is affecting the abilities of The American Legion to effectively conduct our site visits and inform veterans in the communities of these hospitals.   In anonymous conversations with VA Central Office staff, OCLA was first sent the action plan from VHA on December 6 has not approved or sent the response to Congress.    Furthermore, OCLA just came back to VHA on March 26 to have VHA make adjustments/updates due to the time lag and the information being outdated. 

• Congress, Veteran Service Organizations and veterans that are being treated at medical centers with issues and concerns are frustrated, confused and out of the loop on the steps VA has taken to resolve problems which has led to a diminished confidence and renewed interest and pressing for more accountability on management of these facilities.  Veterans in these communities continuously read newspaper articles which are not accurately portraying the action plan and steps VA is taking to correct issues because of the lack of communication and timeliness of VA offices in Washington DC to work together across VA Central Office and in responding to congressional inquiries.   

• The American Legion urges VA leadership from the Secretary’s office, Office and Public and Intergovernmental Affairs, the Office of Congressional Legislative Affairs and leadership/communication staff from VHA, VBA and NCA to ALL work together to develop a crisis communication team to expedite issues of critical nature as well as better coordination and response for general inquiries to best serve VA local sites leadership in responding to media, veteran service organizations and veterans. 

• Diana Rubens, the VA executive in charge of the nearly 60 offices that process disability benefits compensation claims, collected almost $60,000 in bonuses while presiding over a near seven-fold increase in backlogged claims.

• VA construction chief Glenn Haggstrom collected almost $55,000 in performance bonuses despite presiding over a host of major construction projects plagued by years-long delays and combined cost overruns of $1.5 billion. The Government Accountability Office documented the delays and cost overruns for projects in Las Vegas, Denver, New Orleans and Orlando, Fla., in an April 2013 report. When questioned at a House Committee on Veterans’ Affairs hearing in May, Haggstrom could not explain what he did to earn the bonuses.

St. Louis, Missouri

• More than 1,800 veteran patients of the St. Louis VA Medical Center may have been exposed to HIV and Hepatitis as a result of unsanitary dental equipment. The facility has remained under fire for patient deaths, persistent patient-safety issues and critical reports. Despite the problems at the medical center, the facility’s director from 2009 - 2013, RimaAnn Nelson, received nearly $25,000 in bonuses during her tenure there.

Fayetteville, NC

• A December 2012 audit of the Fayetteville VA Medical Center found facility employees did not complete required suicide prevention follow-ups 90 percent of the time for patients at a high risk of suicide. The audit also found the center “noncompliant” in cleanliness of patient care areas, environmental safety, dental clinic safety, training and testing procedures. In July 2012, during an investigation that substantiated patient misdiagnosis complaints, VA’s inspector general found the responsible physician failed to properly review medication information 56 percent of the time, a step that is “critical to appropriate evaluation, treatment planning, and safety.” Fayetteville VA Medical Center Director Elizabeth B. Goolsby received a performance bonus of $7,604 in 2012.

Dallas, Texas (SWS Visit Feb 4-5, 2014)

• Dallas VA Medical Center Director Jeff Milligan and regional director Lawrence Biro have received a combined $50,000 in bonuses since 2011 despite a series of allegations from VA workers, patients and family members regarding poor care at the facility as well as more than 30 certification agency complaints against the medical center in the last three years.

Philadelphia, Pennsylvania

• The director of VA’s Philadelphia regional office, Thomas Lastowka, received a $23,000 bonus in 2011 despite a doubling in the backlog of disability compensation claims at the office between 2010 and 2011.

Phoenix, Arizona (ROAR Visit April 1-4, 2014)

• Phoenix VA Regional Office Director Sandra Flint has received more than $53,000 in bonuses since 2007 despite a doubling in the office’s backlog of disability compensation claims since 2009.

Columbia, South Carolina (Site Visit Scheduled April 15, 16, 2014)

• Columbia VA Regional Office Director Carl Hawkins received almost $80,000 in bonuses despite a doubling in the office’s backlog of disability compensation claims and inappropriate shredding of disability claims documents.

• In September 2013, six deaths were linked to delayed screenings for colorectal cancer at the veterans medical center in Columbia, S.C., the Veterans Affairs Department reported. The VA’s inspector general determined that the William Jennings Bryan Dorn VA Medical Center fell behind with its screenings because critical nursing positions went unfilled for months. It also found that only about $275,000 of $1 million provided to the hospital to alleviate the backlog had been used over the course of a year.

Waco, Texas

• Carl Lowe, the former director of the VA regional office in Waco, Texas, raked in more than $53,000 in bonuses as the office’s average disability claims processing time grew to historic levels, forcing veterans to wait longer than anywhere else in the country.

Buffalo, New York

• David West, a VA health official in New York, pocketed nearly $26,000 in bonuses while overseeing chronic misuse of insulin pens that potentially exposed hundreds of veterans to blood-borne illnesses.

Dayton, Ohio

• For nearly 18 years, the dental clinic at the Dayton VA Medical Center allowed unsanitary practices, potentially exposing hundreds of patients to hepatitis B and hepatitis C. Dayton VA Medical Center Director Guy Richardson then collected an $11,874 bonus despite an investigation into the exposures. After nine of the exposed patients tested positive Hepatitis B and Hepatitis C, Richardson was promoted.

Pittsburgh, Pennsylvania (Site Visit Nov. 5-6, 2013)

• After persistent management failures led to a deadly Legionnaires’ disease outbreak in the VA Pittsburgh Healthcare System, VA Pittsburgh director Terry Gerigk Wolf received a perfect performance review and regional director Michael Moreland, who oversees VA Pittsburgh, collected a $63,000 bonus.

Atlanta, Georgia (Site Visit Jan. 28, 2014)

• Despite four preventable patient deaths, three of which VA’s inspector general linked to widespread mismanagement, former Atlanta VA Medical Center Director James Clark received $65,000 in bonuses over four years. Additionally, the facility’s current director, Leslie Wiggins, maintains that no employees responsible for the mismanagement linked to the deaths should be fired.

Roseburg, Oregon (Site Visit Jan.9-10, 2014)

• Ray Velez, an active Legionnaire from American Legion Post 61 in Junction City, went to the Roseburg VA Medical Center this past June for what should have been a routine hernia operation. After the surgery, Roseburg VA Medical Center staff told Irene Lillie, Velez’s daughter, that her father’s blood pressure had “dropped suddenly and he was having difficulty breathing.” Since the Roseburg VA Medical Center does not have an Intensive Care Unit, Velez was taken to PeaceHealth Sacred Heart Medical Center at Riverbend in Springfield, Oregon. Unfortunately, Velez passed away en route PeaceHealth Sacred Heart Medical Center due to “intra-dominal bleeding, shock, hyperkalemia, acidosis, respiratory failure and recent ventral hernia surgery.”  

Butler, Pennsylvania (Site Visit Jan. 8-9, 2014)

• An attorney for the prime contractor of a Department of Veterans Affairs outpatient center being built in Butler County declined to comment Friday, July 12, 2013 about the VA's investigation of the contractor that led the agency to stop work on the $75 million project.

• The VA Butler Healthcare Center was scheduled to open in 2015, but the termination of the lease left its future in doubt. The VA broke ground on the center in April 2013. The Department of Veterans Affairs yanked its lease with an Ohio company that was building a $75 million health center for vets in Butler, accusing the firm of “false and misleading representations” during bidding. The VA ordered work halted in June when it began to uncover problems with the project.

• The Department of Veterans Affairs failed to properly check the qualifications of the former developer of an outpatient center in Butler County, according to a highly critical report by the VA's Office of Inspector General released Monday. The report says the VA improperly calculated that a 20-year lease with Westar Development Co., valued at $157 million, would be cheaper than the VA building and owning the $75 million outpatient center on its own.

Orlando, Florida/Denver, Colorado (Orlando SWS Visit-Feb.11-12, 2014) (Denver SWS Visit-May 13-14, 2014)

• Costs substantially increased and schedules were delayed for Department of Veterans Affairs' (VA) largest medical-center construction projects in Denver, Colorado; Las Vegas, Nevada; New Orleans, Louisiana; and Orlando, Florida. As of November 2012, the cost increases for these projects ranged from 59 percent to 144 percent, with a total cost increase of nearly $1.5 billion and an average increase of approximately $366 million. The delays for these projects range from 14 to 74 months, resulting in an average delay of 35 months per project. In commenting on a draft of this report, VA contends that using the initial completion date from the construction contract would be more accurate than using the initial completion date provided to Congress; however, using this date would not account for how VA managed these projects prior to the award of the construction contract. Several factors, including changes to veterans' health care needs and site-acquisition issues contributed to increased costs and schedule delays at these sites.

Jackson, Mississippi (Site Visit Jan.21-22, 2014)

• At the G. V. Sonny Montgomery VA Medical Center in Jackson, MS, multiple whistleblower complaints have been raised by employees who were losing confidence in the medical center’s ability to treat veterans. The complaints ranged from improper sterilization of instruments to missed diagnoses of fatal illnesses, as well as hospital management policies. 

Augusta, Georgia (Site Visit Mar. 11-12, 2014)

• CNVAMC leadership first learned of delays in providing gastrointestinal (GI) services to veterans on August 30, 2012.  Of the 4,580 delayed GI consults, a quality management review team determined 81 cases for physician case review.  Seven of the 81 cases may have been adversely affected by delays in care.  Six of seven institutional disclosures were completed and three cancer-related deaths may have been affected by delays in diagnosis. Factors contributing to the 4,580 patient backlogs included an explosion of baby boomers turning 50 and requiring screening, the medical center’s non-anticipation of a spike in GI consult demand, lack of an integrated data base for tracking GI procedures, and GI physician recruitment challenges. 

• On Tuesday, April 1, 2014, it was revealed that Veterans Affairs Department financial manager Jed Fillingim was involved in a deadly incident while traveling on business for the agency in 2010. Police and federal investigators found Fillingim drove a government truck after drinking with two colleagues at a bar near Dallas while attending a June 2010 conference for federal employees. One of the two colleagues, Mississippi-based VA employee Amy Wheat, who had also been drinking that night, fell out of the truck while it was moving and died. She suffered severe head injuries and a severed leg in the fall. Blood covered the truck and one of its wheel wells, according to police reports.

• Though he resigned from his position with the agency’s Jackson, Miss., medical center five months later, the News4 I-Team has learned Fillingim was rehired in March 2011 and has since assumed a high-level managerial position in Augusta, Ga., earning more than $100,000 per year.

Memphis, Tennessee

• In October of 2013, The VA Office of Inspector General Office (VA OIG) of Healthcare Inspections conducted an inspection in response to an allegation of inadequate care for patients who died in the Emergency Department (ED) at the Memphis VA Medical Center (the facility), Memphis, TN. The complainant alleged that a patient died after a physician ordered a medication for which the patient had a known drug allergy; another patient died after being administered multiple sedating drugs and not being monitored properly; and a third patient died after delays in getting treatment for very high blood pressure.

Des Moines, Iowa

• The VA Office of Inspector General Office of Healthcare Inspections conducted an inspection in response to a request by Senators Charles Grassley and Tom Harkin, both of whom received allegations of ongoing administrative irregularities, leadership lapses, and quality of care concerns over the past 2 years at the VA Central Iowa Health Care System.

San Francisco, California

• In a VA Inspector General report on the San Francisco VA hospital and clinic, the agency's inspector general reviewed 264 opiate prescription renewals and found that in 53 percent of cases, the doctor renewing the prescription had not seen the patient or talked to him or her over the telephone.