A little known VA hiring loophole resulted in the Togus VA Health Care System unwittingly hiring a convicted killer as head chaplain. “VHA, where patient safety is number one!”
In yet another example of what has become a complete breakdown in VA hiring, officials are receiving a lot of attention by the House Veterans’ Affairs Committee about the problem.
We have covered questionable hiring by Veterans Affairs for some time. This new instance of problematic VA hiring practices is really the proverbial icing on the cake – hiring a convicted murderer to head spiritual matters in VA Health Care facilities surprised even me.
Hi and welcome to another edition of Monday Morning Quarterback for Veterans. I am your host, Benjamin Krause, creator of DisabledVeterans.org. This is a news outlet where we dare pull back the veil, behind which the federal government hides, to examine the real impacts of bad policy making on disabled veterans.
Topics for this MMQB on VA Hiring
We will be covering the following veterans news stories:
- Convicted killer hired as head chaplain for VA Health Care facility
- IG says VA lost its focus on health care – VA Health Care out to lunch
- Canadian veterans suffering same injustices
References for upcoming House Committee hearings:
- Construction Problems
- Mental Health Care Access
- Student Veteran Success
Summaries of last week’s governing oversight reports:
– VA Office of Inspector General
- Review of VA Loma Linda Health Care System, California
- Review of Portland VA Medical Center System, Oregon
- Questionable Cardiac Treatment and Management Problems, Edward Hines, Jr., VA Hospital, Illinois
- Review of VA Caribbean Health Care System, Puerto Rico
– Government Accountability Office
- VA Health Care Delays Evaluated
- VA Health Care Tissue Product Safety
Non-VA news of interest:
- BLM Land grab for Chinese Government turned back
Togus VA hires convicted killer as chaplain
House Committee leadership promises to look more closely into defunct hiring practices of VA after its hiring of a convicted felon at the VA Health Care System in Togus, Maine.
The Togus VA Health Care System hired a chaplain convicted of killing his wife. VA Health Administration officials claimed to be unaware of the conviction prior to hiring the killer.
The chaplain, James Luoma, a Pentecostal minister and Vietnam veteran, now heads the Togus VA chaplain system. In 1986, he pled guilty to manslaughter in the killing of his wife, Sherry. Luoma was released on good behavior, in 2004, when he became a minister.
Luoma previously worked at the Dayton, Ohio VA Medical Center as a chaplain. Apparently, a loophole in the hiring process allowed the Togus VA to only base its hiring on the background check of the previous VA. If something slipped through the cracks at some earlier point, the person could slip into a highly sensitive area without detection. Here, it looks like Luoma slipped through on this loophole and is now in charge of the chaplaincy program at the facility.
Moving forward, Rep. Jeff Miller and Rep. Michael Michaud promise to examine VA’s hiring processes to ensure that next time VA hires a murder, VA is at least aware of that fact.
Source: Morning Sentinel
Read More – Convicted killer hired as chaplain
IG says VA lost its focus on health care
“I believe that VA has lost its focus on the importance of providing quality medical care as its primary mission,” said John Daigh during a committee hearing.
John Daigh is the assistant inspector general for healthcare inspections of VA Health Care Systems.
During the April 9 hearing, Daigh went on to state, “There is no good explanation for these events. They are not consistent with good medical practice, they’re not consistent with common sense and they’re not consistent with VA policies that exist.”
Daigh indicated that VA Health Administration managers are no longer evaluating the quality of care being provided at VA Health Care facilities. Instead, they assume the health care is high quality. As a solution, Daigh pointed out that the medical errors could be better prevented with better leadership and a review of tools available.
Thomas Lynch, assistant deputy under secretary for health for clinical operations admitted the errors but also said VA Health Administration is committed to doing better.
“About six months ago, using some initial data that we were beginning to collect, we sent over $100 million out to the field for facilities to contract for fee-basis services. We reduced the wait time, the backlog at that point by almost 50 percent or 50,000 patients.”
“We can set the filters on this system to look at delays at variable lengths of time and as we get control of the system slowly reduce backlog from 90 days to 60 days to 30 days based on the information that we get.”
Debra Draper, director at the Government Accountability Office, told lawmakers she was skeptical of VA’s claims for improvement.
“In 2012 VHA created a database to capture all consults system-wide; however, the data were deemed inadequate for monitoring purposes. One issue was the lack of standard processes and uses of the electronic consult system.”
Because of these flaws, the VA Health Care centers have been unable to actually determine who received care in a timely manner.
Read More – IG says VA lost its focus on veterans’ health
Canadian veterans suffering same injustices
Veterans in America are not alone in their fight against a bureaucracy as in the US. In Canada, veterans are facing similar battles against corruption and scandal.
Recently, advocates in our northern neighbor claimed bureaucrats were sabotaging improvements to veterans care and benefits systems.
Currently, one problem is a recent leak of private medical information. Like in the US, bureaucrats at the Canadian Department of Veterans Affairs have gone largely unchecked for the leak.
The only real difference in treatment between US and Canadian problems in their respective veterans’ programs is that veterans of the recent wars in Canada are claiming they get less favorable treatment than older veterans.
For veterans in the US, that kind of claim is clearly not suitable in this country. It has been largely argued that US veterans of the current conflicts receive more benefits than veterans of most other conflicts.
Source: The Canadian Press
Upcoming House Committee Hearings
- April 22, 2014: Construction Conundrums: Delays at Aurora, Colorado VAMC – Subcommittee on Oversight and Investigations
- April 24, 2014: Access to Mental Health Care and Traumatic Brain Injury Services – Subcommittee on Oversight and Investigations
- May 8, 2014: Defining and Improving Success for Student Veterans – Subcommittee on Economic Opportunity
Last week’s VA Oversight Reports
VA Office of Inspector General Oversight Reports
Review of VA Loma Linda Healthcare System, California
The purpose of the review was to evaluate selected health care facility operations, focusing on patient care quality and the environment of care. During the review, OIG provided crime awareness briefings to 492 employees. This review focused on seven operational activities. The facility complied with selected standards in the medication management activity. The facility’s reported accomplishments were an innovative geriatric medical health model, Joint Commission recognition, Affordable Care Act initiatives, and a patient-centered after visit summary. OIG made recommendations for improvement in the following six activities: (1) quality management, (2) environment of care, (3) coordination of care, (4) nurse staffing, (5) pressure ulcer prevention and management, and (6) community living center resident independence and dignity.
Read More – VA Loma Linda Healthcare System
Review of Portland VAMC System, Oregon
The purpose of the review was to evaluate selected health care facility operations, focusing on patient care quality and the environment of care. During the review, OIG provided crime awareness briefings to 294 employees. This review focused on seven operational activities. The facility’s reported accomplishments were its Homeless Program and recognition as a Joint Commission top performer. OIG made recommendations for improvement in all seven of the following activities: (1) quality management, (2) environment of care, (3) medication management, (4) coordination of care, (5) nurse staffing, (6) pressure ulcer prevention and management, and (7) community living center resident independence and dignity.
Read More – Portland VAMC System, Oregon
Questionable Cardiac Treatment and Management Problems, Edward Hines, Jr. VA Hospital, Illinois
OIG conducted an inspection at the Edward Hines, Jr. VA Hospital in Hines, IL, at the request of Senator Richard Durbin and Congresswoman Tammy Duckworth concerning unnecessary cardiac interventions and poor management of cardiovascular care. We substantiated that two patients had questionable indications for coronary bypass surgery and that preoperative planning was inadequate for a patient who underwent coronary artery bypass surgery. We found that coronary interventions may have been inappropriate for nine patients who had undergone cardiac catheterizations during 2010–2013.
We substantiated that there were operating room environmental and equipment deficiencies, hospital beds were often unavailable, there was poor bed utilization, and the facility did not monitor compliance with two of an affiliated academic institution’s contracts. We did not substantiate that a patient who died in the operating room received inappropriate care, the operation should not have been performed at the facility, and that preoperative planning was inadequate. We did not substantiate that there was inadequate staffing or medical support for cardiac surgery, patients had excessively long waits to be admitted from the emergency department, there were delays in or poor quality of echocardiography, non-board certified physicians were assigned to crucial management positions, care was inappropriately provided by trainees and non-physician providers, staff failed to adhere to written policies for the Surgical Intensive Care Unit, and that Surgical Intensive Care Unit physicians sometimes were at an affiliated academic institution during their VA tours of duty, or that there was a lack of fairness of Administrative Investigation Boards. OIG made four recommendations.
Review of VA Caribbean Healthcare System, Puerto Rico
The purpose of the review was to evaluate selected health care facility operations, focusing on patient care quality and the environment of care. During the review, OIG provided crime awareness briefings to 264 employees. This review focused on seven operational activities. The facility complied with selected standards in the following three activities: (1) nurse staffing, (2) pressure ulcer prevention and management, and (3) community living center resident independence and dignity. The facility’s reported accomplishments were receipt of funding from the Veterans Health Administration Innovation Initiative for implementation of a multisensory environment for dementia care and the caregivers support program. OIG made recommendations for improvement in the following four activities: (1) quality management, (2) environment of care, (3) medication management, and (4) coordination of care.
Read More – VA Caribbean Healthcare System, Puerto Rico
Government Accountability Office
VA Health Care: Ongoing and Past Work Identified Access Problems that May Delay Needed Medical Care for Veterans
GAO’s ongoing work examining VHA’s management of outpatient specialty care consults identified examples of delays in veterans receiving outpatient specialty care, as well as limitations in the Department of Veterans Affairs’ (VA), Veterans Health Administration’s (VHA) implementation of new consult business rules designed to standardize aspects of the clinical consult process. For example, for 4 of the 10 physical therapy consults GAO reviewed for one VAMC, between 108 and 152 days elapsed with no apparent actions taken to schedule an appointment for the veteran. For 1 of these consults, several months passed before the veteran was referred for care to a non-VA health care facility. VA medical center (VAMC) officials cited increased demand for services, and patient no-shows and cancelled appointments among the factors that lead to delays and hinder their ability to meet VHA’s guideline of completing consults within 90 days of being requested. GAO’s ongoing work also identified variation in how the five VAMCs reviewed have implemented key aspects of VHA’s business rules, such as strategies for managing future care consults—requests for specialty care appointments that are not clinically needed for more than 90 days. Such variation may limit the usefulness of VHA’s data in monitoring and overseeing consults systemwide. Furthermore, oversight of the implementation of the business rules has been limited and did not include independent verification of VAMC actions. Because this work is ongoing, we are not making recommendations on VHA’s consult process at this time.
In December 2012, GAO reported that VHA’s outpatient medical appointment wait times were unreliable. The reliability of reported wait time performance measures was dependent in part on the consistency with which schedulers recorded desired date—defined as the date on which the patient or health care provider wants the patient to be seen—in the scheduling system. However, VHA’s scheduling policy and training documents were unclear and did not ensure consistent use of the desired date. GAO also reported that inconsistent implementation of VHA’s scheduling policy may have resulted in increased wait times or delays in scheduling timely medical appointments. For example, GAO identified clinics that did not use the electronic wait list to track new patients in need of medical appointments as required by VHA policy, putting these patients at risk for not receiving timely care. VA concurred with the four recommendations included in the report and, in April 2014, reported continued actions to address them. For example, in response to GAO’s recommendation for VA to take actions to improve the reliability of its medical appointment wait time measures, officials stated the department has implemented new patient wait time measures that no longer rely on desired date recorded by a scheduler. VHA officials stated that the department also is continuing to address GAO’s three additional recommendations. Although VA has initiated actions to address GAO’s recommendations, continued work is needed to ensure these actions are fully implemented in a timely fashion. Ultimately, VHA’s ability to ensure and accurately monitor access to timely medical appointments is critical to ensuring quality health care to veterans, who may have medical conditions that worsen if access is delayed.
Read More – GAO-14-509T Delays in Providing Medical Care Needs
VA Health Care: Oversight of Tissue Product Safety
Data from the Veteran’s Health Administration (VHA), within the Department of Veterans Affairs (VA), do not show evidence of VHA receiving contaminated tissue products, although, it is difficult to link adverse events in recipients to such products. VA’s National Center for Patient Safety (NCPS), which began operation in 1999, has not issued any patient safety alerts—mandates for action to address actual or potential threats to life or health—or advisories—guidance to address issues such as equipment design and product failure—related to tissue products potentially received by VA medical centers (VAMC) in the last 10 years. NCPS issues patient safety alerts and advisories for recalls that require specific clinical actions to ensure patient safety. Since NCPS began issuing and recording data on recalls in November 2008, NCPS has notified VAMCs of 13 recalls for tissue products from vendors from which VHA could have received affected products—none of these recalls have resulted in patient safety alerts or advisories. For 6 of the recalls, 27 VAMCs reported to NCPS that they had identified and removed the recalled products from their inventories. For the other 7 recalls, none of the VAMCs had the affected tissue products in their inventories. The 13 recalls were not issued for known tissue product contamination. Instead, most were initiated because of the possibility of contamination, such as compromise of product sterility and incomplete donor records. Further, VHA officials told us that their analysis of VHA data found no evidence of reported adverse events among VHA patients that were caused by contaminated tissue products. According to officials from the Food and Drug Administration (FDA), post-surgical infections often occur, even in the absence of tissue use, and it is often not possible to definitively attribute such infections to a tissue product.
VHA’s identification of recalled tissue products may be limited, although recent actions by the agency may help. VA and VHA rely on FDA to ensure the quality of tissue vendors—who are generally required to register with FDA—but VA and VHA policies do not require that a vendor’s FDA registration status be checked for most purchases. In addition, VHA’s ability to track recalled tissue products in its inventories may be limited by poor inventory management practices. After receiving a recall notice, VAMCs are required to search their inventories for recalled products; however, GAO and VA Office of Inspector General (OIG) have previously reported concerns with the completeness and accuracy of VHA’s inventory data and have made recommendations to improve VHA’s ability to accurately identify all recalled products in VAMCs inventories. VA is in the process of responding to these recommendations. Further, while VAMCs are responsible for checking for and accurately identifying all implanted, applied, or injected tissue products subject to a recall, GAO found that VA and VHA conduct no oversight to ensure this is done and rely on VAMCs, which may have limited ability to conduct this check. For example, VHA officials stated that it is difficult to search for information on implanted tissue products, in part, because there is no automated search capability. VA is taking steps that may enhance its ability to identify tissue products after they have been used.
VA and FDA reviewed facts GAO developed in preparing this testimony. VA and FDA provided technical comments, which were incorporated as appropriate.
Read More – GAO-14-463T Oversight of Tissue Product Safety
Patriot News of Interest
BLM pushes Land Grab for Chinese Gov at expense of Nevada Rancher
The land grab affecting rancher Cliven Bundy has been at the forefront of many patriot websites and news for the past week.
Over the weekend, I read numerous alternative news websites reporting on the topic. The sources stated that the cause of the land grab is rumored to be Chinese government interests.
According to the reports, Senator Harry Reid is working with the Chinese government to take the land. The land was then to be used for building a solar panel manufacturer worth over $5 billion. What is undisclosed is who the workers at the facility would be.
My guess is that more on this issue will surface within hearings in the next few weeks. I assume Republicans will push the issue for their advantage against Senate Democrats supporting the land grab at the expense of citizens.
As an aside, do not discount alternative media, of which DisabledVeterans.org is a member. We have a way of getting at issues a lot quicker than traditional news sources and without the usual special interest bias.