Senate investigation finds ‘systemic’ failures at VA watchdog (USA Today)
A Senate investigation of poor health care at a Veterans Affairs Medical Center in Tomah, Wis., found systemic failures in a VA inspector general’s review of the facility that raise questions about the internal watchdog’s ability to ensure adequate health care for veterans nationwide. The probe by the Senate Homeland Security and Governmental Affairs Committee found the inspector general’s office, which is charged with independently investigating VA complaints, discounted key evidence and witness testimony, needlessly narrowed its inquiry and has no standard for determining wrongdoing. One of the biggest failures identified by Senate investigators was the inspector general’s decision not to release its investigation report, which concluded two providers at the facility had been prescribing alarming levels of narcotics. The facility’s chief of staff at the time was David Houlihan, a physician veterans had nick-named “candy man” because he doled out so many pills. Releasing the report would have forced VA officials to publicly address the issue and ensured follow up by the inspector general to make sure the VA took action. Instead, the inspector general’s office briefed local VA officials and closed the case. A 35-year-old Marine Corps veteran, Jason Simcakoski, died five months later from “mixed drug toxicity” at Tomah days after Houlihan signed off on adding another opiate to the 14 drugs he was already prescribed. The 350-page Senate committee report obtained by USA TODAY also chronicles instances where other agencies could have done more to fix problems at the Tomah VA Medical Center, including the local police, the FBI, DEA, and the VA itself, but it singles out the inspector general. “Perhaps the greatest failure to identify and prevent the tragedies at the Tomah VAMC was the VA Office of Inspector General’s two-year health care inspection of the facility,” the report concludes, adding that despite the dangerous drug prescriptions, the IG did not identify any wrongdoing. After news reports chronicled Simcakoski’s death last year, VA officials conducted another investigation with very different results and ousted Houlihan, a nurse practitioner, and the medical center’s director. “In just three months, the VA investigated and substantiated a majority of the allegations that the VA OIG could not substantiate after several years,” the committee report notes. Sen. Ron Johnson, R-Wis., chairman of the committee, which is holding a hearing on the findings in Tomah on Tuesday, told USA TODAY the failures were “systemic” and indicative of a troubling pattern. “The reasons the problems were allowed to fester for so many years is because in the inspector general’s office, for whatever reason, for years, the inspector general lacked the independence and had lost the sense of what its true mission was, which is being the transparent watchdog of VA system,” he said. The conclusions echo other recent findings about the office tasked under federal law to be an independent watchdog exposing problems at the VA and making recommendations for improvement. The Office of Special Counsel, a federal agency that reviews whistleblower reports of wrongdoing, issued blistering critiques in recent months of the office’s investigations in Illinois, Louisiana, and Texas, which it said were incomplete and overly narrow. USA TODAY also has reported that the VA inspector general failed to release the findings of 140 health care investigations and sat on the results of more than 70 wait-time probes for months. While a new inspector general, Michael Missal, took over the office last month and promised comprehensive investigations and greater transparency, the lead investigators on health care remain in place, including John Daigh, the physician who made the decision to keep the Tomah report secret. A spokesman for the Office of Inspector General, Mike Nacincik, said Friday that IG officials had not finished reviewing the Senate report and so could not comment on the findings. But he said that at the time, Daigh felt it was appropriate not to release the Tomah report when it was finished in 2014 because the investigation did not substantiate wrongdoing. “The OIG has learned important lessons from the Tomah VA Medical Center health care inspections,” Nacincik said.
Missouri Senator to introduce bill to help veterans exposed to mustard gas (NPR)
Sen. Claire McCaskill, D-Mo., plans to introduce legislation today to help World War II veterans who were exposed to mustard gas. The vets were used in classified experiments conducted by the U.S. military, and were sworn to secrecy about their participation for a half-century. Last year, an NPR investigation found the Department of Veterans Affairs failed to notify thousands of mustard gas test subjects of their eligibility to apply for compensation — and that it routinely denied claims from veterans who qualified. In many cases, the VA has said veterans don’t have enough evidence of their participation in the tests to get benefits — even though the tests were kept off official records. McCaskill is naming the bill the Arla Harrell Act, after a man thought to be the last surviving Missourian who served as a mustard gas test subject. Harrell, 89, lives in a nursing home. His repeated claims for compensation have been denied by the VA, as recently as last month. Roughly 60,000 Army and Navy troops were used in the experiments, which sought to prepare the U.S. military to face mustard gas in battle. Mustard gas is known to cause serious illnesses, including leukemia, skin cancer and chronic breathing problems. McCaskill’s office launched its own investigation into the treatment of mustard gas test subjects after NPR published its report. With cooperation from the VA and the Pentagon, McCaskill found that only 40 living veterans are currently receiving compensation for injuries resulting from the experiments, and that 90 percent of veterans’ claims for mustard gas-related injuries have been denied. The bill calls for the VA and the Department of Defense to establish a new policy for processing claims for mustard gas exposures, and to reconsider all previously denied claims. In doing so, the bill says the VA should presume that veterans were exposed to the toxic agents “unless either agency can definitely prove otherwise.”
Learn More: Mustard gas and veterans disability compensation
Obama on Memorial Day: We need to be there for veterans and their families (CBS News)
On his last Memorial Day as president, Mr. Obama laid a wreath Monday at the Tomb of the Unknowns to honor members of the military who died serving their country. His appearance at Arlington National Cemetery carries on a longstanding presidential tradition and comes as the U.S. struggles to end various conflicts in the Middle East. In his remarks, the president referred to those laid to rest at Arlington and their families “the best of us,” and he called on Americans to honor the fallen by caring for those they leave behind – their families and their battle buddies who come home. “We need to be there not just when we need them, but when they need us,” Mr. Obama said of the nation’s veterans. About 6,000 people attended the ceremony, according to a public affairs officer at the amphitheater. Mr. Obama said 20 members of the armed forces had died in combat within the last year. Special operations forces continue to serve in dangerous missions in Syria, Iraq and Afghanistan, even as the U.S. military presence in the latter two countries has been greatly reduced under President Obama’s watch. The focus in Iraq and Syria is on defeating the Islamic State group. In Afghanistan, U.S. troops work with Afghan forces battling the Taliban. Monday morning, the president held a breakfast reception at the White House for family members of fallen service members and veterans groups. In his Saturday weekly address, Mr. Obama commemorated the service of fallen soldiers and urged Americans to engage in acts of remembrance over the weekend, including a plea to “hire a veteran who is ready and willing to serve at home just as they did abroad.”
Legal settlements at VA more than tripled since 2011, many due to medical malpractices (Daily News)
The number of legal settlements made by the Department of Veterans Affairs has more than tripled over the past five years largely due to a spike in medical malpractice cases and bungled construction projects, the Daily News has learned. The yearly total payments skyrocketed to $338 million in 2015 from $98 million in 2011, according to Treasury Department data obtained via a Freedom of Information Act request. The cases include multiple examples of blown diagnosis, botched procedures and substandard care, records show. “After nearly a decade, major reform at the Department of Veterans Affairs is long overdue,” said Daniel Epstein, executive director of the Washington-based group Cause of Action, a government watchdog group. … Veteran advocates say that reflects years of substandard care at the 152 federal hospitals at a time when additional troops who served in Iraq and Afghanistan returned from combat tours. Critics contend the federal government has done little to improve treatment and prevent new cases. VA officials downplayed the costly spike in litigation, noting the number of payouts in fiscal year 2013 represents less than 1% of total number of patients treated each year. But the agency did not respond to multiple requests seeking comment regarding the latest stats. … The department cared for 6.6 million veterans in fiscal year 2014, a 56% jump from fiscal year 2001, records show. And many of the new cases are complicated and require extensive treatment. … “The failures and lapses in care that led to these judgments are not the result of a lack of money or resources,” said Rep. Jeff Miller, a Florida Republican and chairman of the House Veterans Committee. “Rather they stem from VA’s long and well documented history of refusing to seriously hold accountable those who can’t or won’t do their jobs.” The VA’s budget has nearly quadrupled over the past 15 years, increasing 73% in the last seven years alone, he said. … The settlements aren’t just tied to medical mishaps. The VA paid out more than $200 million to the contractor of the maligned Orlando VA Medical Center. VA officials repeatedly blamed lengthy delays on the 1.2 million-square-foot facility on the contractor, Brasfield & Gorrie. But less than a year after the project was finally finished, the VA quietly agreed to pay the Birmingham, Ala.-based firm a series of eight multi-million dollar settlements, totaling some of the largest payouts issued in years, records show. The contractor argued that VA officials lied about how much it would actually cost to build the 134-bed hospital. That deceitfulness forced the firm to pay its subcontractors out of pocket to finish the promised work.
Alternate PTSD therapy for vets ruffles VA feathers, but shows results (Military.com)
Even before she left for Afghanistan, Katie Helmer knew she was going to have trouble when she got back. As a member of the Minnesota National Guard, she was assigned to monitor casualties at a military hospital at Bagram Airfield. From a previous deployment in Kuwait, Helmer knew the psychic toll the ordeal would take on her. When she came home in 2013, she jumped at the chance to get free treatment for post-traumatic stress through a pilot program for a therapy called EMDR, which uses sensory stimulation to connect to triggers from trauma and neutralizes them. After several sessions, she said it worked. “I’ve never been a therapy type of person, but it worked because it was a different kind of therapy, and I didn’t have to do too much of the talking,” Helmer said. Out of that pilot program emerged the Veteran Resilience Project, a Minnesota nonprofit that offers EMDR therapy — which stands for eye movement desensitization and reprocessing — to vets, and says it is getting positive results. There is a rub: The U.S. Department of Veterans Affairs (VA) says the treatment is effective but not one of its top choices for addressing post-traumatic stress disorder (PTSD). In Minneapolis, in fact, the VA doesn’t use it at all. The VA has no objection to the therapy, but it seldom will refer patients for treatment because the VA has the resources — and pays for — other therapies. So EMDR practitioners are joining a growing list of groups seeking to help veterans who say they often find themselves in a David vs. Goliath battle with the VA. And they have not been afraid to step up to make their point. … EMDR is designed to help the brain unlock traumatic memories and reprocess them into more positive thoughts. During a session, the client may be asked to focus on a memory while stimulation is used such as eye movements, tapping or sounds. After each association is processed, the “bilateral” stimulation continues until the original issue is no longer disturbing. EMDR is offered sparingly across the VA system, but access depends on resources available at a local facility, said Paula Schnurr, executive director of the VA’s National Center for PTSD in White River Junction, Vt. … In a statement, Minneapolis VA mental health officials said the Twin Cities hospital instead relies on two other established forms of treatment: prolonged exposure (PE) and cognitive processing therapy (CPT), both proven to be highly effective. The Minneapolis VA, in fact, provides training to other facilities in the two approaches. “We have not developed this service and have instead focused our efforts on providing the highest quality services in PE and CPT,” the Minneapolis VA said in a statement. The St. Cloud VA, the only other VA hospital in Minnesota, said it does offer EMDR to a small number of veterans as part of the hospital’s outpatient mental health program.
Veterans sites in California, Kentucky, Virginia damaged (MilitaryTimes)
Memorials to veterans in a Los Angeles neighborhood and a town in Kentucky, as well as a Civil War veterans cemetery in Virginia, were damaged as the nation prepares to mark Memorial Day, officials said. A Vietnam War memorial in the Venice area of Los Angeles has been extensively defaced by graffiti. The vandalism occurred sometime during the past week, KCAL/KCBS-TV reported. The homespun memorial painted on a block-long wall on Pacific Avenue lists the names of American service members missing in action or otherwise unaccounted for in Southeast Asia. News of the vandalism came as another veterans-related memorial was reported damaged in Henderson, Kentucky. Police say a Memorial Day cross display there that honors the names of 5,000 veterans of conflicts dating back to the Revolutionary War has been damaged by a driver who plowed through the crosses early Saturday. In Virginia, the Petersburg National Battlefield has apparently has been looted, the National Park Service said. Numerous excavations were found at the Civil War battlefield last week, Jeffrey Olson, and agency spokesman, said in a news release Friday. Petersburg National Battlefield is a 2,700-acre park marks where more than 1,000 Union and Confederate soldiers died fighting during the Siege of Petersburg 151 years ago. In Los Angeles’ Venice neighborhood, the wall for missing veterans has been tagged previously, but the latest vandalism covers the bottom half of the memorial for much of its length. To George Francisco, vice president of the Venice Chamber of Commerce, it’s not just graffiti. “It’s a desecration. I mean it’s very simple. There’s no sort of other way around it, said Francisco, who also runs a nonprofit called Veterans Foundation Inc. “I’ve known the sacrifices these people made in an incredibly unpopular war. So to continue the mistreatment of Vietnam veterans is somewhat shocking, somewhat shocking and quite sad,” Francisco said. Painted by a Vietnam veteran and dedicated in 1992, it declares, “You are not forgotten” and states the number of missing as 2,273. According to the Defense POW/MIA Accounting Agency, the number of unaccounted-for Americans was listed at 2,646 in 1973. About half were those missing in action, and the others were those killed in action but the body was not recovered. Since then, the remains of more than 1,000 American have been identified and returned and about 1,600 have still not been accounted for, although efforts continue. In Henderson, Kentucky, Jennifer Richmond, a spokesman for the Henderson Police Department, said the community is devastated and working frantically to repair and replace the crosses that were put on display for a Memorial Day ceremony in Central Park. She said a 27-year-old local man drove straight through the cross display in the Henderson park, about 130 miles west of Louisville, just before 6 a.m. Saturday, but investigators don’t know if it was deliberate. Anthony Burrus has been charged with criminal mischief in the first degree and leaving the scene of an accident. Online jail records do not list an attorney for Burrus.
Graffiti is scrubbed from veteran’s memorial in Los Angeles, but more restoration work remains (Los Angeles Times)
Officials said that the damage from a graffiti attack on a veterans memorial in Venice was so extensive that it will take some time to restore the monument. Volunteers removed much of the graffiti over the Memorial Day weekend but it appears more work will be necessary to fully restore the memorial. The memorial is painted on the side of a Metro building. “We were initially hopeful that the graffiti could be removed without damaging the memorial, but Metro’s contractor says the damage is too extensive,” Metro CEO Phil Washington said in a statement. “Metro will work with the community to gather historical photos so the wall can be restored. In the meantime, Metro will cover the wall as a gesture of respect to the fallen whose names were covered by the graffiti.” Residents expressed outrage over the vandalism. “It’s sad and shocking,” said Venice Chamber of Commerce Vice President George Francisco. “Such ignorance and animosity.” The damage, he said, feels especially personal — his father was a Green Beret in Vietnam and did two combat tours. The mural along Pacific Avenue has a message at the top reading “You Are Not Forgotten” and bears the names of 2,273 soldiers counted as either prisoners of war or missing in action in Vietnam. After the mural’s dedication in 1992, the artist, Peter Stewart, said he was inspired to paint the wall after attending a welcome-home parade for Operation Desert Storm veterans. Since then, the now-fading mural along one of Venice’s main streets has become an important icon. When longtime resident Stewart Oscars drove by Wednesday evening, he noticed the damage and turned to his wife and friend. “Holy mackerel,” he blurted. “Look at this thing.” Oscars, who lives a mile or so from the mural, said he felt instantly nauseous. His mind raced with memories of his classmates who had fought in Vietnam — a couple of whom he understands never returned. He thought, too, of Memorial Day and how veterans’ families will feel when they see the vandalism. “It’s like a direct attack,” he said. “If you have any sense of history, you’d never do this.” Oscars said the graffiti stretched on for about 100 feet.
Donald Trump details $5.6M in charitable contributions to veterans’ groups (ABC News)
Responding to questions about his contributions to veterans’ charities, Donald Trump detailed today the groups that have shared the millions he said he collected at his Iowa fundraiser in January. “I raised close to $6 million. It will probably be over that amount when it’s all said and done, but as of this moment, it’s $5.6 million,” Trump asserted today at a news conference at Trump Tower in New York. Trump said the money has been distributed, blaming the delay on the need to vet the groups. “I had teams of people reviewing statistics, reviewing numbers and also talking to people in the military to find out whether or not the group was deserving of the money,” the presumptive Republican nominee told reporters. He continued, “I wanted to keep it private because I don’t think it’s anybody’s business if I want to send money to the vets.” Reading from a list, Trump said he gave money to various veterans’ charities, including Hope for the Warriors, Homes for Our Troops, the Disabled American Veterans Charitable Service Trust and K9s for Warriors. The largest contribution Trump listed was $1.1 million to the Marine Corps–Law Enforcement Foundation. Trump said that while he wasn’t “too involved” in picking the organizations, he gave the money to Marine Corps–Law Enforcement because they are “fabulous people.” Instead of appearing on an Iowa stage with his presidential competitors at a Jan. 28 Republican debate, Trump hosted what his campaign called a “special event to benefit veterans organizations” that night, later saying it raised $6 million. Later, questions arose as to which organizations benefited from the event, when the groups received the funds and how much was allocated. Trump announced last week he had donated $1 million of his own money. Trump today criticized the media for being “dishonest” and “unfair,” saying he has never received such “bad publicity” for doing a “good job.” “I don’t want the credit for it, but I shouldn’t be lambasted,” he insisted. Democratic candidate Hillary Clinton, meanwhile, unveiled a proposal on veterans and their families and hosted a national press call with Florida veterans to “call out Donald Trump’s hypocrisy,” according to a campaign press release In New York, veterans organized by an outside Democratic group protested outside Trump Tower during the real estate mogul’s news conference.
Military veteran finds a mission nursing fellow vets at VA (Stars and Stripes)
Nursing assistant Tom Alligood wears camouflage scrubs during his emergency room shifts at the Dorn VA hospital because he says it helps other veteran patients realize they’ve “walked over the same dirt,” the 62-year-old former Army tanker says. And he doesn’t just mean the desert sands of Iraq. Alligood means homelessness, job loss and the mental anguish of being a long-time military veteran trying to adjust to the trials of a dog-eat-dog, backstabbing civilian world he says nearly ate him alive. “I need to be around veterans like me. That’s where I get my strength, my ‘positiveness’ from,” says the burly former first sergeant who now sports a long, gray braid on his back. Alligood says he has found a new mission – working in the sprawling Columbia VA hospital and helping as many of his one-time brothers and sisters in arms as he can. And the VA is looking for more people like Alligood. In an attempt to respond to the crisis of lengthy patient wait-times and a malfunctioning bureaucracy, VA Secretary Robert McDonald told Congress the agency hired about 14,000 health care workers last year, including 1,300 doctors and 3,600 nurses. Alligood’s background as a military veteran is a plus, she says, and they can always use more like him. “Veterans know what it takes to serve and what sacrifices they’ve endured and what some of their challenges have been that have affected their health,” the nurse supervisor says. Alligood said he can relate to his veteran-patients because the route he took from being a VA patient to VA caregiver has been a challenging one. After leaving the Army, he took a job managing a concrete block plant. The job was eliminated when the plant was sold. Falling deep in debt, Alligood said he took to sleeping in abandoned buildings after losing his car and his home. Life in homeless shelters didn’t sit right, either. “I wasn’t in the best of shape, mentally and physically,” he said, his rumbling voice catching. “That was the lowest I’ve ever been.” Alligood said counselors told him about a VA program that put homeless veterans into counseling and back to work. He grabbed the chance to put in 40 hours a week transporting other veterans around the hallways of the sprawling Dorn VA Medical Center in wheelchairs and gurneys. “It was for $5.15 an hour, minimum wage. But trust me, that $5.15 meant more to me at that time than anything,” he recalls. As he traversed the hospital’s maze of corridors, Alligood said he made a point of greeting as many people as he could. Alligood’s banter with other veterans caught nursing administrator Ruth Mustard’s ear. She told him the VA would pay for his schooling if he wanted to learn to become a certified nursing assistant and come back to help other veterans. He went back to school and the Florida native returned to the Dorn VA Medical Center, where he’s logged three years in an eldercare unit and six years in the emergency department. “He has a fabulous rapport,” Mustard said. Emergency room nurse Karen Teal says the former first sergeant has a personal touch that put stressed-out patients “instantly at ease.” “He’s our jewel,” Teal says, beaming at her co-worker. Alligood said his days in Iraq and Saudi Arabia help him understand veterans who might be dealing with post-traumatic stress disorder. He recounted one veteran he found experiencing a “flashback” in the ER. “I was able to tell him, ‘I got your back, I got your back,'” Alligood said, telling how he’d gotten down on the floor with the ailing veteran, assuring him he’d reached a safe place. “I don’t feel that this is a job for me. I feel that this is a calling, because I get to help so many people,” Alligood said.