June 23, 2014 -- Updated 1536 GMT (2336 HKT)
STORY HIGHLIGHTS
- Office of Special Counsel sends scathing report on veterans care to White House
- VA's "approach hides the severity of systemic and longstanding problems," agency says
- As part of review, OSC looked at whistleblower allegations at 10 VA hospitals across the country
- It says it's still investigating more than 50 whistleblower disclosures
In one case, a veteran
with a service-connected psychiatric condition was in the facility for
eight years before he received a comprehensive psychiatric evaluation;
in another case, a veteran only had one psychiatric note in his medical
chart in seven years as an inpatient at the Brockton, Massachusetts,
facility.
Examples such as those are the core of the report released Monday by the OSC, an independent government agency that protects whistleblowers.
The agency said it is
still investigating more than 50 whistleblower disclosures involving
patient health or safety allegations at the VA nationwide, and "these
cases represent more than a quarter of all matters referred by OSC for
investigation government-wide," according to the report.
The report also slams the VA's medical review agency, the Office of the Medical Inspector,
or OMI, for its refusal to admit that lapses in care have affected
veterans' health. For example, when the office reviewed the Brockton
psychiatric cases, it confirmed the patient neglect yet "denied that...
(it) had any impact on patient care."
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"The VA, and particularly
the VA's Office of the Medical Inspector (OMI), has consistently used a
'harmless error' defense, where the Department acknowledges problems
but claims patient care is unaffected," the OSC said. "This approach
hides the severity of systemic and longstanding problems."
As part of its review,
the agency looked at whistleblower allegations at 10 VA hospitals, where
it found the VA's review of cases "appears to contradict its own
findings."
According to the OSC, at a
VA hospital in Jackson, Mississippi, the Office of Medical Inspector
substantiated a number of allegations, including
"improper credentialing of providers, inadequate review of radiology
images, unlawful prescriptions for narcotics, noncompliant pharmacy
equipment used to compound chemotherapy drugs, and unsterile medical
equipment."
"In addition, a
persistent patient-care concern involved chronic staffing shortages,"
which led to the creation of "ghost clinics" in which veterans were
scheduled for appointments without an assigned provider and as a
consequence were leaving the facility without receiving treatment.
Despite the numerous
lapses in care at the Jackson VA, the Office of Medical Inspector did
not acknowledge any impact on the health and safety of veterans,
according to the OSC letter.
Monday's letter also
outlined whistleblower complaints ranging from unsterlized surgical
equipment in Ann Arbor, Michigan, to neglect of elderly residents at a
geriatric facility in San Juan, Puerto Rico, to a pulmonologist in
Montgomery, Alabama, who "copied prior provider notes in over 1,200
patient records, likely resulting in inaccurate health information being
recorded."
Other facilities with
substantiated complaints include Grand Junction, Colorado; Buffalo, New
York; Little Rock, Arkansas; and Harlingen, Texas.
The OSC said all these
cases are "part of a troubling pattern of deficient patient care at VA
facilities nationwide, and the continued resistance by the VA, and the
OMI in most cases, to recognize and address the impact of health and
safety of veterans."
The agency also
expressed concern that the VA hasn't adequately addressed whistleblower
complaints of wrongdoing. Referring to the scandal of a secret wait list
at the Phoenix VA facility, the OSC found that "the recent revelations
in Phoenix are the latest and most serious in the years-long pattern of
disclosures from VA whistleblowers and their struggle to overcome a
culture of non-responsiveness. Too frequently, the VA has failed to use
information from whistleblowers to identify and address systemic
concerns that impact patient care."
At a facility in Fort
Collins, Colorado, the Office of Medical Inspector substantiated
allegations made by a VA employee, including a shortage of providers
that led schedulers to cancel veterans' appointments. It found that
3,000 veterans were unable to reschedule appointments and that staff was
instructed to alter wait times.
In May, CNN interviewed
Lisa Lee, who worked as a scheduler at the VA clinic in Fort Collins.
"We were sat down by our supervisor ... and he showed us exactly how to
schedule so it looked like it was within that 14-day period," Lee told
CNN. "They would keep track of schedulers who were complying and getting
100 percent of that 14 day(s) and those of us who were not."
Despite its findings in
Fort Collins, the Office of the Medical Inspector wrote that it "could
not substantiate that the failure to properly train staff resulted in
danger to public health and safety."
In Monday's letter, the
OSC disagreed with that determination, saying the VA's conclusion in
this case "is not only unsupportable on its own, but is also
inconsistent by other VA components examining similar patient-care
issues."
Since November 2013, CNN
has been investigating and publishing reports of wait lists and deaths
of veterans across VA hospitals across the country. In April, details of
the secret wait list in Phoenix, and allegations of 40 veterans dying
there while waiting for care, emerged when retired Phoenix VA physician
Dr. Sam Foote stepped forward; Dr. Foote first appeared on CNN with
details of what happened in Phoenix.
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