Two whistleblowers testified at a Nov. 13 congressional hearing about the culture of negligence that has compromised patient safety at the G.V. (Sonny) Montgomery Department of Veterans Affairs (VA) Medical Center in Jackson, Miss.
The hearing, by the House Veterans Affairs’ Subcommittee on Oversight & Investigations, examined a variety of serious problems at the Jackson VA center. Dr. Phyllis Hollenbeck, M.D., former physician of family medicine at the Jackson VAMC, and Dr. Charles Sherwood, M.D., former chief of ophthalmology at the facility, testified. They had complained to the U.S. Office of Special Counsel in Washington about conditions at the Jackson VAMC, including poor sterilization procedures, understaffing, misdiagnoses and poor management practices that placed patients at risk.
Unsupervised nurse practitioners in Jackson VAMC’s primary-care unit, Hollenbeck said, outnumbered physicians by a ratio of three to one – sometimes four to one. “This same cavalier attitude and laxity by medical center and VISN (Veteran Integrated Service Network) leadership toward safe and proper medical care for the veterans empowered the NPs to prescribe narcotics, without physician supervision and without individual DEA (Drug Enforcement Administration) registration numbers,” Hollenbeck said. This practice violates federal and individual state laws and VA handbook regulations.
The hearing was titled “Correcting ‘Kerfuffles’ – Analyzing Prohibited Practices and Preventable Patient Deaths at Jackson VAMC.” The title referred to a comment from VA Undersecretary of Health Dr. Robert Petzel, who had called the patient deaths as “some public kerfuffles in the paper.” This included the death of Johnnie Lee, an Army veteran and employee of the VAMC, who was left unattended during a skin graft operation only to have a hospital machine drain all of the blood from his body. Leaving a patient attached to the machine was directly in contrast to FDA regulations which call for “frequent monitoring” in such cases.
Other concerns and allegations include a director of Patient Care Services arrested on prescription fraud charges, physicians asked to sign Medicare Home Health Certificates for patients they haven’t seen and patients being seen not by physicians with any regularity, but by nurse practitioners. Problematically, as many as 85 percent of patients were seen by nurse practitioners instead of physicians, and most were unaware they were not being treated by doctors.
American Legion National Commander Dan Dellinger was “appalled” by the conditions revealed at Jackson. “The VA facility in Jackson has failed in its responsibility to protect veterans who depend on it for their health care,” Dellinger said. “When pieces of bone are still attached to surgical instruments that are being used on other patients, putting the lives of our veterans at risk, it is time to overhaul the entire hospital and remove – not transfer – the responsible parties.”
In other news:
House passes COLA bill: On Nov. 12, the House of Representatives by a voice vote approved S. 893, the Veterans Compensation Cost-of-Living Adjustment Act of 2013. This measure passed the Senate on Oct. 28 by unanimous consent. It now goes to the president for his signature. This legislation directs the VA Secretary to increase – effective Dec. 1 – the rates of veterans’ disability compensation, additional compensation for dependents, the clothing allowance for certain disabled veterans, and dependency and indemnity compensation (DIC) for surviving spouses and children. It further requires each such increase to be the same percentage as the increase in benefits provided under title II (Old Age, Survivors and Disability Insurance) of the Social Security Act, on the same effective date.
Letters of support: The American Legion has sent two letters of support in the past 10 days:
• On Nov. 6, a letter was sent to Rep. Judy Chu of California for H.R. 3399, the Veterans Education Counseling Act, a measure to improve the academic and vocational counseling options available to student-veterans. This legislation requires the VA to differentiate between the educational counseling that all GI Bill users are entitled to, and the Voc Rehab program. Additionally, it requires VA to let veterans know that they are entitled to this “basic” educational counseling, and provide information on how to apply for it, prior to the veteran applying for GI Bill benefits. Finally, it would allow veterans to apply for benefits through the eBenefits portal. These provisions are in keeping with our organization’s overall intent to ensure that veterans receive a maximum amount of information when using their earned GI Bill benefits, to ensure that they receive sufficient information in order to gain the most benefit from their education.
• On Nov. 14, a letter was sent to Rep. Kerry Bentivolio of Michigan H.R. 3384, the Veterans’ Entry to Apprenticeship Act, which would amend Title 38, United States Code, to allow veterans to use their educational benefits for enrollment in pre-apprenticeship programs. Current law does not allow veterans to apply their earned GI Bill benefits toward pre-apprenticeship training, which is designed to provide the basic groundwork for a particular trade, and is required in order to become eligible for some apprenticeships.
How we help: Staff from VA&R Division on Veterans Day provided information regarding how The American Legion can help, benefits of joining The American Legion, and health-care benefits to veterans and family members of veterans at the National Mall.
Google event: The Veterans Employment & Education Division attended a Google event titled “Improving Veterans’ College Graduation Rates,” along with Student Veterans of America (SVA) and Veterans of Foreign Wars (VFW), to discuss challenges in veterans’ education and explore data-driven solutions to improve college graduation rates. The Nov. 12 event revolved around graduation rates for military and veteran students; disaggregate the outcome measures by credential type; better information on transfer; a move toward student-level reporting; requiring institutions to report graduation rates by military status to the Integrated Postsecondary Education Data System (IPEDS); the number of students receiving GI Bill benefits; the total dollar amount of tuition and fee benefits awarded to their institution; the number of students receiving DOD’s Tuition Assistance and the total dollar amount of DOD’s Tuition Assistance awarded to their institution. Resolution No. 67 of 2013.
Supporting small businesses: The Veterans Employment & Education Division, along with the Legislative Division, participated in a Nov. 13 Senate Small Business Roundtable hosted by Sen. Mary Landrieu of Louisiana. The American Legion reiterated support for Small Business Administration’s (SBA) veteran business development programs – a namely, the Boots 2 Business (B2B) entrepreneurship program for transitioning servicemembers, Veteran Business Outreach Centers (VBOC) and the Patriot Express Loan (PXL). In testimony, we discussed our support for the full funding of the B2B program, which has already been piloted and is waiting on Congress to pass a budget to allow for its nationwide implementation. In addition, the Legion discussed the need to increase the number of VBOCs in the U.S. and its territories so the B2B programs will have a home in every state. Lastly, the Legion discussed the need for reform in the PXL in order to build this program up to being a premier lending program.
System Worth Saving: On Nov. 14-15, The American Legion’s System Worth Saving Task Force conducted a site visit of the Department of Veterans Affairs Tennessee Valley Healthcare System’s Nashville Campus. During the visit, the task force focused on VA’s accomplishments and progress over the past 10 years, current issues and concerns as well as VA’s five-year strategic plan for several program areas, such as VA’s budget, campus alignment, staffing, enrollment/outreach, hospital programs, information technology and construction programs. On Nov. 13, the task force conducted a town hall meeting at American Legion Post 88 in Nashville for veterans to discuss the Department of Veterans Affairs Tennessee Valley Healthcare System.
Claims: During the week ending Nov. 8, the Board of Veterans’ Appeals reached dispositions on 251 American Legion represented appeals. Of those dispositions 67.7 percent of the denials were overturned with outcomes favorable to the veteran. In 62 cases, the board granted benefits outright after considering The American Legion’s arguments. In 112 cases, The American Legion was able to point out errors in the development of the veteran’s claims which mandated corrective action under the law. Of the total number of dispositions, 67 (26.7 percent) were outright denied.
Future job fairs: The Veterans Employment & Education Division met Nov. 13 with representatives from the U.S. Chamber of Commerce and the CEO of RecruitMilitary regarding their job fairs for fiscal year 2014.
Career fairs: The Employment Division hosted a hiring event Nov. 11 in Des Moines at the Iowa State Fairgrounds, Bruce L. Rastetetter 4-H Exhibits Building. More than 90 employers and veterans service organizations were in attendance. There were 172 veteran and spouse jobseekers that participated in the event. Overall there were 515 resumes accepted by employers, 37 interviews conducted and four on-the-spot hires. Special thanks goes to the U.S. Chamber of Commerce for its role in planning the event along with The American Legion Department of Iowa Employment Chairman Ted Hall, the Iowa National Guard and the Employer Support of the Guard and Reserve (ESGR), whose outreach for this event ensured that it was a success.