VA OIG confirms $5,000,000 in waste by VA Public Affairs


Department of

Veterans Affairs

Review of

Alleged Mismanagement of

the Office of Public and

Intergovernmental Affairs

Outreach Contracts

We substantiated the allegations regarding

OPIA mismanagement of its outreach

contracts. We confirmed that in July 2010,

OPIA awarded a contract to Woodpile to

provide support for outreach campaigns at

an initial cost of $5.2 million. However,

OPIA could not demonstrate that contract

activities resulted in increased awareness of

and access to VA healthcare, benefits, and

services for veterans. We also confirmed

that OPIA solicited significant new outreach

service contracts without evaluating the

effectiveness of the previous contract.

OPIA management stated that leadership

turnover contributed to ineffective oversight

of the outreach contract management and

solicitations. Consequently, Woodpile

contractors performed functions that were

inherently Governmental. Questionable use

of a labor-hour order instead of a

performance-based contract contributed to

invoices for activities that did not clearly

link to accomplishment of VA outreach

goals. By awarding new contracts without

first evaluating the performance of the prior

Woodpile contract, OPIA continued to

expend funds on questionable outreach

activities. OPIA also lacked performance

metrics to fully assess improvements in

access to VA benefits and services for


Congress to put Philadelphia VA’s management problems under further scrutiny – Washington Times

Oscar the Grouch will have lots of company in his garbage can on Friday.

Despite President Obama ordering a new “culture of accountability” at the Department of Veterans Affairs, a congressional hearing Friday will focus on persistent management problems at the agency’s Philadelphia office, where complaints range from phony record keeping to managers comparing veterans to the Sesame Street character Oscar to allegations that a VA manager encouraged employees to pay his wife to read their fortunes.

The House Committee on Veterans’ Affairs will hold the hearing at a community college in Burlington County, New Jersey, which is part of the Philadelphia regional office’s three-state coverage area. A committee spokesman said the probe will focus on “mismanagement, cooking the books in order to make the backlog of claims appear smaller and low employee morale.”

via Congress to put Philadelphia VA’s management problems under further scrutiny – Washington Times.

VA employees accused of misconduct still not fired

Several Central Alabama Veterans Healthcare System employees who engaged in unethical — and in some cases criminal — behavior were still employed as of Nov. 12.

Over the course of several months, the Montgomery Advertiser obtained documents that showed five employees had taken advantage of VA patients, destroyed government property and lied to officials about misconduct.

And now, months later, VA records show several of those individuals are still receiving paychecks. Although information on an employee’s disciplinary action isn’t available to the public, employment status is.

The vocational rehabilitation specialist who brought a recovering veteran in the drug treatment program to a crack house is no longer employed, nor is Andre Hall, the prosthetics health technician who was charged with sexually abusing a veteran patient in December 2013.

But three others still are.

A CAVHCS employee who crashed a government vehicle, failed to report the accident, fabricated evidence and lied to police is still employed more than a year-and-a-half after the incident, records show.

The employee caused more than $5,600 in damages while driving in Barbour County in April 2013. VA police later discovered that the employee wasn’t there on business, and that the employee asked a witness to write a false statement about observing a deer running in front of the car to show he wasn’t at fault, according to the police report.

A VA Police investigation said the employee violated state law by not reporting the accident, violated multiple policies by not properly reporting the accident to the VA, made false statements to investigators, misused government resources and property for personal gain and damaged government property.

The police report also shows that an “enormous” amount of trash, food containers and VA retail store receipts on the floor of the vehicle showed that it wasn’t being properly inspected by the employee, his supervisors or VA employees responsible for maintaining the vehicles.

Court records and VA documents leaked to the Advertiser show that the employee also has a long history of felony arrests and driving violations, even though driving is required for his job.

His job as a vocational rehabilitation specialist in the mental health department requires him to work with a team that helps veterans with disabilities to overcome psychological, developmental and cognitive health barriers so they can get jobs. The position often requires driving veterans to jobs and appointments.

Between 2009 and 2013, the employee was twice charged with driving under the influence of alcohol, possession of marijuana, public lewdness and several moving violations, including speeding and failing to stop at a stop sign.

His salary is $49,520 and he works on the Tuskegee campus.

Another employee, Jason Garrette, who pleaded guilty to criminally negligent homicide after his involvement with a fatal car crash last December, is still employed. He was also charged with driving under the influence of alcohol in connection with the accident, court records show.

A Macon County grand jury indicted him for the homicide Sept. 12, and he pleaded guilty Sept. 25.

Garrette is also a vocational rehabilitation specialist, which requires driving veterans around in government vehicles. His salary is $49,520.

A third employee who police said misused, accepted and assumed control of a Tuskegee VA nursing home patient’s personal funds is also still employed.

The employee was assigned to be the patient’s “guardian angel,” which is part of a VA treatment program. The employee allegedly convinced the 49-year-old patient with dementia to trust her with conducting the patient’s financial activities.

A VA police investigation found that nearly $6,000 of the veteran’s money was withdrawn during a 15-month period and is still unaccounted for. There wasn’t enough evidence to press criminal charges, but police said the employee’s actions were considered patient abuse, and were described as reckless, uncaring and unapologetic toward the veteran.

The report said the employee became the patient’s guardian angel after finding out that the veteran was receiving compensation for her service-related disability. The employee also knew the veteran had been recently divorced and had limited access to family and friend.

The reports didn’t say whether any administrative action was taken, although the case was referred for administrative review.

via VA employees accused of misconduct still not fired.

VA’s firing of Pittsburgh Veterans Affairs director raises new allegations | Pittsburgh Post-Gazette

The families of the veterans who died at the Pittsburgh VA were upset to learn at the HVAC hearing just how big the bonus checks were that Pittsburgh VA executives received despite ignoring the outbreak of legionella

Terry G. Wolf former director of the VAPHS seen here in a happier time.

Not so happy now, former VA Pittsburgh director follow in the footsteps of her mentor Michael Moreland

Terri Wolf former VAPHS Director doesn’t seem so happy now.

The U.S. Department of Veterans Affairs fired the Pittsburgh VA director because of the 2011 and 2012 Legionnaires’ disease outbreak, and it also raised new allegations Thursday of “wasteful spending” against her that it refused to explain.

The VA said it had formally fired Terry Gerigk Wolf, the Pittsburgh VA director for the past seven years, nearly six weeks after it first said it had substantiated charges of “allegations of conduct unbecoming a senior executive” during an investigation.

The Legionnaires’ outbreak led to 22 veterans becoming ill and at least six of them dying. Families of four of them said they were happy to see someone had been held accountable, but they believed Ms. Wolf was being made into a “sacrificial lamb,” as one of them said.

“This is a step in the right direction, but we all know there are others who were responsible, and nothing has been done to them, and we all know who they are,” said Judy Nicklas, daughter-in-law of William E. Nicklas, 87, of Hampton, who died Nov. 23, 2012.

U.S. Rep. Tim Murphy, R-Upper St. Clair, raised that issue during questioning Thursday morning at a House Veterans Affairs Committee hearing when he asked Sloan Gibson, the VA’s deputy director, about accountability at the VA for the outbreak.

Mr. Gibson said he looked into the Pittsburgh matter during the summer to see whether anyone who should have been disciplined actually was. He said in every case in which there was culpability found, action was taken, but “in all likelihood I would not have agreed with the nature of those actions.”

“But I had no leeway to go back and address those because those actions had been closed out completely,” he said, “except in one instance.”

That one instance was the case of Ms. Wolf, who was put on paid leave in June pending an investigation.

Mr. Murphy said it was frustrating to learn recently that David Cord, one of the Pittsburgh VA officials who was involved in the outbreak and who advocated to keep information from the public, was recently promoted to be director of the Erie VA.

“I think that’s indefensible and incomprehensible,” Mr. Murphy told Mr. Gibson, adding that Mr. Cord at one point also “misled” him about whether the Pittsburgh VA had a waiting list.

Mr. Gibson said he would look into Mr. Murphy’s allegation about being misled by Mr. Cord. Mr. Cord could not be reached for comment.

The action to fire Ms. Wolf came almost two years to the day that the Pittsburgh VA first announced in a news release, on Nov. 16, 2012, that four patients had contracted Legionnaires’.

On Thursday, as was the case since that first mention of the outbreak in 2012, the VA failed to explain much and actually raised more questions.

For the first time, the VA said in its news release Thursday, not only did investigators substantiate “allegations of conduct unbecoming a senior executive,” but it also had substantiated allegations of “wasteful spending” against Ms. Wolf.

The VA would not explain why it took six weeks to fire Ms. Wolf, even though a new federal law is supposed to shorten the firing period of senior executives to just 33 days.

“I have no additional information beyond the statement,” VA spokeswoman Ramona Joyce said in an emailed response to questions.

via VA’s firing of Pittsburgh Veterans Affairs director raises new allegations | Pittsburgh Post-Gazette.

Veterans Affairs Department fires Phoenix hospital director | Fox News

The head of the troubled Phoenix veterans’ hospital was fired Monday as the Veterans Affairs Department continued its crackdown on wrongdoing in the wake of a nationwide scandal over long wait times for veterans seeking medical care and falsified records covering up the delays.Sharon Helman, director of the Phoenix VA Health Care System, was ousted nearly seven months after she and two high-ranking officials were placed on administrative leave amid an investigation into allegations that 40 veterans died while awaiting treatment at the hospital. Helman had led the giant Phoenix facility, which treats more than 80,000 veterans a year, since February 2012.The Phoenix hospital was at the center of the wait-time scandal, which led to the ouster of former VA Secretary Eric Shinseki and a new, $16 billion law overhauling the labyrinthine veterans’ health care system.VA Secretary Robert McDonald said Helman’s dismissal underscores the agency’s commitment to hold leaders accountable and ensure that veterans have access to high-quality, timely care.An investigation by the VA’s office of inspector general found that workers at the Phoenix VA hospital falsified waiting lists while their supervisors looked the other way or even directed it, resulting in chronic delays for veterans seeking care. At least 40 patients died while awaiting appointments in Phoenix, the report said, but officials could not “conclusively assert” that delays in care caused the deaths.About 1,700 veterans in need of care were “at risk of being lost or forgotten” after being kept off the official waiting list at the troubled Phoenix hospital, the IG’s office said.”Lack of oversight and misconduct by VA leaders runs counter to our mission of serving veterans, and VA will not tolerate it,” McDonald said in a statement late Monday. “We depend on VA employees and leaders to put the needs of veterans first.”Helman is the fifth senior executive fired or forced to resign in recent weeks in response to the wait-time scandal.

via Veterans Affairs Department fires Phoenix hospital director | Fox News.

Vietnam veteran dies following Do Not Resuscitate error at Sacramento VA hospital

SACRAMENTO – The Veterans Administration confirmed that a “do not resuscitate” armband was mistakenly placed on a patient who died following surgery Friday at the Sacramento VA Medical Center, but insisted the error was not fatal.

Family members identified the patient as Roland Mayo, 65, a Vietnam veteran and former Riverside County deputy sheriff and marshal.

“He was a great guy. He loved his kids. He loved his grandkids,” said Niecy Mayo, who is married to Roland Mayo, Jr. “This came out of the blue.”

Delania Mayo Kenton, the youngest of Mayo’s three grown children, said her father was hospitalized Oct. 8 for a stent replacement in his carotid artery but that complications from previous cancer surgery required a second operation.

Delania, who lives in Southern California, said reports from family members at the hospital were that the second surgery had gone well.

“Friday morning he was smiling and doing fine,” Delania said.

Later, Delania was told, her father began vomiting and then choking on the vomit.

An anonymous tip to News10 on Friday said the staff had mistakenly placed a DNR band on Mayo’s arm, which the VA confirmed on Monday– but the VA said it doesn’t believe the error contributed to Mayo’s death.

VA spokeswoman Tara Ricks offered the following statement:

After an initial investigation, we can confirm that a do not resuscitate (DNR) band was incorrectly placed on one of our patients who passed away on Friday. At the time of the code, the response team reviewed the patient’s medical record and clarified that the patient was not a DNR status. The arm band did not contribute to a delay in the response of the code team, which attempted to resuscitate the patient within minutes of the code being called. At this time, initial findings indicate that timely resuscitation was performed. Leadership at VA Northern California Health Care System has made contact with the patient’s family to apologize and express our sincerest condolences for their loss.

Family members said Mayo’s twin brother and best friend, Noland, was heartbroken over Roland’s death and was too distraught to talk about it.

Delania said the brothers had served together in the US Army’s 101st Airborne Division. They lived a few miles apart in Citrus Heights and spoke on the phone several times a day, she said.

She expressed frustration that hospital officials had not returned her phone calls seeking a detailed explanation of the incident.

Ricks, the VA spokeswoman, said privacy rules prevented staff from releasing information to anyone other than the person identified as Mayo’s next of kin, who is his twin brother.

Because of the circumstances surrounding Roland Mayo’s death, funeral arrangements had not been made.

via Vietnam veteran dies following Do Not Resuscitate error at Sacramento VA hospital.

Virginia businessman indicted on charges he bribed former VA Medical Center Director William Montague |

CLEVELAND, Ohio — A Virginia executive is facing charges that he bribed former Veterans Affairs Medical Center Director William Montague in exchange for confidential information on construction projects.

The 23-count federal indictment charges Mark S. Farmer, 54 with crimes including wire and mail fraud, embezzlement and theft.

Farmer worked for a design firm that performed work for the VA. The business is identified in the indictment only as “Business 75.”

Montague, the former director of the Cleveland and Dayton VA Medical Centers, pleaded guilty earlier this year to 64 counts related to his role in the conspiracy. Last month, Montague said he would cooperate with federal authorities in exchange for a lesser prison sentence. He faced more than six years in prison but now faces as few as 4 ½.

“Bribing a public official to obtain internal government documents and information for a competitive business advantage is illegal,” Stephen D. Anthony, Special Agent in Charge of the Federal Bureau of Investigation’s Cleveland Office said in a press release from the U.S. Attorneys office.

According to federal officials, Montague used his power to give Farmer information concerning VA contracts and business. Montague also lied to other employees about why he was getting the information, officials said.

“Contractors and employees conspiring to defraud the VA is particularly intolerable as the VA struggles to effectively serve our nation’s veterans,” said Gavin McClaren, who heads the Cleveland office of the Inspector General for the U.S. Department of Veterans Affairs.

via Virginia businessman indicted on charges he bribed former VA Medical Center Director William Montague |

Phoenix VA hospital fails outside compliance review

The Department of Veterans Affairs health-care system in Phoenix does not comply with U.S. standards for safety, patient care and management, according to a non-profit organization that reviews medical facilities nationwide.

In findings published online, The Joint Commission says Carl T. Hayden VA Medical Center failed a July inspection in 13 quality-control categories.

Experts who conducted the review in July found that Phoenix administrators did not maintain a “safe, functional environment” or “a culture of safety and quality.” They concluded that the hospital does not have adequate policies and procedures to “guide and support patient care, treatment and services.”

The inspectors also determined that VA employees were unable to report concerns “without retaliatory action from the hospital.”

The Joint Commission is an independent, nongovernmental agency that accredits and certifies more than 20,500 health-care programs in the United States. For many medical centers, accreditation is a precursor to qualify for federal Medicare funding.

Elizabeth Eaken Zhani, media relations manager at the commission, stressed that noncompliance findings do not typically lead to a loss of accreditation. Instead, Phoenix VA has a right to appeal and an opportunity to correct failings so the hospital meets national standards.

The Phoenix VA system serves about 80,000 Arizona veterans. In a written statement Monday, VA officials said plans have been developed with an expectation that compliance issues will be resolved within 120 days.

“We anticipate and welcome a return visit from The Joint Commission within the next month, which is a follow-up survey,” the statement continued.

“We are also working diligently to address the cultural issues identified by The Joint Commission and have implemented a number of items to enable employees to raise concerns about safety or quality without fear of retaliation…”

Zhani said the list of problem areas can be interpreted as a message: “This is where you need to improve. This is where you have gaps in patient safety.”

Of more than 4,000 medical facilities evaluated each year, she said, less than 1 percent are denied accreditation.

via Phoenix VA hospital fails outside compliance review.

Concerned About Retaliation, VA Wants To Restrict When Vets Can View Disability Claims Online – Defense One

Veterans Affairs officials want to change when veterans can view some of their medical records online, fearing that some could become violent if they see negative comments and think their disability claims will be denied.



Jordain Carney is a defense reporter at National Journal. She previously worked as a staff writer for the Hotline, covering congressional and gubernatorial elections in the South. Jordain graduated from the University of Arkansas with a bachelor’s degree in English, political science, and … Full Bio

Veterans must get a medical exam as part of the process for filing a disability claim for a service-related injury. Within days or weeks of the exam, veterans can see the doctor’s forms or notes by using the “Blue Button” on My HealtheVet, the VA’s website for health records.

A group of department officials said Monday that they fear some veterans could see the notes from the exam, assume from this partial picture that their claim is being denied, and take out their anger on local VA officials. They voiced their safety concerns Monday to members of the department’s Advisory Committee on Disability Compensation at their meeting this week in Washington.

“He walks past the [compensation-and-pension] clinic, and he’s very angry. Goes into the C-and-P clinic, and we have an incident of some kind,” said Gerald Cross, the chief officer in the Veterans Health Administration’s office of disability and medical assessment. ”Some of our C-and-P clinics are quite small, … and it doesn’t have much in the way of reasonable defense. We’re very concerned about that.”

Patricia Murray, the director of the VA’s clinical program and administrative operations, said that to try to prevent any misunderstandings, the VA is removing the compensation-and-pension medical exam from a veteran’s online health record until after a decision on his or her disability claim has been made.

“I think sometimes when they see [the medical records], they think the determination to grant [benefits] is solely based on the C-and-P file,” she said, adding that “our examiners feel like they’re sometimes at risk.”

But some committee members were concerned about removing the compensation-and-pension exam records, but not other health documents, from the website.

“I hate to say this, but what is the ethical justification of removing the C-and-P exams from the Blue Button?” asked Michael Simberkoff, executive chief of staff at the VA’s NY Harbor Healthcare System.

But department officials tied the move to one factor: Potential risk to VA staffers. In addition to changing when a veteran can see part of his or her file online, they are also considering adding extra security to the clinics, such as requiring a code to unlock doors.

“Many of the C-and-P docs are females, and they seem to be the ones that seem to have the evening hours or are in these far-flung [clinics],” said Denny Devine, the VA’s project executive for disability and medical assessments. “Those are the ones on our weekly calls raising these concerns.”

The VA received more than 1 million requests for disability exams during fiscal 2014. It has almost 527,500 pay and pension claims currently waiting to be decided, with more than 46 percent—or 244,727—waiting more than 125 days for a decision.

via Concerned About Retaliation, VA Wants To Restrict When Vets Can View Disability Claims Online – Defense One.

Family says VA owes them for Metro Atlanta man’s death – CBS46 News


A Metro Atlanta family said the Atlanta VA Medical Center is responsible for Otis Hughey’s death.

CBS46 first reported this in early October.

Hughey died in April, 2014. His family said the VA Hospital, in Decatur had treated Hughey for prostate cancer. According to Hughey’s family, doctors said Hughey had gotten over the disease.

“I just knew something was wrong with him,” said Fandra Hughey.

Fandra Hughey said her husband, Otis developed a cough in 2013 that wouldn’t stop.

“It was real hoarse and he couldn’t catch his breath,” said Fandra Hughey. “I just miss him, just him.”

Otis went to Urgent Care, and doctors did an x-ray. Results showed a problem with his lungs. Doctors urged him to go to the VA. Otis did, but didn’t get far. Tyrone Matthews, Otis Hughey’s brother said it took a month to get x-rays at the VA. And he didn’t receive treatment until October for lung cancer. By then, his cancer had spread.

“He had got prostate cancer, then lung cancer, then he had lesions on the brain and now he’s gone,” said Fandra Hughey.

Hughey’s family has expressed anger with Dr. Bradford Priddy.

“I did tell him ‘if I see you outside this hospital I will be willing to hurt you,'” said Matthews.

According to Hughey’s family, Dr. Priddy went on record with this statement:

I explained that they were justified in their feelings and that he should have been called back in for those CT scans within a week because I had ordered it for as soon as possible.

“You almost never hear that in a medical malpractice case,” said attorney, Jonathan Johnson. “He was basically blaming the staff for dropping the ball.”

Atlanta VA Medical Center released a statement:

The Atlanta VA Medical Center places the highest priority on delivering quality care while respecting the privacy of Veterans. Our focus has always been to deliver this care in a professional, compassionate and safe environment. When issues occur in our system we conduct reviews to identify, correct and work to prevent additional risk. This matter is currently under review, and as such, it would be inappropriate to comment at this time.

Johnson said he has filed paperwork to sue the VA Medical Center. According to Johnson, the VA Medical center has until February to respond.

via Family says VA owes them for Metro Atlanta man’s death – CBS46 News.