Scranton Veterans Home Cited, Fined

By Walter F. Roche Jr.

A state run nursing home for veterans, with a history of rules violations, has been cited by the state Health Department and fined $11,375 after a patient was injured at the hands of an employee who  then tried to cover up the incident.
The attempted cover up was one of several violations cited in a 43-page inspection report on the Gino J. Merli Veterans Center in Scranton recently made public. When the facility was inspected in September, it  was already operating under a provisional license due to prior violations.
Other violations turned up in the two day inspection include failure to ensure that a patient did not develop bed sores and failure to properly investigate and report multiple thefts from residents.
Joan Nissley, spokeswoman for the state Department of Military and Veterans Affairs said that all the deficiencies have since been corrected and state health officials, on a return visit, agreed. She also said a new commandant has been named to oversee the facility operations.
"As we work through this transition, we continue to closely monitor the situation at Gino Merli to ensure that we are providing Pennsylvania veterans and their spouses with long-term services in a safe secure and caring environment," Nissley wrote in response to questions.

 According to the report, a patient suffering from Multiple Sclerosis and "totally dependent" on at least two aides to get in or out of bed, was injured while a single attendant tried to return him to bed.
Though records indicate a lift was required to move the patient, the attendant attempted to lift him by hand.
The patient's leg was gashed on the bed frame, the report states, and the patient had to be brought to an emergency room for eight stitches to close the wound.
Initially a second aide told facility officials that she had assisted in the transfer. Later, however, after the patient was interviewed a second time, the female aide admitted she was not on hand and had lied to cover for her colleague.
"The resident firmly stated only one male nurse aide was present during the incident on April 23," the report states.
 Nissley said the two employees had been terminated.
In a plan of correction filed with the state, Merli officials said they would establish a monitoring system to ensure that patients were transferred in and out of beds according to the physicians' orders.
The inspectors also found discrepancies in the records for another patient who was discovered to have "newly hatched larvae" in a wound on the left ankle.
Though the larvae and wound on the ankle were noted on Sept. 3, the records showed that it wasn't until Sept. 8 that another entry was made showing the requested treatment had been provided five days earlier.
The inspectors said that the director of nursing "failed to provide an explanation" for the discrepancy.
Nissley said that health officials later found that the proper treatment was implemented and the patient has since recovered.
The review of records showed two cases in which residents who were free of pressure sores on admission developed sores while under the center's care.
One of those patients, who was diagnosed with dementia, developed a pressure sore on his abdomen, apparently from a hand splint. The inspectors concluded that the failure to monitor the patient resulted in "actual harm."
"It is the goal of the facility," the report states, "that residents will not develop bed sores."
The center's plan of correction calls for re-education programs for staffers on the avoidance and treatment of bed sores
 The repeated thefts at the facility, inspectors found, occurred over a five month period. Though there were 11 thefts during that period, only four were reported to the state as required.
Citing a meeting with residents, the report states there were "continued and repeated complaints of misappropriation of resident monies within the facility."
The money went missing, the report states, even though many of the residents said they kept their cash in locked boxes.
In its corrective action plan, the facility said the patient who registered the initial complaint was reimbursed for the $15 that was taken. Staff also will be re-educated on the proper procedure for handling theft complaints.
In yet another citation, the inspectors found two patients were not getting prescribed devices or medications. A resident with diabetes, the records showed, was not given insulin as prescribed by the treating physician.
Also noted were unsanitary conditions including a hallway permeated "with a strong urine-like odor."
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VA PR Czar Got Last Minute Job Boost

By Walter F. Roche Jr.

As one of his last official acts in late 2013, the embattled outgoing Pittsburgh area director of the Department of Veterans Affairs issued a one-page order creating a new job and title for his public affairs chief.
The Oct. 17, 2013 memo from Michael E. Moreland created the full time job of communications director for VISN 4 and named David E. Cowgill to fill that post effective Oct. 20. Cowgill's current annual salary is $124,003.
Though VA officials said Cowgill's salary in his new job is the same pay grade as his old one, federal records show that he earned $118,273 in 2012, $5,730 lower than his current level. Cowgill issued a statement in which he said he had previously served as VISN 4 communications manager on a part-time basis.
In addition recently released records show Cowgill was one of dozens of Pittsburgh area VA employees to be awarded a performance bonus in 2014. Cowgill got $2,750 in bonus payments, records show.
"Leadership made a determination that a full time VISN 4 communications manager was needed and I no longer had the time to perform the dual role of serving as VA Pittsburgh public relations manager," Cowgill wrote in an email response to questions.
He said his pay grade remained the same in the new job "and I did not receive any pay increase or extra compensation for being appointed to the full time communications manager."
Moreland's action creating the full time post came just two weeks after he announced he was stepping down as VISN 4 director and retiring as of Nov. 1. His resignation came amid a congressional investigation into the deaths of six veterans at VISN 4 facilities in a Legionella outbreak.
"I have determined that the duties of a Public Affairs Officer are needed on the full-time basis within the network office," Moreland wrote.
"Although this new position has been established, I expect VAPHS will maintain sufficient staffing to continue to support the Network's public affairs efforts," the Moreland memo continues.
Moreland did not respond to requests for comment.
Though VA officials say Cowgill has no staff, internal memos show he has commandeered the services of many of VA public affairs staffers with a combined annual salary of more than $1 million. That figure include's Cowgill's replacement with a current salary of $110,607.
Cowgill has, through a series of internal directives asserted control of staffers who reported to him in his prior position.
In a March 24, 2014 to the VA's Pittsburgh Health Services public relations manager, Cowgill wrote that the Pittsburgh office "will be required to provide appropriate levels of staffing" to complete a series of functions for his office including the production of VISN's annual report, maintaining the VISN's websites and "VISN 4's public relations and outreach campaigns."
In an April 8 memo to VA's regional mangers, Cowgill requested " Nulph serve as his liaison.
"Ms. Nulph must be provided with the ability to work directly with the VISN 4 Communications Manager and have her Pittsburgh tasks adjusted as required by network priorities," Cowgill's memo states.
Nulph, whose job title is public affairs specialist, has an annual salary of $65,665.
In response to questions, VA spokesman Henry Huntley wrote that Cowgill  "utilizes the services of some VA Pittsburgh Healthcare Systems public affairs department to include occasional web design, photography, videography, video conferencing support and assistance from one public affairs specialist."
Cowgill, in his email, wrote that VA Pittsburgh had been providing support to VISN 4 since 2007.
Data provided by the VA shows that there are 16 persons assigned public affairs duties in the VA Pittsburgh Health Services office. Salaries range from $64,138 to the $110,607 being paid to Cowgill's replacement.
Michael Stelacio, department commander of the Pennsylvania American Legion, said both Moreland and Cowgill should be investigated.
"Mr. Cowgill should have to give an explanation of how he can order everyone around when he has no staff, Stelacio said, adding that Moreland should have to explain why he created Cowgill's job.
Asked about the salaries of the VA's local public relations staff, Stelaccio said that while it seems excessive, the staff has to answer a lot of quesions, particularly during the Legionella outbreak.

Pittsburgh Area VA Employees Shared in 2014 Bonuses

By Walter F. Roche Jr.

A communications manager and a top administrator were among 1,285 Pittsburgh area employees of the Veterans Administration to share in 2014 bonuses of $142 million.
The bonuses to Pittsburgh area VA employees, which were paid in the midst of multiple congressional inquiries into charges that veterans were facing extensive delays in getting needed care, ranged from $11,527 to a low of $145.
In Pittsburgh inquiries focused on deaths caused by a Legionella outbreak.
The nationwide listing was made public in a report from USA Today in the newspaper's Wednesday edition.
The $11,527 bonus went to Anthony Warner, a contract specialist. The $145 payment went to Terry Weightman, a computer specialist.
David E. Cowgill, communications manager for the regional VA service area was paid a $2,750 bonus. His regular salary is $124,003.
Carla Sivek, a top administrator who recently served as the acting regional director, got a $3,250 bonus.
Here is a partial listing of Pittsburgh area bonuses:

Anthony Warner, contract specialist, $11,527
Jennifer Stone-Barash. director, $7,408
Bernadette Heron, pharmacy $4,900
Lisa Longo, pharmacy $4,900
Rosemary Grelish, pharmacy, $4,900
John C. Lowe, pharmacy, $4,900
James F. Baker, finance $3,259
Barbara Forsha, health systems specialist, $3,250
Moira Hughes, health systems specialist, $3,250
Carla Sivek, administrator,$3,250
Joyce Johnson, engineering, $2,820
Charlotte Balou, budget analyst, $2,750
Barbara Becker, program managment, $2,750
Kimberly Butler, health system analyst, $2,750
Teneal Caw, human resources, $2,750
David Cowgill, public affairs, $2,750
William J. Cress, social worker, $2,750
Michelle Dominski, human resources, $2,750
Jennifer Farrar, auditor, $2,750
Douglas Hilliard, prosthetics, $2,750
Debra Hughes, health systems specialist, $2,750
Angela Keen, psychologist,$2,750
Anne Mikolajczak, health systems specialist $2,750

VA Vows to Keep New Inventory Supply System

By Walter F. Roche Jr.

Officials of the U.S. Department of Veterans Affairs say they have no plans to abandon a controversial new inventory control system at its health facilities despite complaints from its own employees.
VA spokesman Henry L. Huntley said in an email response to questions that implementation of the Shipcom Wireless system is not being halted. 
"The Point-of-Use program office is not considering abandoning the VHA Point-of-Use inventory site in any live site or discontinuing the program," Huntley wrote, adding that it is now in use in 17 locations, including Pittsburgh.
The announcement marks a reversal for Pittsburgh area VA employees who had earlier been told that the controversial new system would be put on hold, at least temporarily. They were told Friday that the Shipcom system would be in use starting this week.
Huntley did acknowledge that the program called Catamaran was on an "administrative pause" at some locations.
The comments follow the disclosure of an internal e-mail from an inventory control official in Pittsburgh in which he acknowledged widespread complaints about the new system and told workers that an old inventory system would be put in place, at least temporarily.
In his email last week, inventory chief Vincent Scalamogna wrote, "Leadership has heard your concerns."
He added that plans were being developed to revert to the old system.
Huntley, however, said the email "was from him (Scalamogna) directly to his staff regarding only his facility. Local facility chief logistics officers do not have the authority to halt the national implementation."
The VA spokesman also denied that the implementation of Catamaran has led to any shortages of needed medical supplies.
"Logistics staff is able to stock consumable medical supplies in the point-of-use locations as required. No serious supply issues have been encountered as a result of the implementation or use of the system," Huntley wrote, adding that there were no indications that patient care had been jeopardized.
The Shipcom contract could bring revenues of up to $275 million to the Houston-based company.
Contact Walter F. Roche Jr at wfrochejr999@gmail.com.

Use of VA Inventory/Supply System Scrapped at Least Temporarily

By Walter F. Roche Jr.

A controversial multimillion dollar inventory supply and control system at Pittsburgh area Veterans Affairs facilities is being put aside, at least temporarily, following multiple complaints including warnings that veterans health care could be jeopardized.
The suspension of the Shipcom Wireless system was disclosed to Pittsburgh area VA employees last week and it followed a series of meetings in which workers detailed continuing problems with the system put in place by the Texas based firm.
In an email to employees Thursday, Vincent Scalamogna, an inventory control chief, said plans were being developed to convert back to the old inventory system.
"Leadership has heard your concerns," the email states.
VA officials in Pittsburgh and Washington, D.C. did not respond to requests for comment. Nor did officials of Shipcom.
The contract, which is being implemented at several other VA facilities across the country, drew attention in Pittsburgh when former VISN 4 Director Michael Moreland surfaced as an advisor to Shipcom.
Under the contract Shipcom could ultimately earn some $275 million in payments.
Moreland had resigned from the director's job amid growing criticism of the handling of a legionella outbreak in local facilities that resulted in six known deaths.
Subsequently VA officials barred Moreland's further involvement due to his prior role as the regional director.
Criticism of the Shipcom system and its use of a computer program began nearly as soon as implementation began.
Employees reported long delays in obtaining needed medical supplies and warned that patient care could be affected. At one point recently, no supply requests could be made because the computer system crashed.
Workers reported that they were forced to get some needed supplies from other area non- VA hospitals.
Returning to the old in-house inventory system, however, may pose additional problems. Dozens of supply bins used under the old system have been scrapped.
In his email Scalamogna told employees that meeting already had been scheduled to plan the conversion to the old system.
"After this meeting we will hold meetings with impacted Logistics team members to review, modify and finalize the conversion plan," the email states. "Once our plan is fianlized, I will present it to leadership and seek approval to begin the conversion."
He wrote that the old system would be used until Shipcom and VA officials in Washington could "sort out" the problems with the new computer system called Catamaran.
wfrochejr999@gmail.com

Pittsburgh VA Discovers Emergency Pandemic Supplies Expired

By Walter F. Roche Jr.

Veterans Affairs officials in Pittsburgh have completed a review of hundreds of medical supplies stockpiled for emergencies after learning that some of them had gone well beyond their expiration dates.

The inventory of more than 200 pallets of items, stored in Building 49 at the VA’s H.J. Heinz campus in O’Hara, was completed to determine which items can still be used, said Beth Miga, spokeswoman at the VA Pittsburgh Healthcare System.

“We determined that a hands-on review of our pandemic response supplies was necessary to ensure our inventory records were as accurate as possible,” Miga wrote in an email.

The review was completed this week but Miga would not disclose its results. She said federal law did not permit her to disclose what specific supplies have expired. She would only say that items in seven of 22 categories expired and triggered the review.

Experts say it is difficult to guarantee the efficacy of medical supplies that exceed a manufacturer’s expiration date.

“A reliable stockpile of supplies for combating an infectious disease outbreak or pandemic is essential,” said Dr. Amesh Adalja, an infectious disease physician at the UPMC Center for Health Security. “When certain supplies age exceeds their manufacturer’s expiration date it is difficult to guarantee their efficacy and healthcare workers should have the highest level of confidence in their equipment when treating patients with contagious infectious diseases.”

Those supplies include medications, vaccines, certain medical equipment as well as personal protective equipment for healthcare workers such as masks and respirators, he said.

“The proper handling of these substances is important for patients and public health,” said U.S. Sen. Robert Casey when told about the outdated items. “It’s incumbent upon the VA to replace these items quickly so they’re there in case of emergency and provide the public and local health officials all appropriate information.”

According to Miga, some of the items do not have manufacturer’s expiration dates, “but we are still examining these supplies to determine their status and order replacements if necessary.”<br/>She said the inventory would provide an opportunity “to study our warehouse procedures and ensure that soon-to-expire stocks are shifted for use within the VA system.”<br/>The rules referred to by Miga describe the supplies as being “reserved specifically for the treatment of casualties from a mass casualty event.”<br/>It states that the director of the VA medical facility is responsible for activating when “a local regional or national emergency warrants its use.”

The caches, according to the directive, “are specifically intended to treat veterans, staff and others that may present to the local VA medical facility.”

Michael Stelacio, department commander of the Pennsylvania American Legion, called it unfortunate that supplies expired when they could have been transferred to other VA facilities for immediate use before expiration. “It’s obvious there’s some ineptness,” Stelacio said. “This is another one of these things that has to be corrected.”

Contact: wfrochejr999@gmail.com

VA Pittsburgh Mail Room Functions Probed

By Walter F. Roche Jr.

Notices to some 14,000 area veterans of upcoming medical appointments have been delayed by two factors sparking an ongoing internal investigation of mail room practices .
Beth Miga, a spokeswoman for the Pittsburgh regional office of Veterans Affairs acknowledged Wednesday that an investigation was underway.
According to Miga some delays of up to three weeks were caused by a computer crash, while other shorter delays stemmed from the switching of contractors for mailing services.
As a result of the contract switch, she said, some 10,000 notices had to be mailed from VA facilities in Butler.
 "Due to a change in our mail metering services in June 2015, VA Pittsburgh used mail meter services at VA Butler Healthcare. This issue was not due to a lack of funding, but was an alternate way to send mail and continue to communicate with veterans about their VA care while we brought our new system online," Miga wrote in an email.
She said the mailings were "roughly one to two days" behind our usual schedule and "did not negatively impact the care we provide to veterans."
She said a new contractor, Pitney Bowes, was selected through a competitive process to replace Neopost USA which had the old expiring contract.
As for the computer crash, Miga said that while notices normally arrive several weeks before a scheduled appointment, the delayed notices arrived only a week ahead of the scheduled date.
"We did not have to cancel or reschedule any appointments due to recent mailing delays," she said in an email.
"The delay was due to an unexpected crash in the computer hardware that we use to generate these letters,"she added.
The scheduling of medical appointments and delays in treatment have been major issues in an ongoing review of VA care across the country.
Sparked by congressional inquiries and investigations by the VA's Inspector General charges have also surfaced that in some VA facilities, though not in Pittsburgh, records have been changed to hide lengthy delays in veterans getting needed services.
Former VA Secretary Eric Shinseki resigned earlier this year in the midst of revelations about delayed health care for veterans.

No Bid VA Pittsburgh Contracts Questioned

By Walter F. Roche Jr.



Veterans Administration officials in Pittsburgh failed to properly monitor three multimillion dollar no-bid contracts with a local physicians group and paid multiple invoices for anesthesiology and cardiac surgery services that could not be accounted for.
In a 26-page report issued Friday, the VA Inspector General said that the questionable payments were made under three contracts with the University of Pittsburgh Physicians with a combined value of $11.1 million. The contracts were in 2010 and 2011.
"Our review found that VAPHS was certifying invoices for payment without any substantive review or verification that the hours billed to the VA were actually rendered to the VA," the report states.
The auditors attributed the lapses to the lack of monitoring. In fact the official assigned to monitor work under the contract wasn't even at the same location.
Barbara Forsha, acting regional director of the Pittsburgh VA said in a response to questions said that her office took immediate action "to correct these shortcomings in our system. We are working to complete the recommendations the VA OIG set in the report as quickly as we can."
Wendy Zellner, spokeswoman for UPP said in an email response to questions,"We have a long an effective partnership with the VA and are committed to following all government rules and regulations. We are studying this report to see if any changes in our practices are necessary."

Calling discovery of the monitor's absence "particularly troubling," the auditors said they learned that the monitor's review consisted of simply matching up the hours billed with accompanying time sheets.
"The contracting officer was stationed at another facility and did not and could not conduct any real time monitoring of physician time sheet entries," the IG concluded.
The IG's own review of the time sheets, which included analysis of actual corresponding surgical records found that there were hours billed in anesthesiology and cardiac surgery that could not be accounted for.
In anesthesiology, for instance, a review of 20 days with billings totaling $80,659, found two entries for a total of seven hours that could not be accounted for.
Also cited by the auditors was the practice of physicians signing in up to 12 hours before records showed they actually began performing surgery.
One surgeon signed in at 6 a.m., but the surgery did not begin until 8:10 p.m.
"This practice went undetected for the entire two-year contract," the report states.
In another case, the VA was billed at a full time rate for a physician who was working only part time. Overpayments totaled $44,082, according to the report..
The report also questioned overhead payments to UPP totaling $847,733 which the IG found were not supported or documented to be in compliance with VA directives.
The auditors concluded that the questionable billing as recorded in the time sheets "should have been a red flag."

VISN 4 to Get Another Interim Director

By Walter F. Roche Jr.

Another interim director is about to take over command of the Veterans Administration region covering not only Pittsburgh and Pennsylvania but also parts of two other states.
David Cowgill, a VA spokesman confirmed today that William H. Mills, currently the director of VA operations in Altoona, will take over as VISN 4 director on Aug. 11.

A VA spokesman in Washington said an order to assign Mills to the directors post for a period not to exceed 120 days was "pending approval."
Mills, who was promoted multiple times by former VISN 4 Director Michael Moreland, will replace Carla Siveck who has been serving as an interim director since Dec. 14, 2014.
Moreland resigned under fire on Oct. 4, 2013 in the midst of an outbreak of Legionnaires Disease that took six lives in area VA facilities.
Like Siveck and Moreland, Mills does not have a medical degree. He has a masters in education.
Moreland, who was labeled the poster child for the lack of accountability among VA managers by U.S. Rep. Jeff Miller, a Florida Republican, was replaced by Terry Gerigk Wolf, who was later fired for her role in the Legionnaire outbreak.
Before his appointment to the Altoona post, Mills was the assistant VA director in Lebanon. He has served other jobs within VISN 4 including Memphis and Pittsburgh, also at VA facilities in West Virginia, Kentucky, North Carolina  and Connecticut.
Mills' current salary is $154,390. Sivek's salary in 2014 was $136,611 plus she was paid a $3,000 bonus, federal payroll records show.
Moreland, those same records show, was earning $170,000 a year when he stepped down. He also collected two bonuses totaling nearly $100,000. Those extra payments prompted outrage from members of congress who called for the VA to take back the bonuses.
Contact:wfrochejr999@gmail.com


 
 

Widow of Deceased Pittsburgh Veteran Got Small Fraction of $8 Million Claim

By Walter F. Roche Jr.


The widow of an 87-year-old victim of Legionnaires Disease settled her $8 million suit against the Veterans Administration in Pittsburgh for $225,000.
The details of the settlement were filed in the estate of William Nicklas, who died of Legionnaires Disease on Nov. 23, 2012.  Greta Nicklas had filed an $8 million suit against the VA charging that the agency's Pittsburgh facility was responsible for his death.
The suit was settled before trial along with a handful of other cases from victims of the same Legionnaires outbreak. At the time of the settlements, families involved in the cases declined to disclose any details.
The settlement was approved in Allegheny Probate Court just one month after the Nicklas' family attorney, Harry S. Cohen submitted it.
Calling the proposed payment "fair and appropriate under the circumstances," Cohen noted in his petition Nicklas' advanced age and the fact that he was not employed at the time of his death.
He also said his 25 percent legal fee totaling $56,250 and expenses totaling $18,728 were "fair and earned."
Under the federal Tort Claims Act lawyers fees are capped at 25 percent of any settlement.
That left just a little over $150,000 for Greta Nicklas.
State tax officials, records show, concluded she did not owe any taxes on her share of the payment.
Cohen's petition cited the history of Nicklas illness and death. The veteran first went to the VA's Oakland facility in October of 2012 complaining of breathing problems. He was sent home but returned Nov. 1 and was admitted for treatment of dehydration.
According to the petition, VA officials told the family on Nov. 17, 2012 that he had some kind of an infection. He died six days later and the death was ultimately attributed to the Legionella virus.
The 2011-2012 outbreak created a national controversy resulting in congressional hearings and a shakeup in the leadership of the VA's region covering Pennsylvania and parts of two other states.
Nicklas and five others died in the outbreak while nearly 20 were sickened.
CONTACT: wfrochejr999@gmail.com

VA OIG Disputes Pittsburgh Legionella Allegations

By Walter F. Roche Jr.


The Inspector General for the U.S. Veterans Administration has found that test results for Legionnaires disease were delayed for three veterans treated at a Pittsburgh facility but the delays did not affect the care provided to victims.
In a brief 8-page report made public today the Inspector General said he "substantiated occasional delays in  reporting of Legionella test results."
The report, the result of a formal complaint, included a review of six cases in which patients died from Legionnaires disease and 25 cases in which urine tests showed evidence of Legionella. The cases fell between Jan. 1, 2012 and Dec. 31, 2014.
According to the report one of the six fatal cases in the 2012 outbreak showed evidence of a delay in the reporting of positive test results while delays were found for two of the 25 patients with positive urine test results.
Two test results were delayed for three days, while one was delayed for four days.
"However," the report states, "for all patients with a positive test result, antibiologics effective against Legionella had been initiated empirically either prior to the the date the test was ordered or on the same day,"  Assistant Inspector General Dr. John D. Daigh wrote in the report.
He concluded that as a result the delayed test reporting did not cause death or additional illness for any of the veterans.
 The IG also disputed a claim that VA personnel improperly flushed water systems prior to Legionnella testing thus negating the test results.
"We did not substantiate that water faucets were flushed excessively," the report concluded.
The acting regional directors for the Pittsburgh VA, David S. MacPherson, concurred in the IG's findings.

VA Patient Care Could Be Jeopardized Under New Contract, Workers Warn

By Walter F. Roche Jr.

Internal memos indicate that major problems have surfaced in the ongoing implementation of a   controversial new inventory control and logistics contract at Veterans Administration sites in Western Pennsylvania.
The concerns expressed in a series of emails were raised over a  multimillion dollar contract with Shipcom Wireless, a Texas-based firm that hired former VA regional director Michael E. Moreland. Though Moreland was ordered off work on the VA contract after his hiring became public, implementation of the contract has continued.
In a May 7 email to VA managers, the Chief Logistics Officer at VA Butler Healthcare provided a six page detailed listing of problems encountered in the ongoing implementation.
One memo even warns that patient care could ultimately be put at risk due to the contract.
"The failing system needs to stop before jobs and lives are lost," one memo states.
In a May 22 email to VA managers, union leaders warned that "the inability to provide necessary supplies could result in serious patient safety issues. "
In response a VA spokesman issued a statement denying that patient care could be in jeopardy and defending the contract with a potential $275 million price tag. The pact with four annual  renewal options is also being implemented at several other VA sites.
"Patient care has not been adversely affected by the implementation of the Point Of Use Inventory System," the VA spokesman wrote in response to questions.
He added that VA logistics staff "continues to stock consumable medical supplies in the point of use locations as required."
The spokesman did however, acknowledged that "challenges have been encountered" including the validity of some data and gaining union approval.
He said the new systems has been successfully  implemented at 12 other VA locations.
The emails obtained by the Tribune Review list wide ranging problems including lack of timely training, vastly increased workloads, inconsistent and inaccurate inventory reports.
"The going live process and the weeks that followed after going live were chaotic, very stressful and not well organized," the six page list of problems states.
Also cited were incomplete filling of orders requiring multiple return trips to complete and rapid and constant turnover of contractor staff.
As the VA spokesman acknowledged the Ship.com contract has sparked controversy with local union officials
The local unit of the American Federation of Government Employees filed a formal information request on May 14 seeking a copy of the Ship.com contract and other details on its award and implementation.
In a letter of the same date, Local 2028 leaders, President Kathy Dahl and Executive Vice President Colleen Evans cited 13 specific changes in working conditions resulting from the contract including patient safety concerns.
The letter included a formal demand to bargain over those changes.
Evans said she believes the Shipcom conract is the first step in an effort to outsource more jobs currently held by VA employees.
Moreland, who resigned amidst controversy over the death of VA patients in a legionella outbreak, suddenly surfaced as a consultant to Shipcom in a May 1 visit to the Pittsburgh VA. Subsequently VA officials said he could not serve in that role because of federal conflict of interest rules and statutes limiting the employment roles of former top officials.

Pittsburgh VA Office Improves But Still Makes $496,000 In Improper Payments

By Walter F. Roche Jr.


An audit of the Veterans Administration Pittsburgh regional office  has found substantial improvements but still identified $496,000 in improper payments from 2008 to 2014.
The 19-page audit by the VA Inspector General was issued Wednesday and while it acknowledged improvements, found that further corrections are needed.
"Overall 10 of the 84 (12 per cent) claims reviewed contained processing inaccuracies that resulted in approximately $496,000 in improper payments made from Feb. 2008 to Sept. 2014," the report states.
In  addition to those regular claims errors, the auditors found that 8 of 30 claims for temporary assistance were not properly handled.
The report did cite a significant improvement in the handling of claims for traumatic brain injuries with all 30  claims reviewed found to be handled correctly.
"We noted significant improvement in the number of processing errors from 2011," the report concludes.
The Pittsburgh regional office serves some 500,000 veterans residing in 27 western Pennsylvania counties plus four counties in West Virginia. The staff processes disability claims from area veterans.
According to the audit one veteran was improperly paid $216,392 over six years while another got $98, 277 over a two year period.
Six errors occurred when VA staffers failed to take "timely action" to schedule required medical exams.
Other errors included continued payments to prostate cancer victims when they no longer met medical qualifications for assistance.
The IG reported that Pittsburgh VA officials generally concurred with the findings though they argued that some of the errors should have been classified as "workload issues" rather than quality issues.

Problems Abound at PA. Veterans Homes

By Walter F. Roche Jr.

At one state veterans home health inspectors declared a state of imminent jeopardy as dementia patients were observed wandering unwatched and undetected in a dining area with potentially dangerous food and equipment.
At another facility, a 61-year-old Vietnam veteran who had pleaded to be sent to an emergency room because of excruciating pain was found dead on the floor of a heart attack.
Those incidents coupled with dozens of others are recounted in grim detail in inspection reports for the six Pennsylvania run veterans nursing homes stretching from Erie to Pittsburgh and on to Philadelphia.
The reports, compiled by inspectors from the Pennsylvania Health Department, show that despite outrage from veterans groups and the families of patients just three years ago, the care being provided to veterans in these facilities is often lacking.
A spokesman for the state agency which runs the homes said in response to questions that all the deficiencies were corrected as soon as they were brought to its attention.
"Our priority is always to provide superior care to all of our residents across the state and when deficiencies are identified, we take quick corrective action," said Joan Nissley, the spokeswoman.
It was in late August of last year at the veterans home in  Hollidaysburg that the Vietnam veteran began pleading to be sent to a hospital emergency room because of excruciating pain.
An unnamed physician, however, refused the request, instead ordering new pain pills for the 61-year-old.
According to the Sept. 12, 2014 inspection report, the patient began complaining of extreme pain at 3:40 p.m. on Aug. 29.
Citing a subsequent interview with a nurse, the report states that the patient was "in excruciating pain at the time he requested to go to the emergency room. She (the nurse) indicated that the resident had symptoms that warranted a transfer to the emergency room, but because she did not receive an order from the physician, the resident was not sent."
Instead, at 8:30 p.m., the five-page report states, the on-call physician ordered a stronger pain medication.
"A nursing note dated Aug. 30, 2014 at 12:45 a.m. revealed that the patient ceased to breathe," according to the inspection report.
The records show that veteran was suffering from acute diverticulitis "with associated partial bowel obstruction." He had told the nursing staff his pain was "worse than ever."
"The resident was found on the floor in cardiac arrest," the health official reported. The incident was given the  rating of, "actual harm," under federal inspection guidelines. The Blair County facility was cited for multiple violations of state and federal rules, including failure to respond to the patient's wishes.
When the state inspection team looked back at the patient's treatment record in the two months preceding his death, they found other violations of state and federal rules because staffers failed to follow a physician's medication orders.
Although the doctor had ordered that two pain tablets be administered only when his pain was rated between eight and ten on a scale of one to ten, two pills had been administered on multiple occasions without any indication that the patient's pain had been assessed. In other cases two pills were administered even with a pain rating of less than eight.
As required under state and federal law, officials at the Hollidaysburg facility filed a plan of correction in which they promised to establish a system under which a physician's orders could be overridden by the medical director.
The plan of correction also includes a monitoring system to ensure that physicians' orders are being followed.
Nissley said that the unnamed physician is still employed at Hollidaysburg and is currently caring for patients.
"Resident CR1 is no longer a resident at the facility," the corrective action plan states.
Records show that Daniel S. Monroe died early in the morning of Aug. 30 at the Hollidaysburg facility. He was 61. His family could not be reached for comment.
 At the Southeastern Veterans Home in Spring City Chester County, a state inspector observed a diabetic dementia patient walk into a dining area, open a freezer and then treat himself to a helping of ice cream.
Later two dementia unit patients were observed in the same dining area walking among steam tables used to heat foods up to 140 degrees. The diabetic patient took a second helping of ice cream.
 The inspector then declared that the situation placed as many as 18 dementia patients in "immediate jeopardy" and ordered home officials to take immediate corrective action.
On the same inspection of the 196-bed home, an inspector observed a cart full of medications open and unattended in a patient area.
Also cited in the report was the failure of the top home official to fully investigate the possible abuse of a patient who suffered an unexplained bruise. Nissley said that official has since been replaced and a new security system will prevent a recurrence
At the Gino J. Merli Veterans Center in Scranton, inspectors found that despite admonishments from federal and state regulators to curb the use of powerful antipsychotic drugs on patients suffering from Alzheimer's disease or dementia those drugs were being used with no attempt to even reduce the dosage.
Nissley said the use of antipsychotics has since been reduced at the Scranton facility and monitoring programs have been put in place at the other five veterans homes. 

Reports for the same facility show a pattern of patients suffering worsening ulcers or bed sores after staffers failed to follow required monitoring procedures on patients at risk for ulcers.
In one case late last year required foot checks were apparently not performed on a resident who already had scabbing near his Achilles tendon.
The inspector who visited the facility on Dec. 30, noted that there was no evidence that a foot check had been performed after Dec. 18.
Another resident who had been identified as being at risk for pressure sores at the time of his admission was found to have developed multiple bed sores during his one-year stay.
The facility already had been cited in an Oct. 24, 2014 Medicaid certification inspection for failing to take steps to prevent pressure sores and to stop existing sores from worsening. As that report noted similar problems were noted in still earlier inspections.
As a result of the citations the home was issued only a provisional license.
The Southwestern Veterans Home in Pittsburgh was cited in a recent inspection for the improper handling of bedding. In a report in 2014 inspectors cited the home for giving an improper dose on insulin to a patient.

Two-Year-Old Report of Alleged Patient Abuse in Murfreesboro VA Released

By Walter F. Roche Jr.


More than two years after it was completed, a report has been issued on an investigation of alleged patient abuse at the Alvin C. York veterans facility in Murfreesboro.
The abbreviated report from the Inspector General for the Veterans Administration was one of dozens previously kept secret that were finally released recently following widespread complaints from members of congress.
According to the two-page report, an anonymous complaint was filed charging that a patient at the Murfreesboro community living center was given a doughnut coated with hot sauce.
The hot doughnut was in apparent retaliation for the patient resisting efforts to give him a shower after he had soiled himself.
The IG interviewed a nurse who told them she had witnessed the event. She said she realized the doughnut was doused with hot pepper sauce when she began picking it up after the patient spat it out.
"Nurse A denied the allegation," the report states, adding that "there is no evidence to support the allegation of patient abuse."
The report states that no other staffer interviewed could corroborate the allegation.
The complainant also had charged that following the hot sauce incident the patient refused to leave his bed and, as a result, developed deep vein thrombosis.
The IG report also cited a lack of evidence to support that allegation.
The incident occurred in June of 2012 and the report was completed on March 5, 2013.
Other reports previously kept secret included a complaint that the persons assigned to detect evidence of the legionella bacteria at the Pittsburgh VA were not qualified.
According to the one-page report, the investigation was quickly closed after a Pittsburgh VA official assured the IG that the staff were qualified.
Subsequently a major fatal outbreak of legionaires disease was reported at the the Pittsburgh VA facilities.  Some 22 patients were sickened and six died in 2011 and 2012. Just this week yet another legionella death was reported at the Pittsburgh VA.
wfrochejr999@gmail.com

Nashville VA Probed on Treatment for Suicidal Vet

By Walter F. Roche Jr.

A probe of the care provided to a suicidal veteran at the Nashville Veterans Administration hospital found problems at the facility but could not substantiate the charge that he was turned away.
The report by the VA's Inspector General found that there were no records to show that the unnamed veteran actually went to the emergency department at the facility on the day in question even though they found the veteran to be "very credible."
According to the complaint the veteran told a staffer at the hospital that he was despondent over the death of a fellow veteran and was thinking of shooting himself, but he was nonetheless turned away and told to seek care at a community hospital.
He was later admitted to a community facility and remained there for five days, according to the report. The incident occurred in mid-2014.
Even though he was, in fact, ineligible for care, the inspector general noted that VA policy requires that care be provided in such situations.
Citing "an absence of staff recollection" and lack of records, the IG said he could not "independently evaluate whether or not the facility denied treatment to this veteran. Therefore we cannot substantiate this allegation."
The IG did however, cite the facility for six deficiencies including failure to train staff on suicide prevention, lack of signage and inadequate recording keeping.
wfrochejr999@gmail.com

Warning Issued Over Phoenix VA Patients

By Walter F. Roche Jr.


An alarming 23 per cent of the urology patients at the troubled Veterans Administration facility in Phoenix, AZ may not be getting needed follow-up care and treatment, according to a new report.
In an interim report citing serious concerns, the VA Inspector General said a review of patient records at the facility shows that records for 759 urology patients out of 2,500 did not contain needed information to determine whether they were getting proper care.
"While our review is ongoing," the report states,"some concerning preliminary findings require your immediate attention."
The overall review was undertaken due to concerns that patients were waiting an undue length of time for care because of ongoing staff shortages. Some 3,321 urology patients may have been affected by those shortages, the IG concluded.
Citing a lack of information in electronic medical records for patients who were sent to non-VA providers for evaluation, the report warns that critical information "may remain unseen for several months."
"This finding suggests, the report continues, that the Phoenix VA "has no accurate data on the clinical status of patients."
Citing chronic understaffing, the auditors noted that only one person had been assigned the task of scanning the critical health data into patients' records.
"This finding also suggests that potentially important recommendations and follow-up are not being addressed," the report states.
"It is critical that staffing and administrative processes related to non-VA authorized care be properly administered," the report concludes.
Problems at the Phoenix VA, including extended delays in getting patient care, triggered a barrage of criticism of the care being provided to veterans and led to the resignation of former VA Secretary Eric Shinseki.
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