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.
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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.
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