It’s not just Pheonix

| May 8, 2014

From my paying home……but next time someone says we need to wait and see what happens, send them this……VA

The Department of Veterans Affairs (VA) has come under scrunity by Congress, Veteran Service Organizations, media and in the veterans’ community for its failures in leadership performance and accountability which have resulted in quality of care or patient safety issues that have affected veterans.     The following list below outlines specific VA issues nationally as well as at Local VA Medical Centers and Regional Offices.



  • VA fails to release internal documents that corroborated at least 19 preventable deaths and VA officials did not respond to direct questions in a House Veterans Oversight and Investigations Hearing on April 2, 2014.


  • Florida Governor Scott has convened a state inspection team to examine VA facilities in the wake of quality and patient safety issues.


  • At the conclusion of the Congressional Oversight and Investigation Hearing regarding “Correcting ‘Kerfuffles’ – Analyzing Preventable Patient Deaths at Jackson VAMC” on November 13, 2013, Chairman Coffman requested a report on how the G.V. (Sonny) VAMC is specifically addressing the concerns of understaffing, overbooked patients, lack of oversight for the medical center’s nurse practitioners, lack of patients’ access to physicians, and radiology reports being misread and unread within 30 days. On November 14, 2013, The American Legion requested a copy of the report and as of March 31, 2014, the VA has yet to provide the report. During our System Worth Saving Task Force site visit in Jackson MS on January 20-22, facility director Joe Battle was unable to give The American Legion a copy of the action plan the facility has taken to address the preventable deaths.  Director Battle stated that he could release the report because it was not cleared by VA Central Office.   Upon further requests for this information after our site visit, Veterans Health Administration staff told us that they could not release the report because Office of Congressional Legislative Affairs (OCLA) had not cleared or sent this response to Congress.   Not only is Congress waiting for this information but the delays in OCLA responding to Congress have now spilled over and is affecting the abilities of The American Legion to effectively conduct our site visits and inform veterans in the communities of these hospitals.   In anonymous conversations with VA Central Office staff, OCLA was first sent the action plan from VHA on December 6 has not approved or sent the response to Congress.    Furthermore, OCLA just came back to VHA on March 26 to have VHA make adjustments/updates due to the time lag and the information being outdated.


  • Congress, Veteran Service Organizations and veterans that are being treated at medical centers with issues and concerns are frustrated, confused and out of the loop on the steps VA has taken to resolve problems which has led to a diminished confidence and renewed interest and pressing for more accountability on management of these facilities.  Veterans in these communities continuously read newspaper articles which are not accurately portraying the action plan and steps VA is taking to correct issues because of the lack of communication and timeliness of VA offices in Washington DC to work together across VA Central Office and in responding to congressional inquiries.


  • The American Legion urges VA leadership from the Secretary’s office, Office and Public and Intergovernmental Affairs, the Office of Congressional Legislative Affairs and leadership/communication staff from VHA, VBA and NCA to ALL work together to develop a crisis communication team to expedite issues of critical nature as well as better coordination and response for general inquiries to best serve VA local sites leadership in responding to media, veteran service organizations and veterans.




St. Louis, Missouri


Fayetteville, NC

  • A December 2012 audit of the Fayetteville VA Medical Center found facility employees did not complete required suicide prevention follow-ups 90 percent of the time for patients at a high risk of suicide. The audit also found the center “noncompliant” in cleanliness of patient care areas, environmental safety, dental clinic safety, training and testing procedures. In July 2012, during an investigation that substantiated patient misdiagnosis complaints, VA’s inspector general found the responsible physician failed to properly review medication information 56 percent of the time, a step that is “critical to appropriate evaluation, treatment planning, and safety.” Fayetteville VA Medical Center Director Elizabeth B. Goolsby received a performance bonus of $7,604 in 2012.


Dallas, Texas (SWS Visit Feb 4-5, 2014)


Philadelphia, Pennsylvania


Phoenix, Arizona (ROAR Visit April 1-4, 2014)

  • Phoenix VA Regional Office Director Sandra Flint has received more than $53,000 in bonuses since 2007 despite a doubling in the office’s backlog of disability compensation claims since 2009.


Columbia, South Carolina (Site Visit Scheduled April 15, 16, 2014)


  • In September 2013, six deaths were linked to delayed screenings for colorectal cancer at the veterans medical center in Columbia, S.C., the Veterans Affairs Department reported. The VA’s inspector general determined that the William Jennings Bryan Dorn VA Medical Center fell behind with its screenings because critical nursing positions went unfilled for months. It also found that only about $275,000 of $1 million provided to the hospital to alleviate the backlog had been used over the course of a year.


Waco, Texas

  • Carl Lowe, the former director of the VA regional office in Waco, Texas, raked in more than $53,000 in bonuses as the office’s average disability claims processing time grew to historic levels, forcing veterans to wait longer than anywhere else in the country.


Buffalo, New York


Dayton, Ohio


Pittsburgh, Pennsylvania (Site Visit Nov. 5-6, 2013)


Atlanta, Georgia (Site Visit Jan. 28, 2014)


Roseburg, Oregon (Site Visit Jan.9-10, 2014)

  • Ray Velez, an active Legionnaire from American Legion Post 61 in Junction City, went to the Roseburg VA Medical Center this past June for what should have been a routine hernia operation. After the surgery, Roseburg VA Medical Center staff told Irene Lillie, Velez’s daughter, that her father’s blood pressure had “dropped suddenly and he was having difficulty breathing.” Since the Roseburg VA Medical Center does not have an Intensive Care Unit, Velez was taken to PeaceHealth Sacred Heart Medical Center at Riverbend in Springfield, Oregon. Unfortunately, Velez passed away en route PeaceHealth Sacred Heart Medical Center due to “intra-dominal bleeding, shock, hyperkalemia, acidosis, respiratory failure and recent ventral hernia surgery.”


Butler, Pennsylvania (Site Visit Jan. 8-9, 2014)

  • An attorney for the prime contractor of a Department of Veterans Affairs outpatient center being built in Butler County declined to comment Friday, July 12, 2013 about the VA’s investigation of the contractor that led the agency to stop work on the $75 million project.


  • The VA Butler Healthcare Center was scheduled to open in 2015, but the termination of the lease left its future in doubt. The VA broke ground on the center in April 2013. The Department of Veterans Affairs yanked its lease with an Ohio company that was building a $75 million health center for vets in Butler, accusing the firm of “false and misleading representations” during bidding. The VA ordered work halted in June when it began to uncover problems with the project.



  • The Department of Veterans Affairs failed to properly check the qualifications of the former developer of an outpatient center in Butler County, according to a highly critical report by the VA’s Office of Inspector General released Monday. The report says the VA improperly calculated that a 20-year lease with Westar Development Co., valued at $157 million, would be cheaper than the VA building and owning the $75 million outpatient center on its own.



Orlando, Florida/Denver, Colorado (Orlando SWS Visit-Feb.11-12, 2014) (Denver SWS Visit-May 13-14, 2014)

  • Costs substantially increased and schedules were delayed for Department of Veterans Affairs’ (VA) largest medical-center construction projects in Denver, Colorado; Las Vegas, Nevada; New Orleans, Louisiana; and Orlando, Florida. As of November 2012, the cost increases for these projects ranged from 59 percent to 144 percent, with a total cost increase of nearly $1.5 billion and an average increase of approximately $366 million. The delays for these projects range from 14 to 74 months, resulting in an average delay of 35 months per project. In commenting on a draft of this report, VA contends that using the initial completion date from the construction contract would be more accurate than using the initial completion date provided to Congress; however, using this date would not account for how VA managed these projects prior to the award of the construction contract. Several factors, including changes to veterans’ health care needs and site-acquisition issues contributed to increased costs and schedule delays at these sites.


Jackson, Mississippi (Site Visit Jan.21-22, 2014)

  • At the G. V. Sonny Montgomery VA Medical Center in Jackson, MS, multiple whistleblower complaints have been raised by employees who were losing confidence in the medical center’s ability to treat veterans. The complaints ranged from improper sterilization of instruments to missed diagnoses of fatal illnesses, as well as hospital management policies.


Augusta, Georgia (Site Visit Mar. 11-12, 2014)

  • CNVAMC leadership first learned of delays in providing gastrointestinal (GI) services to veterans on August 30, 2012.  Of the 4,580 delayed GI consults, a quality management review team determined 81 cases for physician case review.  Seven of the 81 cases may have been adversely affected by delays in care.  Six of seven institutional disclosures were completed and three cancer-related deaths may have been affected by delays in diagnosis. Factors contributing to the 4,580 patient backlogs included an explosion of baby boomers turning 50 and requiring screening, the medical center’s non-anticipation of a spike in GI consult demand, lack of an integrated data base for tracking GI procedures, and GI physician recruitment challenges.


  • On Tuesday, April 1, 2014, it was revealed that Veterans Affairs Department financial manager Jed Fillingim was involved in a deadly incident while traveling on business for the agency in 2010. Police and federal investigators found Fillingim drove a government truck after drinking with two colleagues at a bar near Dallas while attending a June 2010 conference for federal employees. One of the two colleagues, Mississippi-based VA employee Amy Wheat, who had also been drinking that night, fell out of the truck while it was moving and died. She suffered severe head injuries and a severed leg in the fall. Blood covered the truck and one of its wheel wells, according to police reports.


  • Though he resigned from his position with the agency’s Jackson, Miss., medical center five months later, the News4 I-Team has learned Fillingim was rehired in March 2011 and has since assumed a high-level managerial position in Augusta, Ga., earning more than $100,000 per year.


Memphis, Tennessee

  • In October of 2013, The VA Office of Inspector General Office (VA OIG) of Healthcare Inspections conducted an inspection in response to an allegation of inadequate care for patients who died in the Emergency Department (ED) at the Memphis VA Medical Center (the facility), Memphis, TN. The complainant alleged that a patient died after a physician ordered a medication for which the patient had a known drug allergy; another patient died after being administered multiple sedating drugs and not being monitored properly; and a third patient died after delays in getting treatment for very high blood pressure.


Des Moines, Iowa

  • The VA Office of Inspector General Office of Healthcare Inspections conducted an inspection in response to a request by Senators Charles Grassley and Tom Harkin, both of whom received allegations of ongoing administrative irregularities, leadership lapses, and quality of care concerns over the past 2 years at the VA Central Iowa Health Care System.


San Francisco, California

  • In a VA Inspector General report on the San Francisco VA hospital and clinic, the agency’s inspector general reviewed 264 opiate prescription renewals and found that in 53 percent of cases, the doctor renewing the prescription had not seen the patient or talked to him or her over the telephone.

Category: Veterans' Affairs Department

Comments (28)

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  1. nbcguy54 says:

    TSO – so whatcha trying to say?? (sarcasm).

    If this was concerning “real” hospitals and care facilities, the shit would be hitting the fan at record speeds and amounts. But since it’s just a few wacked out, tax money sucking veterans that are affected, the general public isn’t going to care. This is bullshit, but have we as veterans ever got anything other than lip service in the past anyway??

    BTW, thanks for the info TSO.

    I think I’ll stick to self medication.

  2. Michael says:

    And let’s not forget Murfreesboro TN VAMC where they were using dirty, unsterilized instruments giving veterans colonoscopies, some with HIV/AIDS. A volunteer blew the wistle on them on the local TV news when her concerns fell on deaf ears for a year.

    • Mike Barbour says:

      The VA motto is “Delay, Deny, Die”. Until they get away from the philosophy that we can’t fire people just move them to a different department so they can screw that up too these atrocities will continue

  3. Hondo says:

    After reading the above, the following quote comes to mind:

    “I don’t give a sh!t what happens. I want you all to stonewall it, let them plead the Fifth Amendment, cover up or anything else, if it’ll save it, save this plan. That’s the whole point. We’re going to protect our people if we can.”

  4. Sparks says:

    Well one thing is clearly evident. VA bonuses are on the uptick. /sarc/

  5. Open Channel D says:

    At what point will it become a national embarrassment? Under this clown car administration, probably never.

    Seriously, it’s beginning to look like the only reason to go to the VA hospital is to execute an extract op.

    • B Woodman says:

      “Seriously, it’s beginning to look like the only reason to go to the VA hospital is to execute an administrator.”

      There, fixed it for ya.

  6. TC says:

    That’s the problem with government performance bonuses, inept managers manage by the milestones that result in higher bonuses, not making decisions based on what’s right. They are good ones out there, but I have seen very few in Gov management positions that I would call a leader.

  7. ANCCPT says:

    Shinseki just got subpoenaed by Congress. I sent the link to the FB page inbox. Money quote:

    “I serve at the pleasure of the president,” Shinseki told the newspaper when asked whether he would step down. “I signed on to make some changes. I have work to do.”

    In other words. ‘Fuck you, American people. I don’t answer to you.’
    Shinseki, if you have any shred of our once shared values as soldiers left, you would resign in disgrace and at least preserve your honor.

  8. H1 says:

    Typo or some weird reference I am not getting..
    From NH but I spent 5 lovely years there at ASU.

  9. Twist says:

    What’s scary is I’m getting ready to go into this system.

  10. Ex-PH2 says:

    The two that are near me aren’t included in that mess. I don’t know if that’s a relief, or if I should take a precautionary approach to either of them. So far, the one I go to seems to do their job properly.

  11. ANCCPT says:

    @H1…FORK EM DEVILS! Beat the Sh*tty Kittys! (Third generation Sun Devil)

    • Hondo says:

      For that fact – and those lavender and yellow school colors – you have my sympathy. (smile)

      • ANCCPT says:

        First of all, Sir, those are fighting words. ASU fans and students have slurred drinking challenges for far less. Second of all, It’s Maroon and Gold, thankyouverymuch. As a side note, people don’t understand how much those undergrads drink. It’s comparable to a combat arms unit on the weekends. Seriously. It’s a hot mess, in more ways than one.

        • Hondo says:

          No, won’t use the Bugs Bunny quote about “maroon” here. (smile)

          Yer endangering your Geneva convention status as a “noncombatant”, laddie. Perhaps all the excess sun up north in that “Valley of Too Damn Much Sun” has gotten to ya.

          All in good fun. So AZ resident for years, and did some graduate-level work at UofA. Both are excellent schools. (smile)

    • H1 says:

      Did your education experience extend to the “Old Main” building?

  12. MAJMike says:

    Golly gosh! Maybe if Shinsiki would just give all of us new hats, everything would be better.

    • Country Singer says:

      I was at a luncheon earlier today. There was an Armor Colonel at my table who brought up what a POS Shinseki is. He started with the current VA debacles and then worked his way back to the berets.

      And as a note, the reason this is being shoved under the carpet by the Obama Regime and the Media (BIRM) is that sooner or later the LIVs will put 2+2 together and figure out that this type of medical “care” is what is waiting for them under ObamaCare.

  13. AMH3 USN says:

    Think Glen Campbeell-” By the time I get an Phoenix appointment, I’ll be croaking….”

  14. Jo says:

    I think now would be a good time for any concerned American with spare time to volunteer at their local center. This might help by having eyes and ears in these facilities.

    • CLAW131 says:

      Jo,my wife tried to do just that, but there ended up being some kind of a Catch-22 to the deal and she just finally gave up on the whole mess. The catch was she couldn’t take the training class until she got an ID card and an ID card wouldn’t be issued until after she attended/completed the class. Figure that one out.

  15. Green Thumb says:

    Texas is about to explode again.

    They are using improper screening diagnostics to screen patients for certain injuries.

    Then the VBA bases ratings on that information.

  16. holdfast says:

    The only thing Shinseki did as Chief of Staff was push berets out to everyone. He got the VA job because he’s a loyal flunky.

    I wonder if he gets treated at a VA facility?