Damage Control at the Dayton VAMC Continues

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As Congressional Representatives in Congress continue to raise questions about how the Department of Veterans Affairs (DVA) has mishandled the Dental Scandal at the Dayton VAMC in Ohio, one Veterans Service Organization has downplayed the incident in defense of the VA.

When I received my latest edition (Mar-Apr) of DAV Magazine, the first thing I noticed was the message from DAV Adjutant Arthur H. Wilson – Quality and Efficiency in Caring for Veterans: For high-quality health care, it’s hard to top the Department of Veterans Affairs in which Adjutant Wilson comes across as downplaying the scandal at the Dayton VAMC in order to defend the entire VA system.

This inspired me to compare what media reports and Ohio political representatives are saying to statements (if any) issued by some Veterans Service Organizations. In addition to noting the views of DAV leadership, I’ve contacted the Ohio state chapters of VFW, the American Legion, and VVA to request a statement of position. When and IF we receive a response, I’ll post it in the comments section.

I do not debate nor have a problem with DAV, or any other VSO, defending the entire VA system, heck that’s why their logos appear in the lobbies of most every VA Medical Center – the VSOs are simply too close to the problem to want it to be a problem.

I also understand the very significant and reasonable   intent of some VSO leaders to ensure America’s Veterans do not lose confidence in the entire VA system due to the criminal negligence on one Hospital.

What I do have a problem with are the words used by DAV Adjutant Arthur H. Wilson to downplay the scandal at the Dayton VAMC. As a patient who has used that dental facility, let me assure Arthur Wilson and the DAV that if he or any other member of the

DAV, or their families were made vulnerable (took their own lives in their hands) to that dentist at the Dayton VAMC, or worse yet if DAV leadership had been diagnosed with Hepatitis or HIV, we at Veterans Today have to seriously doubt that the DAV Adjutant would be singing the same song he has been in his obligation to defend the VA system.

On balance, we understand where VSO leadership is caught between a rock and a hard place in that most cannot look the other way as such scandals go down plus attempt to maintain American Veteran confidence in the VA system. It is an awkward position that I would not want to be in.

However, I do believe and ask our readers who are also DAV members as I am (a Life Member) to request our adjutant to issue an apology to all Veterans in Ohio put at risk by the Dayton VAMC, especially the 9 Vets who tested positive for Hepatitis.

We wish to acknowledge and thank Veteran Advocate Darrell Hampton of Dayton, and Dayton Daily News Reporter Ben Sutherly for staying on top of this scandal. Most of the analysis and reporting below comes from a series of investigative reports done by Ben Sutherly.

ROBERT L. HANAFIN, Major, U.S. Air Force-Retired, U.S. Civil Service-Retired, Veterans Issues Editor, Veterans Today News Network

Vet Group Comes to the Defense of the Dayton VAMC as Politicians Accuse the VA of Evasive Actions.

Dayton VA Medical Center

As I mentioned above, the commentary by DAV Adjutant Arthur H. Wilson inspired me to try and find out what other VSOs were saying about the growing scandal at the Dayton VAMC.

I wanted to compare the attitudes of Vet groups to views of politicians in Ohio accusing the VA of foot dragging.

When this scandal went public back in February 2011 after complaints had been raging for months there were two U.S. Senators, and one U.S. Congressman finally paying attention to what was going down at the Dayton VAMC. (Senators Sherrod Brown, Ron Portman, and Congressman Mike Turner).

Since then the scandal has evolved to having Veterans and Politicians QUESTIONING the oversight of the VA system, requesting VA investigative reports as if the VA had something to hide, inviting Secretary Shinseki to Visit the Dayton VAMC himself to inspect, forcing the transfer of Dayton VAMC Director Guy

Senator Sherrod Brown Meets With VA Secretary Shinseki

Richardson to another paid position at VA Headquarters in DC that the Congressman involved calls an OUTRAGE, the VA’s handling of the investigation EVASIVE, political slogans that Our Veterans Deserve Better, and worse yet an attitude of FEAR among VA Employees reluctant to report the scandal due to potential retaliation from the very Hospital Director that was administratively transferred when the

heat got too hot in the VA kitchen.

Against this backdrop running the spectrum from real outrage (mostly the Vets affected and infected), to political jockeying, one Vet group came out to defend the  entire VA system by downplaying the Dayton VAMC scandal.

The Adjutant of the Disabled American Veterans (DAV) Arthur H. Wilson had this to say about the qualifty of care vs. the scandal at the Dayton VAMC:

“Several comprehensive studies, including those by the Congressional Budget Office (CBO), the Government Accountability Office and the Rand Corporation, agree that the VA provides excellent patient care, equal to or better than most other health systems. Sure, like any other system, the VA has its flaws and lapses. Recent instances of possible patient exposure to hepatitis, HIV and other concerns about patient safety are blots on the VA’s record. But in each case, the VA has gone all-out to inform patients and the public and to provide free screening and treatment if needed. You won’t find that kind of self-initiated responsiveness to medical mistakes in the private sector.”

Quality and Efficiency in Caring for Veterans, March/April 2011 Edition of DAV Magazine, page 3

I have sent media inquiries to the VVA, VFW, and American Legion to determine where these Vet Service Organizations stand on the Dayton VAMC fiasco.

In contrast to DAV’s Adjutant Wilson’s views that “Sure, like any other system, the VA has its flaws and lapses. Recent instances of possible patient exposure to hepatitis, HIV and other concerns about patient safety are blots on the VA’s record. But in each case, the VA has gone all-out to inform patients and the public and to provide free screening and treatment if needed” there are those who challenge that view beginning with the Dayton Daily News, Senators Sherrod Brown, Ron Portman, and Congressman Mike Turner (Republicans and Democrats BTW)

The timetable of this update runs from late February to 14 March 2011.

February 17th, 2011 – Lawmakers urge investigation into oversight of VA dental clinic

Three Dayton area U.S. Congressional Reps called for a VA investigation into the lack of oversight that allowed a dentist at a Dayton VA Medical Center clinic to violate medical standards for nearly two decades, potentially exposing hundreds of veterans to blood-borne pathogens.This goes far beyond simple flaws and lapses at one VAMC.

In late February, Sen. Sherrod Brown, D-Ohio; Sen. Rob Portman, R-Ohio; and Rep. Mike Turner, R-Centerville, sent a letter to Secretary of Veterans Affairs Eric Shinseki, urging him to order a review of oversight practices at the Dayton VA. Read the full story at the Dayton Daily News

On balance there was a comment sent into Congressman Turner’s website:

“Why was there no concern or interest when both of your offices were aware of a serious problem at the Dayton VAMC dental clinic in early September 2010? Of this I am certain.”

I have to somewhat agree with this comment. I cannot speak to how many complaints that Congressman Turner received about the Dayton VAMC over the past several years, and Senator Portman had been a Congressman until elected this past November, but he also had to receive complaints or concerns about the VA. What I do know for sure is the Senator Brown’s offices have been aware of problems and complaints at the Dayton VAMC, since I contacted his office a few years ago to complain about the attitude of upper and middle management at the Dayton VAMC.

March 07, 2011 – Turner calls on Dayton VA to release dental center investigation reports

According to WDTN TV in Dayton, Ohio, Congressman Mike Turner  called on Dayton VA Medical Center director Guy Richardson to release the results of the VA conducted investigations by March 11.

“Our veterans and their families are owed an explanation as to how and why this extreme dereliction from basic medical safety procedures was allowed to continue over 18 years and without oversight by VA management,” Turner said. “These investigative reports will begin to shed some light on this travesty.”

At least nine patients who received dental care at the Dayton VA Medical Center have tested positive in preliminary tests for Hepatitis B and Hepatitis C.

Turner, along with Senators Sherrod Brown and Rob Portman, have requested the Department of Veterans Affairs initiate a national review of the practices at the Dayton VA Medical Center.

Additionally, the lawmakers have called for Secretary Shinseki to direct that a national level Administrative Investigation board (AIB) re-investigate the Dayton Medical Facility. They have also requested copies of the System-wide Ongoing Assessment Review Strategy and all other internal investigations surrounding the incident.

Of significance to any VA Medical Center and the VA system in general,  The fulfillment of Turner’s request for the VA investigation of the Dayton VAMC Dental Clinic allows the Greater Dayton Association of Hospital Administrators began their independent review of the federal investigation.

March 10, 2011 – Rep. Michael Turner Invites Secretary Shinseki to Visit Dayton VA Read more: Congressman Mike Turner invites Secretary Shinseki to Visit Dayton

Congressman Mike Turner penned a letter to Veterans Affairs Secretary Eric Shinseki inviting the Secretary  to visit the Dayton VA Facility.

“Yesterday my Chief of Staff invited you to come to Dayton and you indicated a willingness to consider the invitation. Visiting the Dayton VA Medical Center Dental Clinic will go a long way to reassure the community that the VA is committed to providing the highest quality of care and will do everything within its power to resolve this issue,” Turner wrote Shinseki.

 

Congressman Turner, along with Senators Sherrod Brown and Rob Portman, are still awaiting copies of the VA investigative reports, which they requested nearly a month ago.

Those reports will be provided to the Greater Dayton Area Hospital Association for independent review. The three lawmakers have been working together to understand the events which have occurred at the facility, and have requested that Secretary Shinseki convene a national level investigation into the event at the dental facility, as well as the entire hospital.

March 11, 2011 – Director of Dayton VA removed

According to WDTN TV in DAYTON, Ohio,  Guy Richardson, until now, the director of the Dayton VA Medical Center, has been removed from his position, according to Congressman Mike Turner.

The move comes after it was revealed that nine patients tested positive for hepatitis in screenings conducted because of a dentist who failed to change gloves and sterilize instruments properly between patients.

Turner also said that Congressman Jeff Miller, the chairman of the House Veterans Affairs Committee, will visit the Dayton Veterans Affairs facility March 14.

Also on 11 March, Congressman Turner called what he views as a promotion of Guy Richardson an OUTRAGE!March 11, 2011 – Rep. Turner calls promotion of Dayton VA official an outrage”

U.S. Rep. Mike Turner condemned the Department of Veterans Affairs for moving Dayton VA Medical Center Director Guy Richardson to a headquarters job amidst an investigation into unsanitary conditions at the hospital’s dental clinic.

“Promoting Director Richardson during this investigation is wrong and just another outrage in a series on the part of the VA,”

Turner said in a statement.

“This bait and switch just two days before Richardson was scheduled to meet with the chairman of the House Veterans Affairs Committee and me is unacceptable. We aim to meet with Richardson on Monday and hear first hand just how basic medical safety conditions could deteriorate to this extent under his leadership.”

The VA removed Guy Richardson as director of the Dayton VA Medical Center and replaced him with the former director of a VA medical center in Cleveland.

Richardson was “detailed” to the Veterans Integrated Services Network office in Cincinnati. He could not be reached for comment.

VA spokesman Todd Sledge said the move “is definitely not a promotion for Mr. Richardson,” whose pay will not change.

Richardson’s departure comes in the wake of news that nine patients seen at the Dayton medical center’s dental clinic may have contracted hepatitis B or hepatitis C from a dentist who did not follow basic infection control practices for 18 years. The dentist, Dwight M. Pemberton, 81, of Centerville, performed invasive dental procedures on patients, but failed to change latex gloves and sterilize dental instruments properly between patients, according to VA investigation documents.

William D. Montague has agreed to come out of retirement to serve as acting director of the Dayton VA Medical Center. Montague previously served as director at six different VA medical centers.

March 13, 2011 – VA’s actions ‘evasive,’ Turner says

U.S. Rep. Mike Turner accused the Department of Veterans Affairs of stonewalling him by denying access to Guy Richardson, the former director of the Dayton VA Medical Center.

In a statement released to the media, Turner called the VA’s actions “highly evasive and obstructionist.”

But a VA spokesman said Richardson was never to be at the meeting.

Turner, R-Centerville, and Rep. Jeff Miller, the chairman of the House Veterans Affairs Committee, were at the Dayton VA Medical Center on 11 March for a meeting [with Dayton VAMC leadership] about unsanitary conditions at the hospital’s dental clinic. Turner said he expected Richardson to be at the meeting.

On 11 March, the VA conveniently transferred Richardson to the Veterans Integrated Services Network (VISN) offices in Cincinnati. That same day, Turner condemned the department for giving Richardson a “promotion,” and the VA countered that it wasn’t a promotion and that Richardson’s pay won’t change.

VETERANS TODAY EDITORIAL COMMENT: Having retired from both the Air Force and Civil Service, I can assure our readers that given the circumstances the VA would never have promoted Guy Richardson. However, implementing an administrative transfer only proves that the VA had something to hide (Guy Richardson). The timing of Guy Richardson’s transfer was simply too obvious reinforcing any assertion that the VA simply cannot be trusted regardless which political appointee runs it. I’d have to agree with Congressman Turner that all the VA has done is a blatant attempt at cover-up to protect an upper level manager.

“The VA’s effort to stonewall Congressman Turner and the chairman of the committee with oversight and investigative jurisdiction of the VA shows that the truth remains to be uncovered,” Turner’s statement said.

Turner also included a letter he sent to Eric K. Shinseki, the secretary of Veterans Affairs. VA Press Secretary Drew Brookie said that the VA had been in discussions with Turner’s office, but a meeting with Richardson “was never a component of (the) VA’s proposal for this visit and was never scheduled or agreed to.”

William Schoenhard, VA’s Deputy Under Secretary for Health for Operations and Management, Acting Dayton VA Medical Center Director William D. Montague will both be at the meeting, Brookie said.

March 13th, 2011 – Dayton VA – Our Veterans Deserve Better

At the end of the day, 13 March 2010, Congressman Turner summed up where he was on this VA cover-up.

“In February, the Department of Veterans Affairs (VA) began informing nearly 600 veterans in our community [that number is up for debate] that they could have been infected with a number of blood born diseases due to unsanitary practices by a dentist in the Dayton VA Dental Clinic. Results of preliminary tests conducted by the VA have identified nine veterans as having tested positive for Hepatitis B or C. The fact that any medical practitioner could be so irresponsible is outrageous, let alone at a facility which is charged with caring for those who have protected us from tyranny. Upon learning of this investigation from the VA, I contacted Senators Sherrod Brown and Rob Portman to begin working together towards finding out how and why this had occurred.

On February 16th we sent a letter to Veterans Affairs Secretary Eric Shinseki requesting that the Department of Veterans Affairs initiate a national review of the practices at the Dayton VA Medical Center. Additionally, we called for Secretary Shinseki to direct that a national level Administrative Investigation board (AIB) reinvestigate the Dayton Medical Facility. We also requested copies of the System-wide Ongoing Assessment Review Strategy and all other internal investigations surrounding the incident.

Since my initial request of these documents nearly a month ago, I have yet to receive a response. Dayton VA Director Guy Richardson and the VA pledged to fully cooperate throughout this process, and the time has come for them to do that by releasing these reports. I set a deadline of March 11th to ensure that we can move forward with this process. The fulfillment of our request allows the Greater Dayton Area Hospital Association to begin their independent review of the investigation. This travesty which occurred in our community warrants a community response from those who have proven themselves in this profession.

Local leaders in the healthcare field including Tim Collins of Premier Health Care and Dr. Greg Wise of Kettering Hospital will provide leadership on a technical review of the reports as soon as we receive them. They have an outstanding reputation of integrity and professionalism, and are an important factor in Dayton’s hospitals recently being ranked #1 in quality for the entire State of Ohio and #3 in the entire country for quality outcomes as reported in a study by HealthGrades. Their assessment will ensure the reports receive an objective assessment regarding the quality of care provided. Bryan Bucklew of the Greater Dayton Association of Hospital Administrators (GDAHA), along with GDAHA Board Chair Mary Boosalis, will also review the reports.

While I await word from the VA on the reports, I have also requested a meeting with Secretary Shinseki. Our veterans deserve to be reassured by the Secretary that he is taking action on this matter, and that serious steps are made to ensure that this never occurs again. Furthermore, Jeff Miller, Chairman of the House Veterans Affairs Committee has indicated that he would like to see the facility first hand. I look forward to joining him when he reviews the Dayton VA Hospital and along with my colleagues in the Senate am anxiously awaiting these investigative documents.

March 14, 2011 – VA Employees’ say fear may have put vets’ health at risk

The latest report by Dayton Daily News Reporter Ben Sutherly , finds that a culture of FEAR may have kept workers and supervisors at the Dayton VA Medical Center’s dental clinic from disclosing the unsafe practices of one dentist over 18 years, a congressman said Monday.

U.S. Rep. Jeff Miller, R-Fla., chairman of the House Veterans Affairs Committee, said the clinic is compact and open, so employees’ activities can be easily viewed by their coworkers.

Miller is concerned there may be a widespread culture at the VA in which employees are afraid to speak up when they see issues that affect patients’ health and safety. Dental clinic employees and supervisors had known of the dentist’s infection control lapses for several years, but it wasn’t until July 2010 that two employees reported the problem to an outside VA panel, triggering an investigation.

Veterans Today Editorial Comment: Any concern that there may be a widespread culture at the VA in which employees are afraid to speak up when they see issues that affect patients’ health and safety IS NOT a culture isolated at the Dayton VAMC, but it would be an infestation spread throughout the VA system.

 

“For very few people to have stepped forward is troubling to me,” said Miller, who toured the facility Monday with U.S. Rep. Mike Turner, R-Centerville.

VA officials said Monday they have now contacted all 535 patients who received invasive dental procedures — crown, bridge, root canal, filling and removal — between 1992 and July 2010 from Dr. Dwight M. Pemberton, 81, of Centerville. Invasive procedures accounted for only part of Pemberton’s workload during that period.

The patients are being tested for hepatitis B, hepatitis C and HIV. So far, nine patients have had preliminary positive tests: seven hepatitis C cases and two hepatitis B cases.

Jack Bernstein, an infectious disease physician at the Dayton VA, said many of the seven patients who tested positive initially for hepatitis C have been found not to have active cases of the disease.

“We’re trying to confirm if their test was a false positive,” Bernstein said.

Pemberton was not infected with hepatitis B, hepatitis C or HIV, Bernstein said.

The Department of Veterans Affairs reassigned Dayton VA Medical Center Director Guy Richardson to a newly created regional VA headquarters job in Cincinnati. The reassignment’s timing angered Turner, who along with Miller had hoped to meet with Richardson.

“When we toured [the Dayton VAMC], hardly anyone who was provided to us by the VA had any direct knowledge of what had occurred,” Turner said.

William C. Schoenhard, the VA’s deputy under secretary for health operations and management, said that Richardson is on leave for an undetermined period for a “special family occasion.”

At some point, Schoenhard said, “we’re happy for Guy Richardson to meet with them (elected officials) at whatever venue would be appropriate. There’s certainly an openness and a willingness to provide that.”

The VA has insisted that Richardson, whose salary was $167,328 in 2010, was not promoted. But Turner said he isn’t convinced.

“He certainly was not demoted,” Turner said, noting Richardson moved from being head of a single facility to being part of a leadership structure overseeing several facilities. “To me, that’s a promotion.”

William D. Montague has been named acting director of the Dayton VA Medical Center. Montague said he will be making rounds at the hospital.

“The way I find out what’s going on is I wander,” Montague said in describing his leadership style. “I believe you find out more by going there than asking (department supervisors) to come to you.”

Turner on Monday didn’t rule out the possibility of a criminal investigation into how Pemberton could be allowed to risk veterans’ health with his infection control practices for years.

Veterans Today Editorial Comment: This is the way to go, because this is the only language the VA system UNDERSTANDS!

“It certainly could be possible that all aspects of this could result in additional investigations,” Turner said when asked about law enforcement becoming involved.

Turner also renewed his calls for accountability in the case. Pemberton retired in the midst of the investigation.

“I do not believe the investigation that has been completed thus far tells us enough of what occurred here and how it should be stopped,” Turner said. “I don’t believe the people have been held appropriately accountable, and I’m not certain that the VA has a very good picture of what needs to be done.”

U.S. Rep. Steve Austria, R—Beavercreek, who represents my Congressional District, responded to the VA decision to reassign Richardson.

“When I met one-on-one with Secretary Shinseki earlier this week, I expressed my disappointment in the leadership of the Dayton VA Medical Center,” Austria said. “The American people and especially our veterans expect and deserve better. As a member of the appropriations subcommittee that oversees the Department of Veterans Affairs, I am confident that the action Secretary Shinseki has taken is the right step forward to help prevent incidents like this from occurring in the future.”

Veterans Today takes the position that the Department of Veterans Affairs has made a grave MISTAKE in trying to cover up what happened at the Dayton VAMC by retiring one criminal and transferring another incompetent.

ROBERT L. HANAFIN

 


 

 

 

 


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Readers are more than welcome to use the articles I've posted on Veterans Today, I've had to take a break from VT as Veterans Issues and Peace Activism Editor and staff writer due to personal medical reasons in our military family that take away too much time needed to properly express future stories or respond to readers in a timely manner. My association with VT since its founding in 2004 has been a very rewarding experience for me. Retired from both the Air Force and Civil Service. Went in the regular Army at 17 during Vietnam (1968), stayed in the Army Reserve to complete my eight year commitment in 1976. Served in Air Defense Artillery, and a Mechanized Infantry Division (4MID) at Fort Carson, Co. Used the GI Bill to go to college, worked full time at the VA, and non-scholarship Air Force 2-Year ROTC program for prior service military. Commissioned in the Air Force in 1977. Served as a Military Intelligence Officer from 1977 to 1994. Upon retirement I entered retail drugstore management training with Safeway Drugs Stores in California. Retail Sales Management was not my cup of tea, so I applied my former U.S. Civil Service status with the VA to get my foot in the door at the Justice Department, and later Department of the Navy retiring with disability from the Civil Service in 2000. I've been with Veterans Today since the site originated. I'm now on the Editorial Board. I was also on the Editorial Board of Our Troops News Ladder another progressive leaning Veterans and Military Family news clearing house. I remain married for over 45 years. I am both a Vietnam Era and Gulf War Veteran. I served on Okinawa and Fort Carson, Colorado during Vietnam and in the Office of the Air Force Inspector General at Norton AFB, CA during Desert Storm. I retired from the Air Force in 1994 having worked on the Air Staff and Defense Intelligence Agency at the Pentagon.

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