Health

Ohio Congressman calls for a Congressional Investigation into the VA System.

Congressman Mike Turner (R.OH) plans on pushing for a Congressional Investigation into the Dayton VAMC calling the VA investigation and actions by VA leadership a cover-up.

Though we do not totally doubt the views of Congressman Turner, Veterans Today does question his sincerity and partisan political motivation. However, we also question the partisan motivation of Democrat Senator Sherrod Brown who believes that the scandal at the Dayton VAMC was limited to Dayton and not symptomatic of an entire VA System or Veterans across the nation using the VA being at risk.

We do agree that the VA does reflect a degree of transparency that in fact brings into question Senator Brown’s contention that the Dayton VAMC scandal does not reflect the entire VA system. One need only know where to look to find VA Inspector General Reports that tell a different story from Senator Brown’s view of a VA system that is not broken.

On balance, one needs to dig deeper into these VA/OIG reports to determine how scandals were resolved or personnel, even Veterans involved were punished. However, my point is that the scope of complaints filed with the VA/OIG is not locally or even state focused but NATIONWIDE.

See my comments section below the article for a few examples of VA/OIG investigations just since October 2010. Again on balance, at least the VA does make these investigations  public, so to say the VA has something to hide would not be totally accurate. What we do have a problem with is that when a scandal of the seriousness as that at the Dayton VAMC is being investigated getting the OIG report to the public is a bit time consuming.

Evidently, the media is given some access to the investigation in an attempt by the VA to show it has nothing to hide, but the public in general will know nothing until a final IG report is published.

This is a follow-up story of my earlier update Damage Control at the Dayton VAMC Continues.

A few weeks ago I sent a message to several mainstream Veteran Service Organizations endorsed by the VA requesting their views on the Dayton VAMC scandal.

Thus, far Veterans Today has received only one response outside of the views already expressed by Arthur Wilson at DAV. This was the response to VT from  Mr. Donald R. Lanthorn, Service Director and Legislative Agent for The Ohio American Legion:

“I don’t know what we [the Legion] can say that we haven’t already concerning the regrettable situation at Dayton VA Dental Clinic.  The American Legion has a Department Service Officer employed and located at that facility, and Mr. Tom Greathouse has been keeping us informed as things proceed.

I must say though that we have worked with [incoming Dayton VAMC Director]  Bill Montegue for many years and have the utmost confidence in his ability, candidness and effectiveness in getting a job to completion.  Bill was the director of Cleveland VAMC and managed the major and minor construction programs that have rebuilt Brecksville VAMC in Cleveland, while keeping his word to continue present and expand services to veterans upon the closure of Brecksville.

We are satisfied that with Bill at the helm [that] the VA will fully and fairly address all issues, correct all inadequacies, and put in place proper guidelines and procedures to prevent recurrences. Furthermore, Tom remains at the VAMC to report to management and our Headquarters of concerns in violations of protocols.

Supervisory and peer evaluations should negate any need for The American Legion to presume to evaluate VA employees, especially medical professionals, but we will not hesitate to report any safety issues we discover from patient reporting or observation to VA management.”

Donald R. Lanthorn, Ohio American Legion

I wish to personally thank Mr. Lanthorn for a very candid and optimistic response, especially the part about having an American Legion Veterans Service Officer employed at the Dayton VAMC maybe every Vet Service Organization needs a paid representative in each VA Medical Facility? I was aware that several Veterans Organizations have had outstanding volunteer programs that take quite a fiscal burden off the VA budget, but I was not aware that any Veterans Organization had representation on the VA payroll. This fits in with my own personal desire to see even more Veterans hired by the Department of Veterans Affairs.

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

Trouble at VA went beyond 1 dentist: A VA investigation shows the dental office was poorly managed and understaffed.

By Ben Sutherly, Staff Writer, Dayton Daily News.

Please address questions and comments to Mr. Sutherly at [email protected]daytondailynews.com

Except where noted in [brackets] the entire story and copyright is credited to Ben Sutherly, Staff Writer, the Dayton Daily News.

March 26, 2011. “Problems at the Dayton VA Medical Center’s dental clinic went far beyond Dr. Dwight Pemberton, the dentist whose poor infection control practices may have exposed 535 patients to such diseases as hepatitis and HIV from January 1992 to July 2010.

In sworn testimony given during a Veterans Affairs investigation, workers describe a poorly run, understaffed clinic, where supervisors tolerated inappropriate activities and cut corners, and workers were paralyzed by fear.

According to a post-investigation report, another of the clinic’s eight dentists allegedly broke teeth during extractions and performed unnecessary procedures. Working with that dentist, whose name hasn’t been obtained by the Dayton Daily News, “was just like watching a child be abused,” one worker told investigators.

Clinic dentists even took credit for being primary providers of dental work done by unlicensed students, who were permitted to practice without the required level of supervision, according to the report.

A former patient of Pemberton’s said he received substandard care at the clinic during a visit five years ago. Thomas Woodson of Harrison Twp. told the Dayton Daily News Pemberton enthusiastically introduced him to his fellow dentists after Woodson told him he is a descendant of Thomas Jefferson and slave Sally Hemings. While Pemberton took keen interest in Woodson’s roots, Woodson went home with ill-fitting dentures that he soon quit wearing.

[Failure of Leadership ]

VA Secretary Eric Shinseki acknowledged a “failure of leadership” in Dayton during a federal budget hearing earlier this month, during which he was asked why VA Medical Center Director Guy Richardson had received an $11,874 bonus at the end of federal fiscal 2010.

“I’m not going to try to describe why a bonus was sensible,” Shinseki said.

“This went on for an extended period of time when it wasn’t brought to the attention of leadership, and I again fault that to a failure in leadership.”

Soon after, Richardson was reassigned to a VA regional headquarters job in Cincinnati, described by VA officials as a “lateral move” without a change in pay. Richardson received $167,328 in fiscal 2010.

The VA initially said nine veterans had tested newly positive in preliminary tests for hepatitis B or hepatitis C antibody, but on Friday cut that number to five.

Members of Congress from Ohio have been unimpressed by the VA’s response to the scandal so far.

“These practices are so shocking and outrageous that you would expect the VA to have a very strong and open response to this,” U.S. Rep. Mike Turner, R-Centerville, said Thursday. Instead, he said, the agency “clearly appears to be in cover-up mode.”

Sen. Sherrod Brown, D-Ohio, called the response “slow” but said transparency is improving. The VA [also] has defended its response, pointing to a recent New England Journal of Medicine article that singles out the VA’s disclosure policy for adverse events to patients. The policy, according to the article, “endorses transparency.”

VA officials didn’t defend Pemberton’s actions, but noted not all of the complaints about the second dentist were deemed valid. Dr. Bill Germann, the Dayton VA’s acting chief of staff, said that dentist will likely begin practicing again at the Dayton VA. Germann also said there was appropriate oversight of fourth-year dental students, and dentists appropriately documented work done by those students.

“Based on my knowledge, the comments in the (investigative) report were not totally appropriate,” Germann said.

The dental clinic scandal in Dayton calls into question how accountable people are held throughout VA

The dental clinic scandal in Dayton calls into question how accountable people are held throughout VA, said Ronald Hamowy, a fellow with the Cato Institute and the Independent Institute, both libertarian groups. Hamowy authored “Failure to Provide,” a March 2010 report on the VA.

Hamowy prefers the government stop providing medical care directly to veterans and instead contract for that care to be provided in civilian medical facilities under a Medicare-type program. Though Medicare itself has been abused by clinicians, “there’s less opportunity for waste and corruption,” Hamowy said.

But [Senator] Brown said the dental clinic scandal reflects long-standing issues specific to the Dayton VA that merit a hospital-wide organizational review, not systemic issues across VA nationwide.

“It’s a very good health care delivery system,” Brown said of the VA. “It’s a cultural issue in that VA (in Dayton). It doesn’t extend beyond that VA, but it’s been endemic there for some time.”

Veterans Today Editorial Comment: As mentioned earlier, the very openness and transparency of  VA  Inspector General public reports challenges  Senator Brown’s contention that VA scandals are only endemic to Dayton, Ohio.

Under-performers at understaffed clinic

Dental clinic workers told investigators the clinic was woefully understaffed. The director of the facility’s residency program said the ratio of dental assistants to dentists was too low to support four resident slots and put patients at risk.

“We were critically short dental assistants, not only to run a residency, but to run a dental service,” he told investigators. One assistant was hired in response to his concerns, but the staffing levels remained unacceptably low, the director said.

The shortage of dental assistants also may have had implications for infection control.

Prior to 1992, investigators said Pemberton regularly had at his side a dental assistant, who would prod him to follow hygiene protocols. But in 1992, Pemberton began working alone, and the VA report concluded “it was when he worked alone that (he) presented a clear danger to patients since he would often fail to adhere to established infection control protocols.”

Supervisors for years had been told about Pemberton’s failure to change gloves and sterilize dental instruments, but he was not disciplined and continued to receive raises up until dental clinic workers alerted an outside team of VA inspectors to the infection control issues in July.

“I’ve seen him literally walk from his room with this patient’s denture in one hand, go across to another room, open this patient’s mouth with this denture of the opposite patient in his hand,” one dental assistant testified. “I’ve seen him use the same instruments, the same hand-piece, the same burs all day long on every patient. I’ve seen him go out of the clinic and push the button on the elevators with dirty gloves on. I’ve seen him open lab doors with dirty gloves on; I’ve seen him go in the lunchroom and use the microwave with dirty gloves on.”

Over the years, Pemberton had been counseled about infection control practices. At times, he showed improvement, but eventually lapsed back into old habits, witnesses said.

The NAACP does not run the Dayton VAMC or the Department of Veterans Affairs.

A former dental clinic supervisor blamed intervention by the NAACP for foiling his efforts in the early 1990s to remove Pemberton, who is black. A subsequent dental service chief often changed Pemberton’s instruments so Pemberton wouldn’t continue to use dirty instruments on patient after patient, according to the report. One dental clinic worker said she saw supervisors clean Pemberton’s room at times “because they (knew) what (was) going on, and to cover their [ass] I mean since things have been brought up to them — to cover their own butt.”

Pemberton, 81, of Centerville “repudiated” the claims against him, according to the report. He retired Feb. 11, and thus is no longer subject to possible disciplinary action by the VA. He declined comment for this article.The Dayton Daily News confirmed Pemberton’s name independently, but was unable to do so for other dental clinic employees whose names were also edited from the investigative report.

While some claimed the clinic was chronically understaffed, other testimony suggested some workers weren’t pulling their weight.The dental service chief, for example, admitted under oath that he saw patients only two days a week, despite the dental clinic’s shortage of dentists.

Obsessed Over Genealogy Study Instead of Patient Care

Pemberton, who was paid $165,878 annually before retiring Feb. 11, obsessed over genealogy. He spent “countless hours conducting genealogy research on work computers” when he should have been working on patients, the report claimed. In the report, a VA investigator said patients complained about Pemberton asking questions about their family background and doing genealogy research. One former dental assistant even told VA investigators she suspected Pemberton scheduled follow-up appointments with patients based on his genealogy interests rather than on medical necessity.

“Sometimes he would want me to get a patient back in even though I didn’t feel like there was enough time to do the patient,” the dental assistant told VA investigators.

“And the reason you believe he wanted that was because of the genealogy?”

“It’s possible,” she said.

Another coworker testified Pemberton spent a great deal of his clinical time doing genealogical research and was not productive.

“Was that (lack of productivity) a good thing?” an investigator asked.

“Yes,” the coworker replied. “Very good thing.”

Are VA hospitals subject to enough oversight?

VA hospitals like Dayton’s are subject to both independent and internal oversight.   The Veterans Health Administration monitors the hospitals to identify patient care or systems-related issues. For example, Dayton VA dental clinic employees alerted a VA official to Pemberton’s infection control issues during a System-wide Ongoing Assessment and Review Strategy (SOARS) review at the hospital in late July. The VA’s facilities also are independently monitored by The Joint Commission, an independent nonprofit that accredits and certifies more than 18,000 U.S. health care organizations and programs. In November 2010, a Joint Commission team conducted an unannounced, triennial review of the Dayton hospital. During that review, one surveyor reviewed infection control practices and other aspects of the dental clinic. No adverse findings were reported, the VA said.

The Dayton clinic is not the VA’s only troubled dental clinic.

The Dayton Daily News on March 16 requested recent Joint Commission inspection reports at the Dayton VA from the VA and the Joint Commission. The Joint Commission declined, and the VA has not yet responded. The Dayton clinic is not the VA’s only troubled dental clinic. At a VA medical center in St. Louis, improper cleaning and sterilization of reusable dental equipment posed an infection risk to patients between February 2009 and March 2010. The VA notified 1,812 patients, four of whom tested positive for hepatitis C or hepatitis B, a VA spokesman said.

In a prepared statement, the VA said its medical centers have been “increasingly vigilant” in monitoring and investigating any infection control issues. When VA’s central office learns of actual or potential adverse events, a clinical review board is formed to see if evidence indicates any patient risk and if disclosure of those adverse events to patients and their families “is in the best interest of their health and well-being,” the statement reads.

After Dayton’s dental clinic scandal became public, VA added a dental component to its SOARS review.

“If I go down, everybody’s going down”

The VA report faulted the clinic’s dental service chief not only for failing to take action against Pemberton, but for his “wholly insufficient” professional practice evaluations of staff members. Staff members told investigators the dental service chief stuck his head in the door of operatories where dentists were working on patients, but couldn’t actually see how dentists were doing their work. Only the top of the patient’s head was visible from the doorway. The dental service chief had been hired at the clinic as a dentist to be groomed for the chief role. But one unidentified witness told investigators that he/she wouldn’t have endorsed the dental service chief for the job, though he/she wasn’t asked.

“He was always — for want of a better term — lurking, standing around doorways, and at corners and whatnot, attempting to overhear conversations,” the witness said.

“And he didn’t do much dentistry; he didn’t have very good rapport with the dental residents. Didn’t have very good rapport with anyone, for that matter, in the dental service, except for a couple of the staff dentists. But he was just not, in my mind, a leader that would be able to move the dental service forward in any particular constructive way.”

Following revelations of Pemberton’s poor infection control practices, the dental clinic closed Aug. 19 for staff training and a thorough cleaning. At the same time, a VA administrative investigation board began calling witnesses to provide sworn testimony about the dental clinic’s problems. Two people testified that they felt intimidated by the dental service chief.

“I heard they made you come in at 6:45 in the morning,” the dental chief told one witness while she was lunching outside the VA hospital one day with another witness.

“No, they didn’t make us,” she replied. “We volunteered.”

“Well, I’m still the dental chief and I will be back,” the other witness recalled the dental chief saying. “And if I go down, everybody’s going down.”

Congressman Turner said he’ll continue to push for a congressional investigation in the wake of the scandal.

“As a member of the House armed services committee, I have never dealt with a federal agency that has been so secretive as the VA,” Turner said. “I think they know that there’s more to the story than they’re telling us, and that there’s a lot wrong here.”

But Jack Hetrick, director of the VA network that includes Ohio’s VA medical centers, said he believes the VA is serious about becoming perceived as a high-quality and responsible institution in the public eye, and that officials are taking steps to “make certain our beliefs are reaffirmed by actual practice.”

“I feel confident in reassuring your readers that everything that’s going on at the Dayton VA Medical Center right now is being done with veterans in mind,” Hetrick said.

Unfolding of the Dayton VA scandal TIMELINE

Late July 2010: Two dental clinic employees notify VA officials of infection control lapses at the Dayton VA’s dental clinic during a SOARS (System-Wide Ongoing Assessment and Review Strategy) visit. Four dental clinic employees are reassigned outside the clinic, including dentist Dwight M. Pemberton.

Aug. 19-Sept. 10: Dental clinic is closed for a thorough review, cleaning and employee training.

Nov. 17: Dayton VA notifies the public of the infection control lapses. The disclosure comes shortly after veteran and activist Darrell Hampton contacts elected officials about the dental clinic’s problems.

Nov. 22: The Department of Veterans Affairs’ Office of Inspector General said it will review the clinic’s infection control lapses. That review is ongoing.

Feb. 8: Dayton VA begins contacting 535 patients about free screening for hepatitis B, hepatitis C and HIV. All veterans are contacted by mid-March.

Feb. 11: The dentist whose infection control practices prompted the investigation, Dwight M. Pemberton, retires at age 81.

Feb. 16: Elected officials representing Dayton — Sen. Sherrod Brown, D-Ohio; Sen. Rob Portman, R-Ohio; and Rep. Mike Turner, R-Centerville — request a review of oversight practices at the Dayton VA.

March 11: Dayton VA Medical Center Director Guy Richardson is reassigned to a regional headquarters job. William Montague named acting director.

March 14: The Greater Dayton Area Hospital Association receives additional documents that will be reviewed by clinicians outside the VA system.

March 25: U.S. Reps. Mike Turner, R-Centerville, and Russ Carnahan, D-Mo., request the House Veterans Affairs Committee hold hearings on the medical safety practices at VA medical facilities nationwide.

*************END OF DAYTON DAILY NEWS ARTICLE*****************

Veterans Today Editorial Comment: Note that footnote (60) used in the New England Journal of Medicine (NEJM) article touting the VA was based on a VA directive that yes provides a checklist on what the VA should do in such scandalous situations, but says nothing about how effective the VA is at implementing the checklist?

In fact, this part of the NEJM article has been left out by the VA:

“Although this matrix [used by the VA] reflects important utilitarian considerations, there is a danger that the 1 in 10,000 “threshold” can be unduly emphasized in decision making to the exclusion of other important institutional and professional commitments. In addition, because definitive evidence of harm can usually be established only after a look-back investigation is well under way, disclosure of large-scale adverse events may be warranted before conclusive determination of the magnitude and scope of harm. Nonetheless, the VHA policy represents a valuable resource for all health care institutions. See the entire NEJM article below.

Also note the partisan political emphasis in the two diverse responses. Republican Mike Turner (rightfully BTW) reflects upon the VA under current Democrat control (snicker-snicker) “clearly appears to be in a cover-up mode.”

In comparison to Democrat Senator Sherrod Brown’s defensive –  well the VA response was slow but transparency is improving. Who’d he get his advice from the DAV that also downplayed the scandal. That said, had Shinseki been a political appointee under a Republican President it would be Democrat Senator Brown coming down hard (very hard) on the VA while Congressman Turner would be in the defensive mode. We at Veterans Today believe that the VA system has been politicized long enough.

Former Dayton VAMC Director Guy Richardson, received $167,328 in fiscal 2010, being paid slightly more than Dr. Pemberton who received $165,878 annually before retiring Feb. 11. Maybe here is where some of our federal budget cuts need to come from by lowering the pay of incompetent federal employees instead of awarding them bonuses.

“As a member of the House armed services committee, I have never dealt with a federal agency that has been so secretive as the VA,” Congressman Mike Turner said.

Anyone who knows anything about the Department of Veterans Affairs knows that the Senate or House Armed Services Committee has little or nothing to do with the VA. Mike Turner needs a ‘lateral move’ to the House Veterans Affairs Committee before he can make balanced claims about how secretive the VA is. The Department of Defense is monitored (well almost) by the Armed Services Committee, and if he doesn’t realize this already someone needs to remind Congressman Turner that active duty members do not seriously become Veterans until after they leave the Armed Services at such time we are no longer his problem per se.

Are VA hospitals subject to enough oversight? The Veterans Today News response to that question is if there were enough oversight of the Department of Veterans Affairs, among other people, but most notable Larry Scott’s VA Watchdog.org would never have had a reason to exist nor have such a large and loyal following. In fact, Larry is about to retire as founder and editor of VA Watchdog turning the site over to Jim Strictland.

We at Veterans Today News believe that it has been the increasing political nature of the Department of Veterans Affairs, the failure of Veterans Service Organizations to provide sufficient oversight, and the entrenched bureaucracy biding its time until political appointees move along that REQUIRED Larry Scott, someone, or some group to be an Independent VA Watchdog. The VSOs are simply too close to the VA to offer balanced oversight given the commendable volunteer and transportation roles performed by the VSOs that help keep the VA Budget down by providing free labor to the VA, and most significantly ensuring that Disabled Veterans have a means to get to the VA for appointments and hospitalization.

THE NATIONAL LEVEL SCOPE OF ALLEGED VA PROBLEMS

10/12/2010-Healthcare Inspection Alleged Inappropriate Prescription and Staffing Practices Hampton VA Medical Center Hampton, Virginia.

Report Number 10-01167-06, 10/12/2010 | Summary | Report (PDF)

10/12/2010-Healthcare Inspection Alleged Quality of Care, Personnel, and Other Community Living Center Issues Hampton VA Medical Center Hampton, Virginia

Report Number 10-03275-04, 10/12/2010 | Summary | Report (PDF)

10/14/2010-Healthcare Inspection Quality of Care Issues St. Louis VA Medical Center, St. Louis, Missouri and Minneapolis VA Health Care System, Minneapolis, Minnesota

Report Number 10-03313-08, 10/14/2010 | Summary | Report (PDF)

10/20/2010-Healthcare Inspection Electronic Ordering of Chemotherapy Fargo VA Medical Center Fargo, North Dakota

Report Number 10-02882-11, 10/20/2010 | Summary | Report (PDF)

10/26/2010-Healthcare Inspection Alleged Community Living Center Quality of Care Issues, VA Palo Alto Health Care System, Palo Alto, California

Report Number 10-03526-13, 10/26/2010 | Summary | Report (PDF)

10/29/2010-Administrative Investigation Improper Academic Degree Funding,Improper Detail and Failure to Cooperate with an OIG Investigation, OI&T VA Central Office
Least We Forget – the Suicide at Dayton VAMC

Report Number 09-01123-16, 10/29/2010 | Summary | Report (PDF)

11/9/2010-Healthcare Inspection Suicide After an Emergency Department Visit at the Dayton VA Medical Center, Dayton, Ohio

Report Number 10-02278-26, 11/9/2010 | Summary | Report (PDF)

11/12/2010-Healthcare Inspection Alleged Residency Training Issues in Nuclear Medicine Service Northport VA Medical Center Northport, New York

Report Number 10-01576-28, 11/12/2010 | Summary | Report (PDF)

Here We Have a Case of Cost Savings over Veteran Saving
11/16/2010-Healthcare Inspection Alleged Issues in Fee Basis Care Martinsburg VA Medical Center Martinsburg, West Virginia

Report Number 10-02006-29, 11/16/2010 | Summary | Report (PDF)

 

 

Author Details
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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