More VA madness: Bonuses despite dead patients

By WND Staff

By Michael Volpe

There have been at least seven instances where bonuses have been paid to Veterans Administration officials even though they were on watch when hospitals failed to protect patients, and in one situation, five veterans died.

Using publicly available resources, WND has identified cases in which Eric Shinseki, now chief of the Veterans Administration, has allowed bonuses to managers in the middle of health-related and other scandals. It’s happened at VA hospitals in Pittsburgh, Atlanta, Waco, Dayton, Dallas, Buffalo and for several managers who approved a number of egregious spending items for two human resources conferences in Orlando, Fla.

The House Committee on Veterans Affairs has been investigating the matter and the chairman, Republican Jeff Miller of Florida, told WND that all these scandals taken together produce an environment where failure is rewarded.

“The continuous discovery of more and more instances of VA executives being rewarded despite failing to properly do their job is worrisome, to the say the least. This policy of applauding failure is detrimental to VA’s capability to fulfill its most basic of duties, caring for the needs of our veterans.”

The most troubling case happened in the VA Hospital System in Pittsburgh because Shinseki not only intervened in local staffing decisions but then washed his hands of the mess, only to have that same hospital wind up in another scandal about a year later, this one leading to at least five deaths.

Regional Director Michael Moreland, who oversees five VA hospitals including the Pittsburgh facility, was given the Presidential Distinguished Rank Award, which included a bonus of $62, 895 just three days before a scathing report from the VA Office of Inspector General, which listed a litany of systemic breakdowns at VAPHS that led directly to a legionella outbreak , which caused the deaths of at least five patients.

For the years covered by the OIG report, Moreland had given VAPHS Chief Executive Officer Terry Wolf perfect marks on all performance reviews.

What makes that scandal even more troubling is that this was the third time in six years in which legionella was part of a scandal at that hospital and Shinseki blew up the second scandal while never holding any of the hierarchy responsible for any of the three scandals.

In 2007, then North Carolina Democratic Congressman Brad Miller, the chair of the Sub-Committee on Investigations in the House Committee on Space, Science and Technology, led an investigation into the alleged willful destruction of a strand of legionella from a collection of the well-respected research team of Dr. Victor Yu and his partner Dr. Janet Stout, which allegedly occurred on Dec. 4, 2006. His investigation cited the Associate Chief of Staff Mona Melhem in particular, while holding her superiors, Dr. Raj Jain (Chief of Staff), Terry Wolf, and Michael Moreland, responsible for a failure to oversee.

That entire team was still in place when Dr. Anna Chacko arrived at VAPHS to become the head of radiology in the summer of 2008. She would be at VAPHS for a bit more than a year and a lightning rod the entire time.

Chacko was the subject of numerous complaints of bullying, disruptive and manipulative behavior, which culminated in a decision in favor of her removal from VAPHS by a bureaucratic panel called Administrative Board of Investigation in April 2009.

Chacko immediately reached out to Miller, claiming that she was being retaliated against because she was a whistleblower. The aggressor in this case, Chacko claimed, was Dr. Mona Melhem. Chacko claimed that she had uncovered numerous schemes and failures by Melhem and all reports of bullying behavior were the work of a carefully orchestrated retaliation campaign.

In May 2009, Miller wrote to Shinseki urging him to reverse the decision and install Chacko back in place because she was the aggrieved one .

“Last year, this subcommittee held a hearing to consider actions by Dr. Mona Melhem, a high ranking official at VAPHS. The subcommittee investigation resulted in harsh criticism of the management at VAPHS, and especially of Dr. Melhem’s conduct. The subcommittee concluded that Dr. Melhem ordered the destruction of a 30-year research collection —  destroyed out of personal animosity for the two researchers, and that her explanation of her conduct to the system’s chief of staff was false.

“Dr. Chacko, who was brought in as the fourth chief of the VAPHS radiology department in five years in September of 2008, complained to superiors about Dr. Melhem’s conduct in the radiology department; Dr. Chacko alleged that it was improper and had potentially compromised patient care, including ordering a X-ray for an employee who Dr. Chacko believed to be not eligible for VA care, purchasing unsuitable radiology equipment and materials.”

Shinseki would reverse the decision by VAPHS and Chacko would return to work in August 2009. Allegations of bullying behavior against Chacko continued, and after dozens more reached Moreland himself she was put on administrative leave in October 2009, and terminated, a rarity in VA bureaucracy, in January 2010, this time with no objection from either Miller or Shinseki.

The rest of the hospital hierarchy was still in place, still with no discipline or other structural changes and reforms, when a wholly separate strand of legionella was mishandled, infecting the water supply and leading to an outbreak and the deaths of at least five veterans, according to a report.

And a staff member on the House Committee on Veteran’s Affairs revealed that this pattern speaks to a larger problem with the management style and information gathering techniques of Shinseki.

“The situation certainly gives rise to concerns that Central Office has made decisions while not providing timely and accurate information from leadership in the Pittsburgh Health Care System and VISN 4 (the region which includes VAPHS),” the staffer report said.

VAPHS is not the only example of Shinseki approving bonuses to managers linked to scandals which led to deaths. An investigation by Atlanta’s WBS found that several managers at the VA hospital in Atlanta (VAMC) received tens of thousands in bonuses even as another inspector general report found that VAMC botched how it handled high-risk patients, leading to at least three deaths.

According to the WBS investigation Atlanta VA Medical Center Director James Clark pocketed a $13,000 bonus in 2011 and another $17,000 worth of salary bonuses in 2010. Lawrence Biro, a former regional director of five hospitals, including VAMC, received $18,000 in bonuses during 2011, according to the WBS investigation.

Carl Lowe, director of the Waco VA Regional Office, received bonuses totaling $53,436 between 2007 and 2011, according to an investigation done by the Austin-American Statesman. He received these bonuses despite an August 2013 VA OIG report which found that 40 percent of the disability claims inspectors reviewed at the Waco VA Regional Office were inaccurately processed and requested fresher training for employees over the same time period.

In 2010, Dayton VA Medical Center Director Guy Richardson received an $11,874 bonus even as that center’s dental clinic came under investigation for allowing unsafe sanitary practices by one dentist over 18 years. During 2010, the dental clinic was closed for several weeks and the VA determined it needed to offer free screenings to 535 patients who had received invasive dental procedures from Dwight M. Pemberton, the dentist at the center of the scandal.

A 2013 investigation from television station WIVB of Buffalo found that VA Health Care Upstate New York Network Director David West received nearly $26,000 in executive performance bonuses in 2010 and 2011 even as an investigation by that station found five boxes of records were contaminated with mold and mildew and hundreds more contained mismatched names and Social Security numbers.

An investigation by WFAA in Dallas found two top managers received $50,000 in bonuses over two years (2010-2012) even as the station was investigating the VA hospital in Dallas for substandard care.

In 2012, Maine Republican Sen. Susan Collins raised concerns directly to Shinseki over bonuses to a number of VA managers who were involved in the approval of millions in spending on two human resources conferences in Orlando, Fla., in the summer of 2011. These conferences became the subject of a scathing VAOIG report and are currently being investigated by the House Oversight and Government Reform Committee.

The two conferences cost taxpayers $6.1 million and included such frivolous spending as: $49,516 to produce a parody video, $72,000 for snacks, and $84,000 for promotional items (pens, hats, etc.). One of the managers who received a bonus worked on the parody video.

A report from the Government Accountability Office from July 2013 also came to the conclusion that there were serious and systemic problems with the protocols used to reward performance bonuses in the VA.

“Veterans Health Administration has not reviewed the goals set by medical centers and networks and therefore does not have reasonable assurance that the goals make a clear link between performance pay and providers’ performance,” the report said.

Later in the report, GAO made this point.

“All providers GAO reviewed who were eligible for performance pay received it, including all five providers who had an action taken against them related to clinical performance in the same year the pay was given. The related provider performance issues included failing to read mammograms and other complex images competently, practicing without a current license, and leaving residents unsupervised during surgery.”

WND requests of the VA, and Shinseki, for comment did not generate responses.


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