It's not just Phoenix

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It's not just Phoenix

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)

  • Columbia VA Regional Office Director Carl Hawkins received almost $80,000 in bonuses despite a doubling in the office’s backlog of disability compensation claims and inappropriate shredding of disability claims documents.


  • 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.

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Despite the fact that I had years of programming experience in the software they were using, and the fact that I am a Navy vet, I was never able to even get an interview for multiple job openings at the VA hospital in Topeka.
The only conclusion I could reach was that veterans' preference in hiring was not happening. But what the heck, it's only the law.
I had good treatment (surgery) at the VA hospital in Leavenworth, but it was many years ago.

I agree with Paul about the Leavenworth VA Hospital. I had both knees scoped. One at the Leavenworth VA and one at St. Mary's Hosp in Blue Springs, MO. Recovery time was shorter following my surgery at Leavenworth VA. Yes, things could change with the passing of time but I appreciate the things done for me at the VA.

For the most part my experiences have been very good With El Paso not getting a passing grade back in 97.
However, the problems seem to exist with directors of centers and departments and I believe that the main energizer of the problems is the BONUS' that these directors are given to stay within or below the budgets. By suggestion is to do away with these incentives to save money for BONUS' in all government departments and we can start with the VA.

What I'm reading and shouldn't be anything new to anyone that knows the system is that the bonus' to the "so called Directors" of the VA hospitals is that they use the VA funds to keep things going but not up to standards but enough to keep getting their bonus's. It's no surprise to me that they are getting paid for not doing the job. That seems to be the "norm" when dealing with the taxpayer's money.

We need to demand that those that received bonuses must pay them pay since they performed under par to OUR standards! And those bonuses should be distributed out to the Veterans that were infected and to the families of those that died!


It is not just Arizona. I went to the VA in West Allis, Wi. with ulcerated scar tissue on my right ankle and walked out with osteomyelitis in my left tibia. Of course the VA claimed they were not negligent.
If you believe anything that comes from the VA, then I have a bridge in Brookline to sell you. What's worse is this is what Oboma-care is going to look like if we let government employees get ahold of our medical system.

When we stepped across the line and raised our right hands and swore to defend this country, we were promised that we would receive veterans benefits to include medical, etc. We met our obligation with a great number of our friends paying the ultimate price. As the days wear on, we now learn more and more about the neglect and gamesmanship that is being played on veterans at VA facalities all over the country. The stories read like something you would expect from a 3 world country. However, nothing ever gets fixed. Administrators continue to receive bonuses, non-veterans are making life and death decisions that impact veterans lives. No one seems to care, from the president (non-veteran) all the way down the line. There aren't many veterans left in Congress or the Senate to look out for us. We all know that the latest whistleblowing will cause some noise, but when the dust settles, nothing will change. It will be business as usual, and the bonuses will continue to flow when someone should be going to jail. This is a clear cut case of abuse of a vulnerable adults. Now with this being said, I look forward to reading the next round of horrifing stories from VA hospitals about abuse, neglect, unsanitary conditions and bonuses being paid to the administrators. Keep this in mind, Mr. Holders office isn't going to do anything, he's in the Presidents pocket and should be in jail himself.

I'm sick of promises made not delivered. The only promises being kept right now appear to be tax breaks for the wealthy. Uncle Sugar can't afford to keep those tax break promises AND take care of other promises. like medical care for veterans. At some point, we the people have to realize we already spent the veterans, now we need to pay the bill. All we ever hear about is government waste. We got news for you congress. You're the biggest waste of money in the entire federal government, and you've got some pretty stiff competition in Washington DC. All you can hope for is we, the people, can't get our act together to legally vote changes to YOUR budget. And get rid of your sorry a$$e$.

They are a relatively common dog skin cancer in white dogs that enjoy sunbathing.
These tumors can become quite large, but don't usually spread throughout the body.
then there are stages of gastro intestinal symptoms,
skin symptoms, the nervous system and finally eye complications such
as ulceration of the cornea.

Tucson V A is AWESOME.

In short left wrist broken on duty in 1973. Fort Campbell, Ky med hosp. did not fix the wrist properly as a result they said it had to be rebroke and a plastic bone put in to fix the wrist but I will never have full use of wrist. I was due to get out of Army in a few weeks and had surgery at a VA hospital in Butler, Pa. They said at the time i would never have full use of wrist and arm. Fast forward 40 years the wrist bone the VA put in whore out. Went to VA in Cleveland,Oh. in severe pain. They x-rayed the wrist and said it would have to be repaired. I said lets do it. they said after you quit smoking for six months we will schedule you for surgery. I went to a local hosp. in my town and it was so bad i had to have a plate put in and now I have little to no use of wrist. To top it all off the VA would not pay for the surgery. Also have agent orange related cancer the VA will not allow. Need I say more!

Tucson VA in some cases are ok. However, I'm now seeing an outside specialist Doctor because the Ironwood Clinic had almost 2 years to get the care I needed for this issue. Several times in the last 5 years the nurse will call my home in another county and tell me I have 24 hours to go pee or they will deny my medications. What really strange is, One nurse talks to me like as if I committed some crime and treated like Branded Cattle. And it happened again this month. Then one morning a new Nurse called me and stated that the Administrator wanted me to come to Ironwood clinic then the E.R. Dept. This, right after the Phoenix Veterans Dying Scandals. And myself and Wife/Caregiver complained of very unprofessional treatment. Even the guy who's a patient advocate took the side of the clinic staff. He really pissed me off. My opinion, he needs to be retrained. I worked at this VA for 4 years. In the book I'm writing I've mentioned a lot of facts on how Vets were treated while nurses depended on aids to do care way above their scope of practice. Ok, back on track again. Anyway, I am going to have a Cancer Screening in June 2014 that the Tucson, Arizona VA, 2 years ago, could had already done and treated. My wife and I pray this screening will be negative for Cancer. Oh, and it would be nice once a new Doctor comes into the Clinics, that patients are sent out letters so we can make appointments and get to know our "Trustworthy Doctor" and he or she can get to know us as well. But for now, all they see when looking at us Veterans or Me at least is, through me, not at me. Its all about saving money. And the high brass in the far west offices get their big bonus.

We all know that since we came back home the VA has been a sham. You can say what you want, some are good clinics and hospitals, some are not. That is not the point, We swore an oath before we went into combat to serve and protect this country, even if it meant with our lives - like signing a blank check and throwing it out the window - that is what the government has done to us as combat veterans. I came home in 1971 and have not had good care at all from any VA facility. You can bet now that all this is on the television, someone is going to be the scapegoat and end up in jail and all the politicians will puff up and say they did their duty; bahhh; bahhh.. A change is coming to this country and I do not think the people in Washington can see the forest for the trees. Lock and load.

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News from the World of Military and Veterans Issues. Iraq and A-Stan in parenthesis reflects that the author is currently deployed to that theater.