American Heros

July 19th, 2014

American heroes who work for Va and are very brave whistleblowers .

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President Obama Awards the Medal of Honor to Corporal William “Kyle” Carpenter

June 29th, 2014

President Obama Awards the Medal of Honor to Corporal William “Kyle” Carpenter

by David Hudson
June 19, 2014 at 3:49 PM

Watch on YouTube http://youtu.be/3t5b7qriF1Q

At the White House this afternoon, President Obama awarded the Medal of Honor to Corporal William “Kyle” Carpenter, a retired United States Marine. Corporal Carpenter received the medal for his courageous actions during combat operations against an armed enemy in Helmand Province, Afghanistan.

By all accounts, Kyle shouldn’t be alive today. On November 21, 2010, Kyle’s platoon woke up to the sound of AK-47 fire. As their compound began taking fire, Kyle and Lance Corporal Nicholas Eufrazio took cover up on a roof, low on their backs behind a circle of sandbags. And then a grenade landed nearby, its pin already pulled.

In the President’s remarks, he detailed the horrific events that followed:

Kyle has no memory of what happened next. What we do know is that there on that rooftop he wasn’t just with a fellow Marine, he was with his best friend. Kyle and Nick had met in training. In Afghanistan they patrolled together, day and night, a friendship forged in fire. Kyle says about Nick, “He was my point man, and I loved him like a brother.”

When the grenade landed, other Marines in the compound looked up and saw it happen. Kyle tried to stand. He lunged forward toward that grenade, and then he disappeared into the blast. Keep in mind, at the time, Kyle was just 21 years old. But in that instant, he fulfilled those words of Scripture: “Greater love hath no man than this; that a man lay down his life for his friends.”

They found Kyle lying face down, directly over the blast area. His helmet was riddled with holes. His gear was melted. Part of his Kevlar vest was blown away. One of the doctors who treated him later said Kyle was “literally wounded from the top of his head to his feet.”

“Hand grenades are one of the most awful weapons of war,” the President said. “When it detonates, its fragments shoot out in every direction. And even at a distance, that spray of shrapnel can inflict devastating injuries on the human body. Up close, it’s almost certain death.”

The President honored Kyle today because he “faced down that terrible explosive power, that unforgiving force, with his own body — willingly and deliberately — to protect a fellow Marine.” Kyle was willing to make the ultimate sacrifice to save the lives of others.

President Barack Obama awards the Medal of Honor to Corporal William “Kyle” Carpenter, U.S. Marine Corps (Ret.) during a ceremony in the East Room of the White House. June 19, 2014. (Official White House Photo by Pete Souza)

Kyle’s unselfish and courageous actions resulted in a long and agonizing recovery:

Eventually, Kyle woke up after five weeks in a coma. I want you to consider what Kyle has endured just to stand here today — more than two and a half years in the hospital. Grueling rehabilitation. Brain surgery to remove shrapnel from his head. Nearly 40 surgeries to repair a collapsed lung, fractured fingers, a shattered right arm broken in more than 30 places, multiple skin grafts. He has a new prosthetic eye, a new jaw, new teeth — and one hell of a smile.

President Obama stressed that Kyle’s story and recovery is a model for all Americans of the strength and resilience that defines us. “After everything he’s been through,” the President continued, “he skis, he snowboards, he’s jumped from a plane — with a parachute, thankfully.”

Kyle has run a 6-mile Mud Run and completed the Marine Corps Marathon. He’s in school getting stellar grades. “And by the way, he’s only 24 years old, and says, ‘I am just getting started.’”

Corporal William Kyle Carpenter should not be alive today, but the fact that he is gives us reason to trust that there is indeed a bigger plan. So God bless you, Kyle. God bless all who serve and protect the precious and amazing life that we are blessed with. May God continue to bless and keep strong the United States of America. Semper Fi.

Learn more about Medal of Honor recipient Corporal Kyle Carpenter.

President Barack Obama leads an ovation for Corporal William “Kyle” Carpenter, U.S. Marine Corps (Ret.), after awarding him the Medal of Honor during a ceremony in the East Room of the White House. June 19, 2014. (Official White House Photo by Lawrence Jackson)

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Brandon Man Sentenced To More Than 7 Years For Stolen Identity Refund Fraud FOR IMMEDIATE RELEASE May 16, 2014

June 4th, 2014

Brandon Man Sentenced To More Than 7 Years For Stolen Identity Refund Fraud
FOR IMMEDIATE RELEASE
May 16, 2014

Tampa, Florida – U.S. District Judge Virginia M. Hernandez Covington yesterday sentenced Anthony R. Reeves to seven years and three months in federal prison for multiple counts of wire fraud, theft of government property, and aggravated identity theft. As part of his sentence, the court also entered a money judgment in the amount of $69,585.59, a portion of the proceeds of the charged criminal conduct.

Reeves was found guilty on February 3, 2014, following a bench trial.

According to court documents, on May 8, 2012, Reeves was stopped by a Florida Highway Patrol (FHP) Trooper for speeding and other traffic infractions. After a drug canine alerted on the vehicle, the car was searched. During the search, the trooper found a backpack that contained a laptop, a plastic bag containing 35 debit cards, multiple cell phones, a notebook, and 54 medical records from the Department of Veterans Affairs (VA) James A. Haley Hospital in Tampa. The notebook contained lists of names, social security numbers, email addresses, credit card numbers, and cell phone numbers. The VA medical records contained the names and SSNs of patients. In total, Reeves had the personal identifying information (PII) of 69 veterans and 52 others in his possession. Reeves admitted that he purchased VA medical records from someone whom he knew who worked at the VA, and used the information to file fraudulent tax returns.

Law enforcement conducted an analysis of the laptop, which revealed that it had been used to access numerous debit card accounts in the names of the victims. The IRS then conducted an analysis of the returns associated with Reeves, based on the files on the computer and the identifiers found in his possession. Specifically, Reeves filed at least 71 fraudulent tax returns from tax years 2010 and 2011.

Special Agent in Charge Monty Stokes, Office of Inspector General, U.S. Department of Veterans Affairs said, “This case was the result of federal, state and local law enforcement agencies aggressively pursuing those who commit identity theft. Reeves is no stranger to the criminal justice system. This 7 year, 3 month sentence will hopefully be a deterrent for others, and give him some time to consider if it was really worth it.”

“Yesterday’s sentencing of Mr. Reeves is the final culmination of years of investigation, hard work and the combined efforts of the Internal Revenue Service, the Department of Veterans Affairs, the United States Attorney’s Office and the Florida Highway Patrol,” stated Florida Highway Patrol spokesman Steve Gaskins. “An alert Florida State Trooper conducting routine traffic enforcement, who looked beyond the traffic stop for criminal activity, has led to a highly successful conclusion whereby citizens and especially veterans benefit tremendously.”

This case was investigated by the Department of Veterans Affairs, the Internal Revenue Service – Criminal Investigation, and the Florida Highway Patrol. It was prosecuted by Assistant United States Attorney Sara C. Sweeney.

Laurie Provost, 54, of Sea Girt, was indicted yesterday (May 14) on 23 counts

May 29th, 2014

TRENTON – Acting Attorney General John J. Hoffman announced that the owner of a Union County home health aide agency has been charged in a 30-count indictment for allegedly billing Medicaid and the United States Department of Veterans Affairs more than $100,000 for services never rendered.
Laurie Provost, 54, of Sea Girt, was indicted yesterday (May 14) on 23 counts of second-degree health care claims fraud, and one count each of second- and third-degree theft by deception, third-degree Medicaid fraud, third-degree health care claims fraud, fourth-degree forgery, and two counts of fourth-degree falsifying or tampering with records.

“Through her greed, this defendant allegedly defrauded the Medicaid Program, a program that helps New Jersey’s most vulnerable population and the United States Department of Veterans Affairs, a department aimed at helping those who gave so much for their country,” Acting Attorney General Hoffman said.

“The Medicaid program is in place for people who truly need assistance paying their medical bills,” Acting Insurance Fraud Prosecutor Ronald Chillemi. “It is not there as a piggy bank for unscrupulous health care professionals. The Office of the Insurance Fraud Prosecutor will continue to be vigilant in prosecuting these high priority cases.”

Provost was the owner/operator of Home Care Solutions, located on Commerce Drive in Cranford. Home Care Solutions (HCS) was a home health aid agency that sent home health aides to the homes of Medicaid beneficiaries to provide them with care. The agency also contracted with skilled medical professionals to provide specialized services to patients who required such care. The agency was closed as a result of the Office of the Insurance Fraud Prosecutor’s Medicaid Fraud Control Unit’s investigation.

The state grand jury indictment alleges that between July 23, 2011 and Aug. 7, 2013, Provost, through HCS, submitted hundreds of fraudulent claims to Medicaid and/or one of the managed care organizations that provide services to Medicaid beneficiaries and processes provider claims and payments on behalf of the Medicaid program. It is alleged that Provost knowingly submitted requests for payment for services that were not provided, including billing for services purportedly provided to Medicaid beneficiaries by home health aides while the beneficiaries were hospitalized or on vacation. An investigation by the Office of the Insurance Fraud Prosecutor’s Medicaid Fraud Control Unit determined that, through the fraud, Provost allegedly defrauded Medicaid of more than $100,000.

The investigation determined that between May 12, 2011 and April 9, 2013, Provost allegedly stole over $44,000 from the United States Department of Veteran Affairs by creating the false impression that services were provided to veterans, and therefore HCS was entitled to payment.

The indictment also alleges that between March 6, 2010 and July 11, 2013, Provost committed Medicaid fraud by allegedly making false statements on her agency’s Medicaid provider application. When she submitted HCS’s application to become a Medicaid provider, Provost allegedly hid the fact that her nursing license was suspended. An investigation determined that the Medicaid program would have rejected her application if she disclosed the fact that her nursing license was previously suspended. It is alleged that, as a result of her application fraud, the Medicaid program paid Provost through HCS more than $2 million.

The indictment further alleges that between March 24, 2010 and July 11, 2013, Provost created forged in-service training records, giving the false appearance that HCS met regulation and accreditation standards.

Lastly, between July 21 and Dec. 31, 2009, Provost allegedly submitted documents containing fraudulent statements to the New Jersey Commission on Accreditation regarding HCS’s Director of Nursing. On May 12, 2011, Provost allegedly provided similar fraudulent information to the Department of Veterans Affairs.

Deputy Attorney General Christopher Ruzich and Detective Anthony Iannice of the Office of the Insurance Fraud Prosecutor’s Medicaid Fraud Control Unit coordinated the investigation. Auditor Cleair Budhu assisted in the investigation. Acting Insurance Fraud Prosecutor Chillemi thanked the New Jersey Office of the State Comptroller for referring the matter to the Office of the Insurance Fraud Prosecutor. Acting Insurance Fraud Prosecutor Chillemi also thanked the Department of Veterans Affairs for its assistance in the investigation.

The indictment is merely an accusation and the defendant is presumed innocent until proven guilty. Second-degree crimes carry a maximum sentence of 10 years in state prison and a criminal fine of up to $150,000, while third-degree crimes carry a maximum sentence of five years in state prison and fine of up to $15,000. Fourth-degree crimes carry a maximum sentence of 18 months in jail and a criminal fine of up to $10,000.

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An indictment is merely a formal charge that a defendant has committed a violation of the federal criminal laws, and every defendant is presumed innocent unless, and until, proven guilty.

May 28th, 2014

Nine Individuals Charged With Stealing Approximately $1.4 Million As A Result Of Operation Tombstone
FOR IMMEDIATE RELEASE
May 23, 2014

Jacksonville, Orlando, and Ocala, Florida – United States Attorney A. Lee Bentley, III announces the unsealing of nine separate indictments charging individuals with stealing approximately $1.4 million in federal benefits to which they were not entitled. The penalty for stealing federal benefits is up to ten years in federal prison per count. These nine Middle District of Florida cases arose as the result of Operation Tombstone, an operation initiated and overseen by the Social Security Administration, Office of Inspector General and the investigative work of Special Agents with multiple Offices of Inspectors General of various federal agencies and departments. Currently, 73 federal offices of inspectors general exist under the Inspector General Act of 1978. The offices employ special agents (criminal investigators) and auditors. Their activities include the detection and prevention of fraud, waste, abuse, and mismanagement of the government programs and operations within their parent organizations.

Linda Sue Bellamy (60, Jacksonville) is charged with one count of stealing government property. According to the indictment returned in her case, between October 2005 and October 2013, Bellamy stole approximately $62,518 of government benefits from the Social Security Administration.

According to the indictment returned in her case, Sonia Destine Casbar (57, Ocala) is charged with one count of stealing government property. The indictment alleges that between May 2010 and July 2013, Casbar stole approximately $45,111 of government benefits from the Social Security Administration.

Angela Ann Driggers (53, Callahan) is charged with four counts of stealing government property. The indictment in her case alleges that between April 2005 and December 2013, Driggers stole approximately $131,078.32 of government benefits from the Social Security Administration and the Federal Medicaid Health Care Benefit Program.

According to the indictment returned in her case, Adriyanna Herdener (37, Melbourne) is charged with one count of stealing government property and one count of social security fraud. The indictment alleges that between April 2005 and December 2013, Herdener stole approximately $21,712 of government benefits from the Social Security Administration. Herdener faces a maximum penalty of 10 years in federal prison for stealing government property, and up to 5 years in federal prison for the fraud charge.

According to the indictment returned in her case, Camilla Ann Winterling (57, Liberty Township, Ohio) is charged with four counts of stealing government property. The indictment alleges that between April 1993 and February 2014, Winterling stole a total of approximately $472,788.64 of government benefits from the Social Security Administration and the Department of Veterans Affairs.

Sandra McCray (57, Jacksonville) is charged with two counts of stealing government property. Between July 8, 1995 and February 2014, McCray allegedly stole approximately $142,724.00 of government benefits from the Social Security Administration.

According to the indictment returned in his case, Rickey Nelson (60, Jacksonville) is charged with two counts of stealing government property. The indictment alleges that between April 1999 and March 2014, Nelson stole approximately $205,530.00 of government benefits from the Social Security Administration.

Steven Hutka (67, Jacksonville) is charged with one count of stealing government property. The indictment alleges that between April 1999 and March 2014, Hutka stole approximately $69,351.00 of government benefits from the Social Security Administration.

According to the indictment returned in his case, Daniel Ovshak (64, St. Johns) is charged with two counts of stealing government property. The indictment alleges that between July and December 2013, Ovshak stole approximately $267,701.00 of government benefits from the Social Security Administration.

An indictment is merely a formal charge that a defendant has committed a violation of the federal criminal laws, and every defendant is presumed innocent unless, and until, proven guilty.

Agencies conducting these investigations included the Social Security Administration, Office of Inspector General, the Veterans Administration, Office of Inspector General, the Department of Health and Human Services, Office of Inspector General, and the United States Secret Service. The cases will be prosecuted by Assistant United States Attorneys throughout the Middle District of Florida, including Robert Bodnar, Jackson Boggs, Mac Heavener, and Jay Taylor.

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Business Was Awarded Dozens of Undeserved Contracts Worth $1.2 Million

May 28th, 2014

New Jersey Business Owner Admits Fraudulent Claims Of Service-Disabled Veteran Ownership

FOR IMMEDIATE RELEASE

May 22, 2014

Business Was Awarded Dozens of Undeserved Contracts Worth $1.2 Million

NEWARK, N.J. – The president of a New Jersey-based furniture and design services company admitted today to fraudulently holding her business out as a service-disabled veteran-owned small business, which obtained dozens of government contracts set aside for disabled veterans, U.S. Attorney Paul J. Fishman announced.

Miriam Friedman, 54, of Teaneck, N.J., pleaded guilty to an information charging her with making false claims to the U.S. Department of Veterans Affairs (VA). She entered her guilty plea before U.S. District Judge Esther Salas in Newark federal court.

According to documents filed in this case and statements made in court:

Friedman is the president and owner of Office Dimensions Inc. – which sells furniture and design services to industrial and government customers – controlling all its revenues and running the company’s day-to-day operations. Friedman never served in the U.S. military.

Friedman self-certified in a central registry for government contractors that Office Dimensions was a service-disabled veteran-owned small business. She falsely claimed in the certification that her father-in-law – who was retired, unemployed and had very little involvement with Office Dimensions – was the owner and operator of the business. He had served in the U.S. military, but was not classified as a service-disabled veteran. Friedman then started bidding for VA contracts set aside for service-disabled veterans who own their own businesses.

During her guilty plea proceeding, Friedman admitted that she knew her claims were false, and that they led to dozens of contracts with the VA to provide furniture and interior space planning at VA facilities.

In total, the VA paid approximately $1.2 million to Office Dimensions based on contracts set aside for service-disabled veterans.

The charge carries a maximum potential penalty of five years in prison and a $250,000 fine, or twice the gain or loss caused by the offense. Sentencing is currently scheduled for Sept. 3, 2014, before U.S. District Judge Jose L. Linares.

U.S. Attorney Fishman credited special agents of the U.S. Department of Veterans Affairs, Office of Inspector General, under the direction of Special Agent in Charge Jeffrey G. Hughes; the U.S. General Services Administration, Office of Inspector General, under the direction of Special Agent in Charge James E. Adams; and IRS-Criminal Investigation, under the direction of Acting Special Agent in Charge Jonathan D. Larsen, with the investigation.

The case is being prosecuted by Scott B. McBride, Deputy Chief of the U.S. Attorney’s Economic Crimes Unit, and Assistant U.S. Attorney Danielle A. Walsman of the office’s Health Care and Government Fraud Unit.

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Defense counsel: Brian J. Neary Esq.;Perry Primavera Esq., Hackensack and Hoboken, N.J.

Friedman, Miriam Information

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From: Barbara Hanna, Executive Director Community Settlement Association

May 21st, 2014

Media Release
May 21, 2014
Subject: Community Settlement Asks for Photos of Eastside Veterans

From: Barbara Hanna, Executive Director
Community Settlement Association
4366 Bermuda Avenue, Riverside, CA 92507
951-686-6266, ext 118
bhanna@csariverside.com

As part of a refurbishment and expansion of a WWII Veterans’ Wall inside Riverside’s Community Settlement Association photos of U.S. veterans are being sought of those who grew up on the Eastside. Executive Director Barbara Hanna said “We are proud to have a wall of honor for WWII veterans who grew up on Riverside’s Eastside. But it needs some love and care as it has deteriorated over time. We thought while we do that that we could add photos of men and women who grew up on the East side who served in Korea, Vietnam and more recent wars and conflicts. We appreciate that Margie Quieroz is taking the lead on the renovation.”

Funds would also be appreciated to ensure that the final product is worthy of the veterans’ service to our country. Anyone or any organization that would like to help is encouraged to contact Barbara Hanna at 951-686-6266, ext 118 or bhanna@csariverside.com. Photos may also be dropped off at Settlement with the name of the veteran, their service and the years served.

Community Settlement has served Riverside’s Eastside since 1911. Its address is 4366 Bermuda, just off 14th Street, but its parking lot is adjacent to the Dario Vasquez Park on Sedgwick Street.

THE STATE OF VA HEALTH CARE” MAY 15, 2014 -pg 8

May 15th, 2014

THE STATE OF VA HEALTH CARE” MAY 15, 2014 -pg 8

position recently occupied by a nurse in the GI clinic, who is essential to the delivery of required care, may not be filled while a position that is important to the research or teaching community is filled. The decision by this board, to not fill a clinic position, may have far reaching consequences. The clinic that does not have the nurse may not function properly. The leadership of the clinic is left believing that hospital “leadership” does not understand or does not care about the care provided in that clinic. All a provider can do is ask for clinical positions to be filled, and if they are not filled, either leave VA or agree to work in an environment that provides less than satisfactory care. There is no national process to establish a set of positions that are deemed “essential” to the delivery of health care and thus are priority one for the hospital administration to resource.10 The establishment of “essential positions” in the context of a standard hospital structure would enhance the delivery of quality patient care.
VA hospitals and clinics do not have a standard organizational chart. Some hospitals have a chief of surgery and a chief of anesthesia; others have a chief of the surgical care line. The lack of a common organizational chart for medical facilities results in confusion in assigning local responsibility for actions required by national directives. Variation in staff organization also creates difficulty in comparing the performance of clinical groups between hospitals and clinics.
Leadership, teamwork, communication, and technical competence are among the most important factors in providing quality health care. However, organization, assignment of clear responsibility, and efficiency of operation all make important contributions to the process of improving the quality of health care delivered.
CONCLUSION
The unexpected deaths that the OIG continues to report on at VA facilities could be avoided if VA would focus first on its core mission to deliver quality health care. Its efforts would also be aided by discussion of the best organizational structure to consistently provide quality care. The network system of organization and the accompanying motto, ‘all health care is local,’ served the VA well over the last several decades but does not standardize the organization of medical centers. It is difficult to implement national directives when there are no standard position descriptions or areas of responsibility across the system. VA has embraced the “aircraft checklist” approach to improve the chances that preventable medical errors will not occur in the operating room, but has taken the opposite approach to the assignment of duties and responsibilities in medical centers, where no two hospitals are alike. We believe it is time to review the organizational structure and business rules of VHA to determine if there are changes that would make the delivery of care the priority mission.
Mr. Chairman, that concludes my statement and we would be pleased to answer any questions that you or other Members of the Committee may have.
10 Healthcare Inspection – Delayed Cancer Diagnosis, VA Greater Los Angeles Healthcare System, Los Angeles, California (7/24/2007).
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Senior editors notes and resolutions

As a disabled veteran I have first hand experience within these many years of trying to get Any quality or any care from Vamc.
As I had a stroke @ my Loma Linda veterans hospital ER entrance parking lot on way to an appointment , wham stroke happen as I was driving into and about to park, vision, hearing, voice instantly changed or was gone or going fast. I knew where ER entrance was, then was admitted for having stroke now. Was in hospital from ER to going to many tests, was not allowed to leave my bed, 4 or 5 days later discharged with papers that says I had stroke on right side of brain and never gotten any physical therapy during the stay, the all scheduled doctor visits and prescriptions was cancelled for no reasons . And was told to call a phone number when I called my primary doctor , who refused to see me. And gave no reasons as to why? I then was able to reach my useless new congressman, who simply went along with what va says and that was unacceptable. I contact congressman Miller in Florida to ask for help along with another local congressman but none did help. I called the whitehouse and left the president my direct emails address and told what has happened. His actions was direct, but still Va did nothing. Now back at va and they FINALY recognized me as a certified and verified soldier after waiting 13 yrs for this process to resolve its internal serious, issues as you see above, this continues to be a government failure to be a health care provider for veterans.

So therefore here are immediate solutions to all our veterans medical issues,
1) issue paid accounts I’d cards for immediate medical outside for non va facilities in the USA to be applied anywhere. Now any veteran or active soldier will get immediate active medical help instantly. Since the Vamc all ready does this at some locations , this means now any and all locations we have No Backlogs instantly wiped out.
2) close all Vamc medical facilities so all will have these standards, bathroom with showers is not even in my own Vamc location , where is the medical support if facilities do not comply to basic hospital standards?
3) ” one va policy ” since Vamc systems are NOT alike and NOT communicate with each other except for a very few, is unacceptable , since somebody else says they are me and is getting medical care in long beach, calif. How does that happen, simply put it the Vamc employee had lost or stolen Vamc laptops opened the doors on the Internet for these issues to be created, this ends once we have all Vamc systems on “one va policy” this was also suggested by our president years ago.
4) take note the Vamc are killing veterans as this report as official as it can be makes everyone aware of the facts. In our communities when people die due at intersections we place stop lights to prevent more deaths, so now it is time to close all Vamc facilities before you continue to kill another veteran is an immediate national solutions to end backlogs and secret lists. So therefore put in place national medical standards for all doctors , nurses, employees and maintenance to be on “one va page” to do the best healthcare for me and all veterans who all-ready paid the price for freedom not to be handed down this “PTB” ( prisoner of terrorist BeauroCrazy failed system ) it is time to launch not to moon or mars but to Americans who serve and have served a true commitment to have a life without the new Vamc term they simply tell us is “D.D.D.” I said what is that? Told it means DELAY, DENY, DEATH, my God they are bragging about it in my Vamc and else where. That now stops here today.
5) do you want all Vamc facilities be invaded with protesters in the future or do you want to Do Real Change actively Now?
6) now apply all this to va benefits system so we do not become homeless again as I have been,, they need to send checks not letters that we are swapped with requests, just to be then deleted or denied due to they never have received data that was requested and yes sent to them by fax and mailed and hand delivered but still manages to GET LOST, so let us accidentally have whitehouse, congress, senate and all federal employees checks be ” Lost” or better yet have all of them use the Vamc systems to really Get lost.

Sincerely
Senior editor
Denis G La Bine
Phone number available on request

THE STATE OF VA HEALTH CARE” MAY 15, 2014 -pg 7

May 15th, 2014

THE STATE OF VA HEALTH CARE” MAY 15, 2014 -pg 7

The use of these insulin pens in this fashion violates the core principles of infection control. Multiple personnel in several hospitals over an extended period of time failed to comprehend the impact of the decision to introduce pens of this nature onto inpatient wards. The decision to introduce new technology into hospital use is one that occurs routinely and to be done safely requires facility leaders to coordinate their actions and understand the implications of their decisions. Facilities with a singular focus on delivering high quality medical care should have recognized the risk these devices bring to the inpatient environment and taken appropriate actions to mitigate that risk.
LACK OF ACCURATE QUALITY MANAGEMENT DATA AND STAFFING STANDARDS
The OIG and Government Accountability Office have been reporting for nearly a decade that VHA managers needed to improve efforts for collecting, trending, and analyzing quality management data. We have reported that inaccuracies in some of VHA’s data sources hinder the usability of VHA decision-makers to fully assess their current capacity, optimal resource distribution, productivity across the system, or to establish staffing and productivity standards. Since July 2005, we have reported on inaccurate wait times and lists, and expect to report on the results of multiple reviews that are underway to the Committee later this summer.8 As recently as December 2012, we identified the continuing need for VHA to improve their staffing methodology by implementing productivity standards for specialty care services.9 We determined VHA had not established productivity standards for 31 or 33 specialty care services reviewed, and had not developed staffing plans that addressed facilities’ mission, structure, workforce, recruitment, and retention issues to meet current or projected patient outcomes, clinical effectiveness, and efficiency. VA agreed to put staffing standards for specialty care in place by FY 2015.
OBSERVATIONS
OIG work routinely reports on clinical outcomes or performance that did not meet expectations. We routinely determine that there were opportunities by people and systems to prevent untoward outcomes. In addition to local issues at the facility, there are several organizational issues that impede the efficient and effective operation of VHA and place patients at risk of unexpected outcomes.
Although health care delivery may be the first priority of many within the system, others are focused on research, training the next generation of health care providers, disaster preparedness, homelessness, support for compensation evaluation requirements, and other related missions. This lack of focus on health care delivery as priority one can be seen by the process commonly used at hospitals to fill vacant positions. A resource board reviews open positions and then determines which should be filled. Thus the
8 Audit of the Veterans Health Administration’s Outpatient Scheduling Procedures (7/8/2005); Audit of the Veterans Health Administration’s Outpatient Waiting Times (9/10/2007); Audit of Alleged Manipulation of Waiting Times in Veterans Integrated Service Network 3 (5/19/2008); Review of Veterans’ Access to Mental Health Care (4/23/2012).
9 Audit of VHA’s Physician Staffing Levels for Specialty Care Services (12/27/2012). 7

THE STATE OF VA HEALTH CARE” MAY 15, 2014 -pg 6

May 15th, 2014

THE STATE OF VA HEALTH CARE” MAY 15, 2014 -pg 6

environment.7 This resulted in 700 patients at Buffalo and 260 patients at Salisbury being exposed to the risk of blood borne viral infections when insulin pens, designed to be used with one pen per patient, were instead used improperly such that one pen was used on multiple patients.
In late October 2012, the Buffalo Chief of Pharmacy discovered three insulin pens, which were designed for single-patient use only, with no patient labels in a supply drawer of a medication cart. Facility officials subsequently found three more pens without patient labels in medication carts on three other inpatient units, and, when queried, several nurses reportedly acknowledged using the pens on multiple patients. Inappropriately using single-patient use insulin pens on multiple patients may potentially expose patients to blood borne pathogens.
We identified six factors that contributed to the misuse of insulin pens at Buffalo. We also found that misuse of the insulin pens went undetected for 2 years because even though facility staff often observed pens with no patient labels on the medication carts, they did not report it because they either did not fully comprehend the clinical risks of sharing pens, or they accepted the unlabeled pens as standard practice believing they were both multi-dose and multi-patient devices. We found that VHA did not notify Members of Congress or at-risk patients until January 2013 because of the time required for multiple levels of coordination between VA and VHA and inefficiencies in VHA’s internal review process for large-scale adverse event disclosures.
In addition to the Buffalo incident, nurses at two other facilities were found to have inappropriately used insulin pens on multiple patients. In January 2013, the Salisbury VAMC reported that two nurses had inappropriately used insulin pens on multiple patients. VHA instituted a large-scale adverse event disclosure to notify 266 at-risk patients. At another facility, a nurse acknowledged using a pen on two patients on one occasion. We identified two contributing factors to explain why some nurses misused the insulin pens:
 Facilities did not fully evaluate the risks of using insulin pens on inpatient units, specifically in regards to the impact on nursing procedures.
 Facilities did not provide comprehensive nurse education on the pens.
We found that VHA has processes in place to identify important patient safety alerts, including product recalls, and disseminate this information to facility managers. VHA’s National Center for Patient Safety and Pharmacy Benefits Management Service lead VHA’s efforts to collect patient safety information and share this information with facilities. At the facility level, patient safety managers are responsible for disseminating alerts to appropriate administrative and clinical staff and tracking the facility’s response through a national database. VHA has followed up and tested for evidence of infection in the patients identified in this report.
7 Healthcare Inspection – Inappropriate Use of Insulin Pens, VA Western New York Healthcare System, Buffalo, New York (5/9/2013); Healthcare Inspection – Review of VHA Follow-Up on Inappropriate Use of Insulin Pens at Medical Facilities (8/1/2013).
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