Feds attack local VA scandal results

The findings in a 2014 Department of Veterans Affairs investigation into the Fort Collins clinic’s appointment fixing scandal are “unsupported” and “not reasonable,” according to the federal agency charged with reviewing the investigation.

The Fort Collins VA Clinic and the Cheyenne, Wyoming, Veterans Affairs Medical Center, which oversees the clinic, were embroiled in an appointment fixing scandal last spring when an inspector general’s report found patients were “blind scheduled” and had appointments set in ways that did not follow agency policy.

While the VA acknowledged the wrongdoing — six people were punished as a result — it also found no patients suffered from longer wait times and appointment manipulation.

According to the U.S. Office of Special Counsel, the VA investigators might as well have been speaking from both sides of their mouths.

“In making this determination, the VA finds the employees and management engaged in serious wrongdoing ... but simultaneously determines that these serious shortcomings have no negative impact on patient care,” Special Counsel Carolyn Lerner wrote in her nine-page report.

“... it is troubling that the agency continues to be unwilling to acknowledge that the confirmed wrongdoing posed a possible danger to patients at Fort Collins and Cheyenne.”

The VA investigators found eight patients who died while waiting for appointments at the Cheyenne or Fort Collins VA facilities, all but one of whom were elderly or appeared to have prior medical conditions. The last was a 24-year-old veteran.

He was not scheduled for an appointment for almost three months after his Nov. 1, 2012, enrollment with the local VA. According to VA investigators, the veteran was a “no show” to that April 8, 2013, appointment and died April 17.

The investigator “was unable to obtain further information about his death,” according to a report from the VA to the OSC. Whistleblower Lisa Lee, a former Fort Collins VA employee, told the OSC that the follow-up appointment from the VA, after the unidentified veteran missed his April appointment, was likely “blind scheduled,” or set without his consent, and that the facility did not have guidelines for following up with no-shows.

According to the VA, “there is no evidence that the deaths of these eight veterans resulted from a delay in receiving care.” Cynthia McCormack, director of the Cheyenne VA Medical Center, attributed the errors to misunderstanding the policy. She said her facility also retrained its staff on proper scheduling process. She received a bonus for the year appointment times were found to be manipulated.

Even with that investigation, Lerner wrote that she disagreed that deaths and hospitalizations were the only ways to measure patient harm and called the VA’s findings “a step backward.”

Lerner also wrote in 2014 that the VA “consistently used a ‘harmless error’ defense,” where it absolved itself because it couldn’t find direct lines from wrongdoing to patient harm.

Lerner’s report was sent to the White House and members of the U.S. Senate and House of Representatives committees on Veterans’ Affairs.

Representatives from the House Committee on Veterans’ Affairs and the local Veterans Affairs did not immediately return requests for comment Wednesday.

PREVIOUS:

Fort Collins vet takes on VA over Agent Orange claims

Denver VA halts some surgeries over sterilization concerns

Congress members chide VA for Denver hospital overages