VA: Actions Needed to Address Employee Misconduct Process and Ensure Accountability

Employee misconduct at VA’s medical facilities can have serious consequences for veterans. We looked at how VA deals with employee misconduct and found several opportunities for improvement. For example:

VA doesn’t always maintain required files and documents for adjudication, suggesting that employees may not have received due process.

VA officials found guilty of misconduct sometimes received a lesser punishment than recommended or no punishment.

Whistleblowers were 10 times more likely than their peers to receive disciplinary action within a year of reporting misconduct.

 Why GAO Did This Study

VA provides services and benefits to veterans through hospitals and other facilities nationwide. Misconduct by VA employees can have serious consequences for some veterans, including poor quality of care. GAO was asked to review employee misconduct across VA. This report reviews the extent to which VA (1) collects reliable information associated with employee misconduct and disciplinary actions, (2) adheres to documentation-retention procedures when adjudicating cases of employee misconduct, (3) ensures allegations of misconduct involving senior officials are reviewed according to VA investigative standards and these officials are held accountable, and (4) has procedures to investigate whistle-blower allegations of misconduct; and the extent to which (5) data and whistle-blower testimony indicate whether retaliation for disclosing misconduct occurs at VA.
GAO analyzed 12 information systems across VA to assess the reliability of misconduct data, examined a stratified random sample of 544 misconduct cases from 2009 through 2015, analyzed data and reviewed cases pertaining to senior officials involved in misconduct, reviewed procedures pertaining to whistle-blower investigations, and examined a nongeneralizable sample of whistle-blower disclosures from 2010 to 2014.

What GAO Found

The Department of Veterans Affairs (VA) collects data related to employee misconduct and disciplinary actions, but fragmentation and data-reliability issues impede department-wide analysis of those data. VA maintains six information systems that include partial data related to employee misconduct. For example, VA’s Personnel and Accounting Integrated Data system collects information on disciplinary actions that affect employee leave and pay, but the system does not collect information on other types of disciplinary actions. The system also does not collect information such as the offense or date of occurrence. GAO also identified six other information systems that various VA administrations and program offices use to collect specific information regarding their respective employees’ misconduct and disciplinary actions. GAO’s analysis of all 12 information systems found data-reliability issues—such as missing data, lack of identifiers, and lack of standardization among fields. Without collecting reliable misconduct and disciplinary action data on all cases department-wide, VA’s reporting and decision making on misconduct are impaired.
VA inconsistently adhered to its guidance for documentation retention when adjudicating misconduct allegations, based on GAO’s review of a generalizable sample of 544 out of 23,622 misconduct case files associated with employee disciplinary actions affecting employee pay. GAO estimates that VA would not be able to account for approximately 1,800 case files. Further, GAO estimates that approximately 3,600 of the files did not contain required documentation that employees were adequately informed of their rights during adjudication procedures—such as their entitlement to be represented by an attorney. The absence of files and associated documentation suggests that individuals may not have always received fair and reasonable due process as allegations of misconduct were adjudicated. Nevertheless, VA’s Office of Human Resource Management does not regularly assess the extent to which files and documentation are retained consistently with applicable requirements.
VA did not consistently ensure that allegations of misconduct involving senior officials were reviewed according to investigative standards and these officials were held accountable. For example, based on a review of 23 cases of alleged misconduct by senior officials that the VA Office of Inspector General (OIG) referred to VA facility and program offices for additional investigation, GAO found VA frequently did not include sufficient documentation for its findings, or provide a timely response to the OIG. In addition, VA was unable to produce anydocumentation used to close 2 cases. Further, OIG policy does not require the OIG to verify the completeness of investigations, which would help ensure that facility and program offices had met the requirements for investigating allegations of misconduct. Regarding senior officials, VA did not always take necessary measures to ensure they were held accountable for substantiated misconduct. As the figure below shows, GAO found that the disciplinary action proposed was not taken for 5 of 17 senior officials with substantiated misconduct.
Action Proposed in Department of Veterans Affairs (VA) Office of Accountability Review’s Legacy Referral Tracking List Compared with Final Action Taken

Action Proposed in Department of Veterans Affairs (VA) Office of Accountability Review’s Legacy Referral Tracking List Compared with Final Action Taken

*Adverse action.
As a result of June 2017 legislation, a new office within VA—the Office of Accountability and Whistleblower Protection—will be responsible for receiving and investigating allegations of misconduct involving senior officials.
VA has procedures for investigating whistle-blower complaints, but the procedures allow the program office or facility where a whistle-blower has reported misconduct to conduct the investigation. According to the OIG, it has the option of investigating allegations of misconduct, or exercising a “right of first refusal” whereby it refers allegations of misconduct to the VA facility or program office where the allegation originated. VA does not have oversight measures to ensure that all referred allegations of misconduct are investigated by an entity outside the control of the facility or program office involved in the misconduct, to ensure independence. As a result, GAO found instances where managers investigated themselves for misconduct, presenting a conflict of interest.Data and whistle-blower testimony indicate that retaliation may have occurred at VA. As the table below shows, individuals who filed a disclosure of misconduct with the Office of Special Counsel (OSC) received disciplinary action at a much higher rate than the peer average for the rest of VA in fiscal years 2010–2014.
Data and whistle-blower testimony indicate that retaliation may have occurred at VA. As the table below shows, individuals who filed a disclosure of misconduct with the Office of Special Counsel (OSC) received disciplinary action at a much higher rate than the peer average for the rest of VA in fiscal years 2010–2014.

Comparison of Adverse Disciplinary Action Taken for Nonanonymous Department of Veterans Affairs (VA) Employees Who Reported Wrongdoing and Those Who Did Not, 2010–2014
Employee category Percentage for whom adverse actions were taken
Prior to disclosure Year of disclosure Year after disclosure
Individuals who filed a disclosure 2 10 8
Rest of VA 1 1 1

Additionally, GAO’s interviews with six VA whistle-blowers who claim to have been retaliated against provided anecdotal evidence that retaliation may be occurring. These whistle-blowers alleged that managers in their chain of command took several untraceable actions to retaliate against the whistle- blowers, such as being denied access to computer equipment necessary to complete assignments.

What GAO Recommends

GAO makes numerous recommendations to Veterans Affairs to help enhance its ability to address misconduct issues.
GAO recommends, among other things, that the Secretary of Veterans Affairs

  • develop and implement guidance to collect complete and reliable misconduct and disciplinary-action data department-wide; such guidance should include direction and procedures on addressing blank fields, lack of personnel identifiers, and standardization among fields;
  • direct applicable facility and program offices to adhere to VA’s policies regarding misconduct adjudication documentation;
  • direct the Office of Human Resource Management to routinely assess the extent to which misconduct-related files and documents are retained consistently with applicable requirements;
  • direct the Office of Accountability and Whistleblower Protection (OAWP) to review responses submitted by facility or program offices to ensure evidence produced in senior-official case referrals demonstrates that the required elements have been addressed;
  • direct OAWP to issue written guidance on how OAWP will verify whether appropriate disciplinary action has been implemented; and
  • develop procedures to ensure (1) whistle-blower investigations are reviewed by an official independent of and at least one level above the individual involved in the allegation, and (2) VA employees who report wrongdoing are treated fairly and protected against retaliation.

GAO also recommends, among other things, that the VA OIG

  •  revise its policy and require verification of evidence produced in senior-official case referrals.

VA concurred with nine recommendations and partially concurred with five. In response, GAO modified three of the recommendations. The VA OIG concurred with one recommendation and partially concurred with the other. GAO continues to believe that both are warranted. GAO modified three of the recommendations. The VA OIG concurred with one recommendation and partially concurred with the other. GAO continues to believe that both are warranted.
https://www.gao.gov/products/GAO-18-137

Employee misconduct at VA’s medical facilities can have serious consequences for veterans. We looked at how VA deals with employee misconduct and found several opportunities for improvement. For example:VA doesn’t always maintain required files and documents for adjudication, suggesting that employees may not have received due process.VA officials found guilty of misconduct sometimes received a lesser punishment than recommended or no punishment.Whistleblowers were 10 times more likely than their peers to receive disciplinary action within a year of reporting misconduct.

Problems Ahead at VA – Did Shulkin get fired or resign? This is why it matters – POLITICO

[no_toc]

Fasten your seatbelts, it’s going to be a bumpy ride …

Did Shulkin get fired or resign? This is why it matters.

The debate centers on vague language in the Federal Vacancies Reform Act of 1998, which gives the president broad authority to temporarily fill a vacancy at a federal agency with an acting official if the current office holder “dies, resigns, or is otherwise unable to perform the functions and duties of the office.”

More trouble for an already troubled VA. Those who want to privatize will continue to break the system and veterans will be hurt. I don’t want the VA to be privatized for profit care. I want them to put the money, resources and people into place to fix what we earned. They have told us for years that we deserve the best care, state of the art care, not farm us out to for profit facilities.
Folks in the CHOICE program have trouble getting VA to pay the bills, I don’t see that getting better.
Then we will have to find doctor’s and specialist that accept VA payments. This may prove challenging. 

VA DISABILITY BENEFITS: Opportunities Exist to Better Ensure Successful Appeals Reform GAO-18-349T: Published: Jan 30, 2018

What GAO Found

The Department of Veterans Affairs’ (VA) plan for implementing a new disability appeals process while attending to appeals in the current process addresses most, but not all, elements required by the Veterans Appeals Improvement and Modernization Act of 2017 (Act). VA’s appeals plan addresses 17 of 22 required elements, partially addresses 4, and does not address 1. For example, not addressed is the required element to include the resources needed by the Veterans Benefits Administration (VBA) and the Board of Veterans’ Appeals (Board) to implement the new appeals process and address legacy appeals under the current process. VA needs this information to certify, as specified under the Act, that it has sufficient resources to implement appeals reform and make timely appeals decisions under the new and legacy processes.
VA’s appeals plan reflects certain sound planning practices, but it could benefit from including important details in several key planning areas:
Performance measurement: VA’s plan reflects steps taken to track performance, but could articulate a more complete and balanced set of goals and measures for monitoring and assessing performance on a range of dimensions of success. Specifically, the plan reports that VA is developing a process to track timeliness of the new and legacy processes. However, contrary to sound planning practices, the plan does not include timeliness goals for all five appeals options available to veterans, does not include goals or measures for additional aspects of performance (such as accuracy or cost), and does not explain how VA will monitor or assess the new process compared to the legacy process. Unless VA clearly articulates a complete and balanced set of goals and measures, it could inadvertently incentivize staff to focus on certain aspects of appeals performance over others or fail to improve overall service to veterans.
Project management: VA’s plan includes a master schedule for implementing the new appeals plan; however, this schedule falls short of sound practices because it does not include key planned activities—such as its pilot test of two of the five appeals options. In addition, the schedule does not reflect other sound practices for guiding implementation and establishing accountability—such as articulating interim goals and needed resources for, and interdependencies among, activities. Unless VA augments its master schedule to include all key activities and reflect sound practices, VA may be unable to provide reasonable assurance that it has the essential program management information needed for this complex and important effort.
Risk assessment: VA has taken steps to assess and mitigate some risks related to appeals reform by, for example, pilot testing two of the five appeals options through its Rapid Appeals Modernization Program (RAMP). However, as designed, RAMP does not include key features of a well-developed and documented pilot test. For example, VA has not articulated how it will assess RAMP before proceeding with full implementation. In addition, RAMP is not pilot testing three options and, as a result, VA will not have data on the extent to which veterans will appeal directly to the Board when given the option. Unless VA identifies and mitigates key risks associated with implementing a new process, VA is taking a chance that untested aspects will not perform as desired.

Why GAO Did This Study

VA’s disability compensation program pays cash benefits to veterans with disabilities connected to their military service. In recent years, the number of appeals of VA’s benefit decisions has been rising. For decisions made on appeal in fiscal year 2017, veterans waited an average of 3 years for resolution by either VBA or the Board, and 7 years for resolution by the Board. The Veterans Appeals Improvement and Modernization Act of 2017 makes changes to VA’s current (legacy) appeals process, giving veterans new options to have their claims further reviewed by VBA or appeal directly to the Board. The Act requires VA to submit to Congress and GAO a plan for implementing a new appeals process, and includes a provision for GAO to assess VA’s plan.
This testimony focuses on the extent to which VA’s plan: (1) addresses the required elements in the Act, and (2) reflects sound planning practices identified in prior GAO work. GAO’s work entailed reviewing and assessing VA’s appeals plan and related documents against sound planning practices, and soliciting VA’s views on GAO’s assessments.

What GAO Recommends

In its forthcoming report, GAO is considering recommending that VA: fully address all legally required elements in its appeals plan, articulate how it will monitor and assess the new appeals process as compared to the legacy process, augment its master schedule for implementation, and more fully address risk.

Full Report

Accessible Version

VA Inspector General: Improper wait list used for Colorado vets’ mental health care


As some of you may know there are 3 kinds of lies, lies, damn lies and statistics and the VA uses them all.
Once again we can thank a whistleblower for bring this to our attention.
Even with CHOICE in place due to the VA creating fake wait lists to make their numbers look better than they were and damn the veterans who suffer.
It continues at the Denver Veterans Affairs and we’ve lost at least one veteran that we know about.
“Rep. Mike Coffman, said in an interview that the local VA’s behavior reminded him of the 2014 VA scandal in Phoenix. Investigators there found that at least 35 patients died while waiting for care and medical staff falsified records to make it seem veterans were being seen promptly.”

“At the end of the day it’s the veterans who suffer,” said Rep. Mike Coffman

Read the Full Story:

VA: Improper wait list used for Colo. veterans

DENVER (AP) – A watchdog arm of the U.S. Department of Veterans Affairs said Thursday that the agency’s Denver-area hospital violated policy by keeping improper wait lists to track veterans’ mental health care. Investigators with the VA Office of Inspector General confirmed a whistleblower’s claim that staff kept unauthorized lists instead of using the department’s official wait list system.

VA Burial Benefits: Service-Connected or Non-Service Connected – There’s a Benefit for You

How to Apply for a Veterans Burial Allowance

Source: VA.gov

Find out how to get Veterans burial allowances to help cover burial, funeral, and transportation costs.

Can I get allowances to help pay for a Veteran’s burial and funeral costs?

You may be able to get burial allowances if you’re paying for the burial and funeral costs, and if any of the below relationships or professional roles describes your connection to the Veteran.

One of these must describe your relationship or role. You’re:

  • The Veteran’s surviving spouse (Note: we recognize same-sex marriages), or
  • A surviving child of the Veteran, or
  • A parent of the Veteran, or
  • The executor or administrator of the Veteran’s estate (someone who officially represents the Veteran)

To get this benefit, the Veteran must NOT have received a dishonorable discharge, and one of the below circumstances must be true.

One of these must be true of the Veteran. They:

  • Died as a result of a service-connected disability (a disability related to service), or
  • Had been getting a VA pension or compensation when they died, or
  • Had chosen to get military retired pay instead of compensation, or
  • Died while getting VA care, either at a VA facility or at a facility contracted by VA, or
  • Died while traveling to approved VA care, or
  • Died with a reopened claim for VA compensation or a pension that would have qualified them to get benefits, or
  • Died on or after October 9, 1996, while a patient at a VA-approved state nursing home

Note: Veterans Affairs will also provide an allowance for the cost of transporting a Veteran’s remains for burial in a national cemetery.

When do I need to file a claim?

You must file a claim for a non-service-connected burial allowance within 2 years after the Veteran’s burial or cremation. If a Veteran’s discharge was changed after death from dishonorable to another status, you must file for an allowance claim within 2 years after the discharge update.

There’s no time limit to file for a service-connected burial, plot, or interment allowance.

What kind of benefits can I get?

  • An allowance for burial and funeral costs
  • An allowance for the plot or interment
  • An allowance for transporting the Veteran’s remains for burial in a national cemetery

What documents and information do I need to apply?

You may need a copy of:

  • The Veteran’s military discharge papers (DD214 or other separation documents)
  • The Veteran’s death certificate
  • Any documents you have for the cost of transporting the Veteran’s remains

How do I apply?

You can apply online right now. Apply for Burial Benefits

You can also apply:

By mail
Apply by mail using an Application for Burial Benefits (VA Form 21P-530). 
Download VA Form 21P-530.

Mail the application and other paperwork to your nearest VA regional benefit office. 
Find your nearest VA regional benefit office.

If you have questions, call 1-800-827-1000, Monday through Friday, 8:00 a.m. to 9:00 p.m. (ET). Our TTY number for people with hearing impairments is 711. Or call your VA regional benefit office.


Burial Allowance Amounts

What are the burial allowance amounts for a service-connected death?

StatusMaximum Burial Allowance
If the Veteran died on or after September 11, 2001$2,000
If the Veteran died before September 11, 2001$1,500
If the Veteran is buried in a VA national cemeteryWe may pay you back for some or all of the costs of moving the Veteran’s remains

What are the burial allowance amounts for a non-service-connected death?

StatusMaximum Burial Allowance
If the Veteran died on or after October 1, 2017We’ll pay a $300 burial allowance and $762 for a plot
If the Veteran died on or after October 1, 2016We’ll pay a $300 burial allowance and $749 for a plot
If the Veteran died on or after October 1, 2015We’ll pay a $300 burial allowance and $747 for a plot
If the Veteran died on or after October 1, 2014, but before October 1, 2015We’ll pay a $300 burial allowance and $745 for a plot
If the Veteran died on or after October 1, 2013, but before October 1, 2014We’ll pay a $300 burial allowance and $734 for a plot

What are the burial allowance amounts if the Veteran was hospitalized by VA at the time of their death?

StatusMaximum Burial Allowance
If the Veteran died on or after October 1, 2017We’ll pay a $762 burial allowance and $762 for a plot
If the Veteran died on or after October 1, 2016We’ll pay a $749 burial allowance and $749 for a plot
If the Veteran died on or after October 1, 2015We’ll pay a $747 burial allowance and $747 for a plot
If the Veteran died on or after October 1, 2014, but before October 1, 2015We’ll pay a $745 burial allowance and $745 for a plot
If the Veteran died on or after October 1, 2013, but before October 1, 2014We’ll pay a $734 burial allowance and $734 for a plot
  • We may also pay you back for some or all of the costs of moving the Veteran’s remains if they were hospitalized or in a VA-contracted nursing home at the time of death.
  • We may pay you back for some or all of the costs of moving the Veteran’s remains if they died while traveling to VA-authorized care.

Note: If a Veteran’s remains aren’t claimed, we’ll pay the person or organization responsible for the Veteran’s burial a $300 burial allowance. If the deceased qualifies, we may pay you back for the costs of moving the Veteran’s remains to a VA national cemetery.

Medallions for Veterans Buried in Private Cemeteries

Bronze Medallions

The Department of Veterans Affairs provides a medallion, by request, to be affixed to an existing, privately purchased headstone or marker to signify the deceased’s status as a Veteran.

This device is furnished in lieu of a traditional Government headstone or grave marker for those Veterans who served on or after Apr. 6, 1917 and whose grave in a private cemetery is marked with a privately purchased headstone or marker.

Why choose a medallion: Bronze medallions are durable and can be easily affixed to privately purchased headstones by anyone, avoiding headstone or marker setting fees. The medallion also offers a way to identify the grave as that of a Veteran when a cemetery only allows one headstone per grave, preventing the use of a standard VA marker as a footstone.

Bronze Medallion Sizes: The medallion is available in three sizes: Large(6-3/8”W x 4-3/4”H x 1/2”D), Medium (3-3/4”W x 2-7/8”H x 1/4″D) and Small (2”W x 1-1/2”H x 1/3”D). Each medallion is inscribed with the word “VETERAN” across the top and the branch of service at the bottom.

Medal of Honor Medallion Sizes: The Medal of Honor (MOH) Medallion comes in Medium and Large. Each medallion is inscribed with “MEDAL OF HONOR” at the top and the branch of service at the bottom.

To request a medallion, please use VA Form 40-1330M, Claim for Government Medallion for Placement in a Private Cemetery. When requesting the MOH Medallion, check “OTHER” in block 11 and specify MOH.

Once a claim for a medallion is received and approved, VA will mail the medallion along with a kit that will allow the family or the staff of a private cemetery to affix the device to a headstone, grave marker, mausoleum or columbarium niche cover.

Important: This benefit is only applicable if the grave is marked with a privately purchased headstone or marker. In these instances, eligible Veterans are entitled to either a traditional Government-furnished headstone or marker, or the new medallion, but not both.

For family members of eligible Veterans interested in submitting a claim for the medallion, instructions on how to apply for a medallion are available. Please use: 

Veterans Affairs Secretary Shulkin says “we will not tolerate whistleblower retaliation in the VA”, and yet, 9 months into the new Administration the games continue

Meet the new boss, same as the old boss…
VA Secretary Shulkin says “we will not tolerate whistleblower retaliation in the VA”, however 9 months into the new Administration and the games played at the VA that were going to go away are still being played.
Quoted in the article is Katherine Mitchel, a doc at the Phoenix VA. She lists continuing retaliatory measures, including Veterans Affairs breaching the agreement to settle her grievances.
Katherine Mitchell, a VA physician in Phoenix:
“Although I do have a good relationship with my current immediate supervisor, the overall … retaliation in my current job worsened in January 2017 and continues unabated. The overt retaliation from Veterans Affairs Central Office (VACO) also worsened under the Trump administration … Continue Reading

Dec 2015 –  “Dr. Mitchell told a Senate Veterans’ Affairs field hearing outside Phoenix about “dangerous Emergency Department patient safety defects,” including “a significant lack of nurse triage training, and inadequate nursing triage protocols” and the Phoenix VA hospital’s “dysfunctional institutional culture.” The hospital was at the scandal’s epicenter.”

From the written testimony of Dr. Katherine L. Mitchell to the Senate Committee on VA 12/14/15 Field Hearing

“I am a VA physician who worked within the Phoenix VA Emergency Department (EED)) for almost 10 years until I involuntarily was transferred to a defunct VA clinic in retaliation for repeatedly identifying dangerous ED patient safety deficits . After year s of having my reports of life – threatening conditions ignored by internal Phoenix VA mechanisms I publically became a whistleblower in April 2014 in an attempt to have the VA resolve those many serious problems. I alerted the public and Congress to unsafe conditions in the Phoenix VA Emergency Department, whistleblower retaliation, facility scheduling irregularities, and other issues. After the Veterans Health Administration (VVHA)) formally acknowledged the workplace retaliation against me, I accepted a position within the VA Veterans Integrated Service Network (VVISN)) 18 office as a Specialty Care Medicine coordinator.. Although I continually advocate for improvements at the Phoenix Veterans Affairs ED and Mental Health Clinic, in my current position I have been told by Veterans Affairs administrators that I am not allowed to actively address the known dangerous conditions.”

Washington Post Full Article

Perspective | Victims say VA whistleblower retaliation is growing under Trump, despite rhetoric

When President Trump talked about the importance of protecting “our great, great people, our veterans,” during a White House meeting in March, he said, “No more games going to be played at the VA.”

The VA’s strained relationship with the truth

[no_toc]The Veterans Affairs has had a lot to say in recent years regarding its failed attempts at building Veterans Affairs hospitals. Should VA officials’ construction-related pronouncements be believed?
Sourced through Scoop.it from: www.denverpost.com
Further Reading

Aurora VA hospital: Anatomy of a calamity – The Denver Post

extras.denverpost.com/auroravahospital/

The Denver Post

Aug 9, 2015 – How the VA’s Aurora hospital project spiraled out of control. A 2011 meeting between officials from the veterans affairs department and its construction contractor set the stage for financial disaster. The biggest construction failure in VA history began with a handwritten note …

$571M contract awarded to finish Aurora VA hospital; completion date …

www.bizjournals.com/…/571m-contract-awarded-to-fin…

South Florida Business Journal

Oct 30, 2015 – The U.S. Army Corps of Engineers has awarded a $571 million contract to construction consortium Kiewit-Turner to finish the U.S. Department of Veterans Affairs hospital project in Aurora. … SLIDESHOW: Click above for photos of the VA hospital project from April. … The VA is out of the …

Coffman calls for criminal probe of Aurora VA hospital project – Aurora …

www.aurorasentinel.com/…/coffman-calls-criminal-probe-auroravah

Aurora Sentinel

Apr 7, 2016 – Mike Coffman, R-Aurora, has joined another member of Congress in calling for a criminal probe of the Veterans Affairs hospitalconstruction …