Manchin Questions VA Officials On Clarksburg VAMC Murders

May 11, 2022

Washington,
DC – Today, U.S. Senator Joe Manchin (D-WV), member of the Senate Veterans
Affairs Committee (SVAC), questioned U.S. Department of Veterans Affairs (VA)
and The Joint Commission officers on the horrific murders of a number of Veterans
on the Clarksburg VA Medical Center (VAMC) in 2017 and 2018. At the request of
Senator Manchin, that is the primary complete listening to on the systemic points
uncovered through the Clarksburg VAMC investigation.

Senator
Manchin started, “I
labored laborious as a member of the committee to make sure that horrific murders that
occurred in my dwelling state of West Virginia and particular issues that led to
these murders by no means occurred wherever else within the nation. We should make
significant modifications on the VA in order that Veterans in West Virginia and throughout the
nation can start to rebuild their belief in right this moment’s care. This is the primary
time because the Clarksburg VAMC murders that we’re having a complete look
on the accountability and tradition of the VA and I thanks, I actually
do…Oversight is our obligation on this committee. We should maintain these accountable that
have positioned our Veterans in danger accountable. And I sit up for listening to
from our panelist on how we are able to stop these errors from occurring.”

On
VA retirement insurance policies (video right here):

Senator
Manchin questioned,
“In the latest written testimony, Inspector Missal states that ‘When it comes
to situations, like Clarksburg, the widespread contributing components, the OIG has
recognized are poor, inconsistent or ineffective management that domesticate a
complacent and disengaged medical facility tradition through which the VA purpose of zero
affected person hurt is unbelievable, if not not possible.’ That’s clearly the case on the
Clarksburg VAMC, and but people in positions of management have been capable of
merely resign and maintain their beneficial VA advantages, like retirement advantages…How
can we maintain the VA leaders accountable with situations just like the murders at
Clarksburg? How do these folks keep within the system? How are they capable of retire
with their advantages with such disrespect, such neglect and malfeasance of doing
their job?”

On
VA hiring processes (video right here):

Senator
Manchin continued,
“Dr. Clancy, in recent times, our Veterans have skilled large breaches of
belief in all of the VA staff, particularly on the Clarksburg VAMC, the place an
worker who murdered a number of Veterans by no means went by way of a correct hiring
course of…How’s the VA up to date its hiring course of to mirror the teachings discovered
in vetting? You solely needed to make one telephone name and so they might have caught this
lady earlier than she ever bought within the door.”

On
The Joint Commission (video right here):

Senator
Manchin questioned,
“I’m extraordinarily involved in regards to the present state of the connection between
The Joint Commission and the VA. Like I stated initially of this listening to,
The Joint Commission persistently gave the Clarksburg VAMC a passing rating for
accreditation. Before and after the horrific murders occurred on the facility.
The Joint Commission was even on web site on the Clarksburg VAMC for evaluate, which
Clarksburg handed. They handed it, that was much less
than eight weeks earlier than the murders started. That yr, the VA paid the Joint
Commission, nearly $6 million for his or her
companies. And that basically would not sit proper with me – realizing the quantity of
cash that we have invested there and the return we bought – as a Senator or as a
West Virginian. It all comes again to accountability. How did The Joint
Commission miss this blatant oversight throughout their May 2017 on web site survey?”

Background
data on the Senate Veterans Affairs Committee listening to:

Homicides
in Clarksburg, West Virginia:

A
May 2021 OIG report detailed the case of a nursing assistant on the Louis A.
Johnson VAMC in Clarksburg, West Virginia, who intentionally administered
insulin to at the least 9 sufferers all through 2017 and 2018, leading to
profound hypoglycemia and 7 of those sufferers’ deaths. As a part of this
report, OIG made fourteen suggestions to stop additional antagonistic high quality of
care incidents, together with suggestions for the VAMC to make sure that all employees
are skilled on reporting affected person security occasions, in addition to suggestions for
the VA Under Secretary for Health (USH) to find out the feasibility of a
rescue medicine flagging system and to reevaluate how VHA collects and
analyzes mortality knowledge from VAMCs.

VA
OIG Report:

The
OIG signifies that the overarching difficulty was a scarcity of accountability inside
the Clarksburg VAMC’s scientific healthcare crew and administrative management.
The most obtrusive downside within the case of the VA worker was the dearth of
adjudication of her background verify, which might have flagged the authorized
expenses in opposition to her for mistreatment of an inmate whereas she was employed on the
North Central Regional Jail. This background verify adjudication was required to
be accomplished by the ability adjudicator, however by no means befell over her 4
years of employment.

Additionally,
throughout the Clarksburg VAMC’s management there was constant negligence at every
supervisory degree overseeing the worker all the best way to the previous Director,
Dr. Glenn Snider. Specific faults embrace:

not securing the medicine ward or the medicine
carts which ought to have been monitored by cameras;
failure to establish the extremely uncommon pattern of
hypoglycemia in non-diabetic sufferers, failure to diagnose the reason for
that hypoglycemia as soon as it was found;
lastly, the Patient Safety Department was not notified
of the hypoglycemia or the suspicious dying as a result of a scarcity of coaching to
declare 

Take-aways:

Overall, a tradition of affected person security was defunct, not
prioritized and sluggish to enhance on the facility even after the
investigations started.
Arguably probably the most egregious failure is that the
adjudication of the worker’s background investigation through the hiring
course of was not accomplished. More assets and a spotlight must be paid
to the VA prioritizing thorough hiring course of. Background checks are
accomplished and obtainable to VA adjudicators by the Office of Personnel
Management (OPM). The worker’s background verify had been flagged by OPM.

Structure, guidelines, and normal working practices
throughout the facility have been casual and careless, which resulted in missed
alternatives to cease the worker. The worker was capable of have poor
efficiency with out consequence and entry to medication she mustn’t have
had.

The
Joint Commission

The
Joint Commission is an accreditation group that inspects 80% of U.S.
well being care organizations, together with VA medical services. This consists of
the Clarksburg VAMC, which acquired passing accreditation scores from TJC
through the time the worker was murdering sufferers, regardless of the VA Office
of Inspector General investigation discovering obtrusive oversight failures, like
unlocked drug carts the worker stole insulin from to kill her sufferers.

TJC
is contracted by the VA. Its estimated annual income is over $300 million per
yr.

Background:

TJC conducts 18-39-month cyclic surveys, that are
unannounced. We have heard suggestions from civilian docs that they’re
warned and might put together previous to the surveys, which may very well be the identical for
VA services.
The federal authorities and practically all states acknowledge
TJC’s judgements in some a part of their licensing course of.
TJC accredited 99% of inspected hospitals in 2005 and
revoked the accreditation of lower than 1% of hospitals that weren’t in
compliance. In over 30 circumstances, hospitals retained their accreditation even
although their failures led to severe harm or dying of sufferers.
While these are civilian circumstances, the failures at
Clarksburg that led to the murders are indicative that these issues
exist with TJC’s federal prospects.

Witnesses:

Panel
1:

Carolyn M. Clancy, MD, Assistant Under Secretary for Health, Discovery,
Education and Affiliate Networks, Veterans Health Administration,
Department of Veterans Affairs

Accompanied by:

Erica M. Scavella, MD, FACP, FACHE, Assistant Under Secretary for
Health for Clinical Services/Chief Medical Officer
Kristine Groves, Executive Director, Office of Quality Management

Panel
2:

The Honorable Michael J. Missal, Inspector General, Department
of Veterans Affairs

Accompanied by: Julie Kroviak, MD, Deputy Assistant Inspector
General, Office of Healthcare Inspections, Office of Inspector General,
Department of Veterans Affairs

Jonathan B. Perlin, MD, PhD, MSHA, MACP, FACMI, President and Chief
Executive Officer, The Joint Commission
Gregg S. Meyer, MD, MSc, President of the Community Division and
Executive Vice President of Value Based Care, Mass General Brigham, and
Professor of Medicine, Massachusetts General Hospital and Harvard Medical
School

To
view a timeline of Senator Manchin’s efforts on the Clarksburg VAMC, click on
right here.

Full
video of Senator Manchin through the Senate Veterans Affairs Committee listening to
may be discovered right here.

https://www.manchin.senate.gov/newsroom/press-releases/manchin-questions-va-officials-on-clarksburg-vamc-murders

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