7 Point Plan to Fix the VA to improve Veteran Medical /Mental Healthcare

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VA (Veterans Administration) Reform, to improve VA operation and services for Veterans.

In the VA Reform, the following conditions and changes are needed to prevent worsening of medical/mental health conditions, delay In care, Veteran death and Veteran suicide.

In light of the recent suicide of former Army SGT Veteran John Toombs; the second on VA grounds at the Veteran Administration Murfreesboro, TN and care related suicide this year. The eighth Veteran on VA property suicide within the year as well. These silenced voices should be able to speak the loudest now in support of the VA Reform purposed.

1) Require members in key positions of leadership to have been:
a) a Veteran,
b) a current or former customer of VA services at the Veteran patient level.

As they would have firsthand experience and knowledge of “the VA experience” that Veterans go through when they seek care at the VA. This would do more to improve VA care and services for Veterans.

2) Require interns that choose to intern at the VA to:
a) Sign a 2-3 year post internship employment agreement,
b) Held accountable for improper documentation or interference in treatment.

This holds true more with the mental health care aspect; as it is difficult enough as it is for a Veteran to open up and trust the Provider, Social Worker, etc… A constant rotation of these service providers can do more harm to a Veteran and seriously impact their Veteran’s Care Plan.

Since, documentation is key in any treatment plan; any failures in proper documentation that negatively impacts a Veteran’s medical / mental health care diagnosis / treatment should result in a government imposed fine and / or revocation of certification / licensing. Too many Veterans have this occur and they end up falling through the cracks and much needed treatment is delayed or doesn’t happen.

3) With the increased use of Contracted Providers:
a) Create a Veteran perspective course, make it reoccurring and required,
b) Have a higher amount of accountability in failure of care.

When a Provider is dealing with a Veteran, the mindset of the Veteran for the most part is not taken into account. Most providers are either unaware or do not give much credence to the “Suck it up” mindset that has been drilled into the minds of Service members and that it becomes so integrated that it follows the patient into their Civilian mindset. As an example, a Veteran may vocalize they are in pain; however, present as if they are not in as much pain as they are saying. For a Veteran to come for care, it probably became such a problematic issue that they just simply got tired of it all and decided to get care. If minimized by the provider, it may result in the Veteran just giving up on treatment. Veterans will have higher pain thresholds and tolerances to issues.

Contracted Providers should be held accountable for gross negligence even at the smallest levels of care. Once again with a governmental fine and / or license suspension or revocation. They should be providing the same care as they do in their private practices or other place(s) of employment.

4) Update 45 CFR 160.103, paragraph (2)(iv) of the definition of “protected health information”, regarding members medical/mental health records after their death.
a) to include open access to spouse, immediate family, any family member if none of the previous mentioned exist or members with a Power of Attorney if none of the previous exist or by direction of the previously mentioned .
b) require record maintenance from 10 years to match the 50 year requirement.

The spouse or family members, immediate or otherwise, have a right to such information to determine if the care being provided led to or was a contributing factor in the death of their loved one. Such as in the incident surrounding the recent suicide of John Toombs at the Murfreesboro, TN VA.

5) Higher accountability of employees:
a) instead of moving VA employees from location to location to avoid termination, terminate their employment if they continue to fail at correcting their practices,
b) Patient Advocates actually document complaints about providers, services, etc… Regardless of their own personal interest or bias.
c) Patients should feel protected from reprisal when reporting issues,
d) Proactive care, services and system improvement.

It is a common statement that Veterans know and that is, “Someone can kill someone and not get fired at the VA.” There is always a level of truth to things that people say or what is perceived.

There are many Veterans that go to the Patient Advocate and nothing is documented and there is no history of complaints against a doctor, service, etc… So the issue is never addressed or corrected.

Patients also have expressed that when they reported an issue that their care was actually worsened and they regretted reporting the issue they had.

Process improvement should always be in place, problems should not have to be dealt with after they hit the news or after a Veteran has taken their life or Veterans being infected with a disease.

6) Drug and alcohol treatment program improvement:
a) PTSD driven approach in care (for those this applies),
b) if patient appears to be a potential harm to themselves or others, they be admitted under psychiatric observation for a 48 or 72 hour period, especially in the event a patient has not followed all inpatient treatment requirements,
c) an understanding that the addiction is secondary to the primary issue; PTSD, in the cases that the Veteran suffers from PTSD.

In the recent suicide video published on Facebook by John Toombs, he mentions one option being “checked into a psych ward.” This denotes that the provider may have though he might have been a threat to himself. Although, John Toombs may have missed two days of medication, he still had a right to treatment and the provider not to take anything personally, which is what is perceived in this case.

7) The termination of redundant studies, such as the effectiveness of Service dogs for Veterans suffering with PTSD:
a) There are enough studies and proven cases of Service dogs are a benefit,
b) this is perceived as a waste of money, just by it’s nature.

Money being spent on whether or not a Service dog benefits a Veteran suffering from PTSD takes money that could be used in other areas to help improve care of Veterans. Really all a provider has to do is ask the same standard questions of their patients with PTSD, that have a Service dog to get the answers they are looking for and documented.

We would like to see each item addressed as a whole and if need be this petition for the sake of simplifying the process approached individually to reach the same ends.

So many Veterans have made sacrifices both great and small, their health care should not be exceeded by those who have not made such sacrifices. These services have been earned by them, through their service. They have not failed us, let’s not fail them.

Below is a list of incidents and failures by the VA:

***Reported VA Incidents***
So you all understand how serious the issues with the VA are, we've complied a list of reported VA incidents. We say that, because, each state has different requirements and not all incidents are required to be reported or the VA has failed to report them on their own.
***Reported on VA property Veteran suicides 2015-2016***
Unamed male - 22 DEC 2016 - Albuquerque, NM​ - This has not been released  and is being covered up
John Toombs - 23 NOV 2016 - Murfreesboro, TN
Unnamed (Mt Juliet man) - 15 JUL 2015 - Murfreesboro, TN
*** Second one in just over a year at Murfreesboro, TN***
Peter Kaisen - 24 AUG 2016 - Northport, NY
Unnamed male - 6 SEP 2016 - Des Moines, IA
Brian Ketchum - 8 JUL 2016 - Iowa City, IA
Charles Ingram - 23 MAR 2016 - Northfield, NJ
Gary Dorman - 20 NOV 2015 - Philadelphia, PA
Michelle Lawghorst - 31 MAR 2015 - Pittsburg, PA
Richard Miles - 19 MAR 2015 - Des Moines, IA
David Cranmer - 10 MAR 2015 - Brentwood, PA
Thomas Young - 23 JUL 2015 - Hines, IL
Thomas Murphy - 13 MAY 2015 - Phoenix, AZ

Reported VA incidents:
11 DEC 2016 – Florida VA, a dead Veteran’s body is found in the VA facilities shower. Body remained unattended to for over 9 hours.
7 DEC 2016 – The discovery of the secret VA internal rating list.
6 DEC 2016 – Report was released showing suicide care issues and failings at the Phoenix VA.
2 DEC 2016 - It is discovered that contracted doctors are instructed to minimize their patient contacts to less than 4 times a year, because it will interfere with Accession and profit margin. Accession is the intake of new Veterans into the VA, this is part of the profit margin process for the companies that supply the contracted services.
1 DEC 2016 - Wisconsin VA, dentist possibly infects 600 Veterans with HIV, Hep C and Hep B.
(Second reported case of possible infection of Veterans by a VA dentist, first reported case 6 JUL 2010 – St. Louis VA. )
23 NOV 2016 – Veteran John Toombs hangs himself on Murfreesboro, TN VA property, as result of VA care. *** Second one in just over a year at Murfreesboro, TN VA***
27 OCT 2016 – Report released shows Veterans TBI treatment and care delayed, because thousands of Veterans were improperly examined.
4 OCT 2016 – Phoenix, AZ VA, 200 more Veterans die since 2015 waiting for care, new backlog for this VA.
3 OCT 2016 – Tahlihina, OK VA, Veteran Owen R. Petterson, dies after 21 days, after being admitted to VA for an infection. His bandages were found not to have been changed and maggots were found in the rotting, infected flesh.
29 SEP 2016 – Chicago, IL VA, unclaimed bodies in morgue stacked and rotting for months.
23 SEP 2016 – Northport, NY VA, Veteran’s suicide in parking lot launches investigation regarding $20 million worth of art being purchased by VA.
20 SEP 2016 – Long Island, NY VA, under investigation for fraud and failing to report patient deaths.
6 SEP 2016 - Des Moines, IA VA, Unnamed male takes his life on VA property
24 AUG 2016 - Northport, NY VA, Veteran Peter Kaisen takes his life in VA parking lot after being refused care at VA ER.
11 AUG 2016 – Minnesota hospitals and doctors turn away Veterans for care, because VA CHOICE program fails to pay bills for CHOICE VA approved treatment.
23 JUL 2015 - Hines, IL VA, Thomas Young took his life on VA property after being put to voice message system and leaving message on VA Crisis Line.
8 JUL 2016 – Murfreesboro, TN VA, Homeless Veteran with a Service dog was kicked out of the ER because of his Service dog. Veteran was there to be treated for an infection. Dog was a legitimate Service dog for PTSD.
8 JUL 2016 - Iowa City, IA VA, Brian Ketchum took his life on VA property after failure of care at the VA.
3 JUL 2016 – New Mexico VA, Veteran collapses on VA property 500 yards from the VA ER and dies waiting for 30 minutes for ambulance.
30 JUN 2016 – Veteran Crisis Line scandal. Calls either hung up on, forwarded or sent straight to voice message.
31 MAY 2016 – Memphis, TN VA, improper disposal of body parts, resulting in backup in VA plumbing.
12 MAY 2016 – Stow, OH, report shows VA had to ban 750 VA approved fiduciaries for misuse, mismanagement and stealing of Veteran’s money, since 2012. Nicole Whelsh was one of those banned, she currently is a Stow, OH Assistant Prosecutor, who has not yet been disbarred. The VA has lost oversight and is slow to prosecute.
4 APR 2016 – VA fails to protect Veterans, by not revoking GI Bill authority to predatory For-profit schools with worthless degrees.
23 MAR 2016 - Northfield, NJ - Charles Ingram took his life on VA property, by lighting himself on fire in the parking lot.
4 FEB 2016 – Wikes-Barre VA Medical Center in Pennsylvania, PA, Nurse assists in emergency surgery on Veteran. Nurse’s name - Richard Pier.
23 JAN 2016 – VA ER supposed to be open 24/7 found close when Veteran Chris Neiween attempt to get care. After profusely apologizing and promising to pay the private medical bills of a veteran who was locked out of a VA emergency room and had to struggle to get to a non-VA facility, the VA has broken its promise and completely ignored the vet for months.
20 NOV 2015 - Philadelphia, PA, Gary Dorman took his life on VA property, due to lack of care.
28 SEP 2015 VA executives Diana Rubens and Kimberly Graves defraud the VA of $400,000.
15 JUL 2015 - Murfreesboro, TN VA, Unnamed (Mt Juliet man) takes his life in VA parking lot.
AUG 2015 – Tomath, WI VA, Veteran Jason Simcakoski died through negligence and over prescribing of medications. IG Report – to date 307,000 Veterans died waiting for care and IG still has 867,000 IG cases pending.
MAY 2015 – A report discloses the following incidents at the VA:
a) Tomah,WI VA, it was discovered that a doctor was over prescribing pain killers and other medications, resulting in at least 1 reported death.
b) Malcom Randell VA, Valdesta, GA, doctor prescribed medication without conducting proper follow up lab work and testing. Also, prescribed psychiatric drugs not using current protocols.
c) Tampa, FL VA, doctor discovered to be over prescribing pain medications.
d) West Palm Beach, FL VA, Veteran patient dependent on a ventilator was checked into a VA facility with untrained staff, was later found with ventilator disconnected and in cardiac arrest. They were able to revive him.
e) Wichita, KS VA, VA staff do not resuscitate a Veteran, due to a DNR mistake. Paperwork was not uploaded into the system.
f) Asheville, NC VA, a Veteran’s leg was broken during surgery and treatment of the break was delayed.
g) Lebanon, NC VA, a Veteran’s face caught on fire during surgery, this was the second reported incident. The first reported incident was in 2011, Steven Anthoney at the Martinsburg, VA VA facility.
h) Lexington, NC VA, Veteran’s lung X-rays showed he had lung cancer, the Veteran was not notified for 8 months and he died as a result.
i) Pittsburgh, PA VA, 31 Veterans may have been implanted with defective aortic stents, the stent company notified VA of possible defect and provides the VA with a sample patient notification letter. The VA fails to notify the Veterans of the possible defect.
31 MAR 2015 - Pittsburg, PA VA, Veteran Michelle Lawghorst takes her life in the VA parking lot.
19 MAR 2015 - Des Moines, IA VA, Veteran Richard Miles takes his life on VA property.
10 MAR 2015 - Brentwood, PA, VA, Veteran David Cranmer takes his life on VA property.
13 MAY 2015 - Phoenix, AZ VA, Veteran Thomas Murphy takes his life on VA property.
JAN 2015 - The VA decides to start a $14 million study on if Service dogs help Veterans with PTSD. Program to run until 2018, involving 230 Veterans.
23 JUL 2014 – Orange City, FL VA Outpatient Facility, Veteran Jeffery Duck for an appointment, was forgotten and locked inside the facility by VA employees. He had to call 911 and even tripped the burglar alarm.
JUN 2014 – Brokton, MA, it was discovered that 1 – Veteran was in a long term mental health ward for 8 years before he received a comprehensive evaluation and 1 – Veteran had been there 7 years before a medical note had ever been placed in his medical file.
JUN 2014 – Phoenix, AZ VA, The secret wait list scandal breaks. One of the patients that died as a result was Navy Veteran Thomas Breen; 23 NOV 2013.
24 JUN 14 – Phoenix, AZ VA, it was discovered that the VA was hiding Veteran deaths; their deaths were changed to alive in the VA system to improve their numbers.
14 JAN 2013 – Buffalo, NY VA, 700 Veterans were possibly exposed to HIV, Hep C and Hep B when it was discovered that the VA was reusing insulin pens on different patients.
2003 -2009 – It was discover that 3 VA facilities may have infected 10,000 Veterans with HIV, Hep C and Hep B through improper sterilization of colonoscopies. The VA facilities were Murfreesboro, TN VA, Augusta, GA VA and Miami, FL VA.
5 AUG 2008 – Arkansas VA, was discovered to have multiple violations in human experimentation, missing consent forms, secret HIV testing and failure to report over 105 deaths.



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