Source: United States Senator for West Virginia Joe Manchin
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 officials on the horrific murders of multiple Veterans at the Clarksburg VA Medical Center (VAMC) in 2017 and 2018. At the request of Senator Manchin, this is the first comprehensive hearing on the systemic issues uncovered during the Clarksburg VAMC investigation.
Senator Manchin began, “I worked hard as a member of the committee to ensure that horrific murders that occurred in my home state of West Virginia and specific problems that led to these murders never happened anywhere else in the country. We must make meaningful changes at the VA so that Veterans in West Virginia and across the country can begin to rebuild their trust in today’s care. This is the first time since the Clarksburg VAMC murders that we are having a comprehensive look at the accountability and culture of the VA and I thank you, I truly do…Oversight is our duty on this committee. We must hold those responsible that have placed our Veterans at risk accountable. And I look forward to hearing from our panelist on how we can prevent these mistakes from occurring.”
On VA retirement policies (video here):
Senator Manchin questioned, “In the recent written testimony, Inspector Missal states that ‘When it comes to instances, like Clarksburg, the common contributing factors, the OIG has identified are poor, inconsistent or ineffective leadership that cultivate a complacent and disengaged medical facility culture in which the VA goal of zero patient harm is improbable, if not impossible.’ That’s clearly the case at the Clarksburg VAMC, and yet individuals in positions of leadership were able to simply resign and keep their valuable VA benefits, like retirement benefits…How do we hold the VA leaders responsible with instances like the murders at Clarksburg? How do those people stay in the system? How are they able to retire with their benefits with such disrespect, such neglect and malfeasance of doing their job?”
On VA hiring processes (video here):
Senator Manchin continued, “Dr. Clancy, in recent years, our Veterans have experienced massive breaches of trust in all the VA employees, especially at the Clarksburg VAMC, where an employee who murdered multiple Veterans never went through a proper hiring process…How’s the VA updated its hiring process to reflect the lessons learned in vetting? You only had to make one phone call and they could have caught this woman before she ever got in the door.”
On The Joint Commission (video here):
Senator Manchin questioned, “I’m extremely concerned about the current state of the relationship between The Joint Commission and the VA. Like I said at the beginning of this hearing, The Joint Commission consistently gave the Clarksburg VAMC a passing score for accreditation. Before and after the horrific murders occurred at the facility. The Joint Commission was even on site at the Clarksburg VAMC for review, which Clarksburg passed. They passed it, that was less than eight weeks before the murders began. That year, the VA paid the Joint Commission, almost $6 million for their services. And that really doesn’t sit right with me – knowing the amount of money that we’ve invested there and the return we got – as a Senator or as a West Virginian. It all comes back to accountability. How did The Joint Commission miss this blatant oversight during their May 2017 on site survey?”
Background information on the Senate Veterans Affairs Committee hearing:
Homicides in Clarksburg, West Virginia:
A May 2021 OIG report detailed the case of a nursing assistant at the Louis A. Johnson VAMC in Clarksburg, West Virginia, who deliberately administered insulin to at least nine patients throughout 2017 and 2018, resulting in profound hypoglycemia and seven of these patients’ deaths. As part of this report, OIG made fourteen recommendations to prevent further adverse quality of care incidents, including recommendations for the VAMC to ensure that all staff are trained on reporting patient safety events, as well as recommendations for the VA Under Secretary for Health (USH) to determine the feasibility of a rescue medication flagging system and to reevaluate how VHA collects and analyzes mortality data from VAMCs.
VA OIG Report:
The OIG indicates that the overarching issue was a lack of accountability within the Clarksburg VAMC’s clinical healthcare team and administrative leadership. The most glaring problem in the case of the VA employee was the lack of adjudication of her background check, which would have flagged the legal charges against her for mistreatment of an inmate while she was employed at the North Central Regional Jail. This background check adjudication was required to be completed by the facility adjudicator, but never took place over her four years of employment.
Additionally, within the Clarksburg VAMC’s leadership there was consistent negligence at each supervisory level overseeing the employee all the way to the former Director, Dr. Glenn Snider. Specific faults include:
- not securing the medication ward or the medication carts which should have been monitored by cameras;
- failure to identify the highly unusual trend of hypoglycemia in non-diabetic patients, failure to diagnose the cause of that hypoglycemia once it was discovered;
- finally, the Patient Safety Department was not notified of the hypoglycemia or the suspicious death due to a lack of training to declare
Take-aways:
- Overall, a culture of patient safety was defunct, not prioritized and slow to improve at the facility even after the investigations began.
- Arguably the most egregious failure is that the adjudication of the employee’s background investigation during the hiring process was not completed. More resources and attention needs to be paid to the VA prioritizing thorough hiring process. Background checks are completed and available to VA adjudicators by the Office of Personnel Management (OPM). The employee’s background check had been flagged by OPM.
- Structure, rules, and standard operating practices within the facility were informal and careless, which resulted in missed opportunities to stop the employee. The employee was able to have poor performance without consequence and access to drugs she should not have had.
The Joint Commission
The Joint Commission is an accreditation organization that inspects 80% of U.S. health care organizations, including VA medical facilities. This includes the Clarksburg VAMC, which received passing accreditation scores from TJC during the time the employee was murdering patients, despite the VA Office of Inspector General investigation finding glaring oversight failures, like unlocked drug carts the employee stole insulin from to kill her patients.
TJC is contracted by the VA. Its estimated annual revenue is over $300 million per year.
Background:
- TJC conducts 18-39-month cyclic surveys, which are unannounced. We have heard feedback from civilian doctors that they are warned and can prepare prior to the surveys, which could be the same for VA facilities.
- The federal government and nearly all states recognize TJC’s judgements in some part of their licensing process.
- TJC accredited 99% of inspected hospitals in 2005 and revoked the accreditation of less than 1% of hospitals that were not in compliance. In over 30 cases, hospitals retained their accreditation even though their failures led to serious injury or death of patients.
- While those are civilian cases, the failures at Clarksburg that led to the murders are indicative that these problems exist with TJC’s federal customers.
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 at the Clarksburg VAMC, click here.
Full video of Senator Manchin during the Senate Veterans Affairs Committee hearing can be found here.