Friday, October 21, 2011






Panderer-in-Chief Barack needs to start firing some people immediately. How is Shinseki still over the VA after the scandal at the Miami VA Medical Center in 2009? Or the continued problems at the Miami VA Medical Center? As was noted at the start of a hearing last week, the Miami facility was in "the spotlight" two years ago when "endoscopes were not reprocessed correctly, placing over two thousand veterans at risk of exposure to disease." The instruments were used and reused and not steralized from one patient to another. In other words, a needle exchange for intravaneous drug users treated people better and more safely than the Miami VA Medical Center did. Back in July, Fred Tasker (Miami Herald) reported that 5 veterans using the Miami, the Murfreesboro or the Augusta facilities had "tested positive for HIV, 25 for hepatitis C and eight for hepatitis B."
That was the public safety scandal two years ago. You might think they'd get their house in order. But when you don't have a functioning head of the VA and you don't have a president who holds Cabinet heads accountable, you get one problem after another.
Last Wednesday, October 12th, the House Veterans Affairs Committee held a hearing on the facility and its myriad of problems. The hearing was scheduled to begin at 10:00 a.m. If it started on time, I missed the first 90 minutes (I was at the Subcommittee on National Security, Homeland Defense and Foreign Operations hearing). Any reference to opening remarks in the hearing will be the prepared remarks. I walked in as a tooth-pulling exchange between the Chair and the director of the facility was taking place. One that was apparently characteristic of the hearing as evidenced by US House Rep Bill Johnson's comment immediately following the exchange that "Are -- I'm just curious are you -- are you astutely hearing the responses to the questions that this Committee is asking and some of the answers we're getting?"
For those wondering here's part of the exchange immediately before Johnson spoke. Committee Chair Jeff Miller is speaking to Mary Berrocal who is the director of the Miami facility.
Chair Jeff Miller: So would you know if a veteran had come to your facility with a particular disease return home and then expire the next day? Would you have anyway of knowing that?
Mary Berrocal: Usually what happens is we -- Any deaths, we do review and there is -- Where indicated we do peer reviews, where the death is not expected, peer reviews are done and we --
Chair Jeff Miller: So there is a way that you would know if a veteran presented 24 hours prior to their death at your facility but was sent home? You would have a way of tracking that?
Mary Berrocal: Every -- every morning, we get a report on, uh, on anything that is unusual that might have happened, uhm, on the evening before or the day before. We get a report every single morning. I meet with my leadership. Uh, the staff in the ER presents their information following that, you know, we stay with the leadership and discuss anything we might need to follow up on.
Chair Jeff Miller: Is it unusual that a veteran would come to your facility, be dischaged -- not just discharged, but just be sent home, not admitted, and would pass away the next day? Would you consider that unusual? And if you do consider that unusual, is that something that you would report then to the VISN that this has occurred?
Mary Berrocal: Uh, we would normally report deaths, uh, unexpected deaths to the network, yes.
Chair Jeff Miller: So this particular, if an incident like this did occur, it would have been reported to the VISN?
Mary Berrocal: It would be my expectation that it would be reported. If it's an unexpected death, there are reports that, uh, that go forward.
Chair Jeff Miller: Regardless --
Mary Berrocal: Now we don't independently, like in an issue, report every single death if it's an expected death.
Chair Jeff Miller: Regardless of what the peer review may have found, you would still report it?
Mary Berrocal: Uh, the peer review's focus, uh, specifically on the provider to determine whether it was a, uh, uhm, something that didn't go the way it should go in that direction.
Chair Jeff Miller: If a --
Mary Berrocal: So yes.
Chair Jeff Miller: If a vet -- Okay, let's go inside the facility. Now we have somebody who has been admitted to the facility and is having surgery. If there is a death on the operating table, what would prevent that death from being reported to VISN?
Mary Berrocal: Uh, those, uh, would be reported to the network.
Chair Jeff Miller: All deaths on an operating table are reported --
Mary Berrocal: Are reported, should be reported. There's a system that we put through to report unexpected deaths.
Chair Jeff Miller: All deaths on the operating table are reported to the VISN?

Mary Berrocal: Yes, sir.
Chair Jeff Miller: All deaths?
Mary Berrocal: Unexpected deaths are reported.
Chair Jeff Miller: There's a difference now: Unexpected deaths or deaths? If a patient dies on the operating table, is that reported regardless? Is that reported to the VISN? And if not, why not?
Mary Berrocal: It would be my expectation that it would be reported.
Chair Jeff Miller: Is there a root cause analysis on every death on the operating table?
Mary Berrocal: There, uh, there would be, uh, a root cause analysis, again, if it's an unexpected death, there would be a root cause analysis --
Chair Jeff Miller: What would be an expected death on an operating table?
Mary Berrocal: [Sighs.]
Chair Jeff Miller: I would expect if I went in for surgery, you wouldn't expect me to die. You'd expect me to recover. Now what is an expected or an unexpected death? What is that?
Mary Berrocal: Again, it's, you know, I'm not a clinician.
Chair Jeff Miller: You're the director of the medical center.
Mary Berrocal: Correct.
Chair Jeff Miller: For now.
Mary Berrocal: Not a clinician. I, uh -- I, uh, I am not a clinician, uh, but, uhm, I, uhm, I would expect that -- I-I would -- Any unexpected death would be something where, you know, if they, uhm, found something that they were not expecting to find. Uh, I, uh-uh, you know, I believe that, uh, any death would --
Chair Jeff Miller: Who makes the determination as to whether it's expected or unexpected?
Mary Berrocal: [Long pause while she shakes her head repeatedly] There are systems in place to, uhm, to report, and we -- [a man hands her a note] and we've had, we've had a variety of -- of, uhm, of groups come and look and determine that we have done things appropriately. [Reading from card passed to her] All deaths are reported and they are investigated but not necesserarily through, uh, the RCA process. We do investigate, again, we do peer reviews to determine --
Chair Jeff Miller: Is a peer review punative?
Mary Berrocal: Uh, it could lead to be. But, uh, not necessarily a peer review. There's a group of peers that review to see whether or not the care that was provided was adequate care.
Chair Jeff Miller: So if everybody just decides that the care was adequate and that it was an expected death, you may not even report that to the VISN, right?
Mary Berrocal: Then there's a committee that, uh, reviews after, there's a, uh, peer review, it goes to a committee and then a deterimination is made. There is -- There are rankings or scores that are provided determining whether or not it's a --
Chair Jeff Miller: Who makes the final determination as to whether or not it is sent to VISN?
Mary Berrocal: They are sent to the VISN. The deaths are reported to the VISN.
Chair Jeff Miller: All deaths? All of them? Is there ever a death that's not reported to the VISN.
Mary Berrocal: Uhm, uh, we have, for example, deaths in the hospice, these would be expected, you know.
Chair Jeff Miller: I'm talking about on the operating table.
Mary Berrocal: I would expect --
Chair Jeff Miller: I'll let you think on that. Mr. Johnson?
There are a number of developments that are questionable and speak to a lack of oversight from the VA. But let's note the scandal from two years ago. When you give someone AIDS because you are not cleaning your equipment, the head of the facility needs to go down with everyone else. That's Mary Berrocal. Hepatitis is nothing nice to have either but what took place under Berrocal's watch, grasp this, is going to result in big money pay outs (there's already one lawsuit seeking approximately 30 million dollars). And most jurors would vote (I certainly would) to award the victim the maximum amount of money. Grasp that Mary Berrocal is paying a penny in any settlements or law suits or anything. The screw ups at her facility cost the US tax payer.
People have diseases they caught from Berrocal's facility because Berrocal didn't know how to supervise a facility. She shouldn't be running it. And grasp that she was removed from her position. Temporarily. Fred Tasker (Miami Herald) was reporting a year ago, "Mary Berrocal, director of the Miami Veterans Administration Healthcare System who was temporarily reassigned in July during a scandal in which thousands of South Florida veterans were given colonoscopies with improperly cleaned equipment, was back on the job Friday. It happened quietly. The announcement was made internally, without public notice. VA officials at the local, regional and national levels failed to return phone calls and e-mails seeking comment." They brought her back. And brought her back to leadership. After people were infected with diseases under her watch, she was put back in charge.
Where is the leadership at the VA? And maybe Barack needs to get off his candy ass and demand Shinseki's resignation. Maybe then, the VA will realize that these actions are not acceptable, do not show leadership and are not what the veteran expects from a medical center or what the US tax payer considers work worth paying for.
US House Rep Johnson noted a Fred Tasker Miami Herald article from last month: "Miami Veterans Administration hospital director Mary Berrocal and her former chief of staff, Dr. John Vara, should be disciplined for 'lack of oversight' that led to long delays in notifying 79 local veterans that they might have been infected with HIV or hepatitis through improperly performed colonoscopies at the hospital, a VA board has concluded." Johnson noted this information while questioning William Schoenhard (Deputy Under Secretary for Health for Operations and Management, Veterans Health Administration, VA). Johnson pointed out that the information in the article was only obtained via a Freedom of Information request and . . .
US House Rep Bill Johnson: In documents submitted to us just last night, by the VA, only a draft unsigned and undated recommendation for action war provided and then 30 minutes before today's hearing a notice of admonishment was provided that was dated December of 2010 with no specific day. Can you clarify and explain this discrephancy and how that fits into your 'we're going to hold leadership accountable'? Yeah.
William Schoenhard: Yes, sir. The AIB recommended administrative action. The one that I conveyned, the national AIB, after the second disclosure of the veteran who had not been contacted and found that there was reason to take administrative action against the medical director and the chief of staff. The way that works in VA then is that I shared that report with Mr. Weaver and he took the administrative action. He may want to speak to the process we use in VA and in government to
US House Rep Bill Johnson: What administrative action was taken?
William Schoenhard: An admonishment was issued against both these individuals.
US House Rep Bill Johnson: A-a veteran escapes the facility and dies --
William Schoenhard: No, sir. This was taken predating this incident.
US House Rep Bill Johnson: Okay. So this admonishment that came through the Miami Herald incident from a previous AIB, correct? Have I got this right?
William Schoenhard: That's correct, sir.
US House Rep Bill Johnson: Then the patient that escaped the center and subsequently committed suicide happened after that, correct?
William Schoenhard: That's correct, sir.
US House Rep Bill Johnson: Right. So, do you think the admonishment worked?
William Schoenhard: I think --
US House Rep Bill Johnson: Next question. Can you provide to this Committee, Mr. Schoenhard or Mr. Weaver, a record of disciplinary actions from the Miami VAMC over the last 24 months? I would specifically like to see -- and with the Chairman's approval -- I would like to see the incident -- you don't have to give us names for privacy -- I would like to see the incident and the action and what level of leadership and management that action was taken against. Miss Berrocal, last week, one of your employees was arrested for selling names of veterans. In the past six years, it's estimated that more than 3,000 veterans' information has been sold. Have you alerted any veterans that their information may have been compromised and if so how have you done that?
Mary Berrocal: Actually, this was an investigation that was done by the IG and it was a covert operation. I learned about it at the time shortly before they were going to be arresting the individual and at the time what we knew was there was more than one, there was information on 18 individuals that was compromised and then, uh, uh, on --
US House Rep Bill Johnson: Have those veterans been notified?
Mary Berrocal: The, uh, the, uh, --
US House Rep Bill Johnson: Yes or no, have those veterans been notified? You talked earlier about a process for making sure that veterans are notified. I've heard that from various pieces of testimony this morning --
Mary Berrocal: We-we are in the process now of finding
US House Rep Bill Johnson: So they have not been notified? When was the guy arrested?
Mary Berrocal: Uh, this just happened in the last --
US House Rep Bill Johnson: And you didn't know anything about the investigation prior to his arrest?
Mary Berrrocal: I knew that they were doing an investigation and that they had some concerns The individual --
US House Rep Bill Johnson: So prudent leadership would be poised and ready to act if the investigation proved out, right? That you would immediately begin to notify those veterans whose information had been compromised. And you're saying that as of today, there have still been no veterans notified? You're only in the process of? 18 veterans. How long does that take? I can make 18 phone calls in 30 minutes.
Mary Berrocal: We have, uh, worked with our privacy officer to make sure that the, uh, information is done and, uhm, that we communicate to those veterans as we need to.
US House Rep Bill Johnson: Okay and have they been communicated with?
Mary Berrocal: I believe so. I --
US House Rep Bill Johnson: You believe so?
Mary Berrocal: Yes, sir.
US House Rep Bill Johnson: But you're not certain?
Mary Berrocal: The 18 have been communicated. The individual in the case --
US House Rep Bill Johnson: A few minutes ago, you told me you were in the process of notifying them. Now you're saying that they have been notified?
Mary Berrocal: We have communicated with the -- with the privacy officer whose --
US House Rep Bill Johnson: No, no, no. I'm not asking if you communicated with the privacy officer. Have the veterans whose information has been compromised been notified that there information has been compromised and sold by an employee under your direction?
Mary Berrocal: I will have to get that information for you.
US House Rep Bill Johnson: Okay. So now you don't know. First it was you've got a process. Then 'they have been notified.' And now you don't know. Mr. Schoenhard, if I'm the wing commander, I'm paying real close attention to these answers. Mr. Chairman, I yield back.
Chair Jeff Miller: I can answer the question for you. According to AIG last night, they have not been contacted.