Inspector General says lack of leadership led to widespread problems at DC VA Abbreviated from STARS AND STRIPES Credit: NIKKI WENTLING - WASHINGTON — A culture of complacency at the Department of Veterans Affairs medical center in Washington D.C. allowed widespread failures to persist for years, putting veterans at risk and weakening core functions of the hospital, according to new findings from the VA Inspector General’s Office. An extensive report released Wednesday by the inspector general details “systemic” and “formidable” problems at the Washington DC VA Medical Center since 2013. “Failed leadership at multiple levels within VA put patients and assets at the DC VA Medical Center at unnecessary risk and resulted in a breakdown of core services,” VA Inspector General Michael Missal said in a written statement. “It created a climate of complacency that allowed these conditions to exist for years.” The issues were many and varied. Inspectors found a consistent lack of medical supplies and equipment, dirty and unsterile conditions, a flawed inventory system and chronic understaffing. They also discovered a backlog of thousands of delayed orders for items such as eyeglasses, hearing aids, surgical implants and prosthetic limbs. More than 1,300 boxes containing veterans’ personal health and identification information were found unsecured in a warehouse, the hospital basement and a trash bin, according to the report. Millions of dollars were spent without the controls to determine whether the expenses were necessary. Hospital and regional leaders were tipped off about the problems multiple times during the past five years but didn’t intervene, the report states. Inspectors said they deflected blame and failed to address the “prevalent and deeply intertwined” issues with any sense of urgency. “It was difficult to pinpoint precisely how the conditions described in this report could have persisted at the medical center for so many years,” inspectors wrote. “At the core, the IG noted an unwillingness or inability of leaders to take responsibility… [and] found that a culture of complacency and a sense of futility pervaded offices at multiple levels.” The former director, Brian Hawkins, was immediately removed from his duties and officially fired in September. He was replaced by Lawrence Connell, a senior adviser at VA headquarters. “I was not aware of these issues,” he told reporters during a Wednesday news conference at the hospital, which is located just three miles from the White House and VA headquarters. “This report has identified unacceptable findings of grave concern to all of us in leadership,” Shulkin said. “This represents to me a failure of the VA system at every level – a failure at the facility level, a failure at the network level and a failure at the central office.” Some of the findings at the Washington hospital likely exist at other VA facilities, Shulkin said. He’s ordered reviews of job vacancies at all facilities and tasked an independent health care organization to conduct onsite, unannounced inspections of VA hospitals nationwide, he said. Shulkin also announced leadership changes. Bryan Gamble, who helped lead the Orlando VA, was moved to Washington to oversee three VA networks of particular concern, including the VA Capitol Health Care Network of which the Washington hospital is a part. The other two are the New England Healthcare System and the Desert Pacific Healthcare Network. Together, the three networks are responsible for about 20 VA hospitals. Shulkin announced the retirement of Michael Mayo-Smith, the leader of the New England network, and Marie Weldon, who is in charge of the Desert Pacific network in Phoenix, at the end of the month. On Tuesday, members of Congress called on Mayo-Smith to be removed from his position. Rep. Annie Kuster, D-N.H., criticized his response to findings last year of deteriorating conditions at the VA hospital in Manchester, N.H. “These choices on retiring were totally the choice of the individuals. There should be no attempt to read into anybody being forced out of this organization,” Shulkin said. Restructuring will start in those regions, and the changes will likely extend across the country, Shulkin said. A restructuring plan is expected to be in place by May. VA leadership first reviewed the IG’s full report last month. In a written response, Carolyn Clancy, the executive in charge of the VA health care system, insisted “substantial progress” had been made at the Washington facility since the interim report was issued in April 2017. The VA awarded a nearly $9 million contract to construct a 14,200-square-foot sterile processing space at the DC hospital that will be completed in 2019, Clancy wrote in a letter attached to Wednesday’s report. The agency also spent $3.1 million on surgical instruments for the hospital, she said. The 43-person team that completed the investigation concluded that no patients had died or been physically harmed because of the problems outlined in the report. They credited a group of committed staff members who “worked around these challenges and improvised as necessary” to provide the best possible treatment, the report states. “We are all grateful to the staff at the DC VAMC who demonstrated strength, creativity and commitment to ensure that veterans were safe during this difficult time,” Clancy wrote in her response. However, inspectors determined patients were put at risk and their medical care affected. The report cites incidents of surgical procedures being delayed or canceled because of a lack of supplies and instruments, and some veterans waited months to get the equipment that they needed. As of March 2017, the hospital had more than 10,900 delayed orders, including nine for prosthetic limbs. In one case, a veteran requested a new artificial leg because of pain and waited more than a year to get one. In the end, the veteran moved away from the Washington area and received a new prosthetic from a VA facility in a different state – 417 days after he first requested it. For more information visit the full article here “There is no doubt there have been unfortunate distractions,” he said. “Those days are over. My leadership team is totally focused on this work.”
VFW to Congress: 'Repeal Sequestration Once and for All' Testimony caps the 2018 VFW Legislative Conference WASHINGTON – This morning, before a joint hearing of the Senate and House Veterans’ Affairs Committees, the Veterans of Foreign Wars of the U.S. delivered testimony focused on ending sequestration and improving the care, services and programs provided by the Department of Veterans Affairs.  “The VFW is pleased Congress recently passed a bipartisan budget agreement to alleviate the sequester’s impact on our military and veterans, but you only delayed its return by two years,” VFW National Commander Keith Harman told members of the committees. “Our service members, veterans and their families are counting on you to repeal sequestration once and for all!” Harman commended the committee members in attendance for making some VFW-proposed changes to the Choice Program that have improved access to care, but reminded them the Choice Program is merely a stopgap, and must be replaced with a permanent and improved program that would: Ensure timely access to high quality care; Consolidate VA’s community care programs into an easily understood and administered program; and Consolidate funding. “In addition, any bill to improve how veterans’ access private-sector care must also correct problems at VA medical facilities,” said Harman. “This is why the VFW calls on Congress to pass the Caring for Veterans Act of 2017, which would ensure veterans have timely access to high-quality health care that is tailored to their unique needs.” Harman also conveyed the VFW’s strong support for the full expansion of caregiver benefits to veterans of all eras, stating “As a multigenerational organization with roots tracing back to the Spanish-American War, and with members from every war and contingency operation through Iraq, Afghanistan and Syria, the VFW believes it is disgraceful that Congress has failed to properly recognize the sacrifices of those who have put their lives on hold to care for their pre-9/11 veterans.” The VFW national commander went on to note the VFW’s support of several “common sense” proposals included in the president’s budget, such as closing the loophole which allows flight schools to charge exorbitant fees for flight training and authorizing VA doctors to practice medicine across state lines. Several other key points in Harman’s testimony included the VFW’s support for VA’s adoption of the same electronic health care record as the Department of Defense, providing VA the resources it needs to meet the demand on its mental health services, and working to ensure women veterans have access to health care and services designed to fit their needs. Video of today’s testimony will be available at today at 2 p.m. EST, and the written version can be accessed here.  Today’s testimony marks the end of the 2018 VFW Legislative Conference, where approximately 500 VFW leaders traveled to the nation’s capital to discuss various veterans’ issues, as well as the VFW’s expectations of lawmakers.  Other notable events from this year’s conference included: A VFW-hosted dinner at the National Press Club for more than 70 wounded, ill and injured warriors and caregivers from Walter Reed National Military Medical Center, along with their families; Rep. Rodney P. Frelinghuysen (R-N.J.) being presented the VFW Congressional Award in recognition of his years of unwavering support to veterans, service members and their families; VFW Voice of Democracy winner Robyn Anzulis, sponsored by VFW Post 10076 and its Auxiliary in Mt. Airy, Md., receiving the $30,000 T.C. Selman Memorial Scholarship award; and VFW Patriot’s Pen winner Karolina Mazur, sponsored by VFW Post 521 and its Auxiliary in Owings Mills, Md., receiving her $5,000 award.
WASHINGTON — Department of Veterans Affairs Secretary David Shulkin will be reorganizing the agency from top to bottom, starting with national headquarters essentially taking over and consolidating oversight of VA medical centers in 12 states. This is a historic change for the VA. Three regional directors who oversaw 23 hospitals serving nearly 3 million veterans are removed, and their offices report now to a new executive in Washington. Two of the directors opted to retire — Michael Mayo-Smith, who oversaw VA medical centers in New England, and Marie Wheldon, director of VA hospitals in Arizona, New Mexico and Southern California. The third, Joseph Williams, was reassigned. He had supervised VA facilities in West Virginia, Maryland and Washington. Shulkin’s moves follow an inspector general report released Wednesday that found local, regional and national VA officials knew for years about severe financial and equipment mismanagement at the Washington VA medical center but didn’t fix the issues. Various national policy offices had received reports about the problems dating back to 2013, but Shulkin had not been informed, the inspector general said. “I recognize this as a system failure issue, and this isn’t just about fixing the specific problems that the report mentions,” he told USA TODAY. “Essentially this is the opportunity to address similar issues around the country.” Shulkin assigned Bryan Gamble, a former private-sector health care executive who has been working at the Orlando, Fla., VA medical center, to take over oversight of the three regions and to lead an effort to draft a plan to reorganize VA regional governance as a whole by July 1. Since the 1990s, the agency hospitals have been divided into regions, each with its own director. Currently there are 21 such regions. Those directors then report to national headquarters. But over the years, the extra layers of bureaucracy have grown, defusing accountability and at times throwing up barriers to improvement of front-line health care provided to veterans. For example, VA officials at the local, regional and national level knew for years about widespread falsification of patient wait times before a national crisis exploded in the headlines in 2014. The secretary at the time, Eric Shinseki, was not aware of the breadth of the problems. He resigned amid the fallout. VA officials at multiple levels also knew about dangerous rates of opiate prescriptions doled out at a VA medical center in Wisconsin, but the issue wasn’t fixed until news reports revealed a veteran died from mixed drug toxicity at the hospital in 2015.
By Gigi Haddad “Moral Injury” was popularized in the in the mid-1990s, by Jonathan Shay who was working with veterans suffering from psychological trauma. In his book, “Achilles in  Vietnam”, Dr. Shay describes the moral injury as a result of being ordered to do something in a high-stakes situation that violates an individual’s moral beliefs. Soldiers are often ordered to carry out immoral acts such as killing enemy soldiers, tossing grenades into houses, burning down villages and are told to do so regardless of age, innocence, or loss of life. These atrocities become hard memories that many veterans cannot shake. Due to the fact that many symptoms overlap, many may believe that “Moral Injury” is the same disorder as those with PTSD or traumatic brain injuries. Yet, there are differences. The biggest distinguishing factor of “Moral Injury” is the persistent sense of guilt, shame, and ethical “drift” where veterans no longer have a clear sense of right or wrong. In treating veterans with moral injuries, clinicians tend to focus on addressing the symptoms and often advocate for the patient to forgive his or her self. But forgiveness may not be the key to help veterans heal. Soldiers often describe the traumatic events connected with moral injury in terms of split loyalties or of having to make the impossible decision of betraying one ideal for another. Betrayals like these are not easily fixed. In order to help those who suffer from moral injury, the focus should shift from forgiveness to creative deeds of atonement (volunteering, being a good parent, etc.). Recovery from moral injury begins with identifying the causes and communities that were sacrificed in the heat of battle and finding creative ways to re-establish loyalty to those causes. Once establishing a path forward from the irrevocable that haunt them, veterans can better overcome the hidden problem of Moral injuries.
David Garrett, a disabled veteran who had served in Iraq and Afghanistan, returned from war to find that he had no home and sadly, he is not the only one. Nearly 50,000 veterans sleep on the streets each night. The biggest reason as to why this is a growing problem is simple: they need lawyers. According to a new study from the Department of Veterans Affairs, at least five out of the top ten problems leading to homelessness among veterans cannot be solved without legal help. Legal assistance is critical to ensure that veterans find justice to get the benefits they have earned and a step to ensuring a roof over their heads. Many veterans also have physical and mental disabilities that would make them eligible for disability compensation. Yet, without an official diagnosis, the VA can deny an application for disability compensation, leaving veterans with no jobs and no benefits, resulting in homelessness for many. There are now many emerging partnerships between civil legal-aid and community health and housing organizations can permanently transform veterans’ lives but require investment to meet the need. Congress can also help by passing the veterans omnibus bill, section 608 of which would authorize the VA to provide funding to the organization that provides civil legal services to veterans who are homeless or at risk of being homeless.Still, until bigger action is taken, many veterans face homelessness and instability. By Gigi Haddad Source:
TOLEDO - A three-judge panel has rejected a local woman's appeal of her sentence as "frivolous" after she was convicted of helping to steal $220,000 from the Fremont VFW. Ohio 6th District Court of Appeals Judges Mark Pietrykowski, Thomas Osowik and Christine Mayle on Friday affirmed the Sandusky County Common Pleas Court's decision to sentence Jodi Martin, 43, to 12 months in prison after she pleaded guilty to felony theft from the VFW over a five-year period while working as a manager of the post's canteen. In May 2017, Sandusky County Assistant Prosecutor Mark Mulligan sought 60 days in jail for Martin as part of her plea, but Sandusky County Pleas Court Judge John Dewey said he was "troubled" and "offended" by Martin's actions and gave her the maximum sentence of 12 months for her plea to a fifth-degree felony. "I am not a member of the VFW, and I didn't serve in the military, but I am personally offended myself at this amount of money that comes up missing," Dewey said before sentencing Martin last May. Martin's appeals attorney, Brett Klimkowsky, filed a brief with the 6th District Court of Appeals in Toledo to withdraw as Martin's appeals attorney, effectively dropping Martin's appeal. As part of her sentencing, Martin was ordered to pay $175,000 in restitution to the VFW. Andrea Valdez, 40, of Fremont, also was found guilty of participating in the theft from the VFW's gambling business from 2010 to 2014 and was sentenced to 18 months in prison. The more than $220,000 that was stolen from the VFW had been designated for community Little League scholarships and scholarships for local graduating seniors. As part of her sentence, Valdez was ordered to pay $75,000 in restitution. Although the women were ordered to pay restitution, Craig Schwartz, the VFW post's quartermaster, said he does not expect to see much, if any, of the money again. "It's going to be tough to get that money back," Schwartz last May. "But justice was served." Because Martin accepted a plea deal, the three-judge panel said the "appellant understood the nature of her guilty plea and answered affirmatively when advised of each of her constitutional rights she would be forfeiting by not proceeding to trial," the decision said. The judges also stated that Martin knew the court was not bound by the 60-day jail sentence the prosecutor proposed and could face the maximum sentenced of 12 months, which Dewey gave Martin at her sentencing on May 22, 2017. "We agree with counsel and find no error in the plea before the trial court," the judges opined. "The motion of counsel for appellant requesting to withdraw as counsel is granted, and this appeal is found to be wholly frivolous."   Source: The News Messenger
In a dual effort, the Department of Defense and the Veterans Affairs have worked together to create an easier solution to discharges from the military. The advancement is in the form of a new and upcoming online tool that helps upgrade the system in which discharges are required. The process is pretty simple and very much anticipated as the former system drew complaints and lack of clear-cut instruction to handle upgrades. Officials in charge of the upgrade made announcements about the process and stated that the process was relatively simple, something that veterans and participants of the program are grateful for. "By answering a few short questions, veterans will know which board they need to go to, what form to fill out, any special guidance applicable to their case, where to send their application, and some helpful tips for appealing their discharge. Any veterans who believe their discharge was unjust, erroneous, or warrants an upgrade are encouraged to use this tool and then apply for review." This is a great opportunity for those who feel like they were let go of their service in the military unfairly. Among anticipated participants in the program are those who were medically discharged for reasons that may include post-traumatic stress disorder or those who suffer from traumatic brain injuries. Among the other possible inclusions, those whose discharges fall under the “Don’t Ask, Don’t Tell” policy, or those like them may be included in this initiative. This is an incredible amount of progress, as this is long awaited and serves the veterans who served justly. As Robert Wilkie states, "We are thrilled to have partnered with the Department of Veterans Affairs in developing this wonderful and easily-accessible tool.” Wilkie goes on to say, "We support our veterans, whether they served recently or long ago, and we are excited to introduce a tool that will individualize the guidance for those who desire an upgrade or change in their military discharge." Wilkie is a Fayetteville native and undersecretary of defense for personnel and readiness. It is this type of progress that breathes new life in the Veterans Affairs as well as the Department of Defense. There is more much updates and inclusions to come in the future. It will be interesting to see how the advancements will change the scope of how the military is viewed.      
Sen. Johnny Isakson, R-Ga., is chairman of the Senate Committee on Veterans’ Affairs and he is committed to our veterans. He understands the predicament we, civilians, put our veterans through upon their arrival. When Isakson became chairman of the U.S. Senate Committee on Veterans’ Affairs at the start of 2015, he made a personal commitment to work with anyone willing to fix the problems at the VA. And that is the type of initiative that one needs to see to acknowledge that work is being done. There will always be this type of committed work outstanding, but as long as we have honest, hardworking people in appointed power, the advancements will chip away at the need. Isakson states that since holding that title, progress has been made. In 2017, “positive productive and bipartisan progress” has been made that has overshadowed years in the past. Last year, the Senate has added ten major pieces of veterans legislation, all of which have been signed into law. This type of work has helped reform the VA and strengthen veterans’ health care, benefits and support. This is monumental as it worth talking about. Isakson goes on to say that, “We have one of the most bipartisan and productive committees in the Senate. Every single member of our committee, (within the Veterans’ Affairs committee) Republican and Democrat alike, have put aside partisan differences and worked together on behalf of our nation’s veterans.” This is also really important to note because that means that lawmakers are working together despite their differences and this is an incredible show of progress and maturity. Some of the newer legislation has improved veterans’ lives. Here are a few examples: “Veterans Affairs Accountability and Whistleblower Protection Act,” we’ve given VA’s leaders the tools to remove poor-performing or negligent employees. This is important because prior to the bill being made, there wasn’t any real sense of protection for either party. Another example is this: “The Enhancing Veteran Care Act” authorizes VA to contract with non-profits that accredit health care organizations to investigate VA medical centers and improve accountability. With the “Veterans Appeals Improvement and Modernization Act,” we’re working to break down bureaucratic barriers and help develop an improved, more responsive and quicker system for veterans. Lastly, the “VA Prescription Drug Accountability Act” allows the VA to take every necessary precaution to ensure patients are aware of the dangers of opioid addiction by sharing patient information with state prescription monitoring programs. All of these changes have exponentially helped our veterans and consequently their families. In closing, Isakson states that “At the start of 2017, senators on the VA Committee vowed to find common ground on behalf of veterans, and we have significant, positive results to show for it. We still have work to do, but we are heading in the right direction.”  
9/11 era veterans (those who served in Afghanistan and Iraq) and the battle of their healthcare has been a long saga and at times a thorn in the side, for those who desperately need help post serving. It should be simple to give those who served healthcare, but it has been a hardship to maneuver. There is, of course, no easy fix. The stresses of choosing to serve our country have been painfully evident for years, and it seems like we are just starting to become more active in advocating for our veterans. In 2014, the suicide rate among veterans was about twenty-two percent higher than among adults who had not served in the military, the VA reported in September. The VA has had persistent problems trying to care for the more than four million service members who have left duty since the start of the U.S.'s 16-year war in Afghanistan. With the number of the veterans so large and the numbers of people available to help significantly smaller, especially since the number of those who are equipped to help in the most needed ways, there is a challenge to emotionally and physically see every veteran. That is when veterans struggle if they are not seen. Due to the aforementioned circumstances, a committee has started to fight for veterans’ healthcare rights as they are entitled to them. While many veterans do indeed receive good mental health care through Veterans Affairs, it's inconsistent across the system, according to the report from the National Academies of Sciences, Engineering, and Medicine-nonprofit institutions that inform public policy. The detailed, 439-page assessment of the VA's mental health services was ordered by Congress in 2013 and completed by a committee of eighteen academics. The academics have worked together for those who are not in the perfect position to speak about those issues. And what they witnessed and heard is something that everyone should be aware of. What was reported that mundane issues like navigating parking for therapy were something that was a stressor for them, if they were dealing with mental illnesses, getting help did seem like an uphill battle as the need was high, yet the support they felt was limited. As stated in the committee’s findings, other factors such as lack of social support, distance, and fear of revealing a mental health issue may discourage veterans from seeking care at all. This is something we should be able to change and with this progress set in place, we should be on target to do so. Breaking down barriers to care will require reaching out to veterans and streamlining application processes, as well as investments in the VA workforce, facilities, and technology, according to the report. Emily Blair, manager of military and veterans policy at the National Alliance on Mental Illness, a nonprofit advocacy group, realizes that their goal of giving adequate healthcare to all veterans in three to five years is “an optimistic goal”, but is worth shooting for the stars for.
The Department of Veteran Affairs operates several different programs for those who are either survivors of the military or their families, such as spouse, parent, or child. One of the programs is called My Way Forward. On their official government website, it states that families of veterans or survivors are eligible for benefits regardless of whether their lost loved one was serving or already retired at the time of their death. Benefits available through the Veteran Affairs are varied and considerable, so take the time to become familiar with the programs. You can find more information at One of the more notable benefits is funeral services and that is offered to the veteran if their death was from a service-related injury, passed away in a Veteran Affairs facility or were in receipt of compensation or pension. The Veteran affairs cover the burial at a national cemetery which doesn’t cost the family anything. Their headstone is also covered. According to White Oak Crematorium, these benefits can have a range of anywhere between $300 to $2,000 depending on the veteran’s service status at their time of death. You can find more information at There are several organizations that give support to the families of the deceased. It is important to realize that while the family and friends may grieve a certain way, survivors of the same incident, may grieve in an entirely different way. These are only a few different organizations that help, but there isn’t one right organization. The Tragedy Assistance Program for Survivors (TAPS) is based in Washington, D.C., offers peer support network and grief-counseling referral service, which is an incredible resource. Mothers of fallen soldiers can find support from those who’ve had similar experiences through the American Gold Star Mothers. The Society of Military Widows helps military widows which is very helpful to find a new normal, whatever that may look like for them. If your loved one passed away on active duty as a result of service-connected disabilities or was fully disabled for 10 years prior to their death, you may be eligible for a tax-free monetary benefit. This is due to the Dependency and Indemnity Compensation. This is something that families should look into. You may be eligible for financial benefits. The DEA program has been made available to children of veterans who have been injured or passed away during active duty, offering them education and training. Health and educational benefits are also available to family members. This is important to utilize if only needed for a short time. You can find more information at