Less than a decade after a federal investigation into the Marion Veterans Affairs Medical Center resulted in wholesale changes to its surgical department, the Marion VA is again under investigation.
The Veterans Affairs Congressional Oversight and Investigation Subcommittee is looking into allegations made by whistle-blowers and other informers from within the Marion facility -- among them that radiology tests were misread and the mistakes were covered up; that employees who complained about what they considered mismanagement within the VA were bullied or in some cases reclassified or fired; that nepotism has figured into some hirings; and that in general the culture inside the VA is not transparent.
Officials said various complaints have been made to congressman Mike Bost (R-Murphysboro), who is vice chairman of the Congressional Oversight and Investigation Subcommittee; U.S. Sens. Dick Durbin and Tammy Duckworth; the Office of Inspector General; and the Office of Special Council.
The investigation is ongoing, and no date has been set for its conclusion. It was originally expected to be completed by Sept. 1, but Bost said it wasn't ready.
"People obviously want answers as soon as possible," he said, "but we want the investigation to be conducted in the most thorough and professional manner."
JoAnn Ginsberg, who was appointed director of the Marion VA in September 2016, told this newspaper in a Sept. 11 email that the VA welcomes the investigation.
"In fact, I have requested that several oversight bodies visit to take a look at our organization to validate our successes and provide feedback for improvement," she wrote.
"We continuously strive to provide high quality care to our veterans, and always welcome suggestions to improve our processes."
And, while "events at the Marion VAMC are concerning, there are currently no indications that patient safety is an issue," U.S. Secretary of Veterans Affairs David Shulkin wrote to Durbin and Duckworth on Aug. 10, in response to their calls for an investigation.
Bost cites a May 31, 2017 internal memo from the VA National Center for Patient Safety, which said the Marion facility has experienced significant declines in patient safety culture metrics and employee morale since those areas were assessed by the VA in 2014.
In its 2014 assessment, the Marion VA facility was found to be "above average" in all but three assessment areas, a dramatic turnaround from 2008, when a report from the VA Office of the Inspector General found that at least nine patient deaths in Marion were "directly attributable" to surgical mistakes and poor post-surgical practices, and that more than a dozen additional patients had suffered serious harm.
The 2008 report added that the surgical unit was in "complete disarray," with some doctors performing surgeries they weren't qualified to perform, and that hospital administrators responded slowly or not at all to complaints or problems that surfaced.
"They had a very bad report in 2008," Bost said.
However, the 2014 report indicated the problems found in 2008 had all been remedied, Bost added.
Then, in 2015, a "significant number of emails and phone calls from the Marion staff," started being received, prompting the VA National Center for Patient Safety to visit the Marion facility.
On May 31, 2017, the NCPS released an internal memo, detailing allegations of retaliation, unprofessional conduct and bullying toward CLC employees, nepotism and a lack of transparency.
The memo also said whistleblowers allege the "culture has led to personnel problems" -- problems it said "were exacerbated by alleged poor management and communication structures, distrust between some Marion employees and management, a history of retaliation toward employees raising issues, and a lack of accountability across all grade levels."
The memo cites reported instances in which reports from employees to leadership regarding patient safety concerns "have either disappeared or were not appropriately submitted to (the) new director (Ginsberg) by leadership staff."
One of the most disturbing allegations in the NCPS memo is an employee complaint stating that since October 2016, 15 veterans who were at the Community Living Center for rehabilitation died during or shortly after discharge.
The CLC is a 54-bed nursing home facility on the VA campus, providing short-stay and skilled care rehabilitation, respite, geriatric and general nursing care.
As well, a follow-up assessment of the Marion VA Medical Center made in 2016 showed that in two short years the facility was now listed as "below average" in all areas, Bost said.
"I want to know how they slipped back so fast," Bost said.
"We are requesting from the VA all information from top to bottom," he said, adding he expects the investigation to lead to a Congressional hearing.
At a town hall meeting at the Marion VFW on Aug. 22, veteran Rocky Morris of Benton questioned Seth Barlage, associate director of operations, about the reported CLC deaths.
Barlage said there were actually 12 deaths, not 15.
He added those deaths were in all the hospice unit.
"What do people go there for?" he asked the audience. "It's expected."
Bost and his subcommittee chairman, Jack Bergman (R-Michigan) have ordered a review of all deaths in the CLC and reported deaths after discharge from the CLC, from October 2016 to present.
Aware of the complaints coming from Marion VA employees, Duckworth and Durbin this past spring urged an independent investigation by the Inspector General into patient care and management at the Marion VA Medical Center, saying employees there alleged mismanagement, including nepotism and intimidation, that resulted in the resignations "of desperately needed medical professionals and a shortage of clinical staff."
In a July 13, 2017 letter to Shulkin, the senators said they had serious concerns with "the lack of progress in improving patient care and safety" at the Marion facility.
"Simply put," they wrote, "the Marion VA Medical Center appears to be plagued by a hostile work environment that makes it difficult to recruit, hire, and retain talented medical professionals and clinical staff."
Ginsberg, who was hired after the latest patient safety culture survey was done in June/July 2016, said in her email that inviting oversight bodies into the VA has resulted in 25 reviews since January of 2017.
This newspaper requested a detailed list last week of those reviews, which has not been received.
Bost, meanwhile, said he considers the ongoing investigation to be an integral part of the VA structure.
"We do this because we want to make sure our vets are getting the best possible care they can get," he said.
