Department of Veterans Affairs clinics in Colorado kept secret wait lists of patients and underreported chronic delays in treatment, according to an investigation Thursday that was the second report this week of failures in VA handling of mental health care.
The VA Inspector General found that the agency’s health care facilities in Denver, Golden and Colorado Springs used “unofficial wait lists” and failed to follow rules for keeping track of veterans seeking treatment for problems such as post-traumatic stress disorder.
“The lists did not effectively identify veterans waiting for care or the length of their wait time,” the report said. “As a result, facility management could not make effective staffing decisions to ensure it addressed all requests.”
The VA clinic in Colorado Springs underreported patient wait times in 91 percent of cases in fiscal 2016 and wrongly denied at least 210 veterans access to the popular Veterans Choice Program that allows treatment by private doctors.
“Veterans experienced under-reported delays by an estimated 50 days for initial treatment, and management did not have assurance that staff attempted to schedule all veterans,” the inspector general said.
Lawmakers requested the investigation last year after a whistleblower reported that the Colorado Springs clinic may have falsified documents after a 26-year-old Army Ranger committed suicide while waiting for post-traumatic stress disorder care. Those lawmakers said Thursday that the report confirmed some of their worst fears.
“Putting veterans on secret wait lists is not acceptable,” said Sen. Ron Johnson, Wisconsin Republican and chairman of the Senate Homeland Security and Governmental Affairs Committee. “The VA should implement changes to provide the highest quality care for our veterans and hold wrongdoers accountable.”
Sen. Cory Gardner, Colorado Republican, said the report “highlights even more VA mismanagement and lack of accountability in Colorado.”
“This cannot happen again, and it’s time for the VA to finally wake up and ensure our men and women are getting the best care possible,” Mr. Gardner said.
The report said unofficial wait lists for 44 group therapy clinics “contained 3,775 individual entries,” but investigators couldn’t determine “which veterans had received care, which were actively waiting to receive care, or for how long.”
The findings were reminiscent of one of the VA’s biggest scandals during the Obama administration — the use of secret wait lists in Phoenix, where dozens of veterans died while awaiting appointments for medical care.
The report was the second probe this week to uncover ongoing concerns about the way the VA handles mental health treatment in its vast system. The IG also reported this week that a VA clinic in New Jersey repeatedly failed to provide mental health care for a Gulf War veteran in the months before he committed suicide by setting himself on fire in front of the clinic.
The VA clinic in Northfield, New Jersey, canceled a counseling appointment for Navy veteran Charles Ingram, 51, in 2015 because no therapist was available. The agency didn’t reschedule an appointment until Ingram came back to the clinic, then gave him an appointment for three months later, the department’s Office of Inspector General found.
Before his next counseling session, on a Saturday in March 2016, Ingram walked nine miles from his home to the clinic, doused himself in gasoline and set himself on fire on a grassy area next to the parking lot. The clinic was closed at the time; a bystander tried to put out the fire with a blanket. A medical helicopter flew Ingram to a hospital in Philadelphia, where he died that night.
The inspector general found “a series of … staff failures prevented the patient from receiving requested [mental health] care during the 11 months prior to his death, including deficiencies in the [clinic’s] management of walk-in patients, no-shows, clinic cancellations, termination of services.”
“These failures led to a lack of follow-up and therapy for this patient who denied suicidal ideation yet, according to a family member, was in distress,” the report said. “The patient was very upset with VA and the [clinic] because he believed staff did not return calls and were rude, and he experienced problems scheduling appointments.”
Each day, an average of 22 veterans commit suicide, a VA report concluded in 2016. Ingram had undergone a divorce and then lost his job about a month before he killed himself. The veteran had received mental health treatment at the clinic since 2011, but often was required to wait more than a month for appointments.
In the year before his death, Ingram hadn’t seen a therapist. VA policy requires reaching out to such veterans, but the IG concluded “we found no attempts to follow this process.”
After the death, VA Secretary David Shulkin devoted more resources to the clinic, removed the hospital director in charge of the facility and ordered new management for the clinic.
The regional VA office said it agreed with the report’s findings and is instituting other managerial improvements to be completed by March 2018.
VA officials said schedulers at the clinic have received more training.