Audit cites lack of staff, false records at Grand Rapids veterans home
By Paul Egan and Kathleen Gray | Detroit Free Press | Published: February 19, 2016
LANSING, Mich. (Tribune News Service) — Lawmakers said Thursday they were disturbed after seeing a draft of a highly critical state audit, set for release Friday, that cites staffing shortages and mishandling of abuse complaints at the Grand Rapids Home for Veterans.
Care by nursing assistants was privatized at the facility in 2013 as a cost-cutting measure, but the home is chronically understaffed. And many of of the abuse and neglect complaints the auditor surveyed were not forwarded to the nursing director, as required, according to an audit draft summary obtained by the Free Press.
Also, state employees at the home mishandled prescription medication, the report says.
Two Senate committees announced Thursday they would hold hearings on the audit.
State Rep. Holly Hughes, R-Montague, vice chairwoman of the House Committee on Military and Veterans Affairs, said the report from Michigan Auditor General Doug Ringler is very disturbing.
"The mistreatment of our nation's heroes is unacceptable and must be stopped," Hughes said in a news release.
"We will get to the bottom of this and demand accountability from the people responsible."
The Free Press obtained a two-page summary of the report, stamped "draft." The draft report said the contractor the state hired to provide nursing aides, J2S Group, did not meet staffing requirements 81% of the time during four sampled months.
Auditors looked at surveillance video to show that only 47% of required room checks and 33% of fall-alarm checks were done, even though the home produced documentation that the checks occurred, the Associated Press reported after receiving a copy of the report from the state late Thursday. The audit found that of 38 abuse or neglect complaints made over a 23-month period, nine were not forwarded to the nursing director and stayed with the managers of departments against which the complaints were lodged — a violation of policy, the AP said.
Lauren DeVol, a spokeswoman for the Department of Military and Veterans Affairs, which runs the home, did not respond to telephone and e-mail messages seeking comment. J2S, the contractor, did not immediately respond to a phone message seeking comment.
The state estimated it would save about $4 million a year after it laid off about 150 state nursing aides and turned the work over to the contractor. The Civil Service Commission approved the privatization of the nursing assistant jobs in 2013 after hearing complaints about the quality of care J2S provides from union members, family members and residents. J2S had earlier provided fill-in nursing assistant help at the home.
Among the confirmed incidents later recounted to a legislative committee was one in which a nursing assistant placed tape over a veteran's mouth, although there was a dispute over whether the incident was part of a game or an act of cruelty.
Sen. David Knezek, D-Dearborn Heights, minority vice chairman of the Senate Military, Veterans and Homeland Security Committee, said that "pinching pennies at the expense of our servicemen and women is deplorable."
"Our veterans deserve exemplary care, as well as government accountability," Knezek said in a news release. "I am committed to working together to give our veterans the benefits they earned."
The time for talk is over, Knezek said, and joint investigative hearings with subpoena powers are needed "so that we can immediately hear directly from staff members and patients."
"I'm angry," said Sen. Margaret O'Brien, R-Portage, chairwoman of the committee. She said problems at the home are widespread and have persisted despite promises they would be corrected after an earlier audit, in 2013. O'Brien said she's prepared to work across the aisle to address them with urgency.
In addition to the understaffing issue, the auditor found:
--The home did not track or properly investigate or respond to residents' complaints, including complaints of abuse and neglect.
--The home did not properly administer non-narcotic prescription drugs, causing insurance reimbursement problems and potential quality of care issues. During the period the auditor reviewed, many prescriptions were refilled either late or five days early.
--The home also had not established adequate controls over non-narcotic pharmaceuticals, which were valued at $5.2 million over the 23-month review period, to ensure that they were not lost or misused.
--The home did not bill residents' insurance companies for all eligible prescription drugs and did not follow up with insurers when claims for prescription drugs were rejected. Those practices put at risk up to $883,700 in eligible insurance reimbursements over 23 months, the draft audit summary said.
In the audit, the agency agreed with the findings and said it is making changes to comply with recommendations. The home will discontinue the use of fall-alarm sensors in beds and wheelchairs after reviewing research indicating that the pressure-sensitive devices can increase rates of falling and limit mobility, the AP said.
Rep. Tom Barrett, R-Potterville, chairman of the House Committee on Military and Veterans Affairs, said he is "outraged to learn that our veterans are not receiving even the most basic of their care needs."
Brandon Dillon, chairman of the Michigan Democratic Party, said it's "the height of hypocrisy" for Hughes to say she will now get to the bottom of the mistreatment of Michigan veterans. In 2011, she voted for reductions in the departmental budget, which provided for the privatization move, he said.
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