Audit: Veterans home did not properly investigate abuse

Jonathan Oosting
Detroit News Lansing Bureau
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Lansing — State legislators plan to hold investigative hearings on “a troubling pattern of mismanagement” at the Grand Rapids Home for Veterans, which a new state audit finds failed to properly investigate allegations of abuse and neglect.

A report from The Office of the Auditor General, obtained by The Detroit News prior to public release Friday, revealed troubling issues at the state-run veterans’ home, a partially privatized facility where a combination of state and contract workers care for more than 430 residents.

“What is happening at the Grand Rapids Home for Veterans is unacceptable and a disservice to those who served our country,” state Sen. Margaret O’Brien, R-Portage, said in a statement. “Serious changes must be made.”

Auditors said the home was not providing sufficient care to residents, citing the facility for five “material conditions” and four “reportable conditions,” including:

■Failure to track, properly investigate or respond to member complaints, including allegations of abuse and neglect. During a 23-month period reviewed by auditors, the home did not send nine or 10 complaints of alleged abuse or neglect to the director of nursing. All 91 complaints during the period were forwarded to the department manager who was the subject of the complaint.

■Failure to meet required staffing needs. The contractor did not provide adequate staffing 81 percent of the time during the 4-month period reviewed by state auditors. The home was up to 22 staff members short on any given day.

■Documentation of member location and alarm checks that never occurred. Auditors reviewed surveillance video and confirmed that 43 percent of location checks did not happen even though the home reported a 100 percent rate. Supervisors certified 17 of the 25 location checks that did not occur. Thirty-three percent of alarm checks did not happen despite the home’s 96 percent reporting rate.

Leslie Shanlian, CEO of the Michigan Veterans Affairs Agency, said the state is already taking steps to address concerns raised by the audit, including improper complaint investigation procedures.

The allegations of abuse and neglect cited in the audit were investigated by the home, she said, but not by the director or nursing, who was on leave during the review period. The agency is now requiring all complaints to be addressed in 72 hours and has shortened the window to 24 hours for allegations of neglect and abuse.

“We are doing a lot,” said Shanlian, who was appointed by agency director Jeff Barnes in October. “There’s a lot of work to be done. It’s been broken for decades — it’s not a recent thing. It’s going to take some time to (fix), but we are moving very quickly to get the standard of care to where we want it.”

A summary report of the audit distributed Thursday prompted swift calls to action from legislators on both sides of the aisle.

Sens. O’Brien and Peter MacGregor, R-Rockford, announced plans to hold joint hearings before their Veterans, Military Affairs and Homeland Security and Oversight committees. The hearing dates have not yet been set.

Sen. David Knezek, a military veteran and minority vice chairman of the Senate committee, said he was “devastated” by the audit findings.

“Now is not the time for talk. It’s time to take action. Joint investigative hearings, with subpoena power, are necessary and should be held at the Grand Rapids Home for Veterans so that we can immediately hear directly from staff members and patients,” said Knezek, D-Dearborn Heights.

State Rep. Holly Hughes, vice chairwoman of the House Committee on Military and Veterans Affairs, issued a statement calling the preliminary report “very disturbing.”

“The mistreatment of our nation’s heroes is unacceptable and must be stopped. When the full report is issued Friday, I intend to look over every detail of it and look even closer into this issue over next few weeks and months,” said Hughes, R-White River Township.

Michigan legislators opted to partially privatize the facility in 2011, a move that was projected to save the Department of Military and Veterans Affairs $4.2 million a year.

J2s Group Healthforce of Grand Rapids won a state contract to supply “competency evaluated nursing assistants” at the Veterans Home, and records show the state has paid the company more than $6 million since 2013.

Unions, which had represented about 180 state workers who were laid off under the privatization plan, have been highly critical of alleged understaffing at the Grand Rapids facility.

“Once they took over, there has been complaint after complaint after complaint,” said Nick Ciaramitaro of American Federation of State, County and Municipal Employees Council 25, who said former workers continue to visit residents at the facility and are concerned about conditions.

Mike McWhirter, an employee assistance representative for UAW Local 6000, raised alarms over staffing levels at the veterans’ home during a March 2013 meeting of the state Civil Service Commission.

“We’ve been very vocal about these concerns from Day One, and this went back to them trying to save moneys or shift moneys around there,” McWhirter said Thursday, referring to the state contract for privatized nursing care.

“It’s embarrassing, it’s shameful that they would allow them to cut corners for veterans who have, it goes without saying fought to protect our country.”

The understaffing issues cited in the audit were based on contractual requirements, according to Shanlian, who said the Grand Rapids home remained in full compliance with staffing standards set by the U.S. Department of Veterans Administration.

The agency is working with J2s to amend its contract by allowing full payout only if the company meets performance goals. The contract expires at the end of September, and Shanlian said the agency will evaluate its options at that time.

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