Transcripts For CSPAN2 Veterans Affairs Officials Testify On

Health administration that leave facility facilities open to diversion and harm. It is an incredible Patient Safety issue that puts veterans, va employees and the public at tremendous risk. Unfortunately, the news has recently been filled with story after story of Drug Diversions in the va. In little rock medical supplies and website were used to order and divert 4,000 oxycodone bills and viagra at the cost of the va. This technician was selling the drugs on the street where they had a value of more than 160,000. A va facility in florida, a registered nurse was apparently steeling oxycodone and hydro morphine from the hospital to feed her addiction. These are medications that should have been going to veterans for their care. These issues are in part a result of va having inadequate procedures in place to safeguard against theft and diversion of controlled substances. A recent Government Accountability office audit found one va center missed 43 of the required monthly inspections mostly in critical carriers such as the operating room and intensive care. Three other facilities didnt follow all of the requirements for inspections of controlled substances. This is not the first instance where weaknesses were identified in v arbss controlled substance Inspection Program. In 2009 and 2014 the va office of Inspector General found some medical facilities were not conducting monthly inspections and some inspections were incomplete. Va has been given multiple opportunities to address these concerns. This leaves me wondering what va is doing to repair the lax oversight and apparent abuse absence of accountability regarding these issues within va. To make matters worse, there are also issues with drug testing employees to ensure they are suitable to provide care to our veterans. A 2015 office of Inspector General report found that Va Medical Centers were not conducting preemployment and random drug tests for testing positions in many instances across vha which amounted to tens of thousands of employees not receiving drug tests required by the Drugfree Workplace Program. Most recently in january of 2017, the oig found high backlogs in background checks to include drug testing for high risk positions at the atlanta Va Medical Center. It is precisely these tools that have been put into place to help protect patients and Health Care Organizations from drug diverz versions and harm. However, va doesnt seem to be taking them as serious as it should. Based on the oversight reports and numerous diversion instances we will discuss today i am concerned that vas controlled substance Oversight Program is not working and that staff who fail to follow proper procedures are not being held accountable for violations. In case after case, what we see are examples of drugs being diverted for personal use or personal gain. Yet there doesnt seem to be much progress made by the va to correct the glaring problems that allow it to happen. What is more concerning is the programs to help deter diversion or identify illegal employee drug use are not being implemented. We are in the midst of an Opioid Epidemic it and it is time to make changes to avoid putting veterans and employees woo serve them atrisk. I recognize representative custard now. I am particularly interested as the founding cochair of your Congressional Task force to combat the heroin epidemic. This afternoon we are examining vas role in ensureing that Prescription Drugs are safely controlled in va medical facilities. Less than a year ago, former chairman kaufmann and i held a hearing on this issue in colorado because the Drug Enforcement agency, dea, found several violations in the denver vamc. We continue to hear disturbing reports from hospitals and clinics in our community that some Health Care Employees are stealing controlled substances for their own personal use for personal gain. We know that these cases are on the rise throughout the country. One Health Care Employee diverting controlled substance can be a serious risk and cause significant harm to many patients. We learned this in New Hampshire with the technician who was injecting himself with fentanyl and it turned out this had started at the Baltimore Va Medical Center and continued in more than a dozen hospitals in other states infecting up to 50 patients in our community with hepatitis c and some of these patients were veterans. From this example, it is clear that the nationwide trend of opiate diversion impacts our va. The Va Health System is one of the nations leading prescribers of opioid medication. Diversion threatens veterans and hampersdri addressing the opioi epidemic. Preventing this should be an ern. That is wie i find the findings why troublesome. It is unacceptable some va facilities are not conducting routine inspections to prevent and identify diversion. Background investigations that could identify finding employees who have a diverted drug or Substance Abuse problem were backlogged in atlanta. Health care employees at the atlanta medical care center were not subject to drug testing for six months which could identify diversion of drugs. We need to get to the bottom of why these safeguards and processes are not being followed. I want to know if the procedures if followed would work to prevent Drug Diversion and i want to know if va has the resources it needs to conduct inspections, background checks and administer the drugfree program. I am also concerned about the va hiring freeze that is currently in place and that va, hr employees are not exempt. The gao and ig identified the staff need more personnel and training to identify the inspections. They identified the need for more personal to address the backlog in atlanta. Without adequate support staff in place, va medical facilities will continue to struggle to comply with the procedures and programs that they must follow to ensure our veterans receive safe care. Finally, i look forward to learning about progress at the va with regard to the Opioid Safety Initiative we passed within the comprehensive Addiction Recovery program to bring down the rate of opioid pr prescriptions for all of our veterans. We must do everything we can to help veterans suffering from chronic pain and veterans struggling from Substance Abuse and addiction. The Opioid Epidemic is destroying the lives of veterans and their families in New Hampshire and all across the country. We need to Work Together to find Innovative Solutions to end this epidemic. The heroin does not chose ours. We can Work Together and we are proud champions of the comprehensive recovery addiction act we passed last year. Thank you and i yield back. Thank you, Ranking Member kuster. I ask all members wave their opening remarks as per this committees custom. With that, i welcome our first and only panel who is seated at the witness table. We have dr. Carolyn clancey who is accompanied by dr. Michael valentino, chief consultant for the pharmacy management benefits services. We have Deputy Assistant Inspector General for audits and evaluations. Who is accompianed by amy. And we have randal williamson, the director of the Health Care Team for the government accou Accountability Office and dr. Keith burg, chairman of the mayo clinic enterprise medication diversion prevention committee. I ask that the witnesses please stand and raise your right hand. Do you solemnly swear under penalty of perjury that the testimony you are about to provide is to truth, the whole truth, and nothing but the truth . Please be seated. Let the record reflect that all witnesses have answered in the affirm affirm affirm. Good afternoon, thank you for the opportunity to discuss oversight of controlled substances and Drugfree Workplace Programs at va facilities. I will address inspections to minimize diversion, drug testing for selected employees and our commitment to accountability for employees who do not live up to core values. I am accompanied by mark valentino. The report from the controlled Inspection Programs in four facilities has prompted a swift response. We conquered with the six recommendations and expect them to be fully implemented by october of this year. We have a Conference Call to launch the action plans and provide tools that support the effort and distribution of written instructions. Additional dissemination efforts are planned over the next two weekz. Selected instances of n noncompliance were revealed but i believe the system is working to give us the tools to detect diversion rapidly and take action when it does occur. Vha implemented internal controls in the early 1980s and in many cases these measures exceed those required by the controlled substance act and we believe they align closely with the mayo clinics best practices. Data through march 11th, 2016 show vas controlled substance loss rate is 8100,000 and it is vas own internal control that led to the vast majority of diversion cases being identified. The use of Illegal Drugs by va employees is inconsistent with the special trust placed in those who care for veterans. The Inspector General recently reviewed allegations at the Atlanta Va Center of backlog of investigations and found mandatory drug testing of new hires did not occur over a six month period resulting in a backlog of about 200 background investigations. It was found the Drugfree Workplace Program was not ad n min administered. Atlanta va leadership implemented a number of changes in 2016 such as moving the Human Resources department under the direct super vision of the Medical Center director and developing a secondary database for tracking all investigations and we expect the backlog is cleared by the end of march and if not we will keep you informed. Va has made strides to improve the Drugfree Workplace Program. In october 2015, drug Program Coordinators began certifying on a monthly bases and employees were selected on a monthly program. The va is developing procedures to ensure the drug testing coding of employees in approximately 180,000 testing positions is accurate and complete. On march 1st of 2016, the assistant secretary for Human Resources and administration published a memorandum stating 100 percent of all people selected be drug tested prior to appointment. Va works with local, state and federal Law Enforcement agencies to identify specific geographic areas with reported mail losses and the clusters have led to successful arrests prosecutions and convictions. Va has developed a culture of reporting and developed a practice of over raring than und underreporting suspects diversion. I am proud of the services we provide to veterans including Prescription Drug services. As a whole our nation needs to come up with a better alternative to Pain Management than opioids. Va is at the forefront of the challenge with our Safety Initiative which pioneered in august of 2013. We are actively reducing the number of opioids we prescribe and the number of veterans receiving the prescriptions. We are offering a variety of treatments for chronic pain such as chiropractor and acupuncture and other things. This will make it easier to maintain oversight. With support from congress, we look forward to continuing to improve our oversight and further improve the care of our veterans and the care they deserve. Thank you for the opportunity to testify and i look forward to your questions. Thank you, dr. Clancy. Mr. Doll, you are recognized. Mr. Chairman, Ranking Member, and members of the subcommittee thank you for the opportunity to testify from the office of Inspector Generals work related to Drugfree Workplace Programs and oversight of the controlled Drug Services of the va. I am accompanied by a member of the oig health care inspector staff in manchester, New Hampshire and a former va pharmaci pharmacist. The goal was establishing a drug free federal workplace. It was a condition for all employees to refrain from using Illegal Drugs on and off the job. Positions such as physicians, nurses, police officers, and Motor Vehicle operators are among those tested. The oig has completed two project to assess the program. In march 2015, we issued the results detailing an audit of the program and identified Program Weaknesses in three areas. First, preemployment applicant drug testing. If a tested mrakz application has a positive test they should decline employment but we reported va did not drug test all applicants assigned a testing prior to appointment. Instead they selected 310. Second, random employee drug testing. We estimated the rate was 68 of employees selected in fiscal year 2013. In our review of 22 randal facilities, four didnt test any randomly selected employees. Ten had compliance rates ranging from 1039 and the remaining tested at least 80 of selected employees. 9 of employees in testing positions were fought subject to random drug testing because they were not properly coded with the drug test code in vas personal system. Those not subjects were nurses, doctors and addictions therapy therapists. We reported the va lacks sufficient oversight to whether all employees are referred to the positive drug results. Based on the work, we determined the va program was not accomplishing its primary goal of ensuring illegal drug use was eliminated. A more recent report focused on Human Resources at the atlanta va. We backed an allegation there was no drug testing employees in testing assigned positions for six months in 20142015. Despite the lack of drug testing we found no indication the management at the local or National Level was aware of the lapse. The atlanta Va Medical Center lacked assurance employees washington have been subject to drug testing remained suitable for employment during this period. We made two suggestions and the va reported they have taken action on the recommendations. Va requires that facilities ensure the controlled substance Inspection Program is implemented and maintained. The iog reviewed the management of controlled substances during the combined Assessment Program revieu iews and we rolled up th results of the work and they reference tat. The iog has a Program Related to Drug Diversion focus on three categories. The diversion of controlled and noncontrolled drugs. It is a serious issue that the oig pursues. The diversion of non controlled and controlled drugs are stolen for the purpose of illegal sales and the diversion of controlled substance by a theft of mailed pharmaceuticals. Mailed pharmaceuticals are vulnerable to staff at any point with the most common occurrence being theft of employee by the mail carrier. The oversight of the drug free Workplace Program is done through audits and inspections. This oversight is necessary to ensure va takes the steps necessary to reduce risks for the safety and wellbeing of veteran employees and veterans. We actively investigate Drug Diversion and seek prosecution for those involve in Drug Diversion. We have concluded vshg a lacked reasonable assurance is achieving a drugfree workplace and adequately controlling controlledsubstances. This ends my testimony. Mr. Williamson, you are now recognized for five minutes. Thank you, chairman and Ranking Member and members of the subcommittee. The increase in prescribing use of opioids over the last two decad decades has brought with it the need for medical facilities to undertake efforts to prevent diversion of opioids and other controlled substance biez facility employees for their own personal use. Diversion of controlled substances can compromise patient treatment, be costly to the facility and cause harm in our communities for those that are recipients of illegally obtained controlled substances. I am hear to discuss our reports on the effort to prevent diversion of opioids and or controlled substances through its controlled Patient Safety<\/a> issue that puts veterans, va employees and the public at tremendous risk. Unfortunately, the news has recently been filled with story after story of Drug Diversion<\/a>s in the va. In little rock medical supplies and website were used to order and divert 4,000 oxycodone bills and viagra at the cost of the va. This technician was selling the drugs on the street where they had a value of more than 160,000. A va facility in florida, a registered nurse was apparently steeling oxycodone and hydro morphine from the hospital to feed her addiction. These are medications that should have been going to veterans for their care. These issues are in part a result of va having inadequate procedures in place to safeguard against theft and diversion of controlled substances. A recent Government Accountability<\/a> office audit found one va center missed 43 of the required monthly inspections mostly in critical carriers such as the operating room and intensive care. Three other facilities didnt follow all of the requirements for inspections of controlled substances. This is not the first instance where weaknesses were identified in v arbss controlled substance Inspection Program<\/a>. In 2009 and 2014 the va office of Inspector General<\/a> found some medical facilities were not conducting monthly inspections and some inspections were incomplete. Va has been given multiple opportunities to address these concerns. This leaves me wondering what va is doing to repair the lax oversight and apparent abuse absence of accountability regarding these issues within va. To make matters worse, there are also issues with drug testing employees to ensure they are suitable to provide care to our veterans. A 2015 office of Inspector General<\/a> report found that Va Medical Centers<\/a> were not conducting preemployment and random drug tests for testing positions in many instances across vha which amounted to tens of thousands of employees not receiving drug tests required by the Drugfree Workplace Program<\/a>. Most recently in january of 2017, the oig found high backlogs in background checks to include drug testing for high risk positions at the atlanta Va Medical Center<\/a>. It is precisely these tools that have been put into place to help protect patients and Health Care Organizations<\/a> from drug diverz versions and harm. However, va doesnt seem to be taking them as serious as it should. Based on the oversight reports and numerous diversion instances we will discuss today i am concerned that vas controlled substance Oversight Program<\/a> is not working and that staff who fail to follow proper procedures are not being held accountable for violations. In case after case, what we see are examples of drugs being diverted for personal use or personal gain. Yet there doesnt seem to be much progress made by the va to correct the glaring problems that allow it to happen. What is more concerning is the programs to help deter diversion or identify illegal employee drug use are not being implemented. We are in the midst of an Opioid Epidemic<\/a> it and it is time to make changes to avoid putting veterans and employees woo serve them atrisk. I recognize representative custard now. I am particularly interested as the founding cochair of your Congressional Task<\/a> force to combat the heroin epidemic. This afternoon we are examining vas role in ensureing that Prescription Drug<\/a>s are safely controlled in va medical facilities. Less than a year ago, former chairman kaufmann and i held a hearing on this issue in colorado because the Drug Enforcement<\/a> agency, dea, found several violations in the denver vamc. We continue to hear disturbing reports from hospitals and clinics in our community that some Health Care Employees<\/a> are stealing controlled substances for their own personal use for personal gain. We know that these cases are on the rise throughout the country. One Health Care Employee<\/a> diverting controlled substance can be a serious risk and cause significant harm to many patients. We learned this in New Hampshire<\/a> with the technician who was injecting himself with fentanyl and it turned out this had started at the Baltimore Va Medical Center<\/a> and continued in more than a dozen hospitals in other states infecting up to 50 patients in our community with hepatitis c and some of these patients were veterans. From this example, it is clear that the nationwide trend of opiate diversion impacts our va. The Va Health System<\/a> is one of the nations leading prescribers of opioid medication. Diversion threatens veterans and hampersdri addressing the opioi epidemic. Preventing this should be an ern. That is wie i find the findings why troublesome. It is unacceptable some va facilities are not conducting routine inspections to prevent and identify diversion. Background investigations that could identify finding employees who have a diverted drug or Substance Abuse<\/a> problem were backlogged in atlanta. Health care employees at the atlanta medical care center were not subject to drug testing for six months which could identify diversion of drugs. We need to get to the bottom of why these safeguards and processes are not being followed. I want to know if the procedures if followed would work to prevent Drug Diversion<\/a> and i want to know if va has the resources it needs to conduct inspections, background checks and administer the drugfree program. I am also concerned about the va hiring freeze that is currently in place and that va, hr employees are not exempt. The gao and ig identified the staff need more personnel and training to identify the inspections. They identified the need for more personal to address the backlog in atlanta. Without adequate support staff in place, va medical facilities will continue to struggle to comply with the procedures and programs that they must follow to ensure our veterans receive safe care. Finally, i look forward to learning about progress at the va with regard to the Opioid Safety Initiative<\/a> we passed within the comprehensive Addiction Recovery<\/a> program to bring down the rate of opioid pr prescriptions for all of our veterans. We must do everything we can to help veterans suffering from chronic pain and veterans struggling from Substance Abuse<\/a> and addiction. The Opioid Epidemic<\/a> is destroying the lives of veterans and their families in New Hampshire<\/a> and all across the country. We need to Work Together<\/a> to find Innovative Solutions<\/a> to end this epidemic. The heroin does not chose ours. We can Work Together<\/a> and we are proud champions of the comprehensive recovery addiction act we passed last year. Thank you and i yield back. Thank you, Ranking Member<\/a> kuster. I ask all members wave their opening remarks as per this committees custom. With that, i welcome our first and only panel who is seated at the witness table. We have dr. Carolyn clancey who is accompanied by dr. Michael valentino, chief consultant for the pharmacy management benefits services. We have Deputy Assistant<\/a> Inspector General<\/a> for audits and evaluations. Who is accompianed by amy. And we have randal williamson, the director of the Health Care Team<\/a> for the government accou Accountability Office<\/a> and dr. Keith burg, chairman of the mayo clinic enterprise medication diversion prevention committee. I ask that the witnesses please stand and raise your right hand. Do you solemnly swear under penalty of perjury that the testimony you are about to provide is to truth, the whole truth, and nothing but the truth . Please be seated. Let the record reflect that all witnesses have answered in the affirm affirm affirm. Good afternoon, thank you for the opportunity to discuss oversight of controlled substances and Drugfree Workplace Program<\/a>s at va facilities. I will address inspections to minimize diversion, drug testing for selected employees and our commitment to accountability for employees who do not live up to core values. I am accompanied by mark valentino. The report from the controlled Inspection Program<\/a>s in four facilities has prompted a swift response. We conquered with the six recommendations and expect them to be fully implemented by october of this year. We have a Conference Call<\/a> to launch the action plans and provide tools that support the effort and distribution of written instructions. Additional dissemination efforts are planned over the next two weekz. Selected instances of n noncompliance were revealed but i believe the system is working to give us the tools to detect diversion rapidly and take action when it does occur. Vha implemented internal controls in the early 1980s and in many cases these measures exceed those required by the controlled substance act and we believe they align closely with the mayo clinics best practices. Data through march 11th, 2016 show vas controlled substance loss rate is 8100,000 and it is vas own internal control that led to the vast majority of diversion cases being identified. The use of Illegal Drugs<\/a> by va employees is inconsistent with the special trust placed in those who care for veterans. The Inspector General<\/a> recently reviewed allegations at the Atlanta Va Center<\/a> of backlog of investigations and found mandatory drug testing of new hires did not occur over a six month period resulting in a backlog of about 200 background investigations. It was found the Drugfree Workplace Program<\/a> was not ad n min administered. Atlanta va leadership implemented a number of changes in 2016 such as moving the Human Resources<\/a> department under the direct super vision of the Medical Center<\/a> director and developing a secondary database for tracking all investigations and we expect the backlog is cleared by the end of march and if not we will keep you informed. Va has made strides to improve the Drugfree Workplace Program<\/a>. In october 2015, drug Program Coordinators<\/a> began certifying on a monthly bases and employees were selected on a monthly program. The va is developing procedures to ensure the drug testing coding of employees in approximately 180,000 testing positions is accurate and complete. On march 1st of 2016, the assistant secretary for Human Resources<\/a> and administration published a memorandum stating 100 percent of all people selected be drug tested prior to appointment. Va works with local, state and federal Law Enforcement<\/a> agencies to identify specific geographic areas with reported mail losses and the clusters have led to successful arrests prosecutions and convictions. Va has developed a culture of reporting and developed a practice of over raring than und underreporting suspects diversion. I am proud of the services we provide to veterans including Prescription Drug<\/a> services. As a whole our nation needs to come up with a better alternative to Pain Management<\/a> than opioids. Va is at the forefront of the challenge with our Safety Initiative<\/a> which pioneered in august of 2013. We are actively reducing the number of opioids we prescribe and the number of veterans receiving the prescriptions. We are offering a variety of treatments for chronic pain such as chiropractor and acupuncture and other things. This will make it easier to maintain oversight. With support from congress, we look forward to continuing to improve our oversight and further improve the care of our veterans and the care they deserve. Thank you for the opportunity to testify and i look forward to your questions. Thank you, dr. Clancy. Mr. Doll, you are recognized. Mr. Chairman, Ranking Member<\/a>, and members of the subcommittee thank you for the opportunity to testify from the office of Inspector General<\/a>s work related to Drugfree Workplace Program<\/a>s and oversight of the controlled Drug Services<\/a> of the va. I am accompanied by a member of the oig health care inspector staff in manchester, New Hampshire<\/a> and a former va pharmaci pharmacist. The goal was establishing a drug free federal workplace. It was a condition for all employees to refrain from using Illegal Drugs<\/a> on and off the job. Positions such as physicians, nurses, police officers, and Motor Vehicle<\/a> operators are among those tested. The oig has completed two project to assess the program. In march 2015, we issued the results detailing an audit of the program and identified Program Weaknesses<\/a> in three areas. First, preemployment applicant drug testing. If a tested mrakz application has a positive test they should decline employment but we reported va did not drug test all applicants assigned a testing prior to appointment. Instead they selected 310. Second, random employee drug testing. We estimated the rate was 68 of employees selected in fiscal year 2013. In our review of 22 randal facilities, four didnt test any randomly selected employees. Ten had compliance rates ranging from 1039 and the remaining tested at least 80 of selected employees. 9 of employees in testing positions were fought subject to random drug testing because they were not properly coded with the drug test code in vas personal system. Those not subjects were nurses, doctors and addictions therapy therapists. We reported the va lacks sufficient oversight to whether all employees are referred to the positive drug results. Based on the work, we determined the va program was not accomplishing its primary goal of ensuring illegal drug use was eliminated. A more recent report focused on Human Resources<\/a> at the atlanta va. We backed an allegation there was no drug testing employees in testing assigned positions for six months in 20142015. Despite the lack of drug testing we found no indication the management at the local or National Level<\/a> was aware of the lapse. The atlanta Va Medical Center<\/a> lacked assurance employees washington have been subject to drug testing remained suitable for employment during this period. We made two suggestions and the va reported they have taken action on the recommendations. Va requires that facilities ensure the controlled substance Inspection Program<\/a> is implemented and maintained. The iog reviewed the management of controlled substances during the combined Assessment Program<\/a> revieu iews and we rolled up th results of the work and they reference tat. The iog has a Program Related<\/a> to Drug Diversion<\/a> focus on three categories. The diversion of controlled and noncontrolled drugs. It is a serious issue that the oig pursues. The diversion of non controlled and controlled drugs are stolen for the purpose of illegal sales and the diversion of controlled substance by a theft of mailed pharmaceuticals. Mailed pharmaceuticals are vulnerable to staff at any point with the most common occurrence being theft of employee by the mail carrier. The oversight of the drug free Workplace Program<\/a> is done through audits and inspections. This oversight is necessary to ensure va takes the steps necessary to reduce risks for the safety and wellbeing of veteran employees and veterans. We actively investigate Drug Diversion<\/a> and seek prosecution for those involve in Drug Diversion<\/a>. We have concluded vshg a lacked reasonable assurance is achieving a drugfree workplace and adequately controlling controlledsubstances. This ends my testimony. Mr. Williamson, you are now recognized for five minutes. Thank you, chairman and Ranking Member<\/a> and members of the subcommittee. The increase in prescribing use of opioids over the last two decad decades has brought with it the need for medical facilities to undertake efforts to prevent diversion of opioids and other controlled substance biez facility employees for their own personal use. Diversion of controlled substances can compromise patient treatment, be costly to the facility and cause harm in our communities for those that are recipients of illegally obtained controlled substances. I am hear to discuss our reports on the effort to prevent diversion of opioids and or controlled substances through its controlled Inspection Program<\/a>s. All va med sl facilities with controlled substances are required to undertake monthly inspections of all areas within the facilities that are authorized to have controlled substances. Each facility director is responsible for overseeing the Inspection Program<\/a> and appointing a coordinator to conduct the inspections. Usually the coordinators and the inspectors have other responsibilities within each facility and work parttime on the Inspection Program<\/a>. The coordinator is responsible for ensuring monthly inspections are conduct and a summary is done as well. We found they were not being conducted and needed improvements. First, monthly inspections are fought always being conducts as required. We visited four va medical facilities across the country and found over a 14 month period one facility missed 43 of the required inspection while another missed 17 . The operating rooms in one facility for one was not inspected because we were told the inspectors had to review before or after the operating hours and couldnt. Second, the inspectors didnt always follow the requirements as was the case for 34 facilities we vised. Inspectors dont verify the controlled substances were properly transferred from pharmacies to automated dispensaries in patient carriers. Or inspectors didnt count all of the controlled substances stored in patient carriers. Third, we found local written inspection procedures were not fully conducted. These three weaknesses increase the risk of diversion at av facilities. We found many of the problems were allowed to happen due to poor oversight at the facility and network level. Director didnt perform oversight responsibilities consistently including monthly inspection reports and implementing corrective actions if missed inspections or other problems are identified. We found two of the managers had oversight responsibilities for the Medical Center<\/a>s we visited did not review facilities quarterly trend reports as required. The controlled inspection coordinator is required to prepare and submit the quarterly reports based on trends identified in the monthly inspections. Further, one of the two networks actually did review the quarterly trend reports took no action to ensure one of the facilities in our review that had not prepared quarterly trend reports had a corrective action plan to do so in the future. They also concurred with our other recommendations to improve the process. This concludes my opening remarks. You are now recognized for five minutes. Ranking members of the subcommittee, thank you for the opportunity to speak to you about the healthcare workplace. Such crimes endanger all patients, employers and even themselves. We have no duties diversions only fairly recently is the degree of risk to vulnerable patients revealed such as blood poisoning by bacteria or viruses transmitted swapping syringes in the commission of the crimes and the process many have been infected with fatal illnesses. Ive attached a paper authored by the investigators outlining the outbreaks over the tenyear period that resulted in illness and death in patients and one of these scenarios included Veterans Affairs<\/a> patients being exposed to approximately 50 patients. This individual was referred to earlier in the introduction comments. A radio technologist for troublethattraveled working fore employment agencies fired from multiple jobs for delivering send thefentanyl for his own ust lying about the job applications and in the absence of the National Registry<\/a> he had no trouble finding employment. In the sweeps he would send them once he had previously. The patients described were extremely vulnerable positions undergoing an invasive procedure under anesthesia or an intensive care unit. Such is unacceptable and that the Drug Enforcement<\/a> administration requires stringent drug control policies and procedures to be put in place to protect the substances from attack across all points of the manufacturing and distribution dispensing and administration spectrum. The drugs used in the setting are highly sought after drugs of abuse by addicts and those that profit from the sale of stolen drugs. Experience at the clinic and elsewhere showed the necessity of having robust surveillance detection investigation and intervention programs in place to minimize the risk to all involved. While i will be impossible to eliminate from the healthcare workplace, it is imperative to systems rapidly detect and halt such activity. I have attached an article from the Clinic Office<\/a> and myself included that outlines the program to its very successful implementation. While we continue to try to improve the system is effective in the implementation of seven years ago. They come from a diverse background including pharmacy techs, nursing students, nursing assistants, janitors, patient Family Member<\/a>s, nursing home attendants, hospice workers and strangers off the street. The stories are incredible. It isnt good enough to merely have effective policies and procedures on the looks. They must be rigorously followed. They are clever and desperate and they will gravitate into areas they perceive the drugs to be most vulnerable to attack. It behooves any facility to heavy rotation for being effective in terminating and prosecuting Drug Diversion<\/a>. Only by doing so can we protect the most vulnerable from the preventable harm. As i stated this problem will never go away so he must become good at Rapid Intervention<\/a> only by instituting and folding these policies and procedures will this be possible. I think the committee for its attention and stand ready to answer any questions that you may have. Thank you. The statements of those provided will be entered into the record. We will now proceed to questioning. In your testimony you state the va performs an actual account of all controlled substances every 72 hours. Who performs the counts and overseas that they actually occur at each facility lack . When i made a visit last week, pharmacy technicians are doing that and they are double counting as they are doing it so in other words there are two assistance verifying because it is prone to a missing one and so forth and that is further verified by a supervisor. Given the weaknesses identified and more recently by the gao, how can the Central Office<\/a> be sure that these accounts are taking place and that they are accurate . We have good policies in place, but its important that they are rigorously followed. We are exploring right now how we might do a backup audit to make sure the policies are followed. As i mentioned in the opening weve already disseminated the written statements to the field and wed be happy to make a comment available for the record or just for your interest but again its very important to note that this actually happens and our aspirations are as good as what we are delivering on. How many cases from Drug Diversion<\/a> has the control Program Identified<\/a> in the last two years . What i have here is a poster we could make available to the committee if you could turn that around of controlled substance losses by type so the data that we looked at specifically goes from january 2014 of march 11 to 2016. What you see is 91. 4 of the losses occur outside of our facility and that leaves about 1. 5 from employees. But again this is something we are checking all the time and if there is any question whatsoever police are engaged as well as the Inspector General<\/a>s office and they have been most helpful. Of those losses that occur outside of the loss will you be able to provide the subcommittee a list of the facilities where theyve been reported stolen in the last two years . We would be happy to do that. What is the role of the Medical Center<\/a> directors . In terms of ensuring inspections and proper oversight . They are the key at the facility level to look at the monthly inspection report picking up any issues that come to pass from inspections that are not done correctly and things that coordinate the report to them and they are responsible for holding somebody accountable for correcting that. I have about a minute left. The office of Human Resources<\/a> management reported that they interpreted language and a drugfree workplace handbook to require only some job finalists protesting the designated positions to be drug tested before being employed. Would this be an acceptable practice in your organization . I believe in our organization we do a postoffer of employment testing on all applicants. What are the consequences for hiring healthcare workers prior to drug testing or completing background checks . You might be letting the fox in the henhouse or somebody that would test positive but is in fact an addict into an area they can get their hands on drugs. There is an exampltheres an exn the denver area about three years ago. Spending three years in prison for infecting patients but in the church that she was a heroine addict that took a job in the facility and started diverging. Ranking member coaster you are recognized for five minutes. Thank you mr. Chair and the panel and dig for their helpful reports. I want to focus on the evidence demonstrating we know what a successful Drug Diversion<\/a> program would look like and yet, we continue to have this problem and my question is currently they gave authorit give authorie individual facilities to implement these inspection procedures. But is there any reason and i guess this is for doctor clancy why they couldnt streamline the process and apply one standard to all the subtleties and in fat have an Inspection Team<\/a> based out of the Central Office<\/a> that would go out . It seems fine hearing is this is an added task in fact one was a Food Service Worker<\/a> and this was just an add on and it doesnt seem we are taking it sufficiently seriously. They would go out without advanced warning and do these check. That is exactly what we are going to be looking into and i think what we need to look at is a how much can be done remotely and how much requires onsite presence and how much can we identify ahead of time that are likely to have the most challenges i suspect in some instances we know what facilities are likely to be complying and for which one was the facility in the report based on many other things i knew about that particular facility, and i was not and could be surprised by the distribution of the others, but we need to make sure a great policies are implemented consistently. And at least have consisten consistency. Im concerned about having a system that would be consistent throughout. I have a couple minutes i want to return to the issue of reducing the amount of medication generally in fact be a population. We had testimony from the medical researcher that out of the 60,000 surgeries a year, 99 of people get over your dedication and one in 15 will become a chronic user of the opiates and that is what is stating. Can you think of other examples you would have in the system . The portion of that is named for those that died under our care and i was literally speaking with his father yesterday and ive been most impressed by the family honoring the experience of making sure that we provide better care. Theyve been on the forefront of reducing the use of opioids. The number receiving opioids weve seen a 56 reduction in the number receiving another type of drug at risk for adverse reactions. We are doing much more frequent urine testing to minimize from patients, veterans and selling the drugs they got in the pa to elsewhere so the answer is positive that you are taking the medication you received. We are seeing the overall dosage but has decreased quite significantly and we have also seen these results at the time we have seen an overall growth in the number of veterans that we are serving. I want to be clear we are not done and we will continue to monitor this. I am proud of the work we are doing to offer veterans alternatives to chronic Pain Management<\/a>. M my tim mai tai mishap that i would say to the chair as we continue i would love to have further testimony about the pain programs and how we can bring down the use of the opiate medication. Thank you. You are recognized for five minutes. I would like to continue down that same the Ranking Member<\/a> asked the first part of the question i was going to ask. The reports from 2009 and 2014 on the weakness of the controlled substance program, you kind of explained what the Central Office<\/a> was doing, but what about that level what are we doing there . Every one of the networks as a pharmacy lead. I will say that its my understanding there is a variability in terms of how many other members of the team they have. Many of them are quite strong in reviewing the reports and providing that oversight. Others it is my understanding i would be happy to provide more detail for the record, but i think we need a very consistent approach. It is the facilitys responsibility. Here is the second line of the network and Central Office<\/a> providing what is sometimes referred to as the third line of defense. I am quoting from the practices of the audit which is an area we just started up within my group. And i know youve been trying to do that since the 2014 report, but why do you suppose when all of a sudden the gao came back many of the same weaknesses showed up again quack what are we not doing to move quick enough to deal with this and it is getting to the point not just in the va but nationwide we have to set the example. That is precisely how we think of it is setting up an example. I think to some extent i believe it was mr. Williamson reverted to the fact that some of the coordinators of collateral duties. I do know for many of the facilities anesthesia and the operating rooms tend to be areas probably because of the hours where thereve been problems conducting inspections and every facility has been in the system has been directed and redirected quite recently to have a backup coordinator. My colleague from the pharmacy who is here today, one of his top lieutenants came with me the other day and noticed maybe there was a little problem conducting the inspections throughout the month if you let it go to the end of the month which is understandable but nonetheless, if stuff happens that means you would have slipped and so forth, so that is the kind of thing we can and will improve on. My next question in the investigation related to the reports, how many positions identified as no background check completed with a high risk for the testing designated positions, do you know that . The report didnt get into the background investigations. The report was focused on the atlanta Medical Center<\/a>. I wouldnt have that information on hand but i would be happy to look at that. We want everyone tested because as you described and somebody on the panel did come everyone is at risk. Anyone with the higher, that being said we will drop down to those positions weve definitely got to do some backing up and make sure. I am short on time here. This is a question im sure people will ask both your Healthcare Organizations<\/a> hire prior to the background check lacks no. What risks are associated with hiring a clinical staff prior to a background check . One source of frustration is when we are interviewing an applicant the Employment Law<\/a> prohibits to. We have had such people come in that developed an addiction and then in retrospect theyve gone through treatment for cocaine abuse in the past so in some ways we are barred from asking those questions that we would complete the postoffer of employment drug testing. If i could add first off let me say this, and im running short on time dot this is an issue ive dealt with on the state level and here as well but one thing we want to remember that is vitally important is the tests are because this disease. I had a friend at one time when we begged him to talk to us he gave us information that wasnt correct and he came back and said to us what part of an addict dont you understand, so thats why it is important and not only to the question but to make sure that we do the followup checks and the concern i see is the holes in the system. We want to do everything we can to empower you to try to stop this epidemic. It doesnt matter what your race or gender is or economic status we have to continue to work on this, so thank you very much. You are recognized for five minutes. Thank you all for being here. You and i have a long history in this. For the committees sake for the new members, the first piece of legislation we offered in 2008 went to the va to step set up Pain Management<\/a>. That was with a lot of work from Boston Scientific<\/a> and all of the best practices. This is one of those issues of the seamlessness between the private sector and va. My colleagues and the Ranking Member<\/a> know the fundamental issue here is Pain Management<\/a>. We go through these issues that create its own problem. The diligence on the control side we can always do better on that and i think there have been some great suggestions but i would suggest that program was never fully implemented. Did we ever fully implement it before it expired . Of im not sure but i can get back to you. I d do know thanks to the legislation the representative was asking about in the bill, we are now making sure there is Pain Management<\/a> expertise and teams accessible by all the facilities. For some of the facilities that will be partly virtual but as an integrated system but it builds on that same principle that is happening in the private sector because most of us knows because of the sheer volume of just how much collaboration do you have with experts that are out there . We consult with others broadly and when the they publid their guidelines last year, they drew on expertise from a number of folks including from your district. But because as you said this is all about a Common Health<\/a> challenge shared by the country. Thank you for being here. I think the thing about this is to not think everything is reactive and this recent Opioid Epidemic<\/a> and overdoses and Everything Else<\/a> that come with it but that was not a surprise to many folks like yourself but when you said mayo clinic saw there were some holes in their youve turned around and recognized them as one of the best how long did it take to implement that before you expected to see change . We were probably about a year and a half in creating the system and that was in response to the timbre and a version that ended up on the front page of the paper and embarrassed us. We tried to work through every spot in the supply chain where we were vulnerable and figured out a plan to address that. It takes time to go through that process. And you have how many facilities . We have the midwest minnesota facility and surrounding area. We also have Jacksonville Florida<\/a> and some small surrounding areas in scottsdale arizona. The 50,000 plus employees. 70,000. So this is a big healthcare system. I think one of the frustrations and i know it frustrates you also the slowness of the reacting to the situations that the bureaucracy takes time. You are feeling comfortable now that there is with the new legislation with an emphasis on this the situations come up that are unacceptable and the thing for many of us, we know that what happened in the situations have been brought to life are happening in the private sector are the responsibilities of va both from an oversight and legal responsibility and an ethical responsibility. Do you feel like it is moving quickly enough for you . Of i am excited how enthusiastic the employees are about this. Its a National Problem<\/a> and im excited by the progress that we will be tracking this closely. They are embarrassed by this and we recognize when its not done right, the issue in the surrounding area is intact and this is a tragic situation. The news for all of us is we can do something about it because we have that ability in the va and i guess i am just looking to see these things implemented as quickly as we can and i know you are. Thank you all for your testimony. Thank you. You are recognized for five minutes. Thank you very much. You were in the Inspector General<\/a>s office, correct . And you were in the Government Accountability<\/a> office. Okay, great. The last eight years or so you have repeatedly reported theres a problem with keeping track of drugs and the facilities making sure they are not stolen and so forth ansoforth and so on is th . What you both concluded that we still have a problem . I do think based on the recent work there is an issue. Doctor clancycoming before the deputy undersecretary for health and organizational excellence. What does that mean, does that mean keeping track of who has these harmful drugs to make sure they are not put into the wrong hands . It means providing oversight for quality, safety of care and integrity and integrity about compliance. What person at the va, what one person is responsible for this problem . That would be the undersecretary for health. Right now that is some one in an acting position. The undersecretary was recently confirmed you report to that individu individual . Yes. When someone is caught stealing drugs and selling them or making them available to folks that shouldnt have them like the veterans that were working so hard to help, what action is taken . It depends on the specifics. Do you call the cops . And what sort of actions recently have taken place in the system that you can share about people being held responsible for this abuse . Youve probably seen from newspaper articles that a fair number of people leapt out of the intention of Law Enforcement<\/a> have been convicted and are serving time and paying their debt to society and we would be happy to get a list. That would be great. Thank you. Integrated Service Network<\/a>s, how are they involved in this . We have Hospital Clinics<\/a> and so forth including alaska and hawaii and even a clinic in manoa and so forth so the system is organized into these networks. What does the integrated Service Network<\/a> to . They manage and provide oversight. So they are responsible for making sure we have a good headcount so to speak. Who is the head person over there . Theres 18 of these networks. We will make sure we get a list of these people. Have been found traveling around the country that you deal with separate facilities that there is an inconsistency and i think the congresswoman had this question earlier, there is an inconsistency in which medical facilities do a better job than not involving the protocols . Absolutely. How do you fix the problem . There was one facility that wwe looked at and what was going on there was commitment and leadership from the medical director right down to the inspectors come and thats what you need a. So there is an example at the va. What would you guess, what percentage of the facilities are doing this while . Ten or 15 . So theres 85 of the va facilities around the country that are dispensing drugs illegally or in a hurtful way, correct . I wouldnt say dispensing them is illegally. As a result they get into the wrong hands. Correct. Okay. You were in the private sector over at mayo outside of the government sector. Have you found with an effective Drug Control Program<\/a> that you can save money . I believe we can and if you were to ask the executives at the hospital thats being sued with multiple lawsuits they wish they had a more effective system. Besides avoiding the litigation, is there a way to save money when you have a program like this . That is extremely hard to quantify. To have a system in place is not an inexpensive endeavor in itself. But it allows you to we heard the word on the street is dont go to work because you will steal drugs they will catch you. Thank you mr. Chairman very much. Thank you. You are recognized for five minutes. Thank you, gentlemen. Mr. Chairman, doctor clancy i serve on a constituency that has a Veterans Hospital<\/a> at the lake city and his testimony here that we didnt read out loud but i think you are familiar with. They had a problem recently with a nurse misappropriating the drugs. Can you discuss the protocols that have been established at that lake city facility in the wake of the incident to restore the quality of care and level of Workplace Safety<\/a> for the community and also tell me if the current controlled substance coordinator and that somebody is properly certified in the education on the management of controlled substances an in the supply chain and management policies. I would be happy to take that for the record. The first focus was protecting patients and holding the individual accountable. To promote that in the lake city facility. I am familiar with that but not all the details of the followup. We will find that out. Let me depart for the second. You are an expert in Substance Abuse<\/a> and how it comes to pass. I am a surgeon and ive managed rooms and hospitals and clinics and this is a problem we all have to address. Its part of the problem with healthcare. Ive seen this study at the state level as well. Im looking at this particular pie chart data suggests 90 of the problem with a version and controlled substances is occurring not in th the healthe facilities that the United States<\/a> Postal Service<\/a> and eps. I have looked at a lot of Drug Diversion<\/a> programs in my 35 year career as a surgeon. I have never seen anything like this reported. This is perilously close to the old excuse of my dog ate my homework. Do you believe 90 of the problem in this country occurs on the United States<\/a> Postal Service<\/a> . I am not qualified to comment because that is not where we see it. Im basically assigned within the walls of the healthcare facility. So what happens without, i dont know. That is and what w isnt what w. We see other forms of diversion. Perhaps i should redirect the question to say to you mean 90 of the problem occurs in the Veterans Administration<\/a> facility or do you say that the employees aof the United States<\/a> Postal Service<\/a> and United States<\/a> Parcel Service<\/a> for people who victimized them and are getting 90 of the drugs . What i am saying and i would ask my colleague to elaborate as between the time that a prescription is put in an envelope, and understanding we have a central order facility which for most prescriptions works extraordinarily well. There is a high order of business, very large volumes. Somewhere between fair and the home it was supposed to go. On that occasion weve heard that is diverted from a Family Member<\/a> but i it couldnt be any one of those points and thats where we are working with the outside of Law Enforcement<\/a>. Lets drill down on this a little bit further because it doesnt look like we were putting it off on the Postal Service<\/a>. The va is getting a seat of the drugs from who they purchase it from and then they are distributing it in their system. Somewhere between once they have the drug and pass it off to another part they are being diverted. Is that the system . I have to say 35 years, ive never heard this kind of accusation. 90 of the problems and the postal system im flabbergasted mr. Chairman of the records reflect my we looked at this and one of the first things we tried to obtain his good data. I would be very suspicious of those because the losses are not always synonymous with diversion so we have to be careful of that. But the reporting system, we didnt have a very good reporting system for the Drug Diversion<\/a> cases, so i i would e very suspicious of any data. I am, too. Thank you. You are recognized for five minutes. Thank you mr. Chairman. I want to go back. We all know there is a drug epidemic and certainly in the state i live in there is. Is there any idea how many veterans died of a Drug Overdose<\/a> both with diazepam and opioid . We do track that very closely and we would be happy to get that for the record. The other thing as ive looked at the graph, i couldnt figure out how you would determine 90 and if somebody is home and says i didnt get my drugs, one good thing if there is any good thing about Electronic Health<\/a> records, what used to happen to us when we liveweclose our office at five e would start calling and ask about well i just had surgery, we had a practice two weeks ago and doctor so and so didnt leave me enough medicine. I would pull it up and say you dont see a patient in our practice. People are clever being able to get drugs. When you see 90 , how in the world could you ever figure that number out. You see the post office doesnt deliver it, how do you know that . I can help with that. Its based on a number of reports from january, 2014 through march of 2016. Whenever we have lost, we have a template at the individual facility. What happened, who did you report it to. In those reports we are able to glean information and identify if it was a situation where a ba staff member of a bird at a drug or whether it was a patient calling and saying i didnt get my package come in our packages are signed with tracking information so we can tell where it is in the delivery stream and at some point if the patient says they dont get it, we have one of two situations. Either they did, or a Family Member<\/a> or it went missing somewhere. So i agreed with these ma agreee diversions, but they are reports. My time is short. It looked to me like if there is a real problem that looks like there may be a better way to deliver these medications to people than sending them in the mail. If that is where nine out of the ten problems are and we are losing a lot of people it looks like that is a sloppy system if that is the case. Anyway, in the written testimony you said 92 of them are lost in the mail and you answered how you got that information. In the forms 106 submitted to the committee we learned of instances where the controlled substances were mailed to the wrong address or worse to the wrong veteran. How many cases went missing or were delivered to the wrong address or the wrong person . That is really stalled to keep the sloppy. We would be happy to get that for the record. We appreciate that. Please take it for the record and bring those to the committee. For now, what are they doing to ensure that they get the right prescription that is just sloppy work when you mail it to the wrong address or the wrong person for the sake. There is a big part of the effort initiated in the transformation that includes making sure Veterans Data<\/a> is integrated iintegrated into soue after home they get multiple services from us so when they move, change phone numbers to have accurate information. Everything that is mailed out is dark for what it is that it can be tracked. If a veteran calls a facility and says my medication didnt come they can actually track it whether it is Postal Service<\/a> or ups and ultimately that is helpful in figuring out what happened. That is that a system that we want to continue . You are absolutely right this is an area it is not working as well as it should. If we required every veteran to come in to pick up their controlled substances we could certainly do that. I think it would create unintended consequences. Some of the veterans live very far away so we may have to look at other options. I would agree. We have a situation now thirtysomething thousand people these are all deaths that are preventable and it is disturbing when you have as many people drive debate could die if Drug Overdose<\/a> deaths so it is a huge problem for the country. I yield back. You are recognized for a followup question. I would like to follow up on what the chairman is talking about. It is clear to me and everybody in the room they are doing a horrible job when it comes to this issue. Why do we have to dispense the pills from the va . How many do we have in this country . We have a bunch of them. Why cant we have pharmacies around the country closer to where the population is . I am sure as my colleague noted it works well for other types of medications and as we work through how to reduce the area of the vulnerability, there may be a lot of other options. So in other words it probably makes sense but maybe it is better if it is closer to home where folks come in and they are known and we have a problem here. I think we ought to consider that. I dont know what the protocol is but i bet you can come back and report to us. I would like to follow up if i can. You said roughly ten or 15 of the facilities are doing this right. That means there are 80 or 85 . There is a bunch of them that are doing it wrong. I have an idea. Why dont we get you to talk to the great staff and find out who is doing it right and we will have to staff call the folks that are doing it right and lets find out why and then we can have this nice person come before the committee and then we can see okay weve had these folks that are doing it right and now we have a problem that they are doing it wrong. Maybe you can tell us why he are doing it wrong, just an idea. What do you think about that, do you think that would work . I missed the last part. Do you think that would work to help the folks doing it wrong . Best practices it would not hurt to share them. We are trying to get this right because we have a lot of veterans in pain and problems having to become folks having problems. Anything we can do to help you folks we will do that and i know a great staff will be in touch to get the names we talked about. We often do sharing of best practices and have an initiative on that and i think it is a splendid idea. Have you been doing it the last eight years . We focused a lot on reducing opioid the last couple of years. But you still have about 80 that are not doing it right. I am not quite as confident i think that may be a slightly pessimistic projection but i will tell you that when we look i will let you know. Mr. Chairman, even more reason to get the folks that are doing it right to come and report to us and have the person in charge of everybody tell us why the other folks are not doing it right. Thanks to everyone, thanks to the witnesses. This has been a great next first step as we move forward on this issue. You are now excused and its clear from the testimony today as well as the cases we hear about in the news that Drug Diversion<\/a> is a major problem in the facilities. The lack of oversight and lack of accountability for failing to monitor distribution storage is trolling. We hope by bringing the issue to light that will encourage them to take the steps necessary to impose better oversight and control. I look forward to hearing back on the progress and the changes the va is making and i would ask unanimous consent all members have five legislative days to revise and extend remarks and include extraneous material. Without objection, so ordered and i would like to thank all of the witnesses and audience members for joining in todays conversation and with that, the hearing is adjourned. 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