Transcripts For CSPAN2 Veterans Affairs Officials Testify On Opioid Theft 20170228

A house panel looks at efforts to curb abuse on the Health Care Facilities. The Veterans Affairs subcommittee also heard about the sale of drugs by pa employees. Congressman jack berkman of michigan chairs to hearing. Good afternoon. The hearing will come to order. I want to welcome everyone who has joined us today. Today we will address the lack of oversight and internal controls regarding substances in the Veterans Health administration that leave facilities open in veteran harm. The diversion of drugs from the Va Health Care facilities is an incredible Patient Safety issue that pits veterans, va employees and the public at a tremendous risk. Unfortunately, the news has recently been filled with the story within the va. In little rock arkansas a technician reportedly used his access to medical supplies, websites to order and biggert 4,000 oxycodone pills over 3,000 hydrocodone and more than 14,000 viagra andsign alice pills at the cost of more than 70,000. This technician was allegedly selling these drugs on thes street where they had a value of more than 160,000. Aat a bj facility in florida for a registered nurse. The stealing oxycodone andsteelg hydro morpheme to feed her addiction. Keep in mind these are occasions that should have been going to veterans for their care. These issues are in part a result of the va having ang adequate procedures in place to safeguard against that and diversion of controlled substances. A recent Government Accountability office audit requested by the committee founn one va medical cente center mis of the required monthly inspections must be in Critical Care areas such as the operating room and the intensive care unit. In addition, three other facilities dont follow all of the requirements for controlled substances. This is not the first instance where weaknesses were identified in the controlled substancee idi 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. The va has been given multiple opportunities to address these concerns. This leaves me wondering what they are doing to repair the oversight and apparent abuse and absence of accountability regarding these issues within the bha. To make matters worse, there are also issues with drug testing employees to ensure they are suitable to provide care. In 2015 the office of Inspector General report found that Medical Centers were not conducting preemployment and random drug tests for testing designated positions in manysti instances across the bha that amounted to tens of thousands of employees not receiving drug tests required by the Drugfree Workplace Program. Most recently in january of 2017, they found high backlogs and background checks to include testing for highrisk positions medihe atlanta Va Medical Center. It is precisely these tools that have been put into place to help protect patients and Healthcare Organizations from Drug Diversions and harm. However, the va doesnt seem to be taking them seriously as it should. Based on the oversight reports and numerous incidents we will discuss today, im concerned that the controlled substance Oversight Program is not workink and that the staff that failed to follow proper procedures are not being held accountable for violations. In case after case with vcr examples of drugs being diverted from personal use or personal gain but there doesnt seem to be much progress made by the va to protect the growing problems that allow it to happen. What is even more concerning is the programs that help deter thc diversion are identified as divi illegal employee use not being consistently in the va Health System. We are in the midst of an Opioid Epidemic and its time for the va to start making effective changechangeis to avoid puttingd the employees that serve them at risk. With that i recognize the Ranking Member for her opening statement. Thank you mr. Chairman and thank you for choosing this topic. I am particularly interested as the cochair of the Congressional Task force to combat theta epidemic and i appreciate this testimony. We are again examining the role ensuring that Prescription Drugs are safely controlled in the va medical facilities. Ti i spent a year ago the former chairman and i held a hearing of the subcommittee on this very issue in colorado because the b Drug Enforcement agency found several violations. We continue to hear disturbing reports in hospitals and clinics in the communities that some healthcarHealth Care Employeese stealing controlled substances for their own personal use or personal gain. We know the cases are on the rise throughout the country. One Health Care Employees diverging the substances can be a Public Health risk and can cause significant harm to many patients. We learned this lesson the hard way in New Hampshire with a technician who was injecting himself at a hospital in New Hampshire but it turned out this started at the Baltimore Va Medical Center and continued at more than a dozen hospitals in other states infecting up to 50 patients in the community with hepatitis c and some of the patients were veterans. From this example it is clear the nationwide trend alsoso impacts the va. The whole system is one of the leading prescribers of opioid medication. The diversion threatens the safety of the veterans and hampers efforts to address the Opioid Epidemic in the communities. I find them particularly troublesome. Some of the facilities are not conducting routine inspections to prevent and identify drugent diversion. Background investigations that could potentially identify finding employees who have diverted drugs or who may have a Substance Abuse problem or backlogs in atlanta. Employees at the atlanta Medical Center were not subject to drug testing for six months, which could identify the diversion of Prescription Drugs. We need to get to the bottom of why the safeguards and processes are not being followed. I want to know if the procedure is what worked to prevent the diversion and i want to know if they have the resources it needs to conduct the end actions and administer it drugfreekground Workplace Program. M. I am also concerned about the vr hiring freeze thats currently in place and that the employees are not exempt. The identified with the staff need more personnel and training to properly conduct these inspections. They also identified the need for more personnel to address the background check backlog inl atlanta. Without adequate support staff in place, the va medical facilities would continue to struggle to comply with the procedures and programs thatog they must follow to ensure that our veterans receive safe care. Finally, i look forward to learning about progress at the va with regards to the Opioid Safety Initiative that we passed within the comprehensive Addiction Recovery program just last year to bring down the rate of prescriptions for all of our veterans. We must do everything we can to help the veterans suffering from chronic pain and to help veterans struggling with Substance Abuse and addiction. The Opioid Epidemic is destroying the lives of veterans and their families and communities across New Hampshire and all across the country and we need to Work Together to find Innovative Solutions to end this epidemic. As i say to my colleagues, they do not choose ours and peace. We can Work Together and we are proud champions of the comprehensive Addiction Recovery act that we passed last congress did i look forward to hearing about the compliance. Thank you, mr. Tremaine and i cd i yield back. You and thank you. I would ask all members waved her opening remarks per the committees custom. With that i would welcome the first and only panel that is now seated at the witness table. On the panel, we have Carolyn Clancy the deputy undersecretary for health organizational excellence. She is accompanied by doctor michael valentino, chief consultant for the Pharmacy Benefits Management Services of the Veterans Health administration. Em we also have the Deputy Assistant Inspector General for audits and evaluations. He is accompanied by a unique about the Health System specialist for the office of healthcare inspections and office of the Inspector General. Finally, mr. Randall williamson, the director of the Health Care Team for the Government Accountability office and keith, consultant and anesthesiology chairman of the mayo clinic enterprise medication diversion prevention committee. I ask that th the witnesses plee stand and raise your right hand. Do you solemnly swear under penalty of perjury testimony yot are about to provide us the truth, the whole truth and nothing but the truth . Please be seated. Let the record reflect all witnesses answered in the affirmative. You are now recognized for five minutes. Afternoon chairman, Ranking Member and members of theafterno subcommittee thank you for the opportunity to discuss oversight of the substances and Drugfree Workplace Program of the facilities. For the selected employees and a commitment to accountability for employees who do not live up to the core values and then accompanied as you mentioned by mike valentino. We recently released a report on the medical facility substanceom programs and floor of thero facilities prompted a swift response. We concurred with the six recommendations and are now implementing them and expect them to be fully implemented by october of this year. We conducted a Conference Call last week with over 450 failed the staff to launch the plans and to provide tools that support that effort followed bya distribution of written instructions. Additional dissemination efforts are planned over the next two weeks. Although the gao and vaar Inspector General identified the selected instances of noncompliance in these robust controls, i believe the system is working as designed to make it difficult for the va staff today for drugs and most importantly, to give us the tools to be able to detect it rapidly and take action when it does occur. We implemented robust controlled substance internal controls in the early 1980s and in many cases, these measures exceed those required by the controlled substance act and we believe they aligned closely with the mayo clinics recommended best practices. Data from january 22014 through march 11 to 2016 show the va report of the controlled substances loss rate is. 008 or eight per 100,000. It is the va internal controls that lead to the vast majority of diversion cases being identified. The use of Illegal Drugs by the employees is inconsistent with the special trust placed in those that care for veterans. The Inspector General recently reviewed allegations of the atlanta Va Medical Center of a backlog of the background investigations and found that mandatory drug testing of new hires did not occur over a sixmonth period resulting in a backlog of about 200 background investigations. Bo it was also found the Drugfree Workplace Program was not administered from november 2014 through may 2015. Atlanta va leadership implemented a number of changese in 2016 in response to these ofn recommendations, such as moving the Human Resources department under the direct supervision of the Medical Center director and developing a secondary database for the staffing and tracking of the health backgroundatabase investigations. We expect that backlog will be cleared by the end of this thish and if not, we will keep you informed. In addition theyve made Great Strides towards improving the Drugfree Workplace Program and in october of 2015, drug Program Coordinators began certifying on a monthly basis that employees selected for the random drug testing were tested when they were tested or why they were not tested. The va is also developing procedures to ensure the drug testing coding is approximately with 180,000 testing designated positions as accurate and complete. On march 1 of 20 team, the assistant secretary for Human Resources and administration published a memorandum stating that 100 of all applicants tentatively selected for the appointment of a testing position be drug tested prior to appointment. The va works closely with local, state and federal s lawenforcement entities to identify specific geographic areas with recorded losses and the identification lead to successful arrests, prosecutions and convictions. Theyve developed a culture of controlled substance reporting and adopted a practice of over rather than under reporting suspected cases of diversion. Mr. Chairman, im proud of the Health Care Facilities provided to the veterans includingng Prescription Drug services. The issues we are discussing here today are closely related to the nations overarching struggle with opioid use. As a whole, the nation needs to come up with a better alternative to the Pain Management and opioids. The va is at the forefront with the Safety Initiative that wevl pioneered in august of 2013. We are active in reducing the number to the number of the veterans receiving these prescriptions. Instead, we are offering a variety of complementary and Integrative Medicine treatments for chronic pain such as chiropractic and acupuncture among many other options. Initiatives like these will reduce the number of controlled substances prescribed making it easier to maintain the oversight. With support from congress we look forward to continuing to improve the oversight of Drugfree Workplace Programs which will further improve the care of our veterans and the care that they deserve. Thank you for the opportunity to testify and i look forward to your questions. You are now recognized for five minutes. Mr. Chairman, Ranking Member and members of the subcommitteet thank you for the opportunity to testify on the office of Inspector Generals work related to Drugfree Workplace Programs at the oversight of the controlled substances and va facilities. I am accompanied by a member off the healthcare inspections staff who is also a former va pharmacist. A the federal Drugfree Workplace Program was initiated with the goal of establishing a drugfree federal workplace. The program made it a condition of employment for all federalac. Employees to refrain from using Illegal Drugs on or off duty. The va has designated occupational series as testing designated positions including positions such as positions, nurses, Police Officers and Motor Vehicle operators. In recent years, the oig completed two projects that assist the aspects of a Drugfree Workplace Program. In march, 2015, the oig issued a report detailing the results of an audit of the program. We identified the program a weaknesses in three areas. Ograme first, preemployment drug testing. If a tested applicant has a verified positive test result, the va should decline a final offer of employment however, we reported they did not ensure compliance with policy to drug test all applicants selected for a testing designated physician prior to employment. Instead, they selected only about three of every ten applicants for testing. Second, employee random drug testing. We estimated they achieved a National Drug testing rate of 68 of employees selected for random drug testing in the fiscal year 2013. In the review of the 22 randomly selected facilities, we found four of the facilities didnt test any randomly selected employees, the compliance was from 31 to 89 while the remaining eight facilities tested at least 90 of the randomly selected and put his. We also estimated at least 9 of about 206,000 are not subject to the possibility of the random testing because they were not properly coated with a drug test code into a personal system. Those not subjected to random drug testing included physicians, nurses and addiction to this. Doctor finally, reasonable suspicion drug testing we reported a lack of sufficient oversight practices to monitor whether physicians refer to when please with a positive drug test result to the Employee Assistance program. Based on the work we determined that the program was not accomplishing its primary goal of ensuring illegal drug use was eliminated in the workplace was safe. We made five recommendations and as of today, one recommendation remains open. A more recent report focused on the Human Resource issues at the atlanta Va Medical Center area during this review we substantiated an allegation that there was no drug testing of employees and testing designated positions for at least six months and 2014 and 2015. Despite the lack of drug testing for six months, we found no indications in the management at either the local where the National Level was aware of the laps. Because no drug testing occurred across the atlanta va medical centecenter lack assurancecentet employees who should have been subject to drug testing in this period remain suitable employment. We made two recommendationss focused on the Drugfree Workplace Program and they reported they had taken actiono on the recommendations. They also require managers at the facilities ensure that a controlled substance Inspection Program is implemented and maintained. The oig has reviewed the management of substances during the combined Assessment Program reviews. Weve rolled out the results of the work in june, 2014 and the gao references that work in the recent report. The oig also has a vigorous Investigative Program related to the Drug Diversion. We can really focus on three categories. First of a controlled an the co controlled substances by employees. The diversion by Healthcare Providers for personal use is a serious issue that they diligently pursue. Next the diversion of controlled and non controlled substances for illegal distribution which involve cases where the pharmaceuticals are diverted or stolen for the purpose of illegal sales. S. Also the diversion of controlled substances by a theft of mail pharmaceuticals. Our investigations have revealed mail pharmaceuticals are vulnerable to theft at any point in the process with the most common occurrence being theft by employees of the mail carrier. In conclusion, the oig providedr crosscutting oversight of the Workplace Program and controlled substances inspections throughod the audit and inspections. Inspections. This oversight is necessary to ensure they take the steps necessary to reduce risks to the safety and wellbeing of the veterans and employees by havini and following Proper Program controls. Weve also actively investigated the Drug Diversion and seek prosecution for those engaged in the Drug Diversion. A stonework in recent years we concluded that they lacked alu reasonable assurance achieving the workplace adequately securing the controlled substances. Mr. Chairman, this concludes my statement and he would be happy to answer any questions that you or other members may have. Thank you. Mr. Williamson, you are recognized for five minutes. Thank you mr. Chairman and members of the subcommittee. The increase in the prescribing and use of opioids over the last two decades sometimes referred to as the opioid exclusion havee brought with it the need for medical facilities to undertake efforts to event of a version of opioids and other controlled substances by the facility employees for their own personal use. The diversion of the substances can compromise patient treatment and can be costly for the facility and can cause harm in the communities for those that are recipients of illegally obtained controlled substance. I am here today to discuss the recent report on the efforts to prevent the diversion of opioids and other controlled substances with controlled substance Inspection Programs. The va medical facilities control the 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 andbl appointing a coordinator to manage those that conduct the inspections. Usually both the coordinator and inspectors have othersibiliti responsibilities in each facilities and work parttime on the Inspection Program. P the coordinator is responsible for ensuring monthly inspections are conducted and for submitting reports to the facility summarizing the inspections. We found that the program isnt being managed according to the policies and needed an improvement in certain areas. First, monthly inspections are not always being conducted as it is required. We visited four of the became medical facilities across the country and found over a 14 month period one facility missed 43 of the required inspections while another missed 17 . The operating rooms in one facility for example were not inspected at all because we were told that the inspectors need to arrive before or after the normal operating room hours and couldnt do so because of the conflicting work schedules. Second, when conducting the inspections, facility inspectors didnt always follow the policy requirements as was the case for three of the four facilities we visited. For example inspectors that dont always verify the controlled substances have been properly transferred from pharmacies to automated dispensing machines and patient care areas or inspectors did it all of the controlled substance accounts stored in patient care areas. Third, we found local reconstruction procedures were not fully consistent with the policy requirements. We found this at three of the four hospitals that we visited. These three weaknesses increase the risk of diversion of the facilities. E we found many of the problems. Were a thought to have been in part because of the oversight at the Facility Network levels. Facility directors that two of the four facilities didnt consistently perform the oversight responsibilities for the Inspection Program that include reviewing monthly inspection reports and implementing corrective actions if missed inspections were other problems are identified. D inspei also, we found two of the four Network Managers who had oversight responsibilities for the Medical Centers we visited did not review the facilities quarterly trend reports as required. The controlled substance coordinator is required to prepare and submit the Quarterly Report based on the trends identified in the monthly inspections. Further, one of the networks actually did review the trend reports and took no action to ensure that one of the facilities in the review had not prepared quarterly churn reports foa corrective action plan to do so in the future. Aside from the oversight weaknesses, we found but there is limited training for coordinators to better ensure that they have a complete and detailed understanding of the inspection procedures. Finally, two of the facilities we visited had backup coordinators to help manage inspection processes and complete inspections when the primary coordinator or inspectors couldnt carry out their responsibilities because of depressing job duties or unforeseen circumstances. We recommend that they adopt this type of practice systemwide and the va conquered. They also concurred with our five other recommendations to improve the process and providee the oversight. This concludes my opening p remarks. Thank you mr. Williamson. You are now recognized for five minutes. Chairman, Ranking Member and members of the subcommittee, thank you for the opportunity to speak today about the healthcare workplace. T such diversion is a crime that endangers all patients and healthcare employers, coworkers and even those themselves. Weve long known the hazards of patients being deprived pain medications by diversion on the recently as the grave risk to extremely vulnerable patients revealed by optics of disease such as blood poisoning by bacteria or viruses transmitted by drugged inverters swapping syringes in the commission of their crimes. In the process many patientsth have been infected with potentially fatal illnesses. Ive attached for the review a paper authored by the cdc investigators outlining six outbreaks over a tenyear period. It resulted in illness and death in patients. One of thes these diversion infn scenarios included Veterans Affairs patients exposed and communicated to the tightest c. To approximately 50 patients. This individual was referred to earlier in the introduction comments. This was a radiation technologist that traveledor working for multiple employment agencies and had been fired from multiple jobs for delivering for his own use but lighting of the previous terminations on job applications in the absence of a National Registry of the radiation technologist he had no trouble finding employment. In the u. S. Wont syringes on the anesthesia carts with ones he had previously used to inject himself and he would inject himself with a stolen drug, tap water and repeat the process for the next patient. In this manner he conveyed the onus to many innocent victims. They were extremely vulnerable positions either under anesthesia or in an intensive care unit. Such is unacceptable and thesuc recognition of the Drug Enforcement administration for stringent drug policies and procedures to be put in place to protect the control substances were attacked across all points of the manufacturing distribution dispensing the spectrum. Ing 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 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 Members, 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. 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 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 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 has the control Program Identified 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 Generals 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 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 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 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 based out of the Central Office that would go out . It seems fine hearing is this is an added task in fact one was a Food Service Worker 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. 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 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 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 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. 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 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 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. That was with a lot of work from Boston Scientific 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 know the fundamental issue here is Pain Management. 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 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 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 and overdoses and Everything Else 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 yes. But as you said that this is a Common Health tallmadge by the country. Thanks for being here you and your colleagues but the the id it is not to make everything reactive with this epidemic is not a surprise to many folks like yourself but when you said mayo clinic you decided to turn around to recognize as one of the best, how long did it take you to implement that you expected to see change . Probably ea year and a half to create the system and that is in response to the diversion of the frontpage of the newspaper to embarrass us. We tried to work through every spots of the supply chain reword vulnerable in did take some time to go through that process. Company facilities . We have the minnesota excility and surrounding area. s not. This is a big health caree system sometimes the slowness of these situationsony. With the emphasis on this. Corr . In our responsibility on the legal and ethical responsibility do feel like it is moving quickly quick. By a admix cited how enthusiastic our employees what im excited by the progress me have made. I get did they are embarrassed this is a tragic situation but the news for all of us is we could do something about and quickly. And i faked before your testimony. With the Inspector General quick. Qsr. Q with the Government Accountability office quick. Over the last eight years reported there in isaak problem with keeping track . Would you agree we still have a problem . I would think that gao recent work and that there is an issue. Dr. Clancy. The deputy undersecretary for Health Excellence what does that mean . On the s recehas these drugs . For integrity is about compliance. What person now the s veterans of frustration is responsible for this problem . N convic be undersecretary of health. Right now that is someone in enacting position the undersecretary was recentlyy confirmed. Q report to that person . When somebody is caught stealing drugs and making them available what action was taken quick. Ne it depends on the us circumstances. You call the cops . Yes. What sort of actions recently have taken place that is responsible for the abuse . Affair number of people they brought to the attention of lawenforcemente p. That are serving time and we would be happy to get you will list for the record. Integrated services networks. Do a be all over the country including alaska and hawaii. W so it is the span of reach the system is organized into these networks what does the integrated Service Networks do . E reggaes provide oversight. Also to make sure they have us good head count. There are those in your area . But what about the consistency . How do you fix that problem . There is one facility that we looked at and what was going on there was a commitment and leadership right down to the inspector. So there is an example so what percentage is doing this as well quick. 10 or 15 so of those facilities around the country dispensing drugs illegally greg. Would not say illegally. S. And the privatesector but have you found with an effective Drug Control Program you can save money . I believe that we can. In this there a way to have a program like this . Is to have an effect is not be in expensive endeavor. So the word is dont go to work for mail because if you steal drugs they will catch you. Your recognized for five minutes. With that lake city facility and the testimony recently with the nurse can you discuss those corrective actions . With that control substance coordinator with the management of control substances. I could take that for the record. First focus is to protect patients and hold accountable by will get the rest of the information. I am not familiar with the details of the of followup. Q. Are inexpert of Substance Abuse and how it comes to pass. I am a surgeon and have directed that large clinics. W and let them at the state level as well. Of suggest that 90 percent the problem with diversion of control substance is not in the Health Care Facilities bottles so ups. Rcel looking at a lot of Drug Diversion with a 35 year career i have never seen anything like this reported it is perilous cyclos to the dog be my homework. I am not qualified to comment because that is not how we see it basically i am assigned within the Health Care Facilities. I dont know. That is not what we see. We see other firms of diversion. I should be direct the question what do you mean that 90 percent of the Veterans Administration or the employees or the ups or those who victimize them. And ask my colleague to elaborate. But to understand which for most prescriptions it works very well. A very high order of business somewhere between the Veterans Home where is this supposed to go in and on occasion but it could be any one of those points that is her the Inspector General has been very helpful. Does this look like we were falling off but really it is dependent upon who day get the drugs from. They could be using the Postal Service or ups but once the v. A. Has the drug berry are being diverted. This is outside uh v. A. System. I have to tell liu i have never heard in the postal system. One of the first things and i because loanloss is a not always synonymous with their version but with the Drug Diversion cases. Surgery, your recognize for five minutes. The did there any doubt of trucker Drug Overdose how many of the veterans . Redo track that very closely i could give them for the record. I could not figure of howd, you determine 90 so one in t thing if there is any that what used to have been to western route close the office of 5 00 to say we had a Good Practice so people are very clever to get drugs. When you save 90 how could you ever figure that out . T thesa this is based on a sample we have a of a template so the police since security and the staff member diverted a drug if it was a patient to call and say iin did not give my package. And its the patients as they dont get it or the Family Member got it. These may not be diversions. My time is short. And to deliver those medications to people. T in the looks like it is a sloppy system. Accurate with those da forms where they have substances to be address. , many were missing . That is really sloppy. We would be happy to get that for the record. So bring those to the committee. That is just sloppy work reeling back to the wrong address to a the wrong person for goodness sakes. There is a big part to from the transformation that the data it is integrated from multiple sources or multiple services to have Accurate Information everything is bar coded so if they called up the facility to say my medication did not come there is a tracking number if it is the Postal Service that is helpful to law enforcement. L the virginia will negative v. A. Is a huge system. Your absolutely right it is not working as well as it should to pick of the controlled substances some of the veterans live very far away we must focus some other options. Guys agree with that program not saying that you should do that but well have a situation now of 30,000 people. These are all deaths that our preventable. So it is a huge problem for the entire country. I would like to follow up with the chairman was just talking about. It is clear to me in doing a horrible job. How many pharmacies to we havent this country . I dont know. The new york in the hack every half pharmacies around the country closer to where the population is . I am sure as my colleague noted looking to reduce this area of vulnerability. Maybe if its better fits closer to home . I know what the protocol is but i bet theym that mr. Williamson . U2 said that roughly tedder 15 percent do this right that means 85 percent. We look death for they look negative 58. A bunch of them are doing it wrong. I have an idea why dont we get to talk to our great staff to find out who does a right they will call up those and find out why theyre doing right and this may spur some would be under secretary have him come before the committee then we can say they are doing right maybe you can tell us why 8 to a wrong. Would that work . Best practices. It would not hurt to share them. We have a lot of veterans that have a problem with a opioids and anything we can do to help you we will. And they do do the sharing of best practices. In this particular area. We have focused lot reducing use of alaska oliviers. But it is still 80 greg. I am not quite as confident i think that maybe a pessimistic projection but i will tell you. And with that report to us with the person who did is in charge why arent the other people doing it right . Thanks to the witnesses this has been a great next first the bass may move forward with a very serious issue prepare you are excused as it is clear from the testimony provided today the major problem at the v. A. Facilities with lack of oversight over control substances and accountability to monitor does your be sugar storage restriction we hope by bringing this issue to light to encourage the v. A. To take steps necessary i look forward to hearing the changes that v. A. Is making ask unanimous consent to revise and extend their remarks without objection . So ordered once again thanks to the witnesses for joining in todays conversation. The hearing is adjourned. [inaudible conversations]