Transcripts For CSPAN2 Veterans Affairs Officials Testify On Opioid Theft 20170307

Good afternoon. This 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 controlled substances within the Veterans Health administration that leave facilities open to Drug Diversion and veteran harm. The diversion of drugs from Va Health Care facilities 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 Diversion within va. In little rock, arkansas, a va Pharmacy Technician reportedly used his access to medical suppliers websites to order and divert 4,000 oxycodone pills, over 3,000 hydrocodone pills, and more than 14,000 viagra and cialis pills at a cost to va of more than 70,000. This technician was allegedly selling these drugs on the street where they had a value of more than 160,000. At a va facility in florida, a registered nurse was apparently stealing oxycodone and hydromorphone from the hospital to feed her addiction. Keep in mind, 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 requested by this Committee Found that one Va Medical Center missed 43 of their required monthly inspections, mostly in Critical Care areas such as the operating room and the intensive care unit. In addition, three other facilities did not follow all of vhas requirements for inspections of controlled substances. This is not the first instance where weaknesses were identified in vas controlled substance Inspection Program. In 2009 and 2014, the va office of Inspector General found that 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 absence of accountability regarding these issues within vha. To make matters worse, there are also issues with drug testing employees to ensure that they suitable to provide care to veterans. A 2015 office of Inspector General report found that Va Medical Centers were not conducting preemployment and random drug tests for testing designated positions in many instances across vha, which amounted to tens of thousands of employees not receiving drug tests required by the drug free workplace program. Most recently, in january 2017, the oig found high backlogs in background checks, to include drug testing, for highrisk positions at the atlanta Va Medical Center. It is precisely these tools that have been put in place to help protect patients and Health Care Organizations from Drug Diversion and harm. However, va does not seem to be taking them as seriously as it should. Based on the oversight reports and the numerous diversion incidents 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 does not seem to be much progress being made by va to correct the glaring problems that allow it to happen. What is even more concerning is that programs to help deter diversion or identify illegal employee drug use are not being implemented consistently within the Va Health System. We are in the midst of an Opioid Epidemic, and it is time for va to start making effective changes to avoid putting veterans and the employees who serve them at risk. With that i recognize Ranking Member kuster for her opening statement. Thank you, mr. Chairman, thank you for choosing this topic. Im particularly interest as the culture, the founding cochair of our Congressional Task force to combat the heroin epidemic, and i appreciate his testimony. This afternoon we are again examining the use role in ensuring that Prescription Drugs are simply controlled in va medical facilities. Less than a year ago former chairman coffman and i held a hearing of the subcommittee on this very issue in colorado because the Drug Enforcement agency, dva, found several violations in the denver office. We continue to hear disturbing reports and hospitals and clinics come in our communities at some Health Care Employees are stealing controlled substances for the own personal use or personal gain. We know that these cases are on the rise throughout the country. One Health Care Employee diverting controlled substances can be a Serious 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 is injecting himself with fentanyl at hospital in New Hampshire, but it turned out this it started at the baltimore Va Medical Center and continued in more than a dozen hospitals in other states. Inspecting up to 50 patients in our community hepatitis c and some of his patients were veterans. From this example it is clear that the nationwide trend of opiate diversion also impacts our va. The Va Health System is one of the nations leading prescribers of opioid medication. Diversion in the va threatens the safety of veterans and hampers efforts to address the Opioid Epidemic in our communities. Preventing diversion of these substances should be of paramount concern. Thats what i find the gao and igs findings particularly troublesome. Its unacceptable that some va medical facilities are not conducting routine inspections to prevent and identify Drug Diversion. Background investigations that could potentially identify finding employees who have a diverted drug or who may have a Substance Abuse problem were backlogged in atlanta. Health care employees at atlanta Medical Center were not subject to drug testing for six months which could identify diversion of Prescription 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 when followed would work to prevent Drug Diversion, and want to know if va has the resources it needs to contact the inspections, the background checks, and to administer its Drugfree Workplace Program. Im also concerned about the va hiring freeze that is currently in place, and that the a h. R. Employees are not exempt. The gao and ig identified that stephanie more personal and more training to properly conduct these inspections. They also identified the need for more h. R. Personnel to address the background check backlog in atlanta. Without adequate support staff in place, the a medical facilities will continue to struggle to comply with the procedures and programs that they must follow to ensure that our veterans receive safe care. Finally, i look for to learning about progress at the va with regard to the Opioid Safety Initiative that we passed within the competence of addiction and Recovery Program just last year to bring down the rate of opioid prescriptions for all of our veterans. We must do everything we can to help 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 in 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, the heroin does not choose. We could Work Together and were proud champions of the competence of Addiction Recovery act that we passed last congress. Congress. I look for to hearing about va compliance. Thank you, chairman, and i yield back. Thank you Ranking Member kuster. I asked that all members waved her opening remarks as per this committees custom. With that, i welcome our first and only panel who is now seated at the witness table. On the panel we have dr. Carolyn clancy, deputy undersecretary for help for organizational excellence, she is accompanied by dr. Michael valentino, chief consultant for the Pharmacy Benefits Management Services of the Veterans Health administration. We also have mr. Nick dahl, Deputy Assistant Inspector General for audits and evaluations. He is accompanied by the Health System specials for the office of Health Care Inspections in the office of the Inspector General. Finally we have mr. Randall williamson, the director of the Health Care Team for the Government Accountability office and doctor keith berg, consultant in anesthesiology and chairman of the mayo clinic enterprise, enterprisewide medication diversion prevention committee. I ask that the witnesses please stand and raise your right hand. [witnesses were sworn in] please be seated. Let the record reflect that all witnesses have answered in the affirmative. Dr. Clancy, you are now recognize for five minutes. Good afternoon, chairman bergman, ranking membe, rankingr and members of the subcommittee. Thank you for the opportunity to discuss oversight of controlled substances and Drugfree Workplace Program at the facilities. I will address inspections to minimize diversion drug testing for selected employees and our commitment to accountability for employees who did not live up to our core values. I am a company today by Mike Valentino from pharmacy benefits. Gao was recently released report on medical facility controlled substances Inspection Programs in four of our facilities has prompted a swift response. We concurred with the six recommendations internet and limiting them come expecting to be fully implemented by october of this year. We conducted a Conference Call last week with over 450 fieldbased staff to launch the action plans and to provide tools that support that effort, followed by distribution of written instructions. Additional dissemination efforts are planned over the next two weeks. Although gao and va Inspector General identified selected instances of noncompliance with these robust controls, i believe the system is working as designed to make it difficult for va staff to divert drugs. And most important to give us the tools to be able to detect diversion rapidly and take action when it does occur. The aha incremented robust controls substance internal controls in the early 1980s. In many cases these measures exceed those required by the controlled substances act and we believe they aligned close with the mayo clinic best practices. Data from january 2 of 2014 through march 112016 show that the a report of controlled substances loss rate is. 008 . It is the internal controls the lead to the vast majority of diversion cases being identifi identified. The use of Illegal Drugs by va employees and is inconsistent with the special trust placed in those who care for veterans. Inspector general recently reviewed allegations at atlanta va radical center of the backlog, 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. It was also found the Drugfree Workplace Program was not administered from november 2014 to may of 2015. Atlanta va leadership implemented a number of changes in 2016 in response to these recommendations such as moving the Human Resources department under the direction, direct provision of the director and developing a secondary database for staffing and track it all background investigations. We expect that backlog will be cleared by the end of this march, and if not we will keep you informed. In addition, va has made Great Strides toward improving the Drugfree Workplace Program. An october 2015, drug drug Program Coordinators began certifying on a monthly basis that employs selected for random drug testing were tested, when they were tested, or why there were not tested. The va is developing procedures to ensure the drug testing coding of employees in approximate 180,000 testing designated physicians is accurate and complete. On march 12016 and the assistant secretary for Human Resources and administration published a memorandum stating that 100 of all applicants be drug tested prior to appointment. Va works closely with the local, state and federal Law Enforcement entities to identify specific geographic areas with reported losses and va is identification of lost clusters has to successful arrests, prosecutions and convictions. Va has developed a culture of controlled substance loss reporting and has adopted a a practice of over rather than underreporting suspected cases of diversion. Mr. Chairman, im proud of the health care our facilities provide to our veterans come including Prescription Drug services. The issues were discussing here today are closely related to our nations overarching struggle with opioid use. As a whole our nation needs to come up with a better alternative to Pain Management and opioids. Va is at the forefront of this challenge whether opioid state initiative which we pioneered in august 2013. We are actively reducing the number opioids we prescribe and the number of veterans receiving these prescriptions. Instead, were offering a variety of complementary and integrated medicine treatment for chronic pain such as chiropractic and acupuncture among many other options. Initiatives like these will reduce the number of controlled substances va prescribes making it easier to maintain their oversight. With support from congress we look forward to continuing to improve our oversight of controlled substances and 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 spirit thank you, dr. Clancy. Mr. Dall, you are recognized for five minutes. Mr. Chairman, Ranking Member kuster and members of the subcommittee, thank you for the opportunity to testify today on the office of Inspector Generals work related Drugfree Workplace Programs and oversight of controlled substances at va facilities. I am accompanied by a member of the oig health care inspection staff in manchester, New Hampshire, and is also a former va pharmacist. The federal Drugfree Workplace Program was initiated with the goal of establishing a drugfree federal workplace Pizza Program make it a condition of employment for all federal employees to refrain from using Illegal Drugs on or off duty. Va has designated sensitive occupational series as testing designated positions including positions such as physicians, nurses, Police Officers and Motor Vehicle operators. To drug test all applicants tested for a position right it to deployment. Instead only tested three of every 10 applicants. Second, employee random drug testing. We estimated we achieved a National Drug testing rate of 60 of employees selected for random drug testing in fiscal year 2013. In her view of 22 randomly selected facilities, we found for facilities did not test any randomly selected employees compliance rates from 31 to 89 while the remaining tested 90 of the randomly selected employees. We also estimated at least 9 of 206 dozen employees at tested desk and into positions are not subject to the possibility of random drug testing because they were not properly coded with the drug test code and being his personal system. It is not subjected to random drug testing included physicians, nurses and addiction therapist. Finally, reasonable suspicion drug testing recorded ea . Efficient oversight for all employees with a positive drug test result to the Employee Assistance program. Based on number, we determined vas program is not accomplishment as primary goal of ensuring a legal drug is eliminated and vas safe. I made five recommendations and as of today one remains open. A more recent report on Human Resources issues at the atlanta Va Medical Center. We substantiated an allegation that there was no drug testing employees for at least six months and 24 teen and 2015. Despite the lack of drug testing for six months, weve bought no indications that either the local or National Level was aware of collapse. Because no drug testing occurred, the atlanta Va Medical Center lack insurance and employee subject to drug testing during this period remains suitable for employment. We made two recommendations focused on the drugfree work is program and va reported they action on recommendations. Ba also requires managers at facilities ensure a controlled substance Inspection Program is implemented and maintained. The oig has reviewed the controls of some sister in our program reviews. We rolled up the results of our work in june 2014 ngl references network in a recent report. The oig also has a vigorous investigative program. We focus on three categories. First, diversion of controlled and not controlled substances by vha employees fit the diversion of drugs to help care providers for personal use is a serious issue that the oig diligently pursues. Thanks, diversion of control and not controlled substances for illegal distribution, which involve cases where ba pharmaceuticals are diverted or stolen for the purpose of illegal sale. Also, diversion of controlled substances by that of male pharmaceuticals. Our investigation to Reveal Pharmaceuticals are foldable to staff at any point in the process with the most common occurrence being kept by employees of the mail carrier. Inclusion, oig has provided crosscutting oversight of the work is program a controlled substance inspection tour audit and inspection. The oversight is necessary to ensure via take steps necessary to reduce risks to the safety and wellbeing of veterans in va employees by having a valid and Proper Program controls. But also actively investigate Drug Diversion and seek prosecution for those engaged in Drug Diversion. Based on our work in recent years, weve concluded va lacked reasonable assurance at achieving the drugfree work place. Mr. Chairman, this concludes my statement. We be happy to answer any questions the subcommittee members may have pierced in thank you, mr. Dahl. Mr. Williamson county are recognized for five minutes thank you, Ranking Member bergman, mr. Kuster members of the committee. Prescribing is about beers over the last two decades, sometimes referred to as the opiate explosion has profited the need for medical facilities to undertake effort to prevent diversion of opioids and controlled substances by facility employees for their own personal use. Diversion of controlled substances and compromise christian treatment, can be costly to the facility and can cause harm in our community for those who are recipients obliquely obtain controlled substance. I am here today to discuss every report ive vha efforts to prevent diversion of opioids and other controlled substances through its controlled substance Inspection Programs. All va medical facilities to store and dispense controlled substances are required to undertake monthly inspection of all areas within the facility that are authorized to have controlled substances. Each facility director is responsible for overseeing the Inspection Program and appointing a coordinator to manage and inspect yours to conduct the inspection. Usually the court and inspect areas have other responsibilities with danish facility and work parttime on the Inspection Program. The coordinator is responsible for ensuring that the inspection are conducted and for submitting reports to the facility director, summarizing inspections and any trend. We found that the program is not being managed according to vha policy and needed improvement in certain areas. First, monthly inspections are not always been conducted as required. Weve visited for va medical facilities across the country and founded over a 14 month period one facility miss 43 of the required inspection while another missed 17 . The operating rooms and one facility, for example were not inspected at all because we were told inspectors needed to arrive before or after normal operating room hours and could not do so because of their conflict and work schedules. Second, when conducting inspections, facility inspectors did not ask followup requirements after the case for three of the four facilities they visited. For example, in actors dont always verify the controlled substances have been properly transferred from pharmacies to automated dispensing machines in patient care areas or inspectors didnt always count all of the controlled substances stored in patient care areas. Third, we found the local written inspection procedures not fully consistent with vha policy requirements. We found the problem that three of the four hospitals we visited. These three weaknesses incase the risk of diversion at va facilities. We found many of these problems were about to happen in part due to full oversight at the facility and network level. Facility directors that two of the four facilities they visited did not consistently perform their oversight responsibilities for the Inspection Program which include monthly inspection reports and implementing corrective action if ms. Inspections or other problems are identified. Also, we found two of the Foreign Network managers to let oversight responsibilities for the Medical Centers we visited did not review facilities quarterly print reports as required. The controlled substance inspection coordinator is required to prepare and submit these quarterly reports based on trends identified in the monthly inspections. Further, one of the two networks actually did review the quarterly trend report took no action to ensure that one of the facilities in our review had not prepared quarterly return reports that a corrective action plan to do so in the future. Aside from the oversight weaknesses, we saw limited training for coordinators to better ensure they have a complete and detailed understanding ive vha action procedures. Iannelli, two of the facilities they visited had not been coordinators to help manage inspection process and complete inspections when their primary coordinator or inspectors could not carry out responsibilities because of pressing job duties run for seen circumstances. We recommend va about this product or system worldwide in va concurred. We also concurred with verify that the recommendation to improve the process and provide better oversight. This concludes my opening remarks. Thank you, mr. Williamson. Dr. Berge come youre recognized berge come your berge come your your recognizer by minister of. Chairman bergman, Ranking Members of the Subcommittee Committee met for the opportunity spacebar Drug Diversion in the workplace. Such diversion endangers coworkers, even the vergers themselves to a volley of law nowadays hazards of patients being deprived of pain medication by diversion, only fairly he has the grave risk to extremely vulnerable patients been revealed by outbreaks of disease such as blood poisoning by bacteria or viruses trends and abide sloppiness or ranges in the commission of their crimes. The process of the patients infected with potentially failed each you review a paper offered as by cdc investigators suspect that outbreaks every tenure. They resulted in illness and death in the patients. One of these diversion infections in areas included Veterans Affairs patients being communicated with hepatitis c infection to approximately 50 patients. The individual is referred to earlier in the introductory introduction common spirit radiation that traveled the country working for multiple employment these. Hed been fired for multiple jobs for diverting fentanyl for a sony is in line about previous on job application and absence of a National Registry of radiation technologists of radiation technologist gummi had no trouble finding employment. The dark invasive radiologist with yugoslav fentanyl syringes on the anesthesia cart with once he had previously used to inject himself and excuse themselves to a restroom, inject himself with a stolen sentinel, draw tap water and repeat the process. He conveyed his potentially too many innocent victims. These were all extremely vulnerable position to their undergoing invasive procedure while under anesthesia or intensive care unit. Clearly such behavior is unacceptable in recognition of dangers posed by diversion of Drug Enforcement administration requires drug control policies and procedures put in place to protect controlled substances from attack across all points of the manufacturing distribution, dispensing, administration and disposal spectrum. The drugs used in the Health Care Setting are highly sought after drugs of abuse and by those with profit largely from the sale of stolen drugs. Experience at the mayo clinic and also rush on the necessity of robust surveillance, detection, investigation and intervention programs in order to minimize the risks to all involved. While it will be impossible to completely eliminate Drug Diversion from the Health Care Work place, its imperative robust systems rapidly detect all such activity. Ive attached for your review an article from the mayo clinic authors, myself included which outlines program from inception to very successful implementation. While they continue to improve our system, it is proven quite effective identified seven years ago. The burgers come from a diverse background of physicians, pharmacists, pharmacy tech from a nursing assistants, janitors, patients, patient Family Members, hospice workers and strangers off the street. The stories are incredible but the powerful draw. It is not good enough to have effective policies and procedures on the books. They must be rigorously followed. The burgers are generally clever and desperate and gravitate to areas of the system areas of a system where the procedure is to be most vulnerable to attack. It therefore behooves any facilities have a reputation for being effects of a prosecuting Drug Diversion. Only by doing so can we protect the most vulnerable patients from preventable harm. As i stated, the problem will never go away so we must become very better Rapid Intervention only by instituting a public antidiversion policies and procedures will this be possible. I think the committee for its attention to this important issue and stand ready to answer any questions you may have. Thank you. Thank you, dr. Berge appeared to written statements of those who have provided oral testimony will be entered into the hearing record. We will now proceed to questioning. Dr. Clancy, in your testimony, you state the va performs an actual account of all controlled substance is every 72 hours. Who performs these accounts and who oversees that these accounts actually occur at each facility . So, what i saw when i made a more or less unannounced visit last week is that pharmacy techs who are working in the vault by doing that and they are double counting as they are doing it. So in other words, there are two assistants who are each verifying because counting the blood of pills is prone to missing one and so forth. That is further verified by a supervisor. Given the weaknesses identified by the oig and more recently by gao, how can Va Central Office assure these counts are taking place they are accurate . You have served well. Yes. I think dr. Berge said it well. We have good policies in place but its very important they are rigorously followed. We are exploring right now how we might do some backup audit to make sure that those policies are followed. As i mentioned in my opening, we have argued disseminated written statements to the field. We be happy to make a copy of the memo available for the record or just for your interest. But again, it is very, very important to note that this actually happens, but our aspirations are as good as what we are delivering on. Thank you yes doctor claimed the, how many cases on Drug Diversion has the Inspection Program identified in the last two years . So, what i have here is a post or, which we could make available to the committee. If you could just turn that around, a controlled substance losses by type. So the data that we have a specifically goes from january 2nd 2014 to march 11th at 2016. What you see is 91. 4 of these losses occur outside our facility in the mail system. And that is about 1. 5 i believe from employees internally. But again, this is sent and we are checking all the time. If there is any question whatsoever, ea police are engaged as the spec or Generals Office and theyve been most helpful. And that those losses that occurred at va facilities that i comment will you provide the subcommittee list of those facilities for the drugs have been reported missing or stolen in the last two years . We would be happy to do that. Mr. Williamson, 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 looking at monthly inspection report, picking off any issues that come to pass there for this inspection Comment Section not done correctly, thinks the coordinator report to them and they respond for holding somebody accountable for correcting that. Ive got about a minute left here. Dr. Berge, oig reported the drugfree work by samba to require only some job finalists for test the designated positions to be drug tested before being appointed. Would this be an acceptable practice in your Health Care Organization . I believe in our Health Care Organization we do postoperative employment test team on all applicants. What are the consequences are higher in Health Care Workers drug testing for completing background checks . Well, you might let the fox in the henhouse. You might let a buddy who would test positive and is in fact an addict and an area where they can get their hands on drugs. Theres an example of that in the denver area. About three years ago, kristin parker, now spending three years in federal prison for 1536 patients with hepatitis c he in retrospect, she was a addict who took a job in a facility to diverting sentinel. Thank you. Ranking member custer, recognized for five minutes. Thank you, mr. Chairman. Thank you to our panel. I want to thank the gao and ig for their helpful report. I want to focus in on evidence demonstrating we know what a successful Drug Diversion Deterrence Program would look like and yet we continue to have this problem. My question is currently the va gives authority to the individual facilities to implement these inspection procedures. But is there any reason and i guess this is for dr. Clancy by the va could not streamline this process and apply one standard to all facilities and in fact have been in action team based out of the Central Office that would go out to the business. It seems what i am hearing is that this is often just an added task in fact teamsters services worker. This is just an addon. It doesnt seem as though we are taking it sufficiently seriously and wouldnt it make more sense if we had an office at inspection they would then go out to perhaps, you know, as you did yourself with added and sworn in and do these checks. Thank you, congresswoman. That is exactly what we are looking into. I think what we need to look at is how much of this could be done remotely, how much of it requires onsite presence and frankly how much can we identify ahead of time which facilities are likely to have the most challenges. I suspect that in some instances we need to test this, we will know which facilities are more likely to be compliant. I guessed correctly which one was the facility in the gao report this time many, many other things i knew about that particular facility and i wasnt incredibly surprised by the distribution to the others. Do we need to actually up our game and make sure great policies are implemented consistently. No question about that. And at least have consistency. What i am curious about is having a system that would be consistent throughout. Ive got a couple minutes. I want to return to the issue of reducing the amount of opiate medication generally in the va population. We had testimony from a medical researcher that out of the 60,000 surgeries a year, 99 of people get opiate medication and one in 15 will become a chronic user of opiate dramatically speeding this epidemic. Can you talk to me more about both the program encouraging ideas to reduce the use of opiate medication or any other examples in my town in the system. Of. Can you not read the question. Im happy to report we are on track for other provision. Incredibly enough, the eighth portion is named for a veteran who died under our care and i was literally speaking with his father yesterday. Someone working with us to provide better care. Va has been on the forefront of reducing the use of opioids. Beginning in august of 2013, we have seen a 31 reduction in the number of patients receiving opioids. We have seen a 56 reduction in the number of veterans receiving an opioid and another type of drugs that has a particularly high risk for adverse reactions. We are doing much more frequent testing because we are trying to minimize diversion from patients, veterans actually selling the drugs that they thought at va software. The right answer on a drug screen is positive that youre taking medications received. We see the overall dosage of opioids has decreased quite significantly and weve also seen we have seen these results at a time when weve seen an overall rope and a number of veterans we are serving. I want to be clear we are not done and we will continue to monitor this. I am very proud of the work we are doing to offer veterans alternatives to chronic Pain Management. By time is out. I would say to the chair as we continue a dud to have further testimony and how they can bring down the use of opiate medication. Thank you. Mr. Bost can you recognize for 10 minutes. The Ranking Member asked the first part of the question i was going to ask. I still want to go down that. Reports from 2009 and 2014 on the weakness of the va controlled substance program had. You explain that the Va Central Office is doing. What about what are we doing her . Everyone of fire networks has a pharmacy leave there. And the rest of the team. Many of them are quite i is reviewing so the record in providing oversight. Others, by understanding id be happy to provide more detail for the record. I think we need a very consistent approach. Heres the facilitys responsibility. Here is the second line which should you do not recommend Central Office providing what is referred to as the third line of defense. Im quoting from an internal audit which is in all that we have started up within my group. And i have been doing that since the reporter. They be the same with us to shut up again. What are we not doing correct leg to do with this getting to the point nationwide. I would agree in us precisely how we think of it as setting an example. I think to some extent i believe it was mr. Williamson referred to the fact that some underscore knitters have collateral duties. I note that for many facilities, anesthesia in the operating rooms tend to be areas probably because of the hours where they have problems that inspections. Every facility in our system has been redirected quite recently to have a backup point mayday. My colleague from pharmacy whos here today, not mr. Valentino, one of his top lieutenants came with me the other day. He noticed maybe there is a little problem was not randomly conducting inspections throughout the month. If you let it go to the end of the month, which is understandable, but nonetheless this stuff happens that we, in the google had looked a month and so forth. That is the kind of thing i think we can and will improve on. My next question, in your investigation the 2015 and 2017 reports, how many positions identified as novak and check completed with a high risk for the testing designated as issues, do you know that . The 2015 report did not get into the background investigations. 2017 reports focused only on the atlanta Va Medical Center. I wouldnt have that information at hand, but id be happy to look into that. Could we get a copy to figure that out . As you described and somebody at the panel did that everyone is at risk with this. Anyone would hire. That being will drop them into the highrisk positions. Weve definitely got to do some backing up and make sure. Im short on time here, but dr. Berge, this is the question im sure my constituents and people throughout this nation, which are Health Care Organization higher complete a background check . No. Thats what i thought. With a higher clinical staff without prior background check . One source of frustration is when we are interviewing an applicant for sayer nurse Anesthesia School that Employment Law for business to ask if youd been through treatment or chemical dependency before. We have had such people comment that developed fentanyl addiction and retrospective gone through treatment for abuse in the past. In some ways we are barred or masking some of those questions but we would complete the postoperative employment drug testing. If i cannot, first off let me say this and i know im running short on time, mr. Chairman. This is an issue ive dealt with on the state level in here at this level as well. The one thing we want to remember is how vitally important those tests are because this disease, and it is a disease to be an addict. I had a friend one time when we begged him to talk to us, to give us information, it wasnt correct and they came back and said to us what part of im an addict highlight which you understand. That is life so vitally important to not only to the question, but make sure we do followup checks and the concern i see is both existing and assist in. We want to do everything we can to empower you to try to stop this epidemic that is affecting and it does that not her what your race is, what your gender is, which are associated economic statuses of the weve got to continue to work on this. Thank you are a match. I back. Thank you. Mr. Walls come you recognize her five minutes. Thank you, mr. Chairman. Just for the committees take up the new members, the first piece of legislation that we authored in 2008 was went to the va to set up the Pain Management. Dallas with a lot of work that came in from the mayo clinic, Boston Scientific and other best practices working in conjunction with the va. This is one of those issues the seamlessness between the private sector and the va is pretty strong. We all have the same issues. My colleagues are getting added in the Ranking Member nospace are the fundamental issue here is Pain Management in the beginning of our nation goes through cyclical issues of issuing opioids, pulling them back which creates its own problem. The diligence on the control side we can always do better on that. I would suggest to all of us, and i write that program, dr. Clancy, was never fully implemented yet we have this discussion 18 months ago. Did we ever fully implement before it expired . Im not sure, but i could get back you. But i do know is thanks to the new legislation representative pastor was asking about bill, we are now making sure that there is Pain Management expertise and teams accessible by our facilities. For some of our facilities, that is partly virtual. As an integrated system, we can do that. Is fully implemented the same thing happening in the private sector. The va goes, so goes the rest of the system because of the sheer volume of this. How much collaboration do you have with extras that are out there . Im just meeting. Berge today although we have mutual college friends. We consult with others pretty broadly. In fact ,com,com ma when the cdc published guideline opioids last year, the true expertise from a number of folks in the va including your district. As you said, this is all about it, and Health Challenge by the country. Dr. Berge commits a knack for being here. You and your colleagues over the years, the thing about this is not think everything is reactive in the recent opioid academic and the overdoses and Everything Else that come with it was not a surprise to many folks like yourself. When you said mayo clinic saw you had maybe some holes in their come you decided to recognize it as one of the best how long did it take to implement that before you saw are expected to see change . Were probably about a year and a half in creating our system and that was in response to a temporary diversion that ended up on the front page of the news paper and embarrassed us. We try to work through every spot in the supply chain where we were vulnerable and figure out a plan to address that. It takes some time to go through that process. You have facilities how many facilities . We have the midwest minnesota facility and surrounding area. We have set Jacksonville Florida and in small surrounding area and some surrounding area. Your 50,000 plus employees roughly. 70,000 employees. So this is a Big Health Care system. One of the navy frustration tonight offers straight view, to ascend times the slowness reacting to the situation that iraq is the takes time. Youre feeling comfortable now that there is with the new legislation, but the evidence on this, with the situations that come up that are unacceptable. I think for many of us, we know its happened in the situation speculator two that are happening in the private sector. Our responsibility from an oversight and legal responsibility, but also an ethical responsibility is to those batteries did you feel like its moving quickly enough for you . Im excited how it is the ethic employees are about this. This is a national problem. Im excited by the progress weve made, but we will be tracking this very close way. I get it, too. We recognize when its not done right the issue in the surrounding areas impacted this is a tragic situation. The news for all of us in here as we can be sent in about it and do something quickly because we have that ability in the va. Im looking forward to see these things maybe be implemented as quickly as we can and i know you are, too. I thank you for your testimony. Thank you. Mr. Poliquin come you recognize her five minutes. Dahl mr. Dahl, you are the Inspector Generals office, correct . Mr. Williamson with the Government Accountability office . Correct. Okay great, the last eight years or so to repeatedly reported a problem with keeping track of the drugs at the va facility making sure they are not stolen, sold, so forth and so on. But she both conclude we have a problem . Im sorry, missed that. Would you conclude where the problem . Alex sink based on gaos recent work is still an issue. Thank you. Dr. Clancy coming or the deputy undersecretary for organizational excellence. What does that mean . Does that mean apart keeping track of whos got harmful drugs to make sure they are not put in the wrong hands . What it means is providing oversight for quality, safety of care and integrity. Integrity is about compliance. What person wants possible for the problem . That would be the undersecretary for health. That is someone in enacting position. Could you spell that name . Alaigh. Your porch of that individual . Yes. When someone is caught dealing drugs or making them available to folks that shouldnt have been like our veterans that are working so hard to help, what action is taken . It depends on specifics of the circumstance. You call the cops . You do, good. But assertive actions have taken place in the system you can share with us about people held responsible for this use . At the same or newspaper article is that a fair number of people we have brought to the attention of line was meant have in fact been convicted after serving time. They are paid their debt to society. We would be happy to get you a list for the record. Will make sure we get at this. Integrated Service Network among who are they, what did they do and how are they involved in this . We have facilities, Hospital Clinics in go forth all over the country including alaska and hawaii and guam and even a clinic in manoa and so forth. Big, big screen average. The system is organized into these networks. And what does the integrated Service Network do . They manage and provide oversight for the facilities. Said they are responsible for making sure that we have a good headcount so to speak for the drugs arent being dispersed. S. , correct. Okay, good. Who is that person . Their 18th in your area that would be. There miss that. We look at a list of these people also. Mr. Williamson, have you found in traveling around the country dealing with separate va facilities that there is inconsistency and i think congresswoman kuster asked inconsistency in which organizations, which medical facilities do a better job and not an following protocols. Absolutely. Have you fixed the problem . Is one facility with the debt they did everything right. What was going on there with commitment and leadership from the medical director right down to the heirs. Thats what you need. There is an example at the va this can be done correctly . What would you guess, what percentage of the va facilities around the country do this well . 10 , 15 . Mr. Chairman, 85 of the va facilities around the country who are dispensing drugs illegally or the snark away, correct . They are not following the tenets of the air. As a result, these drugs it in the wrong hand. Correct. Okay, good. Dr. Berge, dr. Berge come to you in the mail. Have you found that would benefit the drug controlled program that you can save money . I believe we can. I believe if you ask the executives at the New Hampshire hospital that is being sued, multiple lawsuits that they wish they had a more effective system. Besides avoiding litigation, is there a way to save money when you have an Effect Program like this . Thats extremely hard to quantify. To have an effective system in place is not an expensive endeavor in itself. It allows you we have heard that the word on the straightest ogata worked or mail because if youre going to steal drugs, the catchy. Thank you for being here, mr. Chairman. Thank you. Dr. Dunn, you recognize for five minutes. Thank you, mr. Chairman. Dr. Clancy, i served on a constituency that actually has veterans hospitals lake facility and testimony here that we did not read aloud, but i think you are familiar but a problem in the lakes facility earlier with the nurse misappropriating the drugs. Can you discuss the protocols established at the lake city facility in the wake of this incident to restore the quality of care at the level work place safety for the community and also tell me if your current controlled substance coordinator and not facility is certified and educated on the management of controlled substances and the supply chain and management palace use. Id be happy to take that for the record. Our first focus was protecting patient and holding individual accountable. I look at the rest of the information. That particular instance in the facility. And familiar at the internet, not with all the details of the followup will find that for you. Let me depart for a second, dr. Berge. You are an expert in Substance Abuse i think and how it columns. Im a surgeon. I manage operating rooms. Ive directed hospitals and large clinics. This is a problem we all have to address. Its just part of the job we have to do when we do help care. I have seen a steady at the state level as well. I am looking at this particular pie chart here that suggests 90 of the problem with diversion with control of hudson is this occurred not in the health care facilities, but the United States Postal Service and ups. I want to tell you that ive looked at a lot of Drug Diversion, a lot of problems with this in my 35 year career as a surgeon. I have never seen anything like this reported. This is perilously close to the old excuse the dog ate my homework. Do you believe 90 of the Drug Diversion in this country occurs in the United States Postal Service . Im not qualified to comment on that because that is not where we see it. I am basically assigned within the walls of our health care facility. What happens without, i dont know. That is not what we see at mayo. We see other forms of diversion. Perhaps i should redirect that question in day do you mean by this that 90 of the problem occurs in the Veterans Administration facility mailrooms or are you actually saying that employees of the United States Postal Service United Parcel service or people who pick my send it 90 of diverted drugs . What i am saying and ill ask my colleagues to elaborate that between the time the prescriptions are put in an envelope and understand they have a central mailorder pharmacy, which promotes prescriptions works extraordinarily well with a higher order of business, very large volumes. Somewhere between blair and the Veterans Home where it was supposed to go is where it is diverted. On occasion, weve heard veterans that is actually diverted by a Family Member and so forth. But it could be any one of those points and that is where working with the Inspector General and outside Law Enforcement has been helpful. Lets go down on this further. Looks like we are lacking off on the Postal Service. The va getting receipt of the drugs from who they purchased it from and are distributed in their system. They may be using ups or usps and somewhere between when the va has the drug and passes off another part, the drugs are being diverted. Is that the system . No. This is outside the vha system. I have to tell you in 35 years ive never heard this kind of accusation. 90 of the problem in the postal system. Im flabbergasted, mr. Chairman. Let the record reflect that incredulity. Dr. Dunn, we look at this and one of the first things we tried to obtain with good data. Id be very suspicious of those, too. Bosses are not always synonymous with diversion. Weve got to be careful about. The reporting system for Drug Diversion cases. I would just be very suspicious of any data. I am, too. Thank you. Thank you. Dr. Roe come youre recognized for five minutes. Thank you, mr. Chairman. , to go along with what dr. Don obviously we know theres a drug epidemic concert in the state of tennessee i believe it is. Is there any doubt how many veterans died of a Drug Overdose that both with diazepam and opioid. Dr. Clancy, jeff information on that . We do track that closely and would be happy to get that ready for the record. The other thing i have a say look at this draft more, i couldnt figure out how you determine 90 . If somebody is hauled in just that i didnt get my drugs. One good thing if there is any good thing about Electronic Health record, what used to happen to us were moved closer opposite by the call, people start calling in and after that i just had surgery. We had a big practice two weeks ago dr. Soandso didnt leave me enough medicine. I need you to call a prescription in. You dont need to be patient and are part is. People are very clever at the naval to get drugs. When you say 90 , how in the world could you ever think of that number out because you say here that the post office doesnt deliver it. How do you know that . I can help with that. This is a sad example of reports in january 2014 through march of 2016. So whenever we have a lot to know we have a template that the individual facility fills out. What happened, who did you report to . Dda, oig, police insecurities that one of go for it. In those reports, we are able to glean information and identify it was a situation where it be a staff member of diverted the drug or whether it was a patient calling in saying i didnt get my package. Our packages are sent with tracking information. We can tell where it is than the delivery stream and not some void if the patient size they dont get it, we have one of two situations. Either they did get it or a Family Member got it or it went missing somewhere. So i agree, these may not be diversion, that these are indeed biased reports generated. Me interrupt you. My time is short. It looked to me if we can know how many died, theres a real problem looks like there may be a better way to deliver medications to people and send them out in the mail. If thats where my not 10 of these problems are evident as a lot of people, looks to me like a sloppy system is that the case. Dr. Clancy coming to written testimony said 19 but then any sort of answered how you got that information. Reviewing the dda forms 106 submitted to the committee, weve learned where da got controlled substance to the wrong address or even restaurant veteran. How many were missing in the mail with those delivered to the wrong address into the wrong person . Thats really sloppy. Would be happy to get that for the record. Well, we appreciate that and please take that for the record and no doubt the numbers and bring those numbers to the committee. For now, what is the va doing to ensure they get the right prescription . Sloppy work when you mail it to the wrong address or to the wrong person for goodness sakes. There is a big part of the effort initiated by secretary mcdonald in my transformation that includes make sure Veterans Data is integrated from multiple sources, et cetera and get multiple services from us that when they move, change phone numbers or whatever, weve got accurate information. Everything mailed out his barcoded so that it can detract. If a batter in calls that the facility nsaids buy medications to calm, they can actually track it. As a tracking number weathers post Office Service or ups. Ultimately, that is helpful to Law Enforcement figuring out what happened. Is that a system would want to continue at the va . Is a huge system treating millions of people. Not thousands, the millions. You are absolutely right that this is an area where its not working as well as it should. If we require every veteran require every batter into coming in to pick a controlled substances, we could certainly do that. I think it could create some unintended consequences. Some veteran very far away, so we may have to look at another option for them to get their controlled substances. I agree with that. Im not saying you should do that. We have a situation now where her descent to us in people, these are all deaths preventable. Its really disturbing to me when you have probably as many people die at Drug Overdose as car wrecks now. It is a huge problem for the entire country. Mr. Chairman, i yield back. Mr. Poliquin is recognized for one following question. Thank you, mr. Chairman. I would like to follow up on what chairman trained or was just talking about. It is clear to me and i think everybody in this room that the va and god bless them, they are doing a horrible job when it comes to this issue. Why the heck do we have to does the pills from the va . How many pharmacies to rehab in this country . I dont know, dont care. We have a bunch of them. Why cant we have pharmacies around the country closer to where our population is, or veterans are. Why dont they dispense pills if you guys are doing such a horrible job . Dr. Clancy. Im sure as my colleague noted, first of all mail order works extraordinarily well for other types of medication. As we work through how to reduce this area of vulnerability, there may be a lot of other options. At. If youre getting an aspirin or Something Like that come in accents, but a controlled substance, maybe better if its closer to home or folks come in and they are known by the folks at the pharmacy and weve got a problem here and so forth can do so on. Why not . We have to consider that. I dont know what the protocol is, but a bit these nice folks would come back and report to us. For that to follow up same vein that mr. Dahl him by mr. Williamson county two fellas said roughly 10 or 15 of medical facilities are doing this right. That means 80 or 85 . Well do that to afford the ig of the big da. But that is based on, you know know doing it wrong. A bunch of them are doing it wrong. Correct. Okay, good. I have an idea. Why dont we get you nice folks to talk to our great staff here and find out who is doing a right and we will have our staff, mr. Chairman, call up the folks doing it right and find out why they are doing it right and maybe we can have this nice person, mr. Alaigh, why believe dr. Clancy, you report to come it would be the undersecretary, have him come before the committee and then we can see okay, weve had these folks doing it right. Now we have a problem at the va doing it wrong. Maybe you can tell us what 80 are doing it wrong. Just an idea. What do you think about that, mr. Dahl . Do you think that would work . I missed the last part. You think that would work . Best this is, wouldnt sure to hear them to share them. There you go. We are trying to get this right. Weve got a veteran in pain and having problems with opioids and heroin. Anything we can do to help you folks, well do that. I know our great staffer, cable be in touch with the folks to get the names we talked about. Just wanted to make the point that we often do sharing of best practices and have a Big Initiative im not and thats a splendid idea. Have you been doing up to the last eight years . Not in this particular area. We have focused a lot on reducing opioid. The last couple of years. Is still at 80 not doing it right. I am not quite as confident. I think that they be a slightly pessimistic projection. I will tell you. Mr. Chairman, more reason to get the folks doing it right to come and report to us and maybe have the person in charge of everybody tell us why the other folks are doing it right. If i may, dr. Alaigh is a woman. Wonderful. Thank you very much. Appreciate it. Thank you, mr. Chairman. I yield back my time. Thanks to everyone. Next to the witnesses here this is a great next step as we move forward with a very serious issue here. You are now excuse. It is clear from the testimony provided today as well as numerous cases we hear about in the news that Drug Diversion is a major problem at va facilities. A lack of oversight over das controlled substances and the apparent lack of accountability for failing to monitor proper distribution, storage and destruction is troubling. We hope that by bringing this issue to light, it will encourage the va to take steps necessary to impose better oversight and control. I look forward to hearing back on the progress and changes the va is making. I ask unanimous consent that all members have died legislatilegislati ve days to revise and extend their remarks and a third extraneous material. But that objections the word. I would like to once again thank allah again thank allah for witnesses and not its members for joining in todays conversation. With that, this hearing is adjourned. [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] the u. S. Senate about two n. To continue work on a hospice resolution to repeal an interior Department World on public land use plans. About on the measure scheduled for 6 00 p. M. Eastern. And a Job Administration nominate a week debate in a confirmation in the senate. See my burma nominated to be administered at the centers for medicare and medicaid services, which oversees the Childrens Health Insurance Program and the Health Care Law marketplaces. Right now to the floor of the senate. The presiding officer the senate will come to order