WASHINGTON, D.C. – On Wednesday, Senator Joe Manchin questioned U.S. Department of Veterans Affairs and The Joint Commission officials on the murders of multiple Veterans at the Clarksburg VA Medical Center in 2017 and 2018. According to a release from Manchin, this is the first comprehensive hearing on the systemic issues uncovered during the Clarksburg VAMC investigation.
Here’s what Senator Joe Manchin had to say:
“I worked hard as a member of the committee to ensure that horrific murders that occurred in my home state of West Virginia and specific problems that led to these murders never happened anywhere else in the country. We must make meaningful changes at the VA so that Veterans in West Virginia and across the country can begin to rebuild their trust in today’s care. This is the first time since the Clarksburg VAMC murders that we are having a comprehensive look at the accountability and culture of the VA and I thank you, I truly do…Oversight is our duty on this committee. We must hold those responsible that have placed our Veterans at risk accountable. And I look forward to hearing from our panelist on how we can prevent these mistakes from occurring.”
On VA retirement policies:
“In the recent written testimony, Inspector Missal states that ‘When it comes to instances, like Clarksburg, the common contributing factors, the OIG has identified are poor, inconsistent or ineffective leadership that cultivate a complacent and disengaged medical facility culture in which the VA goal of zero patient harm is improbable, if not impossible.’ That’s clearly the case at the Clarksburg VAMC, and yet individuals in positions of leadership were able to simply resign and keep their valuable VA benefits, like retirement benefits…How do we hold the VA leaders responsible with instances like the murders at Clarksburg? How do those people stay in the system? How are they able to retire with their benefits with such disrespect, such neglect and malfeasance of doing their job?”
On VA hiring processes:
“Dr. Clancy, in recent years, our Veterans have experienced massive breaches of trust in all the VA employees, especially at the Clarksburg VAMC, where an employee who murdered multiple Veterans never went through a proper hiring process…How’s the VA updated its hiring process to reflect the lessons learned in vetting? You only had to make one phone call and they could have caught this woman before she ever got in the door.”
On The Joint Commission:
“I’m extremely concerned about the current state of the relationship between The Joint Commission and the VA. Like I said at the beginning of this hearing, The Joint Commission consistently gave the Clarksburg VAMC a passing score for accreditation. Before and after the horrific murders occurred at the facility. The Joint Commission was even on site at the Clarksburg VAMC for review, which Clarksburg passed. They passed it, that was less than eight weeks before the murders began. That year, the VA paid the Joint Commission almost $6 million for their services. And that really doesn’t sit right with me – knowing the amount of money that we’ve invested there and the return we got – as a Senator or as a West Virginian. It all comes back to accountability. How did The Joint Commission miss this blatant oversight during their May 2017 on site survey?”
Homicides in Clarksburg, West Virginia:
A May 2021 OIG report detailed the case of nursing assistant Rita Mays, who deliberately administered insulin to at least nine patients throughout 2017 and 2018 at the Louis A. Johnson VAMC in Clarksburg, West Virginia. Seven of the patients died.
As part of this report, OIG made fourteen recommendations to prevent further adverse quality of care incidents, including recommendations for the…
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