ODVA audit finds agency is poorly led
The leadership at Oklahoma’s Department of Veterans Affairs “manages by fear” and is comparable to “a puppet regime,” its employees told state auditors.
“This is the most punitive, negative, secretive, dysfunctional environment I have ever worked in. I feel my job is in jeopardy every day that I go to work,” one employee said, according to a three-year audit released Wednesday. “The ODVA is run from central office by lies, deceit and secrets.”
The 75-page audit paints the picture of a dedicated staff caring for veterans at seven long-term care centers around the state and led by effective leadership within each center but constantly exhausted by “a culture of fear and intimidation” at the central office in Oklahoma City.
That culture has led to staffing shortages, which has led to a decline in patient care, though not to the extent that it violates state regulations, according to the audit. Laboratory services are now contracted to an outside firm, the use of specialty diets has been limited and doctors no longer take sick calls, investigators found.
“In several cases, employees even expressed the perception that the number of resident deaths has increased due to level of care changes, as well as the removal of veterans after the closure of the special needs unit at Talihina,” the audit states.
Auditors heard from 254 past and present employees of the ODVA but found some too fearful of retribution to comment. Auditors were told their communications with ODVA staffers were being monitored. Some ODVA staff sought protection before speaking.
Shane Faulkner, a spokesman for the ODVA, issued a terse statement Wednesday.
"We are presently reviewing the state auditor’s report," he said. "Where matters of significance have been raised, we look forward to taking the appropriate corrective action.”
The Talihina Veterans Center in southeast Oklahoma, which opened as a tuberculosis sanatorium nearly a century ago, is a major focus of the audit. There have been talks of relocating the facility and its employees say those talks are driven by a vendetta that leaves them fearing for their jobs and residents’ wellbeing.
The center’s special needs unit for aggressive residents was closed in 2017. The deaths of Vietnam veteran Owen Peterson from sepsis in 2016 and Leonard Smith, a dementia patient who choked on a plastic bag in 2017, led to legislative efforts to close the facility.
In April, Gov. Mary Fallin signed a bill allowing the ODVA to construct a new facility to replace the Talihina Veterans Center.
ODVA managers claimed the special needs unit was closed due to low staffing levels but auditors found terminations
We are presently reviewing the state auditor’s report. Where matters of significance have been raised, we look forward to taking the appropriate corrective action.”
Shane Faulkner, a spokesman for the ODVA
there, while significant, did not differ greatly from other ODVA centers. Auditors also found that mold removal, estimated to cost $50,000, was never conducted in the ventilation system because the special needs unit was closed.
“However, according to staff members at the Talihina center, the same ventilation system feeds into various other sections of the building that are still being used today,” the audit states. “These areas still in use by both staff and veterans include the physical therapy room, exam rooms, and stockrooms.”
Auditors were critical of a decision by ODVA’s central office not to upgrade a nurse call system. The administrator in Talihina repeatedly argued not updating the system risked the lives of patients but those warnings were not acted on, according to the audit.
“The decision to avoid preventive maintenance of the nurse call system could easily be interpreted by the average citizen as management not prioritizing the veterans’ well-being,” auditors wrote.
The audit recommends the Oklahoma Veterans Commission address the toxic management and improve communications. It also should seek an independent evaluation for relocating care centers, ensure costbenefit analyses are performed before outsourcing services and make other minor financial changes, according to the audit.