[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]





ASSESSING VA OVERSIGHT OF DRUG PRESCRIPTION PRACTICES AND PROPER USE OF 
                           MEDICAL FACILITIES

=======================================================================

                             FIELD HEARING

                               before the

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                                 of the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED FOURTEENTH CONGRESS

                             SECOND SESSION

                               __________

                          FRIDAY, MAY 20, 2016

                 FIELD HEARING HELD IN DENVER, COLORADO

                               __________

                           Serial No. 114-70

                               __________

       Printed for the use of the Committee on Veterans' Affairs


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                     COMMITTEE ON VETERANS' AFFAIRS

                     JEFF MILLER, Florida, Chairman

DOUG LAMBORN, Colorado               CORRINE BROWN, Florida, Ranking 
GUS M. BILIRAKIS, Florida, Vice-         Minority Member
    Chairman                         MARK TAKANO, California
DAVID P. ROE, Tennessee              JULIA BROWNLEY, California
DAN BENISHEK, Michigan               DINA TITUS, Nevada
TIM HUELSKAMP, Kansas                RAUL RUIZ, California
MIKE COFFMAN, Colorado               ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio               BETO O'ROURKE, Texas
JACKIE WALORSKI, Indiana             KATHLEEN RICE, New York
RALPH ABRAHAM, Louisiana             TIMOTHY J. WALZ, Minnesota
LEE ZELDIN, New York                 JERRY McNERNEY, California
RYAN COSTELLO, Pennsylvania
AMATA COLEMAN RADEWAGEN, American 
    Samoa
MIKE BOST, Illinois
                       Jon Towers, Staff Director
                Don Phillips, Democratic Staff Director

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATION

                    MIKE COFFMAN, Colorado, Chairman

DOUG LAMBORN, Colorado               ANN M. KUSTER, New Hampshire, 
DAVID P. ROE, Tennessee                  Ranking Member
DAN BENISHEK, Michigan               BETO O'ROURKE, Texas
TIM HUELSKAMP, Kansas                KATHLEEN RICE, New York
JACKIE WALORSKI, Indiana             TIMOTHY J. WALZ, Minnesota

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.

























                            C O N T E N T S

                              ----------                              

                          Friday, May 20, 2016

                                                                   Page

Assessing VA Oversight of Drug Prescription Practices and Proper 
  Use of Medical Facilities......................................     1

                           OPENING STATEMENTS

Mike Coffman, Chairman...........................................     1
Ann M. Kuster, Ranking Member....................................     2

                               WITNESSES

Mr. Ralph Gigliotti, Network Director, Veterans Integrated 
  Service Network 19, U.S. Department of Veterans Affairs........     4
    Prepared Statement...........................................    27

        Accompanied by:

    Ms. Sallie Houser-Hanfelder, Director, Eastern Colorado 
        Health Care System, U.S. Department of Veterans Affairs

    Ellen Mangione, M.D., Chief of Staff, Eastern Colorado Health 
        Care System, U.S. Department of Veterans Affairs

 
ASSESSING VA OVERSIGHT OF DRUG PRESCRIPTION PRACTICES AND PROPER USE OF 
                           MEDICAL FACILITIES

                              ----------                              


                          Friday, May 20, 2016

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                  Subcommittee on Oversight
                                        and Investigations,
                                                   Washington, D.C.
    The Subcommittee met, pursuant to notice, at 9:30 a.m., in 
Old Supreme Court Chambers, State Capital Building, Room 200, 
200 East Colfax Avenue, Denver, CO, Hon. Mike Coffman [Chairman 
of the Subcommittee] presiding.
    Present: Representatives Coffman, Lamborn, and Kuster.

          OPENING STATEMENT OF MIKE COFFMAN, CHAIRMAN

    Mr. Coffman. Good morning. This hearing will come to order.
    First, I want to welcome Congresswoman Ann Kuster from the 
State of New Hampshire, Western New Hampshire, New Hampshire's 
2nd Congressional District, and Congressman Doug Lamborn with 
me here from the 5th Congressional District of Colorado.
    Good morning. This hearing will come to order. I want to 
welcome everyone to today's hearing entitled, ``Assessing VA 
Oversight of Drug Prescription Practices and Proper Use of 
Medical Facilities.''
    The purpose of this hearing is to address numerous issues 
related to VA's handling of prescription and oversight 
practices of controlled substances, as well as its appropriate 
use of medical facilities to benefit veterans. Particularly 
during this hearing, we will discuss issues pertaining to 
quality and access to care, deficiencies in the use of medical 
and research facilities and the absence of accountability in 
cases involving misconduct, both in Colorado and across the 
Nation.
    The House Veterans' Affairs Committee has held numerous 
hearings on the improper prescription practices of VA 
physicians. In one of those hearings, slides from a video were 
shown where multiple VA medical employees stated how they were 
making veterans into drug addicts.
    This hearing follows up on our previous concerns in those 
hearings by looking at VA's internal procedures that likely 
allow for VA's apparent ``prescribe first'' mentality and how 
controlled substances wind up missing, stolen, or in the hands 
of the wrong person.
    One example of where these internal procedures are going 
wrong is at the Denver VA Medical Center. The DEA, Drug 
Enforcement Agency, recently conducted a review of the Denver 
VAMC--for those of you that don't use acronyms, that is the 
Veterans Affairs Medical Center--where it found dozens of 
problems that compromised the safety and legality of the 
facility's prescription practices. Some of those findings 
include mailroom employees with related felony convictions with 
access to controlled substances. This calls into question 
whether the VA conducts proper background checks prior to 
hiring. DEA also found that the facility's random drug testing 
was inadequate.
    A wall to wall audit of inventories performed between 
February and July 2015 found 16 of the 27 medications audited 
did not balance when comparing receiving, dispensing, and 
destruction records, and VA pharmacy leadership failed to 
report theft or loss of controlled substances within DEA time 
requirements, and in some cases failed to report at all.
    In addition to these obvious deficiencies in the Denver 
VAMC's prescription drug oversight, the facility's maintenance 
of research facilities also gives cause for concern. For 
example, numerous pieces of expensive scientific equipment are 
broken or unused. Further, boxes of patient information, some 
water damaged, from research studies dating back to 2011 
remained stacked up in unsecured rooms during our visit last 
month. In some cases, research chemicals are also unsecured and 
unaccounted for within the laboratory.
    I look forward to hearing from the VA witnesses that have 
joined us today in order to get some clarity on these issues. I 
know that these problems are not confined to the Denver VAMC. 
So I look forward to discussing other facilities, and how we 
can help identify systemic problems in order to improve 
services to our veterans.
    With that, I now yield to Ranking Member Kuster for any 
opening remarks she may have.

       OPENING STATEMENT OF ANN M. KUSTER, RANKING MEMBER

    Ms. Kuster. Thank you, Mr. Coffman, and thank you again for 
the invitation to come here to Denver to talk to you about an 
important issue that is threatening not only our VA, but our 
entire country, and that is the issue of opiate use and misuse 
and the diversion of prescription medication.
    This morning we will be examining VA's role in ensuring our 
prescription drugs are safely controlled in all VA medical 
facilities. The VA must make sure that it has the right 
oversight policies in its facilities, and that employees follow 
the policies and regulations to prevent theft, improper use, 
and over-prescription of opioids and other controlled 
substances.
    I am concerned about several of the Drug Enforcement 
Agency's findings in its investigations of the Denver VA 
Medical Center's handling of prescription medication, and I 
want to find out what steps have been taken to correct DEA 
regulation violations. This is one more important step that the 
VA must take to combat the opioid use and abuse epidemic that 
is stealing the lives of so many veterans right here in 
Colorado, in my home state of New Hampshire, and all across the 
Nation.
    Colorado and New Hampshire share many of the same 
statistics on opioid abuse. In both of our states, death from 
drug overdoses are higher than the national average, and death 
from drug overdoses is now the leading cause of death. You 
should be pleased that your state has dropped from number two 
in the Nation down to number 12. In that same timeframe, New 
Hampshire went from number 24 in the Nation to number three, 
and you now have a four times greater chance of dying from an 
opiate drug overdose in New Hampshire than a car accident.
    Colorado is 12th in the Nation now for prescription drug 
misuse. New Hampshire, sadly, has the highest rate of opioid 
addiction. This is why it is important that we all work 
together to address this epidemic.
    As Members of Congress, just last week we passed 18 bills 
in the House of Representatives to address the opioid epidemic, 
and I want to say these were bipartisan bills, and it was a 
very rare week on Capitol Hill. This included the Jason 
Simcakoski PROMISE Act, a bill that Congressman Coffman and I 
championed, which will help improve opioid prescription 
practices at the VA all across the country.
    As a member and founder of the Bipartisan Task Force to 
Combat the Heroin Epidemic, I have now been named to the 
bipartisan House and Senate Conference Committee to work out 
the differences between the House and Senate opioid epidemic 
legislation. I am committed to working with my colleagues to 
get these vital life-saving bills passed into law.
    Now, the VA must also do its part to ensure proper 
oversight and to use the resources and best practices it has 
available to it within the VA, in the community, and through 
its academic affiliates. I know that the Colorado medical 
community is actively involved in educating providers on safe 
prescription of opioids, and that the University of Colorado at 
Denver's Center for Health, Work and Environment provides 
guidelines and tools for health care providers to improve 
chronic pain management, to safely monitor the prescription of 
opioids, and to prevent opioid use and diversion.
    Through its academic affiliation with the University of 
Colorado's School of Medicine, the Denver VA Medical Center can 
work to promote best practices for its practitioners and to 
train our future health care providers on safe prescription 
practices and alternative treatment for managing chronic pain.
    We also will hear this morning about issues concerning 
facilities and access to care for veterans in this community. I 
would like to know what Denver is doing to address the increase 
in patient demand, and if the hospital currently under 
construction will be adequate to meet the current and future 
patient demand, to train future residents at the University of 
Colorado Medical School, and to support important VA-funded 
research.
    I would also like to know what is being done to manage and 
support VA research currently taking place at VA facilities and 
through the medical school, and whether VA facilities are being 
utilized and are adequate to support current efforts.
    We will not solve the opioid abuse epidemic in this 
country, help our veterans affected by the epidemic, or solve 
the VA's patient access problems without our dedicated and 
coordinated efforts.
    And with that, I thank Mr. Coffman and I yield back.
    Order to improve services to our veterans.
    Mr. Coffman. Thank you, Ranking Member Kuster.
    I would like to now introduce our panel. On the panel we 
have Mr. Ralph Gigliotti. Did I say that right? Mr. Gigliotti, 
Network Director of VISN 19. He is accompanied by Ms. Sallie 
Houser-Hanfelder and Dr. Ellen Mangione, the Director and Chief 
of Staff of the Eastern Colorado Health Care System.
    I ask the witnesses to please stand and raise your right 
hand.
    [Witnesses sworn.]
    Mr. Coffman. Thank you very much. Please be seated.
    Let the record reflect that all of the witnesses have 
answered in the affirmative.
    Mr. Gigliotti, you are now recognized for 5 minutes.

              OPENING STATEMENT OF RALPH GIGLIOTTI

    Mr. Gigliotti. Good morning, Mr. Chairman, Ranking Member 
Kuster, and Members of the Committee. Thank you for the 
opportunity to discuss the VA's handling, prescription, 
oversight practices, and appropriate use of controlled 
substances at VA facilities.
    Oversight and handling of prescription drugs. Questions 
have arisen regarding pharmacy practices and accountability in 
VA Eastern Colorado. In the last five years, eight Eastern 
Colorado VA employees have been disciplined or removed for 
illegal possession or use of drugs on VA property.
    In February 2016, DEA reported findings to the executive 
leadership team and pharmacy management. Most items were 
addressed while DEA was on site, which resulted in process 
changes to ensure the safe handling of pharmaceuticals in VA.
    To improve safe pharmacy practices, the VA's Opioid Safety 
Initiative, OSI, was implemented nationwide in August 2013. 
Nationally, results of key clinical measures measured by the 
OSI from July 2012 to March 2016 show a 22 percent reduction in 
a number of patients receiving opioids; a 37 percent increase 
in patients on opioids that have had a urine drug screen to 
help guide treatment decisions; and a 32 percent decrease in 
overall dosage of opioids in VA. This was all achieved during 
the time that VA had seen an overall growth of 3 percent in VA 
outpatient pharmacy service usage. These OSI dashboard metrics 
indicate the overall trends are moving steadily in a desired 
direction.
    VA Eastern Colorado access. Over the past three fiscal 
years, VA Eastern Colorado has seen a consistent increase in 
demand for services, with unique patients increasing by over 13 
percent. We have simultaneously increased the supply of health 
services by 12 percent, but demand has outpaced supply, 
resulting in longer wait times for our veterans. Despite this, 
we have made tremendous strides in decreasing the electronic 
wait list to 543 as of May 2016.
    Over the last three fiscal years, our Colorado Springs 
clinic has seen the most notable increase in workload within 
our catchment area. On February 4th, 2016, the Office of 
Inspector General released a report identifying untimely care 
concerns at this clinic resulting from a complaint received in 
January 2015. The report also identified areas needing 
improvement such as scheduling and referral to the Veterans 
Choice Program.
    OIG acknowledged in the same report that we had already 
executed a number of corrective actions to become compliant 
with its concerns. These included filling vacancies, hiring new 
staff and trainers from entry to executive levels, retraining, 
and practicing continuous quality improvement. We have 
increasingly relied on care in the community to provide health 
services to our growing veteran population.
    The Denver VA campus. Medical and prosthetic research at 
the Denver VA campus, including in some temporary buildings, 
should be moving into its new space at the replacement facility 
on the Fitzsimmons Campus in Aurora. The project is to replace 
the current Denver VA facility which was built in 1948. The 
Army Corps, VA, and Kiewit-Turner are working in close 
collaboration to complete this new facility. The construction 
team is dedicated to achieving VA requirements and criteria, 
while also pursuing cost savings opportunities to maintain the 
current budget. To ensure that previous challenges are not 
repeated, we continue to focus on lessons learned over the 
course of the construction.
    In all phases of the construction and activation, the 
activation team is working in close consultation with our 
military, veteran, and community stakeholders via regular on-
site meetings. The project is currently 67 percent complete.
    Sustainable accountability. VA is committed to creating an 
environment of sustainable accountability in which employees 
know what is expected of them, and then exceed that. 
Sustainable accountability means using taxpayer dollars wisely 
to improve life for our veterans and families. To create this 
culture, we have taken steps such as changing VA leaders' 
performance reviews to include veteran-centric outcome 
objectives, improvements in workforce culture, and focus on 
ICARE, which will allow VA to address these issues as required.
    We have also implemented strong, independent oversight, 
creating the Office of Accountability Review, and by securing 
certification in the Office of Special Counsel's Whistleblower 
Protection Certification Program. The vast majority of VA's 
300,000 employees are committed to serving veterans 
effectively.
    Mr. Chairman, this concludes my testimony, and we are 
prepared to answer any questions that you may have.

    [The prepared statement of Ralph Gigliotti appears in the 
Appendix]

    Mr. Coffman. Thank you. Your written statement will be 
entered into the hearing record.
    We will now proceed to questioning.
    Is there anybody else on the panel to testify at this time?
    [No response.]
    Mr. Coffman. This is to all of you. Chairman Miller wrote a 
letter to Under Secretary Shulkin last month regarding a VA 
police report in your facility that showed in 2014 a VA 
employee was caught during working hours and admitted stealing 
and using a Schedule 2 drug, fentanyl. The employee was not 
disciplined and still works for VA. Can you explain why?
    Mr. Gigliotti. I will let Ms. Houser-Hanfelder handle that 
particular case.
    Ms. Houser-Hanfelder. Thank you. That employee was 
disciplined. That employee is on a Last Chance Agreement, and 
the U.S. Attorney--
    Mr. Coffman. What was the disciplinary action?
    Ms. Houser-Hanfelder. It is the Last Chance Agreement that 
is in the record for the--
    Mr. Coffman. If you don't get fired for being in the 
operating room, stealing a powerful narcotic and using it 
there, if you can't get fired for that, where are the 
boundaries?
    Ms. Houser-Hanfelder. There was also prosecution through 
the court system where they did a preferred statement with her 
going through rehab and doing community service.
    Mr. Coffman. But from the VA standpoint, that is not 
grounds for firing?
    Ms. Houser-Hanfelder. They did not fire her. We did not 
fire her. She did disclose some other information to us that 
enabled us to deal with another employee. But if the question 
is was she disciplined, she is on a Last Chance Agreement for 
the continuation of her career, understanding she has no due 
right processes if she gets an unsatisfactory rating, or if 
there are any other issues with her.
    Mr. Coffman. In all cases of drug theft by VA employees, 
are all subject employees reported to their relevant state 
licensing board?
    Ms. Houser-Hanfelder. That depends on the cases. That 
person does not have a state licensing board. We had no legal 
rights to report her certification. Each case is on an 
individual basis as we go through it with our legal counsel.
    Mr. Coffman. How does VA coordinate with relevant Federal 
and state law enforcement bodies on issues of pharmaceutical 
theft from the Department?
    Dr. Mangione. Thank you, Mr. Chairman. Those are referred 
immediately to the VA police, to the Office of the Inspector 
General, and then also to VISN 19 theft and loss report 
distribution. And in addition, there is a Form 106 which is 
created and submitted to the DEA, along with an email alerting 
them to it.
    Mr. Coffman. Let me--
    Mr. Gigliotti. I was going to say, sir, then working with 
those agencies, the determination would be made in consultation 
with whether prosecution or not would occur.
    Mr. Coffman. Mr. Harter is in the audience. His son 
committed suicide just about a year ago, and this is what Mr. 
Harter writes: ``Towards the end of his junior year at UCCS, 
University of Colorado at Colorado Springs, in April of last 
year, he went to the Colorado Springs Lindstrom VA Clinic and 
told them he was having trouble sleeping, resulting in 
depression. He is a 50 percent disabled, post-traumatic stress 
combat veteran, both Iraq and Afghanistan. The clinic didn't 
schedule him with a doctor. He was seen only by a physician's 
assistant who documented his condition, prescribed a 
psychotropic drug''--let's see if I am pronouncing it right--
``Venlafaxine, and sent him on his way without any further 
follow-up or monitoring. A month later, our son''--and Mr. 
Harter is saying this--``our son shockingly took his own 
life.''
    This is a drug that requires monitoring. Can you elaborate 
on this?
    Mr. Gigliotti. Dr. Mangione?
    Dr. Mangione. Our physician's assistants operate under the 
direction of a physician and a psychiatrist, in this case Dr. 
Bill Bain, who is a psychiatrist. Dr. Brian Bain--I am sorry--
who is a psychiatrist in the Colorado Springs clinic. We do 
audits of all the evaluations that are done by our physician's 
assistants. And in this case the physician's assistant followed 
the procedure appropriately.
    What occurred in this particular situation is a bit 
unclear. It was the intention of the physician's assistant to 
have Mr. Harter come back to the clinic within a limited period 
of time. It is a little bit unclear as to the extent to which 
Mr. Harter, after this was discussed with the physician's 
assistant, wanted to or didn't want to return. He actually had 
a history of cancelling a large number of appointments with the 
clinic. But the intention was that he would come back in the 
next week for monitoring. He also had a social work appointment 
as well.
    Mr. Coffman. What actions were taken when he did not come 
back?
    Dr. Mangione. So there are calls typically made out to the 
particular individual to remind him to come back.
    Mr. Coffman. Okay. Well, we will be asking for all records 
related to this particular case.
    Congressman Lamborn did an informal field hearing in his 
district in Colorado Springs, which I attended, where Mr. 
Harter was able to testify on that, as well as Mrs. Harter, 
about their son, Noah. I thought it was very compelling and 
wanted to raise that case to you today, and we will do follow-
up on that case, obviously concerned about the loss of his life 
and the potential loss of other lives if these situations are 
not corrected.
    Congressman Lamborn, you are now recognized.
    Oh, I am sorry. This is not a good day for me.
    Ranking Member Kuster, you are now recognized for 
questions.
    Ms. Kuster. Thank you very much, Mr. Chairman.
    I will have three lines of questioning, and then we will 
come back?
    Mr. Coffman. We will come back on a second round.
    Ms. Kuster. Okay. So I am going to start with the 
prescription medications and your procedures. I also want to 
get into your pain management, whether you are making any 
changes around that to decrease the use of opiates. And you 
mentioned the taxes for Colorado veterans. I would like to 
briefly touch on that from some previous hearings we have had 
in Washington.
    So if you could help me to understand the corrective 
actions that have been taken to address the DEA's finding in 
its investigation. I am particularly alarmed with the Chair 
about employee theft, and I understand this Last Chance 
Agreement. I am wondering if that employee now is subject to 
drug testing. Is there monitoring that is going on? Just across 
the board, what are the corrections that are happening?
    Because, look, one thing that we have learned, and I have 
now spent the last year-and-a-half on this issue of the 
increased use of opioids and, sadly, the substance use disorder 
and the resulting theft and, in our case in New Hampshire, the 
growth of heroin and, sadly, the deaths. We have had 420 deaths 
in one year, and we are a very small state.
    So help me to understand. You have this DEA report. What 
are the corrective actions? Because if your employees are 
misdirecting heroin or fentanyl or opiates, you have an issue 
with substance use disorder right in-house, or these materials 
are being diverted out to what I assume is a very strong market 
for fentanyl and opiates and everything else, and you have to 
get on top of it.
    So help us to understand that. What are the steps that are 
being taken?
    Dr. Mangione. So maybe I should talk about a couple of 
things and then get into more specifics with your permission, 
Congresswoman Kuster. There are a number of issues that are 
already in place. So, for example, when we receive a sealed 
shipment of a pharmaceutical, there are two people who receive 
it. One is an independent person separate from the pharmacy, 
and then a pharmacist. They unseal that cache together.
    Ms. Kuster. I am sorry to interrupt. But as to specifics, 
do you have cameras now installed in your pharmacy to keep 
track of any attempted diversion?
    Dr. Mangione. We are in the process of installing them, but 
we do not have them yet.
    Ms. Kuster. And what about the tracking? Walk me through 
the tracking for when the package arrives, who has access to 
the information, is it electronic or in print, are there 
passwords being changed on a regular basis.
    Dr. Mangione. Yes, those are really good points. We 
discovered it, and fortunately earlier this week, I had an 
opportunity to speak with some of the other leadership from 
some of the health facilities around Colorado, and we are very 
much on the same path. We absolutely have very consistent ways 
of having two people monitoring-people independent from the 
pharmacy who are monitoring the drugs coming in and then being 
recorded.
    We in the VA have an electronic system that is called the 
VISTA Controlled Substance Tracking System, and even though we 
have all these duplications in the system and two people 
monitoring, at the end of the day, what really helps us the 
most are the electronic systems.
    So the VISTA system allows us to track any controlled 
substance into perpetuity. From the minute they arrive, there 
is an inventory which is created, which is maintained outside 
of the area of the vault where the medication--
    Ms. Kuster. And is there a reconciliation of that inventory 
for diversion, for theft and loss and returns?
    Dr. Mangione. Absolutely. What happens is that that 
information is uploaded into the vault, and the people in the 
vault with the cache actually have to reconcile against that 
particular inventory. Then we complete the loop also with the 
test to say this what we received, this is what you think was 
actually sent to us.
    And then in the vault there are actually--in the 
reconciliation every 72 hours independent people, but also two 
people present at the same time.
    Some of the issues that we were cited for by the DEA, I 
would just like to have an opportunity to explain a couple of 
those. One issue that has come up is been about--
    Mr. Coffman. Please move the microphone closer to you.
    Dr. Mangione [continued]. Okay. Sorry. One of the issues 
that has come up has to do with the biannual review. This is 
actually a national issue, because guidance that has been 
received by VA facilities is that when we do a wall to wall 
survey, that that actually satisfies the DEA requirements for 
the biannual review. We weren't doing our survey, but that was 
not the case. The intention of the biannual review is to review 
controlled substance inventories throughout the entire 
facility, whereas the wall to wall, which is required by the 
VA, is actually just immediately for that particular vault in 
that particular pharmacy, within the walls of that pharmacy. So 
if they are using a different denominator to judge whether or 
not the inventory is consistent, then absolutely, by definition 
you are going to be finding discrepancies.
    Some of the issues that we have found are that, for 
example, in the course of providing medications that have been 
returned to us, controlled substances that need to be 
destroyed, that we ended up putting together the medications 
that had been originally sent out. I can't tell you exactly 
what that is, but that is the central--
    Mr. Gigliotti. Consolidated mail-out pharmacy.
    Dr. Mangione [continued]. That is the pharmacy that does 
mailing out for the facilities. And the medication, even though 
it is sent out by CMOP, is returned to our pharmacy. So the 
practice was that we would take those medications, some of them 
returned by CMOP, and medications that someone might just 
return to us or whatever, we would put them into the same 
inventory, and DEA requested that we separate those out.
    As far as the number of reports, Form 106, that had been 
provided to the VA, in fact, we were over-reporting, and we 
didn't understand that. We had a culture of really trying to 
have a low threshold for letting anybody know we had discovered 
a problem. So we did submit a large number of those. At the 
time they visited us, they pointed out to us that that was, in 
fact, an error.
    One example of an error was that when we had delivered 
successfully a controlled substance to a veteran, and a veteran 
had opened it, and then a couple of days later, for example, 
would report to us that they had not received all of the 
medication, we actually filed a report with the DEA. But DEA 
explained to us that once that controlled substance was in the 
control of a veteran, that we were not responsible for 
reporting. So that was our error. But again--
    Ms. Kuster. It might be worthwhile for you clinically to 
keep track of that information even if--I mean, that sounds to 
me like a veteran who is trying to get additional medication.
    Dr. Mangione. We absolutely do keep track of that, but it 
is not required to be put on the form.
    Ms. Kuster. But do you keep track of it internally?
    Dr. Mangione. Absolutely, because then we can see a trend 
where this happens two or three times with the same veteran--
    Ms. Kuster. Do you know that one of the mentions in the 
report was about random drug testing of your pharmacy 
employees? Do you have random drug testing, and is that 
something that is happening on an ongoing basis?
    Dr. Mangione. There are five to 10 individuals randomly 
drug tested throughout the facility in any particular month. I 
think we would all agree that we would welcome an increase in 
that going forward.
    Ms. Kuster. I mean, one of the things, just for my 
colleagues, we have what is called a special order, but it is 
when Members of Congress came to the well for one evening for 
two hours, Republicans and Democrats telling stories, some very 
personal stories about their constituents, and in some cases 
family members, and I was impressed. There were several Members 
of Congress who have a background in pharmacy, and they were 
very forthcoming that substance use disorder is undiscerning in 
terms of who it chooses, and that pharmacists and people 
working in pharmacies are particularly susceptible.
    Dr. Mangione. One of the other issues that we had is that 
as of March 1st the VA did require drug testing on anybody who 
VA is considering employing prior to applying to any particular 
job category. So it is quite a long list, but it is--
    Ms. Kuster. That was one of the other references that I 
saw, is that you had some employees, and I think even working 
with controlled substances, who may have criminal background 
records related to opiate use or the sale of it.
    Dr. Mangione. My understanding is that those individuals 
were contract employees in our mailroom, and that that 
situation, as far as I understand, has been rectified. But any 
contractor who is employed, to the extent that we do have 
contractors, they actually have a full background check.
    Ms. Kuster. And I think what is important to understand is 
that the mailroom would be, particularly when you are receiving 
these medications by mail in bulk, and that issue that you 
pointed out about the returns, everybody all across the 
country, we are trying to deal with how to safely manage the 
returns of all this medication.
    I will yield back. I want to make sure to give our 
colleagues a chance, and then we can come back to pain 
management for a thorough answer. If there is more and you want 
to submit it for the record, I am sure it will be helpful for 
our Committee. Thank you.
    Mr. Coffman. Congressman Lamborn, you are now recognized.
    Mr. Lamborn. Thank you, Mr. Chairman. I want to thank you 
for your leadership and Chairman Miller, the Full Committee 
Chairman, of bringing to light some of the problems and issues 
the VA has had. Sometimes they have stepped forward and 
addressed them, but other times we are still waiting for an 
adequate response. But I know it hasn't been for lack of effort 
on your part and Chairman Miller's part, and all of us on the 
Committee.
    Mr. Gigliotti--I hope I pronounced that correctly--you 
paint a positive picture of the Lindstrom clinic in Colorado 
Springs in terms of more capacity and having shorter wait 
times.
    Mr. Gigliotti. A shorter electronic wait list, yes.
    Mr. Lamborn. But as you know, the care they receive after 
they are admitted is really the crux of the matter. 
Unfortunately, I still get bad reports in some cases of 
veterans who are not having satisfactory experiences. Just this 
week, we heard from a combat veteran who suffers from chronic 
pain and has a TBI, a traumatic brain injury. Some VA staff 
characterized this veteran who was seeking treatment as ``a 
drug seeker and a drug addict,'' even though the VA substance 
abuse doctor says that that is not right, that he shouldn't be 
determined that way. So it feels like he experienced hostility 
from some of the VA mental staff, and it was just one of the 
disappointments in the last 18 months.
    We also heard recently from Charlie, a comment from someone 
who actually worked at the Lindstrom clinic, but he felt like 
he had to leave because of a poor or even a hostile management 
environment.
    So what are you doing to address the quality of patient 
care once they actually do receive treatment?
    Mr. Gigliotti. Sure, and I will ask Ms. Hanfelder to 
amplify this. Colorado Springs is one of the fastest growing 
districts, if you will, in the country. The clinic, we have 
done some work with our panel sizes so that we are able to see 
more and more veterans, and I will specifically get to your 
question. But at the rate of growth that we are seeing, we need 
to look for ways to expand access points at the site, and the 
site was selected purposely so that it could be expanded.
    So we are now starting the process--sometimes it is a long 
process--to get an addition to that clinic, and we are also 
going to be looking at space throughout Colorado Springs to put 
non-clinical care off of that campus and into more 
administrative buildings so that the clinic is fully utilized 
for clinical space.
    Why don't you talk about some of the leadership changes?
    Ms. Houser-Hanfelder. Sure. Thank you, Congressman Lamborn. 
Back in the meeting that we had in February where we stepped 
through the processes that we were working on to improve 
access, I believe you met the executive leader down in Colorado 
Springs. He brings a new leadership to that particular clinic. 
He brings a military background with him, and he has been 
working diligently on the employee engagement issue.
    We need to know when a veteran walks into any of our sites 
and says he is disrespected or she is disrespected, or they are 
having problems, because that is not what the expectation is 
when they are being treated. They are to be treated with 
respect. Thirty-four percent of our employees are veterans 
themselves. So we are working diligently on the culture all 
over our organization, but Nate has really taken it on in 
Colorado Springs, and we are starting to see that turn. Our 
patient satisfaction scores are going up, and he is holding 
people accountable. So when you get those--I know your office 
sends us those things, we will work on the cases. But we are 
working with our employees.
    If I don't have engaged employees who are satisfied with 
their work, I will not have satisfied veterans, and that is our 
number--I have three priorities as the new director. Access is 
my number-one priority. Sometimes the priority shifts depending 
on what day it is. Number two is getting a replacement facility 
completed and us in it. And the third one is employee 
engagement, because we do have some issues with the culture at 
some of our sites. So we will work on that, and if you will let 
us know when those cases come up, we will deal with them.
    Mr. Lamborn. Thank you.
    Now, let me follow-up lastly, before yielding back to the 
Chairman, on the tragedy of Noah Harter, who took his life a 
year ago. Now, his family alleges that he did receive powerful 
prescription medication to treat depression or the after-
effects of being in combat, but he didn't have the therapy or 
follow-up or counseling from an actual M.D. Are you still doing 
investigation on that? I think you made reference to an 
investigation, and what have you found in regard to that?
    Dr. Mangione. So I would like to say that each suicide is a 
tragedy, but I can't imagine the loss of a child. So I think 
that is an incredible tragedy, and I certainly do sympathize 
with the family.
    We actually met with the family several months ago to 
discuss the care. Dr. Bain was present as well, and I was there 
too. I am not a psychiatrist, so I don't prescribe Venlafaxine, 
but Dr. Bain has a great deal of experience with that, and in 
his review of the case the prescribing of that medication was 
absolutely appropriate in that circumstance, is my 
understanding.
    What we have also done, though, because it does appear that 
Noah was lost to follow-up, for whatever reason, is we 
instituted a situation where when a veteran is about to leave, 
that there be a return-to-clinic order at the time so that the 
support staff who are sitting at the front desk before the 
veteran leaves can confirm with the patient that they will be 
coming back at a particular time. If the veteran says, well, I 
may have discussed this with my provider, but the reality is 
that I am really too busy and I am not going to be coming back 
for one reason or another, that the support staff will now 
alert the provider, and the provider will make a call to that 
veteran, do additional outreach to that individual to say, 
okay, we really do think you do need to come back in at a 
particular time.
    Mr. Lamborn. Well, that seems like a very important step. 
There may be other steps also that should have been done.
    Dr. Mangione. We know that from an efficiency perspective, 
when we have the veteran right there, to actually talk with 
them and make that arrangement to try to follow-up with them on 
their cell phone or something.
    Mr. Lamborn. Well, I hope there is no sense of blaming the 
veteran.
    Dr. Mangione. Absolutely not.
    Mr. Gigliotti. Absolutely not.
    Dr. Mangione. One of the issues that I think is so 
fascinating, the pain used to be fifth vital sign when I was in 
training, about how you really have to do away with all sorts 
of pain, and we as an organization, as well as the country, 
which was referenced before, about the downside of giving 
people opiates to control their pain. In fact, we have a 
researcher who has just received a large grant from the VA to 
study opiates from the veteran's perspective and what really 
works for them from their perspective. We as medical providers 
may have one opinion, but there has been a real dearth of 
information about what the veteran's perspective is.
    Mr. Lamborn. Thank you, Mr. Chairman. I yield back.
    Mr. Coffman. We will go into the second round now.
    On the case of Noah Harter, was there a formal 
investigation done with findings of fact as to what occurred?
    Dr. Mangione. I believe that there was, but my staff can 
check that for you, if there was a root cause analysis 
investigation. I can go back and check.
    Mr. Coffman. So you don't--
    Dr. Mangione. I believe there was a root cause analysis.
    Mr. Coffman. Okay. Can I get a copy of that, then? Because 
if there wasn't one, there should have been one.
    Ms. Houser-Hanfelder. The root cause analysis is a 
protected document, so it wouldn't have been released just 
automatically. We will go back and check to see. There should 
have been also a peer review done. I am sorry, I don't know the 
answer.
    Mr. Coffman. We will put in a formal request.
    Ms. Houser-Hanfelder. Okay, thank you.
    Mr. Coffman. We will put in a formal request for that 
investigation.
    Ms. Houser-Hanfelder. Okay.
    Mr. Coffman. And let me say also, you mentioned the issue 
of drug testing employees, that contract employees who work in 
the mailroom, you are not drug-testing those, are not required 
to drug-test those. I am sorry, could somebody clarify that for 
me?
    Ms. Houser-Hanfelder. If they are within that series, it is 
the contractor's responsibility. I do not believe--and we will 
need to validate this--that it is the VA that drug tests them. 
It is the contract responsibility, and there was a lapse in 
that.
    Mr. Coffman. So we have people with felony drug convictions 
dealing with drugs in your facility?
    Ms. Houser-Hanfelder. My understanding is some of them did 
have that. They were contracted staff. So, yes, we will go back 
and I will get clarification on that.
    Mr. Coffman. Who vets the contractors? Who is responsible 
for vetting contractors, contract staff?
    Ms. Houser-Hanfelder. Contracting, our contract office.
    Mr. Gigliotti. Our contracting staff.
    Mr. Coffman. So what requirement is put on the contractors, 
then, on this issue?
    Mr. Gigliotti. We have to get the specifics. I don't have 
them.
    Mr. Coffman. So you don't know.
    Mr. Gigliotti. I don't.
    Mr. Coffman. You don't know if there is a requirement or if 
there is not a requirement?
    Mr. Gigliotti. I would think--
    Mr. Coffman. Do you think there ought to be a requirement?
    Mr. Gigliotti. Yes.
    Mr. Coffman. That people with felony drug convictions 
shouldn't be working in a VA hospital dealing with these 
controlled substances?
    Mr. Gigliotti. In high-risk areas. Yes, I do. I agree.
    Ms. Houser-Hanfelder. I believe there is.
    Mr. Gigliotti. Right. We will have to get you the exact 
policy.
    Mr. Coffman. And you are saying that you can attest today 
that no VA employee is working at your facilities, no employees 
have felony drug convictions?
    Mr. Gigliotti. Of all of our employees?
    Mr. Coffman. That work in the health care areas.
    Mr. Gigliotti. In high-risk areas, there should be no 
employees--
    Mr. Coffman. How do you define ``high risk''?
    Mr. Gigliotti. It would be in this particular case--
    Mr. Coffman. The one where you had the person shooting up 
inside the surgery, inside the operating room? You would 
consider that high risk?
    Mr. Gigliotti. That position would--
    Mr. Coffman. All right, that would be high risk.
    Last year, DEA informed the Denver VA of its concerns 
regarding employees with felony drug convictions handling drugs 
in the mailroom. Does Denver VA properly conduct all background 
checks as required?
    Ms. Houser-Hanfelder. I am going to say yes, but I would 
like to validate. We do background checks. They are required. 
We don't do them ourselves. There is law enforcement training. 
The center does those for us, and that is a requirement when 
they on-board. Are we 100 percent? I don't know the answer to 
that. I would need to get back with you.
    Mr. Coffman. This issue is of grave concern given DEA also 
identified medications being returned to the Denver VA were not 
being properly received by a pharmacy for destruction. How is 
Denver VA addressing this deficiency?
    Dr. Mangione. Mr. Chairman, I believe that that goes to the 
issue of the CMOP, and the fact that they were receiving both 
controlled substances that had been sent out from the CMOP, and 
that DEA requested that we separate those two out so that there 
were two different inventories, one where the origin of the 
controlled substance was CMOP, as opposed to where the origin 
of the medication was our own pharmacy. I believe that that was 
what was referred to.
    Mr. Coffman. I was just concerned that these rules are 
there for a purpose, and part of it is transparency, to make 
sure that there are no problems. So you certainly have a great 
answer in terms of, oh, we were doing it this way, but it was 
really okay. Was it really okay?
    Dr. Mangione. No. We have resolved that. We resolved that 
immediately when it was pointed out to us.
    Mr. Coffman. Do all facilities in VISN 19 report all cases 
of pharmaceutical theft or missing mail, obviously containing 
pharmaceuticals, to the VA central office?
    Mr. Gigliotti. The reporting goes--ultimately the reporting 
does go to central office. Either diversion or theft, or 
missing, all of that should be reported, yes.
    Mr. Coffman. Is it?
    Mr. Gigliotti. It should be, and we have systems in place. 
If we are talking an N of 1, I can't say--
    Mr. Coffman. You can't verify today--
    Mr. Gigliotti [continued]. I can't say for 100 percent 
certainty, but it should be, and if it is not, then that is a 
matter of accountability.
    Mr. Coffman. Clearly, you were aware that this question was 
going to come up. I just can't believe that you didn't go back 
just to check and say, hey, are we doing this right?
    Mr. Gigliotti. We believe we are doing it right, yes.
    Mr. Coffman. There is a difference between believing and 
knowing.
    Mr. Gigliotti. It is a high-volume issue across a network, 
and our belief is we are doing it right. We work closely with 
the local facility. We have a VISN pharmacy person who does 
announced and unannounced inspections of narcotics, on-site 
visits, and when issues are found in that process, they are 
dealt with.
    Mr. Coffman. Okay. What VA employee, by name, is 
responsible for preventing drug theft and tracking DEA 
inspections within VHA?
    Mr. Gigliotti. What VA employee, by name--
    Mr. Coffman. Who is responsible? Who is responsible for 
preventing drug theft and tracking DEA inspections within VHA 
in your VISN?
    Mr. Gigliotti. In my VISN? Well, ultimately it would be 
either the chief medical officer, Dr. Lee Anderson, and then 
under him is our VISN pharmacy coordinator.
    Mr. Coffman. The VA chief of staff stated to me in a letter 
dated May 13th that VA reviewed thousands of pages of 
documentation regarding the AIB in Denver, which he said VA 
shared with the Committee. While we received the AIB report, we 
did not receive the evidentiary documentation that Mr. Snyder 
and previously the Secretary said was provided. Please convey 
to VA central office that this Subcommittee expects those 
documents to be provided immediately.
    Mr. Gigliotti. I will.
    Mr. Coffman. Ranking Member Kuster?
    Ms. Kuster. Thank you, Mr. Coffman.
    I just want to join my colleagues in my sympathy for the 
family of Noah Harter.
    One step that occurs to me might be happening to your 
processes when you lose track of a patient coming back, is that 
I know from personal experience that you can get a medical/
social check by the local police, and that maybe you want to 
add that to your process so that the family can be reassured 
and families all across the country can be reassured, because 
obviously, somebody with a 50 percent disability, we are 
dealing with somebody who is struggling. We have heard 
testimony in our Committee over and over how hard it is for 
people coming out of the military, veterans in particular, to 
acknowledge their challenges and to seek help. Frankly, this is 
no individual's fault, but the headlines about the VA don't 
always engender confidence in the process.
    So I think maybe adding one more step to the protocol 
rather than just some telephone call--the reality is none of us 
answer our telephones anymore. So it may take a face-to-face 
check, so I would encourage that.
    I just want to switch now to the pain management aspect of 
opiate use and how as the VA nationally we can lead the country 
in reducing the prescriptions of opiates. That is the most 
obvious cause of all of these heroin deaths and, in our case, 
fentanyl and opiates themselves. We have just literally as a 
country gone on a binge, and you would be shocked to see the 
chart. We now consume more opiates in the United States, 75 
percent of the opiates produced in the world, when our 
population pales.
    So what I wanted to ask very specifically--my Chairman, Mr. 
Coffman, was kind enough to come to New Hampshire to do a field 
hearing like this. We had a wonderful witness, Dr. Franklin, 
Julie Franklin from the White River Junction VA, who is working 
in a clinic to reduce opiate use with a group of veterans with 
chronic pain, and she has had fantastic results with 
acupuncture and yoga and physical therapy, and then the whole 
mental health therapy, individual therapy, group therapy, to 
deal with the literal pain, the heart pain and the head pain to 
go with the physical pain.
    They have managed to bring down the use of opiates by 50 
percent. If you don't have this kind of clinic, I highly 
recommend you reach out to her. She is quite extraordinary.
    But what are you doing here in Denver? What education and 
training have Denver VA providers received on safely 
prescribing and safely reducing the prescription of opiate 
dosages in the Denver VA?
    Dr. Mangione. A couple of things. One is that I would say, 
Congresswoman Kuster, is we actually did reach out to 
Manchester and to White River Junction, and we offer 
essentially the same sort of assistance they do. But before I 
talk about that, I want to talk about a couple of the other 
activities that we have going on.
    One is that we have a very active opiate safety committee 
in our facility, and they review every prescription which is 
for greater than 200 morphine milligram equivalents of 
methadone that is being prescribed. Our goal is to go down next 
to reviewing everyone who has 100, and then hopefully 90 and 50 
after that. We haven't quite gotten to that point yet.
    But what happens is--and everybody says, oh, we are going 
to educate people, and we all know that that is a pretty weak 
intervention. But what we do is, we actually do follow-up with 
those individual providers who either have a trend, or now, I 
think we are down to individual patients who are being put on 
these higher doses, to say, you know, let's talk about this 
before you actually proceed with this particular prescription.
    Ms. Kuster. Do you have a procedure for an opiate contract 
with the patient that includes random drug testing?
    Dr. Mangione. We do. In fact, we lead the country in urine 
drug screens. We have a lot of successes.
    Ms. Kuster. I think it is very, very effective. And do you 
have that type of wraparound care with mental health and 
therapy and perhaps even acupuncture, yoga, wellness, those 
types of--
    Dr. Mangione. All of the above. We have cognitive 
behavioral therapy, and this goes to Congressman Lamborn's 
point about--that we need to really understand what the veteran 
needs and what the veteran wants, because for us to say opiates 
aren't good for you anymore--which is why we are so thrilled to 
have this research program now to kind of get the veterans' 
perspective on the tapering of their opiates.
    So we have evidence-based cognitive behavioral therapy, 
relaxation therapy. We are very engaged with physical therapy 
because at the end of the day, what we have learned now is that 
opiates tend to decrease function in individuals, so that 
doesn't serve anyone. Passive motion is not what we are into 
right now. It is really trying to have that active engagement, 
the physical engagement of the individual.
    So we do have people who are trained as part of the DoD in 
both battlefield and in general acupuncture. We also try to 
target our interventions. So, for example, for migraine 
headaches we use botox injections, not opiates that affect the 
entire body. We try to do injections, for example local knee 
injections, or trigger point injections rather than having more 
general, but accompanied by physical therapy as well, and yoga, 
those items that you had mentioned before, and DaVinci, which 
helps with trigger points and pain, very local and limited. So 
we try to get away from those more systemic kinds of 
interventions. My understanding is that we offer everything 
that those other facilities do.
    Ms. Kuster. Thank you very much.
    I will yield back. I just have one more series. Thank you.
    Mr. Coffman. Do you want to go ahead and do it now, or do 
you want to come back? It is up to you.
    Congressman Lamborn, you are now recognized.
    Mr. Lamborn. Thank you, Mr. Chairman.
    Let me ask about the Denver VA research facilities. We see 
that there is terrible disarray at these research facilities. 
There is abandoned, unused, broken laboratory equipment 
everywhere. The sub-zero freezers are not monitored, allowing 
their contents, such as human blood samples, to spoil. 
Centrifuges, cell cultures, laser imagers, scales, and other 
biology equipment costing tens of thousands of dollars are 
sitting unused. Microscopes costing hundreds of thousands of 
dollars are not maintained or are not accounted for. Dust-
covered computers are commonplace, some containing research 
data that are piled up.
    As I look at these photos, I just sense a real disarray in 
some of these research facilities. So how do you explain that 
things have come to this point?
    Ms. Houser-Hanfelder. I will take that, Congressman 
Lamborn. We are in the process, thanks to the Congressional 
delegation of Colorado and the United Veterans of Colorado, of 
getting ready to move into a new research facility. It is part 
of the replacement facility, and it has all the new technology, 
wet labs. Some of the pictures you are seeing here--and I have 
gone through all of our research facilities. The areas you are 
seeing that were once wet labs cannot be redone as wet labs. 
Therefore, we have off-site waivers where many of our 
researchers are working at the university until we get into our 
new site.
    The disarray, I agree with you. In my walk-through, we have 
areas that we are staging to get ready to excess equipment. 
Actually, IT is up in that building. These are secure 
buildings. This isn't like you walk off the street and you walk 
into these buildings.
    So it is in disarray. We are in the process of considering 
what needs to be excessed appropriately through our logistics 
chain, what is going over, what is not going over. The 
chemicals will all be inventoried for movement.
    The research building is going to be one of the first 
buildings that is handed over to us with a completion date 
estimated in December now, so we are hoping to get them moved. 
But we have a lot of lab space that cannot be used for what it 
was built for many, many, many years ago. It doesn't meet the 
standards, and that is why we have off-site waivers with the 
universities that we affiliate with.
    So we are in the process of making sure that what is good 
stays and what is not gets appropriately excessed from our 
property.
    Mr. Lamborn. Looking at these submissions, it is my 
understanding that it has been this way for many years. They 
didn't just happen a few months ago or a few weeks ago. And 
also, staff tells me that they did walk into some of these 
buildings and rooms right off this site.
    Ms. Houser-Hanfelder. All the rooms I went in, you had to 
have access to them. We had research walking with us to do 
that. So I will check into that because that is important.
    We are also in the process of making sure that our 
records--and researchers have not until recently had a--how do 
you get rid of record control for old studies. They now have 
that. One of our transition activities is every one of our 
researchers going through their records, because many are still 
hard copy, to see what, number one, can be destroyed; number 
two, if they can't be destroyed, where can we secure them, 
whether that is at NIOSHA or NARA here in Denver that are 
national repositories, so we don't take up critical space in 
our new facilities with storage records that you have to 
maintain for X number of years but don't need to get into.
    Mr. Lamborn. As I look at these photographs, I see that 
perhaps what you are saying could apply to some things that are 
going to be transferred to a newer facility and then brought 
back up to working order. But it looks to me like in other 
cases, the sorry conditions are allowing things to degenerate 
into where they become broken and unused and wasted, even 
though taxpayers invested a lot of money into purchasing that 
equipment in the first place. If it gets to the point where it 
is just broken and unused, that is not doing good by the 
taxpayer.
    Ms. Houser-Hanfelder. Some of the equipment I saw was very, 
very old equipment, very research-specific equipment that 
should have been excessed many years ago. I don't disagree with 
that. We are going into house cleaning, spring cleaning mode to 
say, okay, if you have space that you are not using because it 
is not able to be used, people tend to start storing stuff in 
it, and we are getting ready to address that with all of our 
facilities as we transition over to the new building.
    It is January 18th is it finished, but there is a lot of 
work to do before we start transitioning. This will be taken 
care of.
    Mr. Lamborn. My fear is that some of the expensive 
equipment, not to mention research or samples, are 
irretrievably lost, and that would be a tragedy.
    Ms. Houser-Hanfelder. Yes, sir.
    Mr. Lamborn. Mr. Chairman, I yield back.
    Mr. Coffman. Thank you.
    We will do one more round, a final round of questions.
    How does VA coordinate pharmaceutical theft from the mail 
with relevant Federal and state law enforcement bodies? Can 
anybody explain that?
    Mr. Gigliotti. Sure. When a theft is suspected, our police 
is engaged. They bring in the Office of the Inspector General, 
and the Office of the Inspector General will bring in the Drug 
Enforcement Agency, and then a determination will be made on 
how to proceed based on the size of the issue involved.
    Mr. Coffman. So you don't coordinate with any state law 
enforcement entities?
    Mr. Gigliotti. Not that I am aware of, no.
    Mr. Coffman. Okay. What oversight is in place--
    Mr. Gigliotti. Let me add to that, if I could.
    Mr. Coffman. Sure.
    Mr. Gigliotti. Some of our issues are with the delivery. 
UPS used to be--we had Federal Express before, but UPS, I think 
we have gone to the United Postal Service in Denver now because 
there were some theft issues with the company themselves, and 
that would have been some coordination with state and local law 
enforcement.
    Mr. Coffman. Okay. What oversight is in place to ensure 
that providers are properly prescribing controlled substances? 
I think we just had the issue with Noah Harter that we 
mentioned, Mr. Harter being present today. What are we doing to 
improve that process, and where are we at?
    Mr. Gigliotti. I will let Dr. Mangione answer.
    Dr. Mangione. So we do have the oversight of the Pain 
Committee, which reviews all of the prescriptions that are over 
a certain level, 200 morphine milligram equivalents, morphine 
equivalents. In addition to that, we have as part of our 
evaluation a system for the physicians every six months, 
particularly our primary care physicians. We look at what they 
are prescribing, what the processes are. There is a wonderful 
software that has been made available by, I believe, VA central 
office, called The Almanac where we can go in and look at the 
individual providers and see what their pattern is and what the 
characteristics of their panel of patients is as far as 
prescribing.
    The other thing that we have done is, we have tried to put 
some additional safeguards in. So if, in fact, a physician is 
prescribing, I believe it is 200 morphine milligram equivalents 
now, that they have to get a second level of approval before 
they can do that. I imagine my goal as we go forward will be 
dropping that so that they have to have an approval for 190 and 
50 as we go forward, a second level of approval and a case 
evaluation.
    Mr. Coffman. Are non-physicians allowed to prescribe drugs? 
In Mr. Harter's case, his son saw a physician's assistant, and 
he was able to get a prescription.
    Dr. Mangione. I don't believe that is a controlled 
substance, and I don't believe that this--I don't know if I can 
say this.
    Mr. Coffman. These are very powerful drugs.
    Dr. Mangione. My understanding is that that was not the 
cause.
    Mr. Coffman. I am sorry. It was not the cause--
    Ms. Houser-Hanfelder. The question of whether that drug was 
a narcotic or not is I think at issue. The PA prescribed it--
    Dr. Mangione. We don't believe that that is a controlled 
substance.
    Mr. Coffman. A drug so powerful that it requires monitoring 
after a patient receives it, a non-physician can prescribe such 
a drug in this case, leading to suicide? A non-physician can do 
that under current VA policy?
    Dr. Mangione. I would ask to be able to follow-up on that.
    Mr. Coffman. Please, and I will be waiting for that answer.
    And does the Eastern Colorado Health Care System use the 
same prescription drug monitoring program that the State of 
Colorado uses?
    Dr. Mangione. Absolutely, and that is another point that I 
think should really be emphasized. Thank you for bringing that 
up. We had a culture that really wanted to be able to engage in 
that quite well before we were able to. My understanding of the 
reason that we were delayed a little bit is because each state 
has its own kind of software, and to be able to interface that 
with the central office software, took a little bit of time for 
us to do. But as soon as that software was available, I believe 
within that month, a couple of weeks, we were already 
participating in that prescription drug monitoring program. I 
think that is a huge step forward. And we actually contribute, 
is my understanding, in addition to being able to see what 
those prescribers in the community--
    Mr. Gigliotti. Right, and that includes our Grand Junction 
facility, too, the entire state.
    Mr. Coffman. Thank you.
    Ranking Member Kuster, you are now recognized.
    Ms. Kuster. Thank you, Mr. Chairman.
    And that was part of this promise that the VA Committee 
passed, that was part of the package of House bills last week 
that will hope to be in the final package that goes to the 
President, two things in particular. One is that the VA all 
across the country use the prescription drug monitoring system; 
and you are absolutely right, it is difficult because it is 
state by state and you are relying upon the quality of the 
data. But I think that is something for your administration to 
stay on top of, to make sure that your physicians are using 
that on a regular basis because it will help us to identify 
sooner in the process people with drug seeking behavior. We 
will be able to get them the treatment they need and save 
lives.
    Number two, there was a bill in the package that will make 
the prescription drug monitoring interstate. It may not be 
quite such a big issue here in Colorado, but in New Hampshire, 
a small state surrounded by literally Vermont, Massachusetts, 
Maine, touching the borders of our districts, we need to make 
sure that we can get that interstate.
    I am going to turn my attention to the testimony about 
access here in Colorado. We have had extensive discussions in 
our Committee and, in fact, indeed on the House floor about the 
Aurora project and the delays and the staff blues and the 
extraordinary cost to taxpayers all across our country. I don't 
mean to re-litigate that. I know you are all looking forward to 
getting it open.
    But I do need to ask, because the country is watching and 
waiting, what is your date of opening? What is the total cost 
of the project? And I am interested in drilling down to the 
added capacity because of the growth in veterans moving to 
Colorado or signing up for VA services. Do you know how many 
beds, how much outpatient? Where are we going to end up? Are we 
going to be back here in a couple of years talking about access 
again? So if you could take that one from the top.
    Ms. Houser-Hanfelder. Let me take a shot at the date of the 
opening. We know based on--I have meetings every week or every 
other week with Corps of Engineers and KT, the contractor. They 
have made a firm commitment that that job will be totally 
finished January 2018. We have about a six-month ramp-up.
    What we are working on now--and I apologize, but I cannot 
give you a hard date--is, we are working with the Corps with 
what we call red zone meetings where the Corps is trying to 
expedite completion of particular buildings early. The issue we 
are talking about right now--and there is a team I am taking to 
New Orleans to watch how they are doing their opening of their 
new facility, and they are taking different parts at different 
times.
    So after we make that trip, have a conversation with 
Fernando Rivera, who is their director, and look at how they 
are doing it in order to provide a safe environment while you 
still have construction going on. I can't give you that date. 
If I had to give you a date, it would be January 2018 plus six 
months for activation. It is our goal to start activating that 
sooner as we get buildings, if we can maintain safe passage 
into those parts of the building.
    Ms. Kuster. Let me ask it a different way, because I think 
this has been going on for 10 years or even longer. When do you 
expect that a veteran will walk through those doors and get 
some kind of help?
    Ms. Houser-Hanfelder. We have veterans there now. We have 
our Life Skills program in the front building, the CVS 
building. I have to see when they can hand us a building that 
you can get into. Otherwise I would say it is January 2018 plus 
six months, which would--
    Mr. Gigliotti. June or July.
    Ms. Houser-Hanfelder [continued]. June or July. July 4th I 
have heard as a date. It is our goal to get in sooner.
    Ms. Kuster. So two-and-a-half years from now?
    Ms. Houser-Hanfelder. Yes.
    Ms. Kuster. And what is the total cost? I think our 
appropriation is $1.6 billion at this point, billion with a 
``B''.
    Mr. Gigliotti. Yes, that has not changed.
    Ms. Houser-Hanfelder. That has not changed.
    Ms. Kuster. Well, do you expect it to come in higher, 
lower?
    Mr. Gigliotti. I think the expectation is on budget.
    Ms. Kuster. So there are no cost savings from here on out?
    Ms. Houser-Hanfelder. I don't know. That is a question to 
go to CFM and to the Corps.
    Ms. Kuster. Okay. And what is the extent of it? How many 
beds? Inpatient/outpatient programs? How many veterans can you 
see? I think in the testimony we had, it was a 24 percent 
increase in one year or something?
    Ms. Houser-Hanfelder. Right.
    Ms. Kuster. How long is this going to help the vets?
    Ms. Houser-Hanfelder. Two years.
    Ms. Kuster. A couple of years? After $1.6 billion, can we 
get a few years out of this one?
    Ms. Houser-Hanfelder. With the majority of that increase 
being in Colorado Springs, the number of beds that we are going 
to have in it is 148. There is a community living center that 
was taken out of that building, out of that project. So those 
30 beds will not be moving over.
    There is a new spinal cord injury center, which is a new 
program for us. That will be in the new building and be able to 
serve the veterans of Colorado and the surrounding areas. Right 
now our veterans go to California for spinal cord treatment for 
the most part.
    Ms. Kuster. So when will the Denver facility be closing 
down, and how many beds are being replaced? Is it a net 
positive, a net increase in beds from the closure of Denver to 
the opening of Aurora?
    Ms. Houser-Hanfelder. It is a positive gain for spinal cord 
injury, otherwise not a gain.
    Ms. Kuster. How many beds are currently in Denver? I am 
curious if we are getting any net gain. You are saying we are 
not going to make any dent in the increase--
    Ms. Houser-Hanfelder. There is not a large net gain of 
beds.
    Mr. Gigliotti. It is a pure replacement other than the 
spinal cord injury.
    Ms. Houser-Hanfelder. Right. There is a PTSD component to 
this that we have right now that was taken out of the--it was 
never in the project. It is under design right now, and it is 
one of the leading PTSD programs in the country, inpatient 
residential programs.
    Ms. Kuster. I know I had some testimony in here or we had 
something in our records about optometry. You have thousands of 
people on a wait list, I think it was something like 7,000 
people. Are we going to make any gains in optometry? Can 
veterans expect to get access in optometry or any other field 
that we are going to start to decrease wait lists and start to 
see more veterans by building this?
    Ms. Houser-Hanfelder. Our wait list is down, down 
tremendously through efficiencies with how we are doing our 
clinics. We also use the Choice Program. We are one of the 
top--
    Ms. Kuster. No, I am aware of what the options are. I am 
trying to focus in here on the taxpayers' extent, the $1.6 
billion, what are we going to get?
    Ms. Houser-Hanfelder. It is a replacement facility that did 
not increase capacity very much from how long it has been on 
the board.
    Ms. Kuster. So what is the rest of the space? How did it 
get so pricey? What else is there?
    Ms. Houser-Hanfelder. It is private rooms. Right now if you 
come into our facility, we don't meet the privacy standards. So 
it is private rooms. It is rooms that are up to a health care 
standard that wasn't available in the `40s. So you have much 
larger--
    Ms. Kuster. What is going to happen to the existing 
hospital? What happens to the Denver facility?
    Mr. Gigliotti. It has not been adjudicated yet. There are 
an array of options that need to be considered, but no decision 
has been made yet.
    Ms. Kuster. But is the intention to close it down, or are 
you going to run two hospitals?
    Mr. Gigliotti. No, it would not be--
    Ms. Houser-Hanfelder. No. The intention is to close it 
down.
    Mr. Gigliotti. Right.
    Ms. Houser-Hanfelder. Our issue right now, and one that we 
are dealing with is that because the CLC was taken out of 
this--
    Ms. Kuster. What is the CLC?
    Ms. Houser-Hanfelder. I am sorry. Community Living Center.
    Mr. Gigliotti. Community Living Center.
    Ms. Kuster. Okay, Community Living Center.
    Ms. Houser-Hanfelder. The question is--and the PTSD program 
won't be done at the same time, may not be done at the same 
time because it is a different construction project--what do 
you do with those programs in that lapse? That is what we are 
looking at now.
    Ms. Kuster. So let's just fast forward. Let's take five 
years. Finally, we have a new facility. What do you expect will 
happen with the Denver facility? Because I assume there are 
carrying costs and expenses to the taxpayer for that?
    Ms. Houser-Hanfelder. Yes. The goal is that we are not in 
it. There is a whole legal way that--
    Mr. Gigliotti. Yes, a GSA process to divest itself of 
Federal property.
    Ms. Houser-Hanfelder. There is a lot of interest. If you 
have been to the facility, the University Hospital used to be 
behind us. That is almost all down now, and that is a very rich 
environment for new development. There is also a hospital 
across the street that has an interest.
    Ms. Kuster. Maybe if we are lucky we can sell it for 
something.
    I am just going to close out my remarks. Colorado, like New 
Hampshire, is rural, with long distances for veterans to 
travel. I drove in from the airport. My understanding is your 
district is out that direction. How are veterans from Denver 
going to get to this facility, people on fixed income, or from 
more rural communities? What is the catchment area? How are 
they going to get there? Because it sounds like we are going to 
have this lovely Taj Mahal once they get there, but how are 
they going to get there?
    Ms. Houser-Hanfelder. The same way they get here. It is 
only about four miles down the road. It looks like it is 
further. We have DAV, Disabled American Veteran, transportation 
system. We had a lot--
    Ms. Kuster. Is there public transportation?
    Ms. Houser-Hanfelder. There is inside of this large area.
    Ms. Kuster. Say, for example, a vet living in Denver can 
get to Aurora on public transportation?
    Mr. Gigliotti. There is light rail and bus service also.
    Ms. Houser-Hanfelder. And we will be on the Anschutz 
Campus, which is where the university is, the Children's 
Hospital, and we are working with them to be part of their 
transportation system from the light rail. The light rail is 
due to be in place, I believe, in November or December. So 
there is this whole new--that is a whole new medical complex 
since 2000.
    Ms. Kuster. Just one last thought, because I keep hearing 
this in our Committee with every medical center across the 
country. Please be attentive on your signage for the veterans.
    Mr. Gigliotti. Yes.
    Ms. Kuster. It just horrifies me that we would have built 
this whole thing and they will get there and they will miss 
their appointment because they can't find where they are going 
to.
    But, thank you very much, and thank you, Mr. Chair, for 
your leadership and for bringing us out here to Denver on such 
a gorgeous day.
    Mr. Coffman. Thank you, Ranking Member Kuster.
    Congressman Lamborn, you are now recognized.
    Mr. Lamborn. Thank you, Mr. Chairman. Thanks for having 
this hearing, as I said earlier.
    I am just going to finish up. Many of my questions have 
already been answered. But what are projections, not here in 
Denver, but down in Colorado Springs, for the Lindstrom Clinic 
one year from now or five years from now?
    Mr. Gigliotti. It is very important for us to explore and 
work within our process. The Deputy Secretary, Sloan Gibson, is 
engaged in this, that we identify space that can be used for 
comp and pen exams, can be used for non-clinical purposes to 
free up the current clinic because of the growth being so 
explosive, to be for clinical care only. And then, it is 
important that we engage in the process to get an addition that 
was in the construction of the clinic with the land with great 
foresight in having the land. Then we would be able to add on 
to that clinic.
    Mr. Lamborn. Can you add just a little more, either one?
    Ms. Houser-Hanfelder. On the expansion or the--
    Mr. Lamborn. The post-addition.
    Mr. Gigliotti. It is hoped for. We would have to get 
conceptual approval through the VA process called SCIP and get 
in that process, and then we get that approval and then we are 
able to start going into some designs. Designs give us a sense 
of some of the costs, and then that competes against other 
projects across the country.
    Ms. Houser-Hanfelder. And one of the other things we are 
doing--and Dr. Mangione can probably speak to this--we have a 
DoD partnership with the Air Force Academy where all of our 
ambulatory surgery is done actually at the Academy. We are 
expanding that, and we are expanding specialty care. We have a 
full-time podiatrist coming on board in July. Not only will he 
work at the Colorado Springs clinic, he will also get surgery 
time at the Air Force Academy.
    So we are looking at how do we bring in specialty care 
services, and Nate is doing a fabulous job saying let me tell 
you what maybe doesn't need to be in this clinical space, and 
can be moved out, so that we can keep adding specialty care.
    We are probably good for one year for primary care growth, 
and after that, we have a trigger point now that says this is 
where our panel sizes are, this is what our, if you will, 
occupancy of those panels are; what is the trigger for bringing 
on the next primary care? And, by the way, what does that mean 
for our specialty care?
    Our goal is, we keep veterans in the community they are to 
get all the care they can get. I-25 is not the easiest route to 
traverse at any given time between here and Colorado Springs. 
It is not as bad as 30 in Texas, but close. So we are working 
on what are the specialty cares we can bring down.
    We are also--our veterans need care, and if we can't 
provide that care, we are partnering in the community in 
Colorado Springs with providers. We have a meeting coming up in 
June where HealthNet is going to come in. The providers who 
provide care to our veterans through Choice are coming to the 
table, and our staff are coming to the table, as well as 
veterans, to have this roundtable conversation about how can we 
make this better, because that is a vital part--40 percent of 
our Choice case work is in Colorado Springs, although they have 
30 percent of the work.
    Mr. Gigliotti. Denver is fifth in the country in Choice 
usage.
    Mr. Lamborn. HealthNet is a very cumbersome access 
provider, and the system is not seamless right now. We did talk 
about--it was the focus of the hearing this morning. I am 
concerned that--I am glad you are having that meeting in June.
    Mr. Gigliotti. We are trying a pilot program in our 
facility in Montana which HealthNet will then vet some 
schedulers at the facility, and that should help improve the 
communication between us and them, and that should help the 
service to the veterans. But it is a pilot program, so we are 
not sure how it will--
    Mr. Lamborn. And to summarize my initial question, do you 
have any projections for one year out or five years out for 
Colorado Springs clinic?
    Mr. Gigliotti. So, as Ms. Hanfelder said, primary care in 
one year should reach its ceiling at the clinic. So it is 
important for us to buy more space, as much as we can, inside 
the clinic by getting functions off that are not directly 
related to care. In five years, we are going to be in a 
position where we are going to need an addition to meet the 
demand if the demand continues. We see it all up and down the 
Front Range. We see it as part of the community, right? 
Colorado Springs, Denver, it just continues to grow, and 
veterans are a sizeable percentage of that growth.
    Ms. Houser-Hanfelder. We also do extended hours, and we do 
Saturday clinics. So we know that to be good stewards of 
taxpayers' dollars, my dollars, we need to make sure that the 
buildings we have are utilized to the capacity that they can, 
because if they are only open eight hours a day, they sit 
empty. So we are working and have been fairly successful with 
the Saturday clinics in Colorado Springs, as well as here in 
Denver.
    Mr. Lamborn. Mr. Chairman, I yield back.
    Mr. Coffman. Thank you, Congressman Lamborn.
    Let me just say right before the concluding remarks, 
Congresswoman Kuster raised the issue of the hospital and the 
cost. Having led the effort in the Congress to strip the VA of 
its construction management authority to ever build another 
hospital again and focus on really what your core competencies 
are, which is providing health care to our veterans and other 
benefits, it is amazing to me--and we are still waiting for 
this administrative investigative board report, the AIB, that 
to my understanding is finished, but is yet to be released to 
the public and to the Congress in its entirety. We have a 
project that, in effect, lost a billion taxpayer dollars where 
no one who is responsible has been held accountable.
    So I think the VA owes that report to the Congress and the 
American people. It is incredible. I mean, as a combat veteran 
and as a taxpayer, it is just offensive what occurred in my 
hometown of Aurora, Colorado. I think there is a GAO report 
from April of 2013 that says, at that time there were four 
hospitals that were under construction, that each were hundreds 
of millions of dollars over budget and years behind schedule, 
and yet the VA took no action in terms of changing personnel 
that were responsible for that.
    Let me give concluding remarks.
    Our thanks to the witnesses. You are now excused.
    Today we have had a chance to hear about ongoing problems 
at medical centers in Colorado and nationwide regarding VA's 
controlled substance oversight practices, as well as its 
appropriate use of medical facilities to benefit veterans.
    I am troubled by the numerous issues that were identified 
today, and I look forward to seeing improvement in these areas, 
both in Denver and across the country, to ensure veterans 
receive the best health care possible.
    I ask unanimous consent that all Members have five 
legislative days to revise and extend their remarks and include 
extraneous material.
    Without objection, so ordered.
    I would like to once again thank all of our witnesses and 
audience members for joining us in today's conversation.
    With that, this hearing is adjourned.

    [Whereupon, at 11:02 a.m., the Subcommittee was adjourned.]




                            A P P E N D I X

                              ----------                              

                 Prepared Statement of Ralph Gigliotti
    Good morning, Mr. Chairman, Ranking Member Kuster, and Members of 
the Committee. Thank you for the opportunity to discuss the VA's 
handling, prescription, oversight practices, and the appropriate use of 
controlled substances at VA facilities. I am accompanied today by 
Sallie Houser-Hanfelder, Director, Eastern Colorado Health Care System, 
and Dr. Ellen Mangione, Chief of Staff, Eastern Colorado Health Care 
System (ECHCS).

Oversight and Handling of Prescription Drugs

    Questions have arisen regarding pharmacy practices and 
accountability in VA ECHCS. Specific inquiries relate to the results of 
a Drug Enforcement Administration (DEA) investigation from July 2015, 
regarding pharmacy discipline practices and prescription and opioid 
drug management. On July 7, 2015, the DEA issued an administrative 
warrant and presented on site at the Denver VA medical center with 
several DEA investigators. The investigators were on site for 
approximately 3 weeks. In February 2016, DEA reported findings to the 
Executive Leadership Team and pharmacy management. Many items were 
addressed verbally while DEA was on site but the DEA investigation 
remains open.
    In the last 5 years, 8 ECHCS VA employees have been disciplined or 
removed for illegal possession or use of drugs on VA property. Either 
disciplinary action was taken or the employee resigned from their 
position.
    To improve safe pharmacy practices, the VA Opioid Safety Initiative 
(OSI) was implemented nationwide in August 2013. The OSI objective is 
to make the totality of opioid use visible at all levels in the 
organization. It includes key clinical indicators such as the number of 
unique pharmacy patients dispensed an opioid, unique patients on long-
term opioids who receive a urine drug screen, the number of patients 
receiving an opioid and a benzodiazepine (which puts them at a higher 
risk of adverse events), and the average Morphine Equivalent Daily Dose 
(MEDD) of opioids. Nationally, results of key clinical metrics for VHA 
measured by the OSI from Quarter 4 FY 2012 (beginning in July 2012) to 
Quarter 2 FY 2016 (ending in March 2016) show:

      151,982 fewer patients receiving opioids (679,376 
patients to 527,394 patients, a 22 percent reduction);'
      51,916 fewer patients receiving opioids and 
benzodiazepines together (122,633 patients to 70,717 patients, a 42 
percent reduction);
      94,045 more patients on opioids that have had a urine 
drug screen to help guide treatment decisions (160,601 patients to 
254,646, a 37 percent increase);
      122,065 fewer patients on long-term opioid therapy 
(438,329 to 316,264, a 28 percent reduction);'
      The overall dosage of opioids is decreasing in the VA 
system as 18,883 fewer patients (59,499 patients to 40,616 patients, a 
32 percent reduction) are receiving greater than or equal to 100 MEDD; 
and
      It is important to note that these desired results of OSI 
have been achieved during a time that VA has seen an overall growth of 
136,944 patients (3,959,852 patients to 4,096,796 patients, a 3 percent 
increase) that have utilized VA outpatient pharmacy services.

    The OSI dashboard metrics indicate the overall trends are moving 
steadily in the desired direction. VA expects this trend to continue as 
it renews its efforts to promote safe pain management therapies. VA 
intends to implement safe opioid prescribing training for all 
prescribers, as the President directed all Federal agencies in his 
October, 21, 2015, presidential memorandum. To date, 70 percent of 
prescribers have received training.

VA ECHCS Access

    Over the past 3 fiscal years (FY), VA ECHCS has experienced a 
consistent increase in demand for services. Unique patients receiving 
services have grown by over 13 percent from 67,070 in April 2014, to 
75,896 in April 2016. We have increased the supply of health services 
over the same time period by 12 percent, completing 571,464 outpatient 
visits through April 2016, compared to 510,109 through April 2014. High 
demand has outpaced this increase in supply, resulting in longer wait 
times for our Veterans in primary care, specialty care, and mental 
health services. Despite this, VA ECHCS has made tremendous strides in 
decreasing the electronic wait list (EWL) from a high of 6,817 in 
January 2016 to 543, as of May 9, 2016.
    VA ECHCS has increasingly relied on the community to provide health 
services to our growing Veteran population. Excluding the Veterans 
Choice Program, expenditures through the Non-VA Medical Care Program 
increased by 28 percent from $112,595,770 in 2014 to $144,313,630 in 
2015. VA ECHCS continues to be in the top five facilities in the nation 
in the volume of referrals to the Veterans Choice Program. Through 
March 2016, VA ECHCS has referred 27,716 episodes of care, resulting in 
17,251 appointments in the community.
    Colorado Springs has seen the most notable increase in workload 
within the VA ECHCS catchment area over the last 3 FYs. On February 4, 
2016, the Office of Inspector General released a report identifying 
untimely care concerns at the Colorado Springs Outpatient Clinic 
resulting from a complaint received in January 2015. The report also 
identified areas, such as scheduling and referrals to the Veterans 
Choice Program, that needed improvement. The department's Office of the 
Inspector General acknowledged in the same report that ECHCS had 
already executed a number of corrective actions to become compliant 
with their concerns. Actions taken include filling vacancies; hiring 
new staff and trainers from entry to executive levels; retraining; and 
practicing continuous quality improvement.
    In January 2016, the Electronic Wait List for Primary Care was 807 
and Optometry was 4,247. As of May 9, 2016, the combined total is 15. 
We expect patient wait times to continue decrease over the next 90 
days. Other access-challenged services in Colorado Springs include 
Podiatry, Physical Therapy, and Dental, and wait times in these 
services have shown significant improvement. Podiatry has opened a 
second Same-Day Access clinic, while Physical Therapy and Dental wait 
times have improved as a result of better clinic management and 
scheduling. As wait times continue to decrease in these services, 
Veterans will receive prompt access to the care they deserve.
    Difficulties in recruiting providers at the Alamosa Community-Based 
Outpatient Clinic (CBOC) and the recent resignation of the primary 
physician prompted a review of how best to provide care to the Veteran 
population in the San Luis Valley. Ongoing recruitments for Alamosa 
have not been successful due to rurality. By law all Veterans in San 
Luis Valley are eligible for the Veterans Choice Program because they 
live more than 40 miles from the nearest VA medical facility. A VA 
medical facility is defined under the Choice Program as a VA hospital, 
a CBOC, or a VA health care center, that has at least one full-time 
primary care physician. Another provider challenge is the resignation 
of one provider and the impending retirement of another. Recently, VA 
has identified two potential physician candidates interested in 
employment at the Alamosa CBOC. However, successful physician 
recruitment will result in the Veteran population no longer being able 
to directly opt into Choice because they will no longer reside more 
than 40 miles from the nearest VA medical facility with a full-time 
primary care physician. Nevertheless, we will work to ensure continuity 
of care for those Veterans who have been treated through the Veterans 
Choice Program in the community.

Denver VA Campus

    Medical and prosthetic research currently located on the Denver VA 
campus, including in some temporary modular buildings, should be moving 
into its new space at the Replacement Facility on the Fitzsimmons 
Campus in Aurora, Colorado. The project is to replace the current 
Denver VA Medical Center which was built in 1948. VA engaged the U.S. 
Army Corps of Engineers (USACE) and entered into an interagency 
agreement (IAA) with USACE to provide services in support of VA's 
construction program. VA and USACE utilize this IAA to engage USACE as 
VA's design and construction agent on our super construction projects 
over $100 million in accordance with VA Expiring Authorities Act of 
2015 (Pubic Law 114-58), enacted on September 30, 2015.
    The USACE, VA, and Kiewit-Turner are working in close collaboration 
to complete the construction in Aurora. The construction team is 
dedicated to meeting the highest possible standard while achieving VA 
requirements and criteria, while also pursuing cost savings 
opportunities to maintain the current budget. To ensure that previous 
challenges are not repeated and to lead improvements in the management 
and execution of our capital asset program as we move forward, we will 
continue to focus on these lessons learned over the course of this 
construction project:

      Integrated master planning to ensure that the planned 
acquisition closes the identified gaps in service and corrects facility 
deficiencies.
      Requiring major medical construction projects to achieve 
at least 35 percent design prior to cost and schedule information being 
published and construction funds requested.
      Implementing a deliberate requirements control process, 
where major acquisition milestones have been identified to review scope 
and cost changes based on the approved budget and scope.
      Institutionalizing a Project Review Board (PRB) - VA's 
Office of Acquisition, Logistics, and Construction worked with USACE to 
establish a PRB for VA that is similar to the structure at the USACE 
District Offices. The PRB regularly provides management with metrics 
and insight to indicate if/when the project requires executive input or 
guidance.
      Using a Project Management Plan - outlines for 
accomplishing the acquisition from planning to activation to ensure 
clear communication throughout the project.
      Establishment of VA Activation Office - Ensures the 
integration of the facility activation into the construction process 
for timely facility openings.
      Conducting pre-construction reviews - Major construction 
projects must undergo a "constructability" review by a private 
construction management firm to review design and engineering factors 
that facilitate ease of construction and ensure project value.
      Integrating Medical Equipment Planners into the 
construction project teams - Each major construction project will 
employ medical equipment planners on the project team from concept 
design through activation.

    The new 148-bed medical center will accommodate inpatient tertiary 
care and ambulatory care functions. Several renewable energy 
initiatives are a part of the project, including efforts to achieve 
LEED certification. In all phases of construction and activation, the 
Activations Team is working in close consultation with our Military, 
Veteran and Community stakeholders. VA ECHCS holds regular on-site 
meetings with the United Veterans Committee of Colorado, as well as 
executive-level meetings with Paralyzed Veterans of America regarding 
the new Spinal Cord Injuries and Disorders (SCI-D) unit. As of the end 
of April 2016, there are approximately 950 Craft construction personnel 
working onsite. The project is 67percent complete.

Security

    Due to undeniably tragic events, other questions have been raised 
regarding the safety and security of our Veterans and employees. Self-
harm and intended injury to others is an unfortunate and rising trend 
in our global community. Colorado has faced its share of tragedy. VA 
ECHCS has taken a proactive approach and high-level trainings have been 
voluntarily scheduled to improve the safety and security of our 
Veterans and employees.
    The VA ECHCS Director requested a security assessment be performed 
by VA Central Office. The team visited the Denver VA Medical Center, 
the replacement hospital facility in Aurora, and the outpatient clinics 
located in Colorado Springs and Golden. At the out-briefing, the team 
did not identify any significant findings, and was complimentary of the 
physical security measures in place. VA ECHCS is eagerly waiting to 
receive the team's written assessment and will rapidly address any 
findings or recommendations made. VA ECHCS has scheduled the VA Law 
Enforcement Training Center to provide an employee educational course 
"Verbal Defense in Healthcare." We anticipate this will help empower 
our staff with additional skills that they can use to keep people safe 
during difficult encounters. VA Police and the Emergency Preparedness 
Coordinator are providing Active Threat Response training and drills 
throughout the organization.

Sustainable Accountability

    VA is committed to creating and environment of sustainable 
accountability, in which employees know what is expected of them and do 
it, and then some. Sustainable accountability means VA uses taxpayer 
dollars wisely and well to improve post-military life for our Veterans 
and their families. To create this culture, we have taken steps such as 
changing Senior Executives' and Medical Center Directors' performance 
reviews to include Veteran-centric outcome objectives. Improvements in 
workforce culture, with a focus on ICARE values, will allow VA to 
address issues as they arise, rather than necessitating employee 
termination following repeated and/or pervasive poor behavior. VA has 
also implemented strong independent oversight by establishing the 
Office of Accountability Review, and by securing certification in OSC's 
2302(c) Whistleblower Protection Certification Program, which ensures 
that Federal agencies meet the statutory obligation to inform their 
workforce about the rights and remedies available to them under the 
Whistleblower Protection Enhancement Act and related civil service 
laws.
    Additionally, VA policy states Senior Executives who are the 
subject of a pending investigation have their performance ratings 
deferred until the investigation is complete. Any adverse finding is 
then addressed in the rating itself. VA implemented the expedited 
Senior Executive removal authority provided by Section 707 of the 
Veterans Access, Choice, and Accountability Act of 2014, and has thus 
far used that authority to propose removal of Senior Executives. 
Furthermore, Federal employees may be terminated for a variety of 
reasons ranging from absence without leave and inability to maintain 
performance standards to serious offenses such as falsification of 
records, misuse of government property, or sexual harassment. The vast 
majority of VA's more than 300,000 employees are committed to serving 
Veterans effectively and well. Where performance or conduct issues 
warrant removal, however, VA takes appropriate action to terminate 
employment.
    Mr. Chairman, this concludes my testimony. My colleagues and I are 
prepared to answer any questions you, Ranking Member Kuster, or other 
Members of the Committee may have.

                                 [all]