GR vets home audit: Missed checks, botched investigations

New CEO says problems listed in audit reflect a previous 'lack of leadership'


LANSING, Mich. (WOOD/AP) — A state audit says workers at a Grand Rapids veterans home falsely claimed they were checking on patients after being alerted of possible falls, failed to properly investigate allegations of abuse and neglect, and took too long to fill prescriptions.

The Grand Rapids Home for Veterans also continued with inadequate staffing levels even as the state filed four complaints against the contractor hired to supply nursing aides.

Auditors used surveillance video to show only 47 percent of bed checks and 33 percent of fall alarm checks were done, even though the home had produced documentation that the checks occurred.

The facility did not track or properly investigate complaints, including allegations of abuse and neglect. It forwarded all 91 complaints documented during the 23-month review period to the manager of the department whom the complaints were filed against. It didn’t forward nine of 10 complaints alleging abuse or neglect to the director of nursing.

During the 23-month review period, 39 percent of non-narcotic prescriptions were refilled late or more than five days early, according to the report. The home is also at risk of losing nearly $1 million in insurance reimbursement for not billing insurance companies for all of the prescriptions it dispensed. Officials didn’t sufficiently disburse deceased or discharged patients’ funds and may have mishandled up to $167,700.

24 Hour News 8 obtained the audit on Thursday, a day earlier than expected.

>>PDF: The audit

“It’s a tragedy. We gave up our years to defend our country with the promise that … there were going to be benefits for us, and then to be treated like an inmate, it’s appalling,” said Catherine Buckley, a veteran and an advocate for change at the Grand Rapids Home for Veterans.

Buckley said the problems have been going on “longer than I’ve been around.”

NEW CEO: PROBLEMS RESULT OF ‘A TOTAL LACK OF ACCOUNTABILITY’

They have also been going on longer than Leslie Shanlian has been the CEO for the Grand Rapids Home for Veterans. She took the job in October 2015.

“Most of the issues in the audit reflect a total lack of leadership, a total lack of implementation of policies and procedures and a total lack of accountability. There are many positions that have turned over, that there are postings for and we continue evaluating everyone in the leadership position because we have to have accountability for our veterans,” Shanlian told 24 Hour News 8 in a phone interview Thursday evening.

Shanlian has hired a chief operating officer to run the Grand Rapids Home for Veterans. She also has a posting for an interim director of nursing and the finance manager for the home has put in paperwork for retirement. She also said the home will be implementing an electronic medical record system in June.

The audit also lists how the facility plans to improve, including making sure staffing meets patient’s needs, properly documenting location checks and stop using fall alarms.

The facility has already taken steps to resolve some of the issues highlighted in the audit. It has hired a staff person specifically for insurance billing, revised its policy on refilling prescriptions and now requires an outside manager to review and investigate complaints.

“When I got there, if a member had a complaint or a concern, it would take three weeks for a resolution to get back to the member. That’s not acceptable,” Shanlian said. “We’ve shortened that to 72 hours. The allegations of abuse, neglect and misappropriation, we resolve within 24 hours. That is an industry expectation and industry standards. Most people would not do this (take on the Grand Rapids Home for Veterans after knowing of its history), I realize, but I look at who’s living there and I look at the good staff there and I can’t walk away from that. I have to fix it. I will do everything I can to fix it and I believe I have the right team to help in fixing that.”

Veteran Catherine Buckley and Catherine Kooyers, a veterans advocate, are optimistic that the proper changes will be made under the new administration.

“A new administrator came on and from what we have seen so far, she seems to be very involved. She’s been doing her research, where we are, where we have been, what do we need to do to change this,” Kooyers said.

“The allegations I believe stem from the old administration and they have to give the new administration a chance. It’s a new set of eyes and everybody seems to be more proactive,” Buckley said.

LAWMAKER: ‘OUR VETERANS DO NOT DESERVE THIS’

Local lawmakers are determined to end the problems now.

“Outrage is probably the one word that I can think of how I feel,” state Rep. Holly Hughes, R-Montague, told 24 Hour News 8 on Thursday. “I feel a lot of anger and want to ask a lot of questions and want to have the full committee review whatever is going to be in the report tomorrow. It’s very disturbing and unacceptable and we don’t treat people in West Michigan this way. Our veterans do not deserve this, nobody deserves what I’ve seen in the preliminary report, and I understand the regular report is not going to be good.”

State Rep. Winnie Brinks, D-Grand Rapids, said she feels the same way and believes that part of the problem is the fact that the home was privatized four years ago and stopped employing state workers.

“It was privatized to save money,” she said. “It was supposed to save about $4.1 million and I think that we have spent less on the home, but the question is, at what cost? It’s not worth it to me to take care of our veterans on the cheap if we can’t do it well.”

Hughes did not have a comment on whether privatization might have played a role.

“I do not know on that angle about that specifically. All I know is our veterans are not being taken care of and our focus is to fix it,” Hughes told 24 Hour News 8.

Shanlian, the home’s CEO, said it isn’t about privatization. She said only one of the findings pointed to contractors not meeting staffing needs.

Rep. Tom Hooker, R-Byron Center, issued the following statement on the audit:

“I am very concerned about the findings that are expected in this report. We will study this issue extensively, and we will hold hearings to get to the bottom of every issue detailed in the report. If significant problems are revealed, we must hold those who are responsible accountable. My uncle was a resident at the Grand Rapids Home for Vets during the time of the report, so this becomes very personal. Our veterans deserve the best possible care – that is the least we can offer in return for their sacrifice for our country. I will do everything I can to make sure they receive it.”

The state Senate Oversight and Veterans, Military Affairs and Homeland Security committees will hold hearings on the Grand Rapids Home for Veterans in the coming weeks.

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