LITTLE ROCK — The medical director of the Little Rock Veterans Home, who has been cited for patient-care violations in every annual state and federal inspection over the past five years, on Thursday terminated his contract with the state effective next month.
Dr. Lee Nayles of Little Rock gave his notice to the home’s director of nursing, said Lawrence Pickard, deputy director for the state agency. Nayles’ contract expires June 30.
Nayles decided to end his contract about two weeks after the U.S. Department of Veterans Affairs denied his application for certification, which would have allowed him to access medical records and refer veterans for care as part of the VA system’s network of physicians.
Since 2007, the state Office of Long Term Care and the VA have noted in their independent annual inspections of the Little Rock facility that Nayles was not properly overseeing care or meeting participation requirements within his job description as medical director. The lack of oversight led to medication errors and other patient care problems, according to inspection reports.
The Little Rock Veterans Home has operated under provisional licenses from the state and the VA for years because of that lack of medical oversight and missing physician and pharmacy contracts for care.
In 2010 after inspectors found no evidence that Nayles had visited the home or signed patient progress notes for more than a year, security guards were required to record the dates and times of the doctor’s visits. The medical director is required to spend 20 hours a month at the home and check each resident’s progress notes every 60 days to ensure compliance with care and medication changes.
Also that year, VA inspectors noted, “Clinical records revealed the Staff Physician of the facility had not signed 60-day orders, phone orders, provided physician visits or recorded medical information in the progress notes for a period of up to a year.”
The director of nursing at the time told inspectors that Nayles didn’t always return her calls.
Despite the inspection findings, Nayles’ $30,000-a-year contract was renewed annually by Dave Fletcher, then-director of the state Department of Veterans Affairs.
Nayles did not return several telephone calls requesting an interview last week.
The doctor’s departure is the latest change within the Arkansas Department of Veterans Affairs, which oversees veterans nursing homes in Little Rock and Fayetteville as well as two state cemeteries.
Over the past month, investigations have revealed violations of federal law at the Little Rock home that were knowingly allowed by state agency leadership. Those included fees of more than $560,000 that were collected over three years from the home’s war-wounded and most-disabled veterans in violation of a 2009 law.
Some of those fees were used to pay Nayles’ state-contracted salary.
Gov. Mike Beebe asked Fletcher to resign as director of the agency two weeks ago and appointed retired National Guard Col. Cissy Rucker to the helm. She officially starts today.
“There are a lot of issues over there, and they’re coming to light,” Rucker said Friday of the Little Rock home. “The highest priorities are the doctor and the pharmacy issues. Right now this is where we’re concentrating the efforts.”
Both of those issues, like the illegal fees, are related to a 2009 federal law that increased VA funding of state veterans homes and required states to use those funds to contract for primary-care and pharmacy services for the veterans. The aim of the legislation was to take some pressure off regional VA hospitals by paying state homes to provide primary care for veterans. All specialized care continues to be handled by VA facilities under the law.
The Arkansas Department of Veterans Affairs has continually failed to comply with those requirements, and the VA’s Central Arkansas Veterans Healthcare System has continued to provide medical primary care and prescription services to the Little Rock home to ensure that veterans receive proper care.
The VA system extended the state’s use of pharmacy services earlier this month, giving the state agency until June 10 to find a provider. Using VA facilities for services the state was receiving federal funds to supply itself resulted in years of double dipping by the state veterans agency.
VA officials met with Fletcher and Pickard several times over the past few years, offering a contract for those services. But the state officials never agreed to the contract, stating that it was too expensive - even though the state was receiving more than $100,000 in federal funds each month to pay for the services.
Federal VA inspectors warned the state agency as far back as 2007 that it was required to contract physician and pharmacy services to comply with the new law that would be published in 2009. The state veterans department told the VA at the time that it was trying to renegotiate Nayles’ contract to make him the primary-care physician. That never happened.
To resolve part of the issue, Fletcher expanded Nayles’ responsibilities late last year - four years after the first warning - making him the primary-care physician for all of the home residents, as well as continuing his role as medical director for the facility, despite inspectors’ repeated concerns about him.
The patient-care infractions cited in those inspections were also violations of Nayles’ state contract.
According to contracts received through a Freedom of Information Act request, the state never amended Nayles’ contract to include the extra duties. Further, the state didn’t pay Nayles for primary care of patients, but instead relied on the doctor to bill the residents’ insurance or have them pay him directly out of pocket. The increased VA per diem paid to the state for the most-disabled veterans is intended to cover all costs and require no additional payment for care.
Nayles was told in 2008 that he was required to attend quarterly quality-assurance meetings at the home.Federal inspectors found that he has not complied with that requirement since.
In 2008, VA inspectors also found that the aging Little Rock facility failed to meet nursing home standards.
Fletcher’s administration told the federal inspectors that “the agency is actively pursuing to have a new building built,” according to the inspection report. Inspectors were also told that a grant had been submitted, and “a bill has been passed to have a new facility built.”
While grants are available from the VA, the state Department of Veterans Affairs has never applied for one. Further, Fletcher never asked the Legislature for more money at the same time he told the VA his agency didn’t have enough money to comply with federal regulations.
“We are moving forward,” Rucker said Friday. “Dr. Nayles will be leaving the home. And we will be looking for another doctor to replace him.”
Central Arkansas Veterans Health Services, which oversees VA medical facilities in Little Rock and North Little Rock, has provided a list of VA-certified doctors for the state agency to consider.
One of the tasks the governor gave Rucker is to determine the cost and feasibility of continuing to operate state veterans homes.
The issue was raised a few months ago by John Dugan, who was hired in February by the state Veterans Affairs Department to advise it on complying with nursing home regulations.
Within one week of beginning work, he wrote a discussion paper to Fletcher pointing out violations of federal law and his recommendations for fixing them.
“Regardless of past history we are legally required to provide primary care and pharmacy services on residents receiving VA per diem,” Dugan wrote to Fletcher. “We need to aggressively deal with these two issues in the short term while we continue to plan for the long term. This is going to cost money that the state is going to have to furnish in order to keep the facility running. ... Then it is probably prudent at this point to begin discussions related to the permanent closure of the facility.”
Fletcher never responded to Dugan’s e-mail.
Front Section, Pages 1 on 05/27/2012