VA veterans crisis line to face new investigation by congressional watchdog agency

The Government Accountability Office plans to investigate multiple
whistleblower allegations of “gross mismanagement” at the Department of
Veterans Affairs veterans crisis line, following a request from Kansas
Republican Sen. Jerry Moran, States Newsroom has learned.

Moran, ranking member on the Senate Veterans’ Affairs Committee, sent
a letter to the VA secretary this week urging the department to fully
cooperate with the investigation by the congressional watchdog agency
and expressing frustration with the way some veterans are being
transferred after calling the crisis line.

Several whistleblowers have told Moran and his staff that veterans
crisis line “responders are currently transferring veterans determined
to present complex needs to an indefinite waiting list for eventual
contact from a special unit,” according to the letter.

While the veterans crisis line must “be staffed by appropriately
trained mental health personnel and available at all times,” the
whistleblowers have alleged the unit that is supposed to address
“callers with complex needs” is “severely understaffed and
undertrained,” according to Moran’s letter.

“Worse yet, a break in record retention is reportedly resulting in a
complete loss of communication with veterans who are disconnected while
waiting on hold in this queue,” Moran wrote to VA Secretary Denis

Moran urged the VA to fully cooperate with the GAO investigation, but
said the department shouldn’t wait until the federal agency issues a
report to address concerns about the veterans crisis line.

Republican staff on the Senate Veterans’ Affairs Committee, speaking
on background to a small group of reporters, said that if a veteran
calling the crisis line displays “disruptive behavior” that person may
be transferred to the “callers with complex needs unit.”

Whistleblowers told the GOP committee staff that could include a
veteran using swear words. But one staffer noted that “when someone is
at a time of crisis, they’re not choosing their words appropriately, so
we have a lot of concern about that.”

Another staffer said, “The callers are transferred and placed on hold
in an informal queue where they are left to wait for a responder on the
callers with complex needs unit.”

“If they’re disconnected on their own or are disconnected for any
reason, then a break in the record leads to no further contacts from the
(veterans crisis line) because they haven’t retained that caller’s
information,” that staffer said.

The GOP Veterans’ Affairs Committee staffers who spoke to reporters
declined to provide details about the whistleblowers in order to protect
the whistleblowers’ anonymity. But the staffers said the “multiple”
whistleblowers are current and former VA employees, whom they described
as “highly credible.”

Earlier problems with crisis line

This isn’t the first time senators or watchdogs have expressed concerns with the veterans crisis line.

The VA Office of Inspector General released a 95-page report in mid-September after a person who used the crisis line committed suicide.

The report found that one employee of the veterans crisis line “did
not complete an adequate assessment of the patient’s suicide risk
factors, including the patient’s suicidal preparatory behavior and
alcohol use, during the text conversation.”

That person also “failed to adequately pursue actions to address the
patient’s suicidal preparatory behavior, including reducing access to
immediate lethal means,” according to the IG report.

The report included 14 separate recommendations for the veterans crisis line and the South Texas Veterans Health Care System.

The Senate Veterans’ Affairs Committee, chaired by Montana Democratic Sen. Jon Tester, held a hearing in late September on veterans’ mental health, including concerns from several lawmakers about the crisis line.

“Last week, a new IG report was released raising more concerns about
the veterans crisis line,” Tester said during that hearing. “The
veterans crisis line is a lifesaving resource for veterans and it must
be a top performing entity within the VA, but as made clear by recent IG
reports, it simply is not.”

Matthew Miller, executive director for suicide prevention at the
Veterans Health Administration within the Department of Veterans
Affairs, testified at the hearing that the agency is “better than what
was depicted in that report and we have to do better than what was
depicted in that report.”

Miller told senators the department had made progress on eight of the
11 recommendations in the IG report that were specifically addressed to
the veterans crisis line.

Louisiana Republican Sen. Bill Cassidy said during the hearing the IG report was “incredibly damning.”

“I’m struck that the executive director who apparently interfered with the OIG report was not fired,” Cassidy said.

“Now we’ve passed accountability measures for people who don’t do
their job, and it sounds like interfering with an investigation of a
suicide, which may have been inappropriately handled on a veterans’
crisis line, is incompetence,” Cassidy added.

The IG report said investigators “concluded that the Director,
Quality and Training, provided advice and information to Responder 1
prior to interviews with the OIG that potentially compromised Responder
1’s candidness.”

The Department of Veterans Affairs and Government Accountability Office didn’t return requests for comment.