The Edmond Sun

April 18, 2013

Deficiencies put Oklahoma veterans at risk

Mark Schlachtenhaufen
The Edmond Sun

OKLA. CITY — Insufficient supervision places veterans center residents’ well-being at risk, according to an audit of the Oklahoma Department of Veterans Affairs.

On Wednesday, State Auditor Gary Jones released the performance audit report of the ODVA. The audit was requested by Gov. Mary Fallin in August 2012 following the resignation of former agency Executive Director Martha Spears.

The request came after the scalding death of a veteran at a Claremore residential care facility and numerous other allegations of patient abuse, neglect and poor quality of care.

“The ODVA exists to serve one of the most revered populations within our state,” Jones said. “The five-month review of ODVA identified a high quality of care in selected parts of ODVA’s operations, but many of its practices fall short of the standard of quality expected by its constituents and their families.”

Wednesday afternoon, Fallin asked the Legislature to send her bills improving accountability regarding the state’s veterans’ centers. The audit revealed an unacceptable lack of oversight and accountability at the ODVA, particularly at the veterans centers, Fallin said.

“These shortcomings are particularly disturbing in light of multiple accusations of abuse and neglect aimed at agency staff, some of which may have resulted in the death of Oklahoma veterans,” Fallin said.

Fallin highlighted Senate Bill 629, which would require veterans’ centers to be inspected by the Department of Health, ensuring that veterans living in long term care facilities are safe and receiving high quality care and services. Senate Bill 235 would centralize the management of veterans’ centers, addressing the inconsistencies in quality highlighted in the ODVA audit.

“I am strongly encouraging lawmakers to send those bills to my desk to be signed into law,” Fallin said.

Oklahoma has a veteran population of 387,000, according to the report. Each of the seven veterans centers is responsible for creating a separate set of policies and procedures outlining steps for compliance with the ODVA procedures as well as state and federal regulations.

Via a statement, ODVA Executive Director John McReynolds said the agency has reviewed the audit, concurs with the findings and has implemented many changes in line with the recommendations. Since June 2012, eight of the nine members of the Veterans War Commission have been replaced, a new executive director has been hired and several other changes to leadership have been made, McReynolds said.

McReynolds said the agency appreciates the efforts of the auditors and it feels the report will help it care for Oklahoma’s war heroes.

“The Oklahoma Department of Veterans Affairs will work diligently to implement the recommendations contained in the audit report, working closely with the members of the War Veterans Commission,” McReynolds said.


The report identified issues including inconsistent training, pervasive substandard wages and disregard by some administrator’s of staff input. These practices have contributed to a problematic work environment where human resources are improperly allocated and undervalued, Jones said.

Auditors found inconsistent policy implementation and insufficient independence in performing internal investigations of alleged misconduct, Jones said.

The result of the agency’s fractured decentralized management structure had the opposite effect of its desired intent to promote accountability, Jones said. The issues could have been effectively managed or avoided altogether with appropriate oversight by the War Veterans Commission, he said.

Other concerns included divisional structure and centralization, a lack of independence and training for internal investigation teams, a lack of adequate monitoring tools to ensure effective veteran center performance and apparent ineffective methods for self-reporting incidents.

Auditors found of the 48 investigations reviewed that were required to be reported five were not reported to the central office, five were not reported to the Oklahoma Department of Human Services and eight were not reported to the Board of Nursing or the state’s Nurse Aide Registry.


The audit report offers multiple recommendations detailing how the commission may overcome its institutional challenges to implement consistency and accountability.

Auditors recommended the agency:

• Modify commission membership. State statutes currently limit potential commissioners to the veteran population;

• Implement ongoing training;

• Create more committees to address specific issues;  

• Improve financial oversight;

• Approve the ODVA’s standard operating procedures to ensure they guard against financial, human and reputational losses;

• Enhance program monitoring and evaluation; and

• Adopt a formal policy for evaluation of the

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