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Department of MEMORANDUM

Veterans Affairs
Date: February 15, 2017

From: (b)(6) Office of Accountability Review


(b)(6) Office of Accountability Review
(b)(6) VISN 10

Subj: AIB Overton Brooks VA Medical Center; Shreveport, LA

To: Director, Office of Accountability Review

PRELIMINARY STATEMENT

SCOPE: On October 18, 2016, you convened an investigation into allegations of senior leader
misconduct at the Overton Brooks VA Medical Center (VAMC). (Exhibit 001). 1 We investigated
these allegations:

1) Medical Center Director (MCD) Toby Mathew.


failed to make timely or effective senior level decisions
o proposals to continue, suspend or revoke provider credentials or
privileges;
o personnel issues;
o staffing issues such as failing to properly staff critical need positions;
belittled, demeaned or otherwise mistreated VA employees;
engaged in retaliation and discrimination;
engaging in prohibited personnel practices;
mistreated a patient and former HR employee by grabbing him by the arm
and berating him.
2) Acting Associate Director for Patient Care Services, Chandra Miller;
retaliated against Tiffany Love
3) (b)(6) (b)(6) and,
endangered the safety of Dr. Patterson when he recommended that the
person who threatened Dr. Patterson only be suspended and returned to
duty
And any other matters related to senior leader accountability discovered during your
investigation.

1
Though we issue this report more than the 45 days designated in the charge memo, it is timely by virtue of your
extension, approved by email on December 16, 2016.

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RESULTS OF INVESTIGATION

The investigation revealed:

1) Medical Center Director (MCD) Toby Mathew:


failed to sign privileging documents timely;
o backdated privileging documents;
o failed to report and remediate the consequence of lapsed
privileges when discovered;
failed to provide a psychologically safe work environment and failed
to model the VAs I CARE values:
o slammed doors and other objects
o raised his voice and yelled at staff
o belittled, demeaned and mistreated VA employees;
retaliated against an employee by moving her without reason after
she brought allegations of hostile work environment to his attention
did not engage in discrimination
did not engage in prohibited personnel practices;
did not engage in any of the other alleged senior leader misconduct;
2) Acting Associate Director for Patient Care Services, Chandra Miller:
did not retaliate against Dr. Tiffany Love; and,
did not engage in any other alleged misconduct
3) (b)(6) (b)(6) and,
did not endanger the safety of Dr. Patterson by providing legal advice;
and,
did not engage in any other alleged misconduct.

Further, our investigation uncovered other allegations of senior leader misconduct, which we
reviewed. Our investigation concluded:

4) Chief of Staff Dr. John Areno:


a. did not act with diligence to stop providers from practicing without
privileges when he knew or should have known that providers at
OBVAMC were providing direct patient care without privileges to do
so;
b. did not act with sufficient diligence to report and mitigate the
possible effect of privileging lapses;
c. did not engage in retaliation toward (b)(6)
d. did not engage in any other alleged senior leader misconduct.
5) Assistant Medical Center Director (b)(6)
a. did not engage in retaliation toward (b)(6)
b. did not engage in any other alleged senior leader misconduct.
6) Senior leaders at OBVAMC
a. properly addressed allegations that sterile instrument packages were

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punctured or otherwise adulterated.

INVESTIGATIVE METHOD

This AIB was conducted through the examination of documents, face-to-face interviews, 2 and
telephonic interviews. The list of exhibits is attached. As necessary, we followed up with some
witnesses by email. Additionally, we toured the executive suite on December 7, 2016, after we
concluded our interview of Mr. Mathew.

PROCEDURAL ISSUES

Witnesses interviewed:

We interviewed the following witnesses under oath:

1. Dr. John Areno, Chief of Staff, OBVAMC


2. (b)(6) , OBVAMC*
3. (b)(6) , OBVAMC
4. (b)(6) , OBVAMC
5. (b)(6) , OBVAMC
6. (b)(6) to ADPCS
7. (b)(6) OBVAMC
8. Susan Edwards, Chief Nurse Ambulatory Care, OBVAMC
9. (b)(6) OBVAMC*
10. (b)(6) OBVAMC
11. Erik Glover, former Associate Director, OBVAMC*
12. (b)(6) OBVAMC
13. (b)(6) OBVAMC
14. (b)(6) OBVAMC
15. (b)(6) OGC, Continental District East
16. (b)(6) OBVAMC
17. (b)(6) OBVAMC
18. Dr. Tiffany Love, Deputy ADPCS, OBVAMC*
19. (b)(6) OBVAMC*
20. (b)(6) (b)(6) , OBVAMC
21. (b)(6) Gulf Coast VAMC*
22. Toby Mathew, Medical Center Director, OBVAMC

2
We travelled to OBVAMC twice to interview witnesses: once in November 14-18, 2016 and again on December 5-8, 2016.
Further, we interviewed witnesses by phone on January 10-13, 2017. The title used for each witness refers to the witnesss VA
status during the relevant time period, not necessarily to the witnesss title now. Asterisks denote witnesses who are no longer
working at OBVAMC.

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23. (b)(6) OBVAMC,
24. Dr. Patrick McGauly, former Chief of Staff, OBVAMC and current doctor*
25. Todd Moore, Chief of Quality, Safety and Value, OBVAMC*
26. (b)(6) OBVAMC
27. (b)(6) OBVAMC*
28. (b)(6) OBVAMC*
29. Dr. James Patterson, Chief of Mental Health Service, OBVAMC
30. (b)(6) OBVAMC
31. (b)(6) OBVAMC
32. (b)(6) OBVAMC
33. (b)(6) OBVAMC
34. (b)(6) OBVAMC
35. Dr. Suzanne Taylor, Assistant Chief of Primary Care, OBVAMC
36. Dr. Richard Wallace, Chief of Primary Care, OBVAMC
37. (b)(6) OBVAMC
38. (b)(6) OBVAMC 3

In addition to testimony, we received documents or other evidence from these individuals:

1. (b)(6) , OBVAMC
2. (b)(6) OBVAMC
3. (b)(6) OBVAMC
4. (b)(6) OBVAMC*
5. (b)(6) VISN 16
6. (b)(6) (b)(6) VHA Healthcare Leadership
Talent Institute

We decided not to interview additional witnesses who may have provided testimony because
the cost and time of such interviews outweighed the potential evidentiary value. 4 For example,
we scheduled Deesha Brown, a former OBVAMC employee, to interview on January 11, 2016.
However, the interview preceding hers ran over and Ms. Brown became unresponsive to email,
text and phone attempts to reschedule. (Exhibit 032.) Similarly, we did not have contact
information for (b)(6) . For reasons stated above, we did not interview her.

1. FINDINGS OF FACT, ANALYSIS AND CONCLUSIONS

BACKGROUND INFORMATION: Overton Brooks VA Medical Center (OBVAMC) consists of one


VHA tertiary care facility and three (3) community-based outpatient clinics serving Veterans in

3
Witnesses changed jobs over time. An asterisk signifies that the witnesss current job title or relationship to the
VA is different than it was at the relevant time period.
4
In some cases, we sought additional clarifying information from witnesses by email.

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fifteen (15) Louisiana parishes, five (5) counties in Southern Arkansas and ten (10) counties in
East Texas. The medical center is classified as a Clinical Referral Level 1C Facility which accepts
referrals from the Southeast Louisiana Veterans Healthcare System located in New Orleans,
Louisiana and the Alexandria VA Health Care System located in Pineville, Louisiana. OBVAMC is
a teaching hospital, providing a complete range of patient care services, with state-of-the-art
technology, as well as education and research. Comprehensive health care is provided through
primary and specialty care in the areas of medicine, surgery, mental health, physical medicine
and rehabilitation, dentistry, radiation oncology, pathology, audiology and imaging. OBVAMC is
part of the South Central VA Health Care Network (VISN 16) which is one of 21 Veterans Service
Networks (VISNs) of the Department of Veterans Affairs (VA). VISN 16 covers service to
Veterans in the states of Oklahoma, Arkansas, Louisiana, Mississippi, and parts of Texas,
Missouri, Alabama and Florida.

ORIGIN OF ALLEGATIONS: The allegations we investigated stem from three different sources:
1) an email on August 10, 2016, from (b)(6) regarding allegations concerning
leaders Toby Mathew and (b)(6) (Exhibit 005); 2) a memo, authored by Dr. James
Patterson and sent to high level VA officials on September 2, 2016 (Exhibit 006); 5 and, a memo,
authored by Dr. Tiffany Love and sent to various top VA officials on October 3, 2016 (Exhibit
008). Dr. Patterson sent subsequent emails in late September (Exhibit 007) and January 2016
(Exhibit 019), wherein he demanded that Mr. Mathew be removed or detailed pending the OAR
investigation. Additionally, we received allegations during our investigation that: 1) (b)(6)
retaliated against (b)(6) and 2) that Dr. Areno and/or Toby Mathew were retaliating
against (b)(6) (Exhibit 026.)

ISSUES IDENTIFIED IN THE CHARGE LETTER

1. Allegations that MCD Toby Mathew engaged in misconduct: failed to make timely
leadership decisions

We investigated whether Mr. Mathew failed to make timely leadership decisions. Our
investigation shows that from approximately January 2015 through July 2016, Mr. Mathew
failed to timely sign the privileging documents of at least 13 providers.

Providers Had Lapsed Privileges Due to Untimely MCD Action

1) (b)(6) : 8-day lapse (Exhibit 034, 035.)


2) (b)(6) : 25-day lapse (Exhibit 040, 041)
5
We did not investigate alleged questionable HR practices because a previous OAR investigation already addressed these
issues. (Exhibit 111.)

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3) (b)(6) : 8-day lapse (Exhibit 037, 038)
4) (b)(6) : 1-day lapse (Exhibit 057, 058.)
5) (b)(6) : 1-day lapse (Exhibit 043, 044)
6) (b)(6) : 1-day lapse (Exhibit 049, 050)
7) (b)(6) : 1-day lapse (Exhibit 052, 053)
8) (b)(6) : 1-day lapse (Exhibit 055, 056)
9) (b)(6) : 1-day lapse (Exhibit 064, 065)
10) (b)(6) : 11-day lapse (Exhibit 121, 122.)
11) (b)(6) : 1-day lapse (Exhibit 123, 124)
12) (b)(6) : 3-day lapse (Exhibit 125, 126)
13) (b)(6) : 1 day lapse (Exhibit 127, 128)

Unprivileged Providers Had Patient Encounters

Ten providers whose privileges lapsed continued to provide direct patient care during the time
their privileges were expired:

(b)(6)

(Exhibit 067; 112; 130; 147.) VISN 16 reported that provider Judi Locati was hired and saw
patients before her privileges were signed. (Exhibit 067.) The PSB recommended approval for
(b)(6) privileges on January 21, 2016. The routing slip indicates (b)(6) privileging
folder was received in the medical center directors office on January 22, 2016. The routing slip
is initialed JA for John Areno, February 3, 2016. (Exhibit 115.) Per OBVAMCs process, the
routing slip should have been routed to Mr. Mathew on or before February 4, 2016. There is no
initial or date for the Medical Center Director. However, Mr. Mathew signed the privileging
folder for (b)(6) on February 19, 2016. (Exhibit 061, Exhibit 109.) The VISN attributed the
incident to miscommunication between HR and the service. (Exhibit 067.)

MCD Privileging Responsibility

Mr. Mathew is the Medical Center Director (MCD) at OBVAMC and a member of the Senior
Executive Service. (Exhibit 021.) Mr. Mathew was the Deputy MCD at Little Rock starting July
2011. He became permanent MCD in OBVMAC on December 4, 2014. (Mathew, p 4, lines 13-

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14.) On the organizational chart and in practice, Mr. Mathew is the senior-most official at
OBVAMC, with overall responsibility for the hospital. (Exhibit 021.) Mr. Mathew describes his
leadership style as involved in various aspects of strategy and management . . . [and he] lead[s]
by example[.] Governing rules provide that providers who practice at OBAMC must be
privileged to do so. The ultimate responsibility for credentialing and privileging resides with the
facility Director. (Exhibit 069, p 5, section 8.) Mr. Mathew is the facility director at OBVAMC.
(Exhibit 073.)

The Privileging Process at OBVAMC

The Professional Standards Board (PSB) at OBVAMC meets bi-weekly to review and process
providers credentialing and privileging. As the Medical Center Director, Mr. Mathew is required
to ensure that the PSB review and Medical Executive Board review is completed and that
providers are privileged to provide patient care. (Mathew, p 189, lines 19-20, and 24; p 190,
lines 1-16.)

Normally, the PSB compiles information and completes the review to validate that the
providers have the appropriate credentials, education, and competency from which to
recommend granting privileges. (Areno, p 66, lines 14-24; p 67, lines 1-6.) Normally, the PSB
meets the first and third Thursday at OBVAMC. (b)(6) is the lead credentialer at OBVAMC.
Normally, the COS would sign the privileges right there at the board once the board
recommends approval. ((b)(6) p 8, lines 8-11). (b)(6)(b)(6) completes the minutes for the PSB
meeting and delivers the minutes and the privileging folders the next day to the COS office.

Once the COS has signed the minutes, the minutes and privileging folders are delivered to the
MCD office. Once the MCD has signed the minutes and the folders, the Medical Staff Office is
notified to pick up the documents. ((b)(6) p 4 line 21-p 9 line 3). The ADPCS reviews and signs
the files prior to the PSB ((b)(6) p 9 line 24- p 10 line 19).

The Routing Slips

Although routing slips are not an official document, they are used to track documents. We
reviewed the relevant routing slips in an attempt to establish a timeline, but we found the
routing slips unreliable for various reasons. Some routing slips had missing information,
contained notations, contained hand-written notes as well as typed content, or were missing.
The routing slip for the January 21, 2016 PSB documents is dated as delivered by the Medical
Staff Office to the Chief of Staff (COS) office on January 22, 2016. John Areno initialed and
dated the routing slip February 3, 2016. There is no receipt date by the Medical Center
Directors Office. Mr. Mathew signed the privileges February 19, 2016. (Exhibit 138.)

The routing slip for the February 4, 2016 PBS documents is dated as delivered by the Medical

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Staff Office to the Chief of Staff (COS) office on February 5, 2016. John Areno initialed and
dated the routing slip February 18, 2016. There is no receipt date by the Medical Center
Directors Office. The document has a notation that Mr. Mathew signed the privileges on
February 19, 2016. (Exhibit 139.) Mr. Mathew signed the February 4, 2016 and January 21,
2016 privileging documents on the same day.

The routing slip for the February 18, 2016 PBS documents is dated as delivered by the Medical
Staff Office to the Chief of Staff (COS) office on February 19, 2016. John Areno initialed and
dated the routing slip February 26, 2016. The Medical Center Director office dated the
documents as received March 10, 2016 and reviewed by (b)(6) March 10, 2016.6 Mr.
Mathew signed the privileging documents on March 18, 2016. (Exhibit 140.) The routing slip
for July 11, 2016 PSB documents is missing. (Exhibit 141.) John Areno signed the privileging
documents July 14, 2016. Mr. Mathew signed the privileging documents July 18, 2016.
Testimony indicates routing slips were not accurate. ((b)(6) p 33, 34.) Similarly, the routing
slip for (b)(6) privileges was dated received after the privileges for (b)(6)
were signed. (Exhibit 116.)

Mr. Mathews Testimony

Mr. Mathew had heard of perceptions of delays in getting privileging minutes signed. (Mathew,
p 209, lines 6-10.) During our interview of Mr. Mathew, he was confident that only three
providers practiced without privileges, asserted that fixes were in place, and seemed to
question the purpose of our investigation given that he had discussed the three providers.
(Mathew, p 74 line 5-9; p 184 line 22; p 185 line 1; p 186 lines10 ; p 187 line 18.) As far as he
was aware, there was only one incident of lapsed privileges. (Mathew, p 195, lines 3-4; p 196,
lines 22-24; p 197, lines 1-20). (b)(6) who worked as Mr. Mathews EA, testified that Mr.
Mathew attempted to fix delays associated with privileging folders, but delays continued.
((b)(6) p 32.)

Policy Violations

From January 2015 through July 2016, 13 providers privileges expired after recommendation
for approval by the PSB and Medical Executive Committee (MEC) while awaiting Mr. Mathews
review and signature. This is in violation of:

VHA Handbook 1100.19 Credentialing and Privileging, dated October 15, 2012
(Exhibit 069, p 5, Sec 8; p 45, Section 14j.) This process must be conducted at least

6
(b)(6) testified that Mr. Mathew had the privileging folders in his office the week of March 7, 2016, on
Monday or Tuesday, and Mr. Mathew removed the folders from his office and placed them on her desk to review.
((b)(6) p 33-35.)

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every two years, but prior to the expiration of such privileges (Exhibit 069 at p. 47,
Section 2 a.)

Overton Brooks VA Medical Center Memorandum 11-42 Credentialing and


Privileging of Providers, dated February 10, 2016. (Exhibit 071, p 2, Sec 3.)

Overton Brooks VA Medical Center Bylaws and Rules of the Medical Staff dated
January 28, 2016, which Mr. Mathew signed on February 1, 2016. (Exhibit 070,
Article VIII Section 8.01 General Provisions.)

The Joint Commission Hospital Program Medical Staff Chapter. (Exhibit 072,
Overview, second paragraph; MS.06.01.07 EP4.)

Department of Health and Human Services, Center for Medicare & Medicaid
Services Ref: S&C-05-04. (Exhibit 133.) 7

OBVAMC Was on Notice re Privileging Issues

On July 15, 2015, the VISN 16 Quality Management team visited OBVAMC. (Exhibit 113.) The
resulting action plan advised OBVAMC to increase awareness of the [Medical Staff] Bylaws
template and integrate new articles into the approved Medical Staff Bylaws. (Exhibit 113.)
The target date for completion was August 30, 2015. (Exhibit 113, p 4.)

Mr. Mathew signed the revised bylaws on February 1, 2016. (Exhibit 070.) It is unclear when
Mr. Mathew received the bylaws for signature. The Medical Staff Bylaws require the Medical
Center Director to act within 30 days of receipt of the recommendation for approval to renew
privileges by the PSB and MEC. (Exhibit 070, p 37.) However, under no circumstances should
providers practice without privileges. (Exhibit 069 at p. 47, Section 2 a). Mr. Mathew testified
it is his responsibility to approve privileging documents the chief of staff presents to him timely,
prior to lapse. (Mathew, p 191, lines 2-6.)

On June 23, 24, 2016, VISN 16s QM visited OBVAMC. (Exhibit 114.) The visit produced a
PowerPoint report. Slide 18 recommended to streamline administrative processes to ensure
policies are approved and distributed timely. (Exhibit 114.)

Mr. Mathew Did Not Complete Relevant TMS Training

Medical Center leadership is required to complete TMS training. It is required to be completed


within three months of serving as a Medical Center Director per VHA Handbook 1100.19
Credentialing and Privileging dated October 15, 2012 page 5 section 8 c. (Exhibit 069).

7
See also 42 CFR 482.12 and 482.22 (explaining that among the conditions for participation in the Medicare or
Medicaid programs is assuring that providers are privileged). (Exhibit 131, 148, 149.)

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However, Mr. Mathew did not complete mandatory TMS Training, Medical Staff Leadership.
(Exhibits 080, 136)

(b)(6)(b)(6) Notified Mr. Mathew and Others and Attempted to Get Privileging Documents
Signed

(b)(6) testified she attempted to raise concerns about expired privileges to others. In
February 2016, she sought advice from (b)(6) , because Mr.
Mathew was not signing privileging documents timely. (Exhibit 119.) ( (b)(6) p 57, line 8-20.)
According to (b)(6)(b)(6) in June and July 2015 she raised her concern (i.e., late signing of
privileging documents) to (b)(6) during a VISN 16
site visit. ((b)(6) p 21, lines 5-23.) (Exhibit 130.) (b)(6)(b)(6) testified she informed the onsite OIG
surveyor ((b)(6) ) during an OBVAMC OIG CAP visit during the OPPE-FPPE review that
there were delays with getting signatures on privileges. ((b)(6) p 58, lines 3-23.) (b)(6)(b)(6)
testified she informed service chiefs that their providers could not see patients because Mr.
Mathew had not signed the privileges ((b)(6) p 34 lines 9-14). (Exhibit 130.) (b)(6)
testified one evening (b)(6)(b)(6) came by the medical center directors
office and asked Mr. Mathew to sign something related to privileging. ((b)(6) p 46.)

When confronted with lapses beyond the three he was originally aware of and asked about
what action he needed to take, Mr. Mathew testified he would consult experts, involve others,
and take appropriate action. (Mathew, p 199, line 1 p 202, line 16.) There is no evidence
that Mr. Mathew actually took such action regarding those privileges he knew had lapsed.

Some Members of the PSB Knew and Did Not Stop Providers

Mr. Mathew attended the ACHE conference on March 14-17, 2016. (Exhibit 146) ((b)(6) p
36-37, 40-41; Taylor, p 40.) He returned on March 18, 2016, which is a Friday. Credible witness
testimony indicates he did not delegate signature authority to allow another official to approve
privileging documents in his absence. (Taylor, p 20 lines 8-14; page 28 line16-page 29 line 9)
(Patterson, p 42 line 15-p 43 line 13). (Wallace, p 10, lines 11-23; p 24, lines 10-18.) Mr.
Mathews testimony regarding delegating authority viz. privileging is contradictory. (Mathew,
p 74; 192-220.) But, in his own testimony Mr. Mathew says he realized his signature authority
was not clearly delegated. (Mathew, p 193-194.)

Although Mr. Mathew does not recall getting a phone call from anyone regarding privileging
while he was at the ACHE conference in March 2016 (Mathew, p 195-196), several witnesses
testified that (b)(6) did call him and that he indicated he would sign the privileging

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documents upon return.8 This is plausible to us because Mr. Mathews conduct after returning
from ACHE is consistent with someone who did not delegate authority to sign privileging
documents. Specifically, he did return and sign the privileging documents at issue on March 18,
2016. If he had delegated authority at this point, another person would have signed the
document. We believe other witnesss recollection of the events of March 17 are more
credible than Mr. Mathews because his testimony is conflicted, he did not recall getting a
phone call, and other witness testimony is more clear and specific. Mr. Mathews account is
uncorroborated and not plausible by comparison.

The evidence indicates that in the absence of executive leadership from Mr. Mathew or Dr.
Areno (which we cover in greater detail below), a small group of PSB and MEB members made a
conscious decision on or about March 17, 2016, after discovering three providers privileges
lapsed, to allow OBVAMC providers to continue to practice while their privileges were expired.
(Taylor, p 28, line 16; p 30, line 9.) (Wallace, p 26, lines 4-19.) (Exhibit 107.) Mr. Mathew was
due to return from ACHE the next day, but the privileges were already expired. Mr. Mathew
was to sign the privileging documents upon return. (Areno, p 15-16 110-111.)

We found no evidence of any attempts by senior leaders or some PSB members9 to stop
unprivileged providers from encountering patients. Witnesses felt that providers had done
nothing wrong to cause their privileges to expire, they were known providers whose practice
had been reviewed by the PSB and MEB and recommended for re-privileging, and they
reasoned that Veteran access to care should not be negatively impacted due Mr. Mathews
signature delays. (Taylor, p 29 line 17; p 30 line 9.) (Wallace p 26, lines 5-15.) Providers likely
did not know they were practicing without privileges. (Wallace, p 26, line 14-15; Exhibit 107.)

Consequences of Violations

Mr. Moore is the Chief of Quality, Safety and Value at OBVAMC. He testified that there are
consequences to a hospital that permits providers to practice with lapsed privileges. Its a
serious issue. (Moore, p 28, lines 12-13; p 34, lines 13-24; p 35, lines 1-7.) Lapsed privileges
could affect a hospitals accreditation and potentially have affected patient care. (Moore, p 32,
lines 23-24; p 33, lines 1-20.) Upon hearing that there were possibly nine lapses in privileging,
Mr. Moore became noticeably troubled during his interview. (Moore, p 33, lines 14-20.) Mr.
Moore wanted to inform the proper authorities. (Id.) There is evidence of risk to hospital

8
(b)(6) testified that Mr. Mathew had the privileging folders in his office the week of March 7, 2016, and he
had her review the folders. ((b)(6) p 33-35.) (b)(6) recollection indicates Mr. Mathew knew of pending
privileging folders in his office prior to the ACHE conference.
9
(b)(6) testified she told service chiefs that providers cant see patients because Mr. Mathew had not signed
off on the privileges. ((b) p 34.)
(6)

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accreditation. (Exhibits 072 & 129.)

On December 7, 2016, (b)(6) sent an email to VISN Network Director Skye McDougall,
indicating that nine providers whose privileges lapsed should be audited while OAR investigated
the matter as possible senior leader misconduct, in order to mitigate the potential effects.
(Exhibit 066.) On December 9, 2016, (b)(6) forwarded via e-mail the patient
workload encounter spreadsheet evidence to Skye McDougall for those nine providers (eight
had patient workload). (Exhibit 081 and 082.)

Following discovery that at least eight providers at OBVAMC had encounters with patients
while not being privileged, VISN 16 evaluated the effect of the identified lapses and directed
action to correct the problem. VISN 16 directed a 100% review of credentialing and privileging
of providers at OBVAMC and directed audits of patient workload during the time of expired
privileges for identified providers. (Exhibit 067.)

VISN 16 reported a total of 136 leadership staff hours were spent on review of OBVAMC
Credentialing and Privileging and patient billing for services rendered by non-privileged
providers. VISN 16 reported that the review of 1st party and 3rd party billings that were paid for
the providers that were identified included active bills, collected closed bills (CC), and canceled
bills (CB), which totaled 76 bills with a value of $39,909.42 for third party bills and $334.75 for
1st party bills. There were a total of 6 Physicians, 2 Dentists, 4 Nurse Practitioners, and 1
Physician Assistant totaling 13 providers who were non-privileged for a period of time. (Exhibit
067.) Insurance cannot be billed for care provided by non-privileged practitioners so the facility
will have to reimburse the insurance companies and cancel any unpaid bills sent to insurance
companies. (Exhibits 129, 133.) A minimum of 350 veteran encounters were seen by non-
privileged providers. (Exhibit 132.)

Backdating Privileging Documents

Related to timely decision making is whether Mr. Mathew backdated privileging documents.
Mr. Mathew testified he was aware of only one instance wherein privileging lapsed. (Mathew,
p 67.) (Exhibits 035, 038, 041.) Mr. Mathew also testified that he backdated the privileging
documents of three providers at issue: (b)(6) . (Exhibits 035, 038, 041.)

Mr. Mathew signed the privileging documents for these providers on 3/18/16, but testified he
first documented the date of his signature as 2/18/16 per the advice of (b)(6) and Dr.
Taylor. Further, he testified that he changed the date back to 3/18/16 on each of the three
privileging documents the following day. (Mathew, p 219, lines 14-22.) (Exhibits 035, 038, 041.)
We deem Mr. Mathews testimony to be an admission that he backdated these documents and
then changed his mind later. Dr. Taylor testified she did not advise Mr. Mathew to backdate

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privileging documents. (Taylor, p 21, lines 6-12.) ((b)(6) p 34, line 22-24; p 35 1-3.) (b)(6)(b)(6)
and Dr. Taylor did not work on Saturday, March 19, 2016. (Exhibit 150 and 151.)

Further, Mr. Mathew testified he sought guidance from the VISN regarding the backdating
issue, but there is no corroborating evidence that Mr. Mathew sought guidance or direction
regarding how to handle the possible impact on patient care and other possible ramifications
associated with lapsed privileges. Incidents of lapsed privileges continued after March 2016.
There were three providers whose privileges lapsed after the backdating incident: (b)(6)

PSB Minutes Were Signed, but Not Dated

Related to backdating documents were questions regarding whether the PSB minutes were
signed timely. Our review of PSB minutes for calendar year 2015 and 2016 through October 6,
2016 indicates that Mr. Mathew did not date his signature on the minutes. The only PSB
minutes found where Mr. Mathew dated his signature was October 24, 2014. (Exhibit 103 and
105.) It is unclear whether Mr. Mathew signed the PSB minutes timely. (Exhibit 105.) Dr. Areno
did not date the PSB minutes, either. (Exhibit 105.) Thus, both Dr. Areno and Mr. Mathew
failed to date their signatures on the minutes.

Other Alleged Delays

Dr. Patterson, the genesis of the allegations (Exhibit 006), alleged Mr. Mathew delays making
numerous leadership decisions. We elicited testimony regarding Mr. Mathews decision-
making tendencies to determine whether there was delay and understand the cause. One
witness we interviewed, Dr. Areno, testified Mr. Mathew is deliberate and thoughtful and this
sometimes means decisions take a little bit longer. (Areno, lines 14-15.) Dr. Areno did not
observe significant deliberate delays. (Id., lines 16-17.) Dr. Areno was reluctant to attribute
delays to his supervisor, Mr. Mathew. (Areno, p 13, lines 14-18.)

However, numerous other witnesses described Mr. Mathew as a micro-manager. ((b)(6) p


85, lines 23-24; p 86, lines 1-4.) (McGauly, p 23, lines 1-15.) ((b)(6) p 25, line 19.) (Moore,
p 6, lines 22-24.) ((b)(6) p 31, lines 8-16.) (Glover, p 56, lines 16-24; p 57, lines 1-5; p 58, lines
17-23.) ( (b)(6) p 11, lines 6-8.) Mr. Mathews micro-management leadership style 10 and his
reluctance to delegating his signature authority when absent likely contributed to lapses. As
compared to Mr. Mathew and Dr. Areno who did not testify to delays in decision-making by the
Medical Center Director, numerous other staff testified to a pattern of delays coming from the

10
For example, Mr. Mathew directed fiscal service to make changes to OBVAMCs FY 15 budget process 18
different times. ((b) p 8, lines 5-10.) ((b)(6) p 10 line 5-16.)
(6)

Page 13 of 36
MCDs office.

Mr. Mathew would often delay action or decision because of minor format errors, typos, or for
no apparent reason. (Patterson, p 67, lines 13-24; p 68, lines 2-11.) ((b)(6) p 33, line 3.)
(b)(6) the Chief of Staff. She testified she would
write issue briefs, Mr. Mathew would make multiple changes to the document; she would
resubmit the original and Mr. Mathew said he liked the original. ((b)(6) p 27, lines 4-18.)
Given his tendency to carefully scrutinize documents and folders, as summarized in testimony,
it is likely that Mr. Mathews desire for optimum results and work products tended to cause
congestion in his office and likely contributed to actual or perceived delay. 11

Witnesses testified OBVAMC staff left or were not hired because of MCD delays. For example,
nurse practitioner (b)(6) left because of a signature delay.
(Taylor, p 13, lines 9-24; p 14, line 1-8.) (Wallace, p 16, line 17.) Providers left other CBOCs
such as Monroe and Texarkana. (Mathew, p 206, lines 4-7.) Mr. Mathew was aware of the
issues. (Mathew, p 206-207.) (Wallace, p 15, line 3 - p17, lines 1-24.) Dr. Patterson attributed
the failure to hire psychiatrist (b)(6) due to Mr. Mathews delayed decision-making.
(Patterson, p 69, lines 10-24; p 70, lines 1-20; Exhibit 079.) Other witnesses noticed similar
problems hiring providers. (McGauly, p 23, lines 4-15.)

The available testimony, while credible, did not establish a clear connection between the non-
privileging delays and Mr. Mathew. The folders witnesses described could have contained any
number of action items, such as privileging documents. We do not know what the contents of
these folders were. 12 Furthermore, budget, staffing, HR process and other factors could have
influenced delays in hiring and retaining staff.

There is sufficient credible testimony and evidence indicating Mr. Mathew did not take timely
action on privileging documents. However, there is insufficient evidence to prove Mr. Mathew

11
Multiple witnesses noticed stacks of folders in Mr. Mathews office and these folders sometimes languished due
to indecision or inaction. ((b)(6) p 32, lines 11-24.) ((b)(6) p 9, lines 23-24; p 10, lines 1-14.) (Glover, p 48, lines
4-24.) ((b)(6) p 21, lines 20-24; p 22, lines 1-13.) (b)(6) testified to instances wherein documents
would sit and sit and sit [in Mr. Mathews office] and not get signed. ((b)(6) p 22, lines 5-9.) ((b)(6) p 11,
lines 12-15.) Mr. Mathew frequently did not sign important documents timely. (Wallace, p 10, lines 22-24; lines 1-
16.) When questioned about these delays, Mr. Mathew attributed them to internal systemic issues such as HR.
(Mathew, p 205, line 3-24; p 206, lines 1-17; p 206, p 207, lines 1-7.)
12
However, this prevalence of folders in Mr. Mathews office tends to explain why privileging signatures were
delayed.

Page 14 of 36
delayed making decisions on other matters. 13 Although there is credible testimony indicating
OBVAMC experienced other delays, we were unable to find specific delayed actions that we
could directly attribute to Mr. Mathew. Thus, this allegation is partially substantiated.

2. Allegations that MCD Toby Mathew engaged in misconduct: failed to provide a


psychologically safe work environment and failed to model the VAs I CARE values by
in that he slammed doors and other objects, raised his voice and yelled at staff,
belittled, demeaned and mistreated VA employees; engaged in retaliation and
discrimination; engaged in prohibited personnel practices; mistreated a patient and
former HR employee by grabbing him by the arm and berating him.

We reviewed the allegation that Mr. Mathew mistreats other employees. There is sufficient,
credible evidence that Mr. Mathew mistreated OBVAMC employees and acted in a manner that
was inconsistent with the VAs core values.

I CARE Values

Senior leaders at the VA should model the VAs core values, summarized succinctly in the
acronym, I CARE. The elements of I CARE are Integrity, Commitment, Advocacy, Respect, and
Excellence. (Exhibit 120.) The VA defines Excellence: Strive for the highest quality and
continuous improvement. Be thoughtful and decisive in leadership, accountable for my actions,
willing to admit mistakes, and rigorous in correcting them. (Exhibit 120.) The VA defines
Respect: Treat all those I serve and with whom I work with dignity and respect. Show respect
to earn it. (Exhibit 120.) The VA defines Integrity: Act with high moral principle. Adhere to the
highest professional standards. Maintain the trust and confidence of all with whom I engage.
(Exhibit 120.)Mr. Mathew completed VA Core Values Training: I CARE Recommitment (VA-
3901227), on March 8, 2015 and March 31, 2016. (Exhibit 080.)

Slamming Doors

In his interview, Mr. Mathew denied engaging in any inappropriate behavior toward others
such as making inappropriate statements, slamming doors in peoples faces and the like.
(Mathew testimony, p 161-164.) Further, Mr. Mathew explained to us that sound-proofing
work to Mr. Mathews office required extra force to apply for the door to shut. (Mathew, p 183,
lines 10-20.) This was offered to us to explain the sound of slamming doors.

The undersigned AIB Team toured the Executive Suite on December 7, 2016, and opened and

13
We did not find sufficient evidence that (b)(6) , some of which was in the library,
could be attributed to Mr. Mathew. The matter is in protracted litigation.

Page 15 of 36
closed the door to Mr. Mathews office to observe and experience the door closing. We were
able to close the door without slamming it. But, the door shut loudly.

When comparing Mr. Mathews testimony to the available evidence, Mr. Mathews denial is
unpersuasive. At least some slamming pre-dated soundproofing in the pentad suite. The door
was modified in May 2016. (Exhibit 068.) Further, we believe people know when the door is
being shut after a conversation ends normally, as opposed to the door shutting on purpose to
unilaterally end a conversation. In February 2015, Mr. Mathew moved offices. Because his
behavior was reported to have occurred over time, we not believe soundproofing offers a
credible explanation for the testimony.

Three witnesses experienced having doors slammed in their face and several witnesses testified
they heard or observed such behavior:

These witnesses experienced Door Slamming in their faces:

(b)(6) (p 16 line 6-7; p17 lines7-19)


(b)(6) (p 6, lines 11-12.)
(b)(6) (p 36, lines 4-15.)

These witnesses observed or heard door slamming:

(b)(6) (p 6, lines 20- p 7, line 6.)


o Witnessed door slammed in (b)(6) face
o Witnessed door slammed in (b)(6) face
(b)(6) (p 8, line 19-23; p 21, lines 1-8.)
o Witnessed door slam on (b)(6) face
Patrick McGauly
o Mr. Mathews practice of slamming doors when angry was common. (p
27, lines 17)
(b)(6)
o Could hear doors slamming from her office, ((b)(6) p 9 line 20- p 10,
line 14.)

These witnesses observed Mr. Mathew slam objects:

(b)(6) experienced Mr. Mathew slamming folders.


Erik Glover observed Mr. Mathew slamming objects. (Glover, p 29, line 2-13.)
(b)(6) said Mr. Mathew slammed the phone down ((b)(6) p 6, lines 6-
12.)

When we weighed the testimony of Mr. Mathew against the testimony of (b)(6) (b)
(6)

Page 16 of 36
(b)(6) and (b)(6) against the testimony of Mr. Mathew, we found the three witnesses
more credible. Mr. Mathew slammed doors in at least three employees faces. Thus, this
allegation is substantiated.

Psychological Safety14

When confronted with the allegation that employees at OBVAMC feel unsafe, Mr. Mathew
testified that he could not speculate as to how other people felt. (Mathew, p 32, lines 18-24; p
33, lines 3-6.) Mr. Mathew testified he provides a psychologically safe workplace through
several programs and systems. (Mathew, p 33.) We found Mr. Mathew to be a sophisticated
witness. His responses to questions about how he makes others feel seemed unconvincing and
unresponsive. For example, we expected a respectful leader modeling I-CARE values would
strongly deny such allegations, feel bad that staff felt unsafe, and demonstrate regret. Instead,
Mr. Mathew declined to speculate, deferred to processes in place at OBVAMC and showed no
genuine concern. (Mathew, p 94, lines 8-9.)

We observed these current or former OBVAMC employees were afraid of the consequences at
work and on their careers for their participation in interviews regarding their experiences with
Mr. Mathew: 15

(b)(6)

(b)(6)

(b)(6)

(b)(6)

(b)(6)

(b)(6)

(b)(6)

Erik Glover
(b)(6)

Witnesses testified they were confident Mr. Mathew would have access to their testimony. For
example:
a. (b)(6) testified that Mr. Mathew will know who testified. ((b)(6) p

14
We encountered evidence that Mr. Mathews behavior was reported to the VISN in late July 2016 or
thereabouts. (b)(6) was detailed to OBVAMC, returned after two months, and informed (b)(6)
of her observations of Mr. Mathews behavior. ((b)(6) p 25.) It is unclear whether (b)(6) relayed
any details to Ms. McDougall.
15
(b)(6) (b)(6) and Erik Glover provided telephonic testimony. Although we did not see their
facial expressions, we could hear the level of anxiety in their voice. We found them to be very sincere when
recollecting their experiences and fears.

Pa
34-37.)
b. (b)(6) heard Mr. Mathew was looking for people who testified.
((b)(6) p 35, lines 1-5.)
c. (b)(6) feared retaliation for testifying. ((b)(6) p 72; p 73, lines 6-24; lines
1-3.)
d. Dr. McGauly inquired if Mr. Mathew would have access to his testimony.
(McGauly, p 3, lines 1-3) He was afraid he would be fired because he is part-
time. (McGauly, p 16, lines 2-8.)
e. Dr. Taylor said she had concerns about testifying. (Taylor, p 36, lines 13-24; p
35, lines 1-3.)
f. (b)(6) testified Mr. Mathew retaliates. ((b)(6) p 8, lines 4-18.)
g. (b)(6) denied being afraid of retaliation and then said Mr. Mathew will
read the testimony he gave. ((b)(6) p 47, line 19 p 48, line 21.)
h. (b)(6) was afraid that Mr. Mathew would read his testimony. ((b)(6)
p 14, 11-20.)

Several witnesses testified that Mr. Mathew knew what testimony they gave in prior
investigations and testified that he communicated to these witnesses that he knew the content
of their testimony. They took this to be intimidating. For example, (b)(6) stated
that she was a witness for another investigation and that Mr. Mathew let her know he knew
what she had said regarding Mr. Mathew slamming the door. ((b)(6) p 6 line 15- p 7 line15.)

Similarly, (b)(6) stated that Mr. Mathew made her aware he knew (b)(6) had talked
with Skye McDougall and that (b) had rolled me under the bus. (b)(6) stated that Mr.
(6)
Mathew verbatim repeated almost everything that she said. ((b)(6) p 7 line 11 - p 9 line
10.) (b)(6) alleged Mr. Mathew said someone put (b)(6) up to it. ((b)(6) p 7,
lines 4 p 8, line 4.) (b)(6) was afraid Mr. Mathew would suspect she was the one who
encouraged (b)(6) to seek help. (Id.) We believe the totality of the evidence shows that
OBVAMC is clouded by a culture of fear.

OBVAMC Employees Felt Demeaned or Belittled

Dr. Patterson alleged and a variety of witnesses testified that Mr. Mathew made them feel
demeaned or belittled. (Exhibit 006; (b)(6) p 19, lines 3-4; p 20, lines 10-15.) Although we
were unable to pinpoint specific dates and times wherein Mr. Mathew made inappropriate
statements, numerous witnesses testified that Mr. Mathew made them feel belittled or
demeaned at work. Mr. Mathew said he does not say or do the kinds of things witnesses
alleged. We take Mr. Mathews testimony as a general denial. (Mathew, p 162-163.)

Page 18 of 36
By comparison, (b)(6) testified about an incident wherein Mr. Mathew threw folders on
the ground as he reviewed them, was dissatisfied with them and told (b)(6) she needed to
look at the folders better. (b)(6) was (b)(6) and
felt demeaned because she had to bend down and pick up the folders. ( (b)(6) p 32 line 11-p
33, line15.) She remembered what she wore that day. (Id.) We believe (b)(6) account
because she is no longer a VA employee, seemed sincere in her testimony, does not stand to
gain from her testimony and her account is corroborated.

We heard similar testimony from others.(b)(6) (b)(6) heard Mr. Mathew make demeaning
comments about Shreveport staff, and heard him say that the new employees he planned to
bring on-board will run circles around the current staff. ((b)(6) p 13, lines 1-24.) He implied
the staff at Shreveport did not know enough. ((b)(6) p 13, lines 5-6.) ((b)(6) p 18, lines 18-
21; p 20, 13-15.) (McGauly testimony, p 40 17-23; p 42, lines 1-17; (b)(6) p 8, lines 6-13.)
(b)(6)(b)(6) said Mr. Mathew made her feel like she was not smart enough. ((b)(6) p 20, lines
2-7.)

(b)(6) testified credibly that when she brought Mr. Mathew work [products], he
described it as stupid, and childish. ((b)(6) p 6, lines 11-12.) He suggested that people
in the South are dumb and that the staff was stupid. ((b)(6) p 5, lines 23-24; p 6, lines 1-24;
p 8, line 19.) (b)(6) witnessed similar behavior. ((b)(6) p 6, lines 2-15.)

Testimony indicates that Mr. Mathew spoke to (b)(6) in a harsh, abusive manner.
((b)(6) p 16, line 23 p 20, line 24.) He spoke in a similar manner to (b)(6)(b)(6)
, (b)(6) (b)(6) and Mr. Glover. ((b)(6) p 15, lines 1-15.)

Several witnesses testified that Mr. Mathew raised his voice when he got angry. (Areno, p 46,
1-13; p 47 lines 21-23.) (b)(6) testified he heard Toby Mathew speak to (b)(6)(b) in a
(6)
very harsh, loud tone on the speakerphone. He could hear every word with the door partially
shut. ((b)(6) p 17, lines 1-21.) The frequency of this type of interaction between Mr.
Mathew and (b)(6) increased over time. ((b)(6) p 19, lines 6-10.) Mr. Mathew would
raise his voice and tell Erik Glover to be quiet. ((b)(6) p 21, lines 23-24; p 22, lines 4-9.) Mr.
Mathew would treat Dr. McGauly in a similar way. (Id., p 20, lines 18-24.) Mr. Mathew yelled
at (b)(6) and was demeaning to her and others. ((b)(6) p 5, lines 10-15; p 6, lines
17-23.) (b)(6) testified that Mr. Matthew called (b)(6) on the phone and yelled and
screamed at her for about 15 minutes because his meetings lasted too long, and told her she
needed to go back to secretary school. ((b)(6) p. 7, lines 1-6.) From her first day of work, (b)
(6)
observed Mr. Mathew was aggressive and belittling to the staff. ((b)(6) p 5, lines 6-10.)

Page 19 of 36
We found the testimony of (b)(6) Dr. McGauly, (b)(6) (b)(6) (b)(6)
and others to be comparatively more credible than Mr. Mathews denial. Each witness
seemed sincere at the interview. By contrast, Mr. Mathew seemed to be a sophisticated
witness who understands due process and does not react emotionally to such an investigation.
(Mathew p 94, lines 20-24; p 95 lines 1-4.) We found him to be more calculating and careful in
his answers. Mr. Mathew stands more to gain from denying wrongdoing than these witnesses
stand to gain from fabricating their experiences and testimony.

When weighing credibility and whether so many different witnesses would recount feeling the
same way about their interactions, we found it unlikely they would recount similar experiences
by coincidence or because they colluded. All witnesses we interviewed, except for Mr.
Mathew, seemed concerned about the outcome. We believe the more likely explanation for
the wide gap in testimony between what Mr. Mathew recalls and what witnesses recounted is
that these witnesses experienced similar behaviors because Mr. Mathews pattern of behavior
is similar. Although Mr. Mathews conduct was covert, the impact on OBVAMC was similar
among witnesses. Based on the totality of the evidence, we believe that Mr. Mathew
mistreated other employees by raising his voice or yelling, and causing them to feel belittled or
demeaned.

Psychological Safety

Witnesses recounted that Mr. Mathew caused them to be afraid. (b)(6) was detailed at
OBVAMC for two months from VISN 16. She described in detail a meeting she had with Mr.
Mathew. ((b)(6) p 24, lines 8-24; p 25, lines 1-21.) According to (b)(6) testimony, Mr.
Mathew spoke to (b)(6) by speakerphone, did not disclose (b)(6) presence
in the office where the call was held, and Mr. Mathew asked (b)(6) what does (b)(6)
think about me? What does she [(b)(6) really have to say about me? ((b)(6) p 24
lines 21-23). (b)(6) was nervous. (Id. p 26, lines 2-3.)

In contrast, Mr. Mathew did not recall the conversation with (b)(6) He then
recalled the meeting, but denied (b)(6) characterization of it. (Mathew, p 156-158.)
(b)(6)(b)(6) recounted a very similar experience wherein Mr. Mathew tested her observations
on the spot with a co-worker. ((b)(6) testimony, p 7, lines 1-8.)

Employees Left OBVAMC Because of Work Environment

Three witnesses testified they left OBVAMC or the VA altogether because of Mr. Mathews
behavior toward them or others. (Patterson, p 64, lines 18-12.) Dr. Patrick McGauly was Chief
of Staff at Overton Brooks from October 2013 to February 2015. He is a Shreveport lifer who

Page 20 of 36
resigned his position as Chief of Staff because of Mr. Mathews treatment of him and others.
(McGauly, p 4 and p 10.) Sometimes he became angry. On one occasion, Dr. McGauly
recounted that he gave Mr. Mathew a ride in his truck and Mr. Mathew screamed at him in his
truck while Dr. McGauly was driving for a distance of 10 miles because he looked at his phone.
(McGauly, p 7, lines 3-9.) Mr. Mathew caused others to cry, caused Dr. McGauly to feel
belittled, screamed at people and created an oppressive work environment. (McGauly, p 18,
lines 21-23.) Several witnesses testified that Dr. McGauly worked extremely long hours,
sometimes arriving at work at 5:00 a.m. ((b)(6) p 9, lines 22-23; p 10, lines 1-3.) Leaving
OBVAMC saddened Dr. McGauly and made him want to vomit. (McGauly, p 25, lines 1-12.) Dr.
McGauly continues to work part-time for the VA because he believes in helping veterans.

(b)(6) to Mr. Mathew from December 2014 until April 2016. (b)(6)
. During her
time working for Mr. Mathew, (b)(6) described being terrified and anxious. ((b)(6)
p 5, lines 22-23.) (b)(6) felt she received constant negative feedback but Mr. Mathew
gave her outstanding performance ratings. ((b)(6) p 88, lines 13-15.) (b)(6)(b)(6) noticed
(b)(6) was very unhappy when she left. ((b)(6) p 21, lines 10-14.)

Erik Glover was Associate Director at OBVAMC from approximately December 2012 until
September 2015.16 Mr. Glover left OBVAMC because it was among the worst leadership
experiences as a leader working for an organization in [his] career. (Glover, p 8.) Mr. Glover
cited psychological safety as among his job dissatisfaction factors. Mr. Glover felt like in a fight
or flight stress situation. (Glover, p 16, lines 22-23.) Secretaries who worked for Mr. Mathew
were in fear. (Glover, p 30, lines 13-24; p 31, 1-9.) Mr. Glover listed people who he knew left
Overton Brooks because of its leadership. (Glover, p 14, 14-16; 33-34.) During his testimony,
Mr. Glover said he left OBVAMC behind him and was bothered emotionally by having to have to
recall events he believed would remain in the past. (Glover, p 45, lines 14-19.)

(b)(6) attributed his decision to take a downgrade from Assistant Fiscal Officer (AFO)
to Auditor, at least in part, to Mr. Mathews high degree of involvement in fiscal matters and to
Mr. Mathews delayed decisions. ((b)(6) p 6, line 21 p 8, line 21.) The dysfunctional
relationship between Mr. Mathew and (b)(6) also affected (b)(6) decision because
(b)(6) felt like it affected his performance as AFO. ( (b)(6) p 8, line 16-21.)

(b)(6) considered leaving OBVAMC because of how she was treated, and was offered a

16
Mr. Glover is currently is Associate Director at the Philadelphia VAMC.

Page 21 of 36
position at another VA location, but Dr. Areno encouraged her to stay. ((b)(6) p 74, lines 10-11;
p 55, lines 4-5.)

Retaliation: Moving Employees after a Conflict with Mr. Mathew

Witnesses alleged Mr. Mathew would move them for retaliatory reasons. Several witnesses
testified that they were inexplicably moved or moved after a conflict with Mr. Mathew. Mr.
Mathew denied moving employees or getting involved at that level of detail. (Mathew, p 49,
lines 11-24; p 50, lines 1-23.) Mr. Mathew testified that The ultimate responsibility for some
of those moves comes to me as medical center director depending on what the issue is.
(Mathew, p 62, lines 19-21.) Mr. Mathew denied that he moved anyone because of a conflict
with him. [M]oves may have been coincidental. (Mathew, p 63, lines 11-14.)

(b)(6)(b)(6)provided credible evidence that she was moved after a conflict with Mr. Mathew.
She testified she was detailed as (b)(6) to the Medical Center Director in
(b)(6) , and then she was detailed away for eight months. ((b)(6) p 10, lines 5-
6.). During her time as (b)(6) she told Mr. Mathew that, All of your direct reports are walking
around saying this is a hostile work environment. This occurred on or about September 1 or 2,
2014. We believe this was a protected disclosure. On or about September 8, 2014, Mr.
Mathew directed (b)(6)(b)(6) to work for Medicine Service.

(b)(6)(b)(6) recalled her birthday was on September 4, 2014, and she asked Mr. Mathew if she
could start her detail after her birthday. ((b)(6) p 10, lines 23-24, p 11, lines 1-3.) Shortly
after her birthday, she was detailed out of the MCDs office and into Medicine Service, ((b)(6)
p 7.) (b)(6)(b)(6) testified the Chief of Medicine, (b)(6) did not know she was detailed
there. Mr. Mathew never told (b)(6)(b)(6) why she was detailed. ((b)(6) p 11.)

There is corroboration for this event. (b)(6) testified she was in a meeting with (b)
(b)(6) and Mr. Mathew and (b)(6) was trying to explain to Mr. Mathew what people were (6)

saying about the environment. (b)(6) testified (b)(6)(b)(6) was in tears and Mr. Mathews
stopped her in the middle of her conversation and said You all can cry hostile work
environment all you want. Nobody is ever going to believe you. (b)(6) testified the next
week Mr. Mathew moved (b)(6)
(b)(6) to the medical service. ( (b)(6) p. 5-6, lines 15 24.) (b)
(6)
testified Mr. Mathews moved (b)(6) because he did not want her on the first
floor. Further, (b)(6) indicated that he moved staff because, He felt like he couldn't trust
them. He thought that they started rumors . . . I guess he just wanted them out of his face.
((b)(6) p. 22, lines 11 19.)

The timing establishes retaliation. (b)(6)(b)(6) alleges Mr. Mathew moved her about a week
Page 22 of 36
after she made comments to him about the perception of a hostile work environment. (b)
(6)
(b)(6) subsequent assignments were partially documented. (Exhibit 135.) However, she did
not understand why she was detailed. ((b)(6) p 11, lines 6-11.) Witnesses noticed that (b)
(b)(6) was moved. ((b)(6) p 5, lines 11-24; (b)(6) (6)
p 9, lines 1-11.) (Exhibit 135.)

We found other similar incident. Mr. Mathew and (b)(6) had a disagreement about parking
as a reasonable accommodation. (Mathew p 181, line 6-20.) ((b) p 38, lines 20-24; p 39, lines
(6)
1-12.) (b)(6) also indicated Mr. Mathew asked him for a list of people with reasonable
accommodations. Thereafter, Mr. Mathew moved (b)(6) nine floors closer to his office,
which caused an immediate reduction in EEO foot traffic to (b)(6) office. ((b)(6) p 19 lines
13-24; p 20, lines 1-24; p 21; lines 1-24; p 21, lines 1-13.) Mr. Mathew moved (b)(6)
from her position as secretary to the medical center director to nursing service. (b)(6)
received no reason for the move. ((b)(6) p 7, lines 7-24; p 8, lines 1-12.) ((b)(6) p 52, lines
17-24; p 53, lines 1-5.) Although Mr. Mathew offered reasons for these moves and attributed
them to coincidence, Mr. Mathew admitted he did not provide the subjects of moves any
reason behind why they were moved. (Mathew, p 64.) Based on the totality of the evidence,
we believe Mr. Mathew moved (b)(6)(b)(6) and that her move was likely substantially
motivated by retaliation.

Although less credible than other witnesses, Dr. Tiffany Love and (b)(6) also testified to
being moved or being threatened with a move out of retaliation because of complaints
regarding Mr. Mathew. ((b)(6) p 39, lines 23-24, p 40, lines 8-19; p 60, lines 13-20.) (Love, p
15, lines 22-24; p 16, lines 2-6.) We do not believe moving Dr. Love and (b)(6) was based
on retaliation.

Even if Mr. Mathew did not directly or otherwise orchestrate employee moves, which seems
unlikely to us, their occurrence without clear purpose or communication contributed to a
pervasive sense of fear of retaliation and dysfunction at OBVAMC.

Retaliation: (b)(6) (b)(6) (b)(6) Husband

suspected Mr. Mathew retaliated against her by denying her (b)(6)


(b)(6)(b)(6)
at OBVAMC. ((b)(6) p 29-30.) (Exhibit 087.) Mr. Mathew allegedly stated (b)(6)
or words to that effect in September 2016. ((b)(6) p 140,
lines 14-18.) (Exhibit 074.) (b)(6) applied for several positions at OBVAMC. (Exhibit 118.)
Human resources received (b)(6) applications via email using the non-competitive hiring
authority. (Exhibit 118.) (b)(6) and another veterans information were received by the
selection officials. The selection officials opted to announce the job for wider consideration.
Both veterans were given consideration. (Exhibit 134.) We found insufficient evidence
indicating (b)(6) was given less than appropriate consideration because of Mr. Mathews

Page 23 of 36
influence. Thus, this allegation is not substantiated.

Retaliation: Non-selection of (b)(6) for AO Job

(b)(6) alleged she was not selected or the AO job because Mr. Mathew retaliated against
her for reporting privileging issues. There is evidence that Mathew influenced (b)(6)
(Romero, p 24 line 16; p 25, line 14.) (Exhibit 075.) (b)(6) asked Areno if he had talked to
Mr. Mathew. (Exhibit 075.) Dr. Areno said he had not yet done so. (Id.) (b)(6) says he
met with the Pentad on December 14, 2016. (Exhibit 108.) Mr. Mathew told him he had to be
patient . . . [and recommended waiting] for better applicants. (Romero, p 20 lines 5-8) In a
subsequent email to investigators, (b)(6) states he informed HR of the non-selection on
December 19, 2016, after he had discussions with Mr. Mathew and Dr. Areno. (Exhibit 108.)
(b)(6) had reasons to re-announce the vacancy apart from the feedback he received
regarding (b)(6)(b)(6) Because there is no evidence of pretext, this allegation is not
substantiated.

Grabbing (b)(6) by the Arm and Touching (b)(6) On the Shoulder

We investigated two allegations that Mr. Mathew touched people inappropriately. Dr.
Patterson alleged Mr. Mathew grabbed an HR employee who is also a veteran, (b)(6) by the
arm, which caused the veteran trauma. (Exhibit 6, p 11-12.) (b)(6) alleged that in a
separate event, Mr. Mathew massaged his shoulders, which was unwelcome.

(b)(6) has a service-connected medical condition. Dr. Patterson did not observe the incident,
but he treated (b)(6) after the incident. (Id.) Dr. Patterson alleges (b)(6) did not wish to work
in OBVAMC anymore because of his experience. However, (b)(6) left OBVAMC after receiving
a proposed removal for failing to pay money he borrowed from a coworker. (Exhibit 106.) (b)
(6)
testified that after he introduced Mr. Mathew incorrectly at a new employee orientation,
Mr. Mathew became angry with him. (b)(6) testified that Mr. Mathew grabbed him by the arm
and (b)(6) reacted by shoving Mr. Mathews hand away. ((b)(6) p 12, line 21-24; p 13, lines 1-
2.) The incident inflamed (b)(6) service-connected medical condition. (b)(6) observed
(b)(6) immediately after the event and he was very upset after he said he was grabbed by the
arm, she noticed he was shaking. ((b)(6) p. 12, lines 7-page 13 line 22.) (b)(6) received a
statement from Mr. Mathew wherein Mr. Mathew said he regretted the incident. (Id. at p 10,
lines 17-22; p 14, lines 11-14.)

Mr. Mathew testified he never grabbed (b)(6) (Mathew, p 11, lines 22.) However, he did touch
(b)(6) on the shoulder to console him because Mr. appeared out of sorts and disheveled.
(Mathew, p 12, line 22-24; p 13, lines 1-13.) There is no eye-witness testimony to this incident
other than the accounts of (b)(6) and Mathew. We found no video evidence and to our
knowledge, there was no camera in the vicinity. However, it is clear that Mr. Mathew touched
Page 24 of 36
(b)(6)

Next, we inquired into an allegation that Mr. Mathew massaged (b)(6) on the shoulder.
((b)(6) p 30, line 6-8.) (b)(6) testified that Mr. Mathew came behind him where he was
sitting and massaged his shoulders ((b)(6) p 30, lines 6-16), but Mr. Mathew recalls
touching (b)(6) on the shoulder only to console him. (Mathew, p 15, lines 18-19.) Mr.
Mathew testified (b)(6) was emotional at this meeting. (Mathew, p 15, line 24.) We
conclude that both accounts have touching on the shoulder in common.

Based on the evidence, we believe Mr. Mathew did touch (b)(6) and that touching caused (b)
(6)
anxiety. Furthermore, Mr. Mathew likely touched (b)(6) on the shoulder. We do not
find sufficient evidence that the touching constituted a massage of the shoulder as alleged.

3. Allegations that Acting Associate Director for Patient Care Services, Chandra Miller
engaged in misconduct

Retaliation against Dr. Love by Chandra Miller for Initiating Fact Finding

Dr. Love alleged a fact finding investigation was initiated by Ms. Miller at the request of Mr.
Mathew, in retaliation of an EEO complaint she had filed against him. (Exhibit 017.) However,
the fact finding investigation was initiated because Ms. Love asked the following racially
charged interview question: Tell me about a time when you had to address a hostile work
environment. Particularly with [C]aucasians bullying African-Americans. What actions did you
take? What was the outcome? (Exhibit 014.) The results of the fact finding indicated that, by
a preponderance of evidence, witnesses testified they viewed the question as inappropriate.
(Exhibit 137) There was a legitimate business reason to pursue a fact-finding investigation into
the conduct of Dr. Love. Thus, the allegation is not substantiated.

4. Allegations that Deputy General Counsel (b)(6) Engaged in Misconduct

(b)(6) legal advice regarding VAMC MHS Social Worker (b)(6)

Dr. Patterson alleged that (b)(6) endangered his safety after the VA police received a
report from (b)(6) , that her patient, (b)(6) (Dr. Pattersons
employee) threatened to harm him, and (b)(6) and Toby Mathew did nothing to address
the threat for five months. (Patterson, p 11, lines 15-22.) (Exhibit 022.) ((b)(6) p 33, lines 9-
12.) (b)(6) received a proposed removal on May 11, 2016. On May 13, 2016, (b)(6)
recanted her statement regarding (b)(6) alleged threat. (Exhibit 25, last page) Dr.
Patterson wanted (b)(6) employment terminated.

(b)(6) was put on AA within two days of receipt of an alleged threat. Dr. Areno took four
months to propose to remove (b)(6) responded to the proposal with
compelling mitigating evidence in writing, that her therapist retracted her statement. (b)
(6)
Page 25 of 36
(b)(6) guidance was based on the evidence. Although we sympathize with Dr. Patterson, who
feels like he was targeted, we cannot substantiate the allegation against (b)(6) Thus, we
found no delay or misconduct attributable to (b)(6)

(b)(6) legal advice regarding VAMC MHS Provider (b)(6)

(b)(6)is a mental health provider at OBVAMC who was disciplined for substandard
patient care, and Dr. Patterson proposed to remove him. Dr. Patterson alleged that (b)(6)
encouraged his patients to give death threats to Dr. Patterson. (Patterson, 17 lines 1-3; page 56
line 14 page 58 line 15.) ((b)(6) p 24 line14-17) (b)(6) has been assigned to the library
pending litigation of over two years. His privileges have expired.

A delay of over two years to remove a provider seems unreasonable to us. However, we are
unable to attribute the delay to (b)(6) who is an attorney and not a decision-maker. The
removal matter is still in litigation.

There is no evidence to substantiate the allegation that (b)(6) endangered the life of Dr.
Patterson by failing to take action in the (b)(6) matter. Thus, this allegation is not
substantiated.

OTHER ISSUES WE IDENTIFIED AND INVESTIGATED

5. Evidence that Chief of Staff Dr. John Areno engaged in misconduct

reports to Dr. Areno. (Areno, p 35.) Dr. Areno testified that (b)(6)(b)(6) shares
(b)(6)(b)(6)
responsibility for the privileging issues, but also admitted he is accountable as well. (Areno, p.
104) Nowhere in his testimony does Dr. Areno detail efforts he made to communicate to Mr.
Mathew that he was not signing privileging documents timely. Dr. Areno testified that he is
partly responsible for making sure the Medical Center Director signs privileging documents
timely. (Areno, p 62-63.)

As early as March 2016 or earlier, Dr. Areno knew or should have known that Mr. Mathew was
not signing privileging documents on time. (Exhibit 107.) ((b)(6) p 32, 33.) (Areno, p 35.)
Although the privileging documents indicate Dr. Areno himself signed the documents timely,
there is no evidence indicating Dr. Areno acted with sufficient diligence to stop providers from
practicing without privileges at OBVAMC, as one would expect of a senior leader. There is no
evidence he acted to stop providers or directed chiefs to stop providers from encountering

17
The transcripts misspell(b)(6) as (b)(6) . The names are interchangeable for purposes of this
investigation.

Page 26 of 36
patients until privileges were approved. There is no evidence Dr. Areno informed others
including Mr. Mathew that there was a serious problem requiring immediate attention; namely,
that providers encounters needed to be audited, that the VISN needed to be involved.
Available evidence shows Mr. Mathew continued to sign privileges late and that providers
continued to provide care without being privileged. Dr. Areno should have stopped the line.
He did not. Thus, Dr. Areno failed to act with sufficient due diligence when he knew or should
have known that providers were practicing medicine at OBVAMC without privileges to do so.
Further, Dr. Areno did not act with sufficient due diligence to report and mitigate the possible
effect flowing from the MCDs failure to sign privileging documents timely.

Retaliation Against (b)(6)

During our investigation, (b)(6)(b)(6) alleged that Mr. Mathew retaliated against her after
reporting Mr. Mathews delays in signing privileging documents. Examples of retaliation
include being assigned additional responsibilities, not having sufficient resources to meet
business demands, and not being selected for the Administrative Officer (AO) job. (Exhibit 086.)
She asked Dr. Areno whether she was being set up to fail. (Exhibit 130.)

The AO job, for which (b)(6)(b)(6) applied, was in Surgical Service. (b)(6) was the selecting
official. Prior to opting not to select, he told (b)(6)
(b)(6) she was the top candidate. (Romero, p
14.) (b)(6) sought Dr. Arenos feedback. (Romero, p 30, lines 12-19.) (b)(6) received
adverse information regarding (b)(6) from Dr. Areno. (Romero, p 23, line 20- p 38, line
24.) (b)(6) attributed privileging issues at OBVAMC to (b)(6) failure to be
persistent. (Romero, p 26, lines 6-22.)

Additionally, (b)(6) testified that he met with the Pentad on December 14, 2016 regarding
the selection. (Exhibit 108.) Mr. Mathew told (b)(6) he had to be patient . . . [and
recommended waiting] for better applicants. (Romero, p 20 lines 5-8) In a subsequent email
to investigators, (b)(6) states he informed HR of the non-selection on December 19, 2016,
after he had discussions with Mr. Mathew and Dr. Areno. (Exhibit 108.)

Despite the nature and extent of the influence from others such as Dr. Areno and Mr. Mathew,
(b)(6) testified the decision to select the AO was his. (Romero, p 15, lines 13-15; p 19, line
15.) Others reaffirmed his decision. (Exhibit 108.) Further, (b)(6) testified credibly that
he based his decision, in part, on the fact that (b)(6) lacked experience with procurement
of surgical instruments. (Romero, p 10, lines 9-24.) He reposted the AO job, and may opt to
select (b)(6) under the reposting because she made the list of qualified applicants.
(Romero, p 36, lines 20-22.) Thus, (b)(6) had reasons to re-announce the vacancy apart
from the feedback he received regarding (b)(6)(b)(6) (b)(6) testified credibly that despite
his decision to announce the AO vacancy again, he encouraged (b)(6) to reapply and stated
(b)(6)

Page 27 of 36
he could very well select (b)(6) if she is the best qualified candidate. (Romero, p 15, line
17-19). (b)(6)(b)(6) said (b)(6) encouraged her to reapply. (Exhibit 086.) Although we found
evidence that Dr. Areno influenced the non-selection of (b)(6) there is insufficient
evidence that retaliation was a significant motivating factor. Thus, this allegation is not
substantiated.

6. Allegation that Assistant Medical Center Director (b)(6) Engaged in


Retaliation toward (b)(6)

We received and reviewed an allegation from (b)(6) that (b)(6) had retaliated
against him by taking his great grand master (GGM) key away. (b)(6) maintained that he
needed the GGM key to do his job as Facility Planner. (Exhibit 100 and 101.) The GGM key
permits the holder to access almost any door at OBVAMC. At the time that (b)(6) was
asked to return the GGM key, he was teleworking five days per week. ((b)(6) p 24, lines 1-5.)

(b)(6) cited the GGM key policy in explaining his decision to retrieve the key from (b)
(6)
((b)(6) p 9, lines 3-9.) In testimony, (b)(6) provided a credible explanation for his
decision to control physical access at OBVAMC. ((b)(6) p 10. Exhibit 076 and 077.) Specifically,
he inventoried the keys and applied the policy, which did not permit (b)(6) to keep it.
((b)(6) p 9-11.) Based on the totality of the evidence, we did not find any credible evidence or
testimony to prove (b)(6) stated reasons for enforcing policy were pretext. Thus, this
allegation is not substantiated.

7. Allegation that senior leaders at OBVAMC failed to properly addressed allegations


that sterile instrument packages were punctured or otherwise adulterated.

Both Dr. Patterson and Dr. Love alleged that OBVAMC leadership failed to address failed to
address allegations that an employee cut slits into instrument packages, which compromised
the sterility of the instruments. (Exhibit 006 and Exhibit 008, p 6.) Dr. Love does not provide
specific dates regarding these incidents. Moreover, we found no emails linking alleged
packaging of sterile instruments to senior leaders at OBVAMC.

Several witnesses testified that service chiefs as well as Chief of Staff John Areno, were aware
of past issues with punctured or inappropriate handling of instruments, but they addressed
these incidents. (Romero, p 40, lines 18-24, p 41, lines 1-7.) (Areno, p 24, lines 19-24; p 25,
lines 1-23; p146, lines 5-24; p 147, lines 1-1-21.) Dr. Areno is not aware of any recent
allegations and is confident that there are safeguards in place to avoid such incidents. (Areno,
p 25, 26 and 27.) Thus, this allegation is not substantiated.

Page 28 of 36
3. CONCLUSION: (b)(6)

SIGNATURES

(b)(6)

______________________ _February, 15, 2017

(b)(6) Date

(b)(6)

______________________ February 15, 2017

(b)(6) Date

(b)(6)

_____________________ February 15, 2017

(b)(6) Date

Page 29 of 36
INDEX TO EXHIBITS

Exhibit Title/Description of Document

001 Charge Memo dated October 18, 2016

002 Charge Memo Amendment to include SME (b)(6) November 9, 2016

003 Extension Request Approved for Shreveport Investigation

004 Report of Investigation

005 Certificate of Completion

006 Briefing Report for (b)(6)

004 Briefing Report for Chandra Miller

004 Briefing Report for (b)(6)

004 Briefing Report for Toby Mathew

005 VISN 16 Email to OAR Re Allegations in Patterson Grievance

006 James Patterson Email to VA Officials of September 2, 2016, Regarding Allegations of


Senior Leader Misconduct at OBVAMC

007 James Patterson Email of September 29, 2016, to VA Officials re Request for Action

008 James Patterson Email dated January 4, 2016, with Subject Second Request for
Action

009 Tiffany Love Email and Allegations re Miller dated October 3, 2016

010 Tiffany Love Email to VISN re Miller October 07, 2016

011 Tiffany Love Email to VISN re Retaliation

011 Tiffany Love Email to VISN re Retaliation

012 Tiffany Love Memo to Miller re AIB

013 Miller Memo to Tiffany Love re AIB

014 Love Notes re Candidate Interview

Page 30 of 36
Exhibit Title/Description of Document

015 James Patterson Email to OAR Investigators re October 27, 2016 re List of Witnesses

016 Patterson List of Prioritized Witnesses

017 Love Fact-finding re Inappropriate Interview Question

018 RESERVED

019 Patterson Email to VA Officials Demanding Action

020 OAR Previous Fact-finding re HR Practices at OBVAMC November 30, 2015

021 RESERVED

022 Death Threat Documentation re (b)(6) 01-06-16

023 RESERVED

024 RESERVED

025 James Patterson Informal Grievance 07-01-16

026 Toby Mathew Decision re Informal Grievance of James Patterson dated 07-27-16

027 John Areno Memo to (b)(6) re Temporary Change in Supervision dated 07-20-16

028 Text Message from James Patterson to (b)(6) re (b)(6) Matter 04-01-15

029 VA Proposal to Remove (b)(6) dated April 22, 2016 and Decision to Suspend
dated 06-27-16

030 (b)(6) Response to VA Proposal to Remove 05-25-16

031 VA Decision re (b)(6) Grievance 11-16-16

032 James Patterson Email to OAR Investigators Re: Continued Problems

032 OAR Attempts to Reach Witness Deesha Brown

033 Email from (b)(6) to OAR Investigators re (b)(6) Proposal

034 Provider (b)(6) Privileging Folder Expired Privileges

035 Provider (b)(6) Privileging Folder Signed 3-18-16

Page 31 of 36
Exhibit Title/Description of Document

036 RESERVED

037 Provider (b)(6) Privileging Folder EXPIRED

038 Provider (b)(6) Privileging Folder

039 RESERVED

040 Provider (b)(6) Privileging Folder MCD Signed 02-24-14 EXPIRED

041 Provider (b)(6) Privileging Folder MCD Signed 03-18-16

042 RESERVED

043 Provider (b)(6) Privileging Folder MCD Signed 02-18-14 EXPIRED

044 Provider (b)(6) Privileging Folder MCD Signed 02-19-16

049 Provider (b)(6) Privileging Folder MCD Signed 02-14-14 EXPIRED

050 Provider (b)(6) Privileging Folder MCD Signed 02-19-16

052 Provider (b)(6) Privileging Folder MCD Signed 02-18-14 EXPIRED

053 Provider (b)(6) Privileging Folder MCD Signed 02-19-16

055 Provider (b)(6) Privileging Folder MCD Signed 02-18-14 EXPIRED

056 Provider (b)(6) Privileging Folder MCD Signed 02-19-16 EXPIRED

057 Provider (b)(6) Privileging Folder MCD Signed 02-19-16 RENEWED

058 Provider (b)(6) Privileging Folder MCD Signed 02-18-14 EXPIRED

059 Provider (b)(6) Privileging Folder MCD Signed 02-19-16

061 Provider (b)(6) Privileging Folder MCD Signed 02-19-16

Page 32 of 36
Exhibit Title/Description of Document

064 Provider (b)(6) Privileging Folder MCD Signed 07-17-14 EXPIRED

065 Provider (b)(6) Privileging Folder MCD Signed 07-18-16

066 Email from OAR Investigator to VISN 16 re Lapsed Privileges

067 VISN 16 Email to OAR re Effect of Lapsed Privileges

068 AIB Investigator Email re Date of Soundproofing Proof of Work

069 VHA Handbook on Credentialing and Privileging 2002

070 OBVCAMC Medical Staff Bylaws 2015 Signed by MCD Toby Mathew 02-01-16

071 OBVAMC Policy and Procedures re Credentialing and Privileging Memorandum MCD
Toby Mathew Signed on 02-10-16

072 Joint Commission Accreditation Standards for the Hospital Manual Medical Staff
Chapter

073 MCD Toby Mathew Position Description for OBVAMC

074 Areno Statement of Clarification 01-24-16

075 Areno Email to OAR Investigators re Delays Issuing (b)(6) Proposal to Remove 01-18-
17

076 OBVAMC Great Grand Master Key Policy 12-06-16

077 Same Email to OAR Investigators re GGM Key and Policy 12-06-16

078 VISN 16 Email to Toby Mathew re Tour of Duty

079 Patterson Email to OAR Investigators re Delays Hiring Providers 11-09-16

080 Mathew TMS Record June 2014 through December 21, 2016

Page 33 of 36
Exhibit Title/Description of Document

081 AIB Member (b)(6) Email to VISN 16 re Lapsed Privileges 12-04-16

082 Attachment to AIB Member (b)(6) Email to VISN 16 re Credentialing Log

085 Email from Investigator (b)(6) to Mathew re Delay 11-17-16

086 (b)(6) Email to Investigators Alleging Retaliation 12-22-26

087 (b)(6) Email to Investigators Identifying (b)(6) by Name 01-26-17

088 Romero Email to OAR Investigators re Discussion of OAR Job Candidates

099 (b)(6) Email w Allegations of Retaliation 11-20-16

100 Attachment to (b)(6) Email w Allegations of Retaliation 11-20-16

101 Areno Memo to (b)(6) re Temporary Change in Supervision 07-20-16

102 HR Email re Current Work Location of Burnom 1-23-17

103 (b)(6) Email to OAR Investigators re Mathew Not Dating PSB Minutes 01-04-17

105 AIB Member (b)(6) to OAR Investigators re Review of PSB Minutes and
Absence of MCD Dates w Signature 12-07-16

106 (b)(6) HR Documents

107 Dr. Wallace Email for the Record 03-16-16

108 Romero Email to OAR Investigators re Discussions with OAR Job Candidates 01-23-17

109 PSB Minutes 01-21-16

110 Love AIB Results 01-05-16

111 OAR Factfinding re HR Practices at OBVAMC ROI 11-30-15

112 Email from AIB Member (b)(6) to AIB re Providers who Had Encounters 01-03-17

Page 34 of 36
Exhibit Title/Description of Document

113 QM Site Visit Action Plan 2015

114 FY 2016 QM Program Review Shreveport 06-24-16

115 PSB Routing Slip Dated 01-22-16

116 (b)(6) Privileges and Routing Slip

117 Patterson Attachment to Email of 09-02-16 MHS RN staffing Crisis

118 HR Email to AIB Member (b)(6) re (b)(6) (b)(6) Application

119 (b)(6) Email to VACO Allen re MCD Not Signing Minutes Timely 02-25-16

120 I CARE Values from VA.gov

121 Mathew Current and Expired Privileges (b)(6)

123 Maier Current and Expired Privileges (b)(6)

125 (b)(6) Current and Expired Privileges

127 (b)(6) l Current and Expired Privileges

129 January 2017 VHA Credentialers Call

131 CFR

132 AIB Member (b)(6) Email AIB Board re Number of Encounters 02-08-17

133 CMS Requirements for Privileging or Providers 11-12-04

134 (b)(6) OBVAMC Application

135 (b)(6) Detail Memos/Letters 2014

136 Mathew TMS Records 2011-2017 YTD

137 Love Fact-finding Analysis 2016 Signed ROI

138 Routing Slip for 01-21-16 PSB

139 Routing Slip for 02-04-16 PSB

Page 35 of 36
Exhibit Title/Description of Document

140 Routing Slip 02-18-16 PSB

141 (b)(6) Email Re 07-11-16 Routing Slip

142 PSB Minutes 02-04-16

143 PSB Minutes 02-18-16

144 PSB Minutes 07-11-16

145 (b)(6) Current and Previous Privileges Vetpro

146 ACHE Conference March 16, 2015

147 Moore Email to AIB Member (b)(6) re Patient Encounters for Locati and Daniels 02-
07-17

148 CFRs for Privileging Issue 482.22

149 CFRs for Privileging Issue 482.12

150 Taylor Email Indicating She Did Not Work on March 19, 2016 02-10-17

151 (b)(6) Email Indicating She Did Not Work on March 19, 2016 02-14-17

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