va whistleblower report

Upload: chad-whitehead

Post on 07-Aug-2018

215 views

Category:

Documents


0 download

TRANSCRIPT

  • 8/21/2019 VA Whistleblower Report

    1/35

      "

    #$%&' "() *+",

    -.&%./$%0 #&123$45)6 $7 8%9/93: /2 7$;. 02< $8$%. 2= 7$>>9?. ?924$/923> 2= $&@9/923 $35 =9>&$4 4$8>$35 %.:) 8'9&' '$?. $35 &23/93 &2%%.>A235.3&. 5./$94> :%2>> 79>7$3$:.7.3/ F0 >.392% BC2==9&9$4>) 8'2 93/.3/923$440 422;.5 /'. 2/'.% 8$0) $?295.5 /'.9% 93'.%.3/%.>A23>9F949/9.>) 59>/2%/.5 /'. /%&2A. 2= /'9> 79>7$3$:.7.3/ $35 >.>F944923> 2= 5244$%> $AA%2A%9$/.5 F0 H23:%.>> 93 >27$;. %.&277.35$/923> /'$/ 02< 7$0 &23>95.% /2 :./ /'. BC F$&; 23 /%$&;D

    "#$%&'()$"* I$&' 2= .3:$:.5 93 /'. J.5.%$4 $&@9/923 A%2&.>> '$> $3 2?.%%9593:%.>A23>9F949/0 /2 /$KA$0.%>D E'2>. 2= 93 $&@9/923 4.$5.%>'9A A2>9/923> 7/$48$0> 4.$5 93 $ 7$33.% >2 $> /2 7$93/$93 /'. A0>/.7>D -.392% B./.%$3> C==$9%>$&@9/923 2==9&9$4>) >) 8'94. .3> $35 %.: $%. >/%9&/40 $5'.%.5 /2D

    L?.% /'. A$>/ =9?. 0.$%>) >27. >.392% BC $&@9/923 $35 =93$3&. 2==9&9$4> '$?.8944=.5D E'.9% 2?.%/ $&/923> $35 5.%.49&/923 2= 5 &27F93.5 '$?. %.> 2= /$KA$0.% 5244$%> F.93: >A.3/ 89/'2 $35%.:D E'.9% $&/923> $35G2% 93$&/923> '$?. $35 &23/93/. >&$%&.:2?.%37.3/ %.>2) $35 7$;. $ 72&;.%0 2= J.5.%$4 4$8> $35 /'. $&@9/923 $35=93$3&. >0>/.7>D

    6 $7 32/ $8$%. 2= $ >93:4. >.392% $&@9/923 4.$5.% F.93: '.45 $&&2 9> 93 >A9/. 2= 3 5.&4$%93: >.%92 8$>/.) =%$7$3$:.7.3/ ?.%59&/>D U3=2%/ 32/ F..393?.>/9:$/.5 $35 %.A2%/.5) $> 5./$94.5 F.428D P28 &$3 8. '245 =%23/R493.> $&&2.392% 4.$5.%> $%. 32/ '.45 $&&2$3&.V 6S7 > A'.5 93 BC L==9&. 2= 63>A.&/2% T.3.%$4 %.A2%/>D C44 $%. 328 5.A$%/.5 =%27BCD U3=2%/.&/$/D

    X$7.3/$F40) $> 5./$94.5 F.428) /'.%. '$?. F..3 .==2%/> F0 >27. >.392% BC 2==9&9$4>)93&4 2= L==9&. 2= C&@9/923 X2:9>/9&> $35 H23>/%P.$4/' C57939>/%$/923) L==9&. 2= T.3.%$4 H2.4) L==9&. 2= 63>A.&/2% T.3.%$4) $35

  • 8/21/2019 VA Whistleblower Report

    2/35

      *

    L==9&. 2= #$3$:.7.3/) /2 &$729/923 $35 /$;.3 %.>A23>9F4. $&/923> /2&2%. ?924$/923> 2= 4$8> '$?. F..3 >&2%3.5) 93/9795$/.5 $35 %.A%9>.5 $:$93>/D

    Q'94. 93/.3/923$4 ?924$/923> 2= J.5.%$4 $&@9/923 $35 =9>&$4 4$8> $55 /2 /'. BCS>

    328 93=$72 Y&2%%2>9?. & $==2%5.5 ?9$ 8%9//.3 &23/%$&/>) 2% F0 2==9&9$4> 89/'2 $44 4.:$4 A%2/.&/923> $==2%5.5 F0&23/%$&/ 4$8D J2% 93>/$3&.) A'$%7$&. $35 7.59&$4 5.?9&.> A%2&.5 89/'2 $%. A%97. .K$7A4.> 2=A2/.3/9$4 5$3:.%> /2 C7.%9&$S> ?./.%$3> .3:.35.%.5 /'%2 2=

    4$8> $35 %.:D Q9/'2) J225 $35 1%/%$/923&.%/9=9&$/923> $%. 32/ $ 4.:$4 %.@923>D C&@.%?9&.>) >$3> &23/%$&/ /.%7> [&2359/923>) $%. 5.?295 2= %.@$=./0 $35 .==9&$&0 2D U3=2%/ 49//4. %.&2. 9= ?./.%$3> $%. '$%7.5 F0 A%25 2% >.%?9&.>2F/$93.5 89/'2 [ &2359/923>D -.A$%$/.40) .$&' 2=/'.>. F%.$&'.> 2= 4$8 7$0 .35$3:.% /'. 49?.> 2= BPC 7.59&$4 %.&9A9.3/>DH244.&/9?.40) 6 F.49.?. /'.0 >.%?. /2 5.&$0 /'. .3/9%. BC '.$4/'R&$%. >0>/.7D

    63 $559/923 /2 ?924$/923> 2= 4$8 $35 A2/.3/9$4 '$%7 /2 ?./.%$3>) 8$>/. 9> .35.79&8'.3 &23/%$&/> $%. 32/ .K.& $%. =4 A$95 =2% :225> 2% >.%?9&.> >&$3 2340 F. 5./.%793.5 /2 F. =$9%R$35R%.$>23$F4. F0 5D 6= &23/%$&/> $%. 32/ .K.& %.@23$F4. A%9&.5./.%793$/923 8944 '$?. F..3 7$5.D 6 &$3 >/$/. 89/'2.%?$/923 /'$/ BC '$> $35&23/93 /2 8$>/. 7944923> 2= 5244$%> F0 A$093: .K&.>>9?. A%9&.> =2% :225> $35>.%?9&.> 5 F.&$. &23/%$&/> 8.%. 32/A%2A.%40 .K.& 8.%. 32/ $&&27A49>'.5 93 $&&2%5$3&. 89/' BC$35 J.5.%$4 %.:D 6 8944 A%2?95. .K$7A4.> F.428D

    63 $559/923) /%$&.$F949/0 $35 $ $35 %.: $%. 59==9&>9F4. /2 %.$49^.D _0 >/$/A$%.3&0 $35 $&&2 $&&.>>9F4. F0 /'. :.3.%$4A. .KA.359/D

  • 8/21/2019 VA Whistleblower Report

    3/35

      a

    C> BCS> -.392% O%2&>923$4 2A93923 /'. BC '$>/$/.5 9/> $33A.35 $/ $ 79397 $35 %.:D _.&$. 8.'$?. 32/ $48$0> A%2A.%40 &23/%$&/.5 =2% :225 $35 >.%?9&.>) 8. '$?. 32/ %.&2%5.5

    2 '$?. 32 95.$ '28 ?.%0 >9^$F4. A2%/923>2= BCS> H23:%.>>923$4 $AA%2A%9$/923> $%. F.93: >A.3/) 8'9&' /'. 4$8 5.7$35>D Q.'$?. .==.&/9?.40 Y'955.3Z 2$&/923> =%27 A&%/97$/.$F2?. 9> &23>.%?$/9?.D 63 Jb", 6 &.%/9=9.5 /'. 1.A$%/7.3/ JO1- >A.35 /2 L#_ $/`"(_D LA.35 7$0 F. 935..5 F. /$/.5 F0 $> 7 '$?. F..3 $35 &23/93/402?.%>/$/.5D 644.:$4 2F49:$/923> >$3> &23/%$&/> $%. 32/ A2>/.5 /2 JO1-) $35 $%. /'32/ A%2A.%40 93&47$44RF93.>> :2$4>D Q. '$?. $332/$/.5 A.%&.3/$:.> /224. :9?.3 /'. 977.3>.93$&& .5 /2 &$4&>&277/.7> '$?. F..3 $4428.5 /2 2A.%$/. 8'.%. F944923> 2= 5244$%> 93 :225> $35>.%?9&.> $%. $&@/%$/.:9& 4.?.4>) 8'$/ =9>&$4 &'.&;> [ F$4$3&.> $%. $F>.3/ /'$/ 82 $%. 2340 7$5. $:$93>/ 93?29&.> 8'.%. = '$?. F..3 4.:$440 2F49:$/.5V

    Q'0 $%. BC >.392% A%2& 32/ $&/9?.40 .3=2%&93:$&@9/923 $35 =9>&$4 4$8>V Q'0 '$?.3S/ >.392% 2==9&9$4> %.>A23>9F4. =2% 8.44R52& 2= A $35 %.:) 8'94. &23/93?@2 2;889A7/135 15< 5,5B=? /.19-/ 710. 80,7.22.2 -, .51C9. 7,D893157.E 3579;

  • 8/21/2019 VA Whistleblower Report

    4/35

      f

    9104.2- /.19-/ 710. 2A2-.D2 J3-/,;- 1 TU2-  7.5-;0A 2;3-. ,6 "$ C;235.22D1514.D.5- 80,7.22.2H $/,2. ,;-S J93$3&9$4 63/.:%9/0 C&/ 2="(d*) $> 2 $35 9359?95 /2/$;. >0>/.7$/9& $35 A%2$&/9?. 7.$> /2 M"N 5.?.42A $35 97A4.7.3/ $AA%2A%9$/.)&2>/R.==.&/9?. 93/.%3$4 &23/%24>g M*N $>>.>> /'. $5.@ 93J.5.%$4 A%2:%$7> $35 2A.%$/923>g MaN >.A$%$/.40 $>>.>> $35 52&g M,N /$;.&2%%.>A23593: &2%%.&/9?. $&/923>g $35 McN %.A2%/ $33>/$/.7.3/>D

    E'.%. $%. 7$30 >.392% 4.$5.%> %.>A23>9F4. =2% /'. >.%92 A%2F4.7> 2/ 493. 2= 5.=.3>.89/' %.:$%5 /2 93/.%3$4 &23/%24>D E'.9% =$949:39=9&$3/5.=.&/ 93 2/%$/.:9& :2?.%3$3&. >0>/.7D 6/ 52.>3S/ /$;. :.39 32% $3 $ $%. 32/ 93 .@

  • 8/21/2019 VA Whistleblower Report

    5/35

      ,

    :2?.%3$3&.D 63 =$&/) 93 70 2A93923 9/ 7$0 '$?. F..3 523. /2 59>:. A2/.3/9$47$/.%9$4 8.$;3.>>.>D 63 /'. >$7. 7../93: 8'.%.93 /'. &2. /'./'%.>'245 =2% 7$/.%9$4 8.$;3.>>.>) /'.0 $4>2 ?2/.5 /2 5%2A $3 93@7$3$:.7.3/ 2= 7239.> %.4$/.5 /2 A 8$> 93 >A9/. 2= 70 =2%&.= 2= 5244$%> 93 944.:$4 .KA.359/ &/D 6 $AA%.&9$/. 02.3/97.3/> $35 =9?. & 93=2%7$/923D b2< $%. &$7. .K.& 02< $%. %.4093: 23 '$?. A%2=2$3&. $35 2F=&$/923D

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

  • 8/21/2019 VA Whistleblower Report

    6/35

      c

    $559/923) 6 $44.:. '. $35 2/'.%> 93/.3/923$440 89/''.45 93=2%7$/923 &23&.%393: /'.>. %.>A23>9F949/9.> $%. >/$/. $35 $>>9>/ /'. -.&%./$%0) 8'2

    >.%?.> $> BCS> P.$5 2= /'. C:.3&0 MPCN 93 $44 7$//.%> A.%/$9393: /2 $&@9/923D C>.3 5 93&4 $35 $&@9/923A%2:%$7> 2= /'. C:.3&0g

    *D  I?$4. A%2:%$7> 23 /'. F$>9> 2= $AA49&$F4.A.%=2%7$3&. 7.$>g $35)

    aD  #$;. $&@9/923 5.&9>923> &23>9>/.3/ 89/' $AA49&$F4. 4$8>) $35 .>/$F49>'&4.$% 493.> 2= $>$/923 2= ) 6 7./ 89/' 2/'.% BC >.392% 2==9&9$4> $F2?. $35 A$%$44.4 /2 '97) %.A2%/93:/'.>. . 2==9&9$4> 93&4) /'. =2%7.% HJL) >.392% 7.7F.%> 2= /'. HJL >/$==) /'. BC H'9.= 2= -/$==)$> 8.44 $> /82 >.392% 7.7F.%> 2= /'. H'9.=S> A.%>23$4 >/$==D C44 .4.&/.5 32/ /2 $&/D 6&23&4A.&/2% T.3.%$4 23 72%. /'$3 23.2&&$>923D E'. L6T 5.&493.5 /2 $&/ $> 8.44D C> $ =2%7.% C%70 63>A.&/2% T.3.%$4) 6

    =29F4.D +#&$\* "

  • 8/21/2019 VA Whistleblower Report

    7/35

      h

    E'%2 A.%925) /'. HCL =$94.5 /2 = &27A49&9/0 89/' BC $35 BPC >.392% 4.$5.%> M93&4/%$/9?. LA.%$/923>) $35 BPCS> H'9.= O%2&.%92 4$A>.> 93 '9> A%2=.>>923$4 ] HCLD 6 523S/ 7$;./'.>. $44.:$/923> 49:'/40) $35 '$?. .K/.3>9?. 52&>.%/923>D

    _.&$. 6 &2. 944.:$4 7$//.%>)32% :$93 > /2 >..; $>>9>/$3&. =%27 H23:%.>>D C> $ %.>95.3&.) $423: 89/' >.?.%$4 7.7F.%> 2= '9> 4.:9>4$/9?. >/$==D P.977.59$/.40 /22; >/$3/9$4 $35 =2%&.= F$>.5 23 70 59>&42>D P.F.:$3 F0 >.3593: -.&%./$%0 -'93>.;9 $ 4.//.% 5$/.5 L&/2F.% *d) *+"" %.@/93:>A.&9=9& 93=2%7$/923 23 /'. O'$%7$&0 O%97. B.352% MOOBN A%2:%$7D H23:%.>>923$4'.$%93:> 8.%. '.45 93 W$3 2A.3 7$%;./ A 944.:$4 $&/9?9/0 89/' %.:$%5> /2 A%2&.;9 93=2%7.5 H23:%.>> 93 '9> 1.&.7F.%*+) *+"" 4.//.% &9/.5 $F2?.D 63 =$&/) BPC &23/934$84.>>3.>> /2 70 &23/$&/> 93 /'. PBCHD E'. BC HCL) $> 8.44 $> 2/'.% >.392% BC $35BPC L==9&9$4> $4>2 ;3.8 . ?924$/923> /2 /'. -.&%./$%0D

    E'. HCL 595 32/'93: 93 '9> %24. /2 =2%&. &.>>$/923 2= 944.:$4 $&/9?9/9.>) 2% '245 /'2>.$&&2. 93 70 ?9.8) '. $35 2/'.% BPC >.392%4.$5.%> &23>A9%.5 /2 89/''245 /'9> 93=2%7$/923 =%27 -.&%./$%0 -'93>.;9D E'9>5.49F.%$/. 5.&.A/923 &23/93 4$/.>/ 93 $1.&.7F.% "() *+"a %.A2%/ >9:3.5 F0 .$&' 2= /'.>. >.392% 2==9&9$4> /2 -.&%./$%0-'93>.;9) %.=4.&/93: /'.%. 8.%. 32 944.:$4 $&/9?9/9.>D -.&%./$%0 -'93>.;9 8$> 532

  • 8/21/2019 VA Whistleblower Report

    8/35

      d

    A%2:%$7 $=/.% 1.&.7F.% *+) *+""D i2/$F40) $4/'2/$/.R2=RA%2&23 6 8$> 32/ $>;.5 /2 >9:3 /'. %.A2%/.K&.A/ =2% /'. =$&/ 9/ &23/$93.5 =$4>. 93=2%7$/923) 8'9&' 6 82. 944.:$4 $&/9?9/9.>D

    -.?.%$4 BC >.392% 2==9&9$4>) 8'2 /.>/9=9.5 5/$3&.) '.$%93: /.>/97230 F0 BCS> >.392% 2==9&9$4) 1.A '$5 %./9%.5 2% 72?.523) $35 /' 32F250 &2 8$> $ =$4>. >/$/.7.3/D E'.%.'$5 F..3 32 93?.>/9:$/923 2= /'. 7$//.%> 93 @/923D 63 =$&/) 23. 2= /'. -.392%IK.& >9//93: $/ /'. 89/3.>> /$F4. '$5 F..3 %.>A23>9F4. =2% /'. BPCA'$%7$&.D E'9> >$7. -.392% IK.&/9=9.5 '.'$5 ]/ %.&.3/40 4.$%3.5 2= /'. 944.:$4 $&/9?9/9.>D P9> /.>/97230 8$> 5.&.A/9?.D 6'$?. 52& 93 70 A2>>.>>923 9%%.=/%$/93: '. 8$> $8$%. 2= /'.

    944.:$4 $&/> 23 #$0 *d) *++(D C559/923$440) '. '$5 F%9.=.5 70>.4= $35 /'. BC HCL 23#$%&' *() *+"") 8'.%.93 '. >/$/.5 '. ;3.8 /'.>. $&/9?9/9.> '$5 F..3 / ", 0.$%>Z A%92%D

    C> A%.?9240 >/$/.5) 32 $AA%2A%9$/. 93?.>/9:$/923 8$> .?.% &2358.%. >97A40 >8.A/ /9/82%/' ' 2= 7944923> 2= 5244$%>D O '.45 $&&22. 8'2 &'2>. /2 &23/93) 8'9&' 6 '$?. 5./$94.5 F.428D

    +#&$\*  " J12 5,- ;5353-31-.< 35 /1G354 -, -1I. .K-01,0

  • 8/21/2019 VA Whistleblower Report

    9/35

      (

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

    8'2 %.=.5 /2 > /2 .;9 '$5 >/$.>D 1.;9 =2%&.=93: 89/'2 8$> Y97A%2A.%Z?.%> Y944.:$4DZ 6 8$> /'. 423. 2==9&9$4 93 /'. %227 8'2 %.=.5 /2 $:%.. 89/' '97DP. F.&$7. ?.%0 $3:%0 89/' 7. $35 2%5.%.5 7. /2 >'$7. 7../93:) #%D P$::>/%27 ?.%0 =2%&.=923$440 $//.7A/.5 /2

    &2.%&. 7. 93/2 /.4493: /'. -.&%./$%0 8'$/ '. 8$3/.5 /2 '.$%D

    \.A%.>.3/$/9?.> =%27 /'. L==9&. 2= T.3.%$4 H2.4 MLTHN) $4>2 A%.>.3/ 93 /'. $F2?.7../93:) :$?. /'. -.&%./$%0 8'$/ 6 &23>95.%.5 /2 F. .K/%.7.40 79>:.392% LTH 7.7F.% 93 $//.35$3&. '$5 A%.?9240 /245 7. 9/8$> Y&2.4S> 79>>923 /2 A%2/.&/ /'. -.&%./$%0 $35 /'. 1.A$%/7.3/DZ P.% $5?9&. /2/'. -.&%./$%0 %.=4.&/.5 '.% A%.?9240 >/$/.5 2A93923D 6 >/.$5=$>/40 7$93/$93.5 8.&2779//.5 944.:$4 $&/> $35 9/ 8$> 2/%$/923D 1.@. 7$//.%>) H23:%.>>923$47.7F.%> 2?.%8'.4793:40 ?9359&$/.5 70 A2>9/923D

    6 8944 32/ &277.3/ 23 /'. =2%7.% -.&%./$%0S> 93/.:%9/0D P28.?.%) 23 /'$/ A$%/9&.3/ $ &4.$% 7.>>$:. /2 .?.%023. 93$//.35$3&.D E'. &.3/%$4 7.>>$:. 8$> &27A49$3&. 89/' J.5.%$4 4$8> $35 %.:93 BC 8$> 32/ %.@

  • 8/21/2019 VA Whistleblower Report

    10/35

      "+

    63 #$%&' *+"a) 59>/$3&. =%27 /'. HCL 93 .==.&/93: /'.9% &.>>$/923) 6%.&2:39^.5 /'. 3..5 /2 >..; 295. $>>9>/$3&.D 6 5.&95.5 /2 32/9=0 /'. BC L6T)$4/'2:9?93:> $F22D #0 79>:9?93:> 8.%. 5 9359&$/.5 23 A$:. >9K 2= /'9> %.A2%/D L3 #$%&' f) *+"a) 6=2%8$%5.5 $ 8%9//.3 '2/493. &27A4$93/ /2 /'. L6TD C -.392% IK.&A235.5 /2 70 &27A4$93/ 89/' >&2%3D E'$/ 2==9&9$4 A'23.5 7.) @/92393: 7072/9?. =2% > /'$/ 6 '$5 $ Y'955.3 $:.35$DZ

    6 8$> 93= $35 %.>A23>9F949/9.> 2= 63>A.&/2%> T.3.%$4) $35 /'. %.>A23>. 6%.&.9?.5 =%27 /'. L6T /2 70 '2/493. &27A4$93/ 8$> &4.$%40 A.%A.359&A.&/2%> T.3.%$4 >8.$% /2 .5 F0 /'. L6T) $35 82 6 8$> 3.?.% 93/.%?9.8.5D

    C/ /'$/ A293/ 6 ;3.8 6 82>9>/$3&. =%27 70 >2%) #%DP$::>/%27D 6/ 8$> $4>2 2F?92 3.9/'.% /'. BC -.&%./$%0 32% '9> >.392% >/$== 82>9>/D E'.0 $AA.$%.5 2340 /2 F. 93/.%.>/.5 93 &2?.%93: 2= A2 &2 2= /'. P2. B./.%$3> C==$9%> H2779//.. /2 $>>9>/):9?.3 /'.0 '$5 A%.?9240 %.?.$4.5 70 %24. $> /'. 8'9>/4. F428.% %.:$%593: 944.:$4BC A'$%7$&. 6 '$5 2F>.%?.5D C> >

  • 8/21/2019 VA Whistleblower Report

    11/35

      ""

    $>>9>/$3&. 93 F%93:93: /'.>. >$ $> 6 93/.35.5D #%D _. %.$>23 7$0 '$?. F..3 &$4&.@&2?.%.5 #%D _. $=%9.35 2= #%D i2%F.%/ 1204.) BPCS> H'9.= O%2&.40 /2:./'.% 23 $ 1.A$%/7.3/ 2= 1.=.3>.H2779>>923 >.?.%$4 0.$%> .$%49.%D O.%'$A> 5DE'. 93=2%7$/923 8$> A2/.3/9$440 ?.%0 5./%97.3/$4 /2 #%D 1204. $35 BPCD C =.88..;> $=/.% 6 >D #%D _. F4>93: 9>> /2 A 2==9&. $=/.% 82%; $35 A9&; 9:'/H2779//..) $35 '. F./%$0.5 32/ 2340 70 /%/) F2 /'. /%/ 2= /'. C7.%9&$3A/%9F F.0235 /'. A$4.D P9> .7$94 32/. /2 #%D 1204.) 8'.%.93'. /'$3;.5 '97 =2% Y/$;93: 977.59$/. >/.A> /2 A%.>.%?. H2779//.. &23=95.3/9$49/0Z

    9> 93&23:% '9> 283 93 /'9> 9449&9/ &23>A9%$&0) $> 8.44 $> &23&.$493: '9> 5.%.49&/9232= 5D P$5 '. F..3 &23&.%3.5 $F2'$%.5 70 4.//.% 89/' '9> &27%$5. #%D 1204.D P. &.%/$9340 5953S/ A%.>.%?. 70&23=95.3/9$49/0) $> 8$> '9> 2F49:$/923D E2 &23=.>> '. ?924$/.5 /'. &2?.3$3/> 2= '9>H23:%.>>923$4 A2>9/923 93 $ 8%9//.3 $579>>923 9> =4$FF.%:$>/93:) :9?.3 /'. =$&/ '. 9> $/%$93.5 $//2%3.0D

    #%D _. > $35 793. $/ BCD -$0 #.>>%>D _. &2%%D

    )$"#("#P O?^Y\?_?#)\* 6 %.4$/. /'. 93>/$3&.> $F2?. /2 >./ /'. >/$:. F.428D E'. 4$84.>>3.>> $35 7$4=.$>$3&.'$?. A.%>9>/.5 93:40 >93&. 70 =$94.5 $//.7A/ /2 F%93: 9/ /2 /'. $//.3/923 2=H'$9%7$3 6>>$ 93 W

  • 8/21/2019 VA Whistleblower Report

    12/35

      "*

    $//.7A/.5 $35 =$94.5 /2 %.A2%/ /2 H23:%.>>D E'.0 $%. 32/ &23>9>/.3/40 $%%$3:.5 93&'%23242:9&$4 2%5.%e

    #,5B=? >.19-/710. (51;-/,03c.< ),DD3-D.5-2*  L3 W233.4 =2% /'.>. 7$>>9?. $35&23/93 2= 4$8 $35 =2% /$;93: 32 A2>9/9?. $&/923> /2 >/2A /'. 944.:$4F.'$?92%D 6 93@.?.%$4 /97.> $> /2 8'$/ &$.5 /'.9% .A9A'$30kD /'.9% >9>/.3&. 4$/. 23 $ J%95$0 $=/.%3223 /'. 4$8 7/ 328 F. 2F>.%?.5) :9?.3 /'.0 '$5F4$/$3/40 9:32%.5 70 $AA.$4> =2% .$%49.% &27A49$3&.D E'. LTH %.>A235.5 /'$/1.A$%/7.3/ 2= W/9&. '$5 %.&.3/40 %

  • 8/21/2019 VA Whistleblower Report

    13/35

      "a

    $&/923> $> F.93: JC\RF$>.5) $35 /'$/ 8$> /'. %.$>23 =2% / 1442-0,DE _7/,.5/102 7>.3/9$440 A%.>.3/93:7. $ !"#$ "&&'()*#) 5.7$3593: 6 &23& H$%. /2 ?./.%$3> 7/.35 977.59$/.40) $35 8. 8944 32/ F. $F4. /2 &$%. =2% ?./.%$3>DZ P9> 93/.3/ 8$> &4.$%DP. 8$> $//.7A/93: /2 93/9795$/. 7. /2 7$;. $ 5.&9>923 /'$/ 8$> 944.:$4 $35

    9%%$/923$4D 6 &23>95.%.5 '9> %.7$%;> .K/%.7.40 &2.%&9?. $35 >R/2R&$%. >&$35$4 Q'9/. P2. %.A2%/D

    C/ 23. A293/) /'. 59>&>923 F.&$7. >2 >/.3.5 /2 /'.&23/%$>/93: $%: =%27 2/'.%> $35 70>.4=) $35 .>>.3/9$440 $:%..5 89/' 7.D P9>>/$/.5 2A93923 8$> /'$/ .?.3 9= 6 $:%..5 89/' /'. 93>/$3/ >&'.7.) >9:393: $ 8$9?.%/'$/ ?.%0 $=/.%3223) BPC 82 2% A.%'$A>0.$%>) :9?.3 /'. >9:39=9&$3/ $72D E'..35R2=R7../93: &23&4923 8$> /'$/ $ >24.5 8$0 $'.$5) &2>D 644.:$4 $&/9?9/0 &23/93 /'. =2442893: #235$0D P.% / =2442893: /'. W

  • 8/21/2019 VA Whistleblower Report

    14/35

      "f

    &4.$% 93 70 7935 #%D #$/;2?>;0 '$5 32 93/.%.>/ 93 &23=2%793: /2 J.5.%$4 4$8D P.8$3/.5 9/ /'. 8$0 '. 8$3/.5 9/) $35 /'. 4$8 F. 5$73.5D

    +#&$\* ),540.223,519 >=?) /.103542 J.0. /.9< 35 `;9A TNNe 15< 14135 35 `;9ATNUNE J3-/ 7,523 &9/.5977.59$/.40 $F2?.) 9> %.A%.'.3>9F4. 93 70 2A93923D 6 .

    /.>/97230D L/'.% 7.7F.%> 2= /'. A$3.4) .>A.&9$440 /'2>. =%27 BPC) 7$0 '$?. F..3$8$%. 2= /'. -.A/.7F.% *++( LTH 2A93923D +#&$\* $/. &P) ,8353,5 /1< C..580,G3? ?7-354 (5.19-/VH 6= 2/'.%> 23/'. A$3.4 ;3.8 2= /'. LTH 2A93923) /'.0 7$0 '$?. 49.5 $35 &23/93 /2 2F>&D C> 9359&$/.5 23 /'. A$:.$F2?.) 93 /'. &23/.3/92 7../93: 23 W

  • 8/21/2019 VA Whistleblower Report

    15/35

      ",

    1.A$%/7.3/ 2= W/9&. M1LWN '$5 %.&.3/40 % 3252.392%BC LTH 2==9&9$4 &9/93: 1LWS> % /'. 97A./ =2% 93&. $/ 4.$>/ *++(D C=/.% $44) LTH '$5 $9> H$%. /2 F. JC\RF$>.5D _$>.5 23 70 8%9//.393@>9>/$3&. =%27 LTH 93 72?93: =2%8$%5 /2 $&&27A49>'%$/9=9&$/923> $:$93>/ 9> H$%. A%2:%$7D C>.392% LTH 2==9&9$4 %.>A235.5) YQ'94. /'. 1$B9/$ &$>. 9> >/944 93 A4$0) 6 %.&277.3532/ 72?93: =2%8$%5DZ C35 =93$440) $> A%.?9240 >/$/.5 $F2?.) -.&%./$%0 -'93>.;9'$5 F..3 F%9.=.5 $35 8$> A%2?95.5 $ 8'9/. A$A.% 93 #$0 *+"a) 8'.%.93 9/ 8$>A293/.5 2$&/923D#0 &.%/9=9&$/923 9> 9%%.=> F.'$?92% 89/' %.:$%5 /2 J.. _$>9> H$%.D C> 9359&$/.5 A%.?9240$F2?.) 6 7$5. $ A4.$ =2% '9> $>>9>/$3&. 93 W$38%9//.3 %.&%9793$/923> 8.%. $35 %.7$93 ?.%0 59>/ 944.:9/97$/.

  • 8/21/2019 VA Whistleblower Report

    16/35

      "c

    A%.>>/2AA.5 $F%/%27S> 93/.%.>/ >A9;.5 727.3/$%940) 8'.3 '. 93@ 9>> =9%>/

    93@93&. W %24. $> /'. BC HCLD #%D 1204.) BPCS> PHC) 8$> $4>2 93 /'. 7../93:$35 595 32/ 59%.&/ %.>A23>9F949/0D

    C> 9359&$/.5 23 A$:. "+ 2= /'9> &2%%.>A235.3&.) 6 '$5 $4>2 %.@/.5 $>>9>/$3&.=%27 /'. BC L6T 93 /'9> 7$//.% 93 #$%&' *+"aD E'9> 8$> /'. %.4$/.5 93>/$3&.8'.%.93 $ >.392% L6T 2==9&9$4 @/923.5 70 72/9?. 93 %.A2%/93: /'. . 7$//.%>D

    H$%. 9> >/944 F.93: A%2?95.5 =2% ?./.%$3> 89/'2/$3&. 8'.%. $3 . . $%. 97A%2A.% A$07.3/>D E'. ?24 F0 /'. BC L==9&. 2= J93$3&. 9> 7$772/'D 6 $7 /245 BPC

    2F49:$/.5 $AA%2K97$/.40 `, F944923 93 F2/' *+"a $35 *+"f $:$93>/ /'. J..R_$>9> H$%.A%2:%$7 $423.) $35 /'.>. ?924$/923> 2= /'. 4$8 .K/.35 F$&; 7$30 0.$%>D

    Q. 7/ &.$>. /'9> 944.:$4 $&/9?9/0 977.59$/.40D Q. 7/ /'.3 &4.$3 &%.$/.5 F0 /'9> :%2>> 79>7$3$:.7.3/ 2= :2?.%37.3/ = $35 944.:$4 $&/9?9/9.>DP$5 #.>>%>D _.A9%.5 93 .>/2AA93: 70 $//.7A/> /2 %.A2%/ /'9>944.:$4 $&/9?9/0 /2 H23:%.>> 3.$%40 /82 0.$%> $:2) 8. &2. &$%5> MTOH>N 8.%. F.93: .5 $&%2>>

    /'. BC 93 ?924$/923 2= J.5.%$4 4$8D E'. >&2A. 2= /'. A%2F4.7 $AA.$%.5 /2 F..32%72) &2?.%93: 3.$%40 .?.%0 7$]2% 2%:$39^$/923 93 /'. BCD 6 977.59$/.40&23/$&/.5 #%D P$::>/%27 /2 2

  • 8/21/2019 VA Whistleblower Report

    17/35

      "h

    D370,B8;07/12.2 10. 79.10B7;-H $, -/. 70. 8.%. 32/ F.93: >.5) /2 93&4DfD  BC L==9&. 2= _93.>> L?.%>9:'/ '$5 32/ &235'245 Ml`a)+++ND,D  E'2$35> 2=

    %.@'245 93 $ 8'24.>$4.

    7$33.% 89/'2) $> %.@

  • 8/21/2019 VA Whistleblower Report

    18/35

      "d

    hD  LF49:$/923> 93 i2D c $F2?. 8.%. 32/ F.93: .3/.%.5 93/2 JO1-) 93 ?924$/9232= J.5.%$4 >/$/2 >;.893: BC >7$44RF93.>> $&&27A49>'7.3/D

    dD  TOH> 8.%. A%97$%940 9>>) F2 /2 .7A420..> 93BC H.3/%$4 L==9&. 2%:$39^$/923>D

    (D  -27. A. H$%5 A%2:%$7 9> $A23>9F949/0 2= /'. BC H'9.= C&@9/923L==9&.%D O%.>.3/40) $35 >93&. /'. 93&.A/923 2= /'. A%2:%$7 93 /'. 795R"((+>) 5$0R/2R5$0 TOH 2A.%$/923> '$?. F..3 5.4.:$/.5 /2 /'. BC L==9&. 2= #$3$:.7.3/D E'9> 9> $=2%7$4 5.4.:$/923) F94$/.%$440 .K.&9^. /'$/ $4/'2 89/' /'. HCLD T9?.3 /'. $F2?.) 6 8$>A $AA$%.3/ 4$&; 2= &23&.%3 $35 $397$/923) 8'.3 6 A%.>.3/.5$44.:$/923> 2= :%2>> 79>7$3$:.7.3/ /2 '97 93 $ A%2:%$7 '. 9> 2?.%$44 %.>A23>9F4.

    =2%D P. &4.$%40 /.4.:%$A'.5 /2 7. 9/ 8$> Y32/ '9> A%2F4.7DZ C4/'2 9= '. 8$> $?29593: $ A$A.% /%$94D

    E'. L6T $&&.A/.5 70 P2/493. &27A4$93/) $35 F.:$3 $3 93?.>/9:$/923 93 W$3/97$/.> 8.%. /'. 428.%4979/ 2= /'. (+ A.%&.3/ &23=95.3&. 93/.%?$4D

    E'. A%2F4.7 9> 935..5 7/'./9&> $35 A/9:$/. 93 .K&.>> 2= `,+# 93 $&/923> 6 A%2?95.5 /2 /'.7 =%27 /'. _%23K) ib BC 2==9&.D E'.05.&4$%.5 70 =93593: /2 F. Y295. /'. >&2A.Z 2= /'.9% 93?.>/9:$/923) F.&$. /'.5244$%> 93?24?.5 8.%. 32/ =%27 *+"*G"aD

    E97. .4$A>.5 =%27 70 939/9$4 &27A4$93/ D 6 $7 ?.%0 32/&27A4.KD 1 F..3 '.45 $&&2 $35 F23.>) >.@A9/. 2= /'.>. 59>&42>D -.392%.K.& 93 2%:$39^$/923> 8'.%. 944.:$4 /%$3>$&/923> 8.%. 7$5. $4>2 %.&.9?.5

  • 8/21/2019 VA Whistleblower Report

    19/35

      "(

    F23.>D 6/ 9> 328 &23=9%7.5 7944923> 2= 5244$%> '$?. F..3 2F49:$/.5 89/'2/$/.5 93 /'.9% %.A40 /2 /'. L6T 93?.>/9:$/923 /'.0 82A.&9=9& 4$&; 2=/%27) P.4.3 E9.%3.0 $35 /'. L6TD E'. L6T 8%2/. /2 7.) >/$/93:/'.0 82/%27$35 #>D E9.%3.0 3.?.% F2/'.%.5 /2 %.A40D #0 &27A4$93/> 7$0 '$?. &$.5 /'.7 /2>A..5 /'. A%2&.>> >49:'/40) $> /'.0 9>> 93 J.F%

  • 8/21/2019 VA Whistleblower Report

    20/35

      *+

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

    49//4. :%23S/ >./ $ A.%>23$4 .K$7A4.D

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

    E'.%. 8.%. $/ 4.$>/ =2>.> /2 '.% >/$/.7.3/) 8'9&' 6 977.59$/.40 7$5. $7$//.% 2= 8%9//.3 %.&2%5D Q'.3 6 =2%8$%5.5 9/ /2 '.% $35 .KA%.>>.5 70 59>7$0 89/'

    '.% 5.&4$%$/923) >'. 5.39.5 7$;93: 9/D 6 523S/ F4$7. '.% =2% '.% =%/%$/923D i2F2509> '.45 $&&2 A$%/9& 93/24.%$F4. 93 70 2A93923D 6= /'. L6T 9>3S/ 93 /'. F93.>> /2.3>

  • 8/21/2019 VA Whistleblower Report

    21/35

      *"

    %.@/.5 $3>8.%> /2 $ 4.3:/'0 >.%9.> 2= @/923> %.:$%593: BC &23/%$&/93:A%$&/9&.> 89/' %.:$%5 /2 A%2>/'./9&>D E'. BC 1.A) $4>2 $3 $472>/ /$== 2==9&.> 89/' /'. .K&.A/923 2= LTHDP. ;3.8 6 82? 7,5-017-354 ,6637.02 122345.< -, ,C9341-. 6;5

  • 8/21/2019 VA Whistleblower Report

    22/35

      **

    O%2&/.7 MJO1-ND 6 = :2$4> 89/' /'9> %.72?$4) $> 2A.35N 82.@ 59%.&/93: > >7$44

    F93.>> :2$4>D 6 93=2%7.5 '97 2340 5244$%> 2F49:$/.5 93: JC\RF$>.5 &23/%$&/> $%.$ JO1- $&@9/923 >A.35 %.&2%5D 6 $4>2$5?9>.5 '97 6 8$> 72?93: /2 %.>&935 $44 &23/%$&/93: 2==9&.% 8$%%$3/> =2% BPCA%2>/'./9&> A.%>233.4D

    E'. BC H'9.= 2= -/$== >/.%340 $>;.5 8'0 6 5953S/ &23>95.% 5244$%> 2F49:$/.5 =2%A%2>/'./9&> /2 F. JC\RF$>.5 /%$3>$&/923>D 6 93=2%7.5 '97 6 595) F923 /'.0 8.%. 32/ JC\ F$>.5) $35 '$5 93 =$&/93=2%7.5 H23:%.>> 2= /'. >$7. 93 /'. #$%&' *a 4.//.%D 6 =/'./9& &23/%$&/93: 2==9&.% 8$%%$3/> 82&935.5 F.&$. /'.0 '$5 323..5 =2% 8$%%$3/>) :9?.3 /'.0 8.%. 2F49:$/93: A%2>/'./9& = 295. /'. JC\D E'.

    BC H'9.= 2= -/$== F.&$7. ?9>9F40 $3:%0) $35 59%.&/.5 7. /2 %.?.%>. /'. 1.A 5.&9>923D T9?.3 6 $&&27A49>'.5 70 :2$4) $579//.540 $ F9/ F$&;'$35.540) 6595 32/ A%2&..5 89/' 70 A4$3 /2 %.72?. A%2>/'./9&> 2F49:$/923> =%27 JO1-) 32%%.72?. HL 8$%%$3/>D

    6 $7 93=2%793: 02< 2= /'9> >2 /'$/ 02< /$35 ]/ '28 428 A$>/ 4.$5.%>'9A '$>F..3 894493: /2 >/22AD 63 f" 0.$%> 2= T2?.%37.3/ >.%?9&.) 6 '$?. 3.?.% >..3$30/'93: &27A$%$F4. 89/' 1.A'$7.5 6S7 $7.7F.% 2= /'. BC >.392% 4.$5.%>'9A /.$7 8'2 93/.3/923$440 49.5 /2 $ H23:%.>>923$47.7F.%D

    E'. $44.:.5 8%23:5293:> &9/.5 93 /'. 4.//.% =%27 H23:%.>>7$3 W2'3>23 8.%. 93 =$&//%.) /'. 1.A$%/7.3/ 82 /'2>. &235

  • 8/21/2019 VA Whistleblower Report

    23/35

      *a

    Z"^^"_ &Z^"P?$\' Y&% [%&_$>\$")_ Q"$>&($ )$%?)$_e 63 $ 4.//.%5$/.5 -.A/.7F.% *c) *+"*) \.AD _944 W2'3>23) H'$9%7$3) PBCH -9:'/ [ 63?.>/9:$/923>) %.@/.5 $3>8.%> /2 @/923> %.:$%593: BC&23/%$&/93: A%$&/9&.> 89/' %.:$%5> /2 >97A49=9.5 $&@9/923 A%2&.5D

    BPC 8$> $>>9:3.5 /2 %.A40 /2 \.AD W2'3>23S> 93@/$%; &23/%$>/ /2 /'..K$7A4. 6 &9/.5 $F2?. =2% /'. A%.?92 >A..50 %.A40 /2 #%D W2'3>23) $ %.A40 8$> 32/A%2?95.5 93@/9:$/923 8$> .?.% &235 8.%. 7$5. $>

    %.@/$/; 9= B6-i a &2.H$%5> $> $ 7.$3> 2= A%2&. /'%.>'245D 6 &A%2A2>93:) $> 9/ 8$> 944.:$4D

    i2 A.%>23M>N 8.%. '.45 $&&2 93 /'.9% 93?.>/9:$/923 2= TOH

  • 8/21/2019 VA Whistleblower Report

    24/35

      *f

    8%23:5293:) 5.&4$%93: /'.7 Y295. /'. >&2A.Z 2= /'.9% 93?.>/9:$/923D E'.0 %.=.5$30 $44.:$/923> 2% .?95.3&. 295. /'. *+"*R*+"a /97.=%$7.) 8'9&' 6 &23>95.%F.D C/ /'. 4.$>/) /'.0 >'2.A$%$/.93?.>/9:$/923 93/2 /'. 7$//.%D

    E'9> %.?.4$/923 2= 8%23:5293: 93 B6-i a /%9::.%.5 7. /2 F.:93 $3 93=2%7$4 %.?9.8 2=A/'./9&>$%.3$D #0 >/$== >.@ 89/'2 8.%. >97A40 2%5.%93: A%25 =%27 ?.352%>) $35 A$093: =2% /'.>. A%2589/' A $AA.$%.5 /2 F. /$;93: A4$&. 23 $ 8'24.>$4. F$>9> $&%2>> BPC) $35 =$&/>>.@/$3/9$/.5 /'9> 8$> /'. &$>.D Q'.3 6 &23=%23/.5 BPCS>#%D 1204. %.:$%593: /'9> 7$//.% 23 >.?.%$4 2&&$>923>) '. %.=.5 /2 %.A40 /2 70.7$94 &2%%.>A235.3&.D

    J $35 4979/$/923> 2= /'.9% 8$%%$3/>D +#&$\* "5 -/. 8.03,< C.6,0.TNUUE =? >)?2 J.0. 1;-/,03c.< -, J10015- 8.02,55.9 ;8 -, -/. _3D89363.<

     ?7:;323-3,5 $/0.2/,9< aLUMNENNNbH (5)?2 /1< 3D80,8.09A J10015-.< /;5D 6 &23>95.%.5 '9> 32/923 F9^$%%.D C> /'. PHC) '. 9> 5.4.:$/.5%.>A23>9F949/0 $35 &23&279/$3/ $ 5.4.:$/923 %.@ '. .3>3S/ %.>A23>9F4. =2% $44 =$&./> 2= /'. BPC A%2&>923D

    63 /'9> 93>/$3&.) #%D P$::>/%27 $&/.5 5.&9>9?.40 $35 &2%%.&/40 93 '9> %24. $> /'. BCHCLD P. 59%.&/.5 /'. 944.:$4 $&/9?9/0 &.$>. 93 1.&.7F.% *+"*D -.@

  • 8/21/2019 VA Whistleblower Report

    25/35

      *,

    59%.&/9?. $35 93 4$/. 1.&.7F.% *+"*) 1.A/%27S> $AA%2A%9$/. $35 4$8=&93593: /'. HCLS> 59%.&/9?.) /'. BC 1.A. 9/923.5 $44 &23/%$&/93: $&/9?9/9.> /2 @.%9.> &23/%$&/93: 2==9&.%>D

    E'. 7$5. F0 BPC =2% Jb *+"a $35 /'. =9%>/ >9K 723/'> 2= Jb *+"f) 93: /'.:2?.%37.3/ A >A%.$5>'../ %.=4.&/> /'.%. 7$0 '$?.F..3 $> 7 A "dR723/' A.%925D 63 /'. A$>/ c+ 5$0>) 6 ?9>9/.5 $ 7$]2% BPC'2>A9/$4) 8'.%.93 /'.0 %.A2%/.5 /'.0 595 32/ 59>&23/93 F..3 .5 /2 &$72D H23/%$&/93: 2==9&.%>) $%7.5 89/' :2?.%37.3/ A>D I$&' 2= /'.>. 944.:$4 A%2& $35 >.@/9/ $3 97A%2A.% A$07.3/D i.9/'.% /'. BC L==9&. 2= #$3$:.7.3/) 32% 9/>>> L?.%>9:'/) A249&. /'.>. /%$3>$&/923> /2 .3> '$?. F..3 A'245D T9?.3 32 &23/%$&/> $%. .K.&

  • 8/21/2019 VA Whistleblower Report

    26/35

      *c

    J.5.%$4 O%2&/.7 $> %.@/$/ $%. &'.$/.5 2. = $%. F.93: 2F49:$/.5D - $%. &'.$/.5 2 [ &2359/923>D I$&' 2= /'.>. 9359?95$&/923>

    &23>/9/ $3 /%27 $35 /'. HJL $%. =/%23:40 &23>95.% %.>&93593: /'. HCL 5.4.:$/923 2= $>79>7$3$:.7.3/ 2= /'9> A%2:%$7D C> 2= /'9> 5$/.) '. '$> 32/ $&/.5 23 70%.&277.35$/923D

    E'.>. =4$:%$3/ ?924$/923> 2= 4$8 8944 >223 F. 7$5. A> $> /2 8'./'.%02< .4.&/ /2 52 $30/'93: &23&.%393: /'9> 93>/$3/ %.@/ =2% $>>9>/$3&. F0 7.D E'.

    T2?.%37.3/ C&&2. H$%5 O%2:%$7 23 #$%&' "d)*+",D C44 9>> 2 %.A2%/ /2 H23:%.>>93 /'. ?.%0 3.$% =D E9.%3.0 '$?. %.4$/.5 /'.>.A%2F4.7> /2 02.4= 2% #%D T9F>23D 63 70 2A93923) /'9> 9> $ &242>>$4 :2?.%3$3&.=$94 9> /'. .4.A'$3/ 93 /'. %227 /'$/ 2/'.%> A%./.35 32/ /2 >..D #2>/59>$AA293/93:40 /2 7.) -I- 7.7F.%> 93 /'. L==9&. 2= #$3$:.7.3/ $%. 32/ 894493: /2

    &23=%23/ /'.>. 9>> '.$5 23) $> /'.0 $%. 5.=939/.40 97A%2A.% A$07.3/>D E'9> 8$>/'. 9>>>923$/.40 $//.7A/.5 $35 =$94.5 /2 &23=%23/ /'. BC -.392% C>>.>>7.3/E.$7 89/' 93 4$/. *+"f) $> 9359&$/.5 23 A$:. =9?. 2= /'9> &2%%.>A235.3&.D

    "^^\P?^ (_\ &Y Y\'\%?^ _([[^h _)>\'(^\_ ?#' &$>\% Q?_$\ g ?Z(_\*63 #$0 *+"f) 6 4.$%3.5 BPC 9> :%2>>40 ?924$/93: /'. J.5.%$4 C&@9/923 \.:. 944.:$4 $&/923>) 8'9&' &23/93 93 $3 .==2%/ /2%9:'/ /'.>. ?924$/923>) 70 >2%) #%D P$::>/%27) $35 /'. BPC H'9.=

    O%2& %.@>/'. BPC '.$4/'R&$%. .3/.%A%9>.D # %.&.9?. $35 A%2&.>>9359?95) 8'94. 5.49?.%93: A%25 23 $ 5$940 F$>9> $&%2>> /'. BPC'.$4/'R&$%. >0>/.7D E'9> 7./'25242:0 9> &2772340 %.=.%%.5 /2 $> $ ]/R93R/97.MW6EN >0>/.7D E'. >0>/.7 9> 5.>9:3.5 /2 .3$F4. 7.59&$4 =$&949/9.> /2 2%5.% A%25

  • 8/21/2019 VA Whistleblower Report

    27/35

      *h

    23. 5$0) $35 :.3.%$440 %.&.9?. /'.7 /'. =2442893: 5$0D E'9> W6E >0>/.7 .49793$/.>/'. 3..5 =2% 8$%.'2.> $35 .KA.3>9?. 93?.3/2%9.> 2= A%25 $&%2>> /'. (++mBPC 7.59&$4 =$&949/9.>D

    #-OB &23/%$&/2%> 5.49?.% A%25 ='.5 =%27

    $8$%5.5 F0 BC &23/%$&/93: A.%>233.4D E'.>. &23/%$&/> 93&4. C:%..7.3/>) _$>9&L%5.%93: C:%..7.3/> 89/' CF949/0 L3. 323A%2=9/ $:.3&9.>) $35 42&$4 2% %.:923$4BPCR$8$%5.5 &23/%$&/>D I>>.3/9$440) A%97. ?.352%> $%. 32/'93: 72%. 2% 4.>> /'$3=9%7> 8. '9%. /2 59>/%9F'2AA93: 49>/Z 2= 9/.7>/'$/ $%. 23 J-- &23/%$&/>D E'. iCH A%97. ?.352% &23/%$&/93: 2==9&.% >/$/.5 &9>/.3/ 89/' A%2:%$7 93/.3/ $/ /'. /97. 2= &23/%$&/$8$%5) $35 $%. 32/ &27A49$3/ 89/' #-OB &23/%$&/> 2% 2%5.%93: 2==9&.% 93>/%DE'. Y>'2AA93: 49>/Z %.=.%%.5 /2 $F2?. 9> .>/97$/.5 /2 &23/$93 3.$%40 f++)+++ 9/.7>)

    $35 9> 2=/.3 F.93: .5 9359>&%9793$/.40 $35 32/ 93 $&&2%5$3&. 89/' /'. JC\D E'9> 9>F4$/$3/40 944.:$4D+#&$\* Y?% eHj 0.:;30.2 Y__ ,0 /'. iCHS> 4$%:.>/ &/27.%) $AA%2K97$/.40 f+n 2= /'. `"d_ 93 $33$4.>2= 7.59&$4 A%25 $35 >.%?9&.> $%. $//%9F 1.A$%/7.3/ 2= 1.=.3>. $35 P.$4/' $35 PD

  • 8/21/2019 VA Whistleblower Report

    28/35

      *d

    -93&. *++*) 9/ '$> F..3 2==9&9$4 BC A249&0 /2 $8$%5 >93:4. 2% 7 /2/'. 7$K97/ J-- &23/%$&/> $8$%5.5 F0 /'. BC iCHD _OC>A%2?95. $ >97A49=9.5 8$0 2= =94493: %.A./9/9?. 3..5>D _0 .>/$F49>'93: _OC> $:$93>/ J--&23/%$&/>) BPC >$?.> ?$>/ $72 2= $57939>/%$/9?. /97.) .49793$/.> /'2$35> 2=

    5$&/923> $&%2>> /'. BPC) $35 /$;. $5?$3/$:. 2= @&2D L/'.% :2?.%37.3/ $:.3&9.> 93: 2 F.3.=9/ 93 /'9>7$33.% $> 8.44D C8$%5 2= _OC> $/ /'. 3$/923$4 4.?.4 $%. $F>24>.3/9$4 932%5.% =2% BPC /2 =944 %.A./9/9?. 3..5> =2% 7.59&$4G>D

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

  • 8/21/2019 VA Whistleblower Report

    29/35

      *(

    O1514.D.5- a[ZOb &6637. -, D1514. =>? 8/10D17.;-37192H "5 DA ,8353,5E-/. LMZ [ZO 80,401D 32 104;1C9A ,5. ,6 -/. C.2-BD1514.< 80,401D2 35 -/.Y. .3?9>923.5 /'.>. &277259/0 7$3$:.7.3/ /.$7> 829?.40 7$3$:.

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

    /'. & .KA9%.) 6 8$> %.&.3/40 =2%&.5 93 70 %24. $> /'. -OI) /2$ >/$35$.;9 $35 /'. -/$35F >24. A. 8$> /2 $8$%5 $35 $57939>/.%&23/%$&/> 93 > 7.59&$4G>>923D E'. -CH 8$> 5.>9:3.5 /2 F.>/225 A.&9$49>/> 939/9$440) $4428/'.7 /2 $/ 7$33.%) 89/' $3 .35R>/$/. 2=$AA%2K97$/.40 "c+ &23/%$&/93: A%2=.>>923$4>D

  • 8/21/2019 VA Whistleblower Report

    30/35

      a+

    E'. >/$35R 32/ $&&27A49>'.5 $&&2%593: /2 A4$3D #%D P$::>/%27 $4428.5 #>DH22A.% $35 #>D _28.% /2 '9%. $/ 8944) 89/'2'2233.4 8.%. 23 F2$%5D

    E'. %.> $AA$4493:D E'. & %.&.3/40 93=2%7.5 70 2==9&. /'.0 '$?. 32/'93: /2 52D C T-R",>$95 '. 8$> 422;93: =2% $ 3.8 ]2F) $> '. 9> /9%.5 2= '$?93: 32 82%;D C T-R"a 8$> 3.$%/.$%> 93 70 2==9&.) $> >'. /245 7. >'. /.4.82%;.5 /'%.. 5$0> $ 8..;) $35 8$/&'.5/.4.?9>923 Y$44 5$0 423:Z F.&$. >'. '$> 32/'93: /2 52D 6 595 32/ >249&9/ /'.93=2%7$/923 >'. A%2?95.5D -'. 8$> :.3'$7.5 2= '.% A%.59&$7.3/ $35&23&.%3.5 $F2&$35$4 %.&.3/40 F%2 .KA2>. %.:$%593: /.4.82%; =%$ 79:'/ &27A$%.D

    Q'94. 6 52 32/ F.49.?. /'.%. 9> =%$

    /.4.82%; A%2:%$7) /'.%. $%. 7944923> 2= 5244$%> &23>/.D 6/ 9> /2/$440 %.&.9?.5 ?9%/ >.392%.K.& 9%%.>A23>9F40 '9%.5 &23/%$&/93: A%2=.>>923$4> $/ $3 .?.% 93&%.$>93: A$&.93 >A9/. 2= 49//4. 82%;) 8. 328 '$?. >.?.%. F'2%/=$44>D E'. -CH) 8'9&' 9>>.5 /2 2A.%$/. $> $ A%2=9/ &.3/.% 93 /'. - 9> 93 $559/923 /2 $AA%2K97$/.40 `**# /'9> >$7. 2==9&. 8$>/.5 23 $ 5/.7 5. :%2>> 93>/$3&.> 2= 8$>/.) =%$ $%. &$93: 7. /2 &$3&.4 2% & 2= 5244$%>

    82%/' 2= /%$9393: =2% 2. A%2=.>>923$4> $%. /'. ?.%0 .7A420..> 8'2 5.>A.%$/.40 %.@&'22493: 93 $3.==2%/ /2 97A%2?. 2 $3 $559/923$4 >.%92 &23>.@ 93$F949/0 /2 5.=93./'.9% 7.59&$4G>D Q. $%. 32/ 4.?.%$:93: 2A.35D BPC 9> /'. 4$%:.>/ 93/.:%$/.5 '.$4/'R&$%. >0>/.7 93 /'. &2

  • 8/21/2019 VA Whistleblower Report

    31/35

      a"

    0.$%> $:2) $/ /'. 59%.&/923 2= -.&%./$%0 -'93>.;9) BPC $35 LCXH &23>9?.40 89/' /'. =9?. 4$%:.>/ 7.59&$4 T%2.TOL> &$/.:2%9&$440 &2%.5 /'$/ BPC &2 72 A.> =2% .?.%R93&%.$>93: @ A.;9 =9?. 0.$%> $:2) $35 $> $&23>.@/.5 F944923> 2= 5244$%> ?9$ 42>/ 2AA2%/ =2% >$?93:>D

    ))^(_" ?#' %\)&OO\#'?$"_*b2< '$?. .7A'$>9^.5 >93&. 02/%9?. /2 52 /'. '$%5 %9:'/ ?>D/'. .$>0 8%23:D b2< $579%$F40 7$93/$93 8. 7/ .3> 2= /%$9393: 9> 9^93: =

    :2?.%37.3/ .7A420..>D E'. =2442893: A%93&9A4.> $%. 93&4/$35$%5DaD  BC 7$3$:.%> $35 >2%> 7/e

    •  CF95. F0 $35 .3=2%&. $44 4$8>g

    •  i.?.% &2779/ O%2'9F9/.5 O.%>233.4 O%$&/9&.>g

    •  i.?.% %./$49$/. $:$93>/ .7A420..> 8'2 F428 /'. 8'9>/4.g•  E$;. 8'9>/4.F428.% 59>&42> >.%9240) $35 8'.3 $AA%2A%9$/.)

    93?.>/9:$/.g

    •  O%272/. $3 $/72>A'.%. /'$/ $4428> .7A420..> /2 >$=.40 %.A2%/

    8%23:5293:> 2% ?924$/923> 2= 4$8) % %.=4.&/ 23 BCD

    Q'94. /'.>. A%93&9A4.> $%. 32/ 3.8) /'. /%$9393: 02. $35 &27A%.'.3>9F4. 8$0D H4.$%40 6S?. A%2?95.5 7$30 .K$7A4.> $F2?..KA2>93: .&%$/923 2= /'.>. A%93&9A4.>) F2/' &/D 6F.49.?. .35.79&) .?.3 $/ /'. '9:'.>/ 4.?.4> 2=BCD o/23 H'/ c+ 5$0> 6 8$> A%9?94.:.5 /2 ?9>9/ /'%.. 7$]2% BC '2>A9/$4>) $/ /'.59%.&/923 2= 1.A23D 6 /22; 89/' 7. >.?.%$4 -.392% IK.& =%2770 >/$==) $35 8$> ]293.5 F0 >.?.%$4 >.392% 7.7F.%> 2= /'. BPC >/$==D LA.&9=9&79>>923 8$> /2 2F>.%?. /'. BPC >

  • 8/21/2019 VA Whistleblower Report

    32/35

      a*

    Q'$/ 6 2F>.%?.5 93 $44 /'%.. '2>A9/$4> 8.%. ?.%0 5.59&$/.5) 8.44R7.$393: BC.7A420..>) 5293: .?.%0/'93: /'.0 &$3 /2 >.%?. C7.%9&$S> ?./.%$3> /2 /'. F.>/ 2=/'.9% $F949/0D P28.?.%) 9>> 8.%. %.A2%/.5 /2 .K.7A49=093: 97A%2A.% 2%7$%:93$49^.5 93/.%3$4 &23/%24>) $> %.=.%%.5 /'%2 &2%%.>A235.3&.D C44

    A293/ /2 5%$7$/9&$440 93.==.&/9?. :2?.%3$3&. $/ $ F$>9& 4.?.4) $> 8.44 $> A2/.3/9$440&2%% '2>A9/$4 >/$0 '$5

    F..3 .K/.35.5 F0 ( 723/'>) 5/'./9&> &'9.= 93=2%7.5 /'.0 '$5 %.&.3/40%.5/2.?.3R0.$% F$&;42: 2= ",)+++ A%2>/'./9& 9/.7>/2 $ 72%. 7$3$:.$F4. F/944 .32%72 c+++R9/.7 F$&;42:D 63$559/923) A%2>/'./9&> >/$== 93=2%7.5 /'. A%.?92 59%.&/2% '$5 F..393: 79>&.44$3.2 2F49:$/923> /2 A$0 =2% ?./.%93$%9$3 &$%. =2%

    ?./.%$3>S A./ 52:>D Q. &23=9%7.5 /'.>. 8.%. 32/ $F $%%$3:.7.3/7$0 :./ >/$35$%5) A2/.3/9$440 5$3:.%2 /%.$/7.3/) $> /'.%. $%. 328%9//.3 /.%7> [ &2359/923> /2 .3=2%&. $ 79397/$35$%5 2= &$%.DE'9> $4>2 =2>/.%> A9/$4 >/$==

    93=2%7.5 /'.0 $%. A$093: =2% 423:R/.%7 &$%. 93: 79>&.44$3.22F49:$/923>D O$093: =2% >.%?9&.> 89/'2 &4.$%40 $3. $%. $4>2.K$7A4.> 2= /'./9&> >A.&9$49>/ %.A2%/.5 $ %./9%.5 BC =.7$4. .7A420..)A%.?9240 .7A420.5 F0 /'$/ '2>A9/$4) 8$> A%2?95.5 $ A%2>/'./9& 497FDE'. >A.&9$49>/ &4$97.5 /'. 9359?95 32/ $ ?./.%$3 $35 2F?924032/ .49:9F4. =2% &$%. F0 /'. BCD E'9> $AA.$%> /2 F. 79>$AA%2A%9$/923 2=:2?.%37.3/ = $35 A.%'$A> ?924$/923 2= $559/923$4 &%9793$4 >/$/D

    Q. 595 32/ >249&9/ /'9> 93=2%7$/923D Q. 595 32/ 93?.>/9:$/. $30 2= /'.>. $44.:$/923>DE'$/ 8$> 32/ 2.%?. $35 :$/'.% '9:'R4.?.4 =$&/>>'2 9> /'. Y/9A 2= $ ?.%0 >9^$F4.9&.F.%:DZ

    L

  • 8/21/2019 VA Whistleblower Report

    33/35

      aa

    .?.% 2 32/ /'. Y?./.%$3 .KA.%9.3&.Z A.% >.D 6 F.49.?.>/$35$%5 ?./.%$3 .KA.%9.3&.> $%. >07A/27> 2= :%.$/.% 944D 6 &23&4.3/9$4 Y?./.%$3 .KA.%9.3&.Z 8944 3.?.% F.$&'9.?$F4. 23 $ &/27$%0 F$>9> =2% /'. ?./.%$3> 8. >.%?.D

    63 70 2A93923 8. 7/ F.:93 977.59$/.40 /2 &27A40 89/' J.5.%$4 4$8> $35 '245/'2>. $&&2A235.3&.D Q.7/ 7$;. .?.%0 .==2%/ /2 %9:'/ 8'$/ '$> F..3 8%23:.5) 8'94. =&42>93: 2.> /2 /'. C7.%9&$3 A>) $35 72>/ 97A2%/$3/40) /2 /'.?./.%$3> 8. >.%?.D Q. $%. 8$>/93: ' 2= 7944923> 2= 5244$%> /'%227. $/>.392% 4.$5.%>'9A 4.?.4>D 6 3..53S/ /.44 02< .?.%0 5244$% 8. 8$>/. 9> $ 5244$% 32/>A.3/ 93 /'. >D

    6 %.&277.35 02< 977.59$/.40 93?9/. .KA.%/> 93 :2?.%37.3/ &23/%$&/93: $35 =9>&$4

    4$8 /2 7../ 89/' 70 >/$== $35 70>.4= =2% /'. A. 2= .K$79393: 70 $44.:$/923>DE'%.. 977.59$/.40 &27. /2 70 7935D E'.>. 93&4 A%.?9240/'. C>>2&9$/. C57939>/%$/2% =2% O%2&4$/923 $/ /'. L==9&. 2=J.5.%$4 O%2&.%?.5 $> /'. C57939>/%$/2% =2% J.5.%$4 O%2&

  • 8/21/2019 VA Whistleblower Report

    34/35

      af

    )^&_"#P %\O?%]_ ?#' &Z_\%=?$"_ O&="#P Y&%Q?%'*6 $7 :293: /2 F. 59%.&/ 93 70 =93$4 %.7$%;>) $> 6 9/ 82/. 2= 70 /97. $3502 9= 6 8.%. &9%&A.&/D 6 '2A. 02< 8944 $&&.A/ 70 2F>.%?$/923> $35A%2=.>>923$4 2A93923> 93 /'. >93&.%. $35 %.>A.&/=.> .K/.3579?. /'$3 6 '$?. 5.A9&/.5 '.%.D

    6 $7 2F?9240 32/ $3 .KA.%/ 93 2/'.% =2 ?9/$4 /2 /'. >> 2= $30:293: &23&.%3) >. =2>.>'$?. 7$]2% 9>> $> 8.44D -27.) >/ /2/$44050>=) 2% ) 2= /'.9359>A.3>9F4. =2. =22/93:> 7/ %.$&' $44 /'. 8$0 /2 F.5%2&; /2 .3>/%/ 2= 97A2%/$3/ 2= $44) 9> 323R.K9>/.3/ 93 >27. &$>.> $/ /'. '9:'.>/ 4.?.4>) $> 6S?.5.A9&/.5 $F2?.D C> $ 02..3 89/' 70 283 .0.>) /'$/ 89/'2/%23: =22/93:> =2% /'.=2/ .;9S>

    4.$5.%>'9A) $%. >A9%$/923$4 95.$4>) $35 :9?.3 A%2A.% 4.$5.%>'9A) 8944&23>/9/2 93 70 2A93923) /'.>2495 =2) %9>; 79/9:$/923).==.&/9?. A%2:%$7 7$3$:.7.3/) 97A%2?.5 .4.&/%239& /224> $35 7$30 2/'.% F$>9&A%2&.>>.> $&%2>> $44 BC => $%.$>D

    6 F.49.?. 02'$%.5 2% >.%?9&.> $&%2>> /'..3/.%A%9>. 9> >2'2%/ %/$44/'. 6HC\I =22/93:> =9%>/) $35 F/93: 2= /'2>. F$>9&R:2?.%3$3&. .4.7.3/> 6S?. 49>/.5 93 /'. A$%$:%$A' $F2?.D 63 70 2A93923) > 8.

    =9K /'. &2%. 2= /'. A%2F4.7) $35 =2%&. $AA%2A%9$/. :2?.%3$3&. $&%2>> /'. .3/.%A%9>.)8. $%. 5227.5 /2 =$94 %29& .4.7.3/> 2= 2>) 02. /'93:> 6S?. &$/$42:.5 $F2?. $35 72%.) F.=2%. %.2%:$39^93:D Q. ;328 02

  • 8/21/2019 VA Whistleblower Report

    35/35

    8$3/ 2 /2 F. A%2?95.5 /'. F.>/ 2= >.%?9&.> 23 $ %.A.$/$F4. F$>9>D E'2>.2= 8'2 .7F%$&. 02'9A 8$3/ 9/ $> 8.44g '28.?.%) 8. $4>2 8$3/ >/$93.597A%2?.7.3/ 423: $=/.% 029F40 .%.&/ $ >/%.%?. /'.7D

    \.2%:$39^$/923 89/'2/$F49>'7.3/ 2= A%2A.% :2?.%3$3&. =9%>/) >..7> $;93 /272?93: /'. = $ %.>; =2%789/'2 72%. 82%; /2 F. 523. 93 =9%740.>/$F49>'93: /'. 6HC\I A%93&9A4.>D 6 F.49.?. 02< 7/ F. %/$44$/923

    2= 6HC\I A%93&9A4.>D 6 ;328 Y%/%23: '$35) 9/> 97A4.7.3/$/923 8944 F. &2%0$/ F.>/D E'9> 9> $ BC ?.%0 $5.A/ $/ Y8$9/93: 2. 8'2523S/ /$35 /'$/ 93/.:%9/0 9> A$%$72'2 %'./2%9&$4 F9& @/923D Q9/'2/%$/923 2=97A%2?.5) %.>A23>9F4. >/.8$%5>'9A) 8'0 82. 7$//.%>D

    p-pW$3 \D J%0.1.A>9>/$3/ -.&%./$%0 =2%

    C&@9/923 [ X2:9>/9&>1.A$%/7.3/ 2= B./.%$3> C==$9%>