Investigative Reports

The OIG’s administrative investigation examined the circumstances surrounding the death of a veteran on the Edith Nourse Rogers Memorial Veterans Hospital campus in Bedford, Massachusetts (the medical center). Mr. Timothy White was a resident of the Bedford Veterans Quarters (BVQ), an independent living facility operated by Caritas Communities, Inc. (Caritas), in space leased to it through VA’s enhanced-use lease program. A month after Mr. White was reported missing, his body was found in the emergency exit stairwell of the building that houses the BVQ. This stairwell down the hall from his room was VA property and not leased to Caritas.The VA police department’s failure to locate Mr. White resulted in part from the police and others at VA not considering the veteran an at-risk missing patient, which would have required a stairwell search. The Veterans Health Administration and the Office of Security and Law Enforcement lacked clear guidance regarding the obligations of VA police to search for nonpatients reported missing on VA property.VA police also did not discover Mr. White in the stairwell because of an improper order by the then police chief to cease patrols of the building in which Mr. White was found. The OIG found that the VA police chief exceeded his authority as both VA policy and the lease required VA police to patrol VA property.Lastly, because medical center staff mistakenly believed the emergency exit stairwells were not VA space, they did not clean them. The confusion among medical center leaders and staff regarding the lease scope and VA’s obligations stemmed from a lack of clear guidance from the Office of Asset and Enterprise Management. Routine police patrols and stairwell cleanings likely would have led to Mr. White being found earlier.VA concurred with the OIG’s seven recommendations to improve policies and procedures.

We did not find any evidence of wrongdoing regarding a contract award.

Joseph Kieffer, a marketer from Los Angeles, was sentenced on September 8, 2021, in U.S. District Court, Central District of California, to six months in prison, three years’ probation, a $10,000 fine, and he was ordered to pay restitution in the amount of $1,250,000 and a money judgment of forfeiture of $328,835. Kieffer previously pleaded guilty to paying kickbacks to marketers and some patients to obtain medically unnecessary compounded drugs, which allowed Fusion RX Compounding Pharmacy to bill health care providers for those drugs. Many of the prescription claims were reimbursed at rates much higher than average medications. The owner of Fusion Rx Compounding Pharmacy was also charged for his role in the scheme. Amtrak’s health insurance plan was fraudulently billed $17,000 as a result. Criminal judicial proceedings for other defendants are pending.

An Amtrak passenger conductor based in Florence, South Carolina, was terminated from employment on September 2, 2021, following his administrative hearing. Our investigation found that the former employee violated company policy by engaging in outside employment while on a medical leave of absence from the company and by being dishonest on his pre-employment physical exam form when responding to questions regarding previous injuries and hospitalizations.

Kevin Nelson, a resident of New York, pleaded guilty in U.S. District Court, Eastern District of New York, on August 30, 2021, to Aggravated Identity Theft for his involvement in an Amtrak eVoucher scheme. Nelson and his co-conspirators used stolen credit card and personal information to make unauthorized purchases of Amtrak tickets and then cancelled or exchanged those tickets for eVouchers. Subsequently, they sold the fraudulently obtained eVouchers on the internet. The approximate loss to Amtrak from the scheme is $450,000. Nelson’s sentencing is pending.

An Amtrak senior manager based in Beech Grove, Indiana, was terminated from employment on August 30, 2021. Our investigation found that the former employee violated company policy by failing to formally document, investigate, and report a workplace violence incident involving an employee and by encouraging another employee to change his statement regarding the incident. Another manager at the Beech Grove facility received a letter of written warning for failure to ensure the incident was properly investigated.

We did not substantiate the allegation that the WV Department of Environmental Protection showed preferential treatment to the West Virginia Governor.

Mark Hernandez, a psychiatrist based in Miami, Florida, Brian Dublynn, Vice President of Safe Haven Recovery Inc, and medical marketer, Jennifer Sanford, pleaded guilty in United States District Court for the Southern District of Florida on August 17, 2021, to conspiracy charges related to a health care fraud investigation. The defendants conspired to defraud private health companies by causing Safe Haven, a substance abuse treatment facility in Miami, along with several clinical laboratories, to submit false and fraudulent claims to health insurance plans for addiction treatment services that were not provided as billed and laboratory tests that were not medically necessary. As a result of the scheme, Amtrak’s insurance providers were fraudulently charged approximately $86,130. The three defendants will be sentenced at a future date.

The OIG investigated allegations that a Bureau of Reclamation (BOR) employee misused a U.S. Government purchase card. Specifically, the complaint alleged that the employee deliberately overbought supplies for a BOR office and gave the excess items to a family member for personal use or sale.We did not substantiate the allegations. We concluded that all the purchases were properly authorized and were consistent with supply requirements at the facility. We also concluded the employee did not improperly dispose of any office supplies.This is a summary of an investigative report we issued to the BOR Commissioner.

We investigated a complaint of whistleblower reprisal by a former employee of a non-profit organization affiliated with the BIA.

An Amtrak trackman/flagman based in Chicago, Illinois, resigned from employment on August 5, 2021, prior to his administrative hearing. Our investigation found that the former employee violated company policies by driving and operating company-owned vehicles without a valid driver’s license on a routine basis. We further determined that he was arrested and convicted on two occasions for operating a vehicle while intoxicated and did not report the incidents to the company as policy required.