A top state official whose department was under investigation had contact with the Virginia Inspector General’s office while it was looking into the Creigh Deeds’ tragedy, according to an article published yesterday in The Daily Progress in Charlottesville.

Virginia Secretary of Health and Human Resources Bill Hazel acknowledged that he called state Inspector General Michael F.A. Morehart to discuss the case while Morehart’s office was conducting its probe. Both men said there was nothing improper about their conversations.

Inspector Generals are independent fact finders and are not supposed to be influenced by state officials, especially when they are conducting probes of their departments.

G. Douglas Bevelacqua, the IG investigator who was conducting the investigation, revealed the two men’s behind-the -scenes conversations. He said  Hazel referred to him as a  “loose cannon” in a call to his boss.

When reporter K. Burnell Evans questioned both officials, this is what they said:

Morehart said he “could not recall” using that phrase (loose cannon), and vaguely remembered the phone call. “I don’t write these things down,” he said.

Asked about the conversation, Hazel responded: Bevelacqua “and I have a different approach to the way we deal with things.”

Bevelacqua resigned earlier this month rather than signing off on the IG report that he claimed Morehart had heavily edited. The report, which was released Thursday, did not find any top managers in the Department of Behavioral Health and Developmental Services at fault even though Bevelacqua had warned them two years before the Deeds tragedy that Virginia hospitals were turning away psychotic patients because of a lack of available beds.

Had the state acted on that warning, Bevelacqua claims the Deeds tragedy could have been prevented.

After criticizing state mental health officials yesterday in my blog, I learned that the top manager, who would have been responsible for implementing the changes that Bevelacqua had recommended, had been promoted to a more senior position within the department.

So here’s the bottom line.

Bevelacqua warned the state that patients were being “streeted” twenty months before the Deeds tragedy. The manager who could have implemented Bevelacqua’s recommendations didn’t implement them. Had they been implemented, Bevelacqua claims the Deeds tragedy would have been avoided. After the Deeds tragedy happened, Bevelacqua claims the department issued a self-serving report that made it sound as if it had acted on Bevelacqua’s findings. When Bevelacqua began investigating the Deeds incident, Secretary Hazel called his boss to discuss the probe. Bevelacqua resigned because he claims his boss watered down his findings. The final report was released Thursday. No top managers were blamed. The manager who didn’t implement Bevelacqua’s recommendations got a promotion.

Deeds will appear Monday at the National Press Club in Washington. But the official who I would like to hear from the most is the governor.

What the heck is going on in your administration?

Lack of accountability faulted in Deeds tragedy

Posted: Friday, March 28, 2014 10:53 pm

The Daily Progress

By K. Burnell Evans

The death of Austin C. “Gus” Deeds was preventable, the official who resigned over a review of the case said Friday.

The state’s mental health agency failed to implement system changes for almost two years that could have resulted in a different outcome in the tragedy, issued an update afterward that concealed its lack of progress and then refused to hold top officials accountable, said G. Douglas Bevelacqua.

And as he worked on a review that would have specified these findings, a state cabinet secretary called his supervisor, Virginia’s inspector general, describing Bevelacqua as “a loose cannon,” he said. Both Bevelacqua and a lawmaker who sponsored the legislation forming the Office of Inspector General described the contact as “inappropriate.”

“I think the inspector general’s job is to speak truth to power on behalf of the citizens of the commonwealth,” Bevelacqua said, “and I don’t think that happened here.”

The comments, released Friday by Bevelacqua in response to the release of a final report in the Deeds case, assail the review’s omissions while acknowledging the findings to be accurate. Deeds stabbed his father, state Sen. R. Creigh Deeds, D-Bath, Nov. 19 before shooting himself at the family’s home in Millboro, 13 hours after efforts to secure him court-ordered mental health care failed. The senator survived.

“We’re not trying to whitewash anything and we’re not trying to hide anything,” state Inspector General Michael Morehart said. “Reasonable people can come to different conclusions about things like this.”

Bevelacqua cited revisions to his work in the Deeds case among the reasons for his resigning a month ago from his post as director of the state inspector general’s Behavioral Health and Human Services Division. Morehart issued the 53-page result of that four-month review Thursday.

An absence of protocols, communications breakdowns resulting in costly delays, barriers to finding care and missteps by the senior clinician tasked with tracking down an available psychiatric bed for Gus Deeds all factored into the outcome, according to the report.

Among the findings were revelations that the clinician called just seven hospitals instead of the 10 he’d claimed to contact in an effort to find a bed before an emergency custody order expired. Had a bed been found, Deeds could have been hospitalized to undergo further evaluation. Instead, he was released.

The report also included information from a three-month study Bevelacqua authored in 2012 that identified 72 cases in which people like Gus Deeds fell through the cracks in similar circumstances.

Had the Department of Behavioral Health responded by Nov. 18 to the recommendations of the 2012 report, Bevelacqua said, “the outcome would have been different, and Gus Deeds would have been admitted to a psychiatric facility for evaluation instead of being released at the expiration of an emergency custody order.”

The Deeds report noted a failure to fully implement the recommendations, some of which were included in a Jan. 15 guidance document issued by the department, Bevelacqua said. A Dec. 4 release concealed the department’s failure to implement the recommendations, he said.

“Those responsible for issuing this disingenuous document, and for failing to act in the 20 months prior to Nov. 19, 2013, have yet to be held accountable,” he said.

A Behavioral Health Department spokeswoman did not respond to a request for comment Friday,

Secretary of Health and Human Resources Bill Hazel said he had taken steps to strengthen the department’s central office, shifting some positions and looking “outside the system” for a new commissioner to replace James W. Stewart III, who retired in January.

The appointment of Debra Ferguson, former senior deputy and chief of clinical operations for the Illinois Department of Human Services’ Division of Mental Health, was announced March 21.

“You may or may not call that accountability, but actions were taken to strengthen the program,” Hazel said.

Both Hazel and Morehart on Friday acknowledged speaking in the weeks and months following Deeds’ death, but said there was nothing wrong with the communication.

“I’m a very simple fellow and I know right is right and I know wrong is wrong,” Morehart said. “I’m not going to tarnish my reputation for anyone.”

Bevelacqua said he was directed to keep Morehart apprised of the investigation following a phone call from Hazel to Morehart the week after Gus Deeds died. Bevelacqua said he was sitting in Morehart’s office when the call came in. Afterward, Bevelacqua said, the inspector general advised him that Hazel was worried that Bevelacqua might be a “loose cannon.”

Morehart said he “could not recall” using that phrase, and vaguely remembered the phone call. “I don’t write these things down,” he said.

Asked about the conversation, Hazel responded: Bevelacqua “and I have a different approach to the way we deal with things.”

The two have butted heads in the past, Bevelacqua said.

“He doesn’t think I’m a team player,” Bevelacqua said, “but I don’t think the inspector general’s office is supposed to be part of the team.”

That made Hazel’s contact with Morehart questionable, Bevelacqua said.

“I think it was highly inappropriate for [Hazel] to contact the inspector general and discuss the person supposedly investigating a high-profile case involving agencies in his portfolio,” Bevelacqua said.

Del. R. Steven Landes, R-Weyers Cave, agreed.

“I would say that would be inappropriate,” said Landes, who proposed a bill this session that would put the power to appoint the inspector general in the hands of the legislature, rather than the governor. Gubernatorial appointments are confirmed by the General Assembly.

Landes said communication between the inspector general and any official presiding over a group under review should have a paper trail.

“When you have phone calls going back and forth, unless there’s someone else in the room, you don’t have a way of knowing what the discussion has been,” he said. “You don’t want the appearance that there was ever any effort to influence an investigation.”

Hazel said there was no such attempt. Morehart described the contact as brief, informational and professional.

“It’s not unusual for an agency head to contact me about a concern,” he said. “I have an open-door policy.”

The state inspector general reports to the governor’s chief of staff, leaving both cabinet secretaries such as Hazel and the state’s top watchdog ultimately under the governor’s watch.

Landes said he voiced concern about that structure when he introduced legislation that helped create the office in 2011.

“I was never real comfortable with that,” Landes said, “but we had to compromise.”

The state inspector general should not report to the governor’s chief of staff, Landes said.

“That way, they would be totally independent,” Landes said, “and I think the office needs to be more independent.”

Landes’ latest bill passed the House, 69-31, but stalled after crossing over to the Senate. Sen. Deeds voted for the bill in committee.

Bevelacqua on Friday called for the Department of Behavioral Health to be removed from the state inspector general’s portfolio of responsibilities, which include internal audits, waste, fraud, abuse and criminal justice.

“In my view, the intentionally concrete language and approach of accountancy and criminal justice are inadequate to address the [office’s] inherently subjective behavioral health mandate,” Bevelacqua stated.

He asked the lawmakers conducting a four-year study proposed by Sen. Deeds to consider creating a separate oversight agency for the Behavioral Health Department.

Bevelacqua also suggested weighing a structural overhaul of the department.

“The [department’s] failure to act on administrative recommendations … until after the Bath County tragedy calls into question if the [department] has outlived its institutional capacity for effective action in the interest of citizens with mental illness,” he stated.

Hazel said the department suffered from a lack of resources following the recession that hampered its ability to respond.

“I’m not attempting to make excuses, it’s an explanation,” he said. “It’s not a matter of pointing fingers. It’s a matter of asking what we can do to fix the system moving forward.”