VA Caregiver Support – Issues Part 2 (Review of VHA Directive 1152)

In this post, part 2, I’ll discuss the VHA Directive 1152 June 14, 2017 to show the violations, alterations and omissions of the law, statue and regulation. It also violates other laws. I will only discuss some of these issues. You can use part 2 to validate statements I made in part 1. In a future post, part 3, I will discuss my redacted medical records to help you validated the other statements in post 1. Again, some slight variations in processes from one VAMC or VISN to another.

Note: The VA CS, VISN CSC, Social Worker Supervisor and CSC have stated the CSC needs access to the Veteran’s medical record and psychotherapy notes to review every 90 days to ensure continued eligibility is meet. I cannot find this requirement in the law, statue, regulation or directive. The CSC would not need access to a Veterans medical record or psychotherapy notes if the Veterans primary care team was performing their clinical responsibilities. 

Also, VA CS is instructing CSCs to access Veterans psychotherapy notes without obtaining a written authorization which is unlawful. HIPAA/Privacy and VA Privacy Policy require the Veteran to provide a written authorization for access to their psychotherapy notes. The CSC does not need access to your psychotherapy notes per HIPAA/Privacy. 

Excerpt from Health and Human Services (HHS). Psychotherapy notes are treated differently from other mental health information both because they contain particularly sensitive information and because they are the personal notes of the therapist that typically are not required or useful for treatment, payment, or health care operations purposes, other than by the mental health professional who created the notes. Therefore, with few exceptions, the Privacy Rule requires a covered entity to obtain a patient’s authorization prior to a disclosure of psychotherapy notes for any reason, including a disclosure for treatment purposes to a health care provider other than the originator of the notes. See 45 CFR 164.508(a)(2). A notable exception exists for disclosures required by other law, such as for mandatory reporting of abuse, and mandatory “duty to warn” situations regarding threats of serious and imminent harm made by the patient (State laws vary as to whether such a warning is mandatory or permissible).

Excerpts from VHA Directive 1152:

1.REASON FOR ISSUE: This Veterans Health Administration (VHA) directive establishes policy for the Caregiver Support Program.

4.RESPONSIBLE OFFICE: The Office of Care Management Social Work Services, Caregiver Support Program, is responsible for the contents of this VHA directive. Questions may be referred to the Director, Caregiver Support Program at 202-461-6780.

Note: Supports my comment in part 1 of the Social Worker Department (SWD) is solely responsible for the clinical and support responsibilities of both caregiver support programs. Why isn’t the VA Medical Department responsible for the clinical responsibilities for both caregiver support programs since social workers are not qualified or authorized to make medical determinations of a licensed medical doctor? 

AUTHORITY: Title 38 United States Code (U.S.C.) 1720G; Title 38 Code of Federal Regulations (CFR) Part 71.

2. BACKGROUND

a. Public Law 111-163, the Caregivers and Veterans Omnibus Health Services Act of 2010, established 38 U.S.C. 1720G, directing VA to establish a Program of Comprehensive Assistance for Family Caregivers and a Program of General Caregiver Support Services. These two programs are collectively referred to as the Caregiver Support Program.

3.DEFINITIONS

Omitted the regulation, 38 CFR 71, § 71.15 – Definitions: 

Primary care team means a group of medical professionals who care for a patient and who are selected by VA based on the clinical needs of the patient. The team must include a primary care provider who coordinates the care, and may include clinical specialists (e.g., a neurologist, psychiatrist, etc.), resident physicians, nurses, physicians’ assistants, nurse practitioners, occupational or rehabilitation therapists, social workers, etc., as indicated by the needs of the particular patient.

Undergoing medical discharge means that the servicemember has been found unfit for duty due to a medical condition by their Service’s Physical Evaluation Board, and a date of medical discharge has been issued. 

a. Activities of Daily Living. For purposes of this directive, activities of daily living means:

(1) Eating. Ability to feed oneself both meals and snacks. NOTE: This refers only to the process of eating, chewing, and swallowing, not preparing the food to be eaten.

Altered the regulation, 38 CFR 71, 71.15 Definition: (6) Inability to feed oneself due to loss of coordination of upper extremities, extreme weakness, inability to swallow, or the need for a non-oral means of nutrition; 

(2) Grooming. Ability to safely tend to personal hygiene needs (i.e., washing face and hands, hair care, shaving, applying makeup, teeth and denture care, nail care of fingers and/or toes).

Altered the regulation, 38 CFR 71, 71.15 Definition: (3) Inability to groom oneself in order to keep oneself clean and presentable; 

(3) Bathing. Ability to wash entire body safely.

Altered the regulation, 38 CFR 71, 71.15 Definition: (2) Inability to bathe; 

(4) Dressing and Undressing. Ability to dress and/or undress upper and lower body with or without dressing aids.

Altered the regulation, 38 CFR 71, 71.15 Definition: (1) Inability to dress or undress oneself; 

(5) Toileting. Ability to maintain perineal hygiene and adjust clothing before and/or after using the toilet or bedpan; ability to manage an ostomy, including cleaning the area around stoma but not managing equipment; or ability to manage urinary catheter or urinal.

Altered the regulation, 38 CFR 71, 71.15 Definition: (5) Inability to toilet or attend to toileting without assistance; 

(6) Prosthetic Adjustment (Use of Assistive Devices). Ability to adjust special prosthetic or orthopedic appliances without assistance. The adjustment of appliances that any person (with or without a disability) would need assistance with should not be scored (for example, supports, belts, lacing at back, etc.).

Altered the regulation, 38 CFR 71, 71.15 Definition: (4) Frequent need of adjustment of any special prosthetic or orthopedic appliance that, by reason of the particular disability, cannot be done without assistance (this does not include the adjustment of appliances that nondisabled persons would be unable to adjust without aid, such as supports, belts, lacing at the back, etc.); 

(7) Mobility. Ability to transfer safely from bed to chair and/or chair to toilet, ability to turn and position self in bed, ability to walk safely on a variety of surfaces, or ability to go upstairs.

Altered the regulation, 38 CFR 71, 71.15 Definition: (7) Difficulty with mobility (walking, going up stairs, transferring from bed to chair, etc.)

d. Need for Supervision or Protection Based on Symptoms or Residuals of Neurological or Other Impairment or Injury. The need for supervision or protection based on symptoms or residuals of neurological or other impairment or injury means requiring supervision or assistance due to one or more of the following:

(1) Seizures. Unable to manage seizures independently (i.e., seizures are not well controlled with medication or Veteran is not able to independently manage the medications, blackouts, or lapses in mental awareness).

Altered the regulation, 38 CFR 71, 71.15 Definition: (1) Seizures (blackouts or lapses in mental awareness, etc.);

(2) Planning and Organizing. Difficult to plan and organize (i.e., complete daily tasks, make and keep appointments, adhere to medication regimen).

Altered the regulation, 38 CFR 71, 71.15 Definition: (2) Difficulty with planning and organizing (such as the ability to adhere to medication regimen);

(3) Safety. Unable to maintain safety with self and others (i.e., Veteran is a risk to self or others and/or is at risk of falling or wandering, cannot safely use electrical appliances, stove top or oven).

Altered the regulation, 38 CFR 71, 71.15 Definition: (3) Safety risks (wandering outside the home, danger of falling, using electrical appliances, etc.);

(4) Sleep. Difficult to regulate sleep without intervention of caregiver.

Altered the regulation, 38 CFR 71, 71.15 Definition: (4) Difficulty with sleep regulation;

(5) Delusions/Hallucinations. Unable to maintain safe behavior in response to delusions (irrational beliefs) or hallucinations (serious disturbances in perception).

Altered the regulation, 38 CFR 71, 71.15 Definition: (5) Delusions or hallucinations; 

(6) Impairment of Recent Memory. Difficult to remember recent events and learn new information.

Altered the regulation, 38 CFR 71, 71.15 Definition: (6) Difficulty with recent memory;

(7) Affective/Behavioral Dysregulation (Self-Regulation). Unable to regulate behavior without exhibiting any of the following behaviors: aggressive or combative with self or others, verbally disruptive including yelling, threatening and excessive profanity, impaired decision making, inability to appropriately stop activities, disruptive, infantile or socially inappropriate behavior.

Altered the regulation, 38 CFR 71, 71.15 Definition: (7) Self regulation (being able to moderate moods, agitation or aggression, etc.

f. Veteran. The term Veteran is defined at 38 U.S.C. 101(2). For purposes of this directive’s discussion of the Program of Comprehensive Assistance for Family Caregivers, the term Veteran includes Servicemembers who apply for or participate in such Program.

Note: The Caregiver is the applicant to participate in the Program of Comprehensive Assistance for Family Caregivers (PCAFC) because the program is for the CAREGIVER.

Altered the regulation, 38 CFR 71, 71.15 Definition: Eligible veteran means a veteran, or a servicemember, who is found eligible for a Family Caregiver under § 71.20. 

Altered the regulation, 38 CFR 71, § 71.20 Eligible veterans and servicemembers: A veteran or servicemember is eligible for a Primary or Secondary Family Caregiver under this part if she or he meets all of the following requirements:

4.POLICY

It is VHA policy that each VA medical facility establish a local Caregiver Support Program to administer the Program of Comprehensive Assistance for Family Caregivers and the Program of General Caregiver Support Services with appropriate staffing and workload capture. NOTE: The Caregiver Support Program is a clinical program, and decisions affecting the furnishing of assistance or support under the Caregiver Support Program are considered medical determinations, which fall under the purview of the VHA clinical appeals process identified in VHA Directive 1041, Appeal of VHA Clinical Decisions, or subsequent policy issue.

Note: Both caregiver support programs are SUPPORT PROGRAMS. It also has it in the title of the Caregiver SUPPORT. No clinical or clinical interventions are provided to the eligible CAREGIVERS of both caregiver support programs.

Violated and altered the law, Public Law 111-163, and statue, 38 USC 1720G: 

Excerpt from Public Law 111-163 and 38 USC 1720G

§1720G. Assistance and support services for caregivers

(a) PROGRAM OF COMPREHENSIVE ASSISTANCE FOR FAMILY CAREGIVERS.—(1)(A) The Secretary shall establish a program of comprehensive assistance for family caregivers of eligible veterans. ‘‘(B) The Secretary shall only provide support under the program required by subparagraph (A) to a family caregiver of an eligible veteran if the Secretary determines it is in the best interest of the eligible veteran to do so.

(b) PROGRAM OF GENERAL CAREGIVER SUPPORT SERVICES.— (1) The Secretary shall establish a program of support services for caregivers of covered veterans who are enrolled in the health care system established under section 1705(a) of this title (including caregivers who do not reside with such veterans).

Violated, Appeals of VHA Clinical Appeals Decisions, VHA Directive 1041. In reference to appeals, 80 FR 1357 January 09, 2015 (regulation 38 CFR 71, final rule and amendments) excerpt from page 1366: 

VHA has a clinical appeals process that will be sufficient to resolve such conflict. Under the VHA appeals process, patients or their representatives have access to a fair and impartial review of disputes regarding clinical determinations or services that are not resolved at the facility level. This process is intended to resolve conflicts about whether an appropriate clinical decision has been made, and the process certainly can resolve whether the adverse decision was based, for example, on a misreading of a date in a military record. Other issues that are being resolved through the VHA clinical appeals process include basic eligibility, determination of ‘‘illness’’ or ‘‘injury,’’ and the tier level assigned for stipend payment. This appeals process does not defy the statutory restriction at 38 U.S.C. 1720G(c)(1) against appeals to the Board of Veterans’ Appeals because it is specifically designed to resolve conflicts based upon medical determinations. We note, however, that not all benefits provided to caregivers are provided under 38 U.S.C. 1720G. Certain benefits afforded to caregivers by 38 U.S.C. 1720G are provided through other statutory authorities, and decisions regarding those benefits are therefore not made under 38 U.S.C. 1720G. For example, decisions by the Secretary affecting the payment of beneficiary travel (under 38 U.S.C. 111(e)(2) as authorized by 38 U.S.C. 1720G(a)(3)(A)(i)(IV)), the provision of CHAMPVA (under 38 U.S.C. 1781 as authorized by 38 U.S.C. 1720G(a)(3)(A)(ii)(IV)), and debt collection and waiver (under 31 U.S.C. 3711 and 38 U.S.C. 5302) are examples of matters decided under statutory authorities other than 38 U.S.C. 1720G. Appeal processes associated with those decisions, under applicable statutes and regulations, may be pursued by caregivers who disagree with a VA decision made under those authorities. See e.g., 38 CFR 70.40, 17.276, 1.900– 1.970.

5.RESPONSIBILITIES

Omitted the regulation, 38 CFR 71, primary care team responsibilities.

f. Veterans Integrated Service Network (VISN) Director. The VISN Director is responsible for:

(1) Ensuring that each VA medical center within the VISN employs at least one full-time equivalent employee in the role of Caregiver Support Coordinator.

(3) Ensuring that the Caregiver Support Program is operated consistently across the VISN.

h. VA Medical Center Director. The VA Medical Center Director is responsible for:

(1) Ensuring a minimum of one full-time equivalent employee Caregiver Support Coordinator position is filled without collateral responsibilities.

(4) Ensuring that locally developed processes and procedures are in place to facilitate Veteran and caregiver access to the services required by the Caregiver Support Program.

(5) Ensuring that applications for the Program of Comprehensive Assistance for Family Caregivers are processed within 45 calendar days after the application was submitted unless a caregiver has not completed the required training or the Veteran is hospitalized during the application process in which case the 45-day period can be extended for up to 90 days after the application was submitted.

i. VA Medical Center Chief of Staff. The Chief of Staff is responsible for:

(1) Developing processes and procedures to facilitate eligibility determinations for the Program of Comprehensive Assistance for Family Caregivers. Such determinations may be made by the Veteran’s VA primary care team. Alternatively, a VA Caregiver Support Program multidisciplinary Clinical Eligibility Team or an individual VA provider may be designated to complete eligibility determinations with input from the Veteran’s primary care team. An eligibility determination shall consider input from the caregiver and Veteran or Veteran’s representative, as applicable. If the Veteran receives treatment from community providers, clinical documentation from the community providers should also be considered to the extent possible. This assessment will consider whether or not participation in the Program of Comprehensive Assistance for Family Caregivers is in the best interest of the Veteran. The assessment will also identify the Veteran’s level of dependency based on the degree to which the Veteran is unable to perform one or more activities of daily living and/or needs supervision or protection based on symptoms or residuals of neurological or other impairment or injury for purposes of determining the applicable stipend.

Altered the regulation, 38 CFR 71, 71.20 and 71.25: 

§ 71.20 – Eligible veterans and servicemembers:

(c) Such serious injury renders the individual in need of personal care services for a minimum of 6 continuous months (based on a clinical determination authorized by the individual’s primary care team), based on any one of the following clinical criteria:

(d) A clinical determination (authorized by the individual’s primary care team) has been made that it is in the best interest of the individual to participate in the program.

§ 71.25 – Approval and designation of Primary and Secondary Family Caregivers:

(c) Assessment, education, and training of applicants. Before VA approves an applicant to serve as a Primary or Secondary Family Caregiver, the applicant must:

(1) Be initially assessed by a VA primary care team as being able to complete caregiver education and training. Such assessment will consider any relevant information specific to the needs of the eligible veteran, as well as:

(2) Complete caregiver training and demonstrate the ability to carry out the specific personal care services, core competencies, and other additional care requirements prescribed by the eligible veteran’s primary care team.

(f) Approval and designation. If the eligible veteran and at least one applicant meet the requirements of this part, VA will approve the application and designate Primary and/or Secondary Family Caregivers, as appropriate. This approval and designation will be a clinical determination authorized by the eligible veteran’s primary care team. Approval and designation is conditioned on the eligible veteran and designated Family Caregivers remaining eligible for caregiver benefits under this part.

In the regulation, 38 CFR 71, final rule and amendment, 80 FR 1357, excerpt from page 1365:

The rule states in §71.25(f) that ‘‘if the eligible veteran and at least one applicant meet the requirements of this part, VA will approve the application and designate Primary and/or Secondary Family Caregivers, as appropriate. This approval and designation will be a clinical determination authorized by the eligible veteran’s primary care team.’’ We intend that the clinical determinations made under §71.20 regarding the veteran’s or servicemember’s initial eligibility as well be authorized by a primary care team versus a single individual, and agree with the commenter that §71.20 be so amended.

(3) Ensuring that initial in-home assessments and ongoing program monitoring (conducted every 90 days, unless otherwise clinically indicated) provide education and support to caregivers, and evaluate the well-being of the Veteran.

Note: It doesn’t state the requirement to inspect every room in a Veterans home. 

(6) Ensuring that all appropriate providers (e.g., primary care, specialty care, and mental health providers) participate in clinical determinations concerning the Veteran’s eligibility for and participation in the Program of Comprehensive Assistance for Family Caregivers and that the timelines set forth in 38 CFR 71.25 and 71.40 are met.

(7) Encouraging discussions of caregiver support at town hall meetings and Community Veterans Engagement Boards (CVEB) as appropriate.

j. Caregiver Support Coordinator. The Caregiver Support Coordinator is responsible for:

(1) Managing and coordinating the application process for the Program of Comprehensive Assistance for Family Caregivers, including assisting Veterans and caregivers to complete VA Form 10-10CG, or successor form, and documenting the application approvals and denials, and participant status changes in the designated Caregiver Support Program data system and electronic health record as appropriate. Caregiver Support Coordinators are responsible for ensuring that caregiver training is made available to caregivers (whether in-person, online, or through other available format) and coordinating with the clinical support staff assigned to the Program of Comprehensive Assistance for Family Caregivers to ensure completion of clinical assessments, required home visits and monitoring every 90 calendar days (unless otherwise clinically indicated).

(8) Educating Primary Care and Mental Health Services staff on the Caregiver Support Program and encouraging all Patient Aligned Care Teams (PACTs) and Behavioral Health Interdisciplinary Program (BHIP) teams to engage the caregiver as part of the Veteran’s health care team.

Note: Reference the above excerpts from the law, statue, regulation and final rule/amendment. 

6.THE PROGRAM OF COMPREHENSIVE ASSISTANCE FOR FAMILY CAREGIVERS

The Program of Comprehensive Assistance for Family Caregivers involves both primary and secondary family caregivers. Its establishment is required by 38 U.S.C. 1720G(a), and rules governing its operation are set forth in 38 CFR Part 71.

(3) Such serious injury renders the individual in need of personal care services from another individual (a caregiver) for a minimum of 6 continuous months based on any one of the following clinical criteria:

Altered and Omitted the words ‘a clinical determination authorized by the individual’s primary care team’ in the regulation, 38 CFR 71, § 71.20 – Eligible veterans and servicemembers:

(c) Such serious injury renders the individual in need of personal care services for a minimum of 6 continuous months (based on a clinical determination authorized by the individual’s primary care team), based on any one of the following clinical criteria:

(4) A clinical determination (authorized by the individual’s primary care team) has been made that it is in the best interest of the individual to participate in the program.

b. Approval and Designation of Primary and Secondary Family Caregivers. A Veteran’s eligibility for the Program of Comprehensive Assistance for Family Caregivers may be determined by the VA Caregiver Support Coordinator who receives the application (as provided in paragraph 6.b.(1)(b)) or the Caregiver Support Coordinator will refer the application to the Veteran’s VA primary care team to complete eligibility determinations. Alternatively, a VA Caregiver Support Program multidisciplinary Clinical Eligibility Team or an individual VA provider may be designated to complete eligibility determinations with input from the Veteran’s primary care team. An eligibility determination shall consider input from the caregiver and Veteran or Veteran’s representative, as applicable. If the Veteran receives treatment from community providers, clinical documentation from the community providers should also be considered to the extent possible. Determining and establishing eligibility is a multi-step process. The entire process should be completed within 45 days after the application was submitted unless a caregiver has not completed the required training or the Veteran is hospitalized during the application process in which case the 45-day period can be extended for up to 90 days after the application was submitted. See 38 CFR 71.40(d)(1). Eligibility determinations include the following steps:

Altered the regulation, 38 CFR 71, § 71.20 – Eligible veterans and servicemembers:

(c) Such serious injury renders the individual in need of personal care services for a minimum of 6 continuous months (based on a clinical determination authorized by the individual’s primary care team), based on any one of the following clinical criteria:

(d) A clinical determination (authorized by the individual’s primary care team) has been made that it is in the best interest of the individual to participate in the program.

Altered the regulation, 38 CFR 71, § 71.25 – Approval and designation of Primary and Secondary Family Caregivers: 

(c) Assessment, education, and training of applicants. Before VA approves an applicant to serve as a Primary or Secondary Family Caregiver, the applicant must:

(1) Be initially assessed by a VA primary care team as being able to complete caregiver education and training. Such assessment will consider any relevant information specific to the needs of the eligible veteran, as well as:

(f) Approval and designation. If the eligible veteran and at least one applicant meet the requirements of this part, VA will approve the application and designate Primary and/or Secondary Family Caregivers, as appropriate. This approval and designation will be a clinical determination authorized by the eligible veteran’s primary care team. Approval and designation is conditioned on the eligible veteran and designated Family Caregivers remaining eligible for caregiver benefits under this part.

In the regulation, 38 CFR 71, final rule and amendment, 80 FR 1357, excerpt from page 1365:

The rule states in §71.25(f) that ‘‘if the eligible veteran and at least one applicant meet the requirements of this part, VA will approve the application and designate Primary and/or Secondary Family Caregivers, as appropriate. This approval and designation will be a clinical determination authorized by the eligible veteran’s primary care team.’’ We intend that the clinical determinations made under §71.20 regarding the veteran’s or servicemember’s initial eligibility as well be authorized by a primary care team versus a single individual, and agree with the commenter that §71.20 be so amended.

(b) Upon receiving the application, a VA Caregiver Support Coordinator will evaluate eligibility by identifying a potentially qualifying injury that was incurred or aggravated in the line of duty in the active military, naval, or air service on or after September 11, 2001, and assessing whether the potentially qualifying injury may render the Veteran in need of personal care services from a caregiver. In performing this initial eligibility evaluation, the Caregiver Support Coordinator will consider input from the caregiver and the Veteran or Veterans’ representative, as applicable. If the Caregiver Support Coordinator determines that the Veteran does not have a potentially qualifying injury that was incurred or aggravated in the line of duty in the active military, naval, or air service on or after September 11, 2001, or the potentially qualifying injury does not render the Veteran in need of personal care services from a caregiver, the Caregiver Support Coordinator will issue the applicant a determination that the applicant is not eligible for the Program of Comprehensive Assistance for Family Caregivers. If the Coordinator does not issue such a determination, the Caregiver Support Coordinator will refer the application to the Veteran’s VA primary care team, a VA Caregiver Support Program multidisciplinary Clinical Eligibility Team or an individual VA provider to perform the required clinical evaluations, including evaluating the Veteran’s level of dependency for purposes of determining the applicable stipend.

Note: This paragraph supports my comments in part 1. The CS has established two (2) clinical eligibility assessments. This paragraph is referring to Caregiver Support Administrative Eligibility Screening Tool completed by the CSC which is actually a more detail Caregiver Program Clinical Eligibility Assessment and it include a lot more clinical eligibility questions which most are unlawful. How can a social worker interrupt a Veterans medical and mental health records to 1) determine serious physical and mental health injuries, and 2) if the injuries require assistance from a caregiver? A CSC is a licensed clinical social worker who isn’t a licensed medical doctor to make these medical determinations or qualified to interrupt medical records or injuries. 

Violated and altered 38 CFR 71. See excerpts from the regulation, 38 CFR 71, and the final rule/amendment, 80 FR 1357 above. This paragraph also contradicts the above paragraph, b., and parts of the responsibilities section. 

(3) Assessment, Training, and Education of Applicants. Before VA approves an application for an applicant to serve as a primary or secondary family caregiver, all of the following requirements must be satisfied:

(a) The applicant must be initially assessed by a VA primary care team as being able to complete caregiver education and training. NOTE: The Veterans Transportation Service may be available for purposes of this assessment in accordance with 38 CFR Part 70, Subpart B. This assessment must consider any relevant information specific to the needs of the Veteran, as well as:

Note: Reference the above paragraph (b), to see the contradictions. 

1. Whether the applicant can communicate and understand details of the treatment plan and any specific instructions related to the care of the Veteran. NOTE: Accommodation for language or hearing impairment will be made to the extent possible and as appropriate.

2. Whether the applicant will be capable of following, without supervision, a treatment plan listing the specific care needs of the Veteran.

(b) Complete caregiver training and demonstrate the ability to carry out the specific personal care services, core competencies, and other additional care requirements prescribed by the Veteran’s primary care team.

(6) Approval and Designation. If VA determines that the Veteran and at least one family caregiver applicant meet the applicable eligibility requirements, VA will approve the application and designate primary and/or secondary family caregivers, as appropriate. This approval and designation is a clinical determination. Approval and designation is conditioned on the Veteran and designated family caregivers remaining eligible for caregiver benefits under this directive. Veterans and family caregivers who are determined ineligible, will be informed that they have the right to file a clinical appeal using the VHA clinical appeals process identified in VHA Directive 1041, Appeal of VHA Clinical Decisions, or subsequent policy issue.

Altered and Omitted the words ‘authorized by the eligible veteran’s primary care team’, 38 CFR 71, § 71.25 Approval and designation of Primary and Secondary Family Caregivers:

(f) Approval and designation. If the eligible veteran and at least one applicant meet the requirements of this part, VA will approve the application and designate Primary and/or Secondary Family Caregivers, as appropriate. This approval and designation will be a clinical determination authorized by the eligible veteran’s primary care team. Approval and designation is conditioned on the eligible veteran and designated Family Caregivers remaining eligible for caregiver benefits under this part.

(5) Monitoring. As discussed above, an initial home visit is required as part of the application process; ongoing interim monitoring is required every 90 calendar days after approval and designation, unless otherwise clinically indicated, to monitor the Veteran’s overall health and well-being and adequacy of care and supervision being provided. Based upon the clinical determination of the Veteran’s primary care team, interim monitoring can be completed through face-to-face visits at a VA medical facility, through Clinical Video Telehealth (CVT), or by telephone; otherwise interim face-to-face in-home visits are required. When a home visit is required for the 90-day (or otherwise) interim monitoring, the home visit may be completed by VA staff or through a contract with a non-VA provider with the use of Purpose of Visit (POV) code 25 for Caregiver Oversight Visits. An annual in-home visit must be conducted, even in cases where the Veteran’s primary care team determines that 90-day (or otherwise) interim monitoring can be accomplished without an in-home visit. The annual in-home visit must be conducted by VA staff and not through a contract with a non-VA provider.

Altered the regulation, 38 CFR 71, § 71.40 – Caregiver benefits:

(b) (2) The primary care team will maintain the eligible veteran’s treatment plan and collaborate with clinical staff making home visits to monitor the eligible veteran’s well-being, adequacy of care and supervision being provided. This monitoring will occur no less often than every 90 days, unless otherwise clinically indicated, and will include an evaluation of the overall health and well-being of the eligible veteran.

Note: Can a social worker lawfully tell licensed medical doctor’s what they can and cannot do or make medical determinations of the clinical responsibilities and requirements for licensed medical doctors? 

c. Revocation by VA.

(1) The Caregiver Support Coordinator may immediately revoke the designation of a family caregiver if the Veteran or individual designated as a family caregiver no longer meets the requirements of 38 CFR Part 71, or if VA makes the clinical determination that having the family caregiver is no longer in the best interest of the Veteran.

Note: Decisions made are medical determinations and medical determinations are authorized by licensed medical doctors. Another example of the CSC making medical determinations of a licensed medical doctor which social workers are not qualified or authorized to make. 

I hope I have provided enough examples supporting my statements in part 1 and showing the following:

  1. Multiple laws being broken/violated, altered or omitted; 
  2. Medical determinations/decisions made by the CSC and other VA CS employees (social workers);
  3. Attempts to exclude the Veteran’s primary care team;
  4. Contradictions from one paragraph and/or section to another; 
  5. Assigns the same clinical respsonbilities to the primary care team and CSC;
  6. It shows the VA CS hiring or forming VA Caregiver Support Program Multidisciplinary Clinical Eligibility Team instead of allowing the primary care team to perform their clinical responsibilities; 
  7. It shows the VA CS (social workers) making medical determinations/decisions to instruct a licensed medical doctor of their clinical responsibilities;
  8. It shows the VA CS (social workers) altering and omitting definitions and words;  
  9. It shows the VA CS wants to send a Veteran to an individual provider instead of their primary care team; 
  10. It doesn’t establish the support responsibilities of the CSC to the caregivers of both caregiver support programs; 
  11. It shows how each VAMC is required to have one (1) CSC which doesn’t support the CSC’s involvement in the primary care team’s clinical responsibilities; 
  12. It doesn’t establish how caregivers of both caregiver support programs apply for their applicable benefits;
  13. It doesn’t establish processes and procedures for reassessments, revocations or appeals;
  14. It shows the VA CS assignment of licensed medical doctor clinical responsibilities to the CSC. 

Why do you think the VA CS wants to exclude a Veteran’s primary care team?

Why do you think the VA CS wants to perform clinical responsibilities of a licensed medical doctor? 

Why do you think the VA CS wants to perform the home assessments?

Why do you think the VA CS wants to control all decisions affecting eligibility (application, clinical assessment, home visit, reassessment, appeals and revocations)? 

Why do you think the VA has allowed this to happen?

In my next post, part 3, I will discuss my redacted medical records to support statements made in part 1. 

 

 

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