Beckley, WV, VAMC
BECKLEY, WV — Early last year, Jonathan Yates, DO, whole health medical director at the Beckley, WV, VAMC, was sentenced to prison for 25 years for sexually abusing veterans in his care and for practicing acupuncture without being credentialed. A new report from the VA Office of Inspector General (OIG) has found that deficiencies in the facility leader’s oversight and a failure to follow up on complaints put Yates in the position where he could abuse veterans and prevented him from being discovered sooner.
Yates was employed at the VAMC from April 2018 through July 2019. In June 2019, the OIG in conjunction with the U.S. Attorney’s office began investigating allegations that Yates was abusing his patients. In May 2020, he was charged with five counts of sexual assault while providing care at the VAMC, including an allegation of temporarily immobilizing a patient with acupuncture needles. Yates pleaded guilty in September 2020 to three counts of deprivation of rights.
According to the OIG, the two years that Yates was in his position at Beckley could have been cut short if facility leaders had followed up on a number of patient complaints or taken action when they discovered he was practicing acupuncture without proper credentials.
These failures were due in part to a lack of oversight—or at least anyone willing to admit they were responsible for that oversight after the fact.
“Current and former facility leaders provided conflicting information about responsibility for the subject physician’s supervision,” the OIG investigators stated in their report. “The OIG could not clearly identify a line of clinical supervision for [Yates] but noted the former Chief of Staff and the Chief of Primary Care functioned as clinical supervisors and provided varying levels of oversight.”
However, the OIG found that neither of those leaders acknowledged responsibility for clinical supervision of the new Whole Health program, which Yates directed.
The report also found that facility leaders failed to properly complete Yates’ professional practice evaluations, which are required to assess the clinical performance of a provider.
In February 2019, the Virginia Department of Health Professionals notified Yates that he was being investigated due to patient complaints of sexual assault at his previous job. Yates informed the Beckley VAMC leadership, who removed him from direct patient practice while the investigation was ongoing, but did not suspend him entirely.
Other Complaints
But this was not the first time Beckley VAMC leadership had heard of Yates being linked with sexual misconduct. Between October 2018 and May 2019, at least four other complaints were made by veterans against Yates concerning inappropriate sexual conduct.
“Facility leaders failed to thoroughly investigate the complaints, nor did they identify and report patient safety concerns,” the report states. “Additionally, facility leaders did not summarily suspend [Yates] as recommended in VHA guidance, as [they] were awaiting the results of the Virginia Department of Health investigation. The OIG determined that former facility leaders’ failure to share information amongst themselves partially contributed to these failures.”
According to the report, the VISN director initiated an Administrative Investigation Board (AIB) in March 2021 to investigate whether facility leaders appropriately addressed patient complaints made against Yates. The AIB only looked at the circumstances around the first complaint and failed to consider the other three.
OIG investigators also discovered that the former associate director for patient care services was aware as early as December 2018 that Yates was performing acupuncture on patients without being credentialed. They instructed Yates to stop and notified the former chief of staff and former facility director, but took no further action, and Yates continued practicing acupuncture.
Exactly how many patients he performed acupuncture on remains unclear, since Yates failed to properly document his procedures. This lack of documentation caused a second wave of concern when, in September 2021, OIG investigators discovered that the hospital had failed to conduct a full electronic health record (EHR) search of patients who might have received acupuncture from Yates. Because Yates was unaccredited and essentially unsupervised, there was also concern about quality and sterility of needles and possible patient exposure to blood-borne infections. Also, the OIG investigators were unable to discover where Yates procured his needles.
A review of the EHR found 48 patients who had documentation of acupuncture. As a result, the VISN went public with its concerns and began offering tests for blood-borne infectious diseases to those patients who received acupuncture.
This is just the latest finding by the OIG that places blame for a recent criminal case on lack of VA oversight. Investigators found similar administrative lapses in at the Clarksburg, WV, VAMC, where a former VA nurse murdered at least eight veterans through insulin injection, and in Fayetteville, AR, where a VA pathologist made hundreds of diagnostic errors because he was drunk on the job.
