Over the past few months, investigations by the Washington Post and Washington City Paper have revealed a series of failures in the Department of Behavioral Health’s response to the opioid crisis in D.C. Life-saving programs have shriveled, and according to the Post, the Department misspent millions of dollars of federal grant money that District residents and treatment providers desperately needed. But no matter how bleak the picture has been, all the revelations have appeared to be mistakes—the devastating results of bad but basically well intentioned decisions, mismanagement, and inter-departmental feuds.

However, City Paper has now uncovered a case in which multiple levels of DBH leadership made a series of deliberate decisions to avoid taking responsibility when, due to its own failures in oversight, DBH allowed fraud to happen right under its nose. In 2014, lower-level DBH employees discovered that Andromeda Transcultural Health—which still has a $250,000 contract with the District—was lying about its work on a million dollar contract it had with DBH. Andromeda was supposed to operate a van that provided mobile health care to heroin users across the city; in reality, they were sending fabricated treatment data to the Department, and the van was abandoned in a parking lot.

When top DBH officials became aware of what DBH’s employees and an internal investigation said looked like substantial fraud, rather than taking the proper steps to pursue the misspent money and notify federal authorities, they ignored the recommendations of DBH’s own Office of Accountability and repeatedly swept the incident under the rug.

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DBH receives millions of dollars a year from the federal government to fund addiction treatment, and perhaps the most important source of its funding is the Substance Abuse Prevention and Treatment Block Grant, which has supported much of the District’s substance abuse treatment system for years. As one condition of receiving the block grant, the District has to use part of the money to proactively test substance users for HIV and then connect people who are HIV-positive to treatment.

So in 2001, in order to fulfill its obligation to the federal government and to connect those in need with treatment, DBH started Project Orion.

The idea behind Project Orion was simple: A van would go around the city to places where people tend to inject heroin, offering people free blood tests. Then, while the people were getting tested, DBH would give them information about options for addiction treatment.

Rather than run the van themselves, DBH hired a contractor to do it. In October 2008, after years working with another provider, they gave the million dollar contract to Andromeda, a health care nonprofit headquartered on Decatur Street NW. For years, the contract went smoothly. Andromeda received their money, and each month, they sent DBH reports of all the people they talked to, tested, and referred to treatment.

Then, according to a later investigation report by one of DBH’s accountability officers, trouble began to bubble to the surface in spring 2014, when DBH employee Jennifer Mumford started asking what oversight DBH was doing for Project Orion, and how they could be sure that Andromeda was doing everything it was supposed to be doing.

So, according to emails and reports obtained by City Paper through the Freedom of Information Act, she and her colleague Jessica Bress decided to check up on the van. At this point, they just wanted to make sure Andromeda was providing all the appropriate services. They then reached out to Andromeda to plan a site visit.

But Andromeda’s response was fishy: According to the investigation report, Andromeda said they would need more advanced notice before DBH could visit the van.

The pair decided to visit the van anyway, without telling Andromeda they were coming. They had a schedule of where the van went at what time and what day, and so they just went.

No van.

That’s when the search began. At least one more DBH employee, Leon Barnes, began driving around the District every day, looking for a huge Winnebago with a One City logo printed on the side of it. He would show up everywhere the van was scheduled to be, and when it was yet again absent on the job, he would keep looking. Then, after a few weeks of this, he finally found the van. It was sitting empty in a lot near DC General.

A couple weeks later, a DBH employee reached out to Andromeda, asking for a report of the van’s activity in the period the search was underway. An Andromeda employee sent over a report listing the van’s activity each day. It said that the van had been at the locations that DBH visited, and that it had tested dozens of people for HIV on the days that the Winnebago was nowhere to be found.

A later internal investigation found that for several months, Andromeda continued to bill the city while the van was in a shop, totaled.

(Dr. Alvaro Guzman, the executive director of Andromeda since 2015, tells City Paper that Andromeda changed its leadership soon after Project Orion fell apart, and that “as a nonprofit organization, we are struggling to continue providing comprehensive care to thousands of patients.” Dr. Ricardo Galbis, who headed Andromeda when the van disappeared, did not respond to City Paper’s request for comment.)

Emails show that by this point, top DBH officials had learned about the missing van. The District is obliged to recoup any federal grant money that is misspent, and the law also requires the District to notify the Office of the Inspector General if they have evidence of potential fraud.

But none of that happened.

Bress—one of the officials who had been involved with the Project Orion grant and helped determine that the van was missing—later told DBH’s Office of Accountability that instead, she was promptly removed from the Project Orion grant “without explanation.”

Asked to comment on why DBH did not pursue the funds or notify external authorities about Project Orion, a spokesperson for DBH tells City Paper: “After completing an investigation into services provided through Project Orion, the Department of Behavioral Health did not continue to fund the vendor to provide early intervention services relating to HIV. Recently, the Department has restructured the grants management process to ensure more responsible and accountable oversight on all grants.”

That would have been the end of the story, except that in spring 2015, one of DBH’s lawyers, Suzanne Fenzel, heard about what happened from Bress. Emails from this time give a potential explanation for why DBH turned a blind eye when they discovered evidence of fraud: DBH had failed to monitor Andromeda’s performance like they were supposed to, and the emails suggest that higher-ups were worried they would get in trouble with the federal government for their lack of oversight.

In April 2015, according to emails obtained through FOIA, Fenzel asked Bress if DBH “followed up to pursue getting some of the funds returned? It sounds like we may have fraud here, or at the least misused funds, with no idea of how long it was going on.”

“I probably shouldn’t have said anything about the van,” Bress responded. “As far as I am aware they are not pursuing return funds because, as I was told, it was our fault for failing to monitor the van.”

Fenzel replied: “Regardless of our failure to monitor they sound like they committed actual fraud in submitting reports and accepting money.”

Fenzel then asked whether several top officials, including Steve Baron—who was in charge of DBH when the van went missing and had recently retired—knew about what happened. Bress said that all of the members of leadership Fenzel mentioned, other than Baron, definitely knew about the van, and that she was not sure if Baron was told.

So Fenzel emailed Barbara Bazron, who became Acting Director of DBH after Baron retired, telling her that DBH should kick off an investigation.

Bazron tells City Paper that “when it was brought to my attention, I directed [DBH’s] Office of Accountability to investigate this matter. When I left the agency in November 2015, the investigation was underway.” Both Baron and Tanya Royster, who was director of DBH from August 2015 until last November, say that they have no memory of the missing van.

In October 2015, DBH Investigator Jamie Meikle sent the final investigative report to Atiya Frame-Shamblee, who has long been in charge of DBH’s Office of Accountability—a position she still maintains. (Frame-Shamblee did not respond to City Paper’s requests for comment).

The report is remarkably damning. After interviewing DBH employees and reviewing dozens of documents and meeting minutes related to Project Orion, Meikle wrote that while the van was “abandoned in a lot… Andromeda was still submitting reports indicating that they were providing community outreach services to District of Columbia (DC) residents.”

Furthermore, he found that the reports themselves were incoherent, with statistical inconsistencies in the numbers they gave and “no correlation between the textual data and statistical data.”

As for DBH’s culpability, he wrote that “based on a preponderance of evidence,” DBH “did not provide the appropriate oversight of Project Orion.” Meikle wrote that the grant agreement required DBH to conduct regular inspections of the van and a variety of other oversight measures, and “there is no evidence to support” that DBH ever carried out any of this oversight.

Finally, he concluded that D.C.’s Office of Inspector General (OIG) should conduct a “comprehensive audit” of the incident.

But that conclusion was not heeded. A spokesperson for the OIG says that the Office has never done an audit or investigation related to Project Orion or Andromeda, and that if DBH asked them to audit the grant, they would have done it.

Meikle’s recommendations appear to have never made it out of Frame-Shamblee’s inbox, and no one outside DBH was ever told what happened with the project. One final time, DBH’s top officials were told by their own employees that they needed to act on the failures of Project Orion. One final time, they neglected to do so.

Today, Andromeda maintains a $250,000 contract with D.C.’s Department of Health, providing outpatient treatment to residents with HIV.