Wednesday, June 01, 2016

Senate Reports Find Even VA Watchdog Has "Systemic" Failures

Entire corrupt, failed VA system needs to be scrapped, audited and the administrators investigated, indicted and prosecuted for the deaths of thousands of Veterans    


While still trying to contain the fallout from a series of negative news reports from last week, the Department of Veterans Affairs on Tuesday finds itself front and center of another media frenzy. A Senate committee issued a report on Tuesday that slammed the agency’s Inspector General and questioned its ability to perform its watchdog role over the VA.

The Senate Homeland Security and Governmental Affairs Committee conducted an investigation into a VA Hospital in Wisconsin after many reports of poor medical care and other problems. 

USA Todayobtained a copy of the report, which is due to be released sometime on Tuesday. According to the newspaper, the report said, “Perhaps the greatest failure to identify and prevent the tragedies at the Tomah VAMC was the VA Office of Inspector General’s two-year health care inspection of the facility.”

VA officials were also criticized for intimidating whistleblowers who raised concerns.

“The over-prescription, retaliation, veterans’ deaths, and abuse of authority at the Tomah VAMC did not occur in a vacuum," the committee report said. "Veterans, employees, and whistleblowers tried for years to get someone to address the problems. Along the way, since at least 2004, there were several opportunities when federal agencies could have investigated further or taken direct action. At each step, however, these opportunities were missed. The tragedies that occurred at the Tomah VAMC were preventable and were the result of systemic executive branch failures."

VA Director McDonald, Obama, Congress have
abandoned Veterans 
The Senate probe reportedly found that during the IG’s investigation into patients complaints, investigators discounted certain evidence, narrowed the scope of the inquiry and failed to release a public report. 

 The Senate found the IG’s failure to publicly release the report was especially egregious because it privately concluded two providers at the facility were prescribing large amounts of opiate painkillers. 

 USA Today reports one physician had even earned the nickname “candy man” from patients.

A few months after the IG report was closed, a patient died at the age of 35 of “mixed drug toxicity.” This death triggered the VA to conduct its own investigation into the Wisconsin hospital.

The second investigation moved quickly, removed doctors and achieved better results. According to USA Today, the Senate report says, “In just three months, the VA investigated and substantiated a majority of the allegations that the VA OIG could not substantiate after several years.”

The Senate Homeland Security and Governmental Affairs Committee, led by Chairman Ron Johnson, will hold a hearing and announce the findings on Tuesday.

McDonald to Veterans: "Take a hike."

In 2011, the inspector general's office at the VA began a lengthy investigation into accusations that opiates were prescribed in dangerous combinations by hospital chief of staff Dr. David Houlihan – nicknamed “Candy Man” for the amount of pills he issued – and nurse practitioner Deborah Frasher. The investigation lasted until 2014 but did not include a finding on whether Houlihan or Frasher had committed any wrongdoing regarding the over-prescription or mixing of drugs. The inspector general’s office only said that there were “potentially serious concerns" about any abuse of narcotic distribution. Kept secret at first, the inspector general’s report was only released publicly in 2015, according to the Senate investigation.

The VA inspector general's investigation represented "perhaps the greatest failure to identify and prevent the tragedies at the Tomah VAMC," the Senate committee report said.

Alan Mallinger, a physician with the VA inspector general's office, led the investigation beginning in 2012. He has said that the issue of prescriptions that involved opiates mixed with other potentially dangerous drugs was not within the scope of his probe.

“The allegation that we had was that he was using opioids to treat PTSD, and that was the allegation we looked at,” Mallinger told the Senate committee, according to USA Today.

Jason Simcakoski, a 35-year-old Marine Corps veteran, died five months after the inspector general’s office addressed local VA officials on its investigation findings, which had yet to be released to the public. Simcakoski died of “mixed drug toxicity” at Tomah, only days after Houlihan added an opiate to 14 other drugs he had been prescribed.

Following reports of Simcakoski's death, the VA again investigated Tomah, eventually firing Houlihan and Frasher as well as the hospital's director. The death of one other patient, Kraig Farrington, was blamed on over-prescription issues, the report said.

“In just three months, the VA investigated and substantiated a majority of the allegations that the VA (office of the inspector general) could not substantiate after several years,” the Senate committee report said.

The committee also faulted the VA for alleged retaliation fears among employees who voiced concern about the prescription policies at the hospital. The report said that two employees were fired from the Tomah hospital after they complained. One of the employees, staff psychologist Dr. Chris Kirkpatrick, later committed suicide.

On Tuesday, the Senate committee held a hearing on the report. Aside from analyzing the "troubled history of the Tomah VA," committee chairman Ron Johnson said another goal of the hearing was to look forward.

"Wrongdoers at the facility level and in Washington have been held accountable," he said in his opening statement. "Now it is vital that we enact necessary reforms to prevent tragedies like what occurred at the Tomah VA from ever happening again."

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