Senate report: Systematic failures at VA watchdog led to veterans’ deaths

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A Senate committee released a scathing report on Tuesday criticizing a government watchdog for failing to prevent deaths at a Department of Veterans Affairs medical center in Wisconsin known as “Candy Land” for its alleged overpresription of drugs.

The VA Office of the Inspector General withheld a case from the public, ignored key evidence, had no standard for substantiating allegations and lacked independence and transparency while investigating allegations of overprescribing, the 359-page report from the Senate Homeland Security and Governmental Affairs Committee said.

The report faulted the inspector general for prolonging the VA’s problems and allowing preventable deaths to continue. Separately, it found systematic failures by several other agencies, including the FBI, DEA and the VA, for their handling of the Tomah, Wis. medical center. 

“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,” the report says.

“The VA OIG dedicated considerable resources to examining allegations of opioid overprescription, abuse of authority and other misconduct at the facility. … Yet, the product of this intensive effort was just an eleven-page administrative closure, which did not substantiate a majority of the allegations and was not publicly issued.”

In written testimony to the committee, current inspector general Michael Missal, who did not work there during the time at issue, said his office has learned from issues in Tomah.

“My office has learned important lessons from the Tomah healthcare inspections that should help us better meet our mission going forward,” said Missal, who was sworn in on May 2. “The changes that we have made should increase the confidence that veterans, veterans service organizations, Congress and the American public have in the OIG.”

The committee’s investigation stemmed from news in 2015 of the death of Jason Simcakoski, a 35-year-old Marine veteran.

Simcakoski died of “mixed drug toxicity” five months after the inspector general closed its investigation without substantiating the allegations of overprescribing.

But the Tomah center was so well-known for its easy access to prescription medications that it was nicknamed Candy Land for at least a decade, according to the committee report. The facility’s chief of staff, David Houlihan, was known as the Candy Man.

After news of Simcakoski’s death, VA officials conducted another investigation and ousted Houlihan.

“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 report says.

The inspector general repeatedly ignored complaints about patient care, according to the report. For example, in 2009, the employees union raised concerns about overprescribing and gave the inspector general a package of documents about their concerns. But the inspector general canceled a meeting with the union, and it’s unclear if the office ever conducted an investigation based on the union’s concerns, the report says.

In another example, in 2011, the inspector general got anonymous complaints about over-prescription, referred it to the VA’s regional office and closed the case.

When an investigation was done, the inspector general decided to administratively close the case after reviewing 200,000 employee emails, interviewing with several employees, reviewing patient information, issuing at least one subpoena and surveilling Houlihan.

The administrative closure means a report was never released publically, and the inspector general’s ability to follow up on recommendations was limited.

“Because the VA OIG did not publish this closure, other patients of the Tomah VAMC—veterans like Thomas Baer—did not know the facility was at the center of an OIG inspection,” the report says, referring to a patient who died in 2015 of an apparent stroke while waiting two hours to be seen.

The report also slammed the inspector general for not having clear standards to substantiate claims, which the report says could compromise the office’s independence.

Further, the inspector general also appeared to ignore issues found by the investigation that didn’t line up with specific complaints sent to a hotline. For example, officials who interviewed Houlihan and another clinician believed the two were under the influence of drugs or alcohol based on constricted pupils, slurred speech and other factors.

The investigators told their superiors, according to the report, but there was no follow up, and the 11-page administrative closure makes no mention of the alleged impairment.

Sen. Ron Johnson (R-Wis.), chairman of the committee, said the lack of transparency and an independent watchdog were the main “culprits” in the issues at Tomah.

“Now that appropriate oversight and publicity have occurred, those responsible for these tragedies have been held accountable,” he said in a written statement. “They no longer work for the VA, and can do no further harm to veterans. I look forward to working with VA officials and the new VA inspector general that I was proud to help confirm to enact necessary reforms to prevent tragedies like what occurred at the Tomah from ever happening again.”

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