Veterans Affairs officials ‘own’ failures at Tomah Medical Center

Officials acknowledge ‘leadership failure’ at Tomah VA Hospital

Officials with the Department of Veterans Affairs say they “own” the problems that have surfaced in a new report by a U.S. Senate committee.

A staff report by the Republican majority of the Senate Homeland Security and Governmental Affairs Committee released Tuesday cites “systemic failures” in an inspector general’s review of the facility.

The report, which was put together by the staff of Sen. Ron Johnson, R-Wisconsin, said the inspector general’s office discounted evidence and testimony. The report says the office also needlessly narrowed its inquiry into the overprescription of opiate painkillers to veterans and has no standard for measuring wrongdoing.

The report says the office’s failure to publish results of an investigation into the Tomah facility “compromised veteran care.” It also says a culture of fear and whistleblower retaliation continues at the facility.

VA inspectors in 2014 found that doctors were overprescribing painkillers. The deaths of three patients remain under investigation.

Johnson held a field hearing in Tomah Tuesday morning, inviting the deputy secretary of the VA, Sloan Gibson, and the new inspector general of the VA Michael Missal.

In his initial comments, Gibson said he “owned” the failures that happened at the facility.

“Avoidable harm to veterans is unacceptable,” Gibson said. “When they do occur, our obligation is to act with urgency to investigate and prevent a recurrence. At Tomah, there was a clear and inexcusable lack of leadership that created and exacerbated these serious problems.”

Missal said he disagreed with the tone and attacks of some of the documents issued from his office during the Tomah investigation conducted by his predecessor.

“We have learned important lessons from this experience, including increasing the transparency of our work, that should help us better meet our mission going forward,” Missal said. “The changes made should increase the confidence that veterans, VSOs, Congress and the public have in us.”

One of the findings of the report included that investigators who came to Tomah thought Dr. David Houlihan, who has been accused of overprescribing medication to veterans, was “impaired” at the time of his interview. That information was left out of the inspector general’s initial report, and investigators instead notified the former medical director of the facility and suggested he perform drug tests of Houlihan and nurse practitioner Deborah Frasher.

Gibson said the report was the first he’d heard of that possibility.

“I reviewed hundreds and hundreds of pages of evidence and I would tell you not doing something about this would be very consistent with the pattern of behavior I saw there, “Gibson said. “It was a failure of leadership, and should not have happened, period.”

Johnson was blunt with reporters about what he thought needed to happen next.

“The new inspector general has to clean house,” Johnson said. He declined to say how many people he thought needed to be let go from the office.

Those who’ve been treated at Tomah, and family of those who have died there, say they are confident things are changing.

“Some of the things we saw in the report were a little frightening and we were surprised by it, obviously,” said Marv Simcakowski, whose son Jason died at the Tomah VA from “mixed drug toxicity.” “Obviously, that’s what this [hearing] is for, is to make it right.”

“I know some veterans feel they’re not getting what they want,” said Vietnam veteran Joe Shaitel of Sparta. “Other veterans are happy with what we get. Sometimes I think there’s a bit too much political in it.”

Democrats are accusing Johnson of using the scandal to score political points as he faces a tough re-election battle against Democrat Russ Feingold.

Veterans at a news conference call organized by the Democratic Party said Tuesday that Johnson is politicizing the issue. U.S. Army Reserve veteran Dave Boetcher said Johnson has shown more passion for talking about the problems than fixing them.

Johnson said Tuesday that he had done nothing political and was using the resources of his committee chairmanship to uncover issues that need fixing in Tomah.

Sen. Tammy Baldwin, D-Wisconsin, said at the hearing Tuesday that both she and Johnson were committed to rooting out issues at the facility.

“I think the fact that we are both here again today sends an important message to this community that we will continue to work across the partisan aisle in order to address the problems at the Tomah VA,” Baldwin said. “In fact, I would describe it as there is no aisle.”

Johnson said the investigation into the Tomah VA facility is not complete.