Senate Probe Finds Epic Failures In VA Facility Review: Medical Center Had Been Prescribing Alarming Amounts Of Narcotics To Veterans

A Senate inquiry into a Veterans Affairs’ Medical Center in Tomah, Wisconsin, over allegations of poor health care found epic failures in the inspector general’s review of the facility, USA Today is reporting.

The committee, tasked with independently investigating VA complaints, witness testimony, and discounting key evidence, brought this to light recently. This development has once again raised doubts over whether VA facilities can provide sufficient health care for veterans across America.

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The probe, which was initiated by the Senate Homeland Security and Government Affairs Committee, found the Inspector General’s office riddled with controversies.

One of the alarming incidents discovered by Senate investigators was the Inspector General’s decision to withhold a report which claimed that two providers at the facility had been prescribing disturbing amounts of narcotics to veterans. David Houlihan was the facility chief of staff during that period, and veterans had nicknamed him the “candy man” because he always doled out plenty of pills.

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The report was meant to make VA officials sit up and address the issue. Instead, the Inspector General closed the case. A Marine Corps veteran, Jason Simcakoski, 35, died five months later from a toxic cocktail of drugs at the facility shortly after Houlihan had added another opiate to the 14 drugs that he had been prescribed previously.

The 350-page Senate committee report said several agencies like the DEA, FBI, and local police should have done more to repair the problems at the medical center, but singles out the Inspector General as the biggest culprit.

“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.”

When news reports trickled out over the death of Simcakoski, VA officials investigated the incident. Soon afterwards, a nurse practitioner, Houlihan, and the medical center’s director were ousted. The committee report strangely noted that “in just three months, the VA investigated and substantiated a majority of the allegations the VA [Office of the Inspector General] could not substantiate after several years.”

Sen. Ron Johnson, chairman of the Senate committee, speaking to reporters Tuesday, said the failures were “systemic” and suggested and even more troubling pattern.

“The reasons the problems were allowed to fester for so many years is because in the Inspector General’s office, for whatever reason, for many years, the Inspector General lacked the independence and had lost the sense of what its true mission was, which is being the transparent watchdog of the VA system.”

This is not the first time that Veterans Affairs’ medical facilities have courted controversy. Recently, employees in as many as 19 states were instructed by their supervisors to forge patient wait times. Some of the employees discovered in over 40 affected VA facilities had been doing this for more than a decade, according to USA Today.

The reports showed that supervisors had told schedulers to influence waiting times in New York, Texas, California, Delaware, Illinois, Arkansas, and many more states, giving a false impression that facilities were adhering to VA performance measures for shorter appointments. The manipulation disguised a great demand required by army personnel who had returned from Afghanistan and Iraq, and aged veterans from the Vietnam War who need ample health care. VA employees kept the list of many veterans outside the scheduling system because they wanted to hide their actual wait times; some veterans died while waiting for health care.

Since then, some reforms have been carried out, but whistleblowers say the problem still abounds. Shea Wilkes, a coordinator of more than 40 whistle-blowers from VA medical facilities across America, confirmed this, but stated that employees were too frightened to come forward.

[Photo by John Moore/Getty Images]