Report: Tomah VA Problems Tied To ‘Systematic Failures’

A U.S. Senate committee probe of health care problems at the Tomah Veterans Affairs Medical Center in western Wisconsin has turned up “systemic failures” in an inspector general’s review of the facility.

A staff report by the Republican majority of the Senate Homeland Security and Governmental Affairs Committee released Tuesday found the VA inspector general’s office discounted evidence and testimony. The report said the office also needlessly narrowed its inquiry and has no standard for measuring wrongdoing.

Most notably, the senate committee’s report included evidence that former Tomah providers may have been using drugs during their employment.

According to a handwritten note from September 2012, officials from the VA Office of the Inspector General informed then-Tomah medical director Mario DeSanctis that Dr. David Houlihan and nurse practitioner Deborah Frasher appeared to be impaired during an interview.

The investigator suggested that DeSanctis perform drug tests on the staff after noting the providers had slurred speech, constricted pupils and other signs of impairment.

Republican Sen. Ron Johnson released the preliminary report Tuesday in conjunction with a congressional committee field hearing in Tomah. He said the lack of follow-up from investigators at the OIG is a “classic example” of how the VA Office of Inspector General did not act on evidence of wrongdoing at the Tomah VA before the death of Marine Corps veteran Jason Simcakowsi.

“We have no idea whether those drug tests were performed. I would think that if they were back in 2012, these tragedies might have been prevented,” Johnson said.

VA Deputy Secretary Sloan Gibson was also in attendance at the Senate hearing in Tomah. He agreed with federal lawmakers that the lack of follow-up on this evidence was inexcusable.

“It was a failure of leadership (that) should not have happened, period,” Gibson said. “And I don’t need a policy or a rule to try to enforce that.”

The VA’s troubles in Tomah have already been a flashpoint in Johnson’s race against former senator Russ Feingold. The Democrat and Johnson have blamed each other for not doing enough to address allegations at the medical center that some have called “Candy Land” because of overprescribed opiates.

Tuesday, Feingold blasted the OIG and also criticized lawmakers, including Johnson, for not acting sooner.

“We have to make sure an incident like this never happens again. It happened in the last few years and I think it’s very regrettable in response to the warnings that were given to those that were in office since 2011,” he said.

Feingold accused Johnson of knowing about problems at the Tomah VA and not acting on them, a claim Johnson denies.

Inspectors for the VA in 2014 found that doctors were over-prescribing painkillers. The deaths of three people who were cared for at Tomah remain under investigation.

The report said 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.

Editor’s note: This story has been updated with additional reporting, including statements from Russ Feingold.