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SURPRISE: OIG Clears Pittsburgh VA Of Legionella Cover-Up

Pittsburgh VA

Benjamin KrauseVA OIG just released its report largely clearing Pittsburgh VA Health Care System of failures leading up to veteran deaths from legionella disease. OIG made no recommendations.

Am I the only person here who is not surprised by the lack of a finding? I feel like I am dying from not surprise.

The finding concluded that there were delays when assessing legionella, but it apparently concluded the delays did not result in treatment delays.

Here is the VA OIG summary of the finding. Do yourself a favor to read through the entire thing to find any nuances or trickery.

DOWNLOAD: VA Pittsburgh Legionella Report

VA OIG Summary:

OIG conducted an inspection in response to complaints about delayed reporting of positive Legionella test results in 2012, potentially delaying treatment and causing death for patients at the VA Pittsburgh Healthcare System, Pittsburgh, PA. The complainant also alleged that water samples for Legionella monitoring were collected improperly by excessively flushing the water line prior to collection in order to obtain false negative results. We substantiated that reporting of positive Legionella test results was occasionally delayed but found no evidence of delays in treatment for patients with Legionnaires’ disease, either for those who died or for those who survived. We did not substantiate that water samples collected for environmental cultures of Legionella were collected improperly.
We made no recommendations.

Source: https://www.va.gov/oig/publications/report-summary.asp?id=3540

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29 thoughts on “SURPRISE: OIG Clears Pittsburgh VA Of Legionella Cover-Up”

  1. I have enjoyed watching the recent explosion of OLDreports posted all over the OIG site. They’re working overtime to show all the hard work they have done over the last decade. It is somewhat pathetic to see, actually, because really it makes them look bad for letting things go that have since become larger issues. For example, Tomah reports and the mental health access issues reported to OIG and Senate by VISN 1’s Tollentino back in 2012, only to be revisited recently in a lengthy report in Maine in 2015.

  2. You are sooooo Right .I was raised in Hamilto Ohio . And a friend was employed by IPSO , P&G’S PR Firm .

  3. P&G’s Pr firm , IPSO now working for veteran affairs . Received an email from veterans affairs site with IPSO Requesting my input . I should trust them , I’m sure there is no alterior motive. Noting large amount of Veteran Affairs on Facebook blowing smoke up our [email protected]$!# , seek mental Health Care at VA ? A [email protected]$!#/^& sick joke .

  4. I see much truth in the joke; politicians and diapers have one thing in common they both have to be changed often for the same reason.

  5. Will you sign my petition? https://wh.gov/i8uvq
    “Hey, look no caps well until now!”
    DITCH VA IG HICKEY! REPORTING C&P EXAMINERS PREVENTING THE “TRUTH OF IT ALL!”
    READY TO ACT AS A TEAM? HERE IS WHERE YOU START! 99,999 in 30 days! This rule is private till it reaches 150 signatures!
    Look, I have been a broken record about how the VA LIES AND REFUSE TO ADMIT TO BAD BEHAVIORS?
    AHIMA LOOK UP ELECTRONIC RECORDS. HOW DID I KNOW MY OWN WAS TAMPERED WITH BY A NURSE? “SHE HAS SEEN HER DOCTOR FOR FIVE YEARS BUT FOR TWO YEARS HE HAS DONE HER PAIN MANAGEMENT.”
    WRONG! 19 year history with my doctor-pain management? Let them think on that one! I know the answer and so does my doctor!

    “TIME TO DITCH THE VA IG BITCH!”
    NEXT WHAT SHALL WE EVER DO ABOUT THE SOAP SELLING VA OIG? CLUE!

  6. This is Frank P. Calderon again, they have the burden of proof to prove we are wrong and undeserving of, or due consideration, and I am not referring to a handout but reciprocation for all we lost in the service of our country and maintaining the freedom, of not only a handful but as I often say for our 365,000,000.+ Americans,including the ingrates that now turn their backs on us, and I can assure many of these do not even deserve it many dodge the draft and and now enjoy the liberty they never earned; do not misunderstand I am not saying this out of bearing a grudge, but i ask who is right they or us.

    Yours for God and Country
    Frank P. Calderon

    1. You know something Frank, I’ll bet there are many people who “avoided the draft”, and are now in high positions throughout our government agencies.
      You may not hold a grudge. Yet, my “Service Number” begins-RA! I have torn feelings over this. About 14 or 15 years ago, I learned the psychiatrist I was assigned to in the VA was a Vietnam War Protestor. When she said she “…was wrong in protesting the veterans.” I couldn’t bear looking at her! When I returned in January 1969, we were greeted by protesters at Sea-Tac airport throwing balloons filled with urine. I’ve NEVER forgotten that. I guess I never will! I’ve also been told I wasn’t welcome in a restaurant. Because I had gone there. That was done in front of my mother, 21 January 1969! I won’t forget that incident either.
      My older sister still won’t talk to me (after 48 years). Because I volunteered to go in the Army. Then volunteered to go to Nam.
      My father and mother understood because my dad was a WWII veteran. He was with General Patton in ALL his campaigns.
      My brother was in during the Cuban thing. He doesn’t talk much about it.
      It wasn’t unti I returned from Nam, where my dad would talk openly with me about his experiences.
      From our talks, I learned our family had an extensive military background going back MANY generations.
      So, you see Frank, I do hold some animosity toward the people who were not willing to join or be drafted in a time period where they could’ve done some form of good….. for us who did go to war for them.
      I hope I’ve explained it well. I sometimes have a hard time getting it out.

  7. Don’y give up the fight we must continue, this is just a challenge we must encounter to test our fortitude and stamina we encountered worse in the service of our country and overcame it, all we do is offer a counter challenge; or in military jargon counter attack..

    Yours for God and Country
    Frank P. Calderon

  8. My belief is all VSO COMMMANDERS SHOULD MAKE A MEETING TO ENOUGH TO CHAT WITH SECRETARY ROBERT McDonald of VETERAN AFFAIRS TO DISCUSS HOW TO IMPROVE VETERANS HEALTHCARE and HOPEFULLY SECRETARY OF VETERANS AFFAIRS ROBERT MC DONALD HAVE ENOUGH CLOUT TO GET VETERANS HEALTHCARE CHANGE FOR THE BEST SOMEWHAT…. FROM THE UNKNOWN VETERAN …..SEMPER FI.

    1. 1.) What you suggest ain’t ever gonna happen!
      2.) If you know anyone in the Cincinnati, (Hamilton and Butler County), Ohio areas, contact them. Ask them about P&G’s reputation. It would be to ask them about ‘Ol Bob. For example, a.) Just what did he do which caused his “sudden departure” in 2013? b.) How many times has P&G got into trouble with the “States and Federal Governments” AND “Non-profits”. The last one I read about was in March 2014, by Greenpeace. It seems they didn’t like the way P&G was obtaining “Dirty Palm Oil”!
      There’s a great deal of information out there concerning ‘Ol Bob McDonald. All one has to do is look.
      Happy Hunting.

  9. OKAY ALL, RMEMBER I AM NOT SHOUTING PLEASE!
    I PUT MYSELF BACK UP ON FACEBOOK. BECAUSE I SO TRULY CARE ABOUT THE YOUNG ONES WHO YES, SOME COULD BE MY OWN CHILDREN. I INVITE ANYONE, TO LOOK ME UP, BOY DO I HAVE MY OWN STORY TO TELL AND UNREAL AS IT IS? A TRUTH IT ALL IS AND OTHERS MIGHT RELATE TO IT. BEN, ALLOW IT PLEASE! YOU CAN SAY DAMN CRAZY OR YOU MIGHT SAY WTH? THIS IS NOT A FICTIONAL STORY ITS THE FACTS OF THE VA OIG AND VA IG HICKEY AND SHE MAY WORRY BECAUSE WHAT I DO HAVE? IT WOULD BE A SLAUGHTER-FESTIVAL IN THE HOUSE AND SENATE. “CALL ME ROGUE? HEY, I AM NOT A PALIN BUT A PERSON AND I WILL SAY IT ALL BECAUSE EVERY VETERAN SHOULD KNOW WHAT A TRIPPY RIDE THIS LIFE HAS BEEN, JOIN ME, POWER IN NUMBERS WE CAN EXPOSE AND SHARE EACH OF OUR STORIES!” “GO ASK ALICE, I THINK SHE KNOWS!”

  10. As so often happens with Washington scandals, it isn’t the original scandal that gets people in the most trouble – it’s the attempted cover-up.
    Tom Petri

    The VA is beyond repair it should be replaced.

  11. Sandra Demoruelle

    Perhaps we aren’t giving OIG credit where credit is due. According to their PR, they are great at pursuing fraud – like the Rhode Island nabbing of 150 grave stones. Its just unfortunate that saving a tax $ doesn’t really do much for Vets and their families.

    1. I also read the article about their “uncovering” the great grave stone robbery by the creep who lives in Rhode Island. What a despicable human being.

      However the one that really caught my eye today was the scumbag who worked at the E. Orange, NJ VA who took 1.2 million in kickbacks and awarded contracts to companies who never completed the work. The companies, which he helped set up, were supposed to be owned by disabled vets. They weren’t.

      There is the problem. This POS plead guilty in September, 2013 and he was supposed to be sentenced in early 2014. He could have received a maximum of 50 years and been fined 2.5 million dollars as well as forfeiture of all his property obtained through the fraud. Instead he wanders around the streets for almost two years (sentenced June 30, 2015). and as of now, none of his assets have been auctioned by the Federal Government. Oh, and his sentence? 46 months and a year supervised probation – no fine. I know what kind of message that sends to me and every other American veteran and taxpayer.

      This creeps wife is a CPA, and it was reported back in 2007, he was involved in many side businesses besides his job at the VA. They spent money on Stock car racing, scuba diving and lots of other things. This while veterans suffered.

      For those of you who have never been to the E. Orange VA, it is a mess. It was a mess in 1969 when I first went there and has gotten worse. It is in an inner city ghetto and you take your life in your hand just driving there. Your chance of being a victim of crime in East Orange? – about one in 157. Once there, at the VA you play ring-a-round-a-rosie trying to find a parking space. It is actually the closest VA to where I live – no thanks, I’ll drive another 10 miles in the opposite direction.
      .

    2. I just got done reading the articles and watched the CBS news report concerning Maynard. He got off extremely light. 1 year probation and community service. But just wait, someone will take him to a higher degree of sentencing. I believe two wrongs don’t make a right, but in this case, I believe something WILL happen to that puke……

  12. The VAOIG is nothing more than a mechanism to rubber-stamp NO ACCOUNTABILITY on the VA’s actions. Big surprise — what are the first two letters in VAOIG? Repeat after me; the VA cannot be trusted to police itself. The OIG has proven time and again it cannot be trusted. People die while the VA lies. We need a completely independent agency to police the VA, but the problem is that this would happen at the federal level, and eventually the new agency would become included in the cronyism where one agency scratches the other’s back.

  13. When did the VA forget that EVERY veteran has the RIGHT to health care. When and how did they forget their mission and every VA facility shows their mission statement when you walk in – huh? what! when is that going to start. What and who is the VA for. I guess I’m misinformed!!! I thought it was for the VETERAN!!!!

  14. Am I the only one to see – look at the Pittsburg VA Health Care System. What a tremendous awesome looking VA building. Billions spent on it and probably half that money just on how great it looks, BUT they are turning away veterans left and right. SHAME-SHAME. Does anyone think the veterans care what it looks like, not the veterans they all they care for is health care. When the vets were hungry out in the field and didn’t get the finest Sirloin steak dinner did they complain – hell no a meal is a meal – food and water to keep going. Those VA leader whine an cry constantly!!
    This reminds me of the guy down the street. He bought a 2013 Cadillac for $45000 wow is it sharp and today it sets in back of his house – doesn’t run. Did not change the oil and the engine is locked up, the tires are flat and it is starting to rust – how ironic that it reminds me of the VA, looks pretty but isn’t worth shit!!!!!!

    Form but no function – examples of the VA Health Care facilities like this is all over the US but no money for VETERANS.
    The word ‘thanks’ eludes me.

    1. If you think the Pittsburgh VA is good lookin’. Take a walk on the wild side of the Los Vegas, Navada VA. It has “leather couches and chairs in waiting rooms”. It also has “Color Changing Walls”!
      Go to their website to indulge your curiosity.
      They have also asked for millions of MORE $$$$ so they can “make improvements!” What did they do, forget to purchase medical equipment?
      Oh, and let’s not forget the Billions of $$$$$$$’s being spent on Lake Nona, Florida, Aurora, Colorado, Los Angeles, California and other U.S. Cities Nationwide so their VA’s “look pretty”!
      It seems, in my opinion, our governmental agency executives have “slipped the bounds of Earth” and are now a few fries short of being a concidered a Happy Meal!!!!!!!!!!!!!!!!!!!!!!!!!

      1. The VA has slipped in a delusional world. Let’s go back to one of the defining moments in American history – The Boston Tea Party. What inspired the Boston Tea Party – ‘ NO TAXATION WITHOUT REPRESNTAION’. Where do the VA think the money comes from – hello!! I comes from the US Government and where do they get their money from – the citizens of the USA and buy the way the veteran’s ARE US citizens – hello VA are you there!!!
        One warning to veterans if you have private health care DO NOT GIVE IT UP. If you do you are screwed. I came close to doing just that then I checked into it and found out that if you need surgery or get cancer or any health care that cannot be directly related to their military and that will be the case and if it was military related the VA will do it very best to prove that it is not, hell, they don’t have to prove anything they can just say no and turn their back on the vet ‘ THE VA WILL NOT ACKNOWLEDGE OR HELP YOU IN ANYWAY’ and that cost will still come out of the veteran’s own pocket!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
        They will help you with cheap medication and do their best to send you into la la land!

      2. USAF Vet, you read my mind! Go to many of Ben’s BLOGs here and you will see I have posted MANY “comments” concerning our “Constitutional Republic”. I have also put much “Historical Information” on here I felt was Germaine to veterans and taxpayers rights!
        Only it takes a “movement”, no matter how small its beginning, to make corrupt situations better! We have seen this all through World History.
        My hopes are, the more people this “SITE” gets out to, the sooner our corrupt elected and appointed officials will realize their time is at an near end.
        With the MANY, and I do mean MANY, individuals “running for many political offices”, it’s hard to tell who is being truthfull. In my opinion, due to each one’s past records. I DON’T believe ANY OF THEM! As a friend of mine likes to say, “We have to best politicians money can buy!”
        In today’s society those words ring so freaking true!
        All government agencies need overhauled. Or, done away with completely! That’s my thoughts, and I’m sticking to them!

  15. It’s not surprising! VAOIG is just a big joke as far as I’m concerned. This new Secretary is a big joke also. He hasn’t fired anyone yet!

  16. Vassilis Margaris

    No Ben, You are not the only one, I know ALL these OIGs, both the DoD and the VA!
    Just need to change their names to “COVER-UPS”
    VAM

  17. This just out. Michelle Obama just redecorated a White House Dinning Room for $600K. This was done AFTER it was reported the U.S.Army was reducing its forces, military and civilians, by 40,000!
    What does she think she’s doing to, not only our military, but the taxpayers in a time of economic uncertainty? Has everyone in the White House lost their grip on reality?
    Why hasn’t Congress and the Senate said or done something about this? Oh wait, they will have to delegate a “committee” to ‘investigate’ right!? They will probably conclude she did no wrong, lmao!!!!!

  18. Since the CDC, physicians, VA OIG and many others say this “disease” is so pervasive in our world (paraphrasing), I have a suggestion. Of course, it may be too simple for the VA people to understand.
    How about all VA’s “flush their systems periodically!” Especially, before anyone is “moved into” a new facility. Say about every 6 to 9 months. And before and after each ‘flushing’, water samples are taken. This way, many tests can be done to insure safe and pure potable water is available to all, employees and veterans/patients!
    I understand this may be way too simple for VA to understand. But, it would insure safety for ALL concerned, don’t ya think?!

    1. I spent 30 yrs in the AF, 19 with AFSOC/23rd AF. I’m now employed at the VA in engineering. @crazyself Water samples are collected and tested more often than you listed. Super Chlorination flushes are done whenever samples dictate. Most M&O(maintenance and Operations) employees work overnight to not interfere with patients to do this. FYI, as an M&O employee I work with peers from other local big name hospitals. They have the same problems. The issues with the VA are not localized with just the VA. Issues happen everywhere. There will never be the perfect system or hospital in everyone’s eyes, just as there is no perfect political party. Of the hundreds of complaints you hear or read about, you are missing the tens of thousands of quality care complements. I have private health insurance and also a priority 1 Disabled Vet. I choose the VA over what I get locally, except for one specialist. I do sit uncomfortably for long periods to get seen on occasions, but understand why, when my Doc doesn’t rush me out after 15 minutes so he can see the next guy on time. I also know it takes a heck of a long time to get an appointment, but I work here now, I see the number seeking treatment vs the number of staff. You have no idea how some of the staff is overworked. Some due to a lack of Doctors and another due to lazy Docs. The administrators won’t fire the lazy Docs (this is my opinion, not a fact I know) because they do see some patients, even though not at a level they would like. The kicker is, there is not enough Doctors available to fill all of the positions. The last check I did on the job boards, there was an immediate need for 1200 Docs. Hard to fire slugs when you can’t fill your current needs. So the dilemma is “how do you rid the rot”? I’m sure leadership would love to know the answer…more money isn’t an option because of the federal pay scale. Congress would need to create a special pay scale for the specialists needed. Bonus’s? Yes they have them, but they are limited by law also. It boils down to how to hire a vascular surgeon who makes $500K down the street at the Heart Hospital when with bonus’s his Federal pay is below that. I have solutions but Congress gets in the way as usual. 1. Make their pay and bonus tax free 2. Free Malpractice Insurance 3. Pay off med school loans 15K or so for every year committed, minimum of 4. (It is the only way you can bring their pay up to the civilian counterpart) Doing this would make the VA attractive and then you get to choose who you hire, not just find whats out there. The next important element is the equipment needed for special surgeries, it is super expensive. We have cards that cost over 100K. Do we get ripped off, yes, just like the guys do next door. Can we do better at not getting ripped off, absolutely. Is the VA getting better, yes, remember we are a large Federal Bureaucracy subject to the same acquisition laws as everyone else, plus the added bonus of having to spend a percentage on disabled veteran owned business’s. Guess who is the worst at ripping us off, that is right the SDVOB. The VA has major strides to get through, but as an insider they are working it.

  19. Since we are on this subject, how about doing a FOIA on the Lake Nona, (Orlando, Fl.) VA. Which just last year caused an outbreak. Because NO ONE flushed the water system before 200 veterans were sent there to be in a ‘hospice’ environment ! I believe there were deaths (plural) attributed to this lack of foresight. That ‘incident’ was on all the “local news stations” in Central Florida. It may have also been reported Nationwide. Yet, no one is talking about what happened here. WHY???

    1. Let me be clear, 200 veterans were sent to the “unfinished” Lake Nona, VA hospital 100 +/- came down with this disease. There were death(s)! No one has reported anything since the “outbreak”! WHY?
      Also, this incident occurred either just last year or the year before.
      Is the reason no one is doing anything about this ‘incident’ because it happened TOO long ago?

  20. Ben, if you FOIA the OIG regarding reports of Legionella at the Wilmington VA, I will wait for the response you get from them so that I will send you some documents that will revive your surprise reflex. Remember, Michael Moreland oversaw Wilmington VA and VISN 4 moves crooked managers around. The current VISN 4 Director is fully aware and so is the VA Secretary THe medical inspector needs to retire already.

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