The supposed OIG watchdog was hit hard yesterday during a post-Memorial Day hearing that highlighted investigation failures and deceptive practices.
The Senate Homeland Security and Governmental Affairs Committee held the hearing to publicly disclose the results of its investigation into the watchdog in light of failures at Tomah VA, in Wisconsin. Tomah VA received the infamous nickname Candyland for negligent prescriptive practices that were linked to at least one Marine veteran death.
The hearing and background investigation evaluated various reports and documents assessed by OIG to determine if the watchdog engaged in cover up.
The result of the investigation should shock no one – there was a cover up ie whitewash.
OIG WATCHDOG TAKEDOWN
The Senate committee released a 350-page report along with a 5000 page PDF document containing all supporting documents. That huge report highlighted numerous chances OIG had to hold Tomah VA employees accountability for the safety of veterans but failed.
DOWNLOAD: Tomah VA Senate Report
It even highlighted one example where OIG’s report ignored reports from its own medical investigators that Dr. David Houlihan and his sidekick, Deb Frasher, were possibly under the influence during questioning.
“The VA OIG did not do enough to address allegations – and firsthand observations from its own inspectors – that Dr. Houlihan was possibly under the influence of a controlled substance.”
Later in the report, it noted one exchange with a special agent about Dr. Houlihan and Frazier possibly being high while on the job:
Q – “Do you recall having these discussions about the – the signs that – that Dr. Houlihan and Deb Frasher appeared to be under the influence of some sort of drugs?”
A – “Yes, I do recall that.” (see PDF page 211)
But when asked if the OIG inspector acted on the revelation that Dr. Houlihan, the former Tomah VA chief of staff, was high at work, the inspectors said, “No.”
Did Dr. Houlihan ignore the one rule of drug pushers? You don’t get high on your own supply, Doc.
The Senate report also highlighted my investigation into Tomah VA and OIG in the wrongful death of Thomas Baer. I plan to discuss this more tomorrow and the opinion of Dr. Lisa Nee that helped highlight OIG’s abuse of the family that belittled the Baer’s death.
For the purposes of this article, the report highlighted that OIG interpreted the Baer Family’s complaint in an effort to unsubstantiate their very reasonable complaints. It also failed to exercise common sense and community stroke standards of care.
In a nutshell, Tomah VA failed to timely diagnose and refer Baer once it became obvious that he suffered a stroke. He later died as a likely result of Tomah VA’s numerous failures.
SENATE REPORT TOMAH VA EXCERPTS
But the Baer case was only a small portion of the enormous report. The executive summary provided the following examples of OIG failures quoted directly from the report:
– From at least 2007 to 2015, serious problems of over-prescription and abuse of authority existed at the Tomah VAMC, resulting in at least two veterans’ deaths and the suicide of a staff psychologist.
– The allegations of over-prescription at the Tomah VAMC were known to law enforcement and executive branch agencies since at least 2009, as were the monikers
“Candy Land”—referring to the facility—and the “Candy Man”—referring to the facility’s chief of staff, Dr. David Houlihan.
– Employees at the Tomah VAMC referred to Dr. Houlihan as the “Candy Man” since at least 2004.
– Despite receiving various complaints over the course of several years, federal law enforcement agencies and other executive branch entities failed to identify or address the root causes. For example:
- VA consultants and peer reviews in connection with the 2007 death of a Tomah VAMC patient showed concerns about prescription practices at the facility.
- The VA headquarters identified higher-than-average prescription rates at the Tomah VAMC in 2013.
- The VA OIG received information about deficient patient care and abuse of authority in 2009 from the Tomah VAMC employees union and apparently ignored the complaints.
- The VA OIG received anonymous complaints about over-prescription in March 2011, referred the matter to the VA’s regional office, and closed the case.
- The VA OIG received a similar complaint about over-prescription in August 2011, initiated a health care inspection, and ultimately closed the case in 2014 with a non-public report.
- The VA OIG received a complaint in March 2012 during its inspection— “HOUSTON, WE NEED SOME HELP DOWN HERE.”
- The VA OIG surveilled Dr. Houlihan and subpoenaed a car dealership in 2012 in connection to Tomah VAMC allegations.
- The Drug Enforcement Administration inquired about potential drug diversion relating to the Tomah VAMC in 2009, 2012, and 2015, but the DEA will not discuss the results of its investigations.
- Less than a year before he died, Jason Simcakoski reached out to multiple local and federal law-enforcement agencies, including the Federal Bureau of Investigation, about drug diversion at the Tomah VAMC. In contemporaneous Facebook and text messages, Mr. Simcakoski claimed he was in contact with the FBI. The FBI denies having a record of its contacts with Mr. Simcakoski.
– A culture of fear and whistleblower retaliation at the Tomah VAMC allowed over prescription and other abuses to continue unaddressed. The belief among Tomah VAMC staff that they could not report wrongdoing compromised patient care.
– The VA OIG’s Office of Healthcare Inspections lacks clear standards for substantiating allegations it receives. The lack of clear standards leads to the potentially arbitrary and subjective treatment of health care inspections.
– The VA OIG inspection team originally intended to publish the findings of its multi-year inspection in a public report before OIG leadership decided to administratively close the inspection without a public report. The failure to publish the results of the Tomah VAMC inspection compromised veteran care at the facility.
– The VA OIG narrowly focused its inspection of the Tomah VAMC on just the allegations it received and did not fully probe other related issues it observed during the inspection, including the interaction of opioids with other medication, and the potential impairment of Dr. Houlihan during an interview with OIG staff.
– The VA OIG ignored findings of independent pharmacy consultants retained to evaluate prescription practices at the Tomah VAMC, including findings that the facility could be in danger of losing its controlled substance license.
– The VA OIG, under acting leadership of Deputy Inspector General Richard Griffin, lacked independence and transparency. The VA OIG dismissed concerns about whistleblower retaliation at the Tomah VAMC and its non-public administrative closure prevented the Tomah community from fully knowing the concerns about the facility.
– There is uncertainty about the date on which the VA OIG completed its Tomah VAMC health care inspection. The administrative closure notes a handwritten date that appears to be March 2014, but internal OIG case tracking documents show an August 2014 date.
– The reporting structure of the Tomah VAMC pharmacy department to the facility’s chief of staff led to conflicts of interests that discouraged pharmacists from reporting concerns about Dr. Houlihan’s prescription practices.
– In addition to managing a large patient case load, Dr. Houlihan served for a time as the facility’s acting director or chief of staff, creating a potential conflict between his administrative duties and his care of veterans at the Tomah VAMC.
– Dr. Houlihan was the facility’s acting director or chief of staff while still seeing patients, creating a conflict of interest with respect to the Tomah VA police’s inquiries into potential drug diversion at the facility.
So how is that? OIG thought the chief of staff, Dr. Houlihan, might be high on the job but did nothing. Rampant conflicts of interest were found but not acted on. Cover-ups seem to be the only thing coming out of OIG.
I remember when they published their whitewash of the Baer case by failing to use common sense and treatment standards to evaluate the claims. In OIG’s hellish quest to cover-up wrongdoing, they tried to make the Baer family look like liars to the public that barely read past the first sentence of any press release.
Luckily, this turned around in the end for the Baers thanks in large part to Dr. Nee’s expert review, but not without taking a real toll on a family that already paid the ultimate price.