Laurels & Lances

Laurels & Lances.

Lance: To Dr. Robert Petzel. The Department of Veterans Affairs’ top health official, appearing at The National Press Club in Washington to tout planned tech upgrades, claimed he had a meeting, then stared straight ahead and refused to acknowledge a Trib reporter’s questions about the Pittsburgh VA Healthcare System’s deadly 2011-12 Legionnaires’ disease outbreak. The doctor’s reprehensible stonewalling speaks volumes about the VA’s arrogance, self-interest, dereliction of its sacred duty to America’s veterans and disregard for public accountability.


VA hospital failures bring senator home | Opinion | Columbus Ledger Enquirer

VA hospital failures bring senator home | Opinion | Columbus Ledger Enquirer.

Under other circumstances Sen. Johnny Isakson might have been showboating for the voters. He is, after all, a politician, even if he isn’t up for reelection until 2016.

But Isakson’s attention to abuses at Atlanta’s VA hospital, ever since those abuses were revealed in a federal report and highlighted in an Atlanta television investigative series, have borne little resemblance to showboating. Neither did his decision to set up a Senate “field hearing,” a rare event that took place Wednesday at Georgia State University.

It all has the ring of genuine outrage. And it’s outrage every Georgian — every American — should share.

Some of the specifics have been outlined in news stories and commentaries, in this newspaper and elsewhere. The short version of a long, ugly story is that mismanagement, neglect and sheer incompetence have led to the deaths of at least three mental health patients at Atlanta VA Medical Center. One committed suicide in the hospital and wasn’t discovered for more than 24 hours. Others simply got lost in the bureaucratic maze. For a time, the report revealed, one out of every five veterans who showed up seeking mental health care never got it.

Among those being asked some tough questions Wednesday were high-ranking officials of the Department of Veterans Affairs and hospital administrators. Isakson pressed Dr. Robert Petzel, VA undersecretary for health, on changes that have been and will be made.

The VA official said there had been “both corrective and administrative actions taken,” and that two people “involved in this process have resigned from, retired from the VA.”

How much responsibility those two unnamed ex-employees bear, and how effective the operational changes will be, are questions impossible to answer, at least for now.

The facility’s new director, Leslie B. Wiggins, who took over leadership of the embattled facility in May, outlined some substantial changes the hospital has made in oversight and patient access. When a TV reporter asked Isakson if he was satisfied, the senator answered, “So far. It’s not finished yet.”

It shouldn’t be. Atlanta VA Medical Center might be today’s Ground Zero for abuse and neglect of American veterans, but there have been too many others in the past and, sadly, there will be more in the future. If there’s anything that gets more lip service and less actual service than our debt to veterans, it would be hard to name.

One vet at the hearing, retired 1st Sgt. Vondell Brown with the Wounded Warrior Project, was quoted in Bloomberg News: “The bottom line is we sit here and talk about policies and procedures and talk about what’s right and what’s wrong, but I think for simple veterans like myself, we really don’t care how much you know until we know how much you care.”


Read more here:

Murphy seeks reversal of bonus given to Pittsburgh VA leaders during Legionnaires’ outbreak – Pittsburgh Post-Gazette

got bonus? Our effort to recognize VA executives who have alredy recognized themselves with a cash bonus while providing substandard service to veterans! More on VAmalpractice.infoMurphy seeks reversal of bonus given to Pittsburgh VA leaders during Legionnaires’ outbreak – Pittsburgh Post-Gazette.

U.S. Rep. Tim Murphy sent a letter to U.S. Veterans Affairs Secretary Eric Shinseki today asking him to rescind recent bonuses given to leaders of the regional and Pittsburgh VA offices given the ongoing revelations about a Legionnaires’ outbreak.

The letter was in response to a letter sent last month to Mr. Murphy, an Upper St. Clair Republican, that upset Mr. Murphy because Mr. Shinseki defended regional VA director Michael Moreland saying Mr. Moreland “is an outstanding professional who continuously demonstrates strength, commitment, integrity, and a relentless commitment to public service.”

Mr. Murphy and Rep. Keith Rothfus, R-Sewickley, wrote to Mr. Shinseki earlier asking why Mr. Moreland and others received bonuses even as the Legionnaires’ outbreak was ongoing.

“In your reply,” Mr. Murphy wrote Mr. Shinseki today, referring to the July letter, “you stated the VA ‘can and will do more to prevent future incidences.’ While preventing the spread of infectious diseases should be a top priority for VA leadership, the department must also hold responsible those in a position of authority who did not adhere to the VA’s own directives and standards of care. And at the very least, the taxpayers should not be giving them bonuses.”

In the final report on the outbreak at the Pittsburgh VA, the federal Centers for Disease Control and Prevention found that in 2011 and 2012 at least 16 veterans were possibly or definitely infected with the disease during stays at the Pittsburgh VA and five more veterans died.

The Pittsburgh Post-Gazette reported two weeks ago that a sixth veteran may also have died after contracting Legionnaires’ at the VA.

Mr. Murphy included a list of all six men’s names in his letter to Mr. Shinseki, writing: “It is in the memory of these veterans that I am writing to you today.”

In addition to asking Mr. Shinseki to rescind bonuses to the leadership at the Pittsburgh VA, Mr. Murphy asked that Mr. Shinseki tell him within 10 business days “whether there have been any suspensions, sanctions or firings of individuals who contributed to the failures that led to the November 2012 outbreak. The review is not over; our congressional investigations continue.



Read more:

Jeff Miller Chairman of the HVAC …Vets deserve better than VA’s practice of rewarding failure | House Committee on Veterans’ Affairs

Vets deserve better than VA’s practice of rewarding failure | House Committee on Veterans’ Affairs.


The Department of Veterans Affairs has received a lot of negative attention lately for failing to adequately deliver the care and benefits America promised our veterans.

In addition to the department’s massive disability-benefits backlog, a disturbing pattern of preventable veteran deaths and other patient-safety issues has emerged at VA hospitals around the country.

Sadly, the department’s widespread and systemic lack of accountability may be encouraging more veteran suffering instead of preventing it.

Examples of the department’s lack of accountability are numerous. But almost as plentiful — and even more shameful — are the many cases where VA employees and executives are being rewarded rather than punished for their incompetence.

Officials with the VA Pittsburgh Healthcare System have botched the handling of a deadly Legionnaires’ disease outbreak at nearly every turn. Five veterans are now dead from the pneumonialike disease. But instead of giving those who failed to prevent the outbreak pink slips, VA gave them glowing performance reviews and huge bonuses.

According to the Centers for Disease Control and Prevention, up to 21 veterans were sickened between February 2011 and November 2012, but that didn’t stop VA Pittsburgh Director Terry Gerigk Wolf from receiving the highest possible score on a VA performance review covering the bulk of the outbreak period.

Shockingly, Wolf’s review makes no mention of the outbreak, and instead praises her for leading a “groundbreaking Civility Initiative” and helping improve her employees’ resume-writing skills.

Memories of the outbreak seem to have eluded VA officials again when they nominated Wolf’s boss, VA regional director Michael Moreland, for the Presidential Rank Award, America’s highest civil-service accolade. For Moreland, the honor included a whopping $62,895 bonus, which he formally accepted just three days after VA’s inspector general reported VA Pittsburgh’s response to the outbreak was plagued by persistent mismanagement.

Most people would find VA’s celebration of Wolf and Moreland in the aftermath of a deadly outbreak they were too incompetent to stop hard to believe. Yet the situation is routine at the department, where failing executives have been collecting massive bonuses for years. Recent examples include the following:

A VA executive in charge of the nearly 60 offices that process disability benefits compensation claims collected almost $60,000 in bonuses while overseeing a near seven-fold increase in backlogged claims.

A VA health official in New York pocketed nearly $26,000 in bonuses while presiding over chronic misuse of insulin pens that potentially exposed hundreds of veterans to blood-borne illnesses.

Two April VA inspector-general reports identified serious instances of mismanagement at the Atlanta VA Medical Center that led to the drug-overdose deaths of two patients and the suicide of another. True to form, VA doled out nearly $65,000 in performance bonuses to the medical-center director who presided over the negligence.

In early May, I spent the day at the Atlanta VAMC, along with several members of Georgia’s congressional delegation. Hospital officials told us that although they had identified specific employees whose actions had contributed to patient deaths, no one had been fired.

When I asked a roomful of Atlanta VAMC leaders if there were any other serious patient-care incidents Congress needed to know about, they said no, failing to reveal a previously unreported suicide the media would expose just four days later.

This alarming pattern of complacency has cast a dark shadow over VA medical centers around the country. For months, Congress has tried in vain to compel VA leaders to take meaningful steps to prevent deaths and adverse incidents. Unfortunately, department officials seem more intent on protecting and rewarding VA’s worst-performing employees than sending a powerful message that substandard care for veterans will not be tolerated.

Our veterans deserve better. For VA’s quality of care to improve, department officials must be willing to hold accountable anyone responsible for letting patients fall through the cracks. Rewarding failure will not help VA better serve those who served our country. It will only lead to more delays and more dead American heroes.

U.S. Rep. Jeff Miller, a Republican from Chumuckla, Fla., is the chairman of the House Committee on Veterans’ Affairs.

Increased testing reveals more evidence of Legionella bacteria | TribLIVE

Increased testing reveals more evidence of Legionella bacteria | TribLIVE.

Stepped-up testing at Veterans Affairs hospitals uncovered a small amount of Legionella bacteria in a patient’s room in O’Hara, a spokesman said Wednesday.

The bacteria turned up in such a low concentration it might not have triggered decontamination or possibly even been detected before the VA Pittsburgh Healthcare System adopted stricter testing procedures this year. The new rules followed a lethal outbreak of Legionnaires’ disease that ended in November.

Since the stricter rules were put in place, nine additional patients were diagnosed with Legionnaires’ disease. Since June 26, all diagnoses were reported to state health officials within 24 hours, as most hospitals are required to do, said VA spokesman David Cowgill. A Tribune-Review investigation found that the VA used to delay reporting some Legionnaires’ cases — once by more than 100 days — in part because state rules don’t apply to the federal hospital system.

Cowgill said eight of those patients caught the disease — a form of pneumonia, from some place other than VA hospitals — while one might have caught it in the University Drive facility in Oakland. The VA disclosed that case in mid-July.

Medical staff relocated the patient at the H.J. Heinz campus after finding Legionella in his room on July 25, Cowgill said. He has not been diagnosed with Legionnaires’, Cowgill said. The bacteria live in water but must be inhaled to infect someone, for instance through water vapor in a shower.

The bacteria turned up in a nursing home-style Community Living Center with 262 beds.

The VA flushed the building’s water lines with hyperchlorinated water the day the sample turned up positive, he said.

“We communicated with our employees and maintained patient care throughout the hyperchlorination treatment period, and our infection control specialists have remained in contact with the relocated patient,” Cowgill said. “He is currently in good health.”

Testers measure Legionella in units called CFUs, for colony-forming units. The concentration found at Heinz was seven CFUs per milliliter of water. National VA guidelines say hospitals should use tests that detect amounts as small as 10 CFUs per milliliter. The VA Pittsburgh’s new guidelines require decontamination after discovery of even one colony.

The Centers for Disease Control and Prevention, in its report on the Pittsburgh outbreak, said there is no safe level of Legionella.

VA administrators in Washington are rewriting hospital guidelines in response to the Pittsburgh Legionnaires’ outbreak, which ended in November. The CDC linked 21 illnesses and five deaths to the outbreak, although a Trib investigation found elevated levels of Legionella in VA Pittsburgh hospitals four years earlier, before the CDC said the outbreak began.

“As we have said, our current and ongoing surveillance regimen is very aggressive, and we classify even a single Legionella colony as a positive test result,” Cowgill said.

Read more: 
Follow us: @triblive on Twitter | triblive on Facebook

Hearing Seeks Answers from VA | Fort Mill Times – Fort Mill, SC

Hearing Seeks Answers from VA | Fort Mill Times – Fort Mill, SC.

Nine out of 16 studied VA medical centers failed to follow policies meant to protect veteran patients from deadly Legionella bacteria, according to a report issued Aug. 1 by VA’s Office of Inspector General. Top VA executives in Pennsylvania and Georgia, where mismanagement has been blamed for deaths caused by Legionella, received salary bonuses and one national award for performance during the outbreak. The combination of those factors has led U.S. Rep. Jeff Miller, R-Fla., chairman of the House Committee on Veterans’ Affairs, to call for a five-year moratorium on all VA executive bonuses.

The issue is expected to reach a crescendo Sept. 9 at the Allegheny County Courthouse in Pittsburgh when a congressional field hearing led by Miller will be conducted. Its title: “Is VA Doing All it Can to Stop Veterans from Dying?”

“The American Legion is seriously concerned over accounts of preventable patient deaths in Pittsburgh and other locations around the country,” American Legion National Commander James E. Koutz said. “We commend Chairman Miller for calling this hearing to get to the bottom of, really, two problems – preventable patient deaths and executive bonuses where they have occurred.”

VA’s Inspector General reported last week that training and risk assessment procedures had not been conducted at nine out of 16 facilities with a history of problems – including three in Pittsburgh – since a 2008 VA directive demanded higher safety standards. In a separate earlier report, the VA IG office reported that mismanagement and leadership breakdowns were to blame for the deaths of no fewer than five VA patients in the Pittsburgh system.

The House Committee on Veterans’ Affairs reported that the purpose of the Sept. 9 hearing “is to examine whether VA has the proper management and accountability structures in place to stop the emerging pattern of preventable veteran deaths and serious patient-safety issues at VA medical centers across the country. In doing so, the committee will specifically look at VA’s handling of recent events inAtlantaPittsburghDallasBuffalo, N.Y., and Jackson, Miss.”

The American Legion’s Veterans Affairs & Rehabilitation Commission is meeting with staff from the VA Inspector General’s Office of Health Care Inspections this week to learn more about the report.

To see the full report, click here.

Performance bonuses for VA executives in states where preventable patient deaths have occurred and, in one case, where federal charges were filed over alleged financial kickbacks, has Koutz and The American Legion demanding answers as well.

“When we hear about salary bonuses or awards for VA directors in health-care systems under investigation for preventable deaths or facing FBI charges, it’s easy to lose faith in their leadership,” said Koutz, who leads the 2.4 million members of the nation’s largest veterans service organization. “Patient care and fiscal responsibility are top priorities of VA health-care leaders. If they break down in either of those areas, they have broken a pact with our nation and our nation’s veterans, who depend on the care they earned and deserve.”

In addition to bonuses paid to executives in Pennsylvania and Georgia where facilities were investigated for preventable patient deaths, the former director of VA’s medical center in Cleveland was recently indicted on federal charges of mail fraud, bribery, money laundering and other crimes; he received over $80,000 in bonuses from VA between 2007 and 2011.

“The American Legion cannot understand why VA would pay bonuses to senior leadership whose performance would come to warrant federal investigations,” Koutz said. “Bonuses for any VA executive should have to be extremely well-justified and fully researched, especially in today’s budget climate. Obviously, that did not happen in these particular cases.”

Miller has called for a “top-to-bottom review” of VA’s performance appraisal system. “Rewarding failure only breeds more failure,” Miller said in May when calling for a five-year moratorium on VA executive bonuses, an amendment which passed unanimously in committee and awaits full consideration by the House. “Until we have complete confidence that VA is holding executives accountable – rather than rewarding them – for their mistakes, no one should get a performance bonus.”

The American Legion has passed one recent resolution requiring that VA only reward bonuses to executives who have met “qualitative and quantitative performance measures developed by VA.”

“It’s clear from these preventable death investigations, and the federal indictment, that performance was not bonus-worthy, regardless how you measure it,” Koutz said.

The chief executive of the Pittsburgh hospital, Terry Wolf, received a $12,924 bonus for 2011, and the VISN (Veterans Integrated Service Network) director, Michael Moreland, who oversees Pittsburgh and nine other VA health-care systems in Pennsylvania, received a bonus of $15,619 and a Presidential Distinguished Rank Award this year, which came with a $62,895 reward, during the Legionella outbreak.

At the Atlanta VA Medical Center, the VA Inspector General linked three patient deaths in 2011 and 2012 to mismanagement and lengthy waiting times for mental health care. James Clark, director of the center at the time, received a $13,822 bonus in 2011. Clark retired last December.

William Montague, former director of the Louis Stokes VA Medical Center in Cleveland, was arrested June 19 by the FBI. He was indicted on 36 counts and accused of accepting bribes for influencing VA decisions and development projects, according to the U.S. Attorney’s Office, Northern District of Ohio. Montague received approximately $73,000 in bonuses between 2007 and 2010 and an additional $8,195 after he was called out of retirement to serve as interim director of the Dayton, Ohio, VA Medical Center.

Stephen Anthony, special agent in charge of the FBI’s Cleveland office, said Montague “misled staff and misused his position to enrich himself and businesses pursuing contracts” with VA.

“VA has many serious challenges to deal with as the troops come home from war and the number of veterans seeking services increases,” Koutz said. “VA now has work to do in order to restore confidence among our nation’s veterans, and to Congress, that executive leaders will be held accountable for the patient care and financial management they are entrusted to provide.”

Little Rock VA Medical Center Police Officer Who Was Convicted of Armored Car Robberry Loses Appeal-Three Ex-Police Officers Lose Armored Car Robbery Appeal | KUAR

VA Police Officer Who Was Convicted of Armored Car Robberry Loses Appeal-Three Ex-Police Officers Lose Armored Car Robbery Appeal | KUAR

Three Ex-Police Officers Lose Armored Car Robbery Appeal | KUAR.

Three former police officers and another man have lost their federal appeal over their convictions for a 2007 North Little Rock armored car robbery.

The 8th U.S. Circuit Court of Appeals on Tuesday upheld the convictions of Allen Clark, Jason Gilbert, Antonio Person and Sterling Platt.

Gilbert appealed his 3 1/2-year prison sentence, which the court also upheld.

Person, who is Gilbert’s cousin, was sentenced to 12 years in prison for leading the robbery, in which more than $400,000 was stolen.

The defendants claimed on appeal that the government didn’t have sufficient evidence to prove a conspiracy. The appeals court disagreed.

Gilbert was a Little Rock police officer, Clark was a Veterans Affairs officer and Platt was an officer at University of Arkansas for Medical Sciences.

Two VA officials retire, three reprimanded in wake of malpractice at Atlanta VA |


VA Director says firings not necessary despite controversey

VA Director says firings not necessary despite controversey

Atlanta VA where two officials retire and three resign in wake of Senate investigation into malpractice!

Atlanta VA where two officials retire and three resign in wake of Senate investigation into malpractice!

Two VA officials retire, three reprimanded |

Two U.S. Veterans Affairs officials have retired, three have been reprimanded and others are facing unspecified “actions” following reports of rampant mismanagement and patient deaths at the Atlanta VA Medical Center in Decatur, a top VA official said Wednesday.

“A number of people have had both corrective and administrative action taken,” Robert Petzel, undersecretary for health for the VA, said at a congressional hearing in Atlanta.

“Two people involved in this process have resigned – retired from the VA. There are number of actions, which are still in the process.”

Petzel did not identify the VA officials involved and said he could not offer more specifics. But he said he has shared additional details with the Senate Veterans’ Affairs Committee.

U.S. Sen. Johnny Isakson led Wednesday’s hearing at Georgia State University in downtown Atlanta. The panel also heard testimony from the VA Office of Inspector General and was expected to hear from the Georgia National Guard, a veteran with the Wounded Warrior Project and community mental healthcare officials.

Isakson called for the hearing after federal inspectors issued scathing audits about the Atlanta VA Medical Center in April. The audits linked pervasive mismanagement to the deaths of three veterans at the 405-bed hospital.

OOPS…VA misdiagnoses veteran with ALS for 2 1/2 years! New finding restores hope for vet misdiagnosed with Lou Gehrig’s disease |

OOPS..VA misdiagnoses veteran with ALS for 2 1/2 years!

via New finding restores hope for vet misdiagnosed with Lou Gehrig’s disease |

Vietnam War veteran John Williams feared he would be a casualty of war 43 years after he left the service, which included harrowing times in Vietnam.

Williams, 67, was diagnosed with diabetes in 1985 and later experienced progressive difficulty with movement and muscular control, which he said was misdiagnosed as ALS (also known as Lou Gehrig’s disease).

“I had made funeral arrangements and began to get my affairs in order after a Veterans Affairs doctor diagnosed me in October 2010 as having Lou Gehrig’s disease,” Williams said.

But, after learning about the Veterans Administration’s War Related Illness and Injury Study Center, Williams received a different diagnosis and, more importantly, a sense of hope.

Williams, who lives in southwest Ocala with Marti, his wife of 42 years, learned about the center, which has hospitals in East Orange, N.J.; Palo Alto, Calif.; and Washington, D.C.; in the VA’s quarterly publication, “Agent Orange Review.”

The publication is focused on possible victims of Agent Orange who have illnesses such as diabetes or Parkinson’s disease and may qualify for VA disability due to exposure to the potent herbicide.

Williams, a native of Waycross, Ga., moved to Starke in 1954. He enlisted in the U.S. Army in 1969, at age 23. He served on reconnaissance missions with the 4th Infantry Division 717th Recon in Vietnam for a year, beginning in July 1969.

“We were often stationed at forward bases and were subject to rocket attacks,” Williams said.

He said his experiences in war left him with post-traumatic stress disorder and that many of his health issues are from exposure to Agent Orange.

“We were often stationed at forward bases and were subject to rocket attacks,” Williams said.

He said his experiences in war left him with post-traumatic stress disorder and that many of his health issues are from exposure to Agent Orange.

“I was most recently working as a pharmaceutical representative and had problems with falling. When we had a presentation, I couldn’t stand up to applaud the speakers,” he said.

Williams’ local VA doctor referred him to the War Related Illness and Injury Study Center. In May, he traveled to Washington, D.C., for an intense battery of tests over four days.

The center’s physician team diagnosed Williams’ ailment as inclusion body myositis, which the National Institute of Neurological Disorders and Stroke of the National Institutes of Health calls a “progressive muscle inflammation accompanied by muscle weakness,” which may bring on “falling and tripping” and additional problems in daily activities.

Williams said the revised diagnosis has given him a new outlook on life.

Williams said he told the group at the center that it was a remarkable irony that a man who was a young soldier serving in Vietnam 45 years ago would be treated in 2013 by a team led by a young Vietnamese doctor during a “lifesaving visit” to their facility.

Williams’ brother, Ben Williams, accompanied him to the hospital and stayed at the nearby Fisher House facility.

“John went from having no hope to having hope. The diagnosis of Lou Gehrig’s disease had been like a death sentence for him,” Ben Williams, a 72-year-old Air Force veteran, said in a telephone interview from his home near Savannah, Ga. “The WRSCII medical team gave my brother a message of hope.”

Fort Wayne’s VA Hospital responds to Dept. of Veterans Affairs inspection report

Fort Wayne’s VA Hospital responds to Dept. of Veterans Affairs inspection report.

ort Wayne’s VA Hospital responds to Dept. of Veterans Affairs inspection report

Updated: Monday, 05 Aug 2013, 6:35 PM EDT
Published : Monday, 05 Aug 2013, 3:42 PM EDT

FORT WAYNE, Ind. (WANE) – The Chief of Staff at the VA Northern Indiana Healthcare System has reviewed the Department of Veterans Affairs inspection of its hospital and it agrees with the findings.

“This was no surprise that at any point for us, meaning we’re identifying these issues and working on these issues,” said Dr. Ajay Dhawan, Fort Wayne’s VA Hospital Chief of Staff.

The Office of Inspector General was called on by Senator Joe Donnelly and Congressman Marlin Stutzman to look into why the hospital suspended inpatient care late last year. Both Donnelly and Stutzman were surprised by the findings and found it “upsetting and inexcusable.”

The inspection found a few critical issues that need to be fixed right away. Some of those issues includes the facility did not effectively and consistently fill upper and mid-level leadership positions. It also found that managers who were in place often did not provide necessary leadership. It also looked at the quality of care given to patients, which was found to be under par.

Dr. Dhawan tells NewsChannel 15 that this report on validates the issues hospital administrators were aware of before the suspension of inpatient care last year. He said administrators have been working to fix these issues since last year, including looking at the level of service it provides in the intensive care unit.

“The answers we might come up with might vary from going to a tri-four level three ICU, to a level four ICU, to no ICU,” said Dr. Dhawan.

Another issue administrators are hammering away at is finding qualified individuals to fill management roles and provide necessary training to their first line staff such as nurses. Dr. Dhawan has been working to fill those positions.

“We’ve had success in finding two additional cardiologists since that time,” he said. “We have hired additional  hospitalists; we’ve found some mid-level managers like chief of primary car, chief of medicine that are now on board.”

In the report, it said the hospital might not be able to provide reliable services to the veterans. Dr. Dhawan said despite the findings, the hospital is more than capable to provide quality care and services to veterans who need it.