A 102-year-old widow of a World War II veteran cannot eat or get dressed without help, but the Veterans Administration is still refusing to grant her benefits.
Even the owner of the care home where 102-year-old Edith Reid lives was shocked when he saw the VA did not think she deserved help.
Reid may be 102-years-old, but when asked about how the VA has treated her, she does not mince words. “I think they’re rotten, absolutely rotten,” Reid said.
Her husband served in the Navy during World War II. For the past two years, her daughter has been trying to get VA benefits to help cover the $2,700-per-month cost to stay at the Palms at O’Neil care home in White Oak.
“She’s 102. She needs assistance in everything she does, dressing, the little things, her hair,” said daughter Carolyn Grimm.
Investigative reporter Paul Van Osdol asked Reid if she could get by on her own.
“Well no, I could not, no way. I’d be lucky if I lived overnight,” Reid said.
But in a letter denying the claim, the VA said they called the Palms and “the administrator told us that they do not provide you with medical care or assistance with your activities of daily living.”
The director of the VA Pittsburgh Healthcare System received top-level ratings on an evaluation from regional director Michael Moreland amid a Legionnaires’ disease outbreak that killed at least five veterans and sickened at least 16 more under her watch, the Tribune-Review has learned.
CEO Terry Gerigk Wolf gave herself high praise for her performance over nearly two pages of the 11-page annual evaluation for the period Oct. 1, 2011, to Sept. 30, 2012, which the Trib obtained. Wolf said she exceeded expectations in all her duties, oversaw consolidation of three hospital campuses into two with the closing of the Highland Drive facility, strengthened ties with veterans and built workplace respect, among other accomplishments. Moreland gave her the top rating in five critical areas when signing off on the evaluation.
But neither Moreland nor Wolf mentioned in the evaluation the discovery of apparently deadly Legionella bacteria at critical levels in the water lines at the VA Pittsburgh.
“I don’t know what’s more disturbing: that five veterans are dead from a Legionnaires’ disease outbreak VA Pittsburgh Healthcare officials were too incompetent to stop, or the fact that some of those same executives feel their dreadful mismanagement of the outbreak doesn’t bear mentioning in their performance reviews,” said Rep. Jeff Miller, the Florida Republican who chairs the House Committee on Veterans’ Affairs.
Wolf and Moreland did not respond to Trib questions or a request for an interview. Pittsburgh VA spokesman David Cowgill would not say why Wolf’s evaluation neglected to discuss Legionella.
“Mrs. Wolf has a long-standing history of successfully leading large, complex health care systems within the VA,” Cowgill wrote in the email. “She is an innovative leader in solving problems and moving the organization forward to face the ever-challenging and changing needs of providing first-rate health care to our nation’s veterans.”
He said the assessment of Wolf, who took over as CEO in April 2007, followed a national VA plan for evaluating senior executives. It emphasizes five core categories: leading change, leading people, building coalitions, demonstrating business acumen and driving results.
Moreland gave Wolf the highest rating in each category. He said she “flawlessly executed” the $592 million budget for the Pittsburgh VA, helping to cut the workforce by about 5 percent — or 126 people — to free some money for “veteran-centered care initiatives.”
Wolf took nearly two pages to outline her achievements, including the management of more than $39.9 million in construction projects and the opening of two new buildings in O’Hara and Oakland. Wolf noted that the O’Hara facility features a putting green at a rehabilitation pavilion.
Twice during her evaluation period, Legionella bacteria hit levels considered alarming under national standards set by the Department of Veterans Affairs, according to test results obtained under the Freedom of Information Act.
The Centers for Disease Control and Prevention later determined as many as 21 veterans contracted the waterborne bacteria — which can lead to a deadly pneumonia by breathing it in from showerheads or other water outlets — between February 2011 and November 2012 on the Oakland and O’Hara campuses.
A Trib investigation found Legionella levels reached threatening levels on five earlier occasions dating back to September 2007, leaving open the possibility that even more veterans were sickened with Legionnaires’ disease. The CDC acknowledged it did not review water testing results back to 2007 and declined a Trib offer to receive the documents.
Judy Nicklas’ father-in-law, World War II Navy veteran William E. Nicklas of Hampton, was among the five veterans who died in the outbreak period.
“This review appears to me to be a case of commanders pinning medals on their own chest while the soldiers are left dying in the fields,” said Nicklas, of Adams in Butler County. “I would urge every veteran to take a stance and protect the services to which they are entitled. Each and every veteran group should speak out to their congressmen and demand a change.”
Miller called Wolf’s glowing evaluation “undeniable proof” that the VA needs to review its performance-appraisal system.
Wolf, whose base salary was listed at $179,700 for 2011, received no performance bonus for her work in fiscal year 2012, according to documents the VA released to the Trib. Under congressional pressure after a host of problems, VA officials in Washington said in April they would defer performance awards for some unspecified department executives.
Moreland and Wolf received performance bonuses of $15,619 and $12,924, respectively, for 2011. Reps. Tim Murphy, R-Upper St. Clair, and Keith Rothfus, R-Sewickley, called for accountability and transparency.
“While veterans are still waiting on average 300 days for their claims to be addressed, and knowing Legionella bacteria was a problem at the Oakland VA for five-plus years, it’s hard to comprehend how performance bonuses are routinely approved for top hospital officials given the systemic failures they’ve presided over,” Murphy said.
A Philadelphia Eagles Fan Responds to the VA’s Callous Disregard of the Death of Five Pittsburgh Steelers Fans
As a Philadelphia area native and Philadelphia Eagles fan, I never thought that I would ever mourn the loss of a Pittsburgh Steelers fan. My father was a lifelong Eagles fan and even worked as an usher at Franklin Field, while he was studying to be a veterinarian at the University of Pennsylvania, so that he could see the games during the fifties. In the sixties and the seventies we had a standing bet. My father would bet me that the Eagles would finish over .500. It was a bet that I won more than I care to remember. Throughout my youth, the Eagles were perennial disappointments, while the Pittsburgh Steelers and Mean Joe Greene seemed invincible. The Pittsburgh nemesis, was undoubtedly magnified in my household, by the fact that my father’s high school, regularly got trounced on Thanksgiving when it played its traditional turkey day game, against the high school that produced Franco Harris, Giuseppe Harris, and host of Harris relatives, who could be counted on to make us thankful that we only had to play them once a year.
The Legionella out break at the Pittsburgh VA, made me put aside my childish envy of Pittsburgh Steeler’s fans and feel the pain that each of these veterans’ families must have felt. My sympathy for them has increased as the Pittsburgh VA’s handling of the tragedy, has become a debacle. Unfortunately, this week’s testimony in Congress showed that the VA has no interest in putting aside its childish ways. Instead, of honoring the deaths of these veterans, by agreeing to the proposed legislation that would make it mandatory for the VA to report, like all other hospitals, infectious diseases, so that other hospitals, can know about them, the VA sent witnesses to testify that the VA thought its reporting should only be “voluntary.”
It is hard to believe that Robert L. Jesse, the VA’s deputy undersecretary for health would testify that the VA’s participation in a system that would provide medical care providers with real time data should be “voluntary.” Perhaps he was hoping that the members of the Committee had not read his recent article where he espouses the importance of access of real time data in providing patient care? While Dr. Jesse’s article states that it is important for the VA to have real time data for patient care, his testimony before Congress, showed little concern for providing real time data to non-VA hospitals about infections that posed risks at non VA hospitals. His article R.L.Jesse Three Principles for Improving Health Care in Managed Care Magazine Online stated:
What can health plans and provider organizations learn from the Veterans Health Administration (VHA) about improving health care delivery? Our experience points, to three key principles: building healthy health care systems; leveraging the interdependence across organizations; and shifting toward sustained provider-patient relationships rather than just encounters.
1. To ensure healthy patients, you must have healthy health care systems. In other words, to deliver true evidence-based care, evidence-based management is necessary to support it. Information, of course, is the key. If information is important enough that it is needed to manage the patient or the system, then it must be acquired as part of the workflow process; we call that transactional quality and management. Real-time data is required for true systems improvement in health care, and in the end, better information will lead to better decisions and, in turn, to better health.(emphasis supplied)
“As I see it, one of the goals of the accountable care organization envisioned in health care reform is to create a focus of responsibility to ensure true continuity.” He never defines what “accountability” or “responsibility” are in the article. During his testimony before Congress, he made it clear they mean nothing; because he said that the VA shouldn’t even have to pay a fine if it did not report another infectious disease outbreak, as the money would come from “patient care”. Interestingly enough, there was never any explanation as to why future fines would be paid for out “patient care” instead of from $64,000 bonuses for executives, luxury office space in the DelMonte Center or conferences in Orlando? This sort of malleable morality is to be expected from a doctor who did medical research that was funded by “the tobacco industry” while he was a professor.
It’s time for the people who run the VA to get some skin in the game. By “run the VA” I don’t mean the Secretary. I mean imposing responsibility on individual VA executives who run the VA’s hospitals. In 2012, these executives received $2,200,000 in bonuses because their efforts delivered such splendid results to our nation’s veterans. If they are rewarded for their success, it seems only fair that when things go wrong, that they should be held accountable for their failures. Five veterans have already proven that voluntary regulations do not mean anything, to the VA’s current entrenched bureaucrats, it is time to send them a message that they get. Fines that will be paid, from out of one government pocket into another government pocket, are nothing more than accounting sleight of hand. Let’s see the VA go after the officials that are responsible for these things the way that the VA prosecutes veterans who have improperly claimed benefits. Perhaps a few jail sentences will deter the VA’s employees from the temptation of not reporting Legionella. Congress should make it a felony to fail to report it. Anything less and these five Steelers fans have died in vain.
W. Robb Graham
Two high-ranking officials of the Department of Veterans Affairs say they support recently introduced legislation requiring hospitals to disclose Legionnaires’ and other infectious diseases to state and local officials. But they want to be exempt from paying fines for failing to do so and, oh, yes, they want the mandate to be “voluntary.”
Robert L. Jesse, the VA’s deputy undersecretary for health, told a House Veterans Affairs subcommittee on Wednesday that the agency “is committed” to better reporting. Jane Clare Joyner, the VA’s assistant general counsel, says fines would be better spent on patient care.
Well, isn’t that special. The same VA that appears to have worked overtime to escape accountability — and, dare we say it, gone to great lengths to hide years and years of repeated Legionella bacterial outbreaks at its Pittsburgh-area hospitals that killed people and sickened others — now wants a special dispensation.
Talk about arrogance.
Congress should not budge one fraction of an inch in demanding rigorous infectious disease reporting to all levels of government. And VA officials, especially those overseeing Pittsburgh operations, should feign no surprise should the Justice Department bring criminal charges for such reprehensibly lax, if not reckless, conduct.
Supporters of the reporting requirement call the fines a “compliance motivator.” Given the VA’s consistent behavior, we can think of no better “compliance motivator” than an indictment and the threat of prison time.
Veteran’s case thrown out of Court for failing to comply with North Carolina Medical Malpractice Expert Pleasing Requirement
This matter is before the court on defendant’s motion to dismiss. Plaintiff has responded, and this matter is ripe for adjudication.
Plaintiff, proceeding pro se, brings this action alleging medical negligence against the United States Department of Veterans Administration (“VA”) resulting from the surgical removal of what he refers to as “tumors” on his body. His allegations include, among other things, improper patient consults, assessments, procedure and policy leading to incorrect surgery, coercion to undergo surgery, lack of informed consent prior to surgery and incorrect surgical procedure.
Plaintiff filed an administrative tort claim with the VA on February 10, 2011, which was denied on April 29, 2011. Following denial of his request for reconsideration, plaintiff filed the complaint in this court on October 23, 2012.
The United States has sovereign immunity unless it waives that immunity, and even if it does waive immunity,  it may be sued only to the extent of the terms of the waiver. United States v. Sherwood, 312 U.S. 584, 586, 61 S. Ct. 767, 85 L. Ed. 1058 (1941). The Federal Torts Claims Act (FTCA} provides a limited waiver of sovereign immunity for a tort committed by a government employee within the scope of his employment. The limited waiver provides that the United States may be held liable only to the extent that a “private person would be held liable to the claimant in accordance with the law of the place where the act or omission occurred.” 28 U.S.C. § 1346(b); see United States v. Muniz, 374 U.S. 150, 152-53, 83 S. Ct. 1850, 10 L. Ed. 2d 805 (1963). Since the acts alleged in the instant case occurred in North Carolina, North Carolina law applies to plaintiff’s FTCA claim.
In North Carolina, a plaintiff alleging medical malpractice must comply with North Carolina Rule of Civil Procedure 9(j), which requires that a plaintiff include in his complaint an assertion that an expert in the same field as the allegedly negligent medical provider’s field of practice reviewed the medical care at issue and is willing to testify that the treatment did not comply with the applicable standard of care. See N.C. Rule Civ. P. 9(j). Failure to comply with Rule 9(j) is grounds  for dismissal. Moore v. Pitt County Mem’l Hosp., 139 F. Supp. 2d 712, 713-14 (E.D.N.C. 2001); Alfaro v. United States, No. 5:09-CT-3073-D, 2011 U.S. Dist. LEXIS 12409, 2011 WL 561320 (E.D.N.C. 2011); Thigpen v. Ngo, 355 N.C. 198, 202, 558 S.E.2d 162 (2002).
Plaintiff seeks to hold the United States liable for personal injury arising out of the furnishing or failure to furnish medical services provided by the VA. Because plaintiff’s claims sound in medical malpractice, he must comply with the certifications requirements of Rule 9(j). See N.C. R. Civ. P. 9(j); N.C. Gen. Stat. § 90-21.11 (defining “health care provider” and “medical malpractice action”).
Plaintiff has failed to comply with Rule 9(j), and therefore his complaint must be dismissed.
For the foregoing reasons, defendant’s motion to dismiss is GRANTED. The clerk is directed to close this case.
This 17th day of June 2013.
/s/ Malcolm J. Howard
Malcolm J. Howard
Senior United States District Judge
Bliss v. United States VA, 2013 U.S. Dist. LEXIS 84796, 1-3 (E.D.N.C. June 17, 2013)
Honorable Mike Coffman,Subcommittee on Oversight and Investigations
June 19, 2013
The three bills we will consider today are the result of investigations conducted by this Subcommittee in the course of its oversight duties that have revealed poor judgment and mismanagement by the Department of Veterans Affairs.
These bills are intended to heighten the protections for our veterans at VA medical centers and prevent the recurrence of problems identified in the investigations.
H.R. 1490, the Veterans’ Privacy Act, was introduced by the Chairman of the Full Committee, Representative Jeff Miller. The bill directs the Secretary of Veterans Affairs to prescribe regulations to ensure that, in the absence of informed consent by the patient or their legal representative, any visual recording can only be conducted under limited circumstances such as under court order.
In April, I introduced H.R. 1792, the Infectious Disease Reporting Act. Based on investigations conducted by this Subcommittee, as well as a hearing in February it is clear that VA needs to be held to the same standard for infectious disease reporting as its healthcare counterparts in each state.
The Infectious Disease Reporting Act will require VA facilities nationwide to comply with state infectious disease reporting requirements. Once reported to the state, this data will be reported to the Centers for Disease Control and Prevention and used to monitor public health. Each state faces its own unique challenges regarding infectious diseases and the Infectious Disease Reporting Act takes this into account. It is baffling to me that the University of Pittsburgh Medical Center Hospital, which sits just a few hundred feet from the Pittsburgh VA medical center, is required to report infectious diseases while the VA hospital is not.
The news reports from Pittsburgh this past weekend detailing the extent of the Legionella problem and that it dates as far back as 2007 underscore the need for this legislation. The fact that VA provided information to reporters that this Subcommittee has been requesting since January is unacceptable. This lack of transparency looks like an attempt to evade legislative oversight and makes me wonder whether there is more to this story than what VA has chosen to reveal.
The need for the infectious disease reporting act is reflected not just in the Legionnaires’ Disease outbreak in Pittsburgh. Just last month almost twenty veterans tested positive for hepatitis A or B after a VA hospital in Buffalo admitted to reusing insulin pens on patients.
Time and again we have heard from VA that they are industry leaders in various areas, but in infectious disease reporting, VA doesn’t even compete.
Our final bill today is H.R. 1804, the Foreign Travel Accountability Act, which was introduced by Congressman Tim Huelskamp, a member of this Subcommittee. This bill directs the Secretary to submit to Congress semiannual reports on foreign travel. The reports will include, among other things, the purpose each trip, the destination, the total cost to the Department.
In January, after VA told him the State Department may have records on VA foreign travel, Chairman Miller sent a request to the State Department for more information. Just last week he received the State Department’s two sentence reply which referred him back to VA. This ridiculous finger pointing clearly exhibits the need for this legislation.
It is important that taxpayer dollars appropriated to VA are properly spent on providing the care and benefits our veterans have earned. Not sending VA employees abroad on taxpayer subsidized vacations that do little to improve the care veterans receive.
The Department of Veterans Affairs would support a bill by Pittsburgh-area congressmen requiring its hospitals to disclose Legionnaires’ and other infectious diseases to state and local health officials, but wants an exemption from proposed fines and would prefer voluntary reporting rules, VA officials said Wednesday.
“VA is committed to expanding and making more consistent its reporting” of diseases to local and state health agencies, Robert L. Jesse, the VA’s principal deputy undersecretary for health, told the House Veterans Affairs subcommittee on oversight and investigations.
Jesse’s comments marked the first position the VA has offered on the legislation, proposed by Reps. Tim Murphy, R-Upper St. Clair, and Mike Doyle, D-Forest Hills, after the Legionnaires’ outbreak in the VA Pittsburgh Healthcare System. At least five veterans died and at least 16 others contracted Legionnaires’ disease between February 2011 and November 2012 at VA campuses in Oakland and O’Hara, according to the federal Centers for Disease Control and Prevention.
It remains unclear whether more veterans may have fallen ill or even died from bacteria-tainted water at the VA Pittsburgh Healthcare System campuses. The Tribune-Review, using documents obtained through a Freedom of Information Act request, reported Sunday that Legionella bacteria were found in water samples dating back to September 2007 — more than five years before the VA publicly disclosed the outbreak. The CDC said it checked medical records back that far but acknowledged it did not ask for earlier water sample reports and did not want the documents when offered by the Trib.
The Trib investigation underscored the need for the bill before the House, said Rep. Mike Coffman, the Colorado Republican who chairs the congressional VA oversight panel.
“The fact that VA provided information to reporters that this subcommittee has been requesting since January is unacceptable,” Coffman said. “This lack of transparency looks like an attempt to evade legislative oversight and makes me wonder whether there is more to this story than what VA has chosen to reveal.”
Pittsburgh VA officials “could have and probably should have” more readily shared information with government health officials as the identified outbreak developed, state Secretary of Health Michael Wolf told the Trib in April. The newspaper revealed then that VA hospitals escape state and local health rules that mandate the reporting of Legionnaires’ and other infectious diseases to government monitors, though many VA hospitals file the reports voluntarily.
Doyle and Murphy’s bill, introduced in May, would require VA facilities to follow any local and state standards for those disclosures. It also would allow state health agencies to pursue civil action and impose the same civil fines for failure to comply with reporting requirements that private hospital systems face.
Jesse told House VA subcommittee members that VA officials would prefer a voluntary reporting approach instead of a congressional mandate, but they agree public disclosures are important to help identify and stop disease outbreaks quickly.
If the proposed bill is adopted, the VA wants an exemption from potential fines for violations, said Jane Clare Joyner, assistant general counsel for the department. She told the congressional panel the VA would rather keep those funds for patient care.
Rep. Dan Benishek, R-Mich., pushed back, saying the fines would encourage VA hospitals to take the reporting requirement seriously.
“We’re just trying to think of a compliance motivator, I guess,” Benishek said.
Rep. Keith Rothfus, R-Edgewood, announced Wednesday he would join as a co-sponsor of the House version of the legislation.
RICHMOND, VA— The McGuire VA Medical Center is working to notify hundreds of patients after a recently hospitalized veteran tested positive for tuberculosis.
As many as 490 patients and staff members may have been exposed to the bacterial disease, according to Darlene Edwards, the Public Affairs Officer for the Richmond VAMC.
The infected veteran was admitted to a community facility in late May, where he was diagnosed with active pulmonary tuberculosis, Edwards said.
8News is told the veteran was hospitalized and discharged from McGuire VA Medical Center in April.
The center is now working with local public health officials for surveillance of the case, Edwards said.
Employees at the center have been notified of the incident, and the center said it is currently working to notify other patients who may have been exposed.
CLEVELAND, Ohio — The former director of the Louis Stokes VA Medical Center accepted bribes and kickbacks from crooked electrical contractor Michael Forlani in exchange for favorable information that helped Forlani receive VA contracts, according to a 36-count indictment released today.
William Montague used his influence to steer companies to lease office space from Forlani, the indictment states. The indictment also accuses Montague of performing consulting work for a private company seeking business from the VA at the same time he was employed by the VA.
The 51-page indictment accuses Montague, 61, of accepting bribes and kickbacks, and of conspiring to defraud the Department of Veterans Affairs in league with Forlani, the former owner of Doan Pyramid Electric.
The indictment documents 18 cases in which cash was e mailed from a business in Texas to Montague’s house in Brecksville. The transactions totaled nearly $50,000.
Montague was arrested today and appeared this afternoon in U.S. District Court in Cleveland, where he pleaded not guilty to the charges.
Assistant U.S. Attorney Antoinette Bacon said the charges carry potential maximum prison sentences of five, 10, 15 or 20 years each, plus fines and forfeiture provisions.
U.S. Magistrate Nancy Vecchiarelli released Montague on his own recognizance, and ordered him not to speak to any witnesses in the case or VA employees — excluding his wife, who works at the VA.
The indictment comes about three weeks after FBI agents and the Depatment of Veterans Affairs criminal investigations division searched Montague’s home in Brecksville.
Forlani, 55, was sentenced in April to eight years in federal prison for racketeering, bribery and other corruption-related charges. Forlani was the primary developer of the $125 million enlarged VA campus on Cleveland’s East Side.
Montague joined the VA in 1975 and retired in 2010. He was the medical center’s director during much of the planning for Forlani’s project.
Forlani’s business, Veterans Development LLC, was selected by the U.S. Department of Veterans Affairs to develop and manage the hospital consolidation project.
The business venture was criticized last year by the U.S. Inspector General as being ill-conceived. The office said that instead of saving an estimated $29 million a year as forecast by Forlani and local VA administrators, the consolidation to Wade Park would cost the VA nearly half a billion dollars over the next 20 years.
“Violating the public trust for personal gain cannot be tolerated, particularly at the expense of our nation’s heroes,” said Gavin McClaren, agent in charge of the VA’s criminal investigations division in Cleveland.