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Report released on painkiller abuse at Tomah VA Medical Center

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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 finds the VA inspector general's office discounted evidence and testimony. The report says the office also needlessly narrowed its inquiry and has no standard for measuring wrongdoing.

The report says 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.

VA inspectors in 2014 found that doctors were over-prescribing painkillers. The deaths of three patients remain under investigation.

One potentially shocking revelation released in the investigation is the possibility of Dr. David Houlihan and his nurse practitioner being "impaired" during their interviews with OIG physicians during a visit in 2012.

"All the Inspector General did was inform the former acting medical director and suggest drug tests for those two individuals," Chairman Ron Johnson, said. "We have no idea of those drug tests were ever performed and my guess is if they had, we may not have suffered tragedies as a result."

The OIG testified Tuesday its inspectors were unable to find any type of criminal activity to support allegations against Dr. Houlihan and the VA.

"Our investigators went undercover looking for evidence of criminality and now I'm left with the problem of these allegations and I just don't have the facts to support many of those allegations, a member of the OIG testified.

MORE: Tomah Investigations From the Beginning 


A report on a yearlong investigation into painkiller abuse at Tomah Veterans Affairs Medical Center is released.

Republican Sen. Ron Johnson released the preliminary report Tuesday in conjunction with a congressional committee field hearing in Tomah. Johnson is chairman of the Senate Committee on Homeland Security and Governmental Affairs.

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.

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.


READ: Tomah VA investigation report


In a news release on the report, Sen. Johnson highlighted some of the issues the investigation uncovered. Among them:

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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.

Kraig Farrington (p. 6)

Jason Simcakoski (p. 45, 293)

Dr. Chris Kirkpatrick (pp. 124, 297)

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. (pp. 22, 29).

Employees at the Tomah VAMC referred to Dr. Houlihan as the “Candy Man” since at least 2004. (p. 24)

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. (pp. 10, 17)

The VA headquarters identified higher-than-average prescription rates at the Tomah VAMC in 2013. (p. 43)

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. (p. 22)

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. (p. 62)

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. (pp. 79, 183)

The VA OIG received a complaint in March 2012 during its inspection—”HOUSTON, WE NEED SOME HELP DOWN HERE.” (p. 105)

The VA OIG surveilled Dr. Houlihan and subpoenaed a car dealership in 2012 in connection to Tomah VAMC allegations. (p. 137, 140)

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. (p. 336)

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. (p. 45)

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. (p. 295)

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. (p. 195)

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. (p. 250)

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. (p. 208)

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. (p. 244)

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. (p. 334)

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. (p. 268)

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. (pp. 41, 229)

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. (p. 53)


READ: Tomah VA investigation report


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