Holding the Government Accountable

Senate Report: VA OIG Failed to Publicize Findings in Tomah

Despite years of media attention and Congressional scrutiny, problems at the Department of Veterans Affairs (VA) continue to surface. Though the VA is primarily responsible for its history of misconduct, the VA Office of Inspector General (OIG) has added to the problem by continuously failing to conduct effective investigations over the years. The most recent example is detailed in a new Senate report that shows wrongdoing at a VA facility continued over an extended period of time due to an inadequate investigation by the VA OIG.

The report tells an unsurprising tale: the OIG has long failed to carry out its duty to be an independent and effective watchdog. The investigation, conducted by the Senate Homeland Security and Governmental Affairs Committee majority staff, found that the VA OIG failed to adequately investigate and publicize VA wrongdoing. The majority staff specifically looked into an OIG review of poor medical care at the Tomah VA Medical Center in Tomah, Wisconsin.

The OIG had received numerous complaints about misconduct at the center, and opened an investigation that lasted from 2011 to 2014. However, according to the Senate report, the OIG had no “clear standard” for substantiating allegations, “selectively narrowed” the scope of its probe, and kept its review private when it was originally intended to be public.

The VA OIG’s initial review documented various instances of misconduct at the facility. One of the most alarming was that two providers at the center—David Houlihan, the facility’s chief of staff, and Deborah Frasher, a nurse practitioner—were known to prescribe dangerous levels of narcotics. Houlihan was even nicknamed the “Candy Man” for his tendency to overprescribe medications.

But none of this information was released. If the review had been made public, the Department would have been forced to investigate and address the OIG’s troubling conclusions. In August 2014, five months after the private review ended, Jason Simcakoski, a 35-year-old Marine Corps veteran and patient at the Tomah facility, died due to “mixed drug toxicity.” An autopsy showed that when Simcakoski died, he had over twelve drugs—a “lethal cocktail”—in his system. Houlihan had approved a fifteenth prescription to be added to Simcakoski’s list of medications just days before the patient’s death. Although the VA had been aware of allegations of overprescription at the Tomah facility for years, it was only after Simcakoski died that the VA conducted its own investigation of the facility. The Senate investigation found that after three months, the VA substantiated many of the allegations that the OIG did not during its three-year investigation. Houlihan and Frasher, as well as Mario DeSanctis, the facility’s director, were fired.

The Senate report verifies what VA whistleblowers have stated: the VA OIG has not been truly independent from the agency itself, and as a result, has failed to carry out its oversight duties. Other organizations, such as the Project On Government Oversight, the Office of Special Counsel (OSC), and the Government Accountability Office (GAO), have also emphasized the failures of the VA and the VA OIG.

In 2014, POGO put out a call to VA whistleblowers who had stories to tell. The result was overwhelming, with nearly a thousand contacting us with information. POGO’s investigation found that the VA suffers from a culture of fear and retaliation against those who dare to raise a dissenting voice. Whistleblowers feel that they cannot report wrongdoing to the VA or the VA OIG without fear of retribution. POGO has advocated for proper treatment of VA whistleblowers, and for the increased independence of the OIG from the VA.

Shockingly, just a few weeks after POGO began working with VA whistleblowers, the VA OIG issued an administrative subpoena demanding the names and information of all VA whistleblowers who had come forward. Since POGO had previously offered to work with the office to share trends and general information without revealing any personal information, it seemed like the OIG was merely on a fishing expedition. It wasn’t until a year later that the VA OIG dropped the subpoena.

The OSC and GAO have also shown that the VA is home to systemic failures, and that the OIG has done little in recent years to investigate VA whistleblower allegations. The OSC documented the experiences of numerous VA whistleblowers, including VA whistleblowers in Tomah, and advocated for their relief after the VA retaliated against them. The OSC has also highlighted the VA OIG’s failure to fully investigate claims of whistleblowers. And the GAO recently published a report detailing manipulated wait times at the VA, which have yet to be addressed by the VA OIG.

Despite the deep-rooted nature of the VA’s and VA OIG’s failures, a significant step forward in accountability was made when the Senate confirmed Michael Missal as permanent head of the OIG in April 2016. Prior to Missal’s appointment, the VA had no permanent Inspector General for over two years. POGO has found that permanent IGs make the offices more independent and effective. Permanent IGs are in no way beholden to the departments they investigate, and so are truly independent from them, and are also able to set long term-plans and investigations for their offices.

Ideally, Missal’s appointment will improve VA whistleblower treatment and give employees confidence that their allegations of misconduct will not jeopardize their jobs. But, while Missal’s appointment is a step in the right direction, it will take more than a permanent IG to make the VA OIG effectively fulfill its role. Continued Congressional attention will be necessary to ensure that the VA OIG performs its investigative duties and supports whistleblowers.