There were “systemic failures” by the federal agency charged with independently investigating complaints at a western Wisconsin Veterans Affairs medical facility known as “Candy Land” because of the free flow of prescription drugs, a U.S. Senate committee probe released Tuesday determined.
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USA Today obtained the 350-page report early.
The committee’s main concern here is the VA Inspector General, saying it lacked transparency, and was too close to the VA to actually protect veterans.
The following year, the VA opened its own investigation after Marine Corps veteran, Jason Simcakoski, died at age 35 of “mixed drug toxicity”.
The inspector general’s internal investigation into the claims of overprescription was “perhaps the greatest failure to identify and prevent the tragedies at the Tomah VAMC”, the report says. Johnson was presiding over a field hearing in Tomah on Tuesday.
Johnson also will release findings from his extensive investigation into the problems at Tomah. The deaths of three people under care at the facility also remain under investigation.
The inspector general’s office needs to “clean house”, said Wisconsin Sen. The report said that two employees were fired from the Tomah hospital after they complained.
“The OIG has learned important lessons from the Tomah VA Medical Center health care inspections”, Nacincik said.
Little progress was made on the case until February 2012, when Alan Mallinger, a physician in the inspector general’s Washington, D.C., office, was put in charge. The investigation lasted until 2014 but did not include a finding on whether Houlihan or Frasher had committed any wrongdoing regarding the over-prescription or mixing of drugs. Frasher, who worked alongside Houlihan, resigned in February 2015.
But that didn’t happen because it was outside the scope of the investigation. Houlihan was nicknamed “candy man” by some patients.
“I would say that the facts you just described”, Daigh said, “would be in my view probably over the outer boundary, but we thought that the totality of the care provided was at the outer-boundary”.
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“It was not valuable in terms of supporting allegations”, he told Senate investigators. She could not immediately be reached for comment Tuesday. Houlihan defended his record in an interview with WKOW in March. The report said he didn’t give proper care to 92 percent of his patients. “I think the outlook is favorable for positive change”. The inspector general’s office only said that there were “potentially serious concerns” about any abuse of narcotic distribution.
