S. Hrg. 114–686 

TOMAH VAMC: EXAMINING PATIENT CARE AND 

ABUSE OF AUTHORITY 

FIELD HEARING 

BEFORE THE

COMMITTEE ON 

HOMELAND SECURITY AND 

GOVERNMENTAL AFFAIRS 

UNITED STATES SENATE 

ONE HUNDRED FOURTEENTH CONGRESS 

SECOND SESSION 

MAY 31, 2016 

Available via the World Wide Web: http://www.fdsys.gov/ 

Printed for the use of the 

Committee on Homeland Security and Governmental Affairs 

( 
TOMAH VAMC—2016 
U.S. GOVERNMENT PUBLISHING OFFICE

WASHINGTON : 

For sale by the Superintendent of Documents, U.S. Government Publishing Office

Internet: bookstore.gpo.gov Phone: toll free (866) 512–1800; DC area (202) 512–1800

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24–127 PDF 2017

S. Hrg. 114–686 

TOMAH VAMC: EXAMINING PATIENT CARE AND 

ABUSE OF AUTHORITY 

HEARING 

BEFORE THE

COMMITTEE ON 

HOMELAND SECURITY AND 

GOVERNMENTAL AFFAIRS 

UNITED STATES SENATE 

ONE HUNDRED FOURTEENTH CONGRESS 

SECOND SESSION 

MAY 31, 2016 

Available via the World Wide Web: http://www.fdsys.gov/ 

Printed for the use of the 

Committee on Homeland Security and Governmental Affairs 

( 
(II) 

COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS 

RON JOHNSON, Wisconsin Chairman 

JOHN MCCAIN, Arizona 

ROB PORTMAN, Ohio 

RAND PAUL, Kentucky 

JAMES LANKFORD, Oklahoma 

MICHAEL B. ENZI, Wyoming 

KELLY AYOTTE, New Hampshire 

JONI ERNST, Iowa 

BEN SASSE, Nebraska 

THOMAS R. CARPER, Delaware 

CLAIRE MCCASKILL, Missouri 

JON TESTER, Montana 

TAMMY BALDWIN, Wisconsin 

HEIDI HEITKAMP, North Dakota 

CORY A. BOOKER, New Jersey 

GARY C. PETERS, Michigan 

CHRISTOPHER R. HIXON, Staff Director 

DAVID N. BREWER, Chief Investigative Counsel 

KYLE P. BROSNAN, Counsel 

BRIAN M. DOWNEY, Senior Investigator 

SCOTT D. WITTMANN, Investigator 

GABRIELLE A. BATKIN, Minority Staff Director 

JOHN P. KILVINGTON, Minority Deputy Staff Director 

BRIAN F. PAPP, JR., Minority Professional Staff Member 

LAURA W. KILBRIDE, Chief Clerk 

BENJAMIN C. GRAZDA, Hearing Clerk 
(III) 

C O N T E N T S 

Page 

TUESDAY, MAY 31, 2016 

Opening statements: 

Senator Johnson ............................................................................................... 1 

Senator Baldwin ............................................................................................... 3 

Congressman Kind ........................................................................................... 17 

Congressman Walz ........................................................................................... 19 

Prepared statements: 

Senator Johnson ............................................................................................... 33 

Senator Carper ................................................................................................. 37 

Senator Baldwin ............................................................................................... 40 

WITNESSES 

Hon. Sloan D. Gibson, Deputy Secretary, U.S. Department of Veterans Affairs; accompanied by Dr. Gavin West, Senior Medical Advisor, Clinical 

Operations ............................................................................................................ 6 

Hon. Michael J. Missal, Inspector General, U.S. Department of Veterans 

Affairs; accompanied by Dr. John D. Daigh Jr., Assistant Inspector General 

for Healthcare Inspections .................................................................................. 10 

ALPHABETICAL LIST OF WITNESSES

Gibson, Hon. Sloan D.: 

Testimony .......................................................................................................... 6 

Prepared statement .......................................................................................... 44 

Missal, Hon. Michael J.: 

Testimony .......................................................................................................... 10 

Prepared statement .......................................................................................... 58 

APPENDIX 

Majority Staff Report ............................................................................................... 63 

Minority Staff Views Memorandum ....................................................................... 439 

Responses to post-hearing questions for the Record from: 

Mr. Gibson ......................................................................................................... 443 

Mr. Missal ......................................................................................................... 454 

(1) 

TOMAH VAMC: EXAMINING PATIENT CARE 

AND ABUSE OF AUTHORITY 

TUESDAY, MAY 31, 2016 

U.S. SENATE, COMMITTEE ON HOMELAND SECURITY

AND GOVERNMENTAL AFFAIRS, Tomah, WI. 

The Committee met, pursuant to notice, at 10 a.m., at Cranberry 

County Lodge, 319 Wittig Road, Tomah, Wisconsin, 54660, Hon. 

Ron Johnson, Chairman of the Committee, presiding. 

Present: Senator Johnson, Senator Baldwin, Hon. Tim Walz, and 

Hon. Ron Kind. 

OPENING STATEMENT OF SENATOR RON JOHNSON 

Senator JOHNSON. This hearing will come to order. 

I think it would be appropriate to start the day, in light of Memorial Day being yesterday, and in light of the tragedies of some 

of the finest among us, suffering at the hands of people that should 

be taking care of them, if we can start this hearing with a moment 

of silence? 

If you will please join me? 

Thank you. 

I would also like to ask anybody who has served in military, and, 

quite honestly, their family members as well, because this is a 

service and sacrifice that affects the entire family, if you could 

please rise and be recognized? 

Thank you all for your service and sacrifice. The purpose of this 

hearing is to make sure that the rest of America honors its promise 

to you. That’s what really is the heart of this hearing. I truly want 

to thank everybody who as appeared and attended this hearing 

today. 

I want to, in particular, thank the surviving family members of 

Jason Simcakoski, Thomas Baer, Chris Kirkpatrick, and Kraig 

Ferrington. 

In March of 2015, we held a hearing where the family members 

stepped forward and whistleblowers stepped forward and provided 

powerful testimony. And, it was powerful testimony. We heard 

from Dr. Noelle Johnson, Mr. Ryan Honl, Marv and Heather 

Simcakoski, and Candace Delis. I have to believe that their testimony had an effect on the officials that were present that day from 

the U.S. Department of Veterans Affairs (VA). 

It is that type of testimony, it is that type of highlighting a problem that is going to be required if we are going to honor the promises of the finest among us. 
2 

1The Majority Staff Report appears in the Appendix on page 63. 

I do want to thank my staff for doing, I think, an extraordinary 

job of laying out the findings of a very rigorous, a very comprehensive investigation into how exactly the problems within the Tomah 

healthcare facility went on for so long without being corrected.1

I do encourage everybody, because I think we have a couple of 

hundred copies, to grab one and read all 359 pages. It lays out exactly what happened with, quite honestly, not all the information. 

I do want to say that certainly it has been my experience, because I have traveled around the State of Wisconsin and visited VA 

healthcare facilities, the vast majority of the doctors, of the nurses, 

of the administrators are doing an excellent job. They are highly 

concerned about the finest among us, about our veterans. And, they 

are doing everything they can to honor those promises. 

But the fact of the matter is, they are working within a singlepayer, government-run bureaucratic healthcare system and there 

just are inherent problems. For example, inherent problems of accountability. Inherent problems, unfortunately, within an Office of 

Inspector General (OIG) that was not living up to its mission. Who, 

I would say, was captured by the VA itself. 

So, the Office of Inspector General under Richard Griffin was 

loyal to the VA instead of being loyal to the finest among us and 

to the American public. 

This Committee, in particular, the Senate oversight committee, 

relies on independent and transparent Inspectors General (IGs). 

Government relies on them. The only hope we have of fixing problems is if you have an Inspector General’s office be the independent, transparent watchdog actually doing its job. 

And, what is very apparent in our 350 page report and the almost 4 or 5,000 supporting documents is that for years the Office 

of Inspector General from the VA did not do its job. 

And, what is an even greater tragedy is that these tragedies here 

at Tomah, I believe, could have been prevented, had the Office of 

Inspector General done its job. 

As far back as 2004, Dr. David Houlihan had been referred to as 

Candy Man. A number of people, as far back as 2008 and 2009, 

were trying to raise the alarm to a number of Departments, a number of Agencies, a number of Offices. And yet, somehow those 

alarms did not go public. 

I do want to play real quickly, if people are ready, and you can 

follow along on page 48, there were logs that Heather Simcakoski 

asked us to basically use the Capitol Police to get into her husband’s cell phone to get a record of his call logs. 

Now, during the course of our investigations, we contacted the 

Federal Bureau of Investigation (FBI) about potential contacts as 

it related to Tomah VA. They claimed there was no contact. And 

yet, we actually have a voice from a message left by a member of 

the FBI, which I would like to play right now if we can. 

[Audio]. Jason, this is Andy Chapman from the FBI returning 

your call. My phone number is (608) 782–6030. Thank you. [End 

of audio]. 

Now, we asked representatives of the FBI and the Drug Enforcement Agency (DEA) to appear today and they declined. They also 
3 

1The prepared statement of Senator Johnson appears in the Appendix on page 33. 

continue to convey to this Committee, to our staff, that they have 

no record of ever having been contacted by Jason Simcakoski. I find 

that puzzling. I find it troubling. 

Again, the failure of the Office of Inspector General to live up to 

its mission was really at the root cause of why these problems continued to go on for so long. 

I do want everybody to refer to page 208 and 209, because I 

think this is a classic example of how the Office of Inspector General, in their inspection, in their investigation here, narrowed its 

scope, refused to look beyond its scope, and, as a result, did not do 

its job. 

In 2008, according to our report, during its site visit, this is the 

first site visit directed by Dr. Alan Mallinger to the Tomah VA following reports that began in 2011. The hotline reports. During its 

site visit to the Tomah Veterans Affairs Medical Center (VAMC), 

VA Office of Inspector General officials interviewed both Dr. 

Houlihan and Deborah Frasher. During the interviews, both Office 

of Inspector General physicians and Special Agent Porter of the VA 

OIG’s criminal division observed that Dr. Houlihan and Ms. 

Frasher appeared to be impaired. 

Now, unfortunately, during that initial investigation visit, Mr. 

Mario DeSanctis was not present. So, the Inspector General’s team 

held a phone conference with Mr. DeSanctis, and in 2009 you can 

read how they informed Mr. DeSanctis about their concern with 

Dr. Houlihan and Nurse Frasher potentially being impaired, potentially being drug users. There are numerous whistleblower reports 

that also suspected that Dr. Houlihan and Nurse Frasher were 

drug users. 

I want people to read exactly what they Office of Inspector General did. All they did was inform Mr. DeSanctis and suggest that 

Mr. DeSanctis perform drug tests on those two individuals. We 

have no idea whether those drug tests were ever performed. I 

would think, if they were, back in 2012, these tragedies might have 

been prevented. 

So, again, the bottom line of what this report shows is it was the 

failure of the Office of Inspector General and the failure of other 

agencies and offices to actually highlight the problems that they 

were made aware of that allowed these tragedies to occur. 

And, we will get into this further in terms of the testimony and 

our questions to it. 

I do ask that my written prepared statement be entered into the 

record1 without objection. 

And, with that, to Senator Baldwin. 

OPENING STATEMENT OF SENATOR BALDWIN 

Senator BALDWIN. Thank you. Thank you, Chairman Johnson. I 

want to thank you for organizing this hearing today and I also 

want to add my words of appreciation to your staff, Senator Carper’s staff and to my staff in terms of the undertaking that resulted 

in this work product. It is a very significant investment on their 

part and we appreciate that. 
4 

I think the fact that we are both here again today sends an important message to this community that we will continue to work 

across the partisan aisle in order to address the problems at the 

Tomah VA. In fact, I would describe it as: there is no aisle. 

As Americans, we are united. We are united by an eternal bond 

with the families and friends of our fallen. And, we are also united 

by the sacred trust that we have with our veterans and their families. 

Today, as we hear the story of how that sacred trust with our 

veterans and their families has been broken, it is important for us 

to keep in mind what unites us. 

One profound thing that I have learned about the tragic problems at the Tomah VA is that veterans, their families, and whistleblowers all want the same thing. They want answers and accountability, but most importantly they want solutions to the problems 

at the Tomah VA so that these sort of tragedies never ever happen 

again. 

What I am committed to is fixing what has been broken. What 

I am focused on is restoring the sacred trust that we have with our 

veterans and their families. 

The Committee’s reports makes clear much of what we have 

known for some time. The problems at the Tomah VA have had 

tragic and preventable consequences. 

The report sheds light on the failures surrounding the deaths of 

Kraig Ferrington, Dr. Christopher Kirkpatrick, Jason Simcakoski 

and Thomas Baer. What this report can never do is repair the damage that their losses have had on families, many of whom are here 

with us today. 

It is just as clear to me today, as it was a long time ago, that 

the VA prescribed Jason Simcakoski a deadly mix of drugs that led 

to his death. And, those responsible at the Tomah VA for this tragic failure should have been held accountable long ago. In fact, they 

should have been accountable before Jason’s death. 

The record is clear, for far too long, serious problems have existed at the Tomah VA and they were simply ignored or not taken 

seriously, as they should have been, by the VA and the VA Inspector General. 

My office was just one of many voices who were trying to expose 

the problems at the VA. 

When my Senate office was first contacted in March 2014 with 

complaints about the Tomah VA, including prescribing practices, 

they came from an anonymous whistleblower. Someone who still 

remains anonymous today. 

We immediately brought those concerns to the Tomah VA and 

then to the VA Office of Inspector General, and then to the U.S. 

Department of Veterans Affairs headquarters in Washington, D.C. 

Four months prior to Jason’s death, I called for a full review and 

investigation from the Tomah VA. 

Two months prior to Jason’s death I called for a full review and 

investigation from the U.S. Department of Veterans Affairs and the 

VA Office of Inspector General. 

On August 30, 2014, Jason tragically died at the Tomah VA as 

a result of what was medically deemed, mixed-drug toxicity. 
5 

1The prepared statement of Senator Carper appears in the Appendix on page 37. 

2Minority Views Memo submitted by Senator Carper appears in the Appendix on page 439. 

The Simcakoski family lost a son, a husband, a father, and we 

lost somebody who faithfully served his country. 

If there is one thing that I want to come out of this hearing and 

one thing that comes from this report, I want it to be this. I want 

everyone to hear the voice of Jason’s wife Heather who said, and 

I quote, ‘‘When I look back at the past, I want to know we made 

a difference. I want to believe we have leaders in our country who 

care. I want to inspire others to never give up because change is 

possible.’’ 

Jason’s family, just like veterans and their families in this community and communities across Wisconsin, are not interested in 

finger pointing and a blame game and neither am I. That is why 

over the past year I have focused on solutions to the problems at 

the VA. I have worked across party lines to advance reforms that 

will improve transparency, strengthen protections for whistleblowers, and to provide stronger oversight of VA prescribing practices. 

I authored a reform that was recently signed into law which requires the VA Inspector General to submit reports to Congress and 

make them available to the public. That is the standard that must 

now be met. 

Last year, I had the honor of working with Jason’s family to develop legislation to provide the VA with the tools that it needs to 

prevent this type of tragedy from occurring to other veterans and 

their families. 

One year ago, I introduced this bipartisan legislation in Jason’s 

name that earned the support of many veterans service organization. And, I am so proud, Senator Johnson, to have you join in this 

effort. 

I am pleased that the House of Representatives recently passed 

a version of Jason’s bill and I am equally grateful to members of 

the Senate Veterans’ Affairs Committee for their bipartisan support of Jason’s bill, the Jason Simcakoski Memorial Opioid Safety 

Act. It is a critical reform and it continues to move forward. Families like Jason’s have a story to tell, and it needs to be heard, and 

the movement of their legislation is strong evidence that their voice 

is being heard. 

My goal is to put these reforms in place to prevent Jason’s tragedy from ever happening to another veteran or any of our veterans’ 

families. 

Change is indeed possible. Heather’s words inspire me and it is 

my hope that they will inspire all of us to work together and to prevent these problems and tragedies from ever happening again. 

I thank you, Senator Johnson, for providing me with this opportunity to join you today and I look forward to continuing our work 

together. 

Senator JOHNSON. Thank you, Senator Baldwin. 

Senator Carper, who is our Ranking Member of the Committee, 

has a statement1 and a Minority Views Memo2 that he would like 

in the record without objection. 
6 

1The prepared statement of Mr. Gibson appears in the Appendix on page 44. 

It is the tradition of this Committee to swear in witnesses, so if 

you will all four rise and raise your right hand? 

Do you swear that the testimony that you will give before this 

Committee will be the truth, the whole truth and nothing but the 

truth, so help you, God? 

Dr. WEST. I do. 

Mr. GIBSON. I do. 

Mr. MISSAL. I do. 

Dr. DAIGH. I do. 

Senator JOHNSON. Please be seated. 

Our first witness is Sloan Gibson. Mr. Gibson is the Deputy Secretary of the Department of Veterans Affairs. Deputy Secretary 

Gibson is accompanied by Dr. Gavin West, Senior Medical Advisor 

of Clinical Operations, Department of Veterans Affairs. Mr. Gibson. 

TESTIMONY OF THE HONORABLE SLOAN GIBSON,1 DEPUTY 

SECRETARY OF THE U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY DR. GAVIN WEST, SENIOR MEDICAL ADVISOR OF CLINICAL OPERATIONS, U.S. DEPARTMENT OF VETERANS AFFAIRS 

Mr. GIBSON. Let me begin by expressing my heartfelt sympathy 

to the Simcakoski family. I know that no words can ease the pain 

of your loss, but I would be remiss if I did not recognize the courage and the compassion and the deep devotion that you have displayed in all the work that you have done since Jason’s death to 

make real difference in the lives of many other veterans. 

Thank you and God bless you. 

I am accompanied today, as you mentioned by Dr. Gavin West. 

I wanted to point out, prior to his appointment to the responsibilities you have described, Dr. West served as the Chief of Primary 

Care and Associate Chief of Medicine, accountable for the delivery 

of evidence-based, high-quality, patient-centered care across VA. 

He continues to practice medicine at the Salt Lake City VA 

Healthcare System where he teaches medical students and treats 

veterans in primary care with a focus on pain management and 

substance abuse. 

He understands the issues and challenges we are facing at 

Tomah from years of traveling across the country working to optimize clinical care at many site visits to VA Medical Centers, including visits here at Tomah. 

Most importantly, perhaps, is that Dr. West served as the cochair of VA’s National Opioid Safety Program. 

Jason’s death forced us to dive deeply into the Tomah system. 

What we found was an organization facing numerous challenges in 

dire need of change and new leadership. 

The problems at Tomah have been well documented. Failures related to the prescribing practices of controlled substances, examples 

of inadequate oversight appear, and failure related to culture. 

We own those challenges and problems, those failures. I own 

those problems, those failures. 
7 

Avoidable harms to veterans are not acceptable. When they do 

occur, our obligation is to act with urgency to investigate and prevent a recurrence. 

At Tomah there was a clear and inexcusable lack of leadership 

that created and exacerbated these serious problems. 

The excellent frontline staff here at Tomah—that you have acknowledged in your comments, Mr. Chairman—working under new 

leadership, is fixing those problems. 

On October 5, we appointed Victoria Brahm as Acting Director. 

In her new role, Vicki did not wait to take action to improve veteran care. On November 27, she began executing Tomah’s 100-Day 

Plan. For those of you that are unfamiliar with this concept, 100- 

Day Plans are a best practice of new leaders as they transition into 

their roles. They are not meant to fix everything, but to set a clear 

and bold direction while delivering near-term tangible results. 

The 100-Day Plan period ended in March, but the work continues 

to transform the way Tomah leaders operate, to change how Tomah 

treats their veteran patients, and to rebuild trust with veterans, 

employees, and the community. 

Thanks to this ambitious plan and the dedication of caring frontline staff, Tomah, once a symbol of the overuse of opioids, is actually on its way to becoming a model for change and best practices. 

Let me highlight some of the great work by Vicki and the staff. 

In April, Tomah completed more than 98 percent of their appointments with in 30 days. In fact, nearly 17,000 appointments 

were completed in April. Of all of those, 217 were over 30 days 

from the day that the veteran wished to be seen. 

Their wait times are consistently among the best in all of the VA. 

For primary care, less than 3 days. Specialty care, less than 6 

days. And, for mental health, a little more than 2 days. 

Vicki and the team are working to restore trust among veterans. 

She is opening lines of communication with our veterans by opening her door, meeting with countless veterans these past months. 

Other continuing efforts include developing an academic detailing team to review the medical center’s most complex chronic pain 

patients and provide additional recommendations for their care. 

To support this initiative, more than 30 primary care and mental 

health providers attended academic detailing educational sessions 

in the month of March. 

She is also creating a veteran pain school to assess and customize alternative pain management strategies for veterans. Importantly, Tomah has reduced the number of veterans receiving 

opioids by nearly one fourth. 

Tomah partners with the Wisconsin State Prescription Drug 

Monitoring Program, a program designed to ensure veterans are 

not obtaining opioid medications from multiple providers. 

Another step forward is the effective use of VA’s audit tool, which 

allows doctors to improve practice and safety by seeing all the 

medications veterans are taking on a single dashboard. 

Vicki has made overdose education and Naloxone rescue kits 

available to patients at risk of accidental or intentional overdose. 

Naloxone has proven effective in reversing an opioid overdose. Simply put, she is finding options, alternatives, and solutions other 

than just a bag of pills. 
8 

Let me tell you about one of Tomah’s best practices. Evidence 

shows that the best outcomes in pain management occur with a 

comprehensive approach across multiple disciplines with the patient as the central focus. This empowers the veteran to be an active participant in decision making regarding pain care options. 

Tomah developed the integrated pain university, which is strongly based on patient education and empowerment. This whole health 

perspective identifies and addresses biological, psychological, and 

social aspects of pain management in conjunction with assessment 

by the Patient Aligned Care Team and any necessary specialty 

consults. 

Additionally, veterans receive information through a variety of 

elective classes taught by their respective health care professionals, 

which include pain medications, pain and nutrition, pain and sleep, 

aroma therapy, mindfulness, the neuroscience of pain, introduction 

to movement, staying motivated, and spirituality. 

The result of these and other efforts. As of the second quarter of 

fiscal year (FY) 2016, just over 9 percent of veterans at Tomah are 

prescribed some form of opioid. 

Across the entire country, across all of the VA’s population, that 

national rate is nearly 13 percent. 

Vicki and the team are also listening. They are listening to veterans, to the community, and to employees. Listening led to the development of the Tomah VAMC Veterans Experience Council and 

Strategic Partnership Committee. The Veterans Experience Council 

will help make sure that Tomah leaders have a clear understanding of how veterans perceive VA, while the Strategic Partnership Committee will work to strengthen and promote a unified approach to veteran care throughout the community. 

Vicki has hosted more than 15 employee listening sessions covering all work shifts at the Medical Center. These listening sessions are critical in getting a sense of how staff can better serve 

veterans while using input from these sessions to improve employee engagement, making sure employees are satisfied with their 

work environment. Monthly staff meetings, quarterly nurse town 

hall, and roundings with local union officers are all part of the 

larger efforts of our commitment to employees. 

As a result of these and many other actions, we are seeing 

Tomah’s performance improve, as measured both internally and by 

veterans themselves. 

By understanding the challenges and taking ownership in the 

problems, Vicki and the leadership team are improving the organizational culture and climate, providing more oversight, effective 

oversight, of care delivery, and addressing problems and prescribing practices. 

While there is more work to be done, this strategic direction has 

led to a real positive change. 

Vicki is modeling effective leadership by taking ownership and 

accepting accountability of past mistakes in order to make tangible 

progressin caring for our Nation’s veterans. 

Bob McDonald and I talk a lot about sustainable accountability. 

Making sure employees understand our mission, values, and strategy. It has accountability that results in positive veteran outcomes, 

not just in the very near term, but over the long term as well. 
9 

And I believe that is what we are seeing here at Tomah. 

Across all of the VA, our work to change prescribing practices 

and develop alternative approaches to pain management is delivering steady progress. We have also developed a predictive model 

and a clinical decisions support tool to identify patients being treated with opioids, who may be at risk of suicide-related events or 

overdose. 

This tool for opioid risk mitigation estimates the likelihood of an 

overdose or suicide event in the next year providing patient-tailored recommendations for risk mitigation and nonopioid pain management options. 

Lessons learned have caused a greater engagement and improves 

lives. 

We are also getting unwanted drugs out of veterans hands. Removal of veterans unwanted and unneeded medications reduces the 

risk of diversion, as well as intentional or unintentional overdose 

or poisonings. 

As of May 1, approximately 27,000 pounds of unwanted and 

unneeded medication have been collected and destroyed in an environmentally responsible manner. 

The overuse and misuse of opioids is a national problem, not just 

a VA problem. What we are doing here at Tomah and across the 

VA is part of a broader national effort to fight opioid addiction and 

overprescribing of powerful drugs. 

Our hope is that VA’s efforts here and elsewhere will become 

part of the national approach that will benefit not just veterans, 

but all Americans. 

We still have work to do. 

With your support and the support of many others, we will succeed. The needs of veterans cannot be secondary to other agendas. 

It is unacceptable to VA leadership and should be unacceptable to 

anyone claiming to care about our Nation’s veterans. 

I need your help to change the dialogue and a perception of this 

facility in order to get the right people interested in these jobs. 

Mr. Chairman, I appreciate your Committee’s support in identifying and resolving challenges here in Tomah. And, we look forward to your questions. 

Senator JOHNSON. Thank you, Mr. Gibson. Our next witness is 

Michael Missal. Mr. Missal is the Inspector General for the Department of Veterans Affairs. 

I had the privilege of going on the Senate floor and asking unanimous consent to have you confirmed. I know Senator Baldwin and 

members were calling for a firm Inspector General and we are glad 

we have one. 

Mr. Missal is accompanied by Dr. John Daigh, Assistant Inspector General for the Healthcare Inspections within the VA Office of 

Inspector General. Inspector General Missal. 
10 

1The prepared statement of Mr. Missal appears in the Appendix on page 58. 

TESTIMONY OF THE HONORABLE MICHAEL J. MISSAL,1 INSPECTOR GENERAL, U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY DR. JOHN DAIGH, ASSISTANT INSPECTOR GENERAL FOR HEALTHCARE INSPECTIONS, OFFICE OF THE INSPECTOR GENERAL, U.S. DEPARTMENT OF 

VETERANS AFFAIRS 

Mr. MISSAL. Thank you. Chairman Johnson, Senator Baldwin. 

Chairman Johnson, Senator Baldwin, Congressman Kind and 

Congressman Walz, thank you for the opportunity to appear today 

regarding the Office of Inspector General’s past inspections of the 

Tomah VA Medical Center and our work in the area of pain management and opioid use. 

I am accompanied by Dr. John Daigh, Assistant Inspector General for Healthcare Inspections. He is a retired Army Colonel and 

has spent over 25 years providing healthcare to soldiers. 

First, on a personal note. I want to thank all veterans for their 

great and selfless service to our Nation. 

In addition, I want to express my sympathies to the families of 

those impacted by events at Tomah. All of us at the OIG need to 

take these experiences and use them to improve VA’s operations. 

Finally, as the son of a World War II veteran, I had a strong reminder of our mission’s importance when I had the great honor of 

attending the wreath laying ceremony at Arlington National Cemetery yesterday. 

On May 2, 2016, I was sworn in as the Inspector General. Since 

then, I have immersed myself to understand the people, work and 

goals of our office. I have been impressed with the OIG staff, many 

of whom are veterans, and their focus on bringing about positive 

changes in the integrity, efficiency and effectiveness of VA operations. While my integration has gone very well, I know there is 

much more to learn. 

I strongly advocate three overriding principals for our office. 

First, we must maintain our independence in all of our work, including avoiding the mere appearance of any undue outside influence. Second, we must be as transparent as possible, while safeguarding the privacy of veterans, whistleblowers, and others. 

Third, we must produce work of the highest quality, making sure 

it is accurate, timely, fair, objective and thorough. 

During my first month, I have spent significant time reviewing 

our healthcare inspections of Tomah. I have also met with the 

Homeland Security staff on two occasions to ensure they have the 

necessary information about our work as it pertains to Tomah. 

My written statement contains a timeline of events related to the 

Tomah Administrative Closure and I will not repeat it here. The 

inspection was administratively closed given the totality of the 

facts identified at that time. 

Specifically, that the allegations could not be substantiated, the 

impact that disclosure of unsubstantiated allegations could have on 

an individual’s reputation and privacy, and knowing our forthcoming 2014 national report would highlight many deficiency in VA 

providers’ compliance with opioid prescribing guidelines. 
11 

I would like to comment on the White Paper about the Tomah 

inspection that was issued by my office on June 4, 2015. I do not 

agree with its tone or the gratuitous attacks on the reputation of 

individuals mentioned in it. It does not meet the high standards expected of our office. 

We have learned important lessons from this experience, including increasing the transparency of our work that should help us 

better meet our mission going forward. 

The changes made should increase the confidence that veterans, 

Veterans Service Organizations (VSOs), Congress, and the public 

have in us. 

Subsequent to last year’s hearing here, we released two additional inspections regarding Tomah. In June we issued a report 

with local and national recommendations focused on acute stroke 

treatment. And, in August we issued a report regarding the unexpected death of a patient during treatment at Tomah. This report 

had four recommendations. 

Notably we recommended that the facility ensure clinicians comply with VA policy regarding written informed consent when administering hazardous drugs. 

The issues associated with the use of opioids to treat chronic 

pain and other conditions are a serious concern, not just at Tomah, 

but throughout our Nation. 

We continue to focus on VA’s opioid prescription practices, publishing two reports on the topics earlier this year. That work identified many of the same issues reported in our May 2014, national 

review. 

We found VA was not following its own policies and procedures 

in six key areas, including follow-up evaluations of patients on 

take-home opioids, prescribing and dispensing of benzodiazepines 

concurrently with opioids, and routine and random urine drug tests 

prior to and during take-home opioid therapy. 

We note VA has taken actions to implement that report’s recommendations, but they must monitor facility compliance with 

opioid prescription policies. 

Later this year we expect to publish a wide-ranging national review of VA’s pain management services, substance use treatment 

programs, use of non-VA treatments, opioid prescribing practices, 

and access to State prescription drug monitoring programs. 

Yesterday our Nation paid tribute to the sacrifices of those who 

gave their lives in our defense. It is a valuable reminder for us at 

the OIG to rededicate ourselves to ensuring that our work is independent, accurate, timely, fair, objective and thorough. 

Dr. Daigh and I look forward to your questions. 

Senator JOHNSON. Thank you, Inspector General Missal. 

Mr. Gibson, let me start with you. When did the problems here 

at Tomah first hit your radar screen? When did you first hear 

about them? And, you have been in the VA how long? 

Mr. GIBSON. I have been in VA for 2 years and 3 months—2 

years and 4 months—right around there. 

I think I am going to go from broad recollection, because I did 

not go back to check the record. I am going to say probably sometime around January. 

Senator JOHNSON. Ok. When the news story broke, basically? 
12 

Mr. GIBSON. Yes, that is correct. 

Senator JOHNSON. So, in your experience with the VA, what 

was—during that time frame, what was the attitude of the VA? 

The main Department with the Office of Inspector General? 

Mr. GIBSON. I would tell you, coming into the organization, I 

have always viewed, whether it is called an IG or some other entity, an auditor, that having a working relationship, a constructive 

relationship, albeit recognizing their independence, is vital, because, at the end of the day, we are after the same thing. 

I have worked to try to create that kind of relationship. I always 

find it amusing when folks suggest that the IG has been management’s lap dog, because, if you go look, they issue over 300 reports 

a year, which means we are getting wire-bushed about six times 

a week, every single week, and you scan the array of IG reports 

and you will find that there is no pandering to VA interest there. 

It is a very strong and independent entity. 

Senator JOHNSON. This Committee, does a lot of work with different Inspectors General. We see kind of a spectrum, quite honestly. 

Mr. GIBSON. I am sure you do. 

Senator JOHNSON. As Ranking Member of a Subcommittee of this 

Committee, we uncovered the corruption within the Office of Inspector General at the Department of Homeland Security and 

Charles Edwards basically moved on ahead of the posse, so have 

seen the lack of independence. 

Mr. GIBSON. Yes. 

Senator JOHNSON. What I thought was quite shocking as we got 

involved in this situation, is that the Office of Inspector General 

had 140 reports on investigations and inspections that it buried, 

that it was covered up, it did not make public. Now, I have mentioned that to other Inspectors General and I asked them, how 

many reports have you not made public? And, they really look at 

me like I am from some other planet. 

I think I have had one Inspector General say, well, there was one 

we did not publish, because of concerns about national security. 

So, do you think it is appropriate that there are 140—now there 

is, by the way, another 70 percent reports on different wait time 

problems that apparently now the Office of Inspector General was 

starting to produce on a rolling basis, but that is a shocking number of reports on investigations and inspections from an independent transparent office that were not made public. 

What is your take on that? 

Mr. GIBSON. Well, my take is that, in general, they should be 

made public. And, I think that is the stance that the IG has taken. 

There have been instances where this Office of Inspector General 

has identified things in the course of their investigation that were 

not related to what they were seeking to look into where they have 

come to me specifically to say, you need to know about this and 

where we have taken appropriate actions in the wake of that. 

That is the kind, I think, frankly, part of what you see here, and 

I was not here 4 years ago, so I cannot talk knowledgeably about 

what was or was not the environment and the practice. But I will 

tell you, over my two plus years here, that the IG has been willing 

to bring things to me, and I think it is a much more principled base 
13 

view. I think some of this, we get wrapped up in the rules, and we 

get so wrapped up in the rules, we lose sight of the principles. 

And so, here is a case where I think, quite frankly, this is my 

view from the outside looking in, where we got focused on the 

rules. And, the rules basically said, this is what we are here to investigate, and we did step back and look more broadly at principles 

and I think the IG has demonstrated the willingness and the ability to do that in subsequent events. I do not know whether they 

learned from this particular instance or from other, but I think 

that is what we owe veterans. 

And, I am going to go back and say that, ahead of anything else, 

this is a leadership failure. There is lots of finger pointing and everything else. At the end of the day, we own this. VA leadership 

owns this. We had ample opportunity over a period of years to fix 

this. That was the leadership’s responsibility. 

And, we failed to get it done. 

Senator JOHNSON. I appreciate that. Dr. Daigh, you were part of 

the inspection team for Tomah, correct? 

Dr. DAIGH. That is correct. 

Senator JOHNSON. One of the things that come across in our report is the confusion over what is the standard for substantiating 

a claim? For example, in so many instances, this was not a he said/ 

she said, which, again, I have been in business. I have had these 

employees situations where it is kind of difficult when it is he said/ 

she said. This is a case with Dr. Houlihan where it was he said/ 

they said. I mean, there was so much corroboration of the allegations. 

How did you come to the conclusion that so many of these 

charges were unsubstantiated? What is the standard? 

Dr. DAIGH. Well, maybe what I could do is go through the allegations one by one and we can talk about them. 

Senator JOHNSON. Let us talk about, why we do not talk about 

the allegations of a climate of fear, a culture of fear within the— 

I mean, there was so many reports and it was so obvious that Dr. 

Houlihan, according to testimony, was a bully and created that and 

retaliated, and there were people fired as a result. And, Chris Kirkpatrick committed suicide after he was fired. I mean, there was so 

much accumulated evidence, how could that not be substantiated? 

Dr. DAIGH. So, we did substantiate that there was an issue with 

the relationship between the Chief of Staff and the pharmacists, 

primarily. And, we transmitted that information to the Veterans 

Health Administration (VHA). It was not a surprise. And, the proof 

that we transmitted that, and that it was not a surprise is at the 

end our review. We sat down and talked with both the Director of 

Tomah and the Veterans Integrated Service Network (VISN) Director, and they told us at the time that we were outbriefing them, 

of the changes they had made so that the Chief of Staff no longer 

supervised the pharmacists. 

They were aware of problems in the pharmacy and were working 

to try to correct them. So, with respect to the relationship between 

the Chief of Staff and the pharmacists, our Administrative Closure 

lays it out clearly that that was an issue. 

It was not, in my view, the primary problem that was addressed 

at Tomah. 
14 

The primary problem was the allegation that Tomah providers 

were providing narcotics outside of the standard of care and that 

narcotics were being distributed in such a way that the rules of law 

were being broken. 

We looked extensively to find out whether that was true or not. 

Medical experts reviewed many charts. We reviewed many 

emails of 17 providers at VA looking for evidence of a problem. Evidence of criminality. 

Our investigators went undercover looking for evidence of criminality. 

So, I am left with the problem of, there are allegations, and I just 

do not have the facts to support many of those allegations. 

Senator JOHNSON. I mean, most people reading our report will 

say there is a lot of substantiated evidence to support that charge. 

Just quick before I turn over to Senator Baldwin. 

On page 270, we have your signature on the Administrative Closure sheet. Every ounce of evidence that we can find shows that 

Administrative Closure occurred in August of 2014. I want everybody to take a look at page 270. It completely looks like this has 

been doctored from 8–12–14 to 3–12–14. 

Dr. DAIGH. It has not been doctored. 

Senator JOHNSON. So what, what further evidence, other than 

this, what appears to be a doctored—— 

VOICE. Liar. 

Senator JOHNSON [continued]. Signature, what other evidence 

would indicate that you closed this out in March versus August? 

Dr. DAIGH. So, when information flows, I would sign a document, 

as I signed this one. And, in the Administrative Closures they come 

to my desk. I sign them and I write a date on it. 

Senator JOHNSON. Is that normally how you write a three? With 

an eight kind of embodied within the three? 

Dr. DAIGH. That is what I wrote. 

Senator JOHNSON. Is there any further evidence that this was actually administratively closed in March of 2014, because everything 

else shows that you administratively closed this in August? 

Dr. DAIGH. No, I do not know what you are talking about. The 

actual date that I signed the report, it then goes into other systems, which are systems of record, and it is entered into what we 

call a different computer system, and it was closed at that time. 

Senator JOHNSON. I find this unbelievably puzzling and I do 

want to get to the bottom of this. Senator Baldwin. 

Senator BALDWIN. Thank you. So, I want to kind of start where 

Senator Johnson left off with regard to this process on this Administrative Closure. 

The report, Committee report outlines a very long inspection, investigation. You used the words somewhat interchangeably. 

Now, the work product after the inspection, the visits, the interviews, etc., seems to have gone through a number of iterations 

prior to there being a decision to make this an Administrative Closure. I know that, and you will see this throughout the Committee 

report, frustrations expressed about documents that were requested from the Inspector General, but were not granted to the 

Committee. 
15 

But we had an opportunity granted by the IG’s office in the 

last couple of weeks to inspect the draft reports. Could not take 

notes—and I did not do it, but my staff went in to see them, and 

so the Committee has reviewed some of the drafts prepared during 

the Tomah investigation, and I was disturbed to learn, after I was 

briefed, that things that the IG staff was aware of did not make 

it into the final Administrative Closure. 

For example, one case study referenced in an IG draft report explained that Dr. Houlihan had increased one patient’s dosage of 

oxycodone more than eight fold in one year. And, that there was 

not always a rationale noted in the chart. During the same time 

frame, this patient had nine refills of a Schedule II controlled substance dispensed more than a week early. 

Probably more disturbing, the case study explained, and I am 

paraphrasing, because there were not copies available, that Dr. 

Houlihan miscalculated the number of pills prescribed to the patient and that Dr. Houlihan made up for the shortage by refilling 

the prescription early. 

Can you explain to me why details of these case studies referenced in the draft report did not make it into the final Administrative Closure? 

Dr. DAIGH. My instruction to the staff was, because the draft report did not substantiate what I thought were the significant allegations that we were looking at, I asked them then to write an Administrative Closure. So, the same people that wrote the draft report wrote the Administrative Closure. There were no instructions 

as to what to put in or what to put out. 

If you will take a look at the 140 Administrative Closures that 

we had done previously, and I will say that it was my understanding and our practice that if I took a hotline, I would either 

publish it to the web or I would note in the Semi-Annual report 

(SAR) to the Congress that we had an Administrative Closure. So 

they were, in my view, made public there, although, albeit, not 

with very much detail. Some years there was a lot of detail, some 

years there was not, but I asked them to write an Administrative 

Closure. So they chose, for I do not know what reason, to shorten 

it up, and it was, 11 pages for the Administrative Closure. Most of 

the Administrative Closures that we publish are one or two pages, 

so they were trying to put in the detail they thought was relevant. 

Senator BALDWIN. Well, I mean, on that Administrative Closure, 

you did note that patients requested early refills, but the document 

does not state that Dr. Houlihan wrote in files that he miscalculated the prescriptions and made up for the shortages by refilling 

the prescriptions. And, to me, this tells a different story. There is 

also no mention that he did not always provide a rationale in the 

charts for substantially increasing already high prescriptions like 

the example I just mentioned. 

So we gathered, in March of 2015, this, the Senate Homeland Security and Governmental Affairs Committee, and you testified. You 

testified that staff at Tomah were at the outer boundary of acceptable prescribing practices. And, this statement seems to imply to 

me that there may have been some unusual practices happening at 

the Tomah facility and within the facility’s leadership. 
16 

So, is the example I just raised the type of thing that was on the 

outer boundary of acceptable prescribing practices or is it beyond 

that boundary. 

Dr. DAIGH. I would say that our view was that, in summary, he 

was at the outer boundary. And, the facts that you described 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. 

Senator BALDWIN. Inspector General Missal, I know you are new 

to this position, but you have read this Committee report, and I 

guess I want to know your opinion on putting out a policy that outlines what the standard ought to be in your Agency for substantiating or unsubstantiating allegations, at least for cases like this 

where you think it might be a close call or right outside those 

boundaries? 

Mr. MISSAL. Yes. I have looked at that. I have had the opportunity to review the report. Standard of care is a complicated issue. 

For instance, when we are doing an investigation, we look to see 

if somebody did something wrong. The standard to me is preponderance of the evidence. Is it more likely than not that somebody 

did it? 

With respect to healthcare inspections, you are looking at the 

quality of care, which is a far more complicated area. And, it really 

depends on a variety of things of what you are looking at. For example, what the literature says, what experts may say, etc., but I 

understand the point. I know it was a significant issue and we intend to look very closely at that and to talk about standard of care 

and the standards that we are going to be using going forward, so 

we will be doing that. 

Senator BALDWIN. Well, with the advantage of hindsight, this 

does not look all that complicated to me. 

Mr. MISSAL. We are going to look at that very closely. 

Senator JOHNSON. Thank you, Senator Baldwin. 

What is amazing is they had a pretty high standard for, substantiating a claim in their OIG report, but yet in the White Paper, 

they had no problem rushing out a report that literally threw the 

whistleblowers and these individuals under the bus. It is really 

quite remarkable. 

I also appreciate the fact that you were talking about the frustration this Committee has had in obtaining the information. I just 

want to refer everybody to page 324. This is what one of the documents looks like provided by the Office of Inspector General, who 

has not yet complied with our full subpoena. I mean, think about 

that. This Committee had to subpoena the Office of Inspector General to get the information. And now, 16 months later, well, it is 

really about a year later, because we issued the subpoena at the 

end of April, still has not been complied with, so, Mr. Missal, again, 

we look forward to working with you on that. 

I do want to welcome Representative Kind and Representative 

Walz from Minnesota, and we will not hold that against you. Congressman Kind. 
17 

OPENING STATEMENT OF CONGRESSMAN KIND 

Mr. KIND. Thank you, Senator. I want to thank you too for yours 

and the Committee’s invitation for me and Representative Walz to 

participate in today’s hearing. 

Yesterday, as many of us were at Memorial Day commemoration 

events, and during it, it is a sober reminder of not only our obligation to honor our fallen heroes, but the unfinished work of making 

sure that our veterans, those who served our nation are receiving 

the care and the treatment that they have earned and that they 

deserve. And, that has always been my guiding star throughout 

this whole process, given the tragedy, given the mistakes that were 

made at Tomah, which, according to your testimony here today, 

has not been unusual in regards to the VA medical system 

throughout the nation. If we keep our focus on the veterans and 

making sure that that is our true guiding star, then hopefully we 

can bring some good out of a tragedy. And, I know that is exactly 

what has been motivating the Simcakoski family this whole time. 

I have been proud and honored to be able to work with each one 

of them when it comes to fixing the problems to ensure that no veteran in the future goes through what that family has done. Jason’s 

wife Heather, and his parents, Linda and Marv, have been intimately involved in not only providing feedback on the legislation 

we have been working on to honor his legacy, the Jason Simcakoski 

Promise Act, but they have even taken the extra step of making 

phone calls to appropriate Committee Members, even to Speaker 

Ryan, about the importance and the urgency of getting this legislation done and implemented as quickly as possible. 

In fact, Heather and Linda and Heather’s daughter Aniah were 

out just out in Washington a couple of weeks ago to make some 

last minute visits, but also to personally witness the passage of the 

Jason Simcakoski Promise Act unanimously on the House floor, 

and we look forward to working with this Committee and you Senators in order to ensure that this reaches the President’s desk and 

get this done and implement it as quickly as possible. 

Heather asked today if I would be willing to read a short twoparagraph statement for the record and I ask unanimous consent 

to do so at this time. 

Senator JOHNSON. Sure. 

Mr. KIND. She writes, and I quote, ‘‘It is encouraging to see the 

Congressional delegation working together in honor of Jason, to ensure no other families go through what we had to endure. We are 

proud of the progress made so far in passing legislation named 

after Jason. We look forward to working with the Congressional 

delegation to make sure the legislation becomes law. 

‘‘We are grateful for an opportunity to see everyone come together to turn such tragedy into something that has the potential 

to save so many lives in the future. As we can continue moving forward, we are committed to remaining focused on the bipartisan 

support for this legislation.’’ 

Clearly the job is not done yet, but I do want to commend Acting 

Director Vicki Brahm, for the progress that has been made at 

Tomah. This comes on the heels of the work that then Acting Director John Rohrer when he came in, and inherited the challenge 

that existed and what they are trying to build on right now—the 
18 

community outreach, working with the staff on best practices, but 

especially listening to the families and to the veterans themselves, 

making sure that they have input and say in what is taking place 

there. 

I think it is important that we stay focused in that endeavor. 

But I also would be remiss if I did not mention the good work 

that has been done at Tomah. I have been somewhat surprised by 

the number of veterans who have gone out of their way to personally notify me at how happy they are with the care and treatment 

they have received at Tomah. Any my guess is this would be fairly 

consistent around the country too. 

So, although there were serious allegations and mistakes made, 

I do not think we should overlook a lot of the dedication, a lot of 

the professionalism, a lot of compassion that is taking place at 

places like Tomah each and every day, and sometimes, given the 

sensation of these stories and what the media tends to focus on, 

that gets lost in kind of the fog of everything that we are trying 

to accomplish. 

But, Mr. Missal, while we have you here, and we know you are 

new to the position, and it has been raised already by the Senators, 

we did have some communication problems with the IG’s office 

when it comes to conducting the investigation, proper notification. 

I know that when I had received an anonymous letter back in 

September of 2011, I immediately forwarded that onto the OIG’s office, asking them to look into it and conduct an investigation. Received notification that they were going to do that and that we be 

notified at the end of that investigation. 

Now, listen, I am a former special prosecutor and I have been involved in a lot of investigations myself. You do not know when you 

go into an investigation how long it is going to take, how complex 

it is going to be. You talk to one witness and suddenly 10 more 

names appear. I get all of that. But what was problematic to me 

and to the Committees of jurisdiction was the lack of notification 

when the IG’s office administratively closed it with certain reforms 

and changes that had to be made and we were operating in the 

dark, because there was no notification again. 

And, I also want to commend Representative Walz who serves on 

the House Committee on Veterans’ Affairs for the work that he has 

done. He has been a good partner through all of this, along with 

Gus Bilirakis, a real bipartisan effort, but we are only as good as 

the information that is given to us. 

And, Dr. Daigh, when the report did come out, and I later found 

out that we were not notified, I called you and others that were involved in the investigation into my office immediately to get clarification on what was taking place. To your credit, you guys owned 

up, that the ball had been dropped, notification was not given when 

the intent was—I know this was coming at the time of Phoenix and 

other news stories that were breaking at the time, but in light of 

all that, I introduced legislation, the Inspector General Transparency Act, which I am glad was included in the year-end budget 

last year, which now requires that notification. 

So, Mr. Missal, on that point specifically, is that going to help in 

your mind, as far as the lines of communication, keeping policy 

makers informed of what changes and reforms have to be made, so 
19 

we can be working together and in tandem to make sure that this 

gets done? 

Mr. MISSAL. Yes, I think it will help, but hopefully we do not 

need legislation to become more transparent. 

My goal is to communicate better with the public, with Congress 

and with the Department on issues. There were a number of mistakes made by my office at the time and we agree that one of the 

mistakes was not keeping Congress better informed on this issue. 

And, I am going to work very hard to make sure that does not happen again. 

Mr. KIND. Mr. Gibson, I appreciate your testimony, written and 

your oral testimony today, about the need to continue on a more 

coordinated, integrated veteran-focused healthcare delivery system. 

I think a lot of ways—the VA system throughout the country has 

been good in driving that, that goal, that momentum in that direction, but, clearly, more work needs to be done. 

Mr. GIBSON. Yes. 

Mr. KIND. Is there any other things that Congress needs to be 

working with the VA on right now to make sure that you are given 

the policy prescription, but also the tools and resources in order to 

get this accomplished? 

Mr. GIBSON. I appreciate the request, and I appreciate your recognizing the good work that goes on every day. Because, you are 

right, it does not get reported. It does not diminish the challenges 

that we have, but it is part of the context. The short answer is yes. 

And, we have been working, really, with both of our authorizing 

committees on an array of legislative priorities that we have, many 

of which get at some of these very issues. I am thinking most immediately of the request to make all of our Medical Center Directors and Network Directors Title 38. 

Quite frankly, if I had that authority in my hip pocket right now, 

the lady sitting behind me would already be the Medical Center Director here. But I am probably going to get in trouble for committing a prohibited personnel practice for having said that, but, she 

is doing awesome work and she is the kind of person—and having 

the kind of ability to, to direct hire and a little flexibility around 

compensation would make that possible, among a large number of 

other priorities that you have identified. Thank you for asking, sir. 

Mr. KIND. Thank you. 

Senator JOHNSON. Congressman Walz. 

OPENING STATEMENT OF CONGRESSMAN WALZ 

Mr. WALZ. Thank you Senator Johnson, for including me in this 

hearing and the past one. 

Thank you, Senator Baldwin and Congressman Kind, for all 

three of you, the work that you do. 

I am Tim Walz. I represent Minnesota’s First Congressional District. It is just a little bit west of here across the river and then 

all the way out to South Dakota. And, that river may separate us 

on football loyalty, but it does not separate us as Americans. 

And, many of my constituents use this facility. 

Also, prior to being in Congress I spend 24 years as an artilleryman and retired as a Command Sergeant Major and spent the last 

10 years on the House Veterans’ Affairs Committee, so I have spent 
20 

the last 35 years, not just talking about veterans issues, but being 

part of that. 

And, I can tell you this—that, as a member of Congress, the security of this nation and the care of our warriors is our number one 

priority. That is also the number one priority of all of you sitting 

out there and every constituent in my District and Ron’s District 

and across Wisconsin and Minnesota. It is also the number one priority of these folks sitting up here. 

And, you just do not get in this and leave. For example, Mr. Gibson, some of you do not know, my capacity of working with him 

prior to his current position was, he ran the United Service Organizations (USO), a fabulous organization that cares for our warriors, 

which he did with grace, skill, effectiveness, and I think for all of 

us trying to find solutions to the best care possible is what we are 

here for, so I appreciate all of you coming out on a day like this. 

And, to the family, you heard it. And, I think that is the thing 

that always most strikes me. In the midst of heart-wrenching tragedy that I will not even attempt to understand, a family seeking 

justice, which they deserve, and we should deliver, but also transferring that into solutions to make sure no other family goes 

through it too, whether they meet them or not. And, that is a very 

powerful call to action for us. So, I look at it as, our responsibility 

is to get them the justice, find out what went wrong, find out who 

is responsible and hold them accountable, but simultaneously making sure that the changes that are being made do not happen. 

And, for some of you to think on this is, there really is nothing 

new under the sun. I think about this, and the folks up here, and 

Ron and I have talked about this and have worked together on. 

The first two things that I was able to do when I got to Congress 

would actually put into law and effected was first increasing the 

budget for the VA Inspector General, which at that time was incredibly low and you simply did not have enough people to go out. 

We would send in a request, and you would say, I do not have people to cover this and we could not find those eyes on it. 

And, secondly was passing step pain management on opioid reduction. In 2007 people were already thinking about that. Not just 

me, but folks up here and folks that understood this were trying 

to implement that. And, I guess for me, we made a good effort, and 

I think the VA and Mr. Gibson are right. This is an issue that is 

systemic to our entire culture. And, it is a huge problem. Now you 

hear lots of people talking about it. That is great, but there are solutions out there. We need to implement them and move them forward. 

And, I know that the bill that I passed went from 2009 to 2014. 

We were only able to implement 31 percent of it by the time it expired in terms of doing this. And, these are best practices that are 

out there. 

So, I think today in the time that we are going to have here 

today, I am going to attempt to try to focus on what has changed 

at Tomah. And, trust me on this. Dr. Houlihan or anyone else involved in this, justice needs to be served and we will find that. Senator Johnson will continue to do that and Senator Baldwin. 

As a member of the House Veterans’ Affairs Committee, I want 

to know what you have done to make a difference. What happens 
21 

with my veterans from Houston County who come over to Tomah 

now and what has changed? 

And, with my remaining time I am going to start on a line of 

questioning on this is, and, Mr. Gibson, maybe you can help me 

with this. How do I know things are better at Tomah? How do I 

know, if someone asked me, is it better at Tomah or is it the same 

thing that happened when the reputation that, that started this 

was there? 

Mr. GIBSON. I think some of the activities that I described earlier, Vicki has been engaging in; the open door with veterans, the 

outreach into the community, and looking for ways where we bring 

the community together to help support our veterans. 

And, one of the things that we started doing recently, because access is such a critical issue for us, is we started, at our kiosks, asking the one very simple question, how satisfied were you that you 

got today’s appointment when you wanted it. At Tomah the answer 

is 93 percent satisfied or completely satisfied. 

They are doing so many things so well. You can look at the sale 

data. 

Many of you may not realize VA leads the country, perhaps 

the world, in reducing healthcare associated infections. Healthcare 

associated infections—second leading cause of death in 

America—more than automobile accidents and breast cancer combined. 

And when, and external studies, when looked, who was, who was 

doing this better than any other organization? It was not the Cleveland Clinic. It was not Kaiser Permanente. It was not Geisinger. 

It was VA. 

Mr. WALZ. Not even Mayo. 

Mr. GIBSON. Guess who? Guess who leads VA? Tomah, in minimizing healthcare associated infections. 

I will tell you, the number one area where they have work to do 

is in employee satisfaction and employee engagement. And, that is 

the culture problem. And, that is why leadership matters so much. 

So, veterans are telling us, you are hearing from veterans that 

are saying—I have heard from veterans here. And, I will tell you, 

my classmate was a patient here in the Community Living Center 

(CLC) for 23 years. And, the family in his obituary said the staff 

here made them feel like they were part of their family. 

That is what is happening with so many of the Wisconsinites 

that are working right here, caring for our veterans, are they doing 

the right thing, but we did not have the right leadership in place. 

And, I think, I think we have a good clue—— 

Mr. WALZ. We need to give them the tools because—— 

Mr. GIBSON. Yes, we do. 

Mr. WALZ. We owe them nothing less. You hear that. 

Mr. GIBSON. Yes. 

Mr. WALZ. But, and equally important as holding accountable, 

and if it is firing, or whatever needs to be done to those people, we 

need to have the ability, as you said, and I am with you on the 

Title 38. We need to be able to hire the best and possible, because 

we cannot fire away to a fix, but we can simultaneously get rid of 

the bad and bring in the good. 

Mr. GIBSON. You got it. 
22 

Mr. WALZ. And, I yield back. 

Mr. GIBSON. You got it. 

Senator JOHNSON. Thank you, Congressman Walz. 

Let me continue on that vein about accountability. 

In 2015 I introduced the Ensuring Veterans Safety Through Accountability Act and I testified with Senator Baldwin when she introduced the Jason Simcakoski—I always forget the full name. 

Senator BALDWIN. Opioid Safety Act. 

Senator JOHNSON. Opioid Safety Act at the Veterans’ Affairs 

Committee. I was more than disappointed when the representatives from the VA testified against the Accountability Act. 

Now, fortunately, a similar provision introduced by Marco Rubio, 

which I cosponsored, was passed by the VA Committee, but having 

been in business for 30 some years, I mean, I understand that 

probably the most corrosive thing to any organization is not being 

able to hold the bad actors accountable. And, yet here you have the 

representatives of VA saying, nah, we do not want that authority 

to hold people accountable. 

I mean, that is at the heart. I agree with you. I think all of us 

here agree. As we tour around and talk to the doctors and nurses, 

and as I said in my opening statement, they do an extraordinary 

job. They are really concerned, but unless we really have the ability 

to hold people accountable, that is what causes these types of tragedies, so is that something that the VA will now embrace? The ability to actually discipline and terminate and hold people accountable 

through the VA system. 

Mr. GIBSON. I would say the answer is an unequivocal yes. 

Senator JOHNSON. Good. We will move on. 

Mr. GIBSON. Well, that has been part of my own personal obligation as a leader since I first got to VA. I am the guy that takes 

action on senior leaders in the department. I am the guy that 

issued the removal on DeSanctis. And, I am the guy that looks at 

other instances of particular notoriety to ensure that we are taking 

the appropriate action. 

Senator JOHNSON. Good. But we want to give you that authority, 

because you have to have it. 

Another piece of legislation I introduced was the Dr. Chris Kirkpatrick—let me give you the full title of that one as well: The 

Christopher Kirkpatrick Whistleblower Protection Act. And, this 

was really prompted by a Committee hearing we had where Sean 

Kirkpatrick testified before our Committee, and one thing that I 

have been literally shocked by, again, coming from the private sector, even though we have all these whistleblower protection laws 

on the books for a hundred years, the level of retaliation against 

those people that have the courage to come forward, like Dr. Noelle 

Johnson, like Ryan Honl, like Chris Kirkpatrick, is jaw dropping. 

So, again, I hope that the VA will embrace and help support the 

passage of that piece of legislation to give those whistleblowers the 

protection they really need. 

And, by the way, I would announce again that my 

Committee has set up the whistleblower hotline. It is just 

whistleblower@ronjohnson.senate.gov. People are using that. And, I 

think it is also an important step that is required, so that whistleblowers within the VA—and, by the way, the highest level of retal-
23 

iation, according to the Office of Special Counsel (OSC), is within 

the Veterans Administration, which is a real problem. 

So, again, will you support the Christopher Kirkpatrick Whistleblower Protection Act? 

Mr. GIBSON. I do not know what is in the Act and I also do not 

know what is in the Accountability legislation you referred to earlier. 

But what I will tell you is that I personally, as the Acting Secretary, met with Carolyn Lerner, the Special Counsel of the United 

States. I committed to VA becoming certified, the first large Federal department that became certified as a whistleblower protecting organization. I have publicly recognized and, and presented 

awards to whistleblowers. I meet with whistleblowers in every location where I go visit. When I came to this location last year, I met 

with Ryan Honl. I do that. Coming out of the private sector, I understand that your most valuable source of information on how to 

do things better are your frontline employees. 

The last thing you want are people that are afraid to raise their 

hand, so everything we are doing as an organization has to do with 

creating that kind of culture. 

A little bit along the lines of what Mike said earlier, I do not 

need a law to tell me to do that. That is back to just good leadership. Not necessarily from me, but from people across the Department. 

Senator JOHNSON. I appreciate that. 

Dr. Daigh, as I am going through the Committee’s report. And, 

you see that the first hotline notice, really, is about March 2011. 

And, for whatever reason, it did not rise to the level. And, then in 

August 2011, partly because of Representative Kind’s inquiry, it all 

of a sudden became a Congressional hotline or Congressional inquiry, gained a little steam and got the notice, but it took until 

2014 to complete this inspection, investigation, and then issue 

some kind of report. 

There is an awful lot of activity and I think the first site visit 

was in 2012, and not a whole lot happened in 2013 into whatever 

date it actually was closed. What was happening during that point 

in time? 

Dr. DAIGH. Well, let me first set the record straight on the issue 

of the date at the bottom of the report. That date is accurate. And, 

if you will look at the e-mails which transmit the pdf of the report 

I signed, you will find that those dates are consistent with the date 

I signed. 

Senator JOHNSON. OK, good. Great. I appreciate that. 

Dr. DAIGH. That is absolutely the truth. And, I believe that data 

may be in your hands now. I am not absolutely sure how many of 

the thousands of records we gave you, you have. 

The problem with this Tomah allegation was, we got a letter very 

early on, that laid out a whole series of cases which alleged that 

there was horrible care provided. And, unfortunately, I received 

many more allegations than I have the resources to investigate or 

inspect. So, with that letter, we read it. I did not have the resources at the date that came in, and so I sent it to VHA. I usually 

send it to one management level above, so it would go the VISN. 

And, the VISN wrote us back a letter with each of the cases out-
24 

lying how the quality of care has been appropriate. So, we read 

that letter. And, we said, OK, this makes sense. We will say that, 

we will close this at this point in time. 

As part of the Combined Assessment Program (CAP) process, we 

have an employee survey where we ask employees what their view 

of the world is with respect to quality of care at a facility. And, we 

did a CAP about that time and a number of Tomah employees indicated that there were concerns about medication abuse at Tomah. 

We had that fact. 

We got a letter from Congressman Kind, saying there was an 

issue, so we said OK. We need to go out to Tomah and figure out 

what the real story is. And so, that launched our hotline review. 

I sent a team out there, as you note, and we made calls before. 

We got all the data we could ahead of time. We went out there. 

And, the allegations continued to increase. I think the Administrative Closure lists 32 or 33 different allegations. 

So, as the allegations increase, you go down more and more 

tracks. And, as we would go down a track, unfortunately we got a 

lot of dead ends. People would say, a certain transaction had occurred at a certain place. We could not find any data for that. We 

could not find evidence for that. 

So, we decided then that what we needed to do was to pull all 

the emails for employees that worked there for a certain period of 

time, so you have to stop and say, ‘‘OK let us go get the emails.’’ 

We had an email pull. It was insufficient the first time. Then we 

had to go actually to their computers and pull the email off their 

computers, and get that back. You have to read that email. We 

were in continuous conversation with the DEA, trying to understand where they were or did they have any issues with this? 

I then met with our agents and they investigated it, the investigators. They agreed to go on-site. So, they went on site and did 

work. So, it took a long time, if you have a relatively small number 

of people and you have allegations that explode, to run down each 

of these tracks. 

Senator JOHNSON. And, I appreciate that, and yes, the VA, when 

they undertook their own investigation, together with this Committee, in just a couple of months pretty well substantiated the 

charge and started holding people accountable, so. 

Dr. DAIGH. I think, for me, the important question is whether or 

not VA was aware as we were doing our work of what we were 

finding and were they aware that there were issues at Tomah? 

And, I believe that they were at the local level, the VISN level, and 

at the Veterans Affairs Central Office (VACO), aware that there 

were issues at Tomah that needed to be addressed and that we 

were in communication with them. Not every fact was presented to 

them until we were able to assemble the facts and put them out 

there, and lay them out for everyone to see clearly. 

Senator JOHNSON. I would argue that the responsibility of the Inspector General is to make that information public and also make 

sure that something is done about it. And, that did not happen. 

I am out of time here. Senator Baldwin. 

Senator BALDWIN. On the issue of accountability, I have a questions for you, Mr. Gibson. 
25 

Dr. Houlihan was fired from the VA. And, at the time that he 

was fired, I wrote to the VA to ensure that veterans would not ultimately be referred to his practice outside the VA through the Veterans Choice Program. 

Subsequently, through public reports, his license was suspended 

by the State of Wisconsin. And, I received a letter back from the 

VA indicating that he would not be eligible to serve veterans under 

the Choice Program because his license was suspended. 

You may or may not be aware, again, through public reporting 

it appears that an Administrative Law Judge (ALJ) has reinstated 

his license during the pendency of proceedings before this State. 

And so, I want to, first of all, get assurances from you that in 

light of that new development, that Dr. Houlihan would not be getting referrals of veterans through the Veterans Choice Program. 

Mr. GIBSON. Absolutely not. 

Senator BALDWIN. And—— 

Senator JOHNSON. Senator Baldwin, if I can briefly interrupt. 

That is an incredibly important point you are making. That Administrative Law Judge is citing the White Paper, so Inspector General 

Missal, would you repudiate that so that that can no longer be 

used by the Administrative Law Judge? That White Paper? 

Mr. MISSAL. Yes. My office took the White Paper off its website, 

so to me that means it no longer is a document of the Inspector 

General’s Office. 

Senator JOHNSON. Thank you. Senator Baldwin. 

Senator BALDWIN. So, this correspondence between me and the 

VA has highlighted for me that nothing in the VA Choice legislation explicitly requires that somebody who is fired or suspended 

from the VA for cause related to their service, to our nation’s veterans, there is nothing that explicitly addresses this in the law. 

And so, I feel like this is a dangerous loophole that we currently 

have. 

I have recently introduced bipartisan legislation that just passed 

the Senate, although it has not made it all the way through the 

legislative process. That legislation requires the VA Secretary to 

block the healthcare provider from participating in community programs if that provider was fired or suspended from the VA, violated his or her medical license, had a Department certification revoked, or otherwise broke the law. 

Secretary Gibson, are there steps that the VA can take right now 

to ensure that this loophole is not being exploited to taken advantage of by other providers other than the case that we are talking 

about today? 

Mr. GIBSON. I have not discussed the matters specifically with 

the folks that are working here in the community, but I will do so. 

There is no reason why we cannot implement a policy that accomplishes the same thing without the need for legislation. 

Senator BALDWIN. During our Chairman’s opening statement, he 

drew our attention to portions of the Committee report discussing 

the concern that two of the witnesses during the inspection were 

impaired, possibly by drugs or alcohol. It was a suspicion. There is 

a lot of discussion in the Committee report on this. 

I think disturbing was that the only two follow-up actions were 

a doctor emailed the VA OIG’s General Counsel wanted to discuss 
26 

a concern regarding possibly an impaired interviewee, or 

interviewees, and subsequently, and off-the-record discussion with 

the Tomah VA’s Director at the time, Mario DeSanctis. 

There is no clear record of whether that tip was followed up on 

or not. 

My question is, will the VA Office of Inspector General adopt 

new policies or procedures so that if this happen in a future case, 

and, of course, we hope it never does, that the IG suspects that a 

witness employed by the VA is under the influence of a controlled 

substance that there is a procedure that will be followed that would 

provide greater accountability and safety for our Nation’s veterans? 

I would like to hear both of you on that, but, this was first noticed by the team doing the inspection, and so, I want to hear what 

the Inspector General has to say about procedures if this should 

ever happen again. And, then I would like to hear from you, Deputy Secretary Gibson. 

Mr. GIBSON. I would love to share my two cents worth, yes, 

ma’am. 

Mr. MISSAL. With respect to my view on that, if I ever see a situation where I think somebody, particularly somebody providing 

healthcare to veterans, may be in a situation where they are impaired in one way, I would immediately make sure appropriate people within VHA or above that were aware of that and to follow up 

and to make sure that that situation was resolved to our satisfaction as quickly as possible. 

Senator BALDWIN. And, in this particular case, do you have any 

knowledge that the Committee does not about whether anything 

was followed up on by Director DeSanctis? 

Mr. MISSAL. I do not have any more information. 

Mr. GIBSON. I am going to tell you, based upon the first time I 

ever heard of this was reading it in the report. First time ever. We 

are right back to leadership. That is what this is about. This is 

about delivering safe care to veterans. And, the failure of leadership that happened here was the failure on the part of the Medical 

Center Director to take appropriate action. 

And, everything that I mentioned earlier, I issued the removal on 

the Medical Center Director. I reviewed hundreds and hundreds of 

pages of evidence. And, I will tell you, not doing something about 

this would be very consistent with the pattern of behavior that I 

saw there. It was a failure of leadership. It should not have happened. Period. 

The principles here, you said, put the veteran at the center of everything that you are doing, and that is exactly what we are trying 

to do. And, understanding—making leadership in the organization 

understand the sense of urgency with which they must act when 

something has been presented to them that suggests, that the safety of the veteran, the care of the veteran, may be at risk, that is 

an urgent situation. You have to act and you have to act timely 

and promptly. That is what these folks have been doing. 

There was an instance that happened—these folks, and I am not 

going to—I will not get into the great details, but here is the 

timeline. They became aware on November 19, 2015, that there 

was misconduct. They launched a Fact Finding the next day, November 20, 2015. The Fact Finding was completed on December 7 
27 

and the proposed removal was issued on December 8. That is the 

kind of timely action and follow-up. That is what good leaders do. 

And, that is what we have to ensure we have in place all across 

this Department. 

Senator JOHNSON. I could not agree more. 

Mr. GIBSON. We do not need a watchdog to tell us how to do our 

job. Important to have a good watchdog, but we do not need one 

to tell us how to do our job. 

Senator JOHNSON. Congressman Kind. 

Mr. KIND. Than you, Senator. 

Mr. Gibson, let me stay with you, because, clearly, one of the 

problems we had at Tomah was chain of command. We had a Chief 

of Staff, in this case Dr. Houlihan, who was also prescribing medication. And, getting back to the team or coordinated approach to 

proper healthcare delivery, there was a culture of intimidation—— 

Mr. GIBSON. Yes. 

Mr. KIND [continuing]. That was created by Dr. Houlihan that 

made it almost impossible for someone with a dissenting view or 

dissenting opinion to come forward in order to change a certain 

treatment regimen. 

Mr. GIBSON. Yes. 

Mr. KIND. Has that been fixed now? Not just in Tomah, but 

throughout the VA Medical System? 

Mr. GIBSON. I know it has been fixed here in Tomah. I think the 

issues that has been raised here prompts a review across our organization to ensure that we have appropriate separation of authority 

here. 

Very early on, in fact, at the very beginning of the Medical Center Director’s tenure, the issue of separating the reporting relationship for pharmacy was raised. The Medical Center Director refused 

to do that, until, I am going to say, roughly a year and a half later, 

when he finally got a new Associate Director in place. We had 

problems in construction with VA and, and the Executive Director 

responsible for that area was encouraged to leave, and he did leave. 

I accepted direct responsibility for construction and facilities 

management until such time as we got the leadership in place. 

That is precisely the kind of action that should have been taken 

here. 

Mr. KIND. That is the thing that probably made me the angriest, 

the information coming out, and probably for more most people in 

this room, was that culture of intimidation. 

Mr. GIBSON. Yes. 

Mr. KIND. The bullying that was taking place. Good people trying 

to do the right thing, keeping the focus on the veterans were cut 

off. And, one instance led to a suicide. Other instances led to firing 

or people leaving their positions because of this culture that was 

created. I think it is just essential that we fix that throughout the 

entire system or we are going to have another hearing somewhere 

else in this country, I am afraid, talking about the same set of 

facts. 

Mr. GIBSON. The day you and I were here in Tomah, last year, 

together, was the day that Houlihan was placed on administrative 

leave. 

Mr. KIND. I remember that. 
28 

Mr. GIBSON. He had been removed from clinical duties, but it became evident to me that he was still exerting undue influence on 

other providers in the organization. That was the day he was removed. 

Mr. KIND. Back to my original question—what more can Congress be doing working with you? I think in your written testimony, you said we have to adequately fund the OSC to make sure 

that there are resources to hire additional investigators. Do you 

still have that opinion? 

Mr. GIBSON. I do. We work very closely and very collaboratively 

with the Office of Special Counsel. I would say to my brethren next 

to me here that there is probably an opportunity for the Office of 

Special Counsel and our IG to work more collaboratively together. 

Sometimes things have gotten in the way of that. But between our 

investigation resources, their investigative resources, and the Office of Special Counsel’s investigative resources, I think there was 

an opportunity for us to do better by taxpayers and better by veterans both. 

Mr. KIND. I would be happy to follow up with you in regards—— 

Mr. GIBSON. Yes. 

Mr. KIND [continuing]. To funding levels and that, but—and I 

know the VA here in Tomah are also exploring more alternatives 

and complimentary forms of medical treatment—— 

Mr. GIBSON. Yes. 

Mr. KIND [continuing]. Just not loading the vets up on a cocktail 

of prescription drugs and expecting that to solve all the problems, 

but there is also a danger of overreacting. And, I have some feedback from veterans that it is a little more difficult for them to get 

the prescription meds, the opioids that they need for proper pain 

management. I know it is a difficult balance, but how well are we 

doing on that front. 

Mr. GIBSON. Dr. West. 

Dr. WEST. Thank you for that question, and you bring up a very 

important point that you cannot overreact, right. I mean, I am a 

physician that still treats patients every week, in my own clinic, 

and you know, I kind of see it every week. 

Forever, the medical system as a whole, including VA and our 

academic centers, was moving forward prescribing pills. We found 

out that was wrong, and that that was actually killing people. 

Now we are turning a big aircraft carrier around, and the way 

we are doing it is through exactly what you mentioned, complimentary and alternative medicines, and there are other medicines to 

treat pain. There are not just opiates. There are neuromodulating 

agents, new agents coming out all the time. 

So, as a clinician, you have to be very sensitive to the patient 

and the individual case and really work through the patient’s—I 

mean, this is all a veteran-centric work-through, and it takes a 

long time. You need things like this. This is a brilliant thing that 

they have come up with at Tomah to support frontline physicians 

in decisionmaking for patients, education for patients, and other 

treatments for patients that they can use for their pain. 

Mr. KIND. I would also encourage the VA to continue the efforts 

to provide an avenue or a line of communication for the family 

members themselves. I still think they are the best line of defense 
29 

in all of this. They are going to know what is working and what 

is not with the loved one and their family, so making sure we foster that receptive environment for them. 

And, finally, Mr. Gibson, we have to get the message to the Directors of all the VA Medical Centers that they have to be as candid and truthful and honest with us, because many of us are visiting these campuses all the time. Check in on the veterans. Find 

out what is working, what is not working. And, I am at Tomah. I 

am up in the Cities. I try to get down to Madison too. And, I am 

always asking, what do I need to be aware of? Are there any problems here that I need to be aware of that we can work with you 

on? 

And, that did not happen, unfortunately, under Director 

DeSanctis’s leadership. And, I was on campus. I was looking him 

in the eyes. What do I need to know? What is going on? Is there 

any problems? And, I later found out that just 2 months, 2 months 

before I had been on campus one time, the IG was there, with the 

conclusion of the report with recommendations and changes that 

they were already moving forward on. And, I asked them and they 

did not breathe of word of it. And, it is just so frustrating, because 

if you lose that trust, and then something like this blows up, there 

is a lot of preventable error and a lot that we could accomplish, so 

we need to communicate with the leadership of our medical centers. They have to be up front and honest with us policymakers for 

us to make the changes that are necessary. 

Mr. GIBSON. One of the things that we have been doing under 

Leaders Developing Leaders, the Secretary and I have personally 

met with the 600 top leaders of the entire Department, and one of 

the messages that we deliver is the message that you just spoke. 

It is the importance of getting news, whether it be good news or 

bad news. This is a 180 degree change for this organization. First 

of all, folks—they were not talking to members of Congress or to 

the media under any circumstance. What we are trying to do is to 

get them to talk, both when there is good news or when there is 

bad news, let us get it out on the table, own the problem, start 

tackling it, and get it fixed. I mean, that is how you earn trust 

back. 

Mr. KIND. I again commend Acting Director Brahm, because the 

open policy that she has had, it has been a sea change, and I am 

sure we are going to see that continue in the future. 

Mr. GIBSON. Yes, sir. 

Senator JOHNSON. Congressman Walz. 

Mr. WALZ. Thank you, Senator. I am going to continue down this 

kind of same line. And, it is about improvement, about working towards that, and you have heard it, culture of fear, and Senator 

Johnson rightfully expressed, and I am grateful for him, on protection of whistleblowers, of making sure, folks. And, I think that is 

an unfortunate name we give people. If you look it up, the synonyms are not positive on this. These are ethical employees trying 

to improve the care for veterans, and that is how they need to be 

referred to and that is how they should be treated. 

And, Deputy Secretary Gibson and I have both privately and 

publicly discussed this issue. And, this is frustrating amongst all 

of you out there and my constituents. Nothing makes me more boil-
30 

ing mad than when you are saying you know someone did something, and then you see they are put on administrative leave with 

pay, and you are thinking, I would have gotten fired at my job on 

that. And, all of us up here—in 5 months, all of us are up for that. 

We get a performance review, and that is good, up or down on how 

it works. There is that sense of frustration, but it is also balancing, 

and you have done—we have talked through this. 

Due process is important to our system of rule of law. That is 

due process for the employee and due process for the veteran and 

their family of trying to strike that balance. 

And, I think as you work with—Mr. Kind is right about this. It 

is the transparency. It is restoring the trust of the veteran and 

their family so that know they are going to get the best care, but 

they trust that it is going to work for them. So, when you hear Mr. 

Gibson talk about this, this is no small matter. When you hear 

Title 38 and some of these terms or whatever, this part of the authority he is talking about. Laws that both the Senate and the 

House passed to allow them to work with their special executive 

service folks. These are the top-ranked administrators. Those are 

the things we are trying to get at. 

And, I am not going—and it is not the appropriate place. I think 

it is an appropriate debate, but the idea of employee due process, 

sometimes this idea that you should be able to walk in, point a finger and say, you are gone, for any reason, I do not think any of 

us want to live under that. And, I do not think any of us want to 

get rid of the good employees who are there. So, what I worry 

about is, we go gung ho to say, just clean the dang place out and 

fire all these. You have a food service worker who has been 

stripped of their right to have someone represent them, bring an 

allegation forward against bad management, and they do not have 

anyone to stand for them, and they are gone. And, the bad management still sits there. 

So, Secretary Gibson, your point on this is you do not need a law 

to do a lot of these things. What you need is an ethical compass 

and the moral responsibility to care for our veterans, which I believe we are starting to get there, but what we are hearing from 

up here is, what can we do to ensure that the public believes that? 

Believes that we are not protecting bad employees? Believe we are 

not protecting and giving rights that no one else in society would 

have for bad employees to continue to draw a paycheck? Does the 

Title 38 and some of these tools—because I can tell you now, if you 

think it takes a long time to fire somebody, try and hire them at 

the VA. It takes longer. 

You have fresh-faced graduates, psychiatrists, wanting to serve 

this nation’s veterans and they wait 9 months to even hear back 

if they are going to get a job. These people are like Sasquatch. If 

you find them, take a picture. Because there is none of them. There 

is none of them. 

And, again, how can we compete if they can go to Mayo Clinic 

or Cleveland Clinic and make five times more? 

Now, I know these people want to serve, but there has to be a 

fairness, so I am just asking you, Mr. Secretary, how do we strike 

this balance between appeasing the public’s right for justice and 

getting rid of bad actors, because I deal with this. 
31 

I am a school teacher too. And, I know people always say, oh, you 

cannot get rid of a bad school teacher. You know who wants to get 

rid of a bad school teacher more than anybody? A good school 

teacher teaching next door to them. 

Do you know who wants to get rid of a bad VA employee? A good 

VA employee. 

So, how would describe what we can do to ensure you have those 

tools? 

Mr. GIBSON. I think first of all, the Title 38 provision around senior executives is precisely the right place to go to give us both the 

authority that we need on hiring as well as the authority that we 

need from a disciplinary standpoint. 

I freely admit there are instances where I start wading into a 

particular case, and I ask out loud, who is the advocate for the veteran in all of this, because there are lots of advocates for the employee. Who is the advocate for the veteran? And, I step up and fill 

that particular void. 

We have to ensure that we are restoring balance there and I 

would tell you, one of the most powerful things that any member 

can do—we all know that there are a lot of good thing going on at 

VA. We all know that. And, when there are opportunities to—I am 

not saying, ‘‘do not talk about the bad things,’’ because there are 

bad things that we have to do, as well, Just tell the whole picture. 

Yes, we have to fix this. We have to fix this, but did you know they 

are doing this? They are doing this? 

Because the real tragedy comes when veterans who need to come 

to VA for help or for care do not, because of what they have been 

reading in the media and they stay away. That is the tragedy. You 

look at some of the suicide numbers and the statistics, and I think 

we are close to coming out with some refined statistics there, but, 

what we have seen consistently when we have looked, is that the 

preponderant number of suicides that veterans commit, each day 

are veterans that are not in the VA Healthcare System. 

And, you look at—the old number has been 17 of the 22 are veterans that are not receiving care at VA. We want those veterans 

into the VA Healthcare System if there is any way, shape or form 

for us to get them. 

There were things that we do—Gavin and I have been having 

this conversation because of some of the transformational work 

that he is doing. If we sat here and spent 30 minutes and talked 

about all of the things that VA does around mental healthcare, you 

would not realize. There is no healthcare organization in America, 

perhaps even in the world, that does the things, that has the capability that VA has. 550,000 completed mental health outpatient appointments every single month. I mean, all of the ancillary support 

services that we alluded to earlier. 

Mr. WALZ. I would argue with you on that. I think this is a very 

important point you are bringing up and this is why that simultaneous—— 

Mr. GIBSON. Thank you very much. 

Mr. WALZ [continuing]. Accountability with improvement, if I 

could, Senator Johnson, just end with this, that we as a Nation 

need to not talk about those 22. We do not need to set expectations 

that this is an outcome that is going to happen. We have to talk 
32 

about names and individuals, so when we are talking about the 

mistake here, it is Jason and his family. 

Mr. GIBSON. Yes. 

Mr. WALZ. What we are going to produce in the future is that 

individual and I think that attitude—— 

Mr. GIBSON. Yes. 

Mr. WALZ [continuing]. Takes us in a better direction. 

Mr. GIBSON. Yes. 

VOICE. Thank you, sir. 

Senator JOHNSON. Thank you, Congressman Walz. 

I want to be respectful of everybody’s time here. Another round 

of questions would definitely eat into that time, so I certainly encourage the Members of the Committee here and the Congressmen 

to certainly submit their questions for the record. I am sure we all 

have additional questions. 

I want to thank our witnesses, but I particularly want to thank 

the families that have suffered this tragedy and the whistleblowers 

for coming forward and having the courage to make this public. I 

know it is not all that easy, but this is what transparency is all 

about. It is what really does produce the kind of accountability 

that, and justice that really is deserved here. 

So, with that—I know I have the magic words here somewhere. 

I have them. 

The hearing record will remain open for 15 days until June 15, 

at 5:00 p.m. for the submission of statements and questions for the 

record. 

This hearing is adjourned. 

[Whereupon, at 11:49 a.m., the Committee was adjourned.] 
(33) 

A P P E N D I X 
34 

Along with staff of Ranking Member Carper and Senator Baldwin, my staff conducted 

bipartisan transcribed interviews of 22 VA and VA OIG employees, totaling nearly 82 

hours of interviews; and 

• Reviewed tens ofthousands of pages of documents. 

In conjunction with today's hearing, I am releasing a 359-page majority staff report detailing our 

findings and recommendations. Our investigation found that these tragedies were preventable 

and the failures were systemic across the executive branch. Here is what we found: 

In 2002, the VA hired Dr. David Houlihan, and it promoted him in 2004 to be chief of staff of 

the Tomah VA. Both times, VA regional leadership was aware of charges against Dr. Houlihan 

from the Iowa State Board of Medical Examiners that he had inappropriate professional 

boundaries with a patient. The VA did not formally address the Iowa allegations against Dr. 

Houlihan until 2009. By that time, VA regional leadership determined that the issue was 

"resolved." 

On Nov. 11, 2007, less than 24 hours after he was discharged from the Tomah VA, veteran Kraig 

Ferrington passed away from "poly medication overdose." Consultants retained and peer 

reviews performed after his death showed deficiencies in the Tomah VA's medication 

management. One VA consultant wrote "there is a general concern regarding the number of 

medications [Mr. Ferrington] was on, and the potential interactions among them." 

In January 2009, the local union for Tomah VA employees alerted the VA OIG about allegations 

of over-prescription at the facility. The VA O!G does not have a record of receiving this 

information. 

In June 2009, a Drug Enforcement Administration investigator interviewed Noelle Johnson, a 

pharmacist at the Tomah VA who was fired after she questioned prescriptions. Dr. Johnson 

showed the DEA 10 examples of patients who had prescriptions that were either too high in 

dosage or too long in length. The DEA examined other allegations in both 2011 and 2012 and 

has informed my staff that they have a current open investigation into the Tomah VA. I invited 

the DEA to testify here today to talk about its work and potential drug diversion relating to the 

Tomah VA, but it declined the invitation. 

On July 14, 2009, the Tomah VA fired Dr. Christopher Kirkpatrick, a clinical psychologist at the 

facility. That evening, he was found dead from a self-inflicted gunshot wound. Prior to his 

death, Dr. Kirkpatrick had tried to raise concerns within the facility about the over-prescription 

of medications. At least one of Dr. Kirkpatrick's supervisors testified to the VA accountability 

board that he felt coerced into disciplining Dr. Kirkpatrick. This same supervisor also testified 

that he disagreed with the decision to fire Dr. Kirkpatrick. 

In September 2009, Roberto Obong became the chief of VA police at the Tomah VA. In starting 

his new job, ChiefObong researched the facility's reputation and found that the Tomah VA was 

known in the community as the "big pillbox." Over ChiefObong's four-year tenure at the 

facility, he did not investigate these allegations. 
35 

In August 2013, VA headquarters conducted a site visit to the Tomah VA. The report of the visit 

noted that the facility dispensed benzodiazepines to older veterans and to veterans diagnosed 

with post-traumatic stress disorder (PTSD) at a rate much higher than the national average. The 

VA merely "encouraged" the facility to "review" whether its medication practices were in 

accordance with national policy. 

In November 2013, less than a year before his death, veteran Jason Simcakoski sought help from 

federal and local1aw enforcement about the Tomah VA. Call logs and voicemails from his cell 

phones show numerous contacts with Tomah police, the VA police, and even the FBI. Our 

investigation found that in early November 2013, Jason placed five separate phone calls to the 

FBI and had conversations totaling more than 30 minutes in length. 

The FBI denies that it has any record of these communications from Mr. Simcakoski. My staff 

even played this voicemail for FBI officials last year to help them get to the bottom of this, and 

still the FBI denies having any communications with Mr. Simcakoski. I invited the FBI to testify 

today to help us understand the discrepancy between what Mr. Simcakoski's phone records show 

and their recollections of the November 2013 timeframe. The FBI declined the invitation. 

These systemic failures from the VA, the 01G, and other agencies were not harmless. In January 

2015, Candace Delis took her 74-year-old father, Thomas Baer, to the Tomah VA. According to 

Ms. Delis, Mr. Baer waited two hours to be seen. During this time, he suffered an apparent 

stroke, but the facility's CT scan machine was down for maintenance that day. Mr. Baer later 

died, and his daughter said that she would never have taken him to the Tomah VA if she had 

known about the facility's problems. 

The public attention brought by news media reports and our investigation is bringing real 

accountability to the Tomah VA and the VA Office oflnspector General. The former Tomah 

VA director and multiple medical professionals who provided substandard care to veterans and 

perpetuated a culture fear among the Tomah VA staff are no longer employed at the facility. 

Richard Griffin-the former deputy VA inspector general who failed to publish hundreds of 

reports of health care inspections, including the Tomah report-retired from federal service last 

July. Finally, in October of last year, President Obama heeded a more-than-year-long call to 

appoint a permanent VA inspector general. I was honored to champion and confirm Michael 

Missal on the floor of the United States Senate to serve as the first permanent inspector general 

of the Department of Veterans Affairs in nearly two years. 

Today we are joined by two witnesses, Mr. Missal and the VA Deputy Secretary Sloan Gibson. 

These two officials will play a key role in helping to fix the problems at the Tomah VA and other 

VA health care facilities to ensure that these tragedies are never repeated. I thank the witnesses 

for attending today' s field hearing. 

We owe a tremendous debt to the men and women who served the nation in uniform. All of us 

bear the important responsibility of ensuring that the finest among us receive the high-quality 

care they deserve. Today's hearing is an important step in providing closure for the families of 

those who died because of mismanagement at the Tomah VA. While we will not be able to fix 
36 

past mistakes, it is necessary that we learn from the tragedies here so that no family has to endure 

such pain in the future. 
37 

Statement of Ranking Member Tom Carper: 

"Tomah VAMC: Examining Patient Care and Abuse of Authority" 

WASHINGTON- Today, the US. Senate Committee on Homeland Security and Governmental 

Affairs held the hearing, "Tomah VAMC: Examining Patient Care and Abuse of Authority. " 

Ranking Member Tom Carper (D-Del) submitted the following statement for the Record: 

First, I want to thank Chairman Ron Johnson and Senator Tammy Baldwin for working together 

to address the serious issues at the Tomah VAMC and for holding this important hearing today. 

Having served 23 years in the U.S. Navy- five years in a hot war in Southeast Asia, 

and 18 years in a cold war on reserve duty- I deeply appreciate the sacrifices that veterans have 

made for our country. I strongly believe that the benefits that the federal government provides to 

America's veterans are not gifts, but rather entitlements that they've earned as a result of their 

courage and sacrifice. So I take the reports in recent years of misconduct and poor management 

at the Veterans Health Administration system seriously. 

Fortunately, Congress has taken some action to address the widely-reported problems the VA has 

been dealing 'With. I was pleased to support the Veterans Access, Choice, and Accountability and 

Transparency Act that was signed into law in 2014. This legislation took several steps to hold 

accountable those responsible for wrongdoing in the Department of Veterans Affairs, and expand 

and improve healthcare services for veterans. It was a good step forward, but we need to remain 

vigilant to ensure that the Department of Veterans Affairs is taking appropriate action to fix what 

went wrong and ensure that our veterans aren't put at risk due to poor care again. 

So I was deeply troubled to learn last year about allegations of poor treatment and a management 

'culture of fear' at the U.S. Department of Veterans Affairs Medical Center (V AMC) in Tomah, 

Wisconsin. A January 2015 report from the Center for Investigative Reporting described a 

disturbing and heartbreaking situation that put veterans in harm's way at a place that should be 

helping them. The report highlighted troubling prescribing practices at the facility and a 

management environment that failed to adequately address concerns raised by employees about 

those practices. 

Shortly after the release of this report, Chairman Johnson directed his staff to begin an 

investigation into many of the issues highlighted in the Center for Investigative Reporting report. 

My staff and Senator Baldwin's staff participated in the Committee's investigation, including 

interviews with 22 individuals with knowledge of the situation at Tomah. 

During the Committee's investigation, our staffs learned about an environment at Tomah, 

especially in the Tomah V AMC's pharmacy and among senior leadership at the facility, that 

made it difficult for medical providers to freely communicate and collaborate to further patient 

care. We also learned that some providers' prescribing practices hurt the veterans they were 

charged with helping. 
38 

The death of Marine Jason Simcakoski, who passed away at the facility after seeking treatment 

for complex mental health issues, comes to mind as one of the most powerful and tragic 

instances of the kind of poor care provided at the Tomah VA. 

Chronic understaffing, a shortage of qualified mental health care professionals, and a lack of 

adequate oversight over the leadership at the Tomah VAMC may have contributed to some of 

the issues we identified. In addition, our staff found that the VA OIG's decision to 

administratively close an investigation it conducted at Tomah without publicly releasing a report 

made it more difficult for the VA and the public to identify and correct what was going wrong. 

The VA conducted its own investigation into the prescribing and management practices at the 

Tomah V AM C. On March 10, 2015, the agency released a memo detailing its preliminary 

findings that largely mirrored ours. The report showed that unsafe clinical practices in areas such 

as pain management and psychiatric care could he at least partially attributable to prescribing 

practices at the facility. The report also confirmed that the reported 'culture of fear' did 

compromise patient care and hurt staff morale. 

All of that said, I should note that the VA has taken a series of steps to address the issues at 

Tomah and to try and restore the trust of veterans who rely on the facility. The former Director 

and Chief of Staff at the facility has been fired and the new leadership there has put into place a 

number of reforms and new initiatives, including an aggressive recruitment campaign intended to 

bring qualified physicians on hoard. Other steps have been taken to improve access to care, 

improve the culture, encourage open communication between leadership and front line 

employees, and provide additional tools for providers at the facility. I am encouraged by these 

initial steps and am optimistic that the quality of care and management practices will improve 

over time. 

I should also note that Chairman Johnson and Senator Baldwin have introduced legislation that 

would protect whistlehlowers at the VA and provide safer and more effective pain management 

services to our nation's veterans. I commend them both on their efforts, and thank them as well 

for working with me in the Senate to swiftly confirm our new VA Inspector General, Mr. 

Michael MissaL My hope is that Mr. Missal can learn from what happened at Tomah and take 

action as necessary to ensure that the problems that plagued the Tomah VAMC are adequately 

addressed there and at VA facilities nationwide. 

I would like to close with a personal experience that I first had when visiting the VA in 

Delaware. I visited the Veterans Hospital near Wilmington, Delaware shortly after emolling in 

graduate school at the University of Delaware in September 1973 to find out what services were 

available to me as a veteran of the Vietnam War. The hospital, built just after World War II, was 

at that time not one that Delaware or its veterans could be proud of. In the years since, I've 

worked to improve the quality of care offered to veterans in Delaware and make sure that our 

hospital is one we could be proud of I'm proud to say that we've made some progress. We've 

expanded access to care in the state with clinics in Dover and Georgetown that serve thousands 

of veterans. And if you talk to the veterans in Delaware who use the VA, for the most part they 

tell you that the people who work there are caring, dedicated men and women who are 

committed to giving veterans the kind of care they deserve. My hope is that the actions taken by 
39 

the VA in response to the issues raised at the Tomah V AMC, including some of the reforms put 

in place by the new leadership there, will go a long way in restoring trust and a high quality of 

care for our veterans in Wisconsin. 

As I've said before, fixing the problems at the VA isn't a partisan issue. It's a shared 

responsibility among Congress, the Administration, and the VA's leadership. We must continue 

to work together to improve veterans' access to health care and to restore both veterans' and 

taxpayers' trust in the VA. It is my hope that we can learn from what happened at Tomah and 

ensure that reforms are put in place to prevent them from occurring to other veterans and their 

families. 
40 

Opening Statement of Senator Tammy Baldwin 

"Tomah V AMC: Examining Patient Care and Abuse of Authority" 

Tuesday, May 31,2016 

As submittedfor the record: 

Thank you, Chairman Johnson. I want to thank you for organizing this hearing today and I also 

want to add my words of appreciation to your staff, Senator Carper's staff and to my staff in 

terms of the undertaking that resulted this work product. It is a very significant investment on 

their part and we appreciate that. 

I think the fact that we are both here again today sends an important message to this community 

that we share a bipartisan commitment to addressing problems at the Tomah VA and that we will 

continue to work across the partisan aisle in order to address the problems at the Tomah VA. In 

fact, I would describe it as, there is no aisle. 

This weekend, I had the honor of attending a Memorial Day ceremony in Union Grove. Across 

Wisconsin and in communities across our nation, Americans joined together to pay tribute to 

everyday heroes who served and sacrificed to protect freedoms that we all cherish. 

As Americans, we are united. We are united by an eternal bond with the families and friends of 

our fallen. We are also united by the sacred trust that we have with our veterans and their 

families. 

I will say this, when you look into the eyes of our American patriots our veterans, our service 

members or a family member who lost one to the ultimate sacrifice, you are reminded of the 

American values that hold us together. You are reminded of the values that define us as one 

nation united. 

Today, as we hear the story of how that sacred trust with our veterans and their families has been 

broken, it's important for us to keep in mind what unites us. 

One profound thing that I have learned about the tragic problems at the Tomah VA is that 

Veterans, their families and whistleblowers all want the same thing. 

They want answers and accountability, but most importantly, they want solutions to the problems 

at the Tomah VA so that these tragedies never ever happen again. 

What I am committed to is fixing what has been broken. What I am focused on is restoring the 

sacred trust we have with our veterans and their families. 

The Committee's report makes clear much of what we have known for some time- the problems 

at the Tomah VA have had tragic and preventable consequences. 
41 

The report sheds light on the failures surrounding the deaths of Kraig Ferrington, Dr. Christopher 

Kirkpatrick, Jason Simcakoski and Thomas Baer. What this report can never do is repair the 

damage that their losses have had on their families, many of whom are here with us today. 

The Committee's report also confirms the report released by the Department of Veterans Affairs 

Office of Inspector General last August that found the Tomah VA leadership and physicians 

entrusted with veterans care failed to keep their promise to a Wisconsin Marine and his family. 

It's just as clear to me today, as it was a long time ago, that the VA prescribed Jason Simcakoski 

a deadly mix of drugs that led to his death. And those responsible at the Tomah VA for this 

tragic failure should have been held accountable long ago. In fact, they should have been held 

accountable before Jason's death. 

The actions taken by the VA last September to replace Mario DeSanctis, the Director of the 

Tomah VA, were long overdue. 

The actions taken by the VA last November to remove David Houlihan, the Tomah VA Chief of 

Staff, from federal employment and revoke his clinical privileges came tragically too late. 

Both the VA and the VA Inspector General failed to do the job that we all expect them to do. 

The result of this failure was a culture of abuse of authority, staff intimidation and retaliation by 

management of employees. The problem of improper prescribing practices, overrncdication and 

high rates of dangerous drug combinations was simply not properly addressed as it should have 

been. The result of this failure was tragic. 

The record is clear. For far too long, serious problems have existed at the Tomah VA and they 

were simply ignored or not taken as seriously as they should have been by the VA and the VA 

Inspector General. 

My office was just one of many voices who were trying to expose the problems at the VA. 

When my Senate office was first contacted in March 2014 with complaints about the Tomah VA, 

including prescribing practices, they came from an anonymous whistleblower, someone who still 

remains anonymous today. 

We immediately brought those concerns to the Tomah VA and then to the VA Office of 

Inspector General, and then to the U.S. Department of Veterans Affairs headquarters in 

Washington D.C. 

Four months prior to Jason's death, I called for a full review and investigation from the Tomah 

VA. 

Two months prior to Jason's death, I called for a full review and investigation from the U.S. 

Department of Veterans Affairs and the VA Office of Inspector General. 
42 

On August 30, 2014, Jason tragically died at the Tomah VA as a result of what was medically 

deemed, "mixed drug toxicity." 

The Simcakoski family lost a son, a husband, a father, and we lost somebody who faithfully 

served his country. 

If there is one thing that I want to come out of this hearing and one thing that comes from this 

report, I want it to be this. 

I want everyone to hear the voice of Jason's wife Heather, who has said, and I quote: 

"When I look back at the past, I want to know we made a difference. I want to believe we have 

leaders in our country who care. I want to inspire others to never give up because change is 

possible." 

Jason's family, just like veterans and their families in this community and communities across 

Wisconsin, are not interested in finger pointing and a blame game. Neither am I. 

That is why over the past year I have focused on solutions to problems at the VA. 

I have worked across party lines to advance reforms that will improve transparency at the VA 

Office oflnspector General, to strengthen protections for whistle blowers and to provide stronger 

oversight of the VA' s prescribing practices. 

I authored a reform that was recently signed into law which requires the VA Inspector General to 

submit reports to Congress and make them available to the public. That is the standard that must 

now be met. 

More must be done to change the status quo at the VA. We must work to build a VA that 

embraces, rather than retaliates against, whistle blowers who want to improve the system. I have 

a tremendous amount of respect for the courage of whistleblowers that have come forward about 

problems at the VA. 

Last year, I had the honor of working with Jason's family to develop legislation to provide the 

VA with the tools it needs to help prevent this type of tragedy from occurring to other veterans 

and their families. 

One year ago, I introduced this bipartisan legislation in Jason's name that earned the support of 

many veterans service organizations and I'm so proud, Senator Johnson, to have you join in this 

effort. 

I am pleased that House of Representatives recently passed a version of Jason's bill and I am 

equally grateful to members of the Senate Committee on Veterans' Affairs for their bipartisan 

support of Jason's bill, the Jason Simcakoski Memorial Opioid Safety Act. It's a critical reform 

and it continues to move forward. Families like Jason's have a story to tell and it needs to be 

heard, and the movement of their legislation is strong evidence that their voice is being heard. 
43 

My goal is to put these reforms in place to prevent Jason's tragedy from ever happening to 

another veteran or any of our veterans' families. 

Change is indeed possible. Heather's words have inspired me and it is my hope that they will 

inspire all of us to work together and prevent these problems and tragedies from ever happening 

again. 

I thank you, Senator Johnson, for providing me with this opportunity to join you today. !look 

forward to continuing our work together. 
44 

STATEMENT OF WITNESS 

SLOAN D GIBSON 

DEPUTY SECRETARY 

DEPARTMENT OF VETERANS AFFAIRS (VA) 

BEFORE THE 

SENATE COMMITTEE ON 

HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS 

MAY 31,2016 

Good morning, Chairman Johnson, Ranking Member Carper, and Members of 

the Committee. Thank you for the opportunity to speak about the quality and culture of 

care at the Department of Veterans Affairs Medical Center (VAMC) in Tomah, 

Wisconsin. I look forward to sharing with you the progress we have made with patient 

safety, employee engagement, leadership changes, and improvements in opioid safety 

and pain management. I am accompanied today by Dr. Gavin West, Senior Medical 

Advisor, Clinical Operations. 

Since our March 30, 2015, hearing, we have worked closely with the Wisconsin 

Congressional delegation and this Committee to investigate harms experienced by 

Veterans served by the Tomah VA Medical Center (VAMC) and to hold individuals 

accountable. In addition, we focused efforts on improvements in mental health, pain 

management, and culture and working environment. Identifying and addressing 

challenges is vital to our mission, as is responding to the needs of our dedicated 

employees. 

Tomah VAMC 

On January 15, 2015, a physician and nurse practitioner were relieved of their 

clinical care duties and the ability to prescribe any medications pending the outcome of 

all investigations. In response to whistleblower allegations of unsafe clinical care and 

prohibited personnel practices at the Tomah VAMC, on January 23, 2015, Dr. Carolyn 

Clancy, who was the Interim Under Secretary for Health at the time, charged a clinical 

review team comprised of leading experts outside the facility and network to assess 

practice patterns, controlled substance prescribing habits, and administrative 
45 

interactions between subordinates and clinical leadership related to opioid prescribing 

practices. 

On March 10, 2015, VA released key findings and recommendations of its initial 

clinical review into opioid prescription practices at the Tomah VAMC. The team made 

specific findings relating to overall opioid utilization at the Tomah VAMC and found that 

an apparent culture of fear at the facility compromised patient care and impacted staff 

satisfaction and morale. Based on these preliminary findings, the team recommended 

that VA consider a more in-depth evaluation of the clinical and administrative practices 

at the Tomah VAMC. Additional cases were brought to the review team's attention, with 

a second in-depth clinical review being conducted by Lumetra, an external quality 

improvement organization, beginning on March 11, 2015. Investigators from the 

independent VA Office of Inspector General (OIG) and the Department of Justice's Drug 

Enforcement Agency have also been on site. 

We are deeply concerned and distressed about the allegations that employees 

who sought to report deficiencies at the Tomah VAMC were ignored, or worse, 

intimidated into silence. VA will not tolerate intimidation or suppression of concerns. An 

administrative review team examined allegations of retaliation against employees and 

other accountability issues related to Tomah VAMC leadership. The clinical review 

teams identified patient safety concerns for some patients at Tomah VAMC based on 

opioid prescribing practices outside generally-accepted standards of care. Two 

physicians were terminated, and two other personnel resigned. 

In order to create a more transparent culture and improve communication with 

Tomah VAMC employees, leadership has taken a number of actions, including town hall 

meetings, supervisory forums, and expanded all-employee communications. These 

were to provide staff support and guidance on how employees can directly and 

confidentially contact and communicate with the team conducting the investigations. In 

addition to actions taken to address culture and communication, the Tomah VAMC 

initiated a number of actions to address opioid/pain management issues. Providers 

transitioned to using an expanded urine drug screen, and facility clinical leadership is 

updating their pain management policies. Electronic patient record tools were deployed 

system wide in March 2015 to make pain management information, including adherence 

2 
46 

to recommended practices, individual risks associated with other medications and 

clinical problems, and impact on pain scores, more easily accessible during patient 

visits. The facility hosted a regional conference on improved pain management, led by 

national experts, in June 2015. 

We have seen tangible improvements; from January 2015 to December 2015, 

there has been a 16-percent reduction in the number of patients receiving opioids and 

benzodiazepines together across VA. During the same time frame, Tomah VAMC has 

achieved a 27-percent reduction. 

Veterans Health Administration (VHA) 

As the Nation's largest integrated health care system, VA recognizes that 

challenges confronting any facility may reflect issues occurring throughout VA as well as 

in health care across the U.S. Chronic pain has an especially profound impact on the 

Veteran population. Almost 60 percent of returning Veterans from service and more 

than 50 percent of older Veterans in the VA health care system live with some form of 

chronic pain. Moreover, the treatment of Veterans' pain is often very complex. Many of 

our Veterans have survived severe battlefield injuries, some repeated, resulting in lifelong moderate to severe pain related to damage to their musculoskeletal system and 

permanent nerve damage, which can impact their physical abilities, emotional health, 

and central nervous system. VA is committed to reducing overreliance on opioid 

medicines, especially in light of the severe negative consequences many patients on 

opioids risk. 

Current VHA Pain Management Collaboration 

To implement effective management of pain, VHA's National Pain Management 

Program oversees several work groups. A National Pain Management Strategy 

Coordinating Committee includes representatives from the VHA Offices of Nursing, 

Pharmacy, Mental Health, Primary Care, Anesthesia, Education, Integrative Health, and 

Physical Medicine and Rehabilitation. Working with the field, these groups develop, 

review and communicate strong pain management practices to VHA clinicians and 

clinical teams. 

3 
47 

The Opioid Safety Initiative (OSI) Toolkit Task Force has published and 

promoted 15 evidenced-based documents and presentations to support provider 

education in OSI through Academic Detailing. More information on the OSI Toolkit can 

be found at the following link: (http://vaww.va.gov/PAINMANAGEMENT/index.asp). 

The Department of Defense (DoD)-VA Health Executive Council's Pain Management 

Workgroup (PMWG) oversees joint projects with DoD that aim to standardize highquality pain care across DoD and VHA. 

VA's Progress in Pain Management 

Chronic pain management is challenging for Veterans and clinicians. VA 

continues to focus on identifying Veteran-centric approaches that can be tailored to 

individual needs and remains committed to using non-pharmacologic measures as well 

as medications safely. Opioids are an effective treatment, but their use requires 

constant vigilance to minimize risks and adverse effects. VA launched a system-wide 

OSI in October 2013 and has seen significant safety improvement in the use of opioids, 

both in terms of the number of Veterans on chronic opioid therapy and the absolute 

doses. The Specialty Care Access Network-Extension for Community Healthcare 

Outcomes (SCAN-ECHO) and the OSI have been designed to integrate with our 

Academic Detailing which is a proven method in changing clinician behavior by 

providing educational outreach to address a difficult medical problem in a population. 

Academic Detailing combines longitudinal monitoring of clinical practices, regular 

feedback to providers on performance, and education and training in safer and more 

effective pain management. 

Rigorous investigations take time, but we did not wait for the completion of the 

investigation to take action to improve care both at Tomah VAMC and across the 

system. In March 2015, we launched the new Opioid Therapy Risk Report tool, which 

provides detailed information on the risk status of Veterans taking opioids to assist VA 

primary care clinicians with pain management treatment plans. This tool is a core 

component of our reinvigorated focus on patient safety and effectiveness. VA's own 

data, as well as the peer-reviewed medical literature, suggest that VA is making 

progress relative to the rest of the Nation. In December 2014, an independent study by 

4 
48 

RTI International health services researcher, Mark Edlund, MD, PhD and colleagues, 

supported by a grant from the National Institute on Drug Abuse, was published in the 

journal PAIN. This study, using VHA pharmacy and administrative data, reviewed the 

duration of opioid therapy, the median daily dose of opioids, and the use of opioids in 

Veterans with substance use disorders and co-morbid chronic non-cancer pain. 

Dr. Edlund and his colleagues found the following: 

• About 50 percent of Veterans with chronic non-cancer pain in this cohort 

received an opioid as part of treatment; 

• Half of all Veterans receiving opioids for chronic non-cancer pain, are receiving 

them short-term (i.e., for less than 90 days per year); 

• The daily opioid dose in VA is generally modest, with a median of 20 Morphine 

Equivalent Daily Dose (MEDD); 

• The use of high-volume opioids (in terms of total annual dose) is not increased in 

VA patients with substance use disorders as has been found to be the case in 

non-VA patients. 

By virtue of VA's central national role in medical student education and residency 

training of primary care physicians and providers, VA will be playing a major role in this 

nationwide transformation effort. But we have already started with our robust education 

and training programs for primary care, such as SCAN-ECHO, Mini-residency, 

Community of Practice calls, two Joint Incentive Fund (JIF) training programs with DoD, 

and dissemination of the OSI Toolkit. 

The Opioid Safety Initiative (051) 

OSI was implemented nationwide in August 2013. OSI's objective is to make the 

totality of opioid use visible at all levels in the organization. It includes key clinical 

indicators such as the number of unique pharmacy patients dispensed an opioid; unique 

patients on long-term opioids who receive a urine drug screen; the number of patients 

receiving an opioid and a benzodiazepine (which puts them at a higher risk of adverse 

events); and the average MEDD of opioids. Results of key clinical metrics for VHA 

measured by OSI from Quarter 4, Fiscal Year (FY) 2012 (beginning in July 2012) to 

Quarter 2, FY 2016 (ending in March 2016) are as follows: 

5 
49 

• 151,982 fewer patients receiving opioids (679,376 patients to 527,394 patients, a 

22-percent reduction). 

• 51,916 fewer patients receiving opioids and benzodiazepines together (122,633 

patients to 70,717 patients, a 42-percent reduction); 

• 94,045 more patients on opioids that have had a urine drug screen to help guide 

treatment decisions (160,601 patients to 254,646, a 37-percent increase); 

122,065 fewer patients on long-term opioid therapy (438,329 to 316,264, a 28-

percent reduction); 

Also, the overall dosage of opioids is decreasing in the VA system as 18,883 fewer 

patients (59,499 patients to 40,616 patients, a 32-percent reduction) are receiving 

greater than or equal to 100 MEDD, a figure associated with greater overdose risk 1

. It 

is important to note that these desired results of the OSI have been achieved during a 

time in which VA has seen an overall growth of 136,944 patients (3,959,852 patients to 

4,096,796 patients, a 3-percent increase) that have utilized VA outpatient pharmacy 

services. 

The OSI dashboard metrics indicate that overall trends are moving steadily in the 

desired direction. OSI is being implemented in a measured way to give VA time to build 

the infrastructure and processes necessary to allow VA clinicians to incorporate new 

pain management strategies into their treatment approaches. A measured process will 

also give VA patients time to adjust to new treatment options and to mitigate any patient 

dissatisfaction that may accompany these changes. 

VA expects this trend to continue as it renews its efforts to promote safe pain 

management therapies. VA intends to implement safe opioid prescribing training for all 

prescribers; 70 percent of prescribers have received training to date. 

Psychotropic Drug Safety Initiative 

The Psychotropic Drug Safety Initiative (PDSI) is a VA nationwide 

psychopharmacology quality improvement (QI) program that was launched in December 

2013, with the aim of improving the safety and effectiveness of psychopharmacologic 

treatment across VA. The initial Phase 1 program broadly looked across multiple 

1

Uang Yl, Turner BJ2. Assessing risk for drug overdose in a national cohort: role for both daily and total opioid 

dose? J Pain. 2015 Apr;16(4):318-25. doi: 10.1016/j.jpain.2014.11.007. Epub 2014 Dec 5. 

http://www_ ncbi _ n I m .nih .gov /p me/ a rticl es/P MC4385393/ 

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50 

classes of medications and mental health diagnoses. Facilities, on average, identified 3 

prescribing measures from among the 20 that served as the focus for their local Ql 

efforts during Phase 1 (priority measures). Facilities were required to prioritize any 

measure where local performance was a significant outlier compared to the rest of the 

VA system (defined as local score> 2 standard deviations worse than the national 

score), but were otherwise given the freedom to identify their own local priorities. Key 

components of the program implemented during Phase 1 included the following: 

• Providing quarterly data on national, Veterans Integrated Service Network 

(VISN), and facility-level performance on prescribing measures to participants; 

• Facilitating clinical review of treatments for Veterans who may benefit from 

improvement in their psychotropic medication regimen via actionable patient lists 

updated daily on the PDSI Clinical Management Dashboard; 

Providing feedback and technical assistance to VISNs and facilities for Ql action 

planning; 

• Coordinating a national Ql learning collaborative; and 

• Developing and disseminating training and educational resources. 

Since its implementation, the PDSI program has had a robust and positive impact on 

the care of Veterans. Out of the 20 prescribing metrics tracked in the initial phase of the 

program, 16 showed improvement in the national score. 

There are several areas of prescribing that showed especially strong 

improvements. Across the system we have decreased use of potentially harmful 

medications in patients with Posttraumatic Stress Disorder (PTSD), including decreased 

use of benzodiazepines, antipsychotics, and the use of complex, multiple-drug 

regimens. We have also decreased the use of benzodiazepines among vulnerable 

populations, such as Veterans with PTSD or dementia and the elderly, as well as 

decreased the use of complex, multiple-drug regimens for patients with depression. We 

have also successfully increased the use of evidence-based medications for treatment 

of substance use disorders, particularly in Veterans with alcohol and opioid addiction. 

These improvements have directly and positively impacted the care of thousands of 

Veterans. 

Overdose Education and Naloxone Distribution (OEND) 

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51 

VA has also undertaken a national initiative to make overdose education and 

naloxone rescue kits available to patients at risk of accidental or intentional overdose. 

Naloxone can reverse an opioid overdose. preventing overdose death and morbidity 

when administered in a timely manner. Distribution of overdose rescue training and 

naloxone kits is a novel intervention within health care settings. and it is being rapidly 

adopted by VA. To date. 3,945 VA providers have begun prescribing these kits to 

at-risk patients. with over 23,330 patients receiving training and kits. Additionally, 172 

opioid overdose reversals have been voluntarily reported with the naloxone VA 

prescribed, demonstrating the potential lifesaving effects of these efforts. 

VA has developed a predictive model and clinical decision-support tool to identify 

patients with opioid prescriptions at risk of suicide-related events and overdose. This 

Stratification Tool for Opioid Risk Mitigation is available nationally, and it estimates the 

likelihood of an overdose or suicide event in the next year, providing patient-tailored 

recommendations for risk mitigation and non-opioid pain management options. VA has 

continued its efforts to ensure that effective substance use disorder treatments are 

available for patients with substance use disorders. knowing that they have an elevated 

risk for suicide and overdose. Greater engagement in VHA substance use disorder 

programs is associated with lower suicide attempt risk and reduced criminal behavior in 

Veterans initiating substance use disorder treatment. VHA continues to increase 

availability of specialty substance use treatment, increasing the number of patients 

treated per year with specialty treatment services and with opioid antagonist treatment 

for opioid use disorders. 

National Take-Back Initiative 

In September 2014, the Drug Enforcement Administration (DEA) published in the 

Federal Register a final rule, effective October 9, 2014, to implement the Secure and 

Responsible Drug Disposal Act of 2010. This rule provides three voluntary methods for 

ultimate users (e.g., Veterans) to dispose of their unwanted/unneeded medications in a 

secure and responsible manner: 1) Mail Back Packages, 2) On-site Collection 

Receptacles. and 3) Take Back Events. VA has been a leader in implementing these 

options for Veterans. We have on-site receptacles in over 70 locations and mail-back 

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52 

envelopes available at all facilities. Services have been actively marketed to Veterans 

through the use of facility flyers and with information on MyHealtheVet and on the VA 

Pharmacy MedSafe website. Both Veterans and staff report a high level of satisfaction 

with this service, and as of May 1 ,· 2016, approximately 27,000 pounds, almost 14 tons, 

of unwanted/unneeded medication have been collected and destroyed in an 

environmentally responsible manner. Removal of this medication from Veterans' homes 

reduces the risk of diversion as well as intentional and unintentional overdoses and 

poisonings. 

Accountability 

In January 2015, the Milwaukee Journal Sentinel and other publications ran an 

article about over-prescription of painkillers by the then-Chief of Staff of the Tomah 

VAMC, who is a psychiatrist, and cited several former Tomah employees' complaints 

about retaliatory behavior after they questioned the Chief of Staff's prescribing 

practices. The article also cited an unpublished March 2014 VA OIG "administrative 

closure" report finding the Chief of Staff's prescriptions were "at considerable variance 

compared with most opioid prescribers" and "raised potentially serious concerns." In 

response to this, we acted quickly to prohibit the Chief of Staff and an affiliated nurse 

practitioner from providing care to Veterans and initiated a comprehensive evaluation of 

the quality of the care they provided. The then-interim Under Secretary for Health 

ordered a series of three clinical reviews to assess practice patterns, prescribing habits, 

and staff interactions at Tomah. In reports issued between March and August 2015, 

these review teams found that the Chief of Staff's prescriptive practices were potentially 

unsafe and that an apparent culture of fear existed at the Tomah facility which 

compromised patient care and damaged staff satisfaction and morale. Simultaneously, 

the VA Office of Accountability Review began a series of administrative investigations 

into alleged rnisrnanagernent by Tomah VAMC leadership. Those reviews led to a 

number of leadership changes at the Tomah facility. The Chief of Staff lost his clinical 

privileges and was removed from Federal employment; his removal is currently pending 

appeal. The former Medical Center Director and Associate Director both resigned. 

Victoria Brahm is the Acting Tomah VAMC Director. Ms. Brahm and her predecessor, 

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53 

John Rohrer, worked closely with facility leaders, union leaders, employees, and 

external stakeholders (including Veterans Service Organizations) to ensure that ongoing 

investigations did not disrupt clinical care and that all voices were heard. 

Organizational Excellence 

VA acknowledges its failures in the Tomah VAMC and is committed to preventing 

situations like this in the future. VA has strategically aligned specific program offices to 

ensure that our Nation's Veterans receive the highest quality health care. These 

aligned offices were incorporated into the Office of the Deputy Under Secretary for 

Health for Organizational Excellence. This new office brings together vital portions of 

VA to focus on assessing and improving quality and safety and to provide the field and 

leadership with analytics and tools to assess how we are performing as an organization. 

The office synthesizes information from internal and external oversight activities to 

promote a strong, ethical, and just culture that builds trust and confidence in Veterans 

health care. The office aims to achieve continuous improvement in health care system 

performance by integrating oversight, compliance, and accountability functions. The 

office conducts internal oversight activities such as investigations, audits, risk 

assessment, and business compliance in accordance with VA policy and industry 

standards and proactively identifies system vulnerabilities and manages risk across 

clinical, administrative, business, and financial domains in order to improve 

organizational efficiency and effectiveness. Because of this new office's oversight and 

safeguards, VA is better positioned to mitigate the risk events like those that took place 

in the Tomah VAMC. 

Actions since the 1 00-Day Plan 

Over the course of the last year, the Tomah VAMC has undergone many 

changes and continues to make improvements. Most recently, the Tomah VAMC has 

taken a series of actions during a 100-day period (November 27,2015, through 

March 6, 2016) to enhance the Veteran experience within the medical center and create 

an environment of sustainable accountability that rebuilds trust with Veterans and the 

American people. The Veteran experience is at the forefront of all we do and cannot be 

10 
54 

decoupled from the employee experience. Improving the employee experience will 

positively impact the Veteran experience. We continue to strive to create an 

organization that both Veterans and employees can be proud to call "MyVA." Tomah 

VAMC leadership has expanded upon initial efforts and delivered a shared strategic 

direction for the medical center in January. These objectives are designed to improve 

and standardize the patient experience, making Tomah VAMC the facility of choice for 

Veterans: 

• The FY 2015 All Employee Workforce Satisfaction and Organizational Climate 

Survey for Tomah VAMC reported nearly all scores were below the national 

average. Surveys to date demonstrate improvement in 8 of 10 survey areas, 

meeting or exceeding the national average in half. 

• Employee Town Halls are conducted monthly. MyVA initiatives are delivered by 

leadership to staff members monthly. More than 15 Employee Listening 

Sessions were held during the 1 00-Day Plan; they are now conducted monthly. 

• Medical center leadership is committed to instituting an Employee Renewal 

Center to assist in combatting compassion fatigue. The Center opened to staff 

on Monday, May 16, 2016. This non-clinical area has been dubbed by 

employees as "R Place." 

• Resources have been provided for managers to create a Personal Development 

Plan (PDP). More than 85 managers and local American Federation of 

Government Employees (AFGE) officers have completed a PDP during the 

"Leaders Developing Leaders" curriculum. 

• Patient Centered Care training continues for new hires and staff. The goal is for 

75 percent of staff to be trained by the end of the year and to create awareness 

and unity among staff members by sharing the patient perspective. 

• VA's Office of Resolution Management was on site February 23-25, 2016, and 

held supervisor training sessions and two all-employee training sessions on 

"Conflict Management" and "Alternative Dispute Resolution." 

VA has also taken several steps to focus on the importance of and improvement 

of leadership-employee interactions. VA recognizes that accountability, visibility, and 

communication are central for effective relationships between supervisors and 

employees. VA has emphasized the importance of, and has tracked rounding and 

monthly staff meetings. In January and February 2016, supervisors met more than 

90 percent of rounding opportunities. Re-establishing a culture of trust within the 

medical center was also a significant priority. During the 100-Day Plan, we provided 

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55 

Psychological Safety Training on Harassment and Workplace Bullying to supervisors 

and frontline staff. Additionally, 85 managers, supervisors, and local AFGE officers 

completed the "Leaders Developing Leaders" curriculum. 

An additional part of this effort was to educate supervisors and managers on 

increasing the quality of staff evaluations through training at the Supervisor's Forum, 

and this will continue during an upcoming 3-day supervisors' course. Previous results 

from All Employee Surveys noted a lack of staff recognition and praise. To address 

this, the "Employee of the Quarter" program was increased to "Employee of the Month" 

with a panel of frontline employees managing the process and determining who is 

selected. Other efforts include a "Recognition Toolkit" created for supervisors and 

non-supervisors. More Patient Experience Cards were displayed and shared, and 

employees were recognized in the Acting Medical Center Director's weekly message. 

"Management by Walking About" is practiced by medical center leadership consistently 

walking through the medical center and being available for impromptu discussions with 

employees and Veterans. Also, in January 2016, the Acting Associate Director for 

Patient Care Services began hosting quarterly Nurse Town Hall Meetings. 

Whistleblower Protection 

VA recognizes the important role that whistleblowing plays in bringing significant 

issues to light. I was and am personally invested in ensuring that the quality of care at 

Tomah VAMC is the best available and that any and all circumstances that led to 

problems at the Tomah VAMC have been diagnosed and fixed. In addition to the many 

formal feedback mechanisms VHA has built into our system, we need and want all 

employees and Veterans to feel empowered to provide a first-hand account of their 

experiences so that we can identify and rectify any problems. The underlying purpose 

of whistleblower protection rules is to encourage the candid disclosure of information 

about problems so that deficiencies are corrected, and unsafe or unlawful behavior is 

quickly rectified. 

There are legal disciplinary options for supervisors who retaliate against 

whistleblowers; they exist to support the primary focus on the flow of information, 

including information on quality, safety, or process improvement. VA is fully committed 

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56 

to correcting deficiencies in its processes and programs and to ensuring fair treatment 

for whistleblowers that bring these deficiencies to light. Secretary McDonald 

consistently communicates his vision of "sustainable accountability," which he describes 

as a workplace culture where VA leaders provide the guidance and resources 

employees need to successfully serve Veterans, and employees are empowered and 

encouraged to inform VA leaders when challenges hinder their ability to succeed. All 

VA employees should feel safe sharing what they know, for the benefit of Veterans and 

as good stewards of the taxpayers' money. 

The Department has taken steps to improve how we address operational 

deficiencies and protect whistleblowers from retaliation. In July 2014, I reorganized and 

assigned new leadership to the VA Office of the Medical Inspector (OM I). OMI moved 

quickly to ensure that whistleblower disclosure allegations were investigated objectively, 

thoroughly, and promptly. Since then, OMI has completed more than 70 initial and 

supplemental investigation reports in 2015. When an investigation substantiates the 

whistleblower's disclosure allegations, OMI and Office of Special Counsel (OSC) work 

closely to track the status of corrective actions to completion. 

VA and OSC also created a process that provides for prompt corrective action, 

referred to as the "expedited process," with relief provided to whistleblowers within who 

have been retaliated weeks of referral, instead of months. This approach allows OSC 

and VA to work together to reduce duplicate investigations and to quickly protect 

whistleblowers from retaliation. As of May 2015, VA had received 28 expedited cases 

and successfully resolved 19 cases. Resolved cases have taken an average of 30 to 

60 days to complete. Once cases are resolved under the expedited process the cases 

are forwarded to the Office of Accountability Review to determine if discipline is 

appropriate. VA has also improved its collaboration with OSC by training employees on 

investigating whistleblower retaliation cases and increasing the number who can work 

these cases. 

VA understands that we can also improve on the timeliness of discipline for 

individuals found responsible for retaliation. One approach is for Congress to support 

OSC at a level that enables OSC to hire more investigators to complete this work. This 

would allow VA's limited investigative assets to focus more in VA's areas of expertise. 

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57 

Because it is extremely important that VA hold its employees accountable, if they have 

retaliated against a whistleblower we welcome OSC's additional assistance on this 

front. 

VA senior leaders, including myself, have made it their practice to meet with 

whistleblowers when traveling, and to engage with them to identify problems and 

propose solutions. I have personally participated in the public recognition of several 

whistleblowers, thanking them for their role in improving Veteran outcomes. This is to 

acknowledge the critical role whistleblowers play in improving the quality, safety, and 

effectiveness of VA programs, and to model to supervisors VA-wide the engaged, open, 

and accepting behavior they should exhibit when subordinates express concerns. 

VA is still working toward the full culture change we must achieve to ensure that 

all employees feel safe disclosing problems, and that those who engage in retaliatory 

behavior are held promptly and meaningfully accountable. VA continues to work with 

whistleblowers, OSC, and Congress to resolve these issues, and we remain deeply 

committed to these endeavors. 

Mr. Chairman, because of the events that took place at Tomah VAMC, VA has 

improved how we manage prescriptions nationwide. We will continue to strive for better 

employee engagement and accountable leadership, all in the name of fulfilling our 

mission to serve Veterans. I look forward to answering any questions you or the 

Committee may have. 

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58 

STATEMENT OF 

MICHAEL J. MISSAL 

INSPECTOR GENERAL 

DEPARTMENT OF VETERANS AFFAIRS 

BEFORE THE 

COMMITTEE ON HOMELAND SECURITY 

AND GOVERNMENTAL AFFAIRS 

UNITED STATES SENATE 

FIELD HEARING ON 

"THE QUALITY AND CULTURE OF CARE AT 

THE DEPARTMENT OF VETERANS AFFAIRS MEDICAL CENTER 

IN TOMAH, WISCONSIN" 

MAY 31,2016 

Mr. Chairman and Members of the Congress, thank you for opportunity to appear today 

and discuss the Office of Inspector General's (OIG) past inspections at the Tomah VA 

Medical Center (VAMC), in Tomah, Wisconsin and the OIG's work in the area of pain 

management and opioid use. I am accompanied by John D. Daigh, Jr., MD, CPA, 

Assistant Inspector General for Health care Inspections. 

On May 2, 2016, I was sworn in as the Inspector General. In the past four weeks, I 

have immersed myself in the work of the OIG to understand better the people, policies, 

workload, strategic goals and priorities of our office. I have been impressed with the 

commitment and efforts of the staff of the OIG to achieve its mission of bringing about 

positive change in the integrity, efficiency and effectiveness of VA operations. While my 

integration into the OIG has gone very well, I know there is much more to learn. 

I recognize and strongly support three overriding principles for the OIG. First, we need 

to maintain our independence in all of our work, including avoiding even the mere 

appearance of any undue outside influence. Second, we need to be as transparent as 

possible in our work, while safeguarding the privacy of veterans, whistleblowers and 

others involved in our work. Third, we need to produce work of the highest quality. This 

includes making sure our work is accurate, timely, fair, objective and thorough. 

In my first four weeks, I have also reviewed the previous work of the OIG with respect to 

our healthcare inspections of the Tomah VA Medical Center. Among other actions, I 

met with the staff of the Homeland Security and Governmental Affairs Committee to 

ensure they have the information about our work necessary for the issues to be covered 

in this hearing. My office has learned important lessons from the Tomah healthcare 

inspections that should help us better meet our mission going forward. The changes 

that we have made should increase the confidence that veterans, veterans service 

organizations, Congress and the American public have in the OIG. 
59 

BACKGROUND 

In March 2011, the OIG Hotline received a complaint regarding prescription practices 

at the Tomah VAMC. We referred the allegations to the Director, Veterans Integrated 

Service Network (VISN) 12, VA Great Lakes Health Care System, who has managerial 

oversight of the Tomah VAMC. A copy of this referral was also sent to the office of the 

Veterans Health Administration (VHA) Chief of Staff. The VISN 12 Director provided a 

detailed response to the allegations on June 22, 2011. This response stated that 16 

allegations involving over 30 patients were unsubstantiated. The VISN 12 Director 

substantiated two allegations involving two patients. As a result of this review, the VISN 

Director initiated an action plan to: 

• Review refill policies at Tomah VAMC. 

• Review Tomah VAMC policies regarding lab testing of patients on narcotics. 

• Evaluate practice trends and approaches to pain management to ensure the 

needed variety of pain approaches is available to Tomah VAMC patients. 

Work with the Tomah Chief of Staff to evaluate pain approaches and the 

effectiveness of such. 

Based on the VISN 12 Director's fact-finding efforts and commitment to take corrective 

action, we closed the complaint. 

In August 2011, the OIG Hotline received a new anonymous complaint with similar 

allegations. Over the course of the next approximately two and a half years, the OIG 

Office of Health care Inspections conducted an extensive inspection of the allegations. 

This inspection included involvement from the OIG's Office of Investigations, the U.S. 

Drug Enforcement Administration, and Tomah and Milwaukee municipal police to 

determine if there was evidence of narcotic abuse at the Tomah VAMC. We reviewed 

patient medical records, peer reviews of providers' practice and pharmacy records. We 

conducted an undercover surveillance operation and reviewed email messages and 

associated files originating from numerous individuals. We interviewed current and 

former VA employees and conducted a site visit that included touring the outpatient 

pharmacy to assess security. 

We could not substantiate the majority of allegations that the OIG received. Although 

the allegations dealing with the extensive use of narcotics at the facility may have had 

some merit, they did not constitute proof of wrongdoing. We did not find any conclusive 

evidence affirming criminal activity, gross clinical incompetence or negligence, or 

administrative practices that were illegal or violated personnel policies. We 

administratively closed the inspection on March 14, 2014 because we believed at the 

time that given the totality of the facts-paramount of which was that the allegations 

were not substantiated, the impact disclosure of unfounded allegations could have on 

an individual's reputation and privacy, and knowing that our forthcoming 2014 national 

report would highlight the many deficiencies in VA provider's compliance with opioid 

prescribing guidelines-an administrative closure was appropriate. 

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60 

We noted several issues of concern and made suggestions to address these concerns 

to the Tomah VAMC Director and the VISN 12 Director. We conducted a telephone 

briefing with the Tomah VAMC Director, the VISN 12 Quality Management Officer, and 

the Organizational Improvement Analyst for the Tomah VAMC on July 3, 2014; and met 

in person with the VISN 12 Director on July 16, 2014, to discuss the following 

suggestions: 

The Facility Director should implement a vehicle by which clinicians and staff can 

openly and constructively communicate concerns and rationale when 

disagreements arise concerning dispensing of opioid prescriptions. 

The Facility Director should review the reporting structure in the context of 

safeguarding bi-directional clinical discourse from actual or perceived administrative 

constraint. 

• The Facility Director should ensure development of guidance, parameters, 

processes, or a specialty clinic-based mechanism to assist clinicians and staff with 

managing complex patients requesting early opioid refills. 

• The Facility Director should consider some variant of the tumor board model as one 

potential avenue by which to foster collaborative interdisciplinary management 

when presented with very complex clinical pain cases. 

The VISN should conduct further evaluation and monitoring of relative and casespecific opioid prescribing at Tomah VAMC on both a facility and individual clinician 

level. 

After publication of a news story regarding this work in January 2015, we posted the 

administrative closure on February 6, 2015. We testified about the 2011 inspection we 

performed of the Tomah VAMC at a similar field hearing on March 30, 2015. We also 

provided Chairman Johnson and several other Members of Congress with a "white 

paper" on June 4, 2015 that was intended to highlight evidence obtained and reviewed 

during the OIG's 2011 Tomah VAMC inspection. 

I do not agree with the tone of the white paper or the gratuitous attacks on the 

reputation of individuals included in it. Going forward, my office and I will work hard to 

ensure that all work from the OIG meets the high standards expected of our office. 

Since the 2011 inspection, the OIG has conducted two additional inspections regarding 

allegations at the Tomah VAMC. On June 18, 2015, we issued Healthcare InspectionCare of an Urgent Care Clinic Patient, Tomah VA Medical Center, Tomah, Wisconsin. 

We made nine recommendations in this report. The recommendations included three 

directed at the national level to review of policies for acute stroke treatment especially in 

rural and/or low complexity VA facilities, to improve processes for identifying 

unauthorized access to VA medical records, and to evaluate rules related to 

reimbursement for a veteran's emergency care at non-VA facilities. 

The remaining six recommendations were directed to the Facility Director. They 

included providing proper education to veterans and their families about the services an 

Urgent Care Center is able to provide, providing proper training of staff regarding 

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61 

treatment of stroke patients and Emergency Department Integration Software training, 

ensuring routine maintenance on equipment is scheduled during low utilization periods, 

and ensuring UCC processes are strengthened to improve triage timeliness. As of 

May 19, 2016, the recommendation that the Facility Director ensure that transfer 

agreements are established as required remained open. 

On August 6, 2015, we issued Healthcare Inspection- Unexpected Death of a Patient 

During Treatment with Multiple Medications, Tomah VA Medical Center, Tomah, 

Wisconsin. We made four recommendations in this report. Two recommendations are 

closed. One recommended a further review by VISN leadership of the care provided 

and a consultation with the appropriate office on any administrative action. The other 

recommendation for the Acting Facility Director dealt with ensuring that emergency 

crash carts at the facility are properly stocked with appropriate medications. As of 

May 9, 2016, two remain open: 

Recommendation 2: The Veterans Health Administration requires written informed 

consent when administering hazardous drugs including buprenorphine. However, 

we did not find evidence of written informed consent for buprenorphine treatment. 

In this case, both psychiatrists involved in the ordering of buprenorphine for the 

patient acknowledged they did not discuss the risks inherent in off-label use of the 

drug with the patient. We recommended that the Acting Facility Director ensure 

compliance with applicable VHA policy that requires informed consent be obtained 

and documented. 

• Recommendation 3: We recommended that the Acting Facility Director review 

elements needed to respond effectively to medical emergencies including staff 

training, equipment, and other resources at both the unit and the facility level and 

take any appropriate actions. 

PAIN MANAGEMENT ISSUES 

The use of opioids to treat chronic pain and other conditions continues to be a serious 

concern not just within VA but throughout the Nation. While opioids are considered an 

important part of pain management, they are also associated with serious adverse 

effects. Patients prescribed opioids frequently have complex comorbid conditions, 

making them more likely to be given multiple medications that can interact dangerously 

with opioid medications and potentially lead to death. Clinicians vary widely in their 

chronic opioid therapy prescribing practices within VA and the nation and there is little 

agreement regarding the appropriate use of opioids for treating pain, especially chronic 

non-cancer pain. 

Recently, the OIG published two inspection reports addressing various aspects of VA 

opioid prescribing practices. 1 Our recent work on this topic identified many of the same 

1 Heatthcare Inspection-Poor Follow-Up Care and Incomplete Assessment of Disability, VA San Diego 

Healthcare System San Diego, California (January 5, 2016); Healthcare Inspection-Quality of Mental 

Health Care Concerns, VA Long Beach Healthcare System, Long Beach, California (March 30, 2016). 

4 
62 

issues we previously reported in our May 2014 national review, Healthcare /nspectionVA Patterns of Dispensing Take-Home Opioids and Monitoring Patients on Opioid 

Therapy. As the findings in our national report demonstrate, VA was not following its 

own policies and procedures in six key areas: acetaminophen prescription practices, 

follow-up evaluations of patients on take-home opioids, concurrent substance use 

treatment with urine drug tests, prescribing and dispensing of benzodiazepines 

concurrently with opioids, routine and random urine drug tests prior to and during takehome opioid therapy, and medication reconciliation. 

We note that VA has taken actions to implement the recommendations in this report, but 

VA must be vigilant in monitoring facility compliance with opioid prescription policies. 

We are currently working on another national review that will review: 

VA's pain management services. 

• VA's substance use treatment programs. 

VA's pain management educational efforts. 

• Patterns of use of non-VA treatments. 

• VA's opioid prescribing practices. 

Access to state prescription drug monitoring programs. 

Oversight of pain management patients. 

We expect to publish our findings by the end of the year. 

CONCLUSION 

Yesterday, our nation paid tribute to the sacrifices of the women and men who gave 

their lives in our defense. It is a valuable reminder for all of us at the OIG to rededicate 

ourselves to ensuring that our work is independent, accurate, timely, fair, objective and 

thorough. We will publish the results of our efforts as permissible under law and will 

ensure that complainant names, patient records, and confidential sources are 

protected. We will also continue to review our practices and policies and make 

whatever additional enhancements are necessary to increase the confidence that 

veterans, veterans service organizations, Congress and the American public have in the 

work of the OIG. We thank the Committee for the opportunity to testify about these 

important issues during this most solemn time. 

5 
63 

THE SYSTEMIC FAILURES AND PREVENTABLE 

TRAGEDIES AT THE TOMAH VA MEDICAL CENTER 

Majority Staff Report of the 

Committee on Homeland Security and Governmental Affairs 

l1nited States Senate 

Senator Ron Johnson, Chairman 

:\lay 31, 2016 
64 

Executive Summary 

The tragedies of the Veterans Affairs Medical Center in Tomah, Wisconsin (Tomah 

V AM C)-the veteran deaths, abuse of authority, and whistle blower retaliation-were 

preventable. The Department of Veterans Affairs (VA), the federal entity entrusted with 

protecting and supporting the finest among us, failed the veterans in and around Tomah, 

Wisconsin. That is the fundament truth to these tragedies. But the fault is not the VA's alone. 

The tragedies of Tomah were the result of systemic failures across the executive branch. 

Precisely how a moderately sized VA facility in a western Wisconsin city came to 

become known as "Candy Land"-for its easy access to prescription medications-is unclear. 

Although the "Candy Land" moniker had been around for over a decade, and despite multiple 

investigations, the root causes were never addressed. Allegations of drug diversion, opioid overprescription, retaliation, and mismanagement festered. As a result, veterans died. 

In January 2015, an article published by the Center for Investigative Reporting exposed 

the realities of the Tomah VAMC. The article told the story of Jason Simcakoski, a 35-year-old 

Marine Corps veteran who passed away at the Tomah VAMC in August 2014 from a lethal 

cocktail of medication. It recounted allegations against the facility's ehief of staff, Dr. David 

Houlihan-who veterans dubbed the "Candy Man"-relating to over-prescription, retaliation, 

and drug diversion. The article also exposed the existence of a then-secret report, written by the 

VA Office of Inspector General (VA OIG) and dated March 12,2014, concerning the Tomah 

VAMC. 

Days after the publication of the article, Senator Ron Johnson, Chairman of the Senate 

Committee on Homeland Security and Governmental Affairs, initiated a bipartisan investigation 

into the allegations surrounding the Tomah V AMC. The investigation has been comprehensive. 

Chairman Johnson requested documents from the VA, the VA OIG, and other federal agencies. 

Chairman Johnson's staff, along with staff of Ranking Member Tom Carper and Senator Tammy 

Baldwin, conducted in-depth transcribed interviews with current and former employees of the 

VA and the VA OIG. Chairman Johnson convened two hearings, including a field hearing in 

Tomah to hear directly from veterans and family members of those affected. Chairman Johnson 

even issued a subpoena to the VA OIG for documents relating to its work at the Tomah VAMC. 

Chairman Johnson's investigation reveals new information about the Tomah V AMC. 

Although much is still unknown-the VA OIG continues to withhold material-one overarching 

conclusion is apparent. Federal executive branch entities missed several opportunities to prevent 

the tragedies at Tomah. 

In 2002, the VA hired Dr. David Houlihan, and it promoted him in 2004 to be chief of 

staff of the Tomah VAMC. Both times, VA regional leadership was aware of charges against 

Dr. Houlihan from the Iowa State Board of Medical Examiners that he had inappropriate 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 
65 

professional "boundaries" with a patient. Subsequently, during Dr. Houlihan's re-credentialing 

in 2009, suddenly "there was a lot of Houlihan attention" within the VA 's regional office. The 

VA regional leadership finally ordered an examination of the Iowa allegations and detennined 

that the issue was "resolved." It could have probed deeper into these allegations when Dr. 

Houlihan was hired or when he was promoted. It did not. 

In the early morning hours of November 11, 2007,just a day after being discharged from 

the Tomah VAMC, veteran Kraig Ferrington passed away from "poly medication overdose." 

Consultants retained and peer reviews performed after his death showed deficiencies in the 

Tomah VAMC's medication management, with one consultant writing "there is a general 

concern regarding the number of medications [Mr. Ferrington] was on, and the potential 

interactions among them." Kraig Ferrington's death could have been an opportunity for the 

Tomah VAMC to revisit its prescription practices. It did not. 

In January 2009, the local union for Tomah VAMC employees alerted the VA OIG about 

allegations of over-prescription at the facility. The union informed the VA OlG that there was 

"several staff whom, in their professional judgment, believe that Dr. Houlihan overmedicates 

patients." The VA OIG could have launched an investigation in to over-prescription at the 

Tomah V AMC at that time. It did not. 

In June 2009, a Drug Enforcement Administration investigator interviewed Noelle 

Johnson, a pharmacist at the Tomah VAMC. Dr. Johnson showed the investigator ten examples 

of patients who, in her opinion, had prescriptions either too high in dosage or too long in length. 

The DEA examined other allegations of opioid over-prescription at the Tomah V AMC in 2011 

and allegations of drug diversion in 2012. With multiple inquiries spanning several years, the 

DEA could have stopped the abuse of opioids at the facility. It did not. 

On July 14, 2009, the Tomah VAMC fired Dr. Christopher Kirkpatrick, a clinical 

psychologist at the facility. That evening, he was found dead from a self-inflicted gunshot 

wound. Prior to his death, Dr. Kirkpatrick had attempted to raise concerns within the facility 

about the over-prescription of medications. The VA could have investigated the circumstances 

of Dr. Kirkpatrick's death and learned of the serious issues he was raising. It did not. 

In September 2009, Roberto Obong became the chief of VA police at the Tomah VAMC. 

In starting his new job, Chief Obong researched the facility's reputation. He learned that the 

Tomah VAMC was known in "the law enforcement community as a big pillbox" and that Dr. 

Houlihan was known as the "Candy Man." Over ChiefObong's four-year tenure at the facility, 

he could have investigated these allegations. He did not. 

In March 20 II, the VA OIG received a phone call alerting it to serious issues at the 

Tomah VAMC. The OIG referred the allegations to the VA's regional office and closed the 

case. When it received additional allegations five months later, in August 20 II, the VA OIG reexamined the matter and began a two-and-a-half-year inquiry into the Tomah V AMC. The VA 

OIG collected hundreds of thousands of emails, interviewed facility staff, coordinated with local 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

ii 
66 

and federal law enforcement, surveilled Dr. Houlihan, and issued at least one subpoena. The 

result of this work was an eleven-page report that was initially kept secret. The VA OIG could 

have fixed the problem. It did not. 

In August 2013, the VA headquarters conducted a site visit to the Tomah VAMC. The 

report of the visit noted that the facility dispensed benzodiazepines for older veterans and for 

veterans diagnosed with post-traumatic stress disorder (PTSD) at a rate much higher than the 

national average. The VA merely "encouraged" the facility to "review" whether its medication 

practices were in accordance with national policy. The VA could have done more to recognize 

the concerns at the Tomah V AMC, understand the root causes, and proactively fix the problems 

at the facility. It did not. 

In November 2013, less than a year before his death, veteran Jason Simcakoski sought 

help from federal and local law enforcement about the Tomah VAMC. Call logs and voicemails 

from his cell phones show numerous contacts with Tomah police, the VA police, and even the 

FBI. An FBI agent left a voicemail on Mr. Simcakoski's phone, but the FBI denies any record of 

these communications. Law enforcement could have investigated Mr. Simcakoski's allegations 

and stopped the abuses. It did not. 

These systemic failures were not harmless. In January 2015, Candace Delis took her 74-

year-old father, Thomas Baer, to the Tomah VAMC. According to Ms. Delis, Mr. Baer waited 

two hours to be seen. During this time, he suffered an apparent stroke, but the facility's CT scan 

machine was down for maintenance that day. Mr. Baer later died, and his daughter said that she 

would never have taken him to the Tomah V AMC if she had known about the facility's 

problems. 

The greatest share of responsibility lies with the VA OIG, the entity charged with 

overseeing and investigating the VA's programs and operations. The VA OIG conducted a 

multi-year inspection of the facility that failed to substantiate allegations it received. In early 

2015, however, in the course of just three months, the VA substantiated similar allegations at the 

Tomah VAMC. 

Chairman Johnson's investigation highlights deficiencies in how the VA OIG conducted 

its work at the Tomah VAMC. The office had no clear standard for substantiating allegations, 

with the burden of proof differing from inspector to inspector. Evidence also suggests that the 

line-level VA OIG inspectors intended to draft a public work product that would explain the 

results their inspection of the Tomah V AMC. Instead, VA OIG leadership chose for unknown 

reasons to issue a short, non-public administrative closure. 

The VA OIG selectively narrowed the focus of its work in Tomah. It limited its inquiry 

to just opioid prescription practices, ignoring the potential consequences of interactions between 

opioids and other drugs, such as benzodiazepines. The VA OIG did not do enough to address 

allegations-and firsthand observations from its own inspectors-that Dr. Houlihan was possibly 

under the influence of a controlled substance. The VA OIG discounted allegations levied by 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

iii 
67 

Tomah V AMC pharmacists about retaliation and abuse, despite interviewing some of the 

pharmacists who suffered the abuse and receiving other firsthand evidence supporting their 

claims. 

Chairman Johnson's investigation has been hampered by the VA OIG's obstruction. In 

April2015, because of the OIG's noncooperation, Chairman Johnson reluctantly issued a 

subpoena to then-Deputy Inspector General Richard Griffin for material relating to the VA 

OIG's work at the Tomah VAMC. Even after Mr. Griffin retired under pressure from Chairman 

Johnson, the VA OIG still has not fully complied with the subpoena. The VA OIG continues to 

withhold valuable information and has heavily redacted some material produced to the 

Chairman. 

In addition, although VA OIG employees were interviewed by Chairman Johnson's staff, 

OIG lawyers often directed them not to answer certain questions and the answers given were not 

always forthcoming. In response to one question from Chairman Johnson's staff, a VA OIG 

witness initially answered, "I don't know." After an OIG lawyer told him that he could answer 

the question, the witness provided a substantive response. 

Chairman Johnson's investigation also details the culture of fear at the Tomah V AMCthe retaliation against employees who sought to speak up about over-prescription. People like 

Dr. Noelle Johnson and Dr. Christopher Kirkpatrick lost their jobs after asking questions about 

prescriptions. The VA OIG-an entity that is supposed to protect VA whistleblowers-piled on, 

issuing an unsolicited white paper that attempted to discredit these whistleblowers. The VA OIG 

went so far as to imply that Dr. Kirkpatrick was a drug dealer and that Dr. Johnson had poor 

interpersonal skills. These facts have no bearing whatsoever on the merits of these 

whistleblowers' allegations. 

What transpired at the Tomah VAMC was indisputably a tragedy. Since January 2015, 

Chairman Johnson's investigation and increased public attention on the facility have led to 

changes. The facility's director, Mario DeSanctis, and its chief of staff, Dr. David Houlihan, 

have been fired. The Deputy VA Inspector General, Richard Griffin, retired under intense 

scrutiny of his work. President Obama heeded the calls of Chairman Johnson and other senators 

to appoint a new VA Inspector General, Michael Missal, who Chainnan Johnson shepherded 

through his Committee to confirmation by the Senate. 

Pressure from Chairman Johnson and others has forced the VA OIG to become more 

transparent, releasing reports that would have otherwise never have been public. A new federal 

law requires greater IG transparency. The VA and the Tomah V AMC have changed their opioid 

prescription practices. VA whistleblowers from across the country are empowered to speak out, 

and Chairman Johnson has provided them with a venue to tell their stories. 

While progress has been made, there is more that can be done to address the problems 

illustrated by the Tomah V AM C. This report presents recommendations from the Committee's 

majority staff that the VA and VA OIG can implement to improve accountability and 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

IV 
68 

transparency. The VA OIG should clarify its standards for substantiating allegations and its 

processes for handling and referring hotline complaints. The VA should limit the patient loads 

of facility management, alter the medical center reporting structure, and establish a procedure for 

pharmacists to communicate prescription concerns. Overall, the VA ought to improve the 

Choice program to give more veterans flexibility in access to health care providers. 

* * * 

For years, veterans, employees, and others were shouting for help at the Tomah VAMC. 

They were pleading with whoever would listen. The VA OIG inspected, the DEA investigated, 

the FBI engaged, the VA inquired. Nothing was fixed. Instead, whistleblowers faced retaliation 

and a "culture of fear" descended upon the facility. 

To fix a problem, it is first necessary to understand it. Since January 2015, Chairman 

Johnson has engaged in a thorough effort to investigate the allegations of opioid overprescription, abuse of authority, whistleblower retaliation, and related issues at the Tomah 

V AMC. While it was not intended at the outset, this inquiry included a critical examination of 

the work of the VA OIG relating to the Tomah V AMC. 

The information presented in this majority staff report is the product of a robust effort by 

Chairman Johnson to gather material from federal agencies, witness interviews, and 

whistleblower accounts. This report painstakingly presents the information received to date 

about the Tomah V AMC. It describes the systemic failures across agencies to identifY and fix 

the problems over the course of a decade. It recounts in detail the course of the VA OIG's health 

care inspection of the Tomah VAMC and explains how the VA OIG failed to fix the problems. 

The report highlights the retaliation faced by whistleblowers who sought to speak out about what 

they saw. Although the majority staff does not have access to all the relevant information, this 

report paints the first comprehensive picture of the allegations surrounding the Tomah VAMC. 

The United States owes a tremendous debt to the men and women who served the nation 

in unifonn. The agencies' failures at the Tomah VAMC do no justice to these men and women. 

To prevent similar tragedies in the future, it is necessary to fully understand what happened in 

the past. Chairman Ron Johnson has undertaken this work for that reason. Although some 

information remains unknown, this majority staff report endeavors to tell the story of the Tomah 

V AMC to help ensure that tragedies like these never happen again. 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

v 
69 

Findings 

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. 

The allegations of over-prescription at the Tomah V AMC 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. 

Employees at the Tomah VAMC referred to Dr. Houlihan as the "Candy Man" since at 

least 2004. 

Despite receiving various complaints over the course of several years, federal lawenforcement agencies and other executive branch entities failed to identify or address the 

root causes. For example: 

o VA consultants and peer reviews in connection with the 2007 death of a Tomah 

VAMC patient showed concerns about prescription practices at the facility. 

o The VA headquarters identified higher-than-average prescription rates at the 

Tomah V AMC in 2013. 

o 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. 

o 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. 

o 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. 

o The VA OIG received a complaint in March 2012 during its inspection-

"HOUSTON, WE NEED SOME HELP DOWN HERE." 

o The VA OIG surveilled Dr. Houlihan and subpoenaed a car dealership in 2012 in 

connection to Tomah VAMC allegations. 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

vi 
70 

o 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. 

o 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 

Face book 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. 

A culture of fear and whistleblower retaliation at the Tomah V AMC allowed overprescription and other abuses to continue unaddressed. The belief among Tomah VAMC 

staff that they could not report wrongdoing compromised patient care. 

The VA O!G'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. 

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 

V AMC inspection compromised veteran care at the facility. 

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. 

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. 

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. 

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. 

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. 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

vii 
71 

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 V AMC. 

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. 

r'i.._ 

(~1 l_.", __ j 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

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Table of Contents 

Executive Summary ....................................................................................................................... i 

Findings ......................................................................................................................................... vi 

Table of Contents ......................................................................................................................... ix 

Table of Figures .......................................................................................................................... xiv 

I. Introduction ........................................................................................................................ 1 

A. The scope of Chairman Johnson's investigation .................................................................. 2 

B. The entities contacted during Chairman Johnson's investigation ........................................ 3 

C. The transcribed interviews conducted during Chairman Johnson's investigation ............... 4 

II. Missed opportunities to prevent the tragedies at Tomah ............................................... 6 

A. The Death of Kraig Ferrington in 2007 was a warning sign of over-prescription at the 

Tomah VAMC ...................................................................................................................... 6 

I. Kraig Ferrington's care at the Tomah VAMC ................................................................. 6 

2. Medical consultants identified significant concerns with Mr. Ferrington's treatment at 

the Tomah VAMC ......................................................................................................... 10 

3. Peer reviews of the Tomah VAMC in connection with Kraig Ferrington's death suggest 

other practitioners would have provided different treatment.. ....................................... 17 

B. The VA apparently did not fully examine past allegations against Dr. David Houlihan 

during his hiring and promotion at the Tomah V AMC ...................................................... 18 

I. Dr. Houlihan's apparent prior misconduct in Iowa ........................................................ 18 

2. The VA did not address the apparent Iowa misconduct until 2009 ............................... 20 

C. The Tomah employees union complained to the VA OIG about over-prescription at the 

Tomah V AMC in 2009, but it is unclear whether the OIG took action ............................. 22 

D. The Drug Enforcement Administration has been investigating potential drug diversion at 

the Tomah VAMC since 2009, with no public results ....................................................... 29 

E. The VA did not investigate the 2009 death of Dr. Christopher Kirkpatrick, who attempted 

to blow the whistle on over-medication ............................................................................. 34 

F. The former Tomah VAMC Police Chief knew the facility was a "big pill box" when he 

took the job in 2009, but never investigated the allegations................... .. ....... 39 

G. VA headquarters noticed higher-than-average prescription rates at the Tomah VAMC in 

2013, and only "encouraged" the facility to "review" its practices ................................... 43 

H. Jason Simcakoski sought help from local and federal law enforcement multiple times in 

November 2013, with no results ......................................................................................... 45 

1. Despite evidence showing multiple contacts and a voicemail, the FBI denied 

communicating with Jason Simcakoski in 2013 ............................................................ 48 

2. Jason Simcakoski's contact with Dr. Houlihan is the subject of a current VA OIG 

criminal investigation .................................................................................................... 53 

III. The VA OIG's health care inspection of the Tomah V AMC ....................................... 56 

A. The VA OIG's hotline process: A primer .......................................................................... 56 

B. The VA OIG's work relating to the Tomah VAMC: A timeline ....................................... 62 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

ix 
73 

1. March II, 2011: The VA OIG received a phone call alleging problems at the Tomah 

VAMC ........................................................................................................................... 62 

2. March 13,2011: The VA OIG receives additional allegations via facsimile about the 

Tomah V AMC from a social worker ............................................................................. 63 

3. March 14, 2011: The VA OIG receives allegations via email about the Tomah 

VAMC ........................................................................................................................... 65 

4. March 15 and 22, 20 II: The VA OIG received two more complaints about the Tomah 

VAMC ........................................................................................................................... 66 

5. March 2011: The VA OIG Office ofHealthcare Inspections hotline group assessed the 

Tomah V AMC allegations ............................................................................................. 68 

6. March 15, 20 II: The VA OIG hotline group referred an allegation of prescription 

hording to the OIG's criminal division, which declined to investigate ......................... 71 

7. April 13, 20 II: The VA OIG referred the Tomah V AMC allegations to VISN 12 and 

Veterans Health Administration Central Office ............................................................ 71 

8. June 21,2011: VISN 12 responded to the Tomah VAMC complaints, unsubstantiating a 

majority of the allegations ............................................................................................. 73 

9. June 28, 2011: The VA OIG closed the March 2011 Tomah VAMC hotline 

complaints ...................................................................................................................... 77 

10. Fall2011: VISN 12's Chief Medical Officer visited the Tomah VAMC, noting "room 

for improvement" ........................................................................................................... 78 

II. August 25, 20 II: The VA OIG hotline group received additional allegations about Dr. 

Houlihan and prescribing practices at the Tomah V AMC ............................................. 79 

12. September I, 20 II: The VA logged an anonymous letter presenting additional 

allegations about the Tomah V AMC ............................................................................. 80 

13. September 2, 20 II: The VA OIG's Chicago office developed a work plan and 

assembled a team to examine the Tomah V AMC allegations ....................................... 81 

14. Fall2011: The VA OIG's Chicago field office slowly assembled infonnation about the 

Tomah VAMC allegations ............................................................................................. 82 

15. September 29, 20 II: The Tomah V AMC Hotline became a "congressional" request. 85 

16. December 20 II: VISN sunnises to VA OIG that "disgruntled employees" could be 

responsible for Tomah V AMC allegations .................................................................... 87 

17. December 2011: The VA OIG team in Chicago requested an extension on their work87 

18. December 2011: Deputy Inspector General Richard Griffin requested the referrals 

relating to the Tomah V AMC allegations ...................................................................... 89 

19. Late 2011: VA OIG headquarters in Washington became increasingly involved the 

Tomah V AMC inspection .............................................................................................. 90 

20. February 2012: Dr. Mallinger contacted the Tomah, Wisconsin, Police Department, 

and learned of a confidential informant with allegations of drug diversion .................. 92 

21. February 17, 2012: The VA OIG developed a Tomah VAMC "work plan" ................ 96 

22. February 27, 2012: The Tomah VAMC inspection was transferred to Washington, D.C. 

and Dr. Mallinger was assigned team leader ................................................................. 98 

23. February 28, 2012: Dr. Mallinger began to communicate with the Drug Enforcement 

Administration about the Tomah V AMC, eventually receiving a list of suspected drug 

diverters ..................................................................................................................... I 0 I 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

X 
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24. March 12, 2012: The VA OJG received another Tomah VAMC complaint-

"HOUSTON, WE NEED SOME HELP DOWN HERE" ........................................... I 05 

25. May 2012: The VA OJG requested Tomah VAMC employee emails ........................ 109 

26. May 2012: The VA OlG conducted a site visit to the Tomah VAMC, with employee 

survey results showing disturbing complaints ............................................................. 112 

27. May lO, 2012: The VA OlG interviewed Dr. Noelle Johnson ................................... 115 

28. May 16,2012: DEA provided the VA OlG with a copy of the Juneau County Sherriff 

report about the suicide of Dr. Christopher Kirkpatrick .............................................. 124 

29. Spring 2012: The VA OJG Criminal Investigation heated up .................................... 126 

30. May 21, 2012: The VA OJG provided the DEA with (b)(7) memo to allow the DEA to 

review portions of patient charts .................................................................................. 130 

31. May 22, 2012: VA OlG inspectors briefed senior VA OJG leadership ....................... 133 

32. May 29, 2012: The VA OIG subpoenaed a Wisconsin Chevrolet dealership ............. 137 

33. Spring 2012: The VA OJG Criminal Investigations Division surveilled Dr. 

Houlihan ....................................................................................................................... 140 

34. Spring 2012: The VA OJG declined to fully pursue the female patient ..................... 142 

35. June 2012: The VA OJG scheduled a site visit of the Tomah VAMC ........................ 144 

36. Summer 2012: The VA OJG prepared for the Tomah VAMC site visit.. ................... 146 

37. August 2012: The VA OJG conducted a site visit of the Tomah VAMC ................... 162 

38. August 22, 2012: The VA OJG conducted its initial interview of Dr. Houlihan at the 

Tomah VAMC ............................................................................................................. 164 

39. August 23, 2012: The VA OJG conducted its second interview of Dr. Houlihan at the 

TomahVAMC ............................................................................................................. l69 

40. August 29, 2012: The VA OJG created a post-site visit "Tomah Hotline Status" 

document with a draft report date of October 2012 ..................................................... 172 

41. September 2012: The VA OJG conducted a phone interview with Tomah V AMC 

Director Mario DeSanctis ............................................................................................ 175 

42. September 2012: VA OJG Special Agent in Charge John Brooks contacted Tomah 

V AMC Director Mario DeSanctis about the DEA's inquiry ....................................... 180 

43. Unknown date in 2011 or 2012: The Drug Enforcement Administration visited VlSN 

12 to discuss the Tomah V AMC .................................................................................. 183 

C. The VA OlG's administrative closure of its health care inspection of the Tomah 

VAMC .............................................................................................................................. 183 

I. The scope of the VA OIG's inspection ........................................................................ 185 

2. Complaints reviewed by the VA OJG ......................................................................... 185 

3. Documents reviewed by the VA OJG .......................................................................... 186 

4. Patient charts and pharmacy information reviewed by the VA OJG ........................... 188 

5. Em ails collected as a part of the VA OJG's health care inspection ............................. 190 

6. The VA OJG's site visit to the facility, interviews conducted, and consultants 

engaged ........................................................................................................................ 190 

D. The findings of the VA OIG's health care inspection ...................................................... 192 

E. Deficiencies in the VA OIG's health care inspection of the Tomah VAMC and its 

administrative closure ....................................................................................................... 195 

I. The VA OlG appears to have no clear standards for substantiating allegations .......... 195 

,_.-c, 

~~o/ ,.,_ ___ \ 

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Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

xi 
75 

2. The VA OIG selectively focused its inspection and seemed to ignore other potential 

problems found during the course of the inspection .................................................... 208 

3. VA OIG staff drafted the Tomah VAMC report as a pub lie document, but management 

made a decision to administratively close the case ...................................................... 250 

4. The VA OIG understated the degree to which Dr. Houlihan's and Deborah Frasher's 

prescription practices were outside the norm ............................................................... 259 

5. With the information available, it is difficult to assert that the VA OIG's email 

collection and review was adequate ............................................................................. 262 

6. There is conflicting information about the date of the VA OIG's closure of the Tomah 

VAMC inspection ........................................................................................................ 268 

F. Subsequent administrative reviews found different outcomes than the VA OIG's Tomah 

V AMC health care inspection .......................................................................................... 282 

1. The March 2015 memorandum from the VA's Under Secretary for Health largely 

substantiated allegations about over-prescription and a culture of fear at the Tomah 

VAMC ......................................................................................................................... 283 

2. A March 2015 draft report by the VISN 12 Chief Medical Officer substantiated 

allegations about improper opioid prescription ........................................................... 292 

3. An August 2015 report by VA OIG on Jason Simcakoski's death substantiated 

hazardous prescription practices .................................................................................. 293 

IV. Whistle blower retaliation and a culture of fear at the Tomah VAMC ..................... 295 

A. The sad state ofwhistleblower protections within the VA .............................................. 295 

B. Dr. Christopher Kirkpatrick ............................................................................................. 297 

1. The circumstances surrounding Dr. Kirkpatrick's termination .................................... 297 

2. There was no VA inquiry into Dr. Kirkpatrick's termination and death ..................... 301 

3. The VA OIG's inquiry into Dr. Kirkpatrick's suicide ................................................. 302 

4. The VA OIG's whitepaper on Dr. Kirkpatrick ............................................................ 304 

C. Dr. Noelle Johnson ........................................................................................................... 309 

D. Ryan Honl. ........................................................................................................................ 311 

E. Lin Ellinghuysen .............................................................................................................. 313 

V. Attempts at stonewalling Chairman Johnson's investigation .................................... 317 

A. Congress has a right to information from the executive branch and other entities .......... 317 

B. The VA Office of Inspector General ................................................................................ 319 

l. Chairman Johnson's efforts to secure the VA OIG's voluntary cooperation .............. 320 

2. The VA OIG has not complied with Chairman Johnson's subpoena .......................... 322 

C. The Drug Enforcement Administration ............................................................................ 336 

I. Chairman Johnson's efforts to secure the voluntary cooperation from the DEA ........ 337 

2. The DEA's stated rationale for its refusal to cooperate with Chainnan Johnson's 

investigation is without merit. ...................................................................................... 340 

3. The DEA sent an information-request letter to the VA after Chairman Johnson's 

inquiry .......................................................................................................................... 342 

D. The Joint Commission ...................................................................................................... 343 

VI. Increased accountability since Chairman Johnson's investigation ........................... 347 

A. Personnel changes at the Tomah VAMC and within the VA OIG leadership ................. 347 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

xii 
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B. Greater transparency from the VA OJG ........................................................................... 348 

C. Legislation proposed to address the problems relating to the Tomah V AMC ................. 349 

I. The Christopher Kirkpatrick Whistleblower Protection Act.. ...................................... 349 

2. The Inspector General Empowerment Act.. ................................................................. 351 

3. The Ensuring Veteran Safety Through Accountability Act ......................................... 352 

4. The Jason Simcakoski Memorial Opioid Safety Act ................................................... 353 

D. Safety at the Tomah VAMC's Community Based Outpatient Clinics ............................. 353 

VII. Recommendations .......................................................................................................... 356 

VIII. Conclusion ....................................................................................................................... 358 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

xiii 
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Table of Figures 

Figure I: AFGE "Questions for Leadership" Document. ........................................................... 24 

Figure 2: AFGE "Questions for Leadership" Document.. ............................................................ 25 

Figure 3: Email from DEA Diversion Investigator to VA OIG Special Agent Porter ................. 31 

Figure 4: DEA's (b)(7) Letter to Tomah VAMC (March 23, 2015) ............................................ 34 

Figure 5: Letter from Deputy Secretary Sloan Gibson to Chairman Johnson .............................. 38 

Figure 6: Jason Simcakoski's contacts with law enforcement... ................................................... 46 

Figure 7: Text message from Jason Simcakoski ........................................................................... 49 

Figure 8: Facebook messages sent by Jason Simcakoski ............................................................. 50 

Figure 9: Letter from FBI to Chairman Johnson regarding Jason Simcakoski's contact with 

FBI .............................................................................................................................. 52 

Figure 10: Report of the initial VA OIG hotline for Tomah V AMC complaints (Mar. II, 2011 )63 

Figure II: Summary of facsimile received by the VA OIG hotline (Mar. 13, 2011) .................. 64 

Figure 12: Email received by VA OIG hotline (Mar. 14, 2011) ................................................... 65 

Figure 13: Email received by VA OIG hotline (Mar. 14, 2011) .................................................. 66 

Figure 14: Email received by the VA OIG hot!ine (Mar. 15, 2011) ............................................. 67 

Figure 15: Email received by the VA OIG hotline (Mar. 22, 2015) ............................................. 68 

Figure 16: VA OIG document concerning the Tomah VAMC .................................................... 70 

Figure 17: VA OIG hotline referral email to VISN 12 and VHA Central Office 

(Apr. 13, 2011) ............................................................................................................ 72 

Figure 18: VISN 12's response memorandum to the Tomah VAMC allegations 

(June 21, 2011) ............................................................................................................ 73 

Figure 19: VA OIG Hotline notification to complainant of closed case (July 5, 2011) ............... 77 

Figure 20: Report of VA OIG hotline complaint (Aug. 25,201 I) ............................................... 80 

Figure 21: Envelope of anonymous complaint (Aug. 18, 2011) ................................................... 81 

Figure 22: Email from Wachita Haywood to VA OIG employees (September 20 2011) ............ 83 

Figure 23: VA Assessment of Criteria for Required Peer Review ............................................... 84 

Figure 24: VA OIG email regarding congressional interest in the Tomah V AMC 

(Oct. 6, 2011) .............................................................................................................. 86 

Figure 25: Email from Catherine Gromek to Dr. John Daigh eta!... ............................................ 89 

Figure 26: Report of Contact with Tomah Police Department.. ................................................... 93 

Figure 27: VA OIG work plan for Tomah V AMC health care inspection ................................... 97 

Figure 28: VA OIG work plan for Tomah VAMC health care inspection ................................... 97 

Figure 29: Report of Contact of Dr. Mallinger's communication with DEA ............................. 101 

Figure 30: Report of Contact of Dr. Mallinger's communication with DEA Diversion 

Investigator ............................................................................................................... I 04 

Figure 31: Hotline complaint regarding the Tomah V AMC (March 12, 20 12) ......................... I 06 

Figure 32: Summary of VA OIG's interview with Tomah VAMC staff physician ................... 108 

Figure 33: Memorandum requesting Tomah VAMC employee emails ..................................... 110 

Figure 34: Memorandum requesting Tomah V AMC employee emails ..................................... II 0 

Figure 35: VA OIG Forensic Laboratory Report of Tomah VAMC email collections .............. 112 

Figure 36: VA OIG Office of Healthcare Inspections Hotline Contact Referral ....................... 114 

Figure 3 7: Tomah V AMC employee survey results ................................................................. 115 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

xiv 
78 

Figure 38: Email from Dr. Alan Mallinger to Yohannes Debesai .............................................. 115 

Figure 39: Excerpt of VA OIG's interview of Dr. Noelle Johnson ............................................ 117 

Figure 40: Excerpt of VA OIG's interview of Dr. Noelle Johnson ............................................ 118 

Figure 41: Excerpt of VA OIG interview of Dr. Noelle Johnson ............................................... 119 

Figure 42: Excerpt of VA OIG's interview ofDr. Noelle Johnson ............................................ 120 

Figure 43: Excerpt of VA OIG's interview of Dr. Noelle Johnson ............................................ 121 

Figure 44: Excerpt of VA OIG interview of Dr. Noelle Johnson ............................................... 122 

Figure 45: Email from Dr. Michael Shepherd to Dr. George Wesley and Dr. Alan Mallinger.. !23 

Figure 46: Email from Dr. Noelle Johnson to Dr. Alan Mallinger.. ........................................... 123 

Figure 47: Email from DEA Diversion Investigator to VA OIG Special Agent Porter ............. 124 

Figure 48: Report ofV A OIG interview with anonymous Tomah VAMC employee ............... 127 

Figure 49: Report of VA OIG interview with anonymous Tomah VAMC employee ............... 128 

Figure 50: Report ofV A OIG interview with anonymous Tomah VAMC employee ............... 128 

Figure 51: Email from Dr. David Houlihan to Victoria Brahm .................................................. 129 

Figure 52: Email from Special Agent Greg Porter to Dr. Alan Mallinger ................................. 129 

Figure 53: Email from DEA Diversion Investigator to VA OIG Special Agent Porter ............. 131 

Figure 54: Email from Suzanne Humeniak to Special Agent Greg Porter ................................. 132 

Figure 55: VA OIG PowerPoint presentation for "11th Floor Briefing" .................................... 133 

Figure 56: VA OIG PowerPoint presentation for "11th Floor Briefing" .................................... 134 

Figure 57: VA OIG PowerPoint presentation for "11th Floor Briefing" .................................... 135 

Figure 58: Email from Lisa Seibert to VA OIG Employees re "Schedule meeting VAMC 

Tomah" ..................................................................................................................... 137 

Figure 59: VA OIG Subpoena Request Form relating to Tomah VAMC inquiry ...................... 139 

Figure 60: Email from Gregg Hirstein to Special Agent Greg Porter ........................................ 140 

Figure 61: Redacted item on Special Agent Porter's memorandum of interview ...................... 140 

Figure 62: Tomah Hotline Status Report (August 29, 2012) ...................................................... 144 

Figure 63: Email from Dr. Alan Mallinger to Dr. Michael Shepherd and Dr. Robert Yang ...... 144 

Figure 64: Excerpt of VA OIG's conversation with Mario DeSanctis ....................................... 145 

Figure 65: Email from Mario DeSanctis to Dr. Michael Shepherd ............................................ 146 

Figure 66: Email from Michael Shepherd to Alan Mallinger. .................................................... 147 

Figure 67: List of planned VA OIG interviews .......................................................................... 148 

Figure 68: List of planned VA OIG interviews .......................................................................... 149 

Figure 69: Email from Dr. Michael Shepherd to Dr. Alan Mallinger ........................................ 150 

Figure 70: Email from Dr. Michael Shepherd to Dr. Alan Mallinger ........................................ 150 

Figure 71: Email from Dr. Michael Shepherd to Dr. Alan Mallinger ........................................ 15 I 

Figure 72: List of Planned VA OIG interviews .......................................................................... 152 

Figure 73: Email from Dr. Alan Mallinger to Cynthia Gallegos ................................................ !53 

Figure 74: Email from Dr. Alan Mallinger to Cynthia Gallegos ................................................ 154 

Figure 75: Email from Mario DeSanctis to Dr. Michael Shepherd ............................................ 155 

Figure 76: Email from Julie Nutting to Dr. Michael Shepherd .................................................. 156 

Figure 77: Email exchange between Maureen Regan and Cynthia Gallegos ............................. 158 

Figure 78: VA OIG site visit schedule for the Tomah V AMC ................................................... !59 

Figure 79: VA OIG site visit schedule for the Tomah VAMC ................................................... 160 

Figure 80: Email from Mario DeSanctis to Dr. Michael Shepherd ........................................... 161 

r~"' 

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Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

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79 

Figure 81: Transcript of VA OIG interview of Dr. Houlihan (Aug. 22, 2012) .......................... 165 

Figure 82: Transcript of VA OIG interview of Dr. Houlihan (Aug. 23, 20 12) .......................... 170 

Figure 83: Transcript of VA OIG interview of Dr. Houlihan (Aug. 23, 2012) .......................... 171 

Figure 84: VA OIG's Tomah Hotline Status (Aug. 29, 20 12) .................................................... 175 

Figure 85: Transcript of VA OIG interview of Mario DeSanctis ............................................... 176 

Figure 86: Transcript of VA OIG interview of Mario DeSanctis ............................................... 179 

Figure 87: Email exchange between John Brooks and Mario DeSanctis ................................... 181 

Figure 88: Email from John Brooks to Dr. Mallinger and Dr. Wesley ...................................... 182 

Figure 89: Dr. Mallinger's handwritten note about potential impairment of Dr. Houlihan and 

Ms. Frasher ............................................................................................................... 210 

Figure 90: Email from Dr. Gottlieb to Maureen Regan requesting to meet about possible 

impaired interviewees ............................................................................................... 215 

Figure 91: Memorandum of interview of Anonymous Tomah VAMC Employee .................... 219 

Figure 92: Memorandum oflnterview of Anonymous Tomah V AMC Employee (page 2) ...... 220 

Figure 93: VA OIG Tomah VAMC Administrative Closure, Comparison of Opioid 

Prescriptions .............................................................................................................. 260 

Figure 94: VA OIG Tomah VAMC Administrative Closure, Comparison of Clinician 

Prescribers ................................................................................................................. 261 

Figure 95: Page II of the VA OIG's administrative closure ...................................................... 270 

Figure 96: Enlarged signature and date of the VA OIG's administrative closure ...................... 270 

Figure 97: Page I of the Master Case Index File of the VA OIG's Tomah V AMC inspection 

(#0267) ...................................................................................................................... 272 

Figure 98: Page 3 of the Master Case Index File of the VA OIG's Tomah VAMC inspection 

(#0267) ...................................................................................................................... 272 

Figure 99: Page I of the Hotline referral regarding the Tomah VAMC (#I 068) ....................... 273 

Figure 100: Page 2 of the Hotline referral regarding the Tomah VAMC (#1068) ..................... 274 

Figure 101: Page 3 of the Hotline referral regarding the Tomah VAMC (#1068) ..................... 275 

Figure I 02: Memorandum on the Clinical Review Findings of the Tomah V AMC .................. 285 

Figure 103: VA OIG white paper (pages 8 and 9) ...................................................................... 306 

Figure 104: Letter from VA Deputy Inspector General Linda Halliday to Chairman Johnson. 309 

Figure 105: VA' s Sec Divert Internal List.. ................................................................................ 314 

Figure 106: Letter from Chairman Johnson to VA Secretary McDonald regarding Sec Divert 

Internal list ................................................................................................................ 315 

Figure 107: Redacted document produced by the VA OIG ........................................................ 324 

Figure 108: Email from Leigh Bradley, VA General Counsel, to Deputy IG Linda Halliday ... 332 

Figure 109: Letter from Chairman Johnson to VA Secretary McDonald regarding CBOC 

security ...................................................................................................................... 355 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

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I. Introduction 

In January 2015, Wisconsinites learned of the detailed reports of "doped up" and 

"zombified" veterans at the Department of Veterans Affairs Medical Center in Tomah, 

Wisconsin (Tomah V AMC). 1 According to the Center for Investigative Reporting, veterans and 

employees at the facility referred to the Tomah VAMC as "Candy Land" and nicknamed the 

facility's chief of staff, Dr. David Houlihan, the "Candy Man" because of his alleged reputation 

for dispensing narcotics like candy? The article brought to light the overdose death of Jason 

Simcakoski, a 35-year old Marine Corps veteran, who died at the Tomah V AMC on August 30, 

2014. Autopsy results showed that when he died, Jason Simcakoski had over a dozen different 

drugs in his system and his cause of death was identified as "mixed drug toxicity."3 Days after 

the initial news accounts, another veteran, Thomas Baer, died at the Tomah V AMC urgent care 

center after waiting hours to be seen for an apparent stroke. 

The Center for Investigative Reporting article also uncovered the existence of a thensecret report that was not made public by the Department of Veterans Affairs Office of Inspector 

General (VA OIG) 4 The VA OIG's eleven-page administrative closure summarized the findings 

of its three-year-long health care inspection of the Tomah V AMC5 Since at least March 2011, 

the VA OIG had received complaints from Tomah V AMC employees and veterans that 

highlighted allegations of questionable prescription practices, administrative abuses including 

whistleblower retaliation, veteran deaths, and drug diversion.6 The VA O!G found that some 

prescribing practices at the Tomah V AMC were "at considerable variance compared with most 

opioid prescribers" in the region and that these prescriptions "raised potentially serious 

concems."7 Despite these findings, the VA OIG did not substantiate the allegations and 

administratively closed its Tomah VAMC inspection on March I2, 2014. The VA OIG did not 

make the report public; it only later released the report in February 2015 amid public scrutiny 8 

1 Aaron Glantz, Opiates Handed out Like Candy to 'Doped-up' Veterans at Wisconsin VA, REVEAL NEWS (Jan. 8, 

2 0 15 ), h ttps://www revealnews. org/ article-legacy /opiates-handed-out -like-candy-to- doped-up-veterans-atwisconsin-val [hereinafter Glantz, Opiates Handed out Like Candy, REVEAL NEWS (Jan. 8, 20 15)]. 

2 Id. 

3 Id. 

4 VA OFFICE OF INSPECTOR GENERAL, TO~AH VAMC ADMINISTRAT!VE CLOSURE, MC!# 2011-04212-HI-0267 

(Mar. 12, 2014) (hereinafter VA O!GTOMAH VAMC ADMINISTRATIVE CLOSURE). 

5 I d. 6 Id 

1 Id. at9. 8 Report Summary: Healthcare Inspection- A 1/eged Inappropriate Prescribing of Controlled Substances and 

Alleged Abuse a/Authority, Tomah VA Medical Center, Tomah, Wisconsin, DEP'T OF VETERANS AFFAIRS, OFFICE 

OF INSPECTOR GENERAL (Feb. 6, 2015), http://www.va.gov/oig/publications/report-summary.asp?id~3283. 

~-" 

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Committee on Homeland Security and Governmental Affairs 

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81 

Immediately after he was made aware of the allegations concerning the Tomah VAMC, 

Senator Ron Johnson, in his capacity as Chairman of the Committee on Homeland Security and 

Governmental Affairs, launched a bipartisan investigation. In January 2015, Chairman Johnson 

directed his staff to examine the allegations relating to the Tomah V AMC-including allegations 

of drug diversion, abuse of authority, patient deaths, retaliation against whistle blowers, and a 

culture of fear at the facility-and the VA OJG's work relating to the Tomah VAMC. Since 

then, Chairman Johnson's staff has been engaged in a comprehensive and detailed investigation 

oftheTomah VAMC. 

This report explains the majority staffs findings over the past fifteen months. The report 

builds off of the preliminary findings presented in the interim report issued by Chairman 

Johnson's staff in June 2015, as well as the Committee's field hearing in Tomah, Wisconsin, in 

March 2015, and other public hearings in Washington, D.C. This report presents new 

information obtained from documents received from the VA, the VA OIG, and other entities, as 

well as information obtained from transcribed interviews with twenty-two current and former 

VA and VA OIG employees. Some questions remain unanswered-the VA OIG still has yet to 

fully comply with Chairman Johnson's April2015 subpoena for relevant documents-but the 

majority staff presents this report now to encourage greater transparency and accountability at 

the Tomah V AMC, the VA OIG, and the VA. 

A. The scope of Chairman Johnson's investigation 

The Committee on Homeland Security and Governmental Affairs of the United States 

Senate serves as the Senate's chief oversight and investigatory committee. The Standing Rules 

of the Senate authorize the Committee to investigate "the efficiency and economy of operations 

of all branches of the Government. "9 In addition, the Senate has specifically authorized the 

Committee to examine "the et1iciency and economy of all branches of the Government including 

the possible existence of fraud, misfeasance, malfeasance, collusion, mismanagement, 

incompetence, corruption, or unethical practices .... " 10 

Although this staff report is comprehensive, it is admittedly with limitations. It does not 

purport to independently assess the appropriateness of medical judgments by professionals at the 

Tomah V AM C. Committee investigators are not doctors, and they do not have the expertise or 

training to determine whether care in a given situation met acceptable medical standards. Any 

critiques of the medial practices at the Tomah VAMC are presented through the findings and 

conclusions of other medical professionals. 

The Committee did not request, receive, or review any medical records of the veterans 

who received care at the Tomah VAMC. Chainnan Johnson chose to exclude that material from 

his review out of respect for the patients and veterans affected. Similarly, the Committee has 

:

0

S. Rule XXV(k); see also S. Res. 445, 108th Cong. (2004). 

S. Res. 73, !14th Cong. (2015). 

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Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

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82 

largely not received peer review material from the VA and the VA OIG. Where the Committee 

received such information, it concerns outside assessment of clinical care and does not contain 

any identifying information about the patients or underlying medical issues. 

B. The entities contacted during Chairman Johnson's investigation 

Over the course of the investigation, Chairman Johnson requested information from a 

number of sources, including federal, state, local, and non-governmental entities. In addition, 

Chairman Johnson's staff had informal communications with federal and local entities. The 

entities contacted during the investigation include: 

The Department of Veterans Affairs; 

The VA Office of Inspector General; 

The Drug Enforcement Administration (DEA); 

The Federal Bureau of Investigation (FBI); 

The United States Attorney's Office for the Western District of Wisconsin; 

The Merit Systems Protection Board (MSPB); 

The Government Accountability Office (GAO); 

The Office of Special Counsel (OSC); 

The Tomah V AMC police department; 

The American Federation of Government Employees (AFGE) Local 007; 

Wisconsin state, county and local Jaw-enforcement entities; 

The Wisconsin Department of Safety and Professional Services; 

The Joint Commission; and 

Dozens ofwhistleblowers who currently work, previously worked, or were treated at 

the Tomah VAMC. 

In total, Chairman Johnson sent twenty-eight letters in connection with his investigation 

of the Tomah VAMC. A number of these entities voluntarily provided information and 

documents responsive to Chairman Johnson's requests. A few agencies declined to provide 

information or documents due to ongoing law-enforcement matters. Out of respect to the lawenforcement equities at stake in this matter, the majority staff chose to defer to the lawenforcement interests. 

The VA OIG, however, took a different tack altogether. Even after Chairman Johnson 

agreed to forgo sensitive patient health information that could be included in the requested 

documents, the VA OIG refused to provide documents on the basis of general and vague 

assertions of "deliberative process" and "attorney client privilege." After multiple requests for 

voluntary compliance, on April 29,2015, Chairman Johnson was forced to issue a subpoena to 

VA Deputy Inspector General Richard Griffin for material about the Tomah VAMC. Even after 

the subpoena, the VA OIG continues to withhold documents that are relevant to the Committee's 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

3 
83 

investigation, including drafts of its Tomah VAMC health care inspection and internal 

communications about the inspection. 

C. The transcribed interviews conducted during Chairman Johnson's 

investigation 

At Chairman Johnson's direction, and with the concurrence of Ranking Member Carper, 

staff conducted twenty-two transcribed interviews of current and former VA and VA OIG staff. 

These transcribed interviews included staff members of Chairman Johnson, Ranking Member 

Carper, and Senator Baldwin, and often lasted several hours. The witnesses were represented by 

counsel and afforded the opportunity to review the transcript of their interviews for accuracy. 

Staff interviewed the following individuals from the VA and the VA OIG: 

Rene Oshinski, Deputy Network Director, Veterans Integrated Service Network (VISN) 

12, VA; 

Dr. Michael Bonner, Former v7SN 12 Chief Medical Officer, VA; 

Donna Leslie, VISN 12 Pharmacy Executive, VA; 

Victoria Brahm, Former VISN 12 Quality Management Officer and current Acting 

Tomah VAMC Facility Director, VA; 

John Rohrer, Former Acting Tomah VAMC Facility Director, VA; 11 

Katherine Pica, Acting Tomah VAMC Chief of Staff, VA; 

Jeff Evanson, Acting Tomah VAMC Associate Director, VA; 

Julie Nutting, Organization Improvement Anafyst, Tomah VAMC, VA; 

Roberto Obong, Former Tomah VAMC ChiefofPofice, VA; 

Dr. Nick Beckey, Director of Pharmacy, West Palm Brach VAMC, VA; 

Dr. Mitchell Nazario, Clinical Pharmacy Specialist, Pain Management, West Palm Beach 

VAMC, VA; 

Linda Ellinghuysen, Registered Nurse, Tomah VAMC; President, American Federation 

of Government Employees Locaf 0007, VA; 

Dr. Laureen Savage, Clinical Pharmacist, Tomah VAMC, VA; 

Diane Streeter, Licensed Practical Nurse, Tomah VAMC; Union Steward, American 

Federation of Government Employees Local 0007, VA; 

Dr. John D. Daigh, Jr., Assistant Inspector General, Office of Healthcare Inspections, VA 

DIG; 

Dr. George Wesley, Physician, Office ofHealthcare Inspections, VA DIG; 

Dr. Alan Mallinger, Senior Physician. Office of Healthcare Inspections, VA DIG; 

Dr. Michael Shepherd, Physician, Office of Healthcare Inspections, VA DIG; 

Dr. Robert Yang, Physician, Office ofHealthcare Inspections, VA DIG; 

11 John Rohrer is the current director of the WilliamS. Middleton Memorial Veterans Hospital in Madison, 

Wisconsin. 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

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84 

Greg Porter, Special Agent, Office of Investigations, VA OJG; and 

Wachita Haywood, Associate Director, Chicago Office of Healthcare Jnsgections, VA 

O!G. 

Staff did not conduct transcribed interviews with Dr. David Houlihan, Deborah Frasher, 

Mario DeSanctis, Ronda Davis, or Margaret Hyde out of respect for possible administrative 

action by the V A. 12 Staff sought not to jeopardize the integrity of these proceedings by 

conducting transcribed interviews with these individuals. 

* * * 

Chairman Johnson's investigation is focused on identifying the root causes of the 

tragedies of the Tomah V AM C. Administrative misconduct, whistleblower retaliation, and a 

lack of VA oversight all directly compromised veteran care at the Tomah V AM C. Under acting 

leadership, the VA OIG lacked the independence and transparency that arc the tenants of 

successful inspectors general. Chairman Johnson launched his investigation to identify the 

problems at the Tomah V AMC as an essential first step to enacting reforms to ensure that 

veterans at the Tomah VAMC and across the United States receive the care they deserve. 

As explained in this report, the majority staff does not possess all relevant information 

about the Tomah VAMC. The VA has not fully produced all of its documents relating to the 

Tomah VAMC, and federal law-enforcement agencies have declined to provide information to 

further Chairman Johnson's inquiry. The VA OIG continues to withhold documents and 

information responsive to Chairman Johnson's April2015 subpoena. 

Despite these instances, Chairman Johnson has received a substantial amount of material 

concerning the Tomah V AM C. The majority staff relies on the information received to present 

the findings and recommendations contained in this staff report. 

12 On June 17, 2015, Dr. Houlihan voluntarily contacted Chairman Johnson's staff to signal his willingness to speak 

with investigators; he again voluntarily contacted staff on June 29,2015, noting a change of heart. Staff also 

conducted an informal telephone conversation with Mr, DeSanctis and his attorney early in the investigation, 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

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85 

II. Missed opportunities to prevent the tragedies at Tomah 

The story of the Tomah V AMC represents a trail of missed opportunities by the executive 

branch-unrealized chances to prevent or to fix a multitude of problems at the facility. For 

years, Tomah VAMC employees, patients, and others pled for help. These cries were ignored, 

warning signs were overlooked, and individuals in key positions failed to heed concerns of the 

Tomah community. The problems at Tomah were preventable. Failures on multiple levels by 

multiple entities within the executive branch to listen to the problems at the Tomah V AMC 

directly compromised veteran care and bred a culture of fear and retaliation at the facility. 

A. The Death ofKraig Ferrington in 2007 was a warning sign of overprescription at the Tomah VAMC 

More than seven years before Jason Simcakoski died at the Tomah VAMC in August 

2014, another veteran died of a drug overdose after receiving care at the Tomah YAM C. The 

death of Kraig Ferrington, a U.S. Army veteran, should have served as a warning to the VA, 

VISN, and the Tomah V AMC about the possible dangers of simultaneously prescribing veterans 

many different drugs. Instead, nothing changed in the wake of Mr. Ferrington's death. There 

was no internal investigation and noV A OIG investigation. 

In early 2015, Kraig Ferrington's sister, Kari Hemb, contacted Chairman Johnson's staff 

with information about Mr. Ferrington's treatment at the Tomah VAMC. She provided the 

Chairman with documents about Mr. Ferrington's care at the Tomah VAMC. Chairman Johnson 

subsequently wrote to VA Secretary Robert McDonald requesting information about the Equal 

Employment Opportunity Commission (EEOC) and tort claims filed against the Tomah V AMC 

in connection with Mr. Ferrington's death13 Chairman Johnson received documents pursuant to 

this request, which help to explain Mr. Ferrington's treatment at the Tomah V AM C. 

1. Kraig Ferrington's care at the Tomah VAMC 

Kraig Ferrington served in the Army from 1982 to 1986. Mr. Ferrington battled with 

substance abuse problems in civilian life, spending time in and out of jaiL In October 2007, Mr. 

Ferrington's sister, Kari Hemb, enrolled him at the Tomah VAMC for medication management 

13 Letter from Han. Ron Johnson, Chainnan, S. Comm. on Homeland Sec. & Governmental Affairs, to Han. Robert 

McDonald, Secretary, Dcp't of Veterans Affairs, at I (Mar. 24, 2015) [hereinafter 3/24/2015 Letter from Chairman 

Johnson, HSGAC, to Secretary McDonald, VA]. 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

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86 

Documents show that Mr. Ferrington was admitted to the Tomah VAMC in the afternoon 

of October 10,2007, to seek help with medication management and PTSD treatment. 14 The 

mental health progress note addendum documenting Mr. Ferrington's admission to the Tomah 

V AMC stated that his sister, Keri Hemb, was managing Mr. Ferrington's medication because she 

was "afraid he will take too many."15 When he was admitted, Ms. Hemb observed that Mr. 

Ferrington was "talking funny" and "calling her by names from his childhood." 16 The Tomah 

VAMC employee who admitted Mr. Ferrington noted that Mr. Ferrington knew what month and 

year it was, but thought the date was October 12 and he "did not know what day of the week it 

was." 17 Mr. Ferrington was placed in an observation bed and was assessed by a physician's 

assistant in the substance abuse program the following moming. 18 When he was admitted, Mr. 

Ferrington indicated that he "would very much like to go through the [substance abuse] 

program." 19 

Mr. Ferrington was evaluated the following day by a physician assistant, with Dr. 

Houlihan serving as the "EXP COSIGNER" of the evaluation.'0 Dr. Houlihan served as the 

attending psychiatrist on the Tomah VAMC mental health wing during Mr. Ferrington's care; 

however, records indicate he did not prescribe any medication to Mr. Ferrington. The documents 

show that the Tomah V AMC continued administering the six non-VA medications Mr. 

Ferrington was prescribed, and placed Mr. Ferrington on a seventh medication? 1 The Tomah 

V AMC diagnosed Mr. Ferrington with a number of substance use disorders and admitted him to 

the substance abuse program. The examination notes show that Mr. Ferrington was given 

"Patient Education" on his diagnosed conditions and the medications he was prescribed.22 The 

note also indicated that Mr. Ferrington was "to be allowed to self medicate while on the ward."23 

Subsequent annotations to Mr. Ferrington's medical records highlight alarming red flags 

with his care at the Tomah VAMC. A Mental Health Progress Note dated October 13, 2007, 

showed that Mr. Ferrington was "restless and incoherent with his speech and makes little or no 

sense."24 The note indicated that Mr. Ferrington's "condition and behaviour [sic] may warren! 

14 Claim for Damage, Injury. or Death for Kraig Ferrington, Ex. 5, at 1 [hereinafter Ferrington Exhibits] (on file with 

Comm.). 

"!d 

16 /d 

'' Id 

"!d. 

19 /d 20 I d. Ex. 6, at l. ln instances where medical students, residents, or some other medical profession enter a course of 

action into a chart, the attending, or senior physician on duty at the time is needed to cosign the entry to show they 

were aware of the entry. See Thomas Payne et aL, The Transition to Electronic Documentation on a Teaching 

Hospital Medical Service, AMIA ANNUAL SYMPOS!l:M PROCEEDINGS (2006), 

http://www ncbi.nlm.nih.gov/pmc/articles/PMC 183 9294/. 21 Ferrington Exhibits, Ex. 6, at 3. 22 Id Ex. 6, at 7. 2) !d. 

"!d. Ex. 7, at 17. 

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Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

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87 

[sic] move to another unit for observation for [patient's] safety and well being [sic ]."25 A note 

logged on October 14, 2007 recounted that Mr. Ferrington was "unable to stay awake" and when 

he was woken up and escorted to his room, Mr. Ferrington "was very lethargic and confused and 

disoriented."26 Earlier that night, Mr. Ferrington had "needed assistance with finding his room 

and to get sleep/rest."27 Later in the morning on October 14, 2007, Mr. Ferrington was 

transferred to the Tomah VAMC Urgent Care unit where staff"voiced concern about him being 

forgetful and confused. "

28 

On October 15, the Tomah VAMC changed Mr. Ferrington's medication regimen. 

Tomah VAMC personnel increased Mr. Ferrington's prescriptions to ten separate medications29 

At this time, Mr. Ferrington was taking both an opioid and a benzodiazepine simultaneously 30 

Around midnight, Tomah VAMC staff observed that Mr. Ferrington was "confused and 

need constant redirection."31 The note taker wrote "[q]uestion if [patient] is able to take his own 

meds. Continue to observe."32 On the morning of October 16, a different Tomah VAMC staff 

member noted that Mr. Ferrington "appears much more alert and oriented in the morning wake 

up hours."33 Nevertheless, the Tomah VAMC employee noted that Mr. Fcrrin~ton "[n]eeds to be 

seen by appropriate staff in regards to his confusion and other related issues."3 Mr. Ferrington 

underwent a psychological evaluation later that morning and interviewed with a social worker 

the next day. 35 

Medical notes indicate that Mr. Ferrington had slept soundly the night of October 18, 

2007. 36 On October 19, Tomah VAMC staff spoke with Ms. Hemb about Mr. Ferrington's care 

and about some of her ground rules for when Mr. Ferrington was to be released to her care.37 

From October 19 to October 23, Tomah VAMC staff reduced Mr. Ferrington's 

prescription for certain medications that made him feel drowsy. 38 A note dated October 23, 

2007, stated that Mr. Ferrington required "very frequent reinforcement and reminders regarding 

his medications what to take and when."39 A social work note on October 23,2007, stated that 

Mr. Ferrington was "having problems managing his medications, is a fall risk, has extreme 

25 !d. Ex. 7, at 17. 

"!d. 

27 ld. 18 !d. Ex. 8,at 18. 29 !d. Ex. 9, at 19-20. )0 !d. 

31 !d. Ex. 9, at 20. 

" !d. 33 /d. Ex. I 0, at 21. 

34 !d. 35 Id. Ex. 10, at 21-26, Ex. 11, at 27. 36 Jd Ex. II, at 27. 37 Jd Ex. II, at 27, Ex. 12, at 28. 

"!d. Ex. 12, at 28. 39 Id. Ex. 13, at31. 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

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88 

difficulty with memory and require[ s J more supervision than routinely provided in [the substance 

abuse] program."40 On October 24, Mr. Ferrington "attempted to attend group this afternoon, but 

after having fallen asleep (and snoring loudly) two times, with rigorous attempts to wake him, he 

was advised to return to his unit."41 

On November 9, Mr. Ferrington was found "to be very drowsy with slurred speech and 

being barely able to keep his eyes open."42 Nevertheless, he was discharfed from the Tomah 

VAMC having completed the Tomah VAMC substance abuse program.4 Mr. Ferrington's 

discharge documents indicate that when he left the Tomah VAMC, he was on II different 

medications 44 The discharge documents indicated that Tomah V AMC staff explained to Mr. 

Ferrington how to take his medications. Ms. Hemb could not pick up Mr. Ferrington on 

November 9, 2007 because of car trouble, but picked him up from the Tomah VAMC on 

November 10, 2007. Mr. Ferrington died in the early morning hours of November 11, 2007 at 

Ms. Hemb's home. The Brown County Medical Examiner determined that the cause of death 

was "poly medication overdose."45 

Mr. Ferrington's autopsy revealed that when he died, he had seven different drugs in his 

system. Autopsy results found the presence ofhydrocodone:6 the benzodiazepines diazcpam47 

and nordiazepam,'8 fluoxetine,'9 amitriptyline, 5° nortriptyline, 5

1 and methadone52 in Mr. 

Ferrington's system when he died. The VA prescribed all of the drugs found in his system, with 

the exception of the methadone, to Mr. Ferrington when he was discharged from the Tomah 

VAMC. There is no evidence that the VA prescribed Mr. Ferrington methadone and it is unclear 

how the methadone made its way into Mr. Ferrington's system. 

40 Id. Ex. 19; see also 4.24.09 Medical Record Synopsis at p. 5 in the pdf 41 Ferrington Exhibits, Ex. 13, at 31. 42 VA Consultant l at 2. 43 Ferrington Exhibits, Ex. 14, at I. 44 I d. 45 Id. Ex. l. 46 Hydrocodone is an "opioid pain medication." Hydrocodone, DRUGS,COM, 

http://www.drugs.com/hydrocodone.html. 

47 Diazepam is a "benzodiazepine,'' or tranquilizer, that is commonly used to treat "anxiety disorders, alcohol 

withdrawal symptoms, or muscle spasms." Diazepam, DRUGS.COM, http://www.drugs.com/diazepam.htrnl. 48 Nordiazcpam is a benzodiazepine derivative and is commonly used to treat anxiety. See Joshua Gunn, 

Understanding the Toxicology of Diazepam, PRACTICAL PAIN MANAGEMENT (Apr. 15, 20!5), 

http://www.practlcalpainmanagcment.com/treatments/pharmacological/understanding-toxicology-diazepam. 

49 Fluoxctine is an antidepressant. Fluoxetine, DRUGS.COM, http://www.d1ugs.com/fluoxetinc html. 50 Amitriptyline is an antidepressant. Amitriptyline, DR\JGS.COM, http://www.drugs.com/amitriptyline html. 51 Nortriptyline is an antidepressant. Nortrip!yline, DRT.:GS.CO;t, http://www.drugs.com/nortriptyline.html. 52 Methadone is an opioid medication that is used as a pain reliever and as part of drug addiction detoxification. 

Methadone, DRUGS.COM, http://www.dmgs.com/methadone.html. 

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2. Medical consultants identified significant concerns with Mr. Ferrington's 

treatment at the Tomah VAMC 

Shortly after Mr. Ferrington passed away, Ms. Hemb filed a wrongful death claim against 

the VA53 Documents obtained related to this claim reveal troubling aspects of Mr. Ferrington's 

care at the Tomah V AMC-revelations that should have been a warning of broader issues with 

the facility. 

As part of the legal proceedings between Ms. Hemb and the VA, both sides sought expert 

opinions of physicians outside the Tomah VAMC to determine whether the medical 

professionals at the Tomah VAMC treated Mr. Ferrington within the standard of care54 The VA 

solicited the opinions of two VA psychiatrists at hospitals other than the Tomah V AMC .

55 Both 

consultants identified significant concerns with Mr. Ferrington's treatment at the Tomah 

VAMC56 To preserve the privacy interests of the consultants, and to allow medical consultants 

inside and outside the VA to continue to provide candid analysis of quality-of-care issues, this 

majority staff report does not identifY the consultants by name. Instead, it marks the consultants 

as "VA Consultant I" and "VA Consultant 2," and refers to both with male pronouns 5 7 

i. Findings of VA Consultant 1 

VA Consultant I began his consultation by summarizing the notes in Mr. Ferrington's 

charts. He found that when Mr. Ferrington died, toxicology results showed "toxic levels of 

Methadone (not prescribed), high levels of fluoxetine and it's [sic] metabolite norfluoxetine, high 

levels of the metabolite of diazepam, and evidence of the presence ofhydrocodone and 

amitryptelene and it's [sic] metabolite."58 VA Consultant I answered a number of questions 

with respect to whether Mr. Ferrington's care at the Tomah VAMC met the required standard of 

care. His findings are summarized below. 

53 See Ferrington July 2 production SF-95 and supporting documents received 54 VA Consultant l Medical Opinion Re.: Administrative Tort Claim: Ferrington, Craig, TCIS 09-713 [hereinafter 

VA Consultant l Medical Opinion] (on file with Comm.); VA Consultant 2 Medical Opinion Re.: Administrative 

Tort Claim: Ferrington, Craig, TCIS 09-713 [hereinafter VA Consultant 2 Medical Opinion] (on file with Comm.). 55 VA Consultant I Medical Opinion; VA Consultant 2 Medical Opinion . 

.1 6 VA Consultant I Medical Opinion; VA Consultant 2 Medical Opinion. 57 Ms. Hemb also hired her own expert, a medical doctor board certified in forenslc pathology who rendered an 

opinion on the care Mr. Ferrington received at the Tomah V AMC. Ms. Hemb's consultant did not draw conclusions 

on whether the Tomah VAMC's treatment of Mr. Ferrington fell inside the standard of care. Ms. Hemb's consultant 

ultimately concluded that "Ferrington died from a lethal mixture of medications given to him at the Tomah VA. But 

for this treatment, Kraig Ferrington would likely still be alive." Ferrington Exhibits, Ex. 15, at!. 58 VA Consultant I Medical Opinion, at 3. 

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a. Standard of care with respect to medication management 

VA Consultant I identified significant concerns with the Tomah VAMC's management 

of Mr. Ferrington's medication regimen. With respect to the medications that Mr. Ferrington was 

on, VA Consultant I wrote: 

[T]here is a general concern regarding the number of medications [Mr. 

Ferrington] was on, and the potential interactions among them. The greatest 

concern in this regard has to do with being on several medications which have a 

warning regarding the potential to cause confusion, unsteadiness, memory 

impairment, unsteadiness, and which generally warn against use with other "CNS 

[central nervous system] depressants" due to a cumulative adverse effect burden 

in such combination. He was being prescribed concomitantly the following CNS 

depressant agents: valium, lorado!, valium, amytriptylene and later ultram and 

vicodin. The only medication that was discontinued due to the presence of all the 

above noted adverse effects was amytriptylene ( elavil) despite ongoing report of 

sedation, unsteadiness, "extreme difficulty with memory" and slurred speech. All 

of these medications and their combination should have suspect with regard 

to these adverse effects, and consideration of this possibility is not evident in 

my perusal of the record. Also, many of the medications he was on had known 

abuse potential. 5

9 

VA Consultant I added that it was "apparent" that the Tomah VAMC did not "adequately 

control [Mr. Ferrinb>ion's] intake of medications or other substances from outside the VA.''60 

The Consultant raised concerns with Mr. Ferrington's continued allowance to self-medicate 

while in the Tomah V AMC's substance abuse program, explaining that "[t]he record clearly 

noted his problems with addiction, with his inappropriate and excessive use of medications, and 

his obvious confusion- all of which are relative contra indications for self-medication due to the 

safety issues of medication misuse."61 With respect to the methadone found in Mr. Ferrington's 

system, the consultant noted that the presence of methadone suggested that Mr. Ferrington was 

able to obtain and use non-prescribed medications while in the program62 

VA Consultant I concluded that "[t]he VA failed to address the risk" of medication 

misuse or abuse when it allowed him to "control his intake of these medications."61 

59 !d. (emphasis added). 60 ld. at 4. 

61 !d. 

62 !d. 

6.\ !d. 

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b. Standard of care with respect to monitoring Mr. Ferrington's behavior at the Tomah VAMC 

VA Consultant 1 noted that the Tomah V AMC staff "was clearly aware" that Mr. 

Ferrington's apparent continued lethargy was "a problem."64 When the Tomah VAMC Medical 

Service evaluated Mr. Ferrington to try and address this issue, VA Consultant 1 found that Mr. 

Ferrington "appeared to have been given short-shrift."65 On this issue, VA Consultant 1 

concluded: 

The decision not to return him to the Medical Service when the problems that lead 

[sic] him to admission were not evidentially resolved is also a failure on the part 

of his treatment team, as there continued to be evidence of this problem on a daily 

basis noted in the record with inadequate response to the serious safety issues 

raised66 

c. Standard of care with respect to medical care 

VA Consultant I identified that Mr. Ferrington suffered from diabetes and pain67 With 

respect to the pain, Mr. Ferrington's pain was addressed using medications.68 VA Consultant 1 

noted that Mr. Ferrington's rehab consultation "suggested [Mr. Ferrington's medication regimen] 

was contraindicated in his case, and they suggested physical therapy."69 VA Consultant 1 

concluded that Mr. Ferrington's pain was "not properly addressed."70 

d. Standard of care with respect to psychiatric care 

On this issue, VA Consultant 1 found that the Tomah VAMC failed to conduct proper 

follow-up on how it treated Mr. Ferrington's depression and anxiety, writing: "I was not able to 

identify evidence that his depression or anxiety treatment was being actively reassessed for 

adequacy of treatment benefit during his stay in the [substance abuse] program."71 

64 Jd at5. 65 Jd 

66 !d. 

67 !d. 

68 !d. 

"!d. 

70 !d. 

71 !d. 

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e. Standard of care with respect to counseling 

VA Consultant I concluded that "[t]here is evidence that [counseling] was not adequately 

addressed."72 He noted that because Mr. Ferrington was oftentimes confused and lethargic, he 

was not able to benefit from group counseling sessions. VA Consultant I explained: 

A patient who is this often and severely confused is unable to benefit from 

psychotherapy groups and activities. His sister reported that all of his therapy 

homework was never completed, which begs the question of whether staff was 

adequately reviewing and monitoring his participation in the program.73 

f. Standard of care with respect to Mr. Ferrington's discharge 

On the issue of Mr. Ferrington's discharge from the Tomah VAMC, VA Consultant I 

concluded that Mr. Ferrington was "clearly not capable of being safely released to home at the 

time of discharge."74 VA Consultant I noted observations from the day prior to discharge that 

Mr. Ferrington appeared "very drowsy with slurred speech and being barely able to keep his eyes 

open."75 In addition, he appeared "sedated" and "very unsteady on his feet"76 On the day of 

discharge, VA Consultant I noted Ms. Hemb's observations: "I was upset when I went to pick 

him up because he was so buzzed I stated I wanted to put him in Complete Detox right then."77 

Ms. Hemb noted that Mr. Ferrington died "not even 8 hours after we got home." 78 

VA Consultant I identified six ways in which the Tomah VAMC failed to meet the 

standard of care with respect to its treatment of Mr. Ferrington: 

n I d. 

I. Inadequate monitoring of medication and allowing Mr. Ferrington to self-medicate; 

2. A failure to reduce or stop medications that are noted to be addictive, sedating, and 

which cause confusion and unsteadiness-symptoms that Mr. Ferrington exhibited; 

3. A failure to adequately respond to frequent presentations of these symptoms, too 

rapid of a return to the unsupervised substance abuse program where Mr. Ferrington 

was sent for evaluation, and a failure to return him for medical admission when these 

same problems were clearly unresolved on his return from the substance abuse 

program; 

4. Allowing Mr. Ferrington to "graduate" from a therapy program through which he was 

frequently slept and for which he failed to complete homework assignments; 

73 Jd. at 6. 

''ld 

"Id. 

76 Id 

77 Jd. 

"I d. 

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5. A failure to address psychological issues raised in the program, which may have lead 

him to seek substances to abuse; and 

6. Allowing Mr. Ferrington to be released home despite appearing physically and 

mentally compromised.79 

VA Consultant I ultimately concluded: 

I believe there is a clear path from the above failures of adequate care and 

monitoring to Mr. Ferrington's death. If these issues were more appropriately 

addressed Mr. Ferrington would not have been allowed to have been on the 

combination of medications he was taken [sic J at the time of discharge nor would 

he have been allowed to return home in the clearly compromised state he was in. 

If toxicology screens were perfonned the staff may have been able to detect illicit 

substance use and address it. Given his proclivity for substance misuse and 

overuse, it is certainly possible that at some point Mr. Ferrington might have 

overdosed and died of the same cause. However, when he was in the care of a 

health care system, it is their responsibility to identify potential causes of risk of 

harm and to try to mitigate them. Having failed to do so, their actions lead 

directly to the death of Mr. Ferrington in my medical opinion. 80 

ii. Findings of VA Consultant 2 

VA Consultant 2 presented a slightly different opinion than VA Consultant 1 on the 

degree of the Tomah V AMC's responsibility for Mr. Ferrington's death. He ultimately found 

that the Tomah VAMC's care was "benign" and "[n]othing that [the Tomah VAMC] did directly 

contributed to his death."81 VA Consultant 2's analysis heavily emphasized the presence of 

methadone in Mr. Ferrington's system at the time of his death and found that the "overdose that 

killed him was with methadone and Valium (these are the two medications that most probably 

suppressed this patient's respiratory drive)."82 Although VA Consultant 2's opinion on the cause 

of Mr. Ferrington's death differed from VA Consultant 1, VA Consultant 2 still identified issues 

of concern with Mr. Ferrington's care at the Tomah V AM C. 

a. Standard of care with respect to medication management 

VA Consultant 2 noted concerns with the Tomah VAMC's management of Mr. 

Ferrington's medication regimen. With respect to the medications Mr. Ferrington was on, VA 

Consultant 2 wrote: 

"Id 

"Jd at 6-7 (emphasis added). 

:~VA Consultant 2 Medical Opinion, at 2. 

Jd at I. 

(~): \ I '------·) 

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While there was and [sic] an attempt to understand why this patient appeared over 

sedated (including the notion that the patient might have sleep apnea with a plan 

for a sleep study after the patient was discharged from residential treatmenthowever this writer could find no evidence that the sleep study was ever 

scheduled) his medications were never completely held to see if his mental status 

cleared. He also appeared to be getting medications from an outside pharmacy; in 

an over separated patient one of the first issues that should have been addressed is 

to determine the relationship between his medication intake and his oversedation. 

It is this writers [sic] belief that the patient should have been detoxed off of the 

benzodiazepine Valium83 

b. Standard of care with respect to monitoring Mr. Ferrington's behavior at the Tomah VAMC 

On the issue of monitoring Mr. Ferrington's' behavior to respond appropriately to his 

sleepiness, VA Consultant 2 did not determine whether the Tomah V AMC met the standard of 

care. The consultant wrote: 

[T]he patient's medications should have been held to see if his mental 

status/oversedation cleared. It should be noted that some clinicians might have 

had ethical concerns about this; as the patient was suffering from severe pain per 

his report. Some of his medications ameliorated his discomfort. 84 

c. Standard of care with respect to medical care 

VA Consultant 2 did not determine whether Mr. Ferrington's medical care at the Tomah 

V AMC met the standard of care. However, he identified areas of concern with how the Tomah 

V AMC treated Mr. Ferrington's diabetes and pain. With respect to the Tomah VAMC's 

treatment of Mr. Ferrington's pain, VA Consultant 2 wrote that the Tomah VAMC staff should 

have completed a "more rigorous workup" to determine the role that Mr. Ferrington's drug 

addiction played in his complaints of pain85 

On the questions of whether Mr. Ferrington received proper psychiatric care or was 

offered appropriate counseling, VA Consultant 2 made no detenninations of whether the facility 

offered the proper standard of care. 86 The consultant summarized the care that Mr. Ferrington 

received and noted some other treatments that were not rendered according to Mr. Ferrington's 

"Jd.at4. 

84 ld. 85 ld. at 5. 

"Jd. 

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medical files. 87 He did not draw a conclusion of whether the omission of those evaluations or 

treatments fell outside of the standard of care. 88 

d. Standard of care with respect to Mr. Ferrington's discharge 

On the issue of Mr. Ferrington's discharge from the Tomah VAMC, VA Consultant 2 

wrote: 

Patient continued to have periods of oversedation up until the time of his 

discharge: this writer does not think the patient was ready for discharge until 

there was a better understanding of why the patient was so oversedated so much 

of the time. In the context of substance use disorder; it strongly suggests 

uncontro !led drug use 89 

When asked to clarify if and how the Tomah V AMC failed to meet the standard of care, VA 

Consultant 2 wrote: 

There should have been a better attempt to understand why this patient was 

oversedated to the extent he was. This might have included serum blood samples 

to obtain blood levels of the medications he was on such as his amitriptyline and 

Valium; if there were excessive blood levels of these medications; the patient 

might have been a slow metabolizer; or taking more than the prescribed doses of 

these medications. If the latter were the case; he certainly was not getting the 

benefit of the substance abuse treatment he was involved in. In an oversedated 

state; the patient would not have been able to fully benefit from the learning and 

psychosocial interventions being provided in the residential program90 

VA Consultant 2 found that that the Tomah V AMC did not "adequately control [Mr. 

Ferrington's] intake of medications or other substances from outside the V A."91 Ultimately, 

however, VA Consultant 2 concluded that the Tomah V AMC was not responsible for Mr. 

Ferrington's death: 

"!d. 

88 !d. 

It is not the belief of this writer that the patient died due to oversedation! 

polypharmacy/overrnedication by the Tomah VA. Proof that this patient did not 

die from VA medications is the fact that the VA did not prescribe the patient the 

medication that most likely killed him; namely methadone92 

89 !d. 

90 Jd.at6. 

91 !d. 

92 !d. 

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3. Peer reviews of the Tomah V AMC in connection with Kraig Ferrington's death 

suggest other practitioners would have provided different treatment 

The VA has an internal mechanism, known as a peer review, to review the care that its 

medical professionals provide to individual patients. Peer reviews are conducted by VA staff 

members and arc graded on an increasing scale of Levels I through 3. When a medical 

professional is reviewed and receives a Levell, the highest level, it means that "most 

experienced, competent practitioners would have handled the case similarly in all of the respects 

listed."93 Level2 peer reviews indicate that "most experienced, competent practitioners might 

have handled the case differently in one or more of the respects listcd."94 Level3 peer reviews 

indicate that "most experienced, competent practitioners would have handled the case differently 

in one or more of the respects listed. "95 

The VA performed peer reviews for three providers in connection with their care of Kraig 

Ferrington. One provider, a physician's assistant in the Tomah VAMC mental health wing, 

received a level 3 for his care of Mr. Ferrington-meaning that most experienced practitioners 

would have treated Mr. Ferrington differently than this physician's assistant had. 96 Another 

medical professional, a clinical substance abuse counselor at the Tomah V AMC, received a level 

2 peer review-meaning that most practitioners might have treated Mr. Ferrington differently 

than the substance abuse counselor had.97 A third provider, a nurse, received no level rating in 

their peer review. 

The peer reviews identified similar issues with the care as the VA's own consultants 

found. For example, the level 3 peer review noted "CONSTANT!! Documentation regarding 

patient falling asleep--slurred speech-unable to walk" and other issues that were "all 

documented" but noted that there was "nothing done" to address this issue. 98 That same peer 

review found that "when discharging, noted patient slee~ing-had report of [patient] being 

'snowed' that am [morning]-still discharged patient."9 It is unclear, however whether the VA 

disciplined any health care providers in connection to their care for Kraig Ferrington. 

* * * 

93 Letter from Office of Regional Counsel, VA Regional Office, Dcp't of Veterans Affairs, to Director, VA Medical 

Center, Tomah, WI, at 14 (Dec.17, 2008) (VA Peer Review) (on file with Comm.). 94 /d. 

95 ld. 

"'Id. 

97 !d. 98 !d. at 10. 

99 !d. 

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The VA ultimately settled the administrative proceeding about its care ofKraig 

Ferrington. 100 The treatment of Kraig Ferrington and Jason Simcakoski's at the Tomah VAMC, 

although seven years apart, are similar. Both patients had a complex mixture of PTSD and 

medication management issues. Both sought care at the Tomah VAMC to regain control of their 

lives. Both were prescribed large amounts of dangerous drugs, and both ultimately died from a 

mixture of drugs. 

Kraig Ferrington's death should have been an opportunity for the Tomah VAMC and the 

VA at large to revisit its prescription practices. His care represents one in a long list of missed 

opportunities to identify problems in prescription practices at the facility and take steps to 

implement solutions. 

B. The VA apparently did not fully examine past allegations against Dr. 

David Houlihan during his hiring and promotion at the Tomah VAMC 

Long before Dr. David Houlihan became the chief of staff at the Tomah VAMC-before 

he was even hired as a psychiatrist there-he was subject to disciplinary charges by the Iowa 

Board of Medical Examiners. These disciplinary proceedings, which cast doubt on Dr. 

Houlihan's judgment as a practitioner, were apparently known to the Tomah V AMC at the time 

of his hiring. From information available to the majority staff, the VA regional leadership 

apparently overlooked these issues in hiring Dr. Houlihan in 2002 and in promoting him to chief 

of staff in 2004. The Tomah VAMC-at the direction of regional leadership--only closely 

examined these issues in 2009. The VA regional leadership's failure to promptly and closely 

examine the Iowa Board of Medical Examiners' actions concerning Dr. Houlihan until well after 

he became chief of staff at the Tomah V AMC represents another missed opportunity to prevent 

the tragic outcomes. 

1. Dr. Houlihan's apparent prior misconduct in Iowa 

On June 5, 2002, the Iowa Board of Medical Examiners charged Dr. Houlihan with 

"engaging in unethical conduct or practice harmful or detrimental to the public when he violated 

appropriate professional physician/patient boundarics." 101 Specifically, Dr. Houlihan was 

accused of hiring two patients to perform work for him, engaging in an inappropriate social 

relationship with a patient, and inappropriately possessing patient medications at his home. 102 

The Iowa Board of Medical Examiners referred these allegations to a "peer review committee 

100 Letter from Office of Regional Counsel, VA Regional Office, Dep't of Veterans Affairs, to Director, VA Medical 

Center, Tomah, WI (Jan. 25, 2011) (on file with Comm.). 101 In re Confidcntiallnvestigation Concerning David Houlihan, No. 02-0l-1429, Settlement Agreement & Final 

Order, OlG 5741, at OIG 5745 [hereinafter Houlihan Settlement Agreement & Final Order]. 102 Iowa Board of Medical Examiners Press Release, at OIG 18. 

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consisting of two Iowa licensed psychiatrists." 103 The panel concluded that Dr. Houlihan "failed 

to maintain proper boundaries with respect to his relationship with a former patient."104 The 

Board filed charges on June 5, 2002. 105 

On April 3, 2003, Dr. Houlihan settled his case with the Board106 The settlement 

agreement noted that Dr. Houlihan had completed a "comprehensive professional boundary 

evaluation" in April 2002. 107 The agreement required Dr. Houlihan to "successfully complete an 

education program on physician-patient boundaries" within 90 days of the order. 108 The Iowa 

Board of Medical Examiners issued a press release on the settlement on April9, 2003. 109 

Dr. Houlihan joined the staff of the Tomah VAMC in 2002 and became chief of staff at 

the facility in 2004. 110 During transcribed interviews with VA and VA OIG personnel, Chairman 

Johnson's staff inquired about the severity of the alleged boundary violations and whether the 

Iowa Board of Medical Examiners' complaint was considered when the VA hired Dr. 

Houlihan. 111 Renee Oshinski, who became deputy VISN 12 director in 2004, stated that she 

believed that the leadership ofVISN 12-the regional entity responsible for the Tomah 

VAMC-saw these allegations during the VA's "hiring process" of Dr. Houlihan112 When 

asked about the severity of these allegations, Ms. Oshinski opined that "things don't get reported 

to State Boards if they are not of consequence. " 113 

The charges from the Iowa Board of Medical Examiners resurfaced when Dr. Houlihan 

was under consideration to become the chief of staff of the Tomah V AMC. According to Ms. 

Oshinski, there were "discussion[s] about issues with his p,revious employment" among VISN 12 

leadership and Tomah V AMC officials during that time. 1 4 When asked why V!SN 12 and 

Tomah VAMC leadership overlooked these concerns and decided to promote him to chief of 

103 Houlihan Settlement Agreement & Final Order, at OIG 5745. 1041d. 

1os Id. 

106 I d. at OIG 5741. 107 I d. at OIG 5742. !08ld 

109 Iowa Board of Medical Examiners Press Release, at OIG 16. 110 David Houlihan eOPF File and Perfom1ance Appraisal (on file with Comm.). 111 See generally, Transcribed Interview with Renee Oshinski, in Washington, D.C. (Dec. 14, 2015) [hereinafter 

Oshinski Transcribed Interview]; Transcribed Interview with Alan Mallinger, in Washington, D.C. (Mar. 8, 2016) 

[hereinafter Mallinger 3/8/2016 Transcribed Interview]; Transcribed Interview with Alan Mallinger, in Washington, 

D.C. (Apr. 6, 20 16) [hereinafter Mallinger 4/6/2016 Transcribed Interview]; Transcribed Interview with Alan 

Mallinger, in Washington, D.C. (Apr. 21, 2016) [hereinafter Mallinger4/21/2016 Transcribed Interview]; 

Transcribed Interview with Katherine Pica, in Tomah, Wis. (Dec. 17, 2015) [hereinafter Pica Transcribed 

Interview]; Transcribed Interview with Michael Bonner, in Tomah, Wis. (Dec. 16, 2015) [hereinafter Bonner 

Transcribed Interview]. 112 Oshinski Transcribed Interview, at 22. 113 Id. at 23. !141d. 

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staff, Ms. Oshinski highlighted three factors she believed contributed to Dr. Houlihan's 

promotion: 

1. Dr. Houlihan had strong support from then-Tomah VAMC Director, Stan 

Johnson; 

2. Dr. Houlihan had worked at the Tomah VAMC for "awhile" and was a "strong" 

provider; and 

3. Difficulties in recruiting psychiatrists to the Tomah VAMC, combined with Dr. 

Houlihan's strength as a provider, led leadership to believe Dr. Houlihan "did 

what he needed to do to clear his record based on what they said in Iowa." 115 

2. The VA did not address the apparent Iowa misconduct until 2009 

Every two years, the VA reviews and recertifies the credentials of its medical 

professionals. 116 This re-crcdentialing process reviews the medical professional's medical 

license and Drug Enforcement Administration license status, and queries the National 

Practitioner's Data Bank and the appropriate state databases. 117 The re-certification process may 

also measure additional metrics depending on the medical professional's specialty11 Once the 

appropriate data are collected and reviewed, the Medical Executive Committee at the 

professional's facility ensures that all the proper documentation is in order and approves, or 

denies, the professional's reappointment for VA privileges. 119 At the facility level, the chief of 

staff is the "key player" in this re-credentialing process. 120 

Dr. Houlihan underwent this typical re-eredentialing procedure in 2003, 2005, and 

2007121 None of these biannual re-credential reviews examined the allegations that the Iowa 

Board of Medical Professionals levied against Dr. Houlihan in 2002. 122 Victoria Brahm, who 

served at the time as VISN 12 Quality Management Officer and Acting ChiefMcdical Officer, 

noted that in 2009 "there was a lot of Houlihan attention" at VISN 12 about his clinical practices 

and other issues. 123 Ms. Brahm explained that the increased attention and communications at the 

VISN level was unusual as the Tomah VAMC was "one hospital that previously hasn't required 

a lot of attention." 124 In light of these concerns, Ms. Brahm stated that she "started to pay a lot of 

115 Id at 25. 116 See generally Memorandum from Katherine Pica, Assoc. Chief of Staff, Tomah V AMC, to Victoria Brahm, 

Acting ChiefMed. Officer, VISN 12 (Nov. 9, 2009), OIG 10458 [hereinafter 11/9/2009 Memo from Katherine Pica 

to Victoria Brahm]. 117, Bonner Transcribed Interview, at 50-51. 118 Id. at 50. 119 !d. at 51-52. 120 !d. at 52. 121 11/9/2009 Memo from Katherine Pica to Victoria Brahm, at OIG 10458-59. 122 ld 123 Transcribed Interview with Victoria Brahm, in Tomah, Wis., at 53 (Dec. 16, 2015) [hereinafter Brahm 

Transcribed Interview]. 124 !d. 

~) '<--... J 

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attention to Tomah" and began taking a closer look at documentation she had not reviewed prior 

to the influx of concerns about Dr. Houlihan. 125 

As part of her increased emphasis on the Tomah VAMC, Ms. Brahm inquired into 

whether the VA had ever reviewed the 2002 allegations against Dr. Houlihan. 126 She believed 

that the VA reviewed these allegations when Dr. Houlihan was hired, but found no 

documentation in his VA employee file to verify that fact. 127 In a transcribed interview, Ms. 

Brahm told Chairman Johnson's staff that through informal discussions with VA personnel, 

leadership agreed that as of 2009, the 2002 issue was in the past and that Dr. Houlihan possessed 

an "unrestricted license."128 Nonetheless, she felt "angst" over the lack of a documented VA 

review and asked Dr. Katherine Pica, the then-Tomah V AMC Associate Chief of Staff, to 

complete an evaluation of the 2002 Iowa allegations. 129 

The results of Ms. Brahm's request were summarized in a November 9, 2009, 

memorandum from Dr. Pica to Ms. Brahm no The memorandum summarized the charges that 

the Iowa Board of Medical Examiners had levied against Dr. Houlihan in 2002. The review 

included verification from a representative of the Iowa Board of Medical Examiners that Dr. 

Houlihan had completed the patient boundary education program within the required 90 days and 

that upon completion of that program, Dr. Houlihan had a "clear, unrestricted license in the State 

oflowa." 131 The memorandum noted that as of February 1, 2004, Dr. Houlihan allowed his Iowa 

license to lapse and that he held a current Wisconsin license. 132 

Dr. Pica's memorandum included an explanation of why the VA failed to document the 

Iowa Medical Board's allegations until 2009. She wrote: 

No issues have been identified during the biennial reappointment processes. 

Since the license issue had been resolved, it has not been addressed as part of the 

2003, 2005, and 2007 reappointments. This oversight will be acknowledged on 

the Service Chief Approval screen at time of future reappointments. A review by 

the Chief Medical Officer will also be obtained on subsequent reappointments. 133 

Chainnan Johnson's staff conducted a transcribed interview of Dr. Pica on December 17, 

2015. When staff sbowed the memorandum to her, Dr. Pica had no recollection of reviewing the 

2002 Iowa Board of Medical Examiners allegations against Dr. Houlihan. 134 She said that she 

!25 ld. 

126 Id at 52-53. 127 /d at 49. 128 I d. at 52. 129 I d. at 49. 130 11/9/2009 Memo from Katherine Pica to Victoria Brahm, at OIG 10458-59. 

"' Id 132 Id. 

13) /d. 134 Pica Transcribed Interview, at 84-92. 

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101 

did not recall creating the memorandum, stating "no. I did not type up this memo." 135 When 

asked who did create the memorandum, Dr. Pica replied, "[t]he credentialer maybe."136 

Although Dr. Pica did not recall reviewing the 2002 Iowa allegations or creatin¥ the 2009 

memorandum, she did acknowledge that it was her signature on the document. 1 7 Despite her 

failure to remember the memorandum, Dr. Pica informed Chairman Johnson's staff that the 2009 

review of Dr. Houlihan's 2002 Iowa allegations was the only time she has signed arecredentialing document for the VA. 138 

Although aware of the charges when he was hired, the VA regional leadership only 

ordered a full examination of the Iowa charges against Dr. Houlihan in 2009-years after he 

became chief of staff at the Tomah V AMC. By that time, leadership determined that the issues 

were "cleared up" and Dr. Houlihan was fit to continue practice. 1 39 In not acting sooner, the VA 

missed an opportunity to carefully examine Dr. Houlihan and potentially prevent the issues at the 

Tomah V AMC before they arose. 

C. The Tomah employees union complained to the VA OIG about overprescription at the Tomah VAMC in 2009, but it is unclear whether the 

OlG took action 

Local 0007 of the American Federation of Government Employees (AFGE) represents 

non-physician employees of the Tomah V AMC. Local 0007 officials told the Committee that 

they raised concerns to the VA OIG about over-prescription practices at the Tomah VAMC in 

2009. 140 However, VA OIG personnel on site at the Tomah V AMC cancelled their scheduled 

meeting with AFG E officials less than one hour before the meeting was scheduled to occur. 141 

According to the AFGE ot1iciais, they supplied a package of documents outlining concerns about 

over-prescription of drugs to veterans and issues with management, among other concerns. 142 

When asked by Chairman Johnson's staff about this information, VA OIG officials said that they 

did not recall receiving the information from AFGE officials in 2009. 143 It is unclear whether the 

VA OIG conducted any investigation as a result of the AFGE's reports. 

135 I d. at 89. 136 Id. at 89. 137 I d. at 93. 

"'I d. at 93-94. 139 Brahm Transcribed Interview, at 49. 140 See Transcribed Interview with Linda Ellinghuysen, in Tomah, Wis., at 85-88 (Dec. 14, 2015) [hereinafter 

Ellinghuyscn Transcribed Interview]. 141 See Memorandum from American Federation of Government Employees (AFGE) Local 1882 AFL-CIO to IG 

Representatives (Jan. 8, 2009), in AFGE Local 0007 June 4, 2015 Document Production, at 2 [hereinafter 1/8/2009 

Memo from AFGE Local 1882 AFL-CIO to IG Representatives]. 142 Ellinghuysen Transcribed Interview, at 141-42. 143 Transcribed Interview with Wachita Haywood, in Washington, D.C., at 70-·72 (Feb. I I, 2016) [hereinafter 

Haywood Transcribed Interview]. 

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In early 2009, the VA OIG visited the Tomah V AMC to examine an unrelated allegation 

of patient abuse. 144 While they were on the facility grounds, Linda Ellinghuysen, an official with 

AFGE Local 0007, scheduled an appointment with the OIG investigators, which was initially 

cancelled. 145 During a transcribed interview, she explained how she presented information to the 

VA OIG. She stated: 

But I had a packet of information and I knew that they were in the library 

conference room, so I went over there and knocked on the door and asked to 

speak with them. And I did not-I got a very cold reception, like they did not 

want to speak with a union rep. 

They asked me ifl called the hotline and I said no. Well, you need to call the 

hotline. And my recall is I said, well, no. You're right here. 

I mean it took enough courage just to go over there. I'm not going to call the 

hotline. I needed to speak with these people. But they didn't want to talk to me, 

so I had a packet of infonnation in a manila envelope and I slid it on the table. 

And I said, there's confidential information in there about narcotics and patient 

suicides and bad behavior by the Chief of Staff. If you're not going to read it, 

please shred it, because it's confidential, but I left it there. 

And then within 20 minutes they called the union office and asked us to come 

over.l46 

Ms. Ellinghuysen's memorandum, dated January 8, 2009, was addressed to unnamed "IG 

Representatives."147 The memorandum read in part: "AFGE Officers were looking forward to 

meeting with you this date at I :OOpm; however, at approximately 12: l5pm today we received a 

telephone call from the P .I. Director, Judith Broad, and she informed the Chief Steward that you 

had cancelled your meeting with us."148 The memorandum explained that the union had 

"glean[ed] valuable information related to Patient Abuse and related to Fraud."149 She provided 

a package of documents that accompanied the memorandum and requested a copy of the IG's 

subsequent findings. 150 

Ms. Ellinghuysen said that the package of documents also included a document titled 

"Questions For Leadership."151 The document highlighted complaints and allegations from two 

separate dates: August 7, 2008, and January 2009. 

144 Ellinghuysen Transcribed Interview, at 69-70. 145 !d. at 70. 146 !d. at 70-71. 147 1/8/2009 Memo from AFGE Local 1882 AFL-CIO to IG Representatives. 148 !d. 

149 !d. 

150 !d. 151 Ellinghuysen Transcribed Interview. at 140. 

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The complaint dated August 7, 2008, included a broad question-"why is the Chief of 

Staff allowed to create a hostile working enviromneut?" 152 The doctmlent noted the difficulties 

that the Tomah V AMC had in retaining providers, issues with the quality of veteran care at the 

facility, and a fear among: the staff that Dr. Houlihan would fire them. 153 The complaint also 

posed questions about the potential misuse of funds. 154 

The "Questions for Leadership'' docmnent also contained allegations date stamped 

January 2009. 155 One of the allegations read: 

There have been several staff reports that Dr. Houlihan is known as the "candy 

man" by several patients here. There are several staff whom. in their professional 

judgement [sic], believe that Dr. Houlihan ovennedicates patients. TI1cre have 

been several patients who have had to be given Narcan [an opiate antidote] due to 

adverse side affects [sic] from too many narcotics and other medications156 

According to a whistleblower who contacted Chainnan Jolmson's staff in May 2015, the "Candy 

Man" moniker dates back to at least 2004. 157 TI1e whistleblower stated that Dr. Houlihan was 

''furious" when he leamed of the niclmame. 158 

FigurE' 1: AFGE ""QuPstions for LeadN·ship" DofumPnt 

Ql!ESTlQlVS Fnr LEADERSHIP 

I. Why is the; Chief ofSt:a:ffa!lowcd to creato a hostile working environment~ 

a. Tncre have ':>ecn wmplaints from health care staff-· they are afraid that 

Dr. Houlihan will get them fin.-d .... as he has cisciplined/or m11de life 

dtfficult for many rroviders (Dr.'s, )lurse Practitioners, PhySJcians 

Ass~t<>nts) a.~ well aa Nursiug staff 

b. Why is it that so ncany p;ov:detll (psychiatrists, P"YChologist$) don't ~lay 

here for long? (It is becat•se they won't put ttp with Dr. Ho·J!iha:l' s 

yelling nnd tl~reaterur.g b~.haviors.) 

152 Que;tions for Leadership, m AFGE Local 0007 June 4. 2015 Document Production. at 3. 153 !d. at 3-1. 154 Jd. 155 !d. at 4. 

156 rd. 157 SeeS. COMM. ON HOMELAND SEC. & GoVER.'-'MENTAL AFFAIRS. MAJORITY STAFF REPORT: TRAGEDY AT TOMAH: 

NITIAL FINDINGS 14 (20 15). 

"'!d. 

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Figui'P 2: AFGE "'Questions for LE>adership" DoC'umPnt 

;r 2. 

There have been O<:veral AtaiT rtports that Dr. Houlihan is known a. the «candy 

man" by several patients here. There life several staff whom, m the.ir professionai 

judgement, believe that Dr. Houlihan qvnrmedrcales oa.tients. There have beon 

seve:al patirnts who have had to be given 1'-ieJ:can.diJe to ad~e side ~ects from 

too many narcotics and otJ-.er m~.dications. or~.,.. .... r h' ""n <w 

Dr. Houlihan, early December 2008, scr.,amed a1 a Registered Phanr.acist. who 

used to be the C'.oordinator of a Pam Clinic at another health ca~·e agency, bec.ause 

>he recommended to him a differect regJmen of pain medications. The 

Phnnnacrst refu$&1 I<> till the pres~ription because the patient wo·~ld have 

overdosed on narr.otrcs 

January 11)()<) 

When Chairman Johnson's staff interviewed Ms. Ellinghuysen, she stated that when she 

provided these documents to VA OIG persmmel at the Tomah facility in January 2009. they were 

initially dismissive of her concems. 1 59 However. Ms. Ellinghuysen said that when she attempted 

to meet with the VA OIG representatives for a second time that day, she was able to speak with 

the OIG staff for about 45 minutes. 160 When Chainnan Johnson's staff inquired about the 

identities of the VA OIG staff, she explained that she could not recall the names. She said: 

A: I do not recall the names. There were two females. One black 

American and one Caucasian. The black American female appeared 

very angry at me when I walked in. But she softened after I went back 

the second time and we stated talking. 

Q: And how long was that that second time? How long did you meet and 

speak with them? 

A: I would guess 45 minutes. 

Q: Do you recall where they were out ofJ Were they out of Chicago? 

Where were these OIG agents from? Where was their home office? 

A: My recollection is Chicago. I camwt be cetiain of that. I don't have 

cards from them. But I thought it was out of Chicago161 

159 El1inglmysen Transcribed Interview, at 86-87. 

160 !d. 

"'Id. 

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Chairman Johnson's staff inquired about the documentation that Ms. Ellinghuysen 

provided to the VA OIG when the OIG employees were at the Tomah V AMC in January 2009. 

She stated: 

Q: This is a January, 2009, memo from you to the IG. I believe, is this the 

document we were referring to earlier when discussing your 

interactions with the IG back in January? 

A: Yes. 

Q: In the corresponding two pages there is a list of questions for 

leadership. Was that also provided to the IG? 

A: I think it was. 

Q: So if we go through it. In January, there's an addendum at the end of 

page 2 of 2. It says, in January 2009, point one, I'll read from it. 

"There have been several staff reports that Dr. Houlihan is known as 

the, quote, Candy Man by several patients here. Several staff whom, in 

their professional judgment, believe that Dr. Houlihan overmedicates 

patients. There have been several patients who have been given 

Narcan due to adverse side affects from too many narcotics and other 

medications." 

So if your recollection is correct, and you included this in your 

Memorandum to the Inspector General's office, did the Inspector 

General's office know about Candy Man as early as 2009 then? 

A: Yes. 

Q: And so when you're in the meeting with the Inspector General's 

office, did they go over any of these documents with you or did you 

just kind of drop it off and leave? I know you said they didn't take any 

notes. 

A: Right. 

Q: Was there any presentation of documents? 

A: I don't recall if I took my own notes, because I only gave them copies, 

or if I had their notes. 

Q: Gave them copies of what? 

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A: Copies of what I put in the manila envelope for them. 

Q: Urn-hum. 

A: And, you know, lots of enclosures. I don't recall sitting down, going 

over paperwork. But what I recall is, the two other officers and I, we 

talked about these issues. And we talked about Candy Land. We talked 

about Candy Man. We talked about narcotics and, you know, by this 

time we had had a couple of suicides in our parking lot and that 

concerned us, because, there again, we can't get in the charts and the 

staff are afraid to freely give information, we're piecing things 

together. 

And we're saying, you know, we think these may be Dr. Houlihan's 

patients, and we're hearing that they have a lot of opioids and benzos 

and all these medications, but we can only, you know, I mean, we tell 

them what we hear, and we expect them to investigate. And that, and 

that did not occur. 162 

Chairman Johnson's staff questioned VA OIG officials about whether they recalled 

receiving these allegations in 2009. In a transcribed interview, staff presented Wachita 

Haywood, the Associate Director of the VA OIG's Chicago Office ofHealthcare Inspections, 

with the January 8, 2009 memorandum from Ms. Ellinghuysen, as well as the "Questions for 

Leadership" document. 163 Chairman Johnson's staff also presented Ms. Haywood with sections 

of Ms. Ellinghuysen's statements where she claims that she spoke to VA OIG officials. 164 Ms. 

Haywood said that she was not present at the 2009 meeting between the VA OIG and the Tomah 

VAMC union officials. 165 

On April 21, 2016, Maureen Regan, Counselor to the VA Inspector General, wrote to 

Chairman Johnson and Ranking Member Caper to offer an account of the VA OIG's 

involvement at the Tomah VAMC in the January 2009 timeframe. The VA OIG's account of the 

interaction differed slightly from Ms. Ellinghuysen's account; however, the VA OIG admitted to 

receiving a copy of Ms. Ellinghuysen's memorandum. 

The VA OIG's account differs from Ms. Ellinghuysen's with respect to the additional 

documentation she provided to the VA OIG in January 2009. Ms. Regan wrote that the VA OIG 

"reviewed OIG records and detennined that there was an on-going healthcare inspection at the 

162 !d. at 140-42. 163 Haywood Transcribed Interview, at 70-74. 164 /d. at 75-81. 165 /d. at81. 

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time that included a site visit." 166 Following the interview with Ms. Haywood, the VA OIG was 

able to identify the two inspectors who were on-site in January 2009. 167 According to Ms. 

Regan: 

The inspectors confirmed that they did receive a copy of the January 8, 2009 

memorandum; however they did not recall receiving any additional documents 

and denied having met with Ms. Ellinghuysen. We showed the inspectors a 

picture of Ms. Ellinghuysen and neither inspector recognized her. We also pulled 

the file for the inspection and did not find any documents relating to the issues 

Ms. Ellinghuysen claims to have raised during that inspection. 168 

Given the different recollections between Ms. Ellinghuysen and the VA OIG, it is unclear 

what information the VA OIG received and whether the VA OIG did any investigation into these 

allegations. Ms. Ellinghuysen explained that she did not follow up with the VA OIG. When 

asked why, she listed three reasons. First, she explained that the cold and dismissive reception 

she received from the VA OIG dissuaded her from following up. 169 Second, she felt that the fact 

that the VA OIG personnel did not take notes at the meeting made it look like "they weren't 

going to do anything" about her allegations. 170 Third, the culture of fear and reprisal at the 

Tomah VAMC, combined with the apparent low likelihood that the VA OIG was going to do 

anything about her allegations, posed a risk that she could face retaliation for her reporting of 

wrongdoing. 1 71 

As part of its subsequent Tomah VAMC health care inspection, the VA OIG reviewed 

the VA "OIG Master Case Index records of 19 cases at Tomah VAMC since 2009." 172 In an 

attempt to ascertain whether the VA OIG received and reviewed Ms. Ellinghuysen's 2009 

allegations, Chairman Johnson's staff asked the VA OIG for a list of the 19 cases referred to in 

the VA OIG's administrative closure. 173 The VA OIG refused to provide that information. 174 

Given the VA OIG's continued obstruction of the investigation, the majority staff is unable to 

166 Letter from Maureen Regan, Counselor to the Inspector General, Dep't of Veterans Affairs, to Han. Ron 

Johnson, Chairman, S. Comm. on Homeland Sec. & Governmental Affairs, and Han. Thomas R. Carper, Ranking 

Member, S. Comm. on Homeland Sec. & Governmental Affairs, at 1 (Apr. 21, 2016) [hereinafter 412112016 Letter 

from Maureen Regan, VA OIG, to Chairman Johnson and Ranking Member Carper, HSGAC]. 167 ld. Ms. Regan's letter also suggests a discrepancy in the identity of the VA OIG inspectors. Ms. Regan wrote 

that "both inspectors are female and both arc African~ American; no Caucasian inspectors were on-site for this 

inspection." !d. This account differs from Ms. Ellinghuysen's recollection that she met with ''one black American 

and one Caucasian." Ellinghuysen Transcribed Interview, at 86-87. 168 4/21/2016 Letter from Maureen Regan, VA OIG, to Chairman Johnson and Ranking Member Carper, HSGAC, at 

I. 

169 Ellinghuysen Transcribed Interview, at 87-88. 170 ld. at 88. 111 Id. 172 VA O!G TOMAJI VAMC ADMJNISTRAT!VE CLOSURE, at 2. 173 E-mail from Majority Staff, HSGAC, to Staff, VA OJG (Mar. 2, 2016,2:27 PM) (on file with Corum.). 174 E-mail from Staff, VA OIG, to Staff, HSGAC (Mar. 16, 2016, 2:20PM) (on file with Corum.). 

(~ "-__ __ ] 

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independently ascertain whether the VA OIG took any action in response to Ms. Ellinghuysen's 

allegations. 

D. The Drug Enforcement Administration has been investigating potential 

drug diversion at the Tomah VAMC since 2009, with no public results 

The DEA is the federal law-enforcement entity charged with enforcing federal drug laws. 

According to information received by Chairman Johnson's staff, the DEA has been examining 

potential drug diversion in and around the Tomah V AMC since at least 2009. In addition to 

investigative actions in 2011 and 2012, the DEA is said to be currently investigating the Tomah 

VAMC. 

On June 19, 2009, a DEA investigator interviewed Dr. Noelle Johnson, a pharmacist at 

the Tomah V AMC. 175 During the interview, Dr. Johnson provided the investigator with about 

ten examples of patients under Dr. Houlihan's care for whom Dr. Johnson believed the narcotic 

prescription was either too high in dosage or too long in length116 Dr. Johnson also apparently 

informed the investi~ator about three "unexplained" deaths of Dr. Houlihan's patients during her 

time at the facility11 The DEA's interview of Dr. Johnson lasted approximately two hours. 178 

During her testimony before Chairman Johnson's field hearing in Tomah in March 2015, Dr. 

Johnson stated that she was interviewed by the DEA on two other occasions. 179 

According to other documents obtained by Chairman Johnson, the DEA investigated 

potential drug diversion at the Tomah VAMC in concert with the VA OIG's inquiry in 2011 and 

2012. VA OIG personnel joined DEA diversion investigators in 2012 in examining potential 

drug abuse at the Tomah facility. On March 28, 2012, VA OIG Special Agent Greg Porter 

joined the DEA and a detective from the Tomah Police Department in interviewing a Tomah 

V AMC police officer. 180 The VA police officer alleged that Dr. Houlihan abused his authority 

175 Noelle Johnson v. Dep 't of Veterans Affairs, MSPB Docket No. CH-1221-1 0-0036-W-1, Tab I at 6 (on file with 

Corum.). Dr. Johnson also confirmed that she was interviewed by the DEA in 2009 in her written testimony for the 

Committee's Field Hearing in Tomah on March 30,2015. Tomah VAMC: Examining Quality. Access, and Culture 

of Overreliance on High-Risk Medications, Joint Field Hearing BefOre S. Comm. on Homeland Sec. & 

Governmental Affairs & H. Comm. on Veterans Affairs, II 4th Cong. (2015) (statement of Dr. Noelle Johnson): VA 

OIG Interview with Noelle Johnson (May 10, 2012), OIG 5935, at OIG 5955, at 78. 176 Noelle A. Johnson v. Dep't of Veterans Affairs, MSPB Docket No. CH-1221-10-0036-W-1, Tab I at 6 (on file 

with Comm.). 177Jd 

!78 !d. 179 Tomah VAMC: Examining Quality, Access, and Culture a/Overreliance on High-Risk Medications, Joint Field 

Hearing Before S. Comm. on Homeland Sec. & Governmental Affairs & H. Comm. on Veterans Affairs, I 14th Cong. 

(2015) (statement of Dr. Noelle Johnson). 180 VA OIG Criminal Investigations Div., Greg Porter, Memorandum of Interview of Tomah VAMC Employee 

(Mar. 28, 2012), O!G 10592, at OIG 10592-93. Dr. Mallinger also spoke with this DEA diversion investigator and 

documented additional details of the March 28, 20!2 meeting. VA OIG Office ofHealthcare Inspections, Alan 

Mallinger, Report of Contact with Diversion Investigator, DEA (Apr. 2, 2012), at OIG 5895. 

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109 

by interfering in VA police activities on the grounds of the Tomah VAMC-specifically, that Dr. 

Houlihan would not allow VA police "to interact with patients, even if they are suspected of 

criminal activity."181 The VA police officer described Dr. Houlihan as having a "short fuse" and 

a "bad temper" when dealing with VA police. 182 

Later, in May 2012, the DEA received from the VA OIG sensitive patient information, 

including patient charts. 183 The DEA diversion investigator wrote in an email to VA OIG 

Special Agent Porter: "We recently obtained authorization from VA OIG [Office of Healthcare 

Inspections] via '(b)(7)' memo to review the portions of the patient charts .... "

184 In September 

2012, the DEA apparently made a Privacy Act request for information from the Tomah VAMC, 

including patient records relating to Dr. Houlihan. 185 

181 VA OJG Office ofHealthcare Inspections, Alan Mallinger, Report of Contact with Diversion Investigator, DEA 

(Apr. 2, 20 12), OIG 5895. 

'"!d. 

183 E-m ails between Greg Porter, VA OJG, and Diversion Investigator, DEA (May 20 12), OIG I 0607, at OJG 

10608-09. 

184 ld. at OIG 10608. 185 E-mail from John Brooks, VA OIG, to George Wesley and Alan Mallinger, VA OJG (Sept. 19, 2012, 12:38 PM), 

at OJG 11507. 

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Figuro 3: Email from DEA Dinrsion lu,·ostigator to VA OIG Special Agent Porter186 

HI Gr.:!&, 

W~ recently o:Jtaincc a>~thorir.a:io, from \/A 01~ OH!vla ''(b){l)• memo to reYiev.t the portions oftrn! p:atien: chan;; of 

tht> following: 

YVe're: still wailing for t11e l~ronnation. !Jne o:tne tteadactle~ with WisconSin 1s tilE' fact that we don't have a 

pre~ription mon:toring progrJm,.like in Illinois, ttt•t .,..auld facifitate S~(ltting doc-~hoppink;.~ IPr~oc~e~ss···· 

Diversion lnvesticator 

Drug Enforcement Administration 

U.S. Departmtnt of J\.lstice 

fJUiwau<ee- Dls:rlct Of'ffr~ 

Pllone' (4141 

(@i: 

rn~: 

During a transc1~bed interview, Chaimla!l Johnson's staff asked Special Agent Pmter 

about the pnrpose of a "(b)(7)" memo. He explained it was "an official request to an agency for 

information that they would not normally release."187 Special Agent Pmter also continued that 

the DEA had an ongoing investigation at the facility in2012. He said: 

Q: So, Agent Porter, speaking about the DEA, from your viewpoint. 

and-and sharing information back and fotih with the DEA, was it 

,., E-mail from Diwrsion Im·estigator, DEA. to Greg Porter, VA OIG (May 21. 2012, I :49 PM). at OIG 10608. 187 Transcribed Interview with Greg Pot1er. in Washington. D.C., at 38 (Jan. 28. 2016) [hereinafter P011er 

Transcribed Interview]. 

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your view, in 2012, that the DEA had an investigation ongoing that 

included the Tomah VA? 

A: Yes. 188 

Although the DEA and OIG shared information about the Tomah V AMC, there is not a 

clear delineation of which agency was charged with investigating the potential diversion of 

controlled substances prescribed at the VA. Special Agent Porter described how the OIG's 

mission differed from the DEA's duties in regards to investigating drug diversion. 189 He 

explained further: 

A: As the [VA OIG] Office of Crimina! Investigations, there are limited 

circumstances where we can obviously take part in investigations, you 

know, assist DEA with, you know, parts of their investigations as 

requested, things like that. You know, unless it-! don't really know 

all of the limited situations, but basically we don't have statutory 

authority as a primary agency to investigate drug diversion, is the 

simplest way to put it. 

Q: Even if the drugs are alleged to be coming from a VA facility? 

A: Yeah, just because it comes from a VA facility doesn't give us primary 

authority, as I understand it, to solely investigate that. We would, you 

know, typically have to be working with DEA, who has the statutory 

authority to investigate those crimes. 

Q: What if the suspect is an employee-Does that change anything?-of 

the VA? 

A: Well, I think if it's happening on VA property and things like that, I 

think that gives us a bigger stake in the game, so to speak. But without 

having to go research it, I couldn't tell you for certain, you know, what 

the limited situations are and things like that. 190 

Special Agent Porter also said that he was unaware of whether any formal delineation of 

responsibility-such as in a memorandum of understanding-existed between the VA OIG and 

DEAl9I 

'" Id. at 151. 

'"I d. at 43-44. 190 !d. at 44. 191 !d. at 44-45. 

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On January 28, 2015, Chairman Johnson wrote to then-DEA Administrator Michele 

Leonhart requesting information and material about the DEA 's investigations into the Tomah 

VAMC. 192 DEA staff informed Chairman Johnson's staff that the DEA would not provide any 

information about its work. 193 On March 3, 2015, Chairman Johnson again wrote to Ms. 

Leonhart to reiterate his request for information about the DEA's investigation of the Tomah 

VAMC194 On March 17, 2015, the DEA responded, again declining to provide any details about 

its work at the facility. 195 

Interestingly, on March 23, 2015-shortly after the DEA informed Chairman Johnson of 

its refusal to provide information about its work at the Tomah VAMC-the Milwaukee office of 

the DEA sent a lengthy "(b)(7)" document request to the Tomah VAMC. 196 The letter requested 

30 separate categories of material, including specific information about Dr. Houlihan and 

Deborah Frasher. 197 When Chairman Johnson's staff attempted to ask Special Agent Porter 

about this (b )(7) letter, a VA OIG attorney interrupted and prevented him from answering. 198 

192 Letter from Hon. Ron Johnson, Chairman, S. Comm. on Homeland Sec. & Governmental Affairs, to Han. 

Michelle M. Leonhart, Administrator, Drug Enforcement Administration, at 2 (Jan. 28, 2015) [hereinafter l/28/20!5 

Letter from Chairman Johnson, HSGAC, to Administrator Leonhart, DEA]. 193 E-mails between Matt Strait, DEA, and Majority Staff, HSGAC (Feb. 5-9, 2015) (on file with Comm.). 194 Letter from Han. Ron Johnson, Chairman, S. Comm. on Homeland Sec. & Governmental Affairs, to Hon. 

Michelle M. Leonhart, Administrator, Drug Enforcement Administration, at 1 (Mar. 3, 2015) [hereinafter 3/3/2015 

Letter from Chairman Johnson, HSGAC, to Administrator Leonhart, DEA]. 195 Letter from Eric J. Akers, Deputy Chief, Office of Congressional & Public Affairs, DEA, to Hon. Ron Johnson, 

Chairman, S. Comm. on Homeland Sec. & Governmental Affairs, at I (Mar. 17, 2015) [hereinafter 3/17/2015 Letter 

from Deputy Chief Akers, DEA, to Chairman Johnson, HSGAC]. 196 Letter from Christopher J. Hackbarth, Acting Asst. Special Agent in Charge, Milwaukee District Office, DEA, to 

Leah Finch, Privacy Office, Tomah VAMC (Mar. 23, 2015). 

"'!d. 

198 Porter Transcribed Interview, at 151. 

Majority Staff Report 

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Figur• 4: DEA's (b)(7) L•tt•r to TomHb VAl\IC (March 23, 2015) 

Ms. Leah Finch 

P1ivacy Officer 

VA Mc<!ical Center 

500 l'cr.;t Vctemt11 Street 

Tomah, Wis~on~in 54660 

U. S. Depnrlmcnl of Justice 

Drug Enforcement Administration 

Milwaukee District Office 

4725 West Electric Avenue 

West Milw•ukee, Wisconsin 53219 

M1trch ?.:\, 2015 " 

The U.S. Drug Enft.m.-emcnt Auministmtion is I'CSfX>n>ible for invc~tigating violn!ion• of the 

C<>ntmlled Sub.<!Hnc•• Act. Our offtce ;, c<mducting a fe<leml investigation re<Jilnling alleged 

offenses of Title 21. United States Code, Scction80l et seq. l'ursunnt to this investigation anu 

purstUllll to Title 5, United Stale.< C(ldc, Scetion 552(a)(b)(7) of thu Privocy Act of 1974, ple11sc 

pwvido the follnwing: 

Despite examining potential dmg diversion in and around the Tomah V AMC for over six 

years, the DEA refuses to discuss what it has done. The DEA has interviewed at least one 

concemed phannacist from the facility, has collected patient chatis, and has now apparently 

requested substantially more infonnation. Even after collecting all this material, the DEA did 

not prevent the abuse of opioids at the Tomah V AM C. 

E. The VA did not investigate the 2009 death of Dr. Christopher 

Kirkpatrick, who attempted to blow the whistle on over-medication 

Dr. Christopher Kirkpatrick was a clinical psychologist at the Tomah VAMC from 

September 2008 to July 2009. Dr. Kirkpatrick raised concems within the facility about 

prescription practices. He faced discipline for blowing the whistle and was eventually fired from 

his position. On the evening of his tennination of employment with the Tomah V Al\1C. Dr. 

Kirl.1Jalrick committed suicide. The VA never investigated his death. 

In April2009, Dr. KirJ...11at:rick ale1ied representatives from the local Tomah VAMC 

employee's tmion about trouble he was having with his innuediate supeiTisor. He wrote of an 

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accusation levied against him that he inappropriately discussed medications with a colleague 

with whom he shared patients. 199 He wrote: 

I have had words with [the colleague] inquiring about medications and possible 

side effect/adverse reactions they were experiencing but these conversations 

happened months ago. These situations put me into an ethical dilemma .... 

Based on what others have told me, I have every reason to be very afraid of Dr. 

Houlihan. I have sacrificed a lot to move up here and do the kind of work I excel 

at and help people in. I need help. 200 

Days later, Dr. Kirkpatrick received a written counseling from his immediate supervisor, 

advising him that he "should not be 'educating' patients about what medications they are on."201 

Dr. Kirkpatrick's supervisor, Dr. Gary Loethen testified to a VA Administrative Investigation 

Board (AlB) in 2015 that he felt coerced into issuing Dr. Kirkpatrick the written counseling. He 

testified: 

Q: I was going to ask you whether you felt Dr. Kirkpatrick's actions 

warranted a reprimand or whether you felt you were simply carrying 

out instructions? 

A: I felt I was carrying out instructions. I testified previously that I was 

quite-! don't know what the right word is-concerned, afraid-of 

Dr. Houlihan and what he would do if I did not comply with whatever 

he wanted me to do regarding the job. So I didn't feel I had any 

choice other than to follow those, those orders 202 

In May 2009, Dr. Kirkpatrick wrote to his immediate supervisor that he and other 

colleagues had "notic[ ed] changes in demeanor in our patients. I do not presume to prescribe 

medications but think it is important there be a dialogue between providers so as to best serve 

our patients."203 

On July 14, 2009, Dr. Kirkpatrick was called into the human resources office at the 

Tomah VAMC, along with his union representative. The union official, Linda Ellinghuysen, 

described the meeting as "gruesome," writing that "management would not listen to any rationale 

199 E-mail from Chris Kirkpatrick, Tomah V AMC, to Dianne Streeter and Linda Ellinghuysen (Apr. 23, 2009), in 

JUNEA\J COUJ>iTY SHERIFF'S DEPARTMENT, CHRIS KIRKPATRICK DEATH INVEST!GAT!OJ>i REPORT 40, 43 (2009). 200 ld. 201 Memorandum from Gary Loethen, M.D., U.S. Dcp't of Veterans Affairs, to Chris Kirkpatrick, M.D., U.S. Dep't 

of Veterans Affairs (Apr. 30, 2009), in JtlNEAU COUNTY SHERIFF'S DEPARTMENT, CHRIS KIRKPATRICK DEATH 

INVESTIGATION REPORT, at 24 (2009). 202 Admin. Board of Investigation Transcribed Interview with Gary Loethen (Apr. 15, 20 I 5), at 20-21 [hereinafter 

AlB Transcribed Interview with Gary Loethen]. 203 Letter from Chris Kirkpatrick, Tomah VAMC, to Gary Loethen, U.S. Dep't of Veterans Affairs (May I 3, 2009), 

in JUNEAU COUNTY SHERIFF'S DEPARTMENT, CHRIS KIRKPATRICK DEATH INVESTIGATION REPORT, at 23 (2009). 

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[sic] argument."204 Dr. Kirkpatrick, who was employed on a temporary status, was fired for 

vague "performance issues" the same day. 205 That evening, Dr. Kirkpatrick was found dead 

from a self-inflicted gunshot wound. 

Dr. Kirkpatrick's supervisor, Dr. Loethen, was present at the meeting during which Dr. 

Kirkpatrick was terminated from the Tomah VAMC. He testified to the VA's AlB in 2015 that 

he did not agree with the decision to fire Dr. Kirkpatrick: 

Q: Did you agree with the decision to remove Dr. Kirkpatrick? 

A: I did not. 

Q: Did you ever express your belief that he should not be removed? 

A: Yes I did. 

Q: Who did you speak with about that? 

A: [The Director of the Residential Post Traumatic Stress Disorder 

Treatment Program] 

Q: What did you tell him, to the best of your recollection? 

A: I told him that I didn't think that, you know, what was going on wasn't 

anything that couldn't be resolved. And if there was this ongoing 

conflict between Dr. Kirkpatrick and [the colleague Dr. Kirkpatrick 

had "words" with in April2009] and [the colleague] had the backing 

of the Chief of Staff, which was a very powerful backing, that 

probably the, the easiest thing to do, if we were going to try and 

resolve the situation, would be to transfer Dr. Kirkpatrick to the 

Mental Health Clinic downstairs and have him work as an outpatient 

therapist in there where he could still treat PTSD patients, but he 

would not have any ongoing direct contact with [the colleaguc]?06 

Dr. Kirkpatrick's brother, Sean Kirkpatrick, testified during a Committee hearing in 

September 2015 about his brother. Mr. Kirkpatrick testified: 

While at the Tomah VA Medical Center, Chris told us that he was concerned 

about the overmedication of many of his veteran patients and raised questions204 Memorandum by Linda Ellinghuysen, Executive V.P., AFGE Locall882, at 1 (2009), in JUNEAU COUNTY 

SHERIFF'S DEPARTMENT, CHRIS KIRKPATRICK DEATH INVESTIGATION REPORT 34 (2009). 205 Memo from VA to Kirkpatrick July !4, 2009. 2116 AlB Transcribed Interview with Gary Loethen, at 22-23. 

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Senator Ron Johnson, Chairman 

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therapy sessions that he was facilitating were not effective, because veterans were 

not alert, lethargic/too impaired and drugged due to the overmedication side 

effects so he could not help them. 207 

Mr. Kirkpatrick continued: "The Tomah VA Medical Center did not disclose the circumstances 

of Chris' termination .... We were told that he had 'missed too many days."'208 

On April20, 2015, Chairman Johnson wrote to VA Secretary McDonald asking about the 

circumstances of Dr. Kirkpatrick's termination and death209 On May 29, 2015, VA Deputy 

Secretary Sloan Gibson responded to Chairman Johnson's letter.210 Deputy Secretary Gibson 

wrote that the "VA did not conduct an investigation into Dr. Kirkpatrick's termination and 

suicide" because "during the July 14, 2009, meeting where Dr. Kirkpatrick was notified that his 

temporary appointment would be terminated effective July 28, 2009, he indicated his intention to 

resign prior to the termination effective date."211 

207 Improving VA Accountability: E,Xamining First-Hand Accounts of Department of Veterans A_ffairs 

Whistleblowers. Hearing before the S. Comm. on Homeland Security and Governmental Affairs, !14th Con g. (201 5) 

(written testimony of Sean Kirkpatrick). 2os Id. 209 Letter from Han. Ron Johnson, Chairman, S. Comm. on Homeland Sec. & Governmental Affairs, to Han. Robert 

McDonald, Secretary, Dep't of Veterans Affairs (Apr. 20, 20 15) [hereina!ler 4/20/2015 Letter from Chainnan 

Johnson, HSGAC, to Secretary McDonald, VA]. 210 Letter from Hon. Sloan Gibson, Deputy Secretary, Dep't of Veterans Affairs, to Hon. Ron Johnson, Chainnan, S. 

Comm. on Homeland Sec. & Governmental Affairs, at 1 (May 29, 2015) [hereinafter 5/29/2015 Letter from Deputy 

Secretary Gibson, VA, to Chainnan Johnson, HSGAC]. 211 Jd. 

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Senator Ron Johnson, Chairman 

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Sloan Gib~on to Chail'mao Johnson 

THE DEPUTY $ECRE1AI<Y OF VETERANS A HAIRS 

WA'3HINGTON 

The Honorable Ron Johnson 

Chairman 

Committee on Homeland Security 

and Governmental Affairs 

United States Senate 

Washtngton. DC 20510 

Dear Mr Chairman 

May 29.2015 

Thank you for your April 20, 2015 letter requesting informatron about 

Dr. Chnstophcr Kirkpatrick's termrnation at the Tomah Dopartmcnt of Veterans Affairs 

(VAl Medrcal Center (VAMC) and tus subsequent death I am respondr119 on behalf of 

~he Oepartrnent 

Wrth respect to VA's protocols fa: invesl!gatrng the suicrdes of employees or 

recently-tenmi:lated employees 1! a su1cide woro to occur on VA property, VA Police 

would secure the scene and begin an inilial investigation in anticipation that the Office of 

the Inspector General (OIG) or the Federal Bureau of lnvest.gatJon would assume 

control o! the 1nvestigatJon The VA Police Service does not have the jurisdiction to 

investigate an ernployee or a recentfy-terrmnatad employee's SUiCide that occurred off 

VA property 

VA dod not conduct an invest1gatron mto Or Kirkpatrick's terrnma!Jon and swclde 

Prior to the ternllnahon of his temporary appointment. Tomah VAMC management 

revrewed Dr Krri<patnck's periormance ~nd conduct Tomah VAMC mar>agemen! did 

not investigate the suicide because! during the July 14, 2009. meeting where 

Dr. Krrkpatflck was notified that hrs tem~orary appointment would be terminated 

effectJve July 28. 2009, he rndJcated his intent1on to res1gn pnor to the termination 

effechve dale. Tomah VAMC management did not receive a resignation letter from 

Dr. K!fkpatrick pnor to his death 

If the VA had investigated the underlying causes of Dr. Kirkpatrick's termination and 

death, it is possible that VA leadership could have leamed additimwl details about the allegations 

of ovemtedication in 2009. The VA's inaction, even iu the face of whistleblower complaints of 

opioid abuse, allowed the culture and conduct of the facility to continue tutaddressed . 

.. . "'- .··~~ 

' i 

\ 

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F. The former Tomah VAMC Police Chief knew the facility was a "big pill 

box" when he took the job in 2009, but never investigated the 

allegations 

Roberto Obong served as Tomah V AMC police chief from September 2009 to September 

2013. 212 He is a combat veteran of the Marine Corps and served in the Los Angeles Police 

Department and in various law enforcement positions throughout the V A.m When he took the 

job as the Tomah V AMC police chief, he said he knew that the law-enforcement community in 

western Wisconsin referred to the Tomah VAMC as a "big pill box."214 Ultimately, despite 

knowing the facility's reputation, Chief Obong did little to address the issues or change the 

facility's culture. 

Chairman Johnson's staff interviewed ChiefObong on December I, 2015. During the 

interview, staff inquired about Chief Obong's familiarity with the Tomah V AMC when he 

applied for the police chief position. Chief Obong replied that he researched the facility and 

spoke to members of the community to Jearn about the facility's reputation in the community and 

to identify areas for improvement. Chief Obong said: "I spoke to the Sheriff. I spoke to the 

Chief of Police. I spoke to the firefighters, you name it. I researched it. Their reputation is 

really not quite well."215 He continued: 

Q: Can you explain what you found out, what was the reputation? 

A: Well what I found out, sir, is that not only they are not providing the 

type of service that they're supposed to provide, meaning poor 

customer service--or customer servant, they're supposed to be veteran 

centric or customer centric and it wasn't. That was a Jot of the main 

complaints. Also, the facility itself is well known in the law 

enforcement community as a big pillbox. 216 

ChiefObong described how he came to this conclusion. He explained that he "Googled 

everything" about the Tomah VAMC and examined news articles about the facility's propensity 

to prescribe large quantities ofnarcotics 217 

ChiefObong also explained that he was aware before his hiring that the Tomah VAMC 

had the nickname "Candy Land" and that a prescriber was described as the "Candy Man."218 

212 Transcribed Interview with Roberto Miguel Vida Obong, in West Palm Beach, Fla., at 7 (Dec. I, 2015) 

[hereinafter Obong Transcribed Interview]. 213 !d. at 7. 214 Jd. at 13. 215 Id. at 12 (emphasis added). 216 Jd. at 13 (emphasis added). 2!7 ld. 

218 Jd. at 74. 

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When asked about his opinion of those monikers, Chief Obong replied: "It's not for me to think 

anything. What I think as a Chief of Police from a law-enforcement perspective is, if it's true, 

I'm pretty sure somebody is already investigating it or had investigated it."219 In particular, 

Chief Obong referred to the VA OIG health care inspection220 

Chief Obong also recalled the discussions he had with local law-enforcement personnel 

before he was hired at the Tomah VAMC. 221 He said that local law-enforcement personnel 

informed him that "the VA is one of the main issues they have because a lot of our veterans are 

gaining so much pills. "222 Chief Obong described accounts of local law-enforcement personnel 

finding large quantities of medications in the Tomah community, in veteran homes, and in the 

belongings of homeless veterans.223 He added that the prevalence of prescription drugs in the 

Tomah area was "out there in the community, and it's out of control" and that law enforcement 

"see it every day."224 ChiefObong elaborated: 

The local law-enforcement agencies are out there complaining. The Coulee 

Regional Law Enforcement Executive Group [asked], "Chief, what can you do 

about this? They are giving these patients tons and tons of prescriptions, and 

they're just sitting in their cabinets not being used. They need to get rid of that at 

some point." It is over prescription. Either that or they just pile it in the cabinets 

they they're not using it.225 

Chairman Johnson's staff inquired whether and how ChiefObong worked with local lawenforcement entities to address the Tomah VAMC's reputation after he became the Tomah 

V AMC Chief of Police. He explained that he reached out to the Monroe County Drug Task 

Force and the Coulee Regional Law Enforcement Executive Group to determine how the VA 

was affecting the community, to start joint investigations with police departments, and to 

implement community policing. 226 Through his work and coordination with local lawenforcement, Chief Obong orchestrated the first buy-bust of narcotics on the Tomah VAMC 

campus in the history of the Tomah V AMC Police Department. 227 Because the Tomah VAMC's 

Police Department's jurisdiction is limited to only the Tomah VAMC campus, ChiefObong 

explained that it was a "miracle" that he was able to get the VA's approval to conduct a 

successful buy-bust operation. 228 Chief Obong recalled conducting two or three joint 

investigations in total during his tenure as the Tomah VAMC Chief ofPolicc229 

019 I d. at 75. 220 ld 

221 Id. at 12-13. 222 ld. at 14. 

ld. at 15. 224 !d. at 76. 

225 ld. 

226 Jd. at 16--17. 227 Jd. at 18-19. 

mid 

m ld at43. 

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During his transcribed interview, Chief Obong explained that Tomah V AMC leadership 

informed him during his selection process that the Tomah VAMC Police Department lacked 

"persistent leadership" and needed a chief to "integrate the police service to other services" at the 

facility. 230 Chief Obong stated that although he was aware of the Tomah VAMC's perception in 

the Tomah community that it contributed to the drug trade, he did not raise those concerns to the 

facility's interview panel.231 

Chairman Johnson's staff asked whether Chief Obong or anyone within the Tomah 

VAMC Police Department investigated Dr. Houlihan in light of Chief Obong's knowledge of the 

monikers "Candy Man" and "Candy Land" and the facility's reputation in the community as the 

"big pill box. "

232 Chief Obong stated that, despite the well-known use of these monikers, he was 

not aware of any VA investiration into Dr. Houlihan for potential criminal activity in connection 

to his prescription practices. 33 Chief Obong explained that the inquiry into the Candy Man and 

Candy Land was instead properly "an OIG case."234 He added that "if they [the VA OIG] ask 

me to dig, then I'll dig, but they didn't. That's not up to me to say."235 When Chairman 

Johnson's staff pointed out that the VA Police and VA OIG are separate entities with separate 

mission statements, Chief Obong replied: 

A: The way it works is simply this; as the Chief of Police, as the top cop, 

if there's any indication that a crime is happening and there is tangible 

evidence, not hearsay but an actual witness, primary witness that says 

that this is happening, we will dig into it, and then we will refer it to 

OIG. That's how we do it. 

Q: So during your tenure as Chief of Police, you or the VA, Tomah VA 

Police did not investigate Dr. Houlihan at all? 

A: Not me personally, 'sir, not on a criminal conviction. 

Q: Did any of your officers? 

A: I'm not quite sure on that one, sir. I have to refer back to old police 

reports on file, if there is such an investigation236 

Chairman Johnson' staff inquired further into any potential Tomah VAMC Police 

Department investigations into Dr. Houlihan under ChiefObong's leadership. ChiefObong 

230 Id at 21. 231 Id. at 20. 232 I d. at 94. 

m ld. at 95. 

234 !d. 

235 Id. 

236 ld. 

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again pointed out that the VA OIG had investigated Dr. Houlihan "in multiple locations" and that 

he "defer[ ed] that information to them because they have the upper hand on that."237 He added 

that "in my case as far as my tenure as Chief of Police there, you know, we did not receive any 

complaint pertaining to [Dr. Houlihan J overprescribing or committing any type of crime that 

would merit some type of Uniform Offense Report or a[ n J investigative report. "

238 

Despite not investigating Dr. Houlihan in light of the facility's reputation, Chief Obong 

defended his time as Police Chief, stating: "During my tenure at the VA out there, we were very 

proactive, not only, not only from a law-enforcement prospective, but criminal investigation. 

We did follow through in all of those cases. We see to it that all cases are closed."239 

It is difficult to agree completely with Chief Obong's assertion that the Tomah VAMC 

Police Department was "proactive" under his leadership. On one hand Chief Obong organized 

and executed a buy-bust on the Tomah VAMC grounds and effectively coordinated with local 

law enforcement on multiple joint investigations. On the other hand, under his leadership, the 

top Tomah VAMC officials did little internally to address or investigate whether providers 

contributed to the Tomah VAMC's reputation as a "big pill box" or to determine whether there 

was any truth to the monikers "Candy Man" and "Candy Land." Chief Obong' s belief that the 

VA OIG was investigating the possibility that providers were overprescribing opioids at the 

Tomah VAMC did not abdicate his responsibilities as the chief law-enforcement officer at the 

facility to investigate whether Tomah VAMC employees were engaging in criminal activity. 

Chief Obong's statements revealed an inherent conflict of interest with the chain of 

command of the Tomah VAMC Police Department and how issues were reported to the VA 

OIG. During his tenure as Chief of Police, ChiefObong reported to the Tomah VAMC 

Associate Director.24° Chief Obong said that he had to notify Tomah VAMC leadership 

whenever he reported an incident to the VA OIG. ChiefObong explained: "[B]eing a good 

leader, you have to be a good follower. You have to know your chain of command. My chain of 

command is the associate director. If she does not know what I'm doing, I will be accountable. 

That is her expectation."241 This reporting structure created the possibility of a conflict of 

interest for investigations concerning senior Tomah V AMC leaders. 

The Tomah VAMC is led by a "Quadrad" of four senior leaders: the facility Director, 

Associate Director, Chief of Staff, and Chief Nurse242 Chief Obong interviewed with the 

"Quadrad" when he was hired at the Tomah V AMC. 243 Because Dr. Houlihan served on the 

Quadrad as the chief of staff, Dr. Houlihan played a role in hiring Chief Obong as the Tomah 

237 Id at 97. 

"'Id 

239 Id at 99. 240 Id at 109. 241 Id at 112-13. 242 Pica Transcribed Interview, at 20, 243 Obong Transcribed Interview, at 8-9. 

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V AMC Chief of Police. This hiring structure, combined with the practice of notifying senior 

facility leadership of VA OIG referral, potentially inhibited robust internal investigations into 

misconduct by Tomah V AMC senior leadership. Although Chief Obong said that he was never 

dissuaded from reporting incidents to the VA OIG, there remains an inherent conflict of interest 

and significant deterrence factor. 

Chief Obong chose not to investigate potential opioid abuse at the Tomah V AMC despite 

knowing the facility's reputation as a "big pill box" and "Candy Land." He reported, via the 

Quadrad, to the individual called "Candy Man." ChiefObong explained that allegations 

concerning the facility-including potential criminal charges-were "an OIG case." He left the 

Tomah VAMC in September 2013, during the VA OIG's inspection of the Tomah V AMC and 

Dr. Houlihan.244 Whatever his reasons, Chief Obong's reluctance to examine the serious 

allegations surrounding the Tomah VAMC represents another missed opportunity to address the 

opioid overprescription. 

G. VA headquarters noticed higher-than-average prescription rates at the 

Tomah VAMC in 2013, and only "encouraged" the facility to "review" its 

practices 

The VA Central Office (VACO) is the Department's headquarters in Washington, D.C. 

According to information received by Chairman Johnson, V ACO identified prescription 

irregularities and excessive wait times for mental health patients at the Tomah VAMC in 2013. 

Chairman Johnson's staff received documents from a whistleblower that included a report of a 

VACO site visit at the Tomah VAMC from August 2013. 245 The stated purpose of the site visit 

was to "review continued compliance to VHA [Veterans Health Administration] standards for 

mental health services at all facilities, identifying both areas for growth and areas of exemplary 

service."246 However, it does not appear that the VA took substantive action to address these 

irregularities at the time as questionable prescription practices at the Tomah VAMC continued 

after this site visit. 

The report of VACO's site visit noted that "(t]he provision ofbenzodiazepines for older 

Veterans and for Veterans diagnosed with (post-traumatic stress disorder (PTSD)] is much 

higher when compared to the national average."247 According to the VACO report, 27.4 percent 

of Tomah VAMC veterans with dementia were prescribed benzodiazepine, as compared to the 

national average of 16.7 percent.248 In addition, V ACO found that the percentage of older 

veterans receiving an antipsychotic medication was higher than the national average-31.8 

244 !d. at 7. 245 VACO Consultative Site Visit Report, Tomah VAMC, August 12-13,2013, at I. 246 V ACO Consultative Site Visit Report, Tomah V AMC, August 12-13 at ]. 247 VACO Consultative Site Visit Report, Tomah VAMC, August 12-13 at 2. 248 VACO Consultative Site Visit Report, Tomah VAMC, August 12-13 at 3. 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

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percent at the Tomah VAMC compared to the national average of 27.6 percent.249 The report 

also noted that Tomah VAMC staff"reported challenges with community placements of older 

Veterans" who have both a serious mental illness and a dementia diagnoses250 On the issue of 

wait times, VACO found that "only 53.19% of new Veteran patients are seen for a mental health 

appointment within 14 days compared to the national average of 67.90%."251 

VA CO's site review also identified issues with how the Tomah V AMC treated PTSD. 

Tomah VAMC staff reported to the VACO consultants that veterans waited up to eight weeks to 

access the PTSD residential program.252 The VACO review found that the Tomah VAMC's 

"score on the proportion of patients with PTSD receiving a benzodiazepine is much higher than 

the national average (facility score 45.3%; compared to the national average of27.7%)."253 

VACO's review found that 17.6 percent of Tomah VAMC veterans with PTSD received antipsychotic medications, higher than the 15.8 percent of veterans with PTSD nationally who 

receive anti-psychotic medications.254 

The V ACO site consultation also solicited concerns from veterans who received care at 

the Tomah VAMC. Veterans told the VACO interviewers that the facility did not always 

consider patient views on their PTSD medications. According to the report: 

Veterans enrolled in the PTSD [Residential Rehabilitation Treatment Program 

(RRTP)) program voiced concerns that the medications they were on prior to 

entering the program were not reviewed and revised, although many felt their 

medications were not helping them or were inappropriate for their care. While 

leadership reported that medication reconciliation takes place, that process does 

not appear to address the patient's subjective experiences about feeling 

information about the medications were not communicated with them directly. 

We recommend a process for enhancing communication with Veterans about 

psychiatric medications as they enter the RRTP to ensure Veterans are satisfied 

with and benefiting from the medications they are taking upon intake and that 

there is adherence to the provision of evidence-based psychopharmacology. The 

facility also is encouraged to review their current safe medication management 

policies, procedures, and current practices in the [mental health] RRTPs to ensure 

that they are consistent with policy requirements?55 

The site visit report made a number of recommendations to improve care at the Tomah 

VAMC. Notably, VACO site consultants recommended that the Tomah V AMC "develop an 

249 V ACO Consultative Site Visit Report, Tomah V AMC, August 12-13 at 3. 250 VACO Consultative Site Visit Report, Tomah VAMC, August 12-13 at 3. 251 V ACO Consultative Site Visit Report, Tomah V AMC, August 12-13 at 3. 252 V ACO Consultative Site Visit Report, Tomah V AMC, August 12-13 at 9. 253 V ACO Consultative Site Visit Report, Tomah VAMC, August 12-13 at I 0. 254 VACO Consultative Site Visit Report, Tomah VAMC, August 12-13 at 10. 255 VACO Consultative Site Visit Report, Tomah VAMC, August 12-13 at 10. 

Majority Staff Report 

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action plan" to address staffing shortages in an effort to reduce wait times for access to mental 

health professionals 256 VACO also "encouraged" the Tomah V AMC to "review their safe 

[medication] management policies, procedures, and practices to ensure that medication needs of 

Veterans are being addressed in a manner consistent with national policy."257 It is unclear what, 

if any, remedial measures the Tomah VAMC put in place to address these issues. 

The VA Central Office noted higher than average prescription rates at the Tomah VAMC 

in 2013 and merely "encouraged" the facility to "review" whether its medication practices were 

in accord with national policy. The VA could have, and should have, done more to recognize the 

problems at the Tomah VAMC in 2013 and understand the root causes. VACO did not, and this 

failure represents one more missed opportunity to prevent the tragedies of the Tomah VAMC. 

H. jason Simcakoski sought help from local and federal law enforcement 

multiple times in November 2013, with no results 

Jason Simcakoski was a Marine Corps veteran who sought care at the Tomah VAMC for 

PTSD and other mental health ailments. On August 30, 2014, Mr. Simcakoski died in the 

Tomah VAMC's mental health ward. The Wisconsin Medical Examiner determined that Mr. 

Simcakoski died of"mixed drug toxicity."258 Autopsy results showed that when he died, Mr. 

Simcakoski had over a dozen different drugs in his system.259 Before his death, while the VA 

OIG and DEA were apparently conducting investigations relating to the Tomah VAMC, Mr. 

Simcakoski attempted to contact both local and federal law enforcement to report drug diversion 

at the Tomah VAMC. 

At the Committee's March 20I5 field hearing in Tomah, Wisconsin, Heather Simcakoski, 

Mr. Simcakoski's widow, testified that he reached out to multiple law-enforcement entities about 

drug diversion at the Tomah VAMC in 2013.260 Mrs. Simcakoski testified: 

There are reports that were made to Dr. Houlihan, the Tomah VA, the Tomah 

City Police Department as well as the FBI regarding patients selling their 

prescriptions back in 2013 making so much money that they had saved enough 

to put a down payment on a house. Thankfully I have voicemails and text 

messages between Jason and the officers- otherwise I am not convinced anyone 

would be listening to this point today. I would like to understand who is 

256 VACO Consultative Site Visit Report, Tomah VAMC, August 12-13 at 12;. 257 VACO Consultative Site Visit Report, Tomah VAMC, August 12-13 at 12-13. 258 Glantz, Opiates Handed out Like Candy, REVEAL NEWS (Jan. 8, 2015). 259 Jd. 

260 Tomah VAMC: Examining Quality, Access, and Culture of Overreliance on High-Risk Medications, Joint Field 

Hearing Before S. Comm. on Homeland Sec. & Governmental Affairs & H. Comm. on Veterans Affairs, !14th Cong. 

(20 15) (statement of Heather Simcakoski). 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

45 
125 

responsible for these reports, where they are, and why no one did anything with 

the reports?261 

After the field hearing, Chainnan Johnson's stafT obtained Mr. Simcakoski's cell phones 

and with the consent of Mrs. Simcakoski, the United States Capitol Police successfully retrieved 

the data off of the phone 262 The majority staff's review of the cell phone records showed that in 

November 20 13-less than a year before his death-Jason Simcakoski contacted multiple lawenforcement entities in westem Wisconsin. In particular, Jason Simcakoski contacted 

representatives from the Federal Bureau oflnvestigation (FBI).263 the city of Tomah Police 

Department (Tomah PD). the Tomah V AMC Police Deprutment (Tomah V AMC PD), and the 

Pmtage County Sheriff's Office264 l11e following chart illustrates Jason Simcakoski's contact 

with law enforcement in the fall of2013. 

Figurf' 6: Jason Simrakoski's. contacts ,-,.·itb law t'nforce-mt'nt· 

Law 

I·· Iuc;o~g vr .. ··• Time of 1)ul<atjou of Date of Contact Enforeement Contact .. EntitY 91Jcgoi~tg ; fOl'c>l~ i···· Phone.can .. · 

October 30, Tomah VAMC 

Police Chief, Incoming (Missed) 8:08PM 0:00 2013 Peny H utTman 

October 30, Tomah VAMC 

2013 Police Chief, Outgoing 8:13PM 6:29 

Peny Huffinru1 

October 31, Tomah VAMC 

2013 Police Chief, Outgoing 10:31 PM 0:24 

Peny Huffman 

October 31, Tomah VAJv1C 

2013 Police Chief, Outgoing 10:32 PM 1:07 

Perry Huffman 

161Jd. 

262 See Letter from Hon. Ron Johnson, Chainnan, S. Conun. on Homeland Sec. & Govenunental Affairs. to Kim 

Dine. C'hief of Police. U.S. Capitol Police (July 13. 2015). At the request of the Simcakoski family, the majority 

staff provided the infonnation obtained from the cell phone5. to the Simcakoski family. the minority staff. and the 

staff of Senator Baldwin. 63 All telephone corre~pondence between Mr. Simcakoski and tl1e FBI was conducted through the FBI satellite 

office in La Cros~e. Wisconsin. 264 See infra Figure 6. 265 The data contained in this chart was obtained from forensic imaging of Jason Simcakoski's cell phones. 266 All times referenced are Coordinated UuiYersal Tin~e (UTC). Wisconsin is located in the Central Time Zone and 

is either fiye or six hours behind UTC. depending on the time of the year. In 2013. daylight savings time ended on 

Sunday. November 3. Prior to November 3, Wisconsin was five hours behind UTC: after November 3, Wisconsin 

was six hours behind UTC. See Time Changes in Chicago Ol·er the Years. TIM:EANDDATE.COM. 

http://v.·ww.timeanddate.com/time/zone/usalchicago . 

. Majority Staff Report 

Committee on Homeland Security and Governmentl1l Affairs 

Senator Ron Johnson, Ch:~irman 

46 
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Date of C~ita~t 

October 31. 

2013 

November I, 

2013 

November I. 

2013 

November 2, 

2013 

November 2, 

2013 

November 2, 

2013 

November 2, 

2013 

November 2. 

2013 

November 2. 

2013 

November 2, 

2013 

November 3, 

2013 

November 3. 

2013 

November4. 

2013 

November 4. 

2013 

November 6. 

2013 

November 6. 

2013 

November 6. 

2013 

Lll:W · ...... · .·· 1·····.· Incobiing •r 

.. · Time of 

I' Enforceme .. t .·. I Contact Duration of 

.· l!:n1ity ···. Qutgoing {VTC)z&~ · . PhoneCan 

Tomah PD Outgoing 10:41 PM 4:48 

TomahVAMC Incoming !2:13AM 7:34 Police 

Tomah PD Outgoing 9:16PM 3:50 

TomabVAMC 

Police Chief, Incoming (Missed) 3:18PM 0:00 

Perry Huffman 

Tomah VAMC 

Police Chief. Outgoing 3:29PM 20:09 

PetTy Huffman 

Portage County 

Sheriff's Outgoing 3:59PM 1:43 

Department 

Pmtage County I 

Sheriffs Outgoing 4:27PM 0:00 

Deprutment 

TomahVAMC 

Police Chief. Outgoing 4:28PM 0:38 

Peny Huffman 

Tomah PD Outgoing 4:29PM 20:14 

Tomah VAMC 

Police Chie[ Incoming 5:53PM 5:29 

Petry Huffman 

Tomah PD Outgoing 4:10PM 2:17 

FBI Outgoing 10:36 PM 1:11 

FBI Outgoing 8:29PM 12:25 

FBI Outgoing 9:25 Pl'vl 2:05 

FBI Outgoing 2:45PM 6:48 

Tomah PD Outgoing i 3:07PM 1:41 

Tomah VAMC Outgoing 3:10PM 3:41 Police 

~Iajority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

47 
127 

' ·.•'.:' •. .. .. . J;;a\V ·• ' ~~~~~o~ •..•...• Tim•:of· 1

> 'Durl.fioi~~r • ))a~~ ~fCd~~~t ·•·.· ~o~~~ui > :;::', •: ••• Contlte't• • . : ' ·• .· ... ~ ' 1 Enti.Y \'t ;:,:cputgoillg ..•. ·. i(triqlilr ~hone(;illl 

November6, TomahVAMC Outgoing 3:14PM 0:03 

2013 Police 

November 6, Tomah VAMC Outgoing 4:23PM 0:20 

2013 Police 

November 7, Tomah VAMC Outgoing 3:04PM 11:30 2013 Police 

November 8, Tomah VAMC Outgoing 6:12PM 1:13 

2013 Police 

November 8, FBI Outgoing 6:43PM 8:24 2013 

November 8, Tomah VAMC Outgoing 9:21PM 2:13 2013 Police 

November 8, Tomah VAMC 

2013 Police Chiei~ Incoming 11:13 PM 12:30 

Peny Huffman 

NovemberS, Tomah VAMC 

2013 Police Chief, Outgoing 11:34 PM 0:52 

Perry Huffman 

November 8, Tomah VAMC 

Police Chief, Outgoing 11:35 PM 1:23 2013 Peny Huffman 

November II, Tomah V A.\1C Outgoing 2:18PM 0:32 2013 Police 

November I L TomahVAMC 

2013 Police Chief, Outgoing 2:18PM 1:34 

Pen-y Huffinan 

1. Despite evidence showing multiple contacts and a voicemail, the FBI denied 

communicating with Jason Simcakoski in 2013 

Mr. Simcakoski's cell phones contained a voicemail from a federal law-enforcement 

officer. On November 4, 2013, at approximately 4:3 7 Pl'v1 UTC, Jason Simcakoski received a 

voicemail from an individual claiming to be an FBI agent who said he was retuming Mr. 

Simcakoski's call to the FBI. The voicemail stated: 

:\Iajority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

48 
128 

Jason, this is Andy Chapman267 from the FBI retuming your call. My phone 

number is (608) 782-6030. l11ank you268 

TI1e phone number that the caller left is the main phone number for the FBI satellite 

office in La Crosse, Wisconsin-the office closest to Tomah with jurisdiction over Monroe 

Cmmty. Tile phone mm1ber also matches the number that Mr. Simcakoski dialed on five 

occasions in early November 2013 269 According to the call logs from Mr. Simcakoski's phones, 

he called the FBI satellite office in La Crosse less than fom hours after he received this 

voicemail.270 TI1is phone call lasted more than twelve minutes. 271 Less than an hom later, Mr. 

Simcakoski again called the phone number of the FBI's La Crosse satellite office and had a 

conversation that lasted more than hvo minutes 272 His subsequent calls to the phone mm1ber of 

the FBI's La Crosse satellite office were on November 6 and November 8, and lasted more than 

six and eight minutes, respectively .

273 

Other records obtained from Mr. Simcakoski 's cell phone suggest he comnnmicated with 

the FBI. On November 4, 2013, at 9:55 PM UTC, just a half hour a Her his final call that night 

with the FBI, Mr. Simcakoski sent a text to his wife: "I talked to the FBI today."274 

Subsequently, in a series ofFacebook messages with another individual on November 6, 2013, 

Mr. Simcakoski wrote: "I'm not working with tomah pd or va pd I'm a lot higher than them .. 

FBI ... . "275 

- 11/.J,)\lli 

'"Due to the quality of the audio. the majority staff is tmable to verify with absolute cet1ainty the name the FBI 

official on tl1e voice mail. 268 Voicemail from FBI to Jason Simcakoski (Nov.4, 2013. 4:37PM UTC) (on file with Conun.). 269 See supra Figure 6. 

:no See supra Figure 6. 

:!?I See supra Figure 6. 

:m See supra Figure 6. 

HJ See supra Figure 6 .. 

'" SMS Text Message from Jason Simcakoski to Heather Simcakoski (Nov. 4, 2013. 9:55:20 PM UTC). 275 Facebook Messages from Jason Simcakoski (Nov. 6, 2013,3:57:46 AM UTC: 3:58:46 AM UTC). 

::\lajority Staff Report 

Committee on Homeland Security and Gonrnmental Affairs 

Senator Ron Johnson, Chairman 

49 
129 

Figure 8: Fact>book mE.>ssages St"Dt by Jason Simcakoski 

lltll\!!:>lt;m!).J BoUy 

: tlml" .. ti'l.n1p' nndy· 

:J ) "· _d 

.•1) 

, lhtu••.f..ittiJL R1nf)' 

Jl 

fliH~':tl.o.'\Ul~l HtJdy. 

tl l 'l -.lt--dl 

l"" ~ j (1 

J.tn•o>..,t;<tn;p Ho!l'f 

tl t,; 

, 

~· 

The majority staff does not know the substance of these phone calls placed to the phone 

number of the FBI's satellite otiice in La Crosse. In an effort to gain better insight, on 

September 14,2015, Chainnan Johnson sent a letter to FBI Director James Comey inquiring 

about the contents of Jason Simcakoski's communications with the FBI and requesting records 

of all communications between Jason Simcakoski and the FBI276 On October 2, 2015, 

Chairman Johnson received a response from Patrick Fallon, Jr., the Acting Deputy Assistant 

Director for the FBI's Criminal Investigative Division, stating that the FBI had no record of 

Jason Simcakoski contacting the FBI. 277 The letter read, in part: 

Our records have not shown that Mr. Simcakoski was in contact with any FBI 

field office. Additionally, when the FBI's Milwaukee Field Office met with 

276 Letter from Hon. Ron Johnson, C'hainnan, S. C'onun. on Homeland Sec. & Govenunental Affairs, to Hon. James 

B. C'omey. Jr., Director. FBI. at l (Sept. 14. 2015). 277 Letter from Patrick F. Fallon, Jr.. Acting Deputy Assistant Director. FBI. to Hon. Ron Johnson. C'hainnan. S. 

Comm. on Homeland Sec. & Govenuuental Affairs (Oct 2. 2015}. 

~ , I 

I 

:\llajority Staff Report 

Committee on Homeland Security and Go\'ernmental Affairs 

Senator Ron Johnson, Chairman 

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130 

Senator Baldwin in February 2015 regarding possible allegations of public 

corruption at the Tomah VA Medical Center, a follow-up interview with Mr. 

Simcakoski's father yielded that Mr. Simcakoski had been in contact with the 

Tomah Police Department and the Tomah VA Police Department.278 

Chairman Johnson's staff met with FBI officials on October 9, 2015, to address the 

discrepancy between what the data on Mr. Simcakoski's phones showed and the FBI's response 

to Chairman Johnson's letter.279 During this meeting, in an effort to assist the FBI in resolving 

the discrepancy, Chairman Johnson's staff played the recording of the November 4, 2013 

voicemail. FBI officials informed staff that there arc no employees at the FBI satellite office in 

La Crosse with similar names to the name on the voicemail.280 The FBI official reiterated that 

the FBI possessed no records of any communications with Jason Simcakoski and that FBI 

personnel in La Crosse did not recall speaking to Mr. Simeakoski.Z81 The FBI official declined 

Chairman Johnson's staff's request to speak with the FBI field personnel directly to confirm this 

information. 282 

278 !d. at I. 279 Meeting between Staff, FBI, and Staff, HSGAC (Oct. 9, 2015). 280ld. 

281 !d. 

2X2 !d. 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

51 
131 

Figurt> 9: Lt>ttt'l' from FBI to Chairman Jolluson Jnsou Simrakoski's routact with FBI 

U.S. l>epartment of Ju•ticc 

FcJcr<l.l Bureau of hl\ estigation 

Washington. DC 205.'5-0001 

GCT ~ 2 1015 

!'he llonc>rabl~ Ron Johnson 

Chainnan 

Committee on Homeland Sc..·urity and Uo,ernmcntal Affairs 

llnited States St•nate 

\\'ashingto11, DC 205!0 

lkar t :hainnan John~on: 

I am writing in rcspon..e to your September I 4, 2015, lt·Ucr to Dircctnr Com<'} 

regarding the lkpattment of Veterans :\tl'airs (VA) Medical Center in Tomah, Wiscon,in, and 

the FRI's intera<:tions with Mr. JaS<>Il Simmkt>>!d. 

Our records haw not shown that \1r. Shncakoski was in cnntact with any Fill 

field office. AdJitionallv, when the Ffll's 7\lilw,utkt•c Field Ot1kc met "ilh Senator Baldwin in 

February 20!5 regarding possible allegations of public comrption at the Tomah V," Mtdical 

Center, a h>IIU\\·llp !lllervkw "ith Mr. Simcakoski'' !ather yicldcJ th<ll 7\fr. Simcakoski had 

heeu in contact With the Tomah Pohcc lk·partment and the rom.ah VA Police Departmt~nt, 

I appreciate your bringing thJs matter to our auentinn. and 1 hope thi~ mtl.1rmannn 

will be helpful to you. 

Sim;crch. 

~~-

Based 011 the infonnation available, the majority sta!T cannot know exactly what Jason 

Simcakoski conummicated to law-enforcement entities in2013. While the FBI maintains that 

they have no records of communications with Jason Simcakoski, his phone records clearly show 

that he reached out to them and otl1er law enforcement entitiE's OlllllUltiple occasions in the fall 

of20!3. Tragically, less than a year after making co11tact with law enforcement entities, Jason 

Simcakoski died at the Tomah VAMC. 

:\Iajority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

52 
132 

2. Jason Simcakoski's contact with Dr. Houlihan is the subject of a current VA OIG 

criminal investigation 

The VA OIG currently has an open criminal investigation based, in part, on a 2013 

communication between Jason Simcakoski and the former Tomah VAMC chief of staff, Dr. 

David Houlihan. The Committee obtained a Report of Contact (ROC) dated November 6, 

2013----during the same period that Mr. Simcakoski's phone records show that he contacted law 

enforcement-completed by Dr. Houlihan detailing a conversation that he had with Mr. 

Simcakoski. 283 The conversation between Dr. Houlihan and Mr. Simcakoski detailed specific 

accounts of drug diversion by another veteran at the Tomah V AMC. 284 The ROC indicated that 

the veteran that was the subject of the ROC sold l 0 pills for $200.00 on one occasion and 

"continued to contact [Mr. Simcakoski] to inquire if he wanted to buy more."285 Mr. Simcakoski 

also informed Dr. Houlihan that the veteran had offered him "oxycodone and methylphenidate" 

[also known as Ritalin] as well.286 

The document also suggests that Mr. Simcakoski may have confronted Dr. Houlihan 

about Dr. Houlihan possibly informing the veteran that Mr. Simcakoski had been in contact with 

law enforcement. The ROC noted that the veteran called Jason a "rat" for speaking to the police 

about drug diversion at the Tomah VAMC.287 Dr. Houlihan wrote: "Jason called the Tomah PO 

who stated that they felt someone such as this MD tipped off the [veteran]. l assured [Jason] that 

I did not nor did I think our VA police tipped the [veteran] off."288 Dr. Houlihan wrote that he 

informed the Tomah V AMC Police of the incident and told the veteran that they would "no 

longer get prescriptions for controlled medications" from the Tomah VAMC "based on credible 

evidence that (the veteran] was diverting [their] medications." Dr. Houlihan concluded the ROC 

by noting that the veteran was welcome to seek admission for detoxification and noted concerns 

that the veteran would "retaliate" against Mr. Simcakoski or against the facility due to Dr. 

Houlihan's orders to restrict medications. 

Chairman Johnson's staff has learned that this ROC is the subject of a current 

investigation of the VA OIG criminal investigation unit. As a part of Chairman Johnson's 

investigation, his staff interviewed VA OIG Special Agent Greg Porter. Special Agent Porter 

was the lead investigator for the VA OIG's criminal investigation unit's involvement with the 

Tomah health care inspection. When staff presented the ROC to Special Agent Porter, he 

refused to answer specific questions about the documents because it was the subject of an open 

investigation. Through further questioning, Chairman Johnson's staff was able to ascertain when 

the VA OIG opened its investigation. After staff entered the ROC into the record and described 

the document, Agent Porter explained: 

283 VA production Tomah Emai1s & Documents (!5-18) 00009!. 284 VA production Tomah Emails & Documents (15-18) 00009!. 

m VA production Tomah Emai1s & Documents (15-18) 00009!. 286 VA production Tomah Emai1s & Documents (!5-18) 00009!. 287 VA production Tomah Emai1s & Documents (15-18) 00009!. 2

" VA production Tomah Emails & Documents (15-18) 000091. 

~1 l~_.\ 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

53 
133 

A: This, again, I have an open investigation and 1-this-1-1 can't really 

get into this. 

Q: So the contents of this report of contact are directly connected to your 

open investigation. 

VAOIG 

Attorney: He-he-! think he just said he can't answer that question. Can you 

answer that question? 

A: I cannot answer that. 

Q: So you have an open investigation in 2016 with something that may 

have occurred in 2013. 

A: Yes, sir. It-my investigation incorporates things that happened in 

2013, yes. 

VAOIG 

Attorney: Can we maybe clarify--when did your investigation open up? 

A: In approximately February of2015 289 

This ROC highlighted specific instances of drug diversion and was recorded during the 

VA OIG's health care inspection of the Tomah VAMC. Parallel to the health care inspection, 

VA OIG criminal investigators conducted their own investigation of the facility in 2012. 

Records indicate that the VA OIG criminal investigation unit closed its investigation of Dr. 

Houlihan on August 28, 20!2290 According to the former Tomah VAMC Police Chief, Roberto 

Obong, protocols require accusations of drug diversion to be forwarded to the VA OIG for 

review. 291 Maureen Regan, Counselor to the VA Inspector General confirmed that pursuant to 

VA regulations, allegations of felonies on VA campuses are referred to the VA OIG for 

invcstigation.292 

It is unclear when VA OIG criminal investigators became aware of Jason Simcakoski's 

reports to Dr. Houlihan of drug diversion at the Tomah VAMC. Special Agent Porter said that 

"prior to the current investigation that I opened in February of2015, I hadn't had this 

289 Porter Transcribed Interview, at 142. 290 VA OJG MCI Search Results, MCI # 2011-04212-DC-0252 (May I, 2015, II :23 AM), OJG 1392, at OJG 1392-

93. 

291 Obong Transcribed Interview, at 27-28. 292 Porter Transcribed Interview, at 143. 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

54 
134 

information or I hadn't seen this document [the ROC], to my recollection."293 He stated that 

Jason Simcakoski's November 2013 report of drug diversion to Dr. Houlihan is "familiar" to him 

in the context of his current and ongoing investigation?94 Nevertheless, it appears that the VA 

OIG was either unaware of, or failed to act upon, Jason Simeakoski's November 2013 

allegations of drug diversion until it opened its investigation in February 2015. It is unclear what 

further actions, if any, local law enforcement or the Tomah VAMC took in response to this 

information. 

What is clear, however, is that Jason Simcakoski attempted multiple times to engage 

local and federal law enforcement in examining drug diversion at the Tomah VAMC. For 

whatever reason, these law-enforcement officials apparently did not pursue the matter. The 

failure to do so represents yet another-and a very serious-missed opportunity to prevent the 

tragedies of the Tomah VAMC. 

* * * 

The overprescription, retaliation, veterans' deaths, and abuse of authority at the Tomah 

VAMC did not occur in a vacuum. Veterans, employees, and whistleblowers tried for years to 

get someone to address the problems. Along the way, since at least 2004, there were several 

opportunities when federal agencies could have inquired further or taken direct action. At each 

step, however, these opportunities were missed. The tragedies that occurred at the Tomah 

V AMC were preventable and were the result of systemic executive branch failures. 

293 Id. at 142. 294 !d. 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

55 
135 

III. The VA DIG's health care inspection ofthe Tomah VAMC 

Perhaps the greatest failure to identify and prevent the tragedies at the Tomah V AMC 

was the VA Office of Inspector General's two-year health care inspection of the facility. The 

VA OIG dedicated considerable resources to examining allegations of opioid overprescription, 

abuse of authority, and other misconduct at the facility. The watchdog collected over 200,000 

employee emails, conducted interviews with Tomah VAMC employees, reviewed patient 

information, issued at least one subpoena, and even surveilled Dr. Houlihan. Yet, the product of 

this intensive effort was just an eleven-page administrative closure, which did not substantiate a 

majority of the allegations and was not publicly issued. 

Months after the VA OIG closed its inspection, in August 2014, Jason Simcakoski died at 

the Tomah VAMC of"mixed drug toxicity." In January 2015, Thomas Baer, a 74-year-old 

veteran, died after receiving treatment at the facility's urgent care center. His daughter, Candace 

Delis, said that she would not have taken her father to the Tomah VAMC if she had known about 

the VA OIG's inspection. After public scrutiny surrounding the Tomah VAMC arose in January 

2015, the VA Central Office in Washington, DC, examined the allegations. In just three months, 

the VA investigated and substantiated a majority of the allegations that the VA OIG could not 

substantiate after several years. 

Chairman Johnson's investigation provides some explanation for the VA OIG' s failed 

inspection. The VA OIG narrowly focused its investigation on overly literal readings of the 

allegations. The office did not have a clear standard for substantiating allegations, as evident by 

the different explanations provided by several different employees. The VA OIG discounted 

allegations from Tomah V AMC pharmacists, despite firsthand evidence to support their claims. 

Chairman Johnson's investigation also shows that the VA OIG team initially intended to draft a 

public work product on the Tomah V AMC, only to see the allegations closed administratively. 

A. The VA DIG's hotline process: A primer 

The VA OIG exists to be an independent watchdog of the VA. One of the primary ways 

that the OIG receives allegations about waste, fraud, abuse, or misconduct is through its OIG 

hot line process. The VA OIG's health care inspection of the Tomah VAMC began as a result of 

complaints received through the OIG Hotline. 

The VA OIG commonly receives hotlincs by e-mail, phone call, fax, and by mail. 295 In 

general, a group of the OIG employees reviews the incoming hotlines, determines the veracity of 

the allegations, and whether the allegations should be sent to a division within OIG for further 

295 VA DIG Hotline Homepage, DEP'T OF VETERANS AFF., OFFICE OF ]NSPECTOR GEN., 

bltn :~~Y~\~~Y~l"'gn~~[gjgJ1ot 1 in~i. 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

56 
136 

review. 296 Dr. Robert Yang, a VA OIG inspector who assisted on the Tomah VAMC inspection, 

also served on the OIG hotline group from 2010 to 2014.297 He described the hotline process 

during a transcribed interview with Chairman Johnson's staff. He said: 

Q: But it is a group. It's not really a committee. 

A: Right. It's more of a group. It's not a-it's not as formal as a 

committee. 

* * * 

Q: And how large is this group? I know it varies, but can you give us aA: It could be as small-well, over time, sort of the membership in this 

group has changed. But at least at this time [in 2011], it could have 

been anything from three to, say, eight members.298 

Dr. John Daigh, the Assistant Inspector General for Health care Inspections, regularly 

receives allegations from the VA OIG's hotline group. In a transcribed interview with Chairman 

Johnson's staff, he explained how his office receives hotline allegations: 

We run a hotline, that being the management of the IG runs a hotline, and a 

portion of those hotline issues come to my office, so I call that our hotline. And 

we have the ability to publish about one a week, so we publish somewhere 

between 50 and 60, 65 hotlines a year. 299 

The OIG's Office of Healthcare Inspections (OHI) may publish a report for approximately 50 to 

65 hotlines during a given year, but Dr. Daigh explained that his office receives about 20 hot line 

complaints a week. He stated: 

Q: On hotlines, you said you publish between 50 to 65 a year. How many, 

roughly, reports or inquiries are put into the hotline? How many 

complaints does the hotline receive, OHI hotline receive in a given 

year? 

296 The VA Office of Inspector General has four divisions. Investigations, Audits and Evaluations 1 Management and 

Administration, and Healthcare Inspections. OJG Organizational Chart, DEP'T OF VETERANS AFF., OFFICE OF 

INSPECTOR GEN., _h_~r_::i~\'}"~~..,~c\~~_:.gQ~-_::~~igl_i,!_h_q_tJJ.:..Qlk:~_h_a_r_L~l?; see also Transcribed Interview with George Blake 

Wesley, in Washington, D.C., at 20-25 (Apr. 20, 2016) [hereinafter Wesley Transcribed Interview]. 297 Transcribed Interview with Robert K. Yang, in Washington, D.C., at 13- 14 (Feb. 17, 2016) [hereinafter Yang 

Transcribed Interview]. 298 ld at 38-39. 299 Transcribed Interview with John D. Daigh, Jr., in Washington, D.C., at 9 (Mar. 23, 2016) [hereinafter Daigh 

Transcribed Interview]. 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

57 
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A: So the number varies by year, but I would say that a rough way to 

think about it is if we got l ,000 complaints in a year, then we get-that 

would be roughly, what, 20 complaints in a week. And so I have the 

opportunity to publish one a week. That means I can publish 5 percent 

of the hotline complaints I get. 

I get on the order of 3,000 to 4,000, somewhere between 2,000 and 

4,000 complaints in a year, so I have the opportunity to publish at 

some rate much Jess than 5 percent, and it has varied over the last, oh, 

6 or 7 years. It's ramped up steadily, with a big bump after Phoenix300 

Overall, according to Dr. Daigh, the VA Office of Healthcare Inspections will only 

publish a report for less than 5 percent of the all incoming hotline complaints 301 Dr. Daigh 

explained that after the Phoenix VAMC wait-list scandal,302 the number of incoming hotlines for 

the Office ofHealthcare Inspections grew "massively."303 Dr. Yang also talked about the 

growing number ofhotlines: 

Q: As your time on the hotline group from 20IO to 2014, can you give the 

Committee a sense of the magnitude of how many allegations and 

hotlines were coming in during your time on that team? Was it kind of 

a pretty steady flow of allegations coming in? Or was there an uptick 

at some point? Can you give us kind of a brief summary of your time 

there? 

A: I can't recall the precise numbers. 

Q: That's okay. 

A: My recollection is that that number has actually been-it had actually 

been steadily increasing over time from when I started, and then it 

actually essentially exploded. I'm trying to think of exactly when it 

sort of skyrocketed, essentially. I'm not sure what a precise date would 

be for that, but basically, in general, it has been increasing over time 

fairly steadily and much more so at some point in the relatively recent 

pastJo4 

300 1d. at 9-l 0. 301 /d. at I 0. 302 The Phoenix YAMC Wait-list scandal became public in April20!4. Scott Bronstein & Drew Griffin, A Fatal 

Wait: Veterans Languish and Die on a VA Hospital's Secret List, CNN (Apr. 23, 2014), 

http :1/www .cnn. com/20 14104/23/heal thlveterans-dying-health-care-delays/. 303 Daigh Transcribed Interview, at 11. 304 Yang Transcribed Interview, at 13-14. 

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Although the volume of incoming hotline complaints has grown dramatically, the manner 

in which the Office of Healthcare Inspections processes these hotlines seems to have not changed 

over time. Dr. Daigh explained: 

Q: And can you kind of walk us through the termination [sic] process that 

OHI uses to determine whether or not to take on a hotline and open up 

an OHI inquiry versus sending it back to VA, VHA, what have you? 

VAOIG 

Attorney: At this time or back in 2011? 

Q: Well, has it changed? 

A: It hasn't substantially changed. The numbers of complaints change a 

little bit year to year, but the basic way we think about it hasn't 

changed. So the first cut would be, does the allegation allege what we 

would consider to be serious issues with patient care? Is there an 

allegation that something happened that resulted in death or harm to a 

patient') That would be those complaints that we would take most 

seriously and try, if possible, to work. 

We also consider in the decision-making process a number of other 

factors. Is the request from a Member of Congress? Is the request 

understandable? In other words, is it written in such a way that, 

although we understand there is an allegation, does it look like there 

might be data that we could actually use to determine the answer to the 

question? 

Was it written by someone who we think would likely have insight 

into and make it more likely that the allegations are truthful or correct? 

So if it is written from a doc or written from a nurse or written from a 

patient or written from a patient's family, we take all those issues into 

consideration in trying to figure out which, you know, 2, 3 percent of 

the complaints that come in that !-that we should accept and work. 

We've always had a committee that meets to look at these complaints. 

We get complaints on a regular basis. I think years ago--and I am 

talking in 2003, '04, '05-we would get few enough complaints that 

you could sit down and-twice a week sit down and look at the 

complaints and decide what to do. When we get, you know, 10 a day 

or we get, you know, 30 or 40 a week, then we have a process whereby 

the hotlines are administratively registered in our office from [the 

hotline group J 53, which would be the large hotline group in the !G. 

We would then send those hotlines out to the team so they can look at 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

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it to the extent possible. We have a VA medical record on our desktop, 

so they would do a little background work to try to figure out whether 

the complaint made sense or not. And then the group which is 

composed of health care inspectors, which are largely nurses and 

social workers, and a doc from my office who rotates in on that 

meeting, they would sit down and have a meeting and decide which 

ones we're going to take. 

So it's been done in that way for a long time 305 

There appears to be no formalized complaint process with the Office of Healthcare Inspections, 

other than employees reading an internal "handbook." 306 The hotline process discussed by Dr. 

Daigh was in place in 2011, when the VA OJG received the hotline allegations about the Tomah 

VAMC.Jo? 

Dr. Alan Mallinger, who was one of the lead VA OJG inspectors on the Tomah VAMC 

inspection, also participated in the hotline group for a period of time. 308 He explained how 

"various factors" determine the hotline group's decision on how to refer complaints 309 He cited 

"the complexity of the case" and "the seriousness of the case" as two factors that "can weigh 

into" deciding how to dispose ofhotline complaints.310 Dr. Mallinger described the hotline 

process as a "case-by-case" decision. 311 

Dr. Yang explained his view on how the VA OJG evaluates hotline complaints.m Like 

Dr. Mallinger, he said that the disposition of a hotline complaint depends on the discretion of the 

hotline group. He explained: 

Q: · Just quickly, what would be the reasons why the hotline group would 

decline looking at an allegation further? Is there certain written 

policies or written standards, or is it sort of like the group sort of has a 

group consensus on accepting a hotline or not? 

A: Are you sort of wondering what is the criteria forQ: Yeah, is there kind of a hard criteria of, you know, these boxes need to 

be checked for the IG to accept a hotline case? Or is it more up to the 

discretion of the hotline group? 

305 Daigh Transcribed Interview, at 11-13. 306 !d. at 13-14. 307 !d. at 14. 308 Mallinger 3/8/2016 Transcribed Interview, at 27. 309 !d. at 28. 310 !d. 

311 !d. 

-'

12 Yang Transcribed Interview, at 10-ll. 

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A: I think it's more up to the discretion of the hotline group. I think there 

were concerns that if we tried to limit it to very specific hard and fast 

rules, that might either limit us from taking a case that people thought 

either should be taken or, vice versa, that we take one where it seems 

unlikely that, you know, something is occurring, where we sort of say, 

"Well, our criteria is sort ot"-so having-it was difficult to come up 

with necessarily sort of a hard and fast sort of rule that if this happens, 

then this absolutely results in a-you know, basically a case sort of 

being accepted as a hotline.313 

Dr. Yang provided his insight into how the VA OIG's hotline group processed hotline 

complaints. He explained that sometimes the VA OIG hotline group would refer an allegation to 

the facility's leadership or the VA's regional office, rather than having the VA OIG examine the 

allegations itself. He stated: 

Typically, the group would come to consensus. We have people, physicians with 

backgrounds and specializations in several areas, and so, not surprisingly, we all 

might bring a slightly different perspective to-and so in the course of discussion, 

there might be a variety of reasons for choosing exactly what sort of route to take 

with a hotline. So if there were cases of serious sort of patient harm, then there 

was typically sort of a bias, especially if we could confirm that in the medical 

record, there would be a bias toward examining that directly. Sometimes, though, 

it actually would be faster for us to actually send it back to the medical center 

because then we could make other people aware of what was going on with the 

complaint. So we would-in that case, it might make more sense to send it back 

because then it would allow people at either the medical center or VISN 

potentially to take action as well. And those kinds of complaints might be 

something where something's occurring somewhere in the facility, and there isn't 

necessarily reasonable expectation the medical center director maybe is aware 

that's what's going on, say the complaint is directed against, say, the chief of a 

service, or we might send it to the VISN so that way it could be reviewed, again, 

by people who weren't involved in the allegation itself.' 14 

In addition to complaints from veterans and practitioners, the VA OIG routinely receives 

complaints from Members of Congress on behalf of their constituents. When the VA OIG 

hotline group receives this type of complaint, they mark the complaint with a unique 

"congressional" label and handle it separately from other hotline complaints. Dr. Daigh said that 

"there is a subtly different process" on how the VA OIG handles congressional requests.315 He 

explained that these requests usually go to the VA OIG's congressional liaison officer and the 

313 ld at 12-13. 314 /d at 17-18. 315 Daigh Transcribed Interview. at 15. 

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Senator Ron Johnson, Chairman 

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incoming letter is logged into the VA OIG system.316 The complaint is then provided to the 

hotline group for review. Dr. Daigh admitted that his office may accept some congressional 

complaints that it may otherwise not have accepted based on the merit of the complaint.317 He 

told the committee that congressional requests "do get a preference in terms of taking their 

allegations over the other ones that we have sometimes."318 Likewise, Dr. Mallinger said that 

congressional cases do take precedent over other cases and that they are important.319 

B. The VA OIG's work relating to the Tomah VAMC: A time line 

1. March 11,2011: The VA OIG received a phone call alleging problems at the Tomah 

VAMC 

From information available to the Committee, the first time that the VA OIG received a 

complaint concemin~ the Tomah V AMC that led the Tomah VAMC healthcare inspection was 

on March 11, 2011 3 0 This complaint came in to the VA OIG's hotline process via a telephone 

call from an individual who originally wanted to serve as a "confidential source."321 

The OIG analyst who received the call described the caller as "cooperative."122 The 

caller disclosed a litany of problems concerning the Tomah VAMC, many of them relating to 

veteran care and the prescription practices at the facility.m Among the allegations recorded by 

the OIG analyst were "reports that veterans fall, Benzo-diazaptine, ritalin, etc are traded/sold. 

The COS [chief of staff] does not like non-prescribing people to question doctor's prescriptions. 

The COS is a believer in giving vets drugs from the VA rather than have them buying them on 

the street and/or drinking to take away the pain."124 The OIG logged the phone call, but the 

contact was not assigned a case number. 325 

3Hi fd. 

3!7 !d. 

]18 !d. 319 Mallinger 3/8/20!6 Transcribed Interview, at 23-24. 320 VA OIG Hotline Contact Case, Contact# 12003 (Mar. II, 2011, 2:51 PM), OIG 5663, at OIG 5663-65. 321 !d. 

322 !d. 

32J Id 324 !d. at OIG 5663. 

325 !d .. 

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Senator Ron Johnson, Chairman 

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Figure 10: Report of the lnitinl VA OIG botliue for Tomah V A.'\IC complaints (\'1~1". 11, 2011)326 

eon .adO.. 

Ol.h1J2011 

ECIISNo 

OADNo 

OIICMo 

OlhorMo 

03/111201102:11,.. 

N 

Z. March 13, 2011: The VA OIG receives additional allegations via facsimile about the 

Tomah VAMC from a social worker 

A few days later. on March 13, 2011, the VA OIG received a 30-page facsirnile 

addressed to "Rep 99" of the OIG's l10tline group.327 The subject of the fax read "Tomah WI" 

and tl1e cover page referenced a case muuber: 2011-02008-HL-0497. 328 The fax also included a 

three-page stmun~g of the problems at the Tomah VAMC. along with a number of press articles 

about the facrhty. - The autl10r, who descnbed 1umself as a social worker, addressed the 

sununa1y to "Agent 99" and described the situation at the Tomah V AMC as"[ e ]thically and 

morally" compelling330 The social worker concluded the fax: 

At this time it would be best to remain anonymous due to the hostile nature of the 

Tomah VA. Please do not let the staff at Tomah read this rep01i. I will send more 

information in the future that addresses individual veterans and their files 3 3l 

316Jd. 

317 Fa" to Representative 99. VA OIG Hotline (Mar. 13. 2011), OIG 5666, at OIG 5666-95. 

"'Jd. at OJG 5666. 319 Id. at OIG 5677-95. 330 Jd. at OIG 5667. 331 Id. at OIG 5669. 

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'Jhe vetenm at th~ Tomah VA are adly not recelviiJi lhe wvltct they ncOO.I'm contaoling you 

~ce I feel compelled to share the many isJUe~ I encountered as u. social wolkcr. Ethically and 

mondly I can no klnpr tum away from !MI.!SI.ItS at the ToJMh, Wisoon3in Vetci'BI\S AIWn. 

'1befe are many al.'US that the VA in TolllDit is failing ita veterans. 

Tire social worker categorized the allegations into four general areas: (1) veterans' access 

to the mental health clinic, (2) medications, (3) medical and mental health staff, and (4) 

management.m The social worker infonned the VA OIG that "veterans call Tomah 'Candy 

Land' and the Chief of staff 'Candy man' because of the medications they receive."JJ4 The 

social worker also presented other allegations, including waiting list issues for veterans receiving 

mental health treatment, veterans who were ovennedicated, veterans who were arrested for 

selling their VA prescription medications, concems about fear and intimidation in the work 

environment, and an assertion that doctors do not wish to prescribe controlled substances 335 

The social worker smrnnarized the issues at the Tomah V AMC in March 20 II as 

"veterans are receiving a good to poor quality of care."336 He requested assistance fmm the OIG 

to look into "the prescriptions prescribes [sic] by the chief of staff and look at the mental health 

and health care progra.tns. "337 The social worker requested anonymity "due to the hostile natme 

of the Tomah VA" and also asked the VA OIG not to allow the Tomah V AMC leadership to 

become aware of the complaint. 338 

One of the press articles that the social worker included in his fax was a June 2010 article 

from the Virgillian-Ptlot titled, "Doctor: Veterans get hooked, not healed, at VA hospital. "

339 

The article recounted the experiences of a VA facility in Hampton Roads, Virginia, where two 

doctors said powerful narcotics were being overprescribed to veterans, leaving them addicted 

wlrile their underlying medical conditions go tmtreated.340 The doctors wamed that the high 

volume of narcotics may be feeding a pipeline of drugs that were resold in the connnunity341 

According to the article, one of the doctors was fired after airing concemsH2 

332 ld. at OIG 5667. 333 !d. at OIG 5667-69. 334 !d. at OIG 5669. 

mId. at OIG 5667-69. 336 ld. at OIG 5669. 337 /d. 

JJS Jd. 

"'Id. at OIG 5690-94. 

HO Jd. 

3.:1-lld 

J.:t!- Jd. 

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Committee on Homeland Security and Governmental Ali airs 

Senator Ron Johnson, Chairman 

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The social worker asked the OIG to review the aiticle because it "is a prime example of 

what the Tomah VA is experiencing."343 The social worker believed there were "similarities" 

between the VA facility in Hampton Roads and the Tomah VAMC "that need attention."H4 In 

addition to the Virginirm-Pilot atticle, the social worker included other articles conceming atTests 

of individuals in the Tomah region a1·ound 2009 and 2010.345 The social worker wrote in the fax 

message that "the local Tomah Police Depattment has made several dmg aiTests in the Tomah 

area regarding veterans and their prescription medications. Many veterans sell their medications 

after they pick them up from the VA. "346 

3. March 14,2011: The VA OIG receives allegations via email about the Tomah VAMC 

One day after the 30-page fax was sent to "Rep 99," the VA OIG hotline group received 

ail email that also raised concems about the Tomah VAMC. 347 This email was addressed to 

"Representative 99."348 The author described himself as an employee of the Tomah VAMC who 

also received care at the facility 349 He explained that he felt compelled to contact the OIG 

because he was "tmable to continue workin~ in this environment and watch veterans [sic] health 

be jeprodised [sic] or posably [sic] worse."3 0 

Figure 12: Email rf!ceived by VA OlG hotline (Mar. 14, 2011)351 

IIA OIG Hotline 

Frarn: 

Sent: 

T<>: 

Subjtct: 

~111:51PM VAOIGHotllno 

REP !!'I 

1\le ~ """fking atlbe \"... -1\'el>ttn rMi,mycm at tile Toma~ VA 

sillc~ I Clln>e bQ~Ie fi'Qltl the in As n m 

"'Olllpcl~d to do~ cight 1hins (If m~ tow v~<rans. I'm una bit 10 cominllt 1\·ort.:ing mthis envoronmem •nd 

Wl'!lcb \'Eiteuup; he::llth ~ J~rod1-ot"d or J'<'!~bJy wtl'rm! 

343 Id. at OIG 5669. 

'"'!d. 

'"'See generally id. at O!G 5677-95. 346 Id. at OIG 5667. 341 E-mail to Representative 99. VA OIG Hotline (Mar. 14. 2011, II :51 PM), at OIG 5696. 

"'!d. 

"'!d. 

"'!d. 

351 !d. Tile redactions were applied by the VA O!G prior to production of the document to the Committee. 

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Senator Ron Johnson, Chairman 

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This email offered more details about the working environment with the Tomah V MIC. 

The author described Dr. Houlihan as the one who controls the environment and explained that 

the three other senior leader do not have as much "influence in the daily operations of 

progra.nnuing or decisionmaking."352 The author alleged that Dr. Houlihan maintained "favorite 

people" at the facility and that if an employee ran afoul of one of Dr. Houlihan's fav01ites, he or 

she would be reported to Dr. Houlihan. The complainant described this situation as "children 

telling o~ each other to a parent in order to look better and to get in the good graces of that 

parent."3 3 

The author acknowledged that colleagues at the facility had discouraged him from going to 

the OIG. writing "I'm not sure that putting my head on the chopping block will do anything but 

cause me to have trouble at work or even lose my job,"354 The author also noted that the 

employee's tmion at the Tomah VAMC. which received complaints about the work euviromuent, 

was "overwhehued with complaints. "355 

Figur• 13: Email r•<•h·•d by VA OIG botlin• (Ylar. 14, 2011) "' 

I'v~ asked seve• a! c<'II~1Je6 wh• Dr. H<>uhhau is still practiciQft a1 To:nah if all cftt.tse mtdJcntio• pr~n"~·1 tt · e worl.: reLII«!tosu;-s ond power atld •-omrol hwes ar( llfQUil(l. Tb(y ~,d, "He s111~i"d an«!"'" b<)ud m.ond he's Sllr.iH<l (o!ber ldV~Jii~~~iotiS here Hes ll!l!ouclla~lc, ••d if)·OU !!'' atler him you "ill lose )'01>1' 

joti or .00·.-ed in the won! job '"'•r ond hoondod u.nil }0\J quit" l wM ,nformcd that others luv• i~vtsrijjll«l 

•ad nothing'""' hapJl<ns Thj, is" laflle 11.1r1 of,.hy l'v< beetJI,.,;nw~ to awrwch th-e OJG. rm notllltc tlv•< 

putting mr h .. d on the c!lowins ~lock ,.;a do onythiny bot cause: me to he''< trouble M I<Nk or even Jc,,. m; 

job, 

The March I 4, 20 II, email received by the VA OIG hotline group had other serious 

allegations. The author levied allegations that Dr. Houlihan was using Tomah V MIC veterans 

to conduct "his research into bellZodiazepine, Ritalin and opiates for healing PTSD." 357 The 

email desc1ibed the "cocktail of medications veterans received" and the health problems that 

veterans experienced after receiving the cocktail of medications 358 

4. March 15 and 22, 2011: The VA OIG received two more complaints about the Tomah 

VAMC 

The OIG hotline group received another email addJ·essed to "REP 99" on March 15, 

20 II. T!Iis short message read: "The list below is liom a coworker who believes the maj01ity of 

veterans are on a great deal the medications that could be unsafe many of them have the 

"' ld. 353 /d. )54 !d. 

-"'Jd. 

356 Jd. 

357 !d. ot OIG 5697. 

lS8 !d. 

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Senator Ron Johnson, Chairman 

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diagnosis ofPsyhalgia. The veteran physiologically has pain and there for [sic] it must be 

treated. See names below."359 

Figm·e 14: Email•·•r•iwd b~·tbe VA OIG hotline (M•r. !5, 2011)36" 

To; 

REP 99 

VA OIG Hotline· 

REP99 

Tuesday, March 15, 2011 3;58:14 PM 

The list helow is fr-on1 a coworker who believes the rnajority of veterans are 

on a great deal the tnedications that could be unsafe n1any of thcrn have the 

diagnosis of Psychalgia. The Yetenm physiologically has pain and there tor it 

must be treated. Sec names below. 

Just a week later, on March 22, 2011, the VA OIG hotiiue received another 

conummicationJ61 This email. like the others, was addressed to "Rep 99" and concerned a 

veteran who "just passed away. "

362 According to the email, the deceased veteran came to the 

Tomah V AMC from ti1e Milwaukee V AMC "because he was denied treatment for substances at 

Milwaukee."363 The veteran allegedly had "drug seeking behavior" and was placed into a 

Tomah V AMC program, which the veteran completed 364 After completing tile program, the 

veteran apparently attempted to get back into the VA to receive more pain medication.365 After 

an unknown ammmt of time back at the VA, the veteran was discharged and later died on March 

21,2011 366 

359 E-mail to Representative 99. VA OIG Hotline (Mar. 15. 2011. 3:58PM), at OIG 5701. 360 The Tomah VAMC is not named in this hotline but documents were produced pursuant to Chainnan Johnson's 

subpoena for the VA OIG's Tomah VAMC inspection. 

"'111e VA OIG hotline contact refe1nl is 2011·12741. 

"'E-mail to Representative 99. VA OIG Hotline (Mar. 18. 201!. 8:14PM). at OIG 5702. 363 Jd. 

364 Jd. 

"' Jd. 366 E-mail from Steven Wise. VA OIG Hotline Refen·als. to Victoria Coates & Misti Kincaid. VA OIG (Mar. 24. 

2011.2:59 PM), OIG 10316, at OIG 10316--10317. 

"-.,_ 

·~~) • I 

\ 

:\-Iajority Staff Report 

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Senator Ron Johnson, Chairman 

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15: Emailreceiwd th• VA OIG hotlin• 

11-12741 

1ur,·n:!,;'y, M.J'"t h."~ • .:-.:n; 1~t01/lM 

[~"'""" ! R£: R!P 99 

: ftotn 

!'fo I VAOIGt-lotlu't >--··-·-·!·· .. ; Sf.lr-.t fl"'ld&y, 1\trrc:h lS~N'll 8:14PM 

Helloflep99 

from 

... ent through the program. He lin!lhl!d 11>1! program.lliii!i--~ hit pam mE>dS beca<•se of h1> diU£ see~l ng b<!h~vfcr. He brok" "" o.wn l~g 10 get ~ck into the VA and set 

more pain med~. Hewu d•~harged abovta wt!ekagoarnlltapl)1lanhe overdosed on h•• medicohons. 

Ho ... e•erwe have towaitforthe Bands, to comebac~ befO<c we can savior sure. 

llyc>u r>@•d me I will be ovtofthP office due to medical issues I will beat home andava•lable if you 

need to email. 

5. March 2011: The VA OJG Office ofHealthcare Inspections hotline group assessed the 

Tomah VAMC allegations 

The VA OIG 's Office of Health care Inspection (OHI) hotline group examined the 

complaints it received in March 20 II via email, telephone, and facsimile about the Tomah 

V AM C. The complaints appear to have been made by the same individual because the email 

references both the facsimile with the news articles and phone call from earlier in March 2011 368 

The l10tline group bundled the contacts together tmder the same OIG case number: 2011-02008-

367 E·mail to Representative 99. VA OJG Hotline (Mar. 18.2011.8:14 PM), at OIG 5702. 368 E-mail to Representative 99. VA OIG Hotline (Mar. 14. 2011. ll :51 PM), at OIG 5696. 

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HL-0497 VAMC, Tomah, WI RP99. The allegation involving the death of a veteran after his 

discharge, hotline number 2011-12741, was also bundled under the -0497 case number. 369 

Dr. Yang, who was part of the VA OIG's hotline group in March 2011, recalled the 

contents of the March 20 II Tomah V AMC allegations and what the group thought about the 

allegations.370 He remembered that the complainants were concerned "about the level of opioid 

prescribing that was occurring" at the Tomah VAMC.m Dr. Yang explained that he "was 

actually one of the people who reviewed material," and he specifically recalled "looking at news 

articles that came in.'m2 He said that he may have also reviewed specific patient charts. 373 

Dr. Yang discussed a specific allegation that patients with additive diagnoses were being 

treated with medications that can cause addiction. He believed this type of treatment "is not an 

uncommon practice, from [my] understanding, of the treatment of addiction, that people may be 

on opioids for-and treated with opioids for their addiction problem. "

374 Dr. Yang explained 

how "there was concern" with the hotline group about the general allegations, but he was 

searching for the "context of are we dealing with a provider who is simply dispensing out of 

control, or are we dealing with a provider who is trying to deal with a very difficult group of 

patients that they're trying to manage?"375 

According to Dr. Yang, there were other factors that contributed to the VA OIG hotline 

group's assessment of the Tomah allegations. He explained that some of the allegations had 

more detail and the group decided to "read through some of the materials that were turned in."376 

The hotline group also sought to better understand the allegations about the prescription of 

opioids.377 Regarding that allegation, Dr. Yang said that "it's oftentimes-prescribing of opioids 

a bit of a gray area in that there is oftentimes no absolute sort of level above or below ."378 He 

attributed that "gray area" of prescribing opioids to being "dependent on the patient."379 

According to an internal OIG document, a source separately notified the OIG of 

allegations that the high prescription rates at the Tomah VAMC related to research on PTSD. 380 

The allegations were also levied in the hotline complaint emailed to the VA OIG on the March 

369 Yang Transcribed Interview, at 33; E·mails between Steven Wise, Victoria Coates, & Michelle Swagler (Mar. 

2425, 2011), OJG 1368, at OIG 1368-69. 370 Yang Transcribed Interview, at 22. 

371 !d. 372 !d. at 24. 

373 !d. 37.J. /d. at 23. 375 !d. 

376 /d. 

377 !d. at 23-24. 

m !d. 

379 !d. 

380 3/17/2011 E-mail from VA OIG Hotline Referrals, at OIG 1387. 

(~ij 1.. I \ l 

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15, 2011 381 When asked whether he examined the clinical study allegation in or around March 

2011, Dr. Yang said that he did not have a recollection one way or another. 382 

Figuro 16: VA OIG docum•ul conc•miug tb• Tomah VAM:CJ" 

The source also reported concerns about the practices of an alloged clinical study involving the 

use of Ritalin fe>r treatment of TBI and PTSD patients and has sent in additional 

documentation. 

Chairman Johnson's staff questioned Dr. Yang on whether he or another member of the 

VA OIG's hotline group communicated directly with complainant. 384 He said that he did not 

recall if a contact occJUTed in this instance, but provided an overview of how the VA OIG hotline 

group typically contacted complainants: 

So in this case, typically we 'II reach out to the complainant if either there are 

questions about we need clarification of what is occuning or we-in some cases, 

complainants give us essentially allegations that are, at least to the best we can 

determine, tminvestigable without additional detaiL And so sometimes we will 

call and say. you know, "In order for us to really pursue this fiuther, we need 

additional information from you." And in those settings, we ny and reach out to 

the complainant. The worst cases are the ones where. tmfmtunately, the 

complainant is anonymous, we do not even known who reached out to--and 

this-and I'm just thinking, again. I can't remember if this was my thought 

thinking of this case specifically, but in general, if we are going to send for a 

response or take something, we don't always sort of reach out to the complainant 

if we feel that the nature of the allegations has been sufficiently prepared. 385 

Dr. Mallinger, a physician with the OIG Healthcare Inspections unit. who later would 

become one of the leading OIG employees conducting the Tomah VAMC inspection, described 

his thoughts upon reviewing tl1e March 2011 allegations about the Tomah V AMC. 386 He called 

the allegations "alarming," stating: 

Q: So during your inspection. did you like-were you able to review what 

actually came in~ That's what I'm t:tying to get at, some of these 

March 2011 allegations. 

A: I did review the entire set, including the news articles. 

381 !d. Allegations received March 15, 2011. Jd. 382 Yang Transcribed Inten·iew. at 32. 

m 31!712011 E-mail from VA OIG Hotline RefetTa!s, at OIG 1387. 

~~ ~~~~ ~~:~~~ribed Interview, at 28. 

386 Dr. Mallinger and Dr. Shepherd explained that they did not review the March 2011 Hotlines tmtil they became 

involved in the Tomah VAMC irL<;pection. 

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Q: Do you recall what your reaction was with these series of submissions 

by a complainant regarding Tomah? Did you think they were serious? 

Did you think that-what was your reaction? 

A: These allegations were to me at the time alanning. You know, they 

have a very-they allege some very serious problems.387 

Another employee, Dr. Michael Shepherd, who would also subsequently work on the Tomah 

VAMC inspection, described the March 2011 complaints as "serious allegations."388 

6. March 15,2011: The VA OIG hotline group referred an allegation of prescription 

hording to the OIG's criminal division, which declined to investigate 

The VA OIG's hotline group referred an allegation of"a patient amassing 300 oxycodone 

tablets" to the OIG's Criminal Division for review on March 15, 2011.389 Ten days later, on 

March 25,2011, the Criminal Division declined to open a formal investigation because the 

allegation had "little criminal information" to potentially investigate. "

390 

7. April13, 2011: The VA OIG referred the Tomah VAMC allegations to VISN 12 and 

Veterans Health Administration Central Office 

Nearly a month after receiving the allegations about the Tomah V AMC, the VA OIG 

referred the allegations to the VA. According to OIG documents, on April l3, 2011, the OIG 

referred the allegations contained in the hotline complaints391 to the VA's regional office, VISN 

12, in Chicago, Illinois.392 The VA 01G explained that the allegations were "declined by OIG's 

Criminal Investigations Division and OIG's Healthcare Inspections Division."393 VISN 12 

received an email from the VA OIG Hotline Referrals that contained numerous allegations and 

provided a response deadline of June 13,2011.394 In the same transmittal email, the OIG hotline 

group sent an "information copy" of the Tomah VAMC allegations to "staff in the office of the 

3

" Mallinger 3/8/2016 Transcribed Interview, at 43-44. 388 Transcribed Interview with Michael Shepherd, in Washington, D.C., at 32,37 (Jan. 27, 2016) [hereinafter 

Shepherd l/27/2016 Transcribed Interview]. 389 VA 0!0 Hotline Input Transaction, MCI II 2011-02008-HL-0497 (May I, 2015. II :50 AM), 0!0 1390, at 0!0 

1391. "51" is the Criminal Division at the VA 0!0. 390 !d. 

391 The Tomah Hotlines sent to VISN 12 were assigned the 0!0 case number 2011-02008-HL-0497. 392 !d. The document reads "54 [VA 0!0 Office of Health Care Inspections] tasks to VISN, but will review 

response." The VISN referred to is VISN 12 in Chicago because the Tomah VAMC is located in VISN 12. 393 !d. at 010 1390: see also Yang Transcribed Interview, at 36. 394 E-mail from Steven Wise, VA 010 Hotline Referrals, to Robin Olson (Apr. 13,2011, 12:58 PM), 010 1435. at 

0!0 1435-37. 

Majority Staff Report 

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VHA Chief of Staff at VHA Central Office."395 It is tmclear what actions, if any, the VHA 

central office took after becoming aware of these allegations. 

FigUI·• 17: VA OIG hotlin• r•f•rral•mail to VIS:'< 12 ond VHA C•ntral Office (Apt-. 13, 2011)396 

Fn:tm: Ill\ QlG Hr:!H .,e !:!('fr.<rr-:,1~ 

S.Rt: W~~$d.:!v, A~nl 13. lOll J:!~SEI PM 

To; ~''· Rcbm 

Cc.: VItA CO lOO':i ::>tal"', ::;,~"''OIe•. H•t.k!:lle D.{OlG) 

Subject; VP. Ott .. Hotl•rp ~elen<1· .Wll·Wootl·HL·V4-9/ VAML lon1<1t1. Wl fUI<J'i 

This referral was r.,vf.ewed :lllf'ld deC:IIn~d by OJG·~ Crlmjn1'1! Investigation• D•~o~••ion "nd OIG'!Ii 

l-loalthcarn ln&poctlon& Otv1~1on 

Office Of Inspector General 

Hotline Case Referral 

R,.r;ponse Due June 1 l. 2011 

? ;r-.e VA Offn:t::.- of lnspec!Or C';en~ral ;OIGJ Holhne: '" refer'~''~J ttn~ fOIIOw1ng aJieq'11Hlfl5 fo• y.::Jur 

r~.,'e"" .n accordance. wtth VA D1r.ect,ve c7Cl 

ALLEGED IMPROP~R OR INCORRECT TREATMENT 

VE'1~:"rans at VAMC r o•n:<~/1 WI ar<e oH.o;>'l prescni:)<C'd IO':>!<::essr"'""' ~rr~o• .. mts -:_>r sl-englhs of 

rr'-.'th•~<llli.Y 5 L:JI•'>IfhJ Ufl .. l~:u:•pldi.Jiu ~de ~:ffedt> 

Dr. Yang, who was patt of the VA OIG's l10tline group in 2011, described his 

recollection of the decision to refer the allegations to v1SN 12. In a h·anscribed interview, he 

told Chainnan Johnson's staff that the hotline group "felt that there were enough serious findings 

that we requested an official response fi·om-and I believe we directed it at the VISN so they 

would be-----it was not just directed to the prescriber."397 

Chairman Johnson's staff questioned Dr. Yang on the reasons for sending serious 

allegations to the VA for review rather than the VA OIG inunediately opening an independent 

examination. Dr. Yang explained that the VA OIG would send allegations to the VA so that the 

agency leadership could be aware of the issues and take remedial actions. He said: 

So whether it gets sent to the VISN or not sometimes isn't so much a fi.mction of 

the seriousness of the case. Sometimes it's a fi.mction of ensuring that people are 

aware of what was going on so that people who, you know, basically have 

responsible [sic) for overseeing the care can take action more rapidly. So 

sometimes actually the more serious cases may be refened specifically because 

we want VA officials to, A, basically have it ou the record that they are aware of 

what is occmring, and then B is hopefully to get them to respond in a way that's 

appropriate. 398 

395 Letter from Hon. Richard Griffin, Deputy Inspector General, VA OIG, to Hon. Tanuny Baldwin, U.S. Senate 

(Mar. 24. 2015), OIG 10198, at OIG 10198-99. 396 E-mail fi·otn Steven Wise, VA OIG Hotline Referrals, to Robin Ohon (Apr. 13, 2011, 12:58 PM), OIG 1435, at 

OIG 1435-37. 397 Yang Transcribed Inten·iew. at 24. 398 Id. at 25. 

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Senator Ron Johnson, Chairman 

72 
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According to Dr. Yang's explanation, it appears that the decision to send the allegations 

about the Tomah V AMC to VISN 12 comport with the OIG's desire to make VA officials 

"awat·e of what was going on."399 The VA OIG Hotline Division notified the complainant on 

Aprill8, 2011, that OIG had "opened a case based on a review of the information you sent to 

om office."400 The notice did not inform the complainant that the OIG had merely forwarded the 

allegations to the VA. 

B. June 21,2011: VISN 12 responded to the Tomah VAMC complaints, unsubstantiating a 

majority of the allegations 

In April2011, the VA OIG refened the allegations conceming the Tomah VAMC to 

v1SN 12 in Chicago, Illinois. Chairman Johnson's staff conducted transcribed interviews with 

four VISN 12 employees to gain a better tmderstanding ofVISN 12's review. VISN 12, in 

general, was accustomed to receiving hotlines. One employee explained that "I don't think a day 

goes by when I don't get a hotline, so that is a v~ry routine eveut."4()1 The same empl?,i0

;e noted 

"we get a lot of IG complamts and those many limes come to the VISN to respond to. • 

Figure 18: VISI" ll's rosponso memot·andum to the Tomah VAMC allegations (June 21, 2011)403 

DEPARTMENT OF 

VETERANS AFFAIRS 

11.... _une ~1 201 ~ 

h·•" Netv.rcr1of Drrector VISN 1.2 i 10N12) 

-.uhJ Hothne Ca'.le '\lurnbe-r 2011 0~008 Hl 0497 

Vl:... O!G Hothne :livislon 

Memorandum 

The VA OIG allowed VISN 12 a two-month period to complete its examination of the 

Tomah VAMC allegations. After requesting a brief extension:04 on June 21, 2011, VISN 12's 

Network Director provided the VA OIG Hotline Division with a six-page memorandum that 

199 Id. 

'

00 E-mails with RepresentatiYe 99, VA OIG Hotline (May 21, 2012). OIG 1381. at OJG 1381-82. 

JOl Os.hinski Transcribed Intervie\\·, at 76. J02 !d. 

"'Memorandmn from Network Director, vlSN 12, to VA OJG Hotline Div. (June 21, 201 I), OJG 1435, at OJG 

1438. 

'

0

' VA OJG Hotline Input Transaction, MCJ # 201 1-02008-HL-0497 (May I, 2015, 11:50 AM), OJG 1390, at OIG 

1391. 

:\lajority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

73 
153 

outlined VISN 12's process and findings for each allegation."05 VlSN 12 found seventeen of the 

nineteen total allegations to be "unsubstantiated," including the allegations about diversion of 

controlled pharmaceuticals, patient dosages increased to unsafe levels, and patients being too 

close to Dr. Houlihan406 

VISN did substantiate an allegation that a patient discharged in June 2011 received 

oxycodone despite a history of violating his narcotic contract.407 Based on this finding, VISN 

issued four recommendations, including a review of the prescription refill policies at the Tomah 

V AMC408 The only other substantiated allegation concerned a veteran who was diagnosed with 

Psychalgia and prescribed unsafe levels of pain medications.409 The VISN created an action plan 

to examine this incident, led by the VISN's Chief Medical Officer (CMO), Dr. Michael 

Bonner.410 

Victoria Brahm, a VA employee for over 34 years and who in April 2011 held the 

position of Chief of Quality Management (QMO) and Chief of Nursing, was among the VISN 

employees who reviewed the Tomah allegations.411 According to Ms. Brahm, the VISN action 

plan examined three main areas at the Tomah V AMC.412 First, it addressed the Tomah VAMC's 

failure to follow early refill guidance, which Ms. Brahm found concerning because "there was 

lots of documentation indicating that early refills were still continuing" with patients who 

regularly received early prescription refills in the past.413 The action plan also sought to institute 

a strong policy rooted in annual urine screens, and associated negative action if the screens 

returned negative. 414 Finally, the action plan sought to address the failure of Tomah VAMC's 

lab panels to properly document and justify such exotic prescription practices. 

In a transcribed interview, Ms. Brahm explained the VISN's concern that the Tomah 

V AMC did not have documentation that other pain management methods were ineffective. She 

stated: 

So when you looked for 24 drugs, I don't think marijuana or Oxycodone was in 

those. So to use a different panel to enhance their panel when they were 

screening. So they wouldn't have seen marijuana usage on those [panels), which 

would have been a big factor in these patients. And then the other thing was to 

assess--the CMO was going to assess whether or not these patients really were 

405 Memorandum from Network Director, VISN 12, to VA OIG Hotline Div. (June 21, 2011 ), OIG 1435, at OJG 

1438-43. 

406 Id 

407 Id at OIG 1441. 408 !d. 

409 Id. at OIG 1441-42. 410 Id. at OIG !442; see also Brahm Transcribed Interview, at 11. 411 Brahm Transcribed Interview, at 9, 96. 412 ld. at 74. 413 !d. at 74-77. 414 !d. at 74. 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

74 
154 

getting all of this other modality that we kept hearing. You know, they flunked 

all this, so we have to use the benzos and opioids because they've done all these 

alternate therapies. Really, because we didn't assess-how can we make more of 

those therapies available? Like aroma therapy. Like acupuncture. Like healing 

touch. Like chiropractors. That kind of thing. Because the documentation was 

not strong, other than verbally saying, these, they had failed. We weren't 

seeing it. 415 

Subsequent transcribed interviews conducted by Chairman Johnson's staff cast some 

doubt on the thoroughness of the VISN 12's review. Chairman Johnson's staff interviewed 

Renee Oshinski, who served as the VISN 12 Deputy Network Director since 2004.416 During 

Ms. Oshinski's interview, Chairman Johnson's staff presented to her the hotline complaints 

received by the VA OIG.417 She said that she had "never seen" these VA OIG hotlines, 

reiterating later "this is not anything I have even seen.'"' 18 When asked to elaborate, Ms. 

Oshinski also offered "an educated guess" that VISN did not receive everything surrounding the 

hotlines.419 Indeed, the VA OIG's referral email only provided VISN 12 with a list of the 

allegations and not all the associated material that the OIG had on record.420 

Ms. Brahm explained that she became aware of the Tomah VAMC hotline complaints 

when they were sent to the VISN and the VISN 12 Network Director Dr. Jeffrey Murawsky 

assigned her as the lead421 Dr. Murawsky instructed Ms. Brahm to ask Jolena Renda, a nurse 

practitioner, to examine the cases 422 Ms. Renda, according to Ms. Brahm, had worked for the 

VISN and performed many of the chart reviews and was familiar with all the Tomah V AMC 

records. 423 Ms. Renda performed the preliminary chart reviews before they were sent "off site" 

for review by a psychiatrist424 Ms. Renda performed a total of five peer reviews, the findings of 

which were two findings of level!, two findings of level 2, and one finding of!evel3.425 Ms. 

Brahm said that she then sent the peer reviews to Dr. Murawsky for his review before the 

eventual response to the VA OIG Hotline Division426 

415 I d. at 74-75 (emphasis added). 416 Oshinski Transcribed Interview, at 9-1 0; VISN 12- Great Lakes Health Care System: Leadership Team, DEP'T 

OF VETERANS AFF., http://www.visnl2.va.gov/about/leadcrship.asp. 417 Oshinski Transcribed Interview, at 77-80. 418 I d. at 79. 419 /d. at 80. 420 The VA OIG Hotline Division April 13, 2011 email transmission to VISN 12. OIG 1435-37. 421 Brahm Transcribed Interview, at 96. 

422 /d. 423 I d. at 99. 424 !d. 

425 ld. at 104. 426 I d. at !04-05. 

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Senator Ron Johnson, Chairman 

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Ms. Brahm stated that after VISN 12 sent its response to the VA OIG, she sent an email 

to Dr. Murawsky requesting that the VA initiate an Administrative Investigation Board (AIB).427 

She said that Dr. Murawsky denied her AlB request. 428 

Ms. Oshinski explained to Chairman Johnson's staff that she had no involvement or input 

into the VISN 12's review of the Tomah VAMC allegations. 429 Despite her not being involved, 

however, the document sent back to the VA OIG on June 21,2011, displays Ms. Oshinski's 

electronic signature on the last page. 430 Ms. Oshinski said that she did recall reviewing the 

document before it was sent to the VA OIG, but she confirmed it was her electronic signature.431 

During her transcribed interview with Chairman Johnson's staff, she explained why her 

electronic signature was attached rather than the signature of Dr. Murawsky. She stated: 

Q: So you signed this document on behalf of Dr. Murawsky who was the 

VISN Director? 

A: I happen to know lot about this today. Is that Dr. Murawsky was on 

travel and had been working with the individuals who responded to 

this and so they sent him everything and he okayed sending it out, and 

our office manager, because he was not in the office, attached my 

electronic signature instead of Dr. Murawsky's.432 

In support of her belief that her signature was a mistake, Ms. Oshinski cited an email that 

Dr. Murawsky sent that gave the office approval to send the document to the VA OIG.433 Not 

only did she believe the signature was mistakenly affixed to the response memorandum, but Ms. 

Oshinski said that she did not agree with VISN 12's conclusions. She explained: 

Q: Correct me if I'm wrong. I sense that you're not too pleased that your 

signature was placed on this? 

A: I'm not very pleased, no, I'm not. I at the time made a comment that I 

was astounded that they were all unsubstantiated.'34 

When asked to elaborate, she responded: 

427 I d. at l 05. 

"' !d. 429 Oshinski Transcribed Interview, at 81. 430 Memorandum from Network Director, VISN 12, to VA OIG Hotline Div. (June 21, 2011), OIG 1435, atOIG 

1443. 

431 Oshinski Transcribed Interview~ at 80. 

"'I d. 433 Id. at 81. 434 ld at 82-83. 

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Senator Ron Johnson, Chairman 

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I just thought with the number that were there-honestly, when we respond to an 

IG repmt, we could either say substantiated, partially substantiated, 

unsubstantiated. With the number of things here, 1 would have thought there 

would have been some prutially or whatever. I mean, just based on the number, 

that it's not a normal response that we would have. but, again, I know that people 

looked at the charts. I don't know who they talked to. 435 

Ms. Oshinski explained that, for her, what differentiated VISN l2's response to the 

Tomah V AMC allegations from other similru· OIG referral was the lack of any "partially 

substantiated" fmdings in the Tomah V AMC review.436 When asked how the VISN handled 

substantiating allegations, she described a lack of"a hru·d-and-fast criteria" and that it is a 

"judgement call of the individuals who ... put[] ... together" the review.437 She fmiher stated 

that she felt the Tomah hotline was an outlier compared to other refen-als due to the number of 

allegations that were in the Tomah complaints438 Ms. Oshinski recalled being "smprised" that 

the OIG sent this to the V1SN and wasn't conducting a separ·ate investigation.439 

9. june 28,2011: The VA OIG dosed the March 2011 Tomah VAMC hotline complaints 

Shortly after it received the v1SN 12 response that did not substar1tiate a majority of the 

allegations. the VA OIG authorized the closure of the case on June 28, 2011 440 The VA OIG 

notified the complainant via an email dated July 5, 2011 that the case was closed441 

Figur• 19: VA OIG Hollin• uotillcafiou to complainant of dosod coso (July 5, 2011)"" 

VA DIG Hotline 

Frorn: 

Senl, 

To: 

Subject: 

Deac-: 

VA OIG Hc111ine 

TUtt'l.t!<IV, .July 05. 2011 9 32 """'1 

Jk JIE\oji.nJ lauo tlowo <m9Yl 

This wtll not1fy you that tho VA Offico of Inspector Gonoral (OIG) has closed Case Numbor 2011-

02008-HL-0497 As we advts~;td you wl1en we openfM:I Hus case, our dectJ~>tOn to do!'ie a Hothne cast'!' 

1s fulcll. and I here nre no appeal nghts. 1nqu1nes tor release ol 100 result!) <Jro considered on a case· 

by-c;,~~e basis in response to written and signed request:; made pursuant to the Freedom of 

lnfonnatJon Act 

"'!d. at 83. 

"'!d. 

437 Jd. at 92-93. 

JJR !d. at 85-86. 

"'!d. at 85. 40 VA OIG Hotline Input Transaction, MCI # 2011-02008-HL-0497 (May !, 2015. 1!:50 AM). OIG 1390. at OIG 

1390-91. 

"'

1 E-mail from Representative 99. VA OIG Hotline (July 5. 2011, 9:32AM). at O!G 1380. -1-12 !d. 

~1ajority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

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10. Fall2011: VISN 12's Chief Medical Officer visited the Tomah VAMC, noting "room for 

improvement" 

Although the VA OIG closed the Tomah VAMC allegations in July 2011, VISN 12 

continued to address the issues disclosed in the OIG complaints. VISN 12's Chief Medical 

Officer, Dr. Bonner,443 served as the lead official on VISN 12's action plan and visited the 

Tomah VAMC in the fall 201 1.444 Dr. Bonner said in a transcribed interview with Chairman 

Johnson's staff that he did not recall seeing the June 20 l 1 referral from the VA OlG, but that he 

did understand that the action plan would be sent to the OIG.445 During his site visit at the 

Tomah VAMC, he had discussions with Dr. Houlihan about the use of urine drug screens, among 

other topics 446 He also reviewed Dr. Houlihan's patient charts. 447 

What Dr. Bonner learned was not encouraging. Dr. Bonner determined the Tomah 

VAMC was not doing urine drug screens "routinely."448 He said that he recalled having thought 

"there was room for improvement" at the facility 449 During his site visit, Dr. Bonner learned 

from staff that the Tomah VAMC did not have an early prescription refill policy. He spoke 

directly with Dr. Houlihan about the facility's early refill policy, random urine drug screens, 

opiate agreements among other "process issues.'r~so Dr. Houlihan apparently responded to the 

conversation well and agreed to institute changes in those specific areas.451 

During his transcribed interview with Chainnan Johnson's staff, Dr. Bonner described his 

impressions of this conversation with Dr. Houlihan. He stated: 

Q: I think you said at the time, you left in September, 20 1 1, pretty much 

feeling that Dr. Houlihan had agreed to fixA: Yeah. 

Q: -these issues? Would that be correct? 

A: Correct. He seemed open to it. I mean, he wasn't, he wasn't resistant 

to it. I mean, this issue of his prescribing habits had, you know, from 

what I had been told had already been-come up and been looked at. 

That's a, that's a clinical provider issue that's separate than process 

443 Dr. Bonner became the Chief Medical Officer at YlSN 12 in December 2010 and left the position in July 2012. 

Bonner Transcribed Interview, at lO. 444 !d. at 21. 445 !d. at 19-21. 446 !d. at 20-21. 447 /d.at21. 448 ld. 

449 ld at 23. 450 !d. at 24. 451 !d. 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

78 
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issues related to overall prescribing. And, you know, I mean, I tried to, 

you know, emphasize to him the need to have a very strong, you know, 

process related to this, esrecially if he was practicing, you know, the 

way he was practicing. 45 

On September 15,2011, Dr. Bonner drafted and sent a two-page memorandum to the 

VISN 12 Network Director, Dr. Murawsky, summarizing the actions completed by the VlSN 12 

in connection with the VA OIG hotline complaints on the Tomah VAMC.453 He told Chairman 

Johnson's staff that he drafted this document after his Tomah VAMC site visit based on a 

"referral for action" he received from Dr. Murawsky.454 

The memorandum tracks closely with Dr. Bonner's recollection of his conversation with 

Dr. Houlihan that the Tomah VAMC would institute new policies. Dr. Bonner's examination of 

the Tomah VAMC included "a review of the Tomah early fill policy" and it found that "no 

written policy was identified."455 His memorandum noted that based on his site visit "[a]n early 

fill policy was developed cooperatively with involvement of primary care, mental health and 

pharmacy and was implemented.'456 In total, three out of the four areas that Dr. Bonner 

examined in his site visit required "action items" to meet applicable guidelines.457 Only one area 

was deemed sufficient, as Dr. Bonner determined that the "Tomah VAMC's pain treatment 

options [met] applicable guidelines."458 Accordingly, VISN 12 took no action in this area. 459 

11. August 25, 2011: The VA OIG hotline group received additional allegations about Dr. 

Houlihan and prescribing practices at the Tomah VAMC 

In late August 2011, less than two months after the VA 010 closed its hotline complaints 

about the Tomah VAMC, it received new allegations via an anonymous phone call about Dr. 

Houlihan and Deborah Frasher, a nurse practitioner at the facility. These allegations would 

eventually become the basis for the VA OIG's health care inspection of the Tomah VAMC that it 

closed in 20I4. 

452 !d. at 26···27. 453 91!5/20 II Memo from Michael Bonner to VISN 12 Network Director, at OJO 19-20. 454 Bonner Transcribed Interview, at 39--40. 455 9/15/2011 Memo from Michael Bonner to VISN 12 Network Director, at 010 19. 456 Jd. 

457 !d. at 010 19-20 458 !d. at 010 20. 459 !d. at 010 20. 

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Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

79 
159 

Figure 20: Repo_!:t of VA OIG hotline complaint (Aug. 25, 2011)460 

Hot:ln.-: Inpnt Tr.!m!li.!Ction 

F'hcal Yaal' ~ An&toly•t WI!,UAA.<; 

CoaplaJ.nt Received 08/25/2011 

Pa~;J 

Cor.r=.eti ve Action 

Oi•po•li tt.on D•t• PTiority CQngr•s•ional Interest ~ 

According to an iutemal OIG document, on August 25, 2011, the OIG hotline group 

received a phone call from an anonymous complainant who provided a number of serious 

allegations that involved Dr. Houlihan and Ms. Frasher.461 The caller alleged Dr. Houlihan and 

Ms. Frasher were abusing their authority and were prescribing "massive doses of opiates to 

veterans with posttraumatic stress disorder (PTSD)."462 The caller further told the VA OIG that 

Dr. Houlihan "writes prescriptions continuously for early re-fills and when questioned, he 

instmcts the pharmacy to fill it anyway."463 At the time of the contact, the OIG docmnent noted 

that the issue had not been previously reported and described the case as having no congressional 

interest464 The hotline complaint received the case number 2011-04212-HL-1068465 

12. September 1, 2011: The VA logged an anonymous letter presenting additional 

allegations about the Tomah VAMC 

Separatelt,· the VA OIG received an anonymous two-page letter alleging problems at the 

Tomah V AMC.'1 6 TI1e letter was postmarked from La Crosse, Wisconsin, and addressed to the 

VA OIG Hotline office in Washington, D.C.467 This letter alleged the same issues concemiug 

Dr. Houlihan that the OIG hotliue group received via a phone call on August 25, 2011 468 The 

date stamp on the envelope was August 18. 2011,469 but the complaint was not Jogged into the 

VA OIG's case management system until September 1, 2011 .'170 

400 VA OIG Hotline Input Transaction. MCI # 2011-04212-HL-1068 (Oct. 3, 201 I. 7:36AM, atOIG 12352. 

"'!d.: Porter Transcribed InterYiew. at 19 (VA OIG Special Agent Porter identified Ms. Frasher as the name under 

the redactions). 4621d. 

463 Jd. 

'64 !d. 

465 Jd. 

466 Anonymous Lener and Envelope. OIG 12354~~n. 467 Envelope, OIG 12357. 

:::VA OIG Hotline Input Transaction. MCI # 2011-04212-HL-1068 (Oct. 3. 2011. 7:36AM). at OIG 12352. 

Envelope. OIG 12357. 

m VA OIG MCI Search Results. MCI # 2011-04212-HJ-0267 (Oct. 3. 2011. 7:25AM), at OIG 12358. 

~~...._ 

~'If • I 

I 

:\Iajority Staff Report 

Committee on Homeland Security and Governmentn1 Affairs 

Senator Ron Johnson, Chairman 

80 
160 

Figur• 21: Enwlop• or anonymous complaint (Aug. 18, 2011)"' 

---,==''"''"-i~~ ___..:....-.._..... . i 

lE. 1!1.UG. :!D.l·l P1"'J l L .~:::-::::.,.. .. ~ 

.. -.... •........ -• ~·· 

VA 1.YI5yJedot. &:n~<tt 

Hott~t'le (S"3E) 

p,o. 6ox ,'io11o 

1., L · ton D.<! .. vvo.smr"lj ' a...oo q 1-0 'Ito 

13. September Z, Z011: The VA OIG's Chicago office developed a work plan and 

assembled a team to examine the Tomah VAMC allegations 

On August 29. 20 II, the VA OIG hot line group presented the complaints about the 

Tomah VAMC to the Oftice ofHealthcare Inspections field office in Chicago, Illinois.472 The 

field office accepted the complaints the following day. 473 The Associate Director of the Chicago 

field office. Wachita Haywood. assigned the hotline complaints to Roberta Thompson,474 but the 

lead OIG point of contact remained Verena Briley-Hudson, the Regional Director of the Chicago 

office.475 Along with other employees from the OIG's Chicago field office,476 a team of three 

physicians-Dr. Michael Sh;liherd. Dr. Thomas Jamieson, and Dr. Alan Mallinger-were 

assigned to the case as well 4 7 

471 Envelope. OIG 12357 . 

.tn E-mails between Steven Wise, Yohanneo;; Debesai, Wachita Hayv.'ood, & Verena Briley-Hudson. VA OIG (Aug. 

29-31. 2011). OIG 11204, at OIG 11205. 473 E-mails betv.'een Steven Wise. Yoha1u1es Debes.ai, Wachita Ha)'1Nood, & Verena Btiley-Hudson. VA OIG (Aug. 

29-3 I. 2011), OIG 11204, at OIG 11204-06. 41' E-mail from Wachita Haywocxl VA OIG, to Robe11a Thompson, VA OIG (Aug. 31. 2011, 9:~3 AM). OIG 

12874. at OIG 1287-1-75. 475 VA OIG MCI Search Results. MCI # 2011-04212-HI-0267 (Oct. 3. 2011. 7:25AM), at O!G 12358: Haywood 

Tran5.ctibed Interview, at 21. 

mE-mail from Yohannes Debesai, VA O!G, to Verena Btiley-Hudson. VA OIG (Aug. 31, 201!. 3:03PM). at OIG 

11204. Verena Briley-Hudson and Robena TI1ompson fi·om the Chicago Field Office were also assigned to the 

Tomah case, Jd. .t7i Jd. 

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This complaint was assigned the case number 2011-04212-Hl-0267,478 which is the case 

number associated with the final administrative closure issued in 2014479 Internal OIG notes 

indicate that by September 2, 2011, the VA OIG team was "developing [a] workplan."480 

14. Fall2011: The VA OIG's Chicago field office slowly assembled information about the 

Tomah VAMC allegations 

According to Ms. Haywood, after receiving the allegations about the Tomah V AMC, she 

called leaders from VISN 12 and the Tomah V AMC to alert them that the OIG had received 

allegations, explain "a little bit about the case," and identify a liaison for the OIG inspectors.481 

Ms. Haywood said that she spoke by phone, at an unknown date, with either Dr. Murawsky or 

Ms. Oshinski of VISN 12 about the Tomah VAMC allegations and hotline. 482 On the morning of 

September 29, 2011, Ms. Haywood spoke with Carla Loging, the secretary to the Tomah VAMC 

Director, about the hotline.483 After the conversation, Ms. Haywood emailed Ms. Loging to 

formally request an "[a]ssigned [l]iaison from Tomah V A.'"84 Ms. Haywood copied on the 

email Dr. Houlihan and OIG staff assigned to the case.485 Dr. Houlihan responded, apprising the 

OIG that Julie Nutting would be the point of contact486 Ms. Haywood described her actions as a 

"courtesy call" and stated that she handled this hotline in "the way I do it all the time."487 

Documents obtained by Chairman Johnson indicate that the VA OIG's progress in 

examining the allegations was slow. The original due date for a report was December 31, 

20 II, 488 but it became clear that the Chicago field office would not meet that timeframe. At the 

end of August 20 II, when the hotline complaint was assigned to the Chicago OIG field office, 

the VA OIG headquarters office provided Dr. Shepherd and Dr. Mallinger with the "old Tomah 

case"-meaning the alle~ations received in March 2011 and closed in July 2011-along with the 

response from VISN 12. 89 

"'The MCJ Number was assigned by Yohannes Debesai on September 7, 2011. OJG Bates number 11203. 479 E-mail from Yohanncs Debesai, VA OIG, to Verena Briley-Hudson, Wachita Haywood, & Judy Brown, VA OJG 

(Sept. 7, 2011, 9:46AM), at OIG 11203; VA O!G TOMAH VAMC ADMINISTRATIVE CLOSURE. 480 VA OIG MCJ Search Results, MCI # 2011-04212-Hl-0267 (Oct. 3, 2011, 7:25AM), O!G 12358, at O!G !2359. 481 Haywood Transcribed Interview, at 26-27. 482 Jd. at 27. 483 E-mail from Wachita Haywood, VA O!G, to Carla Loging, Tomah V AMC (Sept. 29, 2011, 12:44 PM), at OIG 

8987. 

'

84 E-mail from Wacbita Haywood, VA OIG, to Carla Loging, Tomah V AMC (Sept. 29, 2011, 12:44 PM), at OIG 

8987. 

''' Id. 

'" Jd. 487 Haywood Transcribed Interview, at 27. 

'"E-mail from Yohannes Debesai, VA OJG, to Verena Briley-Hudson, VA OIG (Aug. 31,2011,3:03 PM), at OIG 

11204. 

489 E-mail from Yohannes Dcbesai, VA OIG, to George Wesley et al., VA OJG (Aug. 30, 2011, II :02 AM), at OIG 

11207. 

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VA OIG docmnents suggest that only a small amotmt of inspection activity occmred in 

the months between September 2011 and Januruy 2012. Instead, it appears that much of this 

time was spent understanding the closed Tomah V AMC allegations ru1d coordinating between 

the VA OIG's Chicago field office and Washington headqua11ers office. In mid-September 

2011, Ms. Haywood emailed a mm1ber of documents to Dr. Shepherd, Dr. Jamieson, and Dr. 

Mallinger, and other OIG employees from the Chicago field office who were assigned to the 

inspection.490 The docmnents were obtained from VISN 12 and appear to concem Dr. Houlihan. 

Ms. Haywood's email referenced a letter sent by an unknown individual-the VA OIG redacted 

the individual's identity before producing the email to the Conm1ittee-to VISN 12 and to the 

Peer Review Oversight Committee.491 She also noted that another document attached to the 

email was a sulllluary review of Dr. Houlihan's patients conducted by the same tmknown 

individual.492 Ms. Haywood opined the documents were "(i]nteresting reading indeed."493 

Figur~ 22: Email ft•om Wacbita Haywood to VA OIG ~mplor••s (Sept•mher 20 2011)4

" 

Included in these documents is a letter from to the VISN and to the Peer Rev1ew 

Oversight Committee. also did a summary review of his patients and provided his 

opinion back to the committee. There were several Level3, and others were Level 2. Interesting 

readi~g indeed. 

As explained, VA physicians are evaluated by their peers on a three-tier scoring system, 

with Ievell indicating the highest score and level 3 the lowest score. According to Ms. 

Haywood's email, the unknown individual's review of Dr. Houlihan's cases came to "several" 

level 3 conclusions-in which "most experienced. competent practitioners would have managed 

the case differently in one or more aspects listed in the criteria."495 

"'E-mail from Wachita Haywood. VA OIG, to Michael Shepherd. Thomas Jamieson. & Alan Mallinger, VA OIG 

(Sept. 20, 2011, 11:30 PM), at OIG 11201. 

.c~ 91 I d.; OIG Bate$ mnuber OIG 4757-4763. Peer Review Conunittee minutes. VA Memorandun1. 

"'E-mail fi·om Wachita Haywood. VA OIG. to Michael Shepherd. Thomas Jamieson. & Alan Mallinger, VA OIG 

(Sept. 20. 2011. 11:30 PM). at OIG ll201. 

"'!d. 

"'!d. 

"'Veterans Health Affairs. Assessment of Criteria for Required Peer Re\'iew. OIG 4768. at OIG 4769: E-mail from 

Wachita Haywood. VA OIG. to Michael Shepherd. TI10mas Jamieson. & Alan Mallinger, VA OIG (Sept. 20.2011. 

11:30 PM). at OIG 11201. 

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23: VA Assessment of Criteria for 

ASSESSMENT OF CRITERIA FOR REQUIRED PEER REVIEW 

(VHA Ointc::tiva 2004-054 Peat Revlew for Cuality Management} 

(VHA DlrtK:Uvu 2004-036 Mortality A&seu.ment) 

Ms. Haywood also ale1ted the team that VISN 12 planned to review Deborah Frasher's 

patients as well. 497 A little over a week later, on September 29, 2011, VISN 12 provided peer 

reviews for two of Ms. Frasher's patients, along with a "Scope of Practice" document that 

outlined what Ms. Frasher was authorized to do as a nurse practitioner498 

On November 10. 2011, Ms. Nutting, the Tomah VAMC's point of contact with the OIG. 

emailed Roberta Thompson with a hyperlink to a restricted SharePoint site. 499 This site allowed 

the Tomah VAMC to upload documents for OIG's review. She advised the OIG that documents 

would be uploaded soon and restfonded to a question of whether the police staff at Tomah were 

contractors or VA employees50 Five days later, on November 15. 2011, Ms. TI10mpson shared 

the Share Point site with the rest of the OIG team.501 

The VA OIG removed one physician. Dr. Jamieson. from the Tomah VAMC case on 

November 15,2011, after he was assigned to work another congressional request502 In late 

20 II, VA OIG employees in Chicago and Washington continued to share infommtion via phone 

calls and emails. In preparation for a scheduled conference call on the Tomah VAMC hotline 

allegations, Dr. Mallinger emailed Dr. Shepherd and Dr. Jamieson the March 20 II complaints. 

the VISN 12 response. and a1ticles written on Dr. Houhhan503 In the end, Ms. Thompson 

cancelled the conference call on November 17, 2011: there is no indication that the call was 

rescheduled. SIJ.l 

96 Veterans Health Affairs, Assessment of Criteria for Required Peer Review, DIG 4768, at OIG 4769. 

"'E-mail from Wachita Haywood. VA OIG. to Michael Shepherd. Thomas Jamieson, & Alan Mallinger. VA OIG 

(Sept. 20, 2011, 11:30 PM). at OIG 11201. 498 E-mail from Wachita Haywood. VA O!G, to Robetta Thompson, VA OIG, et al. (Sept. 29. 2011. 11:48 AM). at 

OIG 11200. 499 E-mail from Thomas Jamieson. VA O!G, to Robetta Thompson, VA OIG (No\·. 15. 2011. 1:37PM). at OIG 

11190. 

500 /d. The Tomah VAMC' Police Depat1ment .s.taff members are VA employees. not contractors. 501 I d. 

502 !d. 503 E-mail from Alan Mallinger. VA O!G. to Michael Shepherd & Thomas Jamieson. VA O!G (NoY. 8. 2011. 2:42 

PM), at OJG 11197. 

"'E-mail from Robetta Thompson, VA O!G. to Alan Mallinger. VA O!G (Nov. 17.2011.9:34 AM). at OIG 11187. 

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Committee on Homeland Security and GoYernmental Affairs 

Senator Ron Johnson, Chairman 

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15. September 29,2011: The Tomah VAMC Hotline became a "congressional" request 

About one month later, on September 29,2011, Congressman Ron Kind's office sent a 

fax to the VA OIG asking the office to review a comfclaint that the office had received 

concerning "Dr. David Houlihan at the VA Tomah." 05 This anonymous two-page letter was 

identical to the letter the VA OIG received on September I, 2011. 506 The letter raised concerns 

about the prescribing practices of Dr. Houlihan and nurse practitioner Deborah Frasher. The 

complaint described Dr. Houlihan and Ms. Frasher's prescription practices as "escalating at such 

a high rate it is scary."507 

The letter provided a summary of an "incident" in which one of Dr. Houlihan's patients 

allegedly received an early refill on his narcotic medication.508 Shortly after receiving the early 

refill of narcotics, the patient checked himself into the Tomah V AMC in a poor physical 

condition 509 While at the facility, doctors performed a drug screen, which showed that there 

were no opiates in the patient's system.510 This result led the complainant to conclude that the 

patient had sold his medication 511 This patient was admitted to the Tomah VAMC for a month 

longer and, after his discharge, Dr. Houlihan prescribed the patient oxycodone for pain.512 

Allegedly, the patient ended up back in the hospital shortly after due to a "cocaine binge."513 

The complainant concluded: "This is just one of many patients of [Dr. Houlihan's] that are out 

and out drug abusers, but he continues to give them what they want, no questions asked."514 

After receiving the letter from Congressman Kind, the VA OIG's legislative affairs 

officer alerted the congressional staffer via email that the VA OIG had received matching 

allegations separately.515 In the same email, the VA OIG legislative affairs officer inquired 

whether Congressman Kind sought a response and the staffer asked the OIG to prepare a written 

response. 516 On October II, 20 II, the VA OIG sent a response letter to Congressman Kind, 

confirming that the VA OIG had initiated a review of the allegations and planned to provide the 

505 Fax from Han. Ron Kind, Member, U.S. H. of Reps., to VA Inspector General (Sept. 29, 2011), OlG 1484, at 

OIG 1484-86 [hereinafter 9/2912011 Fax from Rep. Ron Kind to VA IG]. 506 VA OIG MCI Search Results, MCI # 2011-04212-Hl-0267 (Oct. 3, 2011,7:25 PM), at OIG 12358; Anonymous 

Letter to VA Inspector General, OIG 12354, at OIG 12354--57; 9/2912011 Fax from Rep. Ron Kind to VA IG, OIG 

1484, at OIG 1484-86. 507 9/2912011 Fax from Rep. Ron Kind to VA IG, at OIG 1486. 508 ld at OIG 1485. so9 Id. 

510 Jd 

511 !d. 512 ld at 1486 5!J ld. 

514 ld 515 850, E-mail from Staff ofHon. Ron Kind, U.S. H. of Reps., to Catherine Gromek, VA OIG (Oct. 4, 2011, 4:29 

PM), at OIG 9962 [hereinafter 1014/2011 E-mail from Staff of Rep. Ron Kind to Catherine Gromek, VA OIG]; VA 

Hotline Input Transaction, MCI # 2011-04212-hl-1068 (Oct. 3, 2011, 7:36AM), OIG 12352, at OIG 12352-53. 516 I 0/4/20 II E-mail from Staff of Rep. Ron Kind to Catherine Gromek, VA OIG, at OIG 9962. 

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Senator Ron Johnson, Chairman 

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results when completed517 This response was signed by Ric hard Griffin, the Deputy Inspector 

General, in lieu of VA Inspector General George Opfer.518 

On October 3, 2011, over a month after receiving the same allegations, the VA OIG 

categorized tllis complaint as a "congressional" complaint and the correspondence was assigned 

a case mm1ber of2011-04212-CR-OOO I. 519 On October 6, the VA OIG 's legislative affairs 

officer infonned Office of Healthcare Inspections and the OIG Hotline Division that the Tomah 

VAMC allegations were now a "cong.ressional."520 According to VA OIG doctnuents, this 

congressional re~uest was assigned the same case number as the OIG hot line contact from 

August 25, 2011. 21 

Fignr• 24: VA OIG •m•il r•gat·diug congrossioual iutorost in tho Tomah V AMC (Oct. 6, 2011)"' 

From: 

Seot 

To: 

Cc: 

Subject: 

Gromek, Catherine A. {OJG) 

Thursday October C6. 2011 2:30 PM 

W1se, Stevt>n (OIG); ~hi!lips, Chf iOIG~; o:G 54 Hotline Managemer.t Team 

Richardson. Dw•gh: (OIGJ 

lor'ld"' VAMC 

The case 2011·4212 HL 1068 and 2011·4214·HI·0267 is now a congressional please no:e !hal in your 

records. Also note tha11he 120 days runs from Sept 1. 2011- so :h1s IS due around the New Year! 

Happy New Year' 

Subsequently, in mid-December 2011, Ms. Haywood sought to understand how the 

Tomah VAMC allegation had become a congressional request and she requested a copy of the 

congressional letter from VA OIG headqumters oflice 513 A response from the OIG central 

office, with Congressman Kind's letter, was sent to her on December 14, 2011 524 

517 Letter from George Opfer. VA OIG. to Hon. Ron Kind, Member. U.S. H. of Reps. (Oct. 11. 2011), OIG 12342, 

at OIG 12342. 

"'!d.; VA OIG ConcmTence and Sunuuary Sheet (Oct. 6. 2011). at OIG 12348. 

"'VA O!G Hotline h1put Transaction. MCI # 2011-04212-CR-001 (May 5. 2015, 11:37 AM). at O!G 1481. 

'"E-mail from Catherine Gromek, VA O!G, to Hotline Mgmt. Team. VA OIG (Oct. 6. 2011.2:30 PM). at OIG 

11199. 

521 Hotline Contact Case. Case# 2011-04212-HL-1058 I H1-0267 (May 5. 2015. 4:18PM), at O!G 1487. 522 E-mail from Catherine Gromek. VA OIG. to Hotline Mgmt. Team. VA OIG (Oct. 6, 2011.2:30 PM). at O!G 

11199. 

523 E-mail from Wachita Haywood, VA OIG. to Yohannes Debesai. VA O!G (Dec. 13. 20ll. 1:22PM). at O!G 

11181 

'"E-mail from Yohauues Debesai. VA OIG. to Alan Mallinger et aL. VA O!G (Dec. 14. 2011. 1:49PM). at OIG 

ll181 

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166 

16. December 2011: VISN surmises to VA OIG that "disgruntled employees" could be 

responsible for Tomah VAMC allegations 

In December 2011, Dr. Mallinger sought out VISN 12 Chief Medical Officer, Dr. 

Bonner, to seek his "insights into the situation" because the August 20 II allegations were not 

"very substantive."525 The insight yielded more of the same from the VA, as Dr. Bonner advised 

the OIG that the Tomah VAMC "had made some changes" and VISN 12 was "hopeful things 

would be better."526 At the time ofthe phone call, Dr. Mallinger recalled having a skeptical view 

of what Dr. Bonner was telling him. 527 

According to Dr. Mallinger, he had another conversation with Dr. Bonner around the 

same time about the Tomah VAMC allegations. Dr. Mallinger described the conversation during 

his transcribed interview with Chairman Johnson's staff. He stated: 

I remember having a conversation with him around that time, and I asked him 

why he thought someone would make these kinds of complaints, you know, 

particularly the March complaint where it wasn't anonymous, and put their 

reputation on the line, you know, if-if there wasn't some kind of a serious 

problem going on there. And his reply to me at the time was that he thought these 

were disgruntled employees making these allegations.528 

Dr. Mallinger recalls noting these conversations with Dr. Bonner, but he continued his work on 

the inspection to determine the veracity of the allegations himself. 529 

17. December 2011: The VA OIG team in Chicago requested an extension on their work 

On December 13, 2011, a few weeks before the original due date for the OIG's work, Ms. 

Thompson emailed Dr. George Wesley, the Director of the Medical Consultation and Review 

Division within the VA OIG's Office of Healthcare Inspections, requesting an extension of the 

due date for the Tomah VAMC hotline. 530 Ms. Thompson communicated to Dr. Wesley that the 

extension is necessary "due to the complexity and scope of the hotline, as well as the workload 

and leave schedules of the staff assigned to the hotline."531 Dr. Shepherd and Dr. Mallinger, 

along with the other employees on the Tomah VAMC inspection, informed Dr. Wesley that a 

525 Mallinger 3/8/2016 Transcribed Interview, at 78; VA OIG Healthcare Transaction Report, MCI # 2011-04212-

Hl-0267 (May I, 2015, II :46 AM), at OIG 1394. 526 Mallinger 3/8/2016 Transcribed Interview, at 78. 527 I d. at 79. 528 Id. at 80. 529 Id. at 81. 530 E-mail from Roberta Thompson, VA OIG, to George Wesley, VA OIG (Dec. 13, 2011, 5:15PM), at OIG 11183 531 Id 

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"realistic" draft report due date was March 31,2012.532 Dr. Wesley granted the extension 

request. 533 

Dr. Mallinger explained that he thought there were several things that contributed to the 

Chicago office requesting an extension. He first believed the Chicago office was "very 

overworked" and had a lot of commitments to other responsibilities. 534 The other reason for the 

delay, according to Dr. Mallinger, was that the case "was a very complex hotline in many 

ways."535 Dr. Mallinger complained that the "allegations were all over the place. You know, 

they ran from law enforcement to clinical practice to personnel practices. They ran into a lot of 

things that we really even can only touch on in selected ways as they related to patient care."536 

He also explained that the VA OlG would typically seek to interview the complainant 

and hopefully gain valuable information to further the inspection. 537 However, because the 

August 2011 allegations were made anonymously, Dr. Mallinger explained that was not an 

avenue for the 010.538 He said the complaint "was kind of like being dropped into the middle of 

the desert, you know, and not really even necessarily knowing what direction to go in."539 

Dr. Mallinger said to Chairman Johnson's staff that the VA OIG inspectors tried to use 

the March 2011 complaint for some leads. The OIG did not interview the March 201I 

complainant, however, because, according to Dr. Mallinger, "[t]hey were different allegations" 

and "the case wasn't reopened."540 When further questioned about the decision whether to 

interview the March 2011 complainant, Dr. Mallinger stated that the VA OIG did not have any 

questions for him after reviewing the documents. He said: 

sJz I d. 

Q: Did you have any thoughts of potentially reaching out to that March 

2011 complainant since an interview of that person wasn't done? 

Because, you know, you're in the desert here, as you're saying, and 

you're looking for leads. Potentially talking to that person from the 

March 2011 complaint might have--could help, maybe. 

A: Well, I can't say that I have any recollection of whether we thought 

about it and didn't do it or didn't think about it. We had a lot of 

material that he had submitted, and in a sense that was a logical 

533 VA OIG Hotline Inspection Work Plan, MCI # 2011-04212-HI-0267, # 2011-04212-CR-0001 (Apr. 30, 2012), 

010 12222, at OIG 12223 [hereinafter VA OlG Hotline Inspection Work Plan].. 534 Mallinger 3/8/2016 Transcribed Interview. at 83. 535 ld. 

536 !d. 

537 ld. 

"'!d. 

139 !d. at 83-84. 540 ld. at 84-85. 

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Senator Ron Johnson, Chairman 

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starting place. And I think that by the time we got through that 

material, I don't think we had questions for him.541 

II is not known if the VA OIG spoke with the M;uch 20 II complainant with the complaint in the 

spring of 20 II. If the VA OIG did interview the complainant then, it appears the information 

was not shared with Dr. Mallinger. 

18. December 2011: Deputy Inspector General Richard Griffin requested the referrals 

relating to the Tomah VAMC allegations 

Separately, in mid-December 201 L Deputy Inspector General Richard Griffin requested 

from a VA OIG legislative affairs officer the "refetTals" couceming the Tomah VAMC and 

another case542 II is unclear what prompted Mr. Griffin to request the refenal relating to the 

Tomah VAMC. 

Figurt' 25: Email from CathPrinP GromE'k to Dr·. John Daigh (>t n.J.543 

Daigh, John {OIG} 

To: 

S<lbjo<t: 

Gromik, C~l'\tnne A. {OlG) 

7h.ursda)', Oe<f'~ 15, 101lll~AM 

Do;gtt Johr (SES) (OIG); Chri>L Pat<itia (SIS) (O!Gl Wo!ill!y. G!!O<~ (SES) (OiG) 

R.-efemtls 

Griff would llke the see tile referrals foe .. and Tomah. 

Dtuing his transcribed interview with Chainnan Johnson's staff, Dr. Daigh said that he 

did not recall the request but that he "always tr[iesJ to answer my boss' request, so I'm goin& 

to-without any specific memmy or notes, I'm going to say I'm sure we talked about this." l

4 

Dr. Wesley also did not recall this request bnt he provided a more in-depth explanation to Mr. 

Griffin's request to see referrals. 545 He explained: 

Let me explain as best I can because I agree the word "refcnals" is complicated, so 

please bear with me. But in that it was now a congressional, it meant Cathy Gromek now 

had an interest in it. She wouldn't have prior or would have been less interested prior. 

Now, the way our building is, it's the lOth floor where the operational oftices are; the 

11th tloor is where Mr. Griffin and counsel and Cathy Gromek are. So now, because of-

"'I d. at 85. 

'"'E-mail from Catherine Gromek. VA OIG. to John Daigh, Patricia Chdst, George Wesley, VA OIG (Dec. 15. 

2011, 11:50 AM). at OIG 10298 $-i] Jd. 

:~ Daigh Transcri~ed Intervie.w. at 32. 

Wesley Transcnbed lnten·Jew, at 119-20. 

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Senator Ron Johnson, Chairman 

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Cathy is now interested in the case-that's what I take from this-because it's a 

congressional. The I I th floor, Mr. Griffin would worry about congressionals. So he 

would weigh in more than he would have if it was a non congressional. 

The thing that bothers me about this email is it says "referrals." Does this mean he 

actually wants to see the raw allegation that came in at the end of-in August? Or does 

he want a briefing on just where we are with the case? I take "referrals" to mean they're 

asking actually-! think he actually wanted to see the raw material, whatever that exhibit 

was.s46 

19. Late 2011: VA OIG headquarters in Washington became increasingly involved the 

Tomah VAMC inspection 

The VA OIG health care inspection of the Tomah VAMC was originally assigned and 

worked from the OIG's office in Chicago, Illinois; however, after a period of time, the OIG team 

in Washington took an increasing role. The VA OIG assigned three physicians to examine the 

Tomah VAMC hotline allegations. Dr. Alan Mallinger and Dr. Michael Shepherd-both of the 

OIG's Washington, D.C. office-actively reviewed the allegations in the fall of20ll, but as the 

year ended, it appears that a decision was made to transfer the inspection to the Washington 

office full time. Dr. Mallinger's work on the inspection grew accordingly. 

During his transcribed interview with Chairman Johnson's staff, Dr. Mallinger said that 

his involvement in the inspection increased in late 2011. He recalled reviewing all of the 

allegations made in March 2011-referred to VISN 12 for action-and the VISN 12 response in 

June 2011.547 He was unclear precisely when he reviewed these documents, but he recalled the 

allegations and described them as "alarming" and involving "some very serious problems."548 

Dr. Mallinger was a member of the VA OIG's hotline team when the 01G received the VISN 12 

response in the summer of 2011. He took note of the response but was not involved in the 

review at that time.549 His involvement changed after the VA OIG received the new anonymous 

allegations in August 2011. 

He told Chairman Johnson's staff that the March 2011 allegations were "serious" and the 

"August allegations were equally as serious" and that some of the allegations in both cases were 

similar550 Dr. Mallinger offered two reasons why, at the time, he believed the allegations 

deserved a second look. First, the August 2011 allegations, he said, contained "alarming 

546 ld. at 120-21. 547 Mallinger 3/8/2016 Transcribed Interview, at 44--45. 548 Jd. at44. 549 !d. at 46. 550 !d. at 46--47. 

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material" that evinced a "pattem."551 Second, he explained that the August 2011 allegations 

convinced him to review the March 2011 allegations. He stated: 

[T]he August allegation that came in was-although it was very well written and 

it was-like I say, it was, you know, equally alarming, it was very, very lacking in 

details. You know, aside from talking about the doctor and the other clinician 

involved, there really weren't any names, there weren't any dates, there weren't 

any places. There was very little for us to hang our hat on in terms of proving or 

disproving those allegations. So I felt that digging into this earlier set of 

allegations, which, you know, had quite a lot of detail in it and had-you know, 

additional documents had come back to us as a result of it, might shed light on the 

August allegations. And so that was why I did the review that I did.552 

During his transcribed interview, Dr. Mallinger recalled the August 201 I letter that was 

mailed to the VA OIG in Washington, DC, and postmarked from La Crosse, Wisconsin.553 He 

did not recall how he was assigned to work the Tomah VAMC allegations other than "it was sort 

of the natural flow of things. You know I had followed Dr. Shepherd around on the previous 

hotline. "

554 Dr. Mallinger described his role in this inspection as "more of the first chair 

position" while Dr. Shepherd took "the second chair position. "555 He explained why he wanted 

to work the case, stating that the allegations "make[] you mad, and you want to do something. 

And I think people wanted to be involved in this .... "556 

During the fall of 2011, Dr. Mallinger and Dr. Shepherd consulted on the Tomah V AMC 

hotline work being performed by the Chicago office, a role Dr. Mallinger described as providing 

medical expertise to support the inspection.557 He recalled that Roberta Thompson, out of the 

Chicago OIG office, was the lead inspector on the inspection at the time.558 At that time, the 

Chicago team was the lead and according to Dr. Mallinger, "[t]hey started collectin? documents" 

but he had difficulty describing what other actions the Chicago team accomplished. 59 

As 2011 ended, the VA OIG had very little to show for its work on the Tomah VAMC 

health care inspection. Other than some document collection by the Chicago OIG office and 

preliminary conversations with VISN 12, the VA OIG felt that the inspection was not moving 

forward. Dr. Wesley noted this lack progress, telling Chairman Johnson's staff that the Chicago 

office "had trouble moving it forward" with the Tomah VAMC inspection. 560 

!d. at 47. 552 !d. at 47-48. 553 !d. at 71-·72. 554 !d. at 72-73. 555 I d. at 73. 556 ld. 

557 !d. at 75. 

558 !d. 559 !d. at 76. 560 Wesley Transcribed Interview, at 106. 

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Around January 2012, Dr. Mallinger had conversations with Roberta Thompson of the 

Chicago OIG Office and told her that he was "concerned that we weren't really moving ahead 

very well" on the inspection561 According to Dr. Mallinger, Ms. Thompson blamed the Chicago 

office's heavy workload, other obligations the office had, and told him the office would 

eventually get to the inspection562 

After this conversation, Dr. Mallinger discussed with Dr. Shepherd and Dr. Wesley his 

concerns about the pace of the inspection. These discussions appear to have resulted in a 

decision that the O!G would "try something new."563 During his transcribed interview with 

Chairman Johnson's staff, Dr. Mallinger explained that a physician from the VA OIG's 

headquarters would be assigned the inspection. He stated: 

I discussed it with Dr. Wesley. And, again, my-again, remember that I was new 

in the organization at this time, and !-so I don't necessarily have institutional 

memory for the way things are usually done. But the way I understood it, they 

were going to try something new. Now, whether it was really new or it was just 

new to me, I'm not sure I'm remembering exactly, but the something new would 

have been to bring it into the central office, put a physician at the charge of it, and 564 

Dr. Mallinger further explained the O!G's decision to try something "new" may have been based 

on the complexity of the allegations. 565 He recalled the office seeking to do the Tomah VAMC 

health care inspection in a different way and, by extension, provide more resources and raise the 

priority of this inspection.566 

20. February 2012: Dr. Mallinger contacted the Tomah, Wisconsin, Police Department, 

and learned of a confidential informant with allegations of drug diversion 

Shortly after speaking with Dr. Wesley about the pace of the inspection and the decision 

to try something "new," Dr. Mallinger took the initiative to contact the Tomah Police 

Department. He memorialized his conversation with two individuals from the Tomah Police 

Department in a report of contact dated February 13, 2012567 The VA OIG redacted the names 

of the Tomah Police Department representatives with whom Dr. Mallinger spoke568 The Tomah 

561 Mallinger 3/8/2016 Transcribed Interview, at 88. 562 !d. 

563 ld. 

564 !d. at 88-89. 

'"!d. at 89. 566 Id 

567 !d. at 109; VA OIG 5905 568 VA OIG Office of Health care Inspections, Alan Mallinger, Report of Contact with Tomah Police Dep't, (Feb. 13, 

2012) OIG 5905, at 5905. 

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Police Department advised Dr. Mallinger about the history of dmg problems at the Tomah 

VAMC, mentioning that between 2006 and 2008 the department conducted "a large cocaine 

conspiracy investigation and arrested several VA employees. " 569 At the time of this 

conversation, the Tomah Police Department had no active drug investigations at the Tomah 

VM1C570 

Despite not having any active drug investigations, the officers told Dr. Mallinger that 

they believed that "excessive ammmts of narcotic drugs are sometimes prescribed by Tomah 

VAMC to individuals who are involved in illegal dmg activities."571 Dr. Mallinger also leamed 

fi·om this coinmtmication that several veterans who had passed away were found with "several 

thousand pills in their possession."572 In addition, Dr. Mallinger leamed that the Tomah VAMC 

had received infonuation from a confidential infom1ant about a veteran selling dmgs obtained by 

prescription from the VA. 573 

of Contact with Tomah Police 

possesston In information to them that a V/\ 

patient by the name was regularly selling the 

drugs he obtained by stated that he has access to 

information on several other drugs obtained by 

prescripl1on lrom the VA, and that he would provide me with these names when he has 

a chance to assemble them. 

During his transcribed interview with Chainuan Johnson's staff, Dr. Mallinger slated that 

he did not leam the identity of the confidential infonnant at the time of the phone calL575 

However, he said that the VA OIG confinned the patient named by the Tomah Police 

Department was in treatment at the Tomah VAMC and was receiving a prescription for narcotic 

medication. 576 Curiously, Dr. Mallinger and the OIG did not dig further. lie stated: 

'" ld. 570 !d. 

57lld .. 

"'ld. 

573 Jd. 

'" ld. 

Q: And did yon confinn whether they were regularly selling the drugs he 

obtained by prescription~ 

A: No. Again, you know, I'm not a law enforcement officer. Youlmow, I 

was looking into the clinical side of it, where were the drugs obtained. 

Q: So did you fann that out to the criminal side of OIG to follow up on, 

or no one looked into thatry 

:;: Mallinger 3/8/2016 Transcribed Interview. at 114-15. 

!d. all15. 

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VAOIG 

Attorney: I believe they tell the police howA: They tell the police where--

Q: So nothing from your inspection? You didn't follow the selling of the 

drugs he obtained. You just lookedA: I did not look into that. 

Q: You just looked into it and confirmed that he was a Tomah patient in 

for treatment and had a narcotic medication prescribed? 

A: That's correct. 577 

During his communication with the Tomah Police Department, Dr. Mallinger recounted 

one particular allegation that the OIG had received and asked whether the officers had any 

further information.578 The allegation was that Dr. Houlihan interfered with a police officer who 

sought to arrest a patient trying to sell his narcotic prescription on VA grounds.579 The allegation 

also claimed that Dr. Houlihan threatened the officer's job580 Dr. Mallinger said that the officers 

were unable to confirm the allegation, but an officer told Dr. Mallinger that the alleged run-in 

between an officer and Dr. Houlihan "was unlikely, since Tomah officers do not routinely patrol 

or access the VA grounds except for occasional traffic stops, and would not in any case be 

detetTed from making an arrest if this was needed. "581 

Dr. Mallinger explained that he did not further examine the past cocaine conspiracy event 

or research arrests of VA employees.582 He described his overall purpose for contacting the 

police as following-up solely on the allegation involving Dr. Houlihan.583 Although the officers 

could not confirm the allegation, they did provide Dr. Mallinger with information about VA 

patients.584 Specifically, they gave him names of VA patients who were suspected of drug 

crimes and, according to Dr. Mallinger, those patient names became "a major part of our 

structured chart review of the information."585 

577 Jd at 115-16. 578 VA OIG Office of Hcalthcare Inspections, Alan Mallinger, Report of Contact with Tomah Police Dep't (Feb. 13, 

2012) OIG 5905, at OIG 5905-06. 579 ld. 

580 Jd. 

58! ld, 

'" Mallinger 3/8/20 16 Transcribed Interview, at 111. 583 Jd. at 111-12. 584 ld. at 114. 585 ld. 

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Later that same week in February 2012, Dr. Mallinger emailed an investigator with the 

Tomah Police Department to follow up on his earlier conversation. Dr. Mallinger wrote that he 

had examined VA records and found some "prescribing irregularities that will provide a basis for 

further investigation of a particular healthcare provider."586 During his transcribed interview, Dr. 

Mallinger confirmed the healthcare provider in question was Tomah nurse practitioner Deborah 

Frasher.587 In his email, Dr. Mallinger asked the police investigator to "collect the names of 

additional individuals [they] discussed" as he believed "this could be very valuable" for the VA 

OIG's inspection. 588 

The Tomah police did not respond initially to Dr. Mallinger's request for more 

information. After not receiving a response, Dr. Mallinger sent a follow-up email nearly a month 

later, on March 16,2012589 In this email Dr. Mallinger reiterated why the information would be 

valuable to the VA OIG's inspection and thanked the Tomah Police Department for their prior 

assistance on the Tomah V AMC590 

An employee of the Tomah Police Department responded on March 20, 2012, copying 

the Chief of Police on the email.591 In that response, the employee advised Dr. Mallinger that the 

Tomah Police Department had recently met with a DEA diversion agent from Milwaukee about 

the prescription issues at the Tomah VAMC. 592 According to the email, the Tomah Police 

learned from the DEA agent that VA OIG had already been in contact with the same DEA agent 

and that the OIG had actually provided the DEA with contact information for the Tomah Police 

Department. 593 The Tomah Police Department told Dr. Mallinger that to maintain the integrity 

of the inquiry, the VA OIG should contact the DEA agent with any additional questions. 594 The 

email added that the Tomah Police Department wanted "to make sure everyone involved in this 

matter has the same infonnation necessary to conduct a thorough and appropriate 

investigation. "595 

After his initial conversation with the Tomah Police Department, and at the suggestion of 

the Tomah officers, Dr. Mallinger contacted the Milwaukee Police Department on February 17, 

2012. 596 The phone conversation concerned the hotline allegations that referenced the 

586 E-mail from Alan Mallinger, VA OIG, to Investigator, Tomah Police Dep't (Feb. 17, 2012, 9:59AM), OIG 

1!!25, at OJG !!!25-26. 

"'Mallinger 3/8/2016 Transcribed Interview, at 139. 588 E-mail from Alan Malinger, VA OIG, to Investigator, Tomah Police Dep't (Feb. 17,2012,9:59 AM), OIG 

11125,atOIG 11126. 589 E-mail from Alan Malinger, VA OIG, to Investigators, Tomah Police Dep't (Mar. 16, 2012, 8:54AM), at OIG 

11125. 

590 /d. 591 E-mail from Tomah Police Dep't to Alan Mallinger, VA OIG (Mar. 20, 2012, 11:15 AM), at OIG 11125. 592 !d. 

59] !d. 

594 !d. 

595 !d. 

596 VA OIG Office of Healthcarc Inspections, Alan Mallinger, Report of Contact with Milwaukee Police Dep't, 

(Feb. 17, 2012), at OIG 5728. 

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Milwaukee Police and the Tomah VAMC. 597 Dr. Mallinger spoke with a detective who was on 

the High Intensity Drug Trafficking Area REACT Interdiction Task Force. 598 The phone call did 

not yield much information. The Milwaukee detective told Dr. Mallinger that "to his knowledge 

the Milwaukee police have no current involvement of concerns about Tomah VA.''599 Dr. 

Mallinger was advised to contact a DEA investigator who handled drug diversion cases in 

Wisconsin600 

21. February 17,2012: The VA OIG developed a Tomah VAMC "work plan" 

While Dr. Mallinger contacted local law enforcement in Wisconsin, the VA 010 's 

Chicago office decided upon its investigative plan for the Tomah V AMC inspection. According 

to documents, the Chicago OIG authored a "work plan" that was approved days before the 

inspection was transferred to Washington, D.C. The document was submitted and signed on 

February 17, 2012, by Roberta Thompson and Laura Spottiswood, both inspectors in the Chicago 

office of the VA OIG. 601 According to her statements during a transcribed interview, Wachita 

Haywood of the Chicago VA OIG Field Office also reviewed and signed off on the work plan. 602 The document described the purpose of the inspection as reviewing allegations submitted to 

the VA OIG on August 26, 2011 which later became a "congressional."603 The three-page work 

plan604 document listed five objectives of the inspection with a final report due date of April30, 

2012605 

597 ld. 598 E-mails from Alan Mallinger, VA OIG, to Detective, Milwaukee Police Dep't (Feb. 27-28, 2012), at OIG 11144; 

see also EXEC. OFFICE OF THE PRESIDENT, OFFICE OF NAT'L DRCG CONTROL POLICY, HIGH INTENSITY DRUG 

TRAFFICKING AREAS PROGRAM REPORT TO CONG. 88 (2011 ), available at 

https;//www.whitehouse.gov/sites/default/liles/ondcp/po!icy-and-research/hidta 2011.pdf. 599 VA OIG Office of Healthcare Inspections, Alan Mallinger, Report of Contact with Milwaukee Police Dep't, 

(Feb. 17, 20 12), at OIG 5728. 600 E-mail from Alan Mallinger, VA OIG, to Detective, Milwaukee Police Dcp't (Feb. 27, 2012, 4:30PM), at OIG 

1114. 

601 VA OIG Hotline Inspection Work Plan, at OIG 12224. 602 Haywood Transcribed Interview, at 47. 603 VA OIG Hotline Inspection Work Plan, at OIG 12222-24. 604 Ms. Haywood advised the committee that the "Work Plan" was a template that was used in the office for all work 

plans. Haywood Transcribed Interview, at 43. 605 VA OIG Hotline Inspection Work Plan, at OIG 12222-24. 

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Figuro 27: VA OIG work for TomRb V A:\1C boRltb c•r• 

WORK PLAN 

HOTLINE INSPECTION 

Quality of Care and Prescribing Practices in Mental Health 

Tomah VA Medical Center, Tomah, Wisconsin 

Project No. 2011-04212-HI-0267 and 201HI4212-CR-0001 

Ms. Haywood, identified as lhe Project Manager in the work plan,607 provided the 

document via email on Febmary 17, 2012, to Dr. Mallinger and Dr. Shepherd.608 She asked the 

physicians to review the document and provide cmmneuts or additions to Ms. Tiwmpson. Ms. 

Haywood ended the email by thanking the physicians for their assistance ou "this complex 

[hotline]. We all are looking forward to moving along: and closing: it out."609 

Figm·• 28: VA OIG work plan for Tomah V A._~C hoalth car• inspoction°10 

4. Resources: 

Project Manag~r: 

Tt'alll Leader': 

Team Members: 

Consultant Costs: 

\Vachila Haywood, RN 

Roherra J Thompson, LC'S\V 

Liura Spotti~wood, RJ\ 

Michael L Sb.::pherd. MD 

:\Jan :vlallingcr. :\-10 

:-.lone 

B. Staff Days/TOY Resources to Complete Projl'ct: 3-.1 day> on site 

C. Rcfcrcm·cs: TBD 

Dming his transcribed interview with Chainnan Johnson's staff, Dr. Mallinger stated that 

he did not recall the "Tomah Work Plan" or developing a similar work plan after the inspection 

was transfened to Washington, D.C. 611 Dr. Mallinger's views on the work plan docmnent were 

not complimentmy. He stated: "I'd say that this work plan is written in such a way that it's not 

606 VA OIG Hotline Inspection Work Plan, at OIG 12222. 607 1v1s. Haywood was the acting director in the Chicago OIG office for a short period time. Ha)"\\'ood Transcribed 

Inten·iew, at 5 L 608 E-mail from Wachita Haywond. VA O!G. to Alan Mallinger & Michael Shepherd. VA OIG (Feb. 17, 2012. 4:45 

PM), at OIG 11148. 

009 !d. 010 VA OIG Hotline Inspection Work Plan. at 12223. 011 Mallinger 318/2016 Transcribed Interview. at 94. 

··!..,_ 

~f I 

I 

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really clear."612 He continued: "You know, Objective I here, to determine if the identified 

providers prescribed massive doses of narcotics for patients who experienced pain and who were 

diagnosed with post-traumatic stress disorder. Well, it's not even clear to me what that means, 

and I don't think it follows the allegations very closely."613 

Dr. Wesley explained that he would typically review work plans because he liked to 

know what was going on but it was not a formal part of his job duties.614 He described the 

document as a "team's first step to turn the complaint into a work plan."615 Dr. Wesley agreed 

that it was unusual that the work plan for the VA OIG's health care inspection of the Tomah 

VAMC took over five months to be developed.616 It appears that the physicians leading the 

Tomah V AMC health care inspection out of the Washington D.C. office neither implemented 

nor followed the "work plan" developed and approved by the VA OIG office in Chicago.617 Dr. 

Mallinger stated: 

Q: Did you follow this work plan? 

A: Well, as I said, I followed the allegations. To the extent that this work 

plan reflects the allegations, I would have followed that area. But I 

think as far as spelling out detailed objectives, that I would have sliced 

and diced the allegations diffcrently. 618 

22. February 27,2012: The Tomah VAMC inspection was transferred to Washington, D.C. 

and Dr. Mallinger was assigned team leader 

According to VA OIG documents, the "transfer" of the Tomah VAMC inspection from 

the Chicago office to Washington, D.C. headquarters appears to have occurred on February 27, 

2012. 619 On this dalo, the Tomah VAMC hotline was referred to Pat Christ, the Deputy Assistant 

Inspector General. 6 0 Dr. Mallinger described Ms. Christ as the head of all OIG regional 

offices. 621 At this time, Dr. Mallinger understood that the Tomah VAMC hotline was the 

responsibility of the OIG central office in Washington, D.C.622 

612 !d. at 95 6t3 Id. 614 Wesley Transcribed Interview, at 139. 615 Id. at 104. 616 !d. 617 Dr. Mallinger held a briefing with 010 central office where he explained where the Tomah Hotline was at and 

where the case was going. Mallinger 3/8/2016 Transcribed Interview, at 96. 618 Id. at 96 . 619 VA 010 Hcalthcare Transaction Report, MCI # 20 11-04212-HI-0267 (May I, 2015, II :46 AM), 010 1394. 

''o !d. 621 Mallinger 3/8/2016 Transcribed Interview, at 90. 622 Id. 

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Senator Ron Johnson, Chairman 

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Originally assigned as a physician consultant on the case, Dr. Mallinger's role changed to 

a "team leader role"-a transition that he said occurred without any formal process. 623 Dr. 

Mallinger told Chairman Johnson's staff that the Tomah VAMC inspection was "still in a way a 

learning case for me."624 He emphasized that although he had assumed the "team leader role," 

Dr. Shepherd and Dr. Wesley took a "very hands-on approach." He explained: 

And, you know, I think there was always-it was never the case that I was alone there. 

You know, there was always the, you know, sort of Dr. Shepherd, you know, there doing 

whatever you want to call it, mentoring or, you know, sort of-because this was, you 

know, still in a way a learning case for me. And I'd say that Dr. Wesley also took a very 

hands-on approach. And, you know, maybe part of the central office issue was to bring it 

a little closer to him, because he did take a very active role. He was-! mean, he was 

on-when we called key people, very often he was on the call. You know, when we got a 

second complainant later that year, you know, he was very key in doing that interview. 

So he actually stepped up and, you know, became very hands-on with it as well. 625 

Dr. Mallinger stated that the Tomah V AMC inspection was the first case in his career on which 

he was the lead inspector626 He explained the case "wasn't being tried in a 'throw it up in the air 

and see what comes down' kind of way. It was being tried with a tremendous amount of support 

from the Ieadership."627 Dr. Mallinger explained that after the referral, the Chicago OHI office's 

role in the Tomah V AMC hotline was over. He said: 

Q: What was the Chicago regional office personnel's role following, you 

know, the referral, so to speak, to Ms. Christ? 

A: Well, then they were gone. 628 

On March 8, 20 I 2, about a week after the inspection was transferred to Washington, 

D.C., in an email to Dr. Shepherd, Dr. Wesley recounted a meeting he had with Dr. Mallinger to 

discuss the Tomah V AMC inspection. This meeting lasted approximately two hours 629 Dr. 

Wesley emailed Dr. Shepherd about the meeting and the decision to "focus our efforts as we did 

for the Palo Alto V AMC case. "

630 The Palo Alto V AMC case to which Dr. Wesley referred was 

a complex psychiatric health care inspection in which Dr. Shepherd served as the lead inspector 

and Dr. Mallinger served as "second chair."631 The restructuring within the Tomah VAMC 

health care inspection would mirror the procedures of the Palo Alto VAMC case-meaning that 

o23 Id 

624 !d. 625 !d. at 90-91. 626 !d. at 91. 627 !d. at 92. 628 !d. at 93. 629 E-mail from George Wesley, VA OIG, to Michael Shepherd, VA OIG (Mar. 8, 2012, 8:13PM), at OIG 11140. 630 ld 631 Mallinger 3/8/2016 Transcribed Interview, at 12. 

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a psychiatrist within the Office of Health Care Ins}iections would lead the inspection and another 

psychologist would serve as a the "second chair." 32 Except in the Tomah VAMC inspection, 

Dr. Mallinger would lead and Dr. Shepherd would serve as the "second chair" for the 

inspection. 633 According to the email, Dr. Wesley requested a separate meeting with Dr. 

Shepherd to go over the proposals and take a break from his "waiting time project."634 When 

Chairman Johnson's staff asked Dr. Mallinger about this meeting, he could not recall the 

conversation.635 

During his transcribed interview, Dr. Wesley said that he recalled sending the email to 

Dr. Mallinger on March 8, 2012636 He also explained what transpired during the two-hour 

meeting. He recalled: 

In other words, taking your first question, do I recall sitting at my word processor 

and writing the email? No. Do I recall the substance of the email? Yes. Despite, I 

think, the very important concerns you've raised about the work plan and the time 

that's traversed, Alan in particular and, to a lesser extent, Dr. Shepherd and Dr. 

Yang were working the case quite extensively, particularly Dr. Mallinger because 

it was his first case, and it may well have been his only case. I only give people 

one or two cases when they start out. So they were gathering lots of data, and the 

data was flowing in, particularly into Alan's office. I'd hear parts of discussions. 

I'd hear talk about Dr. Houlihan and his patients and his prescriptions. I'd hear so 

many of the concerns that make up the case. And I was a little-that's why I say I 

remember the content. I was as little worried that the case and its substance was 

running away from me. So I said to Alan, "We've got to meet, and you've got to 

take me through this whole thing from beginning to end," just the way you folks 

are. "I've got to understand every aspect of it and where you're going"-with or 

without knowing about a work plan. And so I got Alan out of the office. We went 

to a private place, and we sat down for 2 hours, and he took me through 

everything he had done on it, what he was thinking about it, how he analyzed it, 

and so on and so forth. So that's the reference to, "Mike, I had a productive 

almost 2-hour meeting with Alan." Again, do I remember this? No. But I think-! 

hope it's a legitimate inference. After meeting with AI for 2 hours-and you guys 

have met with him; he can stimulate a lot of thinking-! must have wanted to 

share my enthusiasm with Mike and say, "We've got to talk some more." So 

that's what that's about.637 

6

J

2 ld. at 12-16. 633 !d. 

6

J

4 E-mail from George Wesley, VA OJG, to Michael Shepherd, VA OIG (March 8, 2012,8:13 PM), at OJG 11140. 635 Mallinger 3/8/2016 Transcribed Interview, at 100-0!. 

"'Wesley Transcribed Interview, at 141-42. 637 !d. at 142--43. 

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Dr. Wesley also talked about the Chicago office's removal from the Tomah V AMC 

inspection. He described the Tomah VAMC inspection as "so incredibly physician-intense, there 

was very little any of our regional offices could contribute to."638 Dr. Wesley did not recall 

making a decision to remove the Chicago office from the inspection, but he described the 

transfer of the inspection duties as occun·ing "by osmosis."639 He described the Washington 

office's ownership of the Tomah VAMC inspection, saying it had become "Alan [Mallinger] and 

l\1ichael [Shepherd] and Dr. Yang's baby, if you will."640 Dr. Wesley confirmed the Tomah 

VAMC inspection "definitely left Chicago, and clearly, from 2012 on, in any practical sense, it 

was nul by Dr. Mallinger."641 

23. February 28, 2012: Dr. Mallinger began to communicate with the Drug Enforcement 

Administration about the Tomah VAMC, eventually receiving a list of suspected drug 

diverters 

During Feb mary 2012, Dr. Mallinger made a number of contacts with law enforcement, 

both local and federal, to discuss the Tomah V AM C. As explained above, Dr. Mallinger spoke 

with the Tomah Police Department a few weeks before he made contact with the DEAM2 

According to a report of contact dated February 28, 2012, Dr. Mallinger had a conversation with 

an 1midentified DEA employee about the Tomah VAMC, in which he shared the allegations 

about the Tomah V AMC and asked if the DEA possessed any "contributory infotmation. "

643 

Figure 29: Report of Contact of Dr. Mallingor's communication with DEA"' 

Report of Contact 

Date: 2-26-12 

Contacted: 

Subjeet: 

"'!d. at !25. 6l9ld 

6.-i-o Id 

6-tt Id 

Hothne re: 2011-04212-HL-1068· VAMC Tomah, WI (676): 

642 A; of January 20!5, the DEA had a total of 50 employees in the State of Wisconsin. The DEA has a total of 8 

Diversion ln\'estigators. The DEA has three offices in the State of Wisconsin: Milwaukee (District Office). 

~hdison. and Green Bay. Maj. staff email fi·om the DEA April30, 20!5 . 

..,, VA OIG Office of Healthcare Inspections. Alan Mallinger, Report of Contact with DEA (Feb. 28. 2012). at OIG 

5726 . ... , !d. 

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According to the report of contact, the DEA had also "recently received a confidential 

complaint regarding the excessive prescribing practices of opiates at the Tomah VA Medical 

Center."645 The DEA employee confirmed to Dr. Mallinger tbat "he is investigating possible 

drug diversion related to this."646 Dr. Mallinger's report of contact also explained that the 

DEA's "complainant works in the pharmacy and alleges excessive prescribing of opiates by Dr. 

Houlihan to patient [redacted]."647 According to the document, the DEA employee informed 

Dr. Mallinger about his investigative actions up to then-"he had interviewed two employees 

from the VA pharmacy and has reviewed pharmacy records."648 The DEA employee concluded 

the conversation by saying it was too early in the investigation to have reached any conclusions, 

but he promised to keep Dr. Mallinger informed on any developments 649 Dr. Mallinger agreed 

to do the same. 650 

On March 22, 2012, Dr. Mallinger spoke by phone with a DEA diversion investigator. 651 

During the call, the DEA investigator told Dr. Mallinger that the DEA had obtained a list of over 

30 individuals associated with the Tomah V AMC from an investigator at the Tomah Police 

Department. 652 The individuals listed were described as "suspected of possible drug 

diversion."653 The DEA investigator planned to share the list with the VA OIG via fax and 

further advised Dr. Mallinger that the DEA was planning to "visit the Tomah area (but probably 

not the VAMC) next week along with Special Agent Porter of the OIG Chicago Office in 

furtherance of the investigation. "654 

During a transcribed interview with Chairman Johnson's staff, Special Agent Porter said 

that he received the list of30 individuals from Detective Walensky of the Tomah Police 

Department. 655 Special Agent Porter apparently took no action on the list, as he explained that 

his role was limited. He stated: 

645 !d. 

6-:16 !d. 

U47 /d. 

64\! !d. 

649 !d. 

650 !d. 

Q: When you were made aware of this list of individuals associated with 

the Tomah VA, what reaction or what action did you or could you take 

after receiving that infonnation from Detective Walensky? 

A: The-well, action that I did take was basic, just to make myself 

mentally aware that there are these people named. I don't recall taking 

651 VA OIG Office of Health care Inspections, Alan Mallinger, Report of Contact with Diversion Investigator, DEA 

(Mar. 22, 20I2), at OIG 5894. 652 !d. 

653 Id. 

654 I d. 655 Porter Transcribed Interview, at 33-34. 

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any direct action on that at all, other than to let DEA Diversion and the 

Office of Healthcarc Inspections look into their conditions, et cetera, et 

cetera, and their levels of prescriptions and things like that. And the 

Tomah Police can take action where they can, you know, research 

their police reports and the rest of the records to see if any of these 

names were people that had been arrested before, and if so, get the 

details of those incidents, et cetera, ct cetera. I did not take any direct[] 

action on them. That was the police 656 

Dr. Mallinger said that he received the list of 30 suspected individuals and that the OIG 

conducted a review.m He understood the list to have come from the Tomah Police Department 

and that the 30 individuals were suspected of drug crimes. 658 Dr. Mallinger explained that not 

all the individuals on the list were patients at the Tomah V AMC, but the OIG reviewed the 

prescriptions of controlled substances for the individual who were patients.659 Dr. Mallinger 

could not recall whether the OIG structured chart reviews showed any prescription irregularities 

for the 30 individuals on the Tomah Police Department's list. 660 

In April2012, Dr. Mallinger filed additional reports of contacts with a DEA diversion 

investigator. On April2, 2012, Dr. Mallinger received an update on the DEA's "field 

investigation" that occurred on March 28, 2012661 According to Dr. Mallinger, VA OIG Special 

Agent Porter joined the DEA in these actions, jointly interviewing a Tomah VAMC police 

officer and another individual. 662 The VA police officer alleged that Dr. Houlihan abused his 

authority hy interfering in VA police activities on the grounds of the Tomah VAMCspecifically that Dr. Houlihan would not allow VA police to interact with patients even if there is 

suspicion of "criminal activity."663 The VA police officer described Dr. Houlihan as having a 

"short fuse" and a "bad temper" when dealing with VA police. 664 

Dr. Mallinger told Chairman Johnson's staff that he understood the allegation referenced 

in the report of contact of April 2, 20 12 as "[Dr. Houlihan] was trying to exert inappropriate 

authority over the Tomah municipal police."665 The VA OIG health care inspectors did not 

speak with the police officer in question because the identity of the officer was "never revealed" 

656 !d. at 34-35. 657 Mallinger 3/8/2016 Transcribed Interview, at 152-53. 65' Id. at 153. 659 Id. at !52··· 53. 660 Id. at 153. 661 VA OIG Office of Healthcare Inspections, Alan Mallinger, Report of Contact with Diversion Investigator, DEA, 

(Apr. 2, 2012) OIG 5895, at 5895. 662 Id The other individual's name was redacted by the VA OIG. 663 Id 

664 Id 665 Mallinger 4/6/2016 Transcribed Interview, at 217. 

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Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

103 
183 

to Dr. Mallinger. 666 Dr. Mallinger did not recall finding any evidence of improper influence over 

the Tomah VA police by Tomah VAMC senior management. 667 

Figure 30: Rt?oport of Contart of Dr. l\1.allinge•·'s rommuniration with DEA Div(>t'sion IuvPstigator668 

VA OIG Office of Healthcare Inspections 

Holline Inspection- Tomah VA Medical Center 

Report of Contact 

Completed by: Alan G. Mallinger, M.D. 

Date: 4-4-12 

Contacted: 

Subject: 

Dtverston lnvesttgator 

DEA 

Holline re: 2011-04212-HL-1 068: VAMC Tomah, WI (676); RP71 

Two days later, on April4, 2012. Dr. Mallinger again spoke with the DEA diversion 

investigator about the Tomah V AMC 669 During this conversation, the DEA provided the VA 

OIG with the names of three individuals who were potential sources ofinfonnation670 The tluee 

individuals all had worked at the Tomah VAMC. but had since left the facility for a va1iety of 

reasons 671 The sources of information were described as a physician; a phannacist: and the 

former Chief ofPhannacy. who quit working at the facility after being "forced to fire another 

phannacist."672 

Dr. Mallin@:er interviewed two of the individuals whose names were provided by the 

DEA. Dr. Mallinger told Chaimum Johnson's staff that he interviewed the fonner Chief of 

Pharmacy Tom Jaeger and a pharmacist who left Tomah because he was pressured to fill 

prescriptions against his judgement673 During his transcribed intetview, Dr. Mallinger recalled 

what the phannacist told VA OIG inspectors about his time at the Tomah V AMC. Dr. Mallinger 

said: 

660 Jd. at 217. 667 !d. at 218. 668 VA OIG Office of Healthcare Inspections. Alan Ivfallinger. Repott of Contact with Dh·ersion Investigator, DEA. 

(Apr. 4, 2012). OIG 5896. at 5896. 

669 ld. 

670 1d 

671 !d. 

"'Id 

"-' Jd. 

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Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

104 
184 

A: Their story was that they-this was a fairly young, kind of a beginner 

pharmacist who came to Tomah who felt there was kind of a core 

group of patients who were regularly requesting early refills of their 

medications. And that pharmacist felt uncomfortable doing the early 

refills, but was told to fill them. 

Q: By who? 

A: My recollection is by Dr. Houlihan, but, again, you probably have all 

the interviews, so I would leave it to you to verify that. But that's my 

recollection. And he was uncomfortable and felt like, you know, that 

he wasn't fulfilling his requirements as a pharmacist, and so he went to 

work somewhere else. 

Q: So he resigned from the Tomah VA? Is that your understanding? It 

says he left. 

A: He left, yeah. 

Q: Okay. 

A: He wasn't asked to leave, to my recollection. He voluntarily left.674 

24. March 12, 2012: The VA OIG received another Tomah VAMC complaint-"HOUSTON, 

WE NEED SOME HELP DOWN HERE" 

On March 12, 2012, the VA OIG hotline group received a two-page complaint 

concerning the Tomah V AMC.675 According to Dr. Mallinger, this new complaint was important 

and provided "a lot of specific information about people's names that didn't come through in the 

first complaint," aiding the VA OIG's health care inspection. 676 The allegations involved a 

specific case in which a high ranking physician at the Tomah VAMC altered patient notes, 

describing the facility as "an institution that is compromised by an atmosphere of fear and 

intimidation that is incapacitating. "

677 The complainant, a staff physician at the Wausau 

Community-Based Outpatient Clinic (CBOC), had "practiced medicine for thirty years" and said 

"I have never seen such mayhem. The privilege of caring for our vets is the only reason I have 

674 Mallinger 4/6/2016 Transcribed Interview, at 221. 675 This complaint was initially assigned the case number 2012-09567 before it was bundled into the Tomah 

inspection. VA 010 Oflice ofHealthcare Inspections, Alan Mallinger, Report of Contact with Diversion 

Investigator, DEA (Mar. 29, 20! 2), at OJG 5897; VA OfG Hotline Complaint (Mar. 12, 20 12), OJG l I 800. 676 Mallinger Transcribed at 210. 677 VA 010 Hotline Complaint (Mar. 12, 20 12), OJG 11800, at OJG 11800-0!. 

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Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

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185 

not resigned. TI1ese men and women do not deserve this travesty."678 The complaint ended with 

a plea: "HOUSTON WE NEED SOME HELP DOWN HER£."679 Due to the nature of the 

allegations, the VA OIG btmdled this hotline into the previously opened Tomah V AMC 

inspection. 680 

Figur• 31: Hollin• complaint r•gardiug th• Tomah VAMC (March 12, 2012) 681 

I Mor~ than two month5 h~v~ p~ssed sirce I orl~inally contacted :he reg1orallawy~r Wike NewMan and 

Chi( ago !JIG. It anyone" m1ndon~ the 'tore, I want to know.l ~.we practiced n1~dir.n1dor :hlfty vcars. I 

hav~ nev~r seen such mayhem. Th~ pnvilege of caring for Ollr vets is t~e onlv reason I have not resign~d. 

Thr;r rnf'n <1nd womrn no nor rlr-c;pp .. r. th1t.. -rnve~ty' 

HOUSTON WE NEED SOME HELP DOWN HERE. 

The complainant described Dr. Katherine J. Pica, a physician at the Tomah VAMC, as 

the "wrongdoer," and alleged that a VA patient died due to "failure to diagnose bladder cancer 

until disease had metastasized."68" Further, it alleged that the CPRS-the VA's computerized 

patient records system-notes "were altered to make it appear that the patient declined 

recommended evaluation that would have been life-saving. "683 The complainant believed the 

CPRS notes were altered because the complainant had filed a complaint.684 During his 

transcribed interview with Chairman Johnson's staff, Dr. Mallinger stated that the VA OIG 

examined the alleged altering of medical records but he could not recall what happened with this 

allegation. 685 

Other infonnation in the complaint concerned the overall culh1re at the facility and the 

allegation of "ovemse of narcotics. "

686 TI1e complainant provided the VA OIG with names of 

Tomah V AMC employees to contact, including pha1macists who left the facility due to the 

problems. According to the con~lainant, the VA OIG's Chicago office received these or similar 

allegations on Janumy 13, 2012. 7 The complainant wrote: 

I reported [the issnes in this complaint] to the VISN 12 regional lawyer who told 

me he had fmward [sic] it to the IG for VISN 12 in Chicago and it was 

subseqnently forwarded to Washington. This occtuTed in early January 2012. I 

618 VA OIG Hotline Complaint (Mar. 12. 2012). OIG 11800. at OJG 11801; see also Memorandmn ofCom·ersation 

from VA OIG Telephone lntetYiew (Mar. 29. 2012). OIG 13704. 670 VA OIG Hotline Complaint (Mar. 12. 2012). OIG 11800. at OIG 11801. 680 Mallinger 3/8/2016 Trnnscribed Inten:iew. at 127. On March 20,2012, Dr. Mallinger emailed Dr. Shepherd with 

the subject line '"Another Tomah complaint." The body of the email reads: "For discussion today. Note la5-t 

section." E-mail from Alan Mallinger. VA OIG. to Michael Shepherd, VA OIG (Mar. 20. 2012), at OIG 11127. 

'"VA OIG Hotline Complaint (Mar. 12. 2012), OIG 11800. at OIG 11801. 

'" Jd. at OIG 11800. 683 !d. 684 !d. at 01 G 11800--D 1. 

'"Mallinger 3/8/2016 Transcribed Interview. at 128. 

'"VA OIG Hotline Complaint (Mar. 12. 2012). OIG 11800. at OIG 11801. 

'" Jd. 

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Senator Ron Johnson, Chairman 

106 
186 

don't know if any attention has been given to this problem. I had to call to find 

out if my complaint had been received and have become skeptical. 688 

Dr. Mallinger talked about the significance of this particular complaint because the 

complainant was able to elaborate on the concerns and "had a lot ofinformation."689 The OIG 

conducted a phone interview with the complainant on March 29, 2012, a few weeks after it 

received the allegations 690 The complainant identified herself as a staff physician who began at 

the Tomah VAMC in 2009691 The complainant listed specific patients, including a female 

veteran with a 'bad shoulder' who was "treated with a huge amount of narcotic medications for 

her sore shoulder."692 

Dr. Mallinger asked Dr. Wesley to participate in the phone interview with the Tomah 

VAMC staff physician who made the March 12 complaint.693 According to Dr. Wesley, it was 

unusual for him to participate in "the guts of the inspection," but he explained his reasons for 

doing so during a transcribed interview with Chairman Johnson's staff694 Dr. Wesley stated: 

So it was important to me because Alan wanted me to sit in on the meeting, which 

is the exception rather than the rule. It was secondly important to me because I 

thought the complainant was significant. It was thirdly important to me because if 

you remember I talked about the structure of VA, Tomah has four CBOCs feeding 

into it: Wisconsin Rapids, Wausau, La Crosse, and Clark County. So, suddenlylet me make sure this is here. Yeah, it says CBOC. My thinking was now here's 

someone complaining from a CBOC, not from the parent facility but from one of 

its satellites, and that bothered me. So for those three reasons, it was an important 

conversation. 695 

During the interview, the VA OIG learned of an allegation that a veteran "was at kind of 

immediate risk ofhaving their leg inappropriately amputated on the advice and support of Dr. 

Houlihan."696 According to VA OIG documents, Dr. Wesley emailed Dr. Bonner, the VISN 12 

Chief Medical Officer, to request a phone call regarding the allegation.697 At some point, Dr. 

Bonner apparently apprised Dr. Houlihan of the allegation and Dr. Houlihan provided a lengthy 

688 ld. 6

" Mallinger 318/2016 Transcribed Interview, at 127, 129. 690 I d. at 126-27. Drs. Mallinger, Wesley, and Shepherd attended this conference call. VA OIG Office of 

Healthcare Inspections, Alan Mallinger, Report of Contact with Diversion Investigator. DEA (Mar. 29, 2012), at 

OIG 5897. 

691 I d. 

692 I d. 693 Wesley Transcribed Interview, at 159-61; see also 13704-05 694 !d. at 160. 695 !d. at 161--62. 696 Mallinger 31812016 Transcribed Interview, at 127. 697 E-mail from Robert Yang, VA OIG, to Alan Mallinger, VA OIG (Apr. 3, 2012, 9:03 AM), OIG 11081, at OIG 

11081-82. 

(~){ LJ 

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Senator Ron Johnson, Chairman 

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email response on March 30. 2012. describing the circumstances and health of the veteran.698 

Dr. Bmmer forwarded the explanation from Dr. Houlihan to the OIG and described the case as 

"ve1y cballenging."699 He advised the OIG that he would follow the case and opined that the 

complainant "did not have all the infonnation."700 

Other issues arose from the VA OIG's telephone interview with the physician. The OIG 

team learned that the DEA was allegedly subpoenaing records from Dr. Houlihan. 701 The 

complainant also infonued the OIG inspectors that phannacists had concerns about Dr. 

Houlihan's presc1ibing practices and that a number of them left the facility702 The complainant 

also provided the VA OIG team with infonnation for other individuals to contact and the names 

of veterans allegedly diverting prescription medications.703 The complainant also spoke about 

the use of narcotics and speci±lcally issues smrounding Dr. Houlihan. The individual described 

the firing of the Tomah VA phannacist Noelle Johnson. who refused to fill Dr. Houlihan's 

prescriptions and another psychiatrist. John Edwards, who allegedly "would not allow himselfto 

be supervised by Dr. Houlihan."70 ~ 

Figure- 32: Summar~: of VA OIG's intpn·ie-w with Tomah VAMC staffphysician1

ij

5 

We then discussed her concerns about the :Jvcrusc of narcotics at Tomah. She stated 

the COS is Dr. David Ho.11ihan. He 1S know'l for his foul temper. He trashes people's 

careers when he fires them. He fired a psychologist 18 months ago. who then went 

home and committed suicide. 

The complainant also raised the Tomah V AMC's reliance on Foreign Medical Graduates 

(FMGs) to fill medical positions. The complainant alleged that the FMGs were beholden to 

management at the Tomah V AMC and that many would not speak out due to fear of losing their 

immigration status, as it depends on the successful completion of their contractual obligation 

with the VA706 During his transcribed interview with Chainnan Jolmson's staff, Dr. Mallinger 

could not recall if this issue was discussed with the complainant but also admitted that he was 

not ve1y sure what the issue was. 707 He explained that the complainant was not really alleging 

that there has been any retaliation against any FMG. 70S 

"' Jd. at OIG 11081-82. 

"'!d. atOIG 11081. 71){) Jd. 

701 Memorandmn of Conversation from VA OIG Telephone Interview (Mar. 29. 2012). OIG 13704. at OIG 13705. 702 Jd. at OIG 13704-05. 101 Id. 7

().1 VA OIG Office ofHealthcare Inspections. Alan Mallinger. Repol1 of Contact with Dh·ersion Investigator. DEA 

(Mar. 29, 2012). OIG 5897, at OIG 5897-98. 705 I d. at OIG 5897. The psychologist that conunitted suicide after being fired appears to be refening to Dr. 

Christopher Kirkpatrick. 

:::Mallinger 318/2016 Transcribed Interview. at 129-30. 

' !d. at 130-31. 708 Jd. 

(~ • I 

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Committee on Homeland Security and Governmental Affail·s 

Senator Ron Johnson, Chairman 

108 
188 

25. May 2012: The VA OJG requested Tomah VAMC employee emails 

Beginning in May 2012, the VA orO's inspection of the Tomah VAMC continued to 

progress at a slow pace. Now over a year since the initial allegations, and nine months since the 

allegations became a congressional hotline, the 010 team began the process of collecting emails 

of selected Tomah V AMC employees. This facet of the inspection was new to Dr. Mallinger and 

according to documents, Dr. Robert Yang completed the oro memorandum that officially 

requested the email collection.709 

On May 17, 2012, Dr. Yang sent three memoranda to the VA orO's Director of 

Computer Crimes and Forensics Laboratory.710 The memoranda explained that the emails were 

requested in connection to the orO's hotline of the Tomah V AMC and specifically the 

"prescription of narcotics at the facility and possible erosion of internal controls by the facility's 

Chief of Staff."711 Dr. Yang requested the emails from a total of 17 em~loyees at the Tomah 

V AMC, including Dr. Houlihan, Deborah Frasher, and Margaret Hyde. 12 The VA oro also 

collected emails of Dr. Christopher Kirkpatrick, Linda Ellinghuysen, and the former Director of 

the Tomah VAMC, Jerry Molnar. 713 

709 According to OIG documents, Dr. Yang began assisting on the Tomah inspection in Apri12012. E-mail from 

Robert Yang, VA OIG, to Alan Mallinger, VA OIG (Apr. 3, 2012,9:03 AM), OIG I 1081, at OIG I 1081-82; see 

Mallinger 4/21/2016 Transcribed Interview, at 334. 710 The OIG's Computer Crimes and Forensics Laboratory (CCFL) is coded 5 IE. Memorandum from Robert Yang, 

VA, to Director, Computer Crimes and Forensics Laboratory (May I 7, 2012), at OIG 13676. 711 !d. 712 VA OIG MCI Search Results, MCI # 2011-042 I 2-lE-0087 (May 5, 2015, 1 I :53 AM), at OIG 12368. 713 VA OIG documents indicate the following emails were not obtained and processed: Thomas Jaegar, Christopher 

Kirkpatrick, Craig Otting, Jerald Molnar, and Cindy Gile, !d. at OIG 12368--69. 

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Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

109 
189 

Figun- 33: M~morandum t·~qu~sting T omnh V Al\fC empJoyt>t" emails iJ..t 

DEPART:\lENT OF Memorandum l 

VETERANS AFFAIRS 

5/17!12 

'>\~t~: El~ctronic M.'lil Collection I Pro~t>ssing 

Uirl'l'tor, Comput(:r Crim~~ and hn.::n:-.i ... ·~ Labon.Jlu~y ICC I-Ll L'IIEJ 

f'lmiJ~ H hicf J..:s..:ript:cn l'flhc rwj-.;;,.'l wJ ju~tiflt.llion/ :T..i\Ol\ lm l..:qu..:stm~ Ekc:roni\ r.ll.lil {[nuih (\}lklt:nn 

J,·ltntlfy an~ ~:o.:tf!ency nl the r~quel;. 1C~e .ldd:!JfJrlOll paJ!ef q 1f mNe \p.1..::e ·" nee.1e,~:· 

HdiiHli' rt''~~~~d,lh~ .ht• !'nn<:ll• V •\ MC l'r,-..(•n..,I!!Hl nl n: n <\Itt, ·r :tv ·;wd·r;. w1ll ro,,!hl,• 1'111'-H:n nf mh•rr>al 

conlrd<. h~·fb: ;-;"-ilitv':<o \ha~t •"f S(arf 

Figur• 34: M•mornodum r•qu .. tiug Tomah VAMC •mploy•• •mailsm 

hll 'l;,lll<' 

C:hrisrorher K ;, k pJtric k 

I_Jntla t-:IJ:n~.htlV..,l~n 

Till~ (:fkn(iY.~;l; 

Ps\<hnlnp.ist 

Pal inti <,,,kly Km"' 

f'artlit' 

T0mJh VAMC 

TPill;\h VA:\1C 

I 

Dr. Mallinger exRlained the OIG collected around a total of 220,000 emails, including 

800 to 900 attachments. 16 Dr. Mallinger said that because he was not experienced in pulling 

emails. Dr. Yang "stepped into this patticular part" of the inspection as he "had done it 

before." 717 

During a transcribed interview, Chainnan Johnson's staff asked Dr. Mallinger how the 

VA OIG decided which Tomah employees' emails to collect. He responded that the VA OIG 

"pulled different employees for different reasons." 718 It appears. according to his statements, that 

the decision to pull cettain individuals' emails was based on the allegations in the hotlines, 

documents, and other inspection sources. 719 For example. Dr. Mallinger explained that the OIG 

114 Memorandmn from Robert Yang. VA, to Director, Computer Crimes and Forensics Laboratoxy (May 17. 2012), 

at OIG 13676. 

'"Memorandum from Robert Yang, VA, to Director, Computer Crimes and Forensics Laboratmy (May 17. 2012), 

at OIG 13677. 

?Hi ~fallinger 4/6/2016 Transcribed Intervie"v, at 251. 717 !d. at 251. 718 !d. at 251-52. 719 ld. 

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110 
190 

chose to collect Margaret Hyde's email because it would shed light on the "polarization" of the 

facility, which was a "very dysfunctional kind of place" where "two groups had formed." 720 He 

said: 

Margaret Hyde is actually a-she may be a clinical pharmacist, and I'll try and 

remember why we looked at her email. She was someone who I recall was-you 

know, you asked me before about the environment at Tomah and the culture, and 

while a culture of fear is sort of an element of that in terms of the perception of, 

you know, fearful circumstances, the culture at Tomah was really one of 

polarization. It was a very dysfunctional kind of a place in which two groups had 

formed: a very small group that was centered around Dr. Houlihan, and a larger 

group that was a little bit more diverse but was primarily phannacists with a 

smattering of other disciplines in there. And so Dr. Houlihan had some close 

associates who were part of this-you know, the two warring factions, if you 

will-that were part of his faction. And I believe that I'm remembering this 

right-I'm not totally positive, but I believe Margaret Hyde was a clinical 

phannacist who was in Dr. Houlihan's faction, if you will, and who was kind of 

like the only one who was regarded as a good pharmacist by him, if you will. So I 

hope I'm remembering her-I'm hoping I'm putting the name together with who 

that was. But, obviously, we wanted to look at people who were associates to see 

what kind of messages he was giving to them. 721 

Dr. Yang explained that the decision on the email collection was a collaborative effort 

between Dr. Yang and Dr. Mallinger and that they decided to "go with as broad a brush as we 

could and just see what we sort of would find." 722 He further explained the list of employees 

was decided based off of "who we thought might be in communication with Dr. Houlihan."723 

The VA OIG's Office of Investigation Forensic Laboratory closed the email request on 

June 6, 2012. 724 The office succeeded at securing a total of 12 VA employee email accounts.725 

720 I d. at 252-53. 721 Id 722 Yang Transcribed Interview, at 121. 723 ld. at 118-19. 724 VA OIG, Office of Investigation, Forensic Laboratory Report (June 6, 2012), OIG 12370, at OIG 12370-71. 725 Jd. 

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Senator Ron Johnson, Chairman 

Ill 
191 

Figun• 35: V ~~!~-~or~nsic Laboratot·y Report of Tomah V AMC email coll~ctions 726 

FORENSIC LABORATORY REPORT 

HOULIHAN. David 

SYNOPSIS: 

06t06!2012 

APPR ASAC Brian K. Tullis 

Lab n 2011·04212-IE-0087 

File# 2011·0~212-HI-0276 

IT Specialist Sharor1 A. Forbes 

Status. Closed 

Dist 51CH. 51 E, 54 

Department o! Veterans Affairs Office of Inspector General (VA OtG) has received 

allegatrons regarding the Tomah Veteran Affairs Medical Center facility, specifically the 

prescnption of narcotics at the facility and possible erosion of internal controls by the 

Facility's Chrel of Staff. A request lor the email accounts for seventeen current and 

former Department of Veterans Affairs employees was made. 

VA OIG Computer Crime and Forensics Laooratory (CCFL) obtained and processed VA 

email account fries for twelve of the seventeen employees. The results were provided to 

the requestors lor !heir review. 

REQUEST: 

On May 17, 2012, tho CCFL was roquostod to obtain and process tho VA o-m ail 

accounts lor the following employees. 

• David Houilan • Gary Loethen 

• Deborah Frasher • Angela Cournoyer 

• Margaret Hyde • Donna Leslie 

• Mary Forslund • Ron Pelham 

• Zakia Amting iSiddiqi) • John H. Edwards 

• Lrnda Etlrnghuysen • Dean Whrteway 

Z6. May Z01Z: The VA OJG conducted a site visit to the Tomah VAMC, with employee 

survey results showing disturbing complaints 

The VA OIG conducts a number of routine program reviews of VA facilities, including 

the Employee Assessment Review (EAR) and a Combined Assessment Program (CAP) report. 

726 Jd. at 12370. 

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Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

112 
192 

According to the VA OIG, the purpose of the EAR survey is to "get a better understanding of the 

facility and concerns that they [the staffJ may have."727 The EAR survey typically occurs before 

the VA OIG conducts a CAP site visit of a VA facility. 728 The EAR survey is completed by VA 

employees and responses are anonymous 729 Ms. Haywood described the EAR process as an 

"electronic" survey "that the IG sends out to the facility, to the employees, prior to us coming 

onboard so that they can give their comments of different issues, patient safety issues, 

environment and care type things like that."730 The EAR survey generally closes a few weeks 

before the CAP site visit and responses to the survey are collected. The responses may assist the 

CAP team's understanding of potential issues before visiting the facility. According to Ms. 

Haywood, responses to an EAR survey can serve as the basis to opening an OIG investigation.731 

Ms. Haywood told Chairman Johnson's staff that she was involved in the Tomah V AMC 

CAP site visit during the week of May 7, 2012. 732 She confirmed that the VA OIG conducted an 

EAR survey of Tomah VAMC personnel prior to its CAP review of the facility. 733 The EAR 

survey yielded seven specific responses that were flagged by a VA OIG employee and sent to the 

OIG hotlinc group on May 4, 2012.734 The VA OIG hotline group compartmentalized the EAR 

survey comments into a list of complaints and emailcd the list to Dr. Wesley and others serving 

on the OIG's OHI hotline group for their review on May 7, 2012. 735 

727 Letter from Hon. Richard Griffin, Deputy Inspector Gen., to Hon. Ron Johnson, Chairman, S. Comm. on 

Homeland Sec. & Governmental Affairs (Apr. 24, 2015), OJG 10124, at OIG 10129. 728 Office of Inspector Genera/ Reports and Publications, DEP'T OF VETERANS AFFAIRS, OFFICE OF INSPECTOR GEN., 

http://www.va.gov/oig/publieations/._ CAP reviews are part ofOJG's efforts to ensure that quality health care 

services are provided to Veterans. CAP reviews provide cyclical oversight ofVHA health care facilities; their 

purpose is to review selected clinical and administrative operations and to conduct fraud and integrity awareness 

briefing. 

729 Letter from lion. Richard Griffin, Deputy Inspector Gen., to Han. Ron Johnson, Chairman, S. Corum. on 

Homeland Sec. & Governmental Affairs (Apr. 24, 2015), OlG 10124, at OIG 10129. 730 Haywood Transcribed Interview, at 59. 731 !d. at 63. 732 I d. at 58. The CAP Review of the Tomah V AMC was issued September 5, 2012. VA OlG, OFFICE OF 

HEAL THCARE INSPECTIONS, COMBINED ASSESSMENT PROGRAM REVIEW OF THE TOMAH VA MEDICAL CENTER, 

REPORT NO. 12-01337-267 (2012), OIG 13918, at OIG 13918-49. 

m OHI CAP Employee Survey (EAR) Results, Tomah V AMC (May 7, 20 12), OIG 12057; see also Haywood 

Transcribed Interview, at 60. 734 Haywood Transcribed Interview, at 63; see also E-mail from Shirley Carlile, VA OJG, to VA OIG Hotline (May 

4, 2012, 8:14AM), at OIG 13656. 735 E-mail from Yohannes Debesai, VA OIG, to Alan Mallinger, VA OIG (May 10,2012,5:00 PM), OIG10943, at 

OIG I 0943-44. 

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Senator Ron Johnson, Chairman 

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193 

Figure 36: VA OIG Office of Hotline Contact Reft"JTR17

J

6 

OHI Hotline Contact Referral 

1. We are referring the complaint, reported to the OIG Hotline, for your review in accordance 

with OIG GM Directive 316. 

An anor'lymous source reports myriad incidents and concerns at the facility: 

• providers believe in using schedule II narcotics to treat psych patients for PTSO 

• over medicating patients 

use of narcotics and drug abuse at the faclfity 

• the prescribing practices with regards to opiods 

The Chief of Staff prescribes outrageous doses of narcotics to his patients daily 

large amounts of narcotics being ordered for patients 

the subs1ance abuse unit, certain medicalfpsych providers continue to prescribe large 

or benzos, sleeping meds and pain pill to patients. 

Originally, these seven complaints from Tomah VAMC employees were assigned the 

case number 2012-12541 but after OIG personnel discussed the complaints, the hotline group 

decided to bundle the complaints with the ongoing Tomah VAMC inspection on May 10, 

2012. 737 According to OIG documents, the complaints fiom the 2012 Tomah V AMC EAR 

survey included a number of serious concerns, many of which focused on Dr. Houlihan738 l11e 

allegations included potential drug diversion, over-medicated patients, certain providers using 

schedule II narcotics with no botmdaries, and Dr. Houlihan prescribing large doses of narcotics 

to his patients. 739 

Toi.Illlh VAMC employees described the facility's work environment as one in which "no 

one can question the prescribing ... due to fear of retaliation by the COS [chief of staf£]."740 

Another complaint echoed the fear at the facility, explaining that "[t]he people here are afraid of 

having their careers mined if they speak up. It's happened to others."741 

7315 !d. 737 VA OIG Bates nwuber OIG 13825: see also E-mail from Yohanues Debesai, VA OIG, to Alan Mallinger. VA 

O!G (May 10. 2012, 5:00PM). OIG 10943. at OIG 10943-44. 738 Complaints Received from the EAR Sw-vey, Tomah VAMC OIG 5730, at OIG 5730-31. 

1)9 Jd. 7

"

0 Jd. at 5730. 

'"'Id. 

:Vlajority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

114 
194 

Figur• 37: Tomah VAMC 

4. The prescribing practices with regards to opioids at the Tomah facility arc quc5tionablc 

if not downright "ncthtcal. No one can question the prescribtng howcvN due to fear of 

rctal!at1on by the cos. 

Ag3in, in the orca of prescribing chronic opio•ds m our V<:>tcran populatton I strongly 

su~p~ct that there~~ lot<.. of drug dtvenicn. Urine drug SCf~n!l. that dre negativf!: are not 

acted on- controlled sllb,tarKF< are st11! being presaitwd. COS ctoes oat encourage 

getting UDS, narcotic contracts or holding patif'nts accountable for "lost'' medicationsprovidl?t"s encouraged to let 11minor lnfranion~ •! so. 

~. Hw Chief of Staff pre,cribes outrageous dos('S of nan:otks to his patients {i.e. 

oxywdone 1000 mg daily, morph1nc 1200 mg daily'). Heal~ likes to prescribe benzos 

and ~timulant; to patients. It >cern$ he th,nks rnentill he~lth pat<ent~ should be treated 

with pain med> and st1mulants, like that w1ll help thc1r rnent<ll health condition. He uses 

Z7. May 10, Z01Z: The VA OIG interviewed Dr. Noelle Johnson 

Dr. Noelle Jolmson worked as a phannacist at the Tomah VAMC for just under a year 

before she was tired atler raising concems about the presctibing practices at the facility. 

According to infonuation provided to Chainua.tJ Johnson. the VA OIG reached out to Dr. 

Johnson-identified as a "fonner Tomah pha.tmacist (says she was fired for refusing to fil Rx, 

won a 'case' about it)."743 

Figur• 38: Emoil from Dr. Alon Mailing .. · to Yobonn•s D•bosoi 7

" 

742 Id. 

From: 

Si!nt: 

To: 

C<: 

Subj@ct: 

Ma!hnger, Alan (OlG' 

I hurs(ldy, Mily 03, 2012 6:2', P\1 

Dcbcs.ll, Yohannes (OiG) 

Shepherd, Ml:haell, MD (OIG), Wesley, Georgi' (SES) (O!G) 

f.-W ph<JHlld( i\t -.vho :efl fonMh 

1 wt up d P'lOffl' 1ntrrvw.v w t'l <1 forf'1f'r TO!J.ln p";Jrt'l.lC·~: for ned Wf.'d <it l: 

P!P,lw '>Liwdul*' .1 VA'\T~ 1~:'1' /i.)A:> 

ll(•ortw and r...~1kt>. I •.pok.P w th ,J <,('iOl'd forr"lPf for"•<lh ~~a•r.JJCF,! { .. Jys •,h(' \>,d'. l•reJ le~ r<:>lt.s.tng :o •t: R._, wm: <l "c.Jsl'" J')O 't 

lt} "he IS ilvJt!ab:e to l'lt~r'JH~W JnY liTe nt•xt WC't'~ a$ she !5. h<)~E' r~'C)V€11'1!! fro'T' ~I.Hf:{'ry Could yDL gtve tnt" '>:Jme • ~~II:! tifT'!(";. .J"d I w•ll s;:::h;du·P herd\ WPlP 

MJ'tyti:Jrb 

Ala'' 

743 E-mail from Alon Mallinger. VA OIG. to Yohannes Debesai. VA OIG (May 3, 2012.6:25 PM), at OIG 10968. 

"'!d. 

Majority Staff Report 

Committee on Homeland Security and Gonrnmentlll Affairs 

Senator Ron Johnson, Chairman 

115 
195 

The VA OIG phone interview with Dr. Johnson, which occurred on May 10, 2012, lasted 

nearly two and half hours745 Dr. Johnson discussed a number of issues with the VA OIG, 

including concerns related to prescription practices, early refills, and an overall view of the 

unease in the Tomah VAMC phannacy during the 2008 and 2009 period.746 Dr. Wesley, Dr. 

Mallinger, Dr. Shepherd, and Dr. Yang conducted the interview on behalf of the VA 010. 747 

Dr. Johnson told OIG inspectors that she was fired because she refused to fill three 

prescriptions written by Dr. Houlihan. According to Dr. Johnson, one of the prescriptions was 

for 1,080 immediate-release morphine tablets (15 milligrams) for a 30-day supply. Dr. Johnson 

told the OIG that she was alanned because she had "never seen doses like the doses [she has] 

seen come from here, and [she] didn't feel comfortable filling the prescription." She continued: 

"I felt it was unsafe for the veteran."748 When asked about similar experiences during her time as 

a VA pharmacist, Dr. Johnson told the OIG she "never" had a similar situation of feeling 

uncomfortable and refusing to fill a script. 749 

745 The entire Noelle Johnson transcript is found at VA OIG Bates number OIG 5935-5992. 746 VA OIG Interview with ~oelle Johnson (May 10, 2012), OIG 5935. 747 ld. 

"'!d. at OIG 5942. 749 I d. at OIG 5944. 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

116 
196 

Figur{' 39: ExcPl1>t of VA OIG's inter\-i-ew of Dr. ~oellt> Johnson 7

::

0 

150 !d. at OIG 5941. 

···!..,._ 

~~7 l 

}j; 19:f 

:eport and p~t 1r for destruct1on. It qoPs to 

iOur -- hl)l; many levels c•f s1lp~r'llsory pfop:e, 

and tM poiit~ also do .3• :n:;tstLqation ~nd 

rep.:' rt. 

lilt \·.:..~G: Kight. Sc bamallj' i.t 's -- I 

~~~~~,J~:s ~ ~~:c~~~;:~~·~~ of th~ i:.tm31 I 

DR. J\ititiSlJil: Y~c;, ab:ou!Jl•'l;. Rt ~·~iYJI th2 v~ult ptarnari~t, •h3t's wh~rr I rncou,tr~~d I Y.~ trMble. The r.eason I was fued, : bel:<>·;~, I 

w~~ te·:H~E- i chose t~ r~fll~F: ~D fill thrP~ I 

pr2scnpt1o,;:. T~P;' 1¥€t~ all wr1trer bi [If, 

~C·dlta~, it~•1 th" firs: c."e w;,c: fer an lflrn~dHt~ 

~elea.:~ 'llo:ph~e. ~~d L' was l,081) i11111et~i.1te 

celeas-: :norpni:te ta:.:ets tor <1 JO-daj sup~·!;. 

!!~ .. !AhG: !'11 sccr;. :·c·uld l~u saj 

thJt dga1n, I.OGO~ 

D~ .. JOHtlSOll: l/•B•L 

DR. Y~N~: 1,:80. 

DR. 1-tq,r.mFE.;.: Sr. I'm >C•frt'• 1,~=1? 

ll? ... J~~tiSOk irJ:d;ate re'~,;~~ 

:\Iajority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

117 
197 

Figure 40: Excerpt of VA OIG's iuteniew of Dr. :->oelle Johnson"' 

!4 )F. 'IA~G: Just to get a sense, em, 

15 whl~e /CU we:e lr, :c>!Jilbus, d1d you enr l.Ht' :1 

16 

l 

18 

B 

20 

sim: lil:- s: tuatLm •lteri' \'Oil :el: u"rr;r,forta)Je 

and re:usec :c Ill! a scr:pt' 

DL JO.~NSJll: ~ver. The ccms ·- ond 

~ct ~c tc: I fW. I rncJn, this is j u~t the start 

of • t. I ha·:t :~a~pl~s of quitt a few m:m, 

but -~ 

DF. YA~IG: Riqht. 

JP .. :OOIISCitl: -- ar2 n~thir.g \<:l.llparcd :o 

wha: I •as se~u~. I wort in l •orl in :)Uf 

pdlll tlillil :1ne i:1 De> Hoines do Ntll. I '•Je 

never m" an;t1in~ lil.e this. 

J;. \'A%: Su:P. A1C If tH:nS c'l sort 

of :ri; kind of dmgreem~nt ~~~h sort of another 

scr: c: • clicical pr:o~ider, had 'J0c ~\\?! h>d a 

simik S0rt d f•eJple getting UfSet Hd 

screomirg sort ·;f 3t this k:eP 

10 OF- .. JQ1llS)ll; flo. 

L ~f. iNlG: so th:s is :eallJ sort~! a 

12 ·1rst. .n tlllltiple ""/'· 

1 l )r.. JO~NSJ!I: Yes. 

During her interview with VA OIG inspectors. Dr. Johnson recalled a meeting-which 

Dr. Jolmson did not attend-at the Tomah VAMC in which Dr. Houlihan allegedly told a 

mmiber of employees that Dr. Jolmson had tumed him in to the inspector general 752 She became 

aware of this incident from two colleagues. According to Dr. Johnson, she "tumed him in to the 

tmion. which (sic) a grievance with the tmion was to be nimed in to the inspector general.''753 

Dr. Mallinger responded. "I don't think anybody called us that far back. This is back in 2009, 

'"!d. at OIG 5944. 

"'!d.. at O!G 59.16. 

'"!d.. at OIG 5946. at 44-45. 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

118 
198 

right"" 754 Dr. Mallinger did not inquire ftuther, reasoning that "it probably wouldn't have that 

much meaning if you didn't hear it directly. . "755 

Figure 41: Exc•rpt of VA OIG iotoiTiow of Dr. NO<'llo Johnson756 

:::.. tt\~L:~GER: Cl:a;>. C: ~·~··~ l:~~·..: i: '.e 

;.;j~ -~ t-;e::, 'i''J ~f;r·::n,: :here. l~e·:er n-.:..n:. 

:lF .. :o~~~S~li: I • n sm:. 

J? .. H.~.~L:SGIR: l~, ~: s ~-l:ai. ':J. 

·:·c•, ::'1 ';.'r. :h;t it ~T:ibot:;· h'O:J!Jr'· 

1: -- .t ::c,at~i· •culdr,': "·•·;e h,;t n~.::. r.:E~-"~-~ 

lf f:U Clj~': h!~t lt j~~e~:!j d~jMaj, SJ ] ;;~~~ 

:J~ .;t:: fJ:::s o:: ·.r.~ tL:-.gs ,:J el:~·ec~n:d 

i i reeL . 

Dr. Johnson also described to the VA OIG how Tomah V AMC patients would call Dr. 

Houlihan the "Candy Man." She elaborated on the moniker, explaining: "I would hear them say 

things like, well, 'I went to my primary care doctor and she took me off my pain medications. 

but I went to Dr. Houlihan and he put me back on, so he's the guy you need to go to. "'757 The 

VA OIG inspectors did not pose any follow-up questions. 

Dr. Johmon verified allegations in the hotliue complaints received by the VA OIG that a 

muuber of phannacists left the Tomah VAMC. She said during her sho11 time at the facility, 

"probably nine or so phanuacists" left. 758 She explained: 

Titey either just-they're like they can't take it anymore and they're not willing to 

fill those prescriptions or put their license on the line, so they leave, or they can't 

handle him, or they just eventually-most of them leave or-they made an 

example of me. and I think people are afraid to come fmward and afraid to tell the 

tmth about what's going 011. But the DEA is cunently investigating.759 

754 !d. at OIG 5946. 755 !d. at O!G 5947. at 46-47. 756 !d. at O!G 594 7. 

'"!d. at OIG 5955. 758 !d. at OIG 5965. 

"'!d. 

~Iajority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

!19 
199 

Figun• 42: EX<'N-pt of VA OIG's inte-r·vie-l'i of Dr. N"oe-Ue- Johnson 750 

QR. JOHNSON: ~he'{ ettner jus: --

theJ're like ttey c-an'~ tate it anymore a::d 

they're ~ct ·•illln~ to fill those pmsrdptiuns 

or put t~eu lb:r.se on the line, so t~ey ieav~, 

or ccln't haliille lur, ~~ they just ever.tualiy •• 

r10~t of the:t leave cr •• the}' IW:Ie an ~xarple of 

ne, and I t~inl: pec.p:e are afraid to cc1:1e fon•ard 

and afraid LJ tr!l Lh0 truth about what's yoinq 

on. But the DEA is currerotly investigating. 

A9ain, L actuall 1 •• 1 was called by a 

ne>~ )rv~st.iqator a couple weeks aqo •• 

By May 2012, Dr. Mallinger was aware from his contacts with the DEA that it was 

investigating the Tomah VAMC. During her VA OIG interview, Dr. Johnson spoke about her 

interactions with the DEA and the fact she was "called by a new investigator" a few weeks 

before her interview with the OIG761 She described this contact with the DEA as a two-hour 

phone call that covered much of the same material as the OIG interview762 

Dr. Yang asked Dr. Jolmson why she thought Dr. Houlihan was prescribing. such high 

prescription dosages. Dr. Johnson gave two answers: 

760 ld. 

761 !d. 

One is that he's using himself and he gets, you know, whatever-my boss said to 

me once that he acted like he was on a cocaine high, which he does. But what I 

tmthfully feel like is that his patients are diveriing. the medicine and he's getting. a 

kickback. 763 

762 !d. at OIG 5973. 763 /d. a! OIG 5970. 

:\·lajority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

120 
200 

'"!d. 

or VA OIG's iute-rvien' of Dr. ~ot>IIP Johnson 764 

DE, YANG: O!",, g~z. And l know this 

c~~l:; fo: a b1t of speculation, sc• d you dor,'t 

~ant to sat anything along these lines, that's 

fine. De )'OU have an~ ide,; as :o ••hy he Jo:a5 sort 

of d~ inq what -- scrt t'lf this 3 crt of practice 

the 'o(a.y :hat he ~o~as ·· 

nR. JORNSOll: Yr.u lno;.r, p;,ople ~st roe 

tr.ese m;~y qussti:ns, an: t:.ere's ~wo :easons 

t~at I :an :hi~t. O}e is ttat he's ~sin~ himself 

a~d ~<' Jets, yQu know, .1hate~er -- fi'J boss S3td 

to ~e once :h~: he acted li•:~ h: :.~as o~ a c:;~cai ne 

hiqh 1 whic·i he does. But .,.l,dt T lruU::ulLy [eel 

lite is that his patients are ~iv~rti~g the 

:1ed::111e a~.:: he's gett1ng a l;.:.c<b3cl:. 

00. YANG: Uh-huh. 

DR. ll.~L11J'{3ER: l'iha: :'lates you thir.k 

DE. Jt:lHllSotl: 'Jhat 4 5 what I -- 1 

trut!':Eully feel that, because s: :nany -· one, t:Je 

02:55:31 

lkonroe Cclillty SJeriff' s D.;;parbent has been 3 

littl~ invohe1. HiJ~autel? ~~ou~r{ -- ~r 

liilwa~kee Sheri.~t's Depar:m~Jt ~1aS bee:\ involved, 

ard t hej"ve bee1 gl'tt i ng -- the VA is t.nown as 

the place to go to get na~cortcs. I ~ean, there 

~s a huge diversion problen there. And it's not 

a secret. 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

121 
201 

At the conclusion of the interview, Dr. Mallinger expressed his interest in obtaining: a 

statement from Dr. Johnson's Merit Systems Protection Board (MSPB) case file about Dr. 

Houlihan's conversation with two other Tomah V ANIC employees765 Dr. Johnson had the 

statement as it was pru1 of her MSPB case but told the OIG that the Tomah union representatives 

wonld also be a good place to obtain a copy, as they have "documentation of all tbat."766 Dr. 

Mallinger responded that he did not know if the GIG had authority over the union. Directly 

following this exchange, Johnson posed a question for the inspectors about what the OIG had 

done to investigate the Tomah VAMC allegations in 2009. Dr. Mallinger responded: "It wasn't 

us." 

Figure 44: Excerpt of VA OIG intorYiew of Dr. Noelle Jobnson767 

Q~. tV.LL!IlGE?: ~e'l~. I'n Mt sure if 

we nav~ a.~lmLt} r:wer tte ~n::J~,. 

D?. liESLEY: I kn't l:n:~c. But trJ!.'~ 

not -· l'le' L: figu:·~ that o~t. 

[•F.. :OHNSG!I: hr:•l t''Hl '3 wbt T W'l:' 

told. Li~e I told lll:i grie•ra;,ce was qoing -- I 

l-I:).S t :·ld th~ i nsrer.t Jr genH<l I ~as co:ng .:;n 

ir.vest ig~t1or1 ...t:en u·,e s:11tf b>ppe~ed a~d that 

tho :~forut irn ,.-a~ qi_vp;; t~ th(,nl. Eur. :1s I 

:·e,;~ll. nc·thi:og :~ of it. S;:1, Dr. llall:~ger, 

: 'd ask ycu '1bt:t wt;jt h~flp!'lld~ i>rher,; lll'n: f'lll 

quis i.1 2J09 lihe~: we contacted it•u? 

DF. flJ\J,J,TlJGF.~: YeJh. 1l ... asn't us. 

The VA OIG 's reaction to this infonuation is unclear. During his transcribed interview 

with Chairman Johnson's staff, Dr. Wesley could not recall intervie,~ing Dr. Johnson. 768 When 

interviewed by Chaimlatl Johnson's staf[ Dr. Yang did not recall any conversations with Dr. 

Mallinger. Dr. Wesley, or Dr. Shepherd about Dr. Johnson's allegations that Dr. Houlihan was 

on a "cocaine high" or diverting ch·ugs 769 Dr. Yang also said that he was not aware of any 

review of files or prior contacts by individuals at the Tomah V ANI C. 770 However. an email sent 

by Dr. Shepherd contemporaneous with the interview showed that Dr. Shepherd saw the 

conversation as "interesting." 

'"!d. at OIG 5974, at 1~4. 

'" Jd. at OIG 5974. 767 Id. 

768 Wesley Transcribed Interview. at 189. 

;~:Yang Transcribed Interview, at 88. 

Jd. at 91. 

'' t... 

" '-~ 

~2f • I 

\ 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

122 
202 

:Figurr 4!1': Email from Dr. "MichaPI Sbe-ph€'rd to Dr. GE>ot'gt~ \Ve-sle-y and Dr. Alan MallingN'771 

From: Shephe•d. Michael L. MD \OIGi 

Sent lcurscay. May 10. 2012 S:<:6 PM 

To: Wesley. Geocge (5oS) (OlG); Ma Inger, Alan (C>IG! 

!ntNr~Hng intrrviflw. Do we htlV(' <1 ma::.ter !io;;t ol who wr. <Jrr plnnning on intr:rviewing via phone nnd on-c;it~? 

!hanks, 

Months later, on July 26, 2012, Dr. Johnson emailed Dr. Mallinger to send him 

documents relating to her experiences at the Tomah VAMC.772 Although Dr. Johnson told Dr. 

Mallinger that her settlement with the VA cleared her record and name. she seemed disappointed 

that changes at the "facility level" did not occur. She explained: "I want nothing more than the 

safety of those veterans to be a priority."773 

Figm·e 46: Emoil from Dr . .\'oelle Johnson to Dr. Alan 

From: 

Sent 

To: 

Subject: 

John~on, "Joelle A 

Ju.~\:Jay July n ?O:? V.J !>\11 

ro..blhngt'r, Alan (O:G; 

Rt Not>lle ;ohnson DDWI'1!!nts 

r\v, :'IN(! wJ.:, n::~ acknowlt:dgn'rt\t o~ w'OI'~ co;n)li. ,-:;J~t'oq;h :'leVA wa;, t:::il!lW to en:N "to a s.et:·crwnt ! wa;, Jb!e tog(;: 

ne~I~W <:n~ r\'t.crd c!t:>dtl:!d wh:h wr1., ·rlpcn""nt :o r1€ 'luwe·J<>r 'l"~f and fo··E'n::~J W<i'l!IOC l.'".~~g~.:. to be rlplt>P)t,!~!I:'C dt :"<~:> 

:.:~11~:~ ~·vt•l fuc ~'1'.' ;.,\,.t!~) of :,.t' v•!:t•rdth U"'fo-hrhi!<" '{, l"l>:. did :tvt •·,n:mt•n wi:" tfw r~'t>Ji<a:i:..:n 

I t-opf' the doturwnb wN~ l..'>"!~UI wiin~ no:ra ~!t T~re th,m !ht- ~""~'-:\1 of tho~f' v<':,.r;;m to b~ .1 prwri:r.L?t r't> know if tht-'R 11. 

::wvthnlr; e '>C 1ou nt.•cd 

nf'::.!Jf'c:f.JIIy, 

J\od e Jo'· non 

From: tta!l ng~~. Alan (OJG) 

Sent; T,Jt''>rlJy, july 11, 2C!12 10:09 AV 

To:john'>:J'l, ~atoHI:' A, 

Subjett: Hf: Noch~ johns.on Oocu"'l.~nts 

!>''O~ d h,l\.'i.' cJn\ulted '11)' note:. lH:fort:: .:'>.k "g 'f;JU Smu.:- 1t w,h..; >l'l:krrenl, 

"'"'"''''""'c ~:Jf"e W'O't!oi:dt.:i"f{ ; w~ulc ptubotb!v 1 ot ddd :o wh,Jt WI! h<lvc. 1h.lnb 'o'VY r" ... ch fo1 the otn~~~ 

:hll•i:''. !ht•y W('H' very 1.-,;"u! 

771 E-mail from l\1ichael Shepherd. VA OIG. to George Wesley, VA OIG (May 10. 2012. 5:46PM). at OIG 10942. 

mE-mail from Noelle Johnson. Tomah VAMC. to Alan Mallinger. VA OIG (July 26, 2012. 3:09PM), OIG 10693. 

at OIG I 0694. 773 Id at 10693. 7?4 I d. 

:\lajority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

123 
203 

28. May 16, 2012: DEA provided the VA OJG with a copy of the Juneau County Sherriff 

report about the suicide of Dr. Christopher Kirkpatrick 

By May 2012, Dr. Mallinger had established a working relationship with a DEA 

diversion investigator in Milwaukee, Wisconsin. TI~ey both were examining allegations that 

related to Dr. Houlihan and the Tomah VAMC and they agreed to keep each other infonned on 

the progress of their respective work. 775 On May 16, 2012. Dr. Mallinger emailed the DEA 

investigator requesting "a copy of the report we discussed previously, in regard to our case 2011-

04212-Hl-0267. VAMC Tomah. Wl."77 On the same day the DEA investigator responded b~ 

email. attaching the Juneau Com1ty Sheniffs report of Dr. Christopher KirJ.q:Jal!ick's suicide. 77 

It is tmclear how or when the DEA investigator obtained the repmt. 

About a week after providing the repmi to Dr. Mallinger, the DEA agent sent it to VA 

OIG Special Agent Greg Porter. In the transmittal emaiL the DEA agent emphasized, "I think 

the best pmts are the attaclunents and email conespondence. but you may find something I've 

missed regarding controlled substances." 

Figm·e 47: Emnil from DEA Dinrsiou Innstigator to VA OIG Special Agent PortH"' 

From: 

511.'n1: 

Tv; 

5ubjoct: 

Altad'lnt..nts; 

Mo1dty, May 21,2017. 3;J2 PM 

Perter. Gres (O!Gt 

FvJ· report 

lu·Hi'lu VA clo:tor.pdt 

i:Uusdoj.gov> 

/l,tt<H.tled is UK~ JurwJ 1 Ctv Sh~rHf's otfic~ n.•po'i .• r tHuk H"e bes\ PJfl5 Jre th2 attochment~ :;lnd :!mall corrt~s.pondenre. 

but you IlliiY rtnC ~omatlliniil've miH.ed ~ardfnR. 'or.tr:Jifed $Ubo:h.nce5. 

Dlvcrs:lcn l.nvestf{31or 

Dtug Enfoor(:•m•nt Acmin15tr~tion 

During a h·anscribed interview with Chainnan Johnson's stati, Special Agent P01ter 

recalled seeing the report and told staff that he believed this was the first time he becmne awm·e 

of it. 779 He was unsure whether he reviewed the report, but he thought that he "skimmed thwugh 

mE-mails between Alan Mallinger. VA OIG. to Di,·ersion Investigator. DEA (May 16. 2012), OIG 10598. at OIG 

10598-99. 

"'!d. 

::; E-mail from DiYersion lnwstigator. DEA. to Greg P011er. VA OIG (May 2 L 2012. 3:02PM). at OIG 10598 . . !d. 779 Porter Transcribed Jnten·iew. at 80. 

Majority Staff Report 

Committee on Homeland Security ancl Governmental Affairs 

Senator Ron Johnson, Chairman 

124 
204 

it" after it was set to him. 780 Special Agent Porter could not recall if he spoke with the DEA 

about the contents of the report or his reaction. He stated: 

Q: So you received the Juneau County Sheriffs Department report in 

May of 2012, and the diversion investigator on Exhibit 11 said in his 

email, "! think the best parts are the attachments and email 

correspondence, but you may find something I've missed regarding 

controlled substances." After this report was sent to you, did you ever 

discuss with this diversion investigator of the DEA the contents of this 

Juneau County report? 

A: Not that I recall. 

Q: Do you recall reviewing this and can you recall your reaction to 

reviewing these 58 pages [of the Sheriffs report]? 

A: No, I cannot. I would look at-as I sit here looking at it, the first thing 

I would look at is when this happened, and this happened three years 

prior to my investigation at the Tomah, and it was a suicide by 

gunshot. So I wouldn't have given much credence to this as being 

relevant to my investigation.781 

The Juneau County Sherriff report is a publically available document that details the 

death of former Tomah V AMC psychologist, Dr. Christopher Kirkpatrick. 782 Dr. Kirkpatrick 

committed suicide on July 14, 2009-thc same day he was terminated from the Tomah 

VAMC. 783 During his transcribed interview, Dr. Mallinger recalled reviewing the Juneau 

County Sherriffs report, and he spoke about the report in reference to the OIG's request to 

collect Dr. Kirkpatrick's emails. 784 He stated: 

no Id. 

A: So Dr. Kirkpatrick was a psychologist at the Tomah VA who 

committed suicide, and some information about him came to our 

attention, specifically an investigation into his death by the Juneau 

County Sheriffs Department and we reviewed a lot of-and you 

probably have a copy of that, but there was a lot of VA material 

considered in that investigation that had been supplied by a union 

representative who had represented Mr. Kirkpatrick. 

781 !d. at 82-83. 782 JUNEAU COUNTY SHERIFF'S DEPARTMEl'T, CHR!S KIRKPATRICK DEATH INVESTIGATION REPORT (2009). 

Additionally, the VA OJG produced the Juneau Country report pursuant to the Committee's subpoena. 783 Chairman Ron Johnson sent a letter to VA Secretary McDonald regarding Dr. Kirkpatrick's death on April 20, 

2015. 4/2012015 Letter from Chairman Johnson, HSGAC, to Secretary McDonald, VA. 7

"' Mallingcr4/6/2016 Transcribed Interview, at 259. 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

125 
205 

Q: Were you able to pull Dr. Kirkpatrick's emails since he did pass away 

in 2009 and this email pull is in 2012? I just want confirmation you 

were able to pull some of his emails? 

A: I really don't reeall. 785 

Chairman Johnson's staff also inquired about why the VA OIG collected emails from 

Linda Ellinghuysen, the Tomah VAMC union official who represented Dr. Kirkpatrick before 

Tomah V AMC management. In responding, Dr. Mallinger explained how Dr. Kirkpatrick's 

death and the Sherriffs report became part of the VA OIG's inspection. He stated: 

Q: So Linda Ellinghuysen, why was her emails pulled~ 

A: So in the Juneau County sheriffs investigation, there were several 

individuals who were named. And, again, we wanted to look more 

carefully at this because there were allegations that somehow he had 

been critical of Dr. Houlihan's prescribing practices and had been fired 

because of that. And so these people listed below his name-Linda 

Ellinghuysen, as I said, had represented him, Gary Loethen was his 

supervisor, and Cindy Gile was a physician's assistant who supposedly 

he made these comments to about Dr. Houlihan's practice. And so we 

wanted to see whether, you know, we could get any further 

information about any potential administrative abuse that might have 

taken place by looking through these records to basically see if, you 

know, they were sent emails or, you know, that they sent emails that 

would shed further light on that. 786 

29. Spring 2012: The VA OIG Criminal Investigation heated up 

While Dr. Mallinger and other members of the health care inspection team in 

Washington, D.C., continued their work on the Tomah V AMC allegations, the VA O!G Criminal 

Investigations unit in Chicago took an increasingly active role beginning in March 2012. 787 

On March 28,2012, VA OIG Special Agent Porter, along with a detective with the 

Tomah Police Department, and two DEA investigators from Milwaukee interviewed an 

"'!d. at 255-56. 786 Jd. at 256-57. 787 VA OIG Criminal Investigations Div., Greg Porter, Memorandum of Interview of Tomah V AMC Employee 

(Mar. 28, 2012), OIG 10592, at OIG 10592-93. 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

126 
206 

"anonymous Tomah V M1C employee."788 TI1e DEA set up this voluntary interview, which 

took place at the Tomah Police Depmtment m1d lasted for a little over one hour789 According to 

Special Agent Porter's subsequent memorandmn documenting the interview,790 the anonymous 

source was a "full-time employee at the Tomah V M1C" and was in "regular and familiar 

contact" with Dr. Houlihan. 791 The source provided infonnation similar to the allegations in 

some of the Tomah VAMC lwtline complaints. For example, the source told law enforcement 

that "[i]t is widely believed, through word of mouth at the Tomah VAMC, that veterans who 

need certain prescribed opiates andlor other pain killers go directly to Houlihan or Frasher. "

792 

TI1e source also alleged that Tomah V AMC pharmacists had "raised issues about Houlihan and 

Frasher over-prescribing painkillers for veterans, often noting that the same veterm1s would 

receive several presc1iptions in a short amount oftime.''793 

Dm·ing the interview, the source told of the work culture at the facility. TI1e source 

relayed allegations that Ms. Frasher "is often 'stoned' wlille at work," 794 and that "[m]any of the 

employees who have complained have been 'forced-out' or intimidated by Houlihan to the point 

that they resigned or n·m1sfened from the Tomah V AMC. "

795 With Special Agent Porter in 

attendance. the source talked about Dr. Houlihan and his alleged braggadocio about being 

untouchable to the OIG and other law euforcement 796 Finally, the anonymous source stated that 

Dr. Houlihan and Ms. Frasher were allegedly "at the root of the drug diversion/pill-selling by 

veterans at tl1e Tomah VAMC."797 

Figure 48: Roport of VA OIG intotTiew with anonymous Tomah VAMC omploy••'" 

is onen 'stoned'' while at work, meaning! is incoherent, and 

many believe. may have dependency issues involving a cohol and/or pain 

killers. 

"'Id. at OIG 10592-93. Special Agent Porter did not draft the Memorandum oflnten·iew until April 25. 2012. !d. 

at 10592. 

789 ld. 190 TI1e interYiew occm1·ed on ?-.-1arch 28, 2012, but the memorandum authored by Special Agent Porter did not occw· 

until April25. 2012. Jd.: E-mails between Alan Mallinger, George Wesley. & Greg Potter (Apr. 17. 2012), at OIG 

10320. 

791 VA OIG Criminal Investigations Div., Greg Porter, Memorandum of Interview of Tomah VA!v1C' Employee 

(Mar. 28, 20 12). at OIG I 0592. 

"'!d. 

793 Id. at OIG 10592-93. 19

~ During hi~ transcribed interview, Agent Porter confinned that Deborah Frasher is the name of the individual 

redacted in the doctUnents. Porter Transcribed Inten·iew. at 19. 795 VA OIG Criminal Investigations Div., Greg Potter, Memorandum of Interview of Tomah VA.\1(' Employee 

(Mar. 28. 2012). OIG 10592. at OIG 10593. 

"'!d. 

791 !d. 

'"!d. at OIG 10592. 

~"'l.... 

~'Zj ! 

Majority Staff Report 

Committee on Homeland Security and Gonrnmental Affairs 

Senator Ron Johnson, Chaii·man 

127 
207 

of VA OIG inh•n'iew with Tomah VAl\tC 

Houlihan has been known to openly "brag" about the fact that OIG "Can't touch 

him" and that the VA Police cannot contact OIG Without his permission. 

Figure 50: Re-port of VA OIG interl"iew with anonymous Tomah V AMC em(>loyee800 

A. S. concluded the interview by stating Houlihan and- are at the root of drug 

diversion I pill-selling by veterans at the Tomah VAM~ey have created a culture 

of fear within the Tomah VAMC, to which employees are afraid to step forward 

speak their minds 

During a transcribed interview, Chairman Jolmson's staff asked Special Agent Pmier 

about this March 2012 interview with an anonymous Tomah VAMC employee. Special Agent 

Porter recalled his impression of the interview. He stated: 

WelL doing tllis as long as I've been doing this. I document what the person says. 

I don't operate from the vantage point of assuming that they're telling the tmth or 

assuming that they're conect, because that wouldn't be fair to the person that 

they're making an allegation against. 

So, I came away from this interview, you know. acknowledging. okay, there's 

these--pretty much what it says in the memorandum, that these are things either 

my Office of Criminal Investigations or the Office of Healthcare Inspections or 

DEA Diversion or the local police. these are things that different entities can start 

to look at 801 

Two days after the interview at the Tomah Police Department, Dr. Houlihan sent an 

email marked "confidential" to VISN 12 executive Victmia Bra!nn802 In tllis email, sent on 

March 30,2012, Dr. Houlihan wrote to Ms. Bralm1: "I am probably going to step down from the 

COS position following the IG survey."803 Although it is not clear from the email, the "IG 

survey" mentioned by Dr. Houlihan ma6 have been the EAR Survey, which was conducted 

between March 5 and r-rarch 23. 2012. 8 4 

799 Id ot OIG 10593. 800 !d. 801 Pm1er Transcribed Intep;iew. at 20---21, 802 It is not known if Dr. Houlihan was made aware of the March 28. 2012, meeting \.vith the anonymous Tomah 

VAMC employee. See E-mail from David Houlihan. Tomah VAMC. to Victoria Brahm. Tomah V AMC (Mar. 30. 

2012. 12:15 PM). at DIG 90~8. 

SQJ Jd. 

'"The VA OIG EAR Stm·ey occurred between March 5. 2012 and March 23.2012. E-mail fium Marnette 

Dhooghe. VA OIG. to Linda Lutes (May II. 2012. 10:30 AM). at OIG 10294. 

:\lajority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

128 
208 

51: Email from Dr. David Houlihan to Vittol·ia Brahm805 

From: Houlihan, Jav:d J. 

Sent: Frioay, fV ;mh 30, 2012 i 1 :OCJ AM 

To: B·a1m, Victoria P 

Subject: Canf dent a'-just to let you ~now 

A few weeks after the interview with the anonymous Tomah VAMC employee, on April 

17, 2012, Special Agent Potter had a conversation with Dr. Mallinger about the situation at the 

facility. In an email referring to their conversation, Dr. Mallit~er asked Special Agent Porter to 

"send a copy of' the interview "with the VA police officer. "

80 Special Agent Porter responded 

that he did not have an interview repmt and that the officer was "adamant about not being 

identified. "

807 

Figure 52: Email from Sp•rial Agent Greg PortH to Dr. Alan )ialling•r808 

From: Porter, Greg (OIG) 

Sent: Tuesday, April17, 20123:27 PN 

To; ~laflirger, Alan (O!G) 

Subject: RE: Tomoh 

! dan't h3ve .'In intC'rvJcw report, t~S I don't want tl'1t> offic~r w br rrrn.tioned, He w,1S adamal"lt ahout Mt bemg 

identified. he feor.1 oven though h~ name was withheld he would still face scrutiny at the VI<. If yo" need l¢methinR In 

writinz. 1 '"'' >p<ak with John Brooks about il and put somcth·ng together. just let rne know. 

Thanks, 

Dr. Mallinger fmwarded Special Agent Porter's response to his health care inspection 

colleagues, s·eeking advice on how he should respond809 After this email exchange, and for 

unknown reasons, Special Agent Pmter decided to author a memorandmn of interview and 

provided it to Dr. Mallinger via email on May 2, 2012 810 

905 E-mail from DaYid Houlihan. Tomah VAMC. to Victoria Brahm. Tomah VAMC (Mar. 30,2012. 12:15 PM). at 

OIG 9048. 806 E-mail from Alan Mallinger, VA OIG, to Greg Pm1er. VA OIG (Apr. 17, 2012, 2:16PM). OIG 10320, at 10320. 807 Jd. 

"' Jd. 809 Id. 810 E-mail from Greg. Porter. VA OIG. to Alan Mallinger. VA OIG (May 2. 2012. 11:00 AM). at OJG 10308. 

. '-. 

··~·Jf 

i 

:\clajority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

129 
209 

30. May Zl, ZOlZ: The VA DIG provided the DEA with (b)(7) memo to allow the DEA to 

review portions of patient charts 

The DEA continued to work closely with the VA OlG during the spring of 2012. On 

May 21,2012, VA OIG Special Agent Porter emailed a DEA diversion investigator about 

"Pharmacy databases" but the substance of the email is largely unknown due to redactions 

applied by the VA OIG811 The same day, the DEA diversion investigator informed Special 

Agent Porter that the DEA had obtained a "(b)(7)" memo from the VA OIG's Office of 

Healthcare Inspections. 812 The diversion investigator wrote: "We recently obtained authorization 

from VA OIG OHI via '(b)(7)' memo to review the portions of the patient charts of the 

following." The VA OIG redacted the identities of the patients 813 

811 E-mail from Greg Porter, VA OIG, to Diversion Investigator, DEA (May 21, 2012, l: l 0 PM), OIG 10607, at 

OJG !0608-09. 812 E-mail from Diversion Investigator, DEA, to Greg Porter, VA OJG (May 21, 2012, l :49 PM), OJG 10607, at 

01G 10607--08. 813 Id 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

130 
210 

W! recently obtaincc a;.~thoriza:iol fmm VA :JI::i 0~! vla '·'(b)(7r memo to re·tiew the portrons of the patlen: charts: of 

ft'1~ ftlllovlinR,: 

lf••ie're still WCliling for t1e lAformation. One o:the 11eadrche~ with Wiscom;m :'i ttlP f01ct the~t we dOr'l't have a 

prtscr;ptlon ftlOn·tOriflg program. lik~ in IIUoo15,. th;it .,..oytd facilitate spotting doc-sfloppinr.;.,. "!1!1!11••• 

~r·:Joess I 

D"""lonlnvestigat<>r 

1

1 

JD~r~u~g~Emo~r~c·~~~n~t~Ad~m~W~rt~~~t~lo~nL_ ______________________________________________ II' 

U.S. Oeportmerrt of Justice 

Mik.Nau<ee Dls~rk:t offrcePhcne: (414) 

C~IJ· 

rll)<: 

During a transcribed interview, Chainnan Johnson's staff asked Special Agent Porter 

about the purpose of a (b)(7) memo. He explained it was "an official request to an agency for 

infonuation that they would not nonnally release." Special Agent Porter stated: 

814 !d. 

A: The (b )(7) memo is basically--I can only give you a very general 

interpretation of what that is. It's basically an oftlcial request to an 

agency for information that they would not normally release. 

Q: So, the diversion investigator for the Drug Enforcement 

Administration was seeking patient names and patient charts of VA 

::\Iajority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

131 
211 

employees, and I guess this must be at Tomah, at Tomah VA because 

we just don't know with the document in front of us, but would that be 

your tmderstanding? 

A: Yes.815 

Special Agent Porter forwarded the DEA diversion investigator's email to Jolm Brooks, 

the Special Agent in Charge of the Chicago office of the VA OIG 's Criminal Investigations tmit, 

and another employee, a letting them that the list of names in the email "are the vets and they all 

are patients of Houlihan, Frasher or both."816 A colleague of Special Agent Porter responded, 

noting that it was "interesting" that one of the patients "is driving a new [redacted) Chevy 

[redacted)."817 According to Special Agent Porter, the patient identified as driving a new Che'7 

was the same patient who was alleged to have an inappropriate relationship with Dr. Houlihan. 18 

Figuro 54: Email ft·om Suzann• Ht~moniak to Sp.rial Agonl Gc:r.:c•g"-=P-=o.:ct'c:l•cc•·_"_' _______ _ 

Porter, Greg (OIGt 

"FrCJm: 

Scmt: 

To: 

~LibJOCt': 

Atta~bments: 

Grl!g 

Hu-mcniok,. $~.:.::.J!lnC {OlC~ 

Tuesd;;;y, Mdy 22, 2012 10.C7 AM 

romr, &rf"g (OJG) 

Rt; l'ttarrrt~cy:Jatabaso-,; 

••••• • CoTJprehE!ro~lve =t~por: .. zQ12..05·1.l.pdf 

I ~eded the S~ t~ th~ !istb~low,just in CC:'le YOllnt(!ditin thefutllre. AI~D, I 1'-t.Vt! i'lt~chcd-'s n_O 

repo/1 •• isdrio~ing.a ne-...- dtev.-.. lnleresli~lfl. 

From: Porter, ~(OlGI 

Sent f..1onday, Miy Jl, 2Cll 2:57 ~ 

Yo: Brooks, Jchn (OIG) 

Cc: Humcn ak, Suzanrc (O!G) 

Subfect~ ~; Ph:::~rmacy databases 

TilF~P i'lre ttw .Jf"f<; anri they all ar;• patients of HrJUlihun, Fra'iher or both 

On May 23, 2012, Special Agent Porter received another email from the DEA diversion 

investigator with information relating to the Tomah VAMC. In this emaiL the DEA investigator 

attached a 2002 press release from the Iowa Board of Medical Examiners regarding the charges 

against Dr. Houlihan.820 The DEA investigator wwte: "I'll be happy to share any information I 

815 Pmter Transcribed Interview. at 38. 

"'E-mail from Greg Porter, VA OIG. to John Brooks & Susarme Humeniak, VA OIG (May 21,2012. 2:57PM). at 

OIG 10605. 817 E-mail from Suzanne Humeniack. VA OIG. to Greg Pot1er, VA OIG (May 22. 2012. 10:07 AM), at OIG 10605. 818 Potier Transcribed Interview. at 43. 

'"E-mail from Suzatme Humeniack. VA OIG. to Greg: Porter. VA O!G (May 22. 2012, 10:07 AM). al OIG 10605. 820 E-mail from Diwrsion Investigator. DEA. to Greg Porter, VA OIG (May 23. 2012, 11:19 AM). at OIG 10610. 

C\lajority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

132 
212 

have discovered on [redacted]."821 During his transcribed interview with Chairman Johnson's 

staff. Special Agent Porter said that he believed this email showed that the DEA was aware of 

Dr. Houlihan's disciplirmy history ir1 the state oflowa 822 

31. May 22,2012: VA OIG inspectors briefed senior VA OIG leadership 

During the pendency of the VA OIG's Tomah VAMC health care inspection, maj01ity 

staff became aware of at least one hi!d1-level briefing that occurred for senior VA OIG 

leadership. According to documents and statements. preparation for this high-level briefing 

began in late April or early May of20!2. On May 1, 2012, Dr. Wesley asked Dr. Mallinger if he 

was "ready for the [Dr. Daigh] briefing on Tomah. "823 In his transcribed interview with 

Chai1man Johnson's staff, Dr. Wesley explained that this request was connected to "the II th 

floor briefing" at the VA OIG's headquarters 824 

Figur• 55: VA OIG PowHPoint pr•s.ntation for "lltb Floor Bri•fing"825 

mId. 

3-12 Highlights re: Management 

• "The Tomah VAMC is an institution that is 

compromised by an atmosphere of fear and 

intimidation that is incapacitating." 

• " ... one employee even committed suicide the 

night he was fired ... " 

• "I have never seen such mayhem." 

• "HOUSTON WE NEED SOME HELP DOWN 

HERE." 

822 Potter Transctibed InterYiew, at 29. 

'"E-mail fi·om George Wesley, VA OIG, to Alan Mallinger, VA O!G (May!, 2012. 11:40 AM). at OIG 10993: see 

also \Vesley Transcribed InterYiew. at 174-75. 824 Wesley Transcribed InteiTiew, at 174-75. 

"'PowerPoint Presentation Part 1. VA O!G Hotline Refen·al. OIG 12021. at OIG 12035. 

:VIajority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

133 
213 

In pla1ming for the briefing, the inspection team, led by Dr. Mallinger, prepared a 23-

page PowerPoint presentatiou 826 During his transcribed interview with Chairman Jolmson's 

staff. Dr. Mallinger explained that the PowerPoint "was smt of the biggest stmctnred thin~ we 

did, and that was in the spring before the site visit."827 The 23-page Tomah PowerPoint82 

reviewed the "histo1y of multiple complaints" that all involved Dr. Houlihan, alleged rillsprescribing and diversion of opiate dmgs. alleged abuse of administrative authority. and various 

other types of allegations. 829 The PowerPoint summarized some of OIG's "Initial Observations 

and Concems," along with a slide labeled, "Unresolved lssues."830 Among the VA OIG's initial 

concems were potential practices that facilitated drug diversion, unmthodox treatments that 

"may be suboptimal," and pressure on professionals to "practice against their judgment."831 

FigurE> 56: VA OIG PO\n•1·Poiut pre-sflntation for "11th Floor B•·if'fing''832 

r .. ----

Initial Observations and Concerns 

• Patients are receiving unorthodox treatment 

that may be suboptimal 

• Treatment practices in place may facilitate 

drug diversion 

• Professionals on the treatment team are being 

forced to practice against their judgment 

• Clinical checks and balances are undermined 

• Possible administrative abuses 

821"i ~{allinger 4i21/:!016 Transcribed Interview, at 330. 

"'Jd. 

'" TI1e VA O!G Tomah PowerPoint is VA O!G Bates munbers 12021-12041 and 12050-12052. 

'" PowerPoint Presentation Pat1 I, VA OIG Hotline RefetTal, OIG 12021. at OIG 12022. 

Slo PowerPoint Presentation Part2. VA OIG Hotline Referral. OIG 12050, at OIG 12052. 831 Jd. M OIG 12050. 831 Id. 

:\lajority Staff Report 

Committee on Homeland Security nml Governmental AITain 

Senator Ron Johnson, Chairman 

134 
214 

Figurt- 57: VA OIG Pmn.•rPoint prt-st"nta~iou for· '"'11th Floor Brit>fing"833 

Unresolved Issues 

• Role of 51 

• Interaction with the DEA (87 letter} 

• Consultants 

• Site visit 

• Information from Iowa Medical Board 

During his transcribed inteJView with Chainnan Johnson's staff, Dr. Wesley spoke about 

the II th floor briefing about the Tomah V AMC He explained that it occurred "in the first half 

of 2012" and "before the site visit" to the facility. He stated: 

A: Other things I remember, but not necessarily in chronologie order. I 

know 51 [the VA OIG's criminal investigations division] attended the 

site visit, which occutTed in August of 2012. I recall that we had a 

large meeting on the II th floor in which we discussed the case with 

51, 54 [the VA OIG's health care inspections division], and Mr. 

Griffin. And so--

Q: Do you recallA: Let me justQ: Sure. Sony. 

A: They were aware of our work To what degree I can't testify to. 

SB Jd ot O!G 12052. 

:\Iaj ority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

135 
215 

Q: Do you recall when that meeting with 51 and 54 and Mr. Griffin 

occurred? 

A: Only generally. I believe in the first half of2012. 

Q: So before the site visit? 

A: Before the site visit834 

The meeting was scheduled for May 22, 2012,835 and many senior VA OIG officials were 

invited to attend. When Chairman Johnson's staff asked Dr. Wesley which OIG employees 

attended this meeting, his private attorney interjected to assert a privilege on behalf of the VA 

OIG. She stated: 

Q: Can you speak about who attended this meeting and what the meeting 

was actually about? 

Witness 

Attorney: Can !-Maureen [Regan, Counselor to the VA Inspector General] was 

at this meeting, it would appear. I am concerned that this may go into 

areas that the agency would assert a privilege over. This specific 

meeting they haven't talked to me about, but it sounds within 

potentially the areas where they've asked me to assert privilege. I think 

we would need to call Roy [Fredrikson, Deputy Counselor to the VA 

Inspector General]. And, again, if counsel instructs Dr. Wesley after, 

he's their-836 

Documents, however, show that a number of Senior Executive Service (SES) OIG employees 

were notified about the meeting. The list included Maureen Regan, the Counselor to the 

Inspector General; James O'Neill, the former Assistant Inspector General for Investigations; and 

John Daigh, the Assistant Inspector General for Healthcare Inspections. 

834 Wesley Transcribed Interview, at 167. 835 E-mail from Lisa Seibert, VA O!G, to VA O!G Employees (May 2!, 2012, 9:45AM), at OIG 10313. 836 Wesley Transcribed Interview, at 170. 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

136 
216 

Yang, Robert (OIG) 

"Jm: 

.,ent: 

To: 

Subje<t: 

~elbert, Lisa J {OiG) 

Monday. MZ1y 21, 2012 9 45 AM 

Seibert, lisa J {OIG); O'Neill, James J (SES) {Sl·OlG); Daigh, John (SES) (OIG); Regan, 

Maureen T (SES) (OIG): Sullivan, Joe (SES) {O!GJ. Vallowe. Jo<eph (SES) (O!G); Christ. 

Patricia {SES) (01G); Perkins, Darlene (O!G}; Brooks, John {OIG}; Wesley, George (SES} 

(O!G); Mallinger, Alan (OIG); Shepherd, Michael L. MD (OIG); Yang, Robert (O!G) 

Schedule meeting VAMC Tomah 

Roorn 1105 has been reserved for the meetinr, at 3:00pm on Tuesday, May 22. Thank yoll 

Dming a transcribed interview with Chairman Jolmson's staff. Dr. Wesley explained that 

the high-level meeting with senior OIG executives was not typical for hot line allegations. He 

stated: 

Q: Was this t)1le of meeting with these individuals in their positions 

within the IG typical for a hot line'' 

A: No. 

Q: No? 

A: Con·ect. No838 

Dr. Wesley said that he believed the meeting with Deputy Inspector General Griffin 

occurred on May 22.2012. because it was unconunon for the VA OIG to use a PowerPoint 

projector in such a meeting839 Because of the VA OIG's refusal to cooperate with Chairman 

Johnson's iiiVestigation, the precise details of the briefing--{)ther than the PowerPoint 

presentation- remain lmknown. However. in general, Dr. Daigh explained that Deputy 

Inspector General Griffin was briefed "on all of the lwtlines in our inventory on a regular basis, 

and Tomah was clearly one of the hot lines that we briefed.',s40 

32. May 29,2012: The VA OIG subpoenaed a Wisconsin Chevrolet dealership 

The possibility that a female veteran allegedly involved in an inappropriate relationship 

with Dr. Houlihan purchased a new car cau!!ht the attention of the VA OIG841 The VA OIG 

837 E-1mil from Lisa Seibe11. VA OIG. to VA OIG Employees ('\-loy 21. 2012, 9:45AM). at OIG 10313. 838 \Vesley Tranr;cribed InterYiew. at 170-71 _ 839 Id. at 176. 

uo Daigh Transcribed Interview. at 32. 

s<~.! Potter Transcribed Inten:iew. at 43. 

~Iajority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

137 
217 

successfully verified the vehicle purchase through "a public search database that law 

enforcement typically has [with] a little deeper access into public records."842 

Around May 29, 2012, the VA OIG issued a subpoena to a Chevrolet dealership in 

eastern Wisconsitt. 843 Special Agent Porter completed an IG Subpoena Request form, 844 which 

explained the relevant facts that led to the request for a subpoena845 He cited the "numerous hot 

line complaints regarding Dr. David J. Houlihan of the Tomah VAMC, an interview was 

conducted with a confidential Tomah VAMC employee on 03/28/12 who suspected PTSD 

patient/veteran [redacted] is visiting Dr. Houlihan excessively, and possible involved in an 

intimate personal relationship with him."846 

The document sheds some light on the events that led to the OIG subpoena. In late May 

2012, the same Tomah VAMC employee who spoke with law enforcement in March 2012 told a 

Tomah Police Department investigator that Dr. Houlihan "may have recently purchased, or 

assisted [redacted] in the purchase of a vehicle."847 On the same day, May 22,2012, the OIG's 

subpoena request noted that "public record database searches revealed [redacted] owns a 

[redacted] Chevy (valued at approximately $43,000) financed by [redacted]."848 The VA OIG 

inquired with an unknown number of dealers around Wisconsin before finding the dealership.849 

After locating the dealership, an employee at the dealership advised the OIG that the purchase 

information could be obtained via subpoena850 Agent Porter believed the subpoena would "help 

verify or refute the claim that Dr. Houlihan may have purchased or assisted in the purchase of the 

above mentioned vehicle."851 

842 ld at 41; TLO Report, OIG 10539-91. 

"'The VA OIG subpoena is VA OJG Bates number OIG 10594 and is redacted; see also VA OJG, Affidavit of 

Compliance with Subpoena, OIG 10515. 844 Agent Porter explained that this IG Subpoena Request is reviewed and approved by his superiors. Porter 

Transcribed Interview, at 63. 845 VA OIG, 1G Subpoena Request, OJG 10516. 846 Jd. 

847 ld 848 !d. The TLO report was produced by VA OJG heavily redacted. TLO Report, OJG 10539 -91. 849 VA OJG, IG Subpoena Request, OJG 10516. sso Id. 

851 ld. 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

138 
218 

I. Cao:;e A~ent 

l Jregm y J Pc'Tie! 

Department of Veterans Atlai" 

()11lce ofln•pector General 

IG SUBPOE:'\A REQt:EST 

Case Nwnber 

20 11-0-U 12-1>( '-0:!'2 

3. Rcquostmg f!dd Ollicc or RcsidcnU\gcncy: ~- Statutci.s) believed to have been violated: 

J\IA 

51Cll 

Dming a transcribed interview, Special Agent Porter smrunarized what the VA OIG 

found from information received pm·suant to the subpoena. He stated: "I sent the subpoena to 

the car dealership for the pmchase records for the vehicle, and it didn't have any connection to 

Dr. Houlihan at all.''853 According to a May 29, 2012, email between Special Agent Porter and an 

employee at the dealership, the down payment for the vehicle was $25,0008 )-1 Chainnan 

Jolmson's statTasked Special Agent Pm1er if the down payment was paid in cash and he 

recalled: "As I remember it. there was a cash down payment and then the rest financed. "

855 

On the same day, but before the dealership responded to the VA OIG 's subpoena, VA 

OIG persmmel discussed the possibility of accessing Dr. Houlihan's bank accmmt 

information. 856 Specifically, the VA OIG employees considered whether it could get Dr. 

Houlihan's bank account through a system called PAID. 857 Agent Porter explained the PAID 

system in his transcribed interview with Cbainnan Johnson's staff. He stated: "It's like a 

personnel database. It'll show, like, a person's pay grade, the address of record, and things like 

that."858 However, he said that he could not recall whether he ultimately accessed Dr. 

Houlihan's infonnation via PAID. 859 

"'I d. 

&SJ Porter Transcribed Interview, at 62. 

'"E-mail to Greg Porter. VA OIG (May 29, 2012, 2:12PM). at OIG 10613. 855 Potter Transcribed Interview. at 65. 

SS 6 /d. at 87. 

::; E-mail from Gregg Hirstein. VA OIG. to Greg Pot1er. VA OIG (May 29. 2012. 8:53AM). at OIG 1061 L 

Potter Transcribed Interview, at 86. 8

)

9 I d. at 87. 

:'\Iajority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

139 
219 

Porter. Greg (OIG) 

Frvm; 

S•nt: 

To: 

Sub) oct: 

Hirstein, Gregg (O!G) 

luf>d•y, Moy 29,2012 8:53AM 

PMer, Gres (OlG) 

~oulihan Add reS<• 

We aim have ris bank at:CDvnt info through PAID. If HQ wants, wecoJid subpoena that for car payment info.· GAH 

33. Spring 2012: The VA OIG Criminal Investigations Division surveilled Dr. Houlihan 

During the March 28,2012 interview of the anonymous Tomah VAMC employee, 

Special Agent Porter teamed of the allegation that Dr. Houlihan was having an inappropriate 

relationship with a patient 861 The allegation was part of the memorandum that Special Agent 

Porter prepared following the interview, but the VA OIG redacted this allegation fi·om the 

document when it was produced pursuant to Chainnan Jolmson's subpoena. 862 

During Agent P01ier's transcribed interview with Chairman Johnson's staff_ however, he 

confirmed that the redacted portion of his memorandum referenced the allegation that Dr. 

Houlihan was having an inappropriate relationship with a patient. He stated: 

A: There's an item that's completely redacted. I'm hying to figure out 

what that is. 

Q: We are, too. 

A: The--one of the--Dne of the allegations that wasQ: Just for the record, this is the second dash on I 0592. 

'

60 E-mail from Gregg Hirstein. VA OIG. lo Greg Potier. VA OIG (May 19. 2012. 8:53AM). at OIG 10611. 861 VA OIG Criminallrwestigation!'. Div .. Greg Porter, Memorandtun oflnten:iew of Tomah VAMC Employee 

(Mar. 28. 2012). OIG 10592. at OIG !0592-93. 

'" Jd. 863 !d. at I 0592. 

:\lajority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

140 
220 

A: The second dash. It's completely redacted. Basically, there was an 

allegation that Dr.-one of the allegations was Dr. Houlihan was 

having an inappropriate relationship with a female veteran. That wasin addition, that veteran was also rumored to be one of the veterans 

who was heavily overprescribed. So, from that point, we-myself and 

another agent from my office, Fred Lane, L-a-[ n-]e, decided to attempt 

to surveil this veteran patient as well as Dr. Houlihan. 

Q: All right. When you say inappropriate relationship, is this a financial 

relationship, sexual relationship? What type of relationship was it? 

A: It was stated to be a romantic and/or a sexual relationship864 

Special Agent Porter said that after he learned of this allegation, he sought to understand 

the circumstances surrounding the female patient865 He began exploring residential addresses 

where the female patient was known to live 866 He also had the description of the patient's type 

of vehicle as well, but he was ultimately unsuccessful in locating this patient. 867 

Due to the VA OIG's inability to locate the patient, Special Agent Porter explained that 

he "switched gears and went and began surveilling Dr. Houlihan."868 When asked what he found 

in surveilling Dr. Houlihan, Special Agent Porter replied, "[n]othing. Nothing to substantiate 

any of the allegations."869 The surveillance was not extensive. Special Agent Porter said that it 

lasted "[a] couple days, two days. Not around the clock, just-I believe it was two days. I'd 

kind of have to refresh my memory .... "870 He also described how he conducted the 

surveillance. He stated: 

Q: Can you describe, without going into law enforcement methods, how 

you surveil someone in a small town like Tomah? 

A: It's difficult. It's-it was vehicle surveillance. I mean, we weren't 

crawling around in the bushes or anything like that. We just, you 

know, sit down the street in the car, hope that you could find the 

vehicle first. Hopefully, you know, in an ideal situation, they'd come 

out, get in the vehicle and go somewhere, and you'djust follow them. 

With two people, two agents, each in their own vehicle, it's 

864 Potter Transcribed Interview, at 22. 365 I d. at 25. 

8h6 ld. 

s67 Id. 

868 I d. 

'" Id. 870 !d. at 26. 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

141 
221 

challenging to do that in a small town, but, I mean, that's what we 

did. 871 

The VA OIG has not produced documents describing Special Agent Porter's surveillance 

of Dr. Houlihan or the female patient. Special Agent Porter described these actions as a 

"preliminary investigation," and said that the determination to generate paperwork on 

surveillance activities "depends on the type of case and ... what stage of the case you're in."872 

In addition, the precise dates of when the surveillance occurred are unclear due to the absence of 

documentation and because Special Agent Porter could not recall the dates of surveillance during 

his transcribed interview with Chairman Johnson's staff. 873 

34. Spring 2012: The VA OIG declined to fully pursue the female patient 

Surveillance of Dr. Houlihan was not the only option open to the VA OIG. The VA OIG 

knew the identity of the female patient alleged to be engaged in an improper relationship with 

Dr. Houlihan, and had even subpoenaed records about her car purchase. Yet, the VA OIG did 

not fully pursue this lead in its investigation. 

Although the VA OIG's interview with the anonymous Tomah VAMC employee in 

March 2012 yielded a number of allegations, Special Agent Porter explained that he only 

examined the claims involving the inappropriate relationship and the vehicle purchase. He 

stated: 

Q: So did you investigate any of those allegations? 

A: Yes. 

Q: Specifically to drug diversion and pill selling by veterans at the Tomah 

VAMC? 

A: No, not necessarily in regards to that. When you have all these 

different entities approaching this date, it was-you know, you can'tbasically you're way better served having the appropriate entity handle 

that particular part of things. We didn't really have a lot of-as I said 

before, a lot of stake in the game as far as-you know, as far as the 

prescriptions and the diversion angle. That's DEA's thing, so we're 

going to let them do their thing. 

"' /d. at 25-26. 872 Jd. 873 I d. at 29-30. 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

142 
222 

As far as the prescribing practices of doctors or nurse practitioners, 

that's Office ofHealthcare. That's their thing, and we're going to let 

them do their thing. What I determined was-for this particular case, 

my thing--all I really had that I could take a couple shots at trying to 

develop further was the inappropriate relationship with the patient and, 

you know, there was additionally an allegation that Dr. Houlihan had 

bought this female patient a vehicle. And so, you know, those are the 

items that I chose to focus on, because the other items were being 

looked at by the other entities.874 

Despite focusing on only those two allegations-both of which involved the female 

patient-the VA OIG did not pursue the matter. Special Agent Porter stated he did not seek to 

interview the female veteran who was alleged to have a relationship with Dr. Houlihan because 

he "didn't want to ruin any potential case for the police," and "I didn't want to tip her off." In 

his transcribed interview with Chairman Johnson's staff, Special Agent Porter stated: 

Q: In general---did you interview the-the female veteran who was 

alleged to have a relationship with Dr. Houlihan? 

A: No. 

Q: Whynot? 

A: Because she was also a suspect. Well, I should say she was one of the 

people named as being a-the recipient of large amounts of 

prescription medication. So I chose not to interview her because I 

didn't want to-if-if she is involved, if the potential exists for, you 

know, her involvement in a drug diversion ring or sales, or she's doing 

that, I didn't want to ruin any potential case for the police or for any 

other entity that would be investigating. I didn't want to tip her off.875 

Special Agent Porter could not provide a precise time frame of when he decided not to 

interview the female patient, other than to say that it occurred generally in the 2012 period876 

However, a Tomah VAMC hotline status report dated August 29,2012, referred to the 

coordination between the Office of Health care Inspections and the Criminal Investigations 

Division, identifying the patient by the initials "KR."877 

874 !d. at 54~.S6. 875 !d. at 92. 876 /d. at 93-~94. 

"'Tomah Hotline Status as of Aug. 29.2012, at OJG 12928. 

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Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

143 
223 

Figure 62: Tomah Hotline Statu• Report (Augu5t 29, 2012)878 

Cuordinatiun with Dl: 

Further mvcs:igu:ion of patient I<R for drug diw:rswn or inapproprio:c relationship. 

l<lentiJ'ieation uJ' polic-e o!Iker and/or patk·nt who 'wn• subjec:s of complaint. 

35. June 2012: The VA OIG scheduled a site visit of the Tomah VAMC 

In the smmner of2012. the VA OIG began plarming to conduct a site visit of the Tomah 

VAMC. According to documents and statements, in the lead up to the visit, Dr. Mallinger and 

Dr. Shepherd had a phone conversation with the Tomah VAMC Director Mario DeSanctis 879 

TI1e VA OIG had apparently sought to have a conversation with Director DeSanctis about the 

Tomah VAMC allegations earlier, but due to a number of reasons-including a visit by the Joint 

Connnission to the facility-the conversation did not occur until June 2012880 

Figure 63: Email from Dr. Alan Malling•r to Dr. Michael Sb•pherd and Dr. Robert Yang881 

From: Mallinger, Alan (O!G} 

Sent: Monday,June 11.2012 2:17PM 

To: Shepherd, Michael L., MD (OIG); Yang, Robert (OIG) 

Subject: meeting 

Hi Mike and Robert, 

I 

I 

Could we have a meeting tomorrow at 10 to discuss tre next step(s) with Tom a~ ?I 

Regards, 

Alan I 

Dr. Mallinger ar1d Dr. Shepherd had a 15-minute phone call with Director DeSanctis on 

June 19, 2012. 882 Dr. Mallinger and Dr. Shepherd explained the origins of the VA OIG's 

inspection arid the allegatiollS involving Dr. Houlihan and Deborah Frasher. 883 They infonned 

Director DeSanctis tl1at the allegations involved opiate prescribing practices, the dosing of 

"'!d. 

R/9 VA OlG Inten·iew with Mmio DeSanctis, in Tomah. Wis. (Jtme 19, :2012). OIG 6075 [hereinafter 6/19/2012 VA 

OIG lnterYiew of DeSanctis]. 

sso E-mails between Michael Shepherd. VA OIG. and Ma~io DeSanctis, Tomah VAlVIC (May 17-22. 2012). OIG 

10870, at OIG 10870-74. 

": E-mai1s between Michael Shepherd. Alan Mallinger, and Robert Yang. VA OIG (Jtme II. 2012). at OIG 10842. 

"· 6/19/2012 VA OIG Inter\'iew of DeSanctis. at OIG 6075, 883 ld. 

:\Inj ority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

144 
224 

opiates, the appropriateness of the prescribing of opiates 884 They also told him that other 

allegations involved "the administrative style of Dr. Houlihan," and the belief that Dr. Houlihan 

is "a bully."885 

~ he's a bL1li. t~ey say ~e thi~ks he's 

"1!1·.! cf 

In the conversation. Dr. Shepherd described the goal of the VA OIG's inspection as "to 

kind of try to tigure out ifthere's merit to these allegations or not''887 According to a transcript 

of the conversation. Director DeSanctis was the only Tomah VAMC' official involved in the 

conversation, as requested by the OIG888 

Dming the same phone call, Dr. Shepherd advised Director DeSanctis that the VA OIG 

would likely conduct a site visit at the facility in the near fi1ture 889 According to the transcript, 

Director DeSanctis sought to facilitate the OIG's visit. 890 The patiies agreed on a Tomah point 

of contact, who was assigned to assist the OIG on the logistical matters of the site visit. 891 Two 

days after the phone call. Director DeSanctis emailed Dr. Shepherd infonning him that Julie 

Nutting would be the point of contact for the OIG's site visit'" 

as~ !d. 

&s:i !d. 

886 !d. 

"'I d. at OlG 6076. BSS /d. 

'"!d. 

890 !d. 191 !d. at OIG 60i7. 

"'E-mail from Mario DeSanctis. VA OIG, to Michael Shepherd, VA OIG (Aug. 13. 2012. 4:15PM). at OIG 1067!. 

1 •. 

~}f .\lajority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

145 
225 

Fi ure 65: Email from Mario DeSanctis to Dr. Michael She herd893 

from Df:i<;J'lC!!\, \f;t'io V. (SfS:I 

To· ;hl'l\hMrl, M•rt-.M- l, HO (OJ()) 

Cc ~ r'!tlnr ... J 1litr ,1. 

S.e--nt: !"H,.jU'l ,d '8:1\1:14 ~Gli 

Sut:J.j~<C: P(..>.n: tl (-:t't.t<: tc~ OJG 

_\..-1\ fVKn! , .. t .:::lh'1tt.ft·l·¥ \NH 'TW m l:I:!J r:!! 7 N: !ul~ S•t!ln~ ''.It~\~:~~~~ P~ttft')n:l;lnLi' lil!f"lt\~ll~tll 0lftLii•l ticf pb-.r•( '1\Hl!hn ... r ..rid mtmm m~ \o IS'\ !c.Jdcr\1'11[' n1 )'l'JUf lt1tcn:kd YO .. !t 

''''""''! l<llh' ~~' '-li!h!ll: """ kiM'- !h< >tlh)"<'l Of )•>Iff \'I'" h"< :11 "" I.U'(Il\' W< Will •--r m11r qqll"lllul<nfl'l 

36. Summer 2012: The VA OIG prepared for the Tomah VAMC site visit 

After the phone conversation with Director DeSanctis, the VA OIG team began to 

prepare for the Tomah V AMC site visit-planning which inspectors would attend, who they 

would interview, and when they would travel to Tomah. According to documents and 

statements, it appears Dr. Mallinger and Dr. Shepherd were the primary inspectors who 

assembled the interview list and other logistical matters. 

During July 2012, members of the inspection team exchanged emails in preparation for 

the site visit. On July 16, 2012, Dr. Shepherd advised Dr. Mallinger of his schedule for the 

month of August, indicating that the middle to the later part of the month would work best for 

him for the visit894 Ultimately, however, Dr. Shepherd did not make the trip up to the Tomah 

V AMC due to an illness. 895 

mid. 

894 E-mail from Michael Shepherd, VA 010, to Alan Mallinger, VA 010 (July 16, 2012, 2:04PM), at 010 I 0745. 895 Shepherd 1/27/2016 Transcribed Interview, at 108-09. 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

146 
226 

Figur• 66: Email from Mlcha•l Sb•pherd to Alan ctlalling•··S96 

Mallinger, Alan (O!G) 

From: Sh~toht"'d, Mt::.haell, MD tOIG) 

Sent: Monrla·t, 1\u::~w.t 70, 7017 CJ·Ofi. /\. V: 

To: M~lhngN. Alan (O!G) 

lit h!an: I am kchn)l: pi'(! tty undN th-f' wrathN torl<l\1. Vf!:ry <.Cf(' thr\lat, a httlr wl"i<'f'ty, po~: n<Jsal dnp, low f'I'Crj>\y, rhmitl<;, 

Mtd anr~oytnr, couct- thilt kept mr> up tt!l 2 4'J aM. Not particu!<'.tiy ~f'>f'hnr, UJl to trrhtf'ling Starrf'd >t!"~tNda.y by dortor at prnrr.r:at 

care on Jr'lttbiOtKS Unrure how you Wlll"'t to proccc1:1. Let's touch bJsc u':N morr1ni'! mectH'lb 

In addition, Special Agent Greg. Pmier of the VA OIG 's criminal investigations unit 

notified Dr. Mallinger of his availability "to accompany" the health care inspection team to 

Tomah. 897 During. his transcribed interview with Chainnan Johnson's staff. he explained his 

role of joining. the team on the site visit. He stated: 

Q: So mtming up and getting to the August 2012 time frame, and Dr. 

Mallinger and his team coming up to the Tomah facility and you 

joining them, was there any parameters on what you could ask in the 

interviews, or any-was there any things that-were you allowed to 

basically ask what you needed to ask from your standpoint as a 

criminal investigator with the VA IG during these interviews? 

A: Yes. I-I-I pretty much could have asked anj1hing.. There was no--

no one put any-any parameters on me. 1-I-the-I-I guess the---

the only parameter would be that they're talking about medically 

related stuff and I'm not a doctor, so, you know, if-if a lot of the sh1ff 

that they were talking about and the questions they were asking 

pe1iaining. to medically related sh1ff, prescription related sh1ff, I just 

woulch1't have had a knowledge base to go from. to work fi:om898 

Later in his transcribed interview, Special Agent Pmter explained his understanding of why he 

was asked to be at the Tomah site visit. He stated: 

I was-my understanding. is that I was asked to be there in case anyone made any kind of 

utterance of---of criminal activity or anj1hing like that. That was, you know, what I was 

told, and-and, you know. my pmpose for-for being. there, and that didn't happen. 899 

896 E-mail from Michael Shepherd, VA OJG, to Alan Mallinger, VA OJG (Aug. 20, 2012. 9:06AM). at OIG I 0655. 

"'E-mail from Greg Pm1er. VA OIG, to Alan Mallinger. VA OIG (July 27, 2012. 12:14 PM), at OJG 10685. 898 P01ier Transcribed Interview, at 96-97. 899 Id at 98. 

2\lajority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

147 
227 

Dr. Wesley considered attending the site visit and, during his transcribed interview with 

Conunittee staff. he explained why he considered attending the site visit.900 He stated: 

Q: \Vhy would you have-why did you consider attending the site visit? 

A: The hot line was getting more and more complex. As you recalL I'm 

sort of the old hand at this. Dr. Mallinger was still relatively new. So 

for all those reasons, we talked about my going901 

Documents illustrate that the VA OIG team considered conducting interviews with a 

number of different individuals. The lists of individuals lack dates but they do provide an insight 

into how the scope of the site visit changed over time. According to a draft interview list, the 

inspection team needed the approval from Cmmselor to the Inspector GeneraL Maureen Regan, 

to set up interviews with Dr. Houlihan and Deborah Frasher. 

Planned Interviews 

! 

1. Re-lnterview the VISN leadership 

2. 

3. 

All6 outpatient pharmacists presently working at Tomah J 

Dr. Haul ihan? Pending Maureen 

4. Debra Frasher? Pending Maureen 

900 Wes.ley Trausctibed Interview, at 194. 

'"!d. 

002 List ofP!aiUled VA OIG lnten·ie\\'s, at OIG 12214. 

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Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

148 
228 

Re hter.new ::he VISN ie;.dprshtp 

All b outp<Ittent phnmoKt<it~ prc-s.ertly working .lt lrH'Tlclh 

3. Dr. Houlih;m? Pl"ndtng M<i.u'~t''l 

4. Deb· a Fra~h~r? P'!:''ldmg Maureen 

5 Head of Ow: pat en: Psychia~rv? 

Pam MD h \tiwaui:.N! who gf'':S tl""e ccmu!t~ 

V!SN pharma(y •nJntlgcr in M!lwaukC'e (tu·nove1, quant1ty, monetiz-ed \lalue) 

H VJ5N MH OnPC!Gr 

9, Clinic<.~ pharmaci~: on -!ouliharn. :eam-M;.Hg.aret Hyde 

10. VA pellet~ chie-f des1gnee 

11 lnformat"on ~ystem~ (CA>l!tl acce'.s) Derson 

12 Hr,-,Jd of HR 

13 Houl tl.ir l&l-"' folder 

1-1. Otrer ndmt:~ from pnor hte•vt~w~ not alre.Jdy hsted. 

During his transcribed interview with Chairman Jolmson' s staff, Dr. Shepherd recalled 

speaking to other OIG employees about "people we were fcoing to interview" and described the 

development of the inten•iew list as a "dynamic process." 04 He remembered suggesting at the 

time that "it was important we talk to some front-line psychiatrists . ."905 Dr. Shepherd 

903 Jd. 

904 Transcdbed Inter\'iew with Michael Shepherd. in Washington, D.C., at 7 (Feb. 9. 2016) [hereinafter Shepherd 

2/9/2016 Tran;cribed InterYiew]. 905 Jd. at 7. 

'" '@)f , I 

\ 

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Senator Ron Johnson, Chairman 

149 
229 

thought this process would allow the OIG to get the "viewpoint from people on the front line, not 

just people who were, like, in leadership or, you know. or beholden to the leadership ... .''9

0/i 

Because the draft interview lists do not have dates, it is dit1icult to reconstmct a time line 

of how the VA OIG dete1mined who to interview during its Tomah VAMC site visit. From 

information available, however, it appears that several different versions of a draft interview list 

were exchanged. On July 3 L 2012, a few weeks before the site visit. Dr. Shepherd sent an email 

to Dr. Mallinger with an attaclnnent and an explanation that the list would need to be revised and 

updated. A few weeks later, on August 13, Dr. She~herd again emailed Dr. Mallinger a 

doctmient labeled "Tomah Interviews 7-31-2012."9 7 Just 18 minutes later, Dr. Shepherd sent 

another email with a document attached labeled "Planned Inte1views Tomah."908 

Figure~ Email f~om Dr. Mirbael Sbepberd to Dr. Alan "'Iallingei'_~·------------, 

Mallinger. Alan (OlG) i 

From: 

SE-nt: 

To: 

Subject: 

Attachments: 

Sh•uherd. \1Kha•l L, MJ (O!G) 

fue·,tJdy. July iL ?01) l £.? JV 

M;dlmgcr Alan tO:G) 

Tom.;,!· kt-:"vJews 

Tomvl'--lntr-rvtrwo; aoo: 

H1 Alan: Th1~ Wd!!- tt>c list. Howt•vcr. th1nk we ncL-d to rc-vtw an !..I upd.:tc I will ~1ve you e Ciill dftcr 1--otllr~c tr·cetlf"lR 

Than b.. 

Mike 

Figure 70: Email from Dr. ):l.khael Sbepberd to Dr. Alan Malliuger910 

Mallinger, Alan (OlG) 

Shepherd, Michael L.. MD 2 

Monday, August 13, 2012 3:5~)PM I 

Mallinger, Alan (OIG) 

From: 

Sent: 

To: 

Subject: 

Attachments: 

Tomah Interviews 7-31-2012 

Tomah Interviews 7-31-2012.docx 

906 Jd. at 7. 907 E-mail from Michael Shepherd, VA OIG. to Alan Mallinger, VA OIG (Aug. 13. 2012. 3:55PM). at OIG 10675. 908 E-mail from Michael Shepherd. VA OIG. to Alan Mallinger. VA OIG (Aug. 13. 2012. 4:13 PM). at OIG 10673. 909 E-mail from Michael Shepherd. VA OIG, to Alan Mallinger. VA OIG. (July 31. 2012. 3:42 PM). at OIG I 0692. 910 E-mail from Michael Shepherd. VA OIG. to Alan Mallinger. VA OIG (Aug. 13. 2012. 3:55PM). at O!G 10675. 

:\Iajority Staff Report 

Committee on Homeland Security and Governmental Affairs 

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150 
230 

Mallinger, Alan (OIG) 

From: 

Sent: 

To: 

Shepherd, Michael L., MD (OIG) 1 

Monday, August 13, 2012 4:13 PM ~­

Mallinger, Alan (O!G) 

Subject: Planned Interviews Tomah 

_A_tt_a_c_h_m_e_n_t_s: _________ ~~-~~~~1ed Interviews Tomah.docx J 

911 E-mail from Michael Shepherd. VA OIG. to Alan Mallinger. VA O!G (Aug. 13.2012.4:13 PM). at OIG 10673. 

:\-laj ority Staff Report 

Committee on Homeland Security and Governmental Affairs 

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Figul't.' 72: List o!Planued VA OIG iutPrYiPln912 

10 

11 

11 

(}f' ... -:.<t'' -.·::. rt(:J(ollh'tl' ;Sit ... ~ 

1J: -"if'·dn..;.,_,r1.jt-.C6t)( 

14. t:lr $o'l"ltr Ch,t-' MEdi-al ~f<«t "~ V!S\! 

-.lf1 f<"ri"Nhum[~ f!.---;>Jol*'-»~' 1") lb<MII('3!pt\3f~IS"Or ......... . 

It VA.pt..:'~t .. d"'ll!'i(Jil.~~~"'" 

1} lntqHTo..ft<t>r "-¥''~"'" (t .\Z'I'Il -*'d~-~~~ V""'t•n 

n H.M: ).~(l-.:t'li<til•ill• 1111·- lS .\"C<WP"~V'C"3Hr'!~.)ffo1T"~'I-

~11 

Later 011 August 13. 2012, Dr. Mallinger emailed Dr. Shepherd and another OIG 

employee, Cynthia Gallegos, a list of individuals that the team intended to interview.913 He 

" 2 List of Planned VA OIG Interviews. OIG 12929, at OIG 12929-30. 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

!52 
232 

asked Ms. Gallegos to connect with the team's point of contact at the Tomah V AMC, Julie 

Nutting, to set up the interviews for August 21 and 22. 2012 91 ~ The list included Director 

DeSanctis. Dr. Houlihan. Deborah Frasher, and Margaret Hyde, among others 915 

Figure 73: Email from Dr. Alan Mallinger to Cynthia Gallegos916 

Mallinger, Alan (oiG) 

From: 

Sent: 

To: 

Cc: 

SIJbject: 

Tr~ddng: 

Hi Cyn, 

Mailing Of, A:an (OIG) 

Monoay, August 13 2012 G·15 PM 

C.. !egos. Cynth•a (OIG) 

Shepherd Micl1a.- l .. MD (OIG) 

RE: DC on Th-LJrsday 

RcldpWnt 

GaJ~rqot., cvmhta (OIGJ 

She?~ld, M-ch11-ell, MD (OIG) 

-· Real! M4f2C'li;72!5Ar.l 

Read 5iBI20115:~ PM 

Jul~ Nutt,ng is the POC for our visit We have not yet conta<red he,, Lt>., they don't knew wr. are- fO/tllnE Woulti 'fOil be 

able to set up the lnterv\e-w-s fot Wednesday .and Thursday Al.Jgust 21~22? Thre:se Gfe ti'Mi! intend~d interviewees: 

1. ~rio DeSanctis~ F'11cil~ty Oirector(stiould have an entrance Jnter..ofew on arriving and t!)(it inte.rvtew at the end) 

jt~ 7., t/Head of 1nform.1UOn .system~ {want th;~ to be ASAP <,1fter our interview with Mr DeSmltt!'>) 

3 V"AU outpatient dtspenslng phamwc\:U.s pr.@sentty wcrlong ilt Tomah (to In dude Darlene Krock. Yiu lbekwe, Dttvid 

!fush~s, e-ven if they ,){e in different roles nowl{shou!d be about S!x total) 

4. /../"Pharmacy Director (Ron Pelit<Jm) 

:}. Vpirector or Pharmacy O~ra!ions/Servite une !'-..tanager (Jeff Cvanron) 

6 .f/"Jhl~f afSta~f, Dr. David Houflha.n (w.;~nt to mee-t with him twke, rlear the beginning and near the eJ'1d) 

7. V NYrse Prsctttloncr, Oebr<d FriJsher 

Chit-f o1 Mental HPatth 

9. L/clinica1 fJhi'!tf'Tl<tdst, M.ttEan:t Hyde 

10. VChiefVA pchce 

11, HR o;pecrallst·Di!vid 01"chand 

12. HR Director 

~ 0 13. A fewoutpfltient psy.thiatm.t' &t Ton1ah 

14. ~r. \A.Ihiteway- Director opiate work:woup 

15. Chair P& T wmm!ttcc 

lG. t/'l":Untcai pharrnac~t. LlHrf'l!!er'l ,(harnbers 

I Let me know when vou wifl be avnfleb!e in DC and hoPf'fully we tan get togethe-rfor a bit. Al~. ft~:f>l fret- tc caJ! .t~ny t1~ I 

~ __ :_:_:_~_:_:_:_·:_:,_,_______________________________________________________________ _II 

AGM ~ 

The next day, Dr. Mallinger sent another email to Ms. Gallegos, with the subject "Tomah 

Planning." The VA OIG, however, redacted the contents of the email when producing it 

pursuant to Chaim1an Johnson's subpoena. 

'll E-mail from Alan Mallinger, VA OIG. to Cynthia Gallegos, VA OIG (Aug. IJ. 2012. 6:15PM). OIG l.l674. at 

13674. 

'"!d. 

"'!d. 

916 !d. 

:VIajority Staff Report 

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Senator Ron Johnson, Chairman 

!53 
233 

Figurt> 74: Email fr·om Dr. Alan ~falling(lor to Cynthia Gal1t>gos917 

Mallinger, Alan (OlG) 

From: 

Sent: 

To: 

Cc: 

Subject; 

Hi Cynth1a, 

Ma!hnger, Alan (OlG; 

hJPs.rliJy, Augu~t 14, 2012 6·: 1 ~v 

Galk9o~ Cynth!~ (OIG) 

Shepht-·d, ~""ICh.l~l L~ M) (01G) 

!urnd.r' pl.Jnlllfl9 

... , 

11FV 

..... ~---------------- • J\l,1n G. \-IJ!hnger, M.O. 

S"nior PhyS!C!<:<n, Mrcdka! Consult<llion :wd Rf''o't('w 

Of1icc of lrspcctor Gt'!-rcral 

Llcp;ntmPn! o" Vctctiln~ Af'<'llf~ 

ROt I Sttf't"~, NW 

Was.hiqston, :.>c 20001 

On August 16, 2012, Dr. Shepherd emailed Julie Nutting at the Tomah V AMC to 

confinn that Ms. Nutting "was able to liaison" with Ms. Gallegos to anange the site visit 

intetview schedule 918 It appears that Ms. Nutting apprised Director DeSanctis of Dr. Shepherd's 

email, because Director DeSanctis responded on the same day919 In his response, Director 

DeSanctis confirmed that the pla1med interview schedule was received fimn Ms. Gallegos and 

''"VA OIG Bates number OIG I 0665. 918 E-mail from Michael Shepherd. VA OIG. to Julie Nutting. VA (Aug. 16, 2012, 4:33 PM), at OIG 10659. 919 E-mail from Mario DeSanctis, VA OIG, to Julie Nutting, VA (Aug. 16,2012.5:35 PM). at OIG 10658. 

~·-·t... 

/~}1 . ! 

;\lajority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

!54 
234 

that his office was working to confirm staff availability920 Director DeSanctis told Dr. Shepherd 

that he was concemed about "mmors" or "tmnecessaty dismption," and asked him "to keep this 

confidential" in an effott to not "tip off the staff"921 During his transcribed interview with 

C'hainnan Johnson's stall Dr. Shepherd said that contacting Director DeSanctis before the site 

visit was a normal action taken by the OIG. 922 He explained that OIG does not send out a 

"general notice to the entire facility" but "typically tell[ s J the director. "

923 

-----·Original Message---... 

From: DeSanctis, Mario V. (SES) 

To: Shepherd, Michael L., MD (OIG) 

Subject: Schedule for Next Week 

Sent: Aug 16, 2012 5:35 PM 

MikeWe did receive your planned interview schedule for next week from Ms. 

Gallegos. We are checking to see who will be available from your requested, 

list and we will get back with you shortly. I have told my point of contact I 

for your visit, Julie Nutting, not to lock in the times until late Monday or I 

Tuesday, I do not want to keep this confidential and tip off the staff · 

about this any earlier to avoid any rumors or unnecessary disruption. 

Please let me know if you would like me to proceed differently. ThanksI R/Mario 

TI1e next day, on August 17, 2012, Julie Nutting responded to Dr. Shepherd's email as 

welL Ms. Nutting alerted Dr. Shepherd that three individuals who were included on the OIG's 

920 Jd. 

"'!d. Dr. Shepherd forwarded the email to Dr. Mallin~er. Jd. 9

:!2 Shepherd 1/2712016 Transcribed Interviev .. ·. at llO~i 1. 

'" Jd. 

'"E-mail from Mario DeSanctis. VA OIG, to Julie NuHing. VA (Aug:. 16, 2012, 5:35 PM). at OIG l 0658. Even 

though the text reads "I do not want to keep thi' confidential .... " Dr. Shepherd agreed that Director DeSanctis 

meant to say. '"T want to keep this confidential .... " Shepherd 1/27/:!016 Tran5ocribed Inten·iew. at 107. 

'· 

~-~~~ :\lajority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

!55 
235 

interview list would not be at the facility during the two-day OIG site visitns The Tomah 

VAMC Chieflnfonuation Officer (CIO). Chad Babcock, was on leave during the week of the 

site visit. 926 The outpatient dispensing pharmacist, David Hu!Wes, separated from the facility on 

August 17, 2012-the same day as Ms. Nutting's email.927 The third individual, JetiEvanson, 

who was the Tomah VAMC's Service Line Manager,928 was away from the facility that week on 

"travel. "929 

YL·~. Tv'!'>. Gt~l ep,c;, h,1~ 'JL'Cn "co•r'I'IUruc .. dr..m \Vitf• r-tc. I ·•.JVt' Cl.l'lf.r·rcd thut ol: of tPe '>ttJH the teJrt' has rcq.,t;-:.ted to 'rt.'l..'t 

·,v•ih v..-i!· be work,ng 'H:J(\ Wev·t.·~d"v LH Thur'>d<>'/ !or bD:' 1 w1th the t:x<..ep:ion of •·1e fulluwtut; 

• CIHc1 :l.'ii.){O(k, CIO I'· oo l"<lve m•xt '..\'<'t'k 

L)ay r:. i·uehcs, OJip~t ~nt d1~pen$Jn(.' phr"r.<lcl<::t 1as ~ep;n;~er, fnr 1'1(1 Vi\ ~:••,,c vr ~o\"!;;y 

It:!! [vd·J~o·l, ';(~tv~ e luw M,m,•l~c· 1', em 'tJIIP nf~llt w;:c·-: 

Dr \11.''1 tf'W,l'f, J ·r.r~or for C)p~<1':< Wnrkg.'o 1;:;, ., ~taho'lf'c :1: onr of our canes '> tvlf'rhrm.~ tn':f'rJ rw wr~h !wn 

Pll:'a~r::! let ere know t ycJ "ctve fldd t10ra! (l,Je~: or;., 1 t~"1eti ~o ::::u(ll base wi~" Vs. Gc-llo?.f;O:. :oday, b~J: lt":!1k S'le mav be oft 

·occy 

Tltdnk y."J<.l 

Jute 

Chainnan Jolmson's stati interviewed Mr. Evanson on December 17, 2015. During his 

interview. he explained that he did not interact with the VA OIG any time between2011 and 

2014.931 He said: 

'"E-mail fi·om Julie Nutting. VA. to Alan Mallinger. VA OIG (Aug. 17.2012. 3:07PM), OIG 10651, at OIG 

10652. 

926 The Tomah VAMC offered the acting CIO to the OIG. Id. The majority staff is not aware of the OIG 

interviewing: hUn at a later date. 

'"!d. 

928 According to Jeffrey Evanson, the Service Line ~1anag:er position no longer exists at the Tomah VA11C. Mr. 

Evanson desctibed the duties as "the oYeraH m.anager of all the depatimeuts. multiple supetTisors reporting through 

that position. Contract oversight, administrative res.ponsibilities . " Transcribed Interview with Jeffrey E\·ans.on, 

in Tomah, Wis .. at 8 (Dec. 17, 2015) [hereinafter Evanson Transcribed Interview]. 929 E-mail fi·om Julie Nutting. VA to Alan Mallinger. VA OIG (Aug. 17. 2012. 3:07PM). OIG 10651. at OIG 

10652. 

9lo !d. 931 Evanson Transcribed Interview. at 26. 

Majority Staff Report 

Committee on Homeland Security and Gonrnmental Affairs 

Senator Ron Johnson, Chairman 

!56 
236 

Q: Did you interact with the Inspector General at all when they were here 

[in Tomah, Wisconsin]-

A: No. 

Q: -between '11 and '14? 

A: No. 

Q: So you were never interviewed byA: No. 

Q: -the Inspector General? 

A: No932 

About one week before the Tomah VAMC site visit, on August 15, 2012, Cynthia Gallegos sent 

an email to the Counselor to the Inspector General, Maureen Regan. 933 The email, on which Dr. 

Mallinger was copied, is almost completely redacted.934 The VA OIG even redacted the subject 

of the email. The majority staff can only assume it is pertinent to the investigation based on the 

VA OIG's production of the email pursuant to Chairman Johnson's subpoena and the parties 

included on the email. 

932 !d. at 26. 933 E-mails from Cynthia Gallegos, VA OIG, to Maureen Regan, VA OIG (Aug. 15, 2012), at OIG 10662. 934ld 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

!57 
237 

Figure- 77: EtnaiJ (lXchange behH~·en Maure-e-n Regan and Cynthia Gnll(>gos9

_

3

_' _____ _ 

-MaHingtz-Aian (O!G) ---- ~ 

From: Ga.!!eqos, Cynth1a \()lG} 

Se-nt: Wt·mwvl.:~y, Ad9Uq l ~ .?1.'!11 :? l1 >.)M 

To: Rr>g,'ln. v.1urPf'n T ,:scs; (Q!!'jj 

Cc: Ma.lhiinq1

•

1 Subject: R,· r .• A.Iaiinli0.tGil'••••••• 1 

From: Gz ·og•ll. Cynth•o {OlGJ 

Sent: W~cn~'Sday, Aug1.'i-t 15,1012 '2:20 ;;;y 

To: R•g•n. ~·'·'"•1 T (SE\J {01(>) 

C<: l!alljng•••r,iiAiil'ji"lii(OiiliGill •••••••• Subject• 

Good ;rft~rncnn; 

.. ~ ........................... ... Thank you. 

(yr-t•·na 

Cynt.'11o (;(JJI!"gas 

Prqgrorr: Suppo'"t ~uistcmr 

Oft!Cf' of ll•"'oft~ Core lnspNt:na~ {S:4ilA)/ 

Financial Ana/ys1s Divis. on l54D] 

VA OlflCf' of fiB{Jer:tM Gflflf>rOf 

According to intemal VA OIG documents, it appears the OIG prepared multiple versions 

of a Tomah V At'v!C site visit schedule. Both schedules are heavily redacted and tmdated, but 

they suggest that the OIG team planned to interview Director DeSanctis and Dr. Houlihan twice. 

9J5 Jd. 

• ~ 'L.. 

~~f • I 

\ 

~lajority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

158 
238 

936 VA OIG Tomah V AMC Site Visit Schedule for August 22-23. 2012. at OIG 117 39. 

:\lajority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

!59 
239 

Both schedules indicate Director DeSanctis was scheduled to pa~ticipate in an entrance 

interview at 8:30a.m. on August 22,2012, a11d an exit inte1view on August 23. 2012938 Dr. 

Wesley provided a11 expla11atiou of what an entra11ce inte1view involved in his transcribed 

interview with Chainnan Johnson's staff. He stated: 

I'll sta11 by saying remember our investigations are inspections. They're not 

criminal investigations. And when you go on a VA medical center, we tJy to show 

a lot of respect to the medical center. It's almost like going on a military base. 

And. therefore, when we make a site visit, we begin all site visits by having an 

entrance conference with anyone that the Director chooses. It ca11 be the Du·ector 

alone, or it ca11 be 50 people. I'm exaggerati11g there. It can be anyone such as the 

Director alone or it could be a dozen people. And it's to give him or her the 

courtesy of letting them know we're there and, likewise, letting them know why 

we're there. Usually. we share allegations at the entrance conference. I'll say one 

other thing. \Ve also--in the smne vein of respect, we also do an exit 

conference. 939 

037 !d. at OIG 11740. 

9JR Id. 939 \Ves:ley Transcribed Interview, at 184~85. 

Majority Stuff Report 

Committee on Homelnnd Security and Gonrnmental Affairs 

Senator Ron Johnson, Chairmnn 

160 
240 

However, the OIG team never had an opportunity to interv1ew Director DeSanctis while at the 

facility. On the moming of August 23. 2012, Director DeSanctis emailed Dr. Shepherd, who did 

nor make the trip up lo Tomah due to illness. to alert the OIG that he was "out sick." He wrote to 

Dr. Shepherd that he had "been out sick since Tuesday and [has] not been able to meet the IG 

ream or participate in the visit. "

940 

f ram th!Solrllt'~. M<~no V, (S:S} 

~('1'\t· Thursday, Au~ust Tl, 10}) 07·49 AM 

To· Shcp~('rd, Mtf:r,a('! .. , MJ (OIGJ 

~ubif:c• Out ).d 

M!~t"· 1mt wartrd !(} IM you k'lOW l hdvt' b{'Pn out \ltk 'M'~Cl"' lur .... d.:ty and tt-ave nol bi:>'('n able to mt•et ttw lh ~cam m p.:Jrtl[ip<:~t(' 

m tho v1~H lhh G tl!rwc;., hit'> tr)l;;Uy t,.;krn trw ~in ..... n IPt•l >~NV wrdk. I ft't'"l b.ni 1 roulr1n I be m thl' ofhtt• for 1t I 1'1 rt'l' llf'llW 1f 

yc)\; would <;tilllh:r to mtc-n;i~w rrC" oncr 1 fc-{'!l}('f':«:r. 5-nllnds hlo.rth(' vis.t 1~ g<"Hng well ::~(con'ling to Ju!i<' N1.1rt1ng. Aga1n, 1 

.1pnlog''~' 1\1rtY)l hPm ~ ·~f·tr 

Dr. Shepherd responded to Director DeSanctis, "No problem. Hope you feel better soon. 

We can touch base with you by phone next week when you are feeling better."942 Dr. Shepherd 

forwarded the email to Dr. Mallinger and Monika Gottlieb,943 a Senior Physician in the OIG' s 

Medical Consultation Review who had joined Dr. Mallinger on the site visit 944 It is 1mclear 

whether Director DeSanctis knew at the time be emailed Dr. Shepherd that Dr. Shepherd was 

also ill and not in Tomah. Chainnan Johnson's staff asked Dr. Shepherd why Director DeSanctis 

emailed him and not Dr. Mallinger: 

Q: Can you explain why Mr. DeSanctis was emailing you directly and not 

Alan Mallinger? 

A: Tile only--! can't, other than, for some reason, either--for some 

reason. I was able to get hold of him somehow better. For some 

reason, it fell on me to get a hold of him. In other words, I don't 

remember if Alan was having au issue getting a hold of him and I was 

able to do it, or if Alan asked me to. or ifl said, you know. hey, I'll get 

940 E-mail from Mario DeSancti>. Tomah VAMC. to Michael Shepherd, VA OIG (Aug, 23. 2012. 7:49AM). at OIG 

10643. 

9-1-lld. 

9

"

2 E-ntail from Michael Shepherd. VA OIG, to Mario DeSanctis. Tomah VAMC (Aug. 23, 2012. 8:03AM). at OIG 

l0643. 

'"'Shepherd 1127/2016 TranSCiibed Interview. at 112. 

'"'E-mail from Michael Shepherd. VA OIG, to Alan Mallinger & lv!onika Gottlieb. VA OIG (Aug. 23,2012.8:08 

AM). at OIG 10643. 

·@~/ f 

I 

-'1ajority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

161 
241 

a hold of the director. Somehow, it ended up in my bailiwick to get 

this guy, to get a hold of this guy, and so I did. 945 

37. August 2012: The VA OIG conducted a site visit of the Tomah VAMC 

In August 2012, a year after the VA OIG received hotline allegations involving the 

Tomah VAMC, Dr. Mallinger led a group of OIG employees to Tomah, Wisconsin. The OIG 

interviewed 26 individuals during the two-day site visit.946 The OIG team also "inspected the 

pharmacy pick up and dispensing areas" at the Tomah VAMC.947 The Tomah VAMC Director, 

Mario DeSanctis was not interviewed during the site-visit due to illness.948 The VA OIG instead 

conducted an "entrance'' interview with Sandra Gregar,949 who was the Associate Director of the 

facility at the time. 950 

On August 22, 2012, Dr. Mallinger and his OIG colleagues interviewed Ms. Gregar at the 

facility 951 According to a subsequent report of contact, Ms. Gregar told the OIG she had "only 

became aware of this yesterday" and she offered to "facilitate" the OIG's investigation952 Dr. 

Mallinger provided Ms. Gregar with some background on the OIG's purpose for visiting the 

Tomah VAMC and described the allegations involving prescribing problems, drug diversion, and 

administrative abuses.953 Ms. Gregar told the OIG she had "been aware, peripherally, of this as a 

member of the Quadrad."954 She explained that "[o]ne of the things is that the [chief of staff] is a 

Psychiatrist at the facility and manages some of the most difficult patients. He's asked to take on 

the difficult patients from the staff when nothing else has worked or when the staff doesn't know 

what else to do."955 Ms. Gregar believed Dr. Houlihan's willingness to take on "difficult 

patients" made "him more of a target for some of the staff that wonder about his practices."956 

945 Shepherd 1/27/2016 Transcribed Interview, at 113. 946 VA OlG, Tomah Summary, OIG 12935, at OIG 12936. 947 !d. 948 E-mail from Mario DeSanctis, Tomah V AMC, to Michael Shepherd, VA 01G (Aug, 23, 2012, 7:49 AM), at OIG 

10643. 

949 Sandra Grcgar retired from the Tomah VAMC in October 2012. Gregar Retiring afler 36 Years at VA, TOMAH 

JOURNAL (Oct. 29, 2012 ), http:/ /1acrossetribune.com/tomahjournal/ncws/local!gregar-retiring-after-years-atva/articlc_d50f415e-21df-11 e2-8323-001 a4bcf887a html; Press Release, Dep't of Veterans Affairs, Sandy Cregar 

Retires from Tomah VAMC ajier 36 Years, (Oct. 23, 2012), http://www.wrjc.com/wpcontent/uploads/20 12/ I 0/Gregar-Press-Release.pdf. 

llSO Sandra K. Gregar was appointed as the Associate Director of the Tomah Y AMC on December 7, 2008. Senior 

Management Biographies, http://www.tomah.va.gov/tomahvaleadership.pdf. Chairman Johnson's office reached 

out to interview Sandra Gregar but did not connect. E-mail from Staff, HSGAC (Apr. 13, 2016). 951 Memorandum of Interview of Sandra Gregor (Aug. 22, 2012), at O!G 5911. 952 !d. at OIG 5911. 953 !d. OIG 5912. 954 !d. 

955 Jd. 

956 !d. 

~) '"'--·· _J 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

162 
242 

She spoke about Dr. Houlihan thinking "outside of the box" when it came to treating patients and 

that she had heard patients say to him: "you saved my life."957 

Ms. Gregar told the VA OJG team how the "anonymous statements" and "questions 

about how Dr. Houlihan practices" hurt the facility. She said "[i]t's been a very difficult time 

when stufflike this keeps bubbling up."958 When Dr. Mallinger asked how long these 

complaints have persisted, Ms. Gregar responded: "Much beyond 20 I 1."959 

According to the report of contact, Ms. Gregar served as the Acting Director at the 

Tomah VAMC for a short period between 2008 and 2009, and she recalled "discussions" about 

these issues occurring in December of 2008.960 She described an incident in 2009 in which "a 

pharmacist [ ... ] challenged his prescribing practices."961 The pharmacist is not named in the 

report of contact. 

When Dr. Mallinger asked Ms. Gregar why individuals were complaining to the OJG in 

2011, Ms. Gregar responded the "IG was involved then, too," and she "was aware of these issues 

when I came back in 2008/2009."962 During the interview, Dr. Mallinger asked her whether she 

thought Tomah is "polarized" because of these issues. Ms. Gregar responded: 

From my perspective, it's been fairly new clinical Pharm. D's [sic] who have a 

different or lack of understand [sic] of VA pain mgmt policies/pain directives and 

not really understanding what those are and how they could/should be applied in 

VA hospitals. There's been some misunderstanding on that and moving the pain 

mgmt forward in this facility and addressing the pain. 963 

Ms. Gregar also described the role of the Tomah VAMC union and how it affected the 

facility's environment. Ms. Gregar described it as "an extremely difficult polarizing union" and 

the union creates "a polarizing environment between [management] and staff."964 She added that 

the "union has had significant issues with leadership and management style of Dr. Houlihan in 

the past."965 When questioned about why the complaints mainly focused on Dr. Houlihan, Ms. 

Gregar responded that "they target all of leadership. "966 

957 !d. 

958 !d. 

959 !d. 

900 !d. 

961 !d.. 

962 !d. 

963 !d. at OIG 5912-13. 964 /d. at OIG 5913. 965 Id 

966 I d. 

Majority Stati Report 

Committee on Homeland Security and Governmental Atl'airs 

Senator Ron Johnson, Chairman 

163 
243 

During the interview, a member of the OlG team requested Ms. Gregar "keep this 

discussion confidential and do not discuss this with anyone during and after" the site visit. 967 

Ms. Gregar, according to the document, agreed to the OIG's request for confidentiality, but 

questioned if she should brief Director DeSanctis since "he would not have the perspective" and 

only began working at the Tomah VAMC in February 20!2968 The OlG's report of contact does 

not indicate how the OIG responded. 

When Chairman Johnson's staff interviewed Linda Ellinghuysen, the Tomah VAMC 

union president, she described Ms. Gregar as ruling "with an iron fist and she did not respect the 

police department" at the facility 969 Ms. Ellinghuysen further believed Ms. Gregar was a 

loyalist of Dr. Hou!ihan's.970 Ms. Ellinghuysen agreed, however, that the Tomah VAMC union 

took issue with Dr. Houlihan's leadership and management style. She stated: 

Q: In the paragraph right above it, it says, Dr. Mallinger asked her, you're 

saying maybe this issue is underlying, a polarizing environment? 

Sandy Gregar says, "Union has had significant issues with leadership 

and management style of Dr. Houlihan in the past." Seems to be an 

accurate statement, no? 

A: That is accurate and we have questioned Dr. Houlihan publicly, 

publicly on e-mail, and we've put Dr. Murawsky on those e-mails 

back then. l did that. I have a copy of that e-mail, and it was about a 

patient abuse case where Dr. Houlihan was not treating a veteran 

appropriately. And the Union addressed that. The Union addressed 

Dr. Houlihan with Noelle Johnson. We addressed Dr. Houlihan when 

he fired Dr. Saddiqui, so it didn't matter if it was Sandra Gregar, Dr. 

Houlihan or Joe Smith. lf they violated a law, reg or contract, the 

Union was going to step in.971 

38. August 22,2012: The VA OIG conducted its initial interview of Dr. Houlihan at the 

TomahVAMC 

The VA OIG scheduled two interviews with Dr. Houlihan during its August 2012 site 

visit. 972 A number ofV A OIG employees participated in the interview in person and over the 

967 !d. at OIG 5914. 96, !d. 

969 Ellinghuysen Transcribed Interview, at 47-48. 970 !d. at 48. 971 !d. at 148-49. 972 Dr. Houlihan was interviewed by the VA OIG on August 22, 2012 and August 23, 2012. VA OIG Interview with 

David Houlihan (Aug. 22, 2012), OIG 5423 [hereinafter 8/22/2012 VA OIG Interview of Houlihan]; VA OIG 

Interview with David Houlihan (Aug. 23, 2012), OIG 5396 [hereinafter 8/23/2012 VA OIG Interview of Houlihan]. 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

164 
244 

phone. 973 The first interview occuned on the moming of August 22.2012, and lasted around 25 

minutes 974 

Flgm·• 81: Transuipt of VA OIG int•r,i•w of Dr. Houlibon (Aug. 23, 2012) 

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According to a transcript of the interview produced by the VA OIG pursuant to Chainnan 

Johnson's subpoena. the first interview began with Dr. Mallinger noticing the University of 

Pittsburgh on Dr. Houlihan's curriculmn vitae. Dr. Houlihan said that he had trained at the 

971 Dr. :Michael Shepherd panicipated in both of the Dr. Houlihan inten:lews. via phone. 8/22/2012 VA OIG 

lnterciew of Houlihan. at O!G 5423: 8/23/2012 VA OIG lnter.·iew of Houlihan. at OIG 5399. 974 8122/2012 VA OIG Interview of Houlihan, at O!G 5423. 

"'!d. 

::\·lajority Staff R~port 

Committ~~ on Hom~lanrl s~curity and Gonrnm~ntal Affairs 

s~nator Ron Johnson, Chairman 

165 
245 

University of Pittsburgh; Dr. Mallinger explained how he was a faculty member at the university 

and "wondered if our paths had ever crossed."976 Dr. Houlihan confirmed that he attended the 

university in "the early 90's" and commented that Dr. Mallinger's name "look[ed) quite 

familiar."977 The initial conversation continued with Dr. Houlihan making the comment that 

"combat PTSD" was his specialty "for the most part."978 

After this opening dialogue, Dr. Mallinger explained the reasons why the VA OIG was at 

the Tomah VAMC. He told Dr. Houlihan that the OIG received a "series of allegations about 

kind of a number of issues, some of which had to do with treatment practices .... "

979 Dr. 

Houlihan acknowledged he had "heard about a lot of them firsthand." 980 Dr. Mallinger 

described that the OIG "at this point, really have to take a look and see what's going on. And so 

really our reason for coming to Tomah here is to try to understand the situation a little better and 

hopefully get to know you a little better and your treatment practices a little bit better."981 

Dr. Houlihan told the OIG he had been dealing with many of the allegations for "a long 

time" and specifically described a time-frame of"seven, eight years."982 Dr. Houlihan 

mentioned an earlier OIG com~laint involving him and that he became aware of it via a contact 

with the VISN regional office. 83 Dr. Mallinger asked Dr. Houlihan to explain his opinion on 

using opiates as treatment for PTSD and depression. 984 Dr. Houlihan responded by telling the 

OIG he was "in the process of publishing" a paper involving "five or six veterans."985 It is 

unclear whether Dr. Houlihan published any work after this August 2012 period. 

During his transcribed interview, Chairman Johnson's staff asked Dr. Mallinger about his 

takeaways after the first interview with Dr. Houlihan986 Dr. Mallin~er responded, "I was just 

there to gather information from him and hear his side of the story." 87 When asked for further 

thoughts about Dr. Houlihan, Dr. Mallinger called his treatment practices "unorthodox," saying 

that "they do not reflect the mainstream way" that "a typical psychiatrist would approach treating 

patients."988 He stated: 

Q: So what did you learn about his treatment practices after these 

interviews? 

976 8/22/2012 VA OIG lnterview of Houlihan, at OIG 5424. Dr. Alan Mallinger was a professor at the University of 

Pittsburgh ti·om 1975 through 2003. Mallinger 3/8/20 !6 Transcribed Interview, at 9. 977 8/22/20!2 VA OIG Interview of Houlihan, at OIG 5424. 978 I d. The "Male Participant" in the OIG interview transcript is Dr. Alan Mallinger. 979 ld. 

no ld. 

981 ld. 

982 I d. 

983 I d. at OIG 5426. 984 I d. at OIG 5427. 985 Jd. 

986 Mallinger 4/6/20!6 Transcribed Interview, at 300. 987 I d. at 300. 

'" ld. at 302. 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

166 
246 

A: Well, I can tell you that my impression of Dr. Houlihan is that he 

believes that he's being very genuinely helpful to veterans and is, at 

least from what he says, very committed to caring for veterans. 

Q: Anything more about his prescription practices? 

A: Well, that's a complicated-you know, the whole thing is a very 

complicated issue. You know, as I've said before, it's the-it's trying 

to sort out the whole risk-benefit equation. And, you know, from my 

perspective, I only know what he tells me. I can't know whether what 

he tells me is true or not, so I have to use all the evidence available to 

me. 

I think that he has kind of set himself up to be the one who takes care 

of the very difficult patients. He's made it very clear to, you know, 

other doctors who work there, as they indicated to us, that, you know, 

when they have patients that arc too difficult to feel comfortable taking 

care of, that, you know, they should feel very free to refer those 

patients to him. And I think that he kind of prides himself on having a 

practice of very difficult to treat patients. 

His treatment practices are-you know, I've searched around for the 

right word to describe his treatment practices for a long time, and the 

word that I came up with was "unorthodox." And I think it's 

absolutely true that his treatment practices are unorthodox. They do 

not reflect the mainstream way that, you know, a typical psychiatrist 

would approach treating patients. 

The other side of that equation is that the patient population that he has 

taken on for treatment is very different from the patient population that 

mainstream psychiatrists treat in that, you know, they have very 

serious mental illness, they have-you know, as I said before, most of 

the ones that find their way to him have substance use disorders. Many 

of them have chronic pain. 

They are the kinds of patients who are often not successfully treated. 

One of the hardest things with patients like this is actually retaining 

them in treatment 

* * * 

Certainly I've talked with pharmacists who were prescribing-fearful 

when they were, you know, resisting filling prescriptions for patients. 

These are some seriously difficult people, and I think they challenge 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

167 
247 

all of us in terms of our humanity because they really are the kind of 

people you like to forget about. 

But they're people, and they deserve to be treated. And, you know, if 

his unorthodox methods can offer some hope to people like that, 

then-then that would be a good thing. The problem is knowing 

whether that's what's actually happening there. But that's the picture 

that he paints. And there's some evidence, particularly when you 

consider the patients' perspective, that that indeed-that there may 

indeed be some truth to that. It's a real dilemma. 

You know, on the one hand, you know, he's putting these people on 

addictive drugs, which is not necessarily a good thing in psychiatry in 

the mainstream. On the other hand, they do seem to be coming backand, you know, you can embrace that whole dilemma, put somebody 

on an addictive drug, they come back. It's a bad thing. It's good that 

they come back. It's a bad thing if that's why they're coming back. 

And we don't really know the answer to that. 989 

During the same interview, Dr. Mallinger confronted Dr. Houlihan about being called the 

"Candy Man." Dr. Houlihan responded, "It's Candy Land."990 When interviewed by Chairman 

Johnson's staff, Dr. Mallinger expressed little concern about the meaning of monikers, stating: 

"Well, again, you know, I would say to you what docs it mean? I mean, it'sjust name-calling. 

If he knows it's called 'Candy Land,' you know, the little girl in the fifth grade knew she was 

being called 'Cootie.' You know, what does it-what does it mean? What did it mean to her? 

Nothing."991 Dr. Mallinger further said that the "Candy Land" moniker was of little evidentiary 

value to the VA OIG's inspection, stating: "Well, you know, again, you know, people arc name 

calling, and he's aware of it, obviously, which is what I wanted to know. What I object to is 

using that as evidence. I mean, what is that evidence of?"992 In light of the little weight given to 

the "name-calling," Chairman Johnson's asked Dr. Mallinger why he raised the moniker "Candy 

Man" with Dr. Houlihan at all. He responded: 

Q: So you just wanted to know if he knew that people called him "Candy 

Man.'~ 

A: Well, you know, I was doing a few things with Dr. Houlihan. One is 

that I was trying to establish some rapport with him. And, two, I was 

kind of feeling him out for his attitudes and his beliefs and his 

"'!d. at 301-·04; 8123/2012 VA OIG Interview of Houlihan, at OIG 5431, at 33-34. 990 Mallinger 41612016 Transcribed Interview, at 304. 991 ld. at 305. 992 !d. 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

168 
248 

approaches. And, you know, I don't remember, but, ~ou know, most 

likely I wanted to know how he felt about that label. 93 

Under further questioning about the monikers "Candy Man" and "Candy Land", Dr. 

Mallinger acknowledged that one "can understand why staff would call him names. He's not a 

nice guy. He's mean to the staff"994 Yet, Dr. Mallinger believed these feelings and the 

monikers "just doesn't prove wrongdoing."995 In the same discussion with Chairman Johnson's 

staff, Dr. Mallinger described Tomah as a "polarized atmosphere" and "there's a lot of hostility 

and animosity" at the facility. 996 He called the Tomah V AMC a "dysfunctional system" and 

equated the facility to "a dysfunctional family and people are-you know, everybody's upset 

with everybody else, and that's kind oflike what it is there."997 

39. August 23, 2012: The VA OIG conducted its second interview of Dr. Houlihan at the 

Tomah VAMC 

The first day of the VA OIG's site visit included interviews with other individuals at the 

facility. Nearly 24 hours after speaking with Dr. Houlihan, the OIG team again sat down with 

him. According to the interview transcript, the interview on August 23, 20!2 lasted for over an 

hour. 998 In the interview, Dr. Mallinger said the OIG's first day of interviews at the Tomah 

V AMC as "interesting."999 Dr. Mallinger described complaints that the OIG team received about 

"a lack of professional autonomy." 1000 This statement led into a discussion of"building a 

consensus" regarding early refills at the facility. Dr. Houlihan argued that he was working on 

building a consensus and talking with employees. 1001 Dr. Mallinger apparently did not see the 

progress, telling Dr. Houlihan bluntly: "Well, it's kind of like not happening, you know." 1002 

993 !d. at 305-06. 994 /d. at 306. 995 Mallinger 4/6/2016 Transcribed Interview, at 307. 996 !d. at 307. 997 !d. 

998 8/23/2012 VA O!G Interview of Houlihan, at O!G 5396. 999 !d. at O!G 5397 1000 !d. at OIG 5403. 1001 1d at O!G 5404. 1002 Id 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

169 
249 

Figur• 82: Tramcript ofV A OIG lnt•I"Yi•w of Dr. Houlihan (Aug. 23, 2012)1003 

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During the interview. Dr. Mallinger attempted to better understand how breakdowns in 

communication contributed to Dr. Houlihan's poor relationship with the Tomah VAMC 

pharmacy. Dr. Houlihan explained. ''what happens is. you know, I hear about the chatter. And 

so let's try and clear the air with the chatter." Dr. Mallinger responded, "So the fire has already 

statied there." Dr. Houlihan retmied: "Well, the fire has been there for like about seven 

years."1004 

1003 !d. at OIG 5396. 10"' Id at OIG 5405. 

~Iajority Staff Report 

Committee on Homeland Secul'ity and Governmental AITail·s 

Senator Ron Johnson, Chairman 

170 
250 

Figur• 83: Transcript of VA OIG int•ni•w of Dr. Houlihan (Aug. 23, 2012) I . ' 3 OP .. EOUUHAN: •• sp~dal •• >idl, 1ea1. 

It's that !I ""s around •· i1. wa::. jrcund th>:: 

issues that ·- .. ta'. hap?ECS is, you knw, I hear 

about the cholt,;c. And so let's tcy and r.I~a' 

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1 S le•1e 1 o! and --

During the Tomah VAMC site visit, VA OIG Special Agent Greg Pmter accompanied 

the health care inspection team. In a transcribed inte1view with the Committee, Special Agent 

Porter was asked about how he makes a determination to interview a particular witness or 

suspect. He explained that he did not intetvicw a pruiicular female patient during the spring of 

2012 because she was "a suspect" and he "didn't want to tip her off."1005 Chainnan Johnson's 

staff asked Special Agent Porter whether he had any similar concerns about intetviewing Dr. 

Houlihru1 in August of 2012. Agent Pmter responded: 

Q: I think yon mentioned earlier about you were not the creator of the 

interview list for the August 2012 visit by [Office ofHealthcare 

Inspections] and you joining them. I think you also mentioned, you 

know. from an operational standpoint in an-in an investigation, you 

might not want to tip off certain people. Con·ect" 

A: Con·ect. 

Q: So was the decision to intetview Dr. Houlihan in August of2012 a 

sma1i decision. 11-0in your view? 

A: It was-well, it was prui of their health care review, so to sit and--and 

ask him specific questions about specific people. or about, you know. 

specific criu1es or-or, you know. for exrunple, "Doctor. are you 

divetiing drugs'' or "Doctor. are you getting kickbacks from veterans?" 

1005 Porter Transcribed Interview. at 92. 

~lajority Staff Report 

Committee on Homeland Security and GoHrnmental Affairs 

Senator Ron Johnson, Chairman 

171 
251 

"Doctor, are you doing this?" that would have been probably a poor 

choice at that point. 

But there-as far as-I think I did ask a couple of questions of Dr. 

Houlihan. I-1 kept pretty quiet for most of the interviews. I think 1-1 

asked Dr. Houlihan a question or two. I don't really recall what 

questions they were. 

But I think, at that point, the-the purpose of those interviews were 

more for the healthcare inspection purposes than they were for-for 

criminal. I was-my understanding is that I was asked to be there in 

case anyone made any kind of utterance of-of criminal activity or 

anything like that. That was, you know, what I was told, and-and, 

you know, my purpose for-for being there, and that didn't 

happen. 1 oo6 

According to the transcript of the VA OIG's August 23, 2012 interview, Special Agent 

Porter asked Dr. Houlihan a series of questions about any potential relationships with any 

individuals who work in the sup~ll chain of the narcotics to the Tomah VAMC pharmacy. 1007 

Dr. Houlihan responded, "No." 1 0 Special Agent Porter also asked Dr. Houlihan about whether 

he provided any financial or personal assistance to a patient, which he denied. 1009 Special Agent 

Porter then asked Dr. Houlihan about the "perception that the kind of word around the campfire 

so to speak is that if you need narcotics, go to Dr. Houlihan." Dr. Houlihan responded, "I don't 

think- I think that that might be over-zealous, quite frankly .... " 1010 

40. August 29, 2012: The VA DIG created a post-site visit "Tomah Hotline Status" 

document with a draft report date of October 2012 

After the VA OIG team concluded its two-day site visit of the Tomah VAMC, Dr. 

Mallinger returned to Washington, D.C. and provided his supervisor, Dr. Wesley, with a 

briefing. In a transcribed interview with Chairman Johnson's staff, Dr. Wesley confirmed that 

the team briefed him when they came back from Tomah. 1011 Shortly after their return, the OIG 

produced a "Tomah Hotline Status" document, dated August 29, 2012, which identified specific 

areas in the hotline that had yet to be completed. The document included a goal to "[c]omplete 

[an] initial draft" of the report "by the end of October" 20121012 Dr. Mallinger did not recall this 

document, but offered a long response detailing what OIG did after the site visit. He stated: 

1006 ld. at 97-98. 1007 8/23/2012 VA 010 Interview of Houlihan, at OIG 5410. l008ld. 

1009 Jd. atOIG 5410-11. 1010 Jd. at OIG 5411. 1011 Wesley Transcribed Interview, at 196. 1012 Tomah Hotline Status as of Aug. 29, 2012, at O!G 12928. 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

172 
252 

Q: And then at the bottom it says, "Report. Complete all data collection 

analysis by end of September." And then, "Complete initial draft by 

end of October." Do you recall if an initial draft was completed by 

October of2012? 

A: You know, I don't recall, you know. I know that the final draft was 

completed somewhat later than that. I think that this plan, you know, is 

as of the end of August, and I would say that the-you know, we did 

things-we didn't necessarily follow this plan. And, in particular, you 

know, if !look at the specifics, I mean, we did-we certainly did some 

additional interviews by telephone. The pharmacy data review turned 

out to be much more extensive than we had initially envisioned it. 

And, you know, I'm not sure if it was justified or not, although 

ultimately it produced what was really our main finding, which was 

the high rate of prescribing. 

But, you know, one of the problems ongoing in this whole inspection 

had been that we were coming up with so little that we kept pushing 

into new areas trying to find, you know, that smoking gun, if you will. 

And the pharmacy data request was-you know, I don't think it was 

even fulfilled by the end of September. We asked for quite a bit more 

than we had initially envisioned asking for. And the first things that we 

reviewed from the pharmacy led us then to ask for additional things. lt 

became a process, and it turned out to be kind of a bigger undertaking 

than we had initially envisioned, which, like I say, ultimately, you 

know, produced, you know, kind of the core finding of the report, 

although it, you know, wasn't a damning finding. 

So 1 don't know. I think maybe, you know, we were trying as hard as 

we could to pursue everything that was stated in the allegations, and so 

it took us in a direction of opening up yet another can of worms, if you 

will. 

The email investigation also, you know, I mean, that took some time to 

put together. There were-there was some trouble retrieving some of 

the files that had been stored on people's individual computers. And 

we, you know-ultimately, we got those files, but it took some time to 

get those. So we got a little bit of a later start with that than we had 

wanted to. 

The chart review database, you know, the data cleaning and 

verification, when we finally got around to writing the report, you 

know, after doing all these things, we really-we really did the-that's 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

173 
253 

the structured chart reviews I'm talking about here. We did the data 

verification kind of concert with the writing of the report. So thatthat was actually a process that took about 7 weeks just by itself. You 

know, we would write something, and then we would look into the 

structured chart review to see what we could reliably count on from 

that review to support it, and that would require then going through 

this process of verification, and then we would go back to writing. So 

that was about a 7-week process there. 

And so that is really-you know, I'm not sure-you know, as I look 

back on it, you know, from the perspective of, you know, a long time 

later, end of August, complete the initial draft by end of October, it's 

September, so 2 months, not really a very realistic perspective 

considering the work that we ultimately did. 1013 

1011 Mallinger 4/21/2016 Transcribed Interview. at 327-30. 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

174 
254 

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41. September 2012: The VA OIG conducted a phone interview with Tomah VAMC 

Director Mario DeSanctis 

T11e VA OIG team was unable to interview the Tomah V M1C Director, Mario 

DeSanctis, during their site visit to the facility because the director was ill. As tl1e August 29, 

2012, Tomah Hotline Status docmnent illustrated. the OIG team listed Mario DeSanctis as one of 

the remaining witnesses to interview1014 On September 10, 2012, the OIG team conducted a 

101 ' Tomah Hotline Stams as of Aug. 29, 2012. at OIG 12928. 

:\'lajority Staff Report 

Committee on Homeland Secu1·ity and Governmental Affairs 

Senator Ron Johnson, Chairman 

175 
255 

phone conference with Director DeSanctis. The phone call lasted nearly one hour. 1015 and 

concemed what the OIG team witnessed during their site visit. 1016 The concems about Dr. 

Houlihan and the "fear" that had gripped the f;cility were some of the topics discussed. At the 

end of the phone call, the OIG decided to "go off the record" to alert Director DeSanctis about 

their site-visit observations of Dr. Houlihan and Deborah Frasherl017 

--x ca.se No. 

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1015 The entire Mario DeSanctis OIG phone inten·iew transcript can be found at VA OIG Bate~ number OIG 6084~ 

6103. 

1016 VA OIG Interview with Mario DeSanctis, in Tomah, Wis. (Sept. 10. 2012). OIG 6084 [hereinafter 911012012 

VA OIG Interview of DeSanctis]. 1011 !d. at OIG 6095-96; Handwritten Note ti·om Alan Mallinger (Sept. 10, 2012). at OIG 12364. 

Majority Staff Report 

Committee on Homeland Security and Gonrnmental AITairs 

Senator Ron Johnson, Chairm:m 

176 
256 

During the interview with Director DeSanctis, Dr. Mallinger explained the complaints 

received by the VA OIG, including "allegations that a lot of these drugs are being misused for 

criminal purposes, that people would either be abusing drugs that they get or reselling them, 

which amounts to drug trafficking." 1018 He sought Director DeSanctis' "sense" of the situation 

at the Tomah VAMC, because Director DeSanctis had not been at Tomah "very long." The 

director responded that he was aware of the "sense of friction between the Pharmacy and the 

Chief of Staff' but that his involvement had been "somewhat inconsistent unfortunately."1019 

Director DeSanctis referenced the allegations received by the OIG in March 2011 and 

referred to VISN 12, and how he "got an indication" about the complaints while he was at the 

VISN for training. 1020 He also recalled an OIG Combined Assessment Program (CAP) 

inspection, in which there was an anonymous allegation involving "the over-prescribing of meds 

to psych patients." 1021 Director DeSanctis told the OIG that he "asked Dr. Houlihan to look into" 

the anonymous allegation and requested a response by June 20121022 According to Director 

DeSanctis, he was provided a response and "thought it was good," but thought "we could do 

more than that."1023 

Dr. Mallinger explained his impressions of the Tomah V AMC, saying: "I was very 

impressed with the, you know, the quality of the people, but also the-you know, they really do 

seem to have the best interests of the veterans at heart." 1024 Despite that impression, Dr. 

Mallinger described a "sort of dichotomous, polarized situation has arisen" and he asked Director 

DeSanctis his thoughts on those diverging realties. Director DeSanctis responded: 

I think over time there's some fear there, and I think it's been based on Dr. 

Houlihan's personality, and I think it's been because he was the acting director 

before, and I think we may have lost some objectivity. And I'm trying, and I 

want to re-establish the objectivity in all of this. So I think I can break the tie, you 

know, or this polarization that you talked about. 1025 

Director DeSanctis continued with discussing the "fear" that had taken root at the Tomah 

VAMC, particularly with the pharmacists and technicians at the facility. In passing, he 

10" 9i10/2012 VA 010 Interview of DeSanctis, 010 6085. 1019 Jd. 

1020 Id. at 010 6086, at I 0. 1021 !d. at 010 6086. Every three years, the VA 010 Office of Health Care Inspection reviews every VA Hospital 

through its CAP reviews. The CAP reviews ensure compliance with appropriate protocols and typically include a 

survey of the staff of each hospital. 1022 !d. 

1003 /d. 

1024 /d. at 010 6088. 1025 /d. 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

177 
257 

mentioned the firing of Dr. Noelle Johnson and how that "has had a lasting effect on the 

pharmacy, to where I think even the technicians work[] in fear." 1026 

During his interview of Director DeSanctis, Dr. Mallinger raised concerns about the 

ability for the VA Police handling patients who had some criminal issues connected to drugs. 

Director DeSanctis responded that he did not hold that concern, but cited that the Tomah V AMC 

has "had gaps" in the chief of police position. He also explained, "I don't have a sense of the 

criminal world, although I have met with John Brooks, you know, Special Investigator for our 

area, and he has told me that there's some drug trafficking going on in this area." 1027 

Dr. Mallinger raised other concerns about the Tomah V AMC's role in the drug trade. 

Specifically, Dr. Mallinger told Director DeSanctis that the VA OIG had received information 

from the Tomah Police Department about "specific individuals who are basically getting their 

drugs at Tomah."1028 He described a perception "that Tomah has put itself in sort of the role as a 

drug supplier" for the area, and that "there seems to be genuine concern about what harm might 

be being done to the community."1029 In response, Director DeSanctis opined: "I really think if 

they suspect something like that, they need to act on it and you know, to follow through." 1030 

!026 Id 

1027 !d. at OIG 6089-90. 102' !d. at OIG 6092. 1029 Jd. 

1o3o I d. 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

178 
258 

OR. MAJ,.I.,INGER: But it's a l.so true 

lG yolic., defl&rt.ment th-at you k.ncrw. that they hav~ 

!? concerns about spec1flc individuals who a~e 

bas1cally gettlo.;J the:l.l <h~ugs at Tomah. so 

MR. D~SAN<:TlS 

sua~et so~thing like th•t. th~y need to ~et on 

It and y<>u know. to foll,.., th<ough on 1t. 

36 

inform.!nts tell thern. you know. I mean they 

certeunly do se~~ to be pursuing their law 

enCorcement agendd, bllt rhe·re is this perception, 

~t itself in sort of the role as a dn19 

auppliet, and the~"! s~ert~s to Doe St!ftle genuine, you 

kJXltof. a lot. of tht'!' people who- 'J":'itk at T•;mah ar-e 

? pnt of tM! Tom•h cononYn>ty 

~(j Mk. ~SANCTlS: Yes 

l:> done to the c-~unity. 

103 ' 9/10/2012 VA OIG Iute1Yiew of DeSanctis. OlG 6092. 

:\Iajority Staff Report 

Committee on Homeland Security and Goyernmental Affairs 

Senator Ron Johnson, Chairman 

179 
259 

At the end of the phone interview with Director DeSanctis, Dr. Mallinger raised a 

concern about "very significant Union problems" that he heard during the OIG's interview with 

Associate Director Sandy Gregar. Dr. Mallinger questioned Director DeSanctis about what he 

knew about the Tomah union. Director DeSanctis replied that he was meeting with the union 

every other week and was developing a "good partnership" with the union. 1032 He described 

what he knew about the union, saying "I think there's just been some friction in the past" going 

"back many years, so that's a big part of the culture here too." 1033 

Dr. Mallinger concluded the interview by telling Director DeSanctis that the VA oro still 

had work to do on the inspection, but that a report would be prepared and "it will have specific 

recommendations in it." 1034 Of course, the OIG's eventual final product-the eleven-page 

administrative closure-made no recommendations. Instead, the administrative closure included 

five "suggestions" for Director DeSanctis1035 

42. September 2012: VA OIG Special Agent in Charge John Brooks contacted Tomah 

VAMC Director Mario DeSanctis about the DEA's inquiry 

On September 10, 2012, the Special Agent in Charge (SAC) of the VA OJG's Criminal 

Investigation Division Chicago field office contacted Director DeSanctis seeking information 

about the DEA's actions at the Tomah VAMCI036 SAC John Brooks asked Director DeSanctis, 

"Any word regarding the DEA Privacy Act request?" 1037 Director DeSanctis responded, "Johnnot yet. Will forward to you as soon as I find out more." 1038 This inquiry about the DEA 

occurred on the same day Director DeSanctis had a phone call with Dr. Mallinger, Special Agent 

Porter and other OIG inspectors. 1039 According to the oro interview transcript, the DEA was 

not a topic of conversation. 1040 

1032 ld. at OIG 6094. 

IOJJ ld. at OIG 6095. 1034 !d. at OIG 6093. 1035 VA OIGTOMAH VAMC ADMIN!STRAT!VE CLOSURE, at 10-11. 1036 E-mail from John Brooks, VA OIG, to Mario DeSanctis, Tomah VAMC (Sept. 10,2012, 1:50PM), OIG 11507, 

at OIG 11508-09. John Brooks has since retired as the Special Agent in Charge of the Chicago OIG office. Porter 

Transcribed Interview, at 23, 24, 69. 1037 E-mail !rom John Brooks, VA OIG, to Mario DeSanctis, Tomah VAMC (Sept. !0, 2012, I :50 PM), OIG 11507, 

at OIG 11508--{)9. 10" E-mail from Mario DeSanctis, Tomah VA, to John Brooks, VII. OJG (Sept. 10,2012,4:22 PM), OIG 1!507, at 

OIG 11508. 1039 9110/2012 VA OIG Interview of DeSanctis, OIG 6084. 1040 ld. at OIG 6084-6103. 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

180 
260 

Fignn>· 87: E~~il exchangt> bPhn,•t>u John Brooks and :Mario DE>Sanctis1041 

From: De'>a~cli~, IJa:io V. (SFS) 

Sent: Monday. Sep:rmber 10, 2012 04:22PM 

To: B<ooks. jchn (OIG) 

Subject: Re: 

F!rom: Broc~s. Jo~r (OlG) 

Sent: Mond~y. S<.>p:ember 10. 2012 01:50PM 

To; DeSdr:cb, Mdr,o V. (SES) 

Subject: 

Director M. DeSanctis, 

Any word regard inc :he DEA Pnvacy Act request? 

VR, 

::.:·L~-AL H~.JL~L :..~; t tl..-•. •.'.!L 

•. !.. ·:,_::'~ ,!,t,• p:c:r: :· ·1.. n :·.:..l: ~ .::..rY 

't 11'1' I L ... Ftl :: -.~. 

~ r-. -;::<:::u;- Tl:\r:::~ 7': :.:-.~r :··1 ~,~·.~r ·· -::N 

Tite email conununication between SAC Brooks and Director DeSanctis continued. On 

September 13, 2012, Director DeSanctis notified SAC Brooks that the Tomah V AMC Pt~vacy 

OtTicer was on leave and would not rehtm until September 17, 2012. 1041 On September 17, 

2012, Director DeSanctis wrote to SAC Brooks: "My Privacy Officer is back and she infonned 

me that the Dmg Enforcement Administration Agent" requested infonnation and the agent was 

from the "Milwaukee District Office." 1043 

"" E-mails between Jolm Brooks. VA O!G. and Mario DeSanctis. Tomah VA (Sept. 10, 2012), OIG 11507, at OIG 

11508-09. 

""E-mail ti·orn Mario DeSanctis. Tomah VA. to John Brooks. VA OIG (Sept. 13. 2012. 12:13 PM). OIG 11507, at 

O!G 11508. 1

" 3 E-mail from Mario DeSanctis. Tomah VA. to John Brooks. VA OIG (Sept. 17.2012.8:37 AM), at O!G 11507. 

~Iajority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

181 
261 

Two days later, on September 19, 2012, SAC Brooks sent an email to Dr. Wesley and Dr. 

Mallinger in Washington, D.C. asking to speak1044 SAC Brooks wrote "[t]he VAMC Director 

emailed and called me regarding DEA Diversion Investigator Milwaukee making a request for 

medical records. Apparently the (DEA) are reviewing some of Dr. Houlihans [sic] patients [sic] 

records. "104' 

Figm·~ 88: Email from John Brooks to Dr. ~iallinger and Dr. Wosl~y1046 

--- ~ 

Malhr:qt!r, AlOin (OJG) _ I 

Fro•JI • 

..... 

VJ·wxy<U(JN 1-"'W<l,; :.ll<f'llUb•.ct;J P 

'' \ ,., ;.·• " '/ w~H · ,.,. n.,. ,,, ;; ., ,.,11 ~·~ 

l·ch4•'•<l">P--lltt'\::•~;:;)'i 

I R 

~rC~m: L·~'>~'!'l1, \larnv \\.!:;'>) 

~rt: l.knd<l}. ~p:nh117 . .iC"lE:J?AV. 

ln~ 1t1~1~~.j6~<> I•*•J 

Subjen: rw· ':l.~.t·r~ d :n'ctr>IN •}fl 

iV"-1:a•·' 

\f.,,•\'IJ" l.v I 

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f, ·u: ''<' ~ ~ ~ \ .!.1 •l 

!ctill.!l.•'-'I.'·'J 

l'f\' doll\) '. ~ 

""'E-mail from Jolm Brooks. VA OIG. to George Wesley & Alan Mallinger. VA OIG (Sept. 19, 2012. 12:30 PM). 

atOIG 11507. 1045 !d. 

l0.l6Jd. 

:\lajority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

182 
262 

43. Unknown date in 2011 or 2012: The Drug Enforcement Administration visited VISN 

12 to discuss the Tomah VAMC 

During this period, the VA OIG was not the only investigative agency examining the 

Tomah V AMC. The DEA conducted several investigations relating to the Tomah V AMC from 

2009 to 2015_~ 047 At some point in 2012, the DEA also visited VISN 12 headquarters in 

Chicago. 

Ms. Oshinski, Deputy Director for VISN 12, said that she recalled the DEA appearing at 

the VISN 12 offices at some time during 2011 or 2012. 1048 She recalled that the DEA spoke with 

VISN 12 Network Director Dr. Murawsky at that time. Ms. Oshinski was not invited to the 

meeting but explained that "one day we had a big party of people come" and "we don't normally 

get a lot of suits ... in the VISN office."1049 After the meeting, Ms. Oshinski said that she was 

curious about why the DEA had come to meet with Dr. Murawsky, then-VISN 12 Network 

Director. She asked, and Dr. Murawsky told her it was "something I can't talk to you about."1050 

At some later point in time, Dr. Murawsky disclosed to Ms. Oshinski the reason for the DE A's 

visit-"it was DEA looking at Tomah."1001 

Ms. Oshinski told Chairman Johnson's staff that she was not contacted by the DEA 

during its visit to the V!SN !2 headquarters and that she has never been interviewed by the 

DEA. 1052 Although they were not interviewed by the DEA, at least two VISN employees 

continued to monitor Dr. Houlihan's prescription practices after the DEA's visit to VISN 

headquarters. 1053 

C. The VA OIG's administrative closure of its health care inspection of the 

TomahVAMC 

On or about March 12, 2014, the VA OIG administratively closed its health care 

inspection of the Tomah V AMC. Dr. John Daigh, Assistant Inspector General for Healthcare 

Inspections, signed the administrative closure. The VA OIG initially did not make public its 

report, although it alleged that the report was "available" to the public if an individual filed a 

1047 li28/2015 Letter from Chairman Johnson, HSGAC, to Administrator Leonhart, DEA; 3/3/2015 Letter from 

Chairman Johnson, HSGAC, to Administrator Leonhart, DEA, at 1-2; S. COMM. ON HoMELAND SEC. & 

GOVERNMENTAL AFFAIRS, MAJORITY STAFF REPORT: TRAGEDY AT TOMAH: INITIAL FINDINGS 14 (2015). 1048 Oshinski Transcribed Interview, at 93-95. 1049 I d. at 93-94. 1050 I d. at 94. 

!051 !d. 

1052 !d. at 94-95. 1053 Jd. at 93. 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

183 
263 

Freedom of Information Act (FOIA) request. 1054 The VA OIG has accurately pointed out that it 

lists the number of administrative closures in its semiannual report to Congress1055 However, 

the semiannual reports only list the number of administrative closures without any context or 

details and thus an individual would have to know that an administrative closure of an 

investigation at a particular facility exists in order to submit a FOIA request for the document. 1056 

Under the VA OIG's view of transparency, an interested individual would have to know that the 

OIG conducted a health care inspection of the facility before he or she could submit a FOIA 

request for the document. 

The VA OIG has also disputed when its Tomah health care inspection was made public. 

The VA OIG has asserted that its inspection of the Tomah VAMC was public as of August 29, 

2014-the date on which it provided a copy of the closure to Senator Tammy Baldwin in 

response to her FOIA request. 1057 At that point, however, the VA OIG did not publish the 

Tomah V AMC administrative closure on its website or make the report available to other 

members of the Wisconsin congressional delegation. In reality, the VA OIG Tomah VAMC 

inspection was not made public until it was linked in the Center for investigative Reporting's 

article posted on January 8, 2015. 1058 The VA OJG did not publish the Tomah VAMC 

administrative closure on its website until February 6, 20151059 

At only eleven pages in length, the VA OIG's administrative closure significantly 

understated the breadth of the inspection, the time invested in the inspection, and the resources 

dedicated to the inquiry. The report made no mention of the DEA and VA OIG criminal division 

investigations that occurred concurrent to its health care inspection of the facility. The 

administrative closure completely omitted some aspects of the VA OIG's investigation and 

ignored some facts and documents. The VA OIG provided no analysis or insight into how it 

determined whether to substantiate the allegations it reviewed, and the VA OIG did not explain 

why it chose to administratively close the inspection. 

1054 Shepherd 21912016 Transcribed Interview, at 142-43; see also Donovan Slack, Newly Released VA Reports 

Include Cases of Veteran Harm, Death, USA TODAY (April 29, 20 15), 

htW:I lwww. usa today .com/story /newslpolitics/20 15 /04129/new Iy -released-va-reports/26594 3 531. 

IOl. 112712015 Letter from Deputy Inspector General Griffin, VA OIG, to Chairman Johnson, HSGAC. 1056 Slack, Newly Released VA Reports Include Cases of Veteran Harm, Death, USA TODAY (April29, 2015). 1057 Letter from Richard l Griffin, Deputy Inspector General, Dep't of Veterans Affairs, to Han. Ron Johnson, 

Chairman, S. Comm. on Homeland Sec. & Governmental Affairs, at 2 (Jan. 27, 2015) [hereinafter 112712015 Letter 

from Deputy Inspector General Griffin, VA OlG, to Chairman Johnson, HSGAC]; Shepherd 21912016 Transcribed 

Interview, at 142-43. 1058 Glantz, Opiates Handed out Like Candy, REVEAL l'EWS (Jan. 8, 20 15). 1059 Report Summary: Healthcare Inspection-- Alleged Inappropriate Prescribing of Controlled Substances and 

Alleged Abuse of Authority, Tomah VA Medica/ Center, Tomah, Wisconsin, DEP'T OF VETERANS AFFAIRS, OFFICE 

OF INSPECTOR GENERAL (Feb. 6, 2015), http://www.va.gov/oig/publicationslreport-surnrnary.asp?id~3283. 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

184 
264 

1. The scope ofthe VA OJG's inspection 

As described in the VA OIG's eleven-page administrative closure, the scope of the VA 

OIG's inspection: 

included the assessment of the practice patterns and controlled substance 

prescribing habits of[Dr. Houlihanf 060 and [Deborah Frasher] 1061 as well as the 

administrative interactions of [Dr. Houlihan] with subordinates and his approach 

to clinical leadership, specifically as these related to issues around the prescribing 

of controlled substances. 1062 

In addition, the VA OIG looked for "any concerns by federal and municipal law enforcement 

authorities or other signals of drug diversion related to the practices of [Dr. Houlihan] and 

[Deborah Frasher]." 1063 The VA OIG health care inspection team also reviewed "allegations of 

criminal activity" and "their efforts throughout the inspection were closely coordinated with the 

OIG's Criminal Investigation Division." 1064 These two references are the only mention of 

potential drug diversion or possible criminal activity in the VA OIG' s report. 

2. Complaints reviewed by the VA OIG 

As explained in this staff report, the VA OIG reviewed multiple complaints from multiple 

sources over the course of multiple years during its health care inspection of the Tomah V AM C. 

The administrative closure specifically noted that the VA OIG compiled "various allegations" 

from a number of sources, including: 

A complaint made in March, 2011 by a facility social worker (with a corresponding 

VISN response in June, 2011 and a September, 2011 report from the VISN Chief Medical 

Officer (CMO) on remedial actions taken). 

Anonymous complaints made in August, 2011, via a letter sent to the OIG and 

Congressman Ron Kind of the U.S. House of Representatives. 

A physician at the facility in March, 2012, while the inspection was actively ongoing. 

Several anonymous respondents to an [employee] survey in May, 2012, that was 

conducted prior to a regularly scheduled [ ... ]inspection [of the facility]. 1065 

1060 Identified as "Dr. Z" in the administrative closure. 1061 Identified as "'NP Y" in the administrative closure. 1062 VA OIG TOMAH VAMC ADMINISTRATIVE CLOSURE, at l. 10" I d. 

!064Jd. at 2. 

1065 Id. at l. 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

185 
265 

3. Documents reviewed by the VA OIG 

The VA OlG's administrative closure also listed the documents it reviewed during its 

health care inspection. As listed in the administrative closure, the VA OIG reviewed the 

following documents: 

Statement of Charges, Settlement Agreement and Final Order from [Iowa Board of 

Medical Examiners] concerning charges brought against [Dr. David Houlihan] shortly 

after his date of appointment to the VA. 

Letters from the [VISN 12] Director and the VISN 12 CMO. 

Five peer reviews, and correspondence from [Dr. Houlihan] to the Peer Review Oversight 

Committee and the VlSN 12 regarding allegations made in March, 2011, and subsequent 

actions by VA management. 

Scope of practice documents and routine peer reviews for [nurse practitioner Deborah 

Frasher]. 

OIG Master Case Index records of 19 cases at Tomah V AMC since 2009. 

Ten peer reviews of [Dr. Houlihan's] practice performed in November, 2009, along with 

minutes of a subsequent special session of the Peer Review Committee, and related 

correspondence between [Dr. Houlihan] and the Committee. 

Tomah VAMC police reports of overdoses/suspected overdoses over a three-year period. 

Reports on adverse drug reactions in patients treated by [Dr. Houlihan] and [Ms. Frasher] 

compiled by the Tomah V AMC pharmacy. 

Documents related to the suicide of a Tomah V AMC mental health professional [Dr. 

Kirkpatrick] immediately following termination of employment (memoranda, e-mail 

messages, Sheriffs Department reports, union representation records and related internal 

union correspondence). 

Documents related to the appeal of a terminated Tomah VAMC pharmacist [Dr. Noelle 

Johnson] to the [MSPB] (appellant's brief for MSPB jurisdiction, narrative of [Dr. 

Johnson's] experiences, supporting materials for decisions). 

Relevant [Tomah VAMC] [m]emoranda on pain management, chronic opioid use, and 

adverse drug event surveillance. 

V A/DoD Clinical Practice Guideline on Management ofOpioid Therapy for Chronic 

Pain (May 2010). 

[The VA OIG] also requested Tomah V AMC police reports on sales of prescribed or 

illegal drugs on the Tomah VAMC campus in the preceding three ,1ears, but were told 

there have been no Uniform Offense Reports of such activities. 106 ' 

According to the administrative closure, the VA OIG queried its Master Case Index-the 

OIG's repository for case information-and reviewed 19 cases at the Tomah VAMC since 

looo !d. at 2-3. 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

186 
266 

2009. 1067 As a part of Chairman Johnson's investigation, his staff asked the OIG to identify the 

19 cases reviewed by the OIG during the Tomah V AMC inspection. 1068 The OIG Deputy 

Counselor Roy Fredrikson responded: 

When the Counselor's office reviewed these 19 cases, we discovered the 

complaints involved matters that were completely umelated to the Committee's 

investigation. The topics of these cases include, threats of violence from Veterans, 

theft of property, pornography, potential loss or theft of patient medications 

during shipment, allegations of sexual assault, misappropriation of a Veteran's 

benefits by a family member, off campus misconduct, and quality of care 

(umelated to the subject of the investigation), to name a few. None of these cases 

related to the opioid prescription practices at Tomah, or the conduct of Dr. 

Houlihan, or any other party connected with the OHI Administrative Closure. As 

the cases did not fall within Committee's stated scope of investigation, the 

inappropriate prescribing of controlled substances or abuse of authority at the 

Veterans' Affairs Medical Center in Tomah, we determined this material was not 

responsive. 

Please note, write-ups on MCI cases that were responsive to the scope identified 

by the Committee were provided at Bates 1389-1400. Also, the case above 

involving quality of care was accepted by OHI, and reported out under Case No. 

l 0-02355-242 (September 8, 201 0), which is available on our website. 1069 

When Chairman Johnson's staff interviewed Dr. John Daigh, the Assistant Inspector 

General for Healthcare Inspections, he described the OIG Master Case Index and the 19 Tomah 

cases. He stated: 

Q: Going back to the [administrative] closure, and page 2 specifically, 

there's 12 bulleted items of documents that OHI reviewed pursuant to 

this inspection. 

A: Mm-hmm. 

Q: Number 5lists, "OIG master case index records of 19 cases at Tomah 

V AMC since 2009 ." Are those 19 cases all published reports and 

documents? Or is that just you've had 19 different allegations or 

hotlines come in and your team checked up--checked them at the OIG 

master case index file? 

1067 I d. at 2. The 010 Master Case Index is a corporate management information system that serves as a repository 

for OIG case flies. About the Office of Investigations, DEP'T OF VETERANS AFFAIRS, OFFICE OF INSPECTOR 

GENERAL, http://www.va.gov/oig/about/investigations.asp. 1068 E-mails between Majority Staff, HSGAC, and Staff, VA OIG (Mar. !6, 2016) (on file with the Committee). 1069 !d. 

,~~ 

~) '"-..-__ ) 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

187 
267 

A: I think that I'm going to-you'd have to ask [Dr.] Alan [Mallinger], 

who wrote this, but I think this is the number of cases on the various 

hotlines we've got, starting with the one that we sent out to the VISN 

that came back. I mean, that had a whole series of names attached. I 

don't remember how many cases were on that. And then there were 

cases attached with the couple of other hotlines we got about the same 

time that we decided to open the one that resulted in the admin closure. 

I think it's a summary of those names, is what I think it is. But you'd 

have to talk to Alan on that 1070 

4. Patient charts and pharmacy information reviewed by the VA OIG 

The VA OIG health care inspectors conducted two types of chart reviews: "general chart 

reviews" and "structured chart reviews."1071 As described in the eleven-page administrative 

closure, the VA OIG team conducted "general chart reviews" based on the following metrics: 

Patients who were specifically identified in complainants' allegations. 

Patients who were included in June 2011 peer reviews of [Dr. Houlihan's] practice. 

A patient of [Deborah Frasher] who was identified by an informant to Tomah municipal 

police as being involved in drug diversion. 

Selected individuals from a list of the IOO patients at Tomah VAMC receiving the highest 

doses of opioids. 1072 

In addition, the VA OIG inspection team also conducted "structured chart reviews" based on the 

following metrics: 

All patients in the care of [Dr. Houlihan] and/or [Deborah Frasher] who were among the 

I 00 patients at Tomah having the highest doses of opioids (32 cases). 

Patients on a list provided by the Tomah municipal police department of individuals 

suspected of drug crimes, who were receiving prescriptions for controlled substances 

from any provider at Tomah (24 cases; 15 were patients of [Dr. Houlihan] and/or 

[Deborah Frasher]). 1073 

During Chainnan Johnson's investigation, his staff inquired about the difference between 

general chart reviews and structured chart reviews. 1074 Dr. Mallinger, the lead OIG inspector 

assigned to the health care inspection, explained that a general chart review entailed "going 

1070 Daigh Transcribed Interview, at 154-55. 1071 VA 0!0 TOMAH VAMC ADMINISTRATIVE CLOScRE, at 3. 1072Jd 

1073 Jd. 1074 Mallinger 4/6/2016 Transcribed Interview, at 162-64. 

r--~~ 

(~y ,,, ____ j 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

188 
268 

through the chart and reading ... the entries in the chart kind of in relation to the allegations 

[that] were made, trying to see if what's in the chart fits the allegations." 1075 The charts reviewed 

in the general chart review were "selected from a variety ofsources."1076 Dr. Mallinger 

explained: 

We had compiled a list of the 100 patients at Tomah who had the highest doses of 

opioids, and we took some patients that seemed like it might be fruitful to review 

their charts. There were some cases that had previously been reviewed by the VA 

Medical Center, and so we looked at some ofthose. 1077 

Conversely, in the structured chart reviews, Dr. Mallinger and Dr. Shepherd developed a 

list of questions and criteria that reviewers would answer with the data from the charts of Tomah 

VAMC veterans. 1078 The health care inspection team then solicited the assistance of other VA 

OlG personnel to review the charts and answer the questions with the data from the charts. 1079 

Dr. Mallinger developed the questions with Dr. Shepherd to "get some specific infonnation that 

we felt would be pertinent to the allegations" received by the VA 01G. 1080 The VA OlG health 

care inspectors devised the structured chart reviews as "a way we could get a team involved" to 

"address some specific aspects of the allegations." 1081 Dr. Mallinger and Dr. Shepherd "trained 

several staff members" who "basically went through the charts and ... addressed the specific 

items that were in our questionnaire." 1082 

The VA OlG had two sources of patients for the structured chart reviews. One source 

was a "list of people that we got from the Tomah police, which is people who were suspected of 

being involved in drug crimes." 1083 VA OlG health care inspectors reviewed that list and "found 

the ones who were actually patients at the VA and who were actually taking prescribed 

opioids." 1084 The second source of patients came from a subset of the 100 top opioid recipients 

at the Tomah V AMC. Of those l 00 patients, the VA OIG "pulled out all of the people on that 

list who were patients of either Dr. Houlihan or [Deborah Frasher]."1085 Roughly one-third of 

those 100 patients "were attributable to one of those two physicians" and "20-some" charts were 

from the "police source."1086 In total, the VA OIG reviewed approximately 46 charts as part of 

the structured chart reviews. 1087 

1075 ld at 162. 1076 Id at 163. 1077 Jd at 163. 10" !d. at 162. 1079 Jd. 

1080 !d. at 163. 1081 !d. at 162. 

IOS2 Jd. at 162-·63. 1083 !d. at 163. !084 I d. 

1085 !d. at 163-64. 10"/d. at 164. 1087 ld. 

rJ..., 

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In addition, the VA OIG reviewed spreadsheets of pharmacy records from the Tomah 

VAMC. Specifically, the health care inspection team reviewed the following data: 

Early refills of controlled substances and antidepressants (for comparison) at Tomah 

VAMC over the period ofJanuary 1, 2011 to September 12, 2012. 

Total morphine equivalent amounts of o~ioids dispensed during FY 2012 in all VISN 12 

facilities by site, provider, and patient. 10 8 

5. Emails collected as a part of the VA OIG's health care inspection 

The VA OIG health care inspection team also received emails from the Tomah V AMC 

and VJSN 12 employees. As explained in the eleven-page administrative closure, the VA OIG 

"collected an e-mail dataset for review consisting of227,532 unique e-mail messages and 859 

associated files originating from 17 individua1s." 1089 The administrative closure noted that the 

health care inspection team "searched terms that could signal potential drug seeking behavior, 

such as those related to early refills and urine drug screens, in order to assess what was being 

communicated about these topics, as well as what advice or instructions were being given." 1090 

In addition, the VA OIG team "reviewed messages pertaining to specific individuals in cases 

where administrative/supervisory conflicts were reported to exist." 1091 

6. The VA OIG's site visit to the facility, interviews conducted, and consultants engaged 

On August 22 and 23, 2012, VA OIG health care inspectors conducted a site visit at the 

Tomah V AM C. While on site, the health care inspectors "toured the outpatient pharmacy to 

assess security issues" alleged in the complaints received. 1092 The VA OIG team also met with 

the Tomah V AMC's Acting Chieflnforrnation Officer to "discuss obtaining e-mail tiles" that the 

VA OIG could not retrieve remotely1093 

VA OIG health care inspectors also conducted multiple interviews of Tomah VAMC and 

VISN 12 personnel as part of their inspection. Prior to the site visit, the VA OIG team conducted 

telephonic interviews, including: 

108" VA OIG TOMAH VAMC ADMINISTRATIVE CLOSURE, at 3. 

!089 Id 

1090 !d. 

1091 !d. 1092 Jd at4. 1093 !d. 

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The complainant in the case where he/she was not anonymous. 1094 

Tomah and Milwaukee municipal police officials; a Diversion Investigator from the 

[DEA], United States Department of Justice. 

Current and former Tomah VAMC staff who were identified by complainants as having 

key information, including a nurse practitioner, a physician, and four pharmacists. 

The newly appointed Director of Tomah VAMC. 1095 

The administrative closure explained that during the VA OIG's site visit in August 2012, the 

health care inspectors interviewed the following individuals: 

The Tomah VAMC Associate Director Sandra Gregor (interviewed in place of the 

director, Mario DeSanctis, because he was ill); 

The "Chair of the Pharmacy and Therapeutics Committee"; 

The "Director of the facility's Opioid Workgroup"; 

Chief Roberto Obong; 

The Tomah VAMC's "Pharmacy Director"; 

The "Outpatient Pharmacy Supervisor"; 

"[T]wo clinical pharmacists"; 

"[S]ix outpatient staff pharmacists"; 

"[O]ne contract dispensing pharmacist"; 

"[T]hree psychiatrists"; 

"Two primary care physicians"; 

"[A] physician's assistant"; 

"[A] Human Resources specialist"; 

Dr. David Houlihan; and 

Deborah Frasher. 1 096 

Following the site visit, the VA OIG health care inspectors interviewed the "Medical Center 

Director, the Director of Human Resources, and the VISN Pharmacy Executive." 1097 

Throughout its health care inspection of the Tomah V AMC, the VA OIG also "engaged 

the assistance of three pharmacist consultants to assist [the VA OIG] in evaluating the clinical 

and administrative aspects of [Dr. Houlihan's] interactions with pharmacy staff and the staffs 

roles in facilitating patient safety and appropriately dispensing controlled substances." 1098 The 

1094 Some of the complainants that made allegations to the VA OIG lwt!ine that formed the basis of the VA OJG's 

Tomah VAMC health care inspection made their complaints anonymously. ln those cases, the VA OJG could not 

interview those complainants because they did not know their identities. 1095 VA OJG TOMAH V AMC ADMIN!STRA T!VE CLOSURE, at 4. 

!096 !d. 

1097 Jd. 

l09H Id 

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consultants based their analyses on their· review of the recordings of VA OIG interviews with 

four pha1macists who had previously left the Tomah V AMC1099 

D. The findings of the VA DIG's health care inspection 

All told, as mentioned in the VA OIG's administrative closure, "[a) total of 32 specific 

allegations were made by [the VA OIG's) sources, several of which came to light at various 

points while the inspection was 1mderway."ll 00 The chart below summarizes the allegations the 

VA OIG reviewed as prut of its health care inspection and indicates whether the VA OIG 

substantiated the allegation: 

Allegation reviewed by the VA OIG Substantiated or Unsubstantiated 

"Tomah nnmicipal and Milwaukee police deprutments 

made com~laints about drug: traftickir1g at the Tomah 

VAlv!C''ll I 

"[A)t least five outfatient pharmacy staff left the facility 

in recent years. " 110 

"[Dr. Houlihan] was mismanagillg: a patient with complex 

regional pain syndrome by attempting: to anang:e an 

inappropriate above the knee amputation. ,l!o, 

"[A Jbuse of authority, intimidation and retaliation when 

staff question controlled substance prescription 

practices. " 1107 

"[N]egative urille drug screens (UDS) are not acted on and 

that controlled substances are still prescribed in the face of 

a negative UDS."1109 

1099 Jd. 

uoo !d. nt l. 

1101 Id. nt 4. 

Unsubstantiated''"" 

Substantiated 104 

Unsubst3IItiated '"" 

Unsubst3IItiated ''"" 

Substantiated'''" 

1102 The VA OIG did note that the "Tomah police department reported suspicions that certain Tomah VA!\1C' 

~\ients were misusing their prescribed conu·oHed substances in various \vays including chug diversion." Id. at 4-5. 

-!d. at 5. 1 !O.J. The administratiYe closm·e highlighted \vhy the phanuacists left the f<lcility. !d. 1!05Jd. 

""'!d. 

1107 Jd_ 

1108 The VA OIG explained that it did not substantiate the allegations '"in the context ofha\·ing. obtained multiple 

contradictoty facts and statement dm·ing the course of this inspection. often based on second or third hand accotmts." 

The VA OIG added that while it did not substantiate this allegation. it fotmd that "these are widely held beliefs and 

f~~~Kem<; among most phannacy staff and some other staff." !d. 

!d. "'6. 

~· t,, 

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Allegation reviewed by tbe VA OIG Substantiated or Unsubstantiated 

"[O]pioid contracts are not being 'encouraged' by [Dr. Unsubstantiated . 

Houlihan]."1111 

"Several allegations dealt with general over prescription Unsubstantiated "allegations that 

of narcotics at the facility, and specifically alleged over opioids were prescribed 

prescription by [Dr. Houlihan] and [Deborah Frasher]."11 IJ inappropriately to specific 

individuals or in inappropriate 

doses."1114 

'"Opioids are contraindicated for PTSD, but this is part of Unsubstantiated 110 

[[Dr. Houlihan's]] treatment plan. "'1115 

The VA OIG's health care inspection of the Tomah VAMC either substantiated or 

tmsubstantiated eight of the 32 allegations it analyzed. 1117 While the VA OJG made other 

findings, which are summarized below, its eleven-page administrative closure did not provide a 

clear smnmary of the allegations received and analyzed as pa11 of the inspection. The other 

findings, for which the VA OIG offered no analysis, include: 

1110 The VA DIG found that of the 56 patients they reviewed in the stntctured chru1 review, 52 of them had at least 

one li'DS between JanU.(UJ' 2009 and April 2012. The remaining four patients had no UDS done on that time, 

although all four of them were prescribed opioids. Of the 52 patients that did receive a UDS in that time period. 

there were 5 patients that received opioids in the face of a negati\·e UDS. The VA DIG noted that in a general chm1 

review of one of Deborah Frasher's patients, it found that ''multiple negative UDS (Le .. UDS that did not show 

presence of prescribed medications) were not acted on." Jd. Medical profes5ionals give their patients on opioids 

and other potentially dangeron5 medications UDS to examine whether the patients are actually taking their 

prescribed medication(s). If a patient has a negati\·e UDS. it may be indicative that they are not taking their 

prescribed medications. A negative test can influence how a doctor treats their patient, as well as may be an 

indication of potentially dangerous activities like drug diYersion. 1110 The VA OIG found that ''48 of 56 patients in the stmctured medical record review had an opioid contract. Of 

the patients lacking opioid contracts, [Dr. Houlihan] was a primm)' prescriber of opioids for none. and [Deborah 

Frasher was the primat)' prescriber of opioids for two.'' !d. 1111 Jd. 

1112 The VA OIG fOlmd that "48 of 56 pati-ents in the structured medical record t·eview had an opioid contmct. Of 

the patients lacking opioid contracts. [Dr. Houlihan] was a primary prescriber of opioids for none, and [Deborah 

Frasher was the primat)' prescriber of opioids for t\\"o." Id lll.l !d. 111 .1 The VA OIG noted that the "appropriatene':>s of presctibing opioids to a particular p;,tient or the appropriateness 

of a particular dose utilized is a complex matter that must take into account the patient's history. cmTent medical and 

psychiatric s.tants. social situation and other factors. Tile clinical decision making w1derlying this process is based 

on the practitioner's clinical judgment and other factors that vat)' frorn patient to patient." It was in this context that 

the VA DIG unsubstantiated the allegation!> with respect to opioid over prescription. I d. at 6--7. 1115 Id. at 9. 1116 The VA OIG's review of patient records. emails. and interviews "did not fmd docum·entation that opioids Wet'e 

being used to treat PTSD. In each case. medical record review indicated a histolJl of a pain related condition and use 

of opioids. for treatment of pain." I d. at 9. 

111' S!u~ ld. 

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The Tomah VAMC Chief of Pharmacy reported to Dr. Houlihan "by virtue of his [Dr. 

Houlihan's J administrative leadership position. 1118 

"[S]ome patients at Tomah VAMC had a pattern of early refill requests, which can be a 

potential risk behavior for substance abuse. Pharmacists expressed a reluctance to 

question such early refills."1119 

o A review of pharmacy data showed that Dr. Houlihan, Deborah Frasher and other 

clinicians at the Tomah V AMC "provided more than 7 days early controlled 

substance refills." 1120 

o Prior to April 12, 2012, the Tomah V AMC had a policy that did not allow 

exceptions to the facility's "no early refill rule." However, the policy in place 

when the VA OIG investigated the Tomah V AMC did not forbid exceptions to 

the no early refill rule, nor did it "provide practical guidance, parameters, or 

processes by which to approach early refills or navigate the clinical complexity of 

such exceptions." 1121 

The amounts of opioids prescribed by Dr. Houlihan and Deborah Frasher "in aggregate 

and to individual patients were at considerable variance compared with most opioid 

prescribers in VISN 12."1122 

"Although the allegations dealing with general overuse of narcotics at the facility may 

have had some merit, they do not constitute proof ofwrongdoing." 1123 

The VA OIG "did not find any conclusive evidence affirming criminal activity, gross 

clinical incompetence or negli¥,ence, or administrative practices that were illegal or 

violated personnel policies." 11 4 

"It would seem more clinically appropriate" for complex patients on "unconventional" 

treatment regimens "to be treated by a specialist or subspecialist in their particular 

condition, rather than a nurse practitioner or physician's assistant."1125 

The VA OIG noted "concern" over the "dysfunction of multidisciplinary collaboration in 

patient care," especially between the pharmacy and Dr. Houlihan. The OIG found that 

the Tomah V AMC "appeared to be at a functional impasse with respect to such 

collaboration." 1126 

o The Tomah V AMC pharmacists interviewed by the OIG "uniformly indicated that 

they were reluctant to question any prescription ordered by [Dr. Houlihan] or any 

aberrant behavior by his patients (for example, frequent requests for early refills) 

!IJH/d.at6. 

l J 19 !d. 

!120 !d. 

!121 !d. 

1122 !d. at 7. 1123 /d. at 9 J 124/d. 

1125 The VA OIG added that effective collaboration between providers and pharmacists "provides a system of checks 

and balances that reduces medication errors and enhances general patient safety, and is especially important in this 

setting [the Tomah VAMC] given the quantities and dosage of opioids that are being utilized in seriously ill 

patients." I d. at 9-10. 1126 !d. at I 0. 

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because they feared reprisal, even though most of them could not give a first-hand 

account of negative actions toward them by [Dr. Houlihan]." 1127 

o The fact that the Tomah VAMC Chief of Pharmacy reported to Dr. Houlihan, as 

Tomah VAMC Chief of Staff, "may complicate the perception that "[Dr. 

Houlihan] misuses his authority to compel acquiescence with his clinical 

decisions." 1128 

o On the other hand, Dr. Houlihan "complained that pharmacists (except for one) 

were unwilling to approach him with problems or concerns and were uninterested 

in learning more about his treatment approach and rationale."1129 

The VA OIG offered five "suggestions that should be brought to the attention of the 

facility Director and VISN management .... " The VA OIG's suggested: 

The facility Director should implement a vehicle by which clinicians and staff can openly 

and constructively communicate concerns and rationale when disagreements arise 

concerning dispensing of opioid prescriptions. 

The facility Director should review the reporting structure in the context of safeguarding 

bi-directional clinical discourse from actual or perceived administrative constraint. 

The facility Director should ensure development of guidance, parameters, processes, or a 

specialty clinic based mechanism to assist clinicians and staff with managing complex 

patients requesting early opioid refills. 

The facility Director should consider some variant of the tumor board model as one 

potential avenue by which to foster collaborative interdisciplinary management when 

presented with very complex clinical pain cases. 

The VISN should conduct further evaluation and monitoring of relative and case-specific 

opioid prescribing at Tomah V AMC on both a facility and individual clinician level. 1130 

E. Deficiencies in the VA DIG's health care inspection of the Tomah VAMC 

and its administrative closure 

1. The VA OIG appears to have no dear standards for substantiating allegations 

i. The findings of the VA 0/G's health care inspection of the Tomah VAMC 

The VA OIG's analysis of the problems at the Tomah VAMC demonstrates that the VA 

OIG lacks clear standards for substantiating allegations. Throughout interviews with Chairman 

ll27ld 

1128 !d. 

I !29 ]d. 

1130 Id. at 10-11. 

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Johnson's staff, VA OIG officials were unable to articulate a clear and straightforward standard 

for substantiation. The result is an arbitrary process that threatens to limit OIG independence. 

During a transcribed interview of Dr. Daigh, Chairman Johnson's staff asked him about 

the standard for substantiating an allegation reviewed by the VA OIG Office of Healthcare 

Inspection. Dr. Daigh was unable to provide a concise answer on how the office substantiates 

allegations. Instead, Dr. Daigh answered the question by applying the amorphous standards to 

the Tomah VAMC inspection. When Chairman Johnson's staff tried to get a clear answer on the 

substantiation standards, VA OIG counsel interjected and again spoke about the Tomah VAMC 

allegations. VA OIG counsel later objected to subsequent efforts by Chairman Johnson's staff to 

understand how the Office of Healthcare Inspections substantiated allegations. Dr. Daigh stated: 

Q: What is the standard for substantiating an allegation in [the Office of 

Health care Inspections]? 

A: Well, you have to-1 mean, if-so in this particular-let's talk about 

this particular case. We reviewed-Alan reviewed medical records for 

a good number of cases, reviewed the peer reviews for those cases, 

talked to providers about those cases, and came to the conclusion that 

the practice, as written down on those cases, was within the standard. 

So if you're going to talk about-! mean, you have to have some 

evidence to support that Johnny committed suicide because-because 

his boss wasn't nice to him. Is there any evidence to support that? We 

couldn't find any evidence to support that. I mean, when we look in 

the record, was-was there, in fact, a plan to cut off a gentleman's leg 

because he had pain? We couldn't find any evidence to support that 

allegation. 

When people said there was a possible crime, Alan went to the end of 

the world to find those people who might be able to provide data to 

support that a drug transaction went down here or there or that 

somebody was doing this or that, and it just was all rumor, it just never 

materialized into anything that we could get our hands on. 

When I talked-and !-when I talked-well, so we were unable to get 

any hard evidence for the many, many things that we heard were said 

to be wrong and associated with Candy Man. Had we been able to, we 

would have some evidence. 

Q: So when you're deciding whether or not to substantiate an allegation, 

is more likely than not to have occurred the standard or is it a higher 

standard than that? 

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A: It's some hard evidence that is believable that an event occurred. So if 

somebody just says something happened, that would not likely be 

enough to support it unless multiple people in the conversation agreed 

that that's what happened. 

Q: Can you put a number, a percentage of certainty? 

A: I would-well, it's-l've never really thought about it in those terms, 

but it has to-it has to have-there has to be at least some meat on the 

bones to suggest that there is data to support what's being said. And so 

we looked at emails, we talked to DEA, we talked to all the police 

officers up there, right? Tomah police, VA Tomah police, the 

Milwaukee police. We heard people talk about things; you know, 

citizens made allegations. We go to talk to people who are supposed to 

be part of those transactions, and everything melts away. So we had a 

lot of rumors, but after rumor, I couldn't go beyond rumor. 

Q: SoVAOIG 

Attorney: Can I ask one quick clarifying question? Maybe we can just get to 

the--you're trying to get to a level of evidence or something-that's 

what it seems to me. I would ask: Was there any evidence of the 

allegations, of the salacious allegations that you're talking about, 

cutting the legs off, a drug transaction-! think we were talking about 

an extramarital affair. Did you find any evidence to support that? 

Q: I'm not asking that. I'm asking the operations of the Office of 

Healthcare Inspections. You guys review a lot ofhotlinesA: We do. 

Q: -that include a lot of allegations. 

A: Right. 

Q: And I'm trying to figure out what the standard of the office is to 

substantiate or not substantiate an allegation. 

VAOIG 

Attorney: You asked for a percentage, which suggested that you were looking at 

was it a close call. And I think the question was, was it even a close 

call in this case, which would be a little bit different than-standards 

are-standards are all-you know, you can have preponderance of the 

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evidence. You can have another one. But it's still a judgment call in 

the end. So you were asking him what percentage, and I think there's a 

difference between it was 49-51, or, you know, 50-50 versus there 

wasn't any. So I think that's why [VA OIG Attorney] asked the 

question. 

A: It's usually not a difficult call. It's usually straightforward. Right? I 

mean, you have an allegation. We can almost always find data to 

support the allegation was true or is not true. This hotline was 

extremely difficult, and it took a great deal of time, because everyone 

we talked to--or not everyone. Many of the people we talked to said 

things that, when you actually said, "Okay, if that's true, let me go see 

this," it all just melted away. 

So would it be that when people said a transaction occurred we could 

find evidence of it, would it be that the police had provided something, 

would it be that the DEA had said something, would it be that we had 

something-a fact-that I could write about, then we would have 

written about it. But we really could not find the evidence to support 

these things. And so-so that's why I made the decision I did. 

Q: And so--so everything is-determining whether or not to substantiate 

an individual allegation is your decision when these hotlines come in 

and a product is developed? 

A: I would say that it's usually pretty straightforward. The person who 

writes the report-! mean, you've read the admin closure. The admin 

closure, you know, basically doesn't support the allegations that were 

made. And in the same way a draft would lay out data, an argument by 

which you would decide yes or no, and then you'd say we support it or 

we don't support it, or there's not enough data to support it. They're 

sort ofthe three possibilities. And in this report, there was not the data 

to support those allegations. 

Q: Did Dr. Mallinger substantiate any allegations in this first draft that 

were then unsubstantiated in the final admin closure? 

A: I don't know the answer to that. 

VAOIG 

Attorney: And we would object to that because now you're getting into the 

deliberative process. We already talked about-we've already said on 

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a number of occasions we're not going to discuss drafts and what was 

in drafts. 1131 

During his transcribed interview, Dr. Wesley also provided an equally imprecise answer 

on what standards the Office of Healthcare Inspections uses when deciding whether to 

substantiate an allegation. Dr. Wesley stated that when he is looking whether to substantiate an 

allegation, he looks for "solid evidence." Of course, "solid evidence"-like Dr. Daigh's use of 

the term "hard evidence"-is a subjective and means different things to different people. Dr. 

Wesley stated: 

Q: Dr. Wesley, just a couple questions. One thing we've been trying to 

get a little bit more information on is the standard that the IG's office 

uses for substantiating allegations. We've interviewed Dr. Mallinger 

and other folks at the IG's office, and we've heard, you know, it's a 

high standard; we've heard a number of different things. I'm just 

wondering, from your perspective, is there a set standard at the IG's 

office for substantiating allegations? Or from your perspective, what is 

the standard? 

A: Sure. First of all, it's not a court, so we don't think in terms of beyond 

a reasonable doubt or even 51 percent in preponderance of the 

evidence. 

Having said that, when I ask my staff to do these, I think-! do think 

in terms of is there solid evidence that substantiates something-! look 

for solid evidence. I don't think there's a scale like in a court case, but 

if there's solid evidence that affinns or proves an allegation, that's the 

standard I use. 

Q: From your knowledge, is that standard in writing anywhere? We've 

also heard mixed things. Is that in the handbook? Is that clearly 

communicated to the doctors? For example, did Dr. Mallinger know in 

this case what the standard was for substantiating allegations? That's 

two questions. Sorry. 

A: Did Dr. Mallinger know? I don't know. It's-it's communicated more 

by, again, is there solid evidence, and that's certainly made clear to-! 

certainly make that clear to all of my physicians and all of the regional 

offices. Because I've done this so long, I teach this. I've trained a 

couple generations on how to do these hotlines. I would say the 

standard is find-lay out all the evidence, but, A, is there solid 

1131 Daigh Transcribed Interview) at 96~1 01. 

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evidence? I suppose if there's a battle between evidence, I would go 

towards preponderance of the evidence. 

In general-well, I'll tell you, in practical, real terms, you tend to 

either find evidence that says yea or find evidence that refutes the 

allegation. That's how it works in practical terms. It ends up being 

fairly black and white once you're out in the field and once you do 

these cases. 

Q: Is this in writing anywhere, what you just kind of laid out, within the 

officeA: There may be some better descriptions in writing. I don't have them at 

my fingertips. 

Q: Okay. Do you have any-if it's not in writing, would there be any 

objection to having kind of a formal policy that talks about standards 

of evidence in writing at theA: Not at all, and as I say, there may well be. If there arc, I'm just notI'm not as conversant as !-I'm not conversant in it. 1132 

Likewise, Chairman Johnson's staff questioned Dr. Mallinger about the VA OIG's 

standards for substantiating allegations. Dr. Mallinger was new to the Office of Healthcare 

Inspections when he was assigned the Tomah VAMC inspection. Prior to joining the VA OIG, 

he had spent years in academia, conducting research to further his scholarship in psychiatry. Dr. 

Mallinger spoke to about the differences in conducting scientific research versus substantiating 

allegations at the VA OIG. He explained: 

As far as, you know, what I learned, well, you know, what we do in health care 

inspections is very different from the way things are done in the world of 

medicine and science, if you will. And there's some actually very fundamental 

differences. 

For example, as a scientist-and I spent quite a bit of my career doing this-when 

we do research and we talk about our results, we talk about them in terms of 95 

percent certainty, and we do statistical analyses that sort of establish that. So any 

given piece of scientific research that you see, even if you read about it in the New 

York Times, there's really a one out of20 chance that it's totally wrong. And in 

science, the way that's dealt with is through a process that we call replication; that 

is-and this is one of the problems. You know, like the health-you read the 

1132 Wesley Transcribed Interview, at 204-06. 

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newspaper, and you find out, you know, what's going on in health care, and it 

changes every-well, this is why, because you do one study and it's 95 percent 

certain. It requires what we call replication. It requires another group to do a 

similar study and to come up with comparable findings. And then you can start to 

believe things basically as being true. 

So that's kind of one way of collecting data and analyzing data. It's very different 

in the !G. It's-you know, we approach things much more the way attorneys 

would approach them. You know, we gather evidence. We use the evidence to 

establish facts, and we basically apply reasoning to those facts and draw 

conclusions. So it's a totally different process, and that was a process that I had 

learned it had existed and then learned how to do it. 

So another way that's very different is, you know, like in science, you know, 

we feel pretty good if we are 95 percent certain that something is right. We'll 

go to a meeting and talk about it and present it and be very enthusiastic. And 

in the IG, it's very different. You know, we're held to a much higher 

standard of evidence. So, you know, that evidence and those facts and that 

reasoning all have to be very airtight and have to-you know, I don't know that 

there's such a thing as 100 percent certainty, but they have to be as certain as it's 

possible to be, because nobody's going to replicate our work. It has to be right the 

first time, so the standard of evidence is much higher. 1133 

Because Dr. Mallinger explained that within the VA OIG, health care inspectors needed a 

"much higher" standard of evidence than the 95 percent certainty in the scientific and academic 

worlds, Chairman Johnson's staff asked what metrics the VA OIG uses to substantiate an 

allegation. In response, Dr. Mallinger also spoke about challenges he faced when he first joined 

the VA OIG in properly assessing the office's standards for substantiating allegations. He stated: 

Q: You got into this a little bit earlier. Can you quantify what percentage 

of certainty you would need to substantiate an allegation? So you 

said-you talked about having an academic role in science, you know, 

your findings and your research is done within a 95 percent chance 

of-you know, percent chance of certainty. What percentage threshold 

do you have to cross to substantiate an allegation? 

A: Well, so here's the thing: When I say 95 percent certainty, I can say 

that with certainty because the appropriate statistical analyses have 

been done, and, you know, by agreement of people who've developed 

these mathematical models, we can say that we-we basically 

establish that ourselves. We test the data in such a way that we only 

1133 Mallinger 31812016 Transcribed Interview, at 14-16 (emphasis added). 

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draw a conclusion if it might be wrong one out of 20 times. So I can 

say that exactlyQ: A quick clarifying question. So 95 percent certainty is sort of a best 

practices developed within scientific and academia world asA: That's the standard in the scientific world. 

Q: -as acceptable-okay. Sorry. Continue. Thank you for that 

clarification. 

A: Sure. Not to say you wouldn't like to have it better, and sometimes it is 

better. But, generally, if it's below 95 percent, it's hard to make the 

argument. We don't have-! can't tell you that. You know, I don't 

have a statistical test that tells me how certain I am of the information 

to the !G. I can just tell you that it's-you know, we have to be as sure 

as you can be. 

Q: So as a senior physician within the Office of Health care Inspections, 

when you're doing the inspection, you're the one that's substantiating 

or not substantiating the allegations. Correct? 

A: Well, not the one. This is a process of the group working together with 

a lot of supervision. 

Q: So what standards do you implement then to determine whether or not 

an allegation is substantiated or not? 

A: Well, I have to feel that the facts that have been established 

conclusively show that the allegation is true. 

Q: Are we talking more likely than not? 

A: No. We are talking a much higher standard than that. 

Q: Okay. And would you be able to put a number on it to quantify a 

percentage? 

A: I don't know how I would. Like where would the number come from? 

I would have to make it up. 

Q: Well, right. I'm just trying to figure out what sort of threshold, you 

know, you as a person that does this established for yourself to 

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determine where you feel comfortable substantiating an allegation 

orA: Well, it's kind of like-it doesn't really work like that. You know, 

it's-you know, these are things that we discuss versus a team, and 

then depending on the case, with the various levels of supervision, and 

so, you know, through a process of-in other words, if I think 

something is either substantiated or not substantiated, I have to present 

it to-again, depending on the case, it could be to Dr. Wesley. It could 

be at the staff meeting to Dr. Daigh. It could be to Dr. Shepherd. And 

we have to discuss it. And then, you know, ultimately, when we had an 

IG, that person had to approve it, too. It's-it's-! guess you could say 

it's a process of consensus more so than being able to apply-you 

can't calculate a number like you could with a statistical model. 

Q: Is there any guidance from a central office within the IG on sort of 

establishing those best practices to substantiate allegations? Or is it 

more done on a case-by-case, allegation-by-allegation basis? 

A: I think it's case-by-case. And I have to tell you, when I started in the 

IG, I was more inclined to kind of believe things were established and 

had to learn how high the standard of evidence was. That was part of 

the learning process. It's a very high standard of evidence that's 

applied in the !G. 

Q: What do you mean by learning-you believeA: Through the process of consensus to presenting it to my bosses and 

having them say, "Well, are you sure?" You know, "Why are you 

sure?" 

Q: I was more referring to-you said you were more likely to believe that 

things were established. I'm paraphrasing here. Can you kind of 

elaborate on what you mean by that? 

A: I guess what I would say is, again, this is-my personal inclination 

might have been to accept a lower standard of evidence. 

Q: Understood. 

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A: But as !-through this process of learning how to do my job, I came to 

understand what a high standard of evidence is. 1134 

As these excerpts demonstrate, the standard for substantiation within the VA OIG Office 

of Health care Inspection is very unclear. Three separate employees of VA OIG-at three 

separate levels-were unable to clearly articulate what standards the office uses to substantiate 

an allegation. The differing standards, depending on the inspector, range from a mere 

preponderance of evidence supporting the allegation to a standard upward of 95 percent 

certainty. This lack of clarity allows for the apparent arbitrary application of subjective 

standards that can be molded depending on the inspection. As a result, complainants can 

potentially receive unequal analysis of their complaints when they refer matters to the VA OIG. 

ii. The findings of the VA OIG's health care inspection into the death of Thomas Boer 

The VA OIG's selective and arbitrary substantiation of allegations is also illustrated in its 

health care inspection into the care that veteran Thomas Baer received at the Tomah V AMC in 

January 2015. In January 2015, Candace Delis contacted Chairman Johnson's staff regarding the 

treatment of her father, Thomas Baer, at the Tomah V AMC on January 12, 2015. Ms. Delis 

informed Chairman Johnson's staff that she brought her father to the Tomah VAMC urgent care 

facility on Jannary 12, 2015. The family waited over two hours to be seen by a physician and 

during that time, Mr. Baer suffered a stroke in the Tomah VAMC urgent care center. After the 

first stroke, Mr. Baer underwent an electrocardiogram and a chest x-ray, but the facility's CT 

scan machine was unavailable because it was undergoing "routine, preventative 

maintenance."1135 Soon after, Mr. Baer suffered a massive stroke. 

Tomah VAMC staff informed Ms. Delis that the hospital lacked the necessary equipment 

to properly treat Mr. Baer and that he would be transported to another hospital. There was no 

helicopter available to transport Mr. Baer and he was transported roughly 45 minutes via 

ambulance to Gnndersen Lutheran Medical Center in La Crosse, Wisconsin. 1136 At Gundersen, 

Mr. Baer nnderwent emergency surgery to remove a blood clot in his artery. 1137 Mr. Baer never 

regained conscionsness and he passed away on January 14, 2015. 1138 

1134 /d. at 17-21. 1135 Letter from Dr. Carolyn M. Clancy, Interim Under Secretary for Health, Dep't of Veterans Affairs, to Hon. Ron 

Johnson, Chainnan, S. Comm. on Homeland Sec. & Governmental Affairs, at 3 (Mar. 9, 20!5) [hereinafter 3/9/2015 

Letter from Dr. Clancy, VA, to Chairman Johnson, HSOAC]. 1136 VA 0!0, Office of Health care Inspections, Report No. 15-02456-396, Health care Inspection: Care of an Urgent 

Care Clinic Patient Tomah V AMC, at 15 (20 15) [hereinafter VA 010 Report: Thomas Bacr]. 1137 Tomah VAMC: Examining Quality, Access, and Culture of Overreliance on High-Risk Medications, Joint Field 

Hearing Before S. Comm. on Homeland Sec. & Governmental Affairs & H Comm. on Veterans Affairs !14th Con g. 

(20 15) (statement of Candace Delis, daughter of Thomas Baer, at 2). 1138 Obituary: Thomas P. Boer, LEGACY.COM, 

http://www .1 egacy .com/obituaries/marsh fie ldnewsherald/ obituary .as px ?pid= 1 73 93 6994. 

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Pursuant to a request by Chairman Johnson and Senator Baldwin, the VA OIG conducted 

a health care inspection of Mr. Baer's treatment at the Tomah VAMC. 1139 The VA OIG's 

inspection largely cleared the medical center of any wrongdoing. 1140 However, the VA OIG 

separated out the allegations in a manner that allowed it to take a selective and literal 

interpretation of the allegations. 

For example, the VA OIG's review of Mr. Baer's care did not substantiate the allegation 

that Mr. Baer "waited 3 hours to be seen." 1 141 The report noted that Mr. Baer was not seen by a 

doctor for a considerable period of time-approximately 2 hours and 16 minutes after he was 

checked in to the urgent care clinic. 1 142 However, because this otherwise lengthy period fell46 

minutes short of the precise 3-hour period alleged by Mr. Baer's family, the VA OIG did not 

substantiate the allegation. 1143 

Likewise, the VA OIG did not substantiate the Baer family's allegation that the CT 

scanner at the Tomah VAMC was "broken" on January 12, 2015I 144 The VA OIG found, 

instead, that the CT scanner was "unavailable for use due to routine maintenance at the 

time .... " 1 145 The VA OIG, again, in taking an overly literal interpretation of the allegations, 

discounted criticism about the facility. Whether the CT scan machine was "broken" or 

"unavailable ... due to routine maintenance," tbe tool was not operational when Mr. Baer 

needed it. 

In addition, the OIG separated out Ms. Delis and her mother's account of how the Tomah 

VAMC staff reacted to Mr. Baer's first stroke into three separate allegations. In breaking out the 

allegation in this manner, the VA OIG ultimately concluded "that, overall, the [urgent care 

center J staff acted appropriately in the face of a patient experiencing a sudden and unexpected 

acute ischemic stroke while waiting for a mental health evaluation in a rural hospital that is not 

equipped to treat a health problem of this magnitude." 1146 

The Baer family filed an administrative claim against the VA for the care Mr. Baer 

received at the Tomah V AMC. As part of their claim, the family hired Dr. Lisa Nee, an 

interventional cardiologist, to provide an expert evaluation of Mr. Baer's care at the Tomah 

V AM C. Dr. Nee has "extensive experience and training in the diagnosis, treatment and 

intervention of cerebral vascular disease including acute ischemic stroke." 1 147 Dr. Nee identified 

significant concerns with both Mr. Baer's treatment at the Tomah V AMC and with the VA 

1139 VA OIG Report: Thomas Baer, at i. !140 !d. 

'"'/d. at 16. !142ld 

1143 /d. 

1144 /d. at 18. !145 ld. 

1146 I d. at 25. 1141 Lisa Nee, Krause Law, PLLC, Report on Thomas Baer Stroke, Expert Opinion, at 1 (Oct. 30, 2015) [hereinafter 

Nee Expert Opinion]. 

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OlG's evaluation of Mr. Baer's treatment at the Tomah VAMC urgent care center. The findings 

of Dr. Nee call into question the VA OIG's standards for substantiating allegations. 

Dr. Nee's analysis raises serious concerns with how the Tomah VAMC's initial triage of 

Mr. Baer may have contributed to his fatal outcome. As the VA OIG report and Dr. Nee's 

analysis note, the Baer family called the Tomah VAMC at approximately 9:00a.m. on January 

12, 2015. 1148 A member of the Baer family allegedly informed the nurse at the Tomah V AMC 

that Mr. Baer "generally was not feeling or sleeping well, had balance problems, shortness of 

breath, and disorientation."1149 The nurse, however, told the VA OIG that she "had no 

recollection of being told of respiratory distress, and stated that had she been so informed, she 

would not have directed the family to take the patient to Tomah VAMC."1150 The note in Mr. 

Baer's medical files that document the 9:20a.m. phone call apparently made no mention of Mr. 

Baer's respiratory distress or balance problems. 1151 

This factual dispute is vital in determining the potential culpability of the Tomah VAMC 

in Mr. Baer's care. It appears that the VA OIG, for unknown reasons, credited the account of the 

nurse and the medical record over the statements of the Baer family. If the Baer family did 

inform the Tomah VAMC nurse on the phone of Mr. Baer's difficulty breathing and balance 

issues, Dr. Nee noted that the nurse would have violated the Tomah VAMC policy of referring 

patients with "acute illness and difficulty breathing" to the nearest emergency department. 1152 

Both the VA OIG and Dr. Nee noted that in the approximately 90-minute drive from the 

Baer family home to the Tomah VAMC, Mr. Baer's condition deteriorated. 1153 When the family 

arrived at the facility, Mr. Baer required a wheelchair to get into the urgent care clinic. 1154 Both 

the VA OIG and Dr. Nee noted that the Bacr family informed the "clerical employee" at check in 

that Mr. Baer was presenting the symptoms of"generally not feeling well, balance problems, 

shortness of breath, disorientation, and insomnia."1155 Dr. Nee's opinion states that "this acute 

change in neurologic status should have signaled to medical staff that the patient required 

immediate assessment and emergent physician evaluation. This event is in all likelihood Time 

Zero for symptom onset of Acute Ischemic Stroke (AIS)." 1156 

::::VA OlG Report: Thomas Baer, at II; Nee Expert Opinion, at 5. 

VA OIG Report: Thomas Baer, at II. !150/d. 

l\5\Jd. 

1152 Nee Expert Opinion, at 5. 1153 VA OIG Report: Thomas Baer, at II; Nee Expert Opinion, at 6. 1154 Nee Expert Opinion, at 6. 1155 VA OIG Report: Thomas Baer, at II 1156 Nee Expert Opinion, at 6. "Time Zero" refers to the last known time where the patient's neurological status was 

normal. Step 2: ACLS Stroke Protocol, ACLS-ALGOR1Tl!MS.COM, https://acls-algori!hms.com/adult-strokealgorithm/acls-stroke-protocol-step-2/. 

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Dr. Nee wrote that after Mr. Baer arrived at the Tomah VAMC urgent care clinic, he 

"waited 60 minutes for triage." 1157 She added that "there is no documentation from Tomah 

VAMC records that any neurologic assessment was conducted at this time."1158 

According to Dr. Nee, the Tomah V AMC's failure to initially determine the neurological 

issues with Mr. Baer created a domino effect in which subsequent ineffective triage and 

treatment methods delayed the treatment of Mr. Baer's stroke-like symptoms1159 Dr. Nee wrote 

that "the combination of improper triage and lack of recognition of urgent clinical 

symptomatology resulted in delay of care for this patient displaying symptoms concerning for 

AIS." 1160 Dr. Nee explained: 

The OIG Report states the patient checked in at the UCC front desk at II :09 AM 

with symptoms of weakness (requiring a wheelchair) shortness of breath and new 

onset disorientation. Each of these symptoms requires further investigation; 

collectively they are a red flag for an acute neurological event. There is no further 

investigation into these symptoms by either a medical nurse or physician and no 

neurologic exam is noted in the record. Due to the fact the patient had neurologic 

deviations from his baseline upon presentation to the UCC, Time Zero (TO) for 

the subsequent AIS [major stroke] will be detennined to be 11:09 AM for the 

remainder of this report. Nothing in the record indicates Tomah V AMC 

attempted to ascertain "Time Zero" at any point. Some VAMC facilities 

utilize tools like the Cincinnati Prehospital Stroke Scale (CPSS) when a patient 

arrives with similar symptoms as Mr. Baer's. Failing to ascertain Time Zero is a 

deviation from the standard of care and puts any patient at unnecessary risk of 

permanent injury or death from stroke 

Because there was improper triage and failure to diagnose a possible acute 

neurologic event, the patient was assigned Emergency Severity Index 4 (ESI 

Level4). His vital signs were documented at 12:11 PM and never repeated until 

3:15 PM, however they were copied and pasted into multiple notes, which is a 

violation ofVHA documentation policy. It also violates the Tomah VAMC 

Memorandum which states ESI Level 4 patients should have monitoring and 

documentation hourly by an RN. Vitals were not taken every hour as required. 

Given the symptoms indicated in the EHR [electronic health record] by 12:11 

PM, the patient should have received an ESl Level 2, which would have 

accelerated the speed of his case and resources available to him. 1161 

1157 Nce Expert Opinion, at 6. ttsa Id. 

1159 See id. at 6-7. 1160 Id. at ll. 

116lld. 

r~~ 

\~7 l__~) 

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Dr. Nee also noted concerns with the Tomah VAMC's scheduled maintenance of the 

facility's only CT scanner during Mr. Baer's time in the urgent care clinic. She explained that 

"maintenance records show that at I :30 PM, Tomah VAMC contractors started their preventative 

maintenance on the CT machine, originally scheduled for January 2, 2015." 1162 Mr. Baer 

suffered his first episode, the "mini" or "warning" stroke, five minutes before maintenance began 

on the CT machine. 1163 As she noted, a correct diagnosis of Mr. Baer's mini stroke "likely 

would have resulted in Mr. Baer bein? rushed to get a stat CT scan before the machine was shut 

down for scheduled maintenance." 116 

Dr. Nee's expert opinion provides valuable insight on whether Mr. Baer's treatment at 

the Tomah V AMC on January 12, 2015 met the standard of care. Her perspective as a medical 

professional with experience in treating stroke and other related ailments levies concerns with 

the VA OIG's medical conclusions in its review of Mr. Baer's care. The VA OIG's review of 

Mr. Baer's care shows how the OIG applied an overly literal reading of allegations to 

unsubstantiate claims relating to a deficient standard of care. 

2. The VA OIG selectively focused its inspection and seemed to ignore other potential 

problems found during the course of the inspection 

The VA OIG narrowly and selectively focused on the allegations it received, sometimes 

to the exclusion of other issues it uncovered during the course of the inspection. It appears that 

the VA OIG did not pursue issues it uncovered during the course of the inspection unless the 

issue was directly on point with the precise language of an allegation it received in the hotline. 

Leads were not followed up on, and opportunities for improvement were missed. 

i. The VA OIG appears to not have fully examined allegations of potential drug use by 

Tomah VAMC medical providers 

During its site visit to the Tomah VAMC, VA OIG officials interviewed both Dr. 

Houlihan and Deborah Frasher. During the interviews, both OIG physicians and Special Agent 

Porter of the VA OIG's criminal division observed that Dr. Houlihan and Ms. Frasher appeared 

to be impaired. Documents show that the VA OIG health care inspectors noted their concerns to 

their superiors and the Counselor to the Inspector General Maureen Regan. They also informed 

the facility director, Mario DeSanctis, of their concerns. Despite these observations, the VA OIG 

failed to follow up with Tomah VAMC management about their concerns, and the eleven-page 

administrative closure made no reference to the observations that Dr. Houlihan and Ms. Frasher 

were impaired at the time of their interviews with the VA OIG. 

Jl62Jd.at6. 

1163 !d. 

1164 !d. at 6-7. 

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As a part of Chairman Johnson's requests for documents, the Committee received a 

handwritten note penned by Dr. Mallinger and dated September 10, 2012. The note read: 

At the conclusion of the interview with Mr. DeSanctis, the recorder was turned 

off, and we unofficially informed him of our observation at the site visit that Dr. 

Houlihan had apparently constricted pupils and peripheral vasoconstriction 

(agreed by AGM and MG) and [Redacted] had apparent sedation with small 

slurring of speech and intermittent eye closings (agreed by AGM, MG, and GP). 

We suggested he may want to order some drug tests of the staff. 1165 

1165 Handwritten Note from Alan Mallinger (Sept. I 0, 20 12), at OIG 12364. 

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Figun• 89: Dr. MallingE'r's handwl'iHE'n notE' about potE>ntial impah·mE'Dt o£Dr. Houlihan ~md :\ts. 

FrashE>r 11 t.6 --------------

During the Committee's interview with Special Agent P01ter, Maureen Regan, Counselor 

to the VA Inspector General, confmned to Chairman Johnson's staff that the redacted individual 

in Dr. Mallinger's handwritten note was Nurse Practitioner, Deborah Frasher. 1167 

Chainnan Johnson's staff asked both Special Agent Porter and Dr. Mallinger about their 

observations of Dr. Houlihan and Ms_ Frasher. In their interviews. both Special Agent P01ier 

"" fd_ 1167 Porter Transcribed Interview. at 112. 

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and Dr. Malinger downplayed the seriousness of their observations of Dr. Houlihan and Ms. 

Frasher. For example, Special Agent Porter stated: 

Q: Do you recall having these discussions about the-the signs that-that 

Dr. Houlihan and Deb Frasher appeared to be under the influence of 

some sort of drugs? 

A: Yes, I do recall that. 

Q: Can you elaborate on-on what those discussions were? 

A: Sure. It-! don't know who brought it up, if it was Dr. Mallinger or 

Dr. Gottlieb. One of the two suggested that they thought one or both 

may be under the influence-currently under the influence of drugs or 

alcohol. I don't know specifically which they said. I remember 

saying-concurring that maybe, you know, it was, who knows, maybe 

it was a possibility. Having said that, nothing during the course of their 

interviews stood out to me, and I've been a police officer and given 

DU!s and-and have extensive training in-in recognizing signs and 

symptoms of drug and alcohol usage, and that did not occur to me 

during the interview at all. 

Q: Did-did you share this information with the DEA or local law 

enforcement, that, you know, Dr. Mallinger and other medical 

professionals made these observations? 

A: No. 

Q: Did you act in any other way on this information at all? 

A: No.'l6& 

Later in his transcribed interview, Special Agent Porter stated that he could not recall why 

he concurred with Dr. Mallinger's observation with respect to Ms. Frasher. He stated: 

Q: So do you recall having a discussion about the appearance that Dr. 

Houlihan and Deb Frasher wereA: I recall having a-a brief discussion with Doctors Mallinger and 

Gottlieb about-and, again, I don't remember which posed the issue, 

but, you know, saying that they thought one or both of them, I don't 

1168 ld. at 112-13. 

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remember, were under the influence of something, and l-1 seem to 

remember saying, "Well, you know, it's possible." I don't know. I 

didn't-but-but as I sit here today, I don't recall their interviews and 

thinking anything along those lines at all. 

Q: Right. This, Dr. Mallinger's note on [the handwritten note], notes that 

apparent sedation with slurring of speech and intermittent eye-closing, 

agreed by Alan Mallinger and Monika Gottlieb and Greg Porter. 

VAOIG 

Attorney: That was Deb Frasher's interview, the second one. In other words, 

when you look at the initials, the first one was Dr. Houlihan's, and that 

appears to be Monika Gottlieb and Alan Mallinger. Correct? 

Q: Yes. 

VAOIG 

Attorney: And then the second one is Deb Frasher, and that's where you have 

Mr. Porter's initials. 

Q: Understood. 

VAOIG 

Attorney: Okay. 

Q: So you don't remember anything from your interview of Deb Frasher 

that would be an indicia that she may have been under the influence of 

drugs. 

A: I do not. 

Q: Okay. Did you report this to anybody up the chain in the Criminal 

Division? 

A: No. 

Q: And you said earlier that you didn't report this to the DEA. Did you 

report this to local law enforcement? 

A: No.1169 

1169 /d. at 116-17. 

!'"--, 

\~)1 ~··-·~j 

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During his transcribed interview with Chairman Johnson's staff, Dr. Mallinger explained 

why he wrote the note. With respect to Dr. Houlihan, he explained: 

So during the interview, Dr. Gottlieb and I made some observations with Dr. 

Houlihan regarding his physiological appearance, if you will. We felt that his 

pupils were quite small, and we had what I wrote in the note here as peripheral 

vasoconstriction. What that basically means is that, you know, when you shook 

hands with him, his hands were very cold, and his skin was very white. 

So we, because of all the, you know, stuff going on there, we did not want to 

leave those observations unattended to, if you will. 1170 

Chairman Johnson's staff further inquired about what Dr. Mallinger and Dr. Gottlieb's 

observations meant. Dr. Mallinger stated: 

Q: Are Dr. Houlihan's symptoms indicative of illicit drug use? 

A: Well, it's really impossible to know. You know, first of all, you could 

have those kinds of physiological signs from what's called 

sympathetic nervous system stimulation, adrenaline in your system, if 

he was very nervous about the interview, or if he were in some other 

ways having the kind of flight-or-fight response. Those are signs that 

could-the peripheral vasoconstriction particularly could be a sign of 

that. It could be a sign of taking other things, allergy medicine or other 

kinds of medications that, you know, might have been taken for some, 

you know, appropriate medical purpose, the same with the nurse 

practitioner. Or it could have been illicit drug use. We had no way to 

know that. 

Q: Did you think it was more likely than not it was illicit drug use? 

A: No. We were simply in the frame of mind of pursuing every lead, if 

you will, and leaving no stone unturned. And we had some 

observations. We felt they should be followed up on. And, you know, 

the-you know, we discussed with Dr. Wesley what to do about it, and 

he recommended contacting the hospital director, and the hospital 

director could, you know-you know, we can't do drug tests on 

people, but the hospital director could. 

Q: Did he? 

" 70 Mallinger 4/6/2016 Transcribed Interview, at 308. 

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A: I don't know. 

Q: So you wrote this note down detailing these symptoms. Were you 

concerned that Dr. Houlihan was using illicit drugs? 

A: I was concerned about the possibility, and, you know, because of that, 

you know, that's-that was what we decided, the way we decided to 

handle it.ll7 1 

Dr. Mallinger explained that his observations of Ms. Frasher's appearance were more 

concrete. He stated: 

So in her ease-l think in her case it was actually much more obvious that she 

was-she appeared to be sedated, that she was practically falling asleep during 

the interview in that, you know, her eyes were closing, seemingly she had trouble 

controlling that, that her speech was slightly slurred. Mr. Porter agreed with us on 

that one. He didn't feel comfortable talking about the other signs just because 

that's not consistent with his training, but because of his police training, he felt 

that he could comment on sedation. It's kind of like sobriety, you know, and he 

agreed with us about the findings about the nurse practitioner. 1172 

After recording their observations of Dr. Houlihan and Ms. Frasher during the Tomah 

V AMC site visit, Dr. Mallinger and his colleagues took two courses of action. First, on August 

31, 2012, Dr. Gottlieb emailed Maureen Regan, Counselor to the Inspector General, requesting a 

meetinf to "discuss a concern regarding possible impaired interviewee(s) during a recent site 

visit." 1 73 The VA OIG did not provide Ms. Regan's response to this request. 

1171 Jd. at309-IO. 1172 I d. at 308-09. 

" 73 E-mail from Monika Gottlieb, VA OIG, to Maureen Regan, VA OIG (Aug. 31, 2012, 1:07PM), at OIG 11671. 

,..~...,, 

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\.,__, ,,_.\ 

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Figure 90: Email from Dr. Gottlit"b to Maure-en Regan 1·equestiug to meet about poss.ible impaired 

iuh.•rviewet""i 117 ~ ,-------~-------·--·--···-·----·· 

I Malling~r. Alan (OJG) 

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W? woJld like tc: mE"et wd' you to discuo;s a conc€'rn regardingpo;sibiE" ;mpaired intef"J•e\.\f:'e{s.) during_-. recent ;.it€ v1~it. 

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•l lk;JI'.hra:l.' 11 ,r~·-.·lt,•:1· 

lli'I-'C<:i('l \,cn~; .. J 

Second, the Tomah VAMC health care inspection team infonned their supervisor, Dr. 

\Vesley. of their observationsll 75 Dr. Wesley advised the team to document the observation and 

infonu the Tomah VAMC facility director, Mario DeSanctis1176 VA OIG health care inspectors 

spoke with Mr. DeSanctis on two occasions---on June 19.2012 and again on September 10. 

20121177 At the conclusion of the September 10.2012, interview, the health care inspection team 

informed Mr. DeSanctis of their observations from the August site visit and Dr. Mallinger 

drafted the hand-written note sunrmarizing their observations1178 

The VA OIG conducted no additional follow-up beyond infonning Mr. DeSanctis of the 

observations. The VA OIG also did not inform VlSN 12 personnel of the observations. When 

asked by Chainuan Johnson's staff why the VA OIG did not take additional action, Dr. Wesley 

explained: 

There are about 20 different medicines that cause constricted pupils. So it wasn't 

for us to detennine why Dr. Houlihan had constricted pupils. It wasn't for us to 

determine why the other individual may have been drows,r Maybe he or she was 

up all night. That was for Mr. DeSanctis to figure out. 117 

When asked why the VA OIG did not inform VISN 12 officials of the observations, Dr. Wesley 

replied, "that's a fundamental responsibility of a medical center Director. They're an SES bead 

1174 Jd. 

1175 Mallinger 4/6/2016 Tran!;cribed Inten·iew. at 312-13. 1176 Wesley Transcribed Inten·ie\V, at 197-98. 1177 6119/2012 VA OIG lnten·iew of DeSanctis. OIG 6075: 9i!0/2012 VA OIG lnten·iew of DeSanctis, OIG 6084. 

'"'Handwritten Note from Alan Mallinger (Sept. 10, 2012), at 0!0 12364. 1179 Wesley T ran~cribe:d InterYiew. at :!00-0 L 

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of a major installation. If they can't handle something like that, then they shouldn't be a 

Director." 118D 

Dr. Wesley also stated that because the health care inspection team's observations were 

not part of the hotline, the allegations were not part of the VA OIG' s review. He explained: 

This was not the hotline. The hotline wasn't about Dr. Houlihan's pupils or 

whether the other individual was falling asleep. The hotline was about Dr. 

Houlihan's prescription practices and the culture of fear, and so on and so forth. 

So when I have a team going on site and they observe this, though, I can't let it 

go, nothing happens about it, so share it with the Director or share it up the chain, 

but it's not really-at least the way I analyze it, it wasn't part of the essential 

hotline. It was-if this-if these were impaired individuals, that's a different 

issue. I ISI 

Dr. Wesley is correct that potential drug use by Tomah V AMC personnel was not part of the 

"essential hotline" review. 1182 

The VA OIG criminal investigations division, however, did receive allegations that Ms. 

Frasher was under the influence of drugs while at work at the Tomah VAMC. On March 28, 

2012, Special Agent Greg Porter, two DEA Investigators from Milwaukee, and a detective from 

the Tomah Police Department interviewed an "anonymous Tomah VAMC employee" at the 

Tomah Police Department for approximately one hour and fifteen minutes. 1183 Special Agent 

Porter outlined the details of this interview in a Memorandum of Interview that was produced to 

the Committee pursuant to Chairman Johnson's subpoena1 184 

The anonymous Tomah VAMC employee, referred to as "A.S." in the document is a 

"full-time employee at the Tomah V AMC having regular and familiar contact with Dr. David 

Houlihan and [redacted]." 1185 The employee infonned law-enforcement officials that it was 

"widely believed, through word of mouth at the Tomah VAMC, that veterans who need certain 

prescribed opiates and/or other pain killers go directly to Houlihan or [redacted], who typically 

prescribe medications freely and without many questions." 1186 In a transcribed interview, 

Special Agent Porter initially claimed he did not know the identity of the redacted individual 

referenced in the Memorandum of Interview. However, after VA OIG counsel told him that he 

could disclose the identity, Special Agent Porter confirmed that the redacted individual referred 

to was Deborah Frasher: 

1180 I d. at 201. 1181 /d. at 198-99. 1182 Jd. 

1183 VA 010 Criminal Investigations Div., Greg Porter, Memorandum of Interview of Tomah YAMC Employee 

(Mar. 28, 2012), OJG 10592, at 010 !0592-93. 11 " !d. at 010 10592-93. 

"" ld. at 010 10592. 1186 Id. 

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Q: So, this Tomah employee, you interviewed-you, two DEA 

investigators. This individual says some pretty serious things, you 

know, that they-just recounting the document here, you know, 

veterans who need to be prescribed certain opiates and/or painkillers 

go directly to Houlihan or redacted. To your knowledge, is the 

redacted individual Deborah Frasher? 

A: I don't know. 

Q: Well, were you investigating the prescribing practices of Deb Frasher? 

A: No, I was not. 

VAOIG 

Attorney: You can go ahead and say who--go ahead. 

A: Okay. Yes. Yes, Deborah Frasher. 1187 

Special Agent Porter's Memorandum of Interview continued to noted that "A.S." 

informed law-enforcement personnel, "[redacted] is often 'stoned' while at work, meaning 

[redacted] is incoherent, and many believe [redacted] may have dependency issues involving 

alcohol and/ or pain killers." 1188 Chairman Johnson's staff asked whether the redacted "stoned" 

individual Special Agent Porter mentioned in the Memorandum of Interview was Deborah 

Frasher. He confirmed that it was, stating: 

Q: So, Tomah veterans here are saying that they go to Houlihan and 

Frasher-or Frasher, who prescribed medications freely and without 

questions, if they want to seek drugs. 

The third bullet down, "redacted" is often stoned while at work, 

meaning blank is incoherent and many believe that "redacted" may 

have dependency issues involving alcohol and/or painkillers. Do you 

recall who that individual is? 

A: Yes. 

Q: Who is that individual? 

1 187 Porter Transcribed Interview, at 18-19. 1188 VA OIG Criminal Investigations Div., Greg Porter, Memorandum of Interview of Tomah V AMC Employee 

(Mar. 28, 2012), at OIG 10592. 

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A: Deb Frasher. 1189 

Special Agent Porter's report also noted that "several employees, to include pharmacists, 

have raised issues about Houlihan and [Frasher] over-prescribing painkillers for veterans." 1190 

He wrote that "Houlihan has been known to openly 'brag' about the fact that OIG 'Can't touch 

him' and that the VA Police cannot contact OIG without his permission." 1191 

1189 Porter Transcribed Interview, at 19. 1190 VA OJG Criminal Investigations Div., Greg Porter, Memorandum of Interview of Tomah V AMC Employee 

(Mar. 28, 20 12), at OJG 10592-93. 

""!d. at OJG 10593. 

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r

Fi!llr• 91_:_M•morondum of Int•n·i•w ol_,\_ll_":"Ymom T_<>_~h V A.t~C _J':_mplo~·•• 119'_ __ 

1111 

Ocpar·tment or Veterans .\flair• 

(Jflke of I n•pectur· General 

Criminallnvc•tigatinn• Division 

MEMORANDUM OF INTERVIEW · 

APPR: GAH 

CASE FILE: 2011-04212-DC-0252 

DATE; 03/28112 

TIME: 1645 Hrs 

PLACE: Tomah Pollee Department, 805 Supertor Ave, Tomah, WI 

INTERVIEWEE: Anonymous Tomah VAMC Employee 

INTERVIEW~~BiYi: •• S.AiGiiiiireilg Porter [VA OIG), Detective~h PD). 

lnvestlgator 1 1 (DEA- Milwaukee), and lnv~ (DEAMIIwaukee) 

WRITTEN BY: SA Greg Porter. 412512012 

on 03i28/2012. an employee or the Tomah VA Med~eal Cerlter (VAMC) was lnle"lewed 

at the Tomah Police Department The employee wished to rema1n an anonymous 

source. anti WJII hereafter be referred to as 'A.S.' 

and familiar contact 

summary, A.S 

Dr Houlihan was the acting VAMC Director anc:t Ch1et of Statt at the Tomah 

VAMC pnor to the recent appointment of Dwector Mano DeSancbs. 

It 1s widely believed through v.•orcl of mouth at the Tomah VAMC. that veterans 

who need certain prescnbed opoates and/or other pa1n Killers go directly to 

Houlihan or , who typiCally prescnoe medications freely and "''thou1 many 

qUOSt!OOS. 

is often ·stoned' While at worK meaning- 1s incoherent. and 

many believe- may haYe dependency 1ssues involving alCOhol and/or pain 

killers 

Several VAt.-1C employees to include pharmacists. have ralsod Issues about 

OFFICIAL USE 

1192 Jd at O!G 10592-93. 

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I 
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Figm•p 92; Mt>mo1·andum of Intt>nit>w of Anonymous Tomah V Al'-IC Employf:'(' (pag(' 2)1 193 

Houlihan a~ over-prescribing painkillers for veterans. often noting that 

the same veterans would receive several prescriptions tn a short amount of time. 

Many of the emplOyees who have complamed have been "forced-our or 

intimidated by Houlihan to the point that they resigned or transferred from the 

Tomah VAMC. 

Houlihan has been known to openly ''brag" about the fact that OIG ·can't touch 

htm" and that the VA Police cannot contact OIG without his permtssion 

Hou1111an has lost h1s license to practice medicine 1n the State or Iowa. 

A S. conCluded the tnterview by stat•ng Houlihan and- are at the root or drug 

diversion/ piH-selhng by veterans at the Tomah VAM~ey have created a culture 

of fear wrthin the Tomah VAMC, to which employees are afraid to step forward and/or 

speak thetr minds 

The Interview was terminated at approximately 1800 hrs. 

The VA OIG redacted iu its entirety the second bullet point on the first page of the 

docmnent. Chainnan Johnson's staff inquired about what Special Agent Pmter wrote on that 

redacted poltion of the Memorandum of Interview. Special Agent Pmter explained "there was 

an allegation that Dr.-one of the allegations was Dr. Houlihan was having an inappropriate 

relationship with a female veteran. That was-in addition. that veteran was also mmored to be 

one of the veterans who was heavily overprescribed." 119 ~ 

Based on this allegation, Special Agent Pmter subsequently smveilled the female veteran, 

subpoenaed a car dealership, and coordinated efforts with federal and local law-enforcement 

entities1195 While Special Agent Po1ter's investigation resulted in no written work product and 

was not mentioned anywhere in the administrative closure, his subsequent investigation reveals a 

deficiency with how the VA OIG health care inspection team addressed their observations that 

Dr. Houlihan and Deborah Frasher were potentially impail:ed. 

The different reactions of the two different components of the VA OIG involved with the 

Tomah VAMC are stark. \Vhereas the VA OIG criminal investigators engaged in surveillance 

and issued a subpoena after receiving an allegation of impairment in the workplace, the VA OIG 

health care inspectors did not pursue potential dru~ use by Dr. Houlihan and Deborah Frasher 

because it was not part of the "essential hotline," 1 6 and because those types of allegations were 

1193 !d. 1194 Potter Transcribed Inten·iew. at 22. 1195 Pan IILB. 29, supra. 

""Wesley TranSCJibed InterYiew. al 198-99. 

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the responsibility of the facility director. 1197 The Office ofHealthcare Inspections' narrow focus 

to only the allegations it received through the hotline impeded the flexibility of the inspection 

and led the team to ignore potentially dangerous issues, Even when the health care inspectors 

personally observed evidence that could have potentially corroborated evidence the VA OIG 

learned from an anonymous Tomah V AMC employee in March of 2012, the emphasis on the 

hotlinc allegations meant that the VA OIG did not address those concerns. 1198 

In their transcribed interviews with Chairman Johnson's staff, the VA OIG health care 

inspectors noted the potential patient safety concerns that come with the prospect of practitioners 

providing care under the influence of drugs. Dr. Mallinger stated: 

A: And this is why we notified Mr. DeSanctis, as a patient safety concern. 

And we trust that Mr. DeSanctis did, you know, something appropriate 

with that. But this was not-this was collateral to our inspection, but 

potentially involved patient safety and, therefore, we felt needed some 

sort of an immediate intervention, and this was the intervention that, in 

consultation with Dr. Wesley, we decided to make. 

Q: And did your team conduct any additional-or take any additional 

action besides alerting Director DeSanctis? 

A: No, we did not. 1199 

VA OIG officials confirmed that Dr. Houlihan and Ms. Frasher continued to see patients 

at the Tomah V AMC throughout the health care inspcction. 1200 In light of the potential patient 

safety concerns that accompany the possibility of an impaired medical provider, Chairman 

Johnson's staff asked whether the VA OIG considered trying to place Dr. Houlihan and Ms. 

Frasher on administrative leave while these allegations were investigated. Dr. Wesley stated: 

Q: Was there ever any consideration to place these individuals on leave or 

take away their ability to see patients while this inspection was 

ongoing? 

A: Yeah, I'd like to make two comments on that. One is that was the 

whole purpose of-the most important, that was the whole purpose of 

1197 I d. at 201. 119s Majority staff inquired wtth Dr. Mallinger whether their observations of Dr. Houlihan at the site visit were 

connected to the allegations that were levied against him by the Iowa Board of Medical Examiners in 200212003, 

considering he was accused of possessing patient medications in his home. Dr. Mallinger stated that he viewed the 

Iowa allegations as potential ''boundary" violations with a patient, and not a drug issue. Thus, in Dr. Mallinger's 

view, the observations at the site visit were unrelated to the 1owa allegations. See Mallinger 4/6/2016 Transcribed 

Interview, at 311-12. 1199 /d. at312-l3. 1200 Wesley Transcribed Interview, at 200. 

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telling the Director. That's the Director's decision. lfhe~ifthe 

Director has an impaired practitioner, he's got to decide what to do. 

We have no authority there whatsoever. And in telling Mr. DeSanctis, 

that problem was placed squarely at his feet. 1201 

Thus, the only action the VA OIG took in relation to its inspectors' observations at the 

site visit was to alert Director DeSanctis informally of the observations. The VA OIG conducted 

no additional follow-up with Director DeSanctis to determine whether he took any action with 

the VA OIG's referral, even though their observations potentially raised concerns about patient 

safety. It is unclear what Director DeSanctis did with the information he received from the VA 

OIG. 

ii. The VA 0/G's focus solely on opioids missed larger issues with prescriptions at the 

Tomah VAMC 

As the VA OIG explained in its administrative closure, the health care inspection team 

conducted both structured and general chart reviews of specific Tomah V AMC patients. 1202 

Through those chart reviews, .the VA OIG identified concerns with the lack of action in the face 

of negative urine drug screens at the facility. 1203 Through those chart reviews, the VA OIG also 

unsubstantiated the allegation that "opioid contracts are not being 'encouraged' by [Dr. 

Houlihan]." 1204 After reviewing patient charts, the VA OIG ultimately concluded that it could 

not substantiate allegations that "opioids were prescribed inappropriately to specific individuals 

or in inappropriate doses."1205 The VA OIG's narrow analysis of just opioid prescription 

practices of providers at Tomah VAMC may have overlooked the potentially dangerous 

combination of other drugs with opioids. 

The VA OIG received allegations about prescription practices at the Tomah VAMC that 

were not isolated to just the prescription of opioids. For example, the VA OIG received 

allegations in March 2011 that raised concerns about Dr. Houlihan's use ofbenzodiazepines and 

stimulants in concert with opioids. 1206 In fact, the March 2011 complainant alleged that Dr. 

Houlihan was conducting "his research into benzodiazepine, Ritalin and opiates for healing 

PTSD" at the Tomah VAMC. 1207 The email described the "cocktail of medications" veterans 

received and the health problems that veterans experienced after receiving the cocktail of 

medications. 1208 While the VA OIG referred those allegations to VISN 12 for review, the VA 

OIG was well aware of the concerns about the use of drugs other than opioids. From the text of 

1201 I d. at 200. 1202 VA OIG TOMAH VAMC ADMINISTRATIVE CLOSURE, at 3. 

IJOJ !d. at 6. 

no' !d. 1205 Id. at 7. 1206 E-mail to Representative 99, VA OIG Hotline (Mar. 14, 2011, 11:51 PM), OIG 5696, at OIG 569~97. 1207 !d. at O!G 5697. 120' !d. at OIG 5697-700. 

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the administrative closure, it is not clear whether the VA OIG reviewed or analyzed how the 

opioids prescribed at the Tomah V AMC interacted with the other drugs. 

As the news reports illustrated, drugs other than opioids played a role in the deaths of 

veterans, or other traumatic events. For example, when Jason Simcakoski died, he was found to 

have a "cocktail" of multiple drugs in his system and the cause of death was identified as "mixed 

drug toxicity." 1209 ln addition, according to news reports, Marine Corps veteran and Tomah 

V AMC patient Brian Witkus was "stoned on painkillers and tranquilizers" when he crashed his 

car into an Amish horse and buggy carriage, killing six-week old Ada Mae Miller in 2009. 1210 ln 

addition, Chairman Johnson's investigation found that Kraig Ferrington was on seven different 

medications, including an opioid and tranquilizers when he died of"poly medication overdose" 

after receiving care of the Tomah VAMC in 2007. 1211 

Indeed, the VA OIG's own chart reviews identified concerns with prescription practices 

at the Tomah VAMC that were not isolated to just opioid prescription practice. For the 

structured chart reviews, Dr. Mallinger and Dr. Shepherd developed a list of criteria by which the 

team reviewed the charts of Tomah VAMC patients. 1212 A team of VA OIG personnelincluding Karen McGoff-Yost, a licensed clinical social worker-used these criteria to review 

the charts. 1213 Pursuant to his subpoena, Chainnan Johnson obtained a copy of the document Ms. 

McGoff-Yost drafted in which she recorded her analysis of the charts she reviewed. In this 

document, Ms. McGoff-Yost noted some concerns about the mixture of drugs veterans at the 

Tomah V AMC received. 1214 

Ms. McGoff-Yost reviewed the charts of eight Tomah VAMC veterans.l2l 5 Of the eight 

patient charts she reviewed, all were prescribed opiates. Five of the patients received opioids 

from Deborah Frasher, two received opioid prescriptions from Dr. Houlihan, and one received an 

opioid prescription from a physician's assistant1216 Of those eight patients, six were also 

prescribed a benzodiazcpine in addition to the opioid. 1217 ln addition, three patients were 

prescribed "amphetamine-like substances (Ritalin)." 1218 She noted that the charts indicated that 

the order for the stimulant was to treat Attention Deficit Disorder (ADD). 1219 

1209 Glantz, Opiates Handed out Like Candy, REVEAL NEWS (Jan, 8, 2015). 1210 Aaron Glantz, Devastating Effects of "Candy Land" Reach Beyond Veterans, REVEAL NEWS (Mar. 16, 2015), 

http:/ /lacrossctribunc. com/news/local/ devastating -effects-of-candy-land-reach-beyond-veterans/article_ 68dd 8 5d0-

88fa-5d4a-b9cc-Ofd4611 Obd 19 hlml. 1211 Part ILA.l, supra. 1212 Karen McGoff-Yost, VA OIG, Tomah Hotline: Electronic Health Record Review (Apr. 23, 2012), at OIG 

12197; see also Mallinger 4/6/2016 Transcribed Interview, at 162-63. !213 ld. 

!214/d. 

!215 /d. 

!216 Jd. 

1217 Jd. 

1218/d 

1219 Jd. 

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Ms. McGoff-Yost highlighted additional concerns she identified through her chart 

reviews. Ms. McGoff-Yost "noted two documented instances of Dr. H using himself as a 

reference when he wrote the justification for why he ordered certain meds. The reference refers 

published case studies on the use of Ritalin for PTSD." 1220 She wrote that "[o)rder entered into 

CPRS [the patient's medical record) for the Ritalin says it is for ADD but seems that Dr. His 

using this offlabel for PTSD." 1221 Finally, she wrote that she identified "A LOT [sic) of 

polypharmacy- patients on both uppers and downers, would really love to have a pharmacist 

look at some of these drug combos." 1222 

During a transcribed interview with Dr. Mallinger, Chairman Johnson's staff inquired 

about Ms. McGoff-Yost's observations. Dr. Mallinger downplayed the concerns about 

polyphannacy and other mixtures of medications as they were not part of the allegations they 

received. He explained: 

1220 I d. 

!22! !d. 

!222 !d. 

Q: Moving on, Bullet 7, "Three patients arc prescribed amphetamine-like 

substances (Ritalin). Order indicates this is for ADD. Two ordered by 

NP F and one ordered by Dr. H." If you move down the page, about 

the bottom third, another bullet there says, "Noted two documents 

instances of Dr. H using himself as reference when he wrote the 

justification for why he ordered certain meds. The reference refers to 

public case studies on use of Ritalin for PTSD." The chart notes say 

that the Ritalin was prescribed for ADD, and he's sort of providing 

justification of prescribing Ritalin to treat PTSD, as the notes indicate. 

Did that-that doesn't match up, does it? 

A: Well, I don't know that she's talking about the same patients here. 

Q: Okay. Did any of the charts indicate that these patients were prescribed 

Ritalin for PTSD? 

A: I actually don't know the answer to that. You know, the allegation 

that we had was that he was using opioids to treat PTSD, and that 

was the allegation that we looked at. 

Q: But there was an allegation about a potential research project that he 

may have been doing-Or. Houlihan-with Ritalin, correct? Or was 

that the March 2011 hotlineA: l don't know of any allegation. He had published a small case series on 

some use of stimulants-! don't remember if it was Ritalin or 

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whatever; it was some stimulant-in the treatment ofPTSD. And at 

times he did cite that study in his notes. But I don't really remember 

the exactQ: But he was citing himself, again, in that instance? 

A: He was citing himself. I remember-again, you know, just from doing 

the general chart reviews or for looking in charts-I don't even 

remember from which-I was-! remember that he cited his own 

work in his notes, yeah. 

Q: We could get into that work, too, later. AnotherA: Again, that wasn't really something we were-we were charged with 

determining whether he was treating PTSD with opioids. 1223 

While it is unknown which patients were on certain drugs, Ms. McGoff-Yost's analysis 

appears to highlight the potentially dangerous mixture of opiates, benzodiazepines, and 

stimulants among at least a subset of Tomah VAMC veterans. Dr. Mallinger's statements show 

that the VA 010 health care inspectors narrowly interpreted the scope and the mission of the 

health care inspection. The literal and strict analysis of allegations did not give the health care 

inspectors the flexibility to address other issues that arose over the course of an inspection or 

investigation-namely the potentially dangerous mixture of opioids and benzodiazepines with 

Tomah V AMC veterans. 

Dr. Shepherd, another VA 010 physician who participated in the inspection, also talked 

about Dr. Houlihan's penchant for citing his own work. Dr. Shepherd expressed concern that Dr. 

Houlihan was citing himself as justification for his prescribing practices. 1224 He stated: 

Q: Would you generally cite medical articles that you, yourself, had 

written asA: No. 

Q: -backing it up? 

A: No. 

Q: Do you know or have you been made aware of that potentially Dr. 

Houlihan did do that? 

1223 Mallinger4/6/20I6 Transcribed Interview, at 172-73 (emphasis added). 1224 Shepherd l/27/2016 Transcribed Interview, at 90. 

,.__..,~ 

f~~ ~~l 

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A: Yes. Well, not the absolute, not that there was an absolute 

contraindication, that, umm, Dr. Mallinger had a discussion at one 

point where the discussion was essentially about Dr. Houlihan citing 

his own stuff to, you know, in a sense, to back him-to justify some of 

his stuff up. I think it was on a peer review. And part of that 

conversation or the piece I recall was Dr. Mallinger and I were 

pretty-pretty under--you know, I mean, I don't know how to say 

this-basically, underwhelmed by his-you know, we didn't put 

credence into his citing himself. We thought that was, you knowQ: Did he solely cite himself, or did he provide any additional 

documentation? 

A: I don't-that, I don't recall. But, basically, we thought that was 

crap, I mean, that you would cite yourself. I mean, you know, like, 

you would want to cite, like, a major joumal-1225 

Chairman Johnson received two research documents authored by Dr. Houlihan. The first 

piece is a letter to the editor published in Psychotherapy and Psychomatics entitled "Episodic 

Rage Associated with Primary Aldosteronism Resolved with Adrenalectomy."1226 The second 

piece is a short article published in the Journal of Psychopharmacology entitled 

"Psychostimulant treatment of combat-related posttraumatic stress disorder." 1227 This article was 

a case study of three veterans with PTSD at the Tomah VAMC. Dr. Shepherd explained that 

case studies like this one are "lower down" on the hierarchy of acceptable medical research. 1228 

Dr. Shepherd also said that he was familiar with this article as evidence Dr. Houlihan used to 

support his clinical practices. 1229 

The objective of Dr. Houlihan's case study was to "describe three cases of combat-related 

posttraumatic stress disorder (PTSD), largely refractory to standard medication treatment, who 

responded well to psychostimulant treatment." 1230 The paper summarized a case study of how 

veterans with combat-related PTSD, who had not responded well with traditional treatments for 

PTSD, responded well to psychostimulants, like Ritalin and Adderall. The report noted that 

other than this study, "the literature on psychostimulant use treating PTSD is limited to a single 

case report. " 1231 This report summarized the treatments of three Tomah V AMC veterans and 

1225 ld at 90 (emphasis added). 1226 David Houlihan, Episodic Rage Associated with Primar Aldosteronism Resolved with Adrenalectomy, 80 

PSYCHOTHERAPY & PSYCHOSOMATICS 306 (2011), OIG 330, at 010 330-31. 1227 David Houlihan, Psychostimulant Treatment of Combat-related Posttraumatic Stress Disorder, 25 J. OF 

PSYCHOPHARMACOLOGY 1568 (20 II), OIG 332 [hereinafter Houlihan, Psychostimuion/ Treatment of Combatrelated PTSD]. 

""Shepherd 2/9/2016 Transcribed Interview, at 64. 1229 Id at 56·-57. 1230 Houlihan, Psychostimuiant Treatment of Combat-related PTSD, at OIG 332. 1231 Id at OJG 334 

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noted improvements in the veterans' mental and physical state since they were placed on 

Ritalin. 1232 

Chairman Johnson's staff asked Dr. Shepherd whether the VA OIG health care inspectors 

were concerned about Dr. Houlihan's reliance on this study to support his clinical practice in 

light of allegations of over-prescription. Dr. Shepherd said that he was concerned throughout the 

inspection that Dr. Houlihan and other providers at the Tomah V AMC were potentially 

documenting in the medical charts that they were prescribing certain medications for the 

acceptable medical reasons, but were really prescribing the medications in a matter that furthered 

their own research. He explained: 

Q: During that interview, and you were on the phone with Dr. Houlihan, 

did you guys question the fact that he was citing his own work to back 

up his clinical practice? 

A: Umm, that, I don't recall. I just don't remember. You know, you'd 

have to--! don't remember. !just don't remember. 

Q: But, would it be fair to say that when this revelation and Dr. Mallinger 

having this conversation with you about being underwhelmed by Dr. 

Houlihan citing his own work to back up his clinical practice, l mean, 

that's-that's something that you guys need to look into, no? 

A: I'm not sure what you're asking, because, again, I'd ask for 

clarification, because to clarifY my comment to make sure it's in 

context. You know, we were looking at allegations independently, and 

what I'm saying is in looking at allegations independently, we-just 

because Houlihan cited himself doesn't mean we're, like, oh, okay, 

that's great. You know, we were-had appropriate skepticism about 

him citing himself, you know, in pursuing the allegations from an 

independent, objective standpoint. You know, that's really the point I 

was making, is just because he had written it in response to something 

doesn't mean that we gave it credence, meaning that we thought that 

was, like, oh, yeah. You know, we-you kind of, like, well, we were 

going to look independently. Is this guy prescribing-do we see 

evidence that he's prescribing opiates for PTSD, etcetera. 

Q: And what did you find? 

A: Well, the chart reviews, we couldn't-we couldn't find that he-that 

documentation that seemed to support that he was prescribing opiates 

1232 See generally id. at 010 332-33. 

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for PTSD, because what we found was all-most of his patients-all 

of them-that the patients also had pain issues, and he--and, so-so, 

in other words, his documentation, these people have pain issues 

which you would also treat with opiates, and so you could-and hewe had-Dr. Mallinger and I had a discussion at one point where we 

basically discussed that if he were doing that, meaning if he were, he 

certainlyQ: Doing what? 

A: If, for some reason-if there was an intention to prescribe opiates for 

PTSD, he certainly-it certainly wasn't in the documentation, meaning 

these patients had pain problems, so they had another reason to be on 

opiates and we couldn't find, like, notes saying, you know, I've started 

him on Ritalin or this-! mean, I've started him on this opiate for 

PTSD. 

* * * 

A: -and some other, and there were some patients who were neither of 

theirs, but they were people who had-Alan had put together a list 

based on things like who was getting the highest doses and stuff like 

that. We couldn't find notes that-documentation that seemed to 

indicate that he was prescribing the opiates for the PTSD. And a lot of 

these patients had pain conditions for which you wouldQ: Was Dr. Houlihan prescribing the opioids for pain? 

VAOIG 

Attorney: Let him finish his answer, okay. 

A: However, you know-however, you know, we did-you know, we 

did have a conversation where, umm, one of us raised the potential 

that, you know, this guy may be a guy who's, in a sense, quoteunquote, "smart enough"-in other words we were, you know, 

that skepticism you should have as a, you know, investigator or 

whatever, or inspector, you know, hey, maybe is this guy just 

smart enough or whatever that he makes sure not to document. Do 

you know what I'm saying, like--

Q: Right, because you said there's no clinical purpose of prescribing 

opioids for PTSD. 

A: Not that I'm aware of. 

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Q: Was he the main identifier or diagnose of the opioid for pain purposes? 

A: Now, like I said, the charts that were in our chart review, there werethere were other providers. It was several Houlihan charts, several 

Frasher charts, but then there were some other providers, because of 

the list that Alan [Mallinger] had put together, some of those were 

patients who--you know, it was based on, like, dosage, like, they were 

higher-dose patients. Some of them were because they were names 

that came up in his interviews with other people, like the e-mail you 

showed me here. You know, it might have been some names that came 

up from that-that he got. So, they weren't all Houlihan patients. They 

were Houlihan, Frasher, and a couple other-1233 

None of these concerns about the potential for prescribing medication to advance 

research were addressed in the VA OIG's administrative closure. Because the VA OIG has 

refused to provide copies of drafts of the original document the offtce intended to publish, or 

drafts of the administrative closure, the majority staff has no way of knowing whether the Office 

of Healthcare Inspections considered addressing these issues at any time. The VA OIG, by 

limiting its review to opioid prescription practices, appears to have avoided the issues of mixed 

drug interactions altogether. 

iii. The VA OlG ignored firsthand accounts of the poor state of affairs in the Tomah 

VAMC pharmacy 

The Tomah V AMC pharmacy has been a significant area of concern at the facility for 

many years. Pharmacists raised concerns about prescription practices at the Tomah VAMC 

throughout the years and there was a strained relationship between pharmacists and providers, 

like Dr. Houlihan, at the facility. This strained relationship was further complicated by the fact 

that the Tomah V AMC Chief of Pharmacy reported to Dr. Houlihan as the Tomah VAMC Chief 

of Staff. In the instances in which a pharmacist questioned a doctor's prescription, the 

pharmacist was essentially challenging the clinical judgment and practices of their top-line 

supervisor. These problems created an inherent con1lict of interest when resolving concerns over 

prescriptions that created administrative headaches and may have compromised veteran care. 

The VA OIG examined the con1licts between the pharmacy and Dr. Houlihan during its 

health care inspection of the Tomah VAMC. In the administrative closure, the VA OIG found 

that "the Chief of Pharmacy reports to [Dr. Houlihan] by virtue of [Dr. Houlihan's] 

administrative leadership position."1234 The VA OIG also substantiated that "at least five 

1233 Shepherd l/27/2016 Transcribed Interview, at 98-102 (emphasis added). 1234 VA OIG TOMAH VAMC ADMINISTRATIVE CLOSURE. at 6. 

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outpatient pharmacy staff left the facility in recent years." 1235 However, the health care 

inspection did not substantiate allegations of"abuse of authority, intimidation and retaliation 

when staff question controlled substance prescription practices." 1236 The administrative closure 

explained that the VA OIG did not substantiate these allegations "in the context of having 

obtained multiple contradictory facts and statements during the course of this inspection, often 

based on second or third hand accounts." 1237 In addition, the VA OIG added that although it did 

not substantiate the allegation, it found that perceptions of abuse of authority and intimidation 

with respect to the questioning of prescriptions were "widely held beliefs and concerns among 

most pharmacy staff and some other staff."12l 8 

The VA OIG interviewed several Tomah VAMC pharmacists during its health care 

inspection. Every pharmacist interviewed by the VA OIG "expressed concerns regarding the 

facility's (and ultimately ~Dr. Houlihan's]) expectations for dispensing opioids and other 

controlled substances." 123 The administrative closure swnmarized the pharmacists' concerns as 

follows: 

One pharmacist, a new employee, was not retained by the facility at the conclusion of 

his/her initial employment period. This individual reported that on three occasions he/she 

had refused to fill prescriptions for controlled substances due to concerns about patient 

safety and/or drug diversion. 

A second clinical pharmacist who left the Tomah VAMC reported feeling inappropriately 

blamed by [Dr. Houlihan] for the suicide of a patient. 

A dispensing pharmacist, relatively new to the facility, reported that he believed there 

were 40-50 patients who were regularly presenting to the outpatient phannacy for early 

refills of opioids, and that pharmacists were told by [Dr. Houlihan] they had to fill the· 

prescriptions. He feared this would place his license at risk. 

A clinical pharmacist who had been hired in a supervisory capacity reported that when 

some of the pharmacists expressed discomfort with dispensing high doses of opioids to 

patients, [Dr. Houlihan] would become angry and would insist that this pharmacist 

discipline the other pharmacists under his supervision. 1240 

The VA OIG ultimately unsubstantiated allegations of abuse of authority and 

intimidation by Tomah V AMC management against pharmacists because their allegations were 

formed on the basis of"second or third hand accounts." 1241 However, a review of the transcripts 

of VA OIG interviews with Tomah VAMC pharmacists shows that on multiple occasions, 

Tomah VAMC phannacists told health care inspectors of first-hand accounts in which they 

1235 ld at 5 !236 I d. 

!237 Jd. 

""!d. 

1239 Jd. 

1240 /d. 

1241/d. 

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refused to fill certain prescriptions and of instances in which they were forced by Tomah V AMC 

management to practice against their judgment. In many instances, these pharmacists detailed 

specific negative interactions with Tomah V AMC management when they expressed concerns 

about questionable prescriptions. In addition, they also referenced specific patients or instances 

in which they believed prescription regimes were potentially unsafe. They also told OIG 

inspectors about how their inability to raise concerns about potential patient harm led to an 

apparent culture of fear at the facility. 

a. Dr. Noelle johnson described to the VA OIG her first-hand accounts of abuse and 

questionable prescription practices at the Tomah VAMC 

On May 10,2012, VA OIG inspectors-Dr. Wesley, Dr. Mallinger, Dr. Shepherd and Dr. 

Yang-interviewed Dr. Noelle Johnson over the telephone. Dr. Johnson had worked at the 

Tomah V AMC pharmacist from July 2008 to June 2009. 1242 During her interview with the VA 

OIG, she raised significant, first-hand accounts of abuse from her time at the facility. According 

to a VA OIG transcript of the interview, Dr. Johnson told the VA OIG inspectors: "I was warned 

day one when I got there that whatever I did, don't question him [Dr. Houlihan] because I will be 

fired if I did or at least make my life very difficult .... " 1243 

Dr. Johnson also described pharmacy security procedures at the Tomah V AMC that did 

not properly safeguard controlled substances. She informed the OIG staff that when she started 

at the facility, the door to the vault of the pharmacy-where all of the controlled substances were 

stored-was "left open all day long." 1244 She added that "anybody and everybody had access to 

those controlled substances." 1245 Dr. Mallinger expressed concern about Dr. Johnson's 

revelation about the lax security procedures within the pharmacy: 

VA OIG: Okay. But the message I'm getting is that security wasn't as tight 

there [Tomah V AMCJ as other places you worked. 

Johnson: No, no. So that was very, very different all in itself that, first of all, a 

pharmacist had enough C2s [controlled substances] to do all day long. 

ThereVA OIG: Oh, that's unusual? 

Johnson: Well, it was as far as I was concerned. 

1242 Tomah VAMC: Examining Quality, Access, and Culture of Overreliance on High-Risk Medications, Joint Field 

Hearing Before S. Comm. on Homeland Sec. & Governmental Affairs & H. Comm. on Veterans Affairs !14th Cong. 

(2015) (statement of Dr. Noelle Johnson). 1243 VA OIG Interview with Noelle Johnson (May 10, 2012), OIG 5935, OIG 5939, at 14. 1244 !d. at OIG 5940, at 20. !24.5ld 

~~ LJ 

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VA OIG: Okay. You know, none of us are pharmacists, so this is all sort of 

new, new ground for us 1246 

Dr. Johnson raised three specific prescriptions to VA OIG health care inspectors that she 

refused to fill because she felt they were unsafe. One prescription came up during her 

conversation with the VA OIG health care inspectors about the lax security procedures of the 

Tomah VAMC pharmacy vault. She explained: 

VA OIG: Right. So basically it's-there was a circumvention of the internal 

controls of the pharmacy. 

Johnson: Yes, absolutely. By being the vault pharmacist, that's where I 

encountered the trouble. The reason I was fired, I believe, was 

because I chose to refuse to fill three prescriptions. They were all 

written by Dr. Houlihan, and the first one was for an immediate release 

morphine and it was 1,080 immediate release morphine tablets for a 

30-day supply. 1247 

Dr. Johnson explained to the VA OIG health care inspectors her concerns about this 

particular patient and prescription. The particular veteran was apparently prescribed 36 tablets of 

15 milligram immediate release morphine 1248 Dr. Johnson was concerned that the veteran was 

prescribed all immediate release tablets. She explained that based on her experience with pain 

medication, "you don't most often treat current pain management with strictly immediate release 

prescription." 1249 Dr. Johnson also noted that the patient was diagnosed with "neuropathic pain" 

and 36 tablets of 15 milligram immediate release morphine was "not the medicine [she] would 

be trying to use to treat a neuropathic pain .... " 1250 She added that the veteran "wasn't on any 

type of other adjunct therapy" and emphasized that "the fact that it was all short-acting was 

concerning."1251 VA OIG health care inspectors asked Dr. Johnson who this veteran was and 

when this prescription was issucd. 1252 She recalled that the issue came up in November 2008, 

but she did not recall the veteran's name. 1253 

Dr. Johnson told the VA OIG health care inspectors that she approached Dr. Houlihan 

with this prescription and had a phone conversation about converting the patient. Dr. Johnson 

explained that the conversation "didn't go over well." 1254 The conversation "ended up in a 

1246 !d. at OIG 5941, at 22. 1247 !d. at OJG 5941, at 25. 1248 !d. at OIG 5942, at 26. 1249 Jd. at OIG 5942, at 28. 1250 ld 

'"'!d. 

1252 !d. at OIG 5942. 1253 ld. 

1254 !d. at OJG 5942, at 29. 

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screaming match, him yelling at me profanities and throwing the scripts in the air, threatening to 

punch me."1255 She added that Dr. Houlihan yelled at her "you don't have a right to question me. 

You will [f*****g] fill this if! say you will .... " 1256 Dr. Johnson refused to fill the prescription 

because she believed it was unsafe. 1257 Her supervisor ultimately filled the prescription. 1258 

According to her interview with VA OIG inspectors, Dr. Johnson refused to fill another 

prescription because the veteran in that case was prescribed a potentially dangerous combination 

of drugs. Dr. Johnson told the VA OIG that "almost every patient that came through that was 

Dr. Houlihan's patient was getting some sort of not only narcotic but stimulants, and they were 

getting large doses." 1259 She said that her concern with this prescription was "not only are we 

giving a stimulant to a patient who has no diagnosis of any type of ADHD or anything like that 

in his chart."1260 She added: 

Dr. Houlihan at this point may have told me that he likes to use stimulant 

medications for PTSD, which I do work in a mental health clinic at this moment 

and I do see some stimulants come through, very small amounts of stimulant. But 

I wouldn't say that as far as my knowledge goes that large stimulants are first line 

for PTSD therapy1261 

In this instance, Dr. Johnson explained that the veteran was prescribed 120 milligrams a 

day of a stimulant. 1262 Dr. Johnson told the VA OIG that in her training as a clinical pharmacist, 

she knew that the maximum dose of stimulant is 60 milligrams per day. 1263 She informed the 

VA OIG inspectors that she reviewed the veteran's chart to determine why the veteran was 

prescribed double the maximum dose of stimulant. 1264 She told the VA OIG: 

!255 !d. 

So then I start looking through the chart to see-look for documentation why the 

patient is getting above the max dose, because we don't know. I mean, 

sometimes we do operate above those. 

So I look over the documents for that, and then I start looking through the 

problems or the diagnosis as far as why the patient is even getting it because 

obviously for certain drugs an indication of the dosage is different based on the 

indication. 

1256 !d. at OIG 5943, at 32. 1257 !d. at OIG 5942, at 27, OIG 5944, at 34. 1258 !d. at OIG 5944, at 34. 1259 !d. at OIG 5948, at 50. 1260 !d. at OIG 5948, at 51. !261/d. 

1262 I d. at OIG 5948, at 53. 1263 Jd. at OIG 5948, at 51-52. 

"''I d. 

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So, urn, at this patient, I also looked into his cardiac history that 120 milligrams of 

a stimulant, I was concerned that the patient would have some kind of cardiac 

issue, such as tachycardia. So, and this particular patient did, which even 

concerned me more. So I felt it wasn't safe for the patient to be taking this. Urn, 

at this point, after my first altercation with Dr. Houlihan, I was told I couldn't 

contact him. 1265 

Dr. Johnson told the VA OIG team that her immediate manager, Jeff Everson, and the 

interim Chief of Pharmacy, Erin Narus, told her that Dr. Houlihan "cannot control his temper" 

and that she was "not to contact him for any recommendations or questions." 1266 Instead, she 

was instructed to fax her concerns to Dr. Houlihan. 1267 Dr. Johnson told the VA OIG that when 

she faxed her concerns to Dr. Houlihan, he replied that the patient was "large" and instructed her 

to fill the prescription1268 Ultimately, Dr. Johnson still felt that the prescrifstion was unsafe and 

transferred the prescription to her supervisor, who filled the prescription. 12 9 

Dr. Johnson also described to the VA OIG the potentially dangerous prescriptions of 

benzodiazepines at the Tomah V AMC. She explained: 

Dr. Houlihan was always writing benzodiazepines over the max doses. We're 

talking Alprazolam (inaudible) everything. But he would be six-six milligrams, 

eight milligrams of Alprazolam. lsn 't that a little extreme? You guys are 

psychiatrists, right? So we'd be going benzo-everybody got benzodiazepine, 

and Alprazolam was a favorite, which I think is ironic because we hardly rate for 

that at our VA [the VA facility in Iowa where Dr. Johnson is currently employed]. 

But they always for a benzodiazepine, and they were all on a stimulant, all of 

them. And they were always on above max doses. I've never in any other-both 

VAs that I've been to have ever been even presented with a prescription above a 

max dose for a stimulant. I mean there's reasons. There are safety issues around 

that, and there's reasons there are max doses. 1270 

The third specific prescription that Dr. Johnson told the VA OIG she refused to fill was 

around June 2009 for oxycodone that amounted to "1447 milligrams of morphine-equivalent per 

day." 1271 Dr. Johnson explained to the inspectors her concerns about this prescription. She said: 

1265 !d. at VA OIG 5948, at 52-53. 1266 !d. at OIG 5948-49, at 53-54. 1267 !d. at OIG 5949, at 54. 1268 !d. at OIG 5949, at 54-55. 1269 !d. at OIG 5949. 54-56. 1270 !d. at OJG 5964, at 116-17. The "inaudible" notation was included on the transcript as produced by the VA OIG 

pursuant to Chairman Johnson's subpoena. 1271 /d. at OIG 5950, at 58. 

~~ 

~~) L_{ 

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Johnson: So I started looking to the chart, and, there was a note faxed in thatyou know once you had faxed it in, you can scan it in, and it goes to 

medical records, and it gets scanned in. And there was a note from an 

outside provider saying that the patient had tested positive for 

methadone in additionVA OIG: Oh, geez. 

Johnson: -and no oxycodone. So he tested positive for methadone, but no 

oxycodone. And so therefore, he [the outside provider] was going to 

be tapering the patient off the medication, and he-and that was it. He 

was not taking any more narcotics. Urn, so that was scanned in. 1272 

Dr. Johnson explained that Dr. Houlihan told her that the veteran got the methadone from the 

VA, but that her review of the medical record showed that the veteran had "never, ever gotten 

methadone from the V A."1273 Dr. Johnson refused to fill the prescription and informed the VA 

OIG inspectors that she brought her concerns to her supervisor, who ultimately filled the 

prescription. 1274 

Dr. Johnson explained to the VA OIG in general why she refused to fill prescriptions she 

believed to be dangerous: 

I guess it's not that I am high and mighty, but also--! have more advanced 

clinical experience. I went through a pain clinic. I knew the difference between 

safe and unsafe and right and wrong. And I chose at that time to--even if he was 

going to fire me or make my life difficult, what people would say hell, I was 

going to let them-let him do it. 

I wanted to make sure that the veterans got put first and that their safety was of 

utmost importance. But just I couldn't, I couldn't do it. I couldn't sleep at night, 

and I couldn't, I couldn't let them go through so[ ... ] I made the decision I guess 

to refuse to fill themn75 

In addition, Dr. Johnson told the VA OIG inspectors about another negative interaction 

she had with Dr. Houlihan. Dr. Johnson explained that she received a prescription for a 

controlled substance from Dr. Houlihan on a paper that was not the required prescription pad. 1276 

When she approached Dr. Houlihan to have the prescription written on the correct form, Dr. 

Johnson recalled that Dr. Houlihan "came flailing out of his office, screaming and hollering 

1272 !d. at OIG 5950, at 59-60. 1273 !d. at OIG 5950, at 60-61. 1274 Jd. at OIG 5949, at 56, OIG 5950, at 58. 1275 !d. at OIG 5949-50, at 57-58. 1276 !d. at OIG 5952, at 66. 

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profanities at me that he hates these [f"'****g] ~harmacists and just F this and F that. He put his 

fist up in the air like he was going to hit me."12 7 She told the VA OIG inspectors that she was 

frightened at this exchange. 1278 

Dr. Johnson also spoke to the VA OIG about common early refills for controlled 

substances, and how she was removed from the Tomah V AMC pain committee, even though she 

had an educational background in pain management. 1279 Dr. Johnson recalled her firsthand 

accounts with Deborah Frasher and her propensity to prescribe potentially dangerous mixtures of 

drugs. She explained: 

VA OIG: Okay. Uh, did you have any, uh, interactions with Deborah Frasher? 

Johnson: Deb Frasher was just kind of coming on the-! would like to say the 

Houlihan train when I was leaving. Urn, sbe-1 had one interaction 

with her, and I don't-it wasn't anything significant. I guess I'm just 

trying to remember exactly why we were talking. But it had to do with 

the pain committee and the pain clinic and somebody was saying why 

I had questions about why I couldn't be on this, you know, kicked off. 

And somebody told me that she had a complaint. 

So I confronted her and said, you know, I heard you had a problem or 

complaint. You know, is there something I did wrong, or could we 

talk about this? And she said no, she didn't have any problem with 

me. 

So I do remember having issues her seeing prescriptions sent to her. 

Everything she prescribed, she had an upper, a downer, a 

stimulant. So everybody gets a benzo, everybody gets a stimulant, 

everybody gets some kind of narcotic, and everybody gets some 

kind of antipsychotic. And she told me that she has a cocktail for 

these people. 1280 

Dr. Johnson also talked to the VA OIG inspectors about her interactions with the DEA 

and Dr. Houlihan's nickname among veterans at the Tomah VAMC as the "Candy Man." She 

recalled: 

Johnson: I did not talk to the inspector general myself. I had talked to the DEA. 

A DEA agent actually had contacted me and come to my house. 

1177 !d. at O!G 5952, at 66. 1278 !d. at OIG 5953, at 70. 1279 See id. at OIG 5944, at 35, OIG 5945, at 39-41. 1280 !d. at OIG 5954, at 75~ 76 (emphasis added). 

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VA OIG: I'm sorry. You say the DEA had contacted you? 

Johnson: Yes. 

* * * 

VA OIG: And what was the DEA's concern? 

Johnson: Diversion. Many of our patients were not testing like-first of all, we 

were told by Dr. Houlihan we were not supposed to be drug testing our 

patients because we were liable when they didn't test positive and then 

we wrote the order. Yet I know he forced other providers to write the 

order when their patients didn't test positive. 

* * * 

Johnson: So my concern was, I mean, the patients that would go down the 

hallway-Or. Houlihan's name is the Candy Man. I would hear the 

patients in the hallway talk about him and call him the Candy Man. I 

would hear them say things like, well, I went to my primary care 

doctor and she took me off my pain medicines, but I went to Dr. 

Houlihan and he put me back on, so he's the guy you need to go to.t28t 

As the transcript of her interview with VA OIG inspectors demonstrates, Dr. 

Johnson relayed concerns about a litany of issues that arose during her tenure at the 

Tomah V AMC. She described to the VA OIG specific, firsthand experiences and 

observations about patient safety and administrative abuses at the Tomah VAMC. The 

transcript of her interview undercuts the VA OIG's assertion that the allegations they 

received about the Tomah V AMC pharmacy were based on second and third-hand 

accounts. The VA OIG health care inspectors interviewed other Tomah VAMC 

pharmacists who also relayed first-hand accounts of abuses at the Tomah V AMC. 

b. First-hand accounts given by other pharmacists to the VA O!G about abuse and questionable 

prescription practices at the Tomah VAMC 

In addition to Dr. Noelle Johnson, the VA OIG interviewed other Tomah VAMC 

pharmacists during their review of the Tomah V AM C. Each pharmacist relayed specific 

instances of abuse or questionable prescription practices at the Tomah VAMC. The VA 

OIG provided the transcripts of their interviews with the Tomah V AMC phannacists 

1281 /d. at O!G 5954-55 at 75-79 (emphasis added). 

r/'"-~ 

\~r ~-~1 

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pursuant to Chairman Johnson's subpoena. However, the OIG redacted the names of the 

pharmacists and other information. 

For example, one pharmacist informed the VA OIG health care inspectors of a 

specific patient, a young male Iraq war veteran, that she believed was abusing his drugs. 

She explained: 

Witness: There's like certain patients that you see that you know are abusing the 

drugs. There's a [redacted] that's no longer in our-[redacted] that's 

no longer being treated here. I think he went to [redacted] and ended 

up not-if you look in the files there, you'll find that [redacted] was a 

pharmacist 

He had come to this place a couple times on a narcan drip overdose. 

He lost his meds all the time. That was back when I said I first started 

doing non-formularies. 1282 

OxyContin we did not .... I mean [another Tomah VAMC 

pharmacist] and I were just-we didn't let anyone get it We put 

brakes on it No, no, no. More whatever. And Houlihan walked 

down. One time I disapproved it He walked down and said "you will 

approve it" 

Now I had seen this kid because I'm in the military and I'm a veteran. 

He had one of the-when you first came back, and I was there in '03, 

'04, those black-! don't know, are you a vet? No. 

Okay, there's a certain jacket you have, a black fleece was the under 

thing. Are you military? 

VAOIG: Yes 

Witness: The black .. , . the Army had the black first-yes, first time they were 

issued were out in Iraq. And so, not everyone had it at the time, and I 

saw this young kid walking around with it, and I was like, "oh he looks 

like my nephew." A nice, young, blond-haired kid. 

He had to have OxyContin, and the kid was literally jumping up and 

down going I wasn't going to approve it, but I disapproved it 

Houlihan walks in, and says, 'you will approve it" And so I said, 

1282 See Paul Pinsonault, When Your Drug Is Not on Formulary, PJIARMEXEC.COM (June I, 2002), 

http://www.phannexec.com/whcn-your-drug-not-formulary. 

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"okay." He told him, "You're going to get it." Houlihan walked down 

the hallway and the kid goes. "Yeah, you're the man Houlihan." 

Now, if he's got a bad back that needs OxyContin? 

VA O!G: I guess it was working well. 

Witness: He hadn't gotten it yet. 

VAOIG: Okay 

VA O!G: So he did that in the presence of--

Witness: In the hallway, where the old outpatient pharmacy used to be. And 

like I said, I had watched the kid because I was like "I had one of those 

jackets." I had it issued to me when I was out in Iraq, because you ... 

you couldn't buy them. And so it was like, you know, you know that 

person is a recent vet and just got back. 

And so, that kid? Read about him. Just a big druggie. He had 

problems, his [redacted] said. They'll be notes, the nurses were 

writing notes. Look at the 402 notes and stuff on him. 

VA OIG: So you had to approve it because it was sustained release. 

Witness: I had to approve it because Houlihan told me. 1283 

The same phannacist recounted a meeting during which Dr. Houlihan yelled at 

her and accused Dr. Johnson of turning him into the VA O!G. She explained: 

VA OIG: According to some reports that I've heard, there was a meeting held 

during that time in early 2009, and at that meeting, Dr. Houlihan 

talked about Noel [sic] [Johnson] turning him in to the !G. 

Witness: Oh, was that a medsec (phonetic) meeting? Because he yelled at me at 

one of those. 

VA O!G: That's all I know about the meeting. 

Witness: There was a meeting where Tom Jaeger at the time and I went to and I 

got a report on PNT (phonetic) because I the secretary for the PNT for 

1283 VA OIG Interview of Tomah VAMC Phannacist 1 (Aug. 23, 2012), OIG 6050-51, at 12-15 (emphasis added). 

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a while. And I spccifically-I mean the room kind of was like this. 

Houlihan was going to be up front and Tom Jaeger and I both sat 

against the wall like right up there. 

He joined and just yelled. I mean he was just wild. He was like-you 

can tell the whole time he was like this until-and he just goes, 

"somebody from the pharmacy turned me into the IG." And !just 

like-I just looked at him and I said "it wasn't me, and it is nobody in 

pharmacy that I know of' turned him in. 

VA OIG: And what was it about? 

Witness: I-I don't. He was just mad about it. 

VA OIG: No. I mean what was he turned in for? 

Witness: l don't know. I assume excessive narcotic prescribing. 

VA OlG: Because I think actually nobody turned him into the IG. 

Witness: I don't think so. l think the union told me that they did something but 

it was-the union came and told me that they had done something and 

it wasn't Noel [sic]. But he was adamant that it was pharmacy. I said, 

"it wasn't me or anybody that I know." 1284 

Another pharmacist, who was relatively new to the Tomah V AMC, also brought 

up specific concerns about high narcotic prescriptions at the facility in a conversation 

with VA OIG inspectors. The pharmacist explained: 

Witness: I just started and urn, yes, when I got here-it seemed very outrageous 

what I saw here with the narcotics and all that stuff. 

VA OIG: Did that compare to like previous jobs you've had? 

Witness: Yeah, because I-to meVA OIG: Where did you used to work? 

Witness: l used to work at Walgrecns. 

VA OIG: Here in Tomah? 

"''/d. at O!G 6052. at 17-18. 

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Witness: No, in [redacted] 

VA OIG: Oh, okay. 

Witness: I'm from [redacted]. We moved out here. And, urn, to me, high doses 

were like 240 tablets of Percocet and I'm coming over here, and I'm 

seeing, wow, okay, 400 and something for a month Oxycodones, 

(inaudible), you know, stuff like that, and I'm like, "Okay, isn't that 

excessive?" 

In the beginning I would check out the records, well they've been 

getting this for a while now, urn, you know, ask my coworkers, "Oh 

that's-that's okay, it's normal." 

So you know, you don't question too much, if! do feel that something 

is too high I would go to my supervisor ... 1285 

The same pharmacist spoke about how early refills were common at the Tomah 

V AMC pharmacy and recounted a specific instance in which a veteran requested an early 

refill for a controlled substance prescription. The pharmacist stated: 

Witness: Urn, well I can say my-my first experience I think was probably, 

what, my first month-and-a-half. I came into contact with urn, I was in 

the window and I think her name is, [redacted]. 

Urn she came in with-with her order for a C-2, I believe it was 

Oxycodone, and urn, it was early-it was an early fill, and I told her 

straight out, you know, "we're going to talk with your doctor and see 

if it's okay," cause you know we have to, urn document. 

VA OIG: Did she give you a reason why she was there early? 

Witness: Urn, I don't believe so. I really-1 really don't remember. 

VA OIG: Okay. 

Witness: Urn, she said, "No its due today." She points out to the paper, "the 

date" and I'm like, "Yeah the date says its due in maybe three days or 

four days," I really don't remember. 

'"'VA OIG Interview with Tomah VAMC Pharmacist 2 (Aug. 23, 2012), OIG 5122· 23 at 5-6. 

--~ 

(~o/ t,_ J 

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But you know, "we'll call the doctor and we'll see what happens. You 

know, just let me talk to Jack." 

VA OIG: And Jack is the supervisor? 

Witness: Yeah. 

VA OIG: Okay. 

Witness: So you know, "all right, let him handle it," and that's the way it 

happened. 

VA OIG: And then what happened? 

Witness: Urn, I believe it got filled. 1286 

It is unclear whether the VA 0 I G reviewed this veteran's chart after the Tomah 

V AMC pharmacist identified her as a veteran that received an early refill. Nevertheless, 

this account is yet another example of a firsthand experience that a Tomah VAMC 

pharmacist told to VA OIG health care inspectors. 

Dr. Wesley and Dr. Mallinger interviewed another Tomah VAMC pharmacist on 

April26, 2012. This pharmacist worked at the Tomah VAMC or at a Community-Based 

Outreach Clinic near the Tomah VAMC for over three years. 1287 The pharmacist told the 

VA OIG health care inspectors of a specific incident in which Dr. Houlihan blamed the 

pharmacist for the suicide of a veteran. 

The pharmacist gave the veteran's name to the VA OIG and explained that the 

veteran was being treated at a clinic for anticoagulation. 1288 The veteran committed 

suicide after the pharmacist refused to fill his prescription because his pill box smelled of 

marijuana and the veteran could not perform a drug test. The veteran's wife claimed that 

the veteran killed himself because "the pharmacist wouldn't give him his pills." 1289 

Because the veteran killed himself within 24 hours of seeing a VA physician, the VA 

conducted a root cause analysis and peer reviews of the individuals involved with the 

treatment of the veteran. 1290 

12"

6 ld. at OIG 5123, at 6--7. 

::::VA OIG Interview with Tomah V AMC Pharmacist 3 (Apr. 26, 20 12), at OIG 5042. 

ld. at OIG 5043, at 13. 1289 ld. at OIG 5047, at 27. 1290 !d. 

,--~._ 

\~r I ' '---. .l 

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The pharmacist was cleared of any wrongdoing but Dr. Houlihan apparently 

blamed the pharmacist for the veteran's suicide. The phannacist described the interaction 

to VA OIG inspectors: 

Witness: You know I was found, you know, not to be at fault for anything or 

whatever. I mean, nothing ever-nothing ever else came out of that, 

but, I mean, I was like-that like was one of the worst things that has 

ever happened to me in my career, and I still get upset by it, and Dr. 

Houlihan to this day tells people that I killed this patient and that 

because of me the patient killed himself. 

* * * 

I have no idea what happened, but the bottom line is that [the veteran] 

killed himself and that Dr. Houlihan has held me accountable for that 

because he said I did not dispense his medication, which is not true. 

Umm, the facility themselves had to do an [Root Cause Analysis]-

VA OIG: Who did he say that to? 

VA OIG: We'll find out. So, umm, couldWitness: And-pardon me? 

VA OIG: I'm-I'm just wondering, how it was that you found out that Dr. 

Houlihan was-did Dr. Houlihan say these things to you directly? 

Witness: Oh, he-he told the chief of staff. He's told Donna Leslie. Umm, or 

not chief of staff. I'm sorry, Chief of Pharmacy. He's told everyone. 

VA OIG: And how do you know that? 

Witness: I mean people have said Dr. Houlihan has said that this patient killed 

themselves because [the pharmacist] did not give him his medications. 

VA OIG: So, umm, can you tell-I guess the first question is did-did he ever 

express that to you directly? 

Witness: No, because I-I tried to stay as far away removed from him because 

of what Noel [sic] Johnson went through with him, the pharmacist he 

fired over her refusing to fill narcotic prescriptions. 

VA OIG: Okay. We can get to that. 

~/~ 

(~7 ~ .. .J 

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Witness: I mean, I was scared as hell ofHoulihan. 1291 

The same pharmacist provided the VA OIG inspectors, Dr. Mallinger and Dr. 

Wesley, with names of individuals who were told that this pharmacist was responsible for 

the veteran's suicide. 1292 A review of the transcripts of subsequent VA OIG interviews 

does not show that VA OIG health care inspectors followed up with those individuals 

about the veteran's suicide or what Dr. Houlihan said about the pharmacist's culpability. 

Instead of conducting follow-up about this incident, the VA OIG did not substantiate the 

allegations of administrative abuse. The VA OIG's only reference to this incident is a 

passing mention in the administrative closure that a "clinical pharmacist who left the 

Tomah VAMC reported feeling inappropriately blamed by [Dr. Houlihan] for the suicide 

of a patient." 1293 

iv. The VA OIG did not heed warnings of pharmacy consultants 

As referenced in the VA OIG's administrative closure, and explained in the majority 

staffs interim report from June 2015, the VA OIG selected three VA pharmacists from outside 

of the Tomah VAMC to act as consultants in the GIG's inspection. 1294 The administrative 

closure noted that the VA OIG used the pharmacy consultants to assist the health care inspectors 

in "evaluating the clinical administrative aspects of [Dr. Houlihan's] interactions with pharmacy 

staff and the staffs roles in facilitating patient safety and appropriately dispensing controlled 

substances." 1295 The inspection team provided the consultants with recordings of four interviews 

conducted of Tomah VAMC pharmacists. 1296 Based on a review of those interviews, the 

pharmacy consultants provided their feedback of the issues within the Tomah VAMC pharmacy. 

Despite receiving significant concerns about the clinical and administrative operations of the 

Tomah V AMC pharmacy in relation to Tomah V AMC management, the administrative closure 

made no mention of what the consultants found. 1297 

The VA OIG health care inspection team called on the pharmacy consultants because 

they did not have a pharmacist on the inspection team and the health care inspectors sought to 

gain a better understanding of the "guidelines and processes that are used" in situations where 

pharmacists feel uncomfortable filling certain prescriptions. 1298 In his transcribed interview with 

Chairman Johnson's staff, Dr. Mallinger explained the consultants' role. He stated: 

1291 I d. at OIG 5047-48, at 27-30. 1292 I d. at OIG 5050, at 38. 1293 VA OIG TOMAH VAMC ADM!K!STRATIVE CLOSURE, at 5. 1294 Id. at 4. !295Jd 

1296 ld. 

1297 See id, 

1298 Shepherd 1/27/2016 Transcribed Interview, at 162. 

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And we tasked these pharmacists with telling us basically whether the way these 

pharmacists dealt with their experiences were, you know, reasonable and 

appropriate. You know, basically we asked them to consider this from the context 

of the usual policies and procedures that pharmacists adhere to in the course of 

doing their jobs, and kind of the usual role expectations that you would have from 

a pharmacist in applying those policies and procedures. So they were kind of our 

quality check, if you will, on the--you know, the evaluation of the experiences 

that the pharmacists reported to us. 1299 

In total, the VA OIG solicited the opinions of three VA pharmacists from outside the 

Tomah VAMC: Dr. Nick Beckey, Dr. Mitchel Nazarrio, and Dr. Janelle Wormuth. Dr. Beckey 

and Dr. Wormuth provided written feedback to the VA OIG health care inspectors, and Dr. 

Nazarrio informed the VA OIG of his analysis orally during a phone call. 1300 All three 

pharmacists identified serious concerns with prescribing practices and management at the Tomah 

VAMC. 

After reviewing the audio recordings of the VA OIG's interviews with the Tomah 

VAMC pharmacists, Dr. Beckey found "several concerns" that present "a significant risk" to the 

facility. Dr. Bcckey identified as follows: 

I. The Tomah VAMC pharmacy was at risk of having its DEA controlled substance 

license either revoked or suspended "due to the lack of sufficient effort to decrease 

the potential for diversion, abuse, and overdose after several red flags were raised"; 

2. The Tomah VAMC pharmacy was at risk of having its Joint Commission 

accreditation revoked or changed to partial accreditation; and 

3. The Tomah VAMC a showed high potential risk of litigation by former or current 

employees. 1301 

Dr. Beckey found that there were "several concerning practices at [the Tomah VAMC] that were 

not only condoned by the Chief ofStaff[Dr. Houlihan], but were insisted on by him when 

concerns were raised by pharmacists and other physicians." 1302 In particular, Dr. Beckey noted 

that (I) veterans were prescribed excessive doses of controlled substances; (2) veterans were 

prescribed an excessive amount of short-acting narcotics with no long-acting agents; and (3) 

providers exhibited a lack of due diligence when issues were raised about patients who 

demonstrated behaviors of abuse or diversion of medications.uoJ 

1299 Mallinger 4/6/2016 Transcribed Interview, at 265. 1300 Nick Beckey, OIG Con5ultation, Tomah VAMC, OJG 1547 [hereinafter Nick Beckey Consultation]; 

Memorandum from Janelle Wormuth, PharmD, Chief, Pharmacy Service, VA Nebraska Western Iowa Health Care 

System, to OJG Review Team & Alan Mallinger (July 12, 2012), OIG 1943 [hereinafter Wormuth Memo]; 

Transcribed Interview with Mitchell Nazarrio, in West Palm Beach, Fla., at 30-31 (Dec. 1, 2015). 1301 Nick Beckey Consultation, at OJG !547. 1302 ld 

1303 /d. 

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With respect to the third finding relating to a lack of due diligence addressing concerns of 

potential drug abuse or diversion behavior, Dr. Beckey noted: 

The interviews were full of examples of patients who received high doses of 

controlled substances with negative urine drug screens for those agents and 

patients being given numerous replacements for controlled substances that were 

either lost or overused. Each time these issues were raised the decision was made 

by the Chief of Staff to insist on the replacement prescription, with no warning or 

follow up of the patients behavior. Additionally, a meeting was called by the 

Chief of Pharmacy that included concerned pharmacists and the Chief of Staff 

told them that nothing could be done about these cases, they were to fill the 

replacement prescriptions as written. 1304 

Dr. Beckey also noted that "more than one" individual at the Tomah V AMC told him that Dr. 

Houlihan was nicknamed the "Candy Man" by the patients "due to the ease in which [Dr. 

Houlihan] prescribed controlled substances." 1305 Dr. Beckey further identified "concerns that 

were raised by local police officers" and "more than one" overdose that occurred in the parking 

lot of the Tomah VAMC. 1306 For each of these points, Dr. Beckey wrote that "[i]t appears that 

there was also no action taken by senior leadership to address these concerns."1307 Dr. Beckey 

also advised the VA OIG that based on his review, the Tomah V AMC was at risk of losing its 

Joint Commission accreditation and posed an increased risk of litigation relating to the 

termination of Tomah VAMC pharmacists. 1308 

Dr. Janelle Wormuth is Chief of Pharmacy Service at a Midwest VA facility and 

provided consultation for the VA OIG based on her review of VA OIG interviews with Tomah 

VAMC pharmacists. 1309 She described the prescriptions written by the Chief of Staff, Dr. 

Houlihan, as "extreme in quantity and dose." 1310 With respect to the Tomah VAMC pharmacy, 

Dr. Wonnuth noted that "safety would be a concern of mine as well." 1311 Dr. Wormuth raised 

significant concerns about the relationship between pharmacists and providers at the Tomah 

VAMC. She wrote: 

1304 !d. 

The environment to practice pharmacy at the Toma [sic] VA does not seem safe. 

It is unacceptable, in my opinion, for an environment to exist that an entire team 

(PACT model of care) is not utilized to care for the patient. Every member of the 

team is valued in what they provide for the care of the patient. Pharmacists at the 

Toma [sic] VA have not been provided an environment to give optimal patient 

1305 !d. at OIG !548. !306 /d. 

\307 ld. 

1308 !d. 

1309 Wormuth Memo, at OIG 1943. 1310 ld. 

Ill\ /d. 

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care. These 4 interviewed pharmacists no longer work at the Toma [sic] VA due 

to their perception that pharmacy practice is not supported. In my opinion, that 

perception is real. The Chief of Staff is not providing an environment where 

pharmacy practice is respected for the safety of patients. In addition, Pharmacy 

leadership has been inconsistent. Given the information on the 4 tapes, I would 

say the Chief of Staff is the reason the environment is hostile at the Toma [sic] VA.I312 

Dr. Wormuth also wrote that she "support[ s] a pharmacist refusing to fill a prescription for a 

patient if the safety of the patient is at risk." 1313 Her "expectations" before a pharmacist refuses 

to fill a prescription are that the pharmacist and provider have a discussion with each other and 

review the patient's prescription history. 1314 

In a transcribed interview with Chairman Johnson's staff, Dr. Beckey discussed his 

expectation that a provider and pharmacist would openly discuss any disagreement over a 

prescription. He spoke of the importance of a dialogue between providers and the dangers 

evident when pharmacists are afraid to speak up about questionable prescriptions. He stated: 

1312 Id 

1313 Id 

!3!4 Id. 

I did just a little presentation for the staff on civility and the dangers associated 

with being afraid of a provider, let's say, or there's a lot of medical errors that 

may occur because somebody just doesn't want to deal with a difficult nurse or a 

difficult provider, so what will happen is, the staff, instead of being yelled at by a 

physician, will choose not to call that physician when normally they would have 

called that physician on something, and so that has been an area of concentration 

for kind oflike in the medical error community kind of to be able to speak up, you 

know. They'll say, you know, "Stop the line" kind of thing is a-is one of the 

things that is trying to be brought up in medicine. "No matter who you are, if you 

see something wrong during a surgery, you should speak up," so it's trying to get 

that kind of culture at this medical center or at any medical center is something 

that people are trying to do within the healthcare field. 

So that was kind of the biggest thing that you seem to obviously have pharmacists 

that were afraid or disgusted because they were speaking up over things that was 

concerning to them, the excessive doses of narcotics, the excessive dose of 

narcotics combined with a stimulant, so, you know, it seems that those all tended 

to be true once they actually looked at the numbers, and the average dose was 

much higher at Tomah, I believe, than at other sites, so that was my biggest-the 

biggest thing that was alarming was the fact that it was, it was brought up and it 

didn't seem to have been acted on by that site.ll\ 5 

1315 Transcribed Interview with Nick Beckey, in West Palm Beach, Fla., at 26-27 (Dec. 1, 2015). 

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Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

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During Dr. Mallinger's transcribed interview, Chairman Johnson's staff asked why the 

VA OIG only provided the consultants with the audio recordings of the four departed Tomah 

VAMC pharmacists. Dr. Mallinger stated: 

Q: Is there a particular reason why they only just received interview 

transcripts-or recordings, excuse me? 

A: Well, because what we wanted from them was to tell us-in other 

words, a pharmacist tells you a story, and they say, "I couldn't do this 

because it was the wrong thing to do." And I don't know whether all 

pharmacists are taught that that's the wrong thing to do or whether this 

particular person, you know, missed pharmacy school that day and 

didn't know it was okay. So we needed a check on the appropriate 

professional behavior of a pharmacist in response to certain situations, 

and they provided us with that check. 1316 

Ultimately, however, the VA OIG did not use any of the information that the consultants 

offered. The VA OIG's administrative closure provided no mention of the consultants' findings, 

nor were the consultants' concerns raised anywhere in the administrative closure. Dr. Mallinger 

explained that the consultants' opinions and analysis were rendered useless because the VA OIG 

health care inspection team did not corroborate the statements that the departed Tomah VAMC 

pharmacists made in the four interviews that the consultants reviewed. He stated: 

A: Now, you know, it's obviously-you know, you can have an opinion 

about these things from the story, but we wanted someone with real 

expertise. We were actually hoping, when we started this, that they 

would, you know, make us-enable us to use the phannacists' 

interviews in a very authoritative way in our inspection. The problem 

got to be that we weren't unable-we were unable to corroborate a lot 

of things that the pharmacists were telling us, and so it had become 

less materiaL I mean, it made a lot of sense at the time, but then when 

we were not getting such consistent stories, it--you know, their-what 

they said was still useful, but it wasn't-you know, we couldn't use it 

to substantiate allegations because we didn't have the consistency of 

the evidence. 

Q: If I could tum your attention to Exhibit 33, OIG Bates 1547, this is Dr. 

Beckey's analysis. He writes here, "After listening to the testimony 

from the four pharmacists interviewed, !"-meaning Dr. Beckey-

"have several concerns related to senior management at this VA. In 

1316 Mallinger 4/6/2016 Transcribed Interview, at 266. 

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particular, I believe these actions place the medical center at 

significant risk of the following: risk of having DEA license either 

revoked or suspended due to lack of a sufficient effort to decrease 

potential for diversion, abuse, and overdose after several red flags 

were raised." This is a pretty serious finding, no~ 

A: Well, here's the thing. The consultant was telling us what they were 

telling us from the perspective of the departed pharmacists. They 

didn't have any other information about Tomah at all. And so they 

were speaking strictly, you know, about these consequential things. 

They were speaking strictly from the perspective of the departed 

pharmacists. He makes that very clear in his write-up. You know, he 

says, if you look down on the third bullet point there at the last 

sentence, he says, you know, "From the interviews it appears that"-

and most of what he writes through here is similarly qualified as, you 

know, representing the point of view of the interviewee. And all of 

these things may be true from the point of view of the interviewee, but 

if we couldn't corroborate what the interviewee told us, then they have 

much less credibility, I guess would be the word. 

Q: And so is it fair to say that since the team couldn't subsequently 

corroborate what the departed pharmacists were saying, that the 

consultations your team received from folks like Dr. Beckey and the 

other pharmacy consultants was not very valuable to the inspection? Is 

that fair to say? 

A: It was not valuable in terms of supporting allegations. 1317 

Because the VA OIG did not provide the consultants with additional information beyond 

the recordings of four interviews, the VA OIG essentially set these consultants up for failure. By 

arbitrarily narrowing the scope of the consultants' review, the VA OIG ignored the potentially 

dangerous elements of the Tomah VAMC pharmacy that the consultants found. The consultants' 

candid assessments of the risks at the Tomah VAMC paint a startling picture of the potentially 

dangerous prescription practices and toxic management at the Tomah VAMC. The VA OIG's 

willingness to discredit the consultants' assessment because the OIG could not corroborate the 

statements of the departed pharmacists prevented an opportunity to improve accountability at the 

Tomah VAMC. 

1317 !d. at 266··68. 

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3. VA OIG staff drafted the Tomah VAMC report as a public document, but management 

made a decision to administratively close the case 

Dr. Mallinger, the lead inspector on the VA OIG's Tomah VAMC health care inspection 

team, originally drafted the results of the Tomah inspection as a report that would be published 

on the VA OIG's website. However, Dr. Daigh, the VA OIG's Assistant Inspector General for 

Healthcare Inspections, decided to administratively close the Tomah V AMC health care 

inspection. The decision to administratively close the health care inspection not only meant that 

the report was not originally published, but it also limited the VA OIG's ability to follow through 

on its suggestions to improve care at the Tomah VAMC. 

Dr. Mallinger and Dr. Shepherd were the primary drafters of the administrative closure of 

the VA OIG's inspection of the Tomah VAMC. By February 2013, Dr. Mallinger was in the 

"very early" drafting stages of the Tomah VAMC report1318 On February 26,2013, Dr. 

Mallinger emailed Dr. Wesley and Dr. Shepherd, writing "in anticipation of our conference call 

tomorrow, I am sending you my working draft of the Tomah report in which the Background 

section is completed. Hopefully this can provide a starting place for our discussion/planning."1319 

Dr. Mallinger confirmed that as of February 26,2013, he was drafting the document with the 

understanding that the document would be a published report. 1320 In other words, as of late 

February 2013, the decision to administratively close the inspection with a nonpublic report had 

not been made. 

Two days later, February 28, 2013, Dr. Mallinger emailed Dr. Wesley with the subject 

"Tomah report."1321 The entire contents of the email were redacted by the VA OIG1322 During 

a transcribed interview with Dr. Mallinger, Chainnan Johnson's staff inquired about how Dr. 

Mallinger worked with his superior, Dr. Wesley, in the drafting process. Dr. Mallinger 

explained: 

Well, Dr. Wesley generally will read things, and he may suggest things for us to 

change, or he may actually, you know, write some of the changes. It really varies 

from report to report. But he's sort of the next level of editing. In other words, I'd 

produce sort of the rougher document, and then he-when I talked about that prepublication editing process that takes place, he's sort of the first element in 

that.J323 

1318 Mallinger 4/21/2016 Transcribed Interview, at 339. 1319 E-mail from Alan Mallinger, VA OIG, to Michael Shepherd & George Wesley, VA OIG (Feb. 26, 2013, 5:43 

PM), at OIG 11381. 1320 Mallinger 4/21/2016 Transcribed Interview, at 340. 1321 E-mail from Alan Mallinger, VA OIG, to George Wesley, VA OIG (Feb. 28, 2013, 6:20PM), at OIG 11372. 1322Jd 

1323 Mallinger 4/21/20 16 Transcribed Interview, at 345. 

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Dr. Mallinger explained that he and Dr. Shepherd interacted only with Dr. Wesley on the 

drafting of the Tomah report. 1324 Dr. Mallinger said that he and Dr. Shepherd were unaware of 

whether their superiors made subsequent edits to the document after they transmitted it to Dr. 

Wesley .

1325 

On March 1, 2013, Dr. Mallinger emailed Dr. Wesley and Dr. Shepherd with the subject 

"Tomah draft." 1326 He wrote: "Enclosed is the current draft with Scope and Methodology 

completed. 1 will start work on the Inspection Results- would appreciate some discussion on 

classifying the issues." 1327 A portion of the email was redacted by the VA 010. 1328 Dr. 

Mallinger did not recall which of the allegations the team had decided to substantiate or 

unsubstantiated at this point in the drafting process. 1329 He did confirm that as of March I, 2013, 

the Tomah VAMC inspection was planned to be completed in a report that would be 

published. 1330 

A month later, on April 3, 2013, Dr. Mallinger emailed Dr. Wesley about the Tomah 

VAMC report. His email read, "[e]nclosed is the draft Tomah report at long last. Thank you for 

your patience and support. I still need to condense case example # 1, so you may want to limit 

your reading of that to the last seven paragraphs. " 1331 The email had an attachment entitled 

"Tomah draft 4-3-13.doc."1332 Dr. Mallinger subsequently emailed Dr. Wesley and Dr. 

Shepherd on April23, 2013 with the subject "slightly revised Tomah draft per discussion" and 

the attachment "Tomah draft 4-23-13.doc."1333 The VA OIG has withheld these drafts from 

Chairman Johnson and the Committee. 

When Chairman Johnson's staff inquired about the "discussion" referenced in Dr. 

Mallinger's April 23rd email, VA OIG counsel interrupted on multiple occasions and prevented 

Dr. Mallinger from answering the questions. 

Q: This is Exhibit 50. Exhibit 50 is an email marked OIG Bates 11240 

from Dr. Mallinger to Dr. Wesley, cc Dr. Shepherd, email sent 

Tuesday, April 23, 2013; subject line: slightly revised Tomah draft for 

discussion; with an attachment, Tomah draft 4-23-13.doc. Do you 

recall the discussion that led to this slightly revised1324 Jd. at 347. 1325 !d. 

1326 E-mail from Alan Mallinger, VA OIG, to George Wesley & Michael Shepherd, VA OIG (Mar. I, 203, 5:45 

PM), at OIG 11370. 1327 !d. 

!328 !d. 1329 Mallinger 4/21/2016 Transcribed Interview, at 355-56. 1330 ld. at 355-57. 1331 E-mail from Alan Mallinger, VA OIG, to George Wesley, VA OIG (Apr. 3, 2013, 9:45PM), at O!G 11280. l332Jd 

1333 E-mail from Alan Mallinger, VA OIG, to George Wesley, VA OIG (Apr. 23, 2013, 2:45 PM), at OIG 11240. 

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VAOIG 

Attorney: That would be deliberative. 

Q: -draft? 

VAOIG 

Attorney: That would be deliberative. lfwe're doing revisions on the draft, that 

is per se deliberative. 

Q: Dr. Mallinger, would you like to answer the question? 

A: I honestly don't have any recollection of it anyway, so--these 

would-you know, it was a long time ago. 

Q: Understood. Do you recall what changed between the version you sent 

to him on April 3rdVAOIG 

Attorney: Again, objection. That's deliberative. 

Q: Can I finish my question, please? 

VAOIG 

Attorney: You're asking about a change in a draft, but go ahead. 

Q: Do you recall what changed between the draft you sent to him on April 

3rd and this draft of April 23rd? 

A: No, I really don't. 

Q: Do you recall if this is a full and complete draft of the report~ 

A: Again, I really-I don't know. 

Q: Do you recall whether the decision had been made to administratively 

close this document or inspection had been made at this point? 

A: It had not been made at that point. 1334 

On May 3, 2013, Dr. Mallinger sent another email to Dr. Wesley with the subject, 

"Tomah current version." 1335 Three days later, on May 6, 2013, Dr. Mallinger again transmitted 

1334 Mallinger 4/2112016 Transcribed Interview, at 362-64. 1335 E-mail from Alan Mallinger, VA OIG, to George Wesley, VA OIG (May 3, 2013, 10:29 PM), OIG 11235. 

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another draft to Dr. Wesley. 1336 According to the transmittal email, this draft included 

"validated" chart review data. 1337 On May 15, 2013, Dr. Mallinger sent another draft to Dr. 

Wesley1338 The subject of that email was "Latest Tomah draft as discussed" and included an 

attachment labeled "Tomah draft 5-15-13.doc." 1339 The VA OIG has not produced any of these 

drafts to Chairman Johnson or the Committee. 

Sometime between the email of May 15,2013, and January 9, 2014, Dr. Daigh decided to 

administratively close the Tomah VAMC health care inspection. 1340 On January 9, 2014, Dr. 

Mallinger emailed Dr. Wesley with the subject line, "Tomah administrative closure" and an 

attachment entitled "Tomah Administrative Closure draft 1-8-14.docx."ll41 Dr. Mallinger's use 

of the term "administrative closure" to refer to the document, instead of the previously-used 

"report" suggests that by January 9, 2014, Dr. Daigh decided to administratively close the VA 

OIG's Tomah VAMC health care inspection. Dr. Mallinger explained to Chairman Johnson's 

staff that his email to Dr. Wesley on January 9, 2014, was when his "input" on the Tomah 

V AMC health care inspection ended. 1342 

Chairman Johnson's staff attempted to explore the differences between the versions Dr. 

Mallinger prepared as a published report in 2013 and the drafts of the administrative closure Dr. 

Mallinger prepared and ultimately sent to Dr. Wesley in January 2014. Again, VA OIG counsel 

interrupted the staffs questioning and directly ordered Dr. Mallinger not to answer questions 

from Chairman Johnson's staff: 

Q: So was this version you sent up to Dr. Wesley in January the final 

version you worked on? 

A: So that was-right. That was when my input to it ended. So I was 

giving her [sic]-to the best of my recollection, I was giving her [sic] 

the most up-to-date copy of it. 

Q: So just to clarify, you did not work on the draft-the drafting of the 

Tomah administrative closure after mid-January of2014? 

A: Not to my recollection. 

Q: Was the version that was the final closure significantly--

1336 E-mail from Alan Mallinger, VA OIG, to George Wesley, VA OIG (May 6, 2013, 5:41 PM), O!G 11230. 1337 !d. 

13" E-mail from Alan Mallinger, VA O!G, to George Wesley, VA O!G (May 15, 2013, I :23 PM), O!G 11226. 1})9 !d. 

1340 Daigh Transcribed Interview, at 96. 1341 E-mail from Alan Mallinger, VA O!G, to George Wesley, VA O!G (Jan. 9, 2014, 12:09 PM), O!G 11224. 1342 Mallinger 4/21/2016 Transcribed Interview, at 37 L 

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VAOIG 

Attorney: I'm going to object to that. 

Q: Can I finish my question, please? 

VAOIG 

Attorney: No, heVAOIG 

Attorney: Let him ask the question and then you can object, andVAOIG 

Attorney: Don't answer before my objection, but please continue. 

Q: Was the version that was the final administrative closure significantly 

different from the version you submitted to Dr. Wesley in January of 

20I4? 

VAOIG 

Attorney: And I object to the question because you're now asking about versions 

of draft reports, which is deliberative. 

Q: Dr. Mallinger, please feel free to answer the question if you'd like. 

VAOIG 

Attorney: Dr. Mallinger, do not answer that question1343 

The VA OIG claims that the Tomah VAMC administrative closure was finalized on 

March 12,2014. 1344 During his transcribed interview with Chairman Johnson's staff, Dr. Daigh 

explained why he decided to administratively close the Tomah VAMC health care inspection. 

He stated: 

Tomah created the other problem, and the problem that Tomah created with-was 

that I do not publish reports that contain a repetition-so our standard report 

repeats the allegations that were given to us. So I do not publish reports that 

repeat salacious allegations that I can't support. So to write a report with all sorts 

of accusations that I can't support and throw that into a small community destroys 

the community and destroys the VA. 

1343 Id at 370-.71. 1344 Tomah VAMC: Examining Quality, Access, and Culture of Overreliance on High-Risk Medications, Joint Field 

Hearing Before S. Comm. on Homeland Sec. & Governmental Affairs & H. Comm. on Veterans Affairs !14th Cong. 

(2015) (statement of John Daigh, Jr.). 

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So in this report, we had allegations that-we had the whole panoply of sort of 

Candy Man allegations, right? You had allegations of people-of criminal 

activities. You had allegations of misuse of narcotics. You had allegations of all 

sorts of misbehavior among folks. And after we had interviewed people, after we 

had looked at all the emails, after we had talked to the DEA, after we had done all 

that work, there would be an allegation, and then I would say I don't have any 

data to support it. 

The second allegation that was out there that was extremely important was that 

Dr. Houlihan was practicing substandard medicine and specifically that he was 

treating PTSD with narcotics. Alan [Mallinger] came to the conclusion that he 

was not treating PTSD with narcotics, that these patients had very complex 

medical history, often involving risk of suicide and other significant behaviors. So 

Alan came back and the other doctors supported that this guy was at the edge of 

what was normal, but we could not say that his practice was not within standard. 

So, again, I would have allegations: 

Allegation: VA is treating patients with narcotics for PTSD. Not supported. 

Allegation: VA is going to cut the leg off of a patient because he has chronic pain. 

Not supported. 

Allegation: A gentleman committed suicide because his boss was unkind to him. 

We looked into that. Unsupported. 

Then there would be in the last paragraph of the report, there would be-there 

would be a statement of what we could support, and that would be that there was 

a lack of trust and some managerial issues between the pharmacist and Dr. 

Houlihan or the chief of staff, which, frankly, is an extremely common finding 

that we have, you know, between different parts of hospitals frequently. 

So I thought that those allegations, unsupported by us, was an inappropriate 

publication. I did, though, believe that even though we didn't have the data to 

support these allegations, we believed that there were issues there, and so we 

wrote suggestions. And I insisted that Alan and George Wesley meet with the 

director and go over what we had as issues fonnally, although as you can see from 

what you've already seen, they're aware of the issues. From the CAP report, we 

briefed them. They knew we were there talking to who we were talking to. We 

talked to the VISN director. And at those meetings, they came forward and told us 

the changes they'd already put into place to deal with the issues that we had 

identified. 

So, you know, I think-so that was the reasoning. It was-if! don't-if I can't 

support the essential things, I think that repeating salacious allegations is not in 

~ "----... J 

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the best interest of the Government or the hospital or the veterans in that 

community1345 

There is a significant difference between an administrative closure and a published report 

of a VA OIG health care inspection. Reports of health care inspections are published on the VA 

OIG's website. Administrative closures are not. Instead, the VA OIG merely lists the number of 

Office of Healthcare Inspections administrative closures it completed in its semiannual reports to 

Congress. Dr. Daigh stated that the VA OIG has "always" made administrative closures "freely 

available when asked." 1346 Of course, a congressional office-or even a concerned citizen, for 

that matter-would have to know of the existence of an inspection and administrative closure in 

order to request information pertaining to that inspection. That type of information is currently 

impossible to obtain from the VA OIG's practice of merely publishing the number of 

administrative closures in its semiannual reports to Congress. 

Published reports go in-depth into the allegations that the VA OIG Office of Healthcare 

Inspections reviewed and provide evidence to support the office's findings. Conversely, 

administrative closures are "brief documents" that are "summar[ies] of the initial evidence" and 

are supposed to be one or two pages1347 Administrative closures are drafted in a different 

manner than published reports. 1348 Published reports also contain recommendations that require 

follow-up from the facility that the VA OIG reviewed. 1349 According to Dr. Mallinger, an 

administrative closure "won't normally contain recommendations," and the Tomah VAMC 

administrative closure contained a number of"suggestions"-rather than recommendations-for 

the facility to implement. 1350 Dr. Mallinger explained the significance of the differences between 

recommendations in published reports and suggestions contained in administrative closures 1351 

With respect to the Tomah V AMC inspection, Dr. Mallinger acknowledged that an 

administrative closure was his "big concern" because the suggestions differed in weight from 

OIG recommendations. 1352 

When Chairman Johnson's staff inquired whether the "suggestions" that appeared in the 

administrative closure were originally written as "recommendations" in initial drafts of the 

Tomah document, VA OIG counsel again objected and refused to allow Dr. Mallinger to answer 

the question. 

A: So recommendations are part of the standard kind of way we deal with 

reports. And as I've said before, you know, we-you know, in a sense 

they're the focus of the report. They're the things that we've identified 

1345 Daigh Transcribed Intenriew, at 93-95. 1346 !d. at 95. 1341 Mallinger 4i21/2016 Transcribed Interview, at 344; Daigh Transcribed Interview, at 96. 1343 Mallinger 4121/2016 Transcribed Interview, at 342-43. 1349 !d. at 379-80. 1150 Jd. at 344. 1351 !d. at 379-80. !3.:'i2 !d. 

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that need to be changed, that we want the VA to change. And those get 

sent to the VA, along with the report, of course, pre-publication. And 

then they have to either concur or not concur with them. And our job is 

to make it so that they want to concur because, as I said, we don't run 

the VA, and if they don't agree, they're not going to do it. So we're 

trying to get them to make these changes. 

So that's what we do, and those recommendations are then followed 

up on. We have like a separate office that follows up on the 

recommendations and, when they've been completed, basically closes 

them out. So it's a very formalized process. 

Suggestions, you know, we don't have-in an administrative closure, 

we don't have a defined process like that. So--and this was actually 

one of the things we-the only-you know, once I heard this was 

going to be an administrative closure, this was my big concern. We 

had things to tell the VA, how are we going to do this? So the way that 

we decided to do it was through having suggestions. So we basically 

made the recommendations as suggestions. And they don't have the 

same formal follow-up process, and they don't require concurrence 

from the VA. But other than that, they're basically what had been the 

recommendations. 

Q: So were these four or five suggestions in an earlier draft actually 

recommendations~ 

VAOIG 

Attorney: Objection, deliberative process. We're not talking about earlier 

drafts. 1353 

The difference between the OIG offering recommendations or mere suggestions appears 

to have had a direct effect on how the VA responding to the Tomah VAMC inspection. In the 

summer of 2014, VA OIG employees-including Dr. Mallinger, Dr. Shepherd, and Dr. 

Wesley-briefed Tomah VAMC Director Mario DeSanctis, then-VISN 12 Quality Management 

Officer Victoria Brahm, and VISN 12 Director Dr. Jeffrey Murawsky about the administrative 

closure's findings and suggestions. 1354 According to Dr. Mallinger, Director DeSanctis informed 

him at some time following the briefing that he chose not to implement one of the OIG's 

suggestions. Dr. Mallinger stated: 

135) Jd. 

1354 VA OIG Office of Health care Inspections, Alan Mallinger, Report of Contact with Jeffrey Murawsky, Nerwork 

Director, VISN 12 (July 16, 2014, I :30 PM), VA OIG 13814; VA OIG Office ofllealthcare Inspections, Report of 

Contact with Mario DeSanctis, Victoria Brahm, & Julie Nutting (July 3, 2014), OIG 13651. 

,/~.._, 

) '·"·; 

c.~N ';· f 

l\_ .. 

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Q: And do you understand-from your understanding, did Director 

DeSanctis implement those changes after receiving this administrative 

closure? 

A: Well, Mr. DeSanctis did make some changes, and he did contact me 

later and tell me that he wasn't going to make one of the changes, that 

he had decided. And so we kind of took it to the next level, to the 

VISN Director. So I think that, you know, it was two people involved 

here, the facility Director and the VISN Director. And I think, again, if 

you go through the specifics, you know, there were some things he 

said he did change. And so there were some-as l said, he contacted 

me later, and he said there was one thing he wasn't going to change. 

AndQ: And what was that thing that he wasn't going to change? 

A: It had to do with who the Director of the pharmacy reports to. We 

had--one of the problems that we identified stmcturally at Tomahand, you know, as I kind of said, and said in the report, you know, 

there was kind of a dysfunctional system at Tomah. And part of the 

dysfunction we felt could be helped by not having the Pharmacy 

Director report to the Chief of Staff becauseQ: Who was-who was the Chief of Staff? 

A: Dr. Houlihan. 

Q: So Director DeSanctis called you after this June 2014 phone call and 

advised you that he was not going to change that process? 

A: l don't know if he called me or emailed me or-but he-we-our 

recommendation was that the Pharmacy Director should report to him 

because, you know, there was already this conflict between Dr. 

Houlihan and the pharmacists. And if you have the Pharmacy Director, 

you know, basically under the Chief of Staff, then he-then there's no 

balance there. The pharmacists are totally at the mercy of whatever the 

Chief of Staff tells them. But if the Pharmacy Director points-reports 

to someone higher, then there's at least a chance for there to be 

balance if there's a disagreement as to how things should be done. So 

that was one of the stmctural things we felt. 

Q: And Director DeSanctis advised you he was not changing Dr. 

Houlihan's role of overseeing the pharmacy? 

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A: That's my recollection. I'm trying to see what he said about it in this 

interview. But my recollection of it is that he contacted me separately 

and said that that was one change that he didn't feel comfortable 

making. 

Q: Did he provide you a reason of why he wasn't comfortable making 

that change? 

A: My recollection is he said he was too busy to have another person 

reporting to him. But I'm not totally sure that's correct. 1355 

Had the VA OIG's work product on its Tomah VAMC health care inspection been a 

published report rather than an administrative closure, the facility would have been required to 

work with the VA OIG to either concur or not concur with the recommendations and explain its 

decision. The published report would have ensured greater transparency with how the VA and 

the OIG addressed the problems at the Tomah VAMC. The VA would have had to explain why 

it agreed or disagreed with the VA OIG's recommendations to change the pharmacy reporting 

structure. The published report and recommendations would have also ensured accountability on 

the part of the VA to explain its reasoning for accepting or rejecting the Inspector General's 

recommendations. The facility's failure to act in this instance would have been well-documented 

and the public would not have had to wait the many months for changes to actually be made. 1356 

Because the VA OIG continues to withhold drafts of the administrative closure-and Dr. 

Mallinger's earlier drafts prepared as a public report-Chairman Johnson and the majority staff 

cannot assess the substantive differences between the versions. It is clear, nonetheless, from the 

available infonnation, that line-level VA OIG employees initially prepared the final product as a 

public report, a vast difference both substantively and procedurally from the nonpublic 

administrative closure. 

4. The VA OIG understated the degree to which Dr. Houlihan's and Deborah Frasher's 

prescription practices were outside the norm 

The VA OIG's analysis in its administrative closure downplayed the seriousness of 

prescription irregularities at the Tomah V AMC. The administrative closure concluded that 

"[a]lthough the allegations dealing with general overuse of narcotics at the facility may have had 

merit, they do not constitute proof ofwrongdoing."1357 However, the administrative closure also 

noted: 

1355 Mallinger 4/2!/20!6 Transcribed Interview, at 376-78. 1356 Currently, the Chief of Pharmacy reports directly to the Associate Director of the Tomah V AM C. The Acting 

Associating Director of the Tomah VAMC is Jeffrey Evanson. Evanson Transcribed Interview, at 63. 1357 VA OIG TOMAH VAMC ADMINISTRATIVE CLOSURE, at 9. 

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Our inspection raised potentially serious concerns that should be brought to the 

attention ofv1SN 12 management for fm1her review. In particular, we noted that 

the amounts of opioid equivalents prescribed by [Dr. Houlihan and Nurse 

Practitioner Frasher], both in the aggregate and per individual patient, were at 

considerable variance compared with most opioid prescribers in VISN ... 1358 

Standing alone, these connnents seem to suggest rather serious allegations that are juxtaposed 

within a rep011 that constitutes "no proof of wrongdoing." TI1e administrative closme included 

charts and other data illustrating the outliers in the amount of opioids that were prescribed at the 

Tomah VAMC. 

Flgnr• 93: VA OIG Tomah VAMC Adminlstratiw Closur•, Compatison ofOpioid P•·•scrlptions 1359 

Table I. Morphine Equivalents Prescribed by each VISN' 12 

~~. 

695 

537 

Total 

VAMC Station In FY 12. 

Unique 

Patients with 

Opioid 

Total Morphine 

Equivalents/Unique 

Patients with Oplold 

====+---Presc,r:lp_!ip,<lS ___ _ 

---f-l:.:l:.c:·~~ 

~,1~ 

In Figure 93 above, "station 676" refers to the Tomah V AM C. As is apparent, the 

Tomah VAMC has the smallest number of patients on opioids in all ofVISN 12. but had the 

fifth-highest total prescribed morphine equivalent. TI1is chart also shows that although the 

Tomah VAMC had the fewest patients in the VISN on opioids. the patients that were prescribed 

opioids received the highest dosages of opioids in the entire VISN. 

13" Id. (emphasis added). 

ll" Id. at 7. 

··~)r f 

\ 

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equivalents) in FY 12 

In Figure 94 above. Deborah Frasher is identified as "NP Y'\ Dr. Houlihan is identified 

as "Dr. Z" and an unnamed physician's assistant at the Tomah VAMC is marked as "PA." As 

the VA OIG noted in its administrative closure. Ms. Frasher was the highest prescriber of opiates 

in VISN 12 out of"3206 providers who wrote prescriptions for opioids." 1361 Dr. Houlihan was 

the "seventh highest opioid prescriber in VISN 12" and the unnamed physician's assistant was 

the "fifth highest prescriber" of opioids in all ofVISN 12 1362 All told, Dr. Houlihan, Ms. 

Frasher. and the physician's assistant at Tomah accmmted for one-third "all morphine 

equivalents prescribed at Tomah VAMC" in fiscal year 2012. 1363 Ms. Frasher prescribed the 

second-most opioids per patient out of all VISN 12 providers. 1364 Dr. Houlihan prescribed the 

fomth-most opioids per patient out of VISN 12 providers1365 

The administrative closure noted that the opioid presc1iptiou practices at the Tomah 

V AMC were at "considerable variance compared with most opioid prescribers in VISN 12" but 

ultimately found no wrongdoing. 1366 The administrative closure downplayed or ignored other 

data about questionable prescriptions practices at Tomah V AM C. For example, in fiscal year 

2012, Tomah V AMC prescribers accounted for 6 of the top 20 highest presc1ibing providers and 

nine of the top 30 highest prescribing provider" in totalmmphine equivalent 1m its dispensedll67 

1 60 !d. at 8. 

116!/d. 

IJ611d. 

D6l Jd. 

ll<>l !d. 

1365 ld, 

"''!d. at 9. 

" 67 Spreadsheet. Equivalence Detem1ined by Total Quantity Dispensed in F¥12. OIG 1947 (showing that Station 

585 has 2 clinicians in the top 10 and 6 in the top 30, which is fully 10 percent less than Tomah VAMC's statistics). 

:\lajority Staff Report 

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The data that the VA OIG collected for fiscal year 2012 also showed the average daily 

morphine equivalent per specific patients. 1368 The data showed that a number of patients at the 

Tomah VAMC were prescribed less than I 0 morphine equivalents per day. However, the data 

also showed outliers in both Dr. Houlihan and Ms. Frasher's prescription practices. For 

example, Ms. Frasher has 31 patients with a daily average greater than I 00 morphine 

equivalents, 1369 and one patient had an average daily morphine equivalent of2,185.mo Dr. 

Houlihan had 20 patients with daily morphine equivalents average over I 00, 1371 and one patient 

with an average daily morphine equivalent of 1,614.1l72 While the administrative closure 

correctly noted that their prescription practices were at "considerable variance" with the rest of 

VISN 12, that statement does not capture the extent to which these professionals' prescription 

practices were outliers1373 

When opioids are prescribed with such frequency, it is important that the facility have in 

place proper safeguards to ensure that the drugs are used only for their proper purpose. One way 

to monitor and prevent improper drug use is to conduct urine drug screens (UDS). Providers 

give patients UDS to ensure that they are actually taking the drugs they are prescribed and not 

diverting them for illegal purpose. If veterans have negative UDS, it may be indicative that they 

arc not taking the drugs they are prescribed and the drugs may potentially be diverted. The VA 

OIG found that at the Tomah VAMC, "negative (UDS] are not acted on and that controlled 

substances are still prescribed in the face of a negative UDS." 1374 The combination of high 

opioid prescriptions with non-action on negative UDS may result in the potential widespread 

diversion of drugs and may have contributed to the Tomah VAMC's perception in the 

community as "Candy Land." Had the VA OIG published its findings in a public report, instead 

of administratively closing the case, the VA could have been forced to respond to the findings 

and address these issues. 

5. With the information available, it is difficult to assert that the VA OIG's email 

collection and review was adequate 

The VA OIG reviewed emails collected from Tomah VAMC and VISN 12 employees 

during its health care inspection of the facility. In its administrative closure, the VA OIG wrote 

that it "collected an e-mail dataset for review consistin9 of 227,532 unique e-mail messages and 

859 associated files originating from 17 individuals."13 5 The administrative closure noted that 

the health care inspection team "searched terms that could signal potential drug seeking 

behavior, such as those related to early refills and urine drug screens, in order to assess what was 

1368 See Spreadsheet, Average Daily Morphine Equivalent per Patient, OIG 2879-4122. 1369 See generally id. at OIG 3188~91. 1370 See id. at OIG 3189. 1371 See generally id. at 3303~05. 1372 See id. at OIG 3304. 1373 See VA OIG TOMAH V AMC ADMIN!STRA TIVE CLOSURE, at 8~9. 1374 See id. at 6. 1375 Id. at 3. 

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being communicated about these topics, as well as what advice or instructions being given." 1376 

In addition, the VA OIG team "reviewed messages pertaining to specific individuals in cases 

where administrative/supervisory conflicts were reported to exist." 1377 

These quoted excerpts are the only mention of email collection in the entire 

administrative closure. The VA OIG did not identify whose emails it collected or why it chose 

those individuals. It does not explain how long staff reviewed emails, or what information the 

inspectors learned from the emails. 

Notably, the VA OIG did not provide Chairman Johnson and the Committee with all of 

the emails it collected as part of its inspection, as required pursuant to the Chairman's 

subpoena. 1378 Instead, the VA OIG provided Chairman Johnson with only a redacted subset of 

emails that were "tagged" as indicating that the VA OIG health care inspectors viewed the 

email. 1379 In a subsequent transcribed interview, a VA OIG attorney explained that the "tagfed" 

emails were the emails that the health care inspectors marked as relevant to their inspection. 380 

Further, the attorney informed Chairman Johnson's staff that not all of the emails collected were 

necessarily part of the VA OIG's case file relating to the Tomah VAMC inspectionnst The VA 

OIG health care inspectors had to take the extra step of "tagging" the email as potentially 

relevant to their inspection in order for the email to qualify as part of the Tomah V AMC case 

tile. 1382 One VA OIG employee who reviewed emails as part of the health care inspection 

recalled tagging "less than a handful" of emails. 1383 

The number of emails cited in the administrative closure is misleading in terms of the 

scope of the VA OIG' s email search. The health care inspection team may have very well 

collected in excess of227,000 emails, but it likely only reviewed a small fraction of that total 

that were "tagged" as potentially relevant. In addition, it appears that the VA OIG ignored 

emails it collected from individuals that could have shed light on administrative abuses and other 

issues at the Tomah VAMC. 

The VA OIG health care inspectors solicited the assistance of the VA O!G criminal 

division to procure the emails of Tomah VAMC and VISN 12 employees. 1384 To obtain the 

emails, Dr. Robert Yang, a physician in the VA OIG's Office ofHealthcare Inspections, wrote 

memoranda to the Director of Computer Crimes and Forensics Laboratory within the VA OIG's 

1376 !d. at 3. 1377 !d. at 3. 1378 Yang Transcribed Interview, at 131-32. 1379 !d. at 130-3!. 1380 Jd at 13!. 1381 Jd at 132. 13S2Jd 

13" !d. at 140. 1384 Memoranda from Robert Yang, VA, to Director, Computer Crimes and Forensics Laboratory (May 17, 2012), 

01G 13676-78. 

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criminal division. 1385 The memoranda included the identity of the employee whose emails the 

VA OIG health care inspectors sought, the sources for the email pull (whether it was from the 

network drive, local computer or both) and whether the emails needed to be decrypted. 1386 Brian 

Tullis, Assistant Special Agent in Charge and Director of the Computer Crimes and Forensics 

division of the VA OIG's Criminallnvestigations unit, facilitated the production of emails to the 

health care inspection team. 1387 

Dr. Yang sent two request memoranda for emails of Tomah VAMC and VJSN 12 

employees. Dr. Yang sent the first request via email to Mr. Tullis on May 17, 2012. 1388 He sent 

the second request memorandum on August 30, 2012. 1389 In total, the VA OIG health care 

inspection team reviewed the emails of the following individuals: 

!385ld 

!386 Id. 

Dr. David Houlihan, Tomah VAMC Chief of Staff; 

Deborah Frasher, Nurse Practitioner, Tomah VAMC; 

Thomas Jaeger, Pharmacist, Tomah VAMC; 

Margaret Hyde, Pharmacist, Tomah VAMC; 

Mary Forslund, Nurse Practitioner, Tomah VAMC; 

Dr. Zakia Amling (Siddiqi), Physician, Minneapolis VAMC (formerly Tomah 

VAMC);IJ9o 

Dr. Christopher Kirkpatrick, Psychologist, Tomah V AMC; 

Linda Ellinghuysen, Patient Safety Nurse, AFGE 007 President, Tomah V AMC; 

Dr. Gary Loethen, Psychologist, Tomah V AMC; 

Cindy Gile, Physician Assistant, Tomah V AMC; 

Angela Cournoyer, Pharmacist, Tomah VAMC; 

Craig Otting, Pharmacist, Tomah VAMC; 1391 

Jerald Molnar, Director, Tomah VAMC; 

Donna Leslie, VISN 12 Pharmacy Executive, VISN 12 Office; 

Ron Pelham, Chief of Pharmacy, Tomah VAMC; 

John H. Edwards, Psychiatrist, Madison VAMC; 

Dr. Dean Whiteway, Physician, Tomah VAMC; and1392 

'"'!d.; E-mail from Brian Tullis, VA OIG, to Robert Yang & Alan Mallinger, VA OIG (July 5, 2012, 8:26AM), 

OIG 10348. 1388 Memorandum from Robert Yang, VA, to Director, Computer Crimes and Forensics Laboratory (May 17, 2012), 

OIG 13676; Memorandum from Robert Yang, VA, to Director, Computer Crimes and Forensics Laboratory (May 

17, 2012), OIG 13677; Memorandum from Robert Yang, VA, to Direclor, Computer Crimes and Forensics 

Laboratory (May 17, 2012), OIG 13678. 1389 Memorandum from Robert Yang, VA, to Director, Computer Crimes and Forensics Laboratory (Aug. 30, 2012), 

OJG 10351. 1390 Memorandum from Robert Yang, VA, to Director, Computer Crimes and Forensics Laboratory (May 17, 20 12), 

01G 13676. 1391 Memorandum from Robert Yang, VA, to Director, Computer Crimes and Forensics Laboratory (May 17, 2012), 

OIG 13677. 

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Roberto Obong, Chief of Police, Tomah VAMC. 1393 

Dr. Yang explained that the VA OIG "reviewed the emails over the course of several 

days. Again, three separate days, we sat down and went through them for about-I'm thinking 

anywhere between 2 and 4 hours at a time." 1394 Dr. Mallinger estimated that the total time 

reviewing emails would "probably be a week ofwork." 1395 

Dr. Mallinger explained to Chairman Johnson's staff during a transcribed interview why 

the VA OIG collected the emails of certain employees. In particular, the VA OIG chose to 

collect emails from Lin Ellinghuysen, the president of the local Tomah employees union, 

although the VA OIG opted not to interview Ms. Ellinghuysen as a part of its inspection. When 

discussing these decisions with Chairman Johnson's staff, Dr. Mallinger stated: 

A: So in the Juneau County sheriffs investigation, there were several 

individuals who were named. And, again, we wanted to look more 

carefully at this because there were allegations that somehow he had 

been critical of Dr. Houlihan's prescribing practices and had been fired 

because of that. And so these people listed below his name-Linda 

Ellinghuysen, as I said, had represented him, Gary Loethen was his 

supervisor, and Cindy Gile was a physician's assistant who supposedly 

he made these comments to about Dr. Houlihan's practice. And so we 

wanted to see whether, you know, we could get any further 

information about any potential administrative abuse that might have 

taken place by looking through these records to basically see if, you 

know, they were sent emails or, you know, that they sent emails that 

would shed further light on that. 

Q: And what did you find? Did you confirm the allegations? Or were 

those unsubstantiated? 

A: Well, there weren't allegations about Dr. Kirkpatrick directly in the 

allegations we received, except for this-you see he's mentioned here 

in the EAR survey. I think it was in the EAR survey. No, I guess not. I 

guess he was mentioned in an interview. l know I saw him go by 

today. But, you know, basically there were-you know, there weren't, 

strictly speaking, allegations but, again, we were looking for 

administrative abuse, and, you know, we have a little latitude to go, 

1392 Memorandum from Robert Yang, VA, to Director, Computer Crimes and Forensics Laboratory (May 17, 2012), 

OJG 13678. 1393 Memorandum from Robert Yang, VA, to Director, Computer Crimes and Forensics Laboratory (Aug. 30, 2012), 

01G 10351. 1394 Yang Transcribed Interview, at 140. 1395 Mallinger 4/21/2016 Transcribed Interview, at 335. 

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you know, take a look at things that turn up in the leads that we 

develop. So that's really what we were doing here, is we were trying to 

determine whether there was any evidence for administrative abuse 

that arose out of this situation. And, basically, frankly, we were trying 

to understand the situation a little bit betterQ: Did have a sit-down interview with Linda Ellinghuysen during this 

inspection? 

A: I don't think so. 

Q: Whynot? 

A: Well, because we didn't really feel that the situation with Dr. 

Kirkpatrick led anywhere. We thought it was another-you know, one 

of many sort of thing that we followed that didn't take us to a 

productive conclusion. 

Q: So did you review Linda Ellinghuysen's emails~ And during that 

review were there emails that illustrated her concerns about the 

facility? 

A: Well, actually, you know, several of her emails were in the Juneau 

County sheriff's report, and whether we got additional fruitful emails 

I'm not really-it's a little hard to remember specifically. 

Q: Do you recall discussions about potentially having a sit-down, inperson interview with Linda Ellinghuysen? 

A: We may have discussed it. I really don't recall any specific 

discussions. 1396 

The Juneau County Sheriff"s report on Dr. Kirkpatrick's suicide contained several emails 

between Ms. Ellinghuysen, Dr. Kirkpatrick, and other union officials. 1397 The emails discussed 

Dr. Kirkpatrick's concerns about overmedicated patients and his belief that he had "eve~ reason 

to be afraid of Dr. Houlihan" for raising those concerns to others at the Tomah VAMC. 1 98 In 

addition, Ms. Ellinghuysen told Chairman Johnson's staff that she had raised concerns to the VA 

OIG about prescription practices and potential retaliation at the Tomah VAMC in January 

1396 Mallinger 4/6/2016 Transcribed Interview, at 256-58. 1397 E-mail exchange between Chris Kirkpatrick, M.D., U.S. Dep't of Veterans Affairs, Dianne Streeter, VA Chief 

Steward, AFGE Local 1882, and Linda Ellinghuysen, Executive V.P., AFGE Local 1882, at l-5 (Apr. 23, 2009) in 

JUNEAU COUNTY SHERIFF'S DEPARTMENT, CHRIS KIRKPATRICK DEATH INVESTIGATION REPORT 40, at 40-44 (2009). 

m 8 !d. at 42-43. 

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2009. 1399 Even in light of these multiple concerns, it does not appear that VA OlG health care 

inspectors carefully reviewed Ms. Ellinghuysen's emails, nor did they attempt to interview her. 

Chairman Johnson's also tried to determine whether the VA OIG interviewed other 

individuals whose emails it collected; however, the VA OIG refused to provide the names of the 

individuals it interviewed. For example, the VA OIG staff collected the emails of Dr. Zakia 

Siddiqi, a former physician at the Tomah VAMC. 1400 Dr. Mallinger explained that the VA OIG 

had pulled Dr. Siddiqi's emails because investigators "had concerns about the possibility of 

retaliation."1401 A report of contact completed bf: Dr. Mallinger on April4, 2012, detailed his 

conversation with a DEA diversion investigator. 402 The report of contact identified potential 

sources of information to further the VA OIG's investigation. One of those sources read: 

[Redacted] (current married name [redacted]). This is a physician currently 

employed at the [redacted], who works in [redacted]. Reportedly she was "fired" 

by Dr. Houlihan for refusing to write an oxycodone prescription for a patient with 

a negative drug screen. This was reported by a former VA pharmacist. 1403 

A subsequent Report of Contact completed by Dr. Mallinger on Aprill7, 2012, recounted a 

conversation with a doctor and that Dr. Mallinger "had gotten her name from DEA Agent 

[redacted] (see ROC 4-4-12)."1404 The Report of Contact noted that the individual was 

"defensive throughout the conversation" and "did not want to talk with the IG." 1405 

During a transcribed interview, Chairman Johnson's staff asked Dr. Mallinger whether 

the individual referenced in the reports of contact was Dr. Siddiqi. VA OIG counsel interrupted 

the Committee's questioning and ordered Dr. Mallinger not to answer the question: 

Q: Is that individual, Dr. Siddiqi, the individualVAOIG 

Attorney: He's not going to answer that question because we said we redacted it. 

Q: Well, I'm going to ask it anyways. 

VAOIG 

1399 Ellinghuysen Transcribed Interview, at 69-72. 1400 Memorandum from RoberJ Yang, VA, to Director, Computer Crimes and Forensics Laboratory (May 17, 2012), 

OIG 13676. 1401 Mallinger 4/6/2016 Transcribed Interview, at 254. 1402 VA OIG Office of Health care Inspections, Alan Mallinger, Reporl of Contact with Diversion Investigator, DEA, 

(Apr. 4, 20 I2), OIG 5896 1403. ld. 

1404 VA O!G Office of Healthcare Inspections, Alan Mallinger, Reporl of Contact with Staff Physical (Apr. 17, 

2012), OIG 5899. 1405 Jd. 

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Attorney: Okay. 

Q: But on Exhibit 25, paragraph 2-

VA orO 

Attorney: It's redact-you're not going to answer anything about redacted 

names. 

Q: So you pulled Dr. Siddiqi's emails. Is what is mentioned in Exhibit 25 

in paragraph 2, did you find anything of that in Dr. Siddiqi's emails? 

VAorG 

Attorney: He's not going to admit that it's Dr. Siddiqi, so---

Q: Would you like to answer, Dr. Mallinger? 

VAorG 

Attorney: No, don't answer. 

VAorG 

Attorney: He can't answer that. 1406 

The VA OIG's obstruction on the identity of the people it interviewed presented 

challenges in determining whether the office interviewed the individuals whose emails they 

collected. Nevertheless, the recitation in the VA DIG's administrative closure of total number of 

em ails collected in a misleading number that does not represent the number of emails actually 

reviewed. Even in a case where the VA OIG collected an individual's email, it did not conduct 

interviews with them. With the limited information available, it is difficult to know with 

certainty whether the VA oro's email collection was adequate to assess the allegations. 

6. There is conflicting information about the date of the VA OIG's closure of the Tomah 

VAMC inspection 

From documents and other information available to the Committee, there is a degree of 

uncertainty as to when the VA oro closed its inspection of the Tomah VAMC. The VA oro 

informed Chairman Johnson through multiple letters and statements that Dr. Daigh 

administratively closed the Tomah VAMC health care inspection on March 12, 20141407 

However, VA oro's Master Case Index (MCI)-the VA oro's case management and tracking 

1406 Mallinger 4/6/2016 Transcribed Interview, at 254-55. 1407 Tomah VAMC: Examining Quality, Access, and Culture of Overreliance on High-Risk Medications, Joint Field 

Hearing Before S. Comm. on Homeland Sec. & Governmental Affairs & H. Comm. on Veterans Affairs !14th Cong. 

(20 15) (statement of John Daigh, Jr.). 

r-''"---

~1 ._ _____ .) 

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system-indicates that the Tomah VAMC administrative closure was not closed until August 

2014.1408 

Dr. Daigh testified during the Committee's tleld hearing in March 2015 that he 

administratively closed the Tomah VAMC health care inspection on March 12, 2014. 1409 

Internal email correspondence from the VA OIG also shows that Dr. Daigh signed the 

administrative closure on March 12, 2014. On the morning of March 12, 2014, Dr. Daigh 

received an email informing him that "[t]he adjusted copy of the Tomah Admin Closure is 

uploaded to your box in SharePoint as well as attached. Edna is preparing a printed copy for 

your signature."1410 Later that afternoon, of March 12, 2014, Dr. Daigh replied, "Thanks ... 

signed and provided to Edna." 1411 

In a transcribed interview with Chairman Johnson's staff, Dr. Daigh explained that his 

signing and dating of an administrative closure marks the conclusion of a health care 

inspection1412 He also reiterated that the Tomah VAMC health care inspection was closed on 

March 12,2014.1413 

Page II of the VA OIG's administrative closure about the Tomah VAMC bears Dr. 

Daigh's signature and a date marking the end of the closure. 1414 The date appears to read 

"3/12114"; however, the "3" appears to have additional markings that would seem to be 

unnecessary for an ordinary marking of the numeral. These additional markings appear to 

suggest that the "3" may have been altered in some form, and could have been an "8" at some 

time. The numeral "8"-for August-would seem to match the information in the VA OIG's 

Master Case Index. 

1408 See VA 010 Health care Transaction Report, MCI 112011-04212-HI-0267 (May I, 2015, II :46 AM), OIG 1394, 

at OIG 1394-96; VA OIG Hotline Input Transaction, MCI # 2011-04212-HL-1068 (May 1, 2015, 11:48 AM), OIG 

1397. 

1409 Tomah VAMC: Examining Quality, Access, and Culture of Overreliance on High-Risk Medications, Joint Field 

Hearing Before S. Comm. on Homeland Sec. & Governmental Affairs & H Comm. on Veterans Affairs I 14th Cong. 

(20 15) (statement of John Daigh, Jr.). 1410 E-mail from Natalie Sadow, VA OIG, to John Daigh, VA 010 (Mar. 12,2014, 11:41 AM), 010 10304. 1411 E-mail from John Daigh, VA OIG, to Natalie Sadow, VA 010 (Mar. 12,2014, 1:20PM), 010 10304. 1412 Daigh Transcribed Interview, at 132. 1413 Jd at 132-33. 1414 Id. at 129. 

r/L,_ 

~~}f I ! L __ .J 

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11 of the VA OIG's administratin~ dosun.• 1415 

Based on our rev1ew, I am administraii\·cly closing this case. 

7.?E!~~- Assistant Inspector tleneral for 

Henlthcure Inspections 

~/12--/1'/ 

Figure 96: Enlarge-d signatnr~ and dah• of the VA OIG~s administrative- closurectt d!GH, JR, M.D.jP ~ Assistant Inspector General for 

Healthcare Inspections 

~/12-/t'/ When Chairman Johnson's staff interviewed Dr. Daigh about the date of the 

administrative closure. he said that he did not recall signing the docmnent. He stated: 

Q: This is au unredacted copy of the administrative closure the 

Committee received pursuant to a request letter from Chairman 

Johnson. The title of the document is "Administi·ative Closure. 

""VA OIGTOMA.HVAMC ADM!t-<1STRATIVE CLOSURE. at ll. 

~, •').._ 

~) • I 

\ 

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Alleged Inappropriate Prescribing of Controlled Substances and 

Alleged Abuse of Authority, Tomah VA Medical Center, Tomah, 

Wisconsin, MCI 25 2011-04212-HI-0267." Dr. Daigh, ifl could tum 

your attention to the last page, please? 

A: Sure. 

Q: Is that your signature on that page there? 

A: Yes. 

Q: What is the date of this document? 

A: I think it says 3/12/14. 

Q: Do you recall dating it when you closed it and signed it? 

A: I typically do, yes. 

Q: But do you recall in this instance? 

A: No1416 

Pursuant to the Chainnan Johnson's subpoena, the Committee received the VA OIG's 

MCI file document for the Tomah V AMC Inspection. The VA OIG gives each hotline a unique 

identifier number to mark its progress in the MCI file. The MCI documents for each hotline 

summarize the allegations the hotline received, marked the dates the VA OIG received the 

allegation, as well as milestones as the team progressed through the health care inspection. In 

addition, the MCI notes when the VA OIG closes each inspection. 

There are two hotline numbers and MCI input documents that refer to the Tomah VAMC 

health care inspection. The VA OIG's administrative closure identified the Tomah health care 

inspection as MCI # 2011-04212-HI-02671417 The VA O!G bundled the hotline it received from 

Congressman Kind in August 2011 with the same inspection that the health care inspection team 

was already conductin~. The referral from Congressman Kind was marked with the MCI # 

2011-04212-HL-1068. 418 

Chairman Johnson's staff reviewed the MCI tracking documents for both of those 

hotlines. The VA OIG's case tracking and management system for MCI# 2011-04212-HI-0267 

1416 Daigh Transcribed Interview, at 128-29. 1417 VA O!G TOMAH V AMC ADMINISTRATIVE CLOSURE, at I. 1418 VA OIG Hotline Input Transaction, MCI # 2011-04212-HL-1068 (May I, 2015, 11:48 AM), OIG 1397. 

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shows that the ''actual completion date" and the "publication date" of the VA OIG's Tomah 

V AMC health care inspection was August 12, 2014. 1419 

Figur• 97: Pag• 1 of th• Mast•r Cas• Ind•x Fil• ofth• VA OIG's Tomah VAMC inspection (#0267)1420 

NHC030 OFFtCE OF INSPECTOR GENERAL 

HEALTH CARE TRANSACTION REPORT 

DATE: 051()112015 11 oUJ A" 

Pa!)a t 

MCINo 

Prajcct lltl& 

2011-042~2·1'-11-0267 Fieeal Y~:ror 21)11 Oato Receivtd m OHI Osro:iZO\ 1 

Reca!vl!dFfDI'TI 

Ro~rtNul'llbor 

~EAl THCARE INSPEClTONS- QUALITY OF CARE· MI<DICATION MI'WAGEMENl TOMAH. 

WI 

05.130/2012 

Ho! 

lin~,ICon[JfUSIOI'llol 

VHJ\M(jthtJICare 

c~ogory Co-de 9 Hcll!'l!! 

Statm !3 ClolaQ Actual COIT'Ipletlon D1t11 

Figuro 98: Pag• 3 ofth• Mast•r Cas• Ind•x Fil• oflb• VA OIG's Tomah VAMC insp•ctiou (#0267)1401 

I NHCD30 

Oat• Workplan Approved 

D<~teofVisit OS1'22f1012 

MO Involved k1 HOIHne 

8t11rt Datn.tlnfo Calleeted 

End CNtallnfoCollt'Cied 

O~MCE OF INSPECTOR GENEAAL 

HEAL Ttl CARE TRANSACTION Ri!PORT 

Hotlinc:t RepDtt Phas-e 

OA.1E; OSii)11201S 11 U AM 

Pagl!l 

Ot1t17 Fil'3t Hl Draft to VHA 

Datr Cnrnrrnmls Rttc'd from 54AAIC on HL 

O.t• Uran to VHA 

Doto Ro<'d Rcrspcnse from VtiA 

Datt!' Final HL Report to 54A. 

Oat• HLto ERO 

In addition, the MCI information from the hotline refened by Congressman Kind- MCI 

# 2011-04212-HL-1068-similarly indicates that the referral was also closed in August 2014. 

The first page of the case-tracking document sununarized what the VA OIG fotmd in the 

administrative closure and notes the "disposition date" as August 14, 2014. 1422 Likewise, page 

two of the document summarized the allegations and displayed the date of the "response 

received" as August 14, 2014. 1423 The third page of the MCI infommtion for the Tomah VAMC 

hotline showed that the hot line was administratively closed on August 14. 2014. The "analyst 

1419 VA OIG llealthcare Transaction Report. MCI # 2011-04212-HI-0267 (May L 2015. 11:46 AM). OIG 1394. at 

OIG 1394-96. 1420 I d. at OIG 1394. 

'"'I d. at OIG 1396. 

""VA OIG Hotline Input Transaction. MCI# 2011-04212-HL-1068 (May!, 2015, 11:48 AM). O!G 1397. 

Wl ld. at OIG 1398. 

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notes" on page three also showed that the achninistrative closme was "received" on August 14, 

2014. 1424 It fmther indicated that the case was "closed partially substantiated" and that 

"Cathy"---likely VA OIG Congressional Relations Officer Catherine Gromek-was given "a 

copy for her congressional case" on August 14, 2014I425 

Figure 99: Page I of the Hotline referrol regarding !be Tomah VAMC (#1068) "'' 

1424 Id. at OIG 1399. l425Jd. 

1426 Id. at OIG 1397. 

05/0l/2015 i.J :48;4? 

P;:~~;re. 1 

J.uoctior:e.J. Area Ci!ldQ 

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Name o! C.ol!l"'laJ.na.nt... 

l".}:ct:Yt~'JS 

Subjoct 

.Rl1.Vt') ;w:r.r·~'" 

Nature Of Compl•int 

l:..i 

: ~,. 

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" 21 !d. at OIG 1398. 

.\lajority Staff Report 

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Senator Ron Johnson, Chairman 

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3 of thf.' Hotlinf.' n•f~Prral tb• Tomab V~'\fC 

k~:::-c ~d.ll"ir: ,~::-"''l~~ f:;~. '>,1 

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When interviewed by Chairman Johnson's staff, Dr. Daigh said that he did not know why 

the case-tracking system for the Tomah V A.1\1C inspection showed that the inspection was 

administratively closed on August 12, 2014. He stated: 

Q: For the record. Exhibit 24 is three pages marked OIG Bates 1394, 

1395. and 1396. It is an Office oflnspector General Health Care 

Transaction Report. The MCI mm1ber is 2011-04212-HI-0267. It is the 

same MCI number as the identified number on Exhibit 22, which is the 

administrative closure for the Tomah health care inspection. Dr. 

Daigh. ifi could tm11 yom attention to the top of 1394 where it says 

"Actual Completion Date." It reads, "8/12/2014." Do you have anywhy would this be ditTerent- why is the ach1al completion date in this 

hotline input transaction report August 12th when you signed off on it 

in Ma1·ch? 

A: So this is not my computer system. This is something called MCI. and 

we keep our data in Share Point, so I have no idea who entered that 

data. 

H2S !d. at OIG 1399. 

'·, 

~),; . I 

\ 

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Q: Who runs MCI? 

A: It's an internal data system that tracks all the hotline material, but 1 

don't know. 

Q: So you don't know why the actual completion date of this hotline is 

8/12/2014? 

A: I have no clue. 

VAOIG 

Attorney: Can we clarify? The question is: Can you answer why the actual 

completion date as reflected in MCI-which he's already said is a 

separate data system. 

Q: How is it a separate data system? What is it separate from? 

A: So my office runs off of a SharePoint site, so we get an allegation from 

hotlines, so a big hotline in the management group at the OIG. And 

then once we get that, we then manage the further flow of data in our 

SharePoint system so we have a way to monitor all the allegations that 

come to us, the decisions that we've made, and then they're processed 

through OHI. So I don't actually know who enters the data on this 

particular document, but it-but, you know, so I don't know why that 

is that way. 

VAOIG 

Attorney: Is the MCI system that one would actually work in? Or is it a database 

system that records cases? 

A: It's a database system that records cases, but we've migrated-again, 

we've migrated to a different-] don't-! don't know who entered this 

data. I really don't. So I don't know who did it, I don't know what it 

reflects. 

Q: Does signing an admin closure mark the conclusion of the inspection? 

A: For us it does, yes. That's why I dated it and why I signed it. 1429 

Both Dr. Daigh and Maureen Regan, Counselor to the Inspector General who 

accompanied Dr. Daigh to his interview with Chairman Johnson's staff, also questioned 

1429 Daigh Transcribed Interview, at 131 ~32. 

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why the VA OIG's case-tracking system showed the hotline about the Tomah VAMC 

referred to the VA OIG indicated that the inspection was closed on August 14, 2014. Dr. 

Daigh said that he did not know why the date for that referral differed from the date on 

the administrative closure. He stated: 

Q: This is a three-page document marked Bates OIG 1397, 1398, and 

1399. It is marked MCI number 2011-04212-HI-1068. A synopsis: 

This is a congressional interest from Congressman Ron Kind delivered 

to Cathy, and this number marks up with and the allegations mark up 

with the complaint sent in with Congressman Kind's. If! could tum 

your attention to 1398, about two- thirds of the way down, the 

referrals, it says, "Referrals. 54 referred to 54." That would be the 

Office of Healthcare Inspections, correct? 

*** 

A: Mm-hmm. 

Q: It says, "Date Referred August 26, 2011. Response Due November 26, 

2011. Response Received August 14, 2014." 

A: Mm-hmm. 

Q: This synopsis is discussing some of the findings, and if you'll tum to 

the first page of the document, the findings of the admin closure, it's 

clear referring to the Tomah inspection at issue here, you know, 

why-do you have an opinion or thought as to why it says that this 

wasn't received until August 14, 2014? 

A: I really don't know. I signed it on the date I signed it. You are correct 

in that the closing of the document I stipulated that we needed to meet 

with the VISN director and the facility director. I then asked days later 

Alan and George Wesley, "Did you meet with the facility director and 

the VISN directorry" And they told me no. So I told them to get out 

there and meet with the facility director and the VISN director. So they 

then did that. So that's why there's a difference in time between when 

I signed it and when that happened. 

The dates here, I really don't know who creates that date or where they 

get it from. But we see ceased work on this on the day 1 signed it, and 

that was the admin closure on our books. So this is-you know, this 

date actually is not the same date you had before, right? Actual 

completion date 8/12, and this says 8/14. 

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••• 

VAOIG 

Attorney: Just to clarify, some of the people who put these analyst notes, they all 

work in Hotline as opposed to Healthcare Inspections? 

A: Yeah, I frankly-! just don't know who enters what data on these 

screens, okay? It's-! don't know. 

Q: So if you tum to the last page of the document, OIG 1399? 

A: Okay. 

Q: Under the box "Attached Documents," it says, "August 26, 2011, 

incoming correspondence. August 26, 2011, Outlook and Paid docs. 

October 7, 2011, 54 accepts case. August 14,2014, 54 admin closure." 

In the "Analyst Notes," it says, "August 26, 2011, WILLIAMSY, 

referred to 54 for review acceptance. August 13, 2014, LAVINEC"--

L-A-V-1-N-E-C-"follow-up email to Cathy in Congressional." And 

then, "August 14, 2014, LAVINEC, received admin closure from 54, 

case closed, partially substantiated. Gave Cathy a copy for her 

congressional case." 

A: Okay. 

Q: Is that what occurred at that time period? 

A: So, routinely, you know, if it's a congressional, then Cathy's given a 

copy of the report, made aware of the report, and so I don'tQ: Wbat congressional is this note talking about, do you know? 

A: It would be this report, which was from our view a congressional from 

Representative Kind to ourQ: Just for the record, Dr. Daigh is holding up Exhibit 22, the admin 

closure. 

VAOIG 

Attorney: Can I just insert, we could save a lot of time, that this is a record put in 

by our Hotline Division. It's not done by Dr. Daigh or his staff. These 

three people on here-Yvonne Williams and Christine Lavine-are 

hotline, and Christine Lavine was actually a rehired annuitant at the 

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time, brought back of everything that was coming in and the mess 

created by the Phoenix issue at this time. So I don't know if he will 

know whether they had a report and put it in late, but it's not a 

document that Dr. Daigh or his staff fill in, and none of these people 

worked for-worked for him. It's just that it's something that 

happened in Hotline, and the dates are out of his control. We can go 

around and around in circles forever, but I think you're asking the 

wrong person, and I'm not sure it's going to be relevant to what 

Hotline put into the system versus the date he had it signed. You have 

an email to Edna at some point in 2014, and-

* •• 

Q: There's no date marks on here from the March 2014 time frame. Do 

you routinely send admin closures to this section of OIG? 

A: The admin closures, I believe, all eventually get logged into the system 

that maintains all reports. So the admin closures are then, I believe, 

kept in MCI someplace as a storage for the reports we've done, and 

that's managed, again, by 53, the Management Group. SoQ: So the admin-just so we understand, an admin closure goes from you 

and your signatureA: Right. 

Q: -to 53 Management. And then Management may send it to this 

Hotline Group? Is that what you're saying? 

A: No. What I'm saying is that reports-so the standard report in the 

publication process is archived by our internal management group 

through the standard SOP of how things are published. If you have an 

admin closure and it's not published, then it goes to--through another 

route and it gets back to the Management Group for OIG, and they 

then take a copy of it right here, and they put it in their big database so 

they have a copy of all the official reports that we did. So the date that 

it moves from a pile to a pile, I don't really know. But these guys are, I 

think, logging in our report into their system, and I don't know what 

these transaction dates mean. 1430 

1410 ld. at 134--40. 

~ L_J 

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Dr. Daigh has been employed by VA OIG since 2002, and has served as the Assistant 

Inspector General for Healthcare Inspections since 2004. 1431 Ms. Regan has been Counselor to 

the Inspector General since 1992. 1432 With a combined 36 years of experience in their current 

positions at the VA OIG, it is surprising that neither Dr. Daigh nor Ms. Regan would know how 

the cases are logged in the MCI center after the Office of Healthcare Inspections administratively 

closes a case. 

One potential reason for the discrepancy in the date that the administrative closure was 

finalized is that the administrative closure was not officially closed in the OIG's systems until 

the VA OIG received a FOIA request for the Tomah VAMC inspection report Throughout this 

investigation, the VA OIG has continually disputed claims that the Tomah VAMC administrative 

closure was not made public until the Center for Investigative Reporting article in January 

2015. 1433 Deputy Inspector General, Richard Griffin, wrote to Chairman Johnson on February 

27,2015: 

In the third paragraph of the letter [Chairman Johnson's February 25, 20!5 letter 

to Deputy Inspector General Griffin] you state that we "did not publicly release 

the eleven-page administrative closure at the time of completion and delayed 

reporting its findings to Congress." As you are aware from various media reports, 

in June 20 !4, Senator Tammy Baldwin contacted our office after she received 

allegations relating to prescription practices at Tomah. She was advised that we 

had completed work on similar allegations and subsequently requested a briefing. 

On July 22, 2014, Dr. David Daigh, the Assistant Inspector General for 

Health care Inspections and Dr. Alan Mallinger, a Senior Physician on staff in the 

Office of Hea!thcare Inspections, provided Senator Baldwin's staff with a 

briefing. Dr. Mallinger is Board Certified in Psychiatry. On August II, 20!4, 

Senator Baldwin requested a copy of the administrative closure under the 

Freedom of Information Act, which was provided on August 29, 2014. We 

received no other requests or allegations relating to Tomah until recently. 1434 

Likewise during a transcribed interview, Maureen Regan, the Counselor to the Inspector 

General, disputed an assertion that the administrative closure was made public in January 2015. 

She stated: 

[T]hat is completely untrue. In August of2014, we gave a copy under FOIA to 

Senator Baldwin. At that point, it became a public document So, she asked for it 

1431 John D. Daigh, Assistant Inspector General for Healthcare Inspections, DEP'T OF VF.TERANS AFFAIRS, OFFTCE 

~~,INSPECTOR GENERAL, http:llwww.va.govloiglaboutlaig-healthcare.asp. 

-Maureen T. Regan, Counselor to the Inspector General, DEP'T OF VETERANS AFFAIRS, OFFICE OF INSPECTOR 

GENERAL, http:llwww.va.govioiglabout/bio-counselor.asp. 1433 Glantz, Opiates Handed out Like Candy, REVEAL NEWS (Jan. 8, 2015). 1434 Letter from Hon. Richard J. Griffin, Deputy Inspector General, Dep't of Veterans Affairs, to Hon. Ron Johnson, 

Chairman, S. Comm. on Homeland Sec. & Governmental Affairs, at 1-2 (Feb. 27, 2015) [hereinafter 2/27/2015 

Letter from Deputy Inspector General Griffin, VA OIG, to Chaim1an Johnson, HSGAC]. 

F"t...,_ 

~1 ., __ .. .\ 

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under FOIA. She got it under FOIA. And then it was after that when allegations 

came out. But it was given out under FOIA when we had a request in August of 

2014.1435 

According to the VA OIG, it received a FOIA request for the administrative closure one 

day before its own case-management document shows that the office administratively closed the 

Tomah Inspection. Dr. Daigh initially denied that the Tomah VAMC administrative closure was 

signed and dated in response to a FOIA request from Congress. 1436 When asked again by staff 

whether a FOIA request could be the reason for the discrepancy in the dates, Dr. Daigh first said 

he was unsure: 

Q: If you go to OIG !396 [the hotline input transaction page for the VA 

OIG Tomah V AMC health care inspection] of this document, the last 

page of it, midway down on the right, it says "Publication Date August 

12, 2014." 

A: Like I said, I don't know. 

Q: It might be the person entering it in from the FOIA request. No? 

A: I have no idea. 

Q: Isn't that kind of another guess? 

A: I'm not going to guess. I don't know. I don't routinely see these 

reports. I don't usually-this information is-I'm not sure how it gets 

to this report. It's-the other spread sheets you've showed me are 

internal documents for my office and how we've dealt with it. This is 

outside my office. 

Q: Is this a headquarters document then? 

A: This would be a management tracking system for the IG, so I'm sure 

that they got-so there are aspects of data that I'm sure they get from 

Yohannes and the other names you've seen on these emails. But who 

actually put that data on there, I don't know. 

Q: What constitutes for the IG a publication? Is it when it's either FOIA'd 

or actually released on your website? 

1435 Shepherd 2/912016 Transcribed Interview, at 142-43. 1436 Daigh Transcribed Interview, at 129. 

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A: So we consider a publication to be on the website, and then the one 

caveat to that is admin closures are publicly notified to the Hill 

through the SAR, but they are not in general published to the Web. 1437 

A review of VA OlG's case tracking system clearly shows that internally, the VA OlG 

case-monitoring mechanism did not register the Tomah V AMC health care inspection as closed 

until August 2014-either one or three days after the FOIA request, depending on the hotline. 

VA OlG personnel interviewed could not provide an explanation as to why the discrepancies in 

the dates exist. Given the confusion in the date as it is written in the administrative closure and 

the VA OlG's refusal to provide drafts and other documents relating to the drafting of the Tomah 

VAMC administrative closure, it is difficult to determine with certainty when the VA OlG 

administratively closed its review of the Tomah VAMC. 

F. Subsequent administrative reviews found different outcomes than the 

VA OIG's Tomah VAMC health care inspection 

The VA OIG's multi-year inspection and corresponding criminal investigation of the 

Tomah VAMC largely cleared providers of any wrongdoing. However, since the Center for 

Investigative Reporting article brought the longstanding problems to light, three subsequent 

investigations into the Tomah V AMC found, among orher problems, inappropriate and unsafe 

prescription practices at the Tomah V AMC. 1438 These investigations, largely spurred on by 

public awareness and transparency to the problems at the facility, have finally begun to lead to 

some accountability for wrongdoers at the Tomah V AMC. 

The VA's Undersecretary for Health released a report in March 2015 that found that 

patients at the Tomah VAMC received high-dose opioid prescriptions that potentially 

jeopardized patient safety. 1439 The review team stated the need for an in-depth evaluation of the 

providers' clinical practices. 1440 Additionally, the VA produced a draft March 2015 report 

authored by the Chief Medical Officer of VISN 12 that found that Dr. Houlihan had failed to 

meet the standard of care in 92 percent of cases reviewed and that Ms. Frasher failed to meet the 

standard of care in 80 percent of cases rcviewed. 1441 Finally, at the request of Chairman Johnson 

and Senator Baldwin, the VA OIG Office of Healthcare Inspections released a report in August 

2015 that found that the prescribing psychologists failed to discuss the risks of off-label drug use 

1437 /d. at !32-33. 1438 VA Central Office (VACO), VACO Clinical Review Visit Report, Tomah VA Medical Center (Mar. 4, 2015) 

[hereinafter Interim VHA Report]; Veterans Health Admin., Draft VISN 12 Focused Clinical Review ReportTomah V AMC (Mar. 26, 2015) [hereinafter Draft VISN 12 Report]; VA OIG Office ofHealthcare Inspections, 

Report No. 15-02131-471, Healthcare Inspection: Unexpected Death of a Patient During Treatment with Multiple 

Medications, Tomah VAMC (Aug. 6, 2015) [hereinafter VHA Healthcare Inspection Report]. 1439 Interim VHA Report. !440 /d. 

1441 Draft VISN 12 Report, at 3. 

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with Jason Simcakoski before his death, and that the facility staff failed to adequately and 

promptly respond when they found Mr. Simcakoski unresponsive. 1442 

1. The March 2015 memorandum from the VA's Under Secretary for Health largely 

substantiated allegations about over-prescription and a culture of fear at the Tomah 

VAMC 

In January 2015, after the public reporting about the Tomah VAMC, the VA's interim 

Under Secretary for Health, Dr. Carolyn Clancy, convened a nine-~erson clinical review team to 

assess the practice patterns and prescribing habits at the facility. 144 The team reviewed internal 

documents and interviewed 18 employees, including facility leadership. 1444 The team submitted 

a report on March 4, 2015, and emphasized "the need for an in-depth evaluation of the clinical 

practices among providers .... " 1445 In the course of two months, the VA substantiated 

allegations that the VA OIG could not substantiate after years of examination. 

The review team found that although fewer patients at the Tomah VAMC received opioid 

medication than the national veteran patient population (11.5 percent versus 14.6 percent), 1446 

patients at the Tomah V AMC received higher dosages of opioids and more frequently received 

opioids and benzodiazepines concomitantly. 1447 Specifically, patients at the Tomah V AMC 

received opioid dosages greater than 400 morphine equivalents per day, 2.5 times as frequently 

as the national veteran patient population ( 1.08 percent versus 0.42 percent), 1448 and received 

opioid dosages between 200 and 300 morphine equivalents per day more frequently than the 

national veteran patient population (1.53 percent versus 1.2 percent). 1449 Additionally, Tomah 

V AMC patients received benzodiazepines and opioids concomitantly-a discouraged practice 

due to risks of complications-almost twice as frequently as the national veteran patient 

population (20.4 percent versus 11.7 percent). 1450 

1442 VHA Hcalthcare Inspection Report, at 13. 1443 Interim VHA Report at 34. The team visited the Tomah VAMC from January 27-January 29, 2015. Id at 3--4. 1444 I d. at 5~6. The team interviewed the following individuals: Mario DeSanctis, Medical Center Director, 

Katherine Pica, Acting Chief of Staff, Carlo Piraino, Associate Director Patient Care Services/Nurse Executive, Paul 

Gardctto, Associate Medical Center Director, David Houlihan, Chief of Staff, and Lin Ellinghuysen, AFGE 

President. I d. The team also interviewed three supervisory staff members and nine frontline staff members, whose 

names were withheld upon employee request. ld. 1445 Id at II. 1446 Memorandum from Carolyn M. Clancy, Interim Under Secretary for Health, Dep't of Veterans Affairs, to 

Secretary, Dep't of Veterans Affairs (Mar. I 0, 20 15) [hereinafter 3/10/2015 Memo from Carolyn Clancy to VA 

Secretary]; Interim VHA Report, at 6-7. 1447 Interim VHA Reportj at 8. 1448 3/10/2015 Memo from Carolyn Clancy to VA Secretary; Interim VHA Report, at 7. 1449 3/10/2015 Memo from Carolyn Clancy to VA Secretary; Interim VHA Report, at 7. 1450 3/10/2015 Memo from Carolyn Clancy to VA Secretary; Interim VHA Report, at 8. 

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A review of 18 patients' medical records "suggested unsafe clinical practices in areas 

such as pain management and psychiatric care," 1451 including the following findings: 

Six of 18 cases revealed patient harm, such as patient falls, that could be at least 

partially attributable to prescribing practices. 1452 

Nine of 18 cases lacked evidence of treatment plan change despite aberrant behaviors 

such as early refill requests and both positive and negative urine drug screen 

results. 1453 

Twelve of 18 cases demonstrate extensive use of opioids and benzodiazepines 

concomitantly. 1454 

Finally, the report found that "an apparent culture of fear" at the facility compromised 

patient care and impacted staff satisfaction and morale. 1455 A staff member in a leadership 

position stated, regarding opioid prescribing practices, "Tomah is different from any place I have 

ever been; someone's going to die."1456 Another staff member reported that "the Chief of Staff, 

patient advocates, and/or Nurse Practitioner frequently 'demand' that prescriptions be ordered by 

providers and filled by pharmacists." 1457 Other staff members described the negative workplace 

environment, explaining, "There is a lot of hopelessness (at Tomah YAM C) ... things are so 

disjointed," 1458 and "You are at risk; you keep your head down."1459 Regarding Dr. Houlihan, 

staff members reported that he "has a passion for control" 1460 and voiced concerns that "there is 

no ability to review or question Dr. Houlihan's cases." 1461 One staff member stated, "thou shall 

not document things in CPRS that embarrass Dr. Houlihan." 1462 

The review team was unable to "directly substantiate[]" the staffs "culture of fear," but 

found "evidence that the Chief of Staff directed patient care through unsolicited comments in the 

patient record .... includ[ing] recommendations for patient care that conflicted with the 

treatment plans developed by other providers and might be viewed as intimidating." 1463 

1451 Interim VHA Report, at 5. 1452 !d. at l 0; 3/1 0/2015 Memo from Carolyn Clancy to VA Secretary. 1453 lnterim VHA Report, at 10; 3/10/2015 Memo from Carolyn Clancy to VA Secretary. 1454 Interim VHA Report, atlO; 3/10/2015 Memo from Carolyn Clancy to VA Secretary. 1455 Interim VHA Report, at5; 3/10/20I5 Memo from Carolyn Clancy to VA Secretary. 1456 Interim VHA Report, atlO. !457 Id. 

l45S !d. at 9. 

l459ld 

146G !d. 

1461 !d. 

1462 !d. 

1463 !d. at IO. 

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Figurt' 102: Memorandum on ~-~e Clinical Re\-it>w Findings of tbt' Tomah V A.\IC1.J64 

DEPARTMENT OF 

VETERANS AFFAIRS 

MArch 1(, 

""Interim VHA Repot1, at 5. 

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Chairman Johnson's staff presented the VA's summary memorandum to VA OIG 

personnel during transcribed interviews in order to obtain their perspective on the VA 's findings. 

In particular, Chairman Johnson's staff sought to understand how the VA OIG's a multi-year 

health care inspection could differ so drastically from the VA's own three-month-long clinical 

review of the same facility. 

When Chairman's Johnson staff presented the document to Dr. Wesley, he claimed that 

the VA was well-aware of the issues at the Tomah VAMC and did little, if anything, to address 

the issues at the facility before the media reports about the facility. He explained: 

A: It's very-from a technical point of view, I have no problem with it. 

Witness 

It's very distressing, though, because of the date, which is March 10, 

2015. As I said, I've taught hotlines for a long time, and one of the 

things I've always worked very hard at is that the IG should not know 

something that VHA [Veterans Health Administration] doesn't. In 

other words, I worry about patient safety. So I don't want to have 

medical facts or information about a patient that VHA doesn't. 

So as we're doing this and as we're crunching numbers and as we're 

going through things, I don't think there's anything we knew that 

VHA either didn't know or didn't have very quick access to. And, in 

fact, after we released the administrative closure, we briefed both Mr. 

DeSanctis and Dr. Murawsky in depth. And when I briefed Mr. 

Murawsky in particular, he seemed to know-know it all, if you wilL 

There was nothing unfamiliar to him. Likewise, he wrote that early 

response, and so he was extremely conversant with the issues. 

And so the reason this bothers me is that up until the Aaron 

Glantz story of January 2015, VHA really did very little, if 

anything. Suddenly, you have a major media story, and then you 

see a memo like this from the--

Attorney: All right. So I'm going to caution you here. That's an honest response, 

butA: Okay. 

Witness 

Attorney: -you don't know-what you know is that you informed VA-VHA 

about what you had found about the administrative closure. You don't 

exactly know--

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A: My professional opinion is throughout the inspection, VHA knew 

what we knew, and so you asked me my reaction. 

Witness 

Attorney: Right. 

A: And my reaction is I find this professionally disturbing becausebecause of the date. 1465 

Chairman Johnson's staff also presented the memorandum to both Dr. Daigh and Dr. 

Mallinger. Both doctors claimed that the VA's findings were not all that different than what the 

VA OIG found in the administrative closure. The doctors went paragraph-by-paragraph to 

compare the VA's findings to what the administrative closure found. 

Paragraph one of the VA's memorandum summarized that in January 2015, Secretary 

McDonald directed Dr. Clancy to conduct a "comprehensive review of medication prescription 

practices at the Tomah [V AMC] .... " 1466 With respect to this paragraph, Dr. Daigh noted that 

the review "would be after we [the VA OIG] had provided our administrative closure and 

discussed with VA our findings at Tomah."1467 

Paragraph two of the VA's memorandum explained that Dr. Clancy "convened a clinical 

review team consisting of nine clinicians and other subject matter experts from across VHA to 

'assess the practice patterns, controlled substance prescribing habits and administrative 

interactions with subordinates and clinical leadership as related to prescribing practices' at the 

Tomah VAMC." 1468 With respect to paragraph two, Dr. Daigh responded: 

Paragraph 2, so it all seems appropriate. They put together a team to look at 

prescribing patterns. I would say that by this time frame in our administrative 

closure we highlighted that there was substantial use of narcotics at Tomah, and I 

think in the data, we provided VISN data as it related to Tomah as a facility and 

also as to some of the prescribers. 

Contemporaneous with this, we had published and reported to the Senate 

Veterans' Affairs Committee a nationwide review of narcotic usage, and we 

found that outrageous amounts of narcotics were being used across VA, at 

essentially every VA hospital you looked at. 1469 

1465 Wesley Transcribed Interview, at 207-09 (emphasis added). 1466 3/10/2015 Memo from Carolyn Clancy to VA Secretary. 1467 Daigh Transcribed Interview, at 147-48. 1468 3/10/2015 Memo from Carolyn Clancy to VA Secretary. 1469 Daigh Transcribed Interview, at 148. The review Dr. Daigh referred to was a 2014 nation-wide review of takehome opioid prescription patterns across the VA. See VA OIG, Office ofHcalthcare Inspections, Report No. 14-

00895-163, Healthcare Inspection-VA Patterns of Dispensing Take-Home Opioids and Monitoring Patients on 

Opioid Therapy (May 14, 20 14), available at http:i/www.va.gov/oig/pubs!V AOIG-l4-00895-l63.pdf. 

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Paragraph three of the V A's memorandum summarized the findings of chart reviews of 

18 Tomah V AMC patients. The memorandum noted that the clinical review team: 

found unsafe clinical practices at the Tomah V AMC in areas such as pain 

management and psychiatric care. More specitically, six of 18 cases revealed that 

patient harm (examples of falls) that could be at least partially attributable to 

prescribing practices (multiple CNS [Central Nervous System] depressants and/or 

high dose opioids ); nine of 18 lacked evidence of changing the treatment plan in 

the face of aberrant behaviors; and twelve of 18 demonstrated extensive use of 

opioids and benzodiazepines. 1470 

Dr. Daigh noted that the V A's findings in paragraph three may not reflect the same data 

that the VA OIG examined in its health care inspection, but that the VHA's findings in this 

paragraph were "reasonable." He explained: 

A: So when you get down here to number three, VA then looked at a 

series of patients, and they found that the care didn't meet standard. 

And so I understand also that, at least from the news-it may not be 

accurate--that Wisconsin looked at Dr. Houlihan's cases or some 

cases of his and came to the same conclusion. So that's fine. 1 think 

that-I think Alan [Mallinger] did an expert job in looking at the cases 

he looked at and dealing with the issues that they were, you know, 

confronted with at Tomah. I think his opinion is a reasonable one. I 

think this is also a reasonable one. I don't know if they looked at the 

same 18 cases we looked at, or different cases. 

I am aware of sort of the peer reviews that were done during this 

period of time, so I am aware that VA's findings, you know, earlier 

were not so critical of his care but more in line with what we had 

found in those issues. ButQ: So the data from this time period is different from the data that was 

being reviewedA: Yes. I think so. I mean, these 18 cases I think are more-are a little 

more recent. And, you know, during this time period there has been 

just a tremendous shift in how society views the treatment of patients 

with opioid dependence. We've gone from pain is, what, the fourth or 

fifth vital sign after the Institute of Medicine study to now, you know, 

CDC is coming out with recommendations about how to not use pain 

1470 3/l 0/20 IS Memo from Carolyn Clancy to VA Secretary. 

'"""' 

(~! ~l 

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medicines, and DOD is about to come out with some-DOD VA is 

coming out with new recommendations where the data doesn't support 

the use of narcotic like it has been used for the last 30 years. So I think 

there's a big emotional shift. People are trying to get their head around 

that. So part of that shift is occurring during this time frame. 1471 

Paragraph four of the VA's memorandum highlighted potentially dangerous prescription 

practices at the Tomah VAMC. The VA found: 

The team made specific findings relating to overall opioid utilization at Tomah 

and other VHA facilities, noting that 11.5% of Tomah patients receive opioid 

medications as compared to 14.6% of patients VA wide. The team also found that 

Tomah patients were 2.5 times more likely than the national average to be 

prescribed opioids greater than 400 morphine equivalents per day (1.08% vs. 

0.42%), and were also more likely than the national average to be prescribed 

opioid doses between 200-300 morphine equivalents per day (1.53% vs. 1.2%). 

With respect to the use ofbenzodiazepincs and opioids concomitantly, which is 

discouraged due to risks of complications, the team found that Tomah VAMC 

was almost double the national average (20.4% vs. II. 7%). 1472 

When Dr. Daigh analyzed the VA 's findings in paragraph four, he talked about how the 

findings are more in line with national trends and did not discuss how it differed from the 

administrative closure. The VA OIG's administrative closure did not analyze the parallel 

prescription of opioids and benzodiazepines at the Tomah VAMC. With respect to paragraph 

four, Dr. Daigh stated: 

And then the data that-paragraph four essentially talks about the use of narcotic 

at Tomah not unlike the data we presented. We found that VA across the system 

was giving both benzos and narcotic to the same patients. It puts providers in a 

little bit of a box because many patients who have substance use disorder 

problems who are very seriously ill also have anxiety disorder where they act out. 

The Tomah data, you know, we just looked at the VJSN look, but when we looked 

at the national look, l mean, I think you could take this data and you could have 

gone to 50 places and find people who were prescribing at the levels they're 

finding that, I mean, I think, if you look at our national data out there, just the 

average amount given. And if you look at the top providers, then you've got 

psychiatrists dealing-you have basically addiction psychiaiJy, and you're out 

there on the very most difficult patients to take care of in psychiatry. So it's-to 

the general surgeon, it's the tumor case that no one else will operate on, you can 

1471 Daigh Transcribed Interview, at 149-50. 1471 3110/2015 Memo from Carolyn Clancy to VA Secretary. 

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always find someone to operate on. In psychiatry, it's the guy that's been addicted 

to narcotic-take the Simcakoski case and some of these other cases-for years, 

you know? People are trying to do the best for them. Sometimes it's better, 

sometimes it's worse. They're just very difficult to care for. 

So, again, when-you know, it's not just a VA problem. If you watch the news 

and you see that the most recently advertised drug, which I have to laugh about, is 

to cure constipation in people who are addicted to opioids. When I first saw that, I 

just started laughing because, I mean, the only data I really have is VA data. But 

when a drug company can make money on the receptor in the gut for opioids and 

then sell it to the general population, that's just a total failure of government 

policies on how to manage patients with pain. And so we're trying to swing 

backi473 

Dr. Mallinger also rendered an opinion about how the VA's findings in paragraph four 

differed from the VA OIG's administrative closure. He noted that the VA's review of opioid 

prescriptions at Tomah reached similar conclusions as the administrative closure-notably that 

prescribers at the Tomah VAMC prescribed high levels of opioids. Dr. Mallinger's explanation 

about how the VA' s analysis of parallel prescription of opioids and benzodiazepines differs from 

the OIG's inspection further illustrates the office's narrow interpretation of allegations it 

received. He stated: 

So as far as number 4 goes, so they found, you know, more or less a similar 

percentage of patients at Tomah on opioids as compared to VA-wide, but that 

they were more likely to be prescribed, you know, high doses. They'd look at that 

in terms of both the more than 400 morphine equivalents per day and also the 200 

to 300 range of morphine equivalents per day. And, again, this agrees with what 

we had in our report, that, you know, there was as high level of prescribing of 

opioids at Tomah. 

* * * 

And the last part of this sentence, use of benzodiazepines and opioids 

concomitantly, here I would say that we didn't really have any allegation 

about that, and we didn't really look at that in our, you know, report. But, 

again, it's higher than the national average. It's 20 percent. But, you know, they 

themselves are saying that the national average of doing this is, you know, 11.7 

percent, say one out of IO. So what we're talking about is if you go to any VA 

medical center in the country and you round up I 00 patients on opioids, 10 of 

them will be on this combination. 1474 

1473 Daigh Transcribed Interview, at 150-52. 1474 Mallinger 4/21/2016 Transcribed Interview, at 395-96 (emphasis added). 

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Paragraph five of the VA's review of the Tomah VAMC addressed the culture of fear at 

the facility. It stated: 

The team also found that an apparent culture of fear at the facility compromised 

patient care and impacted staff satisfaction and morale. Based on these 

preliminary findings, the team recommended that VHA consider a more in-depth 

evaluation of the clinical and administrative practices at the Tomah VAMC. That 

additional review is now ongoingH75 

Dr. Mallinger talked about the VA's findings with respect to paragraph five were actually 

not all that different than the VA OIG's administrative closure. He stated: 

You know, I think 5 basically agrees with what we had in our report, that, you 

know, as we talked about, you know, we didn't really substantiate, if you want to 

call it "administrative abuse" or whatever, but that, you know, there was a widely 

held perception that administrative abuse occurred, and that perception is 

essentially the same as the culture of fear .... So I thought, you know, that really 

pretty much agrees with what we said in the report. 

Dr. Daigh expressed similar sentiments on the VA 's finding that there was a culture of fear at the 

Tomah VAMC. He said: 

The last one, again, apparent culture of fear and compromised care, again, that's 

what they found. I'm not going to dispute that. We certainly have heard people 

vociferously make complaints like that when we were there. I'll just say that when 

we went to look at interpersonal interviews and we went to look at the official 

records we could find, we didn't see the kind of, you know, behind-the-scenes 

email trafftc and other data to support that. There were some people that were 

unhappy, but whether it was as pervasive as they found it, we didn't see that. But 

we did see a problem there. We note that in the report. 1476 

These statements arc puzzling. Not only did the VA OIG not substantiate the 

"allegations of abuse of authority, intimidation and retaliation when staff question controlled 

substance prescription practices," but the administrative closure did not link the problems to 

patient care at the facility. At most, the administrative closure made a passing reference on how 

the perceptions of administrative abuse can lead to breakdowns in communication and prevent 

people from coming forward to report wrongdoing. 1477 Although the VA OIG suggested that the 

Tomah VAMC director should "implement a vehicle by which clinicians and staff can openly 

and constructively communicate concerns and rationale when disagreements arise concerning 

1475 3/10/2015 Memo from Carolyn Clancy to VA Secretary. 1476 Daigh Transcribed Interview, at 152-53. 1477 VA 010 TOMAH VAMC ADM!N!STRATIVE CLOSURE. at I 0. 

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dispensing of opioid prescriptions," 1478 this "suggestion" was non-binding and there was no 

required follow-up from either the VA OIG or the VA. 

Despite the VA OIG's protestations that its health care inspection arrived at the same 

conclusions as the VA's subsequent review, the VA found serious problems at the Tomah 

V AMC where the VA OIG did not. Most notably, with respect to the concomitant prescription 

of medications and administrative abuse at the facility, the VA went further than the OIG in 

identifying areas of serious concern. 

2. A March 2015 draft report by the VISN 12 Chief Medical Officer substantiated 

allegations about improper opioid prescription 

In December 2014, the Chief Medical Officer of VISN 12 directed an external clinical 

team to conduct a review of Dr. David Houlihan's and Deborah Frasher's patient care and 

prescribing practices. 1479 The review team focused on patients who received opioids or 

suboxone1480 The VISN 12 draft report is dated March 26, 2015. 1481 

The review team found that "Dr. Houlihan did not meet the standard of care in 92% of 

the cases reviewed and Ms. Frasher did not meet the standard of care in 80% of cases 

reviewed." 1482 In a significant number of cases, "the care provided was not appropriate and 

documentation was not adequate to support care provided." 1483 Reported problems included: 

Inappropriate use of opioids, suboxone, and stimulants; 

Unsafe combinations of drugs prescribed, including high doses of benzodiazepines 

with opioids and use of multiple benzodiazepines concomitantly; 

High doses of opiates and benzodiazepines for patients with substance abuse 

disorders; 

Lack of oversight of urine drug screens; 

Inappropriate management of chronic pain; and 

Early refills of controlled substances despite ongoing illicit drug use. 1484 

The draft report concluded that "[a]ll of these findings can pose increased risk to patients." 1485 

147S Jd. 

1479 Draft VISN 12 Report, at 3. The external clinical review team consisted of four physicians and a nurse 

practitioner. Id at 4. !480 I d. at 3. 

14 " ld It is unknown if this VISN 12 document was finalized. 1482 ld at 3. 1483 !d. 

1484 /d. at 3, 8. 

1485 !d. at 1 L 

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3. An August 2015 report by VA OIG on }as on Simcakoski's death substantiated 

hazardous prescription practices 

From February to June 2015, at the request of Chairman Johnson and Senator Baldwin, 

the VA OIG Office ofHealthcare Inspections conducted an inspection into the death of Jason 

Simcakoski during his treatment at the Tomah V AMC. 1486 The OIG released a report in August 

2015, finding deficiencies in prescription practices and the facility staffs emergency response. 

The OIG reported that the medical examiner found, and a consultant forensic toxicologist agreed, 

that the findings in Mr. Simcakoski's case "were sufficient to conclude that the cause of death 

was mixed drug toxicity." 1487 

The OIG found that the prescribing psychiatrists failed to comply with the VHA 's 

requirement of obtaining written informed consent when administering hazardous drugs, 

including buprenorphine. 1488 The report referred to two psychiatrists who treated Mr. 

Simcakoski: Psychiatrist I and Psychiatrist 2. The Committee has learned that Psychiatrist I in 

this inspection was Ronda Davis and that Psychiatrist 2 was Dr. Houlihan. 1489 The OIG did not 

find evidence of written information consent for buprenorphine treatment, and both psychiatrists 

acknowledged that they did not discuss the risks inherent in off-label use with Mr. 

Simcakoski. 1490 

Additionally, the OIG reported deficiencies in the facility staffs emergency response. 1491 

The OIG found that that the facility's Short Stay Mental Health Recovery unit did not have 

medication available to use in emergency situations to reverse the effects of possible drug 

overdose. 1492 Flumazenil, which is used to reverse benzodiazepine overdose, was administered 

33 minutes after Mr. Simcakoski was found unresponsive 1493 Furthermore, the OIG found that 

there was confusion among the unit staff regarding emergency response responsibilities1494 

Specifically, unit staff discontinued CPR efforts when facility firefighters arrived, believing that 

the firefighters would take over CPR efforts. 1495 However, the facility firefighters were not 

paramedics or emergency medical technicians and were not designated as first-line staff to 

provide hands-on emergency care. 1496 Finally, the OIG found that there were delays in 

1486 VHA Hcalthcare Inspection Report, at i. 

"''!d. at 8. 14" ld. at i, 10 -1 L 1489 E-mail from Tomah VAMC Whistleblower to Committee (Nov. 12, 2015) (on file with Comm.); Briefing with 

VA (Nov, 12, 2015); see also Bobby Caina Calvan, Wisconsin Veterans Hospital's Former Director No Longer on 

VA Payroll, REVEAL NEWS (Sept. 2, 20 15), https://www.revealnews.org/article/wisconsin-veterans-hospitalsfmmcr-director-no-longer-on-va-payroll/. 

1490 VHA Healthcare Inspection Report, at i, 10-l L 1491 !d. at i, ll. 149::. !d. at i. 1493 ld. at 12. 1494 Id at i, 12. 1495 ld. at 12. l496Jd. 

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"initiating cardiopulmonary resuscitation, calling for medical emergency assistance both within 

the unit and from facility emergency response staff, and applying defibrillator pads to detennine 

cardiac rhythm for possible intervention."1497 

* * * 

Of all the federal entities that examined the Tomah VAMC, the VA OIG was perhaps 

best suited to identify and rectify the problems at the facility. When it first received a complaint 

in March 2011, it opted to refer the matter to the VA's regional office for their review. When the 

VA OIG received a second complaint in August 2011, and then a congressional request shortly 

thereafter, it finally took action. 

Over the course of the subsequent two-plus years, the VA OIG conducted-to its credita sizeable amount of work inspecting the Tomah VAMC. It collected emails from facility 

employees, interviewed witnesses, surveilled Dr. Houlihan, and issued at least one subpoena. 

The work product that the VA OIG produced at the culmination of this inspection simply did not 

match the effort that went into the inquiry. The manner in which the VA OIG closed the report 

also obscured transparency and public accountability in the Tomah VAMC and the VA OIG. 

Chairman Johnson's investigation offers some explanation for the VA OIG's failure at 

the Tomah VAMC. According to statements received by Chairman Johnson's staff, the VA OIG 

lacks clear standards for substantiating allegations-making it difficult to arrive at conclusive 

findings. The VA OIG did not do enough in response to observations about the potential 

impairment of Dr. Houlihan and Deborah Frasher and limited its inquiry to ignore concerns 

about the interaction between opioids and other prescribed medication. The office discounted 

statements from Tomah VAMC pharmacists about abuses and understated the variance in Dr. 

Houlihan's prescription practices. Notably, while the VA OIG failed to substantiate the 

allegations after its lengthy inspection, the VA independently substantiated similar allegations 

after only three months. 

The leadership at the helm of the VA OIG during the course of its health care inspection 

of the Tomah VAMC is gone. Chairman Johnson is hopeful that the new Inspector General 

Michael Missal, will restore trust and accountability in this important office. A transparent and 

effective VA OIG is vital for protecting and support veterans across the nation. 

t497 I d. at i. 

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IV. Whistle blower retaliation and a culture of fear at the Tomah VAMC 

Chainnan Johnson's investigation into the Tomah VAMC shows that the allegations of 

opioid over-prescription, abuse of authority, drug diversion, and more were allowed to fester 

because a "culture of fear" within the facility. Concerned employees were afraid to speak out for 

fear of retaliation. Some employees who raised questions-like Dr. Noelle Johnson or Dr. 

Christopher Kirkpatrick-were fired from their jobs. 

Sadly, the retaliation was not limited to within the Tomah VAMC. The VA OIG-the 

Department's independent watchdog-also retaliated against Tomah VAMC whistlcblowers. In 

an unsolicited white paper-which, at J 3 pages, was longer than the VA OIG's administrative 

closure-the VA OIG defended its work at the facility by attempting to discredit the 

whistleblowers. The VA OIG implied that Dr. Kirkpatrick was a drug dealer and stated that Dr. 

Johnson had "poor interpersonal skills"-facts that have no bearing on the merits of their 

allegations. 149 

It is unfortunate the VA OIG ignored these whistle blowers and dismissed the retaliation 

they faced as "gossip, rumor, and hearsay." 1499 In early 2015, the VA found that "an apparent 

culture of fear at the [Tomah V AMC] compromised patient care and impacted staff satisfaction 

and morale."1500 The VA review team interviewed a number of staff members who expressed 

concerns about the culture at the facility. One employee was quoted as stating "you are at risk; 

you keep your head down" and said that staff must "tolerate the oppression which is waxing and 

waning." 1501 The VA's review team concluded that the employee statements "appear[ed] to 

support concerns related to a culture of fear among Tomah VAMC staff." 1502 

A. The sad state ofwhistleblowerprotections within the VA 

Federal whistleblower laws have existed in some form since the early Twentieth Century. 

In 1978, Congress passed the Civil Service Reform Act, which for the first time provided an 

enforceable right for federal employees to petition Congrcss. 1503 The Act also created the Office 

of Special Counsel (OSC) and the Merit Systems Protection Board. 1504 In 1989, Congress passed 

the Whistleblower Protection Act, which provided protections for federal employees who 

1498 See VA OIG, Whitepaper: Analysis of the Evidence Supporting the Findings oft he VA Office of Inspector 

General, Office ofHealthcare Inspections Administrative Closure of its Inspection of Complaints Regarding the 

Tomah, Wisconsin, VA Medical Center 9 (June 4, 2015) [hcreinatler VA OJG Whitepaper]. 1499 !d. at 10. 1500 3/I0/2015 Memo from Carolyn Clancy to VA Secretary. 1501 Interim VHA Report, at 9. !502 !d. 

1503 Pub. L. 95-454, 92 Stat. 11!! (!978). 1504 !d. 

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disclosed illegal or improper government actions. 1505 Most recently, Congress passed the 

Whistleblower Protection Enhancement Act of 2012, which augmented whistleblower 

protections and expanded the powers of OSC to prevent retaliation. 1506 

Data shows that the VA, as a whole, is not friendly to whistleblowers. The Office of 

Special Counsel investigates and prosecutes whistleblower claims brought by federal 

employees1507 During a hearing held by Chairman Johnson in September 2015, Special Counsel 

Carolyn Lerner testified that VA cases made up approximately 35 percent ofOSC's entire 

retaliation case load in 2015. 1508 In 2014, more VA employees alleged retaliation than 

Department of Defense (DOD) employees, even though the DOD has twice the number of 

civilian employees as the VA. 1509 Special Counsel Lerner similarly testified before the Senate 

Committee on Appropriations that the volume of VA cases is "overwhelming" her agency. 1510 

The whistleblower community has also identified significant concerns with the VA 

OIG's treatment of VA whistleblowers. The Project on Government Oversight (POGO), a nonprofit organization that promotes good government, highlighted the shortcomings of the VA 

OIG's posture towards whistleblowers. In testimony to the Committee, POGO's Executive 

Director, Danielle Brian, explained: 

The perception that an acting IG lacks adequate independence can have a chilling 

effect on the office's natural allies: agency employees and other insiders who are 

in a position to blow the whistle on agency wrongdoing. One former VA 

employee recently stated that the IG's office is "not trusted by most employees 

and usually used in the VA as retaliation" .... 1511 

Other VA whistleblowers have been more direct in their criticism of the VA OIG, calling the 

office a 'joke" for its refusal to properly protect whistleblowers. 1512 

1505 Pub. L. I 0 l-12, I 03 Stat. 16 (1989). 1506 Pub. L. 112-155, 126 Stat. 1465 (2012). 1507 About, U.S. OFFICE OF SPECIAL COUNSEL, https://osc.gov/Pages/about.aspx, 1508 Improving VA Accountability: Examining First-Hand Accounts of Department of Veterans Affairs 

Whistleblowers, Hearing Before S. Comm. on Homeland Sec. & Governmental Affairs, I 14th Cong. (2015) 

(statement of Carolyn Lerner, Special Counsel, U.S. Office of Special Counsel). 1509 Jd. 

1510 Review ofWhistleblower Claims at the Department of Veterans Affairs, Hearing Before Subcomm. on Nfilitary 

Construction, Veterans Affairs, & Related Agencies on the S Comm. on Appropriations, !14th Cong. (2015) 

(statement of Carolyn Lerner, Special Counsel, U.S. Office of Special Counsel). 1511 Watchdogs Needed: Top Government Investigator Positions Left Unfilled for Years, Hearing Before S. Comm. 

on Homeland Sec. & Governmental Affairs, I 14th Con g. (20 I 5) (statement of Daniello Brian, Director, Project on 

Gov't Oversight). 1512 Improving VA Accountability: Examining First-Hand Accounts of Department of Veterans Affairs 

Whistle blowers, Hearing Before S. Comm. on Homeland Sec. & Governmental Affairs, I 14th Cong. (2015) 

(statement of Christopher Shea Wilkes, VA Truth Tellers). 

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The Tomah VAMC is a microcosm of both the VA 's cultural problems with respect to 

whistleblower retaliation and the VA O!G's disregard for whistleblowers. Former employees of 

the Tomah V AM C-Dr. Christopher Kirkpatrick and Dr. Noelle Johnson-were fired from the 

facility after they raised concerns about mismanagement at the facility. In addition, they faced 

attacks from the VA OIG when the OIG issued a "white paper" defending its investigation of the 

Tomah V AMC and disparaging the whistleblowers who took the courageous step to speak out. 

These individuals' stories and subsequent character assassination at the hands of the VA OIG 

illustrate the severe cultural problems within the VA and the VA O!G with respect to protecting 

whistleblowers. 

B. Dr. Christopher Kirkpatrick 

Dr. Christopher Kirkpatrick was a clinical psychologist at the Tomah V AMC who was 

fired after expressing his belief that some of his patients were ovennedicated. On the same day 

of his termination from the Tomah VAMC, Dr. Kirkpatrick took his own life. Despite the 

tragedy of his firing and death-and in the face of reports of broader overmedication and 

employee retaliation at the facility-Chairman Johnson's staff has learned that the VA did not 

examine the circumstances that led to Dr. Kirkpatrick's termination. In addition, Chairman 

Johnson's staff has learned that the VA OIG examined Dr. Kirkpatrick's termination and suicide 

as part of its review of the Tomah VAMC and did not find anything improper with Dr. 

Kirkpatrick's removal from the facility. 

1. The circumstances surrounding Dr. Kirkpatrick's termination 

Dr. Kirkpatrick was hired at the Tomah V AMC in September 2008 as a clinical 

psychologist. In the spring of 2009, he began raising concerns that his patients appeared to be 

overmedicated in their group meetings. He first spoke with a physician's assistant about patients 

they both treated and raised concerns that these veterans were overmedicated. According to 

documents, the physician's assistant reported Dr. Kirkpatrick's comments to the facility's Chief 

of Staff, Dr. Houlihan, who initiated disciplinary actions against Dr. Kirkpatrick. 

On April 30, 2009, Dr. Kirkpatrick received a "written counseling" from his immediate 

supervisor. 1513 The "written counseling" noted that on April 20, 2009, Dr. Kirkpatrick's 

supervisor "spoke with psychologist Chris Kirkpatrick, Psy.D. regarding information [the 

supervisor] received from [Dr. Houlihan] stating that Dr. Kirkpatrick had been criticizing the 

Physician Assistant (PA) assigned to the Residential Program." 1514 The written counseling 

1513 Memorandum from Gary Loethen, M.D., U.S. Dep't of Veterans Affairs, to Chris Kirkpatrick, M.D., U.S. Dep't 

of Veterans Affairs (Apr. 30, 2009), in JUNEAU COUNTY SHERIFF'S DEPARTMENT, CHRIS KIRKPATRICK DEATH 

!NVESTIGA TTON REPORT, at 24 (2009). !514/d 

r·~ 

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"cautioned [Dr. Kirkpatrick] about engaging in any further criticisms of the P A and ... 

counseled that he should avoid advising on medications as it is not in his scope ofpractice."1515 

Emails between Dr. Kirkpatrick and his union representatives shed light on to why Dr. 

Kirkpatrick confronted the PA about their patients. Dr. Kirkpatrick understood that the written 

counseling was ordered because he was "inappropriate somehow in discussing medications that 

patients we both see are prescribed." 1516 He wrote to his union representatives: "I have had 

words with [the P A] inquiring about medications and possible side effect/adverse reactions they 

were experiencing but these conservations happened months ago. These situations put me into 

an ethical dilemma. Why this comes up as an issue now is open to interpretation."' 17 Dr. 

Kirkpatrick implored the union for assistance: "Based on what others have told me, I have every 

reason to be very afraid of Dr. Houlihan. I have sacrificed a lot to move up here and do the kind 

of work I excel at and help people in. I need help." 1518 

wrote: 

On May 13,2009, Dr. Kirkpatrick responded in writing to the written counseling. He 

I was quite surprised to hear of the accusations made by Chief of Staff (COS) in 

your Memorandum of April 30, 2009 as there has been no discussion between the 

Physician Assistant (PA) and myself about medications for a period of at least six 

weeks. Previously, soon after our P A had joined the team, I and several other staff 

had asked questions about medications after noticing changes in demeanor in our 

patients. I do not presume to prescribe medications but think it is important there 

be a dialogue between providers so as to best serve our patients. Patients have 

occasionally asked questions about their medications for which I refer them to 

their physician or other provider. 1519 

Two months later, on July 14, 2009, Dr. Kirkpatrick was fired from the Tomah VAMC. 

Chairman Johnson's staff interviewed Linda Ellinghuysen, the Tomah VAMC employee 

union president who represented Dr. Kirkpatrick in his termination proceedings. Ms. 

Ellinghuysen talked about Dr. Kirkpatrick's discussion of prescription practices with the PA. 

She stated that the PA "worked closely with Dr. Houlihan" and that "Dr. Houlihan, for the most 

1515 /d. 

1516 E-mail from Chris Kirkpatrick, M.D., U.S. Dep't of Veterans Affairs, to Dianne Streeter, VA Chief Steward, 

AFGE Local 1882, and Linda Ellinghuysen, Executive V.P., AFGE Local 1882, (April 23, 2009) in JUNEAU 

COUNTY SHERIFF'S DEPARTMENT, CHRIS KIRKPATRICK DEATIIlNVESTIGATION REPORT 40, at 43 (2009). 1517 E-mail from Chris Kirkpatrick to Dianne Streeter and Linda Ellinghuysen (April 23, 2009) in JUNEAU COUNTY 

REPORT 40, at 43 (2009). ISIS Jd. 

1519 Letter from Chris Kirkpatrick, M.D., U.S. Dep't of Veterans Affairs, to Gary Locthcn, M.D., U.S. Dcp't of 

Veterans Affairs (May 13, 2009), in JUNEAU COL"NTY SHERIFF'S DEPARTMENT, CHRIS KIRKPATRICK DEATH 

lNVESTIGA TION REPORT, at 23 (2009). 

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part, cosigned her medication orders." 1520 When Dr. Kirkpatrick spoke to the PA about their 

shared patients appearing overmedicated, Ms. Ellinghuysen felt the P A "went to the Chief of 

Staff that Chris Kirkpatrick was questioning the medication orders. And that, that- that can't be 

done here, asking [the) Chief of Staffthat." 1521 

Ms. Ellinghuysen also recounted discussions with Dr. Kirkpatrick about a threat he 

received from a patient in April or May 2009. She said that a patient threatened to do bodily 

hann to Dr. Kirkpatrick and his dog and based on that threat, Dr. Kirkpatrick spoke with his 

interdisciplinary team about removing the patient from Dr. Kirkpatrick's care. 1522 Ms. 

Ellinghuysen explained that Dr. Kirkpatrick was disturbed by the threat so he "took a long 

weekend" and expected the patient to be discharged from his team1523 When Dr. Kirkpatrick 

returned to work, the patient was not discharged. Ms. Ellinghuysen said that she, "as a union 

rep, did not hear of a plausible explanation" about why the patient was not dischargcd. 1524 

On July 14, 2009, Dr. Kirkpatrick called Ms. Ellinghuysen and told her that "his bosses 

wanted to speak with him and human resources" and asked Ms. Ellinghuysen if she would 

represent him. 1525 She agreed and accompanied him to the meeting. Also present at the meeting 

were Dr. Kirkpatrick's immediate supervisor and the Tomah VAMC Human Resources 

Coordinator. 

In documents Ms. Ellinghuysen provided to the Juneau County Sherriffs Office after Dr. 

Kirkpatrick's suicide in 2009, she described the meeting as "gruesome" and that "[i]t was 

apparent the COS [Chief of Staff, Dr. David Houlihan) was behind the termination."1526 Ms. 

Ellinghuysen said that the reason given by the Tomah V AMC management for Dr. Kirkpatrick's 

termination was "very vague." 1527 In the meeting and in the document terminating Dr. 

Kirkpatrick, Tomah V AMC management explained "performance issues" were the reason for his 

termination. 1528 According to Ms. Ellinghuysen, Tomah V AMC management "could not specify 

he [Dr. Kirkpatrick] had a specific performance issue. In fact, his two bosses, throughout the 

hour we were there, his two bosses praised him on his performance and his work with 

veterans." 1529 

1520 Ellinghuysen Transcribed Interview, at 92. 

1521 !d. 1522 !d. at 92-93. 1523 Jd. at 93, !524 !d. 

1525 !d. at 94. 1526 Memorandum by Linda Ellinghuysen, Executive V.P., AFGE Local 1882, at I (2009), in JUNEAU COUNTY 

SHERIFF'S DEPARTMENT, CHRIS KIRKPATRICK DEATH INVESTIGATION REPORT 34(2009). 1527 Ellinghuysen Transcribed Interview, at 95. 152B Memorandum from David P. Dechant, Manager, Great Lakes Human Resources Mgmt. Scrv., to Chris 

Kirkpatrick, M.D., U.S. Dep't of Veterans Affairs (July 14, 2009), in JUNEAU COUNTY SHERIFF'S DEPARTMENT, 

CHRIS KIRKPATRICK DEATH INVESTIGATION REPORT 49 (2009); see a/so Ellinghuysen Transcribed Interview, at 95. 1529 !d. a1 95. 

)reJ...'I_ 

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Based on documentation and statements from Ms. Ellinghuysen, it appears the Tomah 

V AMC fired Dr. Kirkpatrick for two reasons. The first issue surrounds Dr. Kirkpatrick's leave 

patterns. 1530 The second reason management cited was an incident in which Dr. Kirkpatrick 

brought his dog into work and another VAMC employee had to clean up after the dogl 531 

On the issue of leave, management cited an incident in which Dr. Kirkpatrick reportedly 

requested vacation leave from 2:30 p.m. to 4:00p.m. on one day, but actually left early at I :00 

p.m. 1532 The second issue cited by management concerned a request that Dr. Kirkpatrick correct 

how he logged his leave time. Even after he was asked to correct the record, Dr. Kirkpatrick still 

apparently logged his leave time inaccurately. 1533 Management also noted that Dr. Kirkpatrick 

took a vacation day on a Friday and then called in sick on the proceeding Mondayl 534 

According to Ms. Ellinghuysen, Dr. Kirkpatrick replied to the question of leave that he 

"didn't have a bank of camp time and [leadership] didn't have budget money for overtime." 1535 

Because Tomah V AMC management was not approving either compensatory time or overtime, 

Dr. Kirkpatrick marked that he was leaving at 2:00, but really left at I :00 because he had worked 

late one night earlier in the week and needed to ensure that he worked exactly 40 hours that 

week. 1536 According to Ms. Ellinghuysen, this type of time-management practice is common in 

the federal government and at the Tomah VAMC. 1537 

Ms. Ellinghuysen further explained that the time management system in pace at the time 

was "complex" and that Dr. Kirkpatrick was a "new employee."1538 Mistakes with filing leave 

time in the new system were common amongst Tomah V AMC employees. "We all mess it up," 

Ms. Ellinghuysen saidl 539 

Tomah V AMC management disagreed with Dr. Kirkpatrick's explanations. Ms. 

Ellinghuysen stated, and documents show, that Tomah V AMC management cited a "pattern of 

leave" with Dr. Kirkpatrick's leave schedule. 1540 According to Ms. Ellinghuysen, Dr. 

1530 Memorandum by Linda Ellinghuysen, at 2 (2009), in JUNEAU COUNTY REPORT 34, at 35 (2009). 1531 !d. 1532 Memorandum by Linda Ellinghuysen, at 1-2 (2009), in JL"NEAU Cou"NTY REPORT 34, at 34-35 (2009). 1533 Memorandum by Linda Ellinghuyscn, at 2 (2009), in JUNEAU COUNTY REPORT 34, at 35 (2009). 1534 I d. 1535 Ellinghuysen Transcribed fnterview, at 96. The "bank of camp time" refers to a time management system that is 

common in the federal government Federal employees work 40 hours per w~ek and overtime or compensatory time 

must be approved by a manager. For example, if an employee works two hours late on Monday, she can receive two 

hours of compensatory time or she can leave work two hours early one day that week-~so long as her weekly hours 

worked equal 40. According to Ms. Ellinghuysen, employees kept track of their own hours in this practice. !d. at 

96-97. 

1536 !d. at 97. 1537 Memorandum by Linda Ellinghuysen, at 1-2 (2009), in JUNEAU COUNTY REPORT 34, at 34-35 (2009). 1537 Ellinghuysen Transcribed Interview, at 97. 1538 !d. 

1539Jd 

1540 Memorandum by Linda Ellinghuysen, at 2 (2009), in JUNEAU COUNTY REPORT 34, at 35 (2009). 

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Kirkpatrick informed Tomah VAMC management that it was the first time he had heard about a 

leave problem but that he would ensure he was present on Tuesday through Thursdays when he 

ran his group counseling sessions. 1541 

During the meeting, Dr. Kirkpatrick explained why he thought he was being terminated. 

Dr. Kirkpatrick told Tomah VAMC management that he was being fired because he placed a 

note in the chart of the veteran that threatened him. 1542 

According to Ms. Ellinghuysen, it became clear that Tomah V AMC management was 

"not going to give this young man another chance." 1543 Tomah VAMC management terminated 

Dr. Kirkpatrick on July 14, 2009. Tragically, Dr. Kirkpatrick was found dead in his apartment 

that evening from a self-inflicted gunshot wound. 

2. There was noV A inquiry into Dr. Kirkpatrick's termination and death 

On April20, 2015, Chairman Johnson wrote to VA Secretary McDonald inquiring 

whether the VA conducted any inquiry into Dr. Kirkpatrick's termination and suicide. 1544 The 

Chairman noted the circumstances surrounding Dr. Kirkpatrick's termination and death and 

asked for information and documents surrounding these events. The VA notified the Chairman 

that it did not investigate Dr. Kirkpatrick's suicide-even though Dr. Kirkpatrick reported 

receiving patient threats-because Dr. Kirkpatrick had announced his intention to resign before 

he committed suicide. 

In a May 29, 2015 letter to Chairman Johnson, VA Deputy Secretary Sloan Gibson 

confirmed that the "VA did not conduct an investigation into Dr. Kirkpatrick's termination and 

suicide. " 1545 Deputy Secretary Gibson elaborated: 

Tomah VAMC management did not investigate [Dr. Kirkpatrick's] suicide 

because during the July 14, 2009, meeting where Dr. Kirkpatrick was notified that 

his temporary appointment would be terminated effective July 28, 2009, he 

indicated his intention to resign prior to the termination effective date. Tomah 

V AMC management did not receive a resignation letter from Dr. Kirkpatrick 

prior to his death. 1546 

1541 Ellinghuysen Transcribed Interview, at 97; see also Memorandum by Linda Ellinghuyscn, at I-2 (2009), in 

JUNEAU COUNTY REPORT 34, at 34-35 (2009). 1542 Ellinghuysen Transcribed Interview, at 98-99; see also Memorandum by Linda Ellinghuysen, at l-2 (2009), in 

JUNEAU COUNTY REPORT 34, at 34-35 (2009). 1543 Ellinghuysen Transcribed Interview, at 98. 1544 4/2012015 Letter from Chairman Johnson, HSGAC, to Secretary McDonald, VA, at l. 1545 5/2912015 Letter from Deputy Secretary Gibson, VA, to Chairman Johnson, HSGAC, at l. 1546 I d. 

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Deputy Secretary Gibson explained, "[t]he VA Police Service does not have the jurisdiction to 

investigate an employee or a recently-terminated employee's suicide that occurred off VA 

property."t547 

Deputy Secretary Gibson exf.lained that the VA Police Service is responsible for 

addressing reported patient threats.1 48 He added that the Tomah V AMC has a committee that 

considers "risk factors and recommendations on flagging patients" consistent with VA 

regulations. 1549 With respect to the patient that allegedly threatened Dr. Kirkpatrick, Deputy 

Secretary Gibson wrote: 

A review of Dr. Kirkpatrick's records identified one Veteran as possibly being the 

Veteran who may have threatened Dr. Kirkpatrick. However the Tomah V AMC 

is not aware of any action taken against this patient regarding threats against Dr. 

Kirkpatrick. 1550 

3. The VA OJG's inquiry into Dr. Kirkpatrick's suicide 

The VA OIG asserted that it examined Dr. Kirkpatrick's termination and suicide as part 

of its Tomah V AMC health care inspection. However, the only mention of Dr. Kirkpatrick's 

termination and suicide appears on page two of the OIG's !!-page administrative closure where 

the VA OIG listed the documents it reviewed as part of its inspection. The reference reads: 

9. Documents related to the suicide of a Tomah V AMC mental health 

professional immediately following termination of employment (memoranda, email messages, Sheriffs Department refsorts, union representation records and 

related internal union correspondence). 551 

The majority staff has learned that the VA OIG pulled Dr. Kirkpatrick's emails as part of 

its review of the facility. 1552 However, the administrative closure made no findings about Dr. 

Kirkpatrick's termination or suicide. 

During transcribed interviews, Chairman Johnson's staff asked VA OIG personnel 

whether the VA OIG investigated Dr. Kirkpatrick's termination and suicide as part of either its 

health care inspection or a separate criminal investigation. Staff presented the Juneau County 

Sheriffs report of Dr. Kirkpatrick's suicide. Dr. Mallinger described the VA OIG's inquiry into 

Dr. Kirkpatrick's suicide, stating: 

1547 ld. 

l548Jd 

1549Jd 

1550 !d. 1551 VA 010 TOMAH VAMC ADMINISTRATIVE CLOSURE, at 2. 1552 Memorandum from Robert Yang, VA, to Director, Computer Crimes and Forensics Laboratory (May 17, 2012), 

at 010 13677. 

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So Dr. Kirkpatrick was a psychologist at the Tomah VA who committed suicide, 

and some information about him came to our attention, specifically an 

investigation into his death by the Juneau County Sheriffs Department and we 

reviewed a lot of-and you probably have a copy of that, but there was a lot of 

VA material considered in that investigation that had been supplied by a union 

representative who had represented Mr. Kirkpatrick1553 

He explained further what the health care inspection team found in reference to Dr. 

Kirkpatrick: 

[B]asically there were-you know, there weren't, strictly speaking, allegations 

but, again, we were looking for administrative abuse, and, you know, we have a 

little latitude to go, you know, take a look at things that turn up in the leads that 

we develop. So that's really what we were doing here, is we were trying to 

determine whether there was any evidence for administrative abuse that arose out 

of this situation. And, basically, frankly, we were trying to understand the 

situation a little bit better-1554 

Ultimately, the team "didn't really feel that the situation with Dr. Kirkpatrick led 

anywhere. We thought it was another-you know, one of many sort of things that we 

followed that didn't take us to a productive conclusion."1555 

In May 2012, Special Agent Greg Porter of the VA OIG's criminal investigation 

unit received an email from a DEA diversion investigator with a copy of the Juneau 

County Sherriffs report. 1556 The DEA investigator opined, "I think the best parts are the 

attachments and email correspondence, but you may find something I've missed 

regarding controlled substances." 1557 Special Agent Porter did not conduct any additional 

follow-up beyond reading the Juneau County Sheriffs report. 1558 He could not recall his 

reaction to the document, but he did not believe its contents were relevant to his 

investigation. He explained: 

Q: Do you recall reviewing this and can you recall your reaction to 

reviewing these 58 pages? 

A: No, I cannot. I would look at-as I sit here looking at it, the first thing 

I would look at is when this happened, and this happened three years 

1553 Mallinger 4/6/2016 Transcribed Interview, at 255. 1554 !d. at 257. 1555 !d. at 258. 1556 E-mail from Diversion Investigator, DEA, to Greg Porter, VA OIG (May 21, 2012, 3:02 PM), OIG 10598. 1557 /d 1558 Porter Transcribed Interview, at 82-83. 

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prior to my investigation at the Tomah, and it was a suicide by 

gunshot. So I wouldn't have given much credence to this as being 

relevant to my investigation] 559 

Chairman Johnson's staff inquired further whether Special Agent Porter found 

any connection to his investigation in the contents of the suicide investigation report. 

Specifically, staff pointed to information contained in the report about potential 

whistle blower retaliation at the Tomah V AMC, allegations surrounding concerns about 

credentialing, the prescription of large quantities of narcotics, and use of the moniker 

"Candy Man."1560 Special Agent Porter did not find that those documents were relevant 

and candidly informed the Committee that all he learned from the document was that Dr. 

Kirkpatrick committed suicide and "may have been a drug user himself." He stated: 

Q: My question is: From reviewing this document and interviews 

preceding this May 2012 time frame, did you become aware that 

similar allegations had been raised in earlier years? 

A: By reading this report, I learned that a doctor had shot himself in 

the head, and there was--as I recall, there were other pieces of 

information to where, you know, he may have been a drug user 

himself, as I recall it. I don't-this report per se didn't influence my 

investigation at all, and I didn't-1561 

This exchange underscores the VA OIG's disregard for Dr. Kirkpatrick's 

whistleblower allegations. Similar to the VA OIG's white paper that attacked the Tomah 

V AMC whistleblowers, Special Agent Porter refused to concede that Dr. Kirkpatrick was 

raising concerns about ovennedication and abuse of authority at the Tomah V AMC. 

Instead, all he apparently gleamed from the Sherriffs report of Dr. Kirkpatrick's death 

was that Dr. Kirkpatrick was a drug user who "shot himself." 

4. The VA OIG's whitepaper on Dr, Kirkpatrick 

On June 4, 2015, VA OIG Deputy Inspector General Richard Griffin sent an unsolicited 

letter to Chairman Johnson that included a "white paper" that purported to support the VA OIG's 

health care inspection. 1562 The letter and white paper were sent to 38 separate Senators and 

Congressmen-many of whom had no involvement whatsoever with the Committee's 

1559 Id. 

1560 Id. at 84. 1561 /d. at 84-85. 1562 Letter from Richard J. Griffin, Deputy Inspector General, Dep't of Veterans Affairs, to Han. Ron Johnson, 

Chairman, S. Comm. on Homeland Sec. & Governmental Affairs, at 3 (June 4, 2015) [hereinafter 6/4/2015 Letter 

from Deputy Inspector General Griffin, VA OIG, to Chainnan Johnson, HSGAC]. 

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investigation or any connection to the Tomah V AM C. On June 18, 2015, the VA OIG issued a 

press release highlighting the white paper and issued at least five separate tweets promoting the 

document. 156J 

The VA GIG's whitepaper attacked the victims and whistleblowers of the Tomah 

V AM C. The document and its unsolicited attacks were particularly alarming because they came 

from the VA OIG-the very office that should protect whistleblowers. 1564 Even Dr. Kirkpatrick, 

who had passed away nearly six years earlier, fell into the VA OIG's crosshairs. Dr. Kirkpatrick 

was not in a position to defend himself and it is repulsive that the VA OIG went to such lengths 

to retaliate against him. 

The VA GIG's white paper references evidence found in Dr. Kirkpatrick's suicide report 

that is irrelevant to Dr. Kirkpatrick's concerns about overmedicated patients at the Tomah 

VAMC, his termination, or his suicide. In the white paper, the VA OIG "strongly" 

recommended that readers undertake a "thorough" review of the Juneau County Sheriffs report 

documenting law enforcement's investigation of Dr. Kirkpatrick's suicide. 1565 The VA OIG 

specifically noted the "voluminous amounts and types of marijuana and what appears [sic] to be 

other illegal substances found in Dr. Kirkpatrick's residence." The VA OIG added: 

The evidence indicates that Dr. Kirkpatrick was likely not only to have been 

using but also distributing the marijuana and other illegal substances. The 

Sheriffs report also lists large amounts of various prescription drugs found onsite, 

some of which were lying around loose with no indication whether they were 

prescribed for Dr. Kirkpatrick and, if so, when and by what provider. 1566 

Nothing in the VA GIG's white paper makes any reference to the actual substance of Dr. 

Kirkpatrick's whistleblowing-the appearance of overmedicated patients at the Tomah VAMC. 

The very same Sheriffs report that the VA OIG cites contained documents referring to the 

Tomah VAMC and Dr. Houlihan as "Candy Land" and "Candy Man," and highlighted Dr. 

Kirkpatrick's concerns about over prescription of narcotics at the facility1567 The VA OIG white 

paper ignored those facts. 

1563 Letter from Hon. Ron Johnson, Chairman, S. Corum. on Homeland Sec. & Governmental Affairs, to Linda 

Halliday, Deputy Inspector General, Dep't of Veterans Affairs, at 2 (July 8, 2015) [hereinafter 7/8/2015 Letter from 

Chairman Johnson, HSGAC, to Deputy Inspector General Halliday, VA OIG). 1564 See generally Whistleblowcr Protection Act. Pub. L. 10 l-12, 1-3 Stat. 16; Pub L. l 03-424, 108 Stat. 4361 

(codified, as amended, in various sections of Title 5 U.S.C.). 1565 VA OIG Whitepaper, at 8. 1566 !d. at 9 (emphasis added). 1567 Memorandum from Linda Ellinghuysen, Executive V.P., AFGE Local1882, to Ben Balkum, President, AFGE 

Local VA Medical Center, !ron Mountain, Ml, at 2-3 (Apr. 17, 2009), in JUNEAU COUNTY SHERIFF'S DEPARTMENT, 

CHRIS KIRKPATRICK DEATH lNVESTlGA TION REPORT 50, at 51-52 (2009). 

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Figure 103: VA OIG white papH (pages 8 aud 9) ---------------

The only sperific dca1h brought f<J our nHt!t~t:ou during th(' inspt•c!iull was th4l of a p,sycholugi:-;.t, 

Christopher Kirkpatrick. 'vhu committcJ suicide alter being tcrminat.:::d from his tC"mpurary 

ptJ;:.;Hion at the Tmnah tnt'th.:al c-enter nn July 14, lUOtl \Vc did 0'-''1 find any cvidt•m.:t~ that 

Dr. Houlihan was in any way rcspon"blc for Dr. KirkJ'~trid(s <ka!h, al!hou~h 1he V1ce 

Prc-~idt>rH of the local ~,:h,tpler of the AmerlC.:'!n Fcde::ntinn of GO'-'l'TJUH("nt J~mpiDyn~::. (AFCif<) 

c,.;prcss.eJ th1s opiniop in dtx·uments "'he prnvidc'd to lhc Jww.m County Sheriff's Dcpartmt:nt 

\\llo v.as r<."Sponsihlc t('~r inve-stigniln}"', ~he suil~fdc. I 711H .. Hl£lY JCCOlHJrh!nd a lhorough review of 

the in-depth Shcrifrs report. t~ ruhlidy Iwuilah!e document~ that l~ !ndudcU m the documents 

produced, Records produced. pp. 5"'1:\-5851, with spctoi!ic il!tt'nlivn to the ;:>ages detailing the 

vpluminous amounts ;md types. of mariju~,.na ,md \\~hat appeMs to [\c other ilkp.1l suhstan\~es 

fnund m Dr. KiikputrH..:k.'s :·e~id.:ncc o.:s well a-::; other item~. mduding. ti s~..~nk" .md u.s,•d device-:::. 

containing marijuana residue. "!1ic evidence mditiHl''i th~tt Dr Kirkputnck was Hkdy not only to 

have t"t:cn using but also di~tnhutin_s, the mariJuana ~md ot:,~..·r iHt~g~tl subsrantt'\j rhe Sbr-rifl":-. 

:cDort ,-tbo li:-;:rs larg(' amounu of various pn:~{:ript;,,n d1ugs fnuntl m1sit~, some nf whkh ".-ere 

lying nround Jnosc with no mdicmton wht.:th~r the~· W\!re prscnbcd !(n iJr. Kirkpatrick and. 1f 

sn~ \Vhcn and hy ~vh<:l pro\,!da, 

On July 8, 2015, Chainnan Johnson sent a letter to VA Deputy Inspector General, Linda 

Halliday, 1568 responding to the VA GIG's attacks against the Tomah VAMC whistleblowers. 

Chainnan Johnson wrote: 

It is beyond belief that the VA OIG could perform a "thorough" review of the 

Sheriffs investigative file, seemingly ignore the evidence with any actua!nJeiit to 

the subject of its inspection, and instead focus solely on infmmatiou to attempt to 

discredit a deceased witness. Both the achninistrative closure and the white paper 

acknowledged the fact that the VA OIG reviewed material relating to Dr. 

Kirk1Jatrick's death during the health care inspection at the Tomah VAMC. 

However, the only analysis of tllis information, which the VA OIG offers with 

scant evidence, appears to consist ofblanling Dr. Kirk1Jatrick and implying dmg 

use contributed to his deatl1. Nowhere does the VA OIG discuss the actual 

evidence in the Juneau County Sheriffs file relevant to the subject matter of its 

inspection of the Tomah VAMC1569 

At a Committee hearing held on September 22, 2015, Chairman Johnson questioned 

Deputy Inspector General Halliday on why the VA OIG would retaliate against Dr. 

1568 Deputy Inspector General Griffin retired from federal service on July 4, 2015. Donovan Slack. Embattled VA 

Watchdog Stepping Down, USA TODAY (June 30. 3015). . 

http://www. usatoday .corn! stOiy/news/politics./.:!0 15/06/ 30/ya-inspector-general~to-resign~this-week-in-face-ofcriticism/2 9 52 54 97 I_ 

"" 7/812015 Letter from Chairman John<OIL HSGAC, to Deputy Inspector General Halliday. VA OIG. at 6. 

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Kirkpatrick. 1570 When asked who prepared the white paper, Deputy Inspector General Halliday 

testified that she had not prepared the document and said she would need to take the question for 

the record. 1571 She testified: 

Chairman Johnson: Were you at all involved in the writing of that white paper? 

Ms. Halliday: I was not. 

Chairman Johnson: Were you aware it was being written and issued? 

Ms. Halliday: I was not. 

Chairman Johnson: It strikes me as, quite honestly, reprehensible .... I want 

assurances that this will be corrected, that amends will be 

made for this reprehensible reprisaL Ms. Halliday? 

Ms. Halliday: As I stated, I did not prepare that document. IChairman Johnson: Who did? Do you know the individuals within the Office 

of Inspector General that wrote this? Who did this? I want 

to know. This Committee wants to know who is involved 

in this. 

Ms. Halliday: The priorChairman Johnson: I want to know every individual who was involved in 

writing this report. 

Ms. Halliday: I would have to take that for the record. 1572 

Chairman Johnson followed up his request from the hearing with a letter to Deputy 

Inspector General Halliday on September 29, 20!5, asking for "all documents and 

communications referring or relating to the drafting or publication of the VA OIG's Tomah 

VAMC white paper .... " 1573 The Chainnan requested all drafts of the white paper, and all 

1570 Improving VA Accountabili(y: Examining First-Hand Accounts of Department of Veterans Affairs 

Whistleb!owers, Hearing Before S. Comm. on Homeland Sec. & Governmental Affairs, !14th Cong. (2015). 1571 Improving VA Accountability: Examining First-Hand Accounts of Department of Veterans Affairs 

Whistleblowers, Hearing Before S. Comm. on Homeland Sec. & Governmental Affairs, !14th Cong. 106-09 (2015) 

(hearing transcript). 

1572 !d. 1573 Letter from Hon. Ron Johnson, Chairman, S. Corum. on Homeland Sec. & Governmental Affairs, to Linda 

Halliday, Deputy Inspector General, Dep't of Veterans Affairs, at 2 (Sept. 29, 2015) [hereinafter 9/29/2015 Letter 

from Chairman Johnson, HSGAC, to Deputy Inspector General Halliday, VA OIG]. 

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387 

emails between VA OIG employees concerning the drafting or publication of the white paper. 1574 

The letter requested the VA OIG produce this infonnation by October 6, 2015. 1575 

On October 6, 2015, Deputy Inspector General Halliday responded to Chairman 

Johnson's letter. The letter reiterated Ms. Halliday's position from her September 22 testimony. 

Ms. Halliday wrote: 

As I stated at the Committee's hearing on September 22,2015, I had no role in 

drafting this document or the decision to release it as I was not the Deputy 

Inspector General at the time. I would emphasize that all staff were operating 

under tbe direction of the former Deputy Inspector General [Richard Griffin), who 

is the responsible official who directed, signed, and issued the document. 157 

Ms. Halliday refused to provide the requested information and said that the drafts were part of 

the agency's deliberative process. She also cited concerns that producing this material would 

somehow jeopardize the independence of the VA OIG. She concluded: 

In consideration of these actions and tbe need to preserve tbe independence and 

integrity of the deliberative proves across the Inspector General community, I 

respectfully ask that you withdraw your request for documents described [in the 

letter]. 1577 

Chairman Johnson has not withdrawn his request, which remains outstanding. The VA 

OIG has not asserted a privilege over this material, but merely claimed that the requested 

documents could include deliberative materials. Even more troubling is the VA OIG's decision 

to avoid accountability for its reprisal against Dr. Kirkpatrick. The VA OIG's callous attacks on 

the Tomah V AMC whistleblowers and its hinting at legal privilege to avoid public scrutiny of its 

decisions are unbecoming of a member of the inspector general community. 

1574ld. 

1575 Jd. 

1576 Letter from Linda Halliday, Deputy Inspector General, Dcp't of Veterans Affairs, to Hon. Ron Johnson, 

Chairman, S. Comm. on Homeland Sec. & Governmental Affairs, at I (Oct. 6, 20 I5) (hereinafter I 0/6/20 I5 Letter 

from Deputy Inspector General Halliday, VA OIG, to Chairman Johnson, HSGAC]. 1577 /d. at 2. 

F'"'-~ 

~·r ~--j 

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Figur{' 104: LPttt>l' from VA to Chairman Johnson 

In consideration of these actions and the need to preserve the independence and 

ontegrity of the dehberatrve process across the Inspector Ge"leral commumty, I 

respectfully ask that you wrthdraw your request for the documents descnbed m 

puragraphs a ar1d b 

am confident that. under your leadership, the Committee and the OIG can forge a new 

relationship, based on mutual respect. cooperation. and a shared mrssion of ensuring 

veterans recerve the care they have earned through their servrce to our Nat1on. I 

· apprecrate your consideratiOn of thrs request 

s~ t?. ,st_.."'~7 LINDA A. HALLIDAY 

Depur;lnspector Ge11eral 

C. Dr. Noelle Johnson 

Dr. Noelle Johnson was a clinical phannacy specialist at the Tomah V AMC from July 

2008 to June 2009. 1578 Dr. Johnson often served as the "hot seat" phannacist at the facility's 

phannacy, in which she would act as the final reviewer of prescriptions before they were 

dispensed to veterans. 1579 On multiple occasions through her tenure in the phannacy, Dr. 

Johnson refused to fill prescriptions because she believed they were unsafe. She was removed 

fi'om the Tomah VAMC just weeks before the conclusion of her probationary employment 

period. She challenged her removal before the Merit Systems Protection Board (MSPB) and 

subsequently reached a settlement with the VA that fully reinstated her employment. Dr. 

Johnson cmTently works at a VA facility in Iowa. 

Dr. Jolmson testified about her experiences in the Tomah VAMC phannacy dm·ing the 

Conmlittee's March 30,2015 field hearing in Tomah, Wisconsin1580 She confirmed that the 

facility was known among the veteran population as "Candy Land" and that veterans referred to 

Dr. Houlihan as the "Candy Man": 

15711 Tomah VAA-fC: E:ramining Quality, Access, and Culture ojOren·e/iance on High~Risk A1edicalians, Joint Field 

Hearing Before S. Comm. on Homeland Sec. & Gol'ernmental Affairs & H. Comm. on Veterans Ajfain I 14th Con~. 

(2015) (statement ofNoelle Jolmson). 1579 Noelle A. Jolmson Y. Dep't of Veterans Affairs, MSPB Docket No. CH-1221-10-0036-W-1, Tab I at I (Dr. 

Jotmson's nan-ative of the events). 1580 Tomah VAMC: E,·amimng Qualiry, Access, and Culture ojOw?rrelrance on High-Risk Medications, Joint Field 

Hearmg Before S. Comm. on Homeland Sec. & GoYernmentol Affairs & H. Comm. on Veterans Ajfmrs I 14th Cong. 

(2015) (statement of Noelle Johmon). 

Majority Staff Report 

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Senator Ron Johnson, Chairman 

309 
389 

The "Candy Man" statement the CIR [Center for Investigative Reporting] 

reference is legitimate. I heard more than one Veteran reference Dr. Houlihan as 

this. I heard a particular [Tomah' V AMC] patient in the hall way say "my prima1y 

care doctor took me off of my narcotics, you need to see Dr. Houlihan because he 

will put you back on them just like he did me." 1581 

She testified about specific instances in which she refused to fill prescriptions that she believed 

to be unsafe. 1582 Dr. Johnson also highlighted instances of other Tomah V AMC employees 

either leaving the facility or facing discipline for questioning potentially unsafe prescriptions. 1583 

In addition to speaking about her efforts to address the issue of overmedication internally 

within the Tomah VAMC, Dr. Johnson testified about how she contacted multiple entities to 

potentially initiate an outside review of the Tomah V AMC. 1584 She testified that she called the 

Wisconsin Pharmacy Board, the Iowa Board of Pharmacy, and the Drug Enforcement 

Administration (DEA), and that she filed a whistleblower claim with the Office of Special 

Counsel.1585 

As the majority staffs interim report discussed, the DEA interviewed Dr. Johnson as part 

of an investigation it conducted on the Tomah V AMC in 2009. According to documents filed as 

part of Dr. Johnson's MSPB appeal, she was interviewed by a DEA investigator on June 19, 

2009. 1586 During the interview, Dr. Johnson showed the DEA investigator approximately ten 

examples of patients under Dr. Houlihan's care who received narcotic prescriptions that in her 

opinion were either too high in dosage or too long in length. 1587 Dr. Johnson informed the DEA 

investigator of three "unexplained suicides" of Dr. Houlihan's patients at the Tomah VAMC 

during her employment. 158 At the conclusion of the two-hour interview, the DEA investigator 

infonned Dr. Johnson that federal prosecutors would be in touch with her and he advised her not 

to fill any prescriptions she felt were unsafe. 1589 Federal law-enforcement officials never 

followed up with Dr. Johnson. 

Like it did to Dr. Kirkpatrick, the VA OIG attacked Dr. Johnson's claims and 

creditability in its white paper. The VA OIG argued that Dr. Johnson had no "personal 

1581 Id. at 6. 1582/d. 

1583 I d. at 6. 1584 ld at 5. 1585 1d. at I, 5. 1586 Noelle A. Johnson v. Dep't of Veterans Affairs, MSPB Docket No. CH-1221-10-0036-W-l, Tab 1 at 6 (Dr. 

Johnson's narrative of the events). Dr. Johnson also confirmed that she was interviewed by the DEA in 2009 in her 

written testimony for the Committee's Field Hearing in Tomah on March 30,2015. Noelle Johnson statement at I. 1587 Noelle A. Johnson v. Dep't of Veterans Affairs, MSPB Docket No. CH-1221-10-0036-W-1, Tab 1 at 6 (Dr. 

Johnson's narrative of the events). 1588 !d. 

1589/d 

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knowledge of the facts and circumstances as they existed during [the OIG's] inspection." 1590 

The VA OIG also downplayed the retaliation Dr. Johnson suffered, saying that she was 

terminated in part because she had "poor interpersonal skills," "repeated negative interactions," 

and had "unsatisfactory" performance. 1591 The VA OIG implied that because Dr. Johnson was 

"only a probationary employee" who "had just completed her training and [the Tomah VAMC] 

was her first position as a pharmacist," her perception that some of Dr. Houlihan's prescriptions 

were unsafe and her belief that she was fired because she questioned those prescriptions was 

somehow inaccurate. 1592 

Nowhere in the white paper, or the actual administrative closure for that matter, did the 

VA OIG actually examine on the merits of Dr. Johnson's allegations. As explained in Chairman 

Johnson's letter to the VA OIG in response to the white paper, the VA OIG failed to 

acknowledge Dr. Johnson's credentials as a pharmacist, or any other facts that paint Dr. Johnson 

in a positive light. 1593 The VA OIG ignored Dr. Johnson's firsthand accounts of abuse and overprescription because they did not occur during the time of the OIG's inspection. The VA OIG 

ignored the twelve separate letters of support signed by Tomah VAMC employees who 

interacted with Dr. Johnson during her tenure at the Tomah VAMC. 1594 The VA OIG 

overlooked Dr. Johnson's "fully successful" performance ratings from her service line 

manager. 1595 Most significantly, the VA OIG failed to acknowledge that Dr. Johnson entered 

into a settlement agreement with the VA in 20 I 0 that fully reinstated her to VA employment. 

Instead, the VA OIG focused solely on cherry-picked documents and information that painted 

Dr. Johnson in a negative light in an effort to discredit her. 

D. Ryan Honl 

Ryan Honl served as a secretary in the Tomah VAMC mental health unit. He is a 

disabled combat veteran of Operation Desert Storm and a graduate of the United States Military 

Academy at West Point, New Y ork. 1596 Mr. Honl began raising concerns about the overprescription of narcotics at the Tomah VAMC, as well as potential scheduling manipulation at 

the facility. 1597 Mr. Honl made complaints to both the VA OIG and the Office of Special 

1590 VA OIG Whitepaper, at 3. 1591 ld. at 9--10. 1597 !d. at 10. 1593 7/8/2015 Letter from Chaim1an Johnson, HSGAC, to Deputy Inspector Halliday, VA O!G, at 3-4. 1594 Noelle A. Johnson v. Dcp't of Veterans Affairs, MSPB Docket No. CH-122!-10-0036-W-l, Attachment T, at 1-

12 (letters of support). 1595 Noelle A. Johnson v. Dep't of Veterans At1'airs. MSPB Docket No. CH-1221-10-0036-W-1, Attachment N (Dr. 

Johnson's pcrfOnnance appraisals). 1596 Tomah VAMC: Examining Quality, Access, and Culture of Overreliance on High-Risk Medications, Join! Field 

Hearing Before S. Comm. on Homeland Sec. & Governmental Affairs & H. Comm on Veterans Affairs !14th Cong. 

(20 15) (statement of Ryan Honl at 1 ). 

""Id. 

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Counsel (OSC) about the issues he observed at the Tomah V AM C. After he made his 

disclosures, he faced several forms of retaliation. 

On the same day that Mr. Honl made a disclosure to the VA OlG, Tomah V AMC 

management "stripped Mr. Honl of his job duties, locked him out of his office, and isolated him 

from his co-workers." 1598 Shortly after the abuse began, Mr. Honl resigned. With the assistance 

of the OSC, Mr. Honl settled with the VA and received "several corrective actions, including the 

removal of negative information from his personnel tile and monetary damages." 1599 

Like Dr. Johnson, Mr. Honl testified during the Committee's March 2015 field hearing in 

Tomah, Wisconsin. He highlighted additional examples of retaliation that he faced at the Tomah 

VAMC after coming forward to reporting wrongdoing. Mr. Honl testified: 

After requesting a patient access report of my medical records, I discovered that a 

half dozen Tomah employees had accessed my electronic medical records after I 

left the facility over a supposed mix up in Secretary McDonald's office 

concerning a complaint about my prescriptions. Although I had never received 

care or prescriptions from the Tomah VA, there were half dozen Tomah nonpharmacy employees in my records. 1600 

Mr. Honl also testified about how Tomah VAMC personnel disclosed and publicized his 

diagnosis ofPTSD in an attempt to discredit his whistleblowing. He testified: 

I had originally informed my supervisor, Lisa Noe, that I had a PTSD diagnosis 

since I was in vocational rehabilitation and my counselor in Indiana needed to 

know information about my employment at the Tomah VA. I asked that this 

remain in confidence. However, as soon as I blew the whistle, I started hearing 

about my instability from other employees. Ultimately, the most troubling [sic] 

occurred since everything came out in the media in January. Dr. Houlihan's 

attorney sent a letter to me threatening a lawsuit for defamation. In an interview 

with the Milwaukee Journal Sentinel, his attorney alluded to my mental health 

status. Shortly after while VA investigators were in the Tomah VA, Police Chief 

Huffman directed that a police report be done on me by my former supervisor, 

Lisa Noe, and two coworkers, Leesha Dukes and Rachel Fleming, four months 

after I resigned over a supposed "threatening incident" that took place while I was 

an employee before I resigned .... In one part of the police report, I'm accused of 

1598 Press Release, U.S. Ofticc of Special Counsel, OSC Secures Relief for Additional VA Whistleblowers (July 22, 

20 15), https:/iosc.gov/Ncws/prl5-l5.pdf. 1599ld 

1600 Tomah VAMC., Examining Quality, Access, and Culture of Overreliance on High-Risk Medications, Joint Field 

Hearing Before S. Comm. on Homeland Sec. & Governmental Affairs & H. Comm. on Veterans Affairs !14th Cong. 

(2015) (statement of Ryan Honl at 2). 

Majority Staff Report 

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312 
392 

acting "crazy." Clearly, my mental health diagnoses are being used by those I 

reported in order to discredit me. 1601 

Like Dr. Kirkpatrick and Dr. Johnson, the VA OIG attempted to attack Mr. Honl's 

creditability as a whistleblower in its white paper, arguing that Mr. Honl had no personal 

knowledge of narcotic over-prescription at the Tomah VAMC. 1602 However, Mr. Honl's tenure 

at the Tomah V AMC gave him a firsthand view of the whistleblower retaliation at the facility 

and the culture of fear at the Tomah VAMC-an issue that the VA OIG examined in its health 

care inspection. As Chainnan Johnson explained in his response to the VA OIG, "[t]o discount 

[Mr.] Honl's testimony on such narrow grounds indicates a tainted and slanted perspective 

within the VA 010." 1603 

E. Lin Ellinghuysen 

On January 21, 2016 the Washington Examiner published an article revealing complaints 

that the Department of Veterans Affairs was "spying on whistleblowers by diverting their emails 

to the secretary's office in Washington, D.C." 1604 The list, titled "Sec Divert Internal" includes 

VA whistleblowers throughout the country. According to the Examiner, "emails from those 

workers are being sent to VA secretary's office in Washington, D.C." 1605 Lin Ellinghuysen, the 

president of AFGE Local 0007 who had been raising concerns about over-medication and 

administrative abuse at the Tomah V AMC for years, appears on the Sec Divert Internallist. 1606 

1601 !d. at 2--3. 1602 VA OIG Whitcpaper, at 3. 1603 7/8/2015 Letter from Chairman Johnson, HSGAC, to Deputy Inspector Halliday, VA OIG, at 7. 

" 04 Pete Kasperowicz, House Probes Claim the VA is Spying on Whistleblower Emails, WASHINGTON EXAMINER 

(Jan. 21, 20 16), http://www.washingtonexaminer.com/house-probes-c1aim-the-va-is-spying-on-whistlcb1oweremai1s/article/2581 072. 1605 !d. 

1606 !d.; see also Memo by Linda Ellinghuysen, President, AFGE Local 0007 (Feb. 2014). 

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313 
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Figure 105: VA's Sec Divl"rt lntl"l'Ual List 

f 

On Febmary 29,2016, Chainnan Jolmson wrote to VA Secretary McDonald inquiring 

why Ms. Ellinghuysen appeared on the "Sec Divert Internal" list of emails that were being 

divertedl607 In the letter, Chainnan Johnson noted that in a Febmary 2016meeting between his 

staff and AFGE tmion officials, Ms. Ellinghnysen informed the statr that she was tmaware that 

she was included on such a Iist. 1608 Ms. Ellinghuysennoted, however, that she noticed a 

mysterious woman's name--a name she did not recognize-included in some group emails she 

had sent in2015 since the public became aware of the tragedies at the Tomah VAMC1609 

1607 Letter from Hon. Ron Johnson. Chain11an, S. Comm. on Homeland Sec. & Governmental Affairs, to Hon. 

Robert McDonald. Secretary, Dep 't of Veterans Affairs, at 2 (Feb. 29, 20 16) [hereinafter 2/29/2016 Letter fi·om 

Chainnan Johnson. HSGAC. to Secretary McDonald, VA]. 160S Jd. 

1609 Id. 

Majority Staff Report 

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Senator Ron Johnson, Chairman 

314 
394 

'l11c llt)nl'~rahk Rol~rt A. ~h::D~~rwld 

~t"t'fr;:'IHf) 

~ I.S. Dep.nrtrn~:nt of Vt:ll:ran ..... Aff,1trs 

810 Vcnnont ,\,t:nue. ~W 

W:bhington. ()(' ~04:!0 

I >car St:crc-tnr;. \h~I)onald: 

llmtcd StJtcs SrnJrr 

rh~ Committee on flmndanO s~.-curity and Oovemmcntal Atlhirs i-,. examining i~o.:ues 

rdming to tht' I>cpanrn .. ·nt of Vctenms A llanos ~icJI\.~at Cente-r tn Tornah, Wi~on~in { fomuh 

\'r\MC~ ~b wdl ~lS allegation-. \1( whistlch!t)Wl.~f rcHlliatlon agamst V t\ t:'rnphlyCcs. f \\Tile 

rcp:;nding .1 rccc!ll H <Hhmgttntl:\-amirta ttrtidt• thatullcgcd that V r\ k-ttdl"rship is sp~ln!:! on 

whiz;;.tlt·bto .. veN hy dJ\trtin~ their "~mails w your of'tlce. 1 i\mong those wh\lS-e cmaits arc 

apll.arentl;· t'i(:ing tt,tc~cd is Lind.1 Ellinghuyscn, Actin~ President ofth" Am~ric~n Federation of 

Cio1.crnment Employees {1\FGE; Local 0(J07 at the Tomah \'A~K', I r~·qucst )'Our a:'lsi.s:tan..:.t' 

with I his inqait), 

Chairman Johnson's letter explained that the existence of a list like the "Sec Divert 

Intemal" list raises significant concems about VA employees' ability to blow the whistle on 

waste. fraud, abuse, and misconduct by VA management. 1610 VA employees need to have 

confidence to raise concerns at their facilities to ensure that veterans receive the care the~ 

desetve. Chainnan Johnson requested matetial about the pmpose and origins of the list. 611 

Chairman Johnson requested that the VA produce this material by March 18.20161612 To date, 

the VA has not produced any material responsive to this request and they do not have a time line 

on when the agency anticipates providing a response to Chainnan Jolmson's inquiry. 

* * * 

By most accounts, the VA is not a friendly environment for whistleblowers. Witnesses 

from across the country who were invited by Chainnan Johnson to testify at a September 2015 

Committee hearing described their experiences. The VA put Brandon Coleman. a veteran and 

VA employee in Phoenix, Arizona. on leave and closed his drug rehabilitation program after M:r. 

1610 Id. at 1. 1611 Id. at 3. 16t2ld 

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395 

Coleman raised concerns about patient suicides. 1613 Shea Wilkes, a VA employee from 

Shreveport, Louisiana, testified that the VA OIG began to investigate him for accessing VA 

records after Mr. Wilkes discovered a secret patient wait list for care at the Shreveport 

facility. 1614 Joseph Colon, a credentialing support specialist with the VA Caribbean Health 

System in San Juan, Puerto Rico, testified about the retaliation he faced after he blew the whistle 

about quality of care issues and misconduct by the director of his facility. 1615 

Sean Kirkpatrick, the brother of Dr. Christopher Kirkpatrick, also testified during that 

hearing. He told Chairman Johnson and the Committee the story of his brother, who raised 

concerns about over-prescription at the Tomah VAMC and was later fircd. 1616 The story of Dr. 

Kirkpatrick was unfortunately familiar to other Tomah VAMC employees. Witnesses described 

a culture of fear at the Tomah VAMC. The VA OIG, the entity that is supposed to protect VA 

whistleblowers, attacked the Tomah V AMC whistleblowers-attempting to discredit their 

allegations through character and ad hominen attacks. 

The Tomah VAMC is an unfortunate case study of the poor state ofwhistleblower 

protection within the VA. Because employees and others were afraid to speak out, the problems 

at the facility continued unabated. In this way, the whistleblower retaliation and culture of fear 

at the Tomah V AMC contributed to the tragedy. 

1613 lmproving VA Accountability: Examining First-Hand Accounts of Department of Veterans Affairs 

Whistleblowers. Hearing before S. Comm. on Homeland Sec. and Governmental Affairs, !14th Cong. (2015) 

(statement by Brandon Coleman at 3 ). 1614 Id. (statement by Shea Wilkes at II). 1615 I d. (statement by Joseph Colon). 1616 /d. (statement by Scan Kirkpatrick). 

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Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

316 
396 

V. Attempts at stonewalling Chairman Johnson's investigation 

Throughout the course of the investigation, Chairman Johnson has received cooperation 

from agencies-such as the Merit Systems Protection Board and the Office of Special Counselthat have been forthcoming with information. Their forthright assistance has greatly aided the 

Committee's fact-finding. Other entities, however, have resisted efforts to obtain information 

about what happened at the Tomah VAMC. By and large, the entities centrally involved in 

investigating abuses at the Tomah VAMC declined to cooperate completely with Chairman 

Johnson's investigation. This posture unnecessarily delayed the fact-finding and prevents 

Congress and Wisconsin veterans from understanding the truth of what really happened at the 

Tomah VAMC. 

A. Congress has a right to information from the executive branch and 

other entities 

The United States Constitution vests Congress with certain enumerated powers, including 

the exclusive right to legislate. Article I of the Constitution authorizes Congress: 

To make all laws which shall be necessary and proper for carrying into execution 

the foregoing powers, and all other powers vested by this Constitution in the 

government of the United States, or in any department or officer thereof. 1617 

Implicit in this delegation is the authority of Congress to gather facts and to ensure that laws 

passed by Congress were faithfully executed. As early as 1792, Congress used its investigative 

power to obtain records and papers relating to the Battle of Wabash in the Northwest 

Territory. 1618 

For nearly I 00 years, the Supreme Court has explained that Congress's lawmaking 

authority necessarily includes a right to information from the executive branch. In Eastland v. 

U.S. Servicemen's Fund, the Supreme Court explained that "[t]his Court has often noted that the 

power to investigate is inherent in the power to make laws because '[a]legislative body cannot 

legislate wisely or effectively in the absence of information respecting the conditions which the 

legislation is intended to affect or change. "'1619 In Barenblatt v. United States, the Court 

elaborated: 

The power of inquiry has been employed by Congress throughout our history, 

over the whole range of the national interests concerning which Congress might 

1617 U.S. Const. art. I, § 8, cl. 18. 16 " 3 ANNALS OF CONG. 490-93 (1792). 1619 Eastlandv. U.S. Servicemen's Fund, 421 U.S. 491, 504 (1975) (citing McGrain v. Daugherty, 273 U.S. 135, 175 

(1927)). 

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legislate or decide upon due investigation not to legislate; it has similarly been 

utilized in determining what to appropriate from the national purse, or whether to 

appropriate. 1620 

The Supreme Court has continually emphasized the breadth of Congress' investigative 

power. "The scope of the power of inquiry," the Court explained in 1959, "is as penetrating and 

far-reaching as the potential power to enact and appropriate under the Constitution." 1621 While 

this investigative power must be exercised "in aid of the legislative function" 1622-in other 

words, "there is no congressional power to expose for the sake of exposure"1623-this focus does 

not restrict "the power of Congress to inquire into and publicize corruption, maladministration or 

inefficiency in agencies of the Govemment." 1624 

Congress's broad authority to conduct investigations includes the ability to compel the 

production of information and materials. In Eastland, the Supreme Court explained that the 

"[i]ssuance of subpoenas ... has long been held to be a legitimate use by Congress of its power 

to investigate." 162 The Court reasoned that "where the legislative body does not itself possess 

the requisite information-which not infrequently is true-recourse must be had to others who 

do possess it." 1626 The congressional "power of inquiry-with process to enforce it-is an 

essential and appropriate auxiliary to the legislative function." 1627 Moreover, committees of 

Congress exercise on behalf of the Congress the power to compel information: "It also has been 

held that the subpoena power may be exercised by a committee acting, as here, on behalf of one 

of the Houses." 1628 

The Senate Committee on Homeland Security and Governmental Affairs serves as the 

Senate's chief oversight and investigative committee. The Standing Rules of the Senate 

authorize the Committee to investigate "the efficiency and economy of operations of all branches 

and functions of the Government." 1629 In addition, the Senate has specifically authorized the 

Committee to examine "the efficiency and economy of all branches of the Government including 

the possible existence of fraud, misfeasance, malfeasance, collusion, mismanagement, 

1620 Barenblatt v. United States, 360 U.S. I 09, Ill (1959). 1621 !d.; see also Eastland v. U.S. Servicemen's Fund, 421 U.S. 491, 501 n.l5 (1975). 1622 Kilbourn v. Thompson, 103 U.S. 168, 189 (1880). 1623 Wmkins v. United States, 354 U.S. 178, 200 ( 1957). 1624 Watkins v. United States, 354 U.S. 178, 200 n.33 (1957). Similarly, lower federal courts have recognized 

Congress's right to information, including material from the executive branch. Jn Murphy v. Department of the 

Army, the Court of Appeals for the District of Columbia noted that "Congress, whether as a body, through 

committees, or otherwise, must have the widest possible access to executive branch information if it is to perform its 

manifold responsibilities effectively." Murphy, 613 F.2d 1151, 1158 (D.C. Cir. 1979). 1625 Eastland, 421 U.S. at 504 n. 15. 1626 McGrain v. Daugherty, 273 U.S. 135, 174-75 (1927). 1627 !d. 1628 Eastland, 421 U.S. at 503-05. 1629 S. Rule XXV(k); see also S. Res. 445, 108th Cong. (2004). 

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Senator Ron Johnson, Chairman 

318 
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incompetence, conuption, or unethical practices .... " 163° Chairman Johnson is investigating 

allegations relating to the Tomah VAMC pursuant to this authority. 

In short, if Congress is to develop laws to fix problems within the executive branch, it 

must first possess all necessary information to identify the root causes of the problems. This 

right to information from the executive branch is rooted in the Constitution and reaffirmed by the 

Supreme Court. In the course of this investigation, however, executive branch entities have 

failed to honor fully Chairman Johnson's requests for material. The stonewalling and lack of 

transparency unreasonably delayed the investigation and hindered accountability for the 

tragedies at the Tomah VAMC. 

B. The VA Office of Inspector General 

At the outset of the investigation, Chairman Johnson's staff contacted the VA OIG to 

seek its assistance in understanding the allegations concerning the Tomah VAMC. In early 

February 2015, Chairman Johnson's staff received a briefing from the VA OIG employees who 

conducted the Tomah V AMC health care inspection about their work. When Chairman 

Johnson's staff asked for the original source material supporting the VA OIG's health care 

inspection, the VA OIG balked and took on an increasingly confrontational tone. Chairman 

Johnson sent four letters to the VA Deputy Inspector General Richard Griffin in spring 2015 in 

an effort to secure its voluntary cooperation, and the Chairman's staff engaged in a number of 

discussions with VA OIG staff. 1631 Chairman Johnson also met personally with Deputy 

Inspector General Griffin on March 2, 2015, to try to reach an accommodation on the production 

of documents. 1632 

The VA OIG's refusal to aid the Chairman Johnson's investigation led to the highly 

unusual-and reluctant-issuance of a subpoena to Deputy Inspector General Griffin for 

documents relating the VA OIG's inspection1633 Although the VA OIG produced some 

documents, its overall posture toward the investigation has not changed since the issuance of the 

subpoena. The VA OIG continues to withhold documents from Chairman Johnson. 

1630 S. Res. 73 § 12, !14th Cong. (2015). 1631 Letter from Hon. Ron Johnson, Chairman, S. Comm. on Homeland Sec. & Governmental Affairs, to Richard 1. 

Griffin, Deputy Inspector General, Dep't of Veterans A!Tairs, at 2 (Feb. 25, 2015); Letter from Han. Ron Johnson, 

Chairman, S. Comm. on Homeland Sec. & Governmental Affairs, to Richard J. Griffin, Deputy Inspector General, 

Dep't of Veterans Affairs, at 2 (Mar. 1 I, 2015); Letter from Bon. Ron Johnson, Chairman, S. Corum. on Homeland 

Sec. & Governmental Affairs. to Richard J. Griffin, Deputy Inspector General, Dep't of Veterans Affairs, at 1-2 

(Mar. 17, 2015); Letter from Han. Ron Johnson, Chairman, S. Comm. on Homeland Sec. & Governmental Affairs, 

to Richard J. Griffin, Deputy Inspector General, Dep't of Veterans Affairs, at 2 (Apr. 20, 2015). 1632 Meeting between Hon. Ron Johnson, Chainnan, S. Comm. on Homeland Sec. & Governmental Affairs, and 

Richard J. Griffin, Deputy Inspector General, VA OIG (Mar. 2, 2015). 1633 Deputy Inspector General Richard Griffin was the most senior official at the VA OIG due to a vacancy in the 

position of the Inspector General. Under Chairman Johnson's leadership, attorney Michael Missal was confirmed as 

the VA Inspector General on April 19, 2016. 

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Senator Ron Johnson, Chairman 

319 
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1. Chairman johnson's efforts to secure the VA DIG's voluntary cooperation 

On February 4, 2015, Chairman Johnson's staff met with employees from the VA OIG to 

discuss the VA OIG's health care inspection of the Tomah VAMC. During this meeting, staff 

learned that the VA OIG had compiled and still possessed a comprehensive investigative file 

gathered during its almost three-year inspection of the Tomah VAMC. 1634 Chairman Johnson's 

staff requested that the VA OIG provide the file to assist with Chairman Johnson's 

investigation. 1635 Following the meeting, Chairman Johnson's staff and VA OIG staff discussed 

the production on the phone and by email on February 11,2015,1636 and February 13,2015, 1637 

under the belief that the VA OIG would produce the file. In one email, VA OIG staff 

represented to Chairman Johnson's staff: 

We are going through the documents-{)fwhich there are many (we tend to 

gather a lot of information)-so let me discuss with our Release of Infonnation 

Office staff about what a reasonable timeline could be for getting you the 

documents_~ 638 

From the outset of these communications with the VA OIG, Chainnan Johnson and his 

staff continually sought to accommodate concerns about patient privacy and narrowed their 

requests accordingly. On February 11, 2015, Chairman Johnson's staff wrote to Catherine 

Gromek, the VA OIG's Congressional Relations Officer, to express Chairman Johnson's 

willingness to resolve the concerns: 

We understand that there may be sensitivities surrounding particular documentsand we're certainly willing to work with you to resolve those matters-but we 

requested the VA OIG investigative file to inform our oversight work. Without 

the entire investigative file, the Committee may not be able to assess effectively 

or fully the situation in Tomah. As a starting point for further discussions about 

the investigative file, it would be helpful for us to know how many documents 

need to be reviewed by your staff and precisely what restrictions the VA OIG 

believes apply to these documents_~ 639 

1634 2/25/2015 Letter from Chairman Johnson, HSGAC, to Deputy Inspector General Griffin, VA OIG, at 2. 

Committee investigators met with Dr. John Daigh, the Assistant Inspector General for Healthcare Inspections, and 

Dr. Alan Mallinger, Senior Physician in the Office of Healthcare Inspections. Id 1635 2/25/2015 Letter from Chairman Johnson, HSGAC, to Deputy Inspector General Griffin, VA OIG, at 3. 1636 !d. at 2; Email from Catherin Gromek, VA OIG, to Comm. Staff, HSGAC (Feb. 11, 2015). 1637 Email from Catherine Gromek, VA OIG, to Comm. Staff, HSGAC (Feb. 13, 2015). 1638 Email from Catherine Gromek, VA OIG, to Comm. Staff, HSGAC (Feb. I I, 2015). 1639 Email from Comm. Staff, HSGAC, to Catherine Gromek, VA OIG (Feb. 11, 2015); Letter from Hon. Ron 

Johnson, Chairman, S. Comm. on Homeland Sec. & Governmental Affairs, to Richard J. Griffin, Deputy Inspector 

General, Dep't of Veterans Affairs, at 2 (Mar. 11, 2015) [hereinafter 3/11/2015 Letter from Chairman Johnson, 

~~ 

)~ 

~· ( "-------J 

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Senator Ron Johnson, Chairman 

320 
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In a subsequent letter to Mr. Griffin, Chairman Johnson reiterated that "the Committee seeks to 

work with the VA OIG to protect sensitive patient information," and stated that "[t]he 

Committee will accept in camera review of this material, as well as appropriate redactions for 

patient-sensitive information."1640 

On February 18, 2015, VA O!G attorneys met with Chairman Johnson's staff and 

indicated that the VA OIG would not produce the investigative file. 1641 Specifically, Maureen 

Regan, Counselor to the Inspector General, told staff that the VA O!G had no obligation to report 

to Congress outside of its semiannual report and even ~uestioned Chairman Johnson's authority 

and purpose for reviewing the VA O!G's inspection. 16 2 Ms. Regan refused to elaborate on the 

VA OlG's position and refused to discuss or provide a list of the types of documents contained 

in the investigative file, despite possessing such a list at the meeting and even referring to it 

during the conversation1643 

Following these unsuccessful discussions with the VA OlG, Chairman Johnson wrote a 

letter to Mr. Griffin on February 25, 2015, formally requesting "the VA OIG's entire 

investigative file pertaining to the Tomah VAMC." 1644 Mr. Griffin responded on February 27, 

2015, declining to produce the material and asserting without citing any legal precedent that 

Chairman Johnson had to justify his request by explaining "why [he] believes [his] needs are 

legitimate." 1645 

Over the next several months, Chairman Johnson's staff continued to seek an 

accommodation on the production of documents from the VA OIG. Staff offered to 

accommodate the VA OIG's by accepting rolling productions, redactions of sensitive veterans' 

health information, and other means to address the VA OIG's stated concerns. 1646 The VA OIG, 

however, refused to articulate any particularized concerns about specific documents, and instead 

asserted broad and generalized concerns about the documents as a whole. The VA OIG 

continuously reiterated its perceived barriers to compliance without proposing any path toward 

accommodation1647 During one phone call, in fact, Ms. Regan summarized the VA OIG's 

HSGAC, to Deputy Inspector General Griffin, VA OIG]; Letter from Hon. Ron Johnson, Chairman, S. Comm. on 

Homeland Sec. & Governmental Affairs, to Richard J. Griffin, Deputy Inspector General, Dep't of Veterans Affairs, 

at 2 (Apr. 20, 2015) [hereinafter 4/20/2015 Letter from Chairman Johnson, HSGAC, to Deputy Inspector General 

Griffin, VA OJG] ("The Committee will accept production of the case file with limited, appropriate redactions for 

sensitive veterans' health information."). 1640 3/11/2015 Letter from Chairman Johnson, HSGAC, to Deputy Inspector General Griffin, VA OlG, at 6. 1641 2/25/2015 Letter from Chairman Johnson, HSGAC, to Deputy Inspector General Griffin, VA OIG, at 2. l6421d 

!643Jd. 

1644 Jd. at3. 1645 2/27/2015 Letter from Deputy Inspector General Griffin, VA OJG, to Chairman Johnson, HSGAC, at 3 (quoting 

13 Op. O.L.C. 153 (1989)). 1646 3/1112015 Letter from Chairman Johnson, HSGAC, to Deputy Inspector General Griffin, VA OJG, at 2. 1647 2/27/2015 Letter from Deputy Inspector General Griffin, VA OJG, to Chairman Johnson, HSGAC. 

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Senator Ron Johnson, Chairman 

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contempt for Chairman Johnson's investigation, claiming: "technically [the VA OIG] doesn't 

have to do anything to a Chairman's letter." 1648 

Chairman Johnson's months-long attempts to secure the VA OIG's voluntary production 

of all documents relating to its Tomah VAMC health care inspection ultimately proved 

unsuccessful. Even with Chairman Johnson's offers to accommodate the VA OIG's concerns 

and seek a mutually agreeable resolution, the VA OIG declined to produce any material about 

the inspection. Chairman Johnson, left with no choice, issued a subpoena to Mr. Griffin for 

documents relating the VA OIG's work at the Tomah V AM C. Chairman Johnson issued the 

subpoena on April29, 2015, with the consent of Ranking Member Tom Carper. 1649 

2. The VA OIG has not complied with Chairman Johnson's subpoena 

Chairman Johnson's subpoena required the VA OIG to produce "[a]ll documents and 

communications obtained, received, reviewed, created, or relied upon by the [VA OIG] during 

its health care inspection of the [Tomah VAMC], or in preparation for its" report of the 

investigation. 1650 The subpoena also compelled the production of communications among VA 

OIG personnel about its Tomah VAMC health care inspection. 1651 

Despite Chairman Johnson's subpoena, the VA OIG continues to stonewall Chainnan 

Johnson's investigation by making inappropriate redactions to material produced and by outright 

refusing to produce other documents. On May 27, 20!5, Roy Fredrikson, the Deputy Counselor 

to the Inspector General, certified to the Committee that the VA OIG had completed the 

production of all documents responsive to Chairman Johnson's subpoena. 1652 In the same 

communication, Fredrickson acknowledged--despite his certification-that the VA OIG has 

redacted information broader than agreed to by the Committee and has knowingly withheld at 

least 1,812 pages of subpoenaed material. 1653 

The VA OIG has applied excessive and improper redactions to the documents it produced 

pursuant to Chairman Johnson's subpoena. Although the subpoena stipulated that the 

Committee would accept limited redactions of patient-specific medical information, 1654 the VA 

164" Telephone Meeting between Comm. staff and VA OIG staff (March 24, 20 I 5). 1649 See Letter from Hon. Ron Johnson, Chairman, and Hon. Thomas R. Carper, Ranking Member, S. Corum. on 

Homeland Sec. & Governmental Affairs, to Richard J. Griffin, Deputy Inspector General, Dep't of Veterans Affairs, 

at 2 (Apr. 29, 2015) [hereinafter 4/29/2015 Letter from Chairman Johnson and Ranking Member Carper, HSGAC, 

to Deputy Inspector General Griffin, VA OIU]. 1650 Subpoena of Richard J. Griffm, Deputy Inspector General, Dep't of Veterans Affairs, issued by Han. Ron 

Johnson, Chairman, S. Comm. on Homeland Sec. & Governmental Affairs, at Schedule A, § I (Apr. 29, 20 15). 1651 ld. at Schedule A, § 4. 1052 E-mail from Roy Fredrikson, Deputy Counselor, Office oflnspector General, Dept. of Veterans Affairs, to Staff, 

HSGAC (May 27, 2015, 9:16AM) [05/27/2015 Email VA OIG Deputy Counselor Frcdrikson to HSGAC staff]. [653 Jd. 

1654 See Subpoena of Richard J. Griffin, Deputy Inspector General, Dep't of Veterans Affairs, issued by Han. Ron 

Johnson, Chairman, S. Comm. on Homeland Sec. & Governmental Affairs, at Schedule A. 

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Senator Ron Johnson, Chairman 

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OIG redacted information that goes well beyond patient-specific information. The VA OIG has 

either refused to produce documents or applied redactions to documents for the following 

reasons: (I) deliberative process privilege; (2) attorney-client privilege; (3) privacy statutes; (4) 

Office of Legal Counsel opinions; and (5) assurances of confidentiality to individuals the office 

interviewed as part of its Tomah inspection. The VA OIG has asserted these privileges and 

claims generally and vaguely, without specifying which privilege or concerns attach to which 

documents withheld. 

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Senator Ron Johnson, Chairman 

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Senator Ron Johnson, Chairman 

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i. Despite requirements of Chairman johnson's subpoena, the VA 0/G has 

not provided a privilege log of withheld material 

In response to Chairman Johnson's subpoena, the VA OIG produced a self-selected 

subset of documents and withheld others. In such circumstances, the instructions of the 

subpoena require the VA OIG to provide a detailed list of the withheld material to assist in 

resolving the dispute. Despite this requirement, the VA OIG refused to provide a detailed basis 

for its privilege claims or to produce a privilege log. Mr. Fredrikson, Deputy Counselor to the 

Inspector General, merely represented in an email to bipartisan Committee staff: 

Additionally, draft reports and communications between IG employees addressing 

the course of the inquiry or the interpretation of evidence has [sic] been redacted 

under the deliberative process privilege. Likewise, all communications by and 

between OIG counsels and OIG personnel has [sic] been withheld under both the 

attorney client and deliberative process privileges. It should be noted that few of 

these communications related to the actual inspection, and none related to the 

findings or the decision to administratively close the inspection. 1655 

The VA OIG's broad assertion of privileges has hindered Chairman Johnson's ability to 

determine the nature of the information withheld or redacted by the VA OIG. Because of the VA 

OIG's noncooperation, Chairman Johnson's staff has been forced to present redacted documents 

to witnesses to determine the context and nature of the documents. Only then did Mr. Fredrikson 

interject and explain why the VA OIG redacted a particular document. 1656 In those instances, 

Mr. Fredrikson or Ms. Regan ordered the VA OIG witnesses not to answer questions relating to 

the document. 

Without more information or a privilege log, Chairman Johnson is unable to assess the 

validity of the VA OIG's privilege claims or to determine the nature of the information that the 

VA OIG is withholding. The VA OIG's petulant refusal to cooperate-even in this small waywith Chairman Johnson's investigation needlessly obstructs the inquiry and prevents Wisconsin 

veterans from understanding all the facts. 

ii. The Deliberative Process Privilege and the Attorney-Client Privilege do 

not absolutely shield the VA OIG's documents from production 

The VA OIG has withheld documents from Chainnan Johnson based on assertions of 

deliberative process privilege and the attorney-client privilege. Although these privileges may 

1655 05/27/20!5 E-mail VA OIG Deputy Counselor Fredrikson to HSGAC staff. On May 18, 2016, new VA 

Inspector General Michael Missal offered to allow Committee staff to review drafts of the report and administrative 

closure in camera in the offices of the VA O!G. Given the lateness of this offer, the drafts could not be reviewed 

prior to the issuance of this staff report. 1656 See e.g., Porter Transcribed Interview. at 19; see also Mallinger 4/21/2016 Transcribed Interview, at 358. 

~)1 "----·-' 

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attach under certain circumstances, they are not an absolute shield from the congressional 

investigative power. The VA OIG has not provided sufficient information to allow Chairman 

Johnson to assess whether the privileges apply in this context. 

a. The Deliberative Process Privilege 

The VA OIG's claims of deliberative process privilege-a form of executive privilegeto avoid compliance with Chairman Johnson's subpoena are unfounded. The VA OIG has 

declined to provide an adequate explanation of its reliance on the deliberative process privilege 

or to provide a privilege Jog of material withheld on the basis of deliberative process. 

The deliberative process privilege may be invoked to shield some disclosure of executive 

branch material. The purpose of the deliberative process privilege is to protect the "decision 

making processes of government agencies" 1657 and to "'prevent injury to the quality of agency 

decisions' by allowing government officials freedom to debate alternative approaches in 

private." 1658 The privilege applies to documents "reflecting advisory opinions, recommendations 

and deliberations comprising part of a process by which governmental decisions and policies are 

formulated." 1659 

The material in question must be (I) "predecisional," meaning it must be "antecedent to 

the adoption of agency policy," and (2) "deliberative," meaning, "it must actually be related to 

the process by which policies are fonnulated." 1660 The privilege does not apply to factual 

material or post-decisional explanative material. A federal court that examined the privilege 

explained: 

The deliberative process privilege does not shield documents that simply state or 

explain a decision the government has already made or protect material that is 

purely factual, unless the material is so inextricably intertwined with the 

deliberative sections of documents that its disclosure would inevitably reveal the 

government's deliberations."1661 

1657 Nat'/ Labor Relations Bd. v. Sears, Roebuck & Co., 421 U.S. 132, !50 (1975) (quoting Tennessean Newspapers, 

Inc. v. Fed. Hous. Admin., 464 F.2d 657, 660 (6th Cir. 1972)). 1658 In reSealed Case (Esp}), 121 F.3d 729, 737 (D.C. Cir. 1997) (quoting Nat'/ Labor Relations Bd. v. Sears, 

Roebuck & Co., 421 U.S. 132, 151-53 (1975)). 1659 Nat'/ Labor Relations Bd. v. Sears, Roebuck & Co., 421 U.S. at !50 (quoting Carl Zeiss Stiftung v. V.E.B. Car 

Zeiss, lena, 40 F.R.D. 318, 324 (D.D.C. 1966)). 1660 E.g., Nat'/ Wildlife Fed'n v. U.S. Forest Serv., 861 F.2d !114, !117 (9th Cir. 1988) (quoting Jordan v. U.S. 

Dep't of Justice, 59! F.2d 753,774 (D.C. Cir. 1978); Envtl. Prot. Agency v. Mink, 410 U.S. 73 (1973); and Texaco 

P.R., Inc. v. Dep't of Consumer Affairs, 60 F.3d 867,884 (1st Cir. 1995)). 1661 1n reSealed Case (Espy}, 121 F.3d at 737; Texaco P.R., Inc. v. Dep't of Consumer Affairs, 60 F.3d at 884-85 

("[F]actual statements or post-decisional documents explaining or justifying a decision already made are not 

shielded." (citing Nat'/ Labor Relations Bd. v. Sears, Roebuck & Co., 421 U.S. 132, 151-52 (1975); Envtl. Prot. 

Agency v. Mink, 410 U.S. 73, 88 (1973))). 

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326 
406 

In other words, the deliberative process privilege is not an absolute or unqualified protection 

against congressional inquiries. 

More recently, a federal court provided more detail on the limits of the deliberative 

process privilege. In Committee on Oversight and Government Reform v. Holder, the U.S. 

District Court for the District of Columbia found that the deliberative process privilege may be 

invoked in response to a congressional subpoena. 1662 The court noted that "the executive branch 

could properly invoke the deliberative process privilege in response to a legislative demand." 1663 

However, the court explained that the deliberative process privilege "can be overcome by a 

sufficient showing of need." 1664 In such a dispute, the court explained that it must: 

balance the competing interests on a flexible, case by case, ad hoc basis, 

considering such factors as the relevance of the evidence, the availability of other 

evidence, the seriousness of the litigation or investigation, the harm that could 

flow from disclosure, the possibility of future timidity by government employees, 

and whether there is reason to believe that the documents would shed light on 

government misconduct, all through the lens of what would advance the 

public's-as well as the parties'-interests. 1665 

The court emphasized that the showing of need required to overcome the deliberative process 

privilege "is a lower threshold to overcome than the privilege that covers Presidential 

communications." 1666 

Other federal courts have consistently explained that "where there is reason to believe the 

documents sought may shed light on government misconduct, 'the privilege is routinely denied'" 

regardless of whether the materials qualify as predecisional and deliberative. 1667 Courts reason 

1662 Comm. on Oversight and Gov't Reform v. Lynch, 2016 WL 225675, *5 (Jan. 19, 2016). 1663 I d. at *5 (citing Order on Mot. for Summ. J. at 3). The Court cited the D.C. Circuit Court's opinion in Espy, 

which stated that "[s]ome aspects of the [deliberative process] privilege, for example the protection accorded the 

mental processes of agency officials, have roots in the constitutional separation of powers." Order on Mot. for 

Sumrn. J. at 2. 1664 Comm. on Oversight and Gov't Reform v. Lynch, 2016 WL 225675, at *5 (citing Order on Mot. for Summ. J. at 

3). 

1665 Comm. on Oversight & Gov 't Reform, U.S. House a/Representatives v. Lynch, Civil Action No. 12-1332 (ABJ), 

2016 WL 225675, at *9 (D.D.C. Jan. 19, 2016) (emphasis added) (citing In reSealed Case (Espy), 121 F.3d 729, 

737-38 (D.C. Cir. 1997)). 1666 OGR v. Holder, at *5 (Jan. 19, 2016) (citing Order on Mot. for Surnm. J. at 3). The Court stated, 

"[c]ongressional or judicial negation of the presidential communications privilege is subject to greater scrutiny than 

denial of the deliberative privilege." Order on Mot. for Summ. J. at 3 (quoting Espy at 745). 1667 In reSealed Case (Espy}, 121 F.3d 729,738 (D.C. Cir. 1997) (quoting Texaco P.R., Inc. v. Dep't of Consumer 

Affairs, 60 F. 3d 867, 885 (lst Cir. 1995)); Singer Sewing Mach. Co. v. Nat'/ Labor Relations Bd., 329 F.2d 200,208 

(4th Cir. 1964) ("Thus, we conclude, where a prima facie case of misconduct is shown, justice requires that the 

mental process rule be held inapplicable."). 

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that "shielding internal government deliberations in this context does not serve 'the public's 

interest in honest, effective government."' 1668 

In this case, the VA OIG's claim of privilege does not absolutely shield its documents 

from production to the Committee. There are allegations of misconduct and mismanagement at 

the Tomah V AMC. The VA OIG's inspection of the Tomah VAMC examined similar issues 

and many of the same individuals, and its investigative file presumably includes informative 

material on these topics. Because there is reason to believe that the VA OIG's documents could 

inform potential misconduct, the VA OIG's insistence on the privilege does not serve the 

public's interest in an honest, effective executive branch. In addition, there are concerns about 

the quality and scope of the VA OIG's inspection of the facility-concerns that can only be fully 

assessed with the VA OIG's own documents. Indeed, in this case, all of the relevant factorsthe relevance and availability of the evidence, the seriousness of the investigation, the harm from 

disclosure, and belief that the documents would disclose potential misconduct-all weigh in 

favor of production pursuant to Chairman Johnson's subpoena. 

b. The Attorney-Client Privilege requires an attorney to be providing legal advice, 

presenting a complicated assertion for in-house attorneys 

The VA OIG has also withheld documents from Chairman Johnson on the basis of 

attorney-client privilege. The VA OIG infonned bipartisan Committee staff in an email: 

"Likewise, all communications by and between OIG counsels and OIG personnel has [sic] been 

withheld under both the attorney client and deliberative process privileges."1669 Although 

congressional proceedings are not bound by the parameters of common law, the Committee may 

choose to accept a valid assertion of the attorney-client privilege. 1670 However, here, the VA 

OIG's attorney-client privilege claim is problematic because the VA OIG declined to provide a 

detailed basis for its privilege claim or a privilege log. 

A valid assertion of the attorney-client privilege requires the cumulative presence of 

several factors in the interaction. "To prove that the attorney-client privilege should apply, the 

1668 In reSealed Case (Espy), 121 F.3d 729, 738 (D.C. Cir. 1997) (quoting Texaco P.R., Inc. v. Dep 't of Consumer 

Affairs, 60 F.3d 867, 885 (I st Cir. 1995)); see Bank of Dearborn v. Saxon, 244 F. Supp. 394, 401-03 (E.D. Mich. 

1965), a[J'd, 337 F.2d 496 (6th Cir. 1967) ("[A] prima facie case of sham and subterfuge had been made out. It 

would seem that the real public interest under such circumstances is not the agency's interest in its administration 

but the citizen's interest in due process .... The authorities do not support the application of the privilege claimed 

to the facts before us."). 1669 05/27/2015 Email VA OIG Deputy Counselor Fredrikson to HSGAC staff. 

"In congressional proceedings, a committee may determine, on a case-by-case basis, whether to accept common law 

testimonial privileges. It can deny a witness' request to invoke privilege when the committee concludes it needs the 

information sought to accomplish its legislative functions. In practice, however, congressional committees have 

followed the courts' guidance in assessing the validity of a common law privilege claim." When Congress Comes 

Calling at 39 (citing Glenn A. Beard, Congress v. The Attorney-Client Privilege: A 'Full and Frank' Discussion, 35 

Am. Crim. L. Rev. 119 ( 1997); CRS Report 95-464, Investigative Oversight: An Introduction to the Law, Practice 

and Procedure of Congressional inquiry, 

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Senator Ron Johnson, Chairman 

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408 

person claiming the privilege must establish: (I) a communication, (2) made in confidence, (3) to 

an attorney, (4) by a client, and (5) for the purpose of seeking or obtaining legal advice." 1671 In 

other words, as one commentator on congressional investigations explained, "the mere fact that 

an individual communicates with an attorney does not make the communication privileged." 1672 

This limitation applies particularly for in-house attorneys whose dual responsibilities may 

overlap. In such circumstances, communications may be sheltered by the attorney-client 

privilege "only upon a clear showing that [in-house counsel] gave [advice] in a professional legal 

capacity." 1673 

The VA OIG's assertion of the attorney-client privilege is complicated by the fact that the 

VA OIG's attorneys serve dual roles as in-house counsel for the VA Inspector General. It is easy 

to fathom a category of documents-for instance, communications about staffing or timing of the 

inspection-on which a VA OIG attorney could comment without offering advice in a 

professional legal capacity. These communications would not qualifY for protection under the 

privilege. However, because the VA OIG refused to provide a detailed explanation for its 

assertion of privilege or a privilege Jog, Chairman Johnson is unable to understand the nature of 

the documents withheld on the basis of the attorney-client privilege. The VA OIG has made no 

"clear showing" that the documents contain advice provided by an attorney in a professional 

legal capacity. Without making such a showing, the VA OIG should not claim attorney-client 

privilege as a basis to withhold documents. 

iii. The VA 0/G relied on statutes that expressly allow disclosure to Congress 

The VA OIG also cited to several federal statutes-the Privacy Act, the Inspector 

General Act (JG Act), 38 U.S.C. § 5701, and 38 U.S.C. § 5705-as bases for withholding 

material about its health care inspection of the Tomah V AMC case file from Chairn1an 

Johnson. 1674 However, each of those statutes contains an express exemption allowing for the 

disclosure of material to Congressi 675 

The VA OIG claimed that the Inspector General Act limits the information that an AG 

may share with Congress. 1676 However, the Act provides inspectors general with discretionary 

1671 When Congress Comes Calling at 39 (citing In re Grand Jury Investigation No. 83-2-35, 723 (F.2d 447,450-51 

(6th Cir. 1983). 1672 When Congress Comes Calling at 39 (citing In re Grand Jury Subpoena Duces Tecum, 112 F.3d 910 (8th Cir. 

1997). 

1673 When Congress Comes Calling at 39 n.252 (citing e.g., Colton v. United States, 306 F.2d 633, 636, 638 (2d Cir. 

1962). 

1674 4/20/2015 Letter from Chairman Johnson, HSGAC, to Deputy Inspector General Griffin, VA OIG, at 4-5. 1675 ld at 5. 1676 2/27/2015 Letter from Deputy Inspector General Griffin, VA OIG, to Chairman Johnson, HSGAC, at 5 ("In 

response to a specific request for all records relating to interviews conducted, particularly with current or former 

employees, Ms. Regan noted that the IG Act itself prohibits the disclosure of the identity of individuals who submit 

complaints or provided information to the IG."). 

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Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

329 
409 

authority as to what information they may disclose. In fact, the Act expressly states that nothing 

in the Act "shall be construed to authorize or permit the withholding of information from 

Congress, or from any committee or subcommittee thereof." 1677 As Chairman Johnson explained 

to Mr. Griffin, other inspectors general have recognized Congress's authority to receive such 

information, including material with "Executive Branch confidentiality interests." 1678 

Additionally, the VA OIG cited statutes specific to veterans' medical information, 

including 38 U.S.C. §§ 5701, 5705, and 7332, as reasons to withhold information from Chairman 

Johnson. 1679 Of note, citing these statutes, the VA OIG withheld peer reviews of Tomah V AMC 

providers it received during its health care inspection. The peer reviews provide important 

information on whether the provider reviewed provided proper care to the patient in the incident 

that was peer reviewed. The majority staff requested the peer review material not to learn the 

identity of the veterans whose care was reviewed, but because the peer reviews could add to the 

staffs understanding about instances in which Tomah VAMC providers provided substandard 

care to veterans. The VA OIG still has not produced geer reviews; however, on May 3, 2016, the 

VA separately produced some peer review material. 1 0 

Two of these statutes cited by the VA OIG contain express exemptions that penni! 

disclosures to Congressi 681 Specifically, 38 U.S.C. § 5705(b)(4) states, "[n]othing in this 

section shall be construed as authority to withhold any record or document from a committee of 

either House of Congress or any joint committee of Congress, if such record or document 

pertains to any matter within the jurisdiction of such committee or joint committee."1682 

Chairman Johnson's committee has jurisdiction pursuant to Rule XXV of the Standing Rules of 

the Senate and Senate Resolution 73 (!14th Congress). Likewise, 38 U.S.C. § 570l(b)(3) allows 

the disclosure of records "[ w ]hen required by any department or other agency of the United 

States Govemment." 1683 Moreover, Chairman Johnson and his staff repeatedly emphasized their 

willingness to "work collaboratively with [the VA OIG] to identify with precision patientsensitive information and limit access to that material appropriately."1684 

The VA OIG also claimed that the VA OIG could not disclose records covered by these 

statutes because these statutes place this authority with the Secretary of the VAI 685 The IG Act 

1677 5 lJ.S.C. § 5(e)(3); 3/11/2015 Letter from Chairman Johnson, HSGAC, to Deputy Inspector General Griffin, VA 

OIG, at 5. 1678 3/11/2015 Lelter !rom Chai1man Johnson, HSGAC, to Deputy Inspector General Griffin, VA OIG, at 5 (quoting 

2/27/2015 Letter from Deputy Inspector General Griffin, VA OIG, to Chairman Johnson, HSGAC). 1679 2/27/2015 Letter trom Deputy Inspector General Griffin, VA OIG, to Chairman Johnson, HSGAC, at 4. 16R

0 See Letter from Robert D. Snyder, Dep't of Veterans Affairs, to Hon. Ron Johnson, Chairman, S. Comm. on 

Homeland Sec. & Governmental Affairs (May 3, 2016). 1681 38 U.S.C. §§ 5705(b)(4), 470l(b)(3); 3/11/2015 Letter from Chairman Johnson, HSGAC, to Deputy Inspector 

General Griffin, VA OIG, at 6. 1682 38 U.S.C. § 5705(b)(4). 1683 38 U.S.C. § 570l(b)(3). 1684 3/11/2015 Letter from Chairman Johnson, HSGAC, to Deputy Inspector General Griffin, VA OIG, at 7. 1685 !d. at 6. 

Majority Staff Report 

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Senator Ron Johnson, Chairman 

330 
410 

makes clear that inspectors general are separate entities from the agencies they oversee, 1686 and 

Chairman Johnson was seeking material from the VA OIG that is in the possession of the OIG. 

The VA OIG need not require approval of the VA to disclose to Chairman Johnson material that 

is in the custody and control of the VA OIG1687 In any event, even assuming the VA OIG 

needed the V A's approval, VA General Counsel Leigh Bradley informed Deputy Inspector 

General Linda Halliday in August 2015 that VA Secretary McDonald had no objections to 

disclosing the peer review material to Chairman Johnson. 1688 Even still, the VA OIG has 

withheld this material. 

1686 5 app. U.S.C. §§ 2, 6; 4/20/2015 Letter from Chairman Johnson, HSGAC, to Deputy Inspector General Griffin, 

VAOIG,at5. 

1687 4/20/2015 Letter from Chairman Johnson, HSGAC, to Deputy Inspector General Griffin, VA OIG, at 5. 1688 Email from Leigh A. Bradley, General Counsel, Dep't of Veterans Affairs, to Linda Halliday, Deputy Inspector 

General, Dep't of Veterans Affairs Off. of Inspector General (Aug. 7, 2015). 

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Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

331 
411 

Figure 108: Email from Leigh B1·adley, VA GenHal Counsel, to Deputy IG Linda Halliday 

rH-,;iilday. linda (OIG) . 

kom: 6udiE-)', Le191

1 A 

Sent: fnda\J, Augu\t Dr 2015 3 02 rM 

To: HJltid..:ry, Unda(O!G} 

Cc: Rt~l·~\ Ma>Jreen T. ;010, <)on.:tghy, tlr.l!Y-3fine- T, ~·1iranda, Bonn,eSubje<:t ((ln;)IE"SStOnal !>ubpo~na fo~ records 

Dear Lynn We receiVed your memorandum to the Secretary, dated August4, 2015. regarding the 

Congressional request for medical quahty assurance records that OIG reviewed in connection with its 

healtl1care 1nspeclion of the Tomah, Wisconsin VAMC O!G's counsel. Maureen Regan, provided me 

the peer review materials that the OIG collected during ~s inspecliofl-{jocuments governed by n1e 

38 U S C Section 5705 We understand that the OIG has determined that these materials are 

responsive to the April 29, 2015 subpoena ISSued to the OIG by the Senate Comm1ttee on Homeland 

Secunty and Governmental Affairs Per yow request I haVB consulted the Secn<tary who has no 

ob!eGlton to OtG's production of those Socbon 5705 materbls in fesponse to the subpoena, 

For your cons1derat1on the following IS language that tho Department generally uses when producmg 

confidential information. We recommend that you consider usmg Slfl11lar language m OIG s 

transmission of these materials to the Commi\lee 

"The enclosed mforn1ation rncludes highly confrdenhal information which, if publicly disclosed, 

could causo harm not only to lfl1portant processes that ensure continuous quality review and 

•mprovement but most 1mportant, to the families of Veterans who may have significant 

Interests in protecting thelf pnvate information The enclOsed materials may be protected 

under the Prrvacy Act 5 U S.C. § 552a. the Health Insurance Portability and Accountab•lily Act 

Pnvacy and Socunty Rule, 45 C.F.R. Parts 160 and 164 (HIPAA) and may also include 

sensitive diagnoses protected from d>sclosure under 38 United States Code (U.S,C.) Section 

i332. Title 38 U.S.C. Section 7332(b)(2)(C)(u) prohibits any re-diSclosure of the tmstence or 

substance of the informat;on. We request that the Comm1Hee keep the record rn a secure 

>oca!lon, limit its use to those purposes consistent wrth the Commrttee's stated oversight 

purpose, and ensure no further disclosure Further. it is our expectation that conlidontial 

1nformation mcluded in this produc!lon 1>0! be released or d>sclosed without prior consultation 

w;th the Department to ensure that Important con!!denl!allty and pnvacy 1nterests are not 

VIOlated ,. 

I hope thiS •s helpful Don't hesitate to call me rf you have follow-up questions 

Lcia:h A. Bmdltt.\ 

Cnt'ral Ctunud llilll'llt of\'t<h•r:m.~ ,\f1~k' 

Upon receiving a copy of the above email from Deputy Inspector General Halliday, 

Chainnan Johnson's staJTcontacted the VA OIG to facilitate the production of peer review 

material. 1689 The Deputy Cmmselor to the VA Inspector General, Roy Fredrikson, refused to 

provide the requested material, even after the Secretary authorized the disclosure of documents 

protected under the statute. In an email to Chainnan Johnson's staff. he wrote: 

1689 Email from Maj, Staff to VA OIG. March4, 2016 (10:12 AM). 

~) , I 

I 

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Senator Ron Johnson, Chairman 

332 
412 

With respect to the attached email, I responded immediately to Ms. Bradley that 

as the 5705 material belonged to the VA, we felt it was their obligation to vet and 

release this material. I note that we neither report nor answer to the Secretary of 

the VA, and any scenario where it appears we are acting on the Secretary's 

authority could be seen as an impediment to our independence. As we noted 

during the last interview with Dr. Yang, during a subsequent discussion between 

OGC and OIG on August 25, 2015, concerning the legal authorities to produce 

this material, the General Counsel advised that irrespective of the Secretary's 

earlier statement, the 5705 material would, nonetheless, need redactions. This 

only strengthened our resolve that the VA needed to examine and redact its 

material, not the OIG. Accordingly we supplied the VA with compact discs 

containing all of the 5705 material associated with the Tomah inspection on two 

separate occasions, Aug 4, and again in late December 2015, to accomplish the 

necessary redactions and respond to Congress. The OIG's position on this matter 

remains consistent. The information in question belongs to the VA, and the VA 

needs to complete its own examination of the information and release as it deems 

appropriate. 1690 

In a further attempt to facilitate the production of the subpoenaed material, Chairman 

Johnson's staff asked Mr. Fredrikson to provide the communications between the VA and the 

VA OIG about the release of the peer review material pursuant to Chairman Johnson's 

subpoena. 1691 Chairman Johnson's staff noted the importance of having "the full record of 

communications between the VA and VA OIG" with respect to the" documents in question so 

that it could obtain the documents that are responsive to Chairman Johnson's subpoena. 1692 The 

VA OIG did not respond to this request. 

Finally, the VA OIG cited to the Privacy Act as a barrier toward compliance with the 

Chairman Johnson's request. 1693 However, the Privacy Act also contains an express exemption 

for disclosing records to Congress. The statute reads: 

No agency shall disclose any record which is contained in a system of records by 

any means of communication to any person, or to another agency ... unless 

disclosure of the record would be1690 Email from Roy Fredrikson to Comm. Staff, March 4, 2016. Email !rom Roy Fredrikson, Deputy Counselor, 

Office of Inspector General, Dept. of Veterans Affairs, to Staff, HSGAC (March 4, 20!6) [03/4/20!6 Email VA 

OIG Deputy Counselor Frcdrikson to HSGAC staff]. 1691 Email from Maj. Staff to VA OIG staff, March 4, 20!6 (2:27PM). 1692 Jd. 

1693 2/27/20 IS Letter from Deputy Inspector General Griffin, VA OIG, to Chairman Johnson, HSGAC, at 4. 

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Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

333 
413 

(9) to either House of Congress, or, to the extent of matter within its 

jurisdiction, any committee or subcommittee thereof, any joint committee 

of Congress or subcommittee of any such joint committee. 1694 

The Privacy Act's exemption contains no limitation on the purpose or use of the records. But 

nonetheless, as detailed above, Chairman Johnson and his Committee have a specific and 

important need for the VA OIG's investigative file. 

iv. The VA OIG relied on Office of Legal Counsel opinion to justify 

withholding information from Chairman Johnson's subpoena 

The VA OIG cited to an opinion issued by the Justice Department's Office Legal Counsel 

(OLC) in 1989 as an additional barrier to compliance with Chairman Johnson's request for the 

Tomah VAMC investigative file. 1695 The VA OIG claimed that the OLC opinion addressed "the 

duty of Congress to justify its requests" and "requires that each branch explain to the other why 

it believes its needs are legitimate." 1696 The VA OIG claimed--despite substantial formal and 

informal communications-that Chairman Johnson and his staff had not sufficiently clarified 

"the specific oversight purpose for the request." 1697 

Contrary to the VA OIG's claims, Chairman Johnson and his staff explained, in 

numerous forms of correspondence, the relevance and necessity of the documents to the 

investigation. 1698 In a March II, 2015letter to Mr. Griffin, Chairman Johnson explained: 

[T]his Committee is the chief investigative committee of the Senate and it is 

examining the circumstances surrounding the recent public reports of malfeasance 

and misfeasance at the Tomah VAMC. The healthcare inspection conducted by 

your office, examining similar issues and many of the same individuals, is highly 

relevant to the Committee's work. 

The need for congressional oversight and potential legislative action necessitates 

the Committee's request for the Tomah VAMC case file. The family of at least 

one veteran who passed away after neglect and delay at the Tomah V AMC has 

said publicly that she would not have taken her father to the Tomah VAMC for 

1694 5 U.S.C. § 552a. 1695 2/27/2015 Letter from Deputy Inspector General Griffin, VA OIG, to Chairman Johnson, HSGAC, at 3. 1696 ld. at 3 (citing Congressional Request, for Confidential Executive Branch Information, 13 Op. O.L.C. !53 

(1989)). 

1697 2/27/2015 Letter from Deputy Inspector General Griffin, VA OIG, to Chairman Johnson, HSGAC, at 3 ("During 

the meeting with your staff on February I 8, 2015, the Counselor to the Inspector General and the Chief Information 

Release Officer attempted to obtain further clarification of the specific oversight purpose for the request. None was 

forthcoming. The Committee staff ... merely cited their authority Jo investigate and that gave the Committee the 

power to obtain any records they wanted."). 1698 See 3/J 112015 Letter from Chairman Johnson, HSGAC, to Deputy Inspector General Griffin, VA OIG, at 4. 

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Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

334 
414 

treatment had she known about the problems in the Tomah V AMC. In addition, 

another veteran died of a narcotic opioid drug overdose at the Tomah facility five 

months after the VA OIG administratively closed its inspection. This veteran 

received treatment from some of the same health care providers that your office 

reviewed in its healthcare inspection. 

Although you believe the VA OJG has been transparent in its inspection of the 

Tomah VAMC, the fact remains that the VA OIG administratively closed its 

inspection of the Tomah VAMC in March 2014 and the rep011 was not posted on 

the VA OJG website until February 2015. According to VA OJG staff, the 

decision to close the inspection rested with the Assistance Inspector General for 

Healthcare Inspections and was never raised to [Mr. Griffin] or Ms. Regan's 

attention. If whistleblowers had not contacted Congress, it is likely that Congress 

would have never learned that the VA OIG conducted a nearly three-year review 

of the opioid practices at the Tomah VAMC. These circumstances compel 

thorough and careful congressional attention. 1699 

Chairman Johnson further explained the relevance and necessity of the documents to 'his 

investigation in an April 20, 2015 letter to Mr. Griffin. He wrote: 

The Committee is investigating allegations of veteran deaths at the Tomah 

V AMC, retaliation against wbistleblowers, and a culture of fear among the 

employees at the facility that date back almost a decade. In the course of this 

work, the Committee has become aware that the VA OJG conducted a multi-year 

inspection of the facility, examining similar issues and many of the same 

individuals. This inspection was administratively closed without publication and 

apparently without [Mr. Griffin's] knowledge or approval. Given these 

circumstances, robust congressional oversight is needed to bring transparency and 

accountability to the Tomah V AMC, the VA, and the VA OIG. 1700 

Despite a clear and repeated statement by Chairman Johnson of the investigative file's 

relevance to his investigation, the VA OIG continues to refuse to produce the file. Chairman 

Johnson and his staff have continually offered to work with the VA OJG to find a mutually 

acceptable resolution that allows Chairman Johnson to obtain all the documents necessary for a 

full and complete understanding of the Tomah V AM C. Under the leadership of former Deputy 

Inspector General Griffin, current Deputy Inspector General Linda Halliday, and Counselor to 

the Inspector General Maureen Regan, the VA OIG has resisted transparency and accountability 

in its work. The majority staff is hopeful that new Inspector General Michael Missal will restore 

trust in the VA OJG and produce all documents subpoenaed by Chairman Johnson. 

l6991d 

1700 4/20/2015 Letter from Chainnan Johnson, HSGAC, to Deputy Inspector General Griffin, VA OJG, at I. 

-~~~-----------------------------------------------------

11 :"\A" Majority Staff Report 

~~ l;f' Committee on Homeland Security and Governmental Affairs l ___ j Senator Ron Johnson, Chairman 

335 
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C. The Drug Enforcement Administration 

The Drug Enforcement Administration (DEA) declined requests from Chairman Johnson 

and his stafi for infonnation about the DEA's work at the Tomah VAMC. The DEA did not 

articulate a protected legal interest in refusing to comply with Chairman Johnson's investigation, 

other than to assert ongoing Jaw-enforcement sensitivities. The DEA declined to cooperate, 

despite evidence suffoesting that it had conducted at least three inquiries concerning the Tomah 

VAMC since 2009. oi Chairman Johnson's investigation has also revealed information that 

suggests that the DEA did not request information from the Tomah V AMC about allegations of 

drug diversion until after Chairman Johnson's request to the DEA. 

As part of its investigation, the Committee obtained the Merit Systems Protection Board 

case file concerning former Tomah VAMC pharmacist, Dr. Noelle Johnson, who brought suit 

against the VA after she was terminated from the facility _I 702 Documents in the file indicate that 

DEA investigators interviewed Dr. Johnson on June 19, 2009, as part of a DEA criminal 

investigation. During the interview, Dr. Johnson reportedly showed the DEA investigator 

examples of multiple patients that, in her clinical opinion, received unsafe narcotic 

prescriptions. I

703 In addition, Dr. Johnson reportedly told the DEA investigator about three 

"unexplained suicides" of Dr. Houlihan's patients at the Tomah VAMC during her employment 

at the facility.I 704 At the conclusion of the interview, the DEA investigator informed Dr. Johnson 

that federal prosecutors would soon contact her and advised her that she should not fill any 

prescriptions that she believed were unsafenos 

The second DEA inquiry into potential drug diversion at the Tomah VAMC was 

apparently ongoing in or around 2011 and 2012 and was referenced in the VA OIG's healthcare 

inspection report of the Tomah VAMCn°6 VA O!G documents revealed that as of August 20 II, 

DEA drug diversion investigators in Milwaukee had initiated an investigation into Dr. Houlihan 

and the Tomah VAMC.I 707 DEA apparently launched its diversion investigation based on 

anonymous complaints that Dr. Houlihan and another medical professional at the Tomah VAMC 

were "excessively prescribing opiate medications to patients with PTSD."I 708 On March 28, 

2012, DEA diversion investigators, the VA OIG investigator, and local law enforcement 

interviewed a Tomah VAMC employee.I 709 The employee told law enforcement that "[Dr.] 

1701 S. COMM. ON HOMELAND SEC. & GOVERNMENTAL AFFAIRS, MAJORITY STAFF REPORT: TRAGEDY AT TOMAH: 

INITIAL FINDINGS 14 (2015). 1702 Noelle A. Johnson v. Dcp't of Veterans Affairs, MSPB Docket No. Cll-1221-10-0036-W-1, Tab I at 6 (Dr. 

Johnson's narrative of the events). 1703ld. 

1704 !d. 

1705 !d. 

1706 VA OIGTOMAHVAMC ADMINISTRATIVE CLOSURE, at 5 n.l. 1707 VA OIG MCI Search Results, MC! # 2011-04212-DC-0252 (May 1, 2015, I I :23 AM), O!G 1392. 1708ld. 

1709 !d.; see also VA OIG Criminal Investigations Div., Greg Porter, Memorandum of Interview of Tomah VAMC 

Employee (Mar. 28, 2012), OIG 10592-93. 

(~1 \ .. _______ j ' 

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Senator Ron Johnson, Chairman 

336 
416 

Houlihan and [Deborah Frasher] are the root of drug diversion/pill-selling by veterans at the 

Tomah VAMC." 1710 The employee also told investigators that particular patients of Dr. 

Houlihan frequently requested early refills in conjunction with their high prescription rates of 

narcoticsi?tt In a meeting between a VA OIG investigator and DEA drug diversion 

investigators on March 13,2012, DEA diversion investigators confirmed that "they had initiated 

a diversion investigators in regards to the Tomah V AMC and local area veterans in Tomah, and 

that they would cooperate with the VA OIG investigation." 1712 

With respect to its most recent work at the Tomah V AMC, the DEA has confirmed that it 

is currently performing an investigation involving the Tomah VAMC. 1m In addition, 

whistle blowers have told Chairman Johnson's staff that DEA investigators were present at 

Tomah VAMC over the course of several months in 2015. The status of the DEA's ongoing 

Tomah investigation-as well as the results of its earlier investigations-is unknown. 

1. Chairman johnson's efforts to secure the voluntary cooperation from the DEA 

For months, Chairman Johnson's staff attempted to gain the DEA's voluntary 

cooperation in assisting the Committee's investigation. On January 28,2015, Chairman Johnson 

wrote to then-DEA Administrator Michele Leonhart re~uesting information, documents, and a 

staff briefing about the DEA's involvement in Tomah. 1 14 At the time of this request, Chairman 

Johnson's staff was only aware of a joint investigation by the DEA and the VA OIG into the 

Tomah VAMC in 2011 and 2012. Chairman Johnson's letter requested the responsive 

information and documents by February II, 20 15.l7l 5 

On February 9, 2015, a DEA congressional liaison informed Chairman Johnson's staff 

that, after consulting with the Justice Department's Office of Legislative Affairs, the DEA had 

chosen to not provide a briefing with specific information about its work at the Tomah 

VAMC. 1716 He stated the DEA chose not to provide the specific information, although he 

expressly acknowledged the DEA was not claiming that any of the information was 

privilegedi 717 Later that day, another DEA official informed Chairman Johnson's staff that the 

1710 VA OIG Criminal Investigations Div., Greg Porter, Memorandum of Interview of Tomah V AMC Employee 

(Mar. 28, 2012), OIG 10592-93 (Deborah Frasher's name is redacted from this document, but during interviews the 

Committee was told it was her name under the redaction). 1711 VA OIG MCI Search Results, MCI # 2011-04212-DC-0252 (May I, 2015, 11:23 AM), OIG 1393. !7!2 I d. 

1713 See 3/17/2015 Letter from Deputy Chief Akers, DEA, to Chairman Johnson, HSGAC ("DEA has an ongoing 

investigation regarding the VAMC-Tomah facility."). 1714 1/28/2015 Letter from Chairman Johnson, HSGAC, to Administrator Leonhart, DEA. 1715 /d. at 3. 1716 Phone Conference between DEA and Maj. Staff(Feb. 9, 2015); Email from Matt Strait, DEA, to Maj. staff(Feb. 

9, 2015). 1717 Phone Conference between DEA and Maj. Staff(Feb. 9, 2015); Email from Matt Strait, DEA, to Maj. staff(Feb. 

9, 2015). 

r.:."'-" 

~o/ l,_ __ j 

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DEA would not provide information responsive to his request, but refused to explain the reasons 

for the DEA's noncooperation.l71 8 

The DEA failed to provide a formal response to the requests in Chairman Johnson's 

initial letter by the date requested. Following the DEA's nonresponse, Chairman Johnson's staff 

attempted to engage the DEA in a discussion to better understand the agency's law-enforcement 

interests and to accommodate these concerns in a manner that still satisfied the Chairman's 

requests for information. 1719 The DEA refused. On February 13,2015, Gary Owen, the Acting 

Chief of DEA's Office of Congressional and Public Affairs, emailed Chairman Johnson's staff 

that "the existence of an ongoing investigation severely limits what DEA is able to provide at 

this time. We will respond in the greatest extent possible consistent with existing policy and 

guidelines (Linder Letter), and at the earliest possible opportunity-without jeopardizing any 

ongoing investigative work." 1720 Mr. Owen did not provide any documents or information in 

response to Chairman Johnson's request. 

On March 3, 2015, Chairman Johnson wrote again to Acting DEA Administrator 

Leonhart reiterating his request for material and a briefing about the DEA's involvement at the 

Tomah VAMC. 1721 The Chairman explained to Administrator Leonhart that the Committee was 

conducting its investigation pursuant to its authority under the Constitution and the Standing 

Rules of the Senate, and that the DEA had not asserted a statutory or constitutional basis for 

refusing to comply with the Committee's investigation. 1722 

On March 17, 2015, Chairman Johnson received a response letter from the DEA. The 

DEA notified Chairman Johnson that "[p ]ursuant to longstanding Department of Justice policy, 

we are not in a position to provide non-public details of our investigation at this time."1723 The 

letter, however, did not specify the particular "longstanding policy" or provide any regulation or 

statute that codified the policy. The DEA offered to briefChainnan Johnson's staff on general 

information about the process for examining allegations of drug diversion. 1724 As an 

accommodation to the DEA, and in an effort to move forward with the investigation, Chairman 

Johnson's staff accepted this offer. 1725 The briefing, which occurred on March 27,2015, was 

extremely limited in scope, and the DEA expressly refused to answer any questions about the 

DEA's work relating to the Tomah VAMC. 1726 The DEA also refused to answer questions about 

its closed investigations concerning the facility. 1727 

1718 Phone Conference between DEA and Maj. Staff(Fcb. 9, 2015); Email from Deputy Chief Eric Akers, DEA, to 

Maj. staff(Feb. 9, 2015). 1719 Email from Maj. staff to Gary Owen, DEA (Feb 12, 2015). 1720 Email from Gary Owen, DEA, to Maj. Staff(Feb. 13, 2015). 1721 3/3/2015 Letter from Chairman Johnson, HSGAC, to Administrator Leonhart, DEA. 1122 I d. at 2, 1723 See 3/17/2015 Letter from Deputy Chief Akers, DEA, to Chairman Johnson, HSGAC, at I. 1724 !d. at 2. 1725 Email from Maj. statTto Deputy Chief Eric Akers, DEA (Mar. 20, 2015). 1726 Briefing between DEA and Maj. Staff(Mar. 27, 2015). 1727 ld. 

Majority Staff Report 

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Senator Ron Johnson, Chairman 

338 
418 

With questions still outstanding following the briefing and the DEA's response letter, 

Chairman Johnson's staff attempted to contact DEA personnel directly involved in the 

investigations of the Tomah V AM C. A DEA congressional liaison interceded and offered to 

facilitate a "conversation" between Chairman Johnson's staff and DEA officials involved in the 

agency's work concerning the Tomah VAMC.l728 When Chairman Johnson's staff suggested a 

date, the DEA revoked its offer and declined to allow the staff to speak with the investigators. 

The DEA congressional liaison wrote: "[I]n keeping with longstanding DOJ and DEA policy, we 

cannot provide additional information regarding this ongoing investigation. Further, it is DEA's 

and DOJ's policy not to provide line agents and investigators for congressional interviews."1729 

Chairman Johnson's staff sought clarification about the DEA's refusal to allow DEA 

personnel to speak with the staff. 1730 In an attempt to understand and accommodate the DEA's 

concerns, staff also asked the DEA congressional liaison to provide a statute or regulation that 

prevents the DEA from cooperating with Chairman Johnson's investigation. 1131 The liaison 

denied ever making an offer to facilitate a conversation between Chairman Johnson's staff and 

DEA personnel-despite his earlier email offering to facilitate a "conversation." Instead, he 

provided a letter dated January 27, 2000, from Robert Raben, then-Assistant Attorney General 

for the Office of Legislative Affairs, to former Congressman John Linder, then-Chairman of the 

House Rules Committee, Subcommittee on Rules and Organization of the House of 

Representatives ("Linder letter"). The DEA cited this letter as the authority for refusing to 

cooperate with the investigation. 

On July 29,2015, in a continuation of the majority staffs attempts to gain the DEA's 

voluntary cooperation, Chairman Johnson's staff contacted the DEA seeking one specific 

document: a 2012 memorandum between the DEA and the VA OIG that authorized the DEA to 

review patient charts of Tomah VAMC veterans. 1732 Chairman Johnson's staff had learned of 

the existence of this document in course of the investigation and determined that it could be 

relevant to understanding the work of both the DEA and the VA OIG in the years leading up to 

the death of Jason Simcakoski. Again, the DEA declined to provide the requested 

information. 1733 The DEA's congressional liaison wrote: 

As we advised the Chairman in our March and July letters, as well as in phone 

calls and e-mails with you and Committee staff, DEA is actively conducting an 

investigation at the Tomah V AM C. The memo that your e-mail is requesting is 

indeed part of this ongoing investigation. Consistent with longstanding 

1728 Email from Matt Strait, DEA, to Maj. staff(May 21, 20!5). 1729 Email from Matt Strait, DEA, to Maj. staff (June 3, 2015). 1730 Email from Maj. Staff to Matt Strait, DEA (June 3, 20 15). 1731 !d. 

17ll Email from Maj. Staff to Department of Justice (July 29, 2015). 1733 Email from Matt Strait, DEA, to Maj. staff(Aug. 7, 2015). 

Majority Staff Report 

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Senator Ron Johnson, Chairman 

339 
419 

Department of Justice policy prohibiting us from discussin~ ongoing matters, it 

would not be appropriate to provide the requested memo. 17 4 

The DEA's response contained some troubling implications. First, the response 

referenced a July letter-when the DEA had only provided a response letter in March 2015. 

Upon further clarification, it became apparent that the DEA was referring to a July 27,2015, 

letter from Assistant Attorney General for Legislative Affairs, Peter Kadzik, in response to a 

separate letter Chairman Johnson wrote to the United States Attorney for the Western District of 

Wisconsin-not a request to the DEA. The inclusion of this July letter as a basis for declining 

the Chairman's information requests echoes the DEA's initial representation in February 2015 

that the DOJ had advised it not to cooperate with Chairman Johnson's investigation. Second, the 

DEA's response implied that the 2012 memorandum sought by Chairman Johnson's staff was 

somehow part of an ongoing law enforcement investigation in 2015. The DEA never provided 

clarity on this point, and it is difficult to understand the connection because the DEA has 

declined to articulate the scope or contours of its ongoing law-enforcement work. Finally, the 

DEA's response to this request demonstrated its blanket refusal to produce any documentation to 

Chairman Johnson--even a narrowly tailored request for a specific document drafted three years 

earlier and transmitted between two separate agencies. 

In sum, Chairman Johnson and his staff have made extensive and reasonable efforts to 

obtain the DEA's voluntary cooperation in providing information necessary for the Committee's 

investigation. Thus far, the DEA has refused to cooperate with these efforts. The DEA has not 

asserted a claim of privilege, nor has it cited a statutory provision that prohibits its cooperation 

with the investigation. The only rationale it has provided for its outright refusal to cooperate 

with the investigation is the non-precedential Linder letter. 

2. The DEA's stated rationale for its refusal to cooperate with Chairman 

Johnson's investigation is without merit 

Throughout the Chairman Johnson's staff's interactions with the DEA, the DEA has 

asserted a "longstanding Department of Justice policy" not to comment or provide any specific 

information to Congress on potentially ongoing-and even closed-law-enforcement matters. 1735 

The DEA, however, has not asserted a claim of privilege on the requested material or identified a 

federal statute that prohibits its cooperation with Chairman Johnson's investigation. The only 

authority the DEA has articulated for its noncooperation with the investigation has been the 

Justice Department's Linder letter. The Linder letter is an insufficient basis for refusing to 

comply with congressional oversight. 

l1341d. 

1735 See 3117/2015 Letter from Deputy Chief Akers, DEA, to Chairman Johnson, HSGAC, at I. 

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Senator Ron Johnson, Chairman 

340 
420 

As explained, the Supreme Court has long recognized Congress' right-rooted in the 

Constitution-to oversee and investigate the operations of the executive branch1736 By contrast, 

the Linder letter is neither rooted in the Constitution nor based on any statutes governing the 

relationship between Congress and the executive branch. The Linder letter is simply that-a 

letter from an executive branch officer to a congressional Subcommittee Chairman with no 

precedential authority in and of itself 

The Linder letter cited to opinions from the Justice Department's Office of Legal Counsel 

(OLC). The OLC is an office charged with providing legal advice to the President and executive 

branch agencies. 1737 These opinions, as merely advisory documents, carry no precedential 

weight on how Congress performs its oversight duties, and do not limit or restrict Congress's 

constitutional right to executive branch material. Instead, the Committee's broad investigative 

authority, as articulated by the Supreme Court, "encompasses inquiries concernin~ the 

administration of existing laws as well as proposed or possibly needed statutes." 17 8 

Even assuming that there is an ongoing law-enforcement interest with respect to the 

DEA 's current work at the Tomah VAMC, this fact does not preclude the DEA from providing 

material to Chairman Johnson about its previous, closed investigations. The Linder letter, in 

fact, states the Justice Department's policy is "whenever possible to provide information about 

closed, rather than open, matters. " 1739 As an attempt at understanding and accommodating the 

DEA's concerns, Chairman Johnson's staff has inquired whether the DEA wollld provide 

information about its closed investigations into the Tomah VAMC. The DEA refused to provide 

information even about its closed investigations. 

Despite the Linder letter, the Justice Department components have provided information 

to Congress about ongoing law-enforcement investigations when the components chose to do so. 

The provision of requested infonnation to Congress does not necessarily compromise an ongoing 

criminal investigation or potential federal prosecution. For example, the existence of an ongoing 

law-enforcement investigation did not prevent the Bureau of Alcohol, Tobacco, Firearms and 

Explosives (ATF) from furnishing information to the House Committee on Oversight and 

Government Reform and the Senate Judiciary Committee about the Fast and Furious gun running 

operation. 1740 Throughout the congressional investigation, the A TF provided infonnation to the 

Committees concerning the ongoing Justice Department investigation into the botched operation, 

as well as the investigations into the murder of U.S. Customs and Border Patrol Agent Brian 

Terry. 1741 The cooperation with the Congress' investigation into Operation Fast and Furious did 

1736 3/3/2015 Letter from Chairman Johnson, HSGAC, to Administrator Leonhatt, DEA, at 2. 1737 U.S. Dep't of Justice, Office of Legal Counsel, "About the Office," http://www.justicc.gov/olc. 1736 Watkins v. United States, 354 U.S. 178, 187 ( 1957). 1739 Letter from Robert Raben, Assistant Attorney Gen. for the Office of Legislative Affairs, Dep't of Justice, to 

Rep. John Linder, Chainnan of H. Comm. on Rules, Subcomm. on Rules and Organization of the House, at 3 (Jan. 

27, 2000) [hereinafter "Under Letter"]. 1740 H. COMM. ON OVERSIGHT & GOV'TREFORM & S. COMM. ON THE JUDICIARY, FAST AND FURIOVS: THE 

ANATOMY OF A FAILED OPERATION (2012). J741ld. 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

341 
421 

not affect the executive branch's ability to prosecute the case of one of Agent Terry's killers, 

Manuel Osorio-Arellanes, who was sentenced to 30 years in federal prison. 1742 

In addition, the Federal Bureau oflnvestigation (FBI) and the Justice Department's 

Public Integrity Section delivered information to the House Committee on Oversight and 

Government Reform about their role in allegations that the Internal Revenue Service targeted 

conservative groups for enhanced scrutiny when applying for tax exempt status. 1743 Again, this 

information concerned the FBI's and the Public Integrity Section's involvement in the targeting 

in 2010 and did not affect the Justice Department's subsequent investigation into the targeting. 

More recently, after a request from Chairman Johnson, the FBI briefed Chainnan Johnson's staff 

about terrorist attack in San Bernardino, California. 1744 

As shown with the previous instances of Justice Department cooperation with 

congressional oversight that touches upon criminal investigations, it is not always the case that 

providing information to Congress will compromise the Justice Department's law-enforcement 

matters. Contrary to the DEA's position, cooperation with Chairman Johnson's investigation is 

not a zero-sum-game-the DEA can, as other Justice Department components have in the past, 

provide information in a manner that does not affect its open investigation. 

3. The DEA sent an information-request letter to the VA after Chairman 

Johnson's inquiry 

Given the DEA's outright refusal to cooperate with Chairman Johnson's investigation, 

his staff was forced to piece together the DEA's involvement in Tomah from other sources. 

Pursuant to a document request that Chainnan Johnson sent to the VA in February 2015, the 

Committee received a letter from the DEA to the Tomah VAMC dated March 23,2015 in which 

the DEA requested documents and information about potential criminal activity at the 

facility. 1745 Specifically, the letter requested substantive information about Tomah VAMC 

personnel matters, prescription practices, facility protocols, and other issues covering potential 

drug diversion. This broad document request letter appears to be the type of information-request 

document that typically begins a law-enforcement investigation. 1746 

The existence of this letter reveals yet another troubling aspect of the DEA's posture 

toward Chairman Johnson's investigation. The DEA's assertion, since the staffs initial contact, 

1742 Ralph Ellis, Man gets 30 years in 'Fast and Furious' death of border agent Brian Terry, CNN (Feb. I2, 20I4), 

http://www .cnn.com/2 0 I4/02/l 0/us/fast -and-furious-sentence. 1743 H. COMM. ON OVERSIGHT & GOV'T REFORM, THE INTERNAL REVENGE SERVICE'S TARGETING OF 

CONSERVATIVE TAX-EXEMPT APPLICATIONS: REPORT OF FINDINGS FOR THE ]13TH CONGRESS (20 14). 1744 Maj. Staff meeting with FBI (Mar. 31, 2016). 1745 Letter from DEA to Leah Finch, Privacy Officer, Department of Veterans Affairs Medical Center, Tomah, 

Wisconsin (Mar. 23, 2015) (on file with Comm.). 1746 Because this letter pertains to an ongoing criminal law enforcement investigation, the Committee has opted to 

defer releasing specifics about the request letter. 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

342 
422 

was that the DEA had an ongoing law-enforcement investigation involving the Tomah V AMC, 

which has prevented the DEA from producing any information about its previous investigations 

into the Tomah VAMC. The DEA has refused to even confirm when its current investigation of 

the Tomah VAMC began. 

However, the DEA information-request letter obtained by the Committee was sent after 

Chairman Johnson's letters to the DEA requesting information on the DEA's past involvement in 

the Tomah V AMC. Without more information from the DEA, this timing suggests that the DEA 

did not open an investigation into the Tomah VAMC--or at least begin its fact-finding in 

earnest-until after Chairman Johnson requested information from the DEA. If accurate, it 

appears that the DEA did not have an ongoing law-enforcement investigation at the time of the 

Chairman's initial letters and therefore had no reason to withhold material on that basis. 

The investigation into the Tomah VAMC gives the Committee the opportunity to paint a 

clear picture of the more than decade-long history of misconduct, whistleblower retaliation, and 

veteran deaths at the facility. The DEA's refusal to cooperate with Chairman Johnson's 

investigation unnecessarily delayed and may have limited the ability to identifY problems and 

propose solutions to the issues facing the Tomah VAMC. Ultimately, out of respect for the lawenforcement equities, the majority staff has not pressed the matter further with the DEA. 

D. The Joint Commission 

The Joint Commission is a non-profit accreditation organization that reviews and 

accredits health care organizations. On August 27, 2013, the Joint Commission received an 

anonymous complaint from a Tomah VAMC employee regarding "medication management and 

leadership standards." Separately, the Joint Commission received and reviewed nine sentinel 

events-unexpected deaths or serious injuries--at the Tomah VAMC since 2004. Of those nine 

events, the Joint Commission is conducting a root cause analysis on three active sentinel event 

investigations of incidents that occurred at the Tomah VAMC. Although it provided some 

general information to the Committee, the Joint Commission declined to provide any information 

on the particular complaints, citing an Illinois state privacy law. 

The Joint Commission evaluates approximately 21,000 healthcare organizations and 

programs throughout the United States, including VA facilities across the country. 1747 The Joint 

Commission accredits hospitals that meet certain performance standards and offer high-quality 

care to their patients. 1748 As part of its accreditation process, the organization makes site visits to 

the facilities under review. The Joint Commission has accredited hospitals for more than 60 

years. According to the Joint Commission, it has accredited approximately 4,032 general, 

1747 About the Joint Commission, THE JOINT CoM~TSSJON, 

~tp:llwww .j ointcommission.org/ about_ us/about_ the joint_ commission_ main. aspx. 

I d. 

,-../~ 

~~) ~ ( "-- ___ ] 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

343 
423 

pediatric, long term acute, psychiatric, rehabilitation and specialty hospitals, and 361 critical 

access hospitals, through a separate accreditation program. 1749 

During its investigation, Chairman Johnson's staff learned that the Joint Commission 

conducted an accreditation site visit at the Tomah VAMC from May 22 to 25,2012. 1750 This 

visit coincided with the VA OlG's health care inspection of the Tomah VAMC, and was only 

three months before the VA OlG conducted its own site visit of the Tomah VAMC. The Joint 

Commission renewed the Tomah V AMC's accreditation, despite identifying a number of 

concerns with the quality of care at the Tomah V AMC. 

The Joint Commission's review found that the Tomah VAMC was in either "partial" or 

"insufficient" compliance in the following areas of review: ( 1) environment of care- equipment 

use; (2) infection protection and control; (3) leadership- information management; (4) life safety 

physical environment; ( 5) availability of resuscitation services throughout the hospital; ( 6) 

human resources -orientation & training; and (7) provision of care, treatment and servicesassessment and care/services. 1751 

On December 9, 2015, Chairman Johnson and Ranking Member Carper wrote a letter to 

Dr. Mark Chassin, President and Chief Executive Officer of the Joint Commission, requesting 

information and documents relating to the Joint Commission's work accrediting the Tomah 

VAMC. 1752 In addition, the Chairman and Ranking Member asked why the Joint Commission 

accredited the Tomah VAMC despite its numerous findings of"partial" or "insufficient" 

compliance in areas of care. 1753 ln particular, the Chairman and Ranking Member also 

requested: 

Information on whether the Joint Commission has ever received reports or allegations 

of over prescription or whistleblower retaliation from the Tomah VAMC; 1754 

Records of all contacts, referrals, or complaints that the Joint Commission had 

received referring or relating to the Tomah V AMC since 2004; 1755 

Information and material about "sentinel event" investigations the Joint Commission 

has conducted at the Tomah VAMC since 2004; 1756 and 

The Joint Commission make the employees who conducted the May 2012 Tomah 

V AMC site visit available to brief Committee staff. 1757 

1749 What is Accreditation?, THE JOINT COMMISSION, 

~~f:/ /ww"':' .j oi ntcom.mi~sion. org/a~cre.ditation/accredi.tation _ main.as~x. 

· The Jomt Commtsston, Accredttatton Survey Review of VA Medtcal Center- Great Lakes Health Care System, 

500 East Veterans Street, Tomah, WI, 54660, Organization Identification Number 2571, 2012 (on file with Comm.). 1751 /d. 

1752 Letter from Han. Ron Johnson, Chairman, S. Comm. on Homeland Sec. & Govcn1mcntal Affairs, and Han. 

Thomas R. Carper, Ranking Member, S. Comm. on Homeland Sec. & Governmental Affairs, to Mark Chassin, 

President & Chief Executive Officer, The Joint Commission (Dec. 9, 201 5). 

""Id. 

1754/d. 

1755 !d. 

1756 ld. 

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Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

344 
424 

The Joint Commission responded to the Committee's inquiry on January 15, 2016. 1758 

On the issue of findings of"partial" and "insufficient" compliance, the Joint Commission wrote 

that the "Tomah V AMC was accredited after successfully addressing the Requirements for 

Improvement (RFI) in its Survey Rcport." 1759 The Joint Commission explained that for hospitals 

that receive RFis, their accreditation decision is delayed until the areas noted in RFis arc 

appropriately addressed. The Joint Commission noted that "observations of 'partial' and 

'insufficient' compliance in the survey report indicate that the relevant standard was not fully 

met and that RFI was cited."1760 Hospitals that have substandard compliance in areas that 

directly impact patient care must fix those issues within 45 calendar days. 1761 Hospitals that have 

substandard compliance in areas that indirectly impact patient care must fix those issues within 

60 calendar days. 1762 

The Joint Commission accredited the Tomah VAMC in 2012 because it found that the 

Tomah VAMC had adequately addressed the problems identified in the May 2012 site visit 

within the allotted time frame. As of today, the Tomah VAMC is an accredited hospital and 

Joint Commission staff has "no knowledge of any serious discussions to change Tomah's 

accreditation status. " 1763 

The Joint Commission also informed the Committee that it received an anonymous 

complaint on August 27, 2013 from a Tomah VAMC employee "related to medication 

management and leadership standards."1764 In addition, the Joint Commission informed the 

Committee that it had conducted reviews of nine separate sentinel events at the Tomah V AMC 

since 2004. Of those nine reviews, the Joint Commission is conducting root cause analyses on 

three "active" sentinel event reviews. 

The Joint Commission refused to provide any additional specific information or 

documentation relating to the August 2013 complaint. In addition, the Joint Commission refused 

to provide information on any of its sentinel event reviews. The Joint Commission cited an 

Illinois state statute as prohibiting its cooperation with the Committee's investigation. 1765 Article 

VI of the U.S. Constitution specifies that federal law-and matters controlled by federal law-is 

supreme to state law. Chairman Johnson's staff has informed the Joint Commission that the 

1757 ld. 

1758 Letter from Mark Chassin, President and Chief Executive Officer, The Joint Commission, to Han. Ron Johnson, 

Chairman, S. Comm. on Homeland Sec. & Governmental Affairs, & Thomas R. Carper, Ranking Member, S. 

Comm. on Homeland Sec. & Governmental Affairs (Jan. 15, 2016). 1759 ld. at 5. 

1760 !d. 

1761 /d. 

1762 !d. 

1763 !d. 

1764 ld. 

1765 The Joint Commission is headquartered in Illinois and thereby claims to be bound by Illinois state statutes. See 

Illinois Medical Studies Act, 735lLL. COMP. STAT. 5/8-2101 (2003). 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

345 
425 

Illinois state statute at issue does not wholly prevent compliance with a congressional 

investigation. Nevertheless, the Joint Commission has refused to cooperate further with the 

investigation. 

* * * 

Chairman Johnson is conducting a robust investigation of the Tomah VAMC, but it has 

not been without difficulties. In the course of his fact-finding, the VA 010, the DEA, and other 

entities have attempted to delay, limit, and withhold information. This noncooperation prevents 

the majority staff from obtaining all relevant information that bears upon the allegations of overprescription, abuse of authority, and retaliation at tbe Tomah YAM C. In turn, the actions of 

these agencies limit the findings and recommendations that can be issued to ensure the problems 

that occurred in Tomah never happen again. The majority staff will continue to gather 

information and press these entities to uphold their commitments to public transparency. 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

346 
426 

VI. Increased accountability since Chairman Johnson's investigation 

Since Chairman Johnson launched his investigation into the Tomah VAMC in January 

2015, individuals have been held accountable, the VA OIG has become more transparent and is 

now operating under new leadership, and new legislation has been proposed to enact reforms to 

the VA and VA OIG. These actions are just the first steps toward increased accountability. 

More must be done, but the changes in place since January 2015 as a result of increased attention 

on the Tomah V AMC will help to improve quality of care for all veterans. 

A. Personnel changes at the Tomah VAMC and within the VA DIG 

leadership 

The scrutiny on the Tomah VAMC since January 2015 has led to personnel changes at 

the facility. Dr. Houlihan no longer serves as the chief of staff at the Tomah VAMC. Mario 

DeSanctis has been replaced as the facility's director. Other providers, such as Deborah Frasher, 

are no longer treating veterans at the facility. The removal of these individuals has played a 

large role in the improvement in the relationship between management and line employees. 

Chairman Johnson's investigation has also led to greater accountability and independence 

at the VA OIG. On January 22, 2015, Chairn1an Johnson wrote to President Obama urging him 

to appoint a permanent inspector general for the Department of Veterans Affairs 1766 Chairman 

Johnson noted concerns over the VA OIG's transparency with respect to its handling of its 

Tomah VAMC health care inspection1767 Through the course of the Chairman's investigation, 

the majority staff came to be increasingly concerned about the VA OIG's cooperation with the 

investigation. On April29, 2015, after months of hostile noncooperation, Chairman Johnson 

subpoenaed VA Deputy Inspector General Richard Griffin for documents relating to the VA 

OIG's health care inspection of the Tomah VAMC. Mr. Griffin refused to fully comply with the 

Committee's subpoena. On June 30,2015, shortly after the VA OIG issued a white paper that 

attacked the whistleblowers of the Tomah VAMC, Mr. Griffin retired from federal service. 

On October 5, 2015, President Obama heeded Chairman Johnson's nearly year-long call 

and appointed Michael Missal to serve as the permanent Inspector General for the Department of 

Veterans Affairs. Mr. Missal was reported favorably by both the Senate Veterans Affairs 

Committee and the Senate Homeland Security and Governmental Affairs Committee, led by 

Chainnan Johnson. On Aprill9, 2016, the Senate confirmed Mr. Missal as VA Inspector 

General. Mr. Missal is the first Senate-confirmed Inspector General at the Department of 

1766 Letter from Hon. Ron Johnson, Chairman, S. Comm. on Homeland Sec. & Governmental Affairs, to Barack H. 

Obama. President ofthe United States (Jan. 22, 2015) (hereinafter 112212015 Letter from Chairman Johnson, 

HSGAC, to President Obama]. 

"''td. 

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427 

Veterans Affairs since the previous Inspector General, George Opfer, retired on December 31, 

2013. 

In speaking on the· Senate floor in support of Mr. Missal's confirmation as VA Inspector 

General, Chairman Johnson said "we have a duty to provide the best care for the finest among 

us, and that begins by having a permanent and independent inspector general in place."1168 He 

added: 

Michael Missal is the tip of the spear to restore much-needed transparency and 

accountability at the VA Office of Inspector General. His presence will go far 

toward accomplishing our shared goal of providing the highest quality care to our 

nation's veterans. The VA has been plagued with problems like those at the 

Tomah facility in my home state, where a veteran died because of a lack of proper 

care and oversight. We need an IG who will boost the confidence of the American 

people when it comes to the care of our veterans. I thank Michael Missal for his 

willingness to serve and look forward to working with him to oversee the VA. 1769 

The majority staff is optimistic that under the new leadership at the VA OIG, the agency 

will finally comply in full with Chairman Johnson's subpoena. When it does, the new personnel 

in place at the VA OIG and Tomah V AMC will help to restore transparency and accountability 

to the VA system. 

B. Greater transparency from the VA OIG 

The VA OIG's health care inspection of the Tomah VAMC was not published when it 

was completed because Dr. Daigh administratively closed the inspection. Over the course of the 

investigation, Chairman Johnson and his staff became aware that the Tomah VAMC 

administrative closure was just one of 140 administrative closures that the VA OIG had failed to 

publish since 2006. 1170 On March 17, 2015 Chairman Johnson wrote then-Deputy Inspector 

General Griffin asking him to release these secret administratively closed health care 

inspections. 1111 Following Chairman Johnson's letter, the VA OIG began publishing the 

previously-unreleased health care inspections on its website. 

1768 Sen. Johnson Speaking on the Senate Floor, YOUTUBE (Apr. 19, 2016), 

https ://www. youtu be. com/watch ?v~ AS bi _ k0y40Q. 1769 Id 

1770 Donovan Slack, VA Doesn't Release 140 Vet Health Care Probe Findings, USA TODAY (March 8, 20 15), 

http://www.usatoday.comistory/ncws/politics/2015/03/08/probcs-of-veterans-health-care-often-not-rc!eased-topublic/245251 09/. 1771 Letter from Han. Ron Johnson, Chairman, S. Comm. on Homeland Sec. & Governmental Affairs, to Richard J. 

Griffin, Deputy Inspector General, Dep't of Veterans Affairs, at 1-2 (Mar. 17, 2015) [hereinafter 3/17/2015 Letter 

from Chairman Johnson, HSGAC, to Deputy Inspector General Griffin, VA OIG]. 

Majority Staft' Report 

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Senator Ron Johnson, Chairman 

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428 

In February 2016, Chairman Johnson learned that the VA OIG was again refusing to 

publish reports of investigations it conducted. 1772 These investigations involved VA OIG 

inquiries into excessive wait times at VA facilities. 1773 The VA OIG investigated 73 VA 

facilities and found scheduling problems in 51 cases. 1774 Although Congress passed a law in 

December 2015 to require O!Gs to publish online all reports that make a "recommendation or 

suggest a corrective action," 1775 the VA OIG reasoned the law did not apply to the agency. 

Catherine Gromek, a VA OIG spokeswoman, explained to the media that because the secret 

reports were not "issued" and because they did not made a "recommendation" or "suggest a 

corrective action," the VA OIG was not required to publish them1776 On February 29, 2016, 

Chairman Johnson wrote to Deputy Inspector General Halliday asking her to release these wait 

times investigations. 1777 The VA OIG began publishing the wait time reports that same 

afternoon. 

C. Legislation proposed to address the problems relating to the Tomah 

VAMC 

Chairman Johnson's investigation of the Tomah VAMC has uncovered significant 

problems in the VA and VA OIG. He has identified areas for improvement in whistleblower 

protection laws and opioid prescription both inside and outside the VA. Other members have 

also proposed measures to begin to address the issues highlighted by the Tomah V AMC. 

1. The Christopher Kirkpatrick Whistle blower Protection Act 

On September 22,2015, Chairman Johnson's Committee held a hearing entitled 

Improving VA Accountability: Examining First-Hand Accounts of Department of Veterans 

Affairs Whistleblowers. 1778 At this hearing, the Committee heard testimony from VA 

whistleblowers, the Office of Special Counsel, and the Deputy Inspector General of the V A. 1779 

One of the witnesses who testified was Sean Kirkpatrick, the brother of Dr. Christopher 

1772 Donovan Slack, VA Watchdog Sits on Wait-time Investigation Reports for lvfonths, USA TODAY (Feb. 24, 2016), 

http://www.usatoday.com/story/news/politics/20 16/02/24/va-inspector-gencral-wait-time-investigationresults/80632212/ [hereinafter Slack, VA Watchdog Sits on Wait-time Investigation Reports for Months, USA 

TODAY (Feb. 24, 20 16)]. 1773 ld. 

1774 Jd 

1775 Consolidated Appropriations Act, Pub. L. No. 114-113 § 239 (2016). 1776 Slack, VA Watchdog Sits on Wait-time Investigation Reports for Months, USA TODAY (Feb. 24, 2016). 1777 Letter from Han. Ron Johnson, Chairman, S. Comm. on Homeland Sec. & Governmental Affairs, to Linda 

Halliday, Deputy Inspector General, Dep't of Veterans Affairs, at 1 (Feb. 29, 20 16) [hereinafter 2/29/2016 Letter 

from Chairman Johnson, HSGAC, to Deputy Inspector General Halliday, VA O!G]. 1778 lmproving VA Accountability: Examining First-Hand Accounts of Department a.( Veterans Affairs 

Whistleblowers, Hearing before S. Comm. on Homeland Sec. and Governmental Affairs, II 4th Cong. (2015). 1779 !d. 

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Senator Ron Johnson, Chairman 

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Kirkpatrick, a clinical psychologist who committed suicide the same day he was fired after 

raising concerns about prescription practices at the Tomah VAMC. ln his testimony, Mr. 

Kirkpatrick listed a number of recommendations for reforms to better protect VA whistleblowers 

and offer support to the men and women that provide care to our nation's veterans. 

On October I, 2015, Chairman Johnson, along with Senator Kelly Ayotte, introduced the 

Dr. Chris Kirkpatrick Whistle blower Protection Act of 2015. 1780 The bill would implement a 

number of Mr. Kirkpatrick's recommendations and would create additional protections for VA 

whistleblowers. With respect to Mr. Kirkpatrick's recommendations, the Dr. Chris Kirkpatrick 

Wbistleblower Protection Act: 

Enacts measures to ensure greater accountability and discipline for all federal 

employees who engage in whistleblower retaliation; 1781 

Requires the VA to conduct outreach to its employees to make them more aware of 

any mental health services, including telemedicine options, that are available to 

them;t782 

Requires the VA to ensure that protocols are in place to address threats from VA 

patients against VA employees who are providing care;

1783 

Allows probationary employees who are granted stays in their disciplinary 

proceedings through OSC priority in receiving a transfer while their disciplinary 

action is pending; 1784 

Requires all agencies to share information with the OSC about a federal employee 

who committed suicide if that employee had, prior to his or her death, (I) made any 

protected disclosure, and (2) had a personnel action taken against him or her by the 

agency. In such circumstances, OSC is required to examine whether the personnel 

action was taken because of the disclosure and take appropriate action; and1785 

Requires Congress's research arm, the Government Accountability Office, to study 

the reporting, staffing, accountability, and chain of command structure of the VA 

police officers at their own medical centers. 1786 

The Dr. Chris Kirkpatrick Whistle blower Protection Act provides additional reforms that 

address issues that arose over the course of Chairman Johnson's investigation. A Tomah VAMC 

whistleblower, Ryan Honl, testified during the Committee's field hearing in March 2015 that 

1780 Dr. Chris Kirkpatrick Whistleblower Protection Act of20!5, S. 2127, !14th Cong. (2015), 

https://www.congress.gov/billlll4th-congress/senate-bill/2!27 [herein after Kirkpatrick Act, S 2127]. 

'"' Id. § 105. 

1782 I d. § 202. 1783 Id. § 203. 1784 I d. § I 02. 1785 Jd. § 106. 

1786/d. § !07. 

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Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

350 
430 

Tomah VAMC employees improperly accessed his medical records after he blew the whistle. 1787 

Because Mr. Honl is a veteran in addition to a VA employee, the VA maintains records about his 

medical history. Other VA whistleblowers who are both veterans and VA employees--including 

two witnesses who testified during the Committee's September 2015 hearing, Brandon Coleman 

and Shea Wilkes-testified that their medical records were also improperly accessed when they 

reported wrongdoing at their VA facilities. 1788 The Dr. Kirkpatrick Act would codify that 

accessing another employee's medical records in retaliation for whistleblowing would qualify as 

a prohibited personnel practice under the law1789 Under the proposal, such an action would give 

the veterans whose files were accessed whistleblower protections, as well as subject the offender 

who accessed the medical records to potential disciplinary action for whistleblower 

retaliation. 1790 

The Dr. Chris Kirkpatrick Whistleblower Protect Act would also provide the Office of 

Special Counsel, the executive branch agency in charge of investigating whistleblower 

retaliation, with additional tools and access to information to better protect all federal 

whistleblowers. 1791 On December 9, 2015, Chairman Johnson's Committee unanimously 

approved the bill and reported it favorably to the full Senate. 

2. The Inspector General Empowerment Act 

Chairman Johnson's investigation also highlighted significant problems with the 

operations of the VA Office of Inspector General. In addition to championing the installation of 

Michael Missal as the first permanent VA Inspector General in nearly two years, Chairman 

Johnson has worked to enact reforms to enhance the independence and transparency of all 

inspectors general. Chairman Johnson has worked closely with Senators Charles Grassley and 

Claire McCaskill to introduce the Inspector General Empowerment Act of 2015. 1792 

On March 4, 2015, Chairman Johnson's Committee unanimously approved Inspector 

General Empowerment Act of2015. The measure included an amendment that Chairman 

Johnson and Senator Tammy Baldwin championed to require all inspectors general to publish on 

their websites any report or audit within three days of the reports' submission "in final form to 

the head of the federal agency or head of the designated federal entity as applicable." 1793 

""Tomah VAMC: Examining Quality, Access, and a Culture of Overreliance on High-Risk Medications, J. 

Hearing before S. Comm. on Homeland Security and Gov't Affairs and H. Comm. on Veterans' Affairs, !14th Cong. 

(2015) (statement of Ryan Honl). 1788 improving VA Accountability: Examining First-Hand Accounts of Department of Veterans Affairs 

Whistleblowers, Hearing before S. Comm. on Homeland Sec. and Governmental Affairs, !14th Cong. (2015) 

(statements by Brandon Coleman and Shea Wilkes). 1789 Kirkpatrick Act, S. 2127, !14th Cong. § 104. 1790 ld. 

1791 Jd. § 103. 1792 Inspector General Empowerment Act of2015, S. 579, !14th Cong. (2015). 179J ld. 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

351 
431 

Chairman Johnson offered a similar amendment to the National Defense Authorization Act of 

2015, and advocated for a version of the amendment-that would apply to just the VA OIG-to 

be included in the Military Construction and Department of Veterans Affairs Appropriations Bill 

of2015. Ultimately, Congress adopted less stringent language that required the VA OIG 

whenever it "issues a work product that makes a recommendation or otherwise suggests 

corrective action" to pose the work product on the VA OIG's website within three days 1794 

Chairman Johnson pushed for these reforms because of the VA OIG's repeated failures to 

publish its work product. Even after Congress demonstrated its strong belief that the VA OIG 

needs to be more transparent, the VA OIG continued to exploit loopholes in the text of the law. 

Clearly, stronger language requiring the VA OIG to publish all work products is needed to 

ensure that the VA OIG is transparent. The nation's veterans and the public deserve to know 

what VA's watchdog is doing to oversee the operations of the VA. 

3. The Ensuring Veteran Safety Through Accountability Act 

Chairman Johnson has also worked to expand accountability across the VA. In the case 

of the Tomah V AMC, it took a congressional investigation and immense pressure from the 

media to begin to bring accountability to the facility. Following the disturbing reports of 

veterans dying while waiting for care at the Phoenix VA Health Care System, Congress enacted 

the Veterans Access, Choice and Accountability Act of2014 (the Choice Act) 1795 The Choice 

Act included provisions to enhance accountability by authorizing the VA Secretary to 

immediately remove senior executives based on poor job performance or misconduct. 1796 The 

law provided for an expedited appeals process for those individuals through the Merit Systems 

Protection Board. 1797 

On April28, 2015, Chairman Johnson, motivated by the tragedies at the Tomah VAMC, 

introduced the Ensuring Veteran Safety Through Accountability Act of2015. 1798 The proposal 

would expand the authority the VA Secretary to remove senior executives for performance or 

misconduct to include the removal of VA health care professionals. On June 24, 2015, Chairman 

Johnson presented his legislation to the Senate Committee on Veterans Affairs. In his testimony, 

Chairman Johnson discussed the deaths ofKraig Ferrington, Dr. Kirkpatrick, Jason Simcakoski, 

and Thomas Baer. He told the Senate Veterans Affairs' Committee that as of June 2015: 

To date, no one at Tomah has been fired. The medical professionals who 

prescribed the lethal cocktail of drugs that killed Jason Simcakoski are still 

collecting a paycheck from the American taxpayer. The events in Tomah make it 

1794 Consolidated Appropriations Act, Pub. L. No. 114-113 § 239 (2016). 1795 Veterans Access, Choice, and Accountability Act of2014, II.R. 3224, !14th Cong. (2014). 1796 Veterans Access, Choice, and Accountability Act of 2014, Pub. L. No. 113-146, § 128 Stat. 1754, § 707 !797 /d. 

1798 Ensuring Veteran Safety Through Accountability Act of 2015, S. 1117, !14th Cong. (2015). 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

352 
432 

abundantly clear that there must be more accountability for VA medical 

professionals. 1799 

The Senate Committee on Veterans Affairs incorporated the objectives of Chairman 

Johnson's proposal into a bill introduced by Senator Marco Rubio, entitled the Department of 

Veterans Affairs Accountability Act of2015. 1800 Senator Rubio's bill, which Chairman Johnson 

cosponsored, would expand those accountability measures in the Choice Act and Chairman 

Johnson's proposal to all VA employees. On October 19, 2015, the Senate Veterans' Affairs' 

Committee favorably reported the Department of Veterans Affairs Accountability Act to the full 

Senate. 

4. The Jason Simcakoski Memorial Opioid Safety Act 

The events that occurred at the Tomah VAMC also inspired the introduction of the Jason 

Simcakoski Memorial Opioid Safety Act by Senator Baldwin. 1801 Chairman Johnson is an 

original cosponsor of this legislation. The bill would direct the VA and the Department of 

Defense to jointly update the VA/DOD Clinical Practice Guidelines for Management ofOpioid 

Therapy for Chronic Pain to include guidelines that were apparently overlooked in the 

prescription of opioids at the Tomah V AMC. The enhanced guidelines would establish best 

practices for prescribing opioids for outpatient treatment of chronic non-cancer pain, 

contraindications for opioid therapy, treatment of PTSD and other mental illnesses and explore 

non-opioid treatment regimens for pain management. 

In addition to updating the VA/DOD Opioid guidelines, the bill would require the VA to 

improve training for VA employees in the area of pain management, implement better tracking 

and monitoring of opioid practices at VA facilities, upgrade the medical records of veterans to 

better track opioid prescription practices, conduct a number of studies on the safe prescription of 

opioids, and better integrate opioid prescription data with the state in which the hospital is 

located. The bill would also require the VA to establish a Pain Management Board at each VISN 

and creates the Office of Patient Advocacy within the VA. 

D. Safety at the Tomah VAMC's Community Based Outpatient Clinics 

On February 10, 2016, Chainnan Johnson's staff met with members of the AFGE Local 

0007 to hear their perspective on the changes at the Tomah V AMC. At the meeting, AFGE 

representatives alerted Chairman Johnson's staff of potentially dangerous issues concerning the 

1799 Pending Health Care and Benefits Legislation, Hearing before the Senate Committee on Veterans' Affairs, 

!14th Cong. (2015) (testimony ofHon. Ron Johnson, Chairman, S. Comm. on Homeland Security & Governmental 

Affairs). 

" 00 Department of Veterans Affairs Accountability Act of 2015, S. 1082, !14th Cong. (2015). 1801 Jason Simcakoski Memorial Opioid Safety Act, S.l641, !14th Cong. (2015). 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

353 
433 

physical security ofCommuuity Based Outpatient Clinics (CBOCs) that serve veterans in the 

communities around the Tomah V AMC. The union leaders described security threatsincluding threats of shootings-that have been received by the staff members of the CBOCs. 

They informed Chairman Johnson's staff that despite these threats, the CBOCs lack basic 

security features like internal doors that lock or card-swipe technology. The AFGE 

representatives explained that the Tomah V AMC's agreement with local law-enforcement 

authorities does not adequately alert CBOC personnel about ongoing emergencies in the 

community. 

On February 12, 2016, Chairman Johnson wrote to VA Secretary McDonald alerting him 

of these concerns and asking the VA to take "appropriate steps to ensure that CBOCs and other 

small VA facilities have adequate safety features in place."1802 In the letter, Chairman Johnson 

also requested a briefing about the CBOC security. The VA has not provided a written response 

to the Chairman's letter or a briefing about measures in place to protect VA employees and 

veterans at CBOC facilities. 

1802 Letter from Han. Ron Johnson, Chairman, S. Comm. on Homeland Sec. & Governmental Affairs, to Han. 

Robert McDonald, Secretary, Dep't of Veterans Affairs, at I (Feb. 12, 2016). 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

354 
434 

109: Lettt>l' from Chairm~u Johnson to VA 

llre Honorahk Robert A. McDonald 

s~.-cretnry 

ll.S. l}epat1rnent of\'cteranfi ,.\fTJlrn 

SIO Vcnnont Avenue, ':-IW 

Washington. DC 2042(! 

Llt:ar Secretary McDonaiJ· 

Umtcd Stares ..5rnm 

February 12. 2016 

The Committee on I iomctand SecuritY and Gc.wemn,emnl Affuirs is t•xamining i.'l'IUe~ 

relatin~ to the Depanment of Veteran.' Affai~ tVA) Medical Center in Tomah., \Vi.s:coruin 

!Tomah VA~rfC). I Y.'rite '\vith t.~tmcern <Jb\)u1 the phrs-kal S«:urity of Community Ba~ 

Outp:llient Clinic• (CBflC") and oth<.-r small Vii facilities 'urmunding !he Toumh VA\1C, 

elsewhere in Wisconsin, and around the c-t)Untry. I rcqu.,.."lit ytltir immediate anention tn this 

serit"~US i~-;ue 

M} gtatT recently met with re-ptc:'>entativcs of the Amen can federation of Ouvcmmt:'nt 

Employe<:> (AfGE) Lo<·al 0007 to discuss th< Tomah VAMC' Ourin~ this meeting. th< AFGE 

representatives alerted my sta!Tto a serious is._lFme im-olving the physical security ofCB(X~s in 

\Viscon.sin. ·rhey dc~ribcd sc~urity lhreab-tntluding threat:; of shootings-that h~:nl! bt.~n 

received by the" fndlitie•. De•pite the" threats, the n~OCs apparently do not have internal 

doors lh.at h'ck, card~swlpt: technology. or bullet pr(){Jf gtus. 'l'ht.:- AFGI~ rep-resoet'ltativ~ also 

stated that the distance of the CBOC• from the Tomuh VAMC make. it drtually impo.,iblo for 

VA. police to rc.srond to an emergency, and that rhc VA ·.'i ag_ret:'mcnt \Vith localli.w.-enfon•emc-nt 

dot~s W)t cff'ectht:ly nler1 Cf\CX' pl.-rsnnncl abou1 ongning emcrge-nt·ie~ in the C(Jmmunity. 

* * * 

Tite public repmting about over-prescription, abuse of authority, and retaliation at the 

Tomah VAMC sparked an effmt to tmderstand and solve the problems. Since January 2015, 

Chainnan Johnson has been dedicated to this task. Since the beginning of this investigation, the 

management of the Tomah VAMC has been replaced and the VA Deputy Inspector General has 

been forced into retirement. Chaimtan Jolmson shepherded the President's nominee to be the 

pennanent Inspector General, Michael Missal, through his conunittee to confirmation by the 

Senate. Chairman Johnson has sponsored and suppmied measures to improve quality of care for 

veterans. ensme transparency in the inspector general coumnmity, and increase accountability 

for VA employees. TI~ere is no doubt that additional work remains. but the measmes achieved 

so far as are building blocks for gt·eater transparency and accountability in the VA. 

~lajority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

355 
435 

VII. Recommendations 

Chairman Johnson's investigation to date demonstrates the need for reforms in the VA 

and the VA OIG to improve accountability and transparency. From the available infonnation, 

there is undoubtedly room for improvement to the VA's quality of care and the OIG's oversight 

of the VA's clinical practices. Without subject matter expertise, the majority staff has limited its 

proposed recommendations to managerial and programmatic suggestions. 

The majority staff submits the following modest recommendations based on the 

information available to date: 

The VA should limit the patient loads of chiefs of staff and other leaders at VA medical 

facilities. 

The VA should alter the reporting structure within its facilities to remove the facility's chief 

of staff from the reporting chain of the facility's pharmacy department, especially in cases 

where the chief of staff maintains a heavy patient load. 

The VA should develop procedures by which a VA pharmacist can communicate concerns 

about prescriptions he or she believes to be unsafe to the prescribing provider. 

The VA should implement safeguards to prevent the unauthorized access of electronic 

medical records for VA employees who have also received care at a VA facility. 

The VA should develop protocols to address threats made by a patient against a VA provider. 

The VA should ensure the independent reporting structure of VA police services to the VA 

Central Office, especially when examining allegations against senior facility leadership. 

The VA should ensure annual training for all VA employees on prohibited personnel 

practices and whistle blower protections. 

The VA should update its guidelines and training relating to pain management and opioid 

therapy. 

The VA should expand access to the Choice Program to allow veterans a say in their health 

care decisions. 

If the VA OIG is conducting a health care inspection that examines the quality of care of a 

particular provider, the VA should consider placing that provider on administrative leave 

during the course of the OIG's inspection. 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

356 
436 

The VA OIG should provide a summary of the substance of its administrative closures in 

each semiannual report to Congress sufficient to inform the public about the allegations, the 

facility, and the nature of the OIG's work. 

The VA OIG Office of Healthcare Inspections should develop and implement clear standards 

for substantiating or unsubstantiating allegations it reviews. 

The VA OIG should develop a memorandum of understanding with the Drug Enforcement 

Administration that clearly outlines each agency's jurisdiction in investigating allegations of 

drug diversion that involve VA personnel, VA property, or other VA equities. 

If, during the course of VA OIG activities, there are concerns about the potential impairment 

of a VA health care provider, the OIG should immediately notify in writing the facility 

Director, the VISN Director, and the Under Secretary for Health. 

The VA OIG should develop and implement a list of factors for the hotline group to consider 

in determining how it disposes of a hotline complaint. 

Congress ought to extend whistleblower protections to probationary employees. 

Congress ought to include unauthorized access to a VA employee's medical records as a 

prohibited personnel practice. 

Congress ought to expand the authority of the VA Secretary to remove VA employees for 

poor performance or misconduct. 

Congress ought to require all inspectors general to publish all work products that make a 

recommendation or otherwise suggest corrective action. 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

357 
437 

VIII. Conclusion 

In the fifteen months since the problems of the Tomah VAMC came to light, 

considerable changes have been made to the facility, the VA, and the VA OIG. New leadership 

exists at the Tomah VAMC and the VA OIG. The VA has instituted a new opioid therapy tool. 

The OIG is more transparent. Whistleblowers within the VA are empowered to speak out about 

waste, fraud, abuse, and mismanagement. These are positive developments sparked by attention 

from Chairman Johnson, other congressional leaders, and the media. 

While improvements are welcome, it is useful and necessary to examine the tragedies at 

the Tomah V AMC to ensure they do not happen again. What occurred at the facility was 

preventable, and the fact that the tragedies were not prevented is the result of systemic executive 

branch failures. For years, veterans and employees sought help, and no entity answered their 

calls. The VA was aware of variances in the Tomah V AMC' s prescription rates, and merely 

"encouraged" the facility to review its policies. The DEA conducted at least three investigations 

surrounding the facility, with little to no public results. Jason Simcakoski contacted the FBI 

several times in November 2013, and an FBI agent left a voicemail on his cell phone-yet the 

FBI states it has no record of these contacts. 

The VA OIG conducted a multi-year inspection of the facility. In the course of its 

inspection, the VA OIG collected hundreds of thousands of documents, interviewed witnesses 

and whistleblowers, reviewed patient charts, surveilled Dr. Houlihan, and issued a subpoena to a 

car dealership in Western Wisconsin. But its final work product-the culmination of all this 

work-was a short eleven-page administrative closure. Because the VA OIG did not publish this 

closure, other patients of the Tomah V AMC-veterans like Thomas Baer---did not know the 

facility was at the center of an OIG inspection. 

Chairman Johnson is conducting a thorough and robust bipartisan investigation of the 

Tomah VAMC. He requested documents and information from the VA, the VA OIG, federal 

law-enforcement agencies, and other entities. Joined by staff from Ranking Member Carper and 

Senator Baldwin, Chainnan Johnson's staff conducted lengthy transcribed interviews with over 

twenty current and former VA and VA OIG employees. His staff also received information from 

whistleblowers in and around the Tomah community. This fact-finding is not complete, as the 

VA OIG is withholding subpoenaed documents and other entities declined to cooperate. 

As detailed in this majority staff report, Chairman Johnson's investigation highlights the 

systemic failures and preventable tragedies of the Tomah VAMC. It also describes the culture of 

fear and whistle blower retaliation that enabled these tragedies to continue. Chairman Johnson 

has undertaken this effort to identify the problems that caused the tragedies of the Tomah 

VAMC. In this spirit, the majority staff report presents modest recommendations for reform to 

improve the management and operations of the VA and the VA OIG. 

In a nation like the United States, no veteran should find him or herself at the mercy of a 

troubled VA facility, or forced to take medications that his or her family feels are unsafe. These 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

358 
438 

men and women fought for Freedom of Speech, Freedom of Religion, and Freedom of 

Association. When they return from the battlefield, they ought to have the freedom to choose the 

healthcare of their choice. The Tomah VAMC is a tragic case study of the alternative. 

The majority staff presents this report as a necessary first step to understand 

comprehensively what occurred at the Tomah VAMC and to put forth proposals to cure those 

ills. This report is not the end of investigation of the Tomah V AMC-not with relevant material 

still outstanding-nor should it be the end of public attention and accountability on the facility, 

the VA, and the VA OIG. The seriousness of the issues, the veterans' deaths, and the subsequent 

heartbreaks deserve continued vigilance. 

Majority Staff Report 

Committee on Homeland Security and Governmental Affairs 

Senator Ron Johnson, Chairman 

359 
439 

MEMORANDUM 

To: Members of the Senate Homeland Security and Governmental Affairs Committee 

From: Ranking Member's Staff of the Senate Homeland Security and Governmental Affairs 

Committee 

Date: May 31, 2016 

Re: Ranking Member Staffs supplemental views regarding the Committee's investigation of 

the Tomah, Wisconsin VA Medical Center 

In 2009, a young psychiatrist committed suicide after being fired from the Veterans 

Affairs Medical Center (V AM C) in Tomah, Wisconsin. In 2014, a U.S. Marine veteran died 

while being treated at the facility. 

Shortly after an alarming January 2015 report about prescription practices and 

mismanagement published by the Center for Investigative Reporting, the U.S. Senate Homeland 

Security and Governmental Affairs Committee (HSGAC) began an investigation into allegations 

of over prescription of opioids, mismanagement, and whistle blower retaliation at the Tomah 

VAMC. 

Minority staff participated thoroughly in the investigation, including in all twenty-two 

transcribed interviews of current and former Department of Veterans Affairs (VA) and VA 

Office of Inspector General (VA OIG) staff, and reviewed tens of thousands of documents 

produced by over a dozen federal and local government agencies and other entities related to the 

Tomah VAMC. 

On May 31, 2016, the HSGAC majority staff released a report titled "The Systemic 

Failures and Preventable Tragedies at the Tomah VA Medical Center" outlining their findings 

and recommendations. The purpose of this memorandum is to provide supplemental views 

concerning the Committee's investigation. 

I. Initial efforts to address problems at the Tomah VAMC were not effective. 

The record before the Committee suggests that issues related to improper prescription 

practices, a dysfunctional management environment, and chronic staffing shortages were known 

to the Tomah VAMC and its regional supervisory office, Veterans Integrated Service Network 

(VISN) 12. 

Then-VISN 12 Network Director Dr. Jeffrey Murawsky appears to have been alerted to 

concerns regarding prescribing practices, management problems, and staffing issues at the 

Tomah VAMC. VISN 12 Pharmacy Executive, Ms. Donna Leslie, told the Committee that these 

concerns were brought to Dr. Murawsky's attention on several occasions. 1 For example, Ms. 

Leslie identified a conference call between VISN 12 and the Tomah VAMC where then-Chief of 

Staff Dr. David Houlihan openly questioned the role of pharmacists, stating "he felt like the 

1 Interview of Donna Leslie at 33, 84, 86, 150, 154, 176, and 195 (Dec. 15, 2015). 
440 

pharmacists at Tomah were the barriers to proper pain management...."2 Ms. Leslie brought 

concerns about this conversation to Dr. Murawsky, but the Committee's record shows that her 

concerns were dismissed.3 

Dr. Houlihan's prescribing practices raised concerns amongst certain VISN 12 

employees, including Ms. Leslie and Ms. Vicki Brahm (then VJSN 12 Quality Management 

Officer and current Acting Tomah V AMC Facility Director). Mses. Leslie and Brahm made 

several efforts to investigate and correct instances of overprescription at Tomah V AMC, but 

were repeatedly rebuffed by senior leadership at both the facility and the regional supervisory 

office, VISN 12. Mses. Leslie and Brahm sought to have Dr. Houlihan's practices peer reviewed 

in 2009.4 When the peer reviews confirmed that, in at least some cases, "most experienced, 

competent practitioners would have handled the case differently" than Dr. Houlihan did, Mses. 

Leslie and Brahm recommended an administrative investigation board review -- a formal VA 

investigation into Dr. Houlihan's prescribing practices which could have subjected Dr. Houlihan 

to disciplinary actions. 5 Dr. Murawsky and then-Tomah VAMC Facility Director, Jerry Molnar, 

rejected this recommendation, and instead opted to implement an action plan tore-review the 

Tomah VAMC's early refill guidance and urine screen policy and practice. 6 Mses. Leslie and 

Brahm's efforts to implement this action plan ceased, however, when the VA OIG began its 

healthcare inspection in late 2011, and the VISN 12 employees were told to "stand down and Jet 

the IG do their investigation."7 

Further, and throughout the VA OIG's multi-year inspection of the Tomah facility, the 

Tomah VAMC Director, Mr. Mario Desanctis, was contacted several times by the VA OIG 

regarding various aspects of the healthcare inspection. During one interview with the VA OIG, 

Mr. Desanctis noted that he was aware of the "sense of friction between the Pharmacy and the 

Chief of Staff' but that his own involvement had been "somewhat inconsistent unfortunately." 8 

In the summer of2014, the VA OIG briefed Mr. Desanctis and others at VISN 12 about the VA 

OIG's administrative closure's findings and suggestions. During the Committee's transcribed 

interview of Dr. Alan Mallinger, who was the lead investigator assigned to the VA OIG's 

healthcare inspection of the facility, it appears that Mr. Desanctis did not implement all of the 

suggestions outlined in the administrative closure report. Specifically, Dr. Mallinger notes that 

Mr. Desanctis contacted him and noted that he would not implement the suggestion that the 

Chief Pharmacist report to the Tomah V AMC' s Associate Director rather than the Chief of 

StatT.9 The Tomah VAMC senior leadership declined to implement both VISN 12 

recommendations (such as conducting an administrative investigative board review for Dr. 

Houlihan) and VA OIG suggestions aimed at addressing problems at the facility. 

2 ld. at 198. 

3 ld. at 199. 

4 Interview of Victoria Brahm at 58-61 (Dec. 16, 20 15). 

5 !d. at 70-72. 

6 /d. at 71-75. 

7 /d. at 78-79. 

8 VA OIG Bates number OIG 6085. 

9 Interview of Alan Mallinger at 378 (Apr. 21, 2016). 
441 

While the record before the Committee suggests that federal law enforcement agencies 

were making inquiries related to the Tomah VAMC since 2009, it is unknown when or if the 

Federal Bureau of Investigation (FBI) or the Drug Enforcement Administration (DEA) began 

any formal investigations. Consistent with longstanding Department of Justice policy, federal 

law enforcement agencies are generally unable to provide information about ongoing 

investigations in order to protect the integrity of those investigations. Thus, the DEA and the 

FBI were unable to provide information to the Committee regarding any potential ongoing 

investigations related to the Tomah VAMC. As such, there is no information before the 

Committee about whether these federal law enforcement agencies had sufficient evidence to 

prosecute specific criminal activity or were deficient in their activities involving the Tomah 

VAMC. 

Finally, certain efforts to inform congressional offices about problems at the Tomah 

V AMC were unsuccessful. For example, an April2009 memorandum regarding opioid 

overprescription at the Tomah VAMC, authored by Ms. Lin Ellinghuysen, President of the 

American Federation of Government Employees Local 0007, was not delivered to the Wisconsin 

delegation as she had intended. 10 In her interview with Committee staff on December 14, 2015, 

Ms. Ellinghuysen explained that she provided the memo to Ben Balkum, then-president of 

another local union chapter, and asked that he give the memorandum to Wisconsin's 

congressional delegation during an upcoming trip he was taking to Washington, DC. 11 Ms. 

Ellinghuysen told the Committee staff that, at the time, she had assumed the memorandum had 

been delivered. 12 She later learned the memorandum was not dclivered. 13 

II. The VA and the VA OIG have implemented corrective actions aimed at improving 

quality of care and management practices, but more improvements are needed 

The VA removed the former Director and former Chief of Staff from their positions at 

the Tomah VAMC. The VA immediately put in place an interim Director, Mr. John Rohrer, who 

took a series of management steps to restore the trust of veterans and employees at the facility. 

Mr. Rohrer met with dozens of Tomah VAMC employees to assess the extent of the facility's 

problems and took action to mend broken lines of communication between management and 

staff at the facility. 

The facility's current Acting Director Ms. Brahm is continuing that work through 

initiatives intended to address many of the issues raised at the Tomah VAMC. These include the 

recently concluded 100-day plan, a multi-pronged approach to addressing communication and 

10 Interview of Linda Ellinghuysen at I33 (December I4, 2015). 

II fd. 

12 !d. at I34. 

13 Ms. Ellinghuysen told the Committee: "I called Ben Balkum about this. I said Ben, did you hand deliver- think 

back, Ben. Did you hand deliver, and I explained the letter to Congressman Kind and Senator Feingold? He said, 

no. I didn't hand-deliver anything to any of them." (!d. at 133.) 
442 

quality of care issues at the facility. 14 Leadership at the facility is also addressing concerns with 

staff shortages through an aggressive effort to recruit qualified physicians to serve veterans at the 

Tomah VAMC. The VA OIG has also begun to address transparency concerns by publishing the 

Tomah V AMC administrative closure report along with dozens of other previously-umeleased 

healthcare inspections. 

Nationally, the VA is also taking steps to address issues surrounding pain management 

and the overprescribing of opiate drugs. The VA launched a system-wide opioid safety initiative 

in 2013 whose objective is to make the totality of opioid use visible at all levels in the 

organization. In March 2015, the VA launched a new Opioid Therapy Risk Report tool, which is 

intended to give providers detailed information on the risk status of veterans taking opioids. 

Finally, the VA launched a psychotropic drug safety initiative with the aim of improving the 

safety and effectiveness of the use of these drugs across the VA. 15 

The new leadership team at the Tomah V AMC has taken several corrective actions to 

provide veterans and employees at the facility with enhanced access to leadership and an 

environment that fosters communication between veterans, employees, and leadership. The VA 

nationally has several initiatives intended to support higher quality care for veterans and better 

pain management. 

Finally, in Congress, legislation sponsored by Senators Baldwin and Johnson would 

address chronic pain management issues across the VA by establishing best practices for 

prescribing opioids and through exploring non-opioid treatment regimens for pain management. 

In addition, the Senate confirmed a new VA Inspector General, Mr. Michael Missal, who has 

committed to improving transparency and addressing the lack of oversight that allowed the 

Tomah VAMC to continue to be mismanaged after the VA OIG's healtheare inspection of the 

facility. 

While these improvements are essential to address the failures at the Tomah V AMC, 

continued oversight by the VA, the VA OIG and Congress is needed to ensure that the facility is 

held accountable and that our veterans receive the quality care and attention they deserve. 

14 U.S. Department of Veterans Affairs. Tomah VAMC /00-Day Plan. (Accessible at 

http: '/www.lomah. va. uov'docs/Tomah ~'o20 I OO-Day_~Jl...:W.El.;J.!l.J2..d_f). 

15 Tomah VAMC- Examining Patient Care and Abuse of Authority: Hearing Before the Senate Committee on 

Homeland Security and Governmental Affairs, I I 4'" Congress (201 6) Statement of Sloan Gibson, Deputy Secretary 

of Veterans Affairs. 
443 

Post-Hearing Questions for the Record 

Submitted to Hon. Sloan Gibson regarding 

"Tomah VAMC: Examining Patient Care and Abuse of Authority" 

Homeland Security and Governmental Affairs Committee 

United States Senate 

May 31,2016 

FROM CHAIRMAN JOHNSON 

QUESTION 1: Was former Tomah VAMC Director, Mario DeSanctis, terminated 

from VA employment, or did he enter into a settlement with the VA that allowed 

him to resign in lieu of termination? How much money did Director DeSanctis 

receive in his settlement with the VA? 

Response: The Department of Veterans Affairs (VA) proposed removal of former 

Tomah Medical Center Director Mario DeSanctis. Mr. DeSanctis appealed his removal 

with the Merit Systems Protection Board. His appeal was settled by an agreement that 

Mr. DeSanctis would voluntarily resign his position and waive all appeal rights in 

exchange for a one-time, lump-sum payment of $88,000.00. 

QUESTION 2: How long was Dr. Houlihan on administrative leave for before he 

was terminated from VA employment? Why? 

Response: Dr. Houlihan was on Authorized Absence from March 10, 2015, through 

November 9, 2015. During this time, multiple clinical reviews were completed by 

providers outside of Veterans Integrated Service Network 12 to assess Dr. Houlihan's 

clinical practice. Once the reviews were received, the medical bylaws required a 

hearing by the Medical Staff Executive Committee where this information was 

presented. Following that hearing, charges were developed, termination was proposed, 

and a subsequent decision to uphold the termination was made. Multiple legal reviews 

were conducted to ensure appropriate human resources regulations were followed to 

ensure that there was no opportunity to overturn the termination on procedural grounds. 

QUESTION 3: The Veterans Access, Choice, and Accountability Act of 2014 

(Choice Act) authorized the Secretary to seek the removal or transfer of Senior 

Executives based on poor performance or misconduct: 

a. Since implementation, how many Senior Executives have been transferred 

under this provision of the Choice Act? For each Senior Executive that has 

been transferred under this provision, please provide their name, the 
444 

reason for transfer, what VA facility the Senior Executive was transferred 

from, and what VA facility the Senior Executive was transferred to. 

Response: Diana Rubens- Veterans Benefits Administration (VBA) Regional Office 

(RO) Director Philadelphia to RO Assistant Director-Houston for Failure to Exercise 

Sound Judgment; and Kimberly Graves- VBA Area Director-Ann Arbor to RO Assistant 

Director-Phoenix for Failure to Exercise Sound Judgment. Both cases were overturned 

by Merit System Protection Board (MSPB). 

b. Since implementation, how many Senior Executives have been terminated 

under this provision of the Choice Act? For each Senior Executive that 

has been terminated under this provision, please provide their name, the 

reason for termination, and what VA facility the Senior Executive was 

terminated from. 

Response: 

Removals: 

Sharon Helman; Phoenix VA Medical Center (VAMC); Lack of Oversight (not 

sustained by the MSPB); Conduct Unbecoming a Senior Executive; and 

Failure to Report Gifts. Note: Ms. Helman has appealed her removal to the 

Federal Circuit. 

James Talton-Central Alabama; Neglect of Duty 

Therese Wolf; Pittsburg VAMC; Conduct Unbecoming a Senior Executive and 

Wasteful Spending 

Mario DeSanctis-Tomah; Conduct Unbecoming a Federal Employee 

Japhet Rivera-Danville; Conduct Unbecoming a Senior Executive, Providing 

Misleading Information during an Administrative Investigation, Failure to Make 

Timely Payment on a Government Credit Card 

Removal reversed by MSPB (currently in litigation): 

Linda Weiss-Albany; Failure to Take Timely Action 

Weiss was removed from federal service for failing to take timely action to 

remove a clinical provider from patient care following Weiss' receipt of reports 

indicating the provider's interactions with patients were unsafe. Ms. Weiss 

appealed her removal to the Merit Systems Protection Board and her case is 

currently being litigated. 

2 
445 

FROM SENATOR BALDWIN 

QUESTION 1: At the hearing, you stated that the Committee report was the first 

time you heard that Dr. Houlihan and Ms. Frasher were possibly impaired or 

intoxicated during their interviews with the VA IG team. 

a. What is VA's protocol for handling cases of potential impairment of its 

employees, specifically healthcare providers? 

Response: The Department of Veterans Affairs (VA) regulations, 38 C.F.R. § 

1.218(a)(7), prohibit the possession or use of alcoholic beverages or any narcotic 

drug, hallucinogen, marijuana, barbiturate, and amphetamine (unless prescribed by 

a phyisician) on VA property. The regulation also states that "[e]ntering [VA] 

property under the influence of any narcotic drug, hallucinogen, marijuana, 

barbiturate, amphetamine, or alcoholic beverage (unless prescribed by a physician) 

is prohibited." Employees who fail to follow this regulation may be disciplined in 

accordance with VA Handbook 5021. 

The Medical Center's Bylaws also provide guidance to medical staff to assist them 

with meeting facility expectations and complying with VA, the Veterans Health 

Administration, The Joint Commission, and local facility requirements. The following 

is the excerpt from the Medical Staff Bylaws template related to Health Status and 

Impaired Professional Program. VA Facilities are encouraged to maintain this 

section in their facility-specific Medical Staff Bylaws: 

HEALTH STATUS AND IMPAIRED PROFESSIONAL PROGRAM 

VHA recognizes its responsibility to assist impaired professionals and 

collaborate with available programs designed to intervene, monitor, refer to 

treatment, and advocate for physicians and dentists. 

A. Where there is evidence that a physician or dentist's practice is impaired 

as a consequence of chemical dependence or mental or physical illness, the 

Chief of Staffs office will be notified. Practitioners are allowed to self-refer to a 

program for assistance for psychiatric, emotional, or physical problems. 

Assistance in the self-referral may be obtained from their Service Chief or Chief 

of Staff. 

B. In cases of known or suspected impairment due to mental illness or 

substance use, the Chief of Staff may request an assessment. 

C. In cases of known or suspected impairment due to physical and/or mental 

illness, the Chief of Staff may request the Director to authorize a Special 

Physical Examination as authorized VA Handbook 5019, Part II, and applicable 

hospital policy. The Special Physical Examination will be tailored to the clinical 

circumstances and may involve a physical examination, imaging studies, 

neuropsychological testing, or other indicated measures. The fitness for duty 

examination will be conducted by or under the direction of the Occupational 

3 
446 

Health Program or outside medical examiner, which will assess the findings 

and make a recommendation on the Practitioner's fitness for duty based on 

such findings. If the determination is unfavorable to the Practitioner, or in cases 

of uncertainty, the findings will be presented to an ad hoc Physical Standards 

Board. 

D. VA and Facility policies, responsibilities and procedures of the Employee 

Assistance Program and the VA Drug-Free Workplace Program are applicable 

for physicians, dentists, and other healthcare professionals. 

E. Confidentiality of the Practitioner seeking referral or referred for assistance 

will be kept, except as limited by law, ethical obligation, or when the safety of a 

patient is threatened. In all instances, every effort will be made to protect the 

confidentiality of the individual referred for assistance. 

F. The hospital will sponsor periodic educational program regarding illness 

and impairment issues. Licensed independent Practitioners will be issued 

written information regarding illness issues at the time of initial appointment and 

re-appointment to the medical staff. 

As stated, the provider may be removed from patient care to ensure the safety of our 

patients. This may be through the "summary suspension" process for privileged 

providers or through VA's Human Resource process for non-privileged providers. 

Reporting to the State Licensing Boards may also be considered in accordance with 

VHA 1100.18, Reporting and Responding to State Licensing Boards. 

The Rehabilitation Act of 1973- Individual with a Disability: Under this Act, an 

individual with a physical or mental impairment that substantially limits one or more 

major life activities; has a record of such impairment; or is regarded as having such 

impairment. Please note: the Americans with Disabilities Act Amendments Act of 

2008 has broadened the coverage of what is considered a disability under the 

Rehabilitation Act of 1973. This means that just about every condition that affects a 

major life activity will be covered under the Act. The caveat is that a condition 

lasting six months or less is not covered. 

Reasonable Accommodation: An agency is required to make reasonable 

accommodation to the known physical and mental limitations of an otherwise 

qualified individual with a disability unless the agency can show that accommodation 

would cause an undue hardship. In this situation there are two issues to consider: 

(1) Has the employee requested an accommodation? (2) Has management 

considered the individual as being disabled? If the answers to the questions are 

"Yes," then reasonable accommodations generally should be provided. 

b. Are facility directors required to take certain actions? 

Response: Managers must assess the evidence and determine if action is 

appropriate to promote the efficiency of the service. If action is appropriate, 

4 
447 

management needs to analyze the aggravating and mitigating factors to determine 

the appropriate level of action to take. The penalties, specified in VA Handbook 

5021, part I, appendix A, paragraph 23, range from a reprimand to removal for 

alcohol-related offenses, and from a suspension to removal for drug-related 

offenses. 

c. Now that you have had time to look into this issue, is there any evidence 

that Director DeScantis or anyone else at the facility took action to address 

this matter? 

Response: Other than informal conversations about impairment information 

possibly being contained in VA's Office of Inspector General (OIG) document 

release, VHA did not have knowledge of the DIG interviewer's allegation until they 

saw documents that the OIG shared with the Committee and a comment from 

Senator Baldwin's staffer about impairment information possibly being contained in 

the DIG document release. 

QUESTION 2: The Jason Simcakoski Memorial Opioid Safety Act would require 

the VA to track and review opioid prescribing rates at each medical facility, 

including the number of concurrent prescriptions of opioids and 

benzodiazepines. It would also mandate that the VA immediately conduct a full 

investigation into a provider or facility- and notify Congress- if any of these 

rates show dangerous or inappropriate outliers that could harm patients. 

a. How does the VA currently track opioid prescriptions, including both 

opioids and benzodiazepines, under the Opioid Therapy Risk Report Tool? 

Response: The Opioid Therapy Risk Report (OTRR) does not "track" opioid 

prescriptions but it allows individual primary care providers to follow, in real time 

while treating Veterans in the clinic, the key variables that influence risks when 

taking chronic opioids. 

Key considerations and relevant information found in OTRR include: 

Documented diagnoses that influence risk 

• Post-Traumatic Stress Disorder 

• Depression 

• Substance Use Disorder 

• Obstructive Sleep Apnea 

Patient interaction with health Providers 

• Last visit date 

• Last Pain Clinic visit date 

• Last Mental Health visit date 

5 
448 

Patient details 

• Results of last Urine Drug Test and date 

• Patient Pain Scores 

Patient Opioid and Benzodiazepine medication history 

o ALL VA Prescribers; dispensing location; strength; day supply; 

morphine equivalents 

• Status of signed iMedConsentTM, required for Opioid Therapy 

How this information is used during patient interactions: 

• Provides provider specific patient list that enables the clinician or team 

to quickly view status of key risk factors and treatment milestones. 

Dramatically reduces the time for data collection to make important 

clinical decisions. 

• Specific patient details can be obtained from the provider patient list, 

printed, and utilized as a patient education tool during a face-to-face 

visit to facilitate a conversation around pain management. This has 

the following benefits: 

o Re-enforces to the patient the doses of current meds 

o Allows conversation concerning early refills 

o Can be used to follow adjustments or tapers over time 

o Provides visual of the relationship between doses of opioids and 

pain scores 

In addition to OTRR, VA has other tools available to assist VHA staff with proactive 

clinical care of patients receiving outpatient opioid prescriptions or with diagnosed 

opioid use disorders, and metrics that provide information on implementation of 

clinical practice guideline recommended practices to improve the safety and 

efficacy of chronic opioid therapy. 

VA will soon be implementing a requirement to consult the state prescription drug 

monitoring program (POMP) report where available, prior to initiating a new opioid 

prescription, and VA is currently uploading its prescribing data to a majority of the 

state PDMPs. 

The Stratification Tool for Opioid Risk Mitigation (STORM) provides clinical 

decision support for the broader population of opioid-exposed patients, including 

patients with short-term prescriptions of outpatient opioid analgesics and patients 

with diagnosed opioid use disorders. STORM incorporates predictive analytics to 

estimate a patient's risk of adverse events including overdose, suicide-related 

events, accidents, and falls based on their clinical history and current prescriptions. 

Risk information is paired with customized, guideline recommended risk reduction 

strategies and non-medication based pain therapies, along with tracking of the use 

of these clinical interventions. This tool is designed with multiple views to facilitate 

individual clinical care encounters, enable proactive implementation of risk 

reduction strategies in patient panels, and guide facility-level quality and process 

improvement efforts. 

6 
449 

A set of Opioid Therapy Guideline Adherence metrics are used to track facility 

rates of opioid prescription and implementation of clinical practice guideline 

recommendations to improve the safety of opioid prescribing and the effectiveness 

of pain care. These metrics guide quality improvement efforts and document the 

declining use of opioid analgesics in VHA. Current data show the substantial 

improvement in use of recommended risk mitigation strategies over the last 

six years, as well as the comprehensive array of pain care options provided to VA 

patients who are also receiving opioid analgesics. This includes provision of 

non-opioid pain pharmacotherapies; rehabilitative treatments, such as physical 

therapy, occupational therapy, exercise or movement-based therapy, integrated 

health treatments, and specialty pain clinic services; and psychosocial and 

behavioral treatments. 

b. What is the process for identifying and investigating potentially dangerous 

prescribers? 

Response: Each facility has a Pain Point of Contact (POC) and an Opioid Safety 

Initiative (OSI) POC (they may be the same person) who track opioid prescribing in 

their facility and identify potentially unsafe practices, which are then addressed using 

education and remediation through the Academic Detailing Program and individual 

consultation with the Pain/OSI POC(s) and pain clinic personnel. 

QUESTION 3. The Jason Simcakoski Memorial Opioid Safety Act would also 

expand the Department's Opioid Safety Initiative, including a requirement that 

every opioid prescriber receives education and training on the updated opioid 

guidelines and on screening and coordinating care for patients with substance 

use disorders. 

a. Can you please provide an update on the implementation of the Opioid 

Safety Initiative in all medical facilities? 

Response: Since 2014, the OSI is reporting on opioid use, opioid doses, use of 

urine drug screens, and co-prescription of benzodiazepines for all Veteran 

Integrated Service Networks (VISN) and for all medical facilities in VHA. See the 

summarized information below: 

Results of key clinical metrics measured by the OS I: 

o From Quarter 4, Fiscal Year (FY) 2012 (beginning in July 2012) to 

Quarter 2, FY 2016 (ending in March 2016) there are: 

o 151 ,982 fewer patients receiving opioids (679,376 patients to 

527,394 patients, a 22-percent reduction). 

o 51,916 fewer patients receiving opioids and benzodiazepines together 

(122,633 patients to 70,717 patients, a 42-percent reduction). 

o 94,045 more patients that have had a urine drug screen to help guide 

treatment decisions (160,601 patients to 254,646, a 37-percent 

increase). 

7 
450 

o 112,846 fewer patients on long-term opioid therapy (438,329 to 

316,264, a 28-percent reduction). 

o The overall dosage of opioids is decreasing in the VA system as 

18,883 fewer patients (59.499 patients to 40,616 patients, a 32-percent 

reduction) are receiving greater than or equal to 1 DO Morphine Equivalent 

Daily Dosing. 

o The desired results of OSI have been achieved during a time when VA has 

seen an overall growth of 107,342 patients (3,959,852 patients to 

4,096,796 patients, a 3-percent increase) that have utilized VA outpatient 

pharmacy services. 

b. Can you also describe the opioid-specific training and education part of 

this new effort? 

Response: VHA estimates that as of September 7, 2016, 54.37% of prescribers 

have been trained in the Talent Management System (TMS). VHA continues to train 

prescribers on opioid safety and continually updates data to reflect that training. 

1) Academic Detailing: The Academic Detailing Service has been working 

closely with VISN Academic Detailing programs and VISN and facility pain 

leaders to educate providers on the OSI, including the development of the 

Opioid Safety Initiative Toolkit. This toolkit was developed by a multidisciplinary task force appointed by the National Pain Management Program to 

provide detailed guidance materials and presentations to standardize safe opioid 

management across the VHA. Academic Detailing is a service for clinicians by 

clinicians that provides individualized, evidence-based, educational outreach 

visits intended to meet the needs of the provider in the context of local 

operations. This service has been effective in altering prescribing habits in a 

variety of practice settings. 

2) The two Joint Incentive Fund (JIF) projects, sponsored by the Pain 

Management Work Group (PMWG) within the Department of Defense (DoD)NA 

Health Executive Council (HEC), as discussed below, have successfully created 

pain management education and training programs to improve pain management 

competencies and safe opioid prescribing system-wide. 

a) The Joint Pain Education Project (JPEP) aims to provide training of clinical 

providers and teams across VHA and DoD with a special emphasis on 

educating clinicians in core concepts and modern approaches to safe and 

effective pain management, including safe opioid prescribing, as well as 

providing education to Veterans and their families. JPEP provides 

system-wide training for clinical educators in general pain management, 

including Integrative Medicine and psychological and physical therapies, as 

well as evidence based approaches to opioid prescribing, which will enable 

them to train interdisciplinary clinical teams in primary care, known as Patient 

Aligned Care Teams (PACT) and provide education for Veterans and their 

8 
451 

families. The JPEP team has identified the following four phases of JPEP 

development: 

• Phase 1: Traditional Instructor-Led Training Curriculum with 31 

trainings that include evidence-based instructional presentations with 

facilitator notes; 

• Phase 2: Traditional Instructor-Led Regional Workshop, showcasing 

three trainings in the Phase 1 lessons; 

• Phase 3: Virtual Instructor-Led Professional Development Trainings; 

these are in progress and include trainings being done in joint DoDNA 

Specialty Care Access Network-Extension of Community Healthcare 

Outcomes (SCAN-ECHO) training sessions; and 

• Phase 4: Self-Paced Asynchronous web-based trainings; this is in 

progress and includes promotional videos, one of which is an 

adaptation of a highly popular video on understanding chronic pain that 

has been adapted for military service personnel and Veterans. 

As part of the JPEP program and in preparation to instruct primary care and 

pain medicine teams, DoD and VA Pain Champions are being educated 

about off-the-shelf pain management course content and training materials. 

• Specific training modules have been developed by the JPEP team to 

address needs of OSI for safe opioid prescribing and safe, appropriate 

medication tapering, as well as to meet the education and training 

needs of all team members regarding the essential elements of good 

pain care. Subject matter experts from VA and DoD worked closely 

together to develop the following four courses that are either in 

production or completed: 

a) Core curriculum for primary care providers and primary care 

pain teams which was completed FY 2015; 

b) Core curriculum for patients, families, and caregivers, which 

was completed and made available in May 2016; 

c) Core curriculum for pain medicine specialty teams which 

continues to be under development and expected to be 

completed by end of FY 2016; and 

d) Core curriculum for pain care transitions which was 

completed in FY 2015. 

• The dissemination of the training material will be combined with an 

ongoing effort to solicit suggestions for further refinements and 

additions to the courses thereby keeping current with the newest 

concepts in the rapidly evolving field of pain management. 

• JPEP courses are available for use by clinicians for continuing 

education credits and clinical decision-support. These courses are 

designed to be used in formal settings, independent study and formal 

educational programs such as SCAN-ECHO, national Community of 

Practice calls (occurring on a monthly basis in the PACT, Primary 

9 
452 

Care/Pain and Post-Deployment Integrated Care Initiative 

communities) and Pain Mini-Residency programs. 

b) The Tiered Acupuncture Training Across Clinical Settings (ATACS) Project 

aims to create access in all clinical settings to different levels of acupuncture 

for Veterans and Servicemembers with pain. The intent of this project is to 

supplement existing pain management capabilities with an integrated 

Complimentary Alternative Medicine approach that may reduce providers' and 

patients' dependency on opioids for treating pain, as well as increase patient 

choices in a patient-centered, proactive care model. 

• The tiered ATACS project plans to build a culture of sustainability 

within medical centers by establishing a cadre of practicing Battlefield 

Acupuncture (BFA) providers and medical acupuncture physician 

faculty throughout DoD and VA health care systems. 

• Since formal training sessions began in late 2013, the tiered AT ACS 

project has trained 46 VA medical acupuncturists as BFA Faculty with 

an additional23 VA providers enrolled in FY 2016 BFA Faculty 

courses. These medical acupuncturists have trained over 2,000 BFA 

providers, who are currently active in VHA and DoD medical centers 

across the country. 

• Distribution of trained BFA providers across the VHA continues to 

expand, as follows: 

1 state has trained over 100 providers 

4 states have trained 51-99 providers 

6 states have trained 26-50 providers 

15 states have trained 1-25 providers 

• Distribution of medical acupuncture trainees (300-hour course 

completion) 

Completed training: 26 trained in 28 states 

Currently enrolled in training: 32 in 9 states 

All VISNs have BFA Faculty for training providers in BFA 

workshops. 

• Clinical support for practicing BFA providers is available through a DoD 

and VA Collaborative Acupuncture Initiative, with a Community of 

Practice call biweekly and Defense Connect Online Webinars to 

advise, educate, and support providers on patient cases and 

acupuncture techniques. This VA/DoD collaborative effort is staffed by 

medical acupuncturists with expertise in BFA and supported by the 

Wounded Warrior Pain Care and National Capital Region Pain 

Initiatives. In addition, as part of the VA sustainment effort, the VA 

ATACS staff has developed with the VA Integrative Health 

Coordinating Committee (IHCC) a social network VA ATACS Pulse 

site. This site supports VA providers with documentation, teaching 

10 
453 

material, frequently asked questions as well as best practice examples. 

The site is managed by the VA AT ACS staff and will continue to be 

managed upon the expiration of the JIF, through a combined effort with 

the National Director of Pain, the IHCC and Office of Patient Centered 

Care and Cultural Transformation. 

3) The PACT Roadmap for Managing Pain, in early implementation, facilitates 

the delivery of the Stepped Care Model for pain management in the primary care 

setting. This road map is providing structure and guidance for both leadership 

and PACTs to transform and deliver an organized approach to comprehensive 

pain care in the framework of the chronic care model and the six essential 

elements for pain. It highlights proactive planning, utilizing appropriate 

resources, services, and strategies to meet the needs of the patient, engaging 

the Veteran and family in self-care and self-management, and ensuring effective 

team communication and coordination of care. 

11 
454 

DEPARTMENT OF VETERANS AFFAIRS 

INSPECTOR GENERAL 

JUL 2 2 2016 

The Honorable Ron Johnson 

Chairman 

Committee on Homeland Security 

and Governmental Affairs 

United States Senate 

Washington, DC 20510 

Dear Chairman Johnson: 

WASHINGTON DC 20420 

Enclosed are the Office of Inspector General's responses to the post-hearing questions 

from the May 31, 2016, hearing "Tomah VAMC: Examining Patient Care and Abuse of 

Authority." Thank you for the opportunity to testify and provide the requested additional 

information. 

Siooocol~ 

~ ~ ..... . 

MICHAEL J. MISSAL 

Enclosure 

Copy to: The Honorable Tom Carper, Ranking Minority Member 

The Honorable Tammy Baldwin 

The Honorable Joni Ernst 
455 

OFFICE OF INSPECTOR GENERAL 

DEPARTMENT OF VETERANS AFFAIRS 

RESPONSE TO 

POST -HEARING QUESTIONS FOR THE RECORD 

FROM THE 

COMMITTEE ON HOMELAND SECURITY 

AND GOVERNMENTAL AFFAIRS 

UNITED STATES SENATE 

MAY 31, 2016 HEARING ON 

"TOMAH VAMC: EXAMINING PATIENT CARE 

AND ABUSE OF AUTHORITY" 

JULY 22, 2016 

FROM CHAIRMAN RON JOHNSON 

1. On September 29, 2015, I wrote to your predecessor, Deputy Inspector General 

Linda Halliday requesting information and material relating to the production 

of the VA OIG's June 4 "white paper" that defended the office's work in Tomah 

and attacked whistleblowers from the facility. On October 6, 2015, 

Ms. Halliday wrote to me, "respectfully requesting" that I withdraw my request 

for information on who authored the "white paper." I have not withdrawn my 

request and I ask that you please provide the following information and 

material with respect to the white paper: 

a. Please provide the identities of all individuals that were involved in the 

drafting and publication of the "white paper." 

OIG Response: The letter was signed by the then Deputy Inspector, Mr. Richard 

Griffin. Mr. Griffin resigned on or about July 4, 2015. As the author, he was 

responsible for the content of the white paper. I have not spoken to him to 

determine who else he may have relied upon with respect to the drafting of the white 

paper. I have spoken to all current senior officials of the Office of Inspector General 

(OIG) and conveyed to them that I do not agree with the tone of the white paper or 

the gratuitous attacks against individuals made in it. I have not identified any current 

employee of the OIG who disagrees with this opinion. I am confident that 

documents produced by this office in the future will meet the highest professional 

standards. 

2. Recently, an administrative law judge with the State of Wisconsin Division of 

Hearing and Appeals issued an opinion immediately restoring Dr. Houlihan's 

license to practice medicine while the Wisconsin Department of Safety and 

Professional Services continues its investigation into his practice of medicine. 

In the opinion, the administrative law judge heavily cites the VA OIG's "white 

paper" as evidence to support her ruling that the suspension of Dr. Houlihan's 
456 

medical license be lifted: 

a. Do you believe that it is appropriate that the administrative law judge 

cited the VA DIG's "white paper" as evidence in her decision? 

b. Will the VA OIG issue a formal retraction of the "white paper"? 

OIG Response: The white paper was intended solely to provide information to the 

Committee. It therefore should not be used for any other purpose. I believe that the 

white paper was retracted when it was removed from the OIG website. 

3. Please produce all 19 cases involving the Tomah VAMC which is referenced in 

the Tomah Administrative closure. 

OIG Response: It is my understanding from reading the majority's final report that 

the underlying interest in these 19 cases is to determine whether any were initiated 

for the purpose of reviewing allegations concerning prescribing practices at the 

Tomah VAMC and the conduct of Dr. David Houlihan that were made by a Tomah 

VA Medical Center (VAMC) union representative in a January 2009 memorandum. 

None of the 19 cases were related to the allegations raised by the union 

representative. 

On March 16,2016, OIG staff provided information about the 19 cases in response 

to a similar request from the majority staff. Specifically, we shared that the 19 cases 

involved matters that were unrelated to the Committee's investigation and that none 

of them related to opioid prescription practices at the Tomah VAMC, the conduct of 

Dr. Houlihan, or any other party connected with the OIG's administrative closure. 

We also identified the various topics these cases covered, which included threats of 

violence from veterans, theft of property, access to pornography on a VA computer, 

potential loss or theft of patient medications during shipment, allegations of sexual 

assault, misappropriation of a veteran's benefits by a family member, off-campus 

misconduct, and quality of care (unrelated to the subject of the Committee's 

investigation). The case involving quality of care was accepted for review by the 

OIG Office of Healthcare Inspections, and we published our final report to our 

website on September 8, 2010, where it is available to the public at: 

http://www. va .qov/oig/54/reports/V AOIG-1 0-02355-242 .pdf. 

I am enclosing a summary of each of the 19 cases that is contained in our Master 

Case Index (MCI) system. Given that none of these cases are related to the 

Committee's investigation, you may not want further information on them beyond the 

summaries. However, after reviewing the summary of the cases, please let me 

know if you would like further information on any of them and we will provide it. 

2 
457 

FROM SENATOR TAMMY BALDWIN 

1. The Committee Report notes a provision that was included in last year's 

appropriations bill and is now law, which I authored with Senator Kirk. This 

provision would increase transparency at the Inspector General's Office and 

was intended to ensure that when the VA OIG completes a report, it is 

promptly shared with the VA Secretary, Congress and the public. 

Prior to your confirmation, the IG's office took an overly strict interpretation of 

this language regarding investigative reports on wait time manipulations at VA 

facilities across the country. I, unfortunately, had to place a hold on your 

confirmation until the office changed course. Thankfully, the IG began 

releasing the 77 reports and we have since had productive conversations on 

this issue. 

a. Now that you have had some time in your role as IG, what is your 

reading of the appropriations language? 

b. What is your overall approach to transparency with Congress and the 

public on your office's work? 

OIG Response: As we previously discussed, I believe it is important for the OIG to 

be as transparent as possible. Our practice is to release promptly reports to the VA 

Secretary, Congress, and the public that are not otherwise prohibited from 

disclosure or would negatively impact law enforcement efforts. All have a right to 

know about our work, while respecting privacy and law enforcement issues. I 

believe that this is consistent with the appropriations bill authored by Senator Kirk 

and you. 

2. Your office maintains a hotline service that receives, screens, and reviews 

whistleblower complaints within the VA. I have heard repeated frustration 

from whistleblowers that when they come forward with abuse allegations, they 

feel like the hotline is a black hole. Whistleblowers have stated 

their complaints are entered in the hotline, but that there are inconsistent 

responses back from your office. 

a. Can you explain the current response process and what improvements 

you are looking to make in the hotline process? 

OIG Response: The OIG takes action on a// contacts made to the OIG Hotline. All 

contacts submitted to the OIG Hotline are reviewed by OIG staff and are entered into 

the OIG's system of records. All contacts undergo a preliminary evaluation to 

determine if they merit further action. 

It should be noted that the OIG counts the number of contacts made to its Hotline. 

During FY 2015, the OIG received 38,098 contacts. The terms 'contact' and 

'complaint' are not synonymous. A single contact may contain an allegation or 

3 
458 

multiple allegations and could be considered a complaint. Conversely, many 

contacts do not contain any allegations, such as when the caller has contacted the 

Hotline merely to request directory assistance to another component of VA. 

Due to the high volume of contacts received by our Hotline, we are not currently able 

to notify each person individually if we do not accept their complaint or allegation for 

further action by our office. We inform individuals in our automated e-mail response, 

by letter mail, and on our website that they will be contacted again only if we open a 

case or need additional information. Additionally, these communications inform 

individuals about the types of complaints the OIG does and does not accept for 

review, provide points of contact for further assistance on common VA complaints 

that are not matters within the OIG's purview, and outline what individuals should 

expect next after submitting a Hotline complaint. 

Because the number of allegations we receive each year far exceeds the number we 

can accept for review, the OIG must be highly selective in the cases we accept. We 

must use our professional judgment to accept only the allegations that we believe 

represent the most serious risks to veterans, beneficiaries, and taxpayers. 

We receive a large volume of complaints that concern one veteran's health care 

experience at one VA medical facility. While health care-related complaints fall 

within the OIG's general purview and we do review a select number of complaints 

regarding a single veteran's experience, it is not possible to open a case for each 

complaint involving a single episode of care. By reviewing and logging all 

complaints, we have the ability to use aggregate data to identify areas that may 

warrant a large-scale or national review, thereby directing our limited resources to 

areas that will benefit the largest number of veterans. 

After undergoing a preliminary review, all contacts are triaged into one of the 

following categories: 

OIG Case. The OIG conducts an investigation, audit, review, evaluation, or 

inspection in order to determine the merit of the allegations. When the OIG 

accepts an allegation for a case, we notify the complainant that an OIG case has 

been opened and when it closes. 

External Referral to VA. External referrals of cases result from allegations 

submitted through our Hotline that the OIG does not accept for review. For 

allegations that are not accepted by the OIG but that appear to warrant further 

review, the OIG makes external referrals to VA in accordance with VA Directive 

0701, Office of Inspector General Hotline Complaint Referrals. VA Directive 

0701 requires that VA review the allegations and submit a written response to the 

OIG that contains: 

• Evidence of an independent review by an official separate from and at a 

higher management level than the alleged wrongdoer. 

4 
459 

o Specific review of all allegations. 

o The findings of each allegation, which are clearly identified as either 

substantiated or unsubstantiated. 

o A description of any corrective action taken or proposed as a result of a 

substantiated allegation, (e.g., change in procedures, disciplinary or 

adverse action taken, etc.). 

o Supporting documentation for the review, such as copies of pertinent 

documents, a summary report of the board of investigations, etc. 

o Designation of a point of contact for additional information. 

We keep the external referral open until we are satisfied with VA's review or open 

an OIG case to review the matter further. When we close an external referral 

that originated through the Hotline, we contact the complainant in writing to 

advise them how to request the results through a Freedom of lnfonnation Act 

(FOIA) request. Many of these external referrals concern the medical care 

provided to a specific veteran during a specific episode of care. 

Non-Case Referral to VA. The OIG will refer certain Hotline contacts directly to 

the appropriate VA office if the allegation appears to warrant some action on that 

facility's part. For example, non-case referrals are made for complaints of staff 

rudeness or medication refill problems. The OIG does not require a response 

from the facility after they have reviewed the case. 

No Further Action. The OIG takes no further action on matters that are not within 

VA's or the OIG's jurisdiction; can be addressed in another legal or administrative 

forum; are not logical, plausible, or supported by available VA records; or are too 

trivial, stale, or vague to warrant further review. When possible, the OIG refers 

the complainant to the appropriate VA program office or Federal agency that can 

provide further assistance on the matter. For example, individuals with 

complaints regarding claim adjudications for VA disability and pension benefits 

are advised to contact the Veterans Benefits Administration (VBA); individuals 

with complaints regarding discrimination are advised to contact VA's Office of 

Resolution Management (ORM); and individuals with allegations of prohibited 

personnel practices, including reprisal for whistleblowing, are advised to contact 

the U.S. Office of Special Counsel (OSC). We also do not review complaints of 

poor quality of care when the veteran or family has filed an administrative tort 

claim. Those investigations are the responsibility of VA's Office of General 

Counsel. 

For some contacts, the OIG is able to assess immediately and invalidate the 

allegation by conducting a review of available VA records. For example, a 

veteran's neighbor might contact the Hotline to report suspected disability fraud. 

The neighbor is convinced the veteran is rated 100 percent disabled, yet the 

veteran is observed regularly performing heavy yard work. The OIG can quickly 

access the veteran's records, and may determine that the individual is either not 

receiving any disability compensation or is rated for a condition that would not 

5 
460 

preclude him from performing physical labor, such as a mental health condition 

like post-traumatic stress disorder. In such instances, it is not necessary for the 

OIG to open a case even though we did take action during the preliminary 

evaluation to invalidate the complaint. 

I recognize the importance and significance of information that we receive through our 

Hotline, particularly from whistle blowers. Whistle blowers are an important source of 

information to our program. I am in the process of reviewing current OIG policies, 

workloads, and priorities with respect to our Hotline and will make any enhancements 

as appropriate. 

FROM SENATOR JONI ERNST 

1. After receiving a complaint to the Office of Inspector General (OIG) Hotline in 

March 2011 regarding prescription practices at the Tomah VAMC, why did the 

OIG decide to refer the allegation to the Director, Veterans Integrated Service 

Network (VISN) 12, VA Great Lakes Health Care System rather than investigate 

the allegation itself? 

OIG Response: As discussed in our response to Question 2 from Senator Baldwin, 

and as more fully explained in our response to your next question below, the OIG 

receives more allegations than we have the resources to review. With respect to 

quality of care allegations, the OIG's Office of Healthcare Inspections reviews each 

one to determine which ones are appropriate for our review. Allegations that are not 

selected for OIG review may be referred to the appropriate office within the Veterans 

Health Administration for review and response in accordance with VA Directive 

0701, Office of Inspector General Hotline Complaint Referrals. With respect to this 

allegation, it was decided, given the then current workload of the OIG and other 

considerations, to refer this allegation regarding prescription practices at the Tomah 

VAMC to the Veterans Integrated SeNice Network 12 for review and response. 

2. What is the standard used by the OIG in determining whether to investigate 

allegations itself or refer them to the VA? 

OIG Response: Since the number of allegations we receive each year far exceeds 

the number we can accept for review, we must be highly selective in the cases we 

accept. We analyze each matter and use our professional judgment to accept the 

allegations we believe represent the most serious risks to veterans, beneficiaries, 

and taxpayers. Many factors influence this decision making process including the 

nature, severity, and scale of the allegation, the level of detail provided to explain 

and/or support the allegation, our ability to contact the complainant for more 

information, and our resource capacity. 

Of particular concern to the OIG are those contacts alleging substandard quality of 

care. For example, to determine whether quality of care allegations should trigger a 

6 
461 

formal inspection, our team of physicians, nurses, and other clinicians consider 

multiple factors including risk to patients and resource availability. The risk 

assessment is particularly important and is informed by the relative scope (the 

number of patients affected) and severity (the actual or potential impact on patients' 

health or safety) of the alleged quality of care issues. 

Other factors that influence whether an allegation receives further consideration from 

the OIG is the level of detail provided and whether the complainant has provided 

contact information. It is critical in most instances that the OIG be able to 

communicate with the complainant to understand the nature of the complaint so as 

to address effectively the issue; otherwise, we are often left with a task akin to 

looking for "a needle in a haystack." For example, if a complainant makes a serious 

but vague allegation that surgery at a medical center is of poor quality, but does not 

provide any further information, it is difficult to address the complainant's issues. 

3. What is the standard used by the OIG in determining that an investigation 

warrants an administrative closure rather than a formal report? 

OIG Response: Reports are the final product resulting when the OIG initiates a 

planned or mandated oversight project or accepts a case arising from an allegation 

submitted through our Hotline or a Member of Congress. There are several different 

types of final reports including administrative investigations, audits, reviews, benefits 

inspections, healthcare inspections, Combined Assessment Program reviews, and 

Community Based Outpatient Clinic reviews. We publish the results of our 

completed work in a final report. 

However, there are certain circumstances where it is not possible or practical for the 

OIG to continue performing a review that will result in a final report, and in these 

situations we may terminate the investigation, audit, review, evaluation, or inspection 

without a final report through an "administrative closure." Situations where an 

administrative closure might be appropriate include when: 

• We determine an allegation is the subject of litigation or a claim filed under 

the Federal Tort Claims Act. 

• We determine the allegation has already been adequately addressed by VA 

prior to our review. 

• The complainant declines to cooperate or provide critical information, without 

which the OIG is not able to conduct a thorough review of the allegations. 

Prior to 2015, the OIG reported the number of administrative closures issued in its 

Semiannual Report to Congress, but we did not post the administrative closures on 

our website as we would with a final report. However, in order to be as transparent 

as possible and keep the Congress and the public informed about our work, the OIG 

now publishes all administrative closures that are not specifically prohibited from 

disclosure by any provision of law. 

7 
462 

4. As you stated in your written testimony, the VA OIG needs to be as 

transparent as possible in its work. Are there ways to address privacy 

concerns without withholding administrative reports from the public -for 

example, by redacting personally identifiable information? 

In addition, with respect to reputational concerns, why would it not be better 

for everyone involved if allegations were addressed and dismissed as 

unsubstantiated in a public report so as to leave no lingering question by the 

person who made the allegation or anyone contacted during the course of the 

OIG's investigation? 

OIG Response: There are ways to address privacy concerns and we do publish 

reports where allegations were not substantiated. As required under the IG Act, all 

report titles are posted on our website within 3 days of being issued to VA. If the 

information in the report is not protected under the Privacy Act or another 

confidentiality statute (which it rnost often is not), the website includes a link to the 

report. However, if the report contains FOIA protected information, our current 

practice is to post only the title and a brief summary until we receive a FOIA request 

for the report. Once we receive three FOIA requests for the report, which generally 

occurs shortly after the report title and summary are posted, we put the full report on 

our website. We are reviewing this practice to determine whether we can post 

reports with protected information more quickly. 

In an effort to release our findings and conclusions publicly, all reports are reviewed 

by our Information Release Office, which is a component of the OIG's Office of the 

Counselor to the Inspector General, for a determination as to whether the report can 

be published on our website in its entirety or whether it contains information, such as 

personally identifiable information, that needs to be redacted. The OIG works 

diligently to write reports: 1) with findings and conclusions that are clear and 

supported, and 2) in such a way that, to the extent possible, they can be made 

public without redactions. 

With respect to the second part of this question, the OIG does publish reports where 

allegations were not substantiated. For example, we recently published a report 

detailing our findings related to allegations that could not be substantiated against a 

senior VA official. The report is available in an unredacted format on our website at: 

http://www.va.gov/oig/pubsNAOIG-15-02747-314.pdf. 

8 
463 

5. How many complaints were received by the OIG hotline in 2015? Of those 

complaints received: 

a. How many resulted in an OIG investigation? 

b. How many were referred back to the VA? 

OIG Response: As noted above, the OIG counts the number of contacts made to 

its Hotline. During FY 2015, the OIG received 38,098 contacts. The terms 'contact' 

and 'complaint' are not synonymous. A single contact may contain an allegation or 

multiple allegations and could be considered a complaint. Conversely, many 

contacts do not contain any allegations, such as when the caller has contacted the 

Hotline merely to request directory assistance to another component of VA. 

During FY 2015, the OIG's Office of Investigations, Office of Audits and Evaluations, 

and Office of Health care Inspections collectively opened 225 cases as a result of 

Hotline contacts. It is important to keep in mind that a single OIG case can often 

address several complaints from many OIG contacts. For example, we received 

approximately 225 allegations regarding wait times issues during the course of our 

review of the 2014 Phoenix VA Health Care System wait times scandal. The 

overarching issues in these 225 allegations were addressed in one interim report 

and one final report. 1 The OIG also opens cases as a result of congressional 

mandates and requests; proactive investigative work; investigative leads from other 

sources; and planned/discretionary audits, reviews, and inspections. 

For an additional 1, 764 Hotline contacts, we initiated an external referral to VA under 

the process outlined in our response to Question 2 from Senator Baldwin. We also 

made non-case referrals to VA for another 497 Hotline contacts, which are also 

described in our response to Question 2 from Senator Baldwin. For more than 

1 ,000 additional contacts, the OIG requested but did not receive the necessary 

consent from the complainant that would have allowed the OIG to take further action 

on the complaint. 

Approximately 33,000 of the FY 2015 contacts to the OIG Hotline required no further 

action by the OIG because they regarded matters that were: 1) not allegations, 2) 

unrelated to VA programs or operations or from prolific communicators, 3) outside 

the OIG's jurisdiction, 4) able to be resolved through other avenues of redress (such 

as another VA office, Federal agency, or legal or administrative forum), 5) not logical 

or plausible, 6) too trivial, stale, or vague, 7) unsupported or invalidated by VA 

record checks, or 8) included as a component of an already open OIG case. Even 

though the OIG ultimately did not open cases for these contacts, OIG staff took 

action on every contact made to the Hotline. All contacts were reviewed by OIG 

staff, were entered into the OIG's system of records, and underwent a preliminary 

1 Interim Report: Review of VHA 's Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths 

at the Phoenix Health Care System (May 28, 2014) and Review of Alleged Patient Deaths, Patient Wait 

Times, and Scheduling Practices at the Phoenix VA Health Care System (August 26, 2014). 

9 
464 

evaluation to determine whether the complaint or allegation merited further action. 

When possible, we also took steps to refer the complainant to the appropriate office 

or agency that could provide assistance. 

6. If complaints received by the OIG hotline in 2015 did not result in an OIG 

investigation or were not referred to the VA, what happened to them? Please 

provide a detailed review of how any remaining complaints were handled by 

the OIG after coming into the hotline. 

OIG Response: As noted above, the OIG takes some degree of action on a// 

contacts made to the OIG Hotline. Each of the 38,098 contacts made to the OIG 

Hotline during FY 2015 was reviewed by OIG staff, entered into the OIG's system of 

records, and evaluated to determine whether the allegation merited further action. 

The review and evaluation of Hotline allegations is conducted by professionals in the 

OIG Hotline, and in many cases, by investigative, audit, and clinical professionals 

throughout the OIG offices of Investigations, Audits and Evaluations, Healthcare 

Inspections, and Contract Review. 

As discussed in greater detail in response to Question 2 from Senator Baldwin, after 

the initial evaluation of every contact, the OIG takes no further action on matters that 

are not within VA's or the OIG's jurisdiction; can be addressed in another legal or 

administrative forum; are not logical, plausible, or supported by available VA 

records; or are too trivial, stale, or vague to warrant further review. When 

appropriate, we redirect complainants to the appropriate VA program office or 

Federal agency that can provide further assistance on matters not accepted by the 

OIG. There are also many instances where the OIG is able to immediately assess 

and invalidate the allegation by conducting a review of available VA records. In such 

instances, it is not necessary for the OIG to open a case even though we did take 

action during the preliminary evaluation to invalidate the complaint. 

Below is a listing of the more common categories of contacts that receive little to no 

further action once they are reviewed, logged, and evaluated by OIG staff. As you 

will see, not all of the contacts were for the purpose of filing a complaint. For those 

that were making a new complaint, we determined the complaint was either outside 

the purview of the OIG; not supported by available VA records; or not logical, 

plausible, substantive, or credible enough to warrant further consideration. When 

possible, the OIG referred the complainant to the appropriate VA program office or 

Federal agency that can provide further assistance on the matter. In instances 

where the complainant was providing additional information for an existing contact or 

case, that information was reviewed and forwarded to the appropriate OIG staff. 

No Complaint/Duplicate Complaint/Request for Information: 

• Business Invitation 

• Caller Ended Call 

• Case Already Opened for Same Matter- No New Information Reported 

• Dead Call 

10 
465 

• Directory Assistance/Request for Information 

• No Allegation- Caller is Merely Voicing Frustration 

• Previous Closed Issue- No New Information Reported to Warrant Action 

• Providing Additional Information for an Existing Case or Contact 

• Request for Status of Case or Contact 

• Request to Explain Hotline Process 

Outside OIG Purview: 

• Beneficiary Travel Reimbursement Claim Dispute 

• Complaint is Already the Subject of a Tort Claim 

• Department of Defense OIG Matter 

• Department of Housing and Urban Development-Veterans Affairs Supportive 

Housing [HUD-VASH] Dispute 

• Department of Labor/Workers' Compensation Claim 

• Education Benefits Dispute 

• FOIA Requests 

• Individual Benefit Dispute 

• Local Police Matter 

• Non-VA Issue 

• National Personnel Record Center Request 

• OPM Matter 

• ORM/Equal Employment Opportunity Matter 

• OSC Matter 

• Patient Advocate Matter 

• Pension Management Center Issue 

• Regional Loan Center Issue 

• State Attorney General Matter 

• Union/Human Resources Matter 

• VA Life Insurance Issue 

• VA Police Matter 

• VBA Call Center Complaint 

Not Logical/Plausible/Substantive/Credible: 

• Benefit Fraud (no proof of alleged activity) 

• Benefit Fraud (VA records did not support the allegation) 

• General/Non-Specific Complaint/For Informational Purposes Only 

• Not Credible/Too Old 

• Preemptive Reporting 

• Third Party Allegations/Hearsay 

11 
466 

7. What steps are being taken to increase communication and improve the 

working relationship between the VA OIG and the Office of the Special 

Counsel? 

OIG Response: One of my immediate priorities has been to understand and resolve 

the concerns between the OSC and the OIG so that we can maintain a positive and 

constructive relationship moving forward. I met with the Special Counsel and some 

of her senior staff within the first two weeks of becoming the Inspector General to 

listen to their views. I am very optimistic that this was a productive first step towards 

building a stronger relationship. 

Moreover, we have streamlined processes to improve communication and our 

working relationship with OSC in several important ways. OSC has statutory 

authority to refer disclosures of information meeting certain criteria to VA for further 

investigation. OSC does not refer cases directly to the OIG. Before VA acts on 

these complaints, VA forwards them to the OIG so that the OIG can determine 

whether or not it has ongoing work that would already address those allegations. 

In the past, the OIG did not have a reliable system for tracking these complaints, or 

for communicating clearly to VA what specific aspects of a case the OIG could 

address. To improve this process, these complaints are now referred to a single 

point of contact within the OIG, who reviews the complaints and determines whether 

there is substantial overlap with ongoing OIG work. If there is, the OIG 

communicates to VA precisely what specific allegations the OIG will address. This 

enables VA to determine how to best address any additional concerns contained 

within the OSC complaint. 

The OIG will soon begin holding monthly conference calls to update OSC on the 

progress of cases which originated with OSC. We are also instituting a process for 

briefing OSC, similar to the briefings we provide to our congressional stakeholders, 

on OSC-related cases at the time of report publication. 

To date, the OIG has received positive feedback from both OSC and VA on how the 

new process has been working. We will continue to look for ways to work effectively 

with OSC, as our office values whistleblowers and their role in improving the 

economy, efficiency, and effectiveness of VA. 

12 
O:IG0041 MCI SEARCH RESULTS (VIEW) 

MCI NUMBER FISCAL YEAR DATE RECEIVE CLOSED DATE TITLE 

2011-04479-IC.0144 2011 091:21/2011 1o.'1oi/2011 

OFFICE ASSIGNED ACTION 

tc-CentraJ F!d (CHI) 

LEAD OIG POC NAME 

JONES, JOHN 6 

FUNCTION CODE 

FOIA REQUESTOR 

DATE: 07/19/2016 01:23 

Page 1 

ST

co

INTEREST 

ON BEHALF OF (FOIA 

Z3-AUSA 

WI 

-was interviewed on 9(7/2011 and admitted mak1ng the aforementioned phone call, but stated he ha dno intentions to harm anyone or bnng weapons to lhe VA ... had 
OIG0041 MCI SEARCH RESULTS (VIEW) DATE: 07/19/2016 01!2

Page 2 

around hJ:> sented a tiusmess c:i:d purporte o be ATF agent' This was: FBl, amJ' La Cro

County Shenff Department regard1ng 1fi111 

The U.S. Attorr1ey's Office of the Western Dis:tnct of Wisconsin declined prosecution for consideration by other authonties. The Monroe Attorney·s Office requested a cop)' of this report. and advtsed had recewed a May Toma.h, Police ?epartment threat referral involvit1Q 

statements made b.,_ to the On 1011312011. ADA Kevm Cronmger deeltned prosecution of thiS case. rt1du:atmg that hrs office Wtll address thiS matter througt'r a 

pending State of Wisconsin case against-
0IG0041 MCI SEARCH RESULTS (VIEW) 

MCI NUMBER FISCAL YEAR DATE RECEIVE 21l11-0447g...OC-0446 2011 09o00/2011 09/2112011 

OFFICE ASStGNED ACTION 

De-central Fld on Referral {INVICHI} 

LEAD OIG POC NAME 

JONES, JOHN B. 

WI 

FUNCTION CODE 

FOIA REQUESTOR 

DATE: 07/19/2016 01:3

Page 1 

ST

INTEREST 

ON BEHALF OF IFOIA 
MCI SEARCH RESULTS (VIEW} 

MCI NUMBER FISCAL YEAR DATE RECEIVE 

2011--{.JJ435-0C..(]JJ5 2011 0012412011 0512712011 

!!!!..§ 

OFFICE ASSIGNED ACTION 

DC-Cenlra1 Fld 01f Refemll (INVfCHI) 

LEAD OIG POC NAME 

PORTER. GREGORY 

FUNCTION CODE 

FOIA REQUESTOR 

DATE; 01:54 

Page 1 

ST

c"

INTEREST 

ON BEHALF OF Cf:'QIA 

... . .'•-. " - -,. •- • ;ft?":: • I - 

676-TOMAJ-I 

67-THREATS 

WI WI 

and Dane County Bomb Squad, who subsequently detemtined there was no 

I made contad: with the VA Police (Officer Johns and Acting Chief Seals} who advised the proper alerts were placed on the subjed tor monitoring while at the VAMC. I made contad 

Lt. WaddeB of the Tomah Pollee and provided him with my contact information shoukj they need any future assistance from OIG 
OIGOOfl MCI SEARCH RESULTS (VI~) MCI NUMBER ASCAL YEAR. DATE RECEIVE CLOSED DATE IJ.ll.g 

2011..{)1995-Hl-0491 2011 

OFFICE ASSIGNED ACTION 

HL-HOU!Ill!! 

LEAD DIG POC NAME 

GAMBlET 

671)...TOMAH 

03i11r2011 

30·1NAPPROPRIATE OR. INCORRECT TREATMENT (Rx) 

33-0ELAY IN DIAGNOSlS OR TREATMENT 

WI 

FUNCTION CODE 

A1ii·MEOICAL CENTER 

FOIA REQUESTOR 

DATE: 07/19/2016 01:4

Page 1 

ST

C

INTEREST 

ON BEHAlF OF <FOIA 

L.g!--~-~~-~1~ ' . . • . ' - 

CASE CLOSED/UNFOUNDED 

A VHA review determined that the allegations v.ere unfounded. The care provided by the Nurse Practitioner was considered appropriate and correc1 given the duration and nature of t

Pre5ent!ng sympto111$ and physical filldings. There were no actions identified as needed by tfle Tomah VA Medical Center in response to the investigation of ir1appropriate or inconec:t treabnent. 

The Tomah VA Medical Center Policy PC-14, "Ordering and Reporting Test R.esutl.$,~ states that non..aitical, non~ent, or normal test results wiU be c:ommunk:ated within seven 

days. The lhroat culture was negative. The communication of results -as processed within the expected seven day time frame. There would be no reason to call the patient given th

negative realll.s; the medications Ofde1ed would continue to be appropriate. 

There were no delays in treatment due to the response of the Wausau Outpatient Clinic chose to seek care in the prNate sector for reasons unknown to our staff wtlen 

symptoms continued. He had Pf',:lvious e~tperienc:e with the VA triage system Which resulted in getting an appoinbnent quickly. Rather than going to the emergency room, he could ha

called Tomah VAMC on Saturday, Deoember 18, 2010, at wtlid'J time he woold have been tr1aged for care appropriately. 
OI:G0041 MCI SEARCH RESULTS (VIBW} DATE: Olt4

Page 2 

-alleges that he informed his PCP that he was experlendng patn in his esophagus after swallowing and was unable to and the symptoms d!d not app

to be associated with the symptoms of strep throat The PCP dtd a strep test and also treated him for stomach acid Olferpl'l)(judion. h& received the results se

days later wdh no follow-up phone call or ,.isit regarding his ailments. 

On- 2010, t1e went to the emergency room (ER) in an extremely dehydrated state and was diagnosed with a viral infection causing esophagitis and esophageal ulcers 
OIG0041 MCI SEARCH RESULTS (VIEW) 

MCI NUMBER FISCAL YEAR DATE RECEIVE 

2011-Q1066-0C..0083 2011 12/2812010 1212812010 

TITLE 

OFFICE ASSIGNED ACTION 

Fld Ofl' Relemtl (INV/CHI) 

LEAD OtG POC NAME 

PORTER, GREGORY 

676-TOMAH 

159-SEXUAl. ASSAULT 

WI WI 

Tomah VA Police UOR#201CH2·27...Q951-4237 

FUNCTION CODE 

FOIA REQUESTOR 

DATE: 07/19/2016 01:4

Page l. 

ST

c"

INTEREST 

ON BEHALF OF fFOIA 

On 12128110, the Tomah VA Police forwarded a repon of an alleged teK\Jal assualt reported by Tomah -alleged that on 12125110, he was 

approaChed bra male subject, who identified himselt' as-· in the building 400 smoking sheller, After small talk., went with-to . .) nearby bathroom 

instructed to performed oral sex on - in a baih"room slall. --did as instructed. Once completed left without incident 

-initially lli!porled the oral sex ad as c::oen:ed, howelo'ef later admitted to VA Police Officers the act was consensual, as he "is gay, and didn't mind at the He on 

state he made the lli!port because he was scared he may have been infected with a seKually transmitted disease. 
OIGQ04l. MCI SEARCH RESULTS (VIEW} DATE::: 07/19/2016 01:4

Page 2 

The VA PoliCe closed the case with no further leads. No further action is being taken by OIG at this time. 
OIG0041 MCI SEARCH RESULTS (VIEW) 

MCI NUMBER FISCAL YEAR DATE RECEIVE CLOSED DATE .!!Jll 

2011..Q0962-Hl..019JI 2011 

OFFICE ASSIGNED ACTION 

Hl·Honiroe 

LEAD OIG PQC NAME 

SMITHD 676~TOMAH 12/1612010 

101-PROBLEMS WITH FACILITIES AND SERVICES 

102-EXCESSlVE WAinNG TIME 

WI 

02/09/2011 

FUNCTION CODE 

A19-MEOJCAl CENTER 

FOIA REQUESTOR 

l)ATB: 07/19/2016 01:4

Page 1 

ST

c.

INTEREST 

ON BEHALF OF {FOLA 

~-l~~~!..~~ 

. -t"' • ' • ' • •• ,' - ' 

A \IHA review concluded PTStfP3tielltS"a«i iiXpeitendng a -dekiY in wart-tiine ;or fCI!oW.up appointments. The-rev.ewronaUde(fthat lhete is-iCiinical pcrsition Opert at the eeoc that 

has not yet been filk!d. Management has- implemented a plan to better serve wrterans they are trailing a psychotherapy orientation group at the medical center in the near future. The

will be efficiency gained with one or two provideB seeing a small group of 4 8 ~terans. The other gain will be a decrease fn the number of •no s-twws" that a prD'IIider experienced. 

Hotline received a complaintfrom an anonymoUS SOurce whO 3tieged th.3t PTS-Dti8tients assigned to the MenfafHearthC3re:crlnics at the medical center andWausau cBOC, are 

experiencing a Nifo month delay fot' scheduled follow-up appointments. 
O:IG0041 MCI SEARCH RESULTS (VIEW} DATE: 07/19/2016 01:0

Page 1 

MCI NUMBER FISCAL YEAR DATE RECEIVE CLOSED OATE !!I..bS ST

2010-02355-til-0242 H01 lmp

OFFtcE ASSIGNED ACTION 

HHiealthcare 

LEAD OIG POC NAME 

676-TOMA.H 

W1 WI 

09106/2010 09/0at2010 Healttu:are ln$P0diorl Re...._ ot Quality r:.l care lsSUI!$ Tomah VA Med,.;al and Williarn S. Middleton 

Meroot1al Vetera/\5 Hosprtal. Tomah aod Mad!son, WI$COI1Sin 

INTEREST FUNCTION CODE 

HOI-SECRETARY ON BEHALF OF (FOIA 

FOIA REQUESTOR 

Healthcare ln.spection Relriew of Quality of care Issues Tomah VA Medical Center and WilliamS. Middleton Memorial Veterans Hospital, Tomah and Madi$on, Wisconsin 
OIG0041 MCI SEARCH RE:SULTS (VIEW} 

MCI NUMBER FISCAL YEAR DATE RECEIVE •••• 

2010-02867-DE-0027 2010 06J3012010 07,1;.11/'2010 

TITLE 

OfFICE ASSIGNED ACTION 

Compu1er RefeiTil!S 

LEAD OIG POC NAME 

STUMME WILLIAM F 

PORNOGRAPHY VA SYSTEMS 

120-ADUL T PORNOGRAPHY VA SYSTEMS 

2010..02667-0C-o268-

WI WI 

FUNCTION CODE 

fOIA REQUESTOR 

DATE: 07/19/2016 01:1

Page l 

ST

""

INTEREST 

VAOIG 

lnvesUQabOll 

ON BEHALF OF {FOIA 

CCFL review of computer round no indications of viewing/possessing Child the submitted hard disk drive. Drive returned to SA Jones. 
0IG004l MCI SEARCH RESULTS (VIEW} 

MCI NUMBER FISCAL YEAR DATE RECEtVE CLOSED DATE TITLE 

l01()-()2a67..0C-0288 2010 OOr'OJ/2010 07129/2010 

OFFICE ASSIGNED ACTION 

OC-Centr:ll Fld O!T Referr.d {INV/CHl) 

LEAD OIG POC NAME 

JONES, JOHN 8_ 

676-TOMA.H 

116-CHILD PORNOGRAPHY (GENERAL} 

1174.:HILD PORNOGRAPHY VA SYSTEMS 

119-AOUl T PORNOGRAPHY (GENERAL) 

120-ADUL T PORNOGRAPHY VA SYSTEMS 

2010-02867 

WI WI 

FUNCTION CODE 

FOtA REQUESTOR 

DATE: 07/19/2016 01:57 

Page l 

ST

c.,

INTEREST 

ON BEHALF OF IFOIA 

revealed "teenw porn were accessed and it was suspeded that child pornography may have been 

SA Jones took possession of the evidence on El/312010, 
MCI SEARCH RESULTS (VIEW) DATE.: 07 5

Page 2 

-··• . II 

On 6/15/2010 SA Jones wftnessed Mar1!. Smith (53CH) relll()VB tile hard drive from lhe computer. Lead and the hard dnve were sent to 51E for analysis of !he hatd drive t

child pomogral)hy on 612912010 CCFL SA Wd Stumme revieWed the hard drNe and found no tndlcallons of child pornography. The hard dl'llle was retumed to S

Jones on 711/2010. The hard drive was remstalled mto the computer by Smith and 'Mtnessed by SA Jones on 7122120l0. AI! rtems turned over to SA Jone$ from VAPD >Nere returne

712812010. 

This matter is dosed due to no child pornography on lhe hard drive 
OIG0041 KCI SEARCH RESULTS (VIBW) DATE: 07/19/2016 02:39 

Paqe 1 

MCf NUMBER FISCAL YEAR DATE RECEIVE: CLOSED DATE ST

21J10-02355-HI·0299 2010 

OFFICE A§SIGNED ACTION 

HI·Healthcare 

LEAD OIG POC NAME 

REED, JENNIFER 

OavidRObey 

607 -MADISON 676-TOMAH 

33-DELA Y IN DIAGNOSIS OR TREATMENT 

Wl Wl 

05105/2010 0910812010 Hl MADISON. 'M ·HEART MEDICATION CHANGE/PATIENT DEATH f Heallhcare Qua!rtv of Care Clo

Issues, Tomah- VA Medical Center and 5 Memorial Velelan$ Ho.5pltat Tomah and Mad!SOf'l, 

WISOOnsin INTEREST 

FUNCTION CODE ON BEHALF OF tFOIA 

FOIA REQUESTOR 

Secretary was cnnooming the dearh o alleges that her husband received poor care. The Secretary asked the OKi to 

revieW the care provided to--
OI:G0041 MCI SEARCH RESULTS (VI:EW) DATE: 07/19/2016 02:3

Page 2 '~iff" Ref£!rred to our ChiCagO IIE!I'miiii:I! Off a and Dr Wesley IF lllii!i~ilUllll !l~ri'll 1· II &i

Continue w/inteNtev.$ and the draft report IS 1n process. 

6/28/10 preliminary draft report sent to Dr. Wesley. 

1n.1110 Report mprogn!ss 

7122110 Report ser~t to 54A for re11iew 

7129/10 Report sent to VISN/Med Center Directors for response due August 1:t 

8/11110 Report received from VISN/Med Center Oirecto~. 8119/10 Final report sent to 54, 

8/31110 Report sent to ERD fur publication 
OIG0041 MCI SEARCH RESULTS (VIEW) 

MC1 NUMBER FtSCAL YEAR DATE RECEIVE CLOSED DATE TITLE 

2()10 0413G'2010 0510312010 

OFFICE ASSIGNED ACT!QN 

Fld Off Refei'T'lll (INV/CHt} 

LEAD OIG POC NAME 

JONES, JOHN B 

676--TOMAH 67-THREATS 

WI WI 

FUNCTION CODE 

FOIA REQUESTOR 

DATE: 07/19/2016 02:2.

Pa.ge 1 

c .

ttii§!.§! 

OH BEHALF OF fFOIA 

... ' -, -· , -_ ,.:' • ' ' M' ", •, ·:- - 

Chief Obong was notified and precautionary actions were taken. This matter is closed. 
OIG0041 MCI SEARCM RESULTS (VIBW) DATE: 01/19/:1016 02:0

Page 1 

MCI NUMBER FISCAl YEAR DATE RECEIVE ClOSED DATE I!!b5 ST

C"

2010..02355-CR-()044 2010 

OFFICE A§SIGNED ACTION 

CR-Congreu.iona! Relations 

LEAD OIG POC NAME 

GROMEK, CATHERINE 

DAVID OBEY 

107...0THER OIJALITY OF CARE ISSUES 

WI 

WI 

04129r2010 PRESCRIPTION CHANGE 

FUNCTION CODE 

FOIA REOUES..!QB 

INTEREST 

ON BEHAlF Of <FOlA 

•••••• - aDeges that her husband received poof care. The Sectetary asked the OIG to 
orG00-41 MCI SEARCH RESULTS (VIEW) 

MCINUMBER DATERECEIVE CLOSEDDATE 

2010-02429-DC-0230 2010 04nt/2010 

, •••• TlTLE 

OSI04n010 VETERAN. MISSING MEDICATION 

OFFICE ASSIGNED ACTION 

OC-Centrnl F"ld Olf Referral {!NV !CHI) 

LEAD OIG POC NAME 

'NILSON, STEVEN L 

676-TOMAH 

66-THEFT OF GOVERNMENT FUNDS OR PROPERTY 

22-DIVE.RS!ON!SALE OF CONTROLLED PHARMACEUTICALS 

WI 

WI 

FUNCTION CODE 

FOIA REQUESTOR 

DATE: 01/19/2016 02:0

Page 1 

ST

Ck

INTEREST 

ON BEHALF OF (fOIA 

A referral was reOei'l;ed from VAMCTOOlah;-Wi$00nift1 alleging that an unknoWn indi\lldual stole a veteran's prescriptiOn medtcatlon betOii!-it arrived 

t'tis P.O. box_ Specifically, on 312912010 veteran nl to the VAMC polial department and reported that he d:id not receive his (vardenafil). -

advised that ttechedo:ed with the pharmacy and was told tru.t his medication was malted to his P.O. box on 311512010 and was on 

third or fourth package of Levitra he d:id not receive. tOld to rde a report with the Tomatt, WI Potic:e Department. 01'1313112010-ad:vi.sed that he filed a report w

the Tomah PoliCe Department regarding his missing medication 

This matter is dosed because it has been reported to local authorities. Office Carpenter was notifed of same. 
OIG0041 MCI SEA.llCH RESULTS (VI.Ini'} 

MCI NUMBER FISCAL YEAR DATE RECEIVE CLOSED DATE ~ 2010-.022<1B..OC~211 2010 0411912010 0910212010 M!SS!NGOX"fCOOO"'~ 

OFFICE ASSIGNED ACTION 

DC·Cenlra! Fld Oft' Refe!Tal {!NV/CHI} 

LEAD OIG POC NAME 

VASIL, RA VMOND P 

675-TOt.'AH 

22-DIVERSIOP-USALE OF CONTROLLED PHARJ.AA.CEUTICALS 

WI 

WI 

FUNCTION CODE 

FOIA REQUESTOR 

DATE: 07/19/201.6 02:4

Page 1. 

ST

c.

ON BEHALF Of ~ (FOIA 

A1> of 91212010 UPS security has not been able to discover a suspect for the missing drugs. This case is nO'N dosed pending UPS finding additional infonnation 

RV 91212010 
OIG0041 MCI SEARCH RESULTS {VIEW) DATE: 07/19/2016 02:2

MCI NUMBER FISCAL YEAR DATE RECEIVE 

2010 04J0712010 £WII2312010 

Tlll.E 

OFFICE ASSIGNED ACTlON 

OC-Centntl Fld 01'1 Referral (INV/CHl) 

LEAD OIG POC NAME 

HIRSTEIN, GREGG A 

676-TOMAH 

66-THEFT OF GOVERNMENT FUNDS OR PROPERTY 

22-DNERSIONISALE Of CONTROLLED PHARMACEUTICALS 

WI WI 

FUNCTION CODE 

FOIA REQUESTOR 

Page 1 

c.

INTEREST 

ON BEHALF OF fFOIA 

----

. ... on 411110 via a taxi cab for health caretrealment While therelliiil':'rfec. that 169 ofhi3180 vic

interviewmg_.,t tile VAMC, VAPO noticed Items in l'lis possession of obvious value, i.e collectable G2WUtc.. Tomah P 

in a 1\ome bUrglary. Tomah PO came to ll'le VAMC, items as evidence, and arrested 

was with-bUt he cannot pro..oe (although he alleges) tha- stole his meds. The __ _._ 
O:IG004:1 KC:I SEARCH RESULTS {V:IEW) DATE~ 07/19/2016 02;2

Page 2 
OJ:G0041 MCJ: SEARCH RESULTS (VIEW) DATE: 07/19/2016 02:2

Page 1 

DATE RECEIVE CLOSED DATE TITLE ST

2010 03/1512010 0311512010 

OfFICE ASSIGNED ACTION 

DC -Central Fie! Off tiNV/CHI) 

LEAD OIG POe NAME 

VASIL, RAYMON.O P 

676-TOMAH 

159-SEXUAL ASSAULT 

WI WI 

FUNCTION CODE 

FOIA REQUESTOR 

INTEREST 

ON BEHALF OF tFOIA 

to m

medQI staff and oo si r1S of assault :e w:.:: 

K.lanll:atM :att:!lrJo:s :.::i raam is across from the nurses' station and nur5eS interviewed advised that they did not see anyone enleriJI' roo
OI:G004l MCI: SEARCH RESULTS (VI:EW) DATE: 07/19/~016 0~:~

Page 2 
OIG0041 HCI SEARCH RESULTS (VIEW) 

MCINUMBER: DATERECEIVE CLOSEDDATE !!!.bS 

2010-00.568-tll--(1141 2010 1111612009 

OFFICE ASSIGNED ACTION 

Hl-Hot11ne 

LEAD OlG POC NAME 

SMfTHO 

676-TOMAH 

107-0THER QUALITY OF CARE ISSUES 

38-POOR COMMUNICATIONS WITH PATIENTIFAMILY 

107...0THER QUALITY OF CARE ISSUES 

107-0THER QUALITY OF CARE ISSUES 

107-0THER QUALITY OF CARE ISSUES 

107-0THER QUALITY OF CARE ISSUES 

107-0THER QUAUTY OF CARE ISSUES 107-0THER QUALITY OF CARE ISSUES 

WI 

0313012010 

FUNCTION CODE 

A01-INPAT!ENT MEDICAl CARE 

FOIA REQUESTOR 

DATE: 07/19/2016 02:5

Page 1 

STA

Oo

INTEREST 

ON BEi-IALF OF IFOIA 

A VHA review of patient's medical recordS f::.OOc:iUdfid he--iec::.elved a:ppiDpri3-teC3_ft! __ accofdTng to his the medical "Staff communicated with patient'$ 

famlty according to policy and procedures. 
OIG0041 MCl SEARCH RESULTS (VIEW) DATE: 07/19/2016 02:5

Page 2 

..... alleged that-'s health began to deteriorate aftet he was transferred 2007, to Unit 406A agatnst the family's wishes_ -alleged she 

presented to the patient advocate conceming the transfer and was advised that if she did not like tt, she could take him outside to another facllrty 

-alleged that whert they inquired about --·scare made tile statement \hat he is an old man, what do you want me to do. w 

-alleged that a request submitted by the family to-·s physician to continue his. therapy after he was transferred to Umt 406A was denied . 

•••• !leged that staff failed to catheter while he was be1ng treated with antibiotics for a bladder infection 

-alleged that on numerous occasions she had to make sure-was getting enough water, because staff would not provide him with any. 

:

;;::alleged that- a delay in stafl turning him or placing him lfl hts wheelchair in a timely manner causing t-um to dewtop bedsores. 

also alleged as a result of staff failing to lfeat-wit/1 antibiotics after he developed an infection, he coded and had to be transferred to GulldeBon Lutheran 

Hospital. 
OIG0041 MCI: SEARCH RESULTS {VIEW) 

MCI NUMBER FISCAL YEAR DATE RECEIVE 

2009-0373J...DC...03<41 2009 0912112009 1011312009 

OFFICE ASSIGNED ACTION 

DC-Central Fld Off Relemil (INVJCHQ 

LEAD OtG POC NAME 

JONES, JOHN B 

676-TOMAH 

159-SEXUAL ASSAULT 

WI WI 

FUNCTION CODE 

FOIA REQUESTOR 

' . 

DATE: 07/19/2016 02:4

Page 1 

""

INTEREST 

ON BEHALF OF fFOIA 

-as investigated by AlB dated for inappropriate behavior with a VA atient off ofVAMC grow :efriended 

r rsr;% .wok:ou: and and . .. 

mecltcal attention for The AlB D:Jneloded staff/patient boundaries and o . 12008-ngaged in a sexual assauh -··.v.u not fou

be entirely aechble or consistent in his mcounting of events and he eiCPressed elements of deception dunng testimony to the AlB. 
0IG0041 MCI SEARCH RESULTS (VIEW} DATE: 07/19/2016 02:4

Page 2 

• "' . . ... 

WS iriteN.E:W ai-h!S- tiOffieO- 009 and stated res,ned from the VAMC o the findings from the AlB released He employed 

dlea a sinulated on a 

stated that to blackmail him. The after the.Y both were drinking and had passed out- and made the 

---had ptJ1 hts pants. -stated that the-PD investigated and the ADA did not file any -stated that 11. was poss1ble tha

may have touched- but they wem both drunk. to mO'Ie on. 

This matter is clcsed as the allegation could not be substantiated 
OIG0041 MCI SEARCH RESULTS (VIEW) 

MCI NUMBER FISCAL 2009 YEAR DATE RECEIVE 08!2'112010 

OFFICE ASSIGNED ACTION 

IC-CEontral Fld ln'o'e!ilisation (CHI) 

LEAD OIG POC NAME 

PORTER. GREGORY 

676-TOMA.H 

42-Gl.JARDIANSH/PfFIDUCIARY FRAUD 

Z3-A.USA 

2009-03362-0C-D313· 

WI 

W1 

FUNCTION CODE 

FOIA REQUESTOR 

DATE: 07/19/2016 02:29 

Page 1 

ST

c .

INTEREST 

ON BEHALF Of lfOIA 

__ .. • • '.. , _ . , - • • r 
Æ 

OIG0041 loiCI SEARCH RESULTS (VIEW) DATE: 07/19/2016 02:2

Page 2 

::-$72,000 in VA has initiated 

On 08125109 •• was interviewed and she admitted to her father's funds for personal gain and gambling. She provided .a voluntary sworn written statement 

to the US. Attorney's Office the Western Dist.ric:l ofWIScansio, but was declined diJeto the f.act that veteran- has dted .and suspec

-has Inherited hiS estate. There IS no monetary loss to the VA