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Families, lawmakers target Pittsburgh VA leaders after critical Legionnaire's report

| Tuesday, April 23, 2013, 11:30 a.m.
Chlorine treatments meant to stop dangerous bacteria that can lead to Legionnaires’ disease are eating away metal pipes across the Veterans Affairs Pittsburgh Healthcare’s plumbing system, threatening long-term damage that could cost millions to correct, an independent evaluation shows.

Outraged families joined lawmakers Tuesday to demand consequences for Pittsburgh VA officials who a new report shows should have done more to prevent a deadly Legionnaires' disease outbreak.

The report released Tuesday by the Veterans Affairs' Office of Inspector General identifies wholesale failures in the Pittsburgh VA Healthcare System to monitor for the disease and the Legionella bacteria that cause it. The disease affected 21 people. Five of them died.

But the 32-page document stops short of assigning blame to specific officials or staff for the outbreak at VA campuses in Oakland (University Drive) and O'Hara (Heinz).

Terry Gerigk Wolf, director and CEO of the Pittsburgh VA Healthcare System, accepted responsibility for the failures in the report during an interview with the Tribune-Review. Wolf said she has not been asked to resign but added that anything could happen.

“Obviously, no one was doing their job,” said Robert Nicklas of Adams, whose 87-year-old father and Navy veteran, William Nicklas, was one of the deaths linked to the outbreak. Robert Nicklas' wife, Judy, added: “It's not the water system at the VA Pittsburgh that needs an overhaul. It's the administration.”

Maureen Ciarolla of Monroeville, whose father, John, 83, also a Navy veteran, was among the five deaths, said people are put on trial and go to jail “for a lot less than what these people did.” She said the new report raises as many questions as it answers.

The Ciarolla and Nicklas families have initiated civil claims against the Pittsburgh VA.

The Legionnaires' outbreak went on from February 2011 to November 2012, when the outbreak became public because the Pittsburgh VA contacted the federal Centers for Disease Control and Prevention. The new report capped a separate investigation by the VA inspector general in Washington that revealed critical communications failures and chronic poor maintenance of an in-house water treatment system meant to prevent the Legionella bacteria, which can cause a deadly form of pneumonia.

Part of the prevention system did not work and was taken out of service in the midst of the outbreak, the reviewers wrote. Pittsburgh VA failed to perform routine flushing of hot water faucets and showers, especially in areas where Legionella might grow. Medical staff also did not ensure adequate testing for Legionella in patients who probably developed pneumonia inside the hospital system, according to the report.

Pittsburgh VA officials said they have begun improving practices to meet and surpass recommendations in the document, announcing what they called “a new era of Legionella control.”

Doctors now look for Legion-ella in every pneumonia patient who might have contracted the disease in the hospital, a toughened standard that officials adopted in November but should have become routine sooner, Dr. Ali Sonel told the Tribune-Review during a briefing Tuesday offered in response to the report.

“In hindsight, yes, there would've been some things we would have done differently,” said Sonel, the Pittsburgh VA's chief of staff. “Can we guarantee that we never have Legionnaires' in any patient? I don't think so.”

Sonel and Wolf, the Pittsburgh VA chief executive, said the Pittsburgh VA now goes beyond national VA standards to sample water for Legionella. Administrators last month announced a $10 million plan to raise water temperatures and better prevent the bacteria in their pipes.

Regional VA Director Michael Moreland, who oversees VA hospitals in Pennsylvania and several other states, said previously he knows of no attempted cover-ups. He was not present Tuesday to answer questions after the report was released.

“We have nothing to hide,” Wolf said during the interview at the H.J. Heinz campus in O'Hara.

Lawmakers told the Trib they weren't satisfied .

“I can't imagine you can have the same people there, with the same culture of bypassing standards, still in charge and expect the system to change,” said U.S. Rep. Tim Murphy, R-Upper St. Clair, one of the lawmakers who sought the inspector general's review.

The inspector general's reviewers pored through documents, interviewed VA workers and conducted on-site visits for their report, which was intended to guide future policy and practices in the national VA system.

Wolf said Pittsburgh VA officials took issue with how some information appears in the report, which cites lapses in documentation about water-system monitoring.

VA plumbers had telephone conversations with a system manufacturer that were not recorded, but that doesn't mean workers failed to address the problem, Wolf said. She said she alerted the CDC herself.

“When I find something wrong, I take action,” Wolf said.

A separate congressional inquiry is under way into the outbreak. David J. Hickton, the U.S. attorney for Western Pennsylvania, promised his office would conduct an independent legal review once the inspector general's office report was out. He declined to discuss the report's findings, spokeswoman Margaret Philbin said.

Staff writers Mike Wereschagin and Lou Kilzer contributed to this report.

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