Pittsburgh VA executives got performance bonuses amidst deadly Legionnaires' spread
By Luis Fábregas and Adam Smeltz
Published: Wednesday, April 24, 2013, 11:06 p.m.
The director of the VA Pittsburgh Healthcare System and the regional director who oversees her each received five-figure performance bonuses for fiscal 2011 while a deadly outbreak of Legionnaires' disease spread through the Oakland and O'Hara hospitals, the Tribune-Review has learned.
Terry Gerigk Wolf, director and CEO of the Pittsburgh VA system, received a $12,924 bonus, records obtained by the Trib show. Michael Moreland, the director of the so-called VISN4 region that includes most of Pennsylvania and all or parts of four other states, received a $15,619 bonus. Both bonuses were awarded for the fiscal year that ended Sept. 30, 2011, when both executives received a base pay of $179,700.
The Legionnaires' disease outbreak, which sickened as many as 21 patients and was linked to five deaths, lasted from February 2011 to November 2012, according to the federal Centers for Disease Control and Prevention. A report by the Veterans Affairs' Office of the Inspector General on Tuesday found widespread management problems contributed to failures in detecting and managing the outbreak.
“Unfortunately, this looks like more proof of VA's well-documented reluctance to hold employees and managers accountable. VA owes us all — especially the families of those who died — an explanation as to why the department awarded these bonuses,” said Rep. Jeff Miller, a Florida Republican and chairman of the House Committee on Veterans' Affairs.
Requests to interview Wolf and Moreland on Wednesday about the bonuses, made through local and national VA spokesmen, went without response.
Asked about the rationale for the bonuses, Mark Ballesteros, a national VA spokesman, sent a two-paragraph statement underscoring the VA's commitment “to providing the safe, high-quality care our veterans have earned and deserve.” The statement did not address the bonuses.
“(The bonuses are) consistent with the systemic problem that they have, which is that it's full speed ahead,” said John Zervanos, a Philadelphia-based attorney representing the family of Navy veteran John Ciarolla, 83, of North Versailles. Ciarolla's death in July 2011 was linked to the Legionnaires' outbreak.
‘Not minding the store'
“They assume everyone is doing the job they're supposed to be doing when people in administrative roles are not minding the store,” Zervanos said. “Yet somehow they're getting performance bonuses when clearly they're not doing what they're supposed to be doing.”
Moreland “doesn't deserve his paycheck, let alone a bonus,” added Ciarolla's daughter, Maureen of Monroeville. “As far as I'm concerned, these people aren't competent to run a hospital of sick people.”
The VA inspector general report found that even though VA hospitals in Oakland and O'Hara were equipped to battle the deadly Legionella bacteria, officials failed to take steps to prevent it. The report did not find fault with a copper-silver ionization water treatment method used to treat and prevent Legionella that has since been halted by VA officials.
Instead, the findings revealed the system was poorly maintained, workers failed to conduct routine flushing of hot water faucets and showers and doctors did not test all patients with hospital-acquired pneumonia for Legionnaires' disease.
The report does not name or assign blame to any specific VA official or staff member. Wolf told the Trib in an interview that she was ultimately responsible. She said she called the CDC when VA officials suspected there was a problem.
VA Pittsburgh officials notified the public of the outbreak on Nov. 16, more than a year after the end of the fiscal year for which the bonuses were issued.
“I didn't sit around and put my feet up on the desk and say, ‘We'll figure it out eventually,' ” Wolf said. “I don't mess around. When I find something wrong, I take action.”
New committee created
An action plan crafted by the VA in response to inspector general recommendations included the creation of a water safety committee which held its first meeting Jan. 31. It will look at all aspects of Legionella control, such as water testing and remediation, and issues with water quality.
Lovetta Ford, an associate director who was in charge of facilities management at the VA Pittsburgh hospitals during most of the outbreak, is chairwoman of the committee, said Dave Cowgill, a Pittsburgh VA spokesman.
Ford, named to her post in April 2011, has a background in social work and lacks the engineering and science background of colleagues in similar positions in other VA hospitals, a Trib investigation previously reported. In addition to degrees in social work, Ford earned a post-master's certification in marital and family therapy from the University of Pittsburgh.
Cowgill said Ford was unavailable for an interview. She was not among VA officials who met with the Trib on Tuesday or in March.
At this week's meeting, VA chief of staff Ali Sonel said officials waited two weeks to tell the public about the outbreak because the infection-control workers thought the Legionella bacteria was limited to a part of the Oakland hospital different from where patients with Legionnaires' had been identified.
“The (infection-control) team was concerned,” Dr. Sonel said. “They kept not being satisfied. They went further and did genetic linkage.”
VA Pittsburgh officials in March introduced a nearly $11 million plan to address water temperature concerns and map the entire plumbing systems at its facilities. The plan calls for installation of mixing valves on all showerheads and faucets to allow high temperatures that can kill Legionella, then cool down the water before it leaves the faucet. The project should be completed by Aug. 31.
A separate contract to map out the plumbing systems has been awarded to Columbus-based Juice Technologies LLC for $668,565, Cowgill said.
Staff writer Mike Wereschagin contributed to this report. Luis Fábregas and Adam Smeltz are staff writersfor Trib Total Media. Fábregas can be reached at 412-320-7998 or firstname.lastname@example.org. Smeltz can be reached at 412-380-5676 or email@example.com.
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