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Second report critical of VA Pittsburgh

| Saturday, May 4, 2013, 12:24 a.m.

VA Pittsburgh workers failed to document any infection surveillance activities near two hospital construction projects and transported post-operative patients in “a dirty freight elevator,” according to findings in a second critical review from the Veterans Affairs' Office of Inspector General in as many weeks.

Between the two reports, VA regional director Michael Moreland, who oversees VA health care facilities in most of Pennsylvania and all or parts of five surrounding states from his Pittsburgh office, received the White House-approved Presidential Distinguished Rank Award at a gala in Washington.

The recognition included a nearly $63,000 bonus, in part for his infection prevention policies, according to a document touting the recipients' accomplishments. Both IG reports highlighted critical failures in those policies.

“It's a sad irony to have received an award for this,” said Rep. Tim Murphy, R-Upper St. Clair. He and Rep. Keith Rothfus, R-Edgeworth, sent a letter to VA Secretary Eric Shinseki on Friday asking him to rescind Moreland's bonus.

Area congressmen and the chair of the House Veterans Affairs Committee have asked VA officials in Washington to review Moreland's nomination for the award and “will take any appropriate action when that review is complete,” national VA spokesman Mark Ballesteros said. He did not answer a request from the Tribune-Review to interview Moreland directly.

In a statement sent to the Western Pennsylvania congressional delegation, VA congressional liaison Aakash Bhatt said the department is deferring 2012 performance awards for some VA senior executives in Pennsylvania. Ballesteros said the VA Pittsburgh system is included in the deferrals but did not give names.

“It's clear to me that somebody's got to go in there and just clean house on this VA,” said Maureen Ciarolla of Monroeville, whose father, John Ciarolla, 83, died during the Legionnaires' outbreak.

The second Inspector General's Office of Healthcare Inspections report, released Thursday, said “post-operative patients were transported from the operating room to patient room floors using a dirty freight elevator” in a Pittsburgh VA facility.

That same report criticized infection control practices at the University Drive campus in Oakland, saying minutes of an internal committee had “no documentation of infection surveillance activities related to” protection from two construction projects.

VA leaders had prior warning for the on-site inspections spotlighted in the report, said Joanne Moffett, a spokeswoman for the VA Office of Inspector General in Washington. She characterized the latest report as a routine review faced by VA facilities nationwide. Pittsburgh VA spokesman David Cowgill did not answer Trib questions on Friday about the report.

Moreland concurred with the inspector general's review findings on March 19, according to a statement added to the end of the report. A reason given for Moreland's national performance bonus was his creation of a liver and kidney transplant program. That program should have prompted stricter Legionella testing, according to VA guidelines — something the first IG report said the Pittsburgh system failed to do.

VA Pittsburgh CEO Terry Wolf, in her written response to the IG review, said that as of March 1, “all post-operative patients are transported using the bed tower elevators. These elevators are only used for patient and/or staff transport.”

As for the lack of infection surveillance at two construction sites, Wolf said that “construction has been added as a standing item for every agenda” of the Infection Control Committee. “Deficiencies are noted during rounds (and) immediate corrective actions taken to correct deficiencies are discussed and recorded in the minutes,” she said.

Moreland and VA Pittsburgh administrators have been under fire since November, when they first disclosed a deadly, two-year-long Legionnaires' disease outbreak at the Oakland and O'Hara hospitals. The outbreak sickened as many as 21 veterans, five of whom died.

Moreland and Wolf received a separate set of performance bonuses in the middle of the outbreak, the Tribune-Review reported on April 25.

In their letter to Shinseki, Murphy and Rothfus called Moreland's bonus “tremendously insensitive and offensive to these victims. Indeed, as taxpayers, it is their money you are directing to Mr. Moreland.”

The congressmen asked Shinseki to meet with the families of veterans who died during the outbreak and to turn over the nomination paperwork that won Moreland his bonus.

Moreland oversees regional Veterans Integrated Service Network 4. Before that, he ran the VA Pittsburgh, where he oversaw the closing of the Specials Pathogens Laboratory, an internationally recognized Legionnaires' research facility. That 2006 decision prompted a congressional hearing in 2008. The Legionnaires' outbreak caused Congress to summon Moreland again for a hearing Feb. 5.

IG investigators who produced Thursday's report were at the VA Pittsburgh during the week of Oct. 29, the week that the Centers for Disease Control and Prevention alerted administrators that Legionella bacteria in their water system matched the bacteria found in two patients.

The IG's criminal investigation continues into VA Pittsburgh Legionnaires' outbreak and top officials' responses to it.

Mike Wereschagin and Adam Smeltz are staff writers for Trib Total Media. Reach Wereschagin at 412-320-7900 or Reach Smeltz at 412-380-5676 or

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