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VA official tells House he did not intentionally mislead on Pittsburgh Legionnaires' outbreak

| Thursday, June 12, 2014, 11:00 p.m.
Dr. Robert Jesse, principal deputy undersecretary at the Department of Veterans Affairs.
Dr. Robert Jesse, principal deputy undersecretary at the Department of Veterans Affairs.

A top Department of Veterans Affairs official testified that he did not intentionally mislead Congress about a possible cause of a deadly Legionnaires' disease outbreak in Pittsburgh.

Dr. Robert Jesse, the VA's acting undersecretary for health, said no one told him about an internal investigation that found lax maintenance, operation and testing of VA Pittsburgh's water disinfection system.

The investigation concluded in December 2012, two months before Jesse told the House Veterans Affairs Committee in a Feb. 5, 2013, hearing that the system was ineffective.

“I was not aware of that report at the time I made that testimony,” Jesse told the same committee on Thursday during a hearing about the VA's bureaucratic structure. He said that structure was, in part, to blame for his missing the report because “somewhere in the traveling of information,” the report never reached him.

Terry Gerigk Wolf, director of the VA Pittsburgh Healthcare System, learned in November 2012 that a hospital plumbing system shut down when workers tried to super-heat water to kill Legionella, the bacteria that cause Legionnaires', a Tribune-Review investigation revealed last month.

Yet Jesse did not mention that revelation in his congressional testimony in February 2013, when he instead told lawmakers that the Pittsburgh VA had raised temperatures to a sufficient level.

His former boss, Dr. Robert Petzel, ordered the internal investigation that spotted other mistakes connected to the outbreak, according to emails the Trib obtained through a Freedom of Information Act request.

Petzel, under increasing scrutiny from Congress over problems with the VA health care system, retired as undersecretary for health on May 16.

Lisa Thomas, the Veterans Health Administration chief of staff, sent a summary of the investigation's findings by email to Petzel and top aides of former VA Secretary Eric Shinseki at 7:25 p.m. Dec. 10, 2012. Jesse was not on the list of recipients.

The House VA committee's chairman, Rep. Jeff Miller, R-Fla., pressed Jesse on whether he disciplined the person who prepared his testimony before Congress since the information was incorrect.

Jesse said he did not know whether that person knew about the report, either.

“There was no intention to mislead. I assure you of that,” Jesse told Miller.

After the hearing, Miller said in a statement: “Clearly, someone within VA tried to hide the fact that an internal VA investigation completed in December of 2012 found that human error — not faulty equipment — led to the VA Pittsburgh Healthcare System Legionnaires' disease outbreak. Therefore, VA needs to explain why Jesse's testimony omitted this crucial fact, who is responsible and how they will be held accountable. We will keep pursuing this matter until we have received answers to these questions.”

Petzel sent a team of investigators to the VA Pittsburgh shortly after the agency disclosed the outbreak publicly on Nov. 16, 2012. The Centers for Disease Control and Prevention identified February 2011 as the likely beginning of the outbreak, during which at least six veterans died and 16 became ill with the lethal form of pneumonia.

A series of Trib stories has shown the presence of elevated levels of Legionella dating to at least 2007, but the CDC declined an offer from the newspaper to review water testing records the Trib obtained.

Investigators discovered workers in Pittsburgh failed to properly maintain the copper-silver ionization system, allowing ion levels to fall too low or spike too high. They said poor education and record-keeping likely contributed to the problems, according to emailed summaries of the report.

Jesse said, “It bothers the heck out me” that he did not see the report, and he defended his testimony to the committee. He noted that the CDC found Legionella growing in water that had adequate levels of copper and silver ions.

“The testimony is true. It's not complete, but it is true,” Jesse said.

Miller's statement after the hearing reflected his exasperation over the discrepancies in the VA's accounts of what happened.

“Today's VA is a case study in how to stonewall the press, the public and Congress,” Miller stated. “Dr. Jesse's answers today — or lack thereof — regarding misleading testimony he provided to our committee in February of 2013 did nothing to dispel this notion.”

Mike Wereschagin and Adam Smeltz are staff writers for Trib Total Media. Wereschagin can be reached at 412-320-7900 or mwereschagin@tribweb.com. Smeltz can be reached at 412-380-5676 or asmeltz@tribweb.com.

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