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Top administrator says VA Pittsburgh officials could face discipline over Legionnaires' outbreak

| Monday, Sept. 9, 2013, 11:06 a.m.
Michael E. Moreland is a former Department of Veterans Affairs regional administrator.
Jasmine Goldband | Tribune-Review
Michael E. Moreland is a former Department of Veterans Affairs regional administrator.
Maureen Ciarolla of Monroeville testifies at a field hearing with the House Committee on Veterans’ Affairs at the Allegheny County Courthouse, Downtown Monday.  Ciarolla's father, John J. Ciarolla, died during the Legionnaires' outbreak in the VA Pittsburgh Healthcare System.
Jasmine Goldband | Tribune-Review
Maureen Ciarolla of Monroeville testifies at a field hearing with the House Committee on Veterans’ Affairs at the Allegheny County Courthouse, Downtown Monday. Ciarolla's father, John J. Ciarolla, died during the Legionnaires' outbreak in the VA Pittsburgh Healthcare System.
U.S. Department of Veterans Affairs Under Secretary for Health Robert Petzel and U.S. Department of Veterans Affairs Network Director Michael Moreland answer questions during a field hearing with the House Committee on Veterans’ Affairs on Sept. 9, 2013 at the Allegheny County Courthouse, Downtown.
Jasmine Goldband | Tribune-Review
U.S. Department of Veterans Affairs Under Secretary for Health Robert Petzel and U.S. Department of Veterans Affairs Network Director Michael Moreland answer questions during a field hearing with the House Committee on Veterans’ Affairs on Sept. 9, 2013 at the Allegheny County Courthouse, Downtown.
Family members of veterans who died during the Legionnaires' outbreak in the VA Pittsburgh Healthcare System. outbreak Maureen Ciarolla of Monroeville (left) Evelyn McChesney of Columbus, Warren County and Judy Nicklas of Butler react to testimony as U.S. Department of Veterans Affairs Under Secretary for Health Robert Petzel and U.S. Department of Veterans Affairs Network Director Michael Moreland answer questions at a field hearing with the House Committee on Veterans’ Affairs at the Allegheny County Courthouse, Downtown Monday.
Jasmine Goldband | Tribune-Review
Family members of veterans who died during the Legionnaires' outbreak in the VA Pittsburgh Healthcare System. outbreak Maureen Ciarolla of Monroeville (left) Evelyn McChesney of Columbus, Warren County and Judy Nicklas of Butler react to testimony as U.S. Department of Veterans Affairs Under Secretary for Health Robert Petzel and U.S. Department of Veterans Affairs Network Director Michael Moreland answer questions at a field hearing with the House Committee on Veterans’ Affairs at the Allegheny County Courthouse, Downtown Monday.
U.S. Department of Veterans Affairs Medical Center executives raise their hands acknowledging bonuses awarded to them during a field hearing with the House Committee on Veterans’ Affairs at the Allegheny County Courthouse, Downtown Monday.
Jasmine Goldband | Tribune-Review
U.S. Department of Veterans Affairs Medical Center executives raise their hands acknowledging bonuses awarded to them during a field hearing with the House Committee on Veterans’ Affairs at the Allegheny County Courthouse, Downtown Monday.

Pittsburgh VA Healthcare System employees could be disciplined over a fatal outbreak of Legionnaires' disease once federal investigators finish a criminal review, a top health administrator in the Department of Veterans Affairs testified on Monday.

But Veterans Affairs Under Secretary Robert Petzel said he would not direct regional director Michael Moreland to return a $63,000 career award announced soon after the outbreak was revealed, stunning lawmakers and families attending a fiery three-hour congressional hearing in the Allegheny County Courthouse.

“Why don't you just slap every veteran in the face? That was outrageous,” Maureen Ciarolla of Monroeville said to the Tribune-Review after testifying at the hearing. Her father, World War II veteran John J. Ciarolla, died during the Legionnaires' outbreak.

During the hearing, Petzel cited “a lifetime of service to America's veterans” in defending Moreland's Presidential Distinguished Rank Award. He said he would have recommended Moreland for the honor despite the five outbreak-linked fatalities found in the VA Pittsburgh Healthcare System.

That wasn't enough to sway lawmakers, who said they left the hearing largely dissatisfied with the VA's answers and vowed to maintain pressure on the department for transparency, accountability and safer medical care.

“The VA let these families down, then took their tax dollars and gave it to those who were in leadership positions when tragedies occurred,” said Rep. Tim Murphy, R-Upper St. Clair. “It's unconscionable, and I hope we'll see a change in culture at the VA so we can begin to rebuild the trust that men and women who wear the uniform have in the VA.”

The session, held by the House Committee on Veterans' Affairs, marked the second congressional hearing on the Legionnaires' outbreak, which began in February 2011 but was not disclosed by the Pittsburgh VA until November 2012. Contaminated water on the VA's Oakland and O'Hara campuses sickened as many as 21 veterans in 2011 and 2012, according to the Centers for Disease Control and Prevention.

A Tribune-Review investigation, however, found evidence of Legionella bacteria contamination in the Pittsburgh VA water system as far back as 2007.

Witnesses at the hearing in February described several probable factors behind the outbreak, such as poor maintenance of water treatment systems meant to prevent the Legionella that cause the disease. Independent federal reviews turned up other key shortcomings, including a failure to test all potential Legionnaires' patients for the ailment.

Those revelations — coupled with five-figure performance bonuses given to Moreland and Terry Gerigk Wolf, the Pittsburgh VA's chief executive — enraged legislators and families of the victims. Their frustration boiled over on Monday, when Pittsburgh VA administrators shared the spotlight with administrators and witnesses over bonuses and care failures at VA systems in Buffalo; Atlanta; Dallas; and Jackson, Miss.

Petzel insisted the problems at these VA systems — including patient suicides and medical misdiagnoses — did not illustrate systemwide troubles as some implied. Rather, he said, limited failures drive the VA to amend policies and procedures to improve the quality of care.

“While no health care system can be made entirely free from inherent risks, when adverse incidents do occur, VA studies them to fully understand what has happened” and to prevent repeat episodes, Petzel said. “In this way, VA designs patient safety systems that reduce the likelihood of errors and lessen the potential harm to patients.”

But committee Chairman Jeff Miller, R-Fla., said the focus on safety systems can neglect a more important concern: people.

“My statement would be that systems are only as good as the people who administer them,” Miller said.

Moreland, who oversees most of Pennsylvania, all of Delaware and parts of four other states from his Pittsburgh regional VA office, said he felt “personally bad” for families of the Legionnaires' victims, saying he is focused on preventing recurrences. Though he said he was proud to receive the presidential award, he acknowledged, “The timing of it was very bad.”

Moreland and Petzel said any formal consequences for responsible parties in the Pittsburgh VA must wait until the VA Office of Inspector General in Washington finishes a criminal review. Petzel said he wasn't sure when that might be complete, though a spokeswoman for Inspector General George Opfer said the investigation was continuing under the direction of the U.S. Attorney's Office for Western Pennsylvania in Pittsburgh.

Rep. Mike Doyle, D-Forest Hills, told families of Legionnaires' victims that Congress will not give up, saying the outbreak “breaks our heart, and it makes our blood boil.”

Some relatives remained skeptical they would ever get full disclosure from the VA, including David Nicklas of Hampton, whose father, William Nicklas, died in the outbreak. But his sister-in-law, Judy Nicklas of Adams, said the families will stick it out.

“I don't think anyone's going away until the answers are out,” she said. “You can run and hide for only so long. We have nothing but time on our hands.”

Adam Smeltz is a staff writer for Trib Total Media. He can be reached at 412-380-5676 or asmeltz@tribweb.com.

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