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VA water systems violate Pa. law, state and federal documents show

| Thursday, June 4, 2015, 10:51 p.m.

Water treatment systems installed at Pittsburgh Veterans Affairs hospitals in the aftermath of a fatal Legionnaires' disease outbreak violate state law and the VA's guidelines, state and federal documents obtained by the Tribune-Review reveal.

The Pennsylvania Department of Environmental Protection warned the VA in October that it needed state permits to operate the chlorination systems used to kill bacteria in the Oakland and O'Hara campuses' water pipes. More than seven months later, despite efforts by a former employee, VA officials hadn't applied for the permits required by state law and VA guidelines, according to a DEP letter sent May 27.

When the letter arrived, “we moved quickly to begin the application process for the permits in question,” said VA spokesman Michael Marcus. He said the VA “is appreciative of DEP's notice of deficiency in our water system permitting” and that officials would meet next week “to begin the permitted process.”

A former VA engineer told the Trib he urged officials to get the permits months ago.

“They should have obtained the permits the day they began feeding chlorine and definitely not 2 12 years later,” said Michael Debich, a former quality assurance engineer for the VA Pittsburgh Healthcare System.

The letter from Kay Frederick, operations section chief for the DEP's Safe Drinking Water program, told VA leaders the hospital water systems “were operating in violation” of state law, and that they needed to hire an engineer and apply for permits.

The letter was sent to Debich, who had left VA about two months earlier.

“As of the date of this letter, the department has not been contacted by you or any VA representative,” Frederick wrote. She left open the possibility of enforcement action or civil penalties and gave the VA 10 days to propose corrections.

DEP spokesman John Poister declined to speculate about any potential fines, but he said the department believes patients are safe. DEP officials are allowing the chlorinators to operate while the VA pursues permits, which are required to help ensure the integrity of large-scale drinking water systems.

“We felt it would be placing patient safety in more jeopardy if we told them to disconnect the system than if we allowed them to continue running it,” Poister said.

VA Pittsburgh installed chlorinators when Centers for Disease Control and Prevention investigators traced a Legionnaires' outbreak to bacteria in the hospitals' water systems. At least six deaths and 16 illnesses were tied to the outbreak, which the CDC said lasted from February 2011 to November 2012.

An award-winning Tribune-Review investigation found Legionella in the VA University Drive system as far back as 2007, suggesting the outbreak likely lasted longer and sickened more veterans than the CDC determined.

In response to the outbreak, VA headquarters in Washington issued national guidelines for Legionella prevention in its hospitals. Waterborne Legionella bacteria can cause a severe and potentially deadly form of pneumonia.

“Installed systems must be specifically approved or recognized for the intended use by the state regulatory water authority,” reads the VA's Aug. 13 national directive.

The VA Pittsburgh installed the chlorination systems in 2013, but the new approach proved problematic even before the DEP's latest warning.

An analysis by Cyrus Rice Water Consultants in Coraopolis revealed the chlorine is eating away at hospital pipes, which could lead to millions of dollars in maintenance costs.

The analysis found VA workers sometimes exceeded chlorine limits set by the Environmental Protection Agency, at least once allowing concentrations of 5 milligrams of chlorine per liter of water — 20 percent higher than federal rules for drinking water allow.

The DEP advised health providers in May 2014 that it would require permits for some water disinfection systems in larger buildings, said Ed Dudek, an assistant vice president at UPMC Presbyterian in Oakland. He said the UPMC hospital system sought permits for at least five Pittsburgh hospitals.

Debich, 48, now a Navy engineer on an island in the Indian Ocean, said he left the VA out of frustration. He said the DEP could have helped the VA if the department had involved state water safety experts faster.

Federal investigators linked mismanagement to failures of the copper-silver disinfection systems the VA hospitals had.

But Marcus defended management of the water system.

“At no time has VA Pittsburgh leadership delayed or prohibited employees from pursuing the necessary permits for or improvements to our water system,” Marcus said, noting that VA leaders meet daily with workers who run the hospitals' water systems.

The VA tests more than 400 water samples each week and hasn't had a case of hospital-acquired Legionnaires' disease since late 2012, Marcus said.

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

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