Congressman Sestak Renews Push For Legislation To Make VA Inspection Reports Accessible

Press Release

In light of a recently-revealed inspection detailing problems at the Philadelphia Veterans Affairs Medical Center (PVAMC) thoracic surgery unit, Congressman Joe Sestak (PA-07) urged VA Secretary Eric Shinseki (see letter below) to support legislation the Congressman introduced to ensure full transparency and accountability for the care provided at Veterans facilities. A 2007 report from the VA's Office of the Medical Inspector (OMI) that reflects a gross lack of accountability in the unit was only brought to Congressman Sestak's attention in the past week because of a Freedom of Information Act (FOIA) request filed by the Pittsburgh Tribune-Review.

The report --conducted during the same period PVAMC patients were receiving substandard prostate cancer treatment and while senior Veterans were frustrated by care in the Community Living Center (CLC) -- documents poor morale and inadequate qualifications of the staff, as well as one instance when a patient was found to be "cold" in a toilet "because he had been dead so long." In his letter to Secretary Shinseki, the Congressman indicates the need for urgent action to change the way the VA handles inspections and points to the need to enact his "Transparency for Americas Heroes Act," which stipulates that inspection records must be easily accessible and placed on the Department's website.

"We have a reporter at the Philadelphia Inquirer who brought to light the problems associated with the prostate cancer treatments. The Philadelphia Daily News and Pittsburgh Tribune-Review broke the story of conditions in the CLC. Now, again, it required a reporter from the Pittsburgh Tribune-Review and a FOIA request to alert the public to another instance of substandard care for our Veterans. Also, were it not for a report by the American Legion, we would not know of administrative problems that resulted in a multi-million dollar billing error with an insurance company. I had specifically told (VA) Chief of Staff Gingrich and (PVAMC) Director Citron that failure to identify any other reports reflecting poorly on the VA would represent a breach of trust and faith with our Veterans, their families and the American public. I am deeply disappointed that not once in my many visits to PVAMC was this inspection mentioned."

"I have introduced legislation (H.R. 3843) to improve the transparency and accountability of the VA Medical System. As one of our nation's most distinguished Veterans, I ask for your full cooperation and support of that legislation," wrote the Congressman to Secretary Shinseki.

In September, Congressman Sestak had visited the Philadelphia VA CLC after a Freedom of Information Act Request had brought to light a report detailing past failures, documented in a previously unrevealed Long Term Care Institute report, to provide a sanitary and safe environment for residents.

"The problems with the thoracic unit reemphasize the requirement for a transparent inspection process of all VA Medical Centers and that will be a focal point of my upcoming meeting with the VA Under-Secretary for Health," said Congressman Sestak, who will be meeting with the Under-Secretary as a result of a long-running dialogue between Congressman Sestak and VA Secretary Eric Shinseki in the aftermath of a series of revelations of poor conditions at VA facilities. "It is important to consider that previous press reports brought to our attention the fact that our Veterans received substandard care for their prostate cancer over the period of 2002-08. This latest report paints a stark picture of problems with thoracic surgery patients in June 2007. That those two programs were simultaneously sub-standard is more than another wake up call --- it is indication that the equivalent of a two alarm fire was raging without the appropriate knowledge of Veterans Service Organizations, Congress or even the VA.

To make matters worse, because representatives of respiratory therapy, physical therapy, and social work services "were not available for interviews" with the Office of the Medical Inspector (OMI) team, we have no idea if there were problems in that area that went unreported.

"We must see this report on the thoracic surgery program in the broader context of the shortcomings in the support our Veterans have received for many years," said Congressman Sestak. "I understand that until 2007, the VA had been grossly under-funded for decades and that for too long VA employees were asked to do too much with too little. I noted in the report the awards the Philadelphia VAMC has received for Parkinson's Research, Mental Illness Research and other important research projects. However, I am especially frustrated by shortcomings in what should be every VAMC's core competency -- patient care.

"Now that we are working to provide the necessary resources to the VA medical system, Americans should expect accountability for how that increased funding is used to improve treatments. Unless there is an open and verifiable system of inspecting VA Medical Centers, Community Living Centers, and Community Based Outpatient Clinics, I am not confident that we will be able to justify the increased investments in VA medical care that I and many Veterans believe are essential."

The following is the full text of Congressman Sestak's letter to VA Secretary Eric Shinseki:

Dear General Shinseki,

Attached is a December, 2007 report by the VA Office of Medical Inspection (OMI) describing unsatisfactory conditions at the Philadelphia VA Medical Center (PVAMC).

I am certain that as you review it you will come to the same conclusions I have;

That there was unsatisfactory care for thoracic surgery patients (2006-2007) at the PVAMC at the same time there was unsatisfactory care for prostate cancer patients (2002-2008).

That while those two conditions were compromising the care of Veterans, OMI requested meetings with respiratory therapy, physical therapy, and social work services, and they were "unavailable" for those meetings. It is inexplicable that employees of the VA can choose not to participate in interviews with OMI.

That the notion of a patient found dead in a toilet and "cold" because of the length of time he was undiscovered is beyond outrageous.

That, once again, it required a FOIA request to bring this condition to light.

I took full notice of the positive comments in this report regarding the many award winning research projects underway at PVAMC. However, the standards of patient care identified in this report were unacceptably low. I had specifically told Chief of Staff Gingrich and Director Citron that failure to identify any other reports reflecting poorly on the VA, would represent a breach of trust and faith with our Veterans, their families and the American public. I am deeply disappointed that not once in my many visits to PVAMC was this inspection mentioned.

I have introduced legislation (H.R. 3843) to improve the transparency and accountability of the VA Medical System. As one of our nation's most distinguished Veterans, I ask for your full cooperation and support of that legislation.

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