TAMMY BALDWIN COMMITTEES: WISCONSIN HEALTH, EDUCATION, LABOR, AND PENSIONS ?t-lnittd ,%tatts 5mm SPECIAL COMMITTEE WASHINGTON, DC 20510 0N AGING COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS Apri17=2014 narcissist; Mr. Mario Desanetis Director, Tomah VA Medical Center 500 East Veterans Street Tomah, Wisconsin 54660 Dear Mr. Desanetis: I am writing on behall?of my constituent, who would like to remain anonymous, regarding concerns with treatment at the Tomah VA. 1 would appreciate your full review and investigation of the following concerns expressed by my constituent: - A large percentage of veterans being treated for substance abuse are for substances including opiates. benzodiazepines and stimulants which were originally prescribed by VA providers. These same veterans continue to be prescribed these substances of abuse while in active treatment. 0 There are a high number ol?instanees in which controlled substances are used prior to alternative interventions lirst being trialed. 0 National guidelines for the treatment of PTSD indicate that veterans in active PTSD treatment should not be prescribed benzodiazepines for the best possible treatment outcome. l-lowever. this is standard practice at the Tomah VA and employees are pressured by management to prescribe substances that are contraindicated by VA National Guidelines. The Of?ce ol?Mental Health has a beginning awareness of the Tomah VA prescribing practices however the process is moving too slow and veterans continue to be hurt waiting for government intervention. Please inform my office of your findings and forward all correspondence to the attention of Mike Helbick in my Milwaukee Senate office at 633 W. Wisconsin Ave. Suite 1920, Milwaukee, WI 53203, or via telephone at 414-297-4451. Thank you for your time and prompt attention to this matter. Sincerely. b7 Tammy Baldwin United States Senator TB :mh DEPARTMENT OF VETERANS AFFAIRS VA Great Lakes Health Care System 500 E. Veterans Street Tomah, WI 54660 May 1, 2014 The Honorable Tammy Baldwin Member, United States Senate Suite 1920 633 W. Wisconsin Avenue Milwaukee, WI 53203 Dear Senator Baldwin: Thank you for allowing us the opportunity to respond to the concerns outlined in your letter, dated April 7, 2014, on behalf of an anonymous constituent concerning his allegations about general prescribing patterns at Tomah Veterans Affairs Medical Center (VAMC). Your letter was fon/varded to Dr. David Skripka, the Associate Chief of Staff for Mental Health, Who assisted in reviewing and investigating these allegations. I offer the following in response: Your constituent?s first allegations stated ?a large percentage of Veterans being treated for substance abuse are for substances including opiates, benzodiazepines, and stimulants which were originally prescribed by VA providers?; and ?these same Veterans continue to be prescribed these substances of abuse while in active treatment?. Dr. Skripka and other staff performed chart reviews of every patient enrolled in Tomah residential treatment program for substance abuse in calendar year 2014. (January 1 to April 8 of 2014). Of the 65 patients enrolled this year, 14 patients were being treated for abuse or addiction to opiates, benzodiazepines, and/or stimulants in any form. Four of those 14 Veterans were being treated with opioid replacement therapies such as buprenorphine or methadone that are recommended for opioid use disorders; buprenorphine and methadone were not included in the findings that follow. Of those 14 patients, only one began the abuse/addiction of a drug class am a VA provider prescribed a medicine from that class. That same patient was also the only one of the 14 patients who was currently prescribed a medication from a drug class that was part of their addiction treatment. The Veteran cited above is a Veteran over the age of 60 with multiple complex medical problems including arthritis, kidney failure, and liver transplant. His primary addiction was to alcohol, but he had also reported overusing both prescribed and nonprescribed opiate pain medications at the time of a hospitalization. His hospital team and outpatient primary care provider collaborated and decided the most appropriate option was to continue treating his pain using a modified regimen that still included opiates, with additional monitoring. That new pain medication regimen was then continued during his residential substance abuse treatment. Some background may be in order before addressing the other allegations. The Departments of Veterans Affairs and Defense have published clinical practice guidelines for the management of Post Traumatic Stress Disorder (PTSD), most recently in 2010. Although the published studies in this area are very limited, those guidelines do recommend that benzodiazepines be considered relatively contraindicated for treatment of PTSD. The following statement is taken from the cover of the clinical guidelines for PTSD noted above: The Department of Veterans Affairs (VA) and the Department of Defense guidelines are based on the best information available at the time of publication. They are designed to provide information and assist in decision-making. They are not intended to define a standard of care and should not be construed as one. Also, they should not be interpreted as prescribing an exclusive course of management. Variations in practice will inevitably and appropriately occur when providers take into account the needs of individual patients, available resources, and limitations that are unique to an institution or type of practice. Every healthcare professional who is making use of these guidelines is responsible for evaluating the appropriateness of applying them in any particular clinical situation. There continues to be some professional debate and controversy relating to benzodiazepines in PTSD, both in terms of general guidelines and in how those guidelines are applied to individual cases. However, the responsibility for individual treatment decisions ultimately lies with the attending physician or other provider responsible for a Veteran's care. Their decisions should be informed by the circumstances, needs, and preferences of that individual patient, and all the informational tools available at the time. Your constituent alleges that prescribing benzodiazepines for Veterans with PTSD is a standard practice, and that employees are pressured by management to prescribe substances, apparently benzodiazepines, not compatible with national guidelines. Dr. Skripka indicates that he has directed the mid-leVel providers that he supervises in the residential substance abuse program to follow certain general principles in their prescribing. These include avoiding changes in pre-existing medication regimens when Veterans enter the program, unless those changes are coordinated with and approved by the outpatient providers who will be resuming clinical responsibility when the Veteran is discharged after 30 or 60 days. This direction has been given to avoid a scenario where there is an abrupt change in medication that might be reversed when they return to their primary outpatient provider. Medical providers across Tomah VAMC have also been directed to speak with patients directly before making changes to medications. Dr. Skripka otherwise strongly denies any institutional or management direction to medical providers indicating they are to initiate or othenNise prescribe benzodiazepines to Veterans as a whole, or to Veterans with PTSD as a whole. He requests that your constituent communicate any specific examples to me directly. Your constituent alleged that there are a ?high? number of instances in which controlled substances are prescribed prior to alternatives being trialed. Dr. Skripka indicated difficulty responding with specific data to such a broad statement, as this includes many types of treatments prescribed for many different conditions by many types of providers. He indicates that there are some conditions for which an initial trial of a controlled substance is appropriate, and also agrees that he has seen cases where he believes appropriate alternative measures that could have been appropriate were not tried first. He believes some of the data tools described below may be helpful, and otherwise encourages your constituent to communicate specific examples that are concerning through the VA channels available. Dr. Skripka did want to acknowledge the overall importance of this issue, and the areas where Tomah VAMC is focusing our improvement efforts. Aggregate measures gathered by the VA at the national level have shown that Veterans at Tomah VAMC with PTSD receive a benzodiazepine or sleeping medication more often than the mean for other VA Medical Centers. However, those measures did not offer the ability to analyze or drill down further, or to distinguish the reason that benzodiazepines are prescribed. A recent Veterns Health Administration (VHA) initiative has been underway in recent months, and promises to offer tools for all VA Medical Centers to review and ?drill down" data relating to prescribing patterns, and to compare themselves to other medical centers. Tomah VAMC participated in this initiative earlier this year, and worked with a Veterans Integrated Service Network (VISN) 12, VA Great Lakes Healthcare System pilot project to offer additional analysis of benzodiazepine prescriptions. This tool can enable theTomah VAMC to obtain aggregate information and analyze cases with Veterans receiving various treatments, including benzodiazepines, correlated with certain diagnoses. This tool also permits us to institute targeted education or monitoring as indicated. Tomah VAMC will be reporting efforts in this area to the VA Office of Mental Health Operations. The Opioid Safety Initiative (OSI) is another VHA initiative, intended to identify patients who are taking long?term opioids in a dose that is considered to be in excess. of the norm. The Tomah VAMC Pain Management Committee is charged with implementing the OSI by evaluating the patient?s use of opioids and providing recommendations for their ongoing use or discontinuance. The Pain Committee is a multidisciplinary committee made up of two physicians, two clinical pharmacists, a nurse practitioner, a clinical nurse specialist, and a A comprehensive medical record review is conducted by the committee and recommendations are made in-person to the prescribing provider. This committee is reviewing two to three cases per week and started in February 2014. In the future, I would strongly encourage your constituent to report their concerns directly so that we may address specific examples and give us the chance to work with their issues at the lowest possible level first. Thank you again for this opportunity to address your constituent's concerns with treatment at the Tomah VAMC. If you have additional questions, please contact David Skripka, M.D., Associate Chief of Staff for Mental Health at (608) 372?1631. Sincerely. ario V. DeSanctis, FACHE Medical Center Director Page 1 of mount HEALTH. Ill-thin". um MHW Ml Hm ?nitrd room tvasrtm?to?. cod-slants DH ?in Mill-lint]. MIME Dear Dr. Maurer: lam writing on behalf of'my constituent, who would like to remain anonymous. regarding conoems with meannent at the Tomah. Wisconsin VA. I would appreciate your Full review and investigation ot?tbe following concerns expressed by my constituent: A large percentage of veterans being treated for substance abuse are for substances including opiates, benzodiazepines and stimulants which were originally prescribed by VA providers. These same veterans continue to be prescribed these substances of abuse while in active treatment. There are a high number of instances in which controlled substances are used prior to alternative interventions first being trialed. National guidelines for the treatment of PTSD indicate that veterans in active PTSD treatment should not be prescribed benaodiaaepines for the best possible treatment outcome. However, this is standard practice at the Tomah VA and employees are pressured by management to prescribe substances that are contraindicated by VA National Guidelines. The '3ch of Mental Health has a beginning awareness of the Tomah VA prescribing practices however the process is moving too slowr and veterans continue to be hurt waitin for government intervention. Please inform my of?ce of your ?ndings and forward all correspondence to the attention of Mike Helbiclt in my Milwaukee Senate of?ce at 633 W. Wisconsin Ave, Suite 1920, Milwaukee. WI 53203, or via telephone at 4 14.29%145] . Thank you for your time and prompt attention to this matter. Sincerely, 7.7 Tammy Baldwin United States Senator TAMMY BALDWIN COMMITTEES: HEALTH, EDUCATION, LABOR, AND PENSIONS BUDGET SPECIAL COMMITTEE WASHINGTON, DC 20510 0N AGING COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS June 25, 2014 COMMITTEE ON ENERGY AND NATURAL RESOURCES Ms. Catherine Gromek Veterans Affairs Of?ce of InSpector General Dear Ms. Gromek: I am writing on behalf of my constituent, who would like to remain anonymous, regarding concerns with treatment at the Tomah. Wisconsin VA. I would appreciate your full review and investigation of the following concerns expressed by my constituent: - A large percentage of veterans being treated for substance abuse are for substances including opiates. benzodiazepines and stimulants which were originally prescribed by VA providers. These same veterans continue to be prescribed these substances of abuse while in active treatment. 0 There are a high number of instances in which controlled substances are used prior to alternative interventions ?rst being trialed. I National guidelines for the treatment indicate that veterans in active PTSD treatment should not be prescribed benzodiazepines For the best possible treatment outcome. However. this is standard practice at the Tomah VA and employees are pressured by management to prescribe substances that are contraindicated by VA National Guidelines. The Of?ce oI?Mental Health has a beginning awareness of the Tomah VA prescribing practices however the process is moving too slow and veterans continue to be hurt waiting for government intervention. Please inform my of?ce of your findings and forward all correSpondence to the attention of Mike Helbick in my Milwaukee Senate office at 633 W. Wisconsin Ave, Suite 1920, Milwaukee, WI 53203, or via telephone at 414-297?445 1. Thank you for your time and prompt attention to this matter. Sincerely, I Tammy Baldwin United States Senator Enclosure DEPARTMENT OF VETERANS AFFAIRS VA Great Lakes Health Care System Veterans Integrated Service Network 12 Tower Four Westbrook Corporate Center 11301 West Cermak Road, Suite 810 Jun 30 AH Westchester, IL 60154 June 27, 2014 The Honorable Tammy Baldwin Member, United States Senate 633 W. Wisconsin Avenue, Suite 1920 Milwaukee, WI 58203 Dear Senator Baldwin: Thank you for allowing us to respond to your letter, dated Jun 12, 2014, on behalf of an anonymous constituent regarding concerns with medication prescribing in patients with substance abuse and [or Post Traumatic Stress Disorder (PTSD). I understand you received correspondence from Mario DeSanctis, Director of Tomah VA Medical Center (VAMC) on May 1, 2014. Since the Tomah VAMC is under my jurisdiction, I would like to clarify and reaffirm the VISN commitment to ensuring safe and effective care and medication management for our Veterans. The Department of Veterans Affairs (VA) has initiated a multi-faceted approach to reduce the use of opioids among America's Veterans using VA health care. This initiative is coupled with an effort focused on This speaks to the heart of your inquiry, and includes re?assessing the use of benzodiazepines in patients with PTSD. The Tomah VAMC has recently begun a comprehensive effort to improve the quality of life for Veterans suffering from chronic pain and those with PTSD. In February of 2014, they established a multi-disciplinary committee to conduct comprehensive medical record reviews for patients receiving opioid medications. The Opioid Safety Initiative works to address the challenge of opioid dependency with an innovative and comprehensive plan that closely monitors dispensing practices system?wide. To help providers reduce opioid use and alleviate a Veterans? pain by using non?prescription methods, the program includes education, testing and tapering programs, and alternative therapies like acupuncture and behavior therapy. We plan to closely monitor the impact this program has at the Tomah VAMC. The National Initiative was launched in January 2014 and is focused on improving the quality of prescribing for mental health disorders. Tomah VAMC recognized the importance of this effort and volunteered to offer additional analysis of benzodiazepine prescriptions. Tomah VAMC will be reporting efforts in this area to the VA Of?ce of Mental Health Operations. The initiatives mentioned above are designed to improve both the quality of prescribing and overall care for chronic pain and mental health disorders. As a network, we are committed to increasing efforts to address and ensure appropriate oversight of evidence based prescribing practices. Thank you for your inquiry and the opportunity to address the concerns raised by your constituent. If you have additional questions, please contact David Houlihan MD, Chief of Staff at (608) 372-3971. Sincerely, Jeffrey A. Murawsky, MD. FACP Network Director, VISN 12 TAMMY BALDWIN wuscousm dammit 695mm gamut WASHINGTON, DC 20510 August 11, 2014 Veterans Affairs Of?ce of InSpector General Dear VA Of?ce of Inspector General: COMMITTEES: HEALTH, EDUCATION. LABOR, AND PENSIONS BUDGET SPECIAL COMMITTEE ON AGING COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS COMMITTEE ON ENERGY AND NATURAL RESOURCES I am writing to request OIG reports dealing with prescription practices at the Tomah VAMC. Please inform my of?ce of your ?ndings and forward all correSpondence to the attention of Mike Helbick in my Milwaukee Senate of?ce at 633 W. Wisconsin Ave., Suite 1920, Milwaukee, WI 53203, or via telephone at 414.297-4451. Thank you for your time and prompt attention to this matter. Sincerely, Tammy Baldwin United States Senator Department of Veterans Affairs Of?ce of Inspector General Washington, DC 20420 August 29. 2014 Mike Helbick Of?ce of U.S. Senator Tammy Baldwin 633 W. Wisconsin Avenue Suite 1920 Milwaukee. WI 53203 Dear Mr. Helbick: This is in reSponse to your Freedom of lnforrnation Act (F OIA) request dated August 11, 2014 in which you asked for a copy of OIG reports dealing with prescription practices at the Tomah VAMC on behalf of United States Senator Tammy Baldwin. Your request was received in this of?ce on August 11. 2014. We have assigned FOIA Tracking Number 14-00966-FOIA to your request. Please refer to it whenever communicating with VA about your request. We have enclosed a copy of the requested records. However, we are withholding all information which, if disclosed, would constitute a clearly unwarranted invasion of an individual's personal privacy under FOIA Exemption 6, 5 U.S.C. 552 Speci?cally, names, job titles and other infon'nation which could reveal the identity of individuals mentioned in the records have been withheld. We do not ?nd any public interest that outweighs the privacy interests of the individuals. You may appeal this decision within 60 calendar days of the date of this determination by submitting a signed, written statement by mail, fax, or email. You may submit your appeal by using either of the following addresses or fax number: U.S. Department of Veterans Affairs Of?ce of Inspector General Of?ce of the Counselor (50C) 810 Vermont Avenue. NW. Washington, DC 20420 (Fax) 202.495.5859 The appeal should include: 1. The name of the FOIA Officer 2. The date of the determination, if any 3. The precise subject matter of the appeal if you choose to appeal only a portion of the determination, you must specify which part of the determination you are appealing. The appeal should include a copy of the request and response, if any. The appeal should be marked "Freedom of Information Act Appeal". Sincerely, DARRYL Chief, Information Release Of?ce Enclosures Administrative Closure Alleged Inappropriate Prescribing of Controlled Substances and Alleged Abuse of Authority Tomah VA Medical Center Tomah, WI 2011-04212-Hl-0267 Background The VA Of?ce of inspector General (010} Of?ce of Healthcarc Inspections (OHI) conducted a review to assess the validity of multiple allegations made by a series of complainants. Common elements among the concerns included alleged misprescribing and diversion of opioid drugs by a high ranking physician at the facility (Dr. Z) and by a Eb?) MEELJY), as well as abuse of administrative and clinical authority by Dr. Z. The various allegations were compiled from: A complaint made in March, 2011 by a facility (with a corresponding VISN response in June, 201] and a September, 201 1 report from the Chief Medical Of?cer (CMO) on remedial actions taken). 0 Anonymous complaints made in August, 2011, via a letter sent to the 016 and Congressman Ron Kind of the US. House of Representatives. 0 A physician at the facility in March, 2012, while the inspection was actively ongoing. By several anonymous reSpondents to an EAR survey in May, 2012, that was conducted prior to a regularly scheduled CAP inSpection. A total of 32 speci?c allegations were made by these sources, several of which came to light at various points while the inspection was underway. The scope of our review included the assessment of the practice patterns and controlled substance prescribing habits of Dr. and Y, as well as the administrative interactions of Dr. with subordinates and his approach to clinical leadership, speci?cally as these related to issues around the prescribing of controlled substances. We also looked for any concerns by Federal and municipal law enforcement authorities or other signals of drug diversion related to the practices of Dr. and Y. Because of the potential seriousness of the allegations and their origination from multiple sources, we performed an VA Of?ce ofinspector losure - MCI 2011-04212-H-0267, Tomh VAMC, Tomh, I exhaustive review of the individual practitioners named. Because of the allegations of criminal activity, our efforts throughout this inspection were closely coordinated with the 016?s Criminal Investigation Division (5 1). We reviewed documents from VA and non-VA sources as follows: l. Statement of Charges, Settlement Agreement and Final Order from a state Medical Board concerning charges brought against Dr. shortly after his date of appointment to the VA. Letters from the Veterans Integrated Service Network (VISN) 12 Director and the VISN 12 CMO. Five peer reviews, and correSpondence from Dr. to the Peer Review Oversight Committee and the [2 regarding allegations made in March, 2011, and subsequent actions by VA management. 4. Scope of practice documents and routine peer reviews on. {It 010 Master Case Index records of [9 cases at Tomah VAMC since 2009. Ten peer reviews of Dr. Z?s practice performed in November, 2009, along with minutes of a subsequent special session of the Peer Review Committee, and related correSpondence between Dr. and the Committee. Tomah VAMC police reports of overdoses/suspected overdoses for a three-year period. Reports on adverse drug reactions in patients treated by Dr. and compiled by the Tomah VAMC pharmacy. Documents related to the suicide of a Tomah VAMC professional immediately following termination of employment (memoranda, e-mail messages, Sheriff?s Department reports, union representation records and related internal union correspondence). 10. Documents related to the appeal of a terminated Tomah VAMC to the Merit Systems Protection Board (MSPB) (appellant?s brief for MSPB jurisdiction, narrative experiences, supporting materials for decisions). I l.Rc evant Medical Center Memoranda on pain management, chronic opioid use, and adverse drug event surveillance. Clinical Practice Guideline on Management of Opioid Therapy for Gnerl . Chronic Pain (May, 2010). . We also requested Tomah VAMC police reports on sales of prescribed or illegal drugs on the Tomah VAMC campus in the preceding three years, but were told there have been no Unifox'm Offense Reports of such activities. We conducted general chart reviews as follows: 1. Patients who were speci?cally identi?ed in complainants? allegations. 2. Patients who were included in June, 201 l, peer reviews of Dr. Z?s practice. 3. A patient 0 who was identified by an informant to Tomah municipal police as being involved in drUg diversion. 4. Selected individuals from a list of the 100 patients at Tomah VAMC receiving the highest doses of opioids We also performed structured chart reviews and compiled the results using a SharePoint?-based data entry tool and Microsoft Excel? spreadsheet as follows: i. All patients in the care of Dr. and/or who were among the 100 patients at Tomah having the highest doses of opioids (32 cases). 2. Patients on a list provided by the Tomah municipal police department of individuals suspected of drug crimes, who were receiving prescriptions for controlled substances from any provider at Tomah (24 cases; l5 were patients of Dr. and/or). We collected an e-mail dataset for review consisting of 227,532 unique e-mail messages and 859 associated ?les originating from 17 individuals. This review was performed using Clearwell so?ware. We searched terms that could signal potential drug seeking behavior, such as those related to early re?lls and urine drug screens, in order to assess what was being communicated about these topics, as well as what advice or instructions were being given. We also reviewed messages pertaining to speci?c individuals in cases where administrative/supervisory con?icts were reported to exist. We reviewed several extensive Microsoft Excel?-based datasets derived from pharmacy records with assistance from the VISN l2 Pharmacy ExecutiVe as follows: 1. Early re?lls of controlled substances and antidepressants (for camparison) at Tomah VAMC over the period of January 1, 2011 to September 12, 2012. 2. Total morphine equivalent amounts of opioids diSpensed dUring FY 2012 in all VISN 12 facilities by site, provider, and patient. VAOf?ceofispeorGeeral - I a We conducted telephone interviews prior to a site visit, including: 1. The complainant in the case where he/she was not anonymous. 2. Tomah and Milwaukee municipal police officials; at Diversion Investigator from the Drug Enforcement Administration (DEA), United States Department of Justice. 3. Current and former Tomah VAMC staff who were identi?ed by complainants as having key information, including a a physician, and four pharmacists. 4. The newly appointed Director of Tomah VAMC. We also engaged the assistance of three pharmacist consultants to assist us in evaluating the clinical and administrative aSpects of Dr. Z?s interactions with pharmacy staff and the staff?s roles in facilitating patient safety and appropriately diSpensing controlled substances. We provided the consultants with access to recordings of the interviews with the four pharmacists who had previously Ie? Tomah VAMC. We conducted a site visit at the facility on from August 22-23, 20 2 -12. We interviewed the Associate Director (the Director was on sick leave), the Chief of Staff, the Mental Health Associate Chief of Staff, the Chair of the Pharmacy and Therapeutics Committee, the Director of the facility's Opioid Workgroup, the facility?s Police Chief, the Pharmacy Director, the Outpatient Pharmacy Supervisor, two clinical pharmacists, six outpatient staff pharmacists, one contract diSpensing pharmacist, three two primary care physicians, a physician?s assistant, a Specialist, Dr. Z, and Y. During the site visit, we toured the outpatient pharmacy to assess security issues that had been raised in interviews. We also met with the Acting Chief Information Officer to discuss obtaining e-mail files that we were unable to retrieve remotely. Following the site visit, we conducted several additional interviews by telephone as follows: the Medical Center Director, the Director of Human Resources, and the VISN Pharmacy Executive. Findings We did not substantiate allegations that the Tomah municipal and Milwaukee police departments made complaints about drug traf?cking at the Tomah VAMC. However, the Tomah police department reported suspicions that certain Tomah VAMC patients were i I 104212-Hl-0267, Tomah VAMC, Tomah, WI 1 misusing their prescribed controlled substances in various ways including drug diversion.l We substantiated the allegation that at least ?ve outpatient pharmacy staff left the facility in recent years. Pharmacists reported various reasons for leaving. The four pharmacists whom we interviewed expressed concerns regarding the facility?s (and ultimately Dr. Z's) expectations for dispensing opioids and other controlled substances. One pharmacist, a new employee, was not retained by the facility at the conclusion of his/her initial employment period. This individual reported that on three occasions he/she had refused to ?ll prescriptions for controlled substances due to concerns about patient safety and/or drug diversion. A second clinical pharmacist who left the Tomah VAMC reported feeling inapprOpriateiy blamed by Dr. for the suicide of a patient. A dispensing pharmacist, relatively new to the facility, reported that he believed there were 40-50 patients who were regularly presenting to the outpatient pharmacy for early re?lls of opioids, and that pharmacists were told by Dr. 2 they had to ?ll the prescriptions. He feared this would place his license at risk. A clinical pharmacist who had been hired in a supervisory capacity reported that when some of the pharmacists expressed discomfort with dispensing high doses of Opioids to patients, Dr. 2 would become angry and would insist that this pharmacist discipline the other pharmacists under his supervision. We did not substantiate the allegation that Dr. 2 was mismanaging a patient with complex regional pain by attempting to arrange an inappropriate above the knee amputation. in the context of having obtained multiple contradictory facts and statements during the course of this inspection, o?en based on second or third hand accounts, we did not substantiate allegations of abuse of authority, intimidation and retaliation when staff question controlled substance prescription practices. While we did not substantiate the allegations of abuse of authority, intimidation and retaliation'when staff question controlled substance prescription practices, we did ?nd that these are widely held beliefs and concerns among most pharmacy staff and among some other staff. Additionally, during the course of their investigations of a few deceased veterans they had noted large quantities of prescribed controlled substances in their (the veterans?) residences. However, no law enforcement actions were being taken. Early in this inspection we became aware that the DEA was actively investigating complaints of inappropriate prescribing and drug diversion at the Tomb VAMC. VA Of?ce of InspectOr General Page 5 distive Closure - Cl 201 Tomah V. oh. i We found that the Chief of Pharmacy reports to Dr. by virtue of his (Dr. Z?s) administrative leadership position. We found that some patients at Tomah VAMC had a pattern of early refill requests, which can be a potential risk behavior for substance abuse. Pharmacists expressed a reluctance to question such early re?lls. Review of a l2 pharmacy leadership data analysis indicated that Dr. Z, Y, and other clinicians at the Tomah VAMC prOVided more than 7 days early controlled substance refills. A pre-April 12, 2012, local facility policy did not allow exceptions to the ?no early re?ll? rule. A newer policy does not prohibit exceptions but does not provide practical guidance, parameters, or processes by which to approach early re?lls or navigate the clinical complexity of such exceptions. We substantiated the allegation that negative urine drug screens (UDS) are not acted on and that controlled substances are still prescribed in the face of a negative UDS. In the course of our review of selected case histories and from the structured medical record review, we found that for some patients, when a UDS was performed and showed absence of prescribed medication, documentation in progress notes did not always acknowledge this or indicate what, if any, clinical intervention or change in treatment was initiated with the patient. For example, we found in a general chart review of a selected case treated byY that multiple negative UDS UDS that did not show presence of prescribed medications) were not acted on. In our structured medical record review, 52 of 56 patients had UDS performed at least one time between January, 2009, and April, 20l2. The remaining four patients had no UDS performed during this time interval spanning more than three years, although all were treated chronically with opioids during this period. Of the 52 patients who had UDS performed at least one time between January, 2009, and April, 20l2, there were ?ve patients who were being prescribed opioids at the time of the negative test, the test failed to con?rm that they were actually taking their prescribed medication. We did not substantiate the allegation that opioid contracts are not being ?encouraged? by Dr. Z. We found that 48 of 56 patients in the structured medical record review had an opioid contract. Of the patients lacking opioid contracts, Dr. 2 was a primary prescriber of Opioids for none, andY was a primary prescriber of Opioids for two. Several allegations dealt with general over prescription of narcotics at the facility, and speci?cally alleged over prescription by Dr. Z. and Y. The appropriateness of prescribing opioids to a particular patient or the appropriateness of a particular dose utilized is a complex matter that must take into account the patient?s history, current . mm VAfficeonspectoaneral . - I Page6 medical and status, social situation. and other factors. The clinical decision making underlying this process is based on the practitioner?s clinical judgment and other factors that vary from patient to patient. in this context, we did not substantiate the allegations that opioids were prescribed inappropriately to speci?c individuals or in inappropriate doses. However, based on the analysis depicted in Tables 1 and 2 below, we determined that the amounts of Opioids prescribed by Dr. and in aggregate and to individual patients were at considerable variance compared with most opioid prescribers in VISN 12. Table 1 below shows prescription drug data prepared by VISN 12. Table 1. Morphine Equivalents Prescribed by each VISN 12 VAMC Station in FY 12. Unique Total Morphine Average Daily Morphine Total Patients with Equivalents/Unique Equivalents Dispensed Morphine Opioid Patients with Opioid (Total Morphine Station Equivalents Prescriptions Prescriptions Equivalents/365 day?)_ .6762 36,845,093 3171 11,619 100,945 585 28,974,019 3570 8,116 79,381 578 66,814,245 9144 7,307 183,053 607 42,341,117 5893 7,185 116,003 556 21,668,793 3390 6,392 59,367 695 51,990,679 9888 5,258 142,440 537 42,127,193 8662 4,863 115,417 As shown in Column 1 for FY 12, the range among VISN 12 facilities for total morphine equivalents was 21,668,793 to 66,814,245. Tomah was ranked 5th [highest to lowest) of the seven facilities in VISN 12. Column 2 indicates that the facility has the smallest number of patients treated with opioids, which in part may re?ect the smaller size of the overall patient population at the facility relative to larger facilities in VISN 12. Column 3 indicates the total morphine equivalents per unique patients treated with opioids. Tomah VAMC ranks highest in this category.3 VISN 12 provided similar data on a provider level for providers throughout VISN 12. For total morphine equivalents prescribed in FY was highest in the VISN ?Tomeh VAMC it is possible that these numbers may not be directly comparable since larger facilities with more extensive surgical and emergency treatment services likely have more patients that are treated acutely for short time frames with smaller opioid doses. However, data presented suggest this may not be the entire explanation. it can be conclusively stated from Table is that the total amount of opioids prescribed in aggregate at the Tomah VAMC is in the middle rane cont - ared with other VISN 12 facilities. Pa 7 VA enera ..sr --H. H). Tea. among 3206 providers who wroteprescriptions for opioids. Dr. was the seventh highest Opioid prescriber in VISN 12, and a?bltG) lat Tomah VAMC was the ?fth highest prescriber. These three providers accounted for 33.3% of all morphine equivalents prescribed at Tomah VAMC in FY 12. Table 2. Ten highest individual VISN 12 clinician prescribers (by morphine equivalents) in FY 12 Ivalonee ate! it PM Total Rtha Total 5 6,011 182 11,543 4,162 271 15,360 3,734 9,560 8.655 427 161 270 989 6,650 Data for the ten highest individual prescribers in the VISN are shown in Table 2. Considering these ten highest prescribers, three were from Tomah VAMC, while two other facilities had two providers each, and the remainder had one or none. Among these ten highest prescribers in the VISN, the total morphine equivalents prescribed for the one year period ranged from 2,427,161 to 5,326,011 morphine equivalents, and morphine equivalents per unique patient ranged from 8,989 to 29,264. Thus, even among these ten highest individual prescribers. there was considerable variation in amounts prescribed; the total morphine equivalents prescribed bY was more than double that prescribed by the tenth highest prescriber in the VISN, and morphine equivalents per unique patient was more than threefold higher. On a per patient basis prescribed 29,264 morphine equivalents per patient (second highest among VISN I2 clinicians) during FY 12; for Dr. Z, the number was comparable (25,142; fourth highest among VISN l2 clinicians). Patient populations can vary from facility to facility, complexity of patient case mix can vary from provider to provider, and individual patient characteristics and needs vary from patient to patient. Nevertheless, it seems clear that the total amount of Opioid and opioid per patient prescribed by and VA Of?ce of Inspector General Page 8 Dr. are at considerable variance compared with most Opioid prescribers in VISN 12, and the data support that total Opioid prescribing for one additional individual prescriber at the facility is likewise unusually high. We did not substantiate the allegation that ?Opioids are contraindicated for PTSD, but this is part of [Dr. Z?s] treatment plan.? In review of patient medical records, emails, and during the course of our interviews we did not find documentation that Opioids were being used to treat PTSD. in each case, medical record review indicated a history of a pain related condition and use of opioids for treatment of pain. At the time of our site visit, Tomah VAMC leadership reported that a Pain Management Committee met on a basis. The Committee was co-chaired byY and a primary care physician with a background in pain management. Other members included another physician with a background in pain management, Dr. as an adjunct member, a We) 4 7 One co-chair told us that the Committee addresses mainly administrative issues but that individual clinical cases were addressed by a smaller group of clinicians. This smaller group consisted oY. the We) and possibly a member of nursing staff not af?liated with the committee. An opioid work group was in the process of being formed. The focus of the work group was to establish surveillance of clinician prescribing patterns. The planned work group included the members of the Pain Management Committee with the addition of the Director of Pharmacy. Summary and Conclusions We did not substantiate the majority of allegations made in the various complaints that OIG received. Although the allegations dealing with general overuse of narcotics at the facility may have had some merit, they do not constitute proof of wrongdoing. We did not ?nd any conclusive evidence af?rming criminal activity, gross clinical incompetence 0r negligence, or administrative practices that were illegal or violated personnel policies. Nevertheless, our inSpection raised potentially serious concerns that should be brought to the attention of VISN 12 management for further review. In particular, we noted that the amounts of opioid equivalents prescribed by Dr. andY, both in aggregate and per individual patient, were at considerable variance compared with most opioid prescribers in the and that a Tomah lwas likewise prescribing an unusually high total opioid amount. Additionally, while it is true that certain clinicians may be treating patients with unusual conditions that require unconventional treatments, VA Of?ce of inspector General Page 9 _a lit re 201104212-Hl-02. oa Wl it would seem more clinically appropriate for such complex patients to be treated by a specialist or subspecialist in their particular condition, rather than [:?iaitet Also of concern was the dysfunction of multidisciplinary collaboration in patient care that we observed, particularly between the pharmacy staff and Dr. Z. Perceptions of abuse of authority, intimidation and retaliation are problematic in themselves because they diminish or even preclude the willingness to communicate concerns about potential safety issues or aberrant patient behaviors. From a systems perspective, facility leadership, staff, and ultimately patients and their safety, benefit when there is an environment of communication, collaborative care, approachability, and functional checks and balances. When effective, such collaboration provides a system of checks and balances that reduces medication errors and enhances general patient safety, and is eSpecially important in this setting given the quantities and dosage of opioids that are being utilized in seriously ill patients. The facility appeared to be at a functional impasse with respect to such collaboration. The pharmacy staff uniformly indicated that they were reluctant to question any prescription ordered by Dr. or any aberrant behavior by his patients (for example, frequent requests for early re?lls) because they feared reprisal, even though most of them could not give a first-hand account of negative actions toward them by Dr. 2. For his part, Dr. complained that pharmacists (except for one) were unwilling to approach him with problems or concerns and were uninterested in learning more about his treatment approach and rationale The Chief of Pharmacy reporting to Dr. by virtue of Dr. Z?s administrative leadership position may complicate the perception that Dr. misuses his authority to compel acquiescence with his clinical decisions. For patients with complex oncology problems, hospitals often have committees known as tumor boards, comprised of clinicians from multiple disciplines (oncology, surgery, radiation oncology, nursing, nutrition among others) that convene periodically to discuss and recommend an integrated plan for patients with complex cases of cancer. There are several suggestions that should be brought to the attention of the facility Director and VISN management, as follows: 0 The facility Director should implement a vehicle by which clinicians and staff can openly and constructively communicate concerns and rationale when disagreements arise concerning dispensing of opioid prescriptions. a: A Of?ce of nral inlelosure - MCI 2011-0212le-0267, To mah VAMC, Tomah. Wt - The facility Director should review the reporting structure in the context of safeguarding bi-directional clinical discourse from actual or perceived administrative constraint. 0 The facility Director should ensure development of guidance, parameters, precesses, or a specialty clinic based mechanism to assist clinicians and staff with managing complex patients requesting early opioid re?lls. - The facility Director should consider some variant of the tumor board model as one potential avenue by which to foster collaborative interdisciplinary management when presented with very complex clinical pain cases. 0 The VISN should conduct further evaluation and monitoring of relative and case-Speci?c Opioid prescribing at Tomah VAMC on both a facility and individual clinician level. I concur with the recommendation for administrative closure of this inspection. The material in this report will be briefed to VISN [2 Senior Staff including the VISN 12 Director and CMO, and to Tomah Director. A report of contact from that brie?ng will be appended to this administrative closure. Based on our review, I am administratively closing this case. I HN D. DAIGH, JR, MD. Assistant Inspector General for Healthcare Inapections VA Offie of I Page 1 TAMMY BALDWIN cot-M I HEALTH, EDUCATION, LABOR, AND PENSIONS Estate ,%tnatt SPECIAL COMMITTEE WASHINGTON, or: some 9N COMMII ON HOMELAND SECURITY January 13, 2015 AND GOVERNMENTAL AFFAIRS ON AND NATURAL RESOURCES The Honorable Robert A. McDonald Secretary of Veterans Affairs 810 Vermont Avenue, NW Washington, DC 20420 Dear Secretary McDonald: 1 am writing to request that you take immediate action to address extremely troubling reports of improper opiate prescribing practices and abuse of administrative authority at the Tomah VA Medical Center. I raised these concerns on behalf of a constituent in April and June of last year, sending letters to the Tomah VA and the VA Of?ce of Inspector General (01G), respectively. In addition, the OIG issued a March 2014 report that raised a number of serious concerns, yet action to address these problems has not been taken. Therefore, I believe it is time for you to intervene and conduct a broad and thorough investigation of the operation of the Tomah VA and ensure that the facility is providing the highest-quality care to Wisconsin veterans. The March 2014 016 report that looked into the aforementioned allegations revealed evidence of extremely high levels of opiate painkiller prescriptions at the Tomah VA during ?scal year 2012, detailing amounts at ?considerable variance? compared to other Veterans Integrated Service Network (VISN) 12 facilities and prescribers. Indeed, out of the seven VISN 12 facilities, the Tomah VA had by far the highest per patient dosage rate. In addition, out of more than 3,200 VISN 12 providers, three physicians at the Tomah VA were the highest, fifth highest, and seventh highest opiate prescribers, accounting for 33% of all opiate prescriptions in VISN 12. Despite these alarming numbers, the OIG did not ?nd evidence of wrongdoing, stating only that ?allegations dealing with general overuse of narcotics at the facility may have had some merit.? I am also concerned by reports of an administrative culture of intimidation and dysfunction at the Tomah VA. According to the 01G report, four pharmacists left the Tomah VA because of ?concerns with the facility?s expectations for dispensing opiods and other controlled substances.? Despite this finding, the 01G did not substantiate allegations of abuse of authority. While I understand that patient populations and their medical needs vary by facility, I am troubled at the 016?s reluctance to recognize a clearly signi?cant problem at the Tomah VA. Coupled with personal accounts from veteran patients, their families, and former employees, the allegations investigated by the GIG?both those substantiated and those unsubstantiated, but otherwise validated by evidence?require action. Additionally, while the OIG report evaluated multiple accusations raised by a series of whistleblowers, it was limited in focus and therefore not a thorough investigation into Tornah VA operations. The veterans that rely on this facility deserve a comprehensive and immediate investigation that determines the full scope of the problem and leads to action. Mr. Secretary, I applaud your reliance on a single metric for evaluating the work: the qualityr of the outcome fer the veteran. While the concerns raised at the Tomah facility are alarming, it bears noting that I believe that the overwhelming majority of Wisconsin VA employees strive every day to provide quality and timely care to our veterans. To achieve and maintain that standard, it is imperative that you take action to address the issues affecting veterans and employees at the Tomah VA. I look forward to working with you toward that goal. Sincerely, my Baldwin United States Senator TAMMY BALDWIN WISCONSIN HEALTH, EDUCATION. LABOR, AND PENSIONS CJ?nittd ?rms amt: SPECIAL COMMITTEE WASHINGTON, DC 20510 ON AGING January 22, 2015 COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS The Honorable Johnny Isakson The Honorable Richard Blumenthal Chairman Ranking Member Senate Committee on Veterans? Affairs Senate Committee on Veterans? Affairs Russell Senate Of?ce Building, Room 412 Russell Senate Of?ce Building, Room 412 Washington, DC 20510 Washington, DC 20510 Dear Chairman Isakson and Ranking Member Blumenthal: I am writing to request that you hold a hearing to address the failure of the Department of Veterans Affairs (VA) to step imprOper opioid prescribing practices and associated abuse of administrative authority at the Tomah VA Medical Center. Additionally, I am concerned that these problems are not unique to the Tomah facility; therefore, I request that the hearing also examine the problem of overmedication across the VA network, particularly the use of opioids for mental health treatment. While I applaud the committee for investigating the problem of overmedication in a hearing last Congress, I believe that more needs to be done to ensure that our nation?s veterans receive the timely, safe, and highest-quality care that they have earned. There are signi?cant risks associated with the use of Opioids, and these addictive medications should not be casually prescribed or absent strict monitoring. I support the recent efforts to reduce the use of opioids, like the Opioid Safety Initiative, but believe that more immediate steps must be taken, including the prompt expansion of alternative medical care for veterans and strengthened oversight of mental health treatment throughout the VA. Indeed, I called for these actions last Congress, supporting S. 1950, a comprehensive veterans bill that included efforts to reduce dependency on narcotic painkillers and improve mental health care. The Tomah VA provides a deeply disturbing case study of overmedication at the VA. A March 2014 OIG report that looked into allegations of extremely high levels of opioid painkiller prescriptions detailed amounts at ?considerable variance? compared to other Veterans Integrated Service Network (VISN) 12 facilities and prescribers. Indeed, out of the seven VISN 12 facilities, the Tomah VA had by far the highest per patient dosage rate. In addition, out of more than 3,200 VISN 12 providers, three physicians at the Tomah VA were the highest, ?fth highest, and seventh highest opioid prescribers, accounting for 33% of all opioid prescriptions in VISN 12. Despite these alarming numbers, the OIG did not ?nd evidence of wrongdoing, stating only that ?allegations dealing with general overuse of narcotics at the facility may have had some merit.? In fact, according to the OIG, these troubling practices were within the bounds of the acceptable VA standard of care. This is particularly troubling in light of the tragic and ultimately fatal overdose of former Marine Jason Simcakoski, who died as a patient at the Tomah VA last fall, and other veterans who reportedly became addicted to drugs as a result of the prescribing practices at Tomah. Clearly, it is past time for the VA standard of care to be thoroughly revised. At my urging, last week Secretary McDonald launched a broad and thorough investigation of the operation of the Tomah VA. In addition, last surmner, I raised concerns about the prescribing practices at Tomah directly to the Tomah facility, to VISN 12 and to headquarters. While the VA did take some steps in Fall 2014 to make changes at Tomah, it is clear that the Department of Veterans Affairs has failed to adequately address the serious problems at this facility. Therefore, to supplement this internal review, the Senate Committee on Veterans? Affairs should exercise its oversight as well. Thank you for your consideration of my request and all that you do in support of our nation?s veterans. Sincerely, Tamm Baldwin United States Senator TAMMY BALDWIN COMMITTEES: HEALTH. EDUCATION, LABOR. AND PENSIONS ??nitrd tantra 0%En?tll SPECIAL COMMITTEE WASHINGTON, DC 20510 0N AGING January 27, 2015 COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS The Honorable Carolyn M. Clancy, MD. COMMITTEE ON ENERGY . AND NATURAL RESOURCES Interim Under Secretary for Health U.S. Department of Veterans Affairs 810 Vermont Avenue, NW Washington, DC 20420 Dear Under Secretary Clancy: I am writing to follow-up on our conversation last week regarding the investigation you are leading into allegations of improper opiate prescribing practices and abuse of administrative authority at the Tomah VA Medical Center. As we discussed, I am pleased that Secretary McDonald agreed to my request to initiate an investigation into these serious allegations and has tasked you?along with Ms. Meghan Flanz of the Of?ce of Accountability Review?to lead it. As you begin your investigation this week in Tomah, I wanted to convey the many serious concerns that have been brought to my attention since I began working on this issue last year so that you can address them in your investigation. The March 2014 Of?ce of Inspector General (OIG) review, media reports, and constituents have shed light on extremely troubling prescription drug practices and management issues at the Tomah facility as well as with the national prescription drug policy. The March 2014 OIG report, which looked into allegations of extremely high levels of Opioid painkiller prescriptions at Tomah, detailed amounts at ?considerable variance? compared to other facilities and prescribers within Veterans Integrated Service Network (VISN) l2?the regional VA Of?ce that supervises Tomah and other VA facilities in Wisconsin, Illinois, Michigan, and Indiana. Indeed, out of the seven medical centers managed by VISN 12, the Tornah VA had by far the highest per patient dosage rate. It is clear that prescription drug distribution and the overall management at Tomah warrant a full investigation. Additionally, despite these alarming numbers, the OIG did not ?nd evidence of wrongdoing, stating only that ?allegations dealing with general overuse of narcotics at the facility may have had some merit." This conclusion seriously calls into question the Department of Veterans Affairs? national standard of care, and I would strongly encourage you to also initiate a national system?wide review of the prescription drug policy to ensure that local VA medical centers?in Wisconsin and across the country?are receiving appropriate direction. The aforementioned concerns are particularly troubling in light of the tragic death of former Marine Jason Simcakoski who passed away on August 30, 2014. My of?ce received the OIG report on August 2014, and it did not address Mr. Simcakoski?s death because the report was completed ?ve months earlier in March 2014. However, we have since learned about some of the disturbing circumstances surrounding his death, and I believe this deserves your full attention. Accordingly, I request that your review address the causes and circumstances that led to Mr. Simcakoski?s death and include a review of the Tomah investigation of his death. There also have been extremely alarming allegations raised regarding VISN 12?s management of its facilities, management and hiring practices at the Tomah VAinability to effectively communicate problems identi?ed at VA facilities. Therefore, I would encourage you to address the following in your investigation: 0 Reports of veterans becoming addicted to drugs as a result of the prescribing practices at the Tomah VA. 0 A comparison of Tomah?s mental health treatment programs relative to best practices in mental health treatment programs within the national VA health system. 0 The circumstances surrounding the hiring of the Tomah VA Chief of Staff, Dr. David Houlihan, a who reportedly engaged in an inappropriate relationship with a patient while practicing in Iowa. I VISN 12?s oversight of facilities within its jurisdiction. 0 How the local and federal VA of?ces and facilities communicate?and respond reports that recommend ?administrative closure? but identify problems. 0 The concerns raised by current and former Tomah VA employees, patients and their families. 0 Allegations of retaliatory behavior against current and former employees at the Tomah VA as well as reports of a culture of fear and intimidation at the facility. 0 Whether it would be apprOpIiate for the Tomah VA to be under the direct supervision of a senior VA of?cial from outside VISN 12 until the investigation is complete. 0 Whether wrongdoing at the Tomah VA could warrant a criminal investigation. Finally, I would strongly encourage you and your team to meet with the whistleblowers who have raised many of these concerns and to do so in a manner that allows individuals to be forthcoming. A broad and detailed investigation of both the Tomah VA and relevant aspects of the national VA health system will provide much needed accountability and information that will allow us to decide how we can best improve the delivery of timely and hi ghest?quality care to veterans in Wisconsin and throughout the country. I look forward to working with you toward that goal. incerely, . Tammy Baldwin United States Senator Cc: The Honorable Robert McDonald, Secretary, Department of Veterans of Affairs Ms. Meghan Flanz, Co?Chair, VA Of?ce of Accountability Review TAMMY BALDWIN COMMITTEES: APPROPRIATIONS BUDGET ?anind germs ?rnatr LABOR, AND PENSIONS WASHINGTON, DC 20510 HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS February 12, 2015 The Honorable Eric H. Holder, Jr. Attorney General US. Department of Justice Of?ce of the Attorney General 950 Avenue, NW Washington, D.C. 20530 Dear Attorney General Holder: I am writing to request that the US. Department of Justice (DOJ) launch an immediate investigation into allegations of criminal wrongdoing at the Tomah Veterans Affairs Medical Center in Tomah, Wisconsin. I am extremely troubled about reports linking the tragic deaths of three Wisconsin veterans to imprOper medical care at the facility. Additionally, I have heard concerns regarding the conduct of the Tomah VA and the Tomah VA Police Department in response to the deaths that occurred at the facility. Finally, concerns regarding the illegal distribution and use of prescription drugs that originated at the Tomah VA facility have been raised. The US. Department of Veterans Affairs (VA) and its Of?ce of Inspector General (OIG) are currently investigating a number of issues related to the Tomah VA, but I believe the seriousness of the allegations warrant an additional external and objective review by a law enforcement agency totally independent from the Department of Veterans Affairs. Accordingly, I request that you investigate both the circumstances surrounding patient deaths and allegations of the illicit distribution of opioids that originated at the Tomah VA facility. At least three veterans?Jason Simcakoski, Thomas Patrick Baer and Jacob Ward?who were treated at the Tomah VA have tragically lost their lives. Below is information surrounding their tragic deaths. 1. Thomas P. Baer, 74, of Marshfield, Wisconsin, passed away in January at Gundersen Hospital in LaCrosse, Wisconsin. Prior to his arrival at Gundersen, Mr. Baer experienced very troubling treatment at the Tomah VA, including excessive wait times, broken medical equipment that was required for his treatment, and inadequate adherence to standard medical protocols. 2. Jason L. Simcakoski, 35, of Stevens Point, Wisconsin, passed away on August 30, 2014, at the Tomah VA. According to reports, Mr. Simcakoski, a former Marine, checked himself into the Tomah facility citing an addiction to opioid painkillers and severe anxiety. At the time of his death from ?mixed drug toxicity,? he reportedly was on 15 different prescription drugs, including tranquilizers, muscle relaxants, and opioid painkillers. 3. Jacob M. Ward, 27, of Milwaukee and formerly of Coon Valley, Wisconsin, passed away on September 4, 2013, at his home in Milwaukee. The Army veteran reportedly became addicted to opioid painkillers and other drugs after treatment for PTSD at the Tomah VA. I would request that you conduct a full investigation of these three tragedies. In addition, I?m concerned about the treatment of other patients who may have died after receiving care at this facility. Therefore, I would encourage your review to not only include the three cases mentioned above, but also include any Tomah VA patient who died after receiving treatment at the facility. The investigation should include a review of both the administration of care and subsequent internal investigations. Regarding the administration of care, please investigate, at a minimum, the following: The circumstances surrounding the deaths 0 The medical treatment these patients received at the Tomah VA 0 The Tomah protocol for treating patients 0 Inappropriate opioid prescribing practices a Whistleblower retaliation 0 Illegal access of con?dential medical records 0 Failure to maintain medical equipment 0 Failure to comply with appropriate triage and medical treatment protocols Regarding the internal investigations and conduct following the deaths, I would ask that you investigate, at a minimum, the following: The investigations conducted by any entity and speci?cally: The Tomah leadership 0 The Tomah VA Police Department 0 The handling of internal facility and law enforcement records 0 The accuracy and completeness of death investigation records and the preservation of evidence In addition, concerns have been raised regarding drug diversion from the facility and the role this has played in illegal drug distribution and use in the area. Therefore, I would ask that you investigate the illegal distribution and use of drugs associated with the Tomah VA facility and the local Tomah area. A broad and detailed investigation of the Tomah VA will provide much needed accountability and information that will help us improve the delivery of timely and highest-quality care to veterans in Wisconsin and throughout the country. To achieve that goal, and in light of the severity of the allegations, I believe the law enforcement authorities, investigative expertise, and independence of the US. Department of Justice are required. Sincerely, Tammy Baldwin United States Senator Cc: Michele M. Leonhart, Administrator, Drug Enforcement Administration