IG Investigation Highlights Critical Failures in Process
Washington DC- Today, U.S. Senator Bob Casey (D-PA) released the following statement after receiving a personal briefing on the VA Inspector General Report.
“The Inspector General’s report is a critical step in making sure these mistakes never happen again. It is clear that existing procedures need improvement, and in many cases the VA failed to follow their own protocols. I am working on legislation to help make sure we keep people safe.”
In November, an outbreak of Legionnaires’ Disease was confirmed at the VA Pittsburgh Health System as a result of water containing Legionella. When the outbreak became public knowledge, Senator Casey called on the VA to explain why the outbreak occurred and to outline steps to ensure veterans have safe water. At Senator Casey’s request, the VA Inspector General investigated the outbreak. The report concludes that:
- Today’s Report indicated that VAPHS did not always follow their own guidelines in combatting Legionella.
- While the VAPHS often had processes in place at key times those processes were not followed.
- Three key failures were inadequate maintenance of the copper silver ion system at all times, failure to conduct routine flushing of hot water faucets and showers, especially in infrequently used areas and failure to conduct appropriate tests on positive cases of hospital acquired pneumonia.
The report also included recommendations for moving forward, key among them that once a process is put in place to combat Legionella, it must be followed. Senator Casey hopes the VA will seriously consider these recommendations and make the necessary improvements.
Senator Casey announced that he is developing legislation to strengthen the reporting requirements when Legionnaires’ Disease and Legionella are detected. The measure would include notification to:
- The Centers for Disease Control;
- The State and County Health Department;
- The Veterans Administration in Washington, DC
- Any provider affiliated with each case
- All employees at the effected VA Health System
Senator Casey is also looking at other potential legislative actions that need to be taken.
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