TOMAH, Wis. There were "systemic failures" by the federal agency charged with independently investigating complaints at a western Wisconsin Veterans Affairs medical facility known as "Candy Land" because of the free flow of prescription drugs, a U.S. Senate committee probe released Tuesday determined.

The report singles out the VA's inspector general's office for "failure to identify and prevent the tragedies" at the Tomah Veterans Affairs Medical Center, including not publicly releasing findings from its probe that could have saved lives and improved operations.

"This is a leadership failure," Sloan Gibson, deputy secretary of the VA, testified at a field hearing of the Senate Homeland Security and Governmental Affairs Committee. "There's lots of finger pointing and everything else. At the end of the day, we own this. VA leadership owns this. We had ample opportunities over the years to fix this."


The report by the Republican majority of the Senate committee found the VA inspector general's office discounted evidence and testimony, needlessly narrowed its inquiry and has no standard for measuring wrongdoing. The report also says a culture of fear and whistleblower retaliation continues at the facility.

The inspector general office's failure to publish results of an investigation into the Tomah facility, which found that two providers there had been prescribing alarming levels of narcotics, "compromised veteran care," the report found.

The inspector general's office needs to "clean house," said Wisconsin Sen. Ron Johnson, chairman of the committee.

Johnson said that he "absolutely" believed there were problems at other VA facilities across the country not being found by the inspector general's office, but the "vast majority" of veterans he speaks with are satisfied with the care they are getting. Johnson said the ultimate solution to problems with health care within the VA system is to give veterans access to the private health care system.

Inspectors for the VA in 2014 found that doctors were over-prescribing opioid painkillers, leading to the "Candy Land" nickname. Jason Simcakoski, a 35-year-old Marine veteran, died from "mixed drug toxicity" at Tomah five months after the inspector general closed the case. He died days after chief of staff Dr. David Houlihan approved adding another opiate to the 14 drugs he had already been prescribed. Houlihan was nicknamed "candy man" by some patients.

"What we heard here was good," Simcacoski's father, Marvin Simcakoski, said after the hearing. "I think the outlook is good for favorable changes."

After Simcakoski's death, the VA conducted its own investigation which led to the firing of Houlihan and the medical center's director Mario Desanctis.


The Senate report found that inspector general investigators suspected Houlihan and nurse practitioner Deborah Frasher "appeared to be impaired" when they were interviewed in 2012, but no action was taken. Houlihan was fired in November 2015 after being on administrative leave for months. Frasher, who worked alongside Houlihan, resigned in February 2015.

Houlihan's attorney, Frank Doherty, disputed the report's findings. He said claims that Houlihan was impaired were "nonsense."

Two listed telephone numbers for Frasher were disconnected. She could not immediately be reached for comment Tuesday.

Democratic Rep. Ron Kind, who represents western Wisconsin in Congress, and Rep. Tim Walz, a veteran and a Democrat from nearby southeastern Minnesota, attended the field hearing along with Johnson and Wisconsin Sen. Tammy Baldwin.

"For far too long, serious problems have existed at the Tomah VA and they were simply ignored or not taken as seriously as they should have been by VA and the VA inspector general," Baldwin said.

Michael Missal, who took over as inspector general for the VA last month, testified that his office made many mistakes and he vowed to improve its operations, including keeping Congress better informed.

Release of the 350-page report comes as Johnson is in the midst of a tough re-election battle against Democrat Russ Feingold. Tomah has already been an issue in the race, with attack ads from both sides blaming Johnson and Feingold, who was in the Senate until 2010, for not doing enough to prevent abuses at the facility.

Johnson, telling reporters before the hearing he intends to be the "watchdog of the watchdog," denied that he was politicizing issues at the VA.

Ryan Honl, a whistleblower who spoke out against practices at the facility, said he felt vindicated by the report. But he said those who let the abuses continue "have a lot to answer for."

Three deaths at the Tomah facility remain under investigation.

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