Panel puts spotlight on Legionnaires'

Congressional hearing increases scrutiny over outbreaks at five VA centers across country

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If the beleaguered leaders of the Veterans Affairs Pittsburgh Healthcare System thought the scrutiny over the Legionnaires' outbreak that occurred there had ended with two inspector general reports in April and August, a congressional hearing this morning will put an end to that.

The hearing by the U.S. House Committee on Veterans Affairs not only will bring more scrutiny to the outbreak, it will do it right here during a three-hour hearing that begins at 9 a.m. in the Allegheny County Courthouse, Downtown.

The hearing -- given the provocative title "A Matter of Life and Death: Examining Preventable Deaths, Patient-Safety Issues and Bonuses for VA Execs Who Oversaw Them" -- is open to the public. For those who can't attend, the committee is streaming the hearing live on its website at

The hearing will hear testimony and ask questions from two panels about issues at five VA medical centers around the country -- Atlanta; Dallas; Buffalo, N.Y.; Jackson, Miss.; and Pittsburgh -- and issues that affect all of them.

But the committee chairman, U.S. Jeff Miller, R-Fla., decided to hold the hearing in Pittsburgh because the problems here illuminated not only the problems that led to the outbreak, he said, but how the VA rewards its top officials with bonuses even as problems persist.

"The glowing performance reviews and huge performance bonuses local VA officials received in the aftermath of the tragic VA Pittsburgh Legionnaires' disease outbreak have made the Steel City the epicenter of the department's accountability scandal," Mr. Miller said in an emailed statement. "We chose the city to send a message to veterans in Pittsburgh and all across the country that Congress simply will not tolerate substandard care for our veterans under any circumstances. When we hear about it, we will investigate it, and keep the pressure on VA until the problems are solved, and those responsible for letting patients fall through the cracks are held accountable."

VA spokesman Mark Ballesteros said in an email statement about the hearing that the VA officials "appreciate Congress' continued interest in the health and welfare of America's Veterans."

"All employees are expected to help VA achieve its mission of providing Veterans the highest quality care possible," he added. "When an incident occurs, the Veterans Health Administration leadership conducts a prompt review to understand what happened, hold those responsible accountable and prevent similar incidents in the future. If employee misconduct or failure to meet performance standards is found to have been a factor, VA will take appropriate corrective action immediately."

The hearing comes on the heels not only of continuing local coverage about the Legionnaires' outbreak but national attention in recent weeks.

The first panel at today's hearing will include testimony from a VA police officer from Buffalo, a VA primary care physician from Jackson, and four family members of veterans from Atlanta, Dallas and Pittsburgh, who will all talk about problems they've experienced at their local VA medical centers.

The two families from Pittsburgh who will speak have over the past nine months become perhaps the best known representatives -- locally and nationally -- for the problems that led to the Legionnaires' outbreak here in 2011 and 2012 that sickened 22 veterans and killed as many as six.

"I agreed to go [and speak] because something has got to be done," said Maureen Ciarolla, the daughter of John Ciarolla, 83, of North Versailles, a Navy veteran who was the first fatality in the Legionnaires' outbreak when he died July 18, 2011, after contracting the disease while a patient at the Pittsburgh VA.

She said the committee contacted her several months ago and asked if she "would tell her story."

"It was an easy call," she said.

Bob and Judy Nicklas, the son and daughter-in-law of William Nicklas, 87, of Hampton, the last of the six Legionnaires' victims, also will speak.

The family was happy to share their story, Mrs. Nicklas said, "and to address the accountability issues."

Acknowledging how difficult it still is nearly nine months after William Nicklas died, she said Bob Nicklas will begin reading from their five minutes of prepared testimony, "but, if he gets too emotional, I'll be there to step in."

The second panel of witnesses will begin with testimony from Robert Petzel, undersecretary for health for the U.S. Department of Veterans Affairs.

He will be accompanied by Thomas Lynch, assistant deputy undersecretary for health for clinical operations and management; four medical center directors from Atlanta, Buffalo, Dallas and Jackson; and Michael Moreland, regional director of the Pittsburgh VA.

Also attending for the VA and available to answer questions will be another four regional directors and Terry Wolf, director of the Pittsburgh VA.

The only members of the 25-member committee who are confirmed as attending the hearing are Mr. Miller and the ranking Democrat on the committee, U.S. Rep. Michael Michaud, D-Maine.

No Pennsylvania representatives sit on the committee, but several Pittsburgh-area congressional representatives are expected to attend and participate.

This is the second congressional hearing involving the Legionnaires' issue this year. In February, the committee's subcommittee on oversight and investigations held a hearing focused solely on the Legionnaires' outbreak at the Pittsburgh VA. Family of victims attended but were not invited to testify.

Whether anything will change as a result of the hearing is a concern of the families, who have their doubts after nine months of asking questions, many of which continue to go unanswered, they said.

"The whole joke of this is [VA officials] keep waiting for it to die down. And it won't," said Ms. Ciarolla of Monroeville. "Nothing will change until somebody comes in and takes control. And it's obvious these people can't do it."

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Sean D. Hamill: or 412-263-2579.


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