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Sep 9, 2021

Tester, Moran, Manchin, Boozman Urge Reforms to Increase Oversight of VA Medical Facilities Nationwide

Independent watchdog reports detailed failed oversight of care for veterans in West Virginia and Arkansas

Senate Veterans’ Affairs Committee Chairman Jon Tester (D-Mont.), Ranking Member Jerry Moran (R-Kan.), U.S. Senators Joe Manchin (D-W.Va.) and John Boozman (R-Ark.) are urging Department of Veterans Affairs (VA) Secretary Denis McDonough to address oversight failures at medical facilities across the country.

“We write to discuss oversight failures at Department of Veterans Affairs (VA) medical facilities,” the Senators wrote in a letter to McDonough. “In particular, we are concerned with the failures at the Louis A. Johnson Veterans Affairs Medical Center in Clarksburg, West Virginia (Clarksburg), and the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas (Fayetteville) that resulted in significant harm and death of veterans in VA’s care. In both instances, facility leadership created cultural conditions that fostered mismanagement and a lack of accountability resulting in tragic outcomes. The Department must work to prevent future similar incidents from occurring, and we request more information about how VA intends to accomplish this objective.”

Earlier this year, VA’s Office of Inspector General (OIG) issued damning reports detailing failures at the Louis A. Johnson Veterans Affairs Medical Center in Clarksburg, West Virginia, and the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas that resulted in death of veterans in these facilities. In Clarksburg, the OIG found that serious, pervasive, and deep-rooted clinical and administrative failures contributed to a nursing assistant’s criminal actions between 2017 and 2018 that resulted in seven counts of murder and one count of assault. In Fayetteville, the OIG found the facility’s Path and Lab Service Chief misdiagnosed more than 3,000 patients over the course of many years, including 589 major diagnostic discrepancies.

They continued, “It is sacrosanct to VA’s mission that veterans trust the medical treatment they receive is high-quality and the people treating them meet all relevant ethical and professional standards required by their field. VA must be proactive in identifying issues with staff as they arise, monitor the quality of care at all levels, and continue to advance a culture of safety at all facilities.”

Last month, Tester, Boozman, and Manchin introduced the Strengthening Oversight for Veterans Act to provide the VA OIG with the authority to subpoena testimony from former VA employees who have left federal service, former contractor personnel who performed work for the Department, or other potentially relevant individuals during the course of its inspections, reviews, and investigations. The VA OIG’s report on Clarksburg noted lack of testimonial subpoena authority limited its ability to conduct a more thorough review.

Read the Senators’ full letter HERE.

Office Contact Information

Senator Tester's Montana staff serves the state from offices in Billings, Bozeman, Butte, Great Falls, Helena, Kalispell, and Missoula. Please bring your concerns with federal agencies, academy nominations, and other situations to one of these Montana offices.


Judge Jameson Federal Building
2900 4th Ave N, Suite 201
Billings, MT 59101
Phone: (406) 252-0550
Fax: (406) 252-7768


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Bozeman, MT 59715
Phone: (406) 586-4450
Fax: (406) 586-7647


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Butte, MT 59701
Phone: (406) 723-3277
Fax: (406) 782-4717

Great Falls

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Great Falls, MT 59401
Phone: (406) 452-9585
Fax: (406) 452-9586


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Suite 104
Helena, MT 59601
Phone: (406) 449-5401
Fax: (406) 449-5462


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Kalispell, MT 59901
Phone: (406) 257-3360
Fax: (406) 257-3974


130 W Front St.
Missoula, MT 59802
Phone: (406) 728-3003
Fax: (406) 728-2193

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