While I have been fighting the Carl T. Hayden VA Medical Center for humane treatment (June 2020) and medical services, making no progress, the Department of Veterans Affairs (VA) has undoubtedly been busy oppressing others, allowing their employees to skate responsibility, and avoiding accountability. For the record, I have not deep-dived the legal proceedings reported below and would remind everyone that those charged are not guilty until a jury of their peers says so in a court of law. I am not passing judgment and am only reporting from official VA-OIG reports, leaving the conclusions mainly to you, the reader. The conclusions offered are mine alone, and you are free to draw your conclusions based upon the data delivered and your due diligence.
The Department of Veterans Affairs – Office of Inspector General (VA-OIG) has been busy filling my inbox all week. Here are the latest stories of shame from the VA Chronicles:
- VA Health Care System (VAHCS) Fort Harrison, Montana, the investigation began with two people calling for help to the Veterans Crisis Line (VCL). From the VA-OIG report, we find the following:
“The VA-OIG substantiated a VCL responder failed to assess caller 1’s homicidal risk factors, address lethal means restriction, complete an adequate risk mitigation plan, communicate critical information to a supervisor, and take actions to prevent a family member’s death. VCL leaders did not consider an administrative investigation board to review the responder’s potential misconduct. The VA-OIG substantiated that two social service assistants (SSAs) failed to dispatch local emergency services for caller 2 following a responder’s rescue request. The VA-OIG identified deficiencies in SSA oversight.
VCL leaders did not fully adhere to Veterans Health Administration (VHA) policies related to reporting and disclosure of adverse events. A facility primary care provider failed to include caller 1’s mental health diagnosis in the assessment and plan of care. Also, the primary care provider did not submit caller 1’s non-VA medical records for scanning into the electronic health record or document a review of the records, as expected by VHA policy.”
I have been trained in emergency psychological triage; this was part of my training as a Chaplain’s Assistant in the US Army. When you work on a crisis line, you cannot not take immediate action to save a life! When my friend called me all depressed and intimated he wanted to end his life, I called 911, explained the situation, and asked for help. They provided help. I was not acting in any official capacity; I was not working a crisis line; I was simply a concerned friend. How can these crisis line employees, managers, and other staff escape accountability and responsibility? The whole chain of events is a lurid report of failure to take action by people duty-bound and placed in positions to act, and they refused to take action; this conduct is inexcusable!
As a substitute teacher, I was a mandatory reporter. If I heard anything untoward, I had to act! As a Chaplain’s Assistant, I was a mandatory reporter, and I was empowered to act, even without my chaplain’s permission, which by the way, pissed off my chaplain; but he refused to see specific soldiers in crisis. Not my fault, but I took my Article 15 with pride! Taking us back to the VA employees who failed miserably the need to take action, and still escaped accountability and responsibility!
- Our next story is a back-slapping congratulatory declaration regarding a soldier committing fraud.
“Shawn Pierre Hobbs, a soldier for the Connecticut Army National Guard and a Rikers Island correction officer employed by the New York City Department of Correction, was arrested yesterday in El Paso, Texas, on wire fraud and aggravated identity theft charges. VA Inspector General Michael J. Missal said, “The charges unsealed today are the result of the hard work and dedication of the VA-OIG’s special agents working with our law enforcement partners. The VA-OIG will seek to hold accountable those who perpetrate fraud and steal benefits that are intended for deserving veterans.”
There are still many details missing in this story that I bet the public will never see. Since no VA Employees were mentioned, I can only surmise that they escaped accountability because the main perpetrator was caught, so according to the VA-OIG, no harm, no foul. I believe that as much as I believe in buffalo wings originating from flying buffalo!
- Our next report is one of such supreme idiocy that words can barely describe the situation and the current findings. Consider the following, you arrive at your doctor’s office and need several routine shots. If the doctor and nurse fail to document these shots properly were delivered, and you have an adverse reaction, they can be held liable for medical negligence under the law. Why does the same not apply to the VA? The following comes from a memorandum issued by the VA-OIG, declaring an investigation is ongoing on this issue, but problems have already been found!
“While reviewing the Veterans Health Administration’s (VHA) plans to document receipt and distribution of the COVID-19 vaccine, the VA Office of Inspector General (VA-OIG) determined that VHA facilities did not consistently document the COVID-19 vaccination status of veterans living in VA’s Community Living Centers (CLCs).
The VA-OIG determined that VHA could not know at a national level whether the vaccine was offered to some CLC residents, and if so, what their status was. Because CLC residents are in the highest COVID-19 vaccine priority group, they should be offered the vaccine, when possible, before other groups of veterans. With vaccine supplies limited, VHA should know which CLC residents still need to be vaccinated.
The VA-OIG found VHA has made important strides in distributing vaccines to CLC residents, but [needs to] move toward more comprehensive and consistent data collection to guide ongoing actions and protect this vulnerable population. Doing so would include making sure all CLCs routinely track refusals and contraindications in a consistent manner. Guidance should be clear that all communications should be consistently documented in accordance with VHA processes.
Similarly, clear guidance and consistent oversight should help ensure CLCs are properly tracking veterans who fall in the 23 percent of CLC residents missing information needed to determine their vaccination status. It was not possible by January 2021 to establish which of the 1,899 veterans in this cohort had been offered the vaccine. The VA-OIG will continue its oversight work on vaccinations within VHA and plans to issue a full report, including specific recommendations. In the meantime, the VA-OIG requests to know what action, if any, VHA takes to mitigate the potential risks identified in this memorandum and the outcome of those actions.”
Essentially, the VA-OIG is claiming the VHA cannot document in their long-term care facilities which residents have and have not been vaccinated against COVID. Can you believe the incredible negligence being witnessed; I cannot! In the US Army, due to chiggers and a violent allergic reaction to them, I spent several weeks in what is called the “Reception Battalion.” My job was documenting who got vaccinated, what shots were received, and I was held responsible if the documentation was incorrect. I have worked in long-term care facilities not owned by the VA and witnessed the time and energy spent documenting everything the patient experiences. I have visited family members in long-term facilities and witnessed the documentation procedures. Yet, miraculously, the VHA does not have to submit themselves to the same level of documentation requirements. Where is that memo, policy guideline, or written procedure? Where are the lawyers? For the VHA to have a problem with documentation of a patient is 100% inexcusable, and people’s heads should roll over this failure to document!
- Our next chronicle of shame is both a good and bad report.
“Muhammad Z. Aabdin, 30, of New York City, has been charged by complaint with offering a bribe to a VA contracting officer in September 2020. Specifically, Aabdin allegedly offered to share profits with the officer in exchange for her awarding VA contracts to Aabdin for personal protective equipment.”
That the VA employee reported, the bribe is a good thing. That a contractor felt comfortable enough to offer a bribe is considerably less of a good thing. Are there additional questions being asked and investigated in this procurement office regarding the offering of bribes and the potential of having previously taken bribes? Where are the supervisors in this affair? The VA persists in hiring from inside for the advancement of careers, not a bad thing, but when a contractor is comfortable offering bribes, there should be many questions being asked of supervisors, directors, and so forth.
The fact that the behavior of VA employees breaking the law is both widespread and well known should be a wake-up call to the leaders of the VA and the elected officials charged by law to scrutinize the government. Except, this behavior has never been scrutinized sufficiently to end the behavior, only scrutinized enough to encourage the behavior, the negligence, and the extreme indifference. Every American Citizen should be outraged and motivated to shout at their elected officials using all communication channels until this abhorrent behavior is sundered forever from the VA body!
Except, I am preaching to crickets. Your taxpayer dollars are funding the abuse of veterans at the hands of the government. Shameful! Inexcusable! Outright blasphemous! Yet, allowed to continue because of apathy; Plato was right!
© 2021 M. Dave Salisbury
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