I fully admit I got behind in April. Dear reader, my apology. I have been whipsawed between emergency room visits, depression, extreme pain, and other issues. Not offering an excuse but a tiny peek into my world as a disabled veteran. Luckily, I have maintained employment because my employer allows me to work from home. My driving privileges are threatened again with removal due to the neurological issues I suffer, and this will dynamically change my life, but this article is not about me, but the continued catastrophe called the Department of Veterans Affairs (VA) and the Inspector General (VA-OIG) reports published.
We begin with a financial efficiency review reported from the inspection of the Durham VAHCS of North Carolina. I know the jokes write themselves when we discuss any government agency and financial efficiency, but I digress. This is a head exploding report of leadership failure in the observation and governance of employees who did not perform the functions they were hired to perform. The VA-OIG found the following from October 1, 2020, through March 31, 2021:
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- The healthcare system had 309 inactive obligations totaling $81.7 million.
- Of these 309 obligations, 200 (totaling over $74 million) had no activity for 181 days or more.
- In a subsample of 20 obligations, VA staff had not reviewed 17, as required.
- Contrary to VA policy, healthcare system staff used purchase cards instead of contracts for 21 of 40 sampled transactions (53 percent), totaling approximately $328,000. These 21 transactions were missing required supporting documentation to verify that the transactions were approved and payments were accurate, resulting in $308,000 in questioned costs.
- 105 more administrative full-time equivalent staff than the expected number, all not doing their jobs as required under Federal Law!
While not all of the findings, those mentioned are the most egregious and in need of corrective action. Would the citizens of Durham, North Carolina, please tell me, has this been reported in the local news? Has anyone lost their jobs as the VAHCS right-sizes the financial department? I can find no additional information that this problem has been corrected, and I am really curious!
Oh, the irony is thick; consider the following:
“The Department of Veterans Affairs Office of Inspector General Training Act of 2021 would help ensure that VA employees continue to be empowered to assist the OIG in improving VA’s operations and using taxpayer dollars to the greatest effect; helping protect patients and improving their care; and ensuring veterans and others receive services and benefits for which they are eligible.”
The above-quoted material originates from Chris Wilber, who testified to Congress’s HVAC Subcommittee on oversight and investigations. What is the number one failure on every comprehensive healthcare inspection (CHIP); the lack of staff training, the inadequacy of staff training, or adequately trained staff. Yet, the statement by the VA-OIG indicates that training has met a threshold for providing adequate training. Let’s talk about a specific action, “the VA secretary signed a directive in September 2021 mandating that all employees complete a one-time training within one year—an important step in improving VA’s culture of accountability.” It is now May 2022; the VA-OIG is pushing for training directives to be legislated, not dependent upon any single VA Secretary. Are you freaking kidding me? Where is the congressional oversight and scrutiny that allows VA training to continue to be subpar and threaten the lives of veterans?
Long have I wondered how the VA could frustrate VA-OIG actions, investigations, inspections, etc. Guess what; the answer has become available:
“… there have been instances in which the OIG has been informed that staff have been told that they cannot share information with OIG investigators without first clearing it through supervisors or leaders—contrary to the Inspector General Act of 1978 (the IG Act), as amended. Under that authority, VA employees at all levels have a duty to cooperate with OIG personnel, including providing information and assistance in a timely manner.”
Employees have been caught lying to the VA-OIG regularly, and what action is taken to remove those employees promptly and efficiently from government service? From direct observation and employee conversations, it is clear that plans are carefully laid before a scheduled VA-OIG visit to present what the VA-OIG wants, but to gloss over the problems, and nothing ever happened to the managers, supervisors, and employees who lied and misdirected the VA-OIG. All contrary to established Federal Law!
Want a specific example of employees intentionally misrepresenting information to the VA-OIG? Look no further than the statement by Chris Wilber, and this incident was covered as a failure of leadership in a previous article.
“Hospital staff at a VA facility in Fayetteville, Arkansas, had concerns about potential substance abuse by the chief of pathology that were not heard and promptly acted on by local management, which allowed him to work while impaired for years. He misdiagnosed about 3,000 patients with errors resulting in death or serious harm and is currently imprisoned. The OIG found a culture in which staff did not report serious concerns about the chief pathologist, in part because they assumed that others had reported him, or they were concerned about reprisal.”
From personal experience, I reported problems to the VA-OIG concerning patient abuse, fraud, waste, and other issues. Never were my concerns acted upon promptly, and I was removed from employment for being a whistleblower. The culture of corruption at the VA is incredible. The examples mentioned by the VA-OIG only further sustain the problem with leadership and how sick the VA truly is as an organization!
We next turn our attention to the VA-OIG report on the inspection of information technology security at the VA Financial Services Center, another head exploding example of leadership failure bordering on criminal! The findings include:
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- component inventory
- vulnerability management
- flaw remediation
- Identifying 252 vulnerabilities, of which 228 the local IT team could not identify.
- the VA-OIG team identified access control deficiencies, as 107 of the 278 FSC systems failed to generate or forward audit logs for analysis.
- the video surveillance system was not fully functional. Ineffective monitoring and recording facility activities supporting information systems minimize the FSC’s incident response capabilities.
How do you spell failure; these findings spell failure to me rather pointedly and dramatically! Want to laugh; staff training remains a concern, but not a finding, of the VA-OIG inspection team. Frankly, with this level of incompetence, staff training should have been a finding.
To be concise and illustrate further the poor leadership, convoluted processes, and brazen noncompliance of VA officials, the following discussion is about two different VA-OIG reports that reached similar conclusions. First, we have the VA-OIG report on “Noncompliant and Deficient Processes and Oversight of State Licensing Board and National Practitioner Data Bank Reporting Policies by VA Medical Facilities.” Second is the VA-OIG report on “Concerns with Consistency and Transparency in the Calculation and Disclosure of Patient Wait Time Data.” Nothing says convoluted processes more than having two written policies, both originating from Washington DC. The superseded policy does not have an expiration date. This means that employees have a designed incompetence excuse ready for not adhering to the most current and applicable policy. Don’t believe me; one of the key findings was, “VHA has presented wait times to the public without clearly and consistently disclosing the basis for their calculations.” Designed incompetence does not come more blatant than this, and who suffers, the veteran. Worse, wait time correction and policy clarification has been stalled by COVID-19, the neverending excuse paying dividends to bureaucrats everywhere!
However, both reports are substantially summated by the VA-OIG; thus, “The lack of programmatic oversight contributed to the failure of VHA leaders to detect and intervene upon facility noncompliance.” Meaning that due to COVID-19, the VHA has refused to do their jobs in deference to the pandemic, and since this is a good enough excuse, the VA-OIG has bought the designed incompetence, lock, stock, and barrel. The VHA leadership is failing; doctors or dentists let go for poor performance were not reported to state and federal boards, so these providers lacking can continue to harm patients. It is a federal law (42 US Code § 11151, US Department of Health and Human Services, Health Resources and Services Administration Bureau of Health Workforce, NPDB Guidebook, October 2018, chap. A., 8 USC ⸹ 7462(a), 38 USC ⸹ 7401(1), among others) that providers let go for cause must be reported within 7-days to the regulatory boards at the state and federal levels. Wait times are hidden because they are so bad; the VHA is embarrassed, so the leaders fall back on designed incompetence to shield themselves while looking for another excuse for poor performance! In both reports, the ramifications of noncompliance are putting people at risk for sentinel events (death, injury, disability, etc.), and the leadership is at best lackadaisical in the performance of their duties.
Where are the congressional overseers in ending the abuse? When will this insanity and bureaucratic inertia end? How many “sentinel events,” including deaths and permanent injuries, will it take until those tasked with scrutinizing the executive branch finally take committed action and hold people accountable? When will the elected representatives stop throwing good taxpayer money at problems that money cannot fix? If these questions are too difficult to answer, please stop running for elected office, for the citizenry is not happy!
We conclude with two related reports so astoundingly obtuse they defy logic and sanity. The first is the annual CliftonLarsonAllen LLP (CLA) audit of the VA’s information security for 2021. The second is the continuing failure of the new electronic health record modernization (EHRM) program. The VA has failed the CLA audit for more than a decade, with many of the hits repeated year-over-year. In fact, the CLA audit is so bad this year; it has taken my mental breath away and stunned me into a gibbering idiot! Reading this report was infuriating; describing it as my head exploding is akin to comparing an M-80 to a nuclear bomb. How in Dante’s Inferno can this level of incompetence be allowed to remain employed? But, as bad as the CLA audit is, the continued failure of the new electronic health record system pales in comparison. The new EHRM continues to suffer from reliability weaknesses, which is polite speak from the VA-OIG for the new system fails to do the job. We are three years from the new extended deadline, we are already past the original deadline, and the system is worthless today than it was a year ago. With this success rate, the new EHRM will be utterly bereft of value and need replacement before the year’s end. How many millions (billions, or trillions) of good dollars must chase this ineptitude before the plug is pulled and those involved held accountable?
Join me in having your head explode:
“Additional deficiencies included known tasks not being reflected on schedules, no risk analysis, lack of longer-term actions scheduled, and no complete baseline schedule or overall schedule that fully integrated individual project schedules. VA also did not comply with federal regulations when it paid its contractor for deliverables before accepting them (reviewing compliance with contract requirements).”
Consider this other gem from the VA-OIG report, “$1.95 billion in cost overruns per year” are estimated, meaning the final tab will be significantly higher and compounded year-over-year. In plain speak, the contractor is being paid for products delivered that fail, the products offered are not usable, there is no schedule of completion, there is no schedule for deliverables, many of the products paid for have never been delivered, and costs are overrunning like a plugged toilet. Worse, no one is being held personally liable for these problems, which were apparent in the last EHRM update from the VA-OIG a year ago! Like the CLA Audit, I am thrilled the VA agrees with the VA-OIG findings, but what are they DOING to fix the problems?
FYI: the image below is a year old, and comes from the last major update to the EHRM.
There is no excuse for behaving like the VA’s bureaucratic legions behave. Bureaucrats, from the city government (including the school board) to the Federal Government, you hold a sacred trust to act better than you are currently performing. I refuse you any leeway for acting like pompous overlords when you are paid through forced taxation! You have trespassed upon my patience and kindness long enough, and the day of reckoning has arrived. You work for me; you work for every taxpayer and citizen in this country, and you have violated our trust, charged us too much and too often, and if you do not begin to show yourself worthy of the sacred trust, we will force you from your cushy jobs and hold you liable for the monies you have squandered! The law is on our side; you need to begin showing you honor our trust and investment forthwith!
© Copyright 2022 – M. Dave Salisbury
The author holds no claims for the art used herein, the pictures were obtained in the public domain, and the intellectual property belongs to those who created the images. Quoted materials remain the property of the original author.
In The Satires, VI, Juvenal poses a question of great importance, “Who will watch the watchmen?” As more and more dirt on a host of politicians comes to the fore, as China expands its heinous reach in the 
On the topic of China, why is 
The US Constitution, in the 10th Amendment, provides all the authority any citizen needs to demand the watchers scrutinize the government and, if required, replace the watchers.
How have the watchmen become millionaires while holding public office? This single question should be the watch cry of every single citizen in America until they are all held accountable and disgraced. You deserve better watchers. Our children deserve better watchers. The world deserves better representatives of the people, by the people, and for the people. Remember this in November!
I hate being lied to! More than I hate being lied to, I detest, with every fiber in my being bureaucrats and the inanity they promulgate to excuse their stupidity and throw a wrench into the works. Today I suffered through yet another call with my VA-appointed primary care provider (PCP). Not an online conference, but a phone call. Who was in the office with the provider and why? How can I guarantee my HIPAA information during a phone call on an unsecured line? How do I know who I am talking to? These concerns and more arise when you receive a phone call to discuss important medical information, and my PCP does not care! My PCP refuses to use the VA’s tools to conduct patient appointments and instead creates workarounds; what an ingenious method for telling lies and spreading falsehoods as bureaucratic inertia; I’m so thrilled!
It is time we end this charade and money pit call the Department of Veterans Affairs, and every other agency of the Federal government bloat! The government should be leading, not lagging, where operational efficiency and fiscal sanity are concerned. I repeat, only for emphasis, are you fed UP yet?
Words fail to describe how much I detest seeing the same abuses week-after-week, month-after-month, and year-over-year. To witness the disaster known colloquially as The Department of Veterans Affairs (VA), as told from the Office of Inspector General (VA-OIG). Not merely witnessing but also being abused by the VA leaves such a bitter taste in my mouth.
Take a moment, read the full articles reporting these crimes, and ask yourself, have ALL the guilty parties been held accountable before the law, or are some parties noticeably missing? If you reach different conclusions, please note this in the comments, and let’s discuss. Show me your thinking, I want to learn!
While the above are not all the reports from the VA-OIG launching 2022, they present the bulk of the criticisms and reflect the need for greater scrutiny and improved leadership at the VA. More to the point, these represent the danger the American public is in from a runaway government that keeps biggering (with a nod to The Lorax and Dr. Seuss)! The VA is abusing your veteran neighbors, and you are paying for it. Doesn’t this stir in you feelings motivating to action? If not, please ask yourself why. Do veterans deserve to be abused relentlessly? Do you like being complicit in a crime perpetrated by bureaucrats, cheered on by elected officials, and paid for by your tax dollars and the future of your children through forced taxation and out-of-control debt? The choice is yours, I know my choice, and I WILL continue to resist the government atrocities every step of the way!
One of the first rules in overseeing junior people working is to make available someone to answer questions, immediately, and render support if needed. I have had the pleasure of training junior people in a myriad of tasks over the years. When I read this Department of Veterans Affairs – Office of Inspector General (VA-OIG) report, a plethora of questions arise, and I deeply question the professionalism and competence of the doctor overseeing the work of residents in a VA Hospital who are performing procedures.
Finally, we come to what I was hoping to be a great report, where the politician’s heads were going to explode at the inefficiencies, the detestable behavior, and the horrendous responses to legally mandated IT infrastructure changes, and why those changes are not happening at the VA. I was not disappointed; I was thoroughly disgusted that his report fell on plastic ears speaking plastic words from wax lips! Statement of Michael Bowman, Office of Inspector General, Department of Veterans Affairs, 
Let me remind you, 
The gall of this director to continue to blame legacy systems that were legislated to have been scrapped between 2000 and 2010 continues to highlight the incompetence of the director in conducting business and holding people accountable for failed projects and overspending of taxpayer monies! The director went further and stated the following, at which time, every single Congressional Representative should have stood and demanded his head. The “VA does not properly manage and secure their IT investments.” Tell me director, why should you remain employed if the VA does not properly manage and secure their IT investments? Is the failure to manage and secure IT investments the root cause for veterans to continue to suffer identity theft from the VA losing their identity?
America, with these bureaucrats in charge, why shouldn’t we be weeping and wailing, and gnashing our teeth in frustration? When will we, the owners of this atrocious government, finally scream ENOUGH and demand a full change of heads at the ballot box? For until the elected representatives are forced out, the bureaucrats abusing us, will only continue! The VA is sick, but the problem lies in the bureaucrats, administrators, and directors leading the VA at the Federal and VISN levels. So many other government agencies are just as sick, or worse, and the same problem arises, the leadership refuses to act, but still expects a big titanium parachute when they leave office! I say it is time to tell them NO!
Plato has a point, “The price of apathy towards public affairs is to be ruled by evil men.” When writing about the Department of Veterans Affairs, the Internal Revenue Service, or the United States Postal Service, one must remember, these organizations have been intentionally designed to be as bad as they are. The government worker refuses accountability, shuns responsibility, and simply wants to exist doing as little as possible for as much as possible.
While Plato has a point about apathy in public affairs leading to being ruled by evil men, what is lost in the discussion are the staff members. Tom Clancy wrote about how a jet airliner took out both houses of the Congress, SCOTUS, and Vice President Jack Ryan suddenly found himself as President Ryan, rebuilding the entire US Government. This Tom Clancy novel takes a person into the inner workings of the US Constitutional Government like no other book I have ever seen. Best of all, he explains the intoxicating power the staff members, the executive assistants, and undersecretaries hold over the political appointees to hinder progress, stymie change, and control their fiefdoms against all forces of influence. This is the root of designed incompetence.
The scourge of designed incompetence must end. If this means eating soup with a knife, then we must eat the bowl of soup to the dregs. But, we must act if we are to save our countries from the politicians and the staff that have infested our governments!
23 February 2021: UPS delivered a letter package containing a single sheet of paper from Dr. Karen MacKichan MD, auto signed, and dated 09 February 2021. Declaring that the Phoenix VA is absolutely correct in behaving as petty tyrants and denying me medical care, illegally sharing and knowing my HIPAA information with VA Police Officers, breaking EMTALA, and treating me to injuries, all because I cannot safely wear a mask. My only infraction at the Phoenix VA is not to wear a mask. Yet, this is considered a “behavioral problem,” and I am wrong for behaving in a manner that insists that my safety comes first!
What are petty tyrants?
On the topic of written directives, written operational policies, written patient guidelines, and written job descriptions and duties, let’s talk about how the VA Police can injure people and not be held accountable! The VA Police attacked me on 07 December 2020, violently pushed, then spun into a wall. My C-and L-Spines did not move, and my T-Spine turned; I dropped like a rock sustaining spinal injuries, knee injuries, and got cut on my right hand and arm. Worse, being handcuffed with my arms behind my back caused bruised wrists that were jerked by more VA Police officers on 10 December when I sought medical attention. I am an 80% disabled person with mobility issues, yet your letter claims all the action of the Phoenix VAMC was in accordance with written policies, guidelines, and directives. Well, I possess a Missouri mindset, “Show ME!” Show me the written and published policies, guidelines, and procedures that allow VA Police Officers to physically assault patients! Show me the written and published policies, guidelines, and procedures that allow me to be refused treatment. Prove through written and accessible documents how the decision for this hodgepodge of ineptitude can label me a “behavioral issue” when my only discretion is not physically and safely wearing a mask!
You claim to have reviewed the actions of the police officers who routinely have medically protected HIPAA information about people being arrested, joke about this information, act in a manner that brings shame to all Federal Police Officers. What happens to these unprofessional officers and their despicable commander? When do my rights to have my HIPAA-protected information withheld from parties who do not need this information? When do all the other veterans being served and not being served by the Phoenix VAMC become protected under HIPAA? I am not the only veteran being refused service, denied care, and abused and injured by the VA Police for not wearing a mask, while also not being a “behavioral issue.”
Your letter discusses “the most effective manner to have the behavioral flag lifted” as “checking-in with the VA Phoenix Police.” Do you know what that entails? Did your “thorough, comprehensive, and independent” investigation uncover what happens at this “check-in?” I was told clearly what happens; I will be evaluated for wearing a mask, found not wearing a mask, arrested, cited, and denied service for not wearing a mask. Then, I will have a black mark on my behavioral flag record for disorderly conduct! I am not disorderly in my behavior because I cannot safely wear a mask! What part of this do you, as a medical doctor, fail to comprehend?
I always interact with the staff at VAMC’s, even when they are wrong, in a respectful manner, knowing that the problems of dumb policies, time-wasting procedures, and bureaucratic inertia are the fault of the leaders hiding in their offices and cubicles. I have been interacting with the VAMC’s across America, and the inept staff, since I left the service in 2004! Never having a problem, never having an issue, and never getting injured by or even interacting with VA Police. This all changed in June 2020. The VAMC refused to write down a comprehensive directive for COVID Patient Mask Wearing. I get blamed for following the unwritten policy and directives, then falsely accused of being “disorderly” in my behavior, then falsely accused, again, for being a “behavioral issue!” I am not in the wrong here! I am not a “behavior issue!” I am not disrupting hospital operations, placing other patients at risk, or being violent! Where are my rights in this farrago and railroading scheme?
Your boilerplate response indicates this issue has reached the final point. I beg to differ! I will have my name cleared of these false charges. I will not be blamed for the ineptitude of the leadership at the Phoenix VAMC and VISN 22! I will not be silent and meek in the corner because you cannot tell the difference between standing for one’s rights against tyranny and compulsion and oppression through bureaucratic fiat! I have done nothing worthy of these fallacious claims, false accusations, and the Phoenix VAMC and VISN 22 will admit this publicly when I am done cleaning my name of the scum you have thrown upon it! Make no mistake; I am not angry, but I will have my rights restored, my name clear, and satisfaction from the injuries and treatment I have been made to suffer!
The Department of Veterans Affairs – Office of Inspector General (VA-OIG) recently released two additional reports on behavior unbecoming at the VA. The first report concerns the delays in diagnosis and treatment in dialysis patients, as well as patient transport at the Fayetteville VA Medical Center in North Carolina. The second is another death of a patient, as well as deficiencies in domiciliary safety and security at the Northeast Ohio Healthcare System in Cleveland.
Bureaucratic inertia is the cause of too many issues, problems, and dead veterans, at the Department of Veterans Affairs. The symptoms include delays in administrative tasks that lead to patients dying for lack of transport to a hospital. The symptoms include cost overrun on every construction project the VA commences. The symptoms include abuse of employees, creating a revolving door in human resources where good people come in with enthusiasm, and leave with anger and contempt, generally at the insistence of a leader who refuses to change. The symptoms include a bureaucrat making a decision that has no logical sense, costs too much and is never held accountable for the harm because the decision-maker can prove they met the byzantine labyrinth of rules, regulations, and policies of the VA.
Secretary Wilkie, until you can overcome the bureaucratic inertia prevalent in the ranks of the leadership between the front-line veteran facing employee and your office, lasting change remains improbable. Real people are dying from bureaucratic inertia. Real veterans are spending their entire lives in the appeal process for benefits and dying without proper treatment. Real families are being torn asunder from the stress of untreated veterans because the bureaucratic inertia cannot be overcome from the outside. I know you need legislative assistance to enact real change and improve the VA. By way of petition, I write this missive to the American citizen asking for your help in providing Sec. Wilkie the tools he needs to fix the VA.
DNC-Consulting 