Comprehensive Healthcare Inspection

When is Enough… ENOUGH? – More Chronicles from the VA

Honest question. I surpassed my ultimate threshold in waiting for the VA to improve in 2010 and stopped accepting the excuses, the platitudes, and the whiny discourse from the VA. Elected officials charged with scrutinizing the US Government, when has patience been surpassed, and you will cease allowing this nefarious Kabuki? The veterans are waiting, the taxpayers are fed up, and you need to make a decision and act.

Consider the following investigation by the Department of Veterans Affairs (VA) – Office of Inspector General (VA-OIG). The scenario:

“The VA Office of Inspector General (VA-OIG) conducted an audit to determine how effectively the Veterans Health Administration (VHA) billed private insurers. [Billing private insurance is a piece of legislation that the VA has haphazardly followed. The VA remains the first party payer and is authorized under 38 USC 1729 to bill and collect reasonable charges for nonservice-connected care where such veterans have other private health insurance.] Prior OIG investigations have shown that VHA has missed opportunities to recover funds that could be used to help finance care for other veterans. VHA’s Office of Community Care (OCC) manages community care programs and bills private insurers when needed. OCC must submit reimbursement claims before insurers’ deadlines are reached, or they may be denied.”

The legislature passed laws demanding action, and the result was:

- - OCC did not establish an effective process to ensure staff billed veterans’ private health insurers as required
  - OCC did not collect an estimated $217.5 million that should have been recovered, a figure that could grow to $805.2 million by September 30, 2022
  - OCC’s billing and revenue collection process also was not synchronized with insurers’ filing deadlines, and claims information was not always available for billing
  - Pending workload volume and staff shortages hindered effective billing
  - OCC was broadly aware of challenges to its process to bill and collect revenue from private insurers; its responses were insufficient to correct these issues.

Hundreds of millions of dollars are sitting on the table, and the VHA – OCC still cannot properly follow the law. Worse, they are slower than molasses running uphill in Michigan in January to pay community providers, inventing hoops and red tape nonstop for providers, which increases the cost of healthcare. This is not the first VA-OIG investigation on this issue in 2022, let alone since 2000; with the same findings, the same recommendations are issued, and nothing improves. Thus, I have two questions:

When is enough ENOUGH?
How does this reflect the VA Administration’s commitment to the vision of the VA?

Consider the following; the VA-OIG regularly conducts comprehensive healthcare inspections of VHA facilities. The findings of these investigations are supposed to spur institutional improvement. Regularly the VA-OIG places the following comments into the reports of these investigations, hoping nobody will ever read the report and find these facts.

“The VA-OIG found deficiencies in identifying sentinel events and conducting institutional disclosures. Additionally, there were repeat findings from the June 2017 comprehensive healthcare inspection related to inter-facility transfers.”

Imagine a private company being inspected by the government for a moment where previous investigation findings were not improved; what would happen? An army of lawyers would descend on the customers looking for those harmed/injured, legions of lawyers would pour through employee records looking for injuries and other potential claims, the government would seize assets and halt production, all this and more. The media would be covering 24/7 news cycles on the slightest allegations of wrongdoing. Elected officials would be hurrying to write legislation and find a media talking head to bloviate to.

What do we hear where the VA is concerned; not even crickets! The VA has played complicit roles in veteran deaths, and still not a peep, word, or even crickets. Remember, these findings occur frequently enough that not finding these remarks is a cause for celebration and is exceedingly rare. Thus, I have two questions:

When is enough ENOUGH?
How does this reflect the VA Administration’s commitment to the vision of the VA?

Other oft findings from comprehensive healthcare inspections include the following:

- - Medical center leaders were generally knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models (SAIL Metrics). – What does “generally knowledgeable” indicate? Why have we accepted general knowledge from those who should have specialized, detailed, and comprehensive knowledge and use this knowledge in daily practice?
  - Outpatient satisfaction survey results were generally higher than VHA averages but revealed opportunities to improve specialty care experiences for female veterans. – Please note beating the VHA average is good but nothing to brag about. Beating the VHA averages is akin to claiming to be the biggest pig in a pig wallow. Sure, you’re big, but you are still covered in mud!
  - Employee satisfaction survey scores for the medical center were lower than VHA averages. – Not a surprising finding in any way, shape, or form. Employee morale is scathingly low, and it shows in every customer interaction! More comparing pigs by size in a pig wallow, and it’s not like the VA would punish whistleblowers, fire productive people, castigate, denigrate, deride, and treat employees like chattel… Oh, wait, yes, it is!

Interestingly, I receive 3-10 of these monthly investigation reports from the VA-OIG, and too often, they read like someone is cutting/pasting the findings from one report to the next. Thus the conclusions of these findings occur frequently enough that not finding these remarks is a cause for celebration and is exceedingly rare. Therefore, I have two questions:

When is enough ENOUGH?
How does this reflect the VA Administration’s commitment to the vision of the VA?

Let us consider another VA-OIG investigation, which, unfortunately, recurs too frequently where inappropriate conduct is a norm, not an exception. VA facility leaders’ response to inappropriate relationships. Regular readers will know how common it is to find inappropriate relationships and sexual misconduct by VA Employees to other employees, underlings, and veterans. The scenario:

“The VA Office of Inspector General (VA-OIG) conducted a healthcare inspection to evaluate leaders’ response to the knowledge of inappropriate provider-patient relationships. The VA-OIG determined that while facility leaders initially addressed three inappropriate relationships between mental health providers (Providers A, B, and C) and mental health patients (Patients A, B, and C), multiple factors affected the effectiveness of those actions.”

Finding the following:

- - The OIG found that effective facility leader actions to investigate and address the inappropriate relationships of Provider A and Provider B occurred only after an Office of Accountability and Whistleblower Protection complaint.
  - Facility leaders ineffectively addressed Provider C’s inappropriate relationship before Patient C died by overdose.
  - Facility leaders failed to report Providers B and C to their state licensing boards promptly.
  - Failed to report Provider A to the appropriate professional certification board.
  - Facility leaders did not take actions to address the circumstances that contributed to the death of Patient C, who was involved in an inappropriate romantic relationship with Provider C.

Regrettably, the VA-OIG could not determine if an adverse patient event occurred when finding that the inappropriate relationship played a role in a veteran’s suicide by overdose. I understand investigative scope creep, but this is ridiculous. You have a dead veteran in an inappropriate relationship with a provider, and you cannot investigate if this was an adverse event. What type of bureaucratic inertia sponsored this madness?

Some items in this investigative report stand out, beginning with the fact that the facility leaders who refused to take action remain employed by the VA! Knowing about problems and not taking prompt and decisive action is negligence in performing one’s duties. Possessing authority and refusing to implement policies and procedures, ensuring compliance by professionals, defies description and should result in VISN leaders losing their jobs! Unfortunately, these inappropriate relationships are not rare; even if the VA-OIG has not gotten around to investigating the problems, ask the VA employees, and you will find the proof of concept and incredibly high frequencies. Hence, I have two questions:

When is enough ENOUGH?
How does this reflect the VA Administration’s commitment to the vision of the VA?

In the annals of government fraud, waste, and abuse, the following VA-OIG investigation must rank in the top 20 somewhere.

“The VA Office of Inspector General (OIG) initiated this review to evaluate whether purchases of iPads and iPhones for veterans met mission needs while minimizing waste during fiscal year (FY) 2020 and through the first two quarters of FY 2021. In July 2020, Connect Care officials purchased 10,000 iPhones with unlimited prepaid data plans for the homeless veterans enrolled in the HUD-VASH program. However, 8,544 of the 10,000 iPhones remained in storage as of July 2021, as demand for the iPhones was much lower than anticipated. The OIG found that this resulted in an estimated $1.8 million wasted data plan costs. The OIG also identified opportunities for improvement regarding data plans for nearly 81,000 iPads purchased. Because Connected Care did not have strong enough oversight procedures for reducing or eliminating data plan waste, it incurred approximately $571,000 in additional wasted data plan costs.”

When I was offered telehealth, I was responsible for providing the equipment and maintaining an Internet connection. This was made clear by the VHA Administrators before they signed off on allowing me telehealth and reiterated by my providers when they renewed permission. How can the VHA and VA leadership and contracting officials imagine this is acceptable? How many of these devices are still in the hands of veterans? How many have broken, been pawned, or otherwise not survived?

Again, not casting aspersions, merely asking questions, namely the following:

When is enough ENOUGH?
How does this reflect the VA Administration’s commitment to the vision of the VA?

I could weep from the frustration felt in reporting another veteran’s death by suicide, receiving care from mental health providers with the VA, and being investigated by the VA-OIG, where the providers are complicit. The scenario:

“The VA Office of Inspector General (VA-OIG) conducted a healthcare inspection to evaluate VA-OIG-identified concerns related to the assessment and documentation practices of a behavioral health certified registered nurse practitioner (BHNP) and leaders’ completion of BHNPs’ ongoing professional practice evaluations (OPPEs).”

The findings:

- - The BHNP did not perform thorough suicide risk assessments for a patient who died by suicide.
  - Identified multiple deficiencies in a BHNP’s assessment and documentation practices, including the absence of comprehensive suicide risk assessments, failure to complete abnormal involuntary movement and metabolic assessments for patients prescribed particular antipsychotic medication, missing informed consent or a risk-benefit discussion when prescribing off-label medications, failure to resolve rule-out diagnoses, and substantial copy and paste use.
  - Finding adverse clinical outcomes for one of eight patients for whom the BHNP did not document a comprehensive suicide risk assessment, as required by The Joint Commission.
  - Finding the Nurse Manager evaluated BHNPs as satisfactory in the OPPE elements of copy and paste use for the fiscal year 2018 through the first half of the fiscal year 2021 and safety plan completion for high-risk suicide patients for February 2020 through the first half of the fiscal year 2021, without these elements being evaluated.

Is it clear why I am asking about where the limitations of patience are? The supervisor was directly responsible for leading the BHNPs and failed, and while it is not mentioned, we can presume this person remains employed. Failed to train staff, failed to supervise staff, refused to do your job. Yet, you remain employed (probably) and (potentially) were promoted, as this is the regular pattern for VA employees caught but who are politically acceptable or connected. The supervisor is directly connected to a dead veteran, a family is weeping this holiday season, friends are missing, and all I can do is keep asking the politicians:

When is enough ENOUGH?
How does this reflect the VA Administration’s commitment to the vision of the VA?

Do you also feel the weight of responsibility; your tax dollars fund this abuse. Representatives of your government are complicit in adverse patient events, including death, and they refuse to engage, holding government employees accountable and fixing the mess. Veterans signed a check, telling the government we will perform duties and obligations. Why aren’t the veterans honored for their sacrifice and respected by elected officials and government employees, especially at the VA?

America Weeps The VA’s mission statement is “to fulfill President Lincoln’s promise “To care for him who shall have borne the battle, and for his widow, and his orphan” by serving and honoring the men and women who are America’s veterans.” The statement is meant to echo the reverence given to the men and women who serve in the American military with honor. Reflecting that this body (the Department of Veterans Affairs) is tasked with serving them respectfully, similar to how they served their nation. One final question is, “Does killing, abusing, and harming veterans equate to honoring the VA mission statement?”

© 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.

“That’s Crazy!!!” – More Chronicles from the VA Chapter 4

Last week, my primary care provider informed me that the VA is no longer responsible for providing my prescriptions as an outside provider that the VA Community Services team sent me to has increased my dosage. My primary care provider pulled a Pontius Pilot and washed her hands, and I am swinging in the wind with more bureaucracy and less service. The best part of the news delivered this last week, the fallacious, seditious, and felonious attack on my character, the behavior problem flag, is controlled by the primary care provider. Boy, I am sick of the bureaucracy of the VA; if only this were the worst of the bureaucratic baloney, the VA is pushing out.

From many VA-OIG reports during COVID, the following, or something close, was a regular statement:

“During COVID-19, VHA’s Office of Community Care (OCC) took steps to ensure veterans continued to have expanded access to health care in the community, as required by the VA MISSION Act of 2018. OCC issued policies to VA facilities to postpone non-urgent appointments and offer alternatives to in-person care, such as telehealth.”

The VA-OIG inspected to see how closely this statement was adhered to during the height of the COVID pandemic. What surprises no one is how badly the VA managed community care during the pandemic.

Findings:

- The VA-OIG found that routine community care consults were unscheduled, averaging 42 days, not meeting VHA’s timeliness goal of 30 days.
- Community care staff faced significant challenges beyond their control that contributed to the scheduling delays, such as the lack of availability of appointments in the community.
- Some patients were hesitant to schedule appointments during the pandemic, failed to return phone calls, or declined care once it was offered. – While some of this is definitely patient-driven, what is not discussed is the abrupt shift, the lack of trust, and the confusion about the need to pay the community providers, among other things, faced by veterans forced into community care. As a reference point, it has been 24-months, and I am still facing requests to pay several community providers due to the VA not paying the bill due to a technicality. The VA claims the provider has to “eat the costs,” but I keep getting statements and calls from collection agencies. Guess the direction of my credit score, the direction of my insurance costs, and how happy I am with community care providers.
- The VA-OIG found community care providers and staff did not consistently comply with requirements to manage routine consults, and leaders lacked tools to sufficiently monitor program operations that could have identified the problems.
- Deficiencies emerged in documenting when patients were contacted about scheduling appointments, designating patients eligible for alternative care, and ensuring staff was trained in ways that would address those weaknesses. – Not to mention that pertinent medical records still haven’t been transmitted, received, and alerted the primary care provider. I had gallbladder removal surgery; no records ever made it to the VA. I have MRIs, CT scans, and ER notes that, even after being hand-delivered, have not been added to my VA electronic health record and presented to the primary care provider to discuss, dating back to 2010.

How’s that community service program working for you? In any other industry, this performance would represent an abysmal failure; but community care represents a healthy opportunity for improvement at the VA. The findings listed are a mere drop in the conclusions discussed in the report. I have a suggestion for the VA, stop overpromising and underdelivering. How about you under-promise and then over-deliver?

The following VA-OIG inspection report focused on the Veteran Health Administration facility’s adherence to guidelines for medication management, and the following explanation is quoted from the report:

“This report describes medication management findings from healthcare inspections initiated at 36 VHA medical facilities from November 4, 2019, through September 21, 2020. Each inspection involved interviews with facility leaders and staff and clinical and administrative processes reviews. The results in this report are a snapshot of VHA performance at the time of the fiscal year 2020 OIG reviews.”

Before we get into the findings, let me elaborate on that statement. The VA-OIG cherry-picked/hand-selected call it what you will, the facilities to inspect. No criteria discuss how these facilities were selected. More, the processes chosen for review were also cherry-picked/hand-selected. Appearing to represent that, the VA-OIG stacked the deck to obtain success, and the VHA still failed, or rather showed weaknesses.

Generally, the VA-OIG rated the VHA facilities as “compliant.” But “weaknesses” were identified; read that as the VHA cannot follow established guidelines, protocols, and processes, even though they wrote and established these guidelines and medication protocols. I call this designed incompetence of a criminal nature, but I am not half as lenient and politically astute as the VA-OIG!

Findings:

- Aberrant behavior risk assessments
- Concurrent benzodiazepine therapy
- Urine drug testing
- Informed consent
- Patient follow-up
- Quality measure oversight.

The following, also from the medication’s adherence inspection, remains significant:

“The OIG examined the following indicators of program
oversight and evaluation:

- - Performance of pain management committee activities
  - Monitoring of quality measures
  - Following the quality improvement process”

For the weaknesses represented in the findings to be prevalent, the “Pain Management Committee activities” represent a general failure of the committee to function! For quality processes to be a finding, monitoring quality signifies that the bureaucrats are NOT doing the jobs they were hired to perform! A quality process fails when the humans tasked with oversight refuse to engage, and the VA-OIG findings testify to the truth of humans actively refusing to do their jobs individually and collectively!

Having read and written about the VA-OIG reports for almost ten years, I swear sentences containing the following represent a majority stake in why the VA-OIG cannot be trusted.

“VA-OIG inspections… underscored the value of independent oversight of care received in these settings to help VA make continuous improvements.”

Really? Are you sure the VA-OIG inspections provide “independent oversight” and spur “continuous improvement” at the inspected VA facilities? I have significant doubts the inspections do anything more than highlight the problems as the VA-OIG inspectors have no teeth, and lying has zero repercussions for the humans defrauding the taxpayer! How do I know this; the VA-OIG reports generally go on to make a claim similar to the following:

“The OIG’s findings show that immediate attention is needed in several critical areas….”

Do you, the dear reader, understand better the frustration of veterans and their families? When the Office of Inspector General (OIG) for the Department of Veterans Affairs (VA) covering the National Cemeteries, Veterans Benefits Administration (VBA), and Veterans Health Administration (VHA), can be deluded, distracted, and duped by conniving and conspiring people, what else can the veterans and their families do BUT become frustrated? This is behavior unacceptable in every industry. In fact, legislation overseeing non-government healthcare is strict in outlawing the conduct observed in government-provided healthcare, but somehow the VA is exempt. Yet, the VA continues to make claims such as the following:

“This is how the VA is delivering on its promise to care for the veteran who has borne the battle, his widow, and his children.”

But don’t take my word for it; the VA-OIG conducted several more Comprehensive Healthcare Inspections (CHIPs), resembling cookie-cutter inspections. Staff training continues to be a major delinquency labeled as “High-Risk.” Behavior Committee continues to be a central sticking point and inspection problem. Cleanliness, tagged under “Quality, Safety, and Value,” continues to represent an area for growth and development. Nurse-to-Nurse communications remain constant as a problem, and electronic medical records are not helping to improve on this problem. Inter-facility transferring of patients, policy, and documentation also resemble a constant issue. I feel like I could summarize a CHIPs report with my eyes closed; tell me, when does the “independent oversight” spur “continuous improvement?”

On the topic of “independent oversight” spurring “continuous improvement,” the VA-OIG conducted a VHA inspection of mental health activities for FY 2020. Declaring:

“This report describes mental health-related findings from healthcare inspections initiated at 36 Veterans Health Administration medical facilities from November 4, 2019, through September 21, 2020, and electronic health record review at five additional facilities. Each inspection involved interviews with facility leaders and staff and clinical and administrative processes.”

Again, how the facilities were selected and the items reviewed appears to have stacked the deck in the VHA’s favor. The VHA is still failing, showing weakness while generally being compliant.

Findings:

- Completion of four follow-up visits within the required time frame
- Appropriate follow-up of veterans with high-risk patient record flags who do not attend mental health appointments
- Suicide prevention training
- Completion of five monthly outreach activities.

Under these four categories, recommendations for improvement included:

- Registered Nurse Credentialling – Source verification of licenses.
- Staff training on Suicide Prevention
- Care Coordination – Especially in transferring the patient, form completion, and evaluating transferred patients
- Medication list transmission during transfers
- Staff Training
- Patient notification
- Attending the Disruptive Behavior Committee

For anyone else keeping record, most of the list above is a repeat from the last several years the mental health inspection has occurred. Color me shocked that the VA would still have issues remaining year-over-year, and if you cannot hear the sarcasm in that statement, I have some suggestions for you!

I am thoroughly sick to death of the VA failing in its mission, then bragging they are providing “Excellence in Healthcare.” If the staff is not trained, they cannot perform their jobs, representing a leadership failure. This is a truth for all industries, occupations, businesses, organizations, etc. Nobody is exempt from this statement of fact, yet the VA-OIG keeps on swallowing this excuse year-over-year, and NO PROGRESS is EVER made!

America, are you aware of what the various government agencies are doing with your money, on your time, and with your consent? If your neighbor took your checkbook and wrote checks you are legally responsible for paying, would you want better services rendered? Elected officials (yes, I am including those at the city, county, state levels of government), why are you NOT scrutinizing the government more effectively and rigorously? You, the elected officials, are the neighbor writing checks; why are YOU NOT doing the job we hired you to perform?

Elected officials, did you know that VA is not required to maintain records of returned bills, as a matter of policy, but those returned bills mailed to veterans are causing hardship for veterans. I cannot recount how many times I have changed my address and my spouse’s address with the VA, on the VA-approved websites, and in-person with VA representatives, and still have had mail not delivered for months due to a wrong address in a legacy system. Yet, the VA is not policy mandated to check returned mail, track that mail to a veteran, and check the different legacy and non-legacy systems for address veracity.

Elected officials, do you read the VA-OIG reports? Honest question, as the following is directly from a VA-OIG report.

“[VHA primary care] providers did not consistently

- - - Identify a surrogate should the patient lose decision-making capacity
    - Address previous advance directives, state-authorized portable orders, and/or life-sustaining treatment plans
    - Address the patient or surrogate’s understanding of the patient’s condition.”

The VA designed the PACT Team to improve care and deliver on the VA’s mission, yet the primary care provider has the following failures weaknesses showing. The VA-OIG can do nothing to improve this glaring oversight, but you were elected to force change and spur “continuous improvement” in the executive branch officers and employees. Well, where are you? The VA-OIG substantiated that a failure in the PACT team led to a delay in a cancer diagnosis, causing increased pain, problems, and resource loss for a veteran; where are the elected officials, and the media for that matter, in raising a holy rhubarb on the PACT Team failing this veteran?

Elected officials, did you catch that statement in the VA-OIG report on the cancer diagnosis?

“Facility leaders have an unwritten expectation that primary care providers conduct a thorough historical review of the patient’s electronic health record starting with the most recent annual note; however, the OIG found that not all of the patient’s providers conducted historical reviews, but instead focused on current issues and problems identified by the patient.”

Having transferred between PACT teams inside the VHA and state-to-state, I can affirm this is exactly what is transpiring in the PACT team; the second most important player, behind the patient, is the primary care provider. When the primary care doctor fails in their job, like dominoes falling, the care of the patients rapidly cascades into a dynamic failure of healthcare in a VHA facility. What are YOU doing to stop this madness and demand accountability?

The electronic health record has a section near the top of the record for “Problem List.” Guess what; when providers fail to keep this section updated, current, and accurate, the healthcare of the patient borders on malpractice requiring only a slight push to arrive with a dead veteran. The VA-OIG found providers and nursing staff failures to update the problems list accurately, keep the problems list current, and regularly discuss the problems list with the most critical member of the PACT team, the patient! Providers failed to comply with sound science, good business practices, and act appropriately for the patient’s health; do you think this might be a slight problem in the PACT team?

I have offered the VA several suggestions for plotting a path forward. Yet, the VA cannot and will not take advice without stern and reproachful measures taken by Congress. Elected officials, it is time for you to act and groundswell the changes needed in every government agency, even if it means reducing the size of government!

Moral Distress IS a Leadership Problem – More Shameful VA Chronicles!

Survived the VA A surprise occurred in this week’s Department of Veterans Affairs – Office of Inspector General (VA-OIG) reports; the Boise VAMC in Idaho performed well in their comprehensive healthcare inspection (CHIp). Even though 10 recommendations were left, the VAMC as a whole is performing above average, with no significant complaints found by the VA-OIG. Congratulations to the Boise VAMC!

VA 3 Let me stress something; leadership is the reason why a VA Healthcare System (VAHCS) or VA Medical Center (VAMC) performs well or poorly! Yet, too often, the leadership IS the root cause of the problems in a VAHCS or VAMC. The Boise VAMC just proved this point precisely; are any Department of Veterans Affairs (VA) leaders in Washington DC paying any attention?

The VA-OIG performed a CHIp in Portland VAHCS and found moral distress in the employees, again! This means that the Eastern end of the state is receiving better care than the western end of Oregon State! Yet another VAHCS or VAMC with employees feeling morally distressed by the commands and directives of their leadership in how they treat veteran patients! The VA-OIG report makes everything sound like rainbows and lollipops at the Portland VAHCS, but if employees feel “morally distressed,” there are problems, just not those included in the CHIp scope! VA 3

Where problems outside the scope of an investigation are concerned, the following is GREAT NEWS!

“Robert Seifert, 63, of Utica, New York, pleaded guilty to making telephonic threats to Albany Stratton VA Medical Center employees. Seifert, who has been convicted twice before of threatening VA employees, admitted that on 14 January 2021, he made three calls to employees for no reason other than to harass and threaten them.”

I am going to repeat it, only for emphasis, “Leave the families out of your anger!” Never, EVER, attack, threaten, or speak against the families. They are OFF LIMITS! I become very frustrated with the VA Leadership, but violence is not the answer, and threatening families is repulsive and counterproductive! Seifert is scheduled for sentencing on 06 October 2021; may the judge throw the book at him, for this is his third conviction for threatening families of VA Employees. VA 3

On the topic of frustrating leadership who need to lose their jobs and reimburse the government for all wages, the following VA-OIG report is the epitome of failed leadership in action!

“The VA’s Office of National Veterans Sports Programs and Special Events (NVSPSE) granted $47 million to organizations with experience in managing adaptive sports programs from fiscal year (FY) 2017 to FY 2020. … The VA-OIG found that the NVSPSE was not effectively managing the program. The NVSPSE’s director had not established adequate internal controls, including developing standard operating procedures for managing adaptive sports grants. As a result, the NVSPSE could not effectively evaluate risks from grant recipients, did not reimburse some recipients’ expenses on time, did not always close out grants on time, and did not appropriately authorize extensions for using funds. By not closing out grants on time, the NVSPSE failed to free up about $346,000 that could have been used for other purposes. It also improperly allowed recipients to spend $328,000 in FY 2017 appropriations outside the approved period and improperly reimbursed 19 recipients a total of about $247,000.”

The VA-OIG recognizes that these failures to audit and control the adaptive sports program properly potentially violate both the Purpose Statute and the Antideficiency Act, federal laws with direct consequences for Federal Employees. I am taking bets. Will anything come out of the director being referred to the lawyers; I doubt any action will ever be taken! That’s not just my cynicism speaking; that is the experience in watching directors at the VA skate accountability and responsibility better than gold-winning Olympic figure skaters. VA 3

In reporting the following VA-OIG report, do not rationalize that every suicidal person will eventually find a way or means to commit suicide. I ask you do not think this for two reasons: one, it is a lie lazy people tell themselves to disregard the act; two, helping people with suicide ideation is not cut and dried textbook medicine. Assisting people with suicide ideation takes time, effort, getting to know the person, and a lot of interlocking care from professionals.

“The patient, who was over 70 years old at the time of death, had diagnoses that included post-traumatic stress disorder and major depression. After approximately 15 years of care at a California VA facility, the patient transferred care to the Las Vegas facility in summer 2019. The VA-OIG substantiated that the patient died by suicide from a VA resident mental health clinic on the day of discharge. The emergency department social worker documented an incomplete comprehensive evaluation. The suicide prevention team did not assign the patient a high risk for suicide patient record flag despite the patient’s stressors and history of suicide behaviors. Staff did not adequately assess the patient’s substance use, incorporate relevant history into the treatment plan, or address the patient’s change in demeanor and concerning statements. The discharge safety plan had not been modified for approximately eight months despite significant life changes. Leaders had not established a mental health treatment coordinator (MHTC) policy. Staff assigned the patient an MHTC at the patient’s tenth visit and four MHTCs over nine months. Staff did not coordinate care with a geropsychologist, with whom the patient had nine appointments. Leaders did not effectively address the patient’s expressed complaints. The VA-OIG substantiated that leaders did not conduct an institutional disclosure” [emphasis mine].

The last sentence is the dead giveaway that the leadership knew there were problems and designed processes intentionally to have an excuse when a patient died! This veteran was suffering to a great degree, and I hope that with his passing, his family and friends can find peace in the knowledge that the veteran is now pain-free. But, the VA leadership should be held legally responsible for this death, they failed this patient, and the world is worse for the veteran’s passing. VA 3

Suicides are hard on family, friends, communities; suicides at any age are the ultimate declaration that failure occurred, the pain was missed, and the medical community and support systems failed. Survivors often feel a great degree of guilt and carry that guilt to their graves. But, when medical providers go out of their way to hide the problems, refusing to document, and declare, it means that the medical community had written the patient off as too costly to save. Who speaks for the loss of intelligence and potential of the failed patient; I do! I-Care

I will continue to speak to the failures of the VA to provide the care they promised, and demand leaders are held accountable and responsible. This was preventable, and the leadership must be held accountable if the system is to be changed! This veteran did not have to die by his own hand, and the medical community at the VA in Southern Nevada HCS, located in Las Vegas, should be ashamed!

Follow this link if you would like to see a recap, with links, to the shenanigans reported by the VA-OIG in June. June 2021 has been a month of incredible and horrendous behavior documented by the VA-OIG of the leadership failures at the VA. The elected leaders of America either need to begin scrutinizing the VA more closely or vacate office. There is no excuse for the continued irrational and detestable behavior at the VA. VA 3

The last two items are testimony recorded before a Senate and a House of Representatives Committee. Statement of deputy inspector general David Case Office of Inspector General, Department of Veterans Affairs before the US Senate Committee on veterans’ affairs hearing on VA electronic health records: modernization and the path ahead 14 July 2021. Statement of Leigh Ann Searight deputy assistant inspector general for audits and evaluations Department of Veterans Affairs – Office of Inspector General before the subcommittee on oversight and investigations committee on Veterans’ Affairs US House of Representatives hearing on modernizing the VA police force: Ensuring accountability 13 July 2021. Frankly, both statements are pure vanilla because the subcommittees refused to act, which was known before making the statement and the hearings. Hence, why should the VA-OIG prepare action plans if the Senate and House will not take action?

Knowledge Check! Repeating, only for emphasis, “Until the US Legislative Branch will do their jobs, and scrutinize the Executive Branch with the intent to demand accountability, no single government agency will ever change.” Want to help veterans? Contact your elected representatives and send them these articles, demanding they take action in support of legislation and scrutinization, demanding accountability and responsibility of government employees who are currently active in refusing to change! Want to help veterans? Share these stories far and wide. Everyone should know what the VA is doing and realize that every government agency from the city to the President is employing tactics to steal liberty, rob freedom, and murder veterans!

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