In what has become typical and usual, the following stories arrive:
“From 2019 to 2021, Ira Westbrook of Bozeman, Montana, served as the fiduciary of an elderly relative who had suffered a stroke and became disabled. A multi-agency investigation found that, during these 16 months, Westbrook stole more than $57,000 in Social Security and VA benefits and used the stolen funds to purchase personal items, including a Jeep Wrangler, a travel trailer, and other day-to-day expenses.”
“From 2016 until 2018, Sloane Signal-Debose of Slidell, Louisiana, served as the fiduciary of a veteran who needed assistance managing his finances. During that time, she took more than $100,000 from the veteran’s accounts, used it as the down payment on a home in her name, and used additional funds from the veteran to pay contractors working on the home. Signal-Debose then submitted false records to VA to hide her misuse of the veteran’s funds. The former fiduciary pleaded guilty to misappropriating funds and faces up to five years in federal prison. The VA OIG conducted this investigation.”
“In 2013, Brandi Goldman of Jonesboro, Arkansas, was married to a US Army reservist who suffered a severe traumatic brain injury in a service-connected accident. As a result of this injury, her husband had many serious physical challenges, and Goldman was appointed as his guardian and fiduciary. Between April 2015 and November 2017, Goldman received more than $258,600 in VA disability payments and $36,000 in Social Security payments. During that timeframe, she withdrew close to $200,000 in cash and accrued about $900 in ATM and overdraft fees. Goldman admitted to spending much cash to fund her methamphetamine habit, spending $150 on methamphetamine two to three times per week. She also admitted that five other people moved into the residence with her and her husband, none of whom paid rent or contributed to expenses, some of whom she regularly gave cash to. She also admitted to paying $68,000 in cash for another home, furnishings for the home, multiple vehicles, and a motor home. Goldman was sentenced to 20 months in prison, three years of supervised release, and $143,000 in restitution after previously pleading guilty to misappropriation by a fiduciary. The VA OIG and Social Security Administration OIG conducted the investigation.”
Why are these stories of particular interest to the supreme legislative body in the United States of America? The executive branch has refused to police its branch of government, and crimes like this have become all too familiar. You, the Congressional bodies of these the United States, are duty-bound and sworn to perform two jobs, scrutinize the executive branch (harshly when necessary), and write laws. You have recently failed too often in monitoring the executive branch, and this story perfectly represents what happens when the executive branch is not examined minutely! Tell the US Public who put you in elected office, how these crimes continue and what programs and processes they MUST change to prevent them in the future.
By pleading for the legislative branch to scrutinize and audit the executive branch minutely, I am in no way condoning or diminishing the personal accountability of those who committed crimes. These three examples are from the October and November press releases of 2022. The widespread ability to commit fraud is a symptom of a more significant problem at the VA. Their leaders have consistently been able to boondoggle, evade, and profit from abusing veterans through designed incompetence, criminal neglect, and obtuse actions. When will Congressional leaders take action to clean up the Federal Government in general and the VA specifically?
The US House of Representatives holds the purse strings for the executive branch; use this leverage to claw back your powers and authority to balance the Federal Government and demand accountability from those empowered to lead their designated branches of the executive branch of government. Let’s talk about patterns; in less than 45 days, three cases of fiduciary fraud were closed, and the speed of closing these cases has escalated throughout 2022. The American people will see more, not less, of these fraudsters being underreported by the US Media before the year ends.
Shifting slightly, let’s talk about government employees and the need for more scrutiny of the executive branch.
“Bruce Minor, of Philadelphia, Pennsylvania, was sentenced to two years in prison, three years of supervised release, and ordered to pay $462,256 in restitution for his scheme to embezzle money from the Philadelphia VA Medical Center. Between December 2015 and September 2019, Minor, a former travel clerk, created fraudulent travel reimbursement claims in the names of at least three other VA medical center employees. He then diverted the funds into bank accounts he controlled. The VA OIG investigated this case.”
“Kyhati Undavia, of Houston, Texas, was sentenced to 27 months in federal prison after previously pleading guilty to conspiracy to commit healthcare fraud. From December 2012 to December 2018, Undavia hired employees to market Memorial Pharmacy, which she controlled and operated, to physicians as a place to submit compounded drug prescriptions. Instead of providing prescriptions directly to the patients who could select a pharmacy of their choice, physicians sent the prescriptions directly to Memorial Pharmacy. Then, Undavia paid the physicians illegal kickbacks for the prescriptions. Beneficiaries often received medicated creams that they did not need or want. Undavia received approximately $22 million from TRICARE, Department of Labor Office of Workers’ Compensation Programs, and CHAMPVA for the prescriptions.”
These stories also fall into the same timeframe mentioned above. But, they are not the only stories from 2022 where VA employees conducted long-term fraud for personal profit. Here’s the rub: hundreds of additional employees knew of these schemes, were probably running their schemes, and haven’t been caught, and nothing is being done by VA leadership to cease the fraud and abuse of veterans by VA employees. There is a culture of corruption at the VA, long hidden by scheming and abusive leaders and condoned by previous Congresses, that must be stopped! What will you, the congressional leaders of the United States, do to halt this insanity, demand personal accountability, and clean house of the designed incompetence that allows these criminal activities to flourish? The American People are waiting!
The following site holds press releases for the VA specifically, but investigations often cross into Social Security, the Department of Defense, state investigatory bodies, the FBI, and more. Suppose nothing else is learned from only perusing this site, that more scrutiny needs to be done to every single department of the executive branch. In that case, we, the American People, might count ourselves lucky. However, this is not the case. The rot from poor leadership, criminal mismanagement, and supreme dereliction of duty is etched deeply into the workings of the executive branch operations, and more needs additional discussion.
03 November 2022, the VA-OIG released a report titled, “VHA Progressed in the Follow-Up of Canceled Appointments during the Pandemic but Could Use Additional Oversight Metrics.” The report only covers the time from 2020 to the present, and regular readers know that the VA has been failing on every measurable metric for over a decade. To couch in politically correct non-threatening jargon, how designed incompetence continues to hamper and hinder is not surprising. That the current Congress has bought the excuses hook, line, and sinker, from the inept VA leadership, was not surprising either. This article is about the future, and the next Congress MUST take immediate and direct action to root cause and improve VA performance!
31 October 2022, the VA-OIG released the following: “Review of VA’s Staffing and Vacancy Reporting under the MISSION Act of 2018.” This is a report about how the VA continues failing to report improvements in hiring practices to the legislative branch. The report details VA leadership’s continued failures through designed incompetence. Tell me, if you were in charge of a report for your business that is essential to receiving funding, would you keep your job if, from 2018 to the present, you still cannot report what is happening and why and be held personally accountable for a report to a legislative body? Don’t take my word for it; read the report, and be careful of the temperature of your blood boiling!
Unfortunately, this behavior is the normal operating procedure for the VA. The same can be easily and quickly witnessed in every other Federal Department of the US Government under the executive branch. As the legislative branch, you are duty-bound to investigate and demand compliance in a timely manner. Where have you been; more importantly, will you allow these problems to continue or kill them?
Do you doubt designed incompetence is a standard operating procedure? Let’s discuss another part of the MISSION Act of 2018 that the VA-OIG recently reported on, “Additional Actions Needed to Fully Implement and Assess Impact of the Patient Referral Coordination Initiative,” dated 27 October 2022. The Referral Coordination Initiative (RCI) is a program to improve timely access to care using community providers. RCI sounds good in theory, but as usual, in the practical application, the program is full of self-serving charlatans, unsupervised or poorly supervised people, weak policies and procedures, and zero accountability! Plus, when the veteran runs into problems with local providers, reporting these problems is so time-consuming as to be ineffectual at best!
A personal example that was reported to the VA when it happened, and nothing was done but to issue the provider a check. Dr. Herekar, Neurologist, clinic: Advanced Neurology Epilepsy & Sleep Center, El Paso, Texas. A VA Primary Care Provider wrote to my employer on VA Letterhead with a wet signature, declaring my inability to wear a mask. Dr. Herekar’s office was presented with this letter and hassled me before both appointments for not wearing a mask, becoming hostile, argumentative, and a nuisance over the mask issue, even after I complied with putting on a face shield. 23 September 2021, over Facebook messenger, I was informed that I would be invited to find a different provider due to my refusal to wear a mask. Imagine that; Facebook Messenger became the medium of choice for ending a patient’s relationship with a medical provider. What did the VA tell me to do; file endless paperwork with TRICARE and then disregard the problem’s urgency. Worse, the medical care for the neurological issues decreased, and I have had to wait, sit, and hope for future consideration and possible treatment. Does this sound like an aberration; it is, unfortunately not!
The VA Leadership realized if community care succeeds, they lose power to control the destiny of veterans. Thus, they implemented the MISSION Act of 2018 with such feet dragging, designing incompetence into every facet of the program, to promote more complaints to Congress, and hopefully to squash the MISSION Act of 2018 and end community care. 07 November 2022, while waiting to speak to representatives of Community Care Services at the VA Out Patient Clinic in EL Paso, the veteran being served ahead of me was told, “The provider does not fax documents, so you will need to go to the provider, and then walk the paperwork back to us.”
The normalcy of reporting providers not submitting paperwork was beyond the pale. Not having secure document transfer processes between the VA and local providers is technically abysmal and unacceptable. Are we in the 1990s, where the cream of technology is sending and receiving a fax? The designed incompetence includes Luddite-like technical disciplines, and the VA_OIG and the Congress should be furious; I know I am!
Before the MISSION Act of 2018, I was making 5 and 6 trips to local providers to retrieve hard copies of medical records, going to the VA Records office, submitting the documents, and then following up 7-14 days later to find out I had to repeat this process as my VA Providers still had not received the records of my interactions with community providers. Interestingly, in 2020 I discovered the treatment records still had not been submitted from community providers into my VA eHealth Record, from treatment received from 2012-2016. Is the pattern of designed incompetence clearer? Is the VA Leadeship’s intransigence more apparent? How about the fraud, waste, and abuse of VA resources?
You, the congressional leaders, must take immediate action, not wait, not hold hearings, concrete action to demand compliance from the executive branch leaders to the congressional leaders who are held accountable to the citizens. America is a representative republic, and it is time the bureaucrats learned the citizens are awake and interested. You, the congressional leaders, are the people’s tool for correcting government abuses; you have two years to show you are dedicated to that principle, or you will be replaced!
© 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.
Paul Harvey is a hero of mine. I miss his voice on the radio. He exuded a calm demeanor, regardless of the terror, the trials, and the terribleness of the news reported and discussed. I do not have Paul Harvey’s sense of calm. When I heard about the 
Imperative to understanding, Military sexual trauma (MST) experienced while serving in the military affects both women and men with potentially severe and long-term consequences. Psychological trauma, such as MST, also increases the risk of physical health conditions such as cardiovascular disease, stroke, and diabetes. The Veterans Health Administration (VHA) requires that each facility has a designated MST Coordinator with at least 20 percent of their time dedicated to protected administrative time. For the record, “protected administrative time” is the time required to be spent on administrative duties, writing clinical notes, ordering supplies, scheduling appointments, administrative responsibilities, and so forth.
Here’s the biggest rub, a veteran can be receiving care from the VA for MST at the VHA and still be denied MST on a VBA claim. I have not heard it working in reverse where a claim is being paid, but the VHA refuses care, but given the failures of the VA as an organization, I would not be surprised to learn this was occurring. How do I know that care can be provided for MST and not be allowed on a claim? I am among a number of MST victims, all-male, who have been regularly denied VBA claims but are receiving care for the psychological harm. Veterans talk to each other. I have heard the stories of fellow veterans being attacked, assaulted, molested, drugged, raped by male and female attackers, and heard how the VBA had revictimized them.
This week, the final three emails from the VA-OIG reflected a VISN wide comprehensive healthcare inspection (CHIp) conducted virtually, a VAMC/VAHCS CHIp conducted in Spokane, Washington, and a program report on the failures in the Veteran-Directed Care Program. The most interesting finding in the CHIps was how short the leadership teams had worked together, a month, and how many open positions for leaders there were, more than half. Talk about glaring symptoms of leadership failure, were the leadership teams broken up from employee turnover? If so, did the employees retire, or were they retired to avoid criminal convictions? With all the investigations for fraud, as discussed on these pages frequently, I can only guess how leaders churn in a VAMC/VAHCS/VISN.
The first week of June is often a period of recovery. I have no idea why, but the first week of June is usually a recovery time. Maybe it was all those years in school; I honestly do not know. However, the world does not stop, and while the media goes 24/7 over the Memorial Day Gun Violence, stories are evolving that need your attention more. I do not say this lightly, as I understand those wounded and killed in gun violence are tragedies and cause for grief, but the corporate media has always used these “major stories” to allow other things to slip past.
Have you heard 
Have you heard the Federal Government remains hell bound and down on destroying the family but is explicitly 
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!
As a veteran who struggles with post-traumatic stress disorder (PTSD), stemming from military sexual trauma (MST), where a first-class petty officer jumped on my back and tried to rape me. When I see the Department of Veterans Affairs – Office of Inspector General (VA-OIG) reports on PTSD from MST, I pay close attention. Since the Department of Veterans Affairs (VA) continues to deny my MST claim because MST does not happen to men, I get agitated when I see these VA-OIG reports repeating year-over-year with the same excuses and designed incompetence. Designed incompetence is all about creating ready-made excuses for failing to perform correctly the role one has been hired or promoted to perform. Consider the following:
Why are the causes of the problems considered designed incompetence, because they never change! At the VBA, the processors all need constant training to remain current in their positions; but never receive the training. The VBA never holds value-added training sufficient to train the employees on their jobs, but this remains the number one excuse to justify poor performance in VA-OIG inspections. Failure to perform the job is also not a new excuse, where the VA-OIG reports are concerned. Not understanding how to ask for help is also not new, and frankly astounds and mystifies observers that those hired remain employed when their performance clearly remains insufficient to the job expectations. While it is unique to the VA to see a procedure manual, it is only natural and expected that the manual is poorly organized, poorly executed, hard to follow, difficult to find, and generally useless. The VA is famous for this designed incompetence trick.
Congress mandates VBA claim error rates; there is supposed to be a quality assurance check to reduce the error rates. Yet, with all the checks, the balances, and the quality assurance programs, the VBA continues to surpass the error rates and physically harms veterans due to their inefficiencies. Yes; a failure rate of 16% is a “Big Deal!”
For the first time in more than a decade of chronicling the VA-OIG reports, I am mentioning a 
Worst of all, this condensed version did not even scratch the surface of the issues reported in just three VA-OIG reports. Shame! Shame! Shame! Shame on the elected officials, Republican, Independent, and Democrat, who have allowed this problem to grow and done nothing! Shame on the myriad of presidents who have done nothing but throw good money after bad, without demanding progress and holding real people responsible for real results! Shame on every single VA employee who shirks their job for easiness to the pain and suffering of a veteran, dependent, or spouse!
The VA Southern Nevada Healthcare System in North Las Vegas, in response to a referral from the U.S. Office of Special Counsel (OSC), was investigated by the VA-OIG after a community healthcare worker was attacked. The VA-OIG findings are appalling, but the reasons for the problem are worse.
The Harry S. Truman Memorial Veterans’ Hospital in Columbia, Missouri, and multiple outpatient clinics was recently provided a comprehensive healthcare inspection, and the leadership team provided 14 recommendations in 7 different areas for improvement. While congratulations are in order, for the patient scores, the employee scores, and the overall conditions discovered. Yet, again staff competency, e.g., training and communication, remain critical articles requiring targeted improvement. Is the pattern emerging discernable; in Nevada, an employee is assaulted and training and communication are blamed, comprehensive healthcare inspections are conducted in three different geographic areas and the same causation factors discovered; training and communication are systemically failing at the VA. But, the evidence continues.
04 October 2016, the VA-OIG released a report on dead veterans after the comprehensive investigation into the Carl T. Hayden VAMC in Phoenix, Arizona. The same event occurred in 2014, at the same hospital, with the same causes and the same conclusions. The core causes for the dead veterans, no written procedures, poor to no training, and reprehensible communication practices. The Phoenix VAMC went out of their way to fire all the employees who reported problems at the Phoenix VAMC before the veterans began dying in 2014, I can only speculate that the same occurred in 2016. Staff was frightened in 2014; they are demoralized in 2020. Nothing has changed at the Carl T. Hayden VAMC in Phoenix, Arizona, after two successive hospital directors, if anything the problems have worsened. The problems worsened because leadership failed to act, failed to write down SOPs, failed to communicate, and failed to train. The hospital directors since 2014 have been appointed from the same pool of candidates who created dead veterans in the first place, and that is a central failure of the VA Secretary and Congressionally elected representatives’ failure to act!
Unfortunately, this is the standard, not the exception for the MSA’s in the HAS (Hospital Administration Services) Department, led by Maritza Pittore, at the Albuquerque VA Hospital. I have witnessed multiple MSA’s committing HIPAA violations through record diving, gossiping about veteran patients, acting rudely, ignoring veteran patients and their families to complete conversations, and refusing to do their jobs. As a point of fact, one assistant director one told me, “if what the VA does was replicated by a non-government hospital, they would be closed down and sued.” While employed from June 2018 thru June 2019, I brought this to the attention of the leadership, including multiple emails and voice conversations with Maritza Pittore, Sonja Brown, and several other high-ranking leaders and their assistants, all to no avail. I have had nursing staff tell me confidentially that they cannot do anything where the MSA’s are concerned because “it’s none of their business and outside their job duties.” Yet, the VA continues to proclaim the MSA, the Nurse, and the doctor, along with the patient, are a “healthcare team.” Upon being discharged, without cause, reason, or justification, I brought this information to the OIG, my congressional and senate representatives, among many others, all to no avail. The level of customer service, especially at this VA Hospital, is far below the pale because the leadership refuses to engage and set standards for customer service, with enforced penalties. 
Update to this article, 10 May 2020: By the first week in April 2020, the Advanced MSA in the clinic was moved to a less customer-facing post and a new MSA hired. The quality of that individual was never experienced due to relocating. The supervisor of the MSA was not very interested in correcting the problems and that showed when I visited with them while trying to obtain an appointment that the Advanced MSA refused to schedule. Change must come to the VA!
DNC-Consulting 