Paul Harvey – Detestable VA Chronicles for Week Ending 07 Aug 2021

Bobblehead DollPaul 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 beheading of a woman in America, in broad daylight, by an illegal immigrant who has been on a one-man crime spree from El Paso to Minneapolis since 2007, my cherub-like demeanor took a tremendous hit.

The Department of Veterans Affairs (VA) – Office of Inspector General (VA-OIG) reports on a couple from Kansas who are flat out despicable, faking blindness to increase disability payments from the VA and Social Security.  Frankly, I hate liars and thieves and agree to the restitution ordered, but I do not agree that the couple deserved probation.  Stealing benefits should come with more than simple probation and restitution.  Where is the community service in distinctive clothing and sandwich boards declaring they are thieves?VA 3

However, this couple represents a symptom, not the disease of the VA and Social Security specifically, and the Federal Government generally.  When leaders act reprehensibly, criminals will test the system to find weaknesses and attempt to benefit from leadership failures.  The disease of poor leadership has far-reaching consequences, and criminal activity is not unexpected.  Who is addressing the disease?  When will the citizens of America receive justice to see the healing of the illness that has captured the government?

Military Sexual Trauma

I-CareImperative 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.

In 2018, the VA-OIG discovered just how detestable and deplorable the VBA’s processes and procedures were for military sexual trauma (MST).  Having been a victim of MST, this issue is of particular interest to me, and I continue to follow this issue closely.  I wish I had some encouraging news on this issue, but the VA-OIG found:

“… Processors did not always follow the updated policies and procedures. VBA leaders did not effectively implement the VA-OIG’s recommendations and did not ensure adequate governance over military sexual trauma claims processing. The VA-OIG concluded that VBA was not properly implementing the recommended changes.”VA 3

In 2016, when claims were being improperly and prematurely denied, the problems were considered a lack of training, a lack of policy, a lack of procedures, and comprehensive guidance was needed.  In 2018, additional training and guidance were needed, time, and leadership were recommended, even though claims were still improperly and prematurely denied.  In 2021, it is now blatantly obvious we have a systemic failure of leadership at the VBA to process claims in a manner that is conducive to good order and discipline!

On the same day, this investigation was released, the VHA investigation results for MST coordinators were released to the public.  I bet you can guess what was found, but let’s allow the VA-OIG the opportunity to detail the failures:

The VA-OIG conducted a national survey and interviews to evaluate MST Coordinators’ duties and perceived challenges.

            • 80% of the respondents reported having been assigned at least 20 percent or more of protected time.
            • 39% reported inadequate resources to fulfill MST Coordinator administrative responsibilities.
            • The VA-OIG found that insufficient protected administrative time, role demands, insufficient support staff, and inadequate funding and outreach materials challenged MST Coordinators’ ability to fulfill role responsibilities.
            • The VA-OIG found that MST Coordinators who reported more dedicated time than other MST Coordinators did not necessarily serve at facilities with higher numbers of patients in MST related care.”VA 3

Did you catch that final point?  Resources are not being adequately provided based upon patient load to locations where veterans need care.  Another symptom of leadership failure, being designed into the organization as a policy and working procedure, meaning this is designed incompetence!

Knowledge Check!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.

What’s worse, MST leads to PTSD, and people are suffering PTSD from a number of traumatic events not receiving care or benefits because the VA refuses to acknowledge these problems.  Admitting a problem is the first step in addiction programs; well, it is also the first step in healing leadership failure, and the VA is suffering from dynamic leadership failure at every level!  Know a veteran whose story needs to be told, refer them to me; let’s get this information out.  I am sick to death of the VA getting away with murder.

Programs and Inspections

VA SealThis 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.

Believe it or not, the Veteran-Directed Care Program is full of faults, problems and is suffering from a lack of leadership as the program balloons.  Color me shocked!  Surely, somewhere in the VA, if only to screw with the gods of perversity and Murphy their prophet, there must be a functioning and well-led program, department, office, etc.Angry Wet Chicken

It is so absurdly depressing to catalog these failures of leadership week after week and never see any improvement.  We see increasing failures, we observe heightened criminal activity, there is undoubtedly raised awareness of needs and moral distress in abusing veterans, but where is the improvement towards achieving excellence?  Where is Congress in scrutinizing the legislative branches, officers, and leaders?

If a congressional representative can order the VA-OIG to investigate the MST Coordinators, which they did, where is Congressional action on the results?  Surely this is not too difficult a question to ask.  Better still, where is Congress?  I have now reached out to all the elected Federal officials in Arizona, Texas, and New Mexico.  Texas, because that is where I have been forced to receive care from.  New Mexico because I now live here.  Arizona because I was physically injured by VA employees there.  The amount of interest received has been less than zero!Angry Grizzly Bear

How can interest be less than zero, you ask.  Well, while I have not received any response to my original complaints, I have received a TON of marketing materials about how those congressional representatives “Care about veterans, the community, pets, animals, and America.”  Maybe, not always in that order, but absolutely with less sentiment than I have for the weeds growing on my sidewalk!  Thus, I ask again, with all sincerity, where is Congress in scrutinizing the government?  I demand to know the “Rest of the Story!”

© 2021 M. Dave Salisbury
All Rights Reserved
The images used herein were obtained in the public domain; this author holds no copyright to the images displayed.

Abominable Enabling – More VA Chronicles of Shame!

Knowledge Check!Before I begin, please allow me to emphasize a key idea, “This is your government!”  Your tax dollars are paying for these shenanigans, and the bureaucrats do not fear you.  I have written some odious critiques in my time about the VA and other government agencies.  My cataloging these incidents does no good unless everyone in America becomes full of righteous indignation and DEMANDS Action through their elected officials!

The Department of Veterans Affairs – Office of Inspector General (VA-OIG) has been super busy this week, and my email box has been chock full of reports.  The VA-OIG reports begin in New Mexico, Albuquerque, where finally the VA-OIG has investigated some of the many complaints and is finally stating what the veterans and active-duty military have been saying for a long time, the NMVAMC leadership stinks!Raymmond G. Murphy

As a patient in Albuquerque VAMC, during the June 2018 window of investigation, I can affirm the integrity of the problem but seriously doubt the VA-OIG conclusions.  I was an employee of the Albuquerque VAMC in June 2018, so I know the leadership involved personally, and I guarantee the problem goes deeper than a lack of training.  The Albuquerque VAMC is fraught with leadership dysfunction, misfeasance, malfeasance, and intentional systemic problems.  Yes, the VISN 22 leaders were advised, and no, the VISN 22 leaders did nothing! There’s no surprise there; VISN 22 is one dead veteran from a major scandal that will make the death list scandals look like a minor nuisance.

From the VA-OIG report, we find the following:

The VA Office of Inspector General (VA-OIG) conducted a healthcare inspection to evaluate allegations that Community Care consults were completed in June 2018 without scanning and attaching available clinical results to patients’ Veterans Health Administration (VHA) electronic health records (EHR).”  “The VA-OIG substantiated that in June 2018, Community Care nurses were completing consults without scanning and attaching clinical documentation to patients’ EHRs.”  “The VA-OIG determined that Community Care nurses lacked a comprehensive orientation and training program. The Chief of Community Care did not verify adherence to consult-related VHA requirements or conduct regular reviews and improvements for departmental performance deficiencies. Additionally, Community Care performance monitoring addressed consult processes before patients receiving care but did not address the consult completion process or identify non-compliance with VHA policy before 2019.”VA 3

Let me break this down; primary care providers sent orders for community care, community care would be delayed, then to clear the backlog, the nurses doing the ordering would pencil-whip the documents claiming that care had been received, canceling the orders of the primary care provider.  Then the patient and the primary care provider would have to start the process for community care all over again.  Wasting time, money, and other resources, the facility leaders and VISN leaders refused to address the deficiencies and correct the problem.  The problems with community care existed before I arrived in Albuquerque in 2016 and continue without stop after this VA-OIG inspection.  I met with providers who had not been paid for years because the community care program was poorly managed and led.  Thus, the leadership enables people to break the trust, break the law, commit fraud, waste, and abuse, then collectively blame the problem on a lack of training, which is designed into the processes as incompetence.

QuestionI keep asking for the politicians and Washington VA Leaders to rip the scab off VISN 22, expose the wound to sunshine disinfectant, and drain the pus for the good of the VA body.  Yet, nothing ever happens, and the leadership continues to get away with abusing veterans, killing veterans, and destroying veterans.  Shame on you, political and administrative leaders!

Speaking of wounds needing sunshine disinfectant, the VA-OIG reports that “Mende Leone, 37, pleaded guilty to misappropriation of a federal benefit by a fiduciary.  As her uncle’s appointed fiduciary, Leone stole at least $151,000 of VA benefits intended for him.”  Continuing to prove that after the VA, families are the second most dangerous entity to the health and support of veterans.  Despicable crime indeed!Plato 2

Unfortunately, the third most dangerous entity to a veteran is the state government where they reside.  California moved very quickly to scoop up money after a veteran died.  At the same time, the Department of Veterans Affairs – Veterans Benefits Administration (VBA) was foot-dragging on deciding on awarding fiduciary control for the veteran in a long-term care facility.  Proving once again, if you want to see government in action, waive money in their faces, and watch them kill each other to obtain someone else’s funds.

The clowns at any circus in the world would make better administrators of the VA than those currently in power positions!  For the second time in as many months, the VA-OIG reports that unreliable information (the politically correct way to say they lied) was blamed for billions in cost overruns on IT infrastructure costs to the VA.  “… the Office of Electronic Health Record Modernization (OEHRM) estimated information technology (IT) infrastructure upgrade costs [but was not] in accordance with established VA standards and Government Accountability Office guidance.  The two $4.3 billion infrastructure upgrade estimates reported to Congress were not reliable and, because of incomplete documentation, determining the accuracy of the estimates was not possible. The VA-OIG also found VA did not report to Congress other IT upgrade costs of about $2.5 billion because OEHRM did not include costs other VA agencies would bear. OEHRM also did not update the cost estimates it provided to Congress.”VA 3

Yet, the US President continues to push to throw more trillions of dollars at the VA when they cannot correctly handle the billions already appropriated to upgrade their IT infrastructure.  The VA-OIG report, just for this farrago, is estimated at $11.1 Billion.  Einstein is famous for claiming that doing something over and over again and expecting different results is the epitome of insanity.  Maybe, it might be time to scrutinize the VA, fire some people, and get actual private-sector employees to fix the bureaucracy and obscene malfeasance in government!Apathy

The following investigation remains ongoing, and those indicted remain innocent until proven guilty in a court of law by a jury of their peers.  However, the investigation needs to be reported for the criminal activity and the lack of leadership that enabled the crimes accused.

Lisa M. Hoffman, 48, of Orange, New Jersey, is charged by indictment with one count each of conspiracy, theft of government property, and theft of medical products.

According to documents filed in this case and statements made in court:

From October 2015 through November 2019, Hoffman was a procurement officer at the VAMC. She used her authority to order large quantities of HIV prescription medications to steal the excess. After the medications arrived, Hoffman waited until co-workers were out of sight and removed them from the VAMC.

Once Hoffman stole the medications, she met her associate, Wagner Checonolasco, aka “Wanny,” generally at Hoffman’s residence so that Hoffman could provide the stolen HIV medications to Checonolasco in exchange for cash. Hoffman and Checonolasco used an encrypted messaging application to plan and execute their thefts and sales of the stolen HIV medications, including arranging for the medications-for-cash exchanges. After obtaining the stolen HIV medications from Hoffman, Checonolasco sold them. During the conspiracy, Hoffman and Checonolasco stole approximately $10 million worth of HIV medications belonging to the VAMC” [emphasis mine].

Where were the other employees and the hospital leadership during this crime?  When I received US Government property, I had to account for every penny, show the receipts, and held to general inspections verifying my veracity.  The supply officer lost $20.00, claimed I had spent the money, and I had to prove my innocence using documentation and a full property audit before I was cleared of the missing money.  You cannot tell me that the leadership and other employees magically are not culpable for their complicity and failure to perform their jobs.VA 3

For example, upon receipt of property, there is an inspection to verify everything purchased arrived.  Then when delivered to different stations, another audit is conducted to ensure nothing disappeared enroute.  If something comes up missing, there is another audit and inspection, as well as a host of paperwork involved in correcting deficiencies and proving where the property went.  Prescription drugs are held to a higher standard with greater penalties for those involved in missing drugs.  Thus, I ask again, where was the leadership who enabled this criminal behavior?  Where were the nurses who noticed missing drugs on inventory lists?  Where were the fellow employees in this scheme?

Multiple reports are circulating that the head of the viral, fungal meningitis outbreak from 2012, Barry Cadden, is being resentenced with stiffer penalties.  As a reminder, “In 2012, 753 patients in 20 states were diagnosed with a fungal infection after receiving injections of MPA manufactured by NECC, and more than 100 patients died as a result.”  Cadden was resentenced to 174 months in prison, forfeiture of $1.4 million, and restitution of $82 million.  Frankly, I still think the sentence is too light; but nobody asked my opinion on sentencing!Gavel

Finally, in our discussion on obscene enabling by VA Leadership, the following VA-OIG reports on COVID preparedness, lessons learned, and the preparation for a pandemic.  Under the heading, “Identified Trends Among VISN 19 Respondents’ Comments on Facility Readiness and Response,” we find “All need to practice infection control protocols (wearing masks and washing hands).”  Are you kidding me?!?!  You are a hospital; hand washing should be second nature and the first line of defense, not the patient wearing a mask.  The VA-OIG gathered this data from VISN 19, which includes the following VAMC’s:

        • Aurora, CO
        • Cheyenne, WY
        • Fort Harrison, MT
        • Grand Junction, CO
        • Muskogee, OK
        • Oklahoma City, OK
        • Salt Lake City, UT
        • Sheridan WY

Having been a patient in three of these VAMC’s I find it highly distressing that hand washing and wearing masks in a hospital setting is a “trend” of “readiness and response to a pandemic.”  How were you delivering care previously?  Why is handwashing suddenly a new activity?  How many patients were endangered by a lack of handwashing?VA 3

I have been a patient in two different VA Hospitals where the nurse routinely pulled off the finger of their glove or did not glove at all, to remove blood, use sharps to give shots, and a host of other activities.  I reported these behaviors as “concerns for patient safety,” and my concerns fell on deaf ears of the leadership.  Now, I see a VA-OIG inspection relating that hand washing is suddenly vital to delivering care, and I have to ask these questions.  Of the eight collated responses from local hospitals, proper hygiene protocols are mentioned in 6.  So, how were you delivering care before the pandemic?

Pigeon RevengeStill, the VA-OIG refuses to investigate the lack of written operational procedures, policies, and mandates for enforced mask-wearing, especially when the mask prohibits or makes unsafe the patient’s breathing.  Why was there no acceptable workaround to see patients with shortness of breath without a forced mask?  Why were patients refused care under EMTALA?  Why are VA Police Officers allowed access to private patient HIPAA-protected information? Fundamental questions about the rights and protections of patients who continue to be violated by the VA Leaders enabling harassment and harming patients, and the VA-OIG remains MIA.  I find this very glaring!

© 2021 M. Dave Salisbury
All Rights Reserved
The images used herein were obtained in the public domain; this author holds no copyright to the images displayed.