Dead Veterans – DNC-Consulting

Front Office vs. Back Office vs. Oversight – Additional VA Horror Stories

Lincoln Weeps Oh, the bitter tears President Lincoln must weep…

One of the most troubling issues facing many organizations is exemplified perfectly by the VA, specifically the Post 9/11 GI Bill. Previously I worked for an online university in a position where I saw GI-Bill problems affecting students on active duty, reserve, guard, and veterans, all being treated in wildly different manners. The school GI-Bill office was expected to be subject matter experts on all things GI-Bill, but they regularly made decisions that harmed the students. By interpreting the regulations and operating procedures differently from student to student. Yet, the Department of Veterans Affairs (VA) is just as confused as the universities trying to bill GI-Bill charges for students.

From a recent VA Office of Inspector General (VA-OIG) report, we find the following:

“The Veterans Benefits Administration (VBA) did not always accurately process enrollments. An estimated 2,500 of 10,000 enrollments from August 1, 2020, through April 1, 2021. About 790 of the estimated errors involved officials either not reporting or underreporting vacation breaks. VBA claims examiners often mishandled enrollments even when the correct information was submitted. The VA-OIG estimated claims examiners incorrectly processed accurately reported vacation breaks for about 1,700 of 2,500 enrollments with errors.”

Why are these enrollments not processed correctly:

“Insufficient training and guidance meant school certifying officials frequently made mistakes.” The VA takes legislation and writes the processes, procedures, and training materials for universities to use for operations and enrollment of military and veteran students. Front office workers interact with students, back office workers interact with internal employees, the VA keeps the records current, and the VA forms the universities’ oversight resembling the blind leading the blind. Yet, the VA cannot write effective training materials, processes, and procedures, conduct training, and support those who support students.

Per the VA-OIG report, the VBA is looking to implement an automated system to prevent these oversight issues from continuing. I do not expect any automated system created by the VBA to work efficiently because of a simple principle, GIGO. The garbage the VBA will put into the system will ALWAYS result in garbage coming out, creating more problems, costing too much money, and still creating issues for students and student-facing employees at universities and colleges across the country. Somehow, the VA-OIG continues to buy these excuses and pipe dreams and reports the same to Congress, which is also purchasing these excuses and poor performances. VA 3

Before someone tries to claim this is isolated to the GI-Bill program, and the GI-Bill program has always been confusing. Using this logic, the health complications at birth can be blamed on the father alone, and the mother’s behaviors do not influence the baby’s health. Here the VA-OIG is reporting on another program governing VA employees, overseen by the OMB, and is incredibly useless as this is a repeated complaint between 2020 and 2022.

“Identity, credential, and access management (ICAM) is a set of tools, policies, and systems used to ensure the right individual has access to the right resource, at the right time, for the right reason in support of federal business objectives. In February 2021, the VA Office of Inspector General (VA-OIG) received a hotline complaint claiming the Office of the Assistant Secretary for Human Resources and Administration/Operations, Security, and Preparedness and the Office of Information and Technology have not agreed since 2016 on roles and responsibilities for VA’s ICAM program. Failures of ICAM contribute to the VA’s inability to effectively comply with the Office of Management and Budget (OMB) policy. The VA-OIG reviewed to determine whether VA effectively governs its ICAM program as required.”

What did the VA-OIG find?

- - The VA did not effectively manage and coordinate its ICAM program, not meeting three of the four OMB governance requirements.
  - The VA did not effectively assign roles and responsibilities, implement a single comprehensive ICAM policy, or meet its technology solutions roadmap goals for fiscal years 2020 and 2021.
  - The VA failed to implement updated digital identity risk management requirements.

Why can’t the VA obey OM oversight?

“These issues occurred primarily because leaders of the different offices performing VA’s ICAM functions have not agreed on how it should be governed. VA risks restricting information from users who need it to perform their job functions without proper governance and leaving information vulnerable to improper use” [emphasis mine].

In this report, the OMB sits as oversight of the VA. The employees are the frontline, and the leaders continue to fail to provide tools, policies, and resources to employees conducting the VA business. What is still an incredibly terrible idea allowing the VA to remain self-governing. Why isn’t the OMB more interested in demanding compliance? Where is Congress scrutinizing how the executive branch agencies are failing and monitoring to improve conduct? VA 3

The VBA cannot still properly and timely adjudicate claims. Again, the VA-OIG lambasted the VBA for improperly adjudicating claims, even with “Special-Focused Reviews.” Essentially the quality assurance (QA) process in claim adjudication continues to fail to help improve claim processing accuracy. From the report:

“The Office of Inspector General (VA-OIG) reviewed VBA’s design and implementation of its special-focused review process, including applying Government Accountability Office (GAO) standards. The VA-OIG team assessed ten special-focused reviews completed from January 2019 through April 2021 and identified weaknesses in all five of GAO’s internal control components. The VA-OIG also found the VBA Compensation Service’s standard operating procedure related to these special-focused reviews does not provide sufficient guidance to support disability claims-processing improvement fully.”

When I worked in QA, root causation was required to prevent future problems. The VA-OIG found that the QA Special-Focused Reviews do not include root causes or explanations for why the claims were readjudicated, stopped, or delayed in VBA processing. Do not repeated issues reflect the need to restrict self-governance until compliance can be observed? VA 3

Why should the VA have its self-governance restricted or prohibited? The following VA-OIG makes clear that the VA cannot govern itself and correct the problems leadership continues to create. Follow the timeline here, quoted directly from the VA-OIG report:

“The VA Office of Inspector General (VA-OIG) conducted this review to determine whether the Veterans Benefits Administration (VBA) accurately adjusted compensation and pension benefit payments for fugitive felons as mandated by law. If VBA does not adjust payments, veterans who are fugitive felons will continue to receive benefits during periods of ineligibility.

In April 2012, VBA instructed regional offices to postpone making decisions on fugitive felon cases while it prepared new guidance. During 2012 and 2013, VBA did not process fugitive felon cases. In June 2014, VBA updated its definition of a fugitive felon to include only referrals indicating escape, flight, or violation of probation or parole conditions. Although VBA then resumed adjusting payments, it did not review the unprocessed 2012 and 2013 cases.

In addition, due to inadequate monitoring, VBA did not process about 46 percent of cases referred by the VA-OIG in 2019 and 2020. Finally, the team found VBA’s notification letters to veterans providing notice of the proposed action and right to a hearing did not always provide the required information. Most commonly, VBA failed to include the reason for the issuance of the arrest warrant.”

The VA has been informed by the VA-OIG multiple times during the decade this problem has been surviving, and 46% of the cases the VA-OIG told the VA to fix still weren’t fixed in 2022. How can any oversight agency still permit the VA to govern itself? The leaders of the VA cannot self-govern, correct course, and make changes timely enough not to create additional expensive problems for veterans. Each of these cases represents either an overpayment, where the VA is clawing funds back, or an underpayment, where the veteran has been shortchanged and is owed money.

When the VA claws money back from making a mistake that overpaid a veteran, dependent, spouse, or other entity, the VA-OIG has found that even here, the VBA cannot act per their policies, follow procedures, or notify veterans in a timely manner. A veteran I got to know who served in Vietnam and caught a round in the heart that blew away a large chunk of his heart. For 50 years or so, this was sufficient to have a 100% disability. On the day he turned 69, his disability rating dropped to 80%, with a coinciding reduction in monthly benefits. The VBA investigated this claim decision and found they had made a mistake, but their mistake would not significantly change the rating, so the veteran was stuck with an 80% rating and was told to go back to work. VA 3

To the best of my knowledge, the claim remains stuck in claims appeal hell, awaiting the judgment of the dark and benighted realms to act. The veteran, who cannot hold a job due to weakness from lacking a significant part of his heart muscles, is driven into bankruptcy. His heart will not regrow, but because his age has met the age when heart problems are actuarially known, the decision was made. The decision was made without notification to the veteran, and the veteran only became aware of the situation when he had monies clawed back by the VA. From the time the decision was made to the date he knew, 18 months had transpired, and the veteran was automatically sent to collections. While this was never allowed to become a VA-OIG investigation, I have spoken to family members and the veteran while volunteering to help disabled people find employment. I-Care

To add the bitter cherry to this crap sundae, this is not the worst abuse I heard in my volunteer efforts. Worse, this is not the worst story I have had related while talking to veterans in my travels across the continental 48 United States. Veterans sit forever in claim hell; they cannot afford to go forward, they are abused when seeking medical help, and every interaction with VA medical providers runs the risk of being the victim of an “adverse medical event.”

To this point, the VA and the VBA have been central to proving that the VA cannot self-govern, oversight is failing, and the back office administrators are hindering the front office operations. Surely the Veterans Health Administration (VHA), where people’s lives are at risk, would not have a similar problem. Unfortunately, you would be wrong, and here is one VHA example, of many, to support this conclusion:

“A VA Medical Center (VAMC) community living center (CLC) staff delayed life-sustaining treatment for a patient (Patient A) who experienced cardiac arrest and died. The VA-OIG also reviewed an allegation regarding a second patient (Patient B) who had resuscitation initiated, despite a do not resuscitate (DNR) order in the electronic health record (EHR).”

Why did one patient die without resuscitation and another get resuscitation without wanting it? The policies and procedures were complicated, and the use of armbands confused the providers. The providers (doctors and nurses) overseeing care had a person in the medical records of these patients and still could not properly act for patient care. The patients had armbands and proper medical documents on file, and the providers still got confused and provided poor care, at best, to the patients involved.

America Weeps In another long-term care facility under VA operation, the following occurred:

“The VA-OIG found that the day charge nurse’s assessment was delayed and incomplete, and the day charge nurse failed to properly document the resident’s reassessments, treatments, and interventions. The VA-OIG substantiated that nursing staff failed to document and carry out a telephone order to transfer the resident to the Emergency Department but could not determine if this impacted the patient’s outcome.”

Let’s take a moment to allow this to sink in fully. Failure to follow a doctor’s orders might have been part of the problem the patient DIED! Yet, the chain of events is sufficiently blurry to mystify the investigators – this I find HIGHLY SUSPECT! But, as the Home Shopping Network reports, “There’s more!”

“The VA-OIG determined that following the resident’s death, facility staff failed to conduct a comprehensive review of events leading up to and contributing to the resident’s death and, due to a lack of coordination of care at the time of discharge from the inpatient unit, the resident did not have the needed equipment upon admission to the CLC.”

I accept that a nurse’s role is stressful, the VA policies do not make their jobs less stressful, and the healthcare leadership (overall) is abysmal on the best days. However, killing a patient is still a BAD thing! I-Care Yet, here we have another dead veteran at the hands of the medical care providers, and the best the VA-OIG can do is make ten (10) recommendations for change. Does anyone believe the VA can continue to self-govern under its current misguided leadership and convoluted organizational structure?

Ask yourself, would the abuse of the veterans mean more if this was your uncle, brother, father, mother, sister, or aunt? They are your family members for the problems which they face; we all face in our constitutional republic. Where is Congress scrutinizing the government? Please become interested, active, and engaged, or we will lose this constitutional republic to the tyranny of the power-hungry despots.

© Copyright 2023 – 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 (Ch 9)

I-Care The Department of Veterans Affairs – Veterans Benefits Administration (VBA) regularly crows about reducing the backlog, improving the veteran experience, and making changes to deliver on the promise. Every so often, another article is spread, mainly by the VA Public Relations department (PR), about how they meet the legislated obligations. Then, unsurprisingly the truth is revealed, the curtain thrown back, and the lie exposed. The Department of Veterans Affairs – Office of Inspector General (VA-OIG) is helping pull the curtain back, and the truth should infuriate every American. In an investigative report dated 22 June 2022 and linked, we find the following:

“… The VBA disregarded privacy procedures so it could use a workload tracking system more quickly without receiving the appropriate security authorization. The Mission Accountability Support Tracker (MAST) helps quantify the work VBA’s support services staff perform in response to employee requests for facility, equipment, and vehicle management; reasonable accommodation; and identification card issuance and renewal. Because staff use personally identifiable information (PII) in their work, the information could be compromised in an unauthorized, unsecured application. The VA-OIG found that VBA and the Office of Information and Technology (OIT) did not correctly follow privacy and security procedures. VBA’s privacy threshold analysis was inaccurate, and OIT did not conduct a privacy impact assessment. OIT’s misclassification of MAST as an asset resulted in insufficient security controls. Further, VBA lacked the authority to operate MAST before using it in regional offices.”

Lacking authority equates to a leadership failure to follow their standard operating procedures (SOP). PII being inappropriately released, nothing new at the VBA, or the VHA for that matter. Losing veterans’ identities and taking advantage of systems for personal gain, regardless of the cost, is nothing new or surprising. This should be where the VA organizational leadership should be focused; yet, what are they doing? Where is Congressional oversight and scrutiny?

FY 2017, the VBA leaders devised a scheme to have third-party vendors conduct compensation and pension exams to deliver on the promise to clear the backlog on veterans’ claims. Since FY 2017, the VBA has paid over $6.5 Billion on this scheme, and the VA-OIG found in a report dated 08 June 2022, “Some of the exams produced by vendors have not met contractual accuracy requirements. As a result, claims processors may have used inaccurate or insufficient medical evidence to decide veterans’ claims.” Is anyone surprised this is the result? The compensation and pension exam is the key to accuracy in claim completion; yet, inaccurate claims are still being adjudicated wrongly, which is significantly damaging veterans and their families!

From the report, we find the following:

“VBA’s governance of and accountability for the exam program needs to improve. The identified deficiencies appear to have persisted, at least partly because of limitations with VBA’s management and oversight of the program at the time of the review.”

The VBA’s leaders designed this scheme, shackled the program with ineptitude, and hindered the improvement of the program. Designed incompetence cannot get any better than this, and the leadership must be held accountable! Fraud, waste, and abuse remain pillars in Federal Government governance, so why are these leaders not being held liable?

Michael Bowman, Director of IT and Security Audits, in recent Congressional Testimony, made the following claim:

“Secure IT systems and networks are essential to VA’s fundamental mission of providing eligible veterans and their families with benefits and services. VA’s information security program and its practices must protect the confidentiality, integrity, and access to VA systems and data.”

The audacity of this director to claim “confidentiality, integrity, and access” as being secure would be laughable if it weren’t so inept! How would a non-VA Employee know the IT system is fraught with problems? VA-OIG report regarding FISMA compliance, Dallas, Texas. The Federal Information Security Modernization Act of 2014 (FISMA). FISMA is a United States federal law that defines a comprehensive framework to protect government information, operations, and assets against natural and manmade threats. FISMA OIG inspections are focused on four security control areas that apply to local facilities. They have been selected based on their level of risk: configuration management controls, contingency planning controls, security management controls, and access controls.

What did the VA-OIG find? “Without effective configuration management, users do not have adequate assurance that the system and network will perform as intended and to the extent needed to support the CMOP’s missions. The access control deficiencies create risks of unauthorized access to critical network resources, inability to respond effectively to incidents, loss of personally identifiable information, or loss of life.” All political speak for inept leaders and deplorable leadership actions. IT/IS systems continue to fail, and the director claims the system has integrity; despicable and detestable!

Worse, the same FISMA inspection occurred at the same outpatient pharmacy mail facility in Tuscon, Arizona. The same problems were found, in the same systems, manned by the same inept people and led by the same poor leadership. Integrity, only if the word means sharing ineptitude between different facilities. Access to systems and data protection, can anyone honestly trust that the IT system at the VBA or VHA is providing the fundamental tools to meet the mission?

On the topic of IT system integrity, can anyone forget the continuing problems in delivering a functional electronic health record system to the VHA? How many billions of dollars must be wasted before Congress stops paying for this albatross? The VA-OIG has substantiated that “… many quality, patient safety, and organizational performance metrics were unavailable, including metrics needed for hospital accreditation. Additionally, the VA-OIG found that access metrics were largely unavailable. The VA-OIG remains concerned that deficits in new EHR metrics may negatively affect organizational performance, quality and patient safety, and access to care.” How’s that integrity doing? Is it trustworthy?

05 May 2022, failures were discovered in a joint DoD and VHA review of the new electronic health record system. The new EHR has no plan to create interoperability, yet interoperability was the main selling point for spending billions of dollars on a new EHR. Would you believe the VA-OIG recommends the DoD and VHA review federal laws and direct the offices overseeing the EHR program to begin complying? Would Congress please ask, why haven’t the program managers for the HER already been complying with Federal Law? How about demanding action to recompense the taxpayers who have been defrauded?

In April 2022, VA-OIG Michael J. Missal addressed Congress in a statement entitled, “At What Cost? – Ensuring Quality Representation in the Veteran Benefit Claims Process.” The VA-OIG’s mission is “preventing and addressing fraud and other crimes, waste, and abuse in VA programs and operations.” General Missal then discussed the integrity of VA processes to “help ensure that veterans receive the benefits, health care, and services they have earned through their service to our country.” Would Congress please ask how the VA-OIG is fulfilling its mission to prevent fraud, waste, and abuse?

“The VA-OIG operates a hotline that receives approximately 30,000 complaints annually from veterans, family members, VA employees, and the public.” If the 30,000 complaints are presumed to be stable, across just the years I have documented the VA’s abuses, then the VA-OIG has received upwards of 360,000 complaints over the last 12 years. Would Congress please ask about the success in promoting change, reducing fraud, waste, and abuse, and curbing the veterans being actively harmed by the VA, the VHA, and VBA?

Congress receives these VA-OIG reports first; what is Congress doing to scrutinize the executive branch? Where is the progress? The VA-OIG reports annually to Congress, but improvement never occurs. Permanent change never occurs. The same people are making the same excuses, using the same flowery language, and nothing ever happens to improve things. Worse, the same people maintain the same jobs, who pays, the veterans and their families, and the American taxpayer through the nose as the VA loses more and more money!

I do not know about any Congressional elected leader, but I am through buying the Kool-Aid the VA-OIG is selling:

“The VA-OIG’s work is focused on protecting VA programs and operations from waste, fraud, and abuse as well as improving their efficiency and effectiveness.”

On a single topic that the VA-OIG has reported on multiple times and remains critically important to all veterans and their families, it is reporting needs for improvement in VHA and VBA suicide prevention. From the report, we find the following:

“… Suicide prevention coordinators at VA medical facilities are required to reach out to veterans referred from the Veterans Crisis Line. Coordinators provide access to assessment, intervention, and effective care; encourage veterans to seek care, benefits, or services with the VA system or in the community; and follow up to connect veterans with appropriate care and services after the call.”

The findings from the VA-OIG report are almost criminal in the negligence of leadership to perform the jobs they hold:

“The VA-OIG found that coordinators mistakenly closed some veteran referrals because coordinators lacked the proper training, guidance, and oversight necessary to maximize chances of reaching at-risk veterans referred by the crisis line. VHA lacked comprehensive performance metrics to assess coordinators’ management of crisis line referrals, and coordinators lacked clear guidance on managing crisis line referrals. Until VHA provides appropriate training, issues adequate guidance, and improves performance metrics, coordinators could miss opportunities to reach and assist at-risk veterans.”

Why did the media bury this report? Suicide prevention continues to be a significant military and veteran issue, but this program’s designed incompetence should be a major story on all media networks. More, this VA-OIG report should be a talking point for every congressional representative seeking re-election. Why is this not the case? Integrity requires honesty, honesty and integrity requires action. When will Congress take action?

How many dead veterans will it take before Congress takes action? 31 May 2022 VA-OIG report:

“The VA Office of Inspector General (OIG) conducted an inspection to review the care of an unresponsive patient by Emergency Department staff and the subsequent response of leaders at the Malcom Randall VA Medical Center (facility) after the patient’s death at the University of Florida Health Shands Hospital (Shands). The OIG determined that facility Emergency Department nurses failed to provide emergency care to an unresponsive patient who arrived by ambulance. Despite emergency medical services (EMS) personnel having relayed, while en route to the facility, the criticality of the patient’s condition and the limited patient identifying information available, Emergency Department nurses and an Administrative Officer of the Day wasted critical time concentrating efforts on whether the patient was a veteran (which the patient was, but not so identified by the nurses) versus patient care. As a result, EMS personnel reloaded the patient into the ambulance for transport to Shands.”

The staff failed to follow EMTALA, and a veteran died due to the inaction and inappropriate focus of the medical providers. This is not the first or second breach of EMTALA, the federal law requiring any patient presenting at an emergency department receiving federal funds to be treated; yet, what will it take to get Congress off their thumbs?

12 May 2022, deficiencies in care led to a patient dying at the Charlie Norwood VAMC, Augusta, Georgia. The VA-OIG substantiated that:

“medical-surgical unit nursing leaders did not have adequate quality controls or training to ensure the provision of safe and effective alcohol withdrawal nursing care.” “Primary care staff failed to provide sufficient care coordination and treatment. A provider failed to address the patient’s abnormal chest images and poor nutrition and failed to communicate test results to the patient as required. A primary care nurse failed to respond to the patient’s secure message request for assistance two days before surgery.

Additionally, a barium swallow test was not scheduled. The surgical team completed a preoperative assessment but failed to detect the patient’s overall poor health. During the patient’s hospital stay after surgery, medical-surgical nurses did not consistently assess alcohol withdrawal symptoms or administer medications as required.”

My wife is fond of saying, these oversights and failures occur in non-Government hospitals, and this incident should not be considered indicative of the whole system lacking similarly. Yet, civilian hospitals have lawyers by the dozen looking for a reason to sue providers for malpractice, and the government hospitals protect against accountability and responsibility. Worse, you will never know the problems unless you track these incidents.

Do you know why I keep declaring there is a problem with designed incompetence; several veterans suffered T-12 burst fractures and multiple rib fractures, all because of poor documentation and even worse communication. This is a life-changing injury, and the VA-OIG found the VA providers to have culpability but no responsibility due to a lack of documentation. Delays in provider documenting in the electronic health record the provider’s notes delayed care for another veteran who also suffered life-changing spinal injuries after receiving non-care at a VA facility. The VA-OIG cannot conclusively document the tie between poor care being received and the injuries sustained by the veteran, all because of delays in the provider documenting treatment.

Tell me, does anything discussed above reflect the words of Inspector General Michael J. Missal, who claimed the following in Congressional Testimony:

“VHA continues to face enormous challenges in providing high-quality care to the millions of veterans it serves. Despite these challenges, the VA-OIG has witnessed countless examples of veterans receiving the care they need and deserve—delivered by a committed, compassionate, and highly skilled workforce [emphasis mine].”

Does a provider killing a veteran reflect a committed, compassionate, or highly skilled workforce? How many veterans must be permanently injured by the VHA providers to reflect a committed, compassionate, and highly skilled workforce? How often will the electronic health record fail before highly skilled workers are displayed?

Plato 2 Unfortunately, the VA-OIG reports discussed are not even the tip of the iceberg of what is happening. My apologies, dear readers; I have been remiss in my reporting duties. Why have I been remiss, because my health went sideways since April when I had a medical procedure completed that was advised but not appropriate. The VHA and VBA are sick organizations and desperately need scrutiny and standards, new leadership, and written organizational policies. Help me force these nefarious characters into the sunshine for a good dose of sunshine disinfectant, and let’s change the world for the better.

© 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 6

I-Care I promised a follow-up article after Chapter 5; it took me the better part of 48 hours to cool down sufficiently to write coherently to effect an update. On 18 March 2002, I wrote about an appointment with my Primary Care Provider (PCP) being tardy, unprepared, and bureaucratese in supposedly holding a phone appointment with me. 01 April 2022, not an “April Fools Joke,” at 0731 hours, lasting 9 minutes, my PCP called me to get my approval to have me changed from her PACT team to another provider’s team. Apparently, in the highly red taped world of PCPs at the El Paso VAHCS, there must be an hour-long handoff call when a provider initiates a change of PACT team. I have my doubts and smell designed incompetence!

Let me pause here for a moment. I generally need two hours to write an article after conducting research. 18 March 2002, it took a bit longer to draft that one due to the need to blow off steam with some choice words and choke down the urge to beat a few brick walls with my fists. I am generally a very controlled person, and the fact that this PCP was so stunningly incompetent, rude, and HIPAA clueless, I admit I lost my cherub-like demeanor! That the patient advocate was able to get my secure message, upload the comments into the electronic medical record, and contact the provider before the provider had even logged the patient notes, speaks volumes about the ineptitude of the PCP. Worse, in the call on 01 April, the PCP was still on speakerphone, still disregarding HIPAA security, and quoted lines out of context from my message to the patient advocate. Speaking volumes about the processes and procedures of the patient advocate’s office to investigate patient claims without breaching confidentiality. Another topic for another day entirely! PACT_model

28 March 2022, I received the following from the patient advocates office, quoted completely:

“We have received your secure message addressing your concerns. I will be sending a Patient Advocate Tracking notification with your concerns to our Primacy Care Service for review. They will be contacting you via telephone to discuss your concerns.”

I never heard anything from this mysterious “Primary Care Service” group/team. 01 April 2022 was the first response, and that was from the PCP. Sourcing the Department of Veterans Affairs (VA) and the Office of Inspector General (VA-OIG), the PCP is the second most important member of the Patient-Aligned Care Teams (PACT) at the VA; the patient is the essential member and an actively engaged and knowledgeable patient is preferred. I promise the VA-OIG has not even scratched the surface of the problems with recalcitrant, snowflake, and bureaucratic PCPs endangering patient health with the VA. Not my first run-in with an inept PCP; I sincerely hope it is my last! PACT 3

In returning to the 01 April call, we find another interesting piece of data. The PCP affirmed that abdominal pain could radiate from, say a hernia, to other parts of the abdomen, but this is for a specialist to diagnose, not a Family Practitioner. Get that; the PCP is directly reversing all the published documentation by the VA and the VA-OIG by declaring that a specialist is the only person who can adequately decipher and detail why pain is occurring—putting all the PCPs in the VA Health Administration under the bus as merely button pushers and drug dealers. Then the PCP has the temerity, nay the chutzpah, to suggest a trust deficiency existing between myself and the PCP. Is it any wonder that people are detested, forlorn, melancholy, madder than a wet chicken with a raging case of hemorrhoids with the care they receive from VA healthcare providers?

Again, I repeat, only for emphasis, when any updates arrive on this issue, I will publish them in their entirety to allow the VA the opportunity to rebut, refute, or explain. Like the ongoing saga with VISN 22, the Phoenix VAMC, and being arrested and injured three times by the VA Police, I am not holding my breath and awaiting a logical response. If this were the only problem in the two weeks since the PCP shenanigans, the VA would be in pretty good shape. Alas, we know, dear readers, that the VA is in dire condition, and the elected leaders need to be scrutinizing the VA a LOT more closely than they are. VA 3

We begin the latest chapter of VA-OIG reports with yet another physician bilking the government:

“Robert Clay Smith, a Louisiana physician, pleaded guilty to conspiracy to commit healthcare fraud, wire fraud, and illegal remunerations (taking kickbacks). According to court documents, the scheme, which ran from 2013 until 2017, involved individuals associated with a medical supply and billing company recruiting Smith to dispense pain creams and patches to his workers’ compensation patients by offering him a split of the profits. The company acted as the billing agent for Smith, handling all the paperwork and submitting the allegedly fraudulent claims to the US Department of Labor, Office of Workers’ Compensation Programs, and private insurers. In exchange, the company paid Smith 50 to 55 percent of the profits collected from successfully billing insurers, at markups of 15 to 20 times what the medications cost.”

Plus the following:

“Robert Schneiderman of Langhorne, Pennsylvania, admitted to participating in a massive compounded-medication kickback scheme that he and others ran out of a pharmacy in Clifton, New Jersey. Schneiderman pleaded guilty in federal court to one count of conspiracy to commit healthcare fraud and one count of conspiracy to violate the Anti-Kickback Statute. From 2014 through 2016, Schneiderman and his coconspirators used Main Avenue Pharmacy, a mail-order pharmacy with a storefront in New Jersey, to run a fraud and kickback scheme involving compounded drugs like scar creams, pain creams, migraine mediation, and vitamins. Schneiderman was the president of Main Avenue Pharmacy and was a founder and CEO of its corporate parent. Main Avenue Pharmacy received over $34 million in reimbursements from healthcare benefit programs on compounded medications alone. Approximately $8 million of that total was paid by federal payers. Schneiderman himself earned over $400,000 through the course of the scheme. This case was investigated by the VA OIG, FBI, Department of Defense OIG, Defense Criminal Investigative Service, and Department of Health and Human Services OIG.”

Don’t forget this one:

“Dr. Harry Doyle, a psychiatrist from Philadelphia, Pennsylvania, and his wife, Sonya Doyle, have agreed to pay $3 million to resolve alleged violations of the False Claims Act. The alleged violations include submitting false billing to the US Department of Labor Office of Workers’ Compensation Programs (OWCP) for psychiatric services that were not provided and upcoding and double-billing patient claims. The Doyles have also agreed to be voluntarily excluded from federal healthcare programs for 25 years as part of the settlement. This is the largest recovery against a single psychiatrist in the history of the OWCP. A multiagency investigation of Dr. Doyle’s practice revealed that from January 2013 through April 2021, the Doyles allegedly billed for services not rendered, some of which occurred when they were not physically present in the United States. This case was investigated by the VA OIG, the Department of Labor OIG, and the United States Postal Service OIG.”

More is coming on this one:

“Ten Texas doctors and a healthcare executive have agreed to pay more than $1.68 million to resolve False Claims Act allegations involving illegal remuneration in violation of the Anti-Kickback Statute and Stark Law. According to a multiagency investigation, from 2015 to 2018, the doctors allegedly received thousands of dollars in illegal remuneration from eight management service organizations (MSOs) in exchange for ordering laboratory tests from Rockdale Hospital doing business as Little River Healthcare, True Health Diagnostics LLC, and Boston Heart Diagnostics Corporation. Little River funded the illegal remuneration to the doctors in the form of volume-based commissions paid to independent contractor recruiters, who used the MSOs to pay numerous doctors for their referrals. The MSO payments to the doctors were disguised as investment returns but were based on and offered in exchange for the doctors’ referrals. As part of their settlements, the defendants have agreed to cooperate with the Department of Justice’s investigations of other parties involved in the alleged law violations. To date, 17 doctors and two healthcare executives involved in this scheme have agreed on settlements totaling more than $2.7 million. The civil settlements resulted from a coordinated effort between the VA OIG, Department of Health and Human Services OIG, Defense Criminal Investigative Service, and the US Attorney’s Office for the Eastern District of Texas [emphasis mine].”

Elected officials, the next time you are asked about the incredible amounts of fraud in government-provided healthcare and insurance, do not buy the media talking points that the fraud is minimal, contained, or anything but designed incompetence on the part of the bureaucrats to act as a jobs program for investigators! The same investigators who are refused sufficient tools to investigate shenanigans by employees in the Federal Government adequately. ?u=http2.bp.blogspot.com-fGEUjJsJ2h4VcJgswaisnIAAAAAAAABcsoFqEewPF_E4s1600quote-if-the-freedom-of-speech-is-taken-away-then-dumb-and-silent-we-may-be-led-like-sheep-to-the-george-washington-193690.jpg&f=1&nofb=1

Frankly, all of these cases need the government workers to be held accountable, and the myriad of red tape loopholes CLOSED! I remember an election; I forget who and the exact when, but a significant election plank in the platform was healthcare reform, promising to clean up the swamp and bring accountability to Washington and the government. The public is still waiting, and I know enough of you have run on this topic from both parties to repaper the walls (inside and outside) of the White House.

Yet, even if only outside providers and executives were scheming, the VA might not be in too bad a condition. Except for the employees of the VA, VHA, and VBA, which continue to be caught up in ethics violations at a minimum:

“The VA-OIG conducted an administrative investigation that included a congressional request to look into allegations that Charmain Bogue, former executive director of the Veterans Benefits Administration’s Education Service, committed ethical violations arising from her spouse’s consulting work for Veterans Education Success (VES). VES is a nonprofit advocacy group that regularly had business before the Education Service. The allegations also pointed to possible incomplete financial disclosures by Ms. Bogue concerning her spouse’s consulting business. In their work, investigators uncovered evidence of other potential conflicts of interest and related misconduct by Ms. Bogue [emphasis mine].”

VA-OIG finding:

1. Bogue participated in Education Service matters involving VES without considering whether it raised an apparent conflict of interest and acted contrary to the ethics guidance she received from her supervisors.
2. Bogue sought résumé feedback from the president of VES to aid in her search for career advancement without considering whether this raised apparent conflict of interest concerns in subsequent VES matters. VES also endorsed Ms. Bogue for presidential nominee positions.
3. Bogue provided insufficient detail about her spouse’s business in 2019 and 2020 public financial disclosures; VA ethics attorneys had found them compliant. She remedied the subsequently identified deficiency in her 2021 disclosure.
4. The OIG found that Ms. Bogue refused to cooperate fully in the OIG’s investigation by refusing to complete her follow-up interview. Her husband and VES president also refused to participate in OIG interviews, and the OIG lacks testimonial subpoena authority over individuals who are not VA employees. Bogue resigned from VA in January 2022.

UPDATE: 14 April 2022 – Sen. Grassley was hoodwinked by the VA on this issue and The Daily Signal (linked) has more of this report. I covered this before, I repeat only for emphasis, when you are discharged from the VA, you lose your ability to be a “whistle-blower.” As a point of fact, this is how the VA is able to hide a lot of their shenanigans, get rid of the person rocking the boat, invent the paperwork, cover the whole incident over as a “bad-apple” and keep you collective heads down and mouths shut until the VA-OIG investigation concludes. The VA’s ability to abuse whistle-blowers is further compounded by Federal Attorneys who cherry-pick the cases they know they can win. Which further protects the VA’s shenanigans and disheartens and mystifies those who have been wrongly terminated. The Daily Signal reflects this pattern of corruption perfectly citing the records obtained by Empower Oversight.

Some commentators have claimed that blaming elected officials for not scrutinizing or not providing tools to investigate entirely is unduly unfair to the congressional representatives. Really?!?!?! The VA-OIG conducts an investigation, the people being investigated refuse to comply, and the VA-OIG is toothless to enforce a full and complete investigation to initiate Attorney General and FBI investigations and actions to recompense the defrauded taxpayer. Ms. Bogue and the VES have invalidated any trust the taxpayer should have in their respective activities, but this, like so many other investigations into VA employees, will die of apathy before anyone is held accountable. Even though a congressional representative demanded an investigation, nobody is being held liable. Nobody is forced to compensate the defrauded taxpayer, yet the taxpayer is still expected to elect the same old representatives to their jobs. Blaming the congressional representatives (legislative branch) for not scrutinizing the executive branch, one of only two jobs these people have, is somehow unfair? NO! Exclamation Mark

Remarkably, between the 18 March disaster with the PCP and 01 April’s compounding idiocy, the VA-OIG published an ironically titled investigation report.

“Improved Governance Would Help Patient Advocates Better Manage Veterans’ Healthcare Complaints.”

Imagine that, more designed incompetence negatively impacting the veterans seeking care at a VA medical facility, stating the obvious by the investigators. Who on earth would be responsible for seeing that regulatory agencies had the tools needed to scrutinize and demand corrective action? Calling all elected officials, did you notice that one of the prima facia tools a veteran has to report problems, conveniently called “patient advocates,” does not have the sufficient authority, adequate oversight, and tools to execute their jobs? The VA-OIG reports the following:

“The Patient Advocacy Program helps advance the Veterans Health Administration’s (VHA) efforts to improve customer service, support veterans’ access to quality care, and provide a mechanism to resolve healthcare issues. Patient advocates document veterans’ concerns, communicate the resolution, provide follow-up and feedback, and identify trends for potential opportunities to improve medical facilities. In FY 2020, VHA tracked about 162,000 serious complaints in its patient advocate tracking systems.”

Angry Wet Chicken On a side topic, VA-OIG, how do you define a “significant complaint” and separate it from other types of complaints? Honest question, the information was, to quote my PCP, “remarkably” missing from your investigation report! Would the VA-OIG like to know why so many veterans’ complaints have risen to a “serious” level? You reported the exact problem:

“A complaint is considered resolved when the complainant communicates the outcome, and the record is closed in the tracking system.”

Maybe, the VA-OIG merely overlooked the logic problem, but complaints increase when the solution pushed down the throats of the veterans does not fix the actual situation. Honest question, no sarcasm involved. Is a “serious” complaint one where significant harm or death to the patient has occurred? Is a serious complaint one that breaks federal laws, EMTALA, comes readily to mind? ?u=https3.bp.blogspot.com-fYRTNk48SCwT8ua0IRDWPIAAAAAAAAFZUpexSmJsN2Kos1600overcoming-adversity-help-yourself-believe-cubby-motivational-1289878102.jpg&f=1&nofb=1

Having had “solutions” forced down my throat, speaking only for myself, I am thoroughly sick of having the patient advocates bureaucratize my complaint, then fail to act, and then compound the problem by quoting policy to me as a reason to close the complaint, when the VHA never have written policies and procedures! Maybe, you might want to look into the root causes of some of those “closed” complaints and ask root causation questions!

What did the VA-OIG find when they investigated the patient advocates?

- VHA lacked adequate governance of the Patient Advocacy Program.
- VHA did not effectively issue and implement adequate policy, monitor complaint practices, and provide guidance to medical facility directors responsible for local program management.
- Patient advocates did not always enter complaints into the system.
- Even though complaint records generally appeared to be closed on time, patient advocates did not always document the communication of the outcomes to the complainants.
- The VA-OIG substantiated an inadequate program policy to identify clear expectations and responsibilities.
- The VA-OIG found that they (patient advocates) did not always adhere to the documentation requirements to show full complaint resolution.
- At the local and VISN levels, responsible personnel did not consistently analyze patient advocate tracking system complaints about trends.

Feel free to read the complete abomination of designed incompetence for yourself. Essentially the VA-OIG concluded that the VHA has been burning taxpayer money in a patient advocacy program, and the designed incompetence is so apparent it can be tracked from L2, where the James Webb telescope is located! Worse, you won’t need the James Webb telescope to see the designed incompetence! James Webb Space Telescope

Unfortunately, I could have guessed the first three findings without looking. Every VA program is designed so ineptly, reprehensibly led, criminally incompetent, and with such dastardly deceptive doings that fiction writers’ storylines have to be written better to sell books. You cannot make this stupidity up and make a profit. Hollywood would run screaming into the night if they made a true story about the ineptitude found at the VA!

Knowledge Check! Elected officials, where are you? The VA-OIG presents copies of their findings to you, and I have yet to witness a single one of you holding the VA Leadership criminally responsible for the failures at the VA. Even when the VA is killing hundreds of veterans, the US Congress refuses even to act upset, let alone scrutinize for a change! Remember how many veterans were intentionally killed in Phoenix waiting for treatment? How many VA employees lost their jobs and pensions or were forced in front of a judge for murder? It is a fair question, where are the elected officials in the legislative branch working to end the criminal “fraud, waste, abuse,” and designed incompetence in the executive branch?

The Year-End Maelstrom! – More VA Shenanigans! (Where is the accountability?)

2021 has finally ended, but before it ended, the Department of Veterans Affairs (VA) – Office of Inspector General (VA-OIG) increased the pace, and the following is but a taste of the year-end insanity foisted into my inbox. With more than 45 emails to sift thru, some of the topics had to be culled, and I regret that I had to cull the emails. Each and every VA-OIG report deserves to be scrutinized, evaluated, and the actors punished, many times with criminal court. I don’t know what’s worse, summating these stories or getting hit with a truck; seeing as I have been hit by a truck, I think the truck is easier.

We begin the recount of VA-OIG stories with another veteran, deceased because the VA Medical Center refused to do their job and provide continuity of care after a 33-day hospital stay. Leaving me wondering if this was intentional malpractice due to the cost of the veteran to the VA. Listen to the findings of the VA-OIG, then make your own decision.

“The Malcom Randall VAMC’s interdisciplinary team (IDT) failed to develop a discharge plan that adequately ensured patient safety and continuity of care. The Malcom Randall VAMC did not have a discharge planning policy that outlined IDT membership, communication expectations, or roles in discharge planning. The OIG found that the occupational therapy provider did not verbally communicate a new recommendation for a home safety assessment or take action to stop the discharge until the safety concerns were addressed. Additionally, an attending physician failed to review written recommendations for home healthcare services from consultative and ancillary providers before composing the discharge plan for the patient. The social worker, who had significant responsibility for ensuring the adequacy and safety of the patient’s discharge plan, also failed to incorporate recommendations by the occupational therapy provider and failed to discuss and offer home health services to manage the patient’s venous leg ulcer and monitor infection of the right leg. The OIG also found that social workers did not consistently complete thorough and detailed psychosocial assessments that would be pertinent to discharge planning.”

Remember when the media became hysterical when then VP Candidate Gov. Sarah Palin suggested ObamaCare would institute “Death Panels?” Bureaucrats decided that the government had invested sufficient money into a patient and was going to stop providing medical care. When this media hissy-fit was going on, I claimed that the VA had been exercising this right to discontinue care for a long time. Several people took umbrage at this commentary; yet, what do we find from the VA-OIG, a dead veteran, five recommendations by the VA-OIG to do the job these “providers” were already hired to perform, and I am left thinking, “Death Panel in action.”

What else should I conclude with no accountability, responsibility, and consequences?

On the topic of holding a job with responsibility and not being held accountable, we find another hit to the VA and their lack of IT/IS security. Desiring brevity but passing along factual information, the following summary has been condensed:

The Federal Risk and Authorization Management Program (FedRAMP) standardizes security and risk assessments for cloud technologies for federal agencies, including VA. In April 2019, the VA Office of Inspector General (VA-OIG) received allegations that VA’s Office of Information and Technology’s (OIT’s) Project Special Forces (PSF) was not following FedRAMP policies or VA policy for deploying software-as-a-service (SaaS) applications.

- - The VA-OIG found that OIT granted security authorizations for applications FedRAMP did not authorize.
    - - Eight of the nine applications cited by the complainant were used on the VA network—some without FedRAMP or VA authorization.
      - Another three applications were approved to operate on VA’s network without FedRAMP authorization.
  - The OIG did not substantiate that PSF-developed applications were improperly managed outside the VA Enterprise Cloud group.
  - PSF did not follow VA security requirements in developing interfaces that allow third parties to “plug into” the VA to send and retrieve data.
    - - OIT personnel stated, “no formal OIT authorization process until April 2019.” After that date, the review team did not find instances of VA-authorized applications without FedRAMP authorization.
  - OIT staff “apparently” misunderstood the FedRAMP authorization requirements for SaaS applications containing data classified as less sensitive.

Please note if you think the VA IT/IS performance has improved since April 2019. You are sadly mistaken, as in 2021, there have been three major VA-OIG reports declaring how IT/IS systems at the VA remain insecure, failing legislative mandates for basic security, and are hopelessly too expensive and useless. I have two VA-Apps on my phone, both of which work “sometimes,” and never sufficiently support the end user. Worse, these apps do not interface with the old software the VA is helplessly tied to while the new software continues to prove its uselessness and security problems in real-world beta testing.

Tell me, would you trust the government, any of the alphabet agencies, with your child to babysit? If not, why do we trust the government to secure our identity? If so, please elaborate, for I would love to know of a government/NGO operating with trust and efficiency.

Continuing under the heading of failure to perform the job hired for, we find the VA-OIG issuing a total of 20 recommendations to Vet Centers. The Vet Centers included record keeping of suicidal veterans seeking mental health support as a point of reference. Not for the first time, but I keep hoping it’s the last. The VA continues to fail veterans, abuse veterans actively, and take advantage of veterans, and I remain unconvinced this torture of their customers is not intentional. Maybe not all employees, for I have met some great employees, but the leadership appears hellbent on killing as many veterans as possible.

Why isn’t this big news, huge headlines, and a major story to the corporate media? Where is the coverage? You cannot convince me that 1)You are not aware of this story and 2) That you are unfamiliar with its implications.

VA statement on GPO printing and mailing delay

WASHINGTON — Due to supply chain and staffing shortages, the vendor contracted by the Government Publishing Office to provide printing services for the Department of Veterans Affairs is experiencing delays in printing and mailing notification letters to Veterans and claimants. The disruption may impact the ability of some claimants to meet required deadlines via written correspondence with the VA.

In response to the mailing delays and to protect the best interest of claimants, the Veterans Benefits Administration is extending its response period by 90-calendar days for claimants with letters dated between July 13, 2021, and Dec. 31, 2021.

For those not aware, everything in the bureaucracy abbreviated as the VA is time-sensitive. Miss a deadline, and you have no opportunity to recoup lost time without investing significant amounts of resources. Since I continue to be in an embroiled battle with the VA over not receiving a proper decision in 2004, time delays represent problems untold due to budget cuts and bureaucracy, and the VBA and VHA bureaucracies will do everything they can not to help you. Then we add the time delays, and the consequences can be disastrous. Think veterans dying with an active application for benefits, and you come close to how big this story is, and not covering it with wall-to-wall coverage is the epitome of lackluster asininity!

It took dead veterans on waiting lists to get bad press through the Media fawning over President Obama; what will it take to penetrate the media quilt for Biden? Continuing under the heading of failing to do the job you were hired to perform, we find another VA-OIG comprehensive healthcare inspection (CHIp). Guess what; this one is beyond utterly dismal and flagrantly reprehensible!

The administration and delivery of care to female veterans continues at its expected and atrocious, slovenly pace, being outstripped by one-winged butterflies. How can the VA Leadership continue to keep their jobs when they allow such incorrigible behavior from lower staff members? Would the elected Representatives and Senators address this question? You were hired to scrutinize the government; that is the only other job you have after writing fair and equitable legislation to all citizens. Why should you be re-elected when this behavior abounds, and you refuse to scrutinize the executive branch officers?

Consider the following, “The VA-OIG audit team estimated that improper payments for acupuncture and chiropractic care amounted to about $136.7 million during fiscal years 2018 and 2019.” Continuing, “The audit team also found that VHA did not always follow guidance when reauthorizing acupuncture and chiropractic care. Not documenting assessments of prior treatments before authorizing additional care may interfere with veterans’ treatment.” Failure to ensure your underlings have established proper processes and procedures that are effective and followed is a prerequisite to holding a leadership position. Where is the leadership at the VA? Where is elected representative scrutiny? What are the consequences for doing a poor job of cleaning the house and protecting the taxpayer?

How big is this problem? Try upwards of $341 Million, on top of the $136 Million already discussed, and before the full force and cost are known on delays in properly notifying veterans in a timely and efficient manner.

“The VA-OIG audit team found that some providers are billing VA at a significantly higher rate for high-level evaluation and management services than their peers in the same specialty. The team determined that in fiscal year (FY) 2020, more than 37,900 non-VA providers billed and were paid for significantly more high-level evaluation and management codes than were all providers in that specialty on average. These non-VA providers received about $39.1 million (13 percent) of the approximately $303.6 million paid for all non-VA evaluation and management services.

Additionally, some providers billed separately for evaluation and management services when the global surgery package was in effect. This package is supposed to cover all surgery-related services for a set period. The review team identified more than 45,600 providers were compensated about $37.8 million in FY 2020 for these evaluation and management services.

Improper payments were not easy to detect because VHA staff did not retrospectively audit medical documentation as required. Additionally, the OIG found no evidence that VHA or contractors trained non-VA providers on documenting evaluation and management services, similar to how VA providers are qualified. The OIG determined VHA risked overpaying for evaluation and management services by about $19.9 million in FY 2020.”

While discussing audits, failed processes, and the lack of consequences for senior leadership, we must break and wish a “Happy Birthday” to the audit hits turning 10, 12, 15, 21, and older. It never ceases to amaze me how these financial failures can continue to age, and nobody is held accountable! May you age out and finally be corrected! Would the elected leaders of America like to know why the VA is consistently failing financial audits?

“VA continued to be challenged in consistently enforcing established policies and procedures throughout its geographically dispersed portfolio of outdated applications and systems.”

Now, explain why we should re-elect any elected official to office?

Elected officials, your job is to scrutinize and write legislation; that is what we, the electorate hired you to do. Do you realize the far-reaching consequences of your failure to perform your job? Let me introduce you to an example:

“Anthony Medrano, a veteran of the US Marine Corps and former employee of VA, admitted that between approximately November 2015 and May 2020, he submitted claims to VA in which he purported to be disabled to obtain caregiver benefits for his wife, when he was actually able-bodied and even participated in fitness challenges and coached youth sports. Medrano was sentenced in federal court to eight months in custody for defrauding VA out of more than $183,000. He executed this scheme while employed by VBA as a veterans service representative, a position in which he explained benefit programs and entitlement criteria to veterans applying for VA benefits.”

Or the following:

“Barry Wayne Hoover of Tampa, Florida, a veteran of the United States Navy, exaggerated the extent of his visual impairment to receive VA disability benefits to which he was not entitled. Specifically, Hoover manipulated the results of subjective tests of his peripheral vision to reflect that he had only a five-degree visual field and was legally blind. VA found that Hoover was 100 percent disabled based on those manipulated tests. Hoover was found guilty of theft of government funds and making a false statement to a federal agency. He faces a maximum penalty of 10 years in federal prison. His sentencing hearing is scheduled for March 2022.”

How about this:

“Professional Family Care Services, Inc. (PFCS), a home health services company based in Fayetteville, North Carolina, has agreed to pay more than $45,000 to settle civil False Claims Act allegations related to fraudulent billings for work by a recently convicted felon under their employ. During 2015 and 2016, PFCS billed VA for home health services provided to W.R., an Army veteran, even though, at that time, W. R. was residing with the company’s employee, Certified Nurse Aide Tracey McNeill. PFCS based its billing for those services on falsified timesheets provided by McNeill, who failed to provide both the time and quality of care required under the VA program. After several months living with McNeill, purportedly receiving home health services provided by McNeill through PFCS, W. R. had to be admitted to the hospital. He was extremely malnourished and ultimately died within a few days of admission. Earlier in 2021, McNeill was convicted of wire fraud for her misconduct related to W. R., sentenced to 12 months and one day in federal prison, and ordered to pay over $90,000 in restitution.”

Morality is exemplified by leadership and then exercised under scrutiny. Because you, the elected officials, refuse to be morally upright and scrutinize the government, the executive branch officers and employees have become careless, irresponsible, and taken the American Taxpayer for a ride!

Each time the VA-OIG reports an investigation beginning with the death of a veteran, the root cause is always a failure of people to do the job they were hired or contracted to perform, and the casualty is a dead or severely injured veteran. The culling of the email included a urologist who performed procedures, puncturing internal organs, and not notifying the patient. Several other CHIp summaries reflected the egregious and despicable leadership hidden at VHAs and VAMCs across the country. Other Vet Centers possess failing bureaucrats just trying to hide until they reach retirement and escape.

America, you deserve better from the alphabet agencies representing the executive branch! Fellow veterans, please do not give up hope; we can still help protect this country from those enemies domestically located who make your lives a living hell. Please pass the word, these VA-OIG investigations deserve to be read, and questions asked! Elections are coming; join the fight as a citizen and run for office.

© Copyright 2021 – 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 (CH 5)

I-Care The end of the year inundation continues unabated. Unfortunately, so to does the failure of the Department of Veterans Affairs (VA) – Office of Inspector General (VA-OIG) to inspire and motivate change. Thus, my continual efforts in opening the transparency and demanding accountability for the VA leadership, and insistence that the American Congress do its job in scrutinizing the executive branch! I repeat, only for emphasis, the US Congress (the US Senate and US House of Representatives collectively) only have two jobs. 1) write laws that are constitutional and for the benefit of all, themselves included, American citizens. 2) scrutinize the executive branch to protect the American Citizen from abuse and runaway actions. Feel free to read the links to each story for more information, the failure of elected officials to act and prevent this behavior is abysmal, and these are just summaries, the full story is detestable!

In yet another fraudulent scheme, the fraudsters are penalized but the VA employees are left without penalty.

Thomas Farese, 79, of Delray Beach, Florida, and Domenic J. Gatto Jr., 47, of Palm Beach Gardens, Florida, are charged in an 11-count indictment with conspiracy to commit wire fraud, conspiracy to commit health care fraud, health care fraud, conspiracy to transact in criminal proceeds, transacting in criminal proceeds, and conspiracy to violate the federal Anti-Kickback Statute. VA 3

Two VA employees, over the course of four years, caused the VA to lose $1.38 million in kickbacks.

Two Chicago-based VA employees were charged in connection with a fraud scheme that involved pocketing cash payments from vendors in exchange for steering orders for medical equipment to those vendors. Andrew Lee is charged with one count of wire fraud, while Kimberly Dyson is charged with one count of conspiracy to commit bribery and four counts of bribery. Lee and Dyson worked as prosthetic clerks in the VHA Prosthetics Service in Chicago, where part of their duties was to select vendors to order medical equipment for VA patients using government purchase cards. The charges allege that Lee and Dyson schemed with coconspirators who owned or operated medical supply and distribution companies, in some cases placing orders for unnecessary and more costly monthly rentals of medical equipment, rather than purchasing the equipment as VA physicians had ordered. The scheme fraudulently caused the VA to overpay one company by more than $1.38 million from 2016 to 2020. Lee and Dyson pocketed kickbacks of at least $220,000 and $39,850, respectively.

From fraud to theft, we find another VA employee improperly taking advantage of their position for personal gain.

Former VA-certified registered nurse anesthetist, Elizabeth Prophitt of Saline, Michigan, was sentenced to three years’ probation for stealing controlled substances, including several opioids, from hospital-dispensing machines. Prophitt pleaded guilty to five counts of obtaining controlled substances by fraud, misrepresentation, or deceit. She used her position as a surgical nurse to steal more than 2,000 vials of Schedule II and Schedule IV controlled substances, which included fentanyl, hydromorphone, morphine, and midazolam. Prophitt would use protected patient information and falsify medical documents to obtain the controlled substances. Instead of using the medication on patients, she diverted the drugs for her own personal use. VA 3

For all those people who shudder when they think of how porous the government is in protecting personal identifiable information (PII), the following should alert and provide more fodder to end the political ambitions of representatives who continue to refuse to do their jobs!

Five out of seven conspirators were convicted for their roles in a scheme to defraud the VA and the Social Security Administration of more than $1.8 million. A Florida jury found Omar Shaquille Bailey and Ronaldo Garfield Green guilty following an eight-day trial, while a third codefendant, Jamare Mason, pleaded guilty on the second day of trial. Two other codefendants, Kadeem Gordon and Mario Ricketts, had pleaded guilty prior to trial, while two remaining codefendants have yet to be apprehended. The members of this conspiracy obtained the personally identifiable information of disabled veterans and Social Security beneficiaries and used this information to fraudulently open bank accounts and prepaid debit cards. They also forged documents in the victims’ names that directed the VA and the Social Security Administration to deposit benefit payments into those fraudulent accounts. The defendants and their coconspirators withdrew these funds from ATMs and banks throughout South Florida and Georgia for their own personal use. Much of the funds were ultimately funneled to the architects of the scheme in Jamaica. The five guilty defendants are awaiting sentencing. VA 3

Please remember, an indictment is not a conviction, and every person is allowed their day in court, in front of a jury of their peers, before sentencing and judgment is passed. With that said, the following indictment is pretty compelling. If found guilty, may the defendant be forced to do community service in distinctive clothing, in a public place, and carrying a sandwich board detailing their crimes. Inexcusable and unforgiveable are terms not used enough for some crimes!

Rosemary Ogbenna of Washington, DC, was named in a 35-count indictment for allegedly carrying out a scheme to steal more than $400,000 in government benefit funds provided by the Social Security Administration (SSA) and VA. According to the indictment, Ogbenna operated a rooming house business and perpetrated the scheme to target some of her tenants. She obtained and maintained control over SSA and VA benefit funds intended for the care of elderly, mentally ill, disabled, and veteran beneficiaries, and used the funds for her own personal use and benefit. VA 3

The Raymond G. Murphy VA Medical Center (VAMC) in Albuquerque, NM is in the news again. No surprise if you, like me, are familiar with the conditions and leadership at this VAMC. Unfortunately, another veteran has died due to the malpractice and malfeasance, abuse, and lack of leadership in the VA.

The VA-OIG determined that poor oversight of resident physicians (residents) likely contributed to the patient’s delayed lung cancer diagnosis. A resident ordered an abdomen and pelvis computed tomography (CT) scan. Although a follow-up chest CT scan was recommended within 90 days, it took 175 days to complete. The chest CT scan results included resolution of a spiculated lung nodule and worsening of opacities in the lung representing a cavitary infection or cancer, and a positron emission tomography/CT (PET/CT) scan was recommended. The follow-up PET/CT scan showed a lesion in the right lung, but a biopsy was not done. The patient was examined and diagnosed with cancer at a non-VA hospital.

The VA-OIG concluded that deficiencies in care coordination between Primary Care, Pulmonary, and Emergency Departments’ staff also contributed to delays. In addition, contract teleradiologists did not use available prior images for comparison. The facility failed to use quality management and patient safety processes to evaluate the care of the patient. VA 3

Here’s the kicker, and it should infuriate every taxpayer in America. The Raymond G. Murphy VAMC was recently found to be meeting all SAIL metrics in a comprehensive healthcare inspection completed by the VA-OIG. SAIL metrics are how the VA leadership are measured in being knowledgeable and competent in these positions. Check out the link on SAIL metrics for more information. Leaving only one question, “How can the VA leadership be found competent, and still be killing veterans?”

Angry Wet Chicken When discussing the abuse of veterans and the failure of VA leadership, it never ceases to surprise me the utter half-truths, bloviations, and oratorial yoga, and logical pretzel twisting that is accepted by the US Congress. The following link takes you to a list of witness testimony given by VA-OIG representatives to the US Congress. If these “witness” statements leave you sick and mentally struggling, don’t say you were not warned. The VA-OIG, like the VA, is replete with verbal contortion performers and nowhere is this most noticeable than in “witness” testimony!

Regarding verbal chicanery, oratorial yoga, and despicable verbal gymnastics to provide job security while taking zero action, here is the link to the Semiannual Report to Congress by the VA-OIG. Don’t say I didn’t warn you, the bureaucrats are out in full force and are playing every card in the deck to protect themselves from Congressional Scrutiny, while attempting to pass themselves off as honest, fair, and doing a good job for the American People. The problem is in Congress not properly scrutinizing these shenanigans and demanding compliance with the law!

VA Seal The remaining 15 notifications from the VA-OIG are the standard reports on comprehensive healthcare inspections (CHIp) where leaders are measured, never found wanting, even though too often the leaders are failing and useless. Other notifications included the audit for data security and IT measures completed by a third-party auditor, and which the VA continues to fail but Congress refuses to hold people accountable. The third and final series of notifications in this batch were several dealing with individual VISN level of local VAHCS/VAMC level inspections on specific topics, such as COVID response, supply chain failures, and other issues.

Unfortunately, the answer is always the same the leaders are inept, inadequate, and incapable of initiating change before a veteran dies, before fraud and abuse occur, or before the VA-OIG makes an attempt to inspire change. Not that the VA-OIG is very capable or properly equipped to inspire change, simply that the VA-OIG made an attempt. The root cause remains clear, Congress refusing to do their job has led to the US Military Veterans being actively abused by the Department of Veterans Affairs. Lackadaisical scrutiny, politicization, and two recent presidents who allowed Congress to label the US Military Veterans as “domestic terrorists,” have had detestable consequences for the American Taxpayer and the US Military Veterans and their families. ?u=http3.bp.blogspot.com-CIl2VSm-mmgTZ0wMvH5UGIAAAAAAAAB20QA9_IiyVhYss1600showme_board3.jpg&f=1&nofb=1

Are you sufficiently inspired to change how you vote, demand elected leaders to act, and improve how the government in America from the city/county to the US President operates?

“That’s Crazy!!!” – More Chronicles From The VA

Bobblehead Doll The week of 27 September 2021 started funkily and has gone downhill rapidly! I reported Monday being refused medical service for not wearing a mask. On Tuesday, I visibly struggled for breath, standing in the VA pulmonologist’s office in front of the pulmonologist who was holding my pulmonology function test results. I am holding a letter showing I cannot wear a mask, wearing a face shield, and being told by the doctor, “I do NOT care, he needs to WEAR A MASK, or I AM NOT SEEING HIM” [emphasis his]. Eventually, the doctor agrees to see me, provided I remain more than 6 feet from him, and he does not have to touch me. The doctor then proceeds to lecture me about getting the vaccine, wearing a mask, and of course, breathing through my breathing difficulties.

As they say on the Home Shopping Network, “But wait, there’s more!” Crazy has only just begun, unfortunately!

A patient with iron-deficiency anemia died at the hands of VA Doctors at the San Juan Puerto Rico VAHCS (2017), and the VA-OIG is just completing and reporting on their death in 2021. The patient who came in for a colonoscopy developed rectal bleeding, which required an anticoagulant, and the patient subsequently died. A tragic set of dominoes was set up and knocked down in this patient’s case, and the VA is entirely at fault for the patient’s death. How badly the patient’s family must feel with this report in hand and knowing they can do absolutely nothing! VA 3

100% crazy indeed; but wait, there’s more!

Justice was served cold and raw, and while I was hoping for a harsher sentence by far, I am still hoping his victims can recoup some of their losses and obtain retraining. “Jonathan Dean Davis, the owner of Retail Ready Career Center in Texas, was sentenced for deceiving the VA of $72 million. Beginning in 2014, he offered six-week heating, ventilation, and air conditioning course, promising to prepare veterans for careers in the HVAC industry. However, upon entering the workforce, many of these veterans discovered that the course had failed to teach them many of the basic skills necessary for entry-level technician jobs. Davis was also ordered to pay $65.2 million in restitution and forfeit $72.5 million to the federal government.”

It is very hard to describe what goes into the GI Bill besides money and time in service. It is even tougher to explain how cheated you feel when the benefit is cut by the government, stolen by school administrators, and reduced by petty rules and regulations. To see your benefits stolen through shoddy training and see your hopes and dreams dashed, as well as your benefit, turned into useless paper, the heartbreak is incredible! The punishment for all involved should have been greater, and some federal employees should have shared the blame for failing to do their jobs! I-Care

Hold onto your seat, folks; the insanity has not even reached its peak yet; there’s more!

“The VA Office of Inspector General (OIG) inspected the VA Illiana Health Care System in Danville, Illinois, to determine the validity of allegations, specific to COVID-19 and the Community Living Center (CLC), of failure to observe infection control practices, failure to minimize the risk of exposure to COVID-19, inconsistent ongoing testing, and failure to notify residents, families, and staff of positive test results. During the inspection, the OIG identified concerns related to leaders’ post-outbreak actions. The VA-OIG substantiated a failure to observe general infection control practices, including in the following areas:

- Leaders failed to minimize the risk of exposure to COVID-19.
- Leaders did not respond adequately to staff exposure.
- Leaders did not have a plan for the transfer and isolation of residents.
- Leaders did not implement recommended infection control measures when performing aerosol-generating procedures and continued to hold group therapies.

The VA-OIG substantiated the lack of a post-baseline testing plan and a failure to test CLC staff after potential exposure. The OIG identified actions taken by leaders following the CLC outbreak that lacked input from frontline staff to identify corrective actions and opportunities for improvement.” This is the politically correct way of saying that the community living center leaders are thoroughly incompetent and should not be trusted in their current positions.

Leadership failure in spades, employees, patients, families all placed at risk because of incompetence and politics of the facility leaders, and the VA-OIG does not have the teeth needed to FIRE and REPLACE the leaders who are clearly out of their depth and ability! For months the media and political leaders have been harping and preaching how dangerous COVID as a viral infection is. Yet, the leaders in the Illiana VAHCS seem to be operating to a different set of rules and policies. Will any elected leader be asking why? Insanity runs deep in Illinois! VA 3

On the topic of COVID-19, and the failures of VA providers to do their jobs, we find another dead veteran due to what in the private sector would be a classic case of malpractice! Yet, care at the VA is protected from malpractice, and the providers are safe from responsibility and accountability for their failures. While the following is specific to North Carolina, similar examples are found across the United States. Insanity thy name is represented in spades at the VA! Angry Wet Chicken

“The VA OIG conducted a healthcare inspection at the Fayetteville VA Coastal Health Care System in North Carolina to assess concerns related to the quality, coordination, and timeliness of care, and the impact of COVID-19 on a patient with unintentional weight loss who was later diagnosed with oral cancer and died at another VA medical center.”

- The VA-OIG substantiated that the primary care provider and dietitians did not provide quality care to the patient.
- The VA-OIG substantiated that dietitians conducted incomplete nutritional assessments.
- The VA-OIG substantiated that the patient’s PACT nurse and dietitians failed to coordinate care by not communicating the family’s request for a face-to-face appointment and the patient’s declining nutritional status to the primary care provider.
- The VA-OIG found that incorrect scheduling resulted in the patient not being seen by a dietitian for a follow-up appointment and a delay in scheduling a non-VA dental appointment.

“The VA-OIG concluded that COVID-19 impacted the care provided by dietitians because of the use of telephone visits, which did not allow dietitians to visually assess the patient’s physical characteristics caused by a declining nutritional status.”

Blaming a viral disease for the failure of people to do their jobs is the height of skullduggery, showing pusillanimous disregard for the patient and a timid weak-kneed, and yellow-bellied timorous approach to medicine. None of you deserve to be in the medical field if you cannot properly take personal protection and see patients who need to be physically seen! Now, let’s call a spade a spade and call out your wimpy, limp-wristed, lily-livered weakling leaders who refuse to act like leaders in a hospital and prefer to act like scared amoebas in a petri dish! There is NO EXCUSE for your paltry excuses, your shady practices, and your hiding in offices and behind the disruptive behavioral committees when your policies and procedures FAIL when YOUR training plans fall apart, and when reality bites hard enough to disrupt hospital operations and your policies are the problem endangering patients! VA 3

Crazy… Thy name is abused in the VA, and the leaders are failing to understand sanity! But … wait, there’s more!

There are times when I describe the insanity at the VHA, VBA, National Cemeteries, and the Department of Veterans Affairs (VA) as designed incompetence. The following is the purest example of designed incompetence witnessed to date. Consider with me the following:

?u=http3.bp.blogspot.com-CIl2VSm-mmgTZ0wMvH5UGIAAAAAAAAB20QA9_IiyVhYss1600showme_board3.jpg&f=1&nofb=1 Blue Water Navy Outreach requirements were met, but processing and procedures remain lacking and need improvement. The VBA was legislatively mandated to extend veteran benefits to a classification of sailors who operated in blue water conditions off Vietnam or within 12 Nautical Miles of Vietnam. The VBA went forward and established the computers, the records, the systems, etc., to handle these claims. The results, a complete farrago!

“The VA-OIG substantiated that the VBA has not established procedures for its employees to follow when the computer search tool they use to determine ship locations during claimant service dates returns unlikely results (for example, providing an inland location in a search for an aircraft carrier). In addition, VBA employees inaccurately decided approximately 46 percent of veterans’ claims (2,100 of 4,600) from April through June 2020, which led to about $37.2 million in improper payments to veterans ($25.2 million in overpayments and $12 million in underpayments) during that period. About 95 percent of these errors resulted from VBA employees deviating from policies governing disability-rating decisions.”

Did you catch that the VBA intentionally designed a system that failed to perform the task because humans and computers were lenient to deviate? Nobody is held accountable for the continued loss of benefits, treatment, and wasted resources of the government and the veterans involved! Here’s the rub, this is NOT the first time this has happened! The VBA is notorious for failures like this and never held accountable by the elected officials hired to scrutinize the government! Name a military excursion where benefits had to be carved out by legislative order, and you will find foot-dragging, designed incompetence, inconsistencies in decision making, and piss-poor performance at every level of the VBA. Why?

Let’s imagine you hold a job that has a reporting requirement to an authorizing body that can shut you down. You arbitrarily change language in metrics and reporting, do not tell the authority but still expect the authority to license you and your efforts. How likely do you think the governing body will look favorably upon your changes? The VA is legislatively mandated to report to Congress on its capacity in five areas, spinal cord injuries, traumatic brain injuries, blind rehabilitation, prosthetics and sensory aids, and mental health. But, by changing the language, metrics, and methods of talking about injuries, the VA can hide, misreport, underreport, overreport, and play reporting games with the report to Congress and the VA-OIG second look get away with the deception. Never forget, the maskirovka comes with veteran patient abuse! Angry Grizzly Bear

The VA-OIG has reported continuously to Congress, to deaf ears and plastic lips, the following, “… VA cannot compare its current mental health capacity with its 1996 capacity because of changes in diagnosis and treatment, service provision, and data collection. For example, VA must report on the number of veterans with “serious mental illness,” but VA no longer uses that term. And non-VA care, which veterans increasingly seek, must be excluded from reports on VA’s capacity to provide care. The OIG believes that by modernizing the reporting metrics, Congress would be better positioned to assess VA’s capacity to provide care for today’s disabled veterans.”

Congress continues NOT to push the VA to adopt 1996 language and metrics for reporting, or change the law to update the language and metrics to capture the data more accurately, thus allowing the lies and deceptions to continue. Will anyone in the media EVER ask Congress WHY? VA 3

What kills me, the insanity discussed in this summation of VA-OIG reports does not even scrape the iceberg. In my email inbox, I have to select between continued financial failures by leaders, veteran suicide during an inpatient residency, and the continued moral distress of employees by facility leaders. I have twenty more VA-OIG reports sitting awaiting summation because the insanity has blossomed, and the VA-OIG is working hard to clear their reports for the end of the calendar year. Each and every one of these reports deserve analysis, discussion, and mega-doses of sunshine disinfectant. The sheer enormity of the insanity means that timely discussion physically cannot occur. By overloading the system, the perpetrators of veteran abuse can escape sunshine disinfectant, and that is a sore injustice!

Pray for the families of those who have died at the hands of the VA providers and for those currently dying under the hands of VA providers. Congress needs to act, and we, the electorate, must hold their feet to the fire until they are consumed, or they stand and do their jobs! There are no excuses for the insanity contained in these VA-OIG reports!

Whiskey-Tango-Foxtrot – The VA Edition: More Shameful VA Chronicles

Angry Grizzly Bear The Department of Veterans Affairs (VA) – Office of Inspector General (VA-OIG) has released the details of an investigation into a veteran’s death. The scope of the investigation included several key items, but the main point was that a nurse failed to contact the patient, the patient went without medication for four days, and on day five, died.

“The facility conducted an internal review of the patient’s care. The OIG found that the review was incomplete and included inaccurate information, and leaders were unable to determine if an institutional disclosure was warranted.”

Failing to coordinate care is a leadership issue, and the leader’s failures caused a veteran’s death. With more veterans using community-based care options, VA leaders must coordinate care more specifically, that medical records are shared timely, and communication occurs. We are several years into expanded community-based care options for veterans; why has the VA not made progress on this issue to date?

Personal storytime, no VA-OIG investigation. I was forcibly moved from the Las Cruces community-based outpatient clinic (CBOC) to the El Paso VAMC due to the felonious and fallacious charges of being a behavioral problem in Phoenix VAMC because I cannot physically and safely wear a mask. My new primary care provider, a nurse practitioner, sent me a letter dated 23 July 2021, almost a month after I submitted documents for completion, informing me they do not feel capable of making a medical determination on my ability to drive. I had submitted some documents from the NM DMV to get a handicap placard and medical clearance for diabetes and my neurological condition. A medical professional is not capable of making a medical determination. Oh, the irony is thick with this one!

The El Paso VAMC spearheaded a program for the VA to begin using nurse practitioners and clinical pharmacists as primary care providers to “reduce the burden” on actual medical doctors. If the nurse practitioner felt medically incapable of making a decision, where was his supervisor? Where was his leadership support team? Is the problem with using no medical doctors clear? Leadership issues abound, and nobody in Congress is taking any action. Nobody in the VA’s highest echelons of leadership is taking any steps to correct the local and VISN level leadership problems. Who suffers; the veterans and their dependents!

Back to recent VA-OIG investigations, we find a doctor from Florida sentenced to six years in the federal prison system, plus restitution and asset forfeiture. From the record, we find the following:

“To attain such high volumes of claims, the conspirators used bribes and kickbacks. Specifically, Davidson and his conspirators illegally purchased thousands of DME claims from so-called “marketers.” The marketers, for their part, had generated the claims under the guise of “telemedicine,” but no telemedicine had occurred. Instead, the “marketers” had bribed doctors to sign the DME brace orders that supported the claims. Davidson and his conspirators paid millions to secure the illegal DME claims for submission to Medicare and CHAMPVA.”

Gavel How many conspirators are Federal Employees? How many are leaders of Federal Employees? Who else knew and profited, and when will they be held culpable for the crimes committed? Dr. Richard Davidson (42) had a lot of help to build a $20 Million healthcare fraud scheme; a lot of that help had to come from Federal Employees. When will government employees finally start being held responsible for the problems they perpetuate? Where is Congress in scrutinizing this case and demanding the legislative branch take action to stop the fraud?

Traveling to Puget Sound Healthcare System in Seattle, Washington, we find the VA-OIG neck-deep in conducting a comprehensive healthcare inspection (CHIp). “The Director and the Chief of Staff had served since 2017, the Deputy Director for Patient Care Services and Associate Director had been in their positions since 2018, and the Deputy Director had served since 2019. Survey data indicated opportunities to improve employee satisfaction and reduce feelings of moral distress. Patient survey results showed that individuals were generally less satisfied with their care compared to VHA averages” [emphasis mine]. More thick irony is being dished out here. Never will the VA-OIG find employees feeling morally distressed and patients being highly satisfied with their care. There is a causal relationship between the level of moral distress in employees and lack of satisfaction from patients, and the problem is found in the leadership at the local VAMC/VAHCS level!

Knowledge Check! Never forget, the Puget Sound VAHCS is where the wait-list death scandal began before that hospital director was moved to Phoenix. Thus, to hear of employees still feeling morally distressed in this VAHCS is not surprising, alarming, but not surprising! To hear that patients still feel cheated is expected, as the VA leaders who took over after the wait-list scandal had been raised in a culture of corruption, where the honest left and the dishonest and disrespectful remained. Some of the VA-OIG’s recommendations include patient follow-up and exit reviews, care coordination, medication management, and patient safety. All of which are symptoms of poor leadership!

My wife just asked me a pertinent question, “Can you trust the VA to provide you honest care?” No, I cannot. Yet, due to ObamaCare, the cost of seeking outside medical service is so astronomical I cannot afford to participate in my company’s medical insurance plans. The VA has a dearth of leadership, coupled with too many managers, lawyers, and labor unions. Yet, who does a veteran complain to? Congress is deaf to our pleas. The VA in Washington is missing in action 100% of the time. The veteran service organizations are all geared to helping get veterans enrolled into VA benefits. Lawyers cost too much. The VA-OIG is limited to making recommendations, and the government protects its own against litigation.

Election In a representative government, the highest authority is the people electing officers to government. Well, I continue to appeal to my fellow veterans, their dependents, and ordinary citizens. Please, help change the VA! Vote new blood into a public office dedicated to correcting and scrutinizing, not writing endless legislation that costs too much and increases debt. Vote new judges into office who will see the problems and not employ judicial overreach to handle issues. Demand accountability from elected officials.

Absurdity so Repugnant it Takes Your Breath Away – More VA Chronicles

Angry Grizzly Bear The Department of Veterans Affairs – Office of Inspector General (VA-OIG)-released six investigation reports in the last two days. Each one is mentally breathtaking at the egregious behavior of bureaucrats! Stupidity that is so repugnant it breaches the laws of morality and leaves the reader stupefied. Every year, for the last decade-plus, the behavior of the Department of Veterans Affairs (VA) has become more obscene, more outlandish, more detestable, and more openly hostile towards veterans; it sickens me to read the investigation reports, write, and catalog these abuses!

Beginning in Queen’s, New York, we find another dead veteran that should never have died the way they did. Improper feeding by a registered nurse (RN) at the New York Harbor Health Care System’s Community Living Center (CLC) contributed to the death of a patient. Let that sink in for a moment, for the rest of the report only goes downhill from this point. My time in medical training was replete with the following aphorism, “If it is not written down, it NEVER happened.” The nursing staff failed to document meals properly. The electronic health record (EHR) was inaccurate and flawed, hindering resuscitation, which was poorly documented, and institutional disclosure acted more like CYA than a medical file. People should have been fired and up on trial for this type of scandalous behavior, especially since a veteran died from this abuse and neglect. But the VA-OIG made their recommendations, the leadership accepted the recommendations, and nothing else will happen. Nobody but the family cares the veteran died needlessly and at the hands of the medical professionals. VA 3

Adjectives elude me. The behavior in Queen’s is appalling, even for the VA. Unfortunately, the list of ineptitude only gets worse!

VA Seal Next, we travel to Austin, Texas, and discover yet another office of information technology (OIT) failing to work, secure data correctly, and protect veterans’ information, as demanded by legislation! The VA-OIG and the local OIT used the same tools, and the local OIT only identified 150 problems, whereas the VA-OIG OIT inspectors found 246. Improper sanitization of media was a pronounced issue, where patient load is upward of 300,000 annually. Inventory practices were noticeable and apparent. Worse, patch and vulnerability programs were practically non-existent if I understand this report correctly. VA 3

If you have read any of these VA Chronicles, you will know that the VA has not passed a Federal Information Security Modernization Act (FISMA) audit, ever! The head of IT was recently in front of Congress to testify why, and the explanations were milk toast adequate at best! But, the elected officials bought the excuse, hook, line, and sinker, as always, and the president wants to spend more money on the VA. What a cathartic example of why elections matter!

Next, we travel to Detroit, Michigan, where a “comprehensive healthcare inspection (CHIp)” was performed at the John D. Dingell VAMC. Before I even read the report, I knew it would say; opportunities exist to improve employee and patient experience. Knowing veterans who are “served” at this VAMC, this was an obvious guess! Again, we find “moral distress” in the workforce, signifying that the employees feel pressured to do everything but what is ethical, legal, moral, and appropriate for the patient at this VAMC. Yet, the leadership team was rated as stable and doing a good job! Quoting Colonel Potter from M*A*S*H here, “HORSE HOCKEY!” VA 3

I will be explicitly clear if a single employee feels “moral distress,” there is a leadership problem, and the leadership is criminally negligent in their duties to oversee staff leaders, supervisors, team leads, and training personnel! This is not the first time “moral distress” was a point of discussion in a CHIp; but, the fact that this problem remains widespread and apparent does mean the problems are originating at a level higher than the VISN, and all the VA and VHA leadership should be losing their jobs! Enough is enough, and the elected officials need to be scrutinizing the government before they lose their next election!

Survived the VA Having been an employee of the Department of Veterans Affairs, working in the Emergency Department of the Albuquerque, NM., VAMC, this next story is exceptionally aggravating and extremely distressing. The VA-OIG determined that the entire Veterans Health Administration (VHA) needs to better monitor, record, and document the timeliness of care and patient flow in the emergency department. Having waited for more than 14 hours in a VA Emergency Department while waiting for care, I know first hand the problems of the Emergency Departments, and I know a lot of the reasons why the documentation is fouled and the flow of patients is amateurish, at best!

Raymmond G. Murphy I worked the shift where a regular, homeless veteran, wheelchair-bound, had fallen and broken his leg. He waited with his broken leg swelling, stuck at an odd angle, and in obvious distress for more than 6-hours because the head nurse that day had a personal grudge against the veteran! I saw how the charts were “adjusted” for timeliness of care, and I reported the problems up the chain to no avail! I had witnessed nurses harangue patients, gossip about them, chart surf in violation of HIPAA, and never was anything done by leadership when it was reported. A patient sat in an expedited treatment room for four hours, listening to the nurse’s gossip and joke, awaiting stitches for a bleeding wound, and never was treated. All because the day shift was getting off and didn’t want to be bothered to treat the patient. The patient’s family reported this behavior to me as they were leaving for a better hospital. I reported the whole incident, included the family’s description, added my observations. The leadership shook the whole incident off as a disgruntled employee (blaming me) making a less than desirable situation worse. VA 3

Thus, when I read this particular VA-OIG report about the inadequacies of the VA Emergency Departments across the entire VHA, it infuriates me into a mindless stupor! Want more data on the failures of the VA Emergency Department; read the rest of the VA Chronicles. I describe my experiences in detail and have logged other veterans who have had the same or worse problems at the VA Emergency Department! I have witnessed doctors treat patients in a dissimilar manner based upon the political clothing the veterans wore into the Emergency Department! So, no, I am not surprised at the record inadequacies of the VHA; if anything, I expect the problem is a lot worse than the VA-OIG was willing to report! VA 3

The VA-OIG collected data on an issue of grave significance from 58 VHA outpatient clinics’ regarding emergency preparedness for the delivery of telemental health care as of November 1, 2019. The review focused on clinic-specific emergency procedures, emergency procedure roles and responsibilities, emergency contact information of staff, and patient safety reporting methods. Not included in the scope of the review was the quality and quantity of telehealth appointments. I mention this oversight as the technical problems in receiving telehealth appointments are sub-par, at best, which would have seriously skewed the data.

The VA-OIG sent out 333 questionnaires, receiving a total of 187 responses, from the 58 identified clinics, and identified the following:

1. 1. Missing telehealth emergency plans and procedures.
  2. Emergency procedures are not specific to telehealthcare or the patient-clinic location.
  3. Lack of a process for annual updates to telehealth emergency procedures.
  4. Undefined emergency procedure roles and responsibilities for telehealth staff
  5. Missing or insufficient emergency contact information.
  6. Lack of a process to verify and communicate emergency contact information
  7. Lack of a consistent process to designate the telehealth setting in patient safety reporting methods.

Consider for a moment; you are a family member of a veteran needing telehealth mental support. Now, how do you feel to know there are no written processes or procedures to support the telehealth provider if your family member gets into a mental health emergency. Time is critical in mental health emergencies; I know this from personal experience as both a provider and a patient, and for these plans, procedures, and processes to be missing is the height of malpractice! Would someone please tell me why elected officials and the media are not screaming mad at this particular report? Especially since the proposed budget from the president wants to double suicide prevention spending at the VA. I read this report and see that the VA-OIG made five recommendations. Are you freaking kidding me?!?!?

Finally, we go to Hawaii and confront the most detestable, outside of the dead veteran, issue possible, failure of the National Cemeteries Administration (NCA) to properly care for the remains of veterans, qualified spouses, and dependents. The NCA awards grants to states to build cemeteries where a veteran, qualifying spouse, and dependents can be laid to rest outside a national cemetery. From the VA-OIG report, we find the following, emphasis mine:

“Grants may be used to establish, expand, or improve veterans cemeteries. The VA-OIG audited the program to assess NCA’s governance and oversight. The audit team also assessed whether critical non-compliance issues at two cemeteries in Hawaii were addressed. The VA-OIG found grants program staff did not rank and award some cemetery grants as regulations required. After grants were awarded, program staff generally ensured cemeteries used grants for their intended purpose. However, NCA did not ensure cemeteries with grants met all national shrine standards for installing permanent markers, maintenance, and safety. The audit team observed non-compliance issues at eight state cemeteries, including critical issues in Hawaii’s Hilo and Makawao cemeteries. As a result, NCA lacks assurance that veterans and family members buried in state veterans cemeteries have been appropriately honored with timely and accurate grave markings, burial locations, and maintenance.” VA 3

NCA, you have one job, ensure the remains of veterans and qualifying spouses and dependents are adequately remembered, safely entombed, and marked appropriately. Yet, you fail at even this simple and easy job; how utterly disgraceful, disgusting, and detestable! How many cemeteries in the Philippines are being adequately cared for? At the last report, none of them were adequately maintained and respected. Even here in the US, you refuse to do your jobs with competency, dignity, and professional pride.

Knowledge Check! The VA is one sick organization, where the mission is being denied, the veterans abused before and after death, and none of the elected representatives can find enough time in their day to even offer a mild rebuke or maintain sufficient interest to scrutinize. America, we have gotten better as a culture in remembering and honoring those who serve and have served, and I, for one, am very grateful for your change of heart. We, the voting citizens of America, need to demand the same culture change from the politicians representing us! As a country, we have come a long way since Vietnam in honoring the military. But those same people who spat and urinated on our troops in Vietnam are now in the Halls of Congress, and their attitudes have not changed in the interim!

NO MORE – An Open Letter to the People of Arizona

To The Citizens of Arizona:

Arizona It has been my pleasure to have lived in Arizona four separate times since 1996. Employment and pleasure have brought me relocation opportunities, and I have enjoyed my time in Arizona. However, since my return in 2005 to the present, I have feared for the soul of Arizona. I have watched as despicable and detestable politicians have won political races that never should have been won. I have witnessed governors act in cowardly and craven methods to thwart the people’s will. I have witnessed those elected to Federal Offices from Arizona stop being held accountable to the electorate until the politicians have set up a hegemony and no longer fear the ballot box. Most egregious of all, I have witnessed the veteran community become increasingly abused as every day ticks past. Patriotism

In April 2021, I wrote about my interactions with Rep. Greg Stanton (D) and his staff, where the VA is concerned. For almost an entire year, I have been injured, cited, and arrested, denied care, had untold HIPAA violations, and other disgraceful conduct taken against me by the administration and leadership of the Carl T. Hayden VAMC. In December 2020, I reached out again to the federally elected representatives, asking for help to clear my name and remove the atrocious behavior of the VA, all to no avail. The Duty of Americans

All four Senators rejected my pleas and never bothered to respond. All of the members of the House of Representatives from Arizona refused to reply, save the staff of Rep. Greg Stanton (D). Except, Rep. Greg Stanton (D) and his staff, did nothing! Had no priority, refused to communicate, could not maintain pressure, and bought the lies and excuses of the Carl T. Hayden VAMC administrators. These are the same administrators who create a crisis for veterans through inaction, duplicitous action, poor behavior, and refusal to perform the jobs they were hired to perform. I have made it clear that the Administrators of the Carl T. Hayden VAMC and VISN 22 are but one dead veteran from another scandal to dwarf the death list scandal that originated with the VA administrators in 2012 and repeated in 2016.

VA 3 No VA Administrator has addressed the root causes of those scandals, and without proper persuasion from Washington, D.C., they never will! Worse, without continuous scrutinization, the bureaucrats will continue to exemplify the duplicity and failures, hiding behind designed incompetence and tissue paper-thin excuses for poor behavior. Yet, what do we find from those enjoying elected office? Zero interest, half-truths, straight lies, misinformation, smoke and mirrors, and plain laziness! We, the electorate, find the politicians sitting on their hands, engaging in hopeless and stupid legislation that will go nowhere, and we find lackadaisical meandering in the House and Senate leadership. I have witnessed amoebic life with more robust spines than the current political leadership in Arizona! Image - Quote Poltics is Dirty

It is true, Arizona is not the only state suffering from political abuse of the basest sort and blackest hue, but Arizona is where I have personally seen the destruction hit the hardest. During Senator McCain’s tenure, my requests for help were rebuffed, but I could still obtain assistance from the House of Representatives members. Now, the political party doesn’t matter, the politicians have plastic ears, and plastic lips, and their hearts are full of desire for political gain and not the electorate’s support. Who loses, the electorate! Who wins, nobody!

America, I ask you, in the year and change between today and the next election cycle, what will you do to change America’s government? Arizona, you have been duped, lied to, and dishonored by those elected to power. What will you do to reclaim the honor, integrity, and political government you deserve and pay so much for? Apathy

Personally, I have been betrayed, and I am sick to death of pleading for reprieve only to have lackluster performance, at best, provided so I would just go away. I know of no honorable politician representing Arizona, and their respective staff is worse than the politician! From the Mayor of Phoenix to the Governor, including the school boards, judges, and so many others, the fear of the ballot box is shrinking, and the bureaucrat is winning. In contrast, the scrutinization of bureaucrats and other duties are dodged to win another term, always with a complicit media running interference.

I did not elect the media to their position, and since the media is not elected, they can be removed. However, while the politicians are elected, the fear of the ballot box needs to be retaught to the politicians. How does a citizen get a politician to fear the ballot box; you first buck the trends and stand like a rock in a stream. Then, as additional rocks begin to stand, a dam is built, forcing change to that stream. Plato 3

If we are to change the government and retain our freedoms and liberties under the Rule of Law, we, the electorate, must first get the politicians to fear the ballot box! We, the electorate, need to also teach accountability and responsibility to those who claim power but who only obtain power from those choosing to be governed! We, the electorate, hold power over these politicians and the bureaucrats spawned in the legislative branch of government. So claim the power that is yours, and join your friends, neighbors, and communities in demanding better from those elected.

Knowledge Check! I heard the mayor’s office in Phoenix complain that they have no power over the Federal Government. To think this is treason of the vilest kind. Let me reiterate something discussed in several previous articles. The local government stands as a bulwark against the county government overstepping its legal boundaries. The city and county stand against the state encroaching against the freedoms and liberties of the state government. The state government defends its citizens from the Federal Government’s encroachment, and the individual citizen is the most potent force in our Republican form of government.

Plato 2 Cease the sophistry of plastic language and do your job! End the tyranny of plastic words and work to aid the citizen in protecting their rights and freedoms from the ever-encroaching thieves of government and the bureaucrats spawned in the darkest pits of legislative fiat! So stand, every American citizen needs to stand and refuse to be governed until those elected are replaced with people willing to take action and honor the Rule of Law, holding previous politicians accountable and responsible for the mess America is currently suffering under. Enough is enough, and I have reached the end of my tolerance, and my cherubic demeanor has been replaced with a hunger for justice!

NO MORE BS: Come, Let us Reason Together

Knowledge Check! In physics, for every action, there is an equal and opposite reaction. I am not a fan of the word reaction, for a reaction places all the control of the action into the control of the original actor, and nature does not work like that. But, to reason, we sometimes must use language common to all to understand each other; thus, it is sufficient to my purposes to use the term reaction in this discussion. A similar law applies to psychology; a human chooses to act, natural consequences follow. The ability to as, agency, and the person being acted upon, the actor, play a significant role in how and why businesses succeed and fail.

Plato 2 Societies, cultures, governments, and countries all rise and fall on the moral agency of the individuals in power, the common citizen, and the collective leaders of those groups of people. I have always liked the movie “The Fiddler on the Roof,” Tevye makes a statement about how without tradition, they would be as shaky as a fiddler on the roof. Bringing a mental image of a fiddler, balancing upon a roof, and having two options, climb down and resume playing, or learn to balance on the roof while playing. Both choices offer natural consequences that are easily understood, especially if you have ever worked on a roof.

Detective 4 I have consistently written about VA Leadership failures for several weeks, rightly calling out the administrators at the local VAHCS and VAMC, the VISN, and the Federal levels. Hospital leadership is not so different than leadership in any other industry, even though the VA has tried to make hospital leadership distinct. Herein lay the problem, an employee, a nursing assistant, has just been sentenced to 7 consecutive life sentences for second-degree murder.

“Mays was employed as a nursing assistant at the VAMC, working the night shift during the same period of time that the veterans in her care died of hypoglycemia while being treated at the hospital. Nursing assistants at the VAMC are not qualified or authorized to administer any medication to patients, including insulin. Mays would sit one-on-one with patients. She admitted to administering insulin to several patients with the intent to cause their deaths” [emphasis mine]. VA 3

We have an affect, but what was the cause?

“While responsibility for these heinous criminal acts lies with Reta Mays, an extensive healthcare inspection by our office found the facility had serious and pervasive clinical and administrative failures that contributed to them going undetected,” said VA Inspector General Michael J. Missal” [emphasis mine]. VA 3

Regardless of her intention, an employee was allowed to commit murder because of the “pervasive clinical and administrative failures” of the VAMC leadership. Now, two days prior to receiving the results of Reta Mays’ court proceedings, I received the Department of Veterans Affairs – Office of Inspector General report on the clinical leadership failures. I have not witnessed a more despicable and damnable report of leadership failures in the decade-plus; I have been following and writing about the Department of Veterans Affairs or any other government agency!

“In June 2018, facility leaders identified nine patients with profound and concerning hypoglycemic events dating from November 2017 to June 2018” [emphasis mine]. VA 3

The scope of the administrative investigation is as follows. Staff from the VA-OIG’s Office of Healthcare Inspections (OHI) assessed the following areas, in parentheses is who owns the problem raised in the investigation:

- - Mays’s hiring and performance (Human Resources)
  - Medication management and security (Pharmacy and Security)
  - Clinical evaluations of unexplained hypoglycemic events (Nursing and Doctoral Staff)
  - Reporting of and responding to the events (Facility Leadership)
  - Quality programs and oversight activities (Facility Leadership)
  - Facility, Veterans Integrated Service Network (VISN), and VHA leaders’ responses and corrective actions (Local and area-wide administrators)
  - During the course of this review (investigation), the OIG also noted areas of concern regarding hospice and palliative care practices and nursing policies and practices (Nursing, Patient Care and Safety, and Hospital Administrators)

Just as logic tells the fiddler on the roof that he has two choices to live a long and musically fruitful life, the investigation reveals that the VAMC leadership had choices and made both poor and potentially criminal choices in this investigation of Mays’ conduct.

“Ultimately, quality health care is dependent on leaders who promote a culture of safety that reduces or eliminates those risks whenever possible. Providing high-quality health care to a diverse and complex patient population demands the support of, and adherence to, an organization-wide culture of safety. When this occurs, a patient-centric environment becomes the “norm.” Conversely, systemic weaknesses in a facility’s culture of safety can have devastating consequences. The OIG found that the facility had serious, pervasive, and deep-rooted clinical and administrative failures that contributed to Ms. Mays’s criminal actions not being identified and stopped earlier. The failures occurred in virtually all the critical functions and areas required to promote patient safety and prevent avoidable adverse events at the facility” (pg ii) [emphasis mine]. VA 3

Before we go further into the report, it must be made clear; the investigation team found the leadership, the hospital administrators responsible for allowing Mays to kill seven patients. Attack another patient with the intent to kill and a potential additional hypoglycemic patient who died under her care but could not be directly linked to Mays. A question arises, how did Mays gain employment with the VA; the answer, a former HR employee, failed to do their job in conducting “… background investigation file and determining her suitability for employment!” In a previous article, I wrote about the hazards the VA was purposefully opening themselves to by using “COVID” as an excuse to delay proper investigations into backgrounds when hiring. Here is a classic case where “COVID” is not related, and failing to investigate a background led to people dying! Plato 3

The VA-OIG last year reported that hiring practices had been relaxed due to COVID and background checks delayed for employees being hired during a pandemic. Yet, when will those background checks be completed? If someone is found unfit due to background checks, will they be forced to return all their wages for lying on a government form? If there is a testament to the need for comprehensive background checks on employees, the seven (7) dead patients who died at the hands of Reta Mays! How many times will this story replicate because the hiring managers are not doing their jobs? VA 3

Let us reason together, is the VA administrators the problem with the VA? Does the VA leadership require immediate and total removal? How would you resolve the issues without breaking the system and further endangering the lives of veterans? Please let me know in the comments section.

I-Care VA Secretary Denis McDonough signed onto the “I-Care” principles as core values in care for veterans in the VAHCS. When can we, the veterans, see that these core principles have been onboarded and are correcting behavior?

“VA Core Values describe how VA will accomplish its mission and inform every interaction with our customers. These Core Values are Integrity, Commitment, Advocacy, Respect, and Excellence — better known as “I CARE.” VA’s Core Values will continue to serve as the right guide for all our interactions and remind us and others that “I CARE.”

- - - - I care about those who have served.
      - I care about my fellow VA employees.
      - I care about choosing “the harder right instead of the easier wrong.”
      - I care about performing my duties to the very best of my abilities.

Mr. Secretary… The veterans are dying now! We are waiting!

Spread the word:

Like this:

Spread the word:

Like this:

Spread the word:

Like this:

Spread the word:

Like this:

Spread the word:

Like this:

Spread the word:

Like this:

Spread the word:

Like this:

Spread the word:

Like this:

Spread the word:

Like this:

Spread the word:

Like this: