Weep America! – The VA Leadership is Becoming Worse! – Part 3

I-CareIn the less than 10-days since I last wrote on the Department of Veterans Affairs (VA), the Department of Veterans Affairs – Office of Inspector General (VA-OIG) has dumped more than ten inspection results over the last three days into my inbox.  Not a record, but the recorded actions are certainly hitting record lows.  Worse, the culture of the VA remains unchanged, even through all the recorded crimes and indignities the veterans suffer under.  Recording and summating the crimes of the VA is so depressing, mainly because of the failure to reform.  But, a little depression will not slow or halt the reporting of these detestable actions of the VA!

The first VA-OIG investigation is more of a report on criminal proceedings concluding with sentencing.  A total of five people, including one VA Employee, have been stung in this investigation.  How thrilling to see accountability and justice served cold!

Francis Engles of Bowie, Maryland, was sentenced to 30 months in prison and ordered to pay $150,000 in restitution for defrauding a VA program dedicated to rehabilitating military veterans with disabilities. As the owner of Engles Security Training School, Engles falsely represented to the VA that his company was providing veterans with months-long courses when, in fact, the school offered veterans far less.”

February 2019, four other individuals were sentenced in related cases following their guilty pleas. First, James King, a former VA employee, was sentenced to 11 years in prison for committing bribery, defrauding the VA, and obstructing justice. Second, Albert Poawui, the owner of Atius Technology Institute, was sentenced to 70 months in prison for committing bribery. Third, Sombo Kanneh, Poawui’s employee, was sentenced to 20 months in prison for conspiracy to commit bribery. Finally, Michelle Stevens, the owner of Eelon Training School, was sentenced to 30 months in prison for committing bribery.”VA 3

Apparently, bilking the GI Bill is a regular fraud opportunity, and the VA employees need to be held more accountable for the loss of these funds!  The GI Bill is a precious commodity and sometimes the only lifeline for a soldier for retraining while awaiting the VBA’s decisions. Therefore, stealing these funds should come with more substantial sentences, more accountability for the employees in the know of fraud, and scrutiny from elected officials!

For the next story, we have several crimes co-occurring; the most egregious is reporting to have been a veteran, fraudulently obtaining benefits, and then trying to use veteran status for preferential contract awarding.  The VA-OIG reports:

Robert S. Stewart, the former owner of Federal Government Experts LLC in Arlington, Virginia, was sentenced to 21 months in prison with three years of supervised release for making false statements to multiple federal agencies in order to fraudulently obtain multimillion-dollar government contracts, COVID-19 emergency relief loans, and undeserved military service benefits.”VA 3

I know the Supreme Court of the United States (SCOTUS) has declared that lying about military service is a freedom of speech issue and not a crime.  However, stolen valor continues to make me sick, and the liars should lose all US Constitutional Rights, as well as be sentenced to punishment most vile!  Having served twice (US Army and US Navy), having been deployed to S. Korea (US Army) and the Persian Gulf (US Navy Multiple Times), stealing valor infuriates me into a raging juggernaut!  I hate liars and thieves, but to steal valor from those deserving goes above and beyond being just a liar and thief, and the conduct deserves punishment most vile!  No, I am not apologetic in taking this stance either!  Burn the American Flag; I disagree with SCOTUS again and becoming a raging juggernaut!  There are lines you do not cross with impunity, and if you cannot scream fire in a crowded theater as “Free Speech,” then acts of stealing valor or burning the American Flag are reasonable restrictions!

I do agree with Justice Oliver Wendell Holmes’ statement:

The ultimate good desired is better reached by free trade in ideas — that the best test of truth is the power of the thought to get itself accepted in the competition of the market, and that truth is the only ground upon which their wishes safely can be carried out.”Angry Grizzly Bear

But stealing valor and burning the American Flag is not “free trade in ideas,” and I support social shaming as part of the punishment most vile for these lepers of society!  Before you burn the Flag or steal valor, serve in uniform, watch a military funeral as a dependent, and then let’s talk about reasonable and valid restrictions upon “free speech!”

Another case, another criminal act, only this time, I am left asking, “How long has this individual been doing business with the VA?”  Regardless, as this is an ongoing case, the following firstly applies: “The charges in the indictment are merely accusations. The defendant is presumed innocent unless and until proven guilty.”  From the VA-OIG report:

Muhammad Z. Aabdin of Bronx, New York, was indicted for offering bribes to a VA contracting officer in exchange for the award of VA contracts for personal protective equipment.”VA 3

It will be interesting to watch this case and future (potential) investigations occur.  However, I have several questions needing to be answered, and the report does nothing to aid in answering the questions raised in the defendant’s arrest and the grand jury indictment.  More to come as the VA-OIG and the US Attorney produce information.  May the US Attorney NOT allow a plea deal!

The VA-OIG has often investigated improper fiscal practices at several VA sites for the VBA, the VHA, and the National Cemeteries.  I could almost quote the following investigation results, only differing on how much money is involved.

The VA Office of Inspector General (VA-OIG) conducted a review to examine whether VA’s Maryland Health Care System appropriately managed purchases and payments for medical equipment and supplies. Fiscal oversight of purchase cards and internal controls governing the use of overtime were also reviewed. The VA-OIG found ineffective processes, internal control weaknesses, and inadequate oversight in five areas: 1. The healthcare system and the Enterprise Equipment Request (EER) portal need improved controls for approving equipment purchases. 2. Healthcare system staff and the prime vendor should prepare timely and accurate planning information to ensure adequate supplies are on hand to fill orders. 3. Even though no inaccurate inventory payments were identified, VA’s inventory system needs controls to ensure correct recording of supply units and costs. 4. The healthcare system purchase card program requires closer monitoring to ensure purchases are authorized and supported by documentation. 5. The healthcare system should strengthen its overtime payment controls to ensure supervisors verify overtime hours were completed before approving timecards for payment.  The VA-OIG team also identified more than $5 million in questioned costs related to identified issues such as undocumented or unapproved purchases” [emphasis mine].VA 3

I have heard the term “Criminal Stupidity” and often wonder when “Criminally Designed Incompetence” will become adopted into common vernacular.  I am so fed up with the excuses, the missing money, and the abuse of taxpayer forbearance by bureaucrats; I could rip my hair out and scream until my voice gives out! But, unfortunately, both actions do absolutely nothing to correct the problem and would make me miserable.  The VA has problems with criminals without and stupidity masked as “designed incompetence” within, and the solution continues to be leadership!

Gravy Train 2What adds fire to my mental processes on criminally designed incompetence, the VA-OIG has two other investigations in my inbox on the need to strengthen fiscal controls, , and more correctly track accounting practices.  Under current legislation, if a private business accounted for their money like the VA, they would be shuttered, and criminal charges levied!  Yet, somehow, the elected representatives cannot apply the same accounting behavior standard to a government agency, as they mandate for private companies!  Anyone else thinks we need stronger demands for scrutiny of government agencies?

Plato 2Adding more fuel to the fire for the IT/IS Departments of the VA, the VA-OIG discovered that the VA still cannot regularly and appropriately log records into its own electronic health record systems!  Are you surprised; as a patient, I know I am not surprised at all.  Worse, the lack of medical records being properly handled influences (negatively, of course) how the VBA makes decisions on claims!

The Office of Inspector General (VA-OIG) evaluated whether VA’s community care staff accurately uploaded records for non-VA medical care to veterans’ electronic health records. Veterans receive non-VA care based on certain criteria, such as the distance from the veteran to the nearest VA facility or the wait time for a VA facility appointment. Records for non-VA care enable Veterans Health Administration (VHA) providers continuity of care and inform treatment decisions. The audit team found that staff at six of the seven VA medical facilities reviewed did not always index, or categorize, these records accurately. Inaccurate indexing of medical records poses a risk to veteran care. It increases the burden on the VHA staff who locate and correct the errors, reducing their time for other tasks. The team reviewed 209 veterans’ mental health medical records that VHA community care staff indexed between April 1, 2019, and September 30, 2019, and found 108 indexing errors for 92 veterans. (Some veterans’ records had more than one error.) Errors included using ambiguous or incorrect document titles, indexing records for non-VA care to the wrong referral or veteran, and entering duplicate records. These errors occurred, in part, due to inadequate procedures, training, quality checks, and quality assurance monitoring and a lack of local facility-level policies.”VA 3

Of course, training and local policies were blamed for the failure to log records properly!  These are automatic designed incompetence excuses that appear every single time the VHA fails, the VBA fails, or they both make significant life-altering decisions for veterans, and the VA-OIG investigates!  The VBA claims it is my duty to ensure outside providers send records to the VA in a timely manner.  The VHA claims they have the documents the VBA wants, and they should read the file.  Who is inconvenienced, not the VHA and the VBA, the veteran?  The person who cannot even look at his digital file without a “Freedom of Information Act” (FOIA) request and 30-45 days of waiting, and even then, the document is heavily redacted for privacy!  Whose privacy, I wonder, the providers, the employees, or the veterans?  Because I guarantee the VA is conducting serious CYA on the records produced!  Let alone IT’s continued failure to protect the veteran from identity theft or IS to protect the files from being accessed without reason by employees.Apathy

May 2021 was a tumultuous month for the VA and the VA-OIG.  If you would like to review how tumultuous or think you might have missed an article or two reporting the VA’s designed incompetence, feel free to review using the following link.  Frankly, I want to see action taken based upon the investigations to clean house, more fully scrutinize the VA, and improve the veteran experience at the VA.  But, I do not tell you how to think or feel about an issue. Instead, I report and summate and leave the rest to you!VA 3

As always, I report and summate upon the good and bad.  If you are a citizen of Indiana or receive your care from either Fort Wayne, Marion, or through the Northern Indiana Health Care System, please count yourself lucky, and pass on the praise to the VAHCS employees.  The VA-OIG conducted a comprehensive Healthcare Inspection and found, “The VA-OIG’s review of the system’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors” [emphasis mine].  While improvements can still be made, this is HUGE news, and the Northern Indiana VAHCS leadership team needs to be back-slapping and congratulating their employees.

Knowledge Check!Thus, my sincerest congratulations go to the Northern Indiana VAHCS, and heaps of shame and scorn remain served cold to the ineffective leadership and useless employees of the VA in general!  America, we should weep, for the VA is not alone in the government agencies in providing world-class detestable service, abuse of the customer (taxpayer), and skirting accountability and responsibility through designed incompetence!  But, when we are done weeping, it is time for action!  Changing the elected representatives, demanding higher scrutinization with actual penalties for failure, and insisting upon fiscal restraint equivalent to the private sector!

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

Do You Feel Represented? – Your Government In Action!

Detective 4I have received feedback that I write about the Department of Veterans Affairs (VA) too much.  Please allow me to explain why.  As a veteran, I am duty-bound to help my fellow brothers and sisters in arms.  As the son of veterans, mother (USN), and father (USN, USARNG), I know the hardships of being dependents of active duty, reserve, and National Guard members of the military.  The enlistment contract doesn’t end when the contract says so for the military member; the families and spouses contract is forever.

The final two reasons I write about the VA are most critical; NO body should be treated like the VA treats the veterans; the actions of the bureaucrats in the VA are not representing me and what I stand for in a representative government.  As I can easily have the Department of Veterans Affairs – Office of Inspector General Reports (VA-OIG) delivered to my inbox, it makes writing about the VA much easier, benchmarking how the government has insulated themselves and forgotten who holds the reigns of power in a representative government.  While not a reason to write about the VA, this final explanation should help you judge whether your representative government appropriately represents you and what you stand for.Why

The VA-OIG reports today begin with behavior that is intolerable and worthy of public shaming.  While the defendant remains innocent until proven guilty, the criminal complaint represents behavior inexcusable!  “Daniel Devaty of Elyria, Ohio, was charged with influencing a federal official by threatening a family member. Devaty allegedly sent a text message to the cell phone of a VA social worker threatening to kill his daughters.”

Angry Grizzly BearAnytime anyone threatens the family members, their behavior is beyond the pale and deserves public shaming and the harshest of criminal penalties.  I do not care if the perpetrator is a politician, a judge, the media, or a private citizen.  Leave the families out of any business dealings!  Hollywood, take note, I am sick to death of you threatening family members in movies, TV shows, or simply as private citizens/influencers.  For too long, you have shirked your public responsibility, and families are OFF LIMITS!  Learn this lesson well!

On the topic of conduct reprehensible, the following VA-OIG report leaves me running out of adjectives to describe the behavior of this VA Employee.  “Robert Sampson of Gulf Breeze, Florida, pleaded guilty to charges of video voyeurism and disorderly conduct. Sampson secretly recorded eight fellow VA employees using a hidden camera, disguised to look like a cell phone charger power adapter, that he placed in a restroom at the VA Joint Ambulatory Care Center in Pensacola on multiple occasions from August 2019 to June 2020.”  May the judge throw the book at him and his punishment be creative and sentence well earned!

VA 3In another VA-OIG report, we have more leadership missing problems, where a fraud scheme existed for 11 years without discovery.  “Erik Santos of Georgia was sentenced to over 11 years in federal prison for defrauding Tricare of approximately $12 million through a compounding pharmacy fraud scheme. In January 2021, Santos pleaded guilty to one count of conspiring to commit healthcare fraud and wire fraud.”  While the US Attorney beats his chest and proclaims they will catch everyone involved in the fraud, how many managers and supervisors inside Federal Government employ will lose their jobs, pensions, and freedom over allowing this fraud to occur?  What processes and procedures will be changed to protect against another fraud scheme?  Who is personally accountable for contracting that permitted this scheme to bloom for more than a decade?

VA 3The following VA-OIG report details how clowns and asylum patients run the IT program for the VA and not professionals!  The VA was tasked explicitly by legislation to meet several IT deadlines on a program for family caregivers as part of the VA MISSION Act of 2018. Unfortunately, not only did the VA fail to get the IT program up and running on time, missed mandatory reporting deadlines, and delivered a software solution 2-years past due, but the “VA did not establish the appropriate security risk category and fully assessed the system’s privacy vulnerabilities.”  Amazing, with all the IT problems the VA suffers from, with all the IS problems the VA suffers from, one would think that, where new technology was concerned, the VA would be practicing better security and using the lessons learned previously.

VA 3Would someone please tell me why private industries would be sued to the Nth degree criminally and civilly for these IT failures, but the government can evade accountability and responsibility; why?  In a representative government, the citizens can, and should, hold the elected representatives and their minions accountable for failing to uphold basic security protocols. So how did the government vote themselves a “Get out of Jail Free” card?

While writing this article, three additional VA-OIG reports have been delivered to my inbox.  The newest VA-OIG report discusses a topic that the VA continues to struggle with, namely transparency.  Apparently, the goblins in Goblin Town still cannot stomach sunlight and prefer to keep their nefarious deeds hidden.  Unfortunately, the lack of transparency in hiring practices leads to more VA-OIG investigations into employee wrongdoing, cost the taxpayers phenomenal fees to rid the government of poor hiring decisions, and all this before the union becomes involved.  From the report, we find the following:

“… VHA delegated much of its data reconciliation to its local facilities, which introduced variability in the process and did not allow for consistent creation, maintenance, and verification of information. VHA also had inadequate business processes to ensure quality data were available to support effective medical facility staffing oversight. Without consistent methods and reliable source documents for managing information, VHA cannot be sure HR Smart data accurately reflect VA’s budget and workload requirements.”VA 3

Did you catch that local facilities were given authority, which increased risks in hiring, all while management cannot perform their functions properly?  I remain convinced that the VA built designed incompetence into every action to protect themselves from ever being forced to take action. But, unfortunately, like always, the news only gets worse!Plato 2

A little background is needed to appreciate the problem in the following VA-OIG report fully.  Coronavirus Aid, Relief and Economic Security (CARES) Act required the VA to report to the OMB how they spent money appropriated for America’s Veterans and the VA during the pandemic.  The following is what the VA-OIG found:

VA met monthly reporting requirements to OMB and Congress on supplemental fund obligations and expenditures. VA also submitted required weekly obligations and expenditures from supplemental funding to OMB by program activity. Of approximately $17.3 billion in medical care supplemental funds, VA reported it had obligated about $7.11 billion and had spent about $5.67 billion by December 29, 2020. The VA-OIG team noted three concerns where VA’s reporting was not complete and accurate: • Obligations were at risk of not being included in VA’s reports. • VA initially delayed the reporting of reimbursable obligated amounts for two months. • VA’s reports contained negative dollar amounts in data fields that should have only positive amounts, which misstated VA’s overall reported obligations. Those concerns indicate weaknesses in how VA and VHA internal controls are structured to meet reporting requirements. Despite the risks identified, VA performed only a limited review at the summary fund level of its COVID-19 obligations and expenditures before reporting. A review of summary funds is not detailed enough to identify potential anomalies and ensure the reliability of externally reported information” [emphasis mine].VA 3

I did not find this in the VA-OIG report. Did anyone ask why the VA failed to meet the reporting for the first two months?  After the FISMA Congressional hearings, everyone knows the VA sucks at information technology and information security (IT/IS). So why was the VA given more money and told to budget it using existing failed software, processes, and procedures?  My work in the finance field is limited; however, when a company cannot handle its finances properly and meet legal obligations, a third-party accounting firm can be hired to handle this for the organization.  OMB, why are we not using this solution at the VA?  OMB, why is a third-party auditing company not conducting in-depth analysis and audits of the VA?  With all the missing taxpayer dollars at the VA and Department of Defense, it seems that you are just as negligent as the agencies you are supposed to monitor.

Theres moreAs they say on the Home Shopping Network, “But wait!  There’s more!”  Unfortunately, the same holds of the VA, just without the enthusiasm!  Each VA Medical Center in the Department of Veterans Affairs – Veterans Health Administration (VHA) is expected to have supplies, also referred to as caches, on hand at all times to handle local emergencies and national health care incidents.  For example, a pandemic!  The VA-OIG investigated these prepared caches and found that only 9 of 144 supply stockpiles were ever mobilized.  The excuses, oh these excuses, are like butt holes, everyone has one, and they stink!

      1. “Medical facility directors reporting supplies were not needed or caches lacked sufficient quantity for meeting pandemic demands.”
      2. “The Veterans Health Administration (VHA) changed the process for mobilizing caches during the pandemic, but without clearly communicating it to medical facility directors” [emphasis mine]. – We have the blind leading the blind, in a darkened room, in a London fog!
      3. The VA-OIG, not the VHA, not the local VAMC, but the inspectors “identified problems with cache maintenance and monitoring.” – Never forget, this is a job of several people, overseen by a director, who reports to facility leaders, and inspectors had to find the maintenance and monitoring problems. Just let that sink in for a minute!
      4. Most caches contained some expired or missing personal protective equipment, diminishing their ability to support pandemic preparedness.” – This is an example of how the VHA is “Defining Excellence in Healthcare!”
      5. The “VHA had incomplete documentation on cache activations, making it difficult to know which caches would need to be restocked.” – See item number 3 above.
      6. Medical facility leaders were not always able to accurately report if their facility’s cache was activated during the pandemic.” – Is the proof sufficient that the VA leadership IS the problem with the VA; yet?VA 3

In the US Navy, a significant part of my job was to maintain and monitor emergency supplies. Additionally, to use and cycle through reserves during drills and replenish those supplies quickly and efficiently not to impair the ship’s ability to protect itself 24/7.  I did my job well enough to earn three people Navy Accommodation Medals.  I took over the emergency stores, and all consumable supplies were expired or consumed.  Within 3-months, I was winning accolades and awards.  Yet, 144 caches of emergency supplies for the VHA need more procedures, more documentation, and more oversight to fulfill the mission correctly.

Knowledge Check!I beg to differ!!!  We need leadership, active, engaged, enthused, leadership!  We need the medical facility leader to stop designing incompetence and do the job they have been hired to perform.  We, the taxpayers, need the oversight instruments of the Federal Government to become a lot more effective at demanding results.  We desperately need the elected officials we have hired to scrutinize the government!  Just imagine if you hired someone to perform a mission-critical job, and in the middle of needing emergency support, the person hired reveals, “Oops, I might not have done my job properly.”  How fast would that person be fired?  Now, why can we not do the same to the government employees?

So, ask yourself, do you feel represented by your government?

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

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 2Societies, 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 4I 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)VA 3

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-CareVA 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!

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

NO MORE BS: Revisiting the VA Wait Scandals

Angry Wet ChickenAs the case for the Department of Veterans Affairs (VA) administrators being the number one problem continues, I wanted to revisit a topic that has been mentioned several times, but not been covered in-depth recently, the scheduling issues at the VA for veterans to obtain an appointment.  Back in 2012, the news media went ballistic over veterans dying while waiting to be seen, due to paper wait-lists, cherry-picking veterans to be seen, and employees being encouraged to practice discrimination.  I was a patient in the Phoenix VA during the first scandal, and the second scandal, and between these two scandals, nothing changed, but the medical center director.

The Department of Veterans Affairs – Office of Inspector General (VA-OIG) 02 May 2017, released a VISN wide inspection report on the topic of scheduling and VA Scheduling Wait Times.  Please note the date of the report, as this is a crucial data point, five (5) years after the Phoenix VA Wait Time Scandal, an entire Veterans Integrated Service Network (VISN) was inspected for compliance with the memos and recommendations after the two VA Wait Scandals at the Carl T. Hayden VA Medical Center, Phoenix, AZ.  The results of this inspection are staggering, detestable, and the practice remains unchanged in VISN 22 which includes the Carl T. Hayden VAMC.VA 3

VISN 6 was selected for the inspection, and includes the following VAMC’s:

      • Charles George VAMC (Asheville, NC)
      • Charlotte Health Care Center (Charlotte, NC)
      • Durham VAMC (Durham, NC)
      • Fayetteville Health Care Center (Fayetteville, NC)
      • Fayetteville VAMC (Fayetteville, NC)
      • Greenville Health Care Center (Greenville, NC)
      • Hampton VAMC (Hampton, VA)
      • Hunter Holmes McGuire VAMC (Richmond, VA)
      • Kernersville Health Care Center (Kernersville, NC)
      • Salem VAMC (Salem, VA)
      • G. (Bill) Hefner VAMC (Salisbury, NC)
      • Wilmington Health Care Center (Wilmington, NC)

The VA-OIG claims they interviewed more than 300 staff and referred 84 patients from the sample to the VA-OIG’s Office of Healthcare Inspections (OHI) for review “We referred the medical records for these veterans to OHI to determine whether inappropriate or untimely care resulted in any harm to the veteran.”  Please keep the following in mind, the findings are reported across the entire VISN, not just one single VAMC or care center.VA 3

Finding 1: “… 36 percent of the appointments for new patients at facilities within VISN 6 during the relevant time period had wait times longer than 30 days. We estimated that the average wait time for this 36 percent was 59 days. These numbers are significantly higher than the wait time data that VHA’s electronic scheduling system showed.”  The result, “The inaccurate wait time data resulted in a significant number of veterans not being eligible for treatment through Choice.”Apathy

Finding 2: The “veterans in VISN 6 who received their care through Choice, our audit estimated that 82 percent of the appointments had wait times longer than 30 days. We estimated that the average wait time for those who received their care through Choice was 84 days.”I-Care

Finding 3: “For veterans who did not receive care through Choice within 30 days, they waited an average of 98 days to receive their care, which ranged in our sample from 31 to 389 days.”

Finding 4: “VISN 6 Medical Facilities Did Not Consistently Provide Timely Access to Health Care Needs for New Patient Appointments and Did Not Have Accurate Wait Time Data.”  This is the section header for a finding so egregious, heads should have rolled.  Understand the basis for scheduling appointments, “We used 30 days from a veteran’s supported preferred appointment date, a referring provider’s clinically indicated date, or the appointment “create date” to determine whether an appointment was timely.”VA 3

“The VA-OIG statistical sample of 618 new patient appointments completed at VISN 6 medical facilities in the first quarter of FY 2016. We reviewed these appointments to determine whether medical facilities provided timely access for new patient appointments, as well as to assess the accuracy of VISN 6 wait time data. Based on this review, we estimated about 20,600 of 57,000 appointments (36 percent) had wait times greater than 30 days. For those 20,600 appointments, we estimated veterans waited an average of 59 days. This was notably higher than the 5,500 appointments (10 percent) that VHA’s electronic scheduling system showed were scheduled greater than 30 days” [emphasis mine].

Is the problem clear, the VA is cooking their own books to reflect lower numbers of appointments waiting to be seen, than they are willing to admit?  Hence, can any statistical data reported from the VA be trusted for veracity?  Here’s the rub, VISN 22, has the exact same problem in both Phoenix and the Albuquerque VAMC’s.  I know this from being an employee and listening to the appointment schedulers discuss how they “schedule” appointments.  I know from experiencing being cherry-picked, e.g., being told the provider needs to see me within 72-hours of a visit to the Emergency Room, but not being able to be scheduled, and placed on a waiting list or the best excuse I have been told, “I double book the appointments to ensure we keep the provider busy all day.”VA 3

I understand there is a provider shortage; but how much of that shortage is being exacerbated by the policies and procedures of the administration, the leadership of the VA?  Will someone please explain to me, how the pernicious veteran killing scandal of wait lists is still being allowed, fed, and supported by the VISN leadership across the entire country?

Finding 5: The VA-OIG broke down 57,000 appointments, per the policies and directives governing scheduling appointments and found:

  • Of 10,700 primary care appointments, 3,500 (33 percent) had wait times greater than 30 days, with an average wait time of 51 days for those 3,500 appointments. This compared to an estimated 1,900 of 10,700 primary care appointments (17 percent) VHA’s electronic scheduling system showed were scheduled greater than 30 days.
  • Of 4,800 mental health care appointments, 780 (16 percent) had wait times greater than 30 days with an average wait time of 59 days for those 780 appointments. This compared to an estimated 260 of 4,800 mental health care appointments (5 percent) VHA’s electronic scheduling system showed were scheduled greater than 30 days.
  • Of 41,500 specialty care appointments, 16,300 (39 percent) had wait times greater than 30 days with an average wait time of 60 days for those 16,300 appointments. This compared to an estimated 3,400 of 41,500 specialty care appointments (8 percent) VHA’s electronic scheduling system showed were scheduled greater than 30 days.
  • We found that VISN 6 did not capture accurate wait time data primarily because medical facility staff did not consistently enter correct clinically indicated or supported preferred appointment dates when scheduling new patient appointments. Requiring schedulers to document those occasions where a veteran has a preferred appointment date is an internal control that mitigates the opportunities for schedulers to routinely and inappropriately designate all scheduled appointments as preferred appointment dates in order to show substantially reduced wait times.
  • Of the estimated 20,600 appointments with wait times greater than 30 days, staff entered incorrect clinically indicated or unsupported preferred appointment dates for 15,300 appointments (74 percent) that made it appear as though the wait time was 30 days or less” [emphasis mine].
  • Root Cause analysis showed, “Because the medical facility did not consistently enter correct clinically indicated or supported preferred appointment dates when scheduling appointments, we estimated staff did not identify about 13,800 of these 15,3004 appointments (90 percent) where veterans should have been added to the Veterans Choice List (VCL)” [emphasis mine].

Angry Grizzly BearThe administration did notconsistently conduct scheduler audits, which have been required since January 2008.”  Memos, policies, guidelines, procedures, none of these are making any difference as the VISN and VAMC leadership simply refuse to do their jobs!  Where were the politicians from 2000 to 2010 when the policies and guidelines were changed to protect veterans from scheduling abuse and improve access to the VA/Choice?  Will someone please ask Speaker Pelosi where she has been as minority and majority speaker of the house since 2000 on protecting veterans from abuses at the hands of the VA!  Will someone grab speakers Boehner and Ryan and demand they return some of their “Titanium Parachutes” because they actively refused to protect veterans from abuse by the VA!  If this is the “VA Healthcare Defining Excellence in the 21st Century,” I would hate to see how the VA defines failure and ineptitude!VA 3

I have said this before and beg your forbearance as I repeat myself for emphasis.  VISN 22, and the Albuquerque and Phoenix VAMC’s are but one dead veteran from another major scandal for the Department of Veterans Affairs.  The administrators will be the 100% responsible, but they will weasel out of accountability, all because of designed incompetence.  I am sick of this abuse towards myself, and any veteran, it is shameful, detestable, and reprehensible.  There are no acceptable excuses for these managerial failures!  There are no justifiable reasons to have schedulers acting in this manner and not being held accountable by supervisors, who are directly held accountable to directors, who have to report to VISN leaders for accountability.  The leadership has failed the veteran and deserves full and complete replacement, as soon as possible!

Knowledge Check!I believe in the little rocks that start landslides.  I know the power of tiny snowflakes that create an avalanche.  I know that if enough veterans, their families, friends, and communities rise up, the elected politicians responsible for scrutinizing the government will be forced to make veteran safety and health at the VA a priority and blessed change will finally arrive in the VA Administration and administrators.  Imagine how you would feel to learn a close friend or family member died waiting for treatment at the VA.  Please respond accordingly!

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

NO MORE BS: VA Leadership IS the Problem!!!

Angry Grizzly BearPSA:  If you have a weak stomach, please feel free to not read this report.  This article is discussing the ongoing and continual problems of the VA leadership to ensure clean medically reusable equipment is available for practitioners use.  While the YUCK factor is high, the issue remains a leadership failure, and worse, it was purposefully designed into the VA organization to spread infectious diseases between veterans!

The Department of Veterans Affairs – Office of Inspector General (VA-OIG) conducted an investigation and reported its findings 16 June 2009.  While still not the first-time endoscopes and colonoscopes being dirty have caused patience significant risks, this report clearly details the failure of VA Leadership as an organizational design flaw.  From page i of the report, we find the following:

Facilities have not complied with management directives to ensure compliance with reprocessing of endoscopes, resulting in a risk of infectious disease to veterans. Reprocessing of endoscopes requires a standardized, monitored approach to ensure that these instruments are safe for use in patient care. The failure of medical facilities to comply on such a large scale with repeated alerts and directives suggests fundamental defects in organizational structure” [emphasis mine].VA 3

Also, from page i the scope of the investigation and those requesting the investigation are detailed:

The VA Office of Inspector General received requests from the Secretary, Chairmen and Ranking Members of VA oversight committees, along with individual members of Congress, regarding the reprocessing of endoscopic equipment at several specific VA medical centers (VAMCs), and to assess the extent of related problems throughout the Veterans Health Administration (VHA). The purpose of the review is to describe the pertinent events at VAMCs where problems were reported, assess VHA’s response to the events, and conduct a system-wide evaluation of current reprocessing practices” [emphasis mine].VA 3

Let us be perfectly clear, since 2009, the VA Federal Officers have been informed and kept abreast of the problems with properly cleaning, sanitizing, and documenting reusable medical equipment, specifically endoscopes and colonoscopes, and have done nothing to fundamentally correct the direction of the VA, the VHA, or the offending VAMC’s.  What good is a memo when it is not applied as a standard operating procedure, where consequences are involved?  How is a memo going to be effective against a culture trained to not do their jobs, no matter the cost to patient safety?  To fully comprehend the problem with reusable medical equipment not being properly cleaned and sterilized (repurposed) see pages seven and eight of the following report linked.  There are a lot of acronyms, but the general sentiment is clear, the VA has an enormous problem with properly cleaning reusable medical equipment!

In a VA-OIG report dated 06 May 2021, we find an employee, after having been caught once, still not being properly supervised, not doing their job, and remaining employed.  This employee was caught falsifying legal documents on the cleanliness of endoscopes, and dirty equipment was used on multiple patients.  The facility conducted an investigation, the VISN conducted another investigation, neither investigation led to any type of fundamental organizational change to protect the patient.  Even the VA-OIG investigation has not led to fundamental organizational changes and improvements in cleaning and sterilizing reusable medical equipment.  Frankly, this should scare the daylights out of every veteran going in for any type of care at the VA.VA 3

Trust is hard won and easily lost.  Right now, can any provider at the VA assure any patient that the reusable medical equipment has been properly cleaned and sterilized before being used on that patient?  Since the VA-OIG report in 2009, the direct answer to this question is a resounding NO!  Again, I ask only for emphasis, if a non-VA hospital, clinic, or provider’s office was caught not properly cleaning, sterilizing, and documenting medically reusable equipment, how could they remain in operation?  The short answer is, they could not; unless they are an abortion clinic, but that’s and entirely different subject.  The Federal Government and the lawyers would descend en masse to shut down the facility, hold the administration accountable, and demand retribution for the patients involved.  Why is the VA Administration and VHA Administration, and the VAMC and VISN Administrations able to escape culpability in risking a patient’s health with dirty medical equipment?

Angry Wet ChickenEvery single Federally elected politician should be up in arms about the double standards between VA hospitals and non-VA hospitals.  If a non-VA hospital is caught with dirty medically reusable equipment, can they use the VA as an example in court as a defense?  NO!  Yet, here is a legal double-standard and precedence that opens the door to more questions.

Returning to the 2009 VA-OIG report, we find how the investigation was methodologically carried out.  The methodology reveals just how widespread and in-depth the investigation is, and how deeply this problem is organizationally wide for the VA.

We visited the facilities which had been the subject of considerable media attention: the Bruce W. Carter VAMC (Miami) in Miami, FL; the Tennessee Valley Healthcare System-Murfreesboro campus (Murfreesboro); and the Charlie Norwood VA Medical Center (Augusta) in Augusta, GA. We reviewed applicable regulations, policies, procedures, and guidelines. Furthermore, 26 inspectors conducted unannounced onsite visits for the total of 42 probability-based randomly selected VHA facilities to examine pertinent endoscope reprocessing documentation.

Because of the unannounced nature of the inspections and for cost-efficiency, a stratified clustering sample design was employed to maximize the number of facilities that could be inspected in a single day. Two probability-based random samples of VHA endoscope reprocessing facilities were selected from the study populations for the unannounced onsite inspection: one for colonoscope reprocessing and another for ENT endoscope reprocessing. With probability sampling, each unit in the study population has a known positive probability of selection. This property of probability sampling avoids selection bias and allows use of statistical theory to make valid inferences from the sample to the study population.”VA 3

Back in 2009, the media was very cognizant of VA issues, then the dead veteran scandal of 2012 and 2017, turned the media’s attention away from how the VA conducts business.  Let me direct your attention to the final sentence of the quoted material above.  As a researcher, this is a gold standard methodology statement for researching a complex organization like the VA, to pick proper probability samples, and to reduce individual inspector bias in the combined report of findings.  Thus, from this quoted material we can presume both that the methods of conducting the research were sound and conclude that the egregious behavior by administrators is VA wide!VA 3

If dirty medical equipment is how the VA defines excellence in the 21st Century, America’s veterans are in trouble deep!  I am now in my eleventh year of writing about the behavior of the VA and how they intentionally treat veterans.  I have witnessed detestable behavior by providers as an employee, and brought this behavior to the administrator’s attention, for which I was discharged without cause!  I have written about instances of negligence so terrible that there should have been a Congressional Blue-Ribbon panel assigned to demand correction and conduct and investigation, but nothing ever transpired.  I have personally experienced providers so inept, their qualifications should be questioned.  I have observed VA employees abuse, harass, threaten, and intentionally hinder treatment.  The behavior of the VA Administration where reusable medical equipment is concerned is so far beyond the pale, words escape me to describe.

Dont Tread On MeI believe in the little rocks that start landslides.  I know the power of tiny snowflakes that create an avalanche.  I know that if enough veterans, their families, friends, and communities rise up, the elected politicians responsible for scrutinizing the government will be forced to make veteran safety and health at the VA a priority and blessed change will finally arrive in the VA Administration and administrators.  Imagine how you would feel to learn a close friend or family member caught an infectious disease during treatment at the VA.  Please respond accordingly!

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