“That’s Crazy!!!” – More Chronicles from the VA Chapter 8

I-CareI fully admit I got behind in April.  Dear reader, my apology.  I have been whipsawed between emergency room visits, depression, extreme pain, and other issues.  Not offering an excuse but a tiny peek into my world as a disabled veteran.  Luckily, I have maintained employment because my employer allows me to work from home.  My driving privileges are threatened again with removal due to the neurological issues I suffer, and this will dynamically change my life, but this article is not about me, but the continued catastrophe called the Department of Veterans Affairs (VA) and the Inspector General (VA-OIG) reports published.

We begin with a financial efficiency review reported from the inspection of the Durham VAHCS of North Carolina.  I know the jokes write themselves when we discuss any government agency and financial efficiency, but I digress.  This is a head exploding report of leadership failure in the observation and governance of employees who did not perform the functions they were hired to perform.  The VA-OIG found the following from October 1, 2020, through March 31, 2021:

    • The healthcare system had 309 inactive obligations totaling $81.7 million.
    • Of these 309 obligations, 200 (totaling over $74 million) had no activity for 181 days or more.
    • In a subsample of 20 obligations, VA staff had not reviewed 17, as required.
    • Contrary to VA policy, healthcare system staff used purchase cards instead of contracts for 21 of 40 sampled transactions (53 percent), totaling approximately $328,000. These 21 transactions were missing required supporting documentation to verify that the transactions were approved and payments were accurate, resulting in $308,000 in questioned costs.
    • 105 more administrative full-time equivalent staff than the expected number, all not doing their jobs as required under Federal Law!

While not all of the findings, those mentioned are the most egregious and in need of corrective action.  Would the citizens of Durham, North Carolina, please tell me, has this been reported in the local news?  Has anyone lost their jobs as the VAHCS right-sizes the financial department?  I can find no additional information that this problem has been corrected, and I am really curious!VA 3

Oh, the irony is thick; consider the following:

The Department of Veterans Affairs Office of Inspector General Training Act of 2021 would help ensure that VA employees continue to be empowered to assist the OIG in improving VA’s operations and using taxpayer dollars to the greatest effect; helping protect patients and improving their care; and ensuring veterans and others receive services and benefits for which they are eligible.”

The above-quoted material originates from Chris Wilber, who testified to Congress’s HVAC Subcommittee on oversight and investigations.  What is the number one failure on every comprehensive healthcare inspection (CHIP); the lack of staff training, the inadequacy of staff training, or adequately trained staff.  Yet, the statement by the VA-OIG indicates that training has met a threshold for providing adequate training.  Let’s talk about a specific action, “the VA secretary signed a directive in September 2021 mandating that all employees complete a one-time training within one year—an important step in improving VA’s culture of accountability.”  It is now May 2022; the VA-OIG is pushing for training directives to be legislated, not dependent upon any single VA Secretary.  Are you freaking kidding me?  Where is the congressional oversight and scrutiny that allows VA training to continue to be subpar and threaten the lives of veterans?

Long have I wondered how the VA could frustrate VA-OIG actions, investigations, inspections, etc.  Guess what; the answer has become available:

“… there have been instances in which the OIG has been informed that staff have been told that they cannot share information with OIG investigators without first clearing it through supervisors or leaders—contrary to the Inspector General Act of 1978 (the IG Act), as amended.  Under that authority, VA employees at all levels have a duty to cooperate with OIG personnel, including providing information and assistance in a timely manner.”

Employees have been caught lying to the VA-OIG regularly, and what action is taken to remove those employees promptly and efficiently from government service?  From direct observation and employee conversations, it is clear that plans are carefully laid before a scheduled VA-OIG visit to present what the VA-OIG wants, but to gloss over the problems, and nothing ever happened to the managers, supervisors, and employees who lied and misdirected the VA-OIG.  All contrary to established Federal Law!VA 3

Want a specific example of employees intentionally misrepresenting information to the VA-OIG?  Look no further than the statement by Chris Wilber, and this incident was covered as a failure of leadership in a previous article.

Hospital staff at a VA facility in Fayetteville, Arkansas, had concerns about potential substance abuse by the chief of pathology that were not heard and promptly acted on by local management, which allowed him to work while impaired for years.  He misdiagnosed about 3,000 patients with errors resulting in death or serious harm and is currently imprisoned.  The OIG found a culture in which staff did not report serious concerns about the chief pathologist, in part because they assumed that others had reported him, or they were concerned about reprisal.”

From personal experience, I reported problems to the VA-OIG concerning patient abuse, fraud, waste, and other issues.  Never were my concerns acted upon promptly, and I was removed from employment for being a whistleblower.  The culture of corruption at the VA is incredible.  The examples mentioned by the VA-OIG only further sustain the problem with leadership and how sick the VA truly is as an organization!VA 3

We next turn our attention to the VA-OIG report on the inspection of information technology security at the VA Financial Services Center, another head exploding example of leadership failure bordering on criminal!  The findings include:

    • component inventory
    • vulnerability management
    • flaw remediation
    • Identifying 252 vulnerabilities, of which 228 the local IT team could not identify.
    • the VA-OIG team identified access control deficiencies, as 107 of the 278 FSC systems failed to generate or forward audit logs for analysis.
    • the video surveillance system was not fully functional. Ineffective monitoring and recording facility activities supporting information systems minimize the FSC’s incident response capabilities.

How do you spell failure; these findings spell failure to me rather pointedly and dramatically!  Want to laugh; staff training remains a concern, but not a finding, of the VA-OIG inspection team.  Frankly, with this level of incompetence, staff training should have been a finding.VA 3

To be concise and illustrate further the poor leadership, convoluted processes, and brazen noncompliance of VA officials, the following discussion is about two different VA-OIG reports that reached similar conclusions.  First, we have the VA-OIG report on “Noncompliant and Deficient Processes and Oversight of State Licensing Board and National Practitioner Data Bank Reporting Policies by VA Medical Facilities.”  Second is the VA-OIG report on “Concerns with Consistency and Transparency in the Calculation and Disclosure of Patient Wait Time Data.”  Nothing says convoluted processes more than having two written policies, both originating from Washington DC.  The superseded policy does not have an expiration date.  This means that employees have a designed incompetence excuse ready for not adhering to the most current and applicable policy.  Don’t believe me; one of the key findings was, “VHA has presented wait times to the public without clearly and consistently disclosing the basis for their calculations.”  Designed incompetence does not come more blatant than this, and who suffers, the veteran.  Worse, wait time correction and policy clarification has been stalled by COVID-19, the neverending excuse paying dividends to bureaucrats everywhere!Timelines for Wait Time Calculations

However, both reports are substantially summated by the VA-OIG; thus, “The lack of programmatic oversight contributed to the failure of VHA leaders to detect and intervene upon facility noncompliance.”  Meaning that due to COVID-19, the VHA has refused to do their jobs in deference to the pandemic, and since this is a good enough excuse, the VA-OIG has bought the designed incompetence, lock, stock, and barrel.  The VHA leadership is failing; doctors or dentists let go for poor performance were not reported to state and federal boards, so these providers lacking can continue to harm patients.  It is a federal law (42 US Code § 11151, US Department of Health and Human Services, Health Resources and Services Administration Bureau of Health Workforce, NPDB Guidebook, October 2018, chap. A., 8 USC ⸹ 7462(a), 38 USC ⸹ 7401(1), among others) that providers let go for cause must be reported within 7-days to the regulatory boards at the state and federal levels.  Wait times are hidden because they are so bad; the VHA is embarrassed, so the leaders fall back on designed incompetence to shield themselves while looking for another excuse for poor performance!  In both reports, the ramifications of noncompliance are putting people at risk for sentinel events (death, injury, disability, etc.), and the leadership is at best lackadaisical in the performance of their duties.  VA 3

Where are the congressional overseers in ending the abuse?  When will this insanity and bureaucratic inertia end?  How many “sentinel events,” including deaths and permanent injuries, will it take until those tasked with scrutinizing the executive branch finally take committed action and hold people accountable?  When will the elected representatives stop throwing good taxpayer money at problems that money cannot fix?  If these questions are too difficult to answer, please stop running for elected office, for the citizenry is not happy!

We conclude with two related reports so astoundingly obtuse they defy logic and sanity.  The first is the annual CliftonLarsonAllen LLP (CLA) audit of the VA’s information security for 2021.  The second is the continuing failure of the new electronic health record modernization (EHRM) program.  The VA has failed the CLA audit for more than a decade, with many of the hits repeated year-over-year.  In fact, the CLA audit is so bad this year; it has taken my mental breath away and stunned me into a gibbering idiot!  Reading this report was infuriating; describing it as my head exploding is akin to comparing an M-80 to a nuclear bomb.  How in Dante’s Inferno can this level of incompetence be allowed to remain employed?  But, as bad as the CLA audit is, the continued failure of the new electronic health record system pales in comparison.  The new EHRM continues to suffer from reliability weaknesses, which is polite speak from the VA-OIG for the new system fails to do the job.  We are three years from the new extended deadline, we are already past the original deadline, and the system is worthless today than it was a year ago.  With this success rate, the new EHRM will be utterly bereft of value and need replacement before the year’s end.  How many millions (billions, or trillions) of good dollars must chase this ineptitude before the plug is pulled and those involved held accountable?VA 3

Join me in having your head explode:

Additional deficiencies included known tasks not being reflected on schedules, no risk analysis, lack of longer-term actions scheduled, and no complete baseline schedule or overall schedule that fully integrated individual project schedules. VA also did not comply with federal regulations when it paid its contractor for deliverables before accepting them (reviewing compliance with contract requirements).”

Consider this other gem from the VA-OIG report, “$1.95 billion in cost overruns per year” are estimated, meaning the final tab will be significantly higher and compounded year-over-year.  In plain speak, the contractor is being paid for products delivered that fail, the products offered are not usable, there is no schedule of completion, there is no schedule for deliverables, many of the products paid for have never been delivered, and costs are overrunning like a plugged toilet. Worse, no one is being held personally liable for these problems, which were apparent in the last EHRM update from the VA-OIG a year ago!  Like the CLA Audit, I am thrilled the VA agrees with the VA-OIG findings, but what are they DOING to fix the problems?

FYI: the image below is a year old, and comes from the last major update to the EHRM.EHR-VA-OIG

?u=https1.bp.blogspot.com-aqaqk18MHoEWRHHsCi_TyIAAAAAAAAAXc7hY4JQuyylIQHYudoR8sbezGZntic4SSwCLcBs640Betrayal2BSayings2Band2BQuotes2Bwww.mostphrases.blogspot.be.jpg&f=1&nofb=1There is no excuse for behaving like the VA’s bureaucratic legions behave.  Bureaucrats, from the city government (including the school board) to the Federal Government, you hold a sacred trust to act better than you are currently performing.  I refuse you any leeway for acting like pompous overlords when you are paid through forced taxation!  You have trespassed upon my patience and kindness long enough, and the day of reckoning has arrived.  You work for me; you work for every taxpayer and citizen in this country, and you have violated our trust, charged us too much and too often, and if you do not begin to show yourself worthy of the sacred trust, we will force you from your cushy jobs and hold you liable for the monies you have squandered!  The law is on our side; you need to begin showing you honor our trust and investment forthwith!

© 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.

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“That’s Crazy!!!” – More Chronicles from the VA Chapter 7

Oh, how I wish and long for, and am working for, the day when the VA is cleaned up, cleaned out, and corrected completely!  The Department of Veterans Affairs (VA) – Office of Inspector General (VA-OIG) has been busy reporting more on the failures of the VA to act.  Yet, where is Congressional action in scrutinizing the executive branch’s actions?  Honest question, repeated only for emphasis; we elected you to do two jobs, write fair and equal legislation for all citizens, and scrutinize the executive branch; when are you going to do your jobs?

Let’s begin with some softball issues repeated from previous VA-OIG comprehensive healthcare inspections (CHIPs), specifically how employees report feeling morally distressed while working at the VA.  Moral distress is a leadership failure and is widespread enough to reflect the problem is not limited to a single VAMC/VAHCS.  From Virginia to California, Maine to Florida, and Montana to Arizona, too many VA facilities are poorly led, poorly administered, and poorly executed.  The VA is actively abusing the veterans for political gain; some have asked why I consider the VA is actively abusing veterans; let me see if additional disclosure can explain the problem.

VHA Directive 1004.08.  VHA defines an institutional disclosure as “a formal process by which VA medical facility leader(s), together with clinicians and others as appropriate, inform the patient or personal representative that an adverse event has occurred during the patient’s care that resulted in, or is reasonably expected to result in, death or serious injury, and provide specific information about the patient’s rights and recourse.”

The above quote is from the regulations governing VA care.  The VA-OIG quotes this directive, which has been published and is openly available, yet repeatedly the VA-OIG finds directors.  Hospital administrators who are informed and able to repeat this directive.  Who repeatedly refuse to follow this directive or train their staff to follow this directive.  When sentinel events occur (death, permanent injury, non-permanent injury, disability, etc.), the families report having no idea what to do because the disclosures were never provided to the veteran or designated caregiver.  Is this not abuse of the patient?  Is this abuse not driven by ideologues who gain from the harm they cause others?  Should this abuse not be scrutinized until it is eliminated?  Please feel free to read some of these comprehensive healthcare inspection reports from the VA-OIG, see the resulting injuries and problems caused by the failures of government medical providers, and then tell me whether these atrocious actions need more or less scrutiny and qualify for the title abuse.

North Carolinian veterans, VISN 6 is all yours, and would you be shocked to learn that even with newer leadership, moral distress remains a persistent problem in the VA employees throughout VISN 6, which just happens to include Durham, Asheville, Fayetteville, Hampton, Richmond, Salem, and Salisbury North Carolina?  Probably this is not unfamiliar as the patient experience survey scores remain persistently below VA averages, reflecting that new leadership is akin to putting lipstick on a pig.  Interestingly, medical staff credentialing remains a significant concern in North Carolina.

Western New York veterans, especially those receiving patient services in the Buffalo VAHCS, do you agree with the VA-OIG report?  The Buffalo VAHCS includes Buffalo, Batavia, Jamestown, Dunkirk, Niagra Falls, Lockport, West Seneca, and Olean, and the comprehensive report is mystifying to me.  For example, the VA-OIG reports that “Patients generally appeared satisfied with their care.”   At the same time, “Employee survey data revealed opportunities for leaders to improve workplace satisfaction and reduce feelings of moral distress.”  This is a combination not generally found in these CHIP inspection reports.  Something is definitely off, and I would love to know what, especially since the leadership needs significant improvement in identifying and reporting sentinel events.  Do you agree with the VA-OIG findings?  Please let me know your firsthand experiences, for the double-talk in this CHIP report is above what I usually observe.

With almost identical findings and recommendations in the Syracuse NY VAMC’s comprehensive healthcare inspection, covering communities of Syracuse, Auburn, Freeville, Potsdam, Rome, Binghampton, Watertown, and Oswego, NY., I am concerned that the veterans in New York are in as bad or worse shape than Phoenix’s veteran community.  Hence, I have to ask the VA-OIG, has something changed in your measurement and analysis tools to report such disparate findings as “Employee survey data revealed opportunities for leaders to improve servant leadership and decrease employees’ feelings of moral distress.  Patients generally appeared satisfied with the care provided?”  The double-talk level is higher in these CHIPs from NY, which is rarely observed outside of Phoenix and VISN 22.  Two final thoughts on the CHIPs, staff training, continues to be a high-risk finding, and this continues to be a leadership failure for every VAMC/VAHCS/VISN in the VA; why has progress not occurred?  Training is a system, and leadership and organizational risk, system redesign, and improvement is a quality, safety, and value problem of the highest importance; why is action never taken by leadership or the congressional representatives who are expected to scrutinize the executive branch?

28 March 2022, the VA-OIG released their long-awaited annual “Comprehensive Healthcare Inspection Summary Report: Evaluation of Medical Staff Privileging in Veterans Health Administration Facilities, Fiscal Year 2020.”  I have been interested to see what, if anything, the VA had accomplished in improving their medical staff privileging.  If I were a congressional representative, knowing that medical staff continues to harm and kill veterans, I would have been anxiously awaiting to see if the repeated hits from past years had finally been rectified.  Unfortunately, the VA continues to live down to expectations (digging the hole ever deeper), suffers from failed leadership, and the veterans continue to die or suffer abuse.

What did the VA-OIG discover?  Understand, “The OIG conducted detailed inspections at 36 VHA medical facilities to ensure leaders implemented medical staff privileging processes in compliance with requirements.  The OIG subsequently issued six recommendations for improvement to the Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders.  The intent is for VHA leaders to use these recommendations to help guide improvements in operations and clinical care at the facility level.  The recommendations address findings that may eventually interfere with the delivery of quality health care.”  The OIG identified deficiencies with focused and ongoing professional practice evaluation, provider exit review, and state licensing board reporting processes.  Specifically:

    • use of minimum criteria for selected specialty licensed independent practitioners’ focused professional practice evaluations
    • inclusion of service-specific criteria in ongoing professional practice evaluations
    • completion of ongoing professional practice evaluations by other providers with similar training and privileges
    • recommendation by executive committees to continue licensed independent practitioners’ privileges based on professional practice evaluation results
    • completion of provider exit review forms within seven business days of licensed independent practitioners’ departure from a medical facility
    • the signing of exit review forms by service chiefs, chiefs of staff, and medical facility directors if licensed healthcare professionals failed to meet generally accepted standards of care
    • initiation of state licensing board reporting within seven business days of supervisors’ signatures on exit review forms to indicate licensed healthcare professionals failed to meet generally accepted standards of care.

The OIG found ongoing issues from the fiscal year 2019 CHIP summary report that warranted repeat recommendations for improvement.  The OIG issued three repeat recommendations related to the following:

    • inclusion of minimum specialty criteria for focused professional practice
      evaluations
    • inclusion of service-specific criteria in ongoing professional practice evaluations
    • recommendation by executive committees of the medical staff in continuing licensed independent practitioners’ privileges based on professional practice evaluation results.

Boiling the findings of the VA-OIG down, essentially, the administrators and leadership are not weeding out poor and horrible practitioners, reporting these underperforming practitioners, and not acting in the best interests of the veterans seeking care at VAMCs and VAHCSs across the country.  I repeat, only for emphasis: Is this not abuse of the patient?  Is this abuse not driven by ideologues who gain from the harm they cause others?  Should this abuse not be scrutinized until it is eliminated?  Please feel free to read some of these comprehensive healthcare inspection reports from the VA-OIG, see the resulting injuries and problems caused by the failures of government medical providers, and then tell me whether these atrocious actions need more or less scrutiny and qualify for the title abuse.  The link to the full report is available; please feel free to make your conclusions and post your thoughts in the comments section.

On a final note for today, consider with me the problems of the Atlanta VAHCS with pallets of unopened mail containing patient health information, community care provider claims needing payment, and a plethora of other unopened mail.  Understand that when community care providers cannot obtain compensation from the VA, they go to the veterans, who then send in correspondence, which is unopened, thus causing more problems, concerns, and issues for an already abused veteran community!  Want your head to explode?  Look at the pictures the VA-OIG helpfully sent along with this VA-OIG report, and ask yourself if any other business or organization could get away with this type of abuse of the customer.

What did the VA-OIG find?  Well, prepare for your head to explode, again:

    • VA Leadership should have established a formal agreement explicitly detailing each office’s responsibilities.
    • VA HCS leaders did not include responsible managers in decision-making discussions and lacked a clear understanding of the volume of mail processing work they were accepting.
    • Atlanta VA HCS did not ensure mailroom staff was adequately prepared or trained to handle or sort the influx of mail. POM (Payment Operations Management) officials were later reluctant to help, citing the verbal agreement.

Buried in the report is this tidbit, “POM is implementing similar transitions at sites across the country; POM and medical facilities need to ensure adequate staff with sufficient training to handle the mail processing workload.  VA concurred with the OIG’s five recommendations.”  Meaning that in a VAMC/VAHCS near you, unopened mail due to verbal agreements will soon add more distress and disgust to the veteran experience.

I have documented in these articles how verbal agreements, verbal standards of work performance, and verbal processes and procedures are the problem and way of life in too many CHIPs and observed practices at the VA.  Yet, these verbal shenanigans are more apparent than in the dilemma Atlanta faces due to unopened mail.  Payment operations to community care providers are on a controlled and fixed timeline.  Failure to process these payments according to the required timeline leaves providers unpaid, which diminishes the community care provider pool of providers.  Talk to a community care provider, and they will discuss the risks of doing business with the VA and the real possibility of not being paid timely enough or being caught in sufficient red tape never to receive payment.

I know of a provider who called me three years after receiving care and was still trying to appeal and correct the paperwork to receive payment.  A provider recently contacted me who wanted to ruin my credit for failing to pay the balance due from care received, and they are charging interest.  Correcting this problem cost me 48 business hours, 20 calls, and frustrations galore.  By the way, the problem still has not been rectified, an appeal is in process, and we have to wait for the VA to make a decision; this incident was caused by the VA changing the process and the paperwork.  The provider told me they are not accepting any more veterans seeking care, the risk is too significant, the timeline to receive payment is too long, and the VA never pays what is charged.  For example, I recently received a declaration declaring payment to a community care provider.  The VA sent me to this provider, which means they knew the prices beforehand and agreed to the fees.  The declaration declared the VA was charged $2,000 and paid $120, not actual amounts, but close enough to communicate the problem.  With inflation, or without inflation, if you were paid less than 1/10th of what you billed (invoiced), would you continue to conduct business with that company or organization?  Now add the unopened mail problem to the mix.  Would you continue to conduct business with this entity?

America, the Department of Veterans Affairs is sick.  All of the other alphabet agencies in the Federal Government are sick.  We continue to elect people who actively refuse to care enough to act according to their mandated duties.  We cannot afford the government we currently have, which is part and parcel of the problem with inflation in America right now!  Debt is entered into to pay for this bloated feckbeast called government; from the city to the federal government, the bloat is too great to be sustained!  Why is the VA able to skirt responsibility, accountability, and improvement?  They can hide behind the size of their convoluted and twisted organizational shield.  Why can the Post Office and the IRS get away with deplorable, at best, customer service?  They are protected by the congress refusing to scrutinize and hold people accountable.  When your head is done exploding, please remember and act in the ballot box to hire better representatives!

© 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-CareI 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.VA 3

UPDATE: 14 April 2022Sen. 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 ChickenOn 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?

© 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 5

I-CareI had originally planned on writing something else today, but my mental train was derailed, caught on fire, and I had to change my plans.  18 March 2022, I received an email signed from Sonja Brown of the Albuquerque VAMCS, who discussed how it takes 10-20 years for the VA to make a decision about which clinics to close, how to build new clinics, and the possibility of change (not) occurring in the New Mexico VA Medical System.  Doesn’t that warm your heart; two decades is a maximum timeframe for ending unprofitable clinics to save the taxpayer money.  Now multiply this problem by every government agency, and we find the reason for reducing the government bloat!VA 3

Luckily, I still have VA-OIG reports to discuss, not that I got behind, but February and March have been especially prolific.  In January, the pace set appears to be sustained, at least for the first quarter of 2022.  Some have commented that I do not write very often about the National Cemetery side of the VA’s voluminous bureaucracy.  Your wish is granted; a whistleblower reported that the Houston National Cemetery was not being operated properly.  The VA-OIG substantiated “some of the claims made by the whistleblower.”  However, the leadership at the Houston National Cemetery had, for the most part, already begun making changes before the VA-OIG arrived.

Thus, I congratulate the Houston National Cemetery leadership for being almost proactive and 100% more responsible than any leadership in the VHA and VBA.  My heartiest gratitude to you and your staff.  May you continue to show initiative, forward-thinking, and attention to detail, and may the rest of the VA’s hegemonically impotent leaders learn from your example.VA 3

A Comprehensive Healthcare Inspection (CHIP) was conducted at the James J. Peters VAMC in the Bronx, NY.  While a lot of the report is cookie-cutter, similar to all the other CHIPs that cross my inbox, I remain fascinated with a frequently used term from the report, “Servant Leadership.”  From the website linked, we find the following to define “servant leadership” at the VA:

We are all leaders, all of the time.
Servant Leadership is an approach for optimizing the delivery of client-centered services by strengthening employees to be an engaged and empowered workforce.  The philosophy and practice of Servant Leadership is one that emphasizes caring, authenticity, and putting clients and employees first, and ahead of personal goals or leadership aspirations.  Servant Leaders strive to meet both organizational objectives and the growth / development of their workforce.”

Please note ALL the grammar and punctuation errors are included in that quote.  Far be it for me to pass along any advice on grammar, spelling, punctuation, and proper communication techniques.  But, even this quoted material reflects the fact that there is a Grand Canyon-like chasm between DC leadership and the worm’s eye-view in a VA Hospital, VBA operations center, or the National Cemetery.  Be a leader at the VA, and you will NOT last your probationary period after hire; I have experienced this personally!VA 3

Worse, try and help the VA from the worm’s eye to see the problems and fix the issues, and the VA Leadership will chop you into little tiny pieces and feed your carcass to the fishes.  Yet, every single CHIP report mentions problems with “servant leadership” as opportunities for growth and development.  More bureaucratese for designed incompetence as an excuse, the VA-OIG will believe.  How sick to death I am of these shenanigans!  Don’t believe me; check out the full CHIP report, it’s linked above, read a few of the other CHIP reports from the VA-OIG, and discuss the actual problems you think the VA is experiencing.

Servant Leadership is officially defined, by Purdue University, quoting Robert Greenleaf from 1970, as:

The servant-leader is servant first.  It begins with the natural feeling that one wants to serve first … a philosophy and set of practices that [enrich] the lives of individuals, builds better organizations and ultimately creates a more just and caring world.”

Notice a problem between the two definitions of servant leadership?  Recognize an issue yet with the entire concept of servant-leadership?  Let me give you a hint through a question, What does a “just and caring world” really define?  The whole concept of servant leadership is easily twisted, plasticized, and framed in a way that removes liberty, destroys justice, and wrecks havoc on a free society, all because the philosophy sounds good, but the practice leaves chaos and destruction in the name of creating a more just and caring world.Servant Leadership and Health Care: Critical Partners in Changing Times

I am not condemning anyone who wants to try and improve their leadership skills through learning servant leadership or applying some of the servant leadership philosophies in their leadership toolbox.  I am merely stating that care and caution should be used when trying to reshape the world on such ambiguous and amorphous terms as “just and caring.”  The VA is trying to force a leadership template for all leaders to follow.  This type of leadership philosophy warps the world and makes leaders into managers with excuses for failure, e.g., designed incompetence.

On a different topic, please read the following carefully:

The VA Office of Inspector General (VA-OIG) reviews nonpharmaceutical proposals submitted to the VA National Acquisition Center (NAC) for Federal Supply Schedule (FSS) contracts valued annually at $10 million or more for high tech medical equipment, $3 million or more for all other FSS contracts, $100,000 or more based on manufacturer sales under dealers or resellers, or as requested by the NAC.”

Here is why the above is critical:

The VA-OIG determined commercial disclosures were accurate, complete, and current for only 24 of the 103 proposals reviewed.  This means 24 proposals were reliable for determining negotiation objectives and fair and reasonable pricing.  The remaining 79 could not reliably be used for negotiations until the noted deficiencies were corrected.  The OIG recommended lower prices than offered for 76 proposals.

If you, in your employment, had a 23% accuracy rate, and someone else had to come behind you, redoing all of your work, how long would you last in your job?  Note there are still 3 proposals that do not meet regulations and requirements out of 103 contract reviews.  Read the rest of this incredible report for yourself and know what your elected representatives are failing to curtail and control.  Then answer the following question: “Why should we re-elect ANY of the current elected officials?”VA 3

On the topic of designed incompetence of an almost criminal nature, we find the VBA still making headlines and breaking rules of ethics, morals, and logic with aplomb!  Before getting into the VA-OIG report, it is crucial to note that the VBA has exclusively gone to a third-party model for Compensation and Pension exams.  The most important part of the VBA’s operations, the comp and pen exam, is now conducted solely by third-party contracts companies.  A VA doctor sees a person trying to get their benefits from the VBA no longer but a third-party physician’s assistant at best, who is (supposedly) overseen by a medical doctor.  The lack of transparency and the complicated processes of the VBA are gordian, and transparency is hidden; read that as missing entirely.You know it's true - Imgflip

Here comes the VA-OIG, not to the rescue, but to rub salt into the wounds of veterans whose claims continue to be denied for lack of evidence.

“[The] VBA complied with the requirements of the law by reinstating 69 questionnaires on its public-facing website.  However, disability benefits questionnaires that were incomplete, inaccurate, or of questionable authenticity from non-VA medical providers were not always processed correctly when determining benefits entitlement—causing underpayments of about $13,900 and overpayments of $74,800 over the nine months studied.

Improper processing occurred because VBA lacked sufficient controls to ensure disability benefits questionnaires from non-VA medical providers were properly relied on when determining entitlement to benefits.”

Let’s let this sink in for a moment.  The VBA moved to a third-party model, then denied access to the VBA’s questionnaires to determine benefits, then had to be forced to reinstate the questionnaires.  Improper VBA processes and procedures led to over and underpayments of benefits, and claims processors still do not have the tools to make informed and logical decisions reliably.  Best of all, veracity (questionable authenticity) remains questioned in the process when the third-party contractor submits the forms for benefits.VA 3

You cannot make this stuff up; fiction writers can come nowhere close to creating a story this inane!  Is designed incompetence as a concept clear now?  The VBA developed a process using a more expensive model and then questioned the inputs for veracity from the contracted party, and the veteran suffered more!  Do you think the VBA intentionally designs its processes to help and create a more just and caring world (servant leadership)?  I think the VBA intentionally designed their processes to screw veterans in the hope they die before the government ever pays money on their claims.  Let me know what you think in the comment section, for this is a travesty of justice anyway I slice the data.

As a veteran who has been trying to get a compensation and pension decision corrected since leaving the service in 2004, having suffered both overpayments, which I had to repay, underpayments, and erroneous overpayments where the funds paid were (eventually) refunded, the news from the VBA designed incompetence is a particular form of hell for me to read and discuss.  I have had the third-party comp and pen exam doctors refuse to see me three times in the last two years.  Delaying a VBA decision repeatedly.  I have had the VBA reject the third-party data and a new comp and pen exam scheduled, rescheduled because I cannot wear a mask, and then conducted by a hostile and infuriating provider who refused to listen to the patient.Are you an Incompetent Developer? - Web Development & Web Design Blog

When veterans talk about fighting the VBA for a fair and honest decision, they mean a literal fight!  Don’t take my word for it; ask veterans how their comp and pen exam has gone; when you find those struggling with the VBA, listen carefully to their stories, and you will hear very similar stories.  The VBA represents government inefficiency, designed incompetence, and bureaucratic inertia to the Nth degree!

The following link might, or might not, work as intended; the link directs you to all testimony recorded from congressional hearings.  If it works, you will be able to read the statement of David Case, Deputy IG, who was testifying before the HVAC subcommittee on drafted legislation “Quality Education for Veterans Act of 2022”.  A brief synopsis from his testimony is included below:

This bill would significantly strengthen the OIG’s efforts to prevent fraud in VA’s education and training programs.  Given that more than $10 billion in taxpayer funds is expended on education and training programs each year and hundreds of thousands of veterans, service members, and family members receive these benefits, the OIG supports efforts to strengthen programmatic and beneficiary protections.  The statutory changes in the draft bill do not appear to be burdensome or costly to educational institutions or VA, and yet they have the potential to make a significant impact on the amount of education fraud that occurs.  The OIG agrees that these changes would work to lessen the harm suffered by veterans and beneficiaries and reduce losses to the government.”

Ever wonder how much a VA-OIG inspection costs or where and how the VA-OIG is funded; here is the answer and the problem.  Tell me, why is the VA-OIG not financed from the VA budget?  Simple question, not hard, and requires an explanation!  The explanation should be detailed, transparent, and I guarantee that the answer will reflect the designed incompetence and failure to scrutinize the executive branch adequately.  The VA is one of the few, if not the only, Federal Government Agency with a specialized inspectorate general, dedicated solely to independent oversight and continuous improvement of the VA.  I think the VA-OIG might be failing in its mission.VA 3

Fraud is rampant in the VA because the VA refuses to act, work, change, and improve.  How will throwing more money at VA programs alleviate the hurt, stop the fraud, and spur continuous improvement?  Almost every week, my inbox fills with accounts of fraud occurring, but the roots of the problems are never addressed, and people are not held accountable for failing to perform the work they were hired to complete.  Failing to hold people responsible promotes fraud, waste, and abuse.  Allowing whistleblowers to be fired promotes a discouraged whistleblowing culture, and the perpetrators are allowed to continue their nefarious misdeeds!  How is the VA-OIG going to tackle these systemic issues in the culture at the VA?  When will continuous improvement begin; I do not want to miss growth and development!

Knowledge Check!America, the VA is sick.  A symptom not a disease; the larger disease is a refusal to act morally upright.  The majority of those employed in the behemoth of government service have little to no moral compunction, are not servants of the taxpayer, and consider themselves “Too BIG to fail.”  We need a smaller government, and I hope this message helps enlighten and support shrinking the government!

© 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 (CH 5)

I-CareThe 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.VA 3

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 ChickenWhen 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 SealThe 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?

© 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 Chapter 3

Bobblehead DollIt is no secret I am on several prescription medications.  I take these under strict medical advice, and three of these prescriptions regard mental health improvements.  However, my prescription reasons were subtly shifted because Phoenix’s last two primary care providers did not listen to the patient.  Since the El Paso primary care physicians appear to be utterly incapable of even attempting to listen, I have now been without a mental health prescription for an entire week.  This is called bureaucratic cold-turkey prescription stoppage!

Not the first time this has happened, especially for this particular medication, a serotonin blocker.  Here’s the rub, the physical and mental withdrawal symptoms of cold turkeying the drug; includes, but is not limited to, the following symptoms, of which I have ALL of the problems!

      • Nightmares
      • Suicidal Ideation/Thoughts/Visions
      • Headaches
      • Heart Palpitations, radiating chest pain
      • Anxiety
      • Depressions
      • Mood Swings
      • Irritability
      • Tinglings and Prickling sensations of the skin
      • “Brain Saps”/”Brain Shivers”/Spaced-Out Zombie Spells
      • Fatigue
      • Dry Mouth
      • Insomnia and Sleepiness – Which is a major whiplash feeling!
      • Pain and neurological events in every part of my body!
      • … and more… Much…  Much… More!

I have been without this medication due to bureaucratic stupidity for several days in the past due to pharmacy issues.  But, this is now the longest I have been without this medication since getting prescribed this medication.  I wish, like anything, I had known some of these withdrawal symptoms before I went to the ER earlier this week for pain and neurological problems; I would have raised the refill issues as part of the ER visit.  I went online looking for other people’s experiences; I want some medical advice before continuing this medication!!!

PACT_modelI am a root cause kind of person; why do I bring this up?  I have had three primary care providers since arriving in the El Paso VAHCS in May 2021.  None of them have gotten any of the medications correct due to a blatant refusal to LISTEN to the patient with the INTENT to understand!  Nurses with VA-provided primary care providers are expected to communicate with patients between 24 and 72 hours post any ER visit.  Since moving to Las Cruces, I have visited the ER twice and have not spoken to the nurse yet!

I have initiated the conversation with the nurse through phone and secure messaging, and the nurse has refused to engage.  Through secure messaging, I am advised, “Secure messaging is not the place to triage a patient, and no question can be answered as this requires triage of a patient.”  No direct phone contact is possible with the clinic.  One must call, get routed to a call center, leave a message, and then hope the clinic calls you back sometime before you die!  Don’t forget; I am the same patient told, “The clinic will not see you in person because you “WILL NOT” wear a mask.”  Completely refusing to understand, accept, and believe that I cannot wear a mask due to medically documented (by the VA medical providers, which medical records they possess) reasons.  Best of all, the veteran is then sent letters and marketing materials urging the veteran to use secure messaging through “MyHealtheVet as a safe and secure way to access your medical team and get your questions and concerns addressed by your PACT team!”  If the VA were a mental health patient, they would have schizophrenia and at least a dual-personality.

PACT 1Snide, rude, and disrespectful staff, all made possible by, supported through, and legally accepted under federal government fiat.  Do you realize that the nurse not doing their job will have any number of valid and acceptable excuses, and these excuses are accepted because of designed intentional incompetence allowed under federal employment laws, regulations, and directives, established by and supported through Congressional oversight?  In Disney’s “Princess Diaries 2: Royal Engagement,” Viscount Mayberry has a line,

Your staff is incompetent and unreliable!”

The VA is incompetent and unreliable, and the victims are the veterans and their families.  We are talking about dangerous drugs, forced addictions, and then the ineptitude of incompetent and irresponsible bureaucrats who refuse to do their jobs in a timely and responsible manner.  But do not take my word for it.  Let’s review what a watchdog organization, the Department of Veterans Affairs (VA) – Office of Inspector General (VA-OIG), has to say on this matter.

VA 3

  • Tracy McNeil, of Raeford, North Carolina, was sentenced to one year and one day in prison and ordered to pay $90,003 in restitution for committing wire fraud involving an elderly veteran in her care. From February 2015 to February 2017, McNeil fraudulently obtained benefits from the VA and the Office of Personnel Management by executing a power of attorney over a disabled veteran who served in the Army and worked for the US Postal Service. The investigation revealed that McNeill arranged for the victim, who had dementia, to move into her home in February 2015 and then directed the VA and OPM to deposit the veteran’s benefits into her bank account. Between April 2015 and December 2016, the VA deposited $11,151, and OPM deposited $61,318 into McNeil’s account. Further, OPM disbursed the veteran’s life insurance for $17,533 to McNeil. Financial analysis showed that most of the funds were spent on McNeill’s expenses, including rent, utilities, credit card payments, and personal purchases.

VA 3

  • Strock Contracting, Inc., of Cheektowaga, New York, has agreed to enter into a consent judgment with the United States for $4.7 million to resolve claims that Strock violated the False Claims Act. The United States filed an action in federal court alleging that Strock Contracting profited financially after fraudulently obtaining federal contracts intended to benefit service-disabled veterans. The United States alleged the company, which was not owned or controlled by a veteran, recruited a service-disabled veteran to create a pass-through company, known as Veterans Enterprises Company, Inc. (VECO), which the Strock Contracting its owner, Lee Strock, controlled. The company allegedly directed VECO to submit false eligibility certifications to the government, obtaining substantial profits on numerous federal contracts.
        • Where are the VA Employees who should know what “fake eligibility certificates” look like?
        • Where are the supervisors who should have been providing training?
        • Where are the Congressional oversight teams in holding the VA accountable?

VA 3

    • William Rich, of Windsor Mill, Maryland, was arrested for allegedly obtaining more than $1 million in veterans and Social Security Administration disability benefits by falsely claiming that he had paraplegia. Allegedly, Rich misrepresented his physical condition in VA disability compensation claims, in communications with the VA, and during medical examinations in pursuit of VA disability benefits. While serving in Iraq in 2005, Rich sustained injuries that resulted in the loss of use of both lower extremities. However, approximately six weeks after his injuries, he made substantial progress toward recovery and was no longer paralyzed. Later records show the VA rated him one hundred percent disabled following an examination in 2007. The examining physician noted that he did not have access to Rich’s complete claims file, so he did not review Rich’s medical history or observe the earlier report. In 2018, the VA OIG conducted an audit of specific claims and learned of conduct by Rich inconsistent with his purported condition. Over the next two years, VA OIG special agents conducted surveillance. They observed Rich walking, going up and downstairs, entering and exiting vehicles, lifting, bending, and carrying items—all without visible limitation or assistance of a medical device, including a wheelchair [emphasis mine].
        • OK, let me be clear, I am glad this veteran got better; I do not in any way condone theft. But, where is the VA in being culpable for FAILURE to do their job correctly?
        • Will the doctor who failed to do their job be held liable for the malpractice performed?

VA 3

    • William H. Precht, of Kent, Ohio, was sentenced to 37 months imprisonment and ordered to pay $1.25 million in restitution after pleading guilty to theft of government property and participating in a bribery and kickback scheme. In October 2010, Precht registered a purported vendor, a company he controlled, as a small disadvantaged business and veteran-owned small business in the VA vendor system. He then used his VA purchase card and other employee cards to purchase over $1 million in alleged medical supplies from the vendor. In addition, from May 2015 through January 2019, he conspired with Robert A. Vitale, a medical sales representative for multiple companies that conducted business with the medical center, to devise a scheme in which Precht would receive kickbacks and other items of value in exchange for steering VA business and other monetary awards to Vitale.VA 3

Speaking of staff being “incompetent and unreliable,” did you know that the VBA is using “COVID-19” as an excuse for being backlogged in cases, AGAIN?  Did you know that COVID-19 was so powerful that it caused the VA to fall 200,000+ cases behind, in an inventory of 600,000+ cases requiring decisioning, with 70,000+ needing additional review for entitlement, and needs to hire 2,000+ new employees to help correct the problem?  Since the VBA continues to fail in staff training, exactly how will hiring new employees help?  Honest question!  With the current staff rated as incompetent and unreliable, not by me only, but by the VA-OIG who has regularly taken these issues and more to Congress asking for additional scrutiny and assistance in improving the VBA, VHA, and National Cemetery specifically and the VA collectively; what exactly can new employees do?VA 3

The VHA cannot plan construction projects and put planned maintenance into proper categories to execute maintenance tasks correctly.  Congress refuses to scrutinize budgets and fiscal compliance for just maintenance of facilities.  How in the world can anyone expect more when the VA cannot even hit the basics of planned maintenance tasks?  I can; I do!

I-CareWhen the VA publishes marketing materials claiming they set standards for excellence and lead the industry, I want them to prove their competence and abilities!  Right now, their failures scream louder than the voices in their own ears, and they refuse to listen to anyone, and I am not happy!  You, the taxpayer, should not accept the performance of ANY government agency, including the entire legislative, judicial, and executive branches of government at the local, county, state, and federal levels, until they correct their behaviors!  It is time to end the charade and put paid to this contemptible behavior and abuse!

© 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.

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

Bobblehead DollThe 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=1Blue 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?LinkedIn VA Image

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!Satire? Obama ISIS Speech Depresses Nation | Hooper's War - Peter Van Buren

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!

© 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.

Chronicling the VA, One Ignominious Story at a Time!

I-CareAs we catalog the VA, occasionally, local services providers must be recognized for their service or their deficiencies.  In the spirit of fairness and transparency, it is time to discuss one of those community providers, Advanced Neurology Epilepsy & Sleep Center (ANESC), Dr. Aamr A. Herekar M.D.  Also, in the spirit of fairness and complete transparency, I have tried to settle my problems through the VA Community Services Offices and an appeal to the management and doctor of ANESC, all to no avail!  Regular readers know I have been in a multi-year battle with the VA over arresting me for not wearing a mask because when I wear a mask, I become a medical emergency.

I possess a note from my doctor, a VA Primary Care Provider, written to my employer on VA Letterhead with a wet signature, declaring my inability to wear a mask.  The VA did not accept this letter and arrested me three times.  Well, Dr. Herekar’s office was presented the same letter, and hassled me before both appointments for not wearing a mask, became hostile, argumentative, and a nuisance over the mask issue, even after I complied with putting on a face shield.  Today (23 September 2021), over Facebook messenger, I was informed that I would be invited to find a different provider due to my refusal to wear a mask.VA 3

Imagine that; Facebook Messenger has become the medium of choice for ending a patient relationship with a medical provider.  How very inappropriate!  How very unprofessional!  How very typical of some of the providers I have been sent to in the community by the VA.  Apparently, the abuse of veterans is spreading from the VA providers to the community providers.  If you are in the El Paso area and receive a referral to Dr. Herekar, please be cautious of his staff.  I have no idea of the efficacy and quality of the doctor, but his staff is absolutely third-rate or less!  The shame of the entire episode, the taxpayer is on the hook for my being abused by the staff.  How deplorable!Foghorn Leghorn - Medication

In reviewing different results reported from the Department of Veterans Affairs (VA) – Office of Inspector General (OIG) comprehensive healthcare inspection (CHIp) of VAMC’s, I am finding some interesting trends.

      1. Why the sudden, as of July 2021, focus on attendance and staffing in behavioral committees? More to the point, why are the behavioral committee’s processes and procedures so draconian?  More specifically, the following is a unique passage too often see in CHIps.
          • High-Risk Processes
            • Disruptive behavior reporting and tracking
            • Disruptive Behavior Reporting System
            • Order of Behavioral Restriction and patient notification documentation
            • Staff training – Isn’t this interesting, staff training is a “High-Risk Process?”
      1. When reporting that patient experience scores are similar to “VHA Averages,” isn’t this like saying a VAMC is as good as another pig in a pile of slop? Why accept averages that are comparable to other VAMC’s?  The leadership at the VAMC’s across the country is failing the veterans, yet the VA-OIG is accepting average performance compared with other VAMC’s.  It sounds like pathetic designed incompetence, wrapped in weak excuses, and deep-fried in a pity party!
      2. Training continues to be a fundamental excuse for failing, and even the VA-OIG seems to have given up and thrown in the towel.VA 3

An example of how training continues to be a fundamental excuse for failing and designed incompetence lies in another CHIp, specifically reporting reusable medical equipment (RME) and sterile processing services (SPS).  The VA-OIG reported the following weaknesses:

      • Standard operating procedures not aligning with manufacturers’ guidelines.
      • Annual risk analysis reporting to the VISN SPS Management Board.
      • SPS chiefs developing, implementing, and enforcing a daily cleaning schedule for all SPS areas
      • Equipment storage, cleaning, and usability.
      • Completion of Level 1 training within 90 days of hire, competency assessments for RME, and monthly continuing education for SPS staff.

All this after the VHA has already been caught with poor cleaning of reusable medical equipment on multiple occasions, where the training of cleaning staff was the primary reason for failing the CHIp from the VA-OIG.  The cycle continues unabated, and training is central to correcting and ending the process.  Yet, even the VA-OIG refuses to address the leadership failures and be part of the training corrective action behaviors.VA 3

In other CHIp reports, we find that completion of training is a high-risk process.  Leading to interesting questions about why and what is involved in staff training to make training high-risk.  What boggles my mind, much of last year, the CHIp reports found moral distress from leadership, this year, nothing; why?  Did the VA-OIG stop asking about this issue?  Certainly, the VA has not corrected this problem.  Am I merely suspicious, or is there a correlation between less focus on employees feeling morally distressed at work and increased focus on patient disruptive behavioral committees?

From other CHIp reports, we find more questions and logic that make no sense.  For example, how can patients be receiving care that meets VHA averages in acceptable care, but the employees reflect severe moral distress?  Does this not indicate that the averages for patient care are set too low?  Would not this be an indicator that leadership is not held to a sufficiently high enough standard of performance?  Worse, on these CHIp reports, we find greater mention of disruptive behavior committee actions, paperwork, training, and actions taken.  Thus, there appears to be a correlational data relationship between disruptive patients, moral distress in employees, failing leadership, and the abuse of the disruptive behavior committee process.  Where are the elected officials asking questions and drawing substantive conclusions regarding the data presented by the VA-OIG?  Heck, where are the VA-OIG data analysts raising alarms and red flags over correlational data points for investigators to act upon?VA 3

As a person who has been fallaciously labeled and erroneously called “disruptive,” this particular topic strikes home.  The system is ripe for abuse by egotistical leaders hell-bent on power-tripping!  When I asked how do you appeal the decisions, I was told lies, given wrong information, and forced to pay fines that I should not have had to pay.  Worse, the Federal Marshals at the courthouse remarked that there had been a significant uptick in veterans in the same situation as mine being fined erroneously by the VA.  Thus, the abuse of the veterans is both widespread and decidedly egregious!

Another recurring issue from the CHIp reports is remarkable from recent VA-OIG investigations, especially since multiple veterans have recently died over the issue, care coordination.  Care coordination includes completing paperwork, filling out the electronic health record, and signing the electronic health record, so the notes are available for other providers to use for follow-on patient treatment, nurse-to-nurse communication, and medication transmission, but most importantly, monitoring and tracking patient whereabouts on the facility’s grounds.  Yet, even with dead veterans with these issues as root causes, the VHA continues to fail in care coordination.  How do you define appalling, detestable, and disgraceful?  Where are the elected officials?  Where are the veteran service organizations in raising rhubarbs about the abuse of veterans at the hands of the VHA?VA 3

Finally, the most astounding and absurd continuous hit point from CHIp to CHIp report is found under the heading of “Quality, Safety, and Value.”  Under this heading falls a lot of topics, but imperative to improvement is the leadership failure to hold meetings attended by the primary audience.  Tell me, in the private sector; your boss calls a meeting of all department heads and their number two person.  If these people are no-shows, how long will they keep their jobs?  Yet, the VA-OIG finds repetitive missed meetings, no follow-up, no remediation, no punitive measures, no corrective actions, and these people are still employed!

Knowledge Check!One of the most bothersome things about reading three weeks’ worth of CHIp reports has been the consistency of the reports.  Too often, the reports read like they were copied.  Maybe this is due to the consistency of failed leadership; perhaps this is due to the lack of originality in thinking in the VHA, VBA, and the VA in general.  Regardless, the CHIp reports raise some concerning issues, specifically around the potential for abuses found in the disruptive behavior committee process and what disruptive behavior is at the VHA and VBA.  For example, if a patient is throwing furniture, this is obviously disruptive.  But, if a patient disagrees with a policy and is politely asking to speak to administration, this is not disruptive, but the patient is treated as disruptive, and that is abusive of the disruptive patient policies.

© 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.

If Everyone Cared – More Detestable VA Stories (Chapter 2)

?u=http3.bp.blogspot.com-CIl2VSm-mmgTZ0wMvH5UGIAAAAAAAAB20QA9_IiyVhYss1600showme_board3.jpg&f=1&nofb=1For the last two weeks, I have been a little remiss in writing.  My cousin passed from diabetes, two of my grandkids got sick with COVID (they are recovering), and I was diagnosed with asthma.  The last two weeks have been a roller-coaster of ups and downs, so imagine my surprise as I went to catalog more of the Department of Veterans Affairs (VA) – Office of Inspector General (VA-OIG) reports, Nickelback’s song, “If Everyone Cared,” was playing.  Pandora certainly appears to have a sense of humor and an innate sense of déjà vu.  I cannot think of a better title to proclaim the need for raising awareness and what is needed to fix the VA.  Until everyone is aware and the scab hiding the infection of the VA are ripped away to be exposed to the sunlight disinfectant, nothing will change, and taxpayers will continue to pay for the abuse of veterans who deserve so much more.  Thus, as we celebrate US Constitution Day, let us remember the veterans who have helped protect and defend the US Constitution and improve the government response!

The VA-OIG reports begin in Kansas City, Missouri, with a $335 Million Fraud Conspiracy, which included $615,000 in tax violations.

By pleading guilty today, Patrick Michael Dingle, 50, admitted that he conspired with Matthew C. McPherson, 45, of Olathe, Kansas, to fraudulently obtain contracts set aside by the federal government for award to small businesses owned and controlled by veterans, service-disabled veterans, and certified minorities.”VA 3

A sentencing hearing will determine if any prison time and what if any, restitution is required in this plea deal.  Frankly, the fact that the fraud existed from 2009-2018 is nothing short of a blatant and utter slap in the face for the taxpayer.  How many federal employees had to have seen the documents, failed to perform due diligence, refused to do their jobs, and were not named as co-conspirators or, at a minimum, facilitators of the crimes?  Is aiding and abetting a criminal operation not a charge that can be brought against the federal employees who empowered this fraud?  Thus, I demand all these people explain why and how an investigation can occur and not include the facilitators, those federal employees, who did not do their jobs!

Assistant US Attorney Paul S. Becker is prosecuting the case. The following agencies assisted in the investigation: the Department of Veterans Affairs, Office of Inspector General; the Department of Defense Criminal Investigative Service; the US General Services Administration, Office of Inspector General; the U.S. Small Business Administration, Office of Inspector General; the Army Criminal Investigation Command, Major Procurement Fraud Unit; the Department of Agriculture, Office of Inspector General; IRS-Criminal Investigation; the US Secret Service; the Air Force Office of Special Investigations, Procurement Fraud; the Naval Criminal Investigative Service; the Defense Contract Audit Agency – Operations Investigative Support (OIS); the US Department of Labor, Office of Inspector General; and the Department of Labor, Employee Benefits Security Administration (EBSA).VA 3

File the following under false imprisonment, and will someone please tell me why those employees involved are not in prison now!  A patient in the inpatient mental health unit and community living center at the Tuscaloosa VAMC in Alabama was falsely imprisoned and kept against their will for more than 2-years.  Was denied access to a patient advocate, which should be a red flag that something is disastrously wrong right there.  Plus, official mail to an elected official was improperly handled by staff to prevent elected officials from knowing about the veteran’s plight.

Here is what the VA-OIG investigation substantiated in their investigation:

    • Staff did not adequately assess the patient’s admission status as voluntary or involuntary and did not follow commitment requirements during the first two of the patient’s three Inpatient Mental Health Unit admissions.
    • Staff did not properly manage a letter from the patient that was intended for a public official.
    • Staff did not correctly identify a surrogate decision-maker and did not address ethical concerns regarding the appropriateness of the patient’s surrogate decision-maker.
    • Staff did not comply with requirements when the patient requested an against medical advice discharge.
    • staff at the facility denied a patient’s discharge requests and did not ensure the patient’s access to a patient advocate.
    • Staff failed to follow informed consent procedures.
    • Staff denied the patient’s discharge requests.
    • Staff did not conduct a sufficient or timely decision-making capacity evaluation and documented unsupported, conflicting decision-making capacity information in the patient’s electronic health record.VA 3

These are serious crimes, not bad administrative practices, felonious crimes.  Yet, the employees skate, the patient was held against their will, and nobody will be responsible for this disaster.  Where are the elected officials?  Where are those hired to scrutinize the government?  In this situation, any other medical organization would be facing lawyers armed with righteous indignation and seeing dollars signs in their dreams.  Yet, because this is the VA, the patient can be harmed, and no one will ever care, and that is a crime the elected officials are guilty of and need to be held to task for!

Moving to Biloxi, Mississippi, we found another VA employee who had sticky fingers and a long time to steal from the government (2009-2020).

Chad Paul Jacob of Saucier, Mississippi, pleaded guilty to stealing personal protective equipment, electronics, and medical equipment while working as the assistant chief of supply chain management for the Gulf Coast Veterans Health Care System in Biloxi. From 2009 through December 2020, Jacob stole and resold VA property at local pawn stores and on his personal eBay account.”VA 3

For eleven years, they were working as the assistant chief of supply.  The employee had how many reporting employees and superiors have had to sit through how many records audits.  In all these eleven years, I cannot believe that nobody ever suspected problems.  Who did the thief learn how to steal from the government from?  How many employees churned, and did any of these employees churn because they tried to report irregularities, and the boss ensured they were disposed of to silence them?  The VA has been taken to several congressional hearings to eliminate the whistle-blower rather than fixing the problems at the VA.  Thus, it is not in any way, shape or form, out of line to be suspicious about employee churn and fraudulent actions taken by a supervisor to eradicate and protect their schemes!  Why are these questions never asked in the VA-OIG investigations where schemes are uncovered by ranking and supervisory personnel?

Remaining in the south and moving next door to Slidell, Lousiana, a doctor, has been indicted for illegally dispensing opioids in a health care fraud scheme.

Adrian Dexter Talbot of Slidell, Louisiana, was charged for his role in distributing Schedule II controlled substances, including oxycodone and morphine, outside the scope of professional practice and for maintaining his clinic to distribute controlled substances illegally. He was also charged with defrauding health care benefit programs of more than $5.1 million, given that the opioid prescriptions were filled using health insurance benefits.”VA 3

Remember, an indictment is not a finding of guilt, and the defendant remains innocent until proven guilty in a court of law by a jury of his peers.  There is a very compelling point made by our founding fathers that need to be repeated here and declared more often in American Society.

“… Should the People of America, once become capable of that deep simulation towards one another and towards foreign nations, which assumes the language of justice and moderation while practicing iniquity and extravagance, and displays the charming pictures in the most captivating manner of candour, frankness, and sincerity.  At the same time, it is rioting in rapine and insolence; this country will be the most miserable habitation in the world.  Because we have no government armed with power capable of contending with human passion unbridled by morality and religionOur Constitution (the US Constitution) was made only for a moral and religious people.  It is wholly inadequate to the government of any other.” – President John Adams

The drug war and the opioid crisis stem from the same problem, a lack of morality and religion.  The duplicity of showing candor, frankness, and sincerity, while at heart there is nothing but ravening appetites and the minds of wolves, is the problem.  Sure, drugs create a social and medical issue out of the unbridled appetites and passions.  The core is the lack of self-restraint from being disconnected to religion and morality and from social duty, responsibility, and accountability.  Thus, making people miserable and looking for a cure.Knowledge Check!

The case above expresses this point clearly; the doctors involved were filling an appetite.  As long as there is an appetite, there will be people willing to risk everything to fill the appetites of others; moral and social disconnection, and the US Constitution cannot govern these people except to their destruction!

Moving to Fort Lauderdale, Florida, we find another series of indictments for more fraud, reflecting the same social disconnection.

Kingsley R. Chin of Fort Lauderdale, Florida, the chief executive officer of SpineFrontier Inc., and Aditya Humad of Cambridge, Massachusetts, the company’s chief financial officer, was indicted on one count of conspiracy to violate the Anti-Kickback Statute, six counts of violations of the Anti-Kickback Statute, and one count of conspiracy to commit money laundering. Chin and Humad allegedly bribed surgeons to use SpineFrontier’s products, and in turn, the company received millions of dollars in revenue from surgeries the surgeons performed.”VA 3

Traveling north to Bedford, Massachusetts, we find another dead veteran and culpability so thick it should be used as a board to apply corrective discipline for all parties involved!  From the report, we see the scope of the investigation for the VA-OIG:

Mr. Timothy White was a resident of the Bedford Veterans Quarters (BVQ), an independent living facility operated by Caritas Communities, Inc. (Caritas), in space leased to it through VA’s enhanced-use lease program. A month after Mr. White was reported missing, his body was found in the emergency exit stairwell of the building that houses the BVQ. This stairwell down the hall from his room was VA property and not leased to Caritas.”VA 3

The VA-OIG found the following as facts in the investigation:

    1. The VA police department’s failure to locate Mr. White resulted in part from the police and others at VA not considering the veteran an at-risk missing patient, which would have required a stairwell search.
    2. The Veterans Health Administration and the Office of Security and Law Enforcement lacked clear guidance regarding the obligations of VA police to search for nonpatients reported missing on VA property.
    3. VA police also did not discover Mr. White in the stairwell because of an improper order by the then-police chief to cease patrols of the building in which Mr. White was found.
    4. The OIG found that the VA police chief exceeded his authority as VA policy, and the lease required VA police to patrol VA property.
    5. Medical center staff mistakenly believed the emergency exit stairwells were not VA space; they did not clean them.
    6. The confusion among medical center leaders and staff regarding the lease scope and VA’s obligations stemmed from a lack of clear guidance from the Office of Asset and Enterprise Management.
    7. Routine police patrols and stairwell cleanings likely would have led to Mr. White being found earlier.

Angry Grizzly BearNow, as logical thinking adults, do you buy the load of excuses being sold here to pass off the blame for a dead veteran?  I know I am certainly NOT buying this load of bull!  Having worked and spoken in-depth to leaders of VA Police Departments, the excuses to not do stairwell checks and camera checks for missing patients are beyond inexcusable!  I know of a situation where a patient was lost on VA property.  Every police officer and staff member, even those on off-shifts, were called in, issued out in teams, and every square inch of the property was investigated until the patient was found.  Yet, somehow this patient was able to DIE unnoticed in a stairwell!  Are you kidding me?!?!?!

Regardless of whether this veteran died of malnourishment, dehydration, exposure, or lack of medication, he died horribly!  The veteran died at the hands of responsible parties, and those parties need to be held accountable for his untimely and atrocious death!  There is NO EXCUSE for this veteran to have died.  SHAME on the administration!  SHAME on the VA Police!  SHAME on the third-party contractor.  SHAME on the leaders of government who have allowed this abuse and refused to act!

Moving west to Chalfont, Pennsylvania, we find more stolen valor and theft of government benefits.

Richard Meleski of Chalfont, Pennsylvania, was sentenced to three years and four months in prison, three years of supervised release, and ordered to pay $302,121 in restitution for stealing VA benefits by pretending to be a veteran who the enemy had captured during combat. In July 2020, Meleski pleaded guilty to one count of healthcare fraud, two counts of mail fraud, one count of stolen valor, two counts of fraudulent military papers, as well as two counts of aiding and abetting straw purchases, and one count of making false statements in connection with receiving Social Security Administration disability benefits.”VA 3

While there are many more VA-OIG reports needing sunshine disinfectant, let us remember Mr. White, who has passed, and the feloniously falsely imprisoned unnamed veteran from today’s VA-OIG recap.  These two veterans especially deserve respect, dignity, and remembrance.  Their families and friends deserve praise and prayers.  America deserves answers, and federal employees need to be held accountable for failing to do the job they are paid tax dollars to perform!

I-Care© 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.

If Everyone Cared – More Detestable VA Stories

I-CareAs I went to catalog more of the Department of Veterans Affairs (VA) – Office of Inspector General (VA-OIG) reports, Nickelback’s song, “If Everyone Cared,” was playing.  I cannot think of a better title to proclaim the need for raising awareness and what is needed to fix the VA.  Until everyone is aware and the scab hiding the infection inside the walls of the VA are ripped away to be exposed to the sunlight disinfectant, nothing will change, and taxpayers will continue to pay for the abuse of veterans who deserve so much more.

We begin with an indictment and a reminder.  An indictment does not indicate guilt or innocence, and the parties mentioned are presumed innocent until proven guilty in a court of law by a jury of their peers.

Scott Mitchell Brown, John Henry Swiencki, and David Jeffery Hughes, Jr., were all charged with one count of conspiring to distribute hydrocodone, oxycodone, and amphetamines. Brown was also indicted for stealing prescription medications, possessing stolen mail, and obtaining unauthorized health information from the Kerrville VA Medical Center in Texas.”VA 3

I am a big fan of punishing liars and thieves of all stripes and support justice served in this case.

David Naylor, 59, of Spring Hill, Florida, was sentenced to two years and three months in federal prison, followed by three years of supervised release, for theft of government funds. Naylor made false representations regarding his physical limitations in connection with his application for VA disability compensation.”VA 3

While the following perpetrator has been caught and sentenced, she represents but the tip of the iceberg.

Rita Copeland, 59, of Portsmouth, Virginia, was sentenced today to nine and half years in prison for wire fraud and aggravated identity theft in connection with schemes to defraud veterans. She operated Veteran Services of the Commonwealth, which claimed to provide veterans with caregiving, contracting, and rental assistance services. In total, from at least 2017 through 2020, Copeland’s schemes impacted at least 29 victims and resulted in a combined loss of approximately $430,000.”VA 3

Again and again, the following questions are asked and never answered; yet, the questions remain pertinent.   Who at the VA had to have known this abuse of veterans was occurring and did nothing to stop the abuse?  There are too many checks and balances, too many hands, and too many inspectors for fraud of any magnitude to exist for very long without raising flags needing investigating.  Where were the VA employees?  Who knew?  What did they not do?  Are they still Federal Employees?

Another veteran died, needlessly at the hands of VA providers, due to ineptitude, failed management, poor training, and a series of unfortunate events that cascaded.  I weep for the family of this veteran and mourn for their loss.  I am sorry you have had to experience this tragedy and wish there was something more I could do than simply spread the story of this deleterious behavior and hope for sunshine disinfectant.  The patient died from “presumed anoxic brain injury (his brain failed to receive enough oxygen).”

The VA-OIG found that physicians’ failure to provide adequate benzodiazepine dosing to address the patient’s delirium tremens, review the patient’s abnormal electrocardiogram before haloperidol administration, and transfer the patient earlier likely contributed to the patient’s deterioration and ultimate death.  The VA-OIG substantiated that a non-VA paramedic documented that the oxygen flow was not active.  Facility leaders and staff reported a lack of knowledge about the failed oxygen delivery. The nursing staff did not complete all required alcohol withdrawal assessments.  A physician improperly ordered restraints, nurses failed to obtain full vital signs while the patient was in restraints, and nurses did not receive restraint training as expected.  The VA-OIG substantiated that facility leaders and staff did not communicate initiation of emergency detention with the patient’s family; however, notification is not required.  Leaders did not conduct an institutional disclosure with the patient’s family timely or in person and did not provide a relevant update.”VA 3

Did you catch that last sentence; while the patient was dying, the facility leaders and providers, including the nursing staff, were more concerned with CYA (covering their own acts) than notifying the family they had screwed up, and their family member had died.  If the nursing and staff did not have the training, why and how could they use restraints on a patient? This is blatantly illegal!VA Seal

Let’s cover one more egregious item from this summary of unfortunate events; I visited a doctor who is transitioning out of medicine who made the following comment, “Medicine has changed, practicing medicine has changed, and the practice of medicine is no longer about treating people, but checking boxes, the patient be damned!”  The patient was a “walking chemistry experiment, and no single nurse or provider took a minute to stop providing care, assess the patient, and stop administering drugs!  Instead, they just kept pumping more drugs in until the patient died and then covered their tracks with designed incompetence to protect their failed inadequacies.  This is not “practicing medicine,” you would not treat an animal in this manner; at least not and keep your license!

A death row convict is not allowed to die from anoxic brain death, as it is considered incredibly painful and a cruel and unusual method of death, which is why the gas chamber has been banned as a legal means of causing death for death row inmates.  Yet, under a medical team’s care, a patient in a VA hospital is allowed to die in this horrific manner, and nobody is held accountable.  Is it any wonder why this article is suitably titled “If Everyone Cared?”LinkedIn VA Image

Not many outside of the veterans affected and their families know that the VA has been pushing opioids for decades down the throats of veterans.  At the height of the opioid crisis, the VA shut off all opioid drugs and told the veterans to seek help for addictions to pain medications.  The VHA did not evaluate the individual patients for need, did not seek alternatives, did not try to reduce dependency over time, simply cut off all opioids, and told the veterans to deal with the problems.  Unfortunately, opioids were not the only drug series that the VHA cut off suddenly on veterans without notice, cause, or individual patient consideration, and deficiencies in coordination for the care of patients and drug mandates from VHA has lead to suicides, murders, and other violent problems as addictions cause social problems.VA 3

When discussing failures to coordinate care for patients, abuse of patients, and the need for patients to be housed in the proper treatment centers for their needs to receive the right care, the following should boil your blood and comes from Fayetteville VAMC in North Carolina.

The VA-OIG identified that the psychiatrist used the involuntary commitment process in a manner that was inconsistent with the state’s established parameters and failed to adequately assess and document the patient’s capacity to make informed decisions and determine whether the patient had a healthcare agent. In addition, the patient’s primary care providers and psychiatrist missed an opportunity to coordinate specialty care needs for the patient.”VA 3

Essentially, a bureaucrat incarcerated a veteran against their wishes, without a trial, an appeal process, and proper medical care.  Now, imagine you are the family of this veteran or a friend, and you see this occur and feel powerless to help, impotent to intercede.  Every avenue you approach is blocked because of the authorities, the bureaucrat in charge who wields their power illegally.  How do you feel?  What do you do?  Where do you turn?  Is it any wonder why this article is suitably titled “If Everyone Cared?”

I-CareAmerica, we need to care about what is happening in our representative government, in our name, with our tax dollars, and to our neighbors, family, and friends.  There are no excuses for the abuses witnessed!  There are no excuses for medical providers to get away with this outrageous behavior in private hospitals or government-paid-for-care.  Let us all heed Nickelback’s song and the intent; let us be the “everyone” who cares!

© 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.