Department of Veterans Affairs – Office of Inspector General

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

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

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

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

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

Why are these enrollments not processed correctly:

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

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

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

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

What did the VA-OIG find?

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

Why can’t the VA obey OM oversight?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

© Copyright 2023 – M. Dave Salisbury
The author holds no claims for the art used herein, the pictures were obtained in the public domain, and the intellectual property belongs to those who created the images. Quoted materials remain the property of the original author.

LIC and The Department of Veterans Affairs

What is LIC?

Low-Intensity Conflict (LIC) is the official name for when individuals or governments hire intermediaries to conduct violent operations from a secure position. LIC is a misnomer; those who have become victims of the barbaric cruelty of those practicing LIC find nothing “Low” about the experience. The conflict is intense, the actions brutal, and the practitioners remain cunning adversaries using and employing willing dupes to hide the true depths of moral decay inherent in the societal destructions and depravations the practitioners are enacting. Many confuse LIC in describing the actions of unbridled violence committed by ideologues under the banner of terrorism. The US Military Joint Chiefs of Staff define LIC as:

“A limited political-military struggle to achieve political, social, economic, or psychological objectives. It is often protracted and ranges from diplomatic, economic, and psychological pressures through terrorism and insurgency. Low-intensity conflict is generally confined to a geographic area and is often characterized by constraints on the weaponry, tactics, and levels of violence (Tinder 1990) [emphasis mine].”

Green (1997) adds a key ingredient to the description of LIC from Tinder (1990).

“… Non-international conflict is a refined term for what [was] formerly known as revolutions or civil wars, particularly when these have developed into major operations with the likelihood or reality of atrocities being committed against non-combatants. Whether civilians or those [rendered] hors de combat, a fact that is often more common in non-international … conflicts, especially when ideological, ethnic, or religious differences are in issue. It is for this reason that it must be borne in mind that the term low-intensity [conflict] has no relation to the severity or violence of the conflict” [emphasis mine].

Lt. Colonel Alan J. Tinder wrote a paper for the Air War College in 1990 titled: “Low-Intensity Conflict.” I have learned much from the Colonel and benchmarked this principle to more thoroughly understand LIC, recognize LIC, and detail LIC for others. The other compelling source is L. C. Green’s paper on “Low-Intensity Conflict and the Law.” I aim to synthesize this information into a manageable topic and aid understanding. Let me state emphatically that the Department of Veterans Affairs (VA) leadership’s actions are nothing short of LIC where employees and veterans/customers are concerned.

Regularly, the Department of Veterans Affairs – Office of Inspector General (VA-OIG) reports on a comprehensive healthcare inspection of a VHA facility, reports on employee morale in the VBA, or sum analysis of an employee or customer surveys, and include in the report a fairly descriptive, yet starkly utilitarian phrase, “reduce staff feelings of moral distress at work.” Generally, the efforts to reduce “moral distress” is left to an underling, an assistant, or a person for whom this is a secondary or collateral duty and is not considered important or relevant.

Do the actions of a leader represent complicity in creating moral distress fit the general definition of LIC? Absolutely. Consider that the leader sets the culture through actions, words, and behaviors, which originate in the thoughts and feelings of the leader. Correcting moral distress is pawned off on a junior staff member as a collateral duty, another method for displaying disrespect and communicating principles of abuse to employees. But there is no physical violence; how does this apply to LIC? Aren’t dead veterans’ examples enough of violent tendencies to justify the definition of LIC? The VA leader operates from a place of security, exemplifies the culture they deem acceptable, and then works through minions to achieve a “to achieve the political, social, economic, or psychological objective.”

Never forget these two critical points in the description of LIC:

“Often protracted and ranges from diplomatic, economic, and psychological pressures.”

“LIC has no relation to the severity or violence of the conflict.”

At the VA, the leadership calls their example politics; keeping your position or advancing is economical, and the psychological pressure to conform is palpable. All fundamental keys to conducting LIC against veterans, taxpayers, dependents, and non-conforming employees. Multiple times Congress has held hearings and listened to how the VA Leadership exacted revenge and retaliation upon those who reported problems to the VA-OIG, their elected congressional leaders, and other investigative parties. Feel free to peruse some of these hearings; you will hear victims relating physical, economic, and mental abuse, and the VA leadership never takes action. Elected officials never scrutinize and hold accountable those executing LIC, and the victims are victimized a second time.

Want another indicator that LIC is being practiced, the VA-OIG, after learning there are problems with moral distress at work, makes the following to slide the issues under the proverbial rub:

“The OIG’s review of the medical center … did not identify any substantial organizational risk factors.”

Signifying that even though the VA-OIG found moral distress is affecting and influencing employee behavior, the VA considers employee moral distress not an “organizational risk factor.” What does an employee who feels morally distressed do in performing their duties? Delay patients’ appointments, make mistakes on medication shipped, slow walk any responsibility to make things more complicated and take longer than they should. Does any of these actions sound familiar; they should, for this is the standard operating procedure for VA employees.

As reported previously, while I worked at the VA, I had intimate observations of what morally distressed employees do. When I wrote to the VA-OIG, I was informed that since I had my employment terminated, I could not be a whistleblower and get my job back. Plus, what I reported could not be actioned because it did not apply. How’s that for protecting the guilty? The VA Leadership is writing procedures and policies to target anyone and everyone who would report problems and seek help. An employee physically assaulted me; the camera mysteriously broke when I reported it, so no evidence was available. Who was at fault? Me; the assistant director promoted the attacker, and I got ostracized. The attacking employee took moral distress to new heights after this incident, and anyone who reported their behavior felt the wrath of the attacker and the VA leadership at the Albuquerque VAMC.

What is horrendous, this is not an isolated incident. What happened to me frequently repeats daily across every VA office. LIC is the overarching term, LIC is the behaviors named, and LIC is what the taxpayers are forced to pay for, all at the expense of veterans, dependents, and employees who see, know, and can do nothing. Repetitions of moral distress in employees, reported by the VA-OIG, are more than 20 just in 2022. The problem is cultural, and the elected officials desperately need to begin doing their second job, scrutinizing the executive branch and holding people accountable, including canceling the retirement packages of those practicing LIC.

Before someone tries to make this a Republican vs. Democrat issue, it is NOT political. LIC is never political, just as LIC is never religious, never racist, not sexist, or any other distinction. These distinctions are excuses, and the reasons do not justify the means for being violent. The leadership at the VA, and many other government agencies, have found that abusing the taxpayer pays well, provides protection, and allows them to exercise dominion to their heart’s content, all with the power of government to justify their deeds.

Do you realize that the VA-OIG has a metric for measuring moral distress, and the only time the VA-OIG reports moral distress among employees is when the results are higher than national averages? How scary is that to ponder? The problem is so prevalent that it only warrants reporting when it exceeds the norm. Thus, moral distress is declared less frequently when the average worsens. Official protection for LIC is provided by LIC, increasing, and the taxpayer is footing the bill.

I have read reports where the moral distress has worsened from year to year. The same leaders exacerbating the problem of employee moral distress are promoted and moved instead of reprimanded, punished, or fired. One of the VA-OIG reports is particularly heinous in hiding moral distress in employees.

“Selected employee survey responses demonstrated satisfaction with leadership and maintenance of an environment where staff felt respected and discrimination was not tolerated. Patient experience survey data implied general satisfaction with the outpatient care provided; however, leaders had opportunities to improve inpatient care satisfaction [emphasis mine].”

Mark Twain is oft quoted as stating, “There are lies, damn lies, and statistics.” How much more valid are these words when results are “selected,” “cherry-picked,” or allowed to “imply generalities?” Those who engage in LIC are criminals, they are comparable to terrorists, and they have infiltrated the bureaucratic halls of government. Employing government power, they form unholy unions with social media outlets and media companies to further silence and abuse, all while increasing protection.

Where does it end? How do we put paid to the tyranny?

It ends when ordinary people decide they have had enough. Ending the LIC-powered tyranny requires nothing more than elected officials scrutinizing the government and doing the jobs they swore to commit. No violence, problematic or arduous tasks, merely following established law and doing the jobs we elected them to accomplish. LIC is always destroyed when the citizens being oppressed stand up for their rights and demand the bullies, tyrants, and fiends cease and desist!

Thomas Paine, writing in “Common Sense,” discussed simplicity, stating:

“I draw my idea of the form of government from a principle in nature, which no art can overturn, viz. that the more simple anything is, the less liable it is to be disordered; and the easier repaired when disordered.”

The American government was established on simplicity, and the US Constitution is a simple document. Using Thomas Paine’s pattern, the disorder in the government is simple to correct; all we need are people insisting that the infection is terminated. Using the systems established in the US Constitution, the US government can be brought to heel, the rot removed, and justice can be delivered to those tyrants employing LIC for personal gain and political profit. LIC is happening in every government agency, and it is time for change to begin. Where are the politicians willing to do the job we elected them to perform?

Mark Twain provides the final word, “The government of my country snubs honest simplicity but fondles artistic villainy, and I think I might have developed into a very capable pickpocket if I had remained in the public service a year or two.” From artistic villainy to LIC is not an arduous shift, merely the extension of abuse of power to a larger audience. Learn, choose, and then make your voice known through elections and peaceful assembly for redress per the US Constitution and Bill of Rights.

© 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.

When is Enough… ENOUGH? – More Chronicles from the VA

Honest question. I surpassed my ultimate threshold in waiting for the VA to improve in 2010 and stopped accepting the excuses, the platitudes, and the whiny discourse from the VA. Elected officials charged with scrutinizing the US Government, when has patience been surpassed, and you will cease allowing this nefarious Kabuki? The veterans are waiting, the taxpayers are fed up, and you need to make a decision and act.

Consider the following investigation by the Department of Veterans Affairs (VA) – Office of Inspector General (VA-OIG). The scenario:

“The VA Office of Inspector General (VA-OIG) conducted an audit to determine how effectively the Veterans Health Administration (VHA) billed private insurers. [Billing private insurance is a piece of legislation that the VA has haphazardly followed. The VA remains the first party payer and is authorized under 38 USC 1729 to bill and collect reasonable charges for nonservice-connected care where such veterans have other private health insurance.] Prior OIG investigations have shown that VHA has missed opportunities to recover funds that could be used to help finance care for other veterans. VHA’s Office of Community Care (OCC) manages community care programs and bills private insurers when needed. OCC must submit reimbursement claims before insurers’ deadlines are reached, or they may be denied.”

The legislature passed laws demanding action, and the result was:

- - OCC did not establish an effective process to ensure staff billed veterans’ private health insurers as required
  - OCC did not collect an estimated $217.5 million that should have been recovered, a figure that could grow to $805.2 million by September 30, 2022
  - OCC’s billing and revenue collection process also was not synchronized with insurers’ filing deadlines, and claims information was not always available for billing
  - Pending workload volume and staff shortages hindered effective billing
  - OCC was broadly aware of challenges to its process to bill and collect revenue from private insurers; its responses were insufficient to correct these issues.

Hundreds of millions of dollars are sitting on the table, and the VHA – OCC still cannot properly follow the law. Worse, they are slower than molasses running uphill in Michigan in January to pay community providers, inventing hoops and red tape nonstop for providers, which increases the cost of healthcare. This is not the first VA-OIG investigation on this issue in 2022, let alone since 2000; with the same findings, the same recommendations are issued, and nothing improves. Thus, I have two questions:

When is enough ENOUGH?
How does this reflect the VA Administration’s commitment to the vision of the VA?

Consider the following; the VA-OIG regularly conducts comprehensive healthcare inspections of VHA facilities. The findings of these investigations are supposed to spur institutional improvement. Regularly the VA-OIG places the following comments into the reports of these investigations, hoping nobody will ever read the report and find these facts.

“The VA-OIG found deficiencies in identifying sentinel events and conducting institutional disclosures. Additionally, there were repeat findings from the June 2017 comprehensive healthcare inspection related to inter-facility transfers.”

Imagine a private company being inspected by the government for a moment where previous investigation findings were not improved; what would happen? An army of lawyers would descend on the customers looking for those harmed/injured, legions of lawyers would pour through employee records looking for injuries and other potential claims, the government would seize assets and halt production, all this and more. The media would be covering 24/7 news cycles on the slightest allegations of wrongdoing. Elected officials would be hurrying to write legislation and find a media talking head to bloviate to.

What do we hear where the VA is concerned; not even crickets! The VA has played complicit roles in veteran deaths, and still not a peep, word, or even crickets. Remember, these findings occur frequently enough that not finding these remarks is a cause for celebration and is exceedingly rare. Thus, I have two questions:

When is enough ENOUGH?
How does this reflect the VA Administration’s commitment to the vision of the VA?

Other oft findings from comprehensive healthcare inspections include the following:

- - Medical center leaders were generally knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models (SAIL Metrics). – What does “generally knowledgeable” indicate? Why have we accepted general knowledge from those who should have specialized, detailed, and comprehensive knowledge and use this knowledge in daily practice?
  - Outpatient satisfaction survey results were generally higher than VHA averages but revealed opportunities to improve specialty care experiences for female veterans. – Please note beating the VHA average is good but nothing to brag about. Beating the VHA averages is akin to claiming to be the biggest pig in a pig wallow. Sure, you’re big, but you are still covered in mud!
  - Employee satisfaction survey scores for the medical center were lower than VHA averages. – Not a surprising finding in any way, shape, or form. Employee morale is scathingly low, and it shows in every customer interaction! More comparing pigs by size in a pig wallow, and it’s not like the VA would punish whistleblowers, fire productive people, castigate, denigrate, deride, and treat employees like chattel… Oh, wait, yes, it is!

Interestingly, I receive 3-10 of these monthly investigation reports from the VA-OIG, and too often, they read like someone is cutting/pasting the findings from one report to the next. Thus the conclusions of these findings occur frequently enough that not finding these remarks is a cause for celebration and is exceedingly rare. Therefore, I have two questions:

When is enough ENOUGH?
How does this reflect the VA Administration’s commitment to the vision of the VA?

Let us consider another VA-OIG investigation, which, unfortunately, recurs too frequently where inappropriate conduct is a norm, not an exception. VA facility leaders’ response to inappropriate relationships. Regular readers will know how common it is to find inappropriate relationships and sexual misconduct by VA Employees to other employees, underlings, and veterans. The scenario:

“The VA Office of Inspector General (VA-OIG) conducted a healthcare inspection to evaluate leaders’ response to the knowledge of inappropriate provider-patient relationships. The VA-OIG determined that while facility leaders initially addressed three inappropriate relationships between mental health providers (Providers A, B, and C) and mental health patients (Patients A, B, and C), multiple factors affected the effectiveness of those actions.”

Finding the following:

- - The OIG found that effective facility leader actions to investigate and address the inappropriate relationships of Provider A and Provider B occurred only after an Office of Accountability and Whistleblower Protection complaint.
  - Facility leaders ineffectively addressed Provider C’s inappropriate relationship before Patient C died by overdose.
  - Facility leaders failed to report Providers B and C to their state licensing boards promptly.
  - Failed to report Provider A to the appropriate professional certification board.
  - Facility leaders did not take actions to address the circumstances that contributed to the death of Patient C, who was involved in an inappropriate romantic relationship with Provider C.

Regrettably, the VA-OIG could not determine if an adverse patient event occurred when finding that the inappropriate relationship played a role in a veteran’s suicide by overdose. I understand investigative scope creep, but this is ridiculous. You have a dead veteran in an inappropriate relationship with a provider, and you cannot investigate if this was an adverse event. What type of bureaucratic inertia sponsored this madness?

Some items in this investigative report stand out, beginning with the fact that the facility leaders who refused to take action remain employed by the VA! Knowing about problems and not taking prompt and decisive action is negligence in performing one’s duties. Possessing authority and refusing to implement policies and procedures, ensuring compliance by professionals, defies description and should result in VISN leaders losing their jobs! Unfortunately, these inappropriate relationships are not rare; even if the VA-OIG has not gotten around to investigating the problems, ask the VA employees, and you will find the proof of concept and incredibly high frequencies. Hence, I have two questions:

When is enough ENOUGH?
How does this reflect the VA Administration’s commitment to the vision of the VA?

In the annals of government fraud, waste, and abuse, the following VA-OIG investigation must rank in the top 20 somewhere.

“The VA Office of Inspector General (OIG) initiated this review to evaluate whether purchases of iPads and iPhones for veterans met mission needs while minimizing waste during fiscal year (FY) 2020 and through the first two quarters of FY 2021. In July 2020, Connect Care officials purchased 10,000 iPhones with unlimited prepaid data plans for the homeless veterans enrolled in the HUD-VASH program. However, 8,544 of the 10,000 iPhones remained in storage as of July 2021, as demand for the iPhones was much lower than anticipated. The OIG found that this resulted in an estimated $1.8 million wasted data plan costs. The OIG also identified opportunities for improvement regarding data plans for nearly 81,000 iPads purchased. Because Connected Care did not have strong enough oversight procedures for reducing or eliminating data plan waste, it incurred approximately $571,000 in additional wasted data plan costs.”

When I was offered telehealth, I was responsible for providing the equipment and maintaining an Internet connection. This was made clear by the VHA Administrators before they signed off on allowing me telehealth and reiterated by my providers when they renewed permission. How can the VHA and VA leadership and contracting officials imagine this is acceptable? How many of these devices are still in the hands of veterans? How many have broken, been pawned, or otherwise not survived?

Again, not casting aspersions, merely asking questions, namely the following:

When is enough ENOUGH?
How does this reflect the VA Administration’s commitment to the vision of the VA?

I could weep from the frustration felt in reporting another veteran’s death by suicide, receiving care from mental health providers with the VA, and being investigated by the VA-OIG, where the providers are complicit. The scenario:

“The VA Office of Inspector General (VA-OIG) conducted a healthcare inspection to evaluate VA-OIG-identified concerns related to the assessment and documentation practices of a behavioral health certified registered nurse practitioner (BHNP) and leaders’ completion of BHNPs’ ongoing professional practice evaluations (OPPEs).”

The findings:

- - The BHNP did not perform thorough suicide risk assessments for a patient who died by suicide.
  - Identified multiple deficiencies in a BHNP’s assessment and documentation practices, including the absence of comprehensive suicide risk assessments, failure to complete abnormal involuntary movement and metabolic assessments for patients prescribed particular antipsychotic medication, missing informed consent or a risk-benefit discussion when prescribing off-label medications, failure to resolve rule-out diagnoses, and substantial copy and paste use.
  - Finding adverse clinical outcomes for one of eight patients for whom the BHNP did not document a comprehensive suicide risk assessment, as required by The Joint Commission.
  - Finding the Nurse Manager evaluated BHNPs as satisfactory in the OPPE elements of copy and paste use for the fiscal year 2018 through the first half of the fiscal year 2021 and safety plan completion for high-risk suicide patients for February 2020 through the first half of the fiscal year 2021, without these elements being evaluated.

Is it clear why I am asking about where the limitations of patience are? The supervisor was directly responsible for leading the BHNPs and failed, and while it is not mentioned, we can presume this person remains employed. Failed to train staff, failed to supervise staff, refused to do your job. Yet, you remain employed (probably) and (potentially) were promoted, as this is the regular pattern for VA employees caught but who are politically acceptable or connected. The supervisor is directly connected to a dead veteran, a family is weeping this holiday season, friends are missing, and all I can do is keep asking the politicians:

When is enough ENOUGH?
How does this reflect the VA Administration’s commitment to the vision of the VA?

Do you also feel the weight of responsibility; your tax dollars fund this abuse. Representatives of your government are complicit in adverse patient events, including death, and they refuse to engage, holding government employees accountable and fixing the mess. Veterans signed a check, telling the government we will perform duties and obligations. Why aren’t the veterans honored for their sacrifice and respected by elected officials and government employees, especially at the VA?

America Weeps The VA’s mission statement is “to fulfill President Lincoln’s promise “To care for him who shall have borne the battle, and for his widow, and his orphan” by serving and honoring the men and women who are America’s veterans.” The statement is meant to echo the reverence given to the men and women who serve in the American military with honor. Reflecting that this body (the Department of Veterans Affairs) is tasked with serving them respectfully, similar to how they served their nation. One final question is, “Does killing, abusing, and harming veterans equate to honoring the VA mission statement?”

Principles of Value – More Chronicles From the VA

Millstone of Designed Incompetence Value is a term many think they understand and, more often, barely grasp. Ralph Barton Perry is the seminal author on all things related to value. As value is an aspect of functioning society and contributes to the wickedness of government, it is only fitting to delve into this concept with a discussion on value, using more examples from the Department of Veterans Affairs – Office of Inspector General (VA-OIG).

Value – using only the American Heritage (5^th Edition) Dictionary, a person would consider themselves learned to know that value is a price or return, monetary or material worth, possessing worth in importance, merit, or utility. Due to specialization, some would know value as the quality of a letter or diphthong, the darkness or lightness of a color, the duration of a tone or rest, or numbers or quantities expressed in algebraic terms. None of these are wrong, and each has direct application to the fields of study, but they do not encapsulate the essence of value.

Ralph Barton Perry expressed a sentiment I support wholeheartedly in his book “General Theory of Value” (1967, Harvard University Press):

“… Bridging the gap between common sense and science. Believing that philosophy must face the facts of life and nature, taking them as both the point of departure and the touchstone of truth, one can never be comprehensive enough.”

In reiterating and describing value, especially as it applies to government, I begin firm in the knowledge that a blog cannot capture all that needs to be said. As noted by Mills, quoted by Perry (p. 35), “The word value, when used without adjunct, always means, in political economy, value in exchange.” It is on this value in exchange we focus our attention, provided we keep a second thought firmly in mind, society at its most basic element is cooperation.

In “Common Sense,” Thomas Paine made this distinction, and Perry elaborated in his books on value. Cooperation in a society is the division of labor mediated by a common purpose. Hence the value in exchange is labor for mutually beneficial specialized tasks that promote society working more efficiently. Or, to better illustrate the point, you do not hire a diesel mechanic to conduct open heart surgery. The mechanic has value in their sphere, and the cardiac surgeon has a different value in their sphere, but society flourishes in the exchange of labor through cooperation.

?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 Consider the role of the master builder in building a major building. Each specialized task, drywall, foundations, painting, plumbing, electrical, etc., must all be done on a schedule and the master builder is ultimately responsible for the entire building once complete. The building is completed promptly and efficiently through exchange and cooperation. But is the master builder responsible for the actions of those specialists; as it pertains to the functionality of the building, the answer is yes! Thus, if a plumber is stealing, an electrician is cheating, or a painter is not using the approved paints, the master builder is responsible to the owner for failing to monitor and closely supervise the subordinate contractors exchanging their skills for political and financial gain.

We must never forget that a reputation is a political title, appointed and maintained over time, and from the experiences of others. The relationship governing issuing reputations, which helps to promote or demote the master builder in society, has value, which is more than monetary remuneration for services rendered. Our reputation is not ours but was granted by others and must be maintained through careful action repeated across life.

Consider the following scenario:

“The Office of Inspector General (VA-OIG) conducted an inspection to assess a safety concern with the new electronic health record (EHR) that resulted in patient harm. The VA-OIG found that the new EHR sent thousands of orders for medical care to an undetectable location, or unknown queue, instead of to the intended location. In December 2021, VHA assessed the risk of the unknown queue as “major severity,” “frequently occurring,” and “very difficult to detect.” Immediate mitigation was needed, but Oracle Cerner (creators of the EHR) failed to inform VA end-users of the unknown queue, placing the burden on VHA to mitigate the problem.

Beginning in June 2021, VHA staff found that the new EHR’s delivery of orders to the unknown queue caused 149 patient harm events. In late 2021, VHA staff provided the Deputy Secretary and the Executive Director for VA’s EHR modernization effort with information on the unknown queue safety concern and identified patient harm. However, after finding over 200 orders in the unknown queue in May 2022, the VA-OIG has concerns with the effectiveness of Cerner’s plan to mitigate the safety risk.”

The EHR contractor designed a problem, blamed the customer, who is also, in this instance, the owner for the problem, and then placed the onus for fixing the contractor’s failure on the owner’s employees to find and mitigate. Using the context mentioned above, one can clearly deduce that this is a negative value not aligned with societal cooperation. The result will be a taxpayer nightmare creating patient harm to veterans. Since Oracle Cerner is being paid with taxpayer dollars, do you, as a taxpayer, feel valued in this transaction? VA 3

Consider another example, recalls of products happen. Mistakes occur frequently enough that since we are all humans, we accept that humans are going to make mistakes and move on. In the following example, the manufacturer made a mistake, owned it, took decisive action to rectify it, and honored their commitments. The problem arises in the VHA’s processes and procedures that govern employee actions in response to a manufacturer admitting a mistake was made.

The scenario:

“The VA-OIG determined that the VHA medication recall process generally met VHA requirements and identified potential vulnerabilities related to the monitoring and reporting of medication recall adverse drug events and variations in the software used to record medication lot numbers. Adverse drug events resulting from recalled medications are not identified as a category or required to be reported in the VA Adverse Drug Event Reporting System. Therefore, the OIG could not determine if VHA monitored all adverse drug events from recalled medications.”

Did you catch that; established procedures lack a category to report and track medication recalls. A quick Internet search concluded that, per the FDA, in 2022 alone (data current as of November), 55 medical devices and 59 drug recalls have occurred. Yet, the VHA has a tracking system that doesn’t categorize drug recalls as adverse drug events. Why? Imagine getting both erectile dysfunction and antidepressants in the same pill bottle. Would not this potentially cause patient harm; of course. Shouldn’t this patient harm event be tracked as an established drug recall event, so all the evidence and information are in a single place, properly labeled, and recorded? Yet, the VA-OIG cannot declare how long the adverse patient drug tracking system has been tracking and recording events related to drug recalls and report similar to the legislative bodies for accountability.

Tell me, is a lack of information socially valuable in understanding the size and scope and adequately understanding the positive and negative aspects of adverse drug event tracking? Variations between VHA facilities open the door to patient harm and increase the risk of veterans going to a VHA facility. Yet, the VA-OIG constantly finds variations in processes and procedures between VHA facilities, recommending reducing variation, and the variation never reflects improvement. Where is the value? Why? Isn’t it amazing the processes and procedures are mostly sufficient, but the processes and procedures did not catch that information was properly being collected and labeled for tracking and reporting purposes? VA 3

If all your neighbors relate XX contractor is horrible to work with, do you hire them to work on your house? Is society growing with cooperation and building value if the contractor is always making a mess and ruining property? Why is the government allowed to harm society, stop cooperation, decrease value, and never be held accountable? Since all elected officials are expected to represent their entire geographical district instead of catering to their political base, do not all of the politicians suffer for the misbehavior of a few? Why are these elected officials not taking action to clean up the government?

Repeatedly the procurement officers, highly specialized contracting officials who work for the VA, fail a VA-OIG audit and use the same excuses constantly, namely the following factors contributing to non-compliance:

- - Officials not understanding their responsibilities
  - Heavy workload
  - Ineffective oversight
  - Prioritization of awarding contracts

Where is the value to society when employees use the same excuses, shirk responsibility for errors and mistakes, and maintain their employment at taxpayer expense? Does this reflect value to the taxpayer for their investment; of course not. So why is this behavior accepted by the officers and investigators of the VA-OIG? Society has self-correcting features that preclude the incompetent from continuing to abuse the customer; why have elected officials designed this abusive and deleterious department? VA 3

David Case, Deputy Inspector General, testified before Congressional Committees (SVAC) on VA’s electronic health record modernization program and stated the following:

“Proper governance and transparency will be necessary to get it right. Failures in these areas risk cascading problems that jeopardize the entire program.”

Great words, but what actions are you taking to reign in the cost overruns, the failed EHR which put patients in harm’s way, and is so convoluted that many employees cannot do their jobs efficiently and productively? The VA-OIG has supported through in-depth investigation that the existing EHR and the new EHR are abysmal failures, are expensive to maintain, install, train, and produce no value to society. Why are we continuing to allow Congress to invest in this EHR madness with American taxpayer dollars and debt? David Case’s testimony covers none of these fundamental questions, and the SVAC elected members never asked these questions as follow-ups to the testimony provided.

Interestingly, review all the testimony on the new EHR by the VA-OIG before Congress, and elected officials ever make accountable the government employees for success or failure. Those testifying never discuss the fundamental problems, those listening elected officials never express disgust (forget outrage) over the core issues, and the taxpayer is left holding an expensive, dead albatross. How does escaping responsibility improve the value of government in society? The government is duty-bound to help enhance cooperation for the growth of society; this is a primary duty of government. Do you see the government as improving or hindering cooperation in American society? VA 3

Repeatedly throughout the last decade of covering the VA-OIG reports, the VA-OIG discusses failed audits, improvements to governance processes and procedures to protect personally identifiable information, how the VA processes are inadequate and cause patient harm, and the list continues. The same problems, the same recommendations, and the same testimony before Congress. Wash, rinse, repeat, ad nauseum ad infinitum. I repeat in words of soberness, and with the conviction of someone who knows, the actions of the VA are unacceptable, and the politicians elected to correct executive branch misbehavior are failing their US Constitutional duty to scrutinize the government. These are millstones we can sunder from the neck of American society. All without violence, using the existing laws on the books, and concrete action can, and needs to, begin immediately!

We conclude with an insight from Perry (p.515):

“The master builder of social justice oversees all the diverse social activities and takes account of their relative importance in the community. But unless those who build know what they are building and are motivated by that rather than by their wage, the unifying purpose is the exclusive prerogative of the master builder.”

Because the elected officials placed in authority by the electorate are not motivated by building society, only by how much money they can squeeze, American Society is suffering. The self-perpetuating machine of doom continues chugging steadily, and until the citizens understand the principles of value and change the elected officials, then holding them personally accountable for powering the destruction of American society and accountable for breaking the trust invested by the people for the people, the course of American society is doom bound.

The Culture of Government – More Chronicles of the VA

Bobblehead Doll In the book “Common Sense” Thomas Paine stated:

“Some writers have so confounded society with government as to leave little or no distinction between them, whereas they are not only different but have different origins. Society is produced by our WANTS, government by our WICKEDNESS; [society] promotes our POSITIVITY by uniting our affections, government promotes NEGATIVITY by restraining our vices. [Society] encourages intercourse, [government] creates distinctions. [Society] is a patron; whereas [government] is a punisher.”

Why is this distinction important; only a government could create a punishing culture in the name of providing support. Only in this role as punisher does a culture of abuse survive, thrive, and plasticize words and actions of hate into support and charity. Society breeds working together and simplicity and are the natural state of all people. According to Thomas Paine, the government “Is a necessary EVIL,” breeding contempt, envy, greed, and malice.

As the Department of Veteran Affairs – Office of Inspector General (VA-OIG) continues to record and report, I continue to summate these reports. Calling for all free-thinking people everywhere to understand the core problems and aid in cutting this millstone from the necks of Americans. Until we can understand the principles which have allowed the government to infiltrate and supplant society, abuses, fraud, and waste will continue. VA 3

Consider the case of Dustin James Ortiz of Des Moines, Iowa, sentenced to 27 months in prison after pleading guilty to wrongfully obtaining and disclosing individually identifiable health information. Ortiz conspired with a then-employee of the Des Moines VA Medical Center to obtain individually identifiable health information of an individual without authorization required by law and then disclosed the records to a third party, as investigated by the VA-OIG. To commit fraud, a VA Employee had to cheat and steal data for personal profit. Has anyone of the government agencies considered the victims; no, because the government breeds a society of liars, cheats, and thieves to empower job security to those who officiate the government.

Had the Department of Veterans Affairs (VA) been a societal construct, the victim would not only be compensated, but revelations of fraud and theft would be treated as they are, crimes against all members of society, not merely a criminal complaint against those who choose to take advantage of others for personal gain. Yet, how often can we express this sentiment and have naysayers claim this is not possible or euphemistic; too often, because populations have been carefully taught and molded into a belief that government is everything but what it is, wickedness, or a necessary evil. VA 3

Consider a VA-OIG investigation into Veterans Benefits Administration education programs where personal data is not secure, not legally protected, and this is designed as a standard business practice. Imagine being placed by legislators in charge of safeguarding taxpayers/veterans/customers’ private data and shirking this primary duty for personal gain and political profit. Is this not the ultimate definition of wickedness and evil? From the VA-OIG investigation, we find the following:

“The lack of standard procedures and oversight has resulted in personally identifiable information not being consistently safeguarded as required. The OIG did not assess whether any information had been inappropriately disclosed but requested that VBA provide follow-up information. VBA agreed to review, research, and evaluate the OIG findings and take corrective action as needed.”

How long will the leaders of the VBA and the VA provide cover and refuse “to review, research, and evaluate the OIG findings and take corrective action as needed.” History has proved that the VBA and the VA are masters of evading discovery, reporting problems, and fixing issues they are legally bound to follow. Why have they become masters at obfuscation; because the legislature (the US House and Senate) refuses to hold people accountable for their wickedness and evil. Lacking accountability and having people responsible allows for more examples of dastardly behavior in the name of the government. VA 3

For example, clear contractual guidelines govern how, when, and what can be purchased or contracted. An entire industry revolves solely around procuring items for government agencies, auditing those transactions and products, tracking the products and services, and more. Yet, what is regularly found in this labyrinth of legislated procurement processes? More fraud, waste, abuse, and nefarious creatures bent on breaking the rules. One of the more egregious examples was the VA-OIG inspection of the VA Boston Healthcare System. What was found:

- - From the healthcare system’s 421 open obligations, the team selected 20 totaling $20.6 million and found half were at least 90 days past their end date, most without being reviewed to see if they were still valid and necessary. Two had residual funds totaling approximately $4,439 that should have been released from obligation and used elsewhere to support veterans.
  - Of 36 purchase card transactions totaling $441,000, the team found 28 lacked evidence to show they were properly approved and that payments were accurate, and 25 were processed by cardholders and approving officials whose duties were not segregated as required. The team also identified ten purchases that should have been procured through contracting but were intentionally split into multiple transactions to stay below the cardholder’s single purchase limit.
  - The team found inaccurate entries in the inventory system that caused it to show insufficient amounts of stock on hand in more than 70 percent of tested cases. The inaccuracies result in inefficient purchasing and receiving and could adversely affect patient care.

In a society, we would not need the VA-OIG to investigate wrongdoing, a simple audit would be conducted, assistance in correcting errors made, and the victims recompensed properly. More to the point, the expensive regulatory bureaus would also not be needed to validate proper action was taken by officials charged with conducting business in the taxpayer’s name. VA 3

It is not a secret that the VA cannot follow its aborted processes where fiscal sanity and fiduciary responsibility are concerned. Imagine being investigated for failures and telling the investigating authorities the following:

- - Unclear policies and systems
  - Ineffective oversight of the closeout process
  - Contracting officers also informed the team that a heavy workload and the prioritization of awarding contracts affected their ability to comply with contract administration requirements.

What never ceases to blow my mind is that only government workers can use these lame excuses and remain employed. Employed on taxpayer funds, supported by governing authorities, paid on taxpayer funds, and never overseen by any political party or the constitutionally bound House or Senate. Honest question if you raised these points with your boss, would you keep your job?

I don’t like it, but I understand the need for the VA-OIG to raise recommendations for improvement in VA Hospitals, Clinics, and other offices. Continuous improvement is a process, and the process requires a long view and steady effort. However, if the same points arise inspection after inspection and the inspectors cannot see change occurring, then continuous improvement is not the term to describe what is transpiring at these facilities. VA 3

The investigative reports come in month after month, the same issues are raised year-over-year, glaring deficiencies are mentioned, recommendations are put forward, and the local site agrees to review, fix, and improve. Nothing ever improves—the exact opposite of continuous improvement. The question is, why does nothing ever improve? The answer, unfortunately, comes back to the difference between society and government, specifically how a government is wickedness personified.

Is calling a government agency wickedness personified harsh or cruel; no! Allow me to explain using a VA-OIG investigation:

“Beginning in the fall of 2017, former VA cardiologist John Giacomini of Atherton, California, repeatedly subjected a subordinate electrophysiologist to unwanted and unwelcome sexual contact, including hugging, kissing, and intimate touching while on VA premises. On November 10, 2017, the victim explicitly told Giacomini she was not interested in a romantic or sexual relationship with him. Nevertheless, Giacomini continued to subject his subordinate to unwanted sexual advances and touching, culminating on December 20, 2017, when Giacomini turned out the lights in an office, pulled the victim out of her chair, and fondled her until a janitor opened the office door and interrupted the encounter. The victim later resigned from her position at VA, citing Giacomini’s behavior as her principal reason for leaving. Giacomini was sentenced to eight months in prison after pleading guilty to abusive sexual contact.”

In the full report, the victim claims she testified because she did not want this to happen again. Meaning that this VA Employee had been accused previously, or as hospitals always do, gossipmongers had related previous episodes. Regardless, for this Chief of Cardiology to feel comfortable abusing another person while at work, there is an issue with sexual harassment and abuse of employees at the VA. This incident with the cardiologist is not the only incident of VA employee sexual harassment in 2022, and the failure of the VA to clean house and correct behaviors anathema to good social order has reached a tipping point. No society or government can long survive with these inhumane actions, so why is the VA allowing these issues to culminate until it can no longer pretend not to see or know about them? VA 3

Society focuses on the victims of crimes; government justifies the abuse of the victim under the name of criminal rights. What happens when the offense is so enormous that statistics represent the victims? The VA-OIG investigated two VA leaders from the Mann-Grandstaff VA Medical Center in Spokane, Washington, where a previous investigation had discovered wrongdoing. These leaders had promised swift review and corrective actions. What did the second investigation find:

“The investigation revealed the leaders’ lack of diligence resulted in delays and misinformation being submitted, which impeded oversight efforts. Failures included:

(1) Submitting a training evaluation plan without disclosing to the OIG that it was in its “infancy” and had not been fully implemented or even approved.

(2) Delaying production of requested proficiency check datasets that should have been available under the submitted evaluation plan.

(3) Providing three summary statistics with errors that doubled the training proficiency test pass rate from initial findings of 44 to 89 percent without the requested methodology.

(4) Overlooking red flags indicating that all failing scores had been removed from reported rates (with the total number of proficiency tests dropping by more than 3,000 in submitted recalculations).

(5) Failing to disclose concerns regarding data reliability and that data were excluded.”

Summing these findings in more straightforward language. The leaders lied and misled investigators, but since the bar for “intentionality” is so high, they were allowed not to have personal responsibility and retained their jobs. How is this an extreme example of wickedness; could you mislead the police or other investigative bodies and avoid jail? Could you lie, get your employer’s reputation tarnished, keep your job and pension, and stay out of jail? VA 3

Maybe the following is a better example of how coordinated and detestable wicked government is:

The VA-OIG announced “criminal charges against 36 defendants in 13 federal districts across the United States for more than $1.2 billion in alleged fraudulent telemedicine, cardiovascular and cancer genetic testing, and durable medical equipment (DME) schemes. The alleged schemes involved the payment of illegal kickbacks and bribes by laboratory owners and operators in exchange for the referral of patients by medical professionals working with fraudulent telemedicine and digital medical technology companies. The charges include some of the first prosecutions in the nation related to fraudulent cardiovascular genetic testing, a burgeoning scheme. One case involved the operator of several clinical laboratories, who was charged with a scheme to pay over $16 million in kickbacks to marketers who, in turn, paid kickbacks to telemedicine companies and call centers in exchange for doctors’ orders. As alleged in court documents, the defendant and others used orders for cardiovascular and cancer genetic testing to submit over $174 million in false and fraudulent claims to Medicare—but the testing results were not used in treating patients” [Emphasis mine].

Dont Tread On Me Do you want to see how corrupt the government is, specifically how abusive the VA is? Feel free to check out the following link, sign up for the email delivery, and become informed; then, you can make your own decision. Thomas Paine discusses how the citizenry builds the government by which they suffer. Have we suffered the slings and arrows from this government sufficiently to throw off the security blanket of government and hold the people punishing us accountable for their crimes against society? The laws of America are sufficient to correct course, provided the citizens are willing to reduce the size, and therefore the abuse, of government and return to a more societal and civilized method of living.

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

I-Care I 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=1 There 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!

“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 1/10^th 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!

“That’s Crazy!!!” – More Chronicles from the VA Chapter 6

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

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

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

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

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

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

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

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

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

Plus the following:

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

Don’t forget this one:

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

More is coming on this one:

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

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

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

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

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

VA-OIG finding:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

“That’s Crazy!!!” – More Chronicles from the VA Chapter 5

I-Care I 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!

That’s Crazy!!! – More Chronicles from the VA (CH 5)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

© 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.

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