Today, I Don’t Have It…

Bait & SwitchI have been trying to find inspiration to write something for several hours now.  There are so many things that trouble and infuriate me, but emotion is not a reason to write, and I will not play on my audience’s emotions to elicit a response.  That is the path of the tyrant and a cheap hack!

But today, I just don’t have it mentally.  The last couple of days with the VA, the continued oppression from the Biden administration, the multiple crises along the US/Mexico border, Afghanistan, volcanoes, … like the DJ said, “The hits just keep on coming!”  My mind feels like the fabric of the world is being shredded, and there is nothing behind the curtain.

My cherub-like demeanor took too much of a hit this week.  To discover that the VA has acceptable limits a provider can hurt/maim/injure/kill patients is beyond the scope of sanity to me.  Now, I admit I am not the smartest person in the room.  If you read the article linked and possess better capabilities and come to a different conclusion, please feel free to explain what is being discussed about dead veterans, a doctor, and how the VA-OIG can allow patients to expire without raising concerns.Curious Owl, HD Birds, 4k Wallpapers, Images, Backgrounds ...

On my desk are five owl statues carved in polished stone.  They surround a stone frog, also in polished stone.  Some days, I am the frog at the mercy of the predators.  Some days, I am the predator looking for frog dinner.  The first owl reminds me of a scrap of verse from my childhood.

There was a wise old bird; the more he saw, the less he spoke, the less he spoke, the more heard, now wasn’t that a wise old bird?”

I first heard this in a movie with John Wayne and Katherine Hepburn, “Rooster Cogburn.”  Never knew if I learned the scrap of verse right or not.  Never cared.  See, Kathrine Hepburn was a strong woman; she played an incredibly strong character wholly equal to John Wayne, and that was important.  In the owl relationships, the female and male are equal partners, and this is important to me.  I encourage people to be the main character in their life stories, be strong, independent, courageous, and never back down from anything!

The second owl is for Winnie-the-Pooh and Owl.  Eyeore and Owl are my favorite characters from Winnie-the-Pooh stories.  The calm demeanor of Owl always impressed me as a character trait to embody.

The third owl is probably the most important and comes from a lesson.  I forget who taught the lesson.  The lesson was “Who?”  I was ranting about somebody, and something, and somewhere, and was belligerent.  The person I was bellowing at kept asking, “Who?”  That’s all they said, and eventually, it dawned on me that the problem wasn’t other people, the place, the situation, the problem was me, and the only thing I could change was me.  I keep forgetting and re-learning this lesson to my chagrin and dismay.  The teacher closed that lesson with a scrap of Latin, “Numquam nothi sudet te.”  I learned the second lesson a lot better than the first.

cropped-laughing-owlThe fourth owl reminds me to laugh.  Have you ever heard owls laugh?  There is a lesson in that for us mortals.  For ages of human history, owls have been revered as wise, yet they possess the ability to laugh.  Maybe, just maybe, we should practice more lessons from the owl and laugh, especially at ourselves.

The fifth owl reminds me of how I feel every time I see an owl, full of wonder and amazement.  I see those eyes and think of the wonderful and amazing things I could see with those eyes.  I think of how the owl can turn their heads and wish my neck could turn like that.  How the owl can minutely control the feathers on the leading edge of their wings to control airflow for silent flight, and I think how cool would that be as a superpower!  As a supreme klutz, the majesty and poetry of motion found in an owl are wonderful to me, and I like being reminded of the wonder in the world.Hear the Many Different Hoots of the Barred Owl | Audubon

One of my favorite memories of my grandmother was playing with her fiber-optic ornament.  This was a heavy base with an electric cord and light shown through hundreds, if not thousands of fiber-optic strands.  The decoration would change colors, and you could group different strands to shine them into different areas.  On my desk is a fiber-optic Christmas tree on a USB plug.

Snowy Owl - Bubo scandiacus image - Free stock photo ...My apologies, dear reader, I do not mean to sound maudlin or pass along depression.  I just don’t have it in me to engage in deeper subjects today, and I pray for your forgiveness.  Please, take the time to hug your loved ones.  Forgive your family and friends, and pray for America to survive the current political mess we find ourselves suffering.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Chronicling the VA, One Ignominious Story at a Time!

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Do you know why I despise Liars?

Please note, I am not looking for sympathy; I do not need it!  I relate the following facts for one reason and one reason alone, transparency.  We need more of it, and right now, the liars and thieves have a rum hold on honest people’s lives, and it is time honest people started fighting back.  The best tool to fight back, transparency; that’s right, sunshine disinfectant, is the only tool an honest person needs to fight the liars and thieves.

Well, here is some well-earned sunshine:

The main character in our story is one HMC Delacruz.  HMC Delacruz was the Independent Duty Corpsman (IDC) for most of my tenure onboard USS Barry (DDG 52) from 2000-2004.  Time uncountable, a person would see HMC Delacruz handwriting a medical record, in pencil, for patients, placing those medical records in blue folders, not the brown medical jackets, but blue folders.  Then at some future date, you would need to refer to those records, a big show of looking for them would be made, piles of medical records would be evidenced outside their blue folder jackets, and the subject would change.  None of my medical documents in blue record file jackets made it off the USS Barry (DDG 52).

I can attest and affirm that medical events occurred, I have scars from several of those events, I can relate I went to medical to be seen, but none of the paper trails is evident.  I saw the medical records filled out and the documents filed; yet, I never received any of those blue jacketed medical records when I left the ship.  During one conversation with HM2 Abeld, HMC Delacruz’s junior IDC, I was informed that when HMC Delacruz made Senior Chief, it was discovered he was throwing medical records over the side and was “encouraged” to leave the service.  I cannot affirm or attest to hearsay; I simply state the facts.  The records were there, and now they are not, and the person at fault is HMC Delacruz, and the US Navy does not appear to care!

There is a single central injury around my spine that the VA declares there are no records to support.  To whit, on or about 30 July 2003, DC1 Rowe pushed me in Repair 5 office while I was moving D-Cell Batteries into the several Repair lockers.  I had 60#’s of batteries in my arms using proper lifting techniques and moved two loads before our encounter.  DC1 Rowe came into Repair 5 screaming about an incident where he had been proved wrong by the XO during a training scenario.  Because I, as the Repair 5 Scene Leader, had been proved right by the XO, he, therefore, accused me of being at fault for his embarrassment.  When DC1 Rowe pushed me, I felt and heard a “Pop” emanating from my lower back; a warm sensation immediately went flowing down the backs of my legs from the lumbar region of my spine.  Think hot water tap opened and pouring down the backs of your legs.  This warm sensation continued without a stop for 10-14 days.  After three days of this sensation, I went to medical, saw HMC Delacruz fill out a paper record, and HMC Delacruz marked me “Fit for full duty.” Since there was no pain, just the warm sensation, no further treatment was ever prescribed or discussed; HMC called this “Lucky” and further remarked, “No pain, no injury.”

From this discussion until Spring 2005, the “warm sensation” continued to flow intermittently and was usually brought on by stretching, lifting, or vigorous/strenuous exercise or activity.  Because I was not experiencing the “warm sensation” when I filed my initial claim and thought the medical records were in my jacket, this injury and the lingering symptoms passed from my mind.  When coupled with my ignorance of the VA, this injury was not mentioned again until September 2011.  When I checked my medical records in September 2011, I discovered these records are not in my file due to continued lower back pain and aggravated leg/foot pain.  According to the Congressional letter received, the medical records I had obtained, circa 2005 (August), came through a Congressional Inquiry and showed the official medical file for Michael David Salisbury XXX-XX-1962.

March 2005, while doing the prescribed stretches for my feet, my back (lower lumbar region) popped, something shifted.  The warm sensation running down my legs intermittently became constant pain, with intermittent burning sensations.  Whole-body shakes increased from several times a month to weekly, then daily, now constantly, bringing reduced stamina and chronic pain & fatigue.  The pain takes my breath away, my feet flared, and anything involving my back, every movement, suddenly requires new dimensions of effort.  The pain radiates from my lower lumbar into my tailbone and runs down my legs into my feet.

In the first quarter of 2011, I saw a Chiropractor and explained my symptoms to him.  He took X-Rays and declared several injuries to my spine, probably adding to the pain and problems in my feet.  He prescribed mechanical decompression and wanted MRIs of my spine.  The VHA has those chiropractor records as I submitted them to my Primary Care Provider and the VBA as part of my spinal claims.  The pain has increased exponentially every year since 2005.  Until my conversation with the VSO in Wyoming regarding this injury and pain (2011), I had no idea the records were missing or the situation I found myself in requiring VA assistance.

The only remaining record I have found in my US Navy Medical Jacket is my out-processing physical from December 2003, where I mentioned back pain.  HMC Delacruz and I spent more than 2 hours discussing the nerves, the spine, the injuries, the foot problems, the shin splints, etc. The only record of that conversation is the out-processing questionnaire that I completed before the exam.  When discharged in April 2004, HMC declared all my records were in my medical jacket.  I did not need a new out-processing physical, which medical determination is also not in my medical file.

Thus, I left the US Navy without a medical examination from the medical record, when in fact, I did have an out-processing medical examination.  That event occurred underway, and those records are not in my medical file.  Both HMC Delacruz and HM2 Abeld knew of my back pain, clumsiness, stumbling, lack of stamina, decreased energy, chronic pain, and breathing problems while on board the ship.  Some of that proof is indicated in the repeated prescription of Ibuprofen; I had a running prescription for the largest Ibuprofen dosage available, taking as needed for pain, usually every 2-4 hours depending on the operational tempo and how often, along with how long, I was wearing an SCBA.

Several other items are missing from my medical files where problems occurred, and HMC Delacruz made a record, but the files are not in the medical record jacket I possess.

  1. My hands were crushed in a falling pipe incident while working on an assignment I shouldn’t have been assigned to while underway. Because there was nothing broken, the skin was not torn, I was marked “Fit for full duty,” prescribed Motrin and Ibuprofen, with the understanding in my command that my hands might be sore for several days and less difficult maintenance should be assigned for a week or so, my command complied and my watch standing doubled to make up for reduced maintenance.
    • The prescription and work assignment came from HMC to my current chief. This type of collusion between HMC and the other chiefs onboard was common practice, and many lower enlisted people, especially engineers, had similar treatment.
    • The standard operating procedure (SOP) was a “Gentlemen’s Understanding” among the chiefs that reduced duty was necessary. Reduced duty chits were not written because no reduced duty looked better on HMC and the command as a whole.
    • The lower enlisted, especially Engineers, were returned to work “fit for full duty.” It was understood that no reduced duty chits would be written.
    • No X-Rays were ever taken of this incident as it occurred while underway. Upon returning to port, my hands were not as sore, so no X-Rays were ordered at that time.
  2. None of my trips and spills when my feet gave way are in my file, including one that occurred during a GQ Drill (2003), right in front of HMC Delacruz, that left my hands and wrists hurting enough to send me to sick call the following day at HMC Delacruz’s insistence. My SCBA hit a particularly tender spot on my spine, my legs collapsed, and I hit the floor like a lead sack.  The first of many collapses to date exactly fitting this same pattern.
    • HMC Delacruz asked how long I had been falling, and we spoke about my feet and the arch problem that had been ongoing since December 2002.
    • HMC Delacruz also asked how my hands were doing after my fall and skid on the non-skid decking, checked for infection in the “Road Rash” on the palms of my hands, and marked me “Fit for full duty.”
  3. All the prescription records in my medical jacket from the rash that developed onboard the ship. I see some of the records, but these are primarily from HM3 Abeld and none from HMC Delacruz.  He prescribed various drugs, salves, pills, and treatments, but the records are missing.
  4. December 2002, when my arches first fell, and the pain in my feet was excruciatingly fresh, HMC Delacruz marked me “Fit for full duty,” prescribed Motrin and Ibuprofen, and colluded with my chief to let me off of running or lifting for a week.
    • If you look in the files, there are no medical reports about my feet from 2002.
    • It was not until HMC Delacruz rotated off the ship that his replacement sent me to Podiatry at the Naval Hospital Norfolk, where a medical case review discovered and documented my actual condition.
    • These records were not in my medical file received from Congressional Inquiry, but the x-rays and medical records should have been stored in the Norfolk Naval Hospital as that is where I was sent and where an initial diagnosis of shin splints and flat feet originated.
  5. The tinnitus worsened during naval service to the point it is at today. After several head injuries, neck injuries, and a 5” Gun Shoot that began while I was under the gun in Repair 2, in the overhead counting inventory without hearing protection.  The inventory assignment during a gun shoot was a prank pulled on the new guy.  I left Repair 2’s overhead with the inventory counted but was so disoriented, hard of hearing, and “compression shocked,” I could barely stand.  Only later did I learn that when a 5” Gun-Shoot is occurring, Repair 2 is supposed to be unmanned and closed as the only separation between Repair 2 and the 5” mount is plate steel.  The prank was courtesy of DC1 Smith and DCCS Cloud, my direct chain of command.

Important to note, the VBA and VHA have both been kept abreast of the spine deterioration, pain increases, mobility decreases, falls, and the host of peripheral nerve issues.  The VHA has been particularly kept apprised of my nerves, making me look like a “bobblehead doll.”  The VHA claims they cannot diagnose the problem until the VBA claims a service-connected problem.  The VBA claims until there is a medical diagnosis and proof of injury during service, I cannot obtain VBA admittance that there is a service connection to the problems or even that a problem exists.  Two bureaucracies act like opposing teams on a tug-of-war, and the patient is stuck suffering in the middle.

Hence, I detest liars.  I hate “gentlemen’s agreements,” “skullduggery,” and secrecy in all its forms and mutations.  Under any circumstances, I cannot condone practical jokes and pranks on the job site that breach safety or play upon ignorance to the harm of others.  Call me if you find yourself in the throes of villains, knaves, liars, and thieves.  I have no problem fighting to help you out!

To my fellow shipmates from the USS Barry (DDG52) 2000-2004, please get in touch with me through LinkedIn.com if you need help corroborating the maltreatment and record problem from medical.  HMC Delacruz’s actions are a blight on the US Navy, and the USS Barry (DDG 52) and the VA bureaucrats only perpetuate the abuse.  If anyone has ideas on how to get injuries sustained in service documented after the fact, please feel to contact me through LinkedIn.com.  I am in the fight deep with the VA, and all assistance is greatly appreciated.

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

I Have a Question – Texas and Afghanistan

01 September 2021, the BBC ran a story quoting President Biden, “Biden vows ‘whole-of-government response to Texas Abortion Law.”  My question is simple, direct, and easy to ask and answer.  “Why will President Biden fight with “whole-of-government” Texas to kill babies, but will not fight with “whole-of-government” extremists and terrorists in Afghanistan to protect Americans and allies?”  Will someone in the media and press corps please ask this simple question!

I-CareOn the topic of asking questions in my inbox right now, I have two weeks of Department of Veterans Affairs (VA) – Office of Inspector General Reports (VA-OIG) where comprehensive healthcare inspections (CHIp) were conducted.  Employee morale from distress contributes to employee churn, and leadership is not being held to task.  Yet, the chief executive will unconstitutionally call out a “whole-of-government” response to Texas exercising state rights on abortion but not help correct veterans being abused.  Why?

America has flooding across the South and North East.  Americans are dead, streets flooded, electricity is out, all from a pretty intense hurricane.  This is a natural disaster; where is the President calling out a “whole-of-government” response for a natural disaster, rallying the bureaucrats to cut red tape, and rushing assistance to these areas?  Yet, a Texan abortion law gets presidential attention.  Why?Angry Grizzly Bear

Private companies got employees and others out of Afghanistan, but the President, who is duty-bound to serve American’s first, refused his job and has so far kept his job.  Where are the House and Senate with impeaching the US President for failure to uphold his oath and carry out his duties?  Where are the US House and Senate leaders picking up the slack and showing leadership in these tumultuous times?  Why are the US House and Senate leadership jumping on the “whole-of-government” fight with Texas instead of ordering a mass military response to rescue Americans and ruin technology and weaponry left in Afghanistan?

Leaving weapons, money, and munitions for the enemy is treasonous and punishable by the Uniform Code of Military Justice (UCMJ).  Why hasn’t General Milley been arrested for following orders that were clearly illegal and getting troops killed in the process?  The military gave comfort and aid to the enemy by order of the President and military leaders.  This is the absolute definition of treason, and the military leaders should have disobeyed those orders.  Why is Afghanistan such a mess?  The military leaders followed illegal orders!

Knowledge Check!A toddler is orphaned today after a mother and older sibling died of heatstroke, all due to the US President’s incalculably stupid decisions on the US/Mexico border.  We have a humanitarian, national security, and health crisis on the US/Mexico border.  The US President and Vice President cannot be bothered to stop their disastrous decisions and reverse course.  When will the media ask for and demand answers to the simple question, “Why?”  Yet, the US President, House, and Senate leaders will call out a “whole-of-government” oppression response to Texas over a piece of legislation that makes sense on abortion.  Another why question deserving a complete and transparent answer from the President and his handlers.

Before calling out a “whole-of-government” response for Texas and their abortion law, which by the way does nothing to restrict anything, how about we call out the government for an answer to infrastructure failing, tax officials abusing power, corrupt bureaucrats, abuse of veterans, and a president who failed in Afghanistan!  Let’s call out a “whole-of-government” response for states harmed by flooding from a hurricane, get the electricity turned back on, get COVID mandates ended, and get businesses running.  Let’s call for a “whole-of-government” response to investigating the corruption in government, the lack of budgeting, missing trillions of dollars, and the military-industrial complex that continues to cost future generations debt.  How about a “whole-of-government” response to the education farrago that is cursing Americans to run dead last because of functional illiteracy?Duty

With 49 other states and a couple of territories to have an abortion on demand, there is no end to competition to have an abortion on demand in America.  Let’s leave Texas alone and fix some real problems!  Better still, let’s answer questions, get some transparency going, and start holding politicians accountable for selling America up the river!

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

If Everyone Cared – More Detestable VA Stories

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Chronicling the VA – May We Remember the “Pobrecito!”

I-CareA Spanish-speaking Mexican colleague taught me this term, “pobrecito,” meaning “poor little one.”  As I chronicle the VA ineptitudes, failures, criminal behaviors, and abusive actions, I am always conscious of the pobrecito, the poor little one, the poor victim who got harmed.  Too often, the victims never receive any compensation, acknowledgment, or retribution, nothing for having become a victim of the VA.  Too often, the Department of Veterans Affairs (VA) – Office of Inspector General (VA-OIG) investigates long after the abuse has occurred, and the victims are not covered in the scope of the investigation, or worse, the victim was killed, and the family is left to mourn, and nobody can help.

Angry Grizzly BearWhy chronicle the VA abuses; because the needs to be held accountable, speak the language, and have tougher skin and broader shoulders than the VA’s normal victims.  The VA is slowly learning they can harm me, but they cannot shut me up!  I will not stop fighting the VA for humane treatment, honorable service, and dedicated systems.  The VA is sick because apathy and inertia were allowed to replace common sense and decency, leadership was replaced with cost accounting and bureaucratic red tape, and human kindness was eradicated and replaced with drones and robots.  I know how to make the VA better; I do not have all the answers, but I know how to launch the revolution and begin cleaning the VA, and I will not stop calling upon those responsible for fixing the mess they created!

Starting this week’s VA-OIG headlines of crimes and inspections, we find a couple in South Florida who used the system to bilk more than $20 Million in purchase order scams.

Earron Starks was sentenced to 30 months’ imprisonment, followed by three years of supervised release, and ordered to pay over $2.4 million in restitution. Carlicha Starks was sentenced to three years of supervised release, including one year of home confinement, and ordered to pay $501,000 in restitution. They paid kickbacks to VA employees as part of a large-scale bribery scheme, which enabled the Starks couple and other corrupt vendors to receive over $20 million in purchase orders from VA medical centers in West Palm Beach and Miami. Fourteen additional defendants were charged for their roles in this scheme.”VA 3

Who’s the pobrecito in this case; the taxpayers, the veterans, and the United States.  Federal Employees had to not only know the crimes occurring but be complicit in the crimes.  Will they lose their retirement benefits, have to repay their wages, and face criminal charges and jail time for their culpability?  Fourteen additional defendants, how many were supervisors in the know and on the payroll who were promoted during this scheme whose supervisors failed to do their jobs and scrutinize the work of their underlings?  The shadiest part of this entire scheme is encapsulated in the following sentence:

All VA Employees were either terminated or resigned.”

Name me one private-sector employer who could get away with a massive scheme and enjoy similar benefits!Survived the VA

We find another VA employee embroiled in theft of equipment which sold the stolen goods in Ohio.

Kevin Rumph, Jr., of Fairburn, Georgia, pleaded guilty to stealing more than $1.9 million in medical products while employed at a VA community-based outpatient clinic in Atlanta. Between 2013 and 2021, Rumph made hundreds of unauthorized purchases of equipment used to treat obstructive sleep apnea. He then stole and sold the equipment to a vendor in Ohio. Sentencing is scheduled for November 17, 2021.”

I have worked in purchasing in both the US Military and in the private sector.  If I went to my bosses with “hundreds of purchase orders for supplies,” they would naturally be curious.  Repetition of hundreds of similar requests would raise red flags and demand audits of my records and proof of need.  Why did this not occur at the VA?VA 3

In the US Navy, I was in charge of ordering stock and saw requests for certain o-rings spike, as I knew the Chief Engineer would spot this and ask why, I asked why, went to the equipment records, dug up the maintenance reports, and asked questions of the mechanics and technicians.  In doing so, we discovered an unreported problem with machinery.  This is called due diligence; why was it not being practiced by the supervisor of Mr. Rumph?  You cannot tell me a seven-year trend line is something that was an anomaly and easily missed in budget reporting year-over-year!

Exclamation MarkLet’s admit a truth for certain; COVID has been a farrago of gargantuan size from day 1.  In acknowledging this, no blame is being proportioned to the front-line workers in any way, shape, or form.  But, the administrators, policymakers, politicians, and government bureaucrats have certainly proved they could unscrew the inscrutable!  Worse, the bureaucrats proved that their idiocy was highly contagious, infecting more people than COVID, spreading faster than COVID, and killing more people than COVID.  Our proof of this concept arrives from Houston and the Michael DeBakey VAMC.

The VA Office of Inspector General (VA-OIG) conducted a healthcare inspection regarding allegations of incompletely screening for COVID-19 and treatment of a patient with serious mental illness who presented for same-day care at the Michael E. DeBakey VA Medical Center (facility).”

Findings:

      • The VA-OIG substantiated that facility staff did not complete the patient’s COVID-19 temperature screening.
      • The VA-OIG substantiated that facility staff failed to manage the patient with COVID-19 symptoms medically.
      • Sent the patient to the drive-through testing area without medical evaluation, did not isolate the patient, complete a care plan, or follow the policy for transporting patients suspected to have COVID-19.
      • The vulnerable patient disappeared while in the facility’s care, was found off-site four days later experiencing a medical emergency, taken back to the facility, and died the following day [emphasis mine]!
      • The VA-OIG determined that the Mental Health Intensive Case Management team failed to address documentation discrepancies related to the patient’s surrogate and educate the family on COVID-19 visitor policy and screening processes.
      • The VA-OIG identified the facility’s noncompliance with the missing patient policy.
      • Facility leaders’ failure to report an adverse event and ensure a timely review of the patient’s episode of care.
      • The VA-OIG identified facility leaders did not timely or accurately disclose to the patient’s family the medical mismanagement that led to the patient’s adverse clinical outcome, e.g., death!
      • The VA-OIG concluded the failure to screen, isolate, and evaluate the patient resulted in potential COVID-19 exposure to staff, patients, and the public when the patient moved through facility grounds.VA 3

What was not covered in the scope of the VA-OIG investigation was whether the staff had proper training on the written policies or if training had been suspended due to the “pandemic health emergency.”  Failure of training has been a running and recurring theme for the VA before the pandemic, and the failures of training have led to thousands of “adverse clinical outcomes” at the VA, up to and even including death.  Yet, as evidenced in this example, small decisions lead to catastrophic events.  The infected patient was mentally unstable and missing for four days; how many people interacted with the patient as a superspreader event?  Who is at blame at this VAMC for this event, the leaders!  They failed their people, failed this patient, and failed this family!

Detective 4Before continuing, we must pause and take a moment to send heartfelt congratulations to two VA Health Care Systems (VAHCS) who passed their comprehensive healthcare inspections (CHIp), if not with flying colors with significant improvement, and are deserving of the highest praise.  Would the leaders of the Fort Harrison VAHCS in Montana and the Western Colorado VAHCS in Grand Junction please stand and take a bow.  Your improvements, conduct, and capacity to achieve reflect that success is possible with good leadership.  Keep up the good work; find ways to improve daily, and may continual success be ever yours!

Finally, we come to a regular topic, the failure of the VA as a whole entity to manage to pass a simple audit on financial matters and the continuing debacle where hiring is concerned during the pandemic.  Let me refresh your memories on the hiring debacle; first, the VA-OIG found that VISN leaders “were generally pleased with the “flexibility” provided during the pandemic for speedier hiring.”  What did the American people get for reduced hiring practices at the VA?  More criminal employees, more employees with shady pasts, more employees with sticky fingers, and more employees who could not find employment in public schools, now working for the federal government.VA 3

How did that relaxing of hiring practices work out for the American people and the veterans receiving care; not very well!  But, let’s all relax; the VISN leaders are “generally pleased.”  Frankly, I would be shocked if anything ruffled the VISN leaders’ feathers long enough for them to care; they are mostly at the top of their career ladders and failing a presidential appointment to Washington, know they are set for life.  So, why rock the boat?!?!

As for financial audits, the VISN leaders know that money continuously is appropriated to carry them and their poor decisions forward.  Just ask the Denver VAMC where the construction cost overruns are still costing the taxpayers, and no one was ever held liable for that boondoggle or any other crime and scheme for that matter.

Question 3Why?  Why are victims left to rot, the assaulters and victimizers promoted, and the VA as an organization left in the hands of disreputable, dishonest, unethical, and immoral people?  Why is the VA a culture of corruption, greed, envy, sloth, and disinterest when the US military is the exact opposite?  America is not what is found in the halls of the VA, why has the VA been allowed to become something anathema to the American people?

Knowledge Check!Great Britain, you find similar in your halls of government.  Your people are amazing; your government workers are just as despicable and deleterious as the American VA, IRS, and DMV.  Australia, great people, absurdly detestable government workers.  France, interesting people, but the government employee seems to have been drug from the bottom of the scum sucked from the Seine.  I have met incredible people in Italy, Greece, Germany, South Korea, etc., but the story rings true everywhere; the government does not represent you.  Pobrecito; what has happened?

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

Ineffective Governance – Chronicling the VA

I-CareIn a scheme fit to fully infuriate patients and pad wallets, the VA providers prescribe medications; generally, the medication provided is a cheap knock-off, a generic mixture, or drugs with rebate incentives where the hospital providers are “encouraged” to use one drug more than another and the “higher cost” is rebated back the hospital in a profit-sharing scheme.  All these schemes and more play out at your local hospital and VA facilities, so please do not think this is industry-specific to the government.  However, as proved by the Department of Veteran Affairs (VA) – Office of Inspector General (VA-OIG) reports, t improper controls and governance wastes the rebates, harms patients, and still cannot get the programs correct.

Angry Wet ChickenI have three prescriptions hindered by the pharmacy practices of the VA, where the knock-off drug is useless, the mixture of the medication does not do as well as the original medicines prescribed, and where the cost of an ingredient has changed one medication to another and made the prescription less effective to the point where more medication is required for less overall effectiveness.  If the patient has to take more medication, does that mean that the cost savings never happened or that the cost savings were pushed down to the customer?  Does the patient even have a voice in the pharmaceutical decisions?  Why?

We begin the VA-OIG reports with a New Jersey man, who from 2017 thru 2020 stole more than $8.2 million in HIV medication from the VA.  Where were the supervisors when procurement officers for the VA over-ordered medication, stole the excess, sold the stolen goods, and pocketed the profits?  Where were the oversight accountants?  Where were the hospital directors?  People had to know, yet somehow the scheme could exist and thrive; this is as much a failure of leadership as it is ineffective governance, poor inventory control, and useless organizational controls.  Truly a pathetic example of VA leadership!VA 3

On the topic of ineffective governance of pharmaceutical contracts, and diversions of drugs, the VA-OIG report the following:

The Veterans Health Administration (VHA) spent about $6.6 billion on prescription drugs in fiscal year (FY) 2019. Most were dispensed to veterans by medical facility pharmacies. VHA pharmacies can return drugs that become damaged or expire before use through a reverse distributor for credit or destruction. In FY 2019, VHA expected to receive about $52 million from drug returns.  The VA-OIG found VHA pharmacy chiefs did not effectively implement the program and did not follow requirements in VA’s contract with the reverse distributor, Pharma Logistics. These issues increased the risk of drug diversion and ultimately put about $18.1 million at risk. Pharmacy chiefs did not always secure, and track drugs held for return or complete required analyses to maximize returns. They also failed to meet contract requirements to return for credit-only drugs due to expire within 120 days. VA’s National Contract Service and network contracting officers needed to do more to ensure contract terms were met. The Office of the Deputy Under Secretary for Health for Policy and Services and the Office of the Deputy Under Secretary for Health for Operations and Management did not effectively govern the program or communicate requirements to medical facilities” [emphasis mine].

VA 3Someone help me out, for I cannot understand how incompetence can be designed into these systems, policies, procedures, and responsible parties retain their positions of power.  What happened in 2018, 2017, 2016, and earlier?  We have a single fiscal year (FY) snapshot at a program that is an absolute failure.  By any measurable standard, that should have ignited a full audit of previous years until finding a successful year when the program worked.  Will there be a follow-up to this investigation to see if the VA-OIG’s recommendations are followed and implemented?  The VA-OIG has the leadership caught dead to rights on ineffective governance of a program worth $6.6 Billion to the American Taxpayer, and no accountability or responsibility of personnel is to be found anywhere.  Why?

Plato 2In a separate investigation, the VA-OIG found:

In October 2020, VA ended its contract with Pharma Logistics.  The vendor continues to process and issue final invoices to facilities as the returned drugs become eligible for and receive manufacturer credit. The final invoice process will continue until at least April 2022.  VHA medical facility pharmacies lost at least an estimated $2.1 million worth of drug return credits because pharmacy chiefs did not always effectively monitor or review job settlement statements before Pharma Logistics issued final invoices.  In addition, although the vendor established a dashboard that provided information on the status of drug return credits at the facility level, it cannot provide a national report on all outstanding credits.  This hurt VHA’s ability to maximize potential drug return credits and minimize the risk of lost credits.  VHA will continue to be unable to ensure it is receiving all credits for drugs returned by medical facilities if pharmacy chiefs do not routinely monitor preliminary invoices, reconcile job settlement statements to identify outstanding credits, and request extensions to final invoices to allow additional time for credit processing. This risk will persist for any future drug return contract(s)—whether awarded nationally or locally—if the reimbursement structure remains the same” [emphasis mine].VA 3

Did you catch that; the vendor created software to help track medications, making it easier to return medicines, and the VA pharmacy chiefs could not follow the dashboard and increased the risk of losing money for the VHA.  You were hired to perform a job; a collateral duty of your job is inventory management, tools are provided and supported to aid you in making decisions, and you refuse to use these tools.  How is this the vendor’s fault?  Why do you still retain your position?  Ineffective governance is barely the tip of the VA’s problematic iceberg created the good ship America has hit!

Liars, Thieves, and Fraud Artists Beware

GavelA Norwood, Massachusetts woman has been indicted, remains presumed innocent until proven guilty in a court of law, by a jury of her peers, for stealing social security and workman’s compensation benefits.  The Norwood woman’s actions are continuing to support the claim that complexity breeds criminal abuse.  Unfortunately, also proving that the government is not doing their jobs in checking tax records before providing benefits.

A man from Georgia has pled guilty to running a Ponzi scheme and defraud the American government during the COVID pandemic.  Frankly, I am thrilled to see another fraudster being stopped before his crimes become astronomical in scale.  I remain convinced that the government procurement system is wide open to abuse, and the complexity of the procurement system is too costly, cumbersome, and risk inviting.  The criminals see too much opportunity in the government procurement system, and the complexity breeds the ability to lie, steal, cheat the American taxpayer.

QuestionThe following remains a case where there are too many lawyers and not enough truth to ascertain what in the world is going on.  If you have further insight, please weigh in.  “Sunrhys LLC, a landlord and property management company, headquartered in Tacoma, Washington, agreed to pay $16,618 to resolve allegations that it violated the False Claims Act by overcharging a tenant and by fraudulently obtaining federal funds from a federal program designed to provide housing to homeless Veterans. The United States alleged that Sunrhys violated the agreement and the HUD-VA Support Housing program requirements by fraudulently overcharging a veteran for monthly rent between July 2019 and April 2020.”

Highlights, Audits, and Inspections

July 2021 – Highlights:

Each month, the Office of Inspector General (OIG) publishes highlights of our investigative work, congressional testimony, and oversight reports. Each month’s highlights are meant to provide a brief overview of the most significant OIG work conducted in that period.”

blue-money-burningThe VA-OIG conducted a financial efficiency review of the Miami VAHCS.  From the findings, the VHA, VBA, National Cemeteries, specifically, and the VA generally, could learn much about fiscal responsibility.  But this was already well documented!  The VA has never successfully passed an audit with transparency, accountability, and responsibility; why am I the only person demanding to know why?  Want to laugh; the VA-OIG recommends “more scrutiny” for financial transactions to the VA as a recommendation.  Like the current system for scrutiny is working, and just a bit more effort will help.  Go ahead and read the report for more specifics; my stomach cannot handle writing about the gross inefficiencies, the actual harm, and out-of-control governance failures.  Fiscal insanity is one thing; what is occurring at the Miami VAHCS is beyond insane and bordering on the unbelievable!  Almost the beginning of the Twilight Zone.

Survived the VAThe Sheridan VAMC in Wyoming continues to be performing well and deserves hearty congratulations for the results of their latest comprehensive healthcare inspection.  I prefer to issue congratulations than butt-kickings, and the congratulations are well deserved.  Keep up the good work moving forward.

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

Everyone Knows Someone – I need Some Help

Bobblehead DollIf you are a regular reader, you know, I am a disabled veteran.  I served in the US Army and the US Navy.  I hate asking for help, but I am in a pickle and need some guidance on resources, so please consider who you know as you read this.  If you prefer to contact me directly, feel free to email me using msalis1@msn.com.

      1. I am trying to put in an Endless Pool. I can pay for the pool; I have the contractor, what I need is a financing solution. I can refinance and roll the complete project into my home mortgage.  The VA has demanded I lose 7% of my body mass before considering even discussing my spinal and neurological problems with me.
            • The pool project also includes a two-car garage for my house, which improves the home value.
            • The pool project includes lawn and curb appeal upgrades, things that my home has not witnessed in several owners, and handicap accessibility upgrades.
            • Several physical therapists have recommended pool therapy, which the VA has previously sent me, but the VA will no longer send me.
      2. Does anyone know a hungry lawyer? The Phoenix VA Police injured me.  Yesterday, the first X-rays of my spine were taken since the 07 and 10 December incidents at the VAMC in Phoenix; my L-Spine now has two curves, one front to back, which is normal, and one to the decidedly abnormal, left!
            • While in Phoenix, I tried to find a lawyer, but the lawyers who could handle the Federal VA were astronomical and wanted their funds upfront.
            • I am not averse to paying for services rendered, but I cannot afford almost $20 grand in legal fees upfront.
            • If not a lawyer, does anyone know how to file a tort claim against the VA?

Broken RobotI have tried multiple times, now in multiple states, to get the elected officials to take up my case, all to no avail.  Regular readers will have seen the articles explaining my efforts.  Frankly, I am at a loss about what to do next or where to turn, so options, ideas, and possibilities are greatly appreciated.  I have contacted the veteran service organizations, both the ones I am a member of and those I am not a member of, and they are only interested in getting me signed up for care at the VA.  Well, not all of them.

Download wounded warrior project transparent logo png - Free PNG Images | TOPpngThe Wounded Warrior Project (WWP) continues to advocate and does a lot of good in the community, and I am especially grateful for their help and support.  As a special shout out, if the Wounded Warriors come around asking for help raising funds, please consider giving, this group is doing a lot to help veterans, and I am proud to be affiliated with them!  As the new kids on the block, the WWP is making a definite name for themselves as a resource for jobs, increasing job skills, activities, family support, and a LOT more!  Like I said, a special shout out, for they have gone out of their way to try and help, and I appreciate their time and assistance.

Working DollarFor the entrepreneurs out there, I know a solid investment opportunity.  Veterans need special equipment, like pools, exercise equipment, etc., for weight loss, weight management, and health improvement.  Generally, smaller communities cannot support gym memberships, exercise pools, and so forth, but the veterans can pay for the tools with suitable financing options.  Here is the business idea, set up a way to finance these things and make yourself some good money in the process.

Anyway, if you know someone and would not mind dropping me a referral, please lend a hand.  I need two solutions as soon as possible.  All assistance is greatly appreciated; even if all you can do is read this post and send good vibes my way, it is greatly appreciated.  Thank you for your time!

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