“That’s Crazy!!!” – More Chronicles from the VA (Ch 9)

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

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

Lacking authority equates to a leadership failure to follow their standard operating procedures (SOP).  PII being inappropriately released, nothing new at the VBA, or the VHA for that matter.  Losing veterans’ identities and taking advantage of systems for personal gain, regardless of the cost, is nothing new or surprising.  This should be where the VA organizational leadership should be focused; yet, what are they doing?  Where is Congressional oversight and scrutiny?VA 3

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

From the report, we find the following:

VBA’s governance of and accountability for the exam program needs to improve.  The identified deficiencies appear to have persisted, at least partly because of limitations with VBA’s management and oversight of the program at the time of the review.”VA 3

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

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

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

The audacity of this director to claim “confidentiality, integrity, and access” as being secure would be laughable if it weren’t so inept!  How would a non-VA Employee know the IT system is fraught with problems?  VA-OIG report regarding FISMA compliance, Dallas, Texas.  The Federal Information Security Modernization Act of 2014 (FISMA).  FISMA is a United States federal law that defines a comprehensive framework to protect government information, operations, and assets against natural and manmade threats.  FISMA OIG inspections are focused on four security control areas that apply to local facilities.  They have been selected based on their level of risk: configuration management controls, contingency planning controls, security management controls, and access controls.VA 3

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

Worse, the same FISMA inspection occurred at the same outpatient pharmacy mail facility in Tuscon, Arizona.  The same problems were found, in the same systems, manned by the same inept people and led by the same poor leadership.  Integrity, only if the word means sharing ineptitude between different facilities.  Access to systems and data protection, can anyone honestly trust that the IT system at the VBA or VHA is providing the fundamental tools to meet the mission?VA 3

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

05 May 2022, failures were discovered in a joint DoD and VHA review of the new electronic health record system.  The new EHR has no plan to create interoperability, yet interoperability was the main selling point for spending billions of dollars on a new EHR.  Would you believe the VA-OIG recommends the DoD and VHA review federal laws and direct the offices overseeing the EHR program to begin complying?  Would Congress please ask, why haven’t the program managers for the HER already been complying with Federal Law?  How about demanding action to recompense the taxpayers who have been defrauded?VA 3

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

The VA-OIG operates a hotline that receives approximately 30,000 complaints annually from veterans, family members, VA employees, and the public.”  If the 30,000 complaints are presumed to be stable, across just the years I have documented the VA’s abuses, then the VA-OIG has received upwards of 360,000 complaints over the last 12 years.  Would Congress please ask about the success in promoting change, reducing fraud, waste, and abuse, and curbing the veterans being actively harmed by the VA, the VHA, and VBA?VA 3

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

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

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

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

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

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

The VA-OIG found that coordinators mistakenly closed some veteran referrals because coordinators lacked the proper training, guidance, and oversight necessary to maximize chances of reaching at-risk veterans referred by the crisis line.  VHA lacked comprehensive performance metrics to assess coordinators’ management of crisis line referrals, and coordinators lacked clear guidance on managing crisis line referrals.  Until VHA provides appropriate training, issues adequate guidance, and improves performance metrics, coordinators could miss opportunities to reach and assist at-risk veterans.”VA 3

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

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

The VA Office of Inspector General (OIG) conducted an inspection to review the care of an unresponsive patient by Emergency Department staff and the subsequent response of leaders at the Malcom Randall VA Medical Center (facility) after the patient’s death at the University of Florida Health Shands Hospital (Shands).  The OIG determined that facility Emergency Department nurses failed to provide emergency care to an unresponsive patient who arrived by ambulance.  Despite emergency medical services (EMS) personnel having relayed, while en route to the facility, the criticality of the patient’s condition and the limited patient identifying information available, Emergency Department nurses and an Administrative Officer of the Day wasted critical time concentrating efforts on whether the patient was a veteran (which the patient was, but not so identified by the nurses) versus patient care.  As a result, EMS personnel reloaded the patient into the ambulance for transport to Shands.”VA 3

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

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

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

Additionally, a barium swallow test was not scheduled.  The surgical team completed a preoperative assessment but failed to detect the patient’s overall poor health.  During the patient’s hospital stay after surgery, medical-surgical nurses did not consistently assess alcohol withdrawal symptoms or administer medications as required.”VA 3

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

Do you know why I keep declaring there is a problem with designed incompetence; several veterans suffered T-12 burst fractures and multiple rib fractures, all because of poor documentation and even worse communication.  This is a life-changing injury, and the VA-OIG found the VA providers to have culpability but no responsibility due to a lack of documentation.  Delays in provider documenting in the electronic health record the provider’s notes delayed care for another veteran who also suffered life-changing spinal injuries after receiving non-care at a VA facility.  The VA-OIG cannot conclusively document the tie between poor care being received and the injuries sustained by the veteran, all because of delays in the provider documenting treatment.VA 3

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

VHA continues to face enormous challenges in providing high-quality care to the millions of veterans it serves.  Despite these challenges, the VA-OIG has witnessed countless examples of veterans receiving the care they need and deserve—delivered by a committed, compassionate, and highly skilled workforce [emphasis mine].”VA 3

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

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

© Copyright 2022 – M. Dave Salisbury
The author holds no claims for the art used herein, the pictures were obtained in the public domain, and the intellectual property belongs to those who created the images.  Quoted materials remain the property of the original author.

Fed UP! – More Detestable Bureaucratism from the VA.

I-CareI hate being lied to!  More than I hate being lied to, I detest, with every fiber in my being bureaucrats and the inanity they promulgate to excuse their stupidity and throw a wrench into the works.  Today I suffered through yet another call with my VA-appointed primary care provider (PCP).  Not an online conference, but a phone call.  Who was in the office with the provider and why?  How can I guarantee my HIPAA information during a phone call on an unsecured line?  How do I know who I am talking to?  These concerns and more arise when you receive a phone call to discuss important medical information, and my PCP does not care!  My PCP refuses to use the VA’s tools to conduct patient appointments and instead creates workarounds; what an ingenious method for telling lies and spreading falsehoods as bureaucratic inertia; I’m so thrilled!

The PCP continuously claimed all my imaging is “normal” and “unremarkable.”  The pain experienced cannot be related, and the sources are questionable.  In polite speak, the PCP is trying to tell me it’s all in my head; a previous provider from the VA already used this as an excuse for not performing their job.  For more than 10-years, I have been fighting the VAHCS for help in reducing pain and in getting to root causes for the problems experienced.  Yet, today’s call was just more of the same BS wrapped in feel-good words, platitudes, and bureaucratic non-answers.  Honestly, after the third time the doctor related, the imaging was normal and unremarkable; I lost my cherub-like demeanor!  I did not swear until I got off the phone, but I am not anywhere close to a happy patient.

Honest question, does the VAHCS troll medical school for the bottom of the barrel, those people who can barely pass a class, let alone qualify for medical privileges?  I need competence, and I get useless lumps.  I ask questions, and the snowflakes pop out of the woodwork like ticks on a deer or fleas on a dog.  I am thoroughly sick of being treated like a know-nothing inconvenience.  The most important person in the VA marketed PACT Team is the patient who will be active, engaged, and informed.  The second most important member of the VA Marketed PACT team is the Primary Care Provider.VA 3

Since 2002 I have had a problem in my gastro-intestinal system; since 2010, the pain has been debilitating, and four years ago, I was diagnosed with non-alcoholic fatty liver disease.  Today, 22 March 2022, the PCP reviewed the problems area on my electronic health record (EHR), which coincidentally resides at the top of the electronic health record and was mentioned four different times by myself, and noted that non-alcoholic fatty liver disease is not listed.  Tell me, how would that make you feel?  The PCP ordered today’s call before the recent imaging appointment on my abdomen and pelvis, but the provider, who called me almost 30-minutes late, did not even look up my record before calling.  Had not studied the imaging results and formulated a plan of action to move forward, yet as the second most important member of the PACT team, I am supposed to trust this bureaucrat; I think NOT!

Through the miracle of modern technology, I had read and researched the imaging results more than 24 hours before the scheduled appointment to discuss the results.  I came prepared, but the provider could not be bothered to prepare for a call they demanded, then had the sheer effrontery to keep repeating that the imaging is “normal” and “unremarkable.”  Then the provider has the gall to tell me, repeatedly, that I was yelling, when in fact, she only did not like being spoken to with emphasis and insistence that she do her job!  Yes, I called her a bureaucrat and a snowflake, whereupon she threatened to hang up the call, but I disconnected first.  I miss those old rotary phones you leased from AT&T, they had heft, and when slammed, they made you feel better about disconnecting a call.PACT_model

From research, it is abundantly clear that pain from hernias can show up or be felt in areas far removed from the hernia site.  Constipation is both an indicator and a symptom of hernias.  Muscle weakness in the legs, burning sensations, and much more are all indicators of a hernia.  Yet, when I asked about all the other pains and problems experienced in my abdomen, I was told the hernia could not be the root cause, and the imaging is “normal and unremarkable,” but the PCP could not answer why these other symptoms are unrelated when asked.  Where is the research, seeing as “Dr. Google,” is discouraged; Johns Hopkins and the Mayo Clinic, plus I have access to the medical libraries at the University of Phoenix and Grand Canyon University.  With less than five minutes of research, I can locate and read data from reputable sources to form the basis of questions to ask a PCP, which is encouraged of patients by the VA.  Yet, the doctor cannot be trusted to provide any intelligent data, do any preparation, or knowledgeably speak to a symptom list; when will the VA answer why their PCP cannot do their job?PACT 1

If only I were the only person experiencing these problems and issues with the VA.

Former VA cardiologist John Giacomini of Atherton, California, pleaded guilty to one count of felony abusive sexual contact.  In the fall of 2017, Giacomini repeatedly subjected a subordinate electrophysiologist to unwanted and unwelcome sexual contact, including hugging, kissing, and intimate touching while on VA premises.  On 10 November 2017, the victim explicitly told Giacomini she was not interested in a romantic or sexual relationship with him.  Nevertheless, Giacomini continued to subject his subordinate to unwanted sexual advances and touching, culminating on 20 December 2017, when Giacomini turned out the lights in an office, pulled the victim out of her chair, and fondled her until a janitor opened the office door and interrupted the encounter.  The victim later resigned from her position at the VA, citing Giacomini’s behavior as her principal reason for leaving.  Sentencing is scheduled for 12 July 2022.VA 3

Will the VA-OIG troll through this former provider’s employment history seek out the other victims, or will this be swept under the rug not to tarnish the VA?  Having been an employee of the VA, will anyone, EVER, look at how employment law is abused by the leaders in the VA and correct the problems?  This incident should never have occurred, nor should it have taken years of abuse to end this despicable behavior.  Yet, what does the VA do, shut both eyes and pretend it does not occur in consequence of the designed culture at the VA.

Why did the victim have to tell another adult that their behavior was unwanted, and quit their job, before the VA took action?  Will there be an inquiry from congress?  Will any lawyers stand up and demand the VA correct this detestable hole that allows this behavior to promulgate?  I am not holding my breath!

Speaking of electronic medical health records, the VA-OIG has issued three separate reports on this topic, and none of them paint the VA with anything that shows competence.  In the report titled:

Medication Management Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VAMC in Spokane, Washington.”  The following findings were related:

Deficiencies in medication data migration and management resulted in patients having inaccurate or incomplete medications in their records or made filling prescriptions accurately more difficult—all of which can affect patient care and safety.  Areas of concern included:

(1) Data migration
(2) Medication formulary availability
(3) Medication order processing
(4) Provider notification and alerts
(5) Controlled substance tracking
(6) Prescription drug monitoring program documentation
(7) Medication reconciliation
(8) Medication list accuracy.”VA 3

As previously stated, I am not as nice and never politically correct.  VA-OIG, please allow me to correct your assertion, “Deficiencies in medication data migration and management resulted in patients having inaccurate or incomplete medications in their records or made filling prescriptions accurately more difficultall of which DO negatively affect patient care and safety.”  Trust is the first casualty in war and in dealing with the VA in ANY form, manner, or method.  When you cannot trust your data to remain confidential, the entire electronic medical record system can only be rated as UNACCEPTABLE!  The upgrading of the electronic medical records system at the VA is a 10-year, multi-billion-dollar fiasco, and as a taxpayer, I am done paying for this system!

Not to be outdone by the medication side of veteran care experiencing failures, the following VA-OIG report was issued:

Care Coordination Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, Washington.”

The EHR rollout caused problems in coordinating veterans’ care, ranging from the flags for patients at high risk for suicide not transferring to veterans and their care providers having trouble accessing video appointments and patient portal messaging.  Tracking outcomes were sometimes lost, and disappearing laboratory orders also resulted.  Although the OIG did not identify associated patient deaths, future deployment of the new EHR without resolving identified deficiencies could increase risks to patient safety.”VA 3

Again, the VA-OIG is practicing political correctness instead of being specific, and upfront, the entire EHR is a disaster, the cost is prohibitive, and any fool should see it is time to pull the plug, cut the losses, and hold the leadership accountable!  Yet, what do we see; the EHR is progressing into infinity and beyond at a snail’s pace!

The final nail in the VA’s EHR coffin should be that nobody involved can communicate with the IT helpdesk for the EHR as the IT ticketing system is unreliable!  Form the VA-OIG, we find the following:

Ticket Process Concerns and Underlying Factors after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, Washington.”

The failure to process and respond to VHA staff ticketing requests for help or report concerns resulted in reporting, tracking, and resolving problems.  These deficiencies made it difficult for clinicians and administrative staff to serve patients and impeded EHR fixes that can affect future sites.  The inspection team also identified five factors contributing to the deficiencies identified in the two companion reports above: usability, training, interoperability, needed fixes, and problem resolution.”VA 3

Imagine for a moment, you are responsible for a multi-billion-dollar IT project, and one of the first issues discovered by the users is the inability to reach out for IT help; how long would you remain employed?  Would you ever expect to ever work again if any of these problems were your legacy for leading the IT improvement on a multi-billion-dollar project?  As a consultant, I know how fast you would be fired and taken to court for business losses.  Why are these leaders exempt?  Where are the blue-ribbon panels and committees demanding people be held accountable for this fiasco?EHR-VA-OIG

When the VA-OIG casually mentions that PCPs are untrustworthy and not using the current tools correctly, should the providers be issued new tools; NO!  Yet, this is the opposite of what common sense declares.  Are you, dear reader, as a taxpayer, fed UP yet?  My wife reminds me, “These problems happen in civilian hospitals.”  No, in fact, they do not.  If data migrated from one patient’s EHR to another patient’s HER, that hospital would be sued and shut down so fast by congress at the federal and state level, all before the media firestorm would have barely begun.  If a patient were jeopardized because their provider could not track medications, that patient would sue for malpractice and possibly a class-action lawsuit.  If an IT project was occurring in the civilian world, and the users could not contact the IT helpdesk, the project would be overhauled so fast, and people fired, new records would have been set.

Knowledge Check!It is time we end this charade and money pit call the Department of Veterans Affairs, and every other agency of the Federal government bloat!  The government should be leading, not lagging, where operational efficiency and fiscal sanity are concerned.  I repeat, only for emphasis, are you fed UP yet?

© Copyright 2022 – M. Dave Salisbury
The author holds no claims for the art used herein, the pictures were obtained in the public domain, and the intellectual property belongs to those who created the images.  Quoted materials remain the property of the original author.

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

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

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

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

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

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

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

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

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

I do agree with Justice Oliver Wendell Holmes’ statement:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

© 2021 M. Dave Salisbury
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