“That’s Crazy!!!” – More Chronicles from the VA – Chapter 2

I-CareAs bad as the last several months have been, I hate adding more bad news; but the Department of Veterans Affairs (VA) – Office of Inspector General (VA-OIG) keeps reporting, and I keep summating.  Due to the absolute overabundance of incredible bureaucratic insanity, today’s article format will necessarily shift to report more and comment less.  Don’t worry, I will still comment on the more egregious examples, for some of these VA-OIG reports are scarier than Joe Biden dressed as a mall Santa at a Fourth of July celebration feeling up little children!

  • 2020 Pre-award reviews of contracts totaled $81 million; guess what:
      • 24 of the 31 contracts awarded contained conflicts of interest.
      • 25 of the 31 contracts had problems with overcharges for hourly rates of services rendered.
      • 6 of the 31 price gouged Medicare.
      • 25 of the 31 contracts, if they had adequately followed the contract process, would have saved taxpayers $16 Million. – Would it shock anyone to hear this is just the “tip of the VA-OIG” report iceberg?

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  • Financial Efficiency Review of the Southeast Louisiana VAHCS in New Orleans; guess what:
      • The VAHCS in New Orleans scored 75% out of 90%. The VA does not try to get a 100% because they regularly fail financial audits as a fact.
      • Actual costs are difficult to relate in dollars and cents because the leaders intentionally hid costs from the VA-OIG, then blamed the new medical center director.
      • Avoidance costs, Purchase card abuse, prime vendor program abuse, and more were employed to avoid proper fiscal practices.
      • Audit, FAILED! No accountability, no person held responsible, and the taxpayer is left holding the bill!

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  • Followup to VAHCS Ozarks Pathology Failures From Dr. Levy Scandal; guess what:
        • Levy Scandal for those who do not remember. – Intentional misdiagnosing, VA coverup, refusal to discuss with patients affected. The report is ghastly!
        • 5% of the patients have now been contacted, and the VA-OIG considers this a “success.” I sure hope you are not part of the 24.5% patient population.
        • Here’s the rub in the 76.5% notification, “an absence of a clearly defined process for clinical providers to alert the Clinical Review Team if later changes in a patient’s health required reconsideration of institutional disclosure.” Does the VA-OIG still want to cheer about that notification rate?
        • Less than 5% of the severely sick patients have been notified of the scandal and the problems created by Dr. Levy. Is this how the VA admits culpability, waiting for the patient to pass?
        • Now, here’s the real kick to the balls; “The VA-OIG determined facility processes related to disclosure of the pathology errors and amending patients electronic health records generally met Veterans Health Administration policy requirements, but opportunities for improvement existed.” – Are you KIDDING ME?

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  • Speaking of fiscal inefficiency and audit failures. The VA continues to overspend and under-deliver on prosthetic devices, especially for shoe inserts.
        • In the fiscal year 2019, such items—artificial limbs, shoes, shoe inserts, and compression garments—accounted for about $318.8 million, or about 9 percent of prosthetic spending.
        • Oversight of prosthetic spending was ineffective, resulting in medical facilities sometimes reimbursing vendors at unreasonable rates.
        • Medical facilities spent about $10 million more than reasonable rates in the six months from October 2019 through March 2020.
        • Rates and data in databases remain unreliable, no oversight, and those in charge of oversight are missing in action. Yet, the VA continues to spend pell-mell.  Does this sound like fiscal responsibility to you?

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  • VA-OIG double-speak lives, and is blatantly observable in the following report, the “Contracting Officer Warranting Program.”
        • For those unfamiliar, a simple explanation: “A warrant gives federal contracting officers the authority to obligate taxpayer dollars. VA’s contracting officers help serve our nation’s veterans by procuring the goods and services required for their care and support.”
        • Never forget – There have been long-standing concerns (Never Resolved) with VA’s contracting officer warrant program. Since 2015, the VA Office of Inspector General (VA-OIG) has issued multiple reports [describing how] warranted contracting officers exceeded their authority and made decisions that put veterans and VA facilities, resources, and information systems at risk.
        • Never forget – The VA-OIG has documented multiple times, and the VA has never resolved, that the VA’s acquisition management has been included on the Government Accountability Office’s (GAO’s) high-risk list for fiscal impropriety and poor contractual adherence.

BUT…

        • The VA-OIG found that while VA’s contracting officer warrant program complied with Federal Acquisition Regulation requirements, opportunities exist to strengthen the program and that the VA lacked assurance that all contracting officer warrants were justified and necessary. – Essentially, this is bureaucrat double-speak for, continue to lie, cheat, steal. We like our job and want to continue, and since Congress doesn’t care, neither do we!

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  • The VHA continues to suffer from employee shortages. I have written about this shortage until I am blue in the face and my fingers ache.  I am fed up telling the VHA how to fix this problem.  If they want answers, call me!

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  • Nurse Bethann Kierczak of Southgate, Michigan, was charged with theft of government property and theft or embezzlement related to a healthcare benefit program. She allegedly stole authentic COVID-19 vaccination record cards from a VA hospital—along with vaccine lot numbers necessary to make the cards appear legitimate—and then resold those cards and information to individuals within the metro Detroit community. – Frankly, with the way the Federal Government is acting, this theft is almost understandable and acceptable.
          • No! I am not condoning an illegal action!  I am simply stating that Pelosi and her ilk do 10-times worse hourly by Congressional standards and get away with those crimes!

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  • Donald Peter Auzine of Baton Rouge, Louisiana, pleaded guilty to conspiracy to commit health care fraud. Bonnie Jean Lawless Diaz of Slidell, Louisiana, pleaded guilty to misprision (or knowing concealment) of the commission of a felony. From March 2014 through October 2016, Auzine, the marketing manager at Prime Pharmacy Solutions, defrauded TRICARE and other benefit programs. Diaz concealed the fraud by knowingly submitting compounded medications for which there was no medical necessity. Both will be sentenced on January 4, 2022.

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  • Amanda Dawn Rains of Fayetteville, Arkansas, pleaded guilty to conspiracy to commit mail, wire, and healthcare fraud, obtaining federal employees’ compensation fraudulently, and paying kickbacks. Rains, a former executive with a Rogers medical supply and billing company, participated in 2013 to 2017, defrauding the US government and private insurance companies.

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  • Robert Seifert of Utica, New York, was sentenced to two years in prison for making telephonic threats to Albany Stratton VA Medical Center employees. He admitted that on January 14, 2021, he made successive calls to three separate employees and left each of them threatening voicemails in which he used demeaning and offensive language. Seifert’s threats caused the employees to fear for their safety and property. He will also serve one year of post-imprisonment supervised release.

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  • Patsy Truglia of Parkland, Florida, pleaded guilty to two counts of conspiracy to commit healthcare fraud and one count of making a false statement in a matter involving a healthcare benefit program. From January 2018 through April 2019, Truglia and other conspirators generated medically unnecessary physicians’ orders via their telemarketing operation for orthotic devices like knee, back, and wrist braces. Truglia, co-defendant Ruth Bianca Fernandez, and other conspirators caused approximately $25 million in fraudulent durable medical equipment claims to be submitted to Medicare, resulting in approximately $12 million in payments.

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  • Larry Ray Bon, 62, was sentenced to over 16 years in prison for shooting a firearm inside the West Palm Beach VA Medical Center in Florida. Bon brought the firearm to the emergency room, and after becoming frustrated with medical staff, he retrieved it from his wheelchair and fired several shots. In March 2020, he pleaded guilty to three counts of assaulting, resisting, or impeding federal employees and one count of possession of a firearm in a federal facility with the intent to commit a crime. At that time, Bon was committed to the custody of the US Attorney General for 25 years of mental health care and treatment at a suitable medical facility. However, Bon was determined to no longer need psychiatric hospitalization and was recently sentenced accordingly.

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Finally, if you want a really good reading, you can visit the VA-OIG page and see the lowlights of the VA-OIG’s reports for yourself by visiting the page here.  Excluded from this list are the usual reports of malfeasance and misfeasance captured in the comprehensive healthcare inspection (CHIp) reports, where we find the exact carbon-copied hits from report to report.  We find moral distress, problems in staffing, continued refusals by leadership to train staff, and the ever-present refusal to attend disruptive committee meetings.  Also omitted from this summation were the inspection of veteran centers and the myriad of failures, bureaucratic ineptitudes, and abysmal behaviors.  Frankly, I could not stand being depressed more by writing and analyzing another moment’s detestable and criminal behavior.Angry Grizzly Bear

What curdles the food in my stomach, this is just the VA.  What about all the other official and unofficial government agencies in the alphabet of the executive, legislative and judicial branches of what we collectively call “the government.”  To all the freedom-loving people in America, please awake and arise; we need you!

© 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.

 

How Do I Know? – An Update on the VA Mandatory Mask Policies and VA Leadership Failures

Question24 May 2021 – 1200-1500 I visited the Las Cruces Community Based Outpatient Clinic (CBOC) in Las Cruces, New Mexico.  Upon entry, I was asked to wear a mask.  I described I could not wear a mask, and the employee said I might be required to wear one but left the decision to those working more closely with me.  I waited in line and was called to the Team 2 window, where a gentleman was more than happy to assist me in getting the paperwork started to change VA hospitals after relocating.  About 45-minutes into my time in this CBOC, the gentleman asked me to wear a mask.  I told him I could not and had brought my VA Doctor’s note as proof.  The gentleman read the letter, confirmed I was good to receive care without the mask, and provided exceptional customer support.

After the past year at the Phoenix VAMC, where my every movement on the property was shadowed by VA Police officers looking for a reason to injure, arrest, cite, and force me from the property, the employees here in Las Cruces was a breath of fresh air.  However, the experiences in Las Cruces provide further evidence of the following facts:

      1. The Hospital Director has statutory authority for adapting and creating policies and procedures that benefit the safety of the employees and the patients. A point I stressed to the leaders of VISN 22 and the Phoenix VAMC to no avail.
      2. The Federal Mask Mandates can be situationally applied for the circumstances of the individual. Yet, another point I have repeatedly stressed since July 2020, and the first time I was injured, arrested, cited, and forced from Federal Property. At the same time, I was being denied emergency care under EMTALA and having my HIPAA information repeatedly violated by the VA Police Officers.
      3. The bombastic and unprofessional behavior of the Federal Police employed at the Carl T. Hayden VAMC is a problem of the leadership, and the failures of leadership to instill professionalism, proper attitudes and behaviors, training, and tactics in approaching and handling situations in the Phoenix VAHCS. At the behavior of the Federal Police Officers in the Phoenix VAHCS, Che Guevara, Mao, Stalin, and Fidel Castro would be proud!VA 3

How can a person be sure the problems caused are a direct result of leadership failures?

ApathyBy tracing behaviors, attitudes, and influence to their source, the police chief acts as he considers appropriate, but the underofficers generationally multiply and mirror his behaviors.  The same is true for the chief who takes his example from the assistant director, director, and hospital leadership.  Chains of command always have this consequence; the example of those above are mirrored, replicated, and multiplied to impress the higher officers to gain attention and promotion opportunities.  Want to take a measure of a leader; look to the most junior person in the chain of command and watch them for behaviors, attitudes, and actions that originate in the leadership.

GavelCase in point, long have I detailed and described the failures of leadership at the VA.  The latest is a wire fraud scheme in Jackson, Mississippi.  From the Department of Veterans Affairs – Office of Inspector General (VA-OIG), we find the following:

Anthony Kelley, the owner of Trendsetters Barber College in Jackson, Mississippi, pleaded guilty to two counts of wire fraud in a scheme to steal federal funds. From October 2016 through March 2019, the college offered a master barber course that was not accredited by the state’s board of barber examiners. Kelley fraudulently represented that this course was approved and, as a result, was allowed to collect GI Bill money from veterans enrolled in the program.”VA 3

As the lowest person in the chain of command, Mr. Kelly was allowed to attempt to commit fraud by the VA.  Never in these reports is the VA employee, their supervisor, and their manager, who were complicit in allowing fraud to occur, mentioned and held accountable.  Somehow, we, the taxpayer, must presume that those committing frauds could hoodwink the Department of Veterans Affairs without any inside help.  Help coming directly or indirectly from government employees charged with investigating, ensuring, and following proper protocols and procedures to protect against theft and fraud.

Angry Grizzly BearLet the US Attorney and VA-OIG special investigators crow about catching the person perpetrating fraud.  Before they break open the champagne, they need to be looking into the leadership that either overtly or covertly allowed this fraud to occur.  The elected officials need to be demanding why fraud opportunities are so rampant at the Department of Veterans Affairs that criminal proceedings are being reported almost every week and asking about the culture of corruption and leadership failures allowing these behaviors to thrive.

Is it a “Culture of Corruption?”

Absolutely; the VA is sick with a culture of corruption!  It is my sad duty to report on another employee who was able to steal from the VA, stealing hydrocodone and oxycodone prescriptions from the VAMC mailroom and mailboxes at some 40 locations in Kerrville, Ingram, and Center Point.

Scott M. Brown, a pharmacy technician at the Kerrville VA Medical Center in Texas, was charged with one count of theft of US mail for stealing hydrocodone and oxycodone prescriptions from the medical center’s mailroom as well as from residential mailboxes between March and April 2021.”VA 3

Currently, Mr. Brown is being held in custody and remains innocent until proven guilty in a court of law by a jury of his peers.  However, the fact that Mr. Brown has been charged and is in custody speaks volumes to the lax leadership that allowed these prescription thefts to occur.  Where is the VA-OIG in asking how the robbery was possible?  Where are the special investigators demanding answers from the leadership on policies and procedures that an employee could easily violate to obtain these drugs?  Who else was involved, or had to know, what was happening and said nothing?Plato 3

The Department of Veterans Affairs has been overtaken by those without skill, knowledge, and ability to understand cause and effect and properly interrupt the cycles of corruption.  Worse, these same people will bleat about how they need more money for technology solutions when their personal example, leadership failures, and human-to-human relationships are the actual problems.  The leaders will bleat like sheep in a corral about engagement, customer service, and industry buzzwords because they have no substance and even less desire to see things change.Plato 2

Recently I detailed the failures at the Department of Veterans Affairs on information technology.  The fallout from the deplorable designed incompetence in the IT/IS infrastructure at the VHA continues to represent just how incompetent the current leaders genuinely are.

To promote compatibility with the Department of Defense’s electronic health record system, VA is replacing its aging record system. This requires VA medical facilities to upgrade their physical infrastructure, including electrical and cabling. The OIG determined from its audit that the Veterans Health Administration’s (VHA) cost estimates for these upgrades were not reliable. VHA’s estimates did not fully meet VA standards for being comprehensive, well-documented, accurate, and credible. The audit team projected that VHA’s June and November 2019 cost estimates were potentially underestimated by as much as $1 billion and $2.6 billion, respectively. This was due in part to facility needs not being well-defined early on. The estimates also omitted escalation and cabling upgrade costs and were based on low estimates at the initial operating sites. Because cost estimates support funding requests, there is a risk that funds intended for other medical facility improvements would need to be diverted to cover program shortfalls. The Office of Electronic Health Record Modernization (OEHRM) also did not meet its obligation to report all program costs to Congress in accordance with statutory requirements. Specifically, OEHRM did not include cost estimates for upgrading physical infrastructure in the program’s life cycle cost estimates in congressionally mandated reports. Although VHA provided OEHRM with an approximately $2.7 billion estimate for physical infrastructure upgrade costs in June 2019, OEHRM did not, in turn, include them in life cycle cost estimate reports to Congress as of January 2021. OEHRM stated it did not disclose these estimates because the upgrades were outside OEHRM’s funding responsibility and that they represented costs assumed by VHA facilities for maintenance—including long-standing needs” [emphasis mine].VA 3

Angry Wet Chicken 2Did you catch that; the office specifically tasked with handling estimates intentionally low-balled estimates, did not include all necessary contractual requirements, and then lied to Congress to cover their hides, and fell back upon designed incompetence to skirt blame, responsibility, and accountability when the VA-OIG came investigating.  Lying to Congress is a CRIME!  Yet, these federal employees can break the law with impunity, and all the VA-OIG can do is make recommendations for improvement!  If you want to read the full report of shame, you can find it here.

Leadership is change; management is stagnation and corruption.  When will the VA start hiring leaders to enforce, demand, and execute change to benefit the taxpayer and the veteran community?  Where are the elected officials willing to work with newly hired VA leadership in establishing legal frameworks for evicting employees who refuse to change from the federal workforce?  When can the veteran community and the taxpayer expect to see real and tangible change at the VA?

Knowledge Check!I am not asking these questions and not expecting an answer!  I am asking these questions looking for and expecting real results to begin immediately, if not sooner!  This is a national embarrassment with a global impact, and it is time for the United States to lead in correcting their detestable government workforce!

© 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.

Weep America! – The VA Leadership is Becoming Worse! – Part 2

Angry Wet ChickenOne of the first rules in overseeing junior people working is to make available someone to answer questions, immediately, and render support if needed.  I have had the pleasure of training junior people in a myriad of tasks over the years.  When I read this Department of Veterans Affairs – Office of Inspector General (VA-OIG) report, a plethora of questions arise, and I deeply question the professionalism and competence of the doctor overseeing the work of residents in a VA Hospital who are performing procedures.

  • Ophthalmology Resident Supervision – Important to note, the patient did not experience any long-term loss of sight over this issue. Congratulations to the resident and the other ophthalmology doctors present!  From the VA-OIG report we find the following:

“… The subject ophthalmologist failed to provide adequate resident supervision and entered inaccurate documentation related to supervision for a single patient case.”  Essentially, the doctor charged with overseeing residents was AWOL, and then compounded his error by falsifying patient records.  The VA-OIG report continues by claiming this falsification was the result of an oversight when using pre-recorded notes for patient files.

Draw your own conclusions.  Personally, I think this doctor needs to be released of all duties where overseeing residents is concerned.  I would also question his ethics and morals for falsifying patient records.  You hold a double position of trust, first as a doctor, second as a teacher and leader of residents, and the behavior witnessed should come with steep repercussions professionally!VA 3

Knowledge Check!On the topic of professional duties, and steep repercussions, drug interactions killed a veteran at the Marion VAMC in Illinois.  Before launching into the VA-OIG’s report, please allow me a moment of your attention.  Drug interactions can arise due to vitamin usage, over-the-counter medications, and from illegal and legal but illicit drug use.  Often, I have claimed that people are walking chemistry experiments, and even vaccines need to be carefully evaluated for drug interaction potential.  Foods can cause drug interactions due to the chemicals in the food.  Drug interactions are a growing problem and every medical professional I have spoken to admits drug interactions are becoming worse by the day.  I do not say this lightly, but I do not hold the medical professionals as fully competent in fighting the drug interaction problem due to the amount of chemicals the average person interacts with daily.  The problem is Big-Parma and the continual push towards more specialized medicines, we are going to see more drug interaction issues.  Unfortunately, drug interaction issues come with the risk of death!

From the VA-OIG report we find the following:

The VA-OIG substantiated that high cholesterol contributed to the patient’s death; however, the death certificate indicated that the primary cause of death was accidental acute multi-drug intoxication. The psychiatrist and staff failed to document providing the patient with education during a telephone encounter regarding potential side effects or adverse drug-drug interactions of medication changes. Contrary to clinical guidance, the psychiatrist prescribed long-term benzodiazepine use for a patient diagnosed with posttraumatic stress disorder. The psychiatrist also failed to address the patient’s two negative urine drug screens for a prescribed medication and failed to address a positive urine drug screen for cannabis. Due to COVID-19, the facility failed to launch the Psychotropic Drug Safety Initiative Phase Four Plan. The primary care provider did not comply with facility policy by failing to enter a return-to-clinic order following an appointment but could not determine if this affected the patient. Primary care and behavioral health staff did not comply with facility policy to telephone the patient or send a letter after the patient missed appointments” [emphasis mine].

The lack of staff to follow procedures and do their job, I will certainly hold them accountable for, especially since Cannabis is involved!  Please do not believe that Cannabis is a non-toxic drug, especially when mixed with other drugs, it can be the fatal trigger in a multi-drug intoxication!VA 3

At 18, low those many years ago, I took the EMT-Basic class, but left for US Army Basic Training before I could certify.  Since then, I have received certification as a combat medic and a Journeyman Firefighter (Any industry) which required a lot of hours studying emergency medicine.  I am experienced in drawing blood, starting IVs in difficult circumstances, and handling a myriad of injuries.  I am not a medical professional by any stretch of the imagination, I simply have a healthy desire to learn, and emergency medicine is a fascinating topic I regularly pursue.  I am not a chemist; I rely upon peer reviewed resources and legal and medical websites to stay current on a host of topics.  With this as my qualifier I am going to make several statements and you can judge their merit.  Feel free to comment.

      1. The first rule of medicine is document everything! My first lesson, first day of EMT training, this point was driven home.  If you do not write it down, it never happened!  Yet, what does the VA-OIG find time after time in reviewing cases at the VHA, lack of documentation of steps taken!  Can you say, “Asinine and abysmal behavior by credentialed professionals?” I know I can!
      2. Aspirin and Alcohol can cause a drug interaction that can be deadly. Both chemicals are readily available in the home and over the counter.  Why is spray paint now requiring proper ID, because people are huffing the stuff and getting a multi-drug intoxication.  Oven cleaner and spray pain can cause serious breathing issues and when mixed together can cause a cheap high, as well as a multi-chemical intoxication leading to breathing paralysis and death!
      3. Cannabis continues to be modified, changed, enhanced, and designed to trigger different chemical reactions in the body. Continuing work that began in earnest in the 1960s for the pot-smokers who wanted a more serious high.  Guess what, cannabis and aspirin along with vitamins can cause multi-drug intoxication problems leading to death!
      4. Vitamin D and Vitamin C have both caused serious drug intoxications during COVID-19. People became frightened and took too many of both or just one and wound up in the ER with life-threatening health problems from toxicity of these vitamins.  India has reported a spike in black mould that has caused serious long-term health problems for diabetics after recovering from COVID.  It is currently presumed that the chemicals used to fight COVID allowed for a natural mould to grow in the body, and that became life-threatening.

The VA-OIG conducted another virtual comprehensive healthcare inspection, and found the same problems continue at another VAMC.  Do you know how tired I am of reading these “comprehensive inspection” results and finding the same problems time after time?  When will the VA actually start enforcing some of these VA-OIG recommendations to effect change?  Better, when will the politicians who are charged with scrutinizing the government tire of seeing the same recommendations and not seeing any change?  Bloody frustrating reading these reports and not seeing improvement!VA 3

Broken RobotFinally, we come to what I was hoping to be a great report, where the politician’s heads were going to explode at the inefficiencies, the detestable behavior, and the horrendous responses to legally mandated IT infrastructure changes, and why those changes are not happening at the VA.  I was not disappointed; I was thoroughly disgusted that his report fell on plastic ears speaking plastic words from wax lips!  Statement of Michael Bowman, Office of Inspector General, Department of Veterans Affairs, Director of IT and Security Audits Division, Before the Subcommittee on Technology Modernization, Committee on Veterans’ Affairs, U.S. House of Representatives, Hearing on Cybersecurity and Risk Management at VA: Addressing Ongoing Challenges and Moving Forward May 20, 2021.  Notice something, the failures at the VA in the IT Department are being called “ongoing challenges.”

Millstone of Designed IncompetenceLet me remind you, FISMA was released on 29 April 2021, and I wrote about the abysmal findings of the VA-OIG.  This report is the accountability statement to the Congressional representatives who should have skewered this bureaucrat and roasted him on a spit with onions and peppers, then served him up for public ridicule after firing him!  For the Director of IT and Security Audits Division to make the following statement is flat out beyond comprehension, “The OIG’s conclusions in the FY 2020 FISMA audit are not new or revelatory—rather, they repeat many of the same concerns with VA’s IT security that the OIG has found for many years.”  What incredible chutzpah to make this comment after that scathing report showed just how deplorable the leadership of the IT and Security Audits Division revealed!  Director Bowman then goes on to downplay the band-aid solutions implemented while decrying the time for improvement is too short and there is not enough money.  Do not forget, “Of the 26 recommendations, 21 have been included in every FISMA audit dating back to at least 2017.”  With at least 15 of these recommendations dating back even further.  Want a full list, as well as how old these recommendations are; you will not find it in the Director’s report to Congress!  Is anybody incensed enough to demand a full accounting of just how old these IT recommendations are?

Detective 4The gall of this director to continue to blame legacy systems that were legislated to have been scrapped between 2000 and 2010 continues to highlight the incompetence of the director in conducting business and holding people accountable for failed projects and overspending of taxpayer monies!  The director went further and stated the following, at which time, every single Congressional Representative should have stood and demanded his head.  The “VA does not properly manage and secure their IT investments.”  Tell me director, why should you remain employed if the VA does not properly manage and secure their IT investments?  Is the failure to manage and secure IT investments the root cause for veterans to continue to suffer identity theft from the VA losing their identity?

The director’s next statement puts his other outrageous comments to sleep.  “Security failures also undermine the trust veterans put in VA to protect their sensitive information and can affect their engagement with programs and services” [emphasis mine].  Talk about such an obvious statement, it’s like the sun coming up on a cloudy day, you just cannot miss that sun rise; you also cannot miss the absurdity of making this statement!  Did some intern write his speech?  You are the director of IT Security and you make this type of comment, did you make this comment with a straight face?  I cannot find the video-record of this Congressional hearing so I can only guess he delivered his lines with a straight face!  Most detestable of all, he continued to make outrageous comments, his plan to move the IT security program at the VA forward is weak, lacking firm deadlines, and continues to allow him and his staff to escape accountability and responsibility.VA 3

Angry Grizzly BearAmerica, with these bureaucrats in charge, why shouldn’t we be weeping and wailing, and gnashing our teeth in frustration?  When will we, the owners of this atrocious government, finally scream ENOUGH and demand a full change of heads at the ballot box?  For until the elected representatives are forced out, the bureaucrats abusing us, will only continue!  The VA is sick, but the problem lies in the bureaucrats, administrators, and directors leading the VA at the Federal and VISN levels.  So many other government agencies are just as sick, or worse, and the same problem arises, the leadership refuses to act, but still expects a big titanium parachute when they leave office!  I say it is time to tell them NO!

© 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.

Uncomfortable Truths: Department of Veterans Affairs, are you listening?

It was surprising that the Department of Veterans Affairs will automatically share health information with third parties without the veterans written consent unless the veteran opts-out in writing or submit a revocation in writing submitted in person or by US mail.  Especially surprising is that the official form for opting-out is not legally active until October 2019, and the deadline for opting-out, in writing, is 30 September 2019.  While this news if significantly troubling, let us define the full problem, courtesy of the Department of Veterans Office of Inspector General (VA-OIG).

I-CareOn 12 September 2019, the VA-OIG completed their investigation into the Beneficiary Fiduciary Field system (BFFS), who handle benefits payments for veterans and other beneficiaries who, due to injury, disease, or age, are unable to manage their financial affairs and are thus vulnerable to fraud or abuse.  The veterans affected are those who are the most susceptible in the veteran population, and the government agency charged with protecting, helping, and supporting these veterans is vulnerable to fraud and misuse.  In fact, the VA-OIG found that the BFFS, “… lacked sufficient controls to ensure the privacy of sensitive data and prevent fraud and misuse. Specifically, finding the VA’s Office of Information and Technology inappropriately set the security risk level for BFFS at moderate instead of high. Risk managers did not follow established standards and did not consider whether information for beneficiaries and fiduciaries stored in the system’s database was sufficiently protected.”

Yet, the VA is now making available to third-parties, the health records of veterans.  Does anyone else see a problem?  Previously I have written about the continuing risk of veteran’s files from being accessed by persons unknown, and how this problem does not slow, simply how the VA has stopped reporting how bad the problem continues to be.  Personally, I have been a victim of ID Theft from VA Data breaches three times.  I have had VA Employees surf my medical records and then use this data to discriminate against me.  I have witnessed blatant HIPAA violations by VA Employees without hospital leaders taking any action.  Now, the VA is going to “share” my medical record access with “interested parties.”  I have some concerns!

Just in case your attention was drifting due to fallacious impeachment proceedings, the VA inappropriately sole-sourced contracts for ambulance services in three separate Veteran Health Administration Regional Procurement Offices (RPO).  The significance of this event is evidenced in the lack of competition for government contracts.  Designed incompetence was the origination of this issue, the contracting officer claimed, “I didn’t know.”  The contracting officer, who must go to school to obtain authority to enter into contracts for the Federal Government, somehow “didn’t know” about the regulations and rules for sole-sourcing a contract.  I have some doubts!

In further news from VA-OIG investigations, we find another contracting officer who claims, “I don’t know,” to hide behind designed incompetence in sole-sourcing contracts.  From the VA-OIG inspection report, “15 sole-source contracts awarded by RPO West with a total value of about $19 million, were inspected to determine whether they were properly justified and approved, and found that this was not done for five contracts worth about $6 million.”  The contracting officers in RPO West, who “misunderstood who the proper approval authority was.”  Are you kidding me?

Blue Money BurningThe VA-OIG reports, “when contracting officers violate federal regulation by failing to obtain the required approval for sole-source contracts, they exceed their contracting authority.”  Contracting officers work with the approving authority, how can they not “know” who they work for and how to obtain proper authorization?  The excuses are weak and inexcusable; as an operation professional, the first step in getting to know the business is to know who answers the questions, who has the authority, and where that person is located.  For contracting officers, the approving authority is the boss, either the employees do not know who they are working for, or there are significant issues in lines of authority, and both situations speak of phenomenal incompetence and failure of leadership.

Just like the Home Shopping Network is always claiming, “But wait, there’s more!”  RPO East, not to be outdone by RPO West, had the VA-OIG inspect “20 sole-source contracts awarded by RPO East totaling $41.4 million. The OIG found RPO East contracting officers did not obtain required approval before awarding 10 contracts worth about $14.2 million.”  The reason these contracts were not appropriately sole-sourced, “because officials did not follow the proper approval process, did not receive the correct guidance, and misinterpreted regulations.”  If RPO West is suffering from “phenomenal incompetence and failure of leadership,” then RPO East is beyond saving under the current leadership, and I call upon Secretary Wilkie and his team to scrub RPO East leadership and start over under strict quality review teams to ensure compliance and correction.  I repeat, only for emphasis, this situation is inexcusable.  The contracting officers must attend school, must know the regulations, and must not “individually interpret” the purchasing rules, and they know this from the first second on the job.  I was made aware of sole-source contracting regulations, and I was not a contracting officer.

RPO West has the follow-through needed to boil someone’s blood.  “The VA-OIG reviewed 15 sole-source contracts awarded by RPO West with a total value of about $19 million to determine whether they were properly justified and approved, and found that this was not done for five contracts worth about $6 million.”  The reason these contracts were not appropriately sole-sourced, “because officials did not follow the proper approval process, did not receive the correct guidance, and misinterpreted regulations.”  I rescind my earlier comments about the ability to save RPO West, I call upon Secretary Wilkie to personally ax the leadership at both RPO East and West, to start on a clean slate the contracting officers, leadership, and then strictly observe and implement a quality control mechanism to protect the taxpayer.

People ProcessesSpeaking of “phenomenal incompetence and failure of leadership.”  Please allow me to prepare the groundwork for the subsequent VA-OIG investigation.  To be a supervisor in the VHA, VBA, or National Cemetery, you first must work in the positions you will be supervising.  This information was passed during a job-interview by the hiring authority and confirmed by several VA directors since.  From the VA-OIG Report, we find, “a supervisor at the VA regional office in Boston, Massachusetts, incorrectly processed system-generated messages known as “work items.”  The supervisor, “incorrectly canceled 33 of 55 work items out of 110 reviewed (that’s a less than 50% accuracy), and improperly cleared another nine work items from the electronic record. Because of these incorrectly processed cases, VA made about $117,300 in improper payments to veterans or other beneficiaries, along with about $8,600 in delayed payments.”  Best of all, the supervisor claimed these work items were improperly handled because, “he did not intentionally process the work items incorrectly, and the errors were the result of working too quickly and misunderstanding procedures.”  You are the supervisor, you are in charge, you should know who to approach for guidance and clarification, you have caused significant harm to veterans who either are not being paid or now must repay funds improperly provided.  There is an obvious question here, “If the supervisor is less than 50% accurate, what is the accuracy of the supervisor’s team?”  While the VA-OIG cannot investigate this question, is the director investigating this question?

If the accuracy of claims handling personnel is less than 50%, how can any veteran be sure their claim has been handled properly?  Having been forced to repay funds to the VA, I can attest to the financial impact these over and underpayments cause for veterans.  When will these decision-making officers be held personally accountable for improper decisions?  Senators, members of the House of Representatives, what are you doing to support improving the VA, in conjunction with Secretary Wilkie?  From what I witness, not enough!

You're FiredFrom the files of “Not Enough,” comes another egregious example.  A patient in a psychological ward in the Philadelphia Pennsylvania VA Medical Center was killed because of a drug-to-drug interaction, were due to insufficient observation, insufficient monitoring, and inadequate action when the patient coded, and a veteran died at the hands of caregivers.  When a patient in a hospital ward, which is monitored electronically and physically, commits suicide, I become very agitated.  When any patient dies at the hands of the healthcare provider, I have officially lost my “cherub-like demeanor” and begin resembling a grizzly bear with a bum tooth, hemorrhoids, and woken too soon from my winter nap.  The VA-OIG Report states the following, “… providers did not monitor the patient for electrocardiogram changes or drug-on-drug interactions.  Staff and providers documented signs consistent with over-sedation but did not intervene, communicate directly with each other, or add team members on as additional signers to the electronic health record.  The facility did not comply with the Veterans Health Administration requirements for issue briefs, root cause analyses, and peer reviews.  The staff did not follow the facility’s observation policy.  Facility providers did not adhere to policies requiring discussion, documentation, and patient signed informed consents prior to initiating methadone treatment.”  The providers knew they had a problem, before the patient got into trouble, and did nothing!  In any civilian hospital, this is called malpractice; but in the VA Hospital system, “this is an unfortunate incident.”  While I am undoubtedly glad leadership acted to remedy this situation in the future; I am very displeased to note it ever occurred.  With all the publicity over the power of methadone as an opioid, with the technology to remedy these problems before the patient dies, I cannot accept this situation could occur in the first place!  This veteran’s death should never have happened and the fact that this veteran died at the hands of providers from over-sedation, is a testament to the incompetence designed into the VA processes that excuses accountability and rewards malfeasance.

Speaking of opioid medication problems, the VA-OIG inspected 779,000 VA patients prescribed opioids, and for 73% (568,670) of those patients there was an insufficient investigation by the primary care providers in consulting the state-operated prescription drug monitoring programs (PDMPs) to ensure over-medication did not occur.  The VA-OIG estimated that 19% of those files improperly handled placed patients at risk because of medications prescribed outside the VA Medical System.  With the constant harangue from the mainstream media over opioid addiction and deaths from opioids, a person might ask, where is the concern?  Why isn’t this a talking point in a Congressional Investigation to understand why, and then begin to implement changes to ensure the VA is not stained with more veteran deaths over opioids.  Finally, with an accuracy rate of less than 25%, it appears to me this problem needs immediate rectification using technology and quality control measures at the local level to improve adherence.

blue-moneyI would like to take a moment and thank the VA-OIG for stepping up to the plate and correcting pre-award contract pricing to save the American taxpayer $515 million because the contracting officer on 16 of 22 proposed pharmaceutical contracts was improperly priced.  In case you are wondering, the accuracy of the contracting officers was less than 75%.  I know of no industry, business, or service organization that can have a 75% or less accuracy rate and remains in business.  As a business operation and purchasing professional, these numbers appear to suggest that the contract officers are either intentionally neglectful, or they are counting on pre-award review to protect them from price gouging; both situations are inexcusable for a contracting officer for the Federal Government.

Thank you!As the Los Angeles Vocational Rehabilitation and Employment program (LA VOCREHAB) was recently featured in an article, I am pleased to see that hiring additional staff has improved performance, per the findings of the VA-OIG.  The VA-OIG Report found accuracy in spending money had increased, compliance, and helping veterans to gain employment had all increased since the damning report from the VA-OIG; thus, congratulations to the LA VOCREHAB program!

© 2019 M. Dave Salisbury

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