As 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:
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- 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:
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- 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:
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- 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.
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- 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.”
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- 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.
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BUT…
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- 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!
- 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.
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- 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.
- 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.
- 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.
- 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.
- 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.
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.
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.
24 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.
By 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.
Case in point, long have I detailed and described the failures of leadership at the VA. The latest is a wire fraud scheme in 
Did 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. 
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!
One 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.
Finally, 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, 
Let me remind you, 
The 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?
On 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.”
The 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.
Speaking 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?
From 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.
I 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.
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!
DNC-Consulting 