“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.

 

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.

NO MORE BS: The Leadership at the VA Continues to Shame Themselves!!!

Bird of PreyI do not believe in coincidences, I just started reporting the VA leadership as being the problem at the VA; the Department of Veterans Affairs – Office of Inspector General (VA-OIG) finally appears to be blaming Department of Veterans Affairs (VA) leadership.  In my inbox are two VA-OIG reports where the facilities’ leadership is being called out for the detestable behavior they continue to exhibit!  In one of the VA-OIG reports, please do not allow the “YUCK!” factor to distract from the problems at hand in the VA Leadership refusing to do the jobs they have been hired to perform!

        1. Bradley Lane Croft, the owner of Universal K-9 Inc. in San Antonio, Texas, was sentenced to nearly 10 years of imprisonment for scheming to defraud the federal government of more than $1.5 million in GI Bill benefits to train service canines and their handlers. In addition to the prison term, Croft pays approximately $1.5 million in restitution.”

November 2019, Judge Ezra found Croft guilty on eight counts of wire fraud, four counts of aggravated identity theft, two counts of money laundering, and two counts of making a false tax return.  Testimony during trial revealed that beginning in 2015, Croft provided false information in applications to the Texas Veterans Commission, including instructors’ names, certifications and training documents to receive GI Bill educational benefit payments.”

VA 3If you have access to more details, please share.  This story did not make a ripple in the news, and I want to know why!  Worse, who at the VA lost their jobs, lost their retirement package, or were sanctioned for allowing this fraud to occur?  2015-2018, three years of deception, where the VA leadership and lower-level employees were supposed to investigate and research documents submitted before awarding contracts?  The court records read like this was an IRS audit for fraudulent tax filing that discovered the school fraud of GI Bill benefits.  The VA never knew until the IRS alerted them.  Hence, I ask again, where was the VA in properly executing its duties to protect the government and the taxpayer from fraud?

      1. During a comprehensive healthcare inspection (virtual) of the Aleda E. Lutz VAMC in Saginaw, Michigan, the VA-OIG was pretty vanilla, except for the following. “Selected employee satisfaction survey results indicated opportunities for the Associate Director for Patient Care Services to improve workplace perceptions and for the Chief of Staff to support an environment where employees felt less moral distress” [emphasis mine].

VA 3Now, I have never personally been a patient in this VAMC or one of its clinics.  However, “moral distress” is a pretty universal phrase meaning that employees feel pressure to commit immoral activities.  The actual term “moral distress” is found in an “All Employee Survey,” where the employees stated that they felt pressured to commit an immoral activity at least once per day.

In the past year, how often did you experience moral distress at work (i.e., you were unsure about the right thing to do or could not carry out what you believed to be the right thing)?”

If an employee feels anywhere between 1.0 and 1.7 times (on average) a day they are being pressured to commit immoral activities, surely this should raise some eyebrows and a lot of questions about the propriety of the leadership team.  Did the VA-OIG take a sample of employees and gather quantitative data on exact actions employees feel they are pressured to commit?  If so, why is the conclusion bereft of actionable items for leadership to take?  If not, why not?  Employees claiming pressure to act in an immoral manner are a significant risk to any business organization.  The VA is already on record for having inferior to worthless administrators; now the veterans and the taxpayers get to know the Aleda E. Lutz VAMC and its clinics have morality issue problems.  Nobody in the VA leadership at the Federal or VISN level cares!

        1. The VA-OIG conducted a review to assess aspects of the care provided to a patient who was struck and killed by a motor vehicle following elopement from a community living center (CLC). The patient suffered from paranoid schizophrenia and was involuntarily civilly committed to the CLC.”

Administrative failures began the day the patient was admitted to the CLC, as discovered by the VA-OIG, “… the patient’s admission to the CLC was inappropriate as indicated by the CLC’s own screening process.”  Added to these concerns, the VA-OIG expressed the following concerns, “… regarding the appropriateness of CLC admission and elopement prevention.”

The OIG determined that interventions implemented by staff were inadequate to mitigate the patient’s risk for elopement. The patient eloped multiple times, and facility staff failed to provide individualized, progressive, mental health-driven interventions to prevent the patient from eloping. The OIG also found that facility staff assigned to care for the patient were inadequately trained in mental health care, and patient safety reports were not completed as required.”

On the day of the patient’s death, the OIG found that facility staff did not follow missing patient procedures after the patient eloped. Facility staff failed to detect that the patient was missing for nearly three hours, and once the patient was noted as missing, facility staff failed to follow policy to locate the patient. In addition, the OIG found that facility leaders did not ensure the facility had a missing patient prevention policy or that staff completed annual missing patient training. The OIG expressed concern that the CLC may not have been utilized as intended, given the lack of mental health standards applicable to CLCs and the complex mental health needs of this patient.”

VA 3Take a minute, imagine you are a family member of this patient.  How are you going to feel when you see the consistent and ongoing problems with the facility?  How helpless would you feel knowing that your family member was missing for hours before it became known to staff this patient, with a history of elopement, was gone?  How frustrated would you be with the administration when you read this report and see that from Day 1 admissions, this CLC was inadequate to the task of seeing to this patient’s needs?  Now, do you understand why I, as a veteran, become so aggravated and upset with the lack of leadership at the VA?  These are my brothers and sisters in arms, and they are being abused and killed by the VA’s lack of leadership.  The only recourse we have is to try and share these horrible tales with our fellow citizens in the hopes of improving the political leadership, to demand change of the executive branch’s VA leadership!  Another needless death at the hands of the VA leadership!

Let me preface this final story a little.  First, if you have a weak stomach, feel free to skip this next story.  Second, an endoscope is an illuminated optical, typically slender, and tubular instrument (a type of borescope) used to look deep into the body and used in procedures called an endoscopy.  Endoscopes are considered reusable medical equipment, and special training and procedures are required to clean and sterilize these scopes properly.  Third, an endoscopy is a procedure used in medicine to look inside the body. The endoscopy procedure uses an endoscope to examine the interior of a hollow organ or cavity of the body. Unlike many other medical imaging techniques, endoscopes are inserted directly into the organ.  Again, if you have a weak stomach, feel free to skip the rest of this article.

      1. Let us travel to the Chillicothe VAMC in Ohio, where we find the VA-OIG with “concerns” over “… responses by facility leaders to a Sterile Processing Services (SPS) employee’s failure to follow endoscope reprocessing [cleaning and sterilization] procedures.” The VA-OIG report stresses the following, “… the VA-OIG also identified concerns related to actions taken by Veteran Health Administration (VHA) leaders.”  Thus, we have one (1) employee and several VHA leaders from the local to the VISN whose actions are at best “questionable” in the cleaning and sterilization processes for an endoscope.

Three separate and similar complaints were raised at this facility for this exact issue!

“… VA-OIG investigations substantiated that the employee did not follow facility reprocessing procedures and falsely documented compliance. The VA-OIG determined that the Facility Director did not develop and implement an adequate plan to monitor the employee’s compliance with SPS procedures following reinstatement to SPS duty, particularly given concerns regarding the employee’s integrity and compliance. Because multiple patients were potentially affected, facility and VISN leaders notified the VHA Clinical Episode Review Team (CERT) for review and disposition. The CERT concluded there was minimal risk to patients and that a large-scale disclosure was not warranted; however, the VA-OIG found that the CERT’s determination may have been based on an inaccurate understanding of the reprocessing equipment’s capabilities” [emphasis mine].

VA 3Here is the other side to this problem. This is not the first time or first facility having problems with employees failing to reprocess medically reusable equipment, refusing to document correctly, or risk patient complications from dirty medical equipment!  This is not the first time the CERT team has made the wrong decision not to warn the patients involved; they might have been put at risk by dirty medical equipment!  The last episode involved colonoscopy equipment, and it was not that long ago I was writing about that incident!  YUCK!!!

Why was the employee not immediately fired for falsification of official documents?  Why did the facility’s and VISN separate investigations not see the directors of patient safety and hospital director fired for failure to perform their jobs?  The Chillicothe VAMC’s entire leadership should be fired in disgrace over this incident.

PACT 1While a patient in the VA Hospital here in Phoenix, I was in a clinic where a mother was trying to gather sufficient records to hold the VA accountable for her son’s permanent disability from sepsis.  The veteran caught sepsis when improperly cleaned scopes were used during a gall bladder removal surgery.  Her son, the veteran, spent 9-months in and out of non-VA hospitals; she had pictures of his bruised and swollen abdomen from the doctors trying to treat the sepsis and keep the veteran alive!  I have no idea whether this mother was successful or not getting the VA to cover the medical expenses and increase her son’s disability.  I only know I never saw her at the VA again, and the VA Police shadowed her as she moved from clinic to clinic, gathering records.  I do not know why records release could not release the proper documents to save this mother the hassle of visiting individual clinics.  I do know I can still see this veteran in the photos his mom showed me, and my blood continues to boil!  Yet, the CERT team asserts that mass notification is not needed in these situations; I demand to know why they can make this decision!

ApathyThe leadership at the VISN levels and the individual hospital levels is sick, inadequate, and desperately in need of a complete replacement to end the culture of corruption found inside the VA.  When employees record moral distress, this should be an automatic red flag, alerting the VISN leaders poor leadership practices are happening, but the VISN never does anything!  Failure of this magnitude would have gotten any non-VA hospital or clinic shuttered and class-action malpractice lawsuits launched.  Yet, when the VA gets caught, the media cannot even be bothered to report on the problem in the local news.  Maximum endurance has been breached, and these administrator problems need immediate attention from the politicians!

Dont Tread On MeHence, I will ask you, dear reader, to please share these VA articles far and wide.  Action is needed before the next veteran to die unnecessarily is a friend or family member of yours!

© 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.