FISMA – DNC-Consulting

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

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

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

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

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

From the report, we find the following:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Abominable Enabling – More VA Chronicles of Shame!

Knowledge Check! Before I begin, please allow me to emphasize a key idea, “This is your government!” Your tax dollars are paying for these shenanigans, and the bureaucrats do not fear you. I have written some odious critiques in my time about the VA and other government agencies. My cataloging these incidents does no good unless everyone in America becomes full of righteous indignation and DEMANDS Action through their elected officials!

The Department of Veterans Affairs – Office of Inspector General (VA-OIG) has been super busy this week, and my email box has been chock full of reports. The VA-OIG reports begin in New Mexico, Albuquerque, where finally the VA-OIG has investigated some of the many complaints and is finally stating what the veterans and active-duty military have been saying for a long time, the NMVAMC leadership stinks! Raymmond G. Murphy

As a patient in Albuquerque VAMC, during the June 2018 window of investigation, I can affirm the integrity of the problem but seriously doubt the VA-OIG conclusions. I was an employee of the Albuquerque VAMC in June 2018, so I know the leadership involved personally, and I guarantee the problem goes deeper than a lack of training. The Albuquerque VAMC is fraught with leadership dysfunction, misfeasance, malfeasance, and intentional systemic problems. Yes, the VISN 22 leaders were advised, and no, the VISN 22 leaders did nothing! There’s no surprise there; VISN 22 is one dead veteran from a major scandal that will make the death list scandals look like a minor nuisance.

From the VA-OIG report, we find the following:

“The VA Office of Inspector General (VA-OIG) conducted a healthcare inspection to evaluate allegations that Community Care consults were completed in June 2018 without scanning and attaching available clinical results to patients’ Veterans Health Administration (VHA) electronic health records (EHR).” “The VA-OIG substantiated that in June 2018, Community Care nurses were completing consults without scanning and attaching clinical documentation to patients’ EHRs.” “The VA-OIG determined that Community Care nurses lacked a comprehensive orientation and training program. The Chief of Community Care did not verify adherence to consult-related VHA requirements or conduct regular reviews and improvements for departmental performance deficiencies. Additionally, Community Care performance monitoring addressed consult processes before patients receiving care but did not address the consult completion process or identify non-compliance with VHA policy before 2019.” VA 3

Let me break this down; primary care providers sent orders for community care, community care would be delayed, then to clear the backlog, the nurses doing the ordering would pencil-whip the documents claiming that care had been received, canceling the orders of the primary care provider. Then the patient and the primary care provider would have to start the process for community care all over again. Wasting time, money, and other resources, the facility leaders and VISN leaders refused to address the deficiencies and correct the problem. The problems with community care existed before I arrived in Albuquerque in 2016 and continue without stop after this VA-OIG inspection. I met with providers who had not been paid for years because the community care program was poorly managed and led. Thus, the leadership enables people to break the trust, break the law, commit fraud, waste, and abuse, then collectively blame the problem on a lack of training, which is designed into the processes as incompetence.

Question I keep asking for the politicians and Washington VA Leaders to rip the scab off VISN 22, expose the wound to sunshine disinfectant, and drain the pus for the good of the VA body. Yet, nothing ever happens, and the leadership continues to get away with abusing veterans, killing veterans, and destroying veterans. Shame on you, political and administrative leaders!

Speaking of wounds needing sunshine disinfectant, the VA-OIG reports that “Mende Leone, 37, pleaded guilty to misappropriation of a federal benefit by a fiduciary. As her uncle’s appointed fiduciary, Leone stole at least $151,000 of VA benefits intended for him.” Continuing to prove that after the VA, families are the second most dangerous entity to the health and support of veterans. Despicable crime indeed! Plato 2

Unfortunately, the third most dangerous entity to a veteran is the state government where they reside. California moved very quickly to scoop up money after a veteran died. At the same time, the Department of Veterans Affairs – Veterans Benefits Administration (VBA) was foot-dragging on deciding on awarding fiduciary control for the veteran in a long-term care facility. Proving once again, if you want to see government in action, waive money in their faces, and watch them kill each other to obtain someone else’s funds.

The clowns at any circus in the world would make better administrators of the VA than those currently in power positions! For the second time in as many months, the VA-OIG reports that unreliable information (the politically correct way to say they lied) was blamed for billions in cost overruns on IT infrastructure costs to the VA. “… the Office of Electronic Health Record Modernization (OEHRM) estimated information technology (IT) infrastructure upgrade costs [but was not] in accordance with established VA standards and Government Accountability Office guidance. The two $4.3 billion infrastructure upgrade estimates reported to Congress were not reliable and, because of incomplete documentation, determining the accuracy of the estimates was not possible. The VA-OIG also found VA did not report to Congress other IT upgrade costs of about $2.5 billion because OEHRM did not include costs other VA agencies would bear. OEHRM also did not update the cost estimates it provided to Congress.” VA 3

Yet, the US President continues to push to throw more trillions of dollars at the VA when they cannot correctly handle the billions already appropriated to upgrade their IT infrastructure. The VA-OIG report, just for this farrago, is estimated at $11.1 Billion. Einstein is famous for claiming that doing something over and over again and expecting different results is the epitome of insanity. Maybe, it might be time to scrutinize the VA, fire some people, and get actual private-sector employees to fix the bureaucracy and obscene malfeasance in government! Apathy

The following investigation remains ongoing, and those indicted remain innocent until proven guilty in a court of law by a jury of their peers. However, the investigation needs to be reported for the criminal activity and the lack of leadership that enabled the crimes accused.

“Lisa M. Hoffman, 48, of Orange, New Jersey, is charged by indictment with one count each of conspiracy, theft of government property, and theft of medical products.

According to documents filed in this case and statements made in court:

From October 2015 through November 2019, Hoffman was a procurement officer at the VAMC. She used her authority to order large quantities of HIV prescription medications to steal the excess. After the medications arrived, Hoffman waited until co-workers were out of sight and removed them from the VAMC.

Once Hoffman stole the medications, she met her associate, Wagner Checonolasco, aka “Wanny,” generally at Hoffman’s residence so that Hoffman could provide the stolen HIV medications to Checonolasco in exchange for cash. Hoffman and Checonolasco used an encrypted messaging application to plan and execute their thefts and sales of the stolen HIV medications, including arranging for the medications-for-cash exchanges. After obtaining the stolen HIV medications from Hoffman, Checonolasco sold them. During the conspiracy, Hoffman and Checonolasco stole approximately $10 million worth of HIV medications belonging to the VAMC” [emphasis mine].

Where were the other employees and the hospital leadership during this crime? When I received US Government property, I had to account for every penny, show the receipts, and held to general inspections verifying my veracity. The supply officer lost $20.00, claimed I had spent the money, and I had to prove my innocence using documentation and a full property audit before I was cleared of the missing money. You cannot tell me that the leadership and other employees magically are not culpable for their complicity and failure to perform their jobs. VA 3

For example, upon receipt of property, there is an inspection to verify everything purchased arrived. Then when delivered to different stations, another audit is conducted to ensure nothing disappeared enroute. If something comes up missing, there is another audit and inspection, as well as a host of paperwork involved in correcting deficiencies and proving where the property went. Prescription drugs are held to a higher standard with greater penalties for those involved in missing drugs. Thus, I ask again, where was the leadership who enabled this criminal behavior? Where were the nurses who noticed missing drugs on inventory lists? Where were the fellow employees in this scheme?

Multiple reports are circulating that the head of the viral, fungal meningitis outbreak from 2012, Barry Cadden, is being resentenced with stiffer penalties. As a reminder, “In 2012, 753 patients in 20 states were diagnosed with a fungal infection after receiving injections of MPA manufactured by NECC, and more than 100 patients died as a result.” Cadden was resentenced to 174 months in prison, forfeiture of $1.4 million, and restitution of $82 million. Frankly, I still think the sentence is too light; but nobody asked my opinion on sentencing! Gavel

Finally, in our discussion on obscene enabling by VA Leadership, the following VA-OIG reports on COVID preparedness, lessons learned, and the preparation for a pandemic. Under the heading, “Identified Trends Among VISN 19 Respondents’ Comments on Facility Readiness and Response,” we find “All need to practice infection control protocols (wearing masks and washing hands).” Are you kidding me?!?! You are a hospital; hand washing should be second nature and the first line of defense, not the patient wearing a mask. The VA-OIG gathered this data from VISN 19, which includes the following VAMC’s:

- - - Aurora, CO
    - Cheyenne, WY
    - Fort Harrison, MT
    - Grand Junction, CO
    - Muskogee, OK
    - Oklahoma City, OK
    - Salt Lake City, UT
    - Sheridan WY

Having been a patient in three of these VAMC’s I find it highly distressing that hand washing and wearing masks in a hospital setting is a “trend” of “readiness and response to a pandemic.” How were you delivering care previously? Why is handwashing suddenly a new activity? How many patients were endangered by a lack of handwashing? VA 3

I have been a patient in two different VA Hospitals where the nurse routinely pulled off the finger of their glove or did not glove at all, to remove blood, use sharps to give shots, and a host of other activities. I reported these behaviors as “concerns for patient safety,” and my concerns fell on deaf ears of the leadership. Now, I see a VA-OIG inspection relating that hand washing is suddenly vital to delivering care, and I have to ask these questions. Of the eight collated responses from local hospitals, proper hygiene protocols are mentioned in 6. So, how were you delivering care before the pandemic?

Pigeon Revenge Still, the VA-OIG refuses to investigate the lack of written operational procedures, policies, and mandates for enforced mask-wearing, especially when the mask prohibits or makes unsafe the patient’s breathing. Why was there no acceptable workaround to see patients with shortness of breath without a forced mask? Why were patients refused care under EMTALA? Why are VA Police Officers allowed access to private patient HIPAA-protected information? Fundamental questions about the rights and protections of patients who continue to be violated by the VA Leaders enabling harassment and harming patients, and the VA-OIG remains MIA. I find this very glaring!

© 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.

Absurdity so Repugnant it Takes Your Breath Away – More VA Chronicles

Angry Grizzly Bear The Department of Veterans Affairs – Office of Inspector General (VA-OIG)-released six investigation reports in the last two days. Each one is mentally breathtaking at the egregious behavior of bureaucrats! Stupidity that is so repugnant it breaches the laws of morality and leaves the reader stupefied. Every year, for the last decade-plus, the behavior of the Department of Veterans Affairs (VA) has become more obscene, more outlandish, more detestable, and more openly hostile towards veterans; it sickens me to read the investigation reports, write, and catalog these abuses!

Beginning in Queen’s, New York, we find another dead veteran that should never have died the way they did. Improper feeding by a registered nurse (RN) at the New York Harbor Health Care System’s Community Living Center (CLC) contributed to the death of a patient. Let that sink in for a moment, for the rest of the report only goes downhill from this point. My time in medical training was replete with the following aphorism, “If it is not written down, it NEVER happened.” The nursing staff failed to document meals properly. The electronic health record (EHR) was inaccurate and flawed, hindering resuscitation, which was poorly documented, and institutional disclosure acted more like CYA than a medical file. People should have been fired and up on trial for this type of scandalous behavior, especially since a veteran died from this abuse and neglect. But the VA-OIG made their recommendations, the leadership accepted the recommendations, and nothing else will happen. Nobody but the family cares the veteran died needlessly and at the hands of the medical professionals. VA 3

Adjectives elude me. The behavior in Queen’s is appalling, even for the VA. Unfortunately, the list of ineptitude only gets worse!

VA Seal Next, we travel to Austin, Texas, and discover yet another office of information technology (OIT) failing to work, secure data correctly, and protect veterans’ information, as demanded by legislation! The VA-OIG and the local OIT used the same tools, and the local OIT only identified 150 problems, whereas the VA-OIG OIT inspectors found 246. Improper sanitization of media was a pronounced issue, where patient load is upward of 300,000 annually. Inventory practices were noticeable and apparent. Worse, patch and vulnerability programs were practically non-existent if I understand this report correctly. VA 3

If you have read any of these VA Chronicles, you will know that the VA has not passed a Federal Information Security Modernization Act (FISMA) audit, ever! The head of IT was recently in front of Congress to testify why, and the explanations were milk toast adequate at best! But, the elected officials bought the excuse, hook, line, and sinker, as always, and the president wants to spend more money on the VA. What a cathartic example of why elections matter!

Next, we travel to Detroit, Michigan, where a “comprehensive healthcare inspection (CHIp)” was performed at the John D. Dingell VAMC. Before I even read the report, I knew it would say; opportunities exist to improve employee and patient experience. Knowing veterans who are “served” at this VAMC, this was an obvious guess! Again, we find “moral distress” in the workforce, signifying that the employees feel pressured to do everything but what is ethical, legal, moral, and appropriate for the patient at this VAMC. Yet, the leadership team was rated as stable and doing a good job! Quoting Colonel Potter from M*A*S*H here, “HORSE HOCKEY!” VA 3

I will be explicitly clear if a single employee feels “moral distress,” there is a leadership problem, and the leadership is criminally negligent in their duties to oversee staff leaders, supervisors, team leads, and training personnel! This is not the first time “moral distress” was a point of discussion in a CHIp; but, the fact that this problem remains widespread and apparent does mean the problems are originating at a level higher than the VISN, and all the VA and VHA leadership should be losing their jobs! Enough is enough, and the elected officials need to be scrutinizing the government before they lose their next election!

Survived the VA Having been an employee of the Department of Veterans Affairs, working in the Emergency Department of the Albuquerque, NM., VAMC, this next story is exceptionally aggravating and extremely distressing. The VA-OIG determined that the entire Veterans Health Administration (VHA) needs to better monitor, record, and document the timeliness of care and patient flow in the emergency department. Having waited for more than 14 hours in a VA Emergency Department while waiting for care, I know first hand the problems of the Emergency Departments, and I know a lot of the reasons why the documentation is fouled and the flow of patients is amateurish, at best!

Raymmond G. Murphy I worked the shift where a regular, homeless veteran, wheelchair-bound, had fallen and broken his leg. He waited with his broken leg swelling, stuck at an odd angle, and in obvious distress for more than 6-hours because the head nurse that day had a personal grudge against the veteran! I saw how the charts were “adjusted” for timeliness of care, and I reported the problems up the chain to no avail! I had witnessed nurses harangue patients, gossip about them, chart surf in violation of HIPAA, and never was anything done by leadership when it was reported. A patient sat in an expedited treatment room for four hours, listening to the nurse’s gossip and joke, awaiting stitches for a bleeding wound, and never was treated. All because the day shift was getting off and didn’t want to be bothered to treat the patient. The patient’s family reported this behavior to me as they were leaving for a better hospital. I reported the whole incident, included the family’s description, added my observations. The leadership shook the whole incident off as a disgruntled employee (blaming me) making a less than desirable situation worse. VA 3

Thus, when I read this particular VA-OIG report about the inadequacies of the VA Emergency Departments across the entire VHA, it infuriates me into a mindless stupor! Want more data on the failures of the VA Emergency Department; read the rest of the VA Chronicles. I describe my experiences in detail and have logged other veterans who have had the same or worse problems at the VA Emergency Department! I have witnessed doctors treat patients in a dissimilar manner based upon the political clothing the veterans wore into the Emergency Department! So, no, I am not surprised at the record inadequacies of the VHA; if anything, I expect the problem is a lot worse than the VA-OIG was willing to report! VA 3

The VA-OIG collected data on an issue of grave significance from 58 VHA outpatient clinics’ regarding emergency preparedness for the delivery of telemental health care as of November 1, 2019. The review focused on clinic-specific emergency procedures, emergency procedure roles and responsibilities, emergency contact information of staff, and patient safety reporting methods. Not included in the scope of the review was the quality and quantity of telehealth appointments. I mention this oversight as the technical problems in receiving telehealth appointments are sub-par, at best, which would have seriously skewed the data.

The VA-OIG sent out 333 questionnaires, receiving a total of 187 responses, from the 58 identified clinics, and identified the following:

1. 1. Missing telehealth emergency plans and procedures.
  2. Emergency procedures are not specific to telehealthcare or the patient-clinic location.
  3. Lack of a process for annual updates to telehealth emergency procedures.
  4. Undefined emergency procedure roles and responsibilities for telehealth staff
  5. Missing or insufficient emergency contact information.
  6. Lack of a process to verify and communicate emergency contact information
  7. Lack of a consistent process to designate the telehealth setting in patient safety reporting methods.

Consider for a moment; you are a family member of a veteran needing telehealth mental support. Now, how do you feel to know there are no written processes or procedures to support the telehealth provider if your family member gets into a mental health emergency. Time is critical in mental health emergencies; I know this from personal experience as both a provider and a patient, and for these plans, procedures, and processes to be missing is the height of malpractice! Would someone please tell me why elected officials and the media are not screaming mad at this particular report? Especially since the proposed budget from the president wants to double suicide prevention spending at the VA. I read this report and see that the VA-OIG made five recommendations. Are you freaking kidding me?!?!?

Finally, we go to Hawaii and confront the most detestable, outside of the dead veteran, issue possible, failure of the National Cemeteries Administration (NCA) to properly care for the remains of veterans, qualified spouses, and dependents. The NCA awards grants to states to build cemeteries where a veteran, qualifying spouse, and dependents can be laid to rest outside a national cemetery. From the VA-OIG report, we find the following, emphasis mine:

“Grants may be used to establish, expand, or improve veterans cemeteries. The VA-OIG audited the program to assess NCA’s governance and oversight. The audit team also assessed whether critical non-compliance issues at two cemeteries in Hawaii were addressed. The VA-OIG found grants program staff did not rank and award some cemetery grants as regulations required. After grants were awarded, program staff generally ensured cemeteries used grants for their intended purpose. However, NCA did not ensure cemeteries with grants met all national shrine standards for installing permanent markers, maintenance, and safety. The audit team observed non-compliance issues at eight state cemeteries, including critical issues in Hawaii’s Hilo and Makawao cemeteries. As a result, NCA lacks assurance that veterans and family members buried in state veterans cemeteries have been appropriately honored with timely and accurate grave markings, burial locations, and maintenance.” VA 3

NCA, you have one job, ensure the remains of veterans and qualifying spouses and dependents are adequately remembered, safely entombed, and marked appropriately. Yet, you fail at even this simple and easy job; how utterly disgraceful, disgusting, and detestable! How many cemeteries in the Philippines are being adequately cared for? At the last report, none of them were adequately maintained and respected. Even here in the US, you refuse to do your jobs with competency, dignity, and professional pride.

Knowledge Check! The VA is one sick organization, where the mission is being denied, the veterans abused before and after death, and none of the elected representatives can find enough time in their day to even offer a mild rebuke or maintain sufficient interest to scrutinize. America, we have gotten better as a culture in remembering and honoring those who serve and have served, and I, for one, am very grateful for your change of heart. We, the voting citizens of America, need to demand the same culture change from the politicians representing us! As a country, we have come a long way since Vietnam in honoring the military. But those same people who spat and urinated on our troops in Vietnam are now in the Halls of Congress, and their attitudes have not changed in the interim!

© 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 3

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

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

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

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

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

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

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

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

I do agree with Justice Oliver Wendell Holmes’ statement:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Do You Feel Represented? – Your Government In Action!

Detective 4 I have received feedback that I write about the Department of Veterans Affairs (VA) too much. Please allow me to explain why. As a veteran, I am duty-bound to help my fellow brothers and sisters in arms. As the son of veterans, mother (USN), and father (USN, USARNG), I know the hardships of being dependents of active duty, reserve, and National Guard members of the military. The enlistment contract doesn’t end when the contract says so for the military member; the families and spouses contract is forever.

The final two reasons I write about the VA are most critical; NO body should be treated like the VA treats the veterans; the actions of the bureaucrats in the VA are not representing me and what I stand for in a representative government. As I can easily have the Department of Veterans Affairs – Office of Inspector General Reports (VA-OIG) delivered to my inbox, it makes writing about the VA much easier, benchmarking how the government has insulated themselves and forgotten who holds the reigns of power in a representative government. While not a reason to write about the VA, this final explanation should help you judge whether your representative government appropriately represents you and what you stand for. Why

The VA-OIG reports today begin with behavior that is intolerable and worthy of public shaming. While the defendant remains innocent until proven guilty, the criminal complaint represents behavior inexcusable! “Daniel Devaty of Elyria, Ohio, was charged with influencing a federal official by threatening a family member. Devaty allegedly sent a text message to the cell phone of a VA social worker threatening to kill his daughters.”

Angry Grizzly Bear Anytime anyone threatens the family members, their behavior is beyond the pale and deserves public shaming and the harshest of criminal penalties. I do not care if the perpetrator is a politician, a judge, the media, or a private citizen. Leave the families out of any business dealings! Hollywood, take note, I am sick to death of you threatening family members in movies, TV shows, or simply as private citizens/influencers. For too long, you have shirked your public responsibility, and families are OFF LIMITS! Learn this lesson well!

On the topic of conduct reprehensible, the following VA-OIG report leaves me running out of adjectives to describe the behavior of this VA Employee. “Robert Sampson of Gulf Breeze, Florida, pleaded guilty to charges of video voyeurism and disorderly conduct. Sampson secretly recorded eight fellow VA employees using a hidden camera, disguised to look like a cell phone charger power adapter, that he placed in a restroom at the VA Joint Ambulatory Care Center in Pensacola on multiple occasions from August 2019 to June 2020.” May the judge throw the book at him and his punishment be creative and sentence well earned!

VA 3 In another VA-OIG report, we have more leadership missing problems, where a fraud scheme existed for 11 years without discovery. “Erik Santos of Georgia was sentenced to over 11 years in federal prison for defrauding Tricare of approximately $12 million through a compounding pharmacy fraud scheme. In January 2021, Santos pleaded guilty to one count of conspiring to commit healthcare fraud and wire fraud.” While the US Attorney beats his chest and proclaims they will catch everyone involved in the fraud, how many managers and supervisors inside Federal Government employ will lose their jobs, pensions, and freedom over allowing this fraud to occur? What processes and procedures will be changed to protect against another fraud scheme? Who is personally accountable for contracting that permitted this scheme to bloom for more than a decade?

VA 3 The following VA-OIG report details how clowns and asylum patients run the IT program for the VA and not professionals! The VA was tasked explicitly by legislation to meet several IT deadlines on a program for family caregivers as part of the VA MISSION Act of 2018. Unfortunately, not only did the VA fail to get the IT program up and running on time, missed mandatory reporting deadlines, and delivered a software solution 2-years past due, but the “VA did not establish the appropriate security risk category and fully assessed the system’s privacy vulnerabilities.” Amazing, with all the IT problems the VA suffers from, with all the IS problems the VA suffers from, one would think that, where new technology was concerned, the VA would be practicing better security and using the lessons learned previously.

VA 3 Would someone please tell me why private industries would be sued to the Nth degree criminally and civilly for these IT failures, but the government can evade accountability and responsibility; why? In a representative government, the citizens can, and should, hold the elected representatives and their minions accountable for failing to uphold basic security protocols. So how did the government vote themselves a “Get out of Jail Free” card?

While writing this article, three additional VA-OIG reports have been delivered to my inbox. The newest VA-OIG report discusses a topic that the VA continues to struggle with, namely transparency. Apparently, the goblins in Goblin Town still cannot stomach sunlight and prefer to keep their nefarious deeds hidden. Unfortunately, the lack of transparency in hiring practices leads to more VA-OIG investigations into employee wrongdoing, cost the taxpayers phenomenal fees to rid the government of poor hiring decisions, and all this before the union becomes involved. From the report, we find the following:

“… VHA delegated much of its data reconciliation to its local facilities, which introduced variability in the process and did not allow for consistent creation, maintenance, and verification of information. VHA also had inadequate business processes to ensure quality data were available to support effective medical facility staffing oversight. Without consistent methods and reliable source documents for managing information, VHA cannot be sure HR Smart data accurately reflect VA’s budget and workload requirements.” VA 3

Did you catch that local facilities were given authority, which increased risks in hiring, all while management cannot perform their functions properly? I remain convinced that the VA built designed incompetence into every action to protect themselves from ever being forced to take action. But, unfortunately, like always, the news only gets worse! Plato 2

A little background is needed to appreciate the problem in the following VA-OIG report fully. Coronavirus Aid, Relief and Economic Security (CARES) Act required the VA to report to the OMB how they spent money appropriated for America’s Veterans and the VA during the pandemic. The following is what the VA-OIG found:

“VA met monthly reporting requirements to OMB and Congress on supplemental fund obligations and expenditures. VA also submitted required weekly obligations and expenditures from supplemental funding to OMB by program activity. Of approximately $17.3 billion in medical care supplemental funds, VA reported it had obligated about $7.11 billion and had spent about $5.67 billion by December 29, 2020. The VA-OIG team noted three concerns where VA’s reporting was not complete and accurate: • Obligations were at risk of not being included in VA’s reports. • VA initially delayed the reporting of reimbursable obligated amounts for two months. • VA’s reports contained negative dollar amounts in data fields that should have only positive amounts, which misstated VA’s overall reported obligations. Those concerns indicate weaknesses in how VA and VHA internal controls are structured to meet reporting requirements. Despite the risks identified, VA performed only a limited review at the summary fund level of its COVID-19 obligations and expenditures before reporting. A review of summary funds is not detailed enough to identify potential anomalies and ensure the reliability of externally reported information” [emphasis mine]. VA 3

I did not find this in the VA-OIG report. Did anyone ask why the VA failed to meet the reporting for the first two months? After the FISMA Congressional hearings, everyone knows the VA sucks at information technology and information security (IT/IS). So why was the VA given more money and told to budget it using existing failed software, processes, and procedures? My work in the finance field is limited; however, when a company cannot handle its finances properly and meet legal obligations, a third-party accounting firm can be hired to handle this for the organization. OMB, why are we not using this solution at the VA? OMB, why is a third-party auditing company not conducting in-depth analysis and audits of the VA? With all the missing taxpayer dollars at the VA and Department of Defense, it seems that you are just as negligent as the agencies you are supposed to monitor.

Theres more As they say on the Home Shopping Network, “But wait! There’s more!” Unfortunately, the same holds of the VA, just without the enthusiasm! Each VA Medical Center in the Department of Veterans Affairs – Veterans Health Administration (VHA) is expected to have supplies, also referred to as caches, on hand at all times to handle local emergencies and national health care incidents. For example, a pandemic! The VA-OIG investigated these prepared caches and found that only 9 of 144 supply stockpiles were ever mobilized. The excuses, oh these excuses, are like butt holes, everyone has one, and they stink!

1. 1. “Medical facility directors reporting supplies were not needed or caches lacked sufficient quantity for meeting pandemic demands.”
  2. “The Veterans Health Administration (VHA) changed the process for mobilizing caches during the pandemic, but without clearly communicating it to medical facility directors” [emphasis mine]. – We have the blind leading the blind, in a darkened room, in a London fog!
  3. The VA-OIG, not the VHA, not the local VAMC, but the inspectors “identified problems with cache maintenance and monitoring.” – Never forget, this is a job of several people, overseen by a director, who reports to facility leaders, and inspectors had to find the maintenance and monitoring problems. Just let that sink in for a minute!
  4. “Most caches contained some expired or missing personal protective equipment, diminishing their ability to support pandemic preparedness.” – This is an example of how the VHA is “Defining Excellence in Healthcare!”
  5. The “VHA had incomplete documentation on cache activations, making it difficult to know which caches would need to be restocked.” – See item number 3 above.
  6. “Medical facility leaders were not always able to accurately report if their facility’s cache was activated during the pandemic.” – Is the proof sufficient that the VA leadership IS the problem with the VA; yet?

In the US Navy, a significant part of my job was to maintain and monitor emergency supplies. Additionally, to use and cycle through reserves during drills and replenish those supplies quickly and efficiently not to impair the ship’s ability to protect itself 24/7. I did my job well enough to earn three people Navy Accommodation Medals. I took over the emergency stores, and all consumable supplies were expired or consumed. Within 3-months, I was winning accolades and awards. Yet, 144 caches of emergency supplies for the VHA need more procedures, more documentation, and more oversight to fulfill the mission correctly.

Knowledge Check! I beg to differ!!! We need leadership, active, engaged, enthused, leadership! We need the medical facility leader to stop designing incompetence and do the job they have been hired to perform. We, the taxpayers, need the oversight instruments of the Federal Government to become a lot more effective at demanding results. We desperately need the elected officials we have hired to scrutinize the government! Just imagine if you hired someone to perform a mission-critical job, and in the middle of needing emergency support, the person hired reveals, “Oops, I might not have done my job properly.” How fast would that person be fired? Now, why can we not do the same to the government employees?

So, ask yourself, do you feel represented by your government?

© 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: Memorial Day 2021 – Are you sure this is “proper” remembering?

Knowledge Check! It is no secret that the Department of Veterans Affairs (VA) is a sick and twisted organization. It is no secret that the Department of Veterans Affairs – Office of Inspector General (VA-OIG) tries to recommend how the VA should be operating in accordance with currently established procedures, methods, and policies for the benefit of the veteran community. It is no secret that I continue to write about the VA in the hopes of sparking interest in communities and obtaining more fair, honest, transparent, and humane treatment for veterans by the Government agency tasked with caring for veterans.

On this Memorial Day, as you sit down to barbecue, family, friends, sports, I would ask that you take a moment and consider if this were how you would like to be remembered? Are the actions described proper for remembering those who sacrificed and came home? Are these actions, which are adding to veteran funerals, an appropriate way for veterans to be leaving this world? If the answer is no, I ask for your help changing the Federal Government by electing people who will scrutinize the government more stringently and demand change in all government agencies. If you deem this behavior acceptable, please leave a comment detailing why you think so. I want to hear your thoughts.

From a VA-OIG report published on Wednesday 26 May 2021, we find the following announcement:

“Phillip Hill, a former VA program analyst, was sentenced to 46 months in prison for stealing personal information from veterans and VA employees while employed at the Central Arkansas Veterans Healthcare System. The investigation revealed that Hill contacted another individual and attempted to sell personal identifying information to a buyer for approximately $100,000.”

Now, I am thrilled this guy was caught. I am glad he will do time behind bars. Yet, why did Assistant US Attorney Jana Harris allow a plea deal? Where are the VA supervisors who should have been monitoring this employee’s work and behavior? What are the details of the deal? The VA continues to have nothing but IT/IS security, and these problems are decades old. Still, the elected representatives allow the criminal behavior to exist until the criminal is caught, and then the elected representative’s crow about cleaning the swamp. Is this how you correctly remember veterans, their sacrifice, and their memories? VA 3

I suppose the following VA-OIG report, released 27 May 2021, should begin with congratulations. The Department of Veteran Affairs – Veterans Benefits Administration (VBA) mostly processed monetary proceeds records accurately. However, the following continues to astound and amaze me:

“Service and pension center staff do not have timeliness measures for proceeds incorporated in their performance standards. Setting a timeliness standard would help encourage the closing of these proceeds. The OIG also found that ineffective monitoring contributed to delays in handling proceeds. The Debt Management Center had only limited internal monitoring but instituted new practices for monitoring proceeds in February 2020, shortly after this audit began” [emphasis mine]. VA 3

Why are government employees not held to a productivity and quality standard? Being a veteran with regular concerns involving the VBA, I cannot help but wonder why quality and productivity are not required? As an industrial and organizational psychologist, the first step in improving responsiveness to customers is to increase productivity and implement quality measures. I know the Federal Government’s legislative branch, e.g., Congress, has insisted on developing quality measures. Yet, the same tired excuses built upon designed incompetence are allowed to survive, and all the VA-OIG can do is issue more recommendations. Consider something; proceeds include payments to dead veterans. How much financial hardship occurs at the passing of a loved one? How much more difficult can that death become when months down the road, money spent is suddenly being demanded back because some incompetent bureaucrat failed to do their job in a timely manner?

Question Is this properly honoring and remembering the veterans and their sacrifice? Is this behavior acceptable in your workplace? Why do we allow this behavior from government workers?

While never having been a patient at the Chillicothe VAMC in Ohio, I have friends who are patients. The stories they tell about care there would shock and amaze many. What infuriates me, the VA-OIG just published their report of a comprehensive inspection of this VAMC, and the results are as tragic as a veteran’s death! The information was released to the public on 27 May 2021. Never forget, the Chillicothe VAMC in Ohio was recently investigated for improper cleaning and sterilization procedures, as well as employee monitoring for compliance for medically reusable equipment, which for this case refers to endoscopes. With this fact in mind, let us review the comprehensive inspection report.

Limitations on findings:

- - “The VA-OIG held interviews and reviewed clinical and administrative processes related to specific areas of focus that affect patient outcomes. Although the VA-OIG reviewed a broad spectrum of processes, the sheer complexity of VA medical facilities limits inspectors’ ability to assess all areas of clinical risk” [emphasis mine].

VA 3 The statement provided here is pretty standard and represents the first limitation to the scope of the investigation; complexity limits inspector ability. Yet, who made the VAMC so complex, the VA. Who has allowed the complexity to grow as designed incompetence, the VA? Why is the VA allowed to cheat their inspector general through complex operations which limit inspector ability and increase patient risk?

The Focus of Inspection (Investigation Scope):

- - The VA-OIG team looks at leadership and organizational risks, and at the time of the inspection, focused on the following additional areas:
    - - COVID-19 pandemic readiness and response
        
        Quality, safety, and value
        
        Medical staff privileging
        
        Medication management (targeting long-term opioid therapy for pain)
        
        Mental health (focusing on the suicide prevention program)
        
        Care coordination (spotlighting life-sustaining treatment decisions)
        
        Women’s health (examining comprehensive care)
        
        High-risk processes (emphasizing reusable medical equipment)

Why Long have I wondered why the second item in the comprehensive inspection is “Quality, Safety, and Value.” When the VA continues to present the bare minimum of quality, disregards patient safety, and due to complexity, offers less value than a broken wrench to a mechanic, but I digress.

Finding One: The VA-OIG issues 12 recommendations to the leadership team, and “selected results showed respondents were generally favorable the national VHA results.” I have been accused of being cynical, which generally is wrong. However, when I see words like “selected results” in an investigation into patient care and concerns, I have to ask, “How hard did the VA-OIG have to dig to find favorable results?” VA 3

Finding Two: Strategic Analytics for Improvement and Learning (SAIL) represents a value model to help define performance expectations within VA. This is the standard language for comprehensive inspections. “In individual interviews, the executive leadership team members were able to speak in-depth about actions taken during the previous 12 months to maintain or improve organizational performance, employee satisfaction, or patient experiences.” If we accept this as a true statement. How was an employee able to fake documents, fail to clean reusable equipment properly, and repeatedly get away with this abysmal behavior at this VA?

Finding Three: Under Quality, Safety, and Value, we find the following tidbit:

“The VA-OIG noted concerns with protected peer reviews, utilization management, and root cause analyses.”

Essentially meaning there are problems with whistleblowers, privacy protection, retaliation against whistleblowers, proper utilization of policies and procedures, and the leadership could not find a problem using root cause analysis if their lives depended upon it. The source for my interpretation of the VA-OIG results arrives from the following:

“VHA Directive 1117, Utilization Management Program, 8 October 2020. Utilization management involves the assessment of the “appropriateness, medical necessity, and the efficiency of health care services, according to evidence-based criteria” [emphasis in the original report].

I have to ask the VA-OIG whether these findings were before or after the employee who endangered patient lives through improper cleaning and sterilization of reusable medical equipment were discovered?

Finding Four: Under medication management, we find the following:

“The VA-OIG team observed compliance with many elements of expected performance, including pain screening, aberrant behavior risk assessment, and documented justification for concurrent therapy with benzodiazepines. However, the VA-OIG identified opportunities for improvement with urine drug testing, informed consent, patient follow-up after therapy initiation, and quality measure monitoring” [emphasis mine].

Vaccine If you read any of the comprehensive inspection reports, you will see this is a common and recurring theme at the VA. Some of the medication policies are being followed, but the same problem with drug testing, informed consent, patient follow-up, and quality measuring monitoring always remain a problem. It is almost as if the SAIL learning matrices do not even exist as a quality improvement tool.

Finding Five: Under High-Risk Processes, the VA-OIG report claims the following:

“The medical center met the requirements for quality assurance monitoring and monthly continuing education. However, the VA-OIG identified deficiencies with standard operating procedures, an airflow directional device, and staff training and competency” [emphasis mine].

Are the SAIL metrics even accurate? Where is the value in the “monthly training and monitoring if there are issues in following standard operating procedures, problems in staff training, as well as staff competency? Do you get it? The training sucks at the VA, and the SAIL metrics do nothing to fix the problem, address the deficiencies, or even improve competency? The same question arises here, from quality, safety, and value; how was an employee able to successfully pencil-whip the paperwork while not doing their job in properly cleaning and sterilizing reusable medical equipment? Where are the SAIL documents that should have identified a problem? Where are the SAIL metrics in aiding in finding root causes for derelict employees? VA 3

Honestly, do you, the taxpayer, consider the Department of Veterans Affairs, which covers the Veterans Health Administration (VHA), the Veterans Benefits Administration (VBA), and the National Cemeteries adequate to remember the veteran correctly? Do you, the taxpayer find value in the leadership and investigative arms of the VA to correct and improve performance? Do you, the taxpayer find that the VA employees are doing their level best to honor, remember, and pass on the legacy of veterans?

On this Memorial Day weekend, please consider the data in this and the other VA-OIG reports regularly relayed on this blog, and ask yourself, are you doing enough to help veterans? I love Memorial Day, and I love my country, but America has some serious problems, and only when the electorate awakens to the issues can real change begin to be implemented. We, the veteran community, need you! We need your voice as we struggle against the incessant attacks from the VA. We need your votes for the elected representative’s intent on scrutinizing the government and demanding action. We need you! Please help us!

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

Question 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.

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. 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!

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

Apathy 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.

Gavel Case 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 Bear Let 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 2 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. 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!

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

Angry Wet Chicken 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.

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. 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 Robot 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, 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 Incompetence Let 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 4 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?

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 Bear America, 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!

NO MORE BS: Information Security Report – VA Administration is STILL Failing!

VA 3 Since the first time the Department of Veterans Affairs (VA) lost my identity, e.g., the unencrypted hard drive incident, I have monitored the VA’s data security practices. Let’s say I have a vested interest in data security, having lost thousands of dollars to identity thieves and having been bankrupted twice! Thus, imagine my surprise when today, the Department of Veterans Affairs – Office of Inspector General (VA-OIG) released the annual audit results of the VA’s information security practices as required by the “Federal Information Security Modernization Act (FISMA)” and saw the VA remains out of compliance! Not just a little out of compliance, but so far out of compliance that they have aged issues that are almost old enough to drink.

Apathy The annual audit is conducted by a third-party, “CliftonLarsonAllen LLP,” who audited 48 major applications and general support systems hosted at 24 VA sites that support the VBA, VHA, and National Cemetery administrations. The VA-OIG reports the following:

“The firm concluded that VA continues to face significant challenges meeting FISMA requirements and made 26 recommendations for improving VA’s information security program. Specifically, VA should address security-related issues that contributed to the information technology material weakness reported in the FY 2020 audit of VA’s consolidated financial statements, improve deployment of security patches, system upgrades, and system configurations that will mitigate significant security vulnerabilities and enforce a consistent process across all field offices. The firm also recommended VA improve performance monitoring to ensure controls are operating as intended at all facilities and communicate identified security deficiencies so the appropriate personnel can mitigate significant risks” [emphasis mine].

Is the connection between application and administration clear? The security deficiencies cannot even get assigned to the right people because organizational communication is ineffective, unclear, and atrociously designed to create designed incompetence or a ready-made excuse for failure! Material weaknesses have been carried forward from one fiscal year (FY) to another since the first breach of data security, e.g., the unencrypted hard drive episode. The administration has a second built-in designed incompetence issue, material deficiencies, even though since 1995, the VA has been “upgrading its IT infrastructure to meet the needs of today’s veterans!” The VA has bragged about how technically up to date they are, but the audit continues to find material weaknesses leading to data insecurity!

Police and Government Lines of Congruence While the VA deserves congratulations on closing two antique audit items, they were expected to close ALL aged items during the 2020 FY. Yet, the administrators were still able to skate responsibility, skirt accountability, and act like Sonja Henie at Oslo. Tell me, if your boss expected you to complete a bunch of items, gave you a full year to complete these items, would you be fired for only completing two items? I know I would! As a project manager, if I didn’t have a plan in writing, showing completion dates, inter-relationships, and explicit action items set up within 30-days of being assigned the tasks, I would have been fired! Yet, somehow these VA Administrators, hired to perform these functions by the Government, cannot even communicate, let alone accomplish tasks assigned! Who were the project managers, contract officers, and program managers, and their respective administration officials, line them up and fire them!

Detective 4 The VA-OIG reports, “Despite VA’s commitment that the recommendations would be closed, some of them have been repeated for multiple years [emphasis mine].” Is the connection between the administration officials, their assigned workers, and the failures and designed incompetence clearly observed? I ask because the VA-OIG closed this report with the most useless conclusion I have seen in years of reading these reports! “The VA-OIG remains concerned that continuing delays in effectively addressing the recommendations could contribute to reporting a material weakness in VA’s information technology security controls during the FY 2021 audit of the department’s consolidated financial statements [emphasis mine].”

Of course, the continued foot-dragging, skating, and designed incompetence will lead to problems in information security, cost veterans their identities and thousands of dollars individually, and continue to make the veterans victims of identity theft! How could you think this would not happen? “Hello!!! McFly, is anyone home?”

Angry Grizzly Bear That the VA administrators continue to hinder improvement at the VA should be grounds for immediate dismissal! Yet, these administrators are allowed to retire with full benefits, cushy benefits packages, and the veteran is left with nothing! Where is Congress in enacting legislation that enables the Government to reduce, remove, or refuse a retirement package for administration employees who cannot or will not act in a manner that reflects competence and ability in following congressional demands and meeting operational standards? Where is Congress working with the VA Secretary on productivity problems caused by administrators who actively hinder improvements at the VA? Why is designed incompetence even allowed as an excuse for failure?

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