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!
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.”
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.
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!
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.”
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!
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.
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!
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?
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?
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
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