I fully admit I got behind in April. Dear reader, my apology. I have been whipsawed between emergency room visits, depression, extreme pain, and other issues. Not offering an excuse but a tiny peek into my world as a disabled veteran. Luckily, I have maintained employment because my employer allows me to work from home. My driving privileges are threatened again with removal due to the neurological issues I suffer, and this will dynamically change my life, but this article is not about me, but the continued catastrophe called the Department of Veterans Affairs (VA) and the Inspector General (VA-OIG) reports published.
We begin with a financial efficiency review reported from the inspection of the Durham VAHCS of North Carolina. I know the jokes write themselves when we discuss any government agency and financial efficiency, but I digress. This is a head exploding report of leadership failure in the observation and governance of employees who did not perform the functions they were hired to perform. The VA-OIG found the following from October 1, 2020, through March 31, 2021:
- The healthcare system had 309 inactive obligations totaling $81.7 million.
- Of these 309 obligations, 200 (totaling over $74 million) had no activity for 181 days or more.
- In a subsample of 20 obligations, VA staff had not reviewed 17, as required.
- Contrary to VA policy, healthcare system staff used purchase cards instead of contracts for 21 of 40 sampled transactions (53 percent), totaling approximately $328,000. These 21 transactions were missing required supporting documentation to verify that the transactions were approved and payments were accurate, resulting in $308,000 in questioned costs.
- 105 more administrative full-time equivalent staff than the expected number, all not doing their jobs as required under Federal Law!
While not all of the findings, those mentioned are the most egregious and in need of corrective action. Would the citizens of Durham, North Carolina, please tell me, has this been reported in the local news? Has anyone lost their jobs as the VAHCS right-sizes the financial department? I can find no additional information that this problem has been corrected, and I am really curious!
Oh, the irony is thick; consider the following:
“The Department of Veterans Affairs Office of Inspector General Training Act of 2021 would help ensure that VA employees continue to be empowered to assist the OIG in improving VA’s operations and using taxpayer dollars to the greatest effect; helping protect patients and improving their care; and ensuring veterans and others receive services and benefits for which they are eligible.”
The above-quoted material originates from Chris Wilber, who testified to Congress’s HVAC Subcommittee on oversight and investigations. What is the number one failure on every comprehensive healthcare inspection (CHIP); the lack of staff training, the inadequacy of staff training, or adequately trained staff. Yet, the statement by the VA-OIG indicates that training has met a threshold for providing adequate training. Let’s talk about a specific action, “the VA secretary signed a directive in September 2021 mandating that all employees complete a one-time training within one year—an important step in improving VA’s culture of accountability.” It is now May 2022; the VA-OIG is pushing for training directives to be legislated, not dependent upon any single VA Secretary. Are you freaking kidding me? Where is the congressional oversight and scrutiny that allows VA training to continue to be subpar and threaten the lives of veterans?
Long have I wondered how the VA could frustrate VA-OIG actions, investigations, inspections, etc. Guess what; the answer has become available:
“… there have been instances in which the OIG has been informed that staff have been told that they cannot share information with OIG investigators without first clearing it through supervisors or leaders—contrary to the Inspector General Act of 1978 (the IG Act), as amended. Under that authority, VA employees at all levels have a duty to cooperate with OIG personnel, including providing information and assistance in a timely manner.”
Employees have been caught lying to the VA-OIG regularly, and what action is taken to remove those employees promptly and efficiently from government service? From direct observation and employee conversations, it is clear that plans are carefully laid before a scheduled VA-OIG visit to present what the VA-OIG wants, but to gloss over the problems, and nothing ever happened to the managers, supervisors, and employees who lied and misdirected the VA-OIG. All contrary to established Federal Law!
Want a specific example of employees intentionally misrepresenting information to the VA-OIG? Look no further than the statement by Chris Wilber, and this incident was covered as a failure of leadership in a previous article.
“Hospital staff at a VA facility in Fayetteville, Arkansas, had concerns about potential substance abuse by the chief of pathology that were not heard and promptly acted on by local management, which allowed him to work while impaired for years. He misdiagnosed about 3,000 patients with errors resulting in death or serious harm and is currently imprisoned. The OIG found a culture in which staff did not report serious concerns about the chief pathologist, in part because they assumed that others had reported him, or they were concerned about reprisal.”
From personal experience, I reported problems to the VA-OIG concerning patient abuse, fraud, waste, and other issues. Never were my concerns acted upon promptly, and I was removed from employment for being a whistleblower. The culture of corruption at the VA is incredible. The examples mentioned by the VA-OIG only further sustain the problem with leadership and how sick the VA truly is as an organization!
We next turn our attention to the VA-OIG report on the inspection of information technology security at the VA Financial Services Center, another head exploding example of leadership failure bordering on criminal! The findings include:
- component inventory
- vulnerability management
- flaw remediation
- Identifying 252 vulnerabilities, of which 228 the local IT team could not identify.
- the VA-OIG team identified access control deficiencies, as 107 of the 278 FSC systems failed to generate or forward audit logs for analysis.
- the video surveillance system was not fully functional. Ineffective monitoring and recording facility activities supporting information systems minimize the FSC’s incident response capabilities.
How do you spell failure; these findings spell failure to me rather pointedly and dramatically! Want to laugh; staff training remains a concern, but not a finding, of the VA-OIG inspection team. Frankly, with this level of incompetence, staff training should have been a finding.
To be concise and illustrate further the poor leadership, convoluted processes, and brazen noncompliance of VA officials, the following discussion is about two different VA-OIG reports that reached similar conclusions. First, we have the VA-OIG report on “Noncompliant and Deficient Processes and Oversight of State Licensing Board and National Practitioner Data Bank Reporting Policies by VA Medical Facilities.” Second is the VA-OIG report on “Concerns with Consistency and Transparency in the Calculation and Disclosure of Patient Wait Time Data.” Nothing says convoluted processes more than having two written policies, both originating from Washington DC. The superseded policy does not have an expiration date. This means that employees have a designed incompetence excuse ready for not adhering to the most current and applicable policy. Don’t believe me; one of the key findings was, “VHA has presented wait times to the public without clearly and consistently disclosing the basis for their calculations.” Designed incompetence does not come more blatant than this, and who suffers, the veteran. Worse, wait time correction and policy clarification has been stalled by COVID-19, the neverending excuse paying dividends to bureaucrats everywhere!
However, both reports are substantially summated by the VA-OIG; thus, “The lack of programmatic oversight contributed to the failure of VHA leaders to detect and intervene upon facility noncompliance.” Meaning that due to COVID-19, the VHA has refused to do their jobs in deference to the pandemic, and since this is a good enough excuse, the VA-OIG has bought the designed incompetence, lock, stock, and barrel. The VHA leadership is failing; doctors or dentists let go for poor performance were not reported to state and federal boards, so these providers lacking can continue to harm patients. It is a federal law (42 US Code § 11151, US Department of Health and Human Services, Health Resources and Services Administration Bureau of Health Workforce, NPDB Guidebook, October 2018, chap. A., 8 USC ⸹ 7462(a), 38 USC ⸹ 7401(1), among others) that providers let go for cause must be reported within 7-days to the regulatory boards at the state and federal levels. Wait times are hidden because they are so bad; the VHA is embarrassed, so the leaders fall back on designed incompetence to shield themselves while looking for another excuse for poor performance! In both reports, the ramifications of noncompliance are putting people at risk for sentinel events (death, injury, disability, etc.), and the leadership is at best lackadaisical in the performance of their duties.
Where are the congressional overseers in ending the abuse? When will this insanity and bureaucratic inertia end? How many “sentinel events,” including deaths and permanent injuries, will it take until those tasked with scrutinizing the executive branch finally take committed action and hold people accountable? When will the elected representatives stop throwing good taxpayer money at problems that money cannot fix? If these questions are too difficult to answer, please stop running for elected office, for the citizenry is not happy!
We conclude with two related reports so astoundingly obtuse they defy logic and sanity. The first is the annual CliftonLarsonAllen LLP (CLA) audit of the VA’s information security for 2021. The second is the continuing failure of the new electronic health record modernization (EHRM) program. The VA has failed the CLA audit for more than a decade, with many of the hits repeated year-over-year. In fact, the CLA audit is so bad this year; it has taken my mental breath away and stunned me into a gibbering idiot! Reading this report was infuriating; describing it as my head exploding is akin to comparing an M-80 to a nuclear bomb. How in Dante’s Inferno can this level of incompetence be allowed to remain employed? But, as bad as the CLA audit is, the continued failure of the new electronic health record system pales in comparison. The new EHRM continues to suffer from reliability weaknesses, which is polite speak from the VA-OIG for the new system fails to do the job. We are three years from the new extended deadline, we are already past the original deadline, and the system is worthless today than it was a year ago. With this success rate, the new EHRM will be utterly bereft of value and need replacement before the year’s end. How many millions (billions, or trillions) of good dollars must chase this ineptitude before the plug is pulled and those involved held accountable?
Join me in having your head explode:
“Additional deficiencies included known tasks not being reflected on schedules, no risk analysis, lack of longer-term actions scheduled, and no complete baseline schedule or overall schedule that fully integrated individual project schedules. VA also did not comply with federal regulations when it paid its contractor for deliverables before accepting them (reviewing compliance with contract requirements).”
Consider this other gem from the VA-OIG report, “$1.95 billion in cost overruns per year” are estimated, meaning the final tab will be significantly higher and compounded year-over-year. In plain speak, the contractor is being paid for products delivered that fail, the products offered are not usable, there is no schedule of completion, there is no schedule for deliverables, many of the products paid for have never been delivered, and costs are overrunning like a plugged toilet. Worse, no one is being held personally liable for these problems, which were apparent in the last EHRM update from the VA-OIG a year ago! Like the CLA Audit, I am thrilled the VA agrees with the VA-OIG findings, but what are they DOING to fix the problems?
FYI: the image below is a year old, and comes from the last major update to the EHRM.
There is no excuse for behaving like the VA’s bureaucratic legions behave. Bureaucrats, from the city government (including the school board) to the Federal Government, you hold a sacred trust to act better than you are currently performing. I refuse you any leeway for acting like pompous overlords when you are paid through forced taxation! You have trespassed upon my patience and kindness long enough, and the day of reckoning has arrived. You work for me; you work for every taxpayer and citizen in this country, and you have violated our trust, charged us too much and too often, and if you do not begin to show yourself worthy of the sacred trust, we will force you from your cushy jobs and hold you liable for the monies you have squandered! The law is on our side; you need to begin showing you honor our trust and investment forthwith!
© 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.