More Repugnant VA Chronicles! – When will this Insanity END?

I-CareMonday and Tuesday this week, 28 and 29 June 2021, the Department of Veterans Affairs – Office of Inspector General (VA-OIG) returned three more investigations, inspections, or criminal reports.  While no veteran is dead in this batch of reports (Thankfully!), the behavior exhibited remains egregious and blatantly criminal, and the bureaucrats and bureaucracy remain intact to continue to commit malfeasance, misfeasance, and malpractice!

Before getting into the VA-OIG reports, I want to hand out some praise.  The El Paso VAHCS was the focus of a major problem just a couple of years ago when the VA Police attacked a veteran and ended up pulling his arm out of his shoulder socket.  I am now a patient at the El Paso VAHCS, being seen at the VA Out-Patient Clinics instead of the Las Cruces Community Based Outpatient Clinic (CBOC).  While the fallacious claims of the Phoenix VAMC continue to dog me, I am very happy to report that the VA Police in El Paso were professional, polite, and the customer service displayed was top-notch.  Growth has occurred since the veteran incident mentioned, and I, for one, am grateful!VA 3

The VA-OIG has announced that Dr. Kenneth C. Ramdat has received one year of probation after being allowed to “plead guilty” to touching two women’s breasts without permission.  When the VA is compared to a criminal syndicate, where the administrators are actively against the employees and the patients, I can see the connection!  What else happened at the Louis A. Johnson VA Hospital in Clarksburg, West Virginia, while this doctor was on staff and is not included in the criminal trial?  West Virginia keeps coming up as another morally distressed VA Health Care System; what is the VISN doing to improve the environment for illegal activity?  If Phoenix and VISN 22 are an example, nothing, which is negligence worthy of criminal investigations!VA 3

How can employees trust each other when plea deals are allowed, and behavior worthy of criminal punishment exists?  I was physically attacked, as an employee, by another employee, and the administration swept the incident under the rug.  After being discharged during probation, I learned that the employee who attacked me had done this previously with no punishment and the revelation that the administration was gunning for my removal for reporting the attack.  How many VA Employees lost their jobs before Dr. Ramdat was finally forced to be held accountable for sexual assault?  Why the plea deal?  Doesn’t this plea deal re-injure the victims, the perpetrator got off, essentially?

Sexual assault pled down to simple assault with probation – criminal syndicate indeed!Plato 2

Kristopher M. Voyles’s trial ended with a sentence of 27-months in prison, 3-years supervised release, and restitution of $20,502.  While this is a good sentence for theft of medical treatment, Mr. Voyles was never charged and investigated for the actual crime, identity theft of a veteran!  Mr. Voyles stole the name, date of birth, and social security number of a veteran fraudulently created documents, and then obtained care.  Thus, theft of medical care was criminal activity.  Until we read, “Subsequent investigation revealed that Voyles had previously been prosecuted by Atlanta, Georgia authorities for using the same veteran’s identity to obtain prescription drugs from the VA Medical Center in Atlanta.”VA 3

Do the veterans targeted know that Mr. Voyles stole their ID and used it fraudulently?  How did Mr. Voyles repeatedly target and steal the identities of veterans?  Is the ID Theft related to any VA data breaches, losses of veteran identities, or IT problems consistently occurring at the VA?  Were any of these questions asked during the “subsequent investigations?”  If so, where are those VA-OIG reports?  This criminal intentionally targeted veterans, stole identities, used those identities; how many other veterans’ identities does he have or have access to?  The Department of Veterans created the problem of ID Theft; when will they be held accountable for the loss of ID?  Better still, when will the data theft from the VA end?

Knowledge Check!Our final example (today) for the repugnant and criminal behavior of VA Employees needs a little background to be fully understood for those outside the military and government employment.  In government, contracting officers liaison between the facility receiving goods and services, the government paying for goods and services, and the third-party hired to provide goods or services.  Some third-party contractors receive government-issued identification cards similar to an employee identification card, both of which are called a “Personal Identity Verification” (PIV) card.  These cards act as keys to the facility, prove identification and authorize the contractor to be doing what they are doing.  The contracting officers are the end-all in the responsible party for that third-party contracted vendor.

VA SealContracting officers and third-party contractors act under Federal Regulation called “Federal Acquisition Regulation (FAR).  FAR is like the Bible; it has everything in it outlining duties, responsibilities, and authorities.  Contracting officers are supposed to know the regulations before contracting goods and services, and they teach the contractor their responsibilities.  Especially where a PIV has been issued, the contracting officer, as the liaison, IS THE Responsible Party, not the contractor.

Now, gauge the following VA-OIG report with these facts in mind.

The VA-OIG “… examined a random sample of 46 professional service and healthcare resource contracts. None of the reviewed contracts had adequate evidence to demonstrate FAR requirements were met. VHA contracting officers’ noncompliance with PIV card requirements occurred because they were unaware of their responsibilities and the requirements. In addition, VHA did not have policies or procedures detailing supervisory oversight of contracting officers’ duties regarding PIV cards, the internal audit office did not review compliance, and there was no automated tool for continuous tracking and monitoring of PIV cards issued; to contractors’ personnel.”VA 3

Did you catch that; a 100% failure in a random sample of contracts, contracting officers, and oversight supervisors were unaware of their roles and responsibilities.  How long has this failure been occurring?  How many government PIVs are available granting access to facilities where the contract has concluded?  This is not the first time the government contracting officers and offices have utterly failed to perform their roles and responsibilities; yet, this is one of the most dangerous to the PIV system’s security, safety, and reliability.  This is just an investigation from the VA, how bad is this problem across the entire government contracting establishment?

QuestionI cannot understand how a contracting officer, with all the training, re-training, and refresher training that is mandated, could use the excuse, “I didn’t know that was part of my job!”  As a person who has worked around contracting officers, I knew this was their job, and I am not a contracting officer.  It is simply common sense; if you facilitate obtaining identification, keys, and access codes, you are responsible for getting these things back!

While the behavior of the contracting officers is part of the problem, the culture of passing the buck and dodging responsibility is readily apparent in the following statement from the VA-OIG list of recommendations.  “The OIG also recommended VHA assess whether the existing and planned information systems could have the functionality to allow effective and routine monitoring of contractors’ PIV cards or a new system is needed.”  Designed incompetence will allow the IT failure to be the problem, to finagle more money from Congress for IT infrastructure upgrades and new systems, as the legacy systems were purposefully designed not to accommodate regular, daily, routine activities!VA 3

I refuse to believe the VA has ever designed a system that works, is cost-effective, does its job, and can be useful.  Why; because, having worked at the VA, been a patient at VAMC’s across the country, and reading the VA-OIG reports, the VA has proven their utter incompetence!  If a local hospital allowed this type of failure in their contracting department, heads would roll, and Congress would be demanding investigations to ensure HIPAA was not breached.  Yet, the VA can get away with murder, and Congress cannot even care, let alone issue a mild rebuke or increase scrutinization.

Angry Wet ChickenThus, I call upon every American to share my disgust and demand action!  Stop allowing this detestable behavior, paid for by taxpayers, to thrive.  End the abuse!  Not just for veterans harmed by the VA bureaucracy, but for your hard-earned tax dollars and the disrespect the elected officials display towards you, the boss!  Tell me, if your employees displayed the same behavior witnessed by elected officials and bureaucrats of all stripes, how long would they keep their jobs?  If your boss showed you the same disrespect, how fast would you be looking for new employment and telling everyone not to apply there?  Now, answer this question, “Why do we accept this abuse by government officials and elected representatives?”

© 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.

Symptom, Not Disease – A VA Chronicle

Carl T. Hayden10 December 2020, The Carl T. Hayden Phoenix VA Medical Center (VAMC), I was arrested for the third time, hassled for the fifth time, and injured for the third time at the hands of the VA Police over my physical inability to wear a mask. The zealous supervisor of the COVID Screening staff threw a fit, for the second time (first in October, again in December), when I asked him about his authority to refuse me care at the VA under EMTALA. Thus, for the third time, I have been denied emergency care under EMTALA by the Phoenix VAMC. I was taken to Holding Cell 2, where multiple officers of the VA Federal Police Force decided that making jokes about my injuries, claiming I was faking my injuries, and insisting they knew more about my injuries than my doctors was an acceptable VA Policing policy. Major Kratz is the bitter cherry on this “crap sundae,” by entering the room, shaking his sausage-like finger in my face, and accusing me of lying about having created an action plan with Jennifer, the supervisor of Patient Advocacy. A symptom, not the disease!

The Department of Veterans Affairs – Office of Inspector General (VA-OIG) has made some startling reports to Congress. Consider, “U.S. Attorney Justin Herdman announced on 20 November 2020, that a grand jury sitting in Cleveland has returned a 28-count indictment charging William H. Precht, age 53, of Kent, Ohio, with theft of government property, conspiracy to commit wire fraud and honest services fraud, wire fraud, and false statements relating to health care matters.” Let me stress; the defendant remains innocent until proven guilty in a trial of his peers. Still, I also stress this incident cost the Department of Veterans Affairs (VA) more than $1,066,348. The scheme was in place from 2010 to 2019, is but another symptom, not the disease, endemic to the VA.

The VA-OIG continues to report, “the owner of a for-profit trade school has been charged with defrauding the U.S. Department of Veterans Affairs and student veterans, announced U.S. Attorney for the Northern District of Texas Erin Nealy Cox.” The defendant, who remains innocent until proven guilty in a court of law by a jury of his peers, defrauded veterans seeking education to the tune of $71 million in GI Bill benefits from the VA and is facing up to 184 years in federal prison. Symptom, not disease, and the VA is full of this type of rot.

VA SealI would never expect a person to believe that the entire VA is full of these symptoms from three examples. Consider that electronic wait-lists, and wait-lists in general, has been a leading cause of death for veterans awaiting care and that the Phoenix VAMC has been in severe trouble on this single issue twice in recent years. Yet, the VA-OIG found, “… wait-list entries were not reviewed and validated as required. Patients were not removed from the wait-list when appropriate, indicating that employees at medical facilities did not review entries daily, and supervisors did not validate the wait-list weekly.” Supervisors not doing their job to oversee work is appropriately performed is the symptom that led to the first two incidents reported in this article. Again, symptoms, not disease.

Another recent example that was buried in “COVID-Media Hysteria,” “Ergonomic office furniture maker Workrite Ergonomics LLC, a Delaware company, and its parent, Knape & Vogt Manufacturing Co. (collectively, Workrite), have agreed to pay $7.1 million to resolve allegations under the False Claims Act that they overcharged the federal government for office furniture under General Services Administration (GSA) contracts, the Department of Justice announced on 3 December 2020.”  This settlement is over a contractual obligation clause to lower prices. “The settlement resolves allegations that Workrite did not fulfill its contractual obligations to provide GSA with accurate information about its commercial sales practices during contract negotiations and did not subsequently extend lower prices to government customers as required by the GSA contract’s price reduction clause.” Not mentioned here are the VA Employees whose job is to monitor the purchases made under the contract, ask questions during contract negotiations, and oversee the contractors and purchasing contracts. Fascinating that the employees responsible for catching these issues early never seem to be held liable for their failures to perform the jobs they have been hired to perform. Symptom, not the disease.

Speaking of symptoms, where supervisors and employees are not performing their jobs properly. “U.S. Attorney Andrew Murray announced on 2 December 2020 that John Paul Cook, 57, of Alexander, N.C. is facing multiple federal charges for defrauding the U.S. Department of Veterans Affairs (the VA) by receiving veteran benefits based on fraudulent service-connected disabilities from 1987 to 2017.” Thirty-years of VA Disability payments, but no VA employee ever asked if he had a driver’s license or other proof of disability. How is this possible; symptom, not disease!

Military Crests“A Florida attorney, on 1 December 2020, admitted his role in a scheme to extort $7.5 million from a California bank, Attorney for the United States Rachael A. Honig announced. Richard L. Williams, 73, of Miami, Florida, pleaded guilty by video-conference before U.S. District Judge Susan D. Wigenton to an information charging him with conspiracy to transmit an interstate communication with the intent to extort.”  Symptom, not disease!

“A Michigan woman was sentenced on 4 December 2020, to three years and five months in prison after pleading guilty to carrying out a scheme to defraud the U.S. Department of Veterans Affairs (VA) of more than $1.7 million in veterans benefits, announced U.S. Attorney Nicholas A. Trutanich for the District of Nevada.” Where were the IT and IS Controls to check for doubled veterans claims? Where were the employees asking for more information when blood types and other medical records mismatched? Administrative controls at the VA are a symptom, not the disease, and the VA Employees who have aided and abetted in allowing this type of trickery need to be held accountable.

Consider the following quote “VA employees are public servants with a solemn duty to care for our nation’s veterans,” said David Spilker, Special Agent in Charge of the VA OIG’s Southeast Field Office. This quote comes from the following case of fraud where the defendants have pled guilty. “Miller Wilson, Jr. (50, Sparr), his daughter, Myoshi Wilson (26, Citra), and his ex-wife, Erica Wilson (43, Ocala) were sentenced today by Senior United States District Judge James D. Whittemore for their roles in a scheme to defraud the U.S. Department of Veterans Affairs health care benefits.” The VA Employee Miller Wilson, Jr., was in charge of VA Payments for non-medical transportation. He established a company to transport VA Patients, received kickbacks for steering work to other companies, and got the other two family members involved in the scheme. Where was his supervisor during all of this “irregular behavior?” Symptom, not the disease.

ProblemsThe VA’s disease comprises numerous large organizations, especially those in the government sector, disconnections between leadership and front-line service providers. This disease goes by several names, but all have the following characteristics:

    • Lack of training
    • Lack of supervision
    • Lack of interest
    • Lack of caring
    • A socially shared sense of entitlement

Frankly, the disease is apathy, compounded by generations of knowledge in protecting oneself to the detriment of all others, including other employees. For example, as an employee, I was physically and verbally assaulted by a senior employee. When another employee and I complained of the maltreatment, the assistant director gave patently false information on how to report the problem, promoted the employee doing the assaulting, and then castigated those who reported this employee’s malbehavior. As the behavior intensified, the director became involved and used other employees on a quid pro quo to remove everyone who reported the employee doing the assaulting.

I-CareBecause this behavior is so ingrained, it has become a defining characteristic and is part of the organizational design. Correcting this behavior requires the same tactic used in pruning trees. Start small, get a core group of people who can work, act, and lead.

  1. Start in the local clinics and hospitals, for the Veterans Benefits Administration and the National Cemetery. Start local, where the worst rot is the most visible.
  2. Write down processes, procedures, operational standards, and behavior guidelines. Once written, begin training, publishing, and speaking about this new managerially acceptable behavior by first living these behaviors.
  3. Start setting organizational examples as fraud and malfeasance raise their heads, remove those involved, promote from within, and train the new leaders using the small core group as mentors.
  4. Cut out the obviously poor growers, first. For example, remove employees for cause, and publicize why. While publicizing why they were removed, communicate the new standards of managerially acceptable behavior.
  5. Train, train, and train. That training is a powerful organizational behavior, cannot be stressed enough. Set exacting standards, do not deviate for the easy and quick, and train others to meet those standards. Training includes mentoring and coaching. Use this opportunity to train, mentor, and coach as tools for encouraging managerially acceptable behaviors that meet the new standards, which begins new growth when the old rot is removed.
  6. Be Brave! Change in an organization requires the same type of bravery that wins soldier medals in battle. Standing when you want to sit is key to pushing back against organizational cancer represented in the current leadership.
  7. Do not quit! Too often, the VA has good intentions, uses valuable marketing tactics, and then drops the delivery ball, and the desired organizational change fizzles. Why does the change fizzle; because the leaders tasked with implementation run out of steam before the entrenched management runs out of excuses. Ending this requires smaller steps and people invested in making the change happen.

Image - Eagle & FlagThe VA has become detestable and is absolutely failing in the VA’s mission, as President Lincoln provided. Get outside the regular hiring pool, demand legislation that allows for change, and begin to prune. The veterans in America are counting on you, the leaders of the VA, to act! Do not let these veterans die because of your apathy and fear!

© Copyright 2020 – 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.
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