Weep America! – The VA Leadership is Becoming Worse! – Part 3

I-CareIn 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 2What 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 2Adding 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 4I 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 BearAnytime 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 3In 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 3The 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 3Would 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 moreAs 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. “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?VA 3

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.

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

Question24 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. 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!VA 3

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

ApathyBy 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.

GavelCase 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 BearLet 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 2Did 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!

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

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

Angry Wet ChickenOne of the first rules in overseeing junior people working is to make available someone to answer questions, immediately, and render support if needed.  I have had the pleasure of training junior people in a myriad of tasks over the years.  When I read this Department of Veterans Affairs – Office of Inspector General (VA-OIG) report, a plethora of questions arise, and I deeply question the professionalism and competence of the doctor overseeing the work of residents in a VA Hospital who are performing procedures.

  • Ophthalmology Resident Supervision – Important to note, the patient did not experience any long-term loss of sight over this issue. Congratulations to the resident and the other ophthalmology doctors present!  From the VA-OIG report we find the following:

“… The subject ophthalmologist failed to provide adequate resident supervision and entered inaccurate documentation related to supervision for a single patient case.”  Essentially, the doctor charged with overseeing residents was AWOL, and then compounded his error by falsifying patient records.  The VA-OIG report continues by claiming this falsification was the result of an oversight when using pre-recorded notes for patient files.

Draw your own conclusions.  Personally, I think this doctor needs to be released of all duties where overseeing residents is concerned.  I would also question his ethics and morals for falsifying patient records.  You hold a double position of trust, first as a doctor, second as a teacher and leader of residents, and the behavior witnessed should come with steep repercussions professionally!VA 3

Knowledge Check!On the topic of professional duties, and steep repercussions, drug interactions killed a veteran at the Marion VAMC in Illinois.  Before launching into the VA-OIG’s report, please allow me a moment of your attention.  Drug interactions can arise due to vitamin usage, over-the-counter medications, and from illegal and legal but illicit drug use.  Often, I have claimed that people are walking chemistry experiments, and even vaccines need to be carefully evaluated for drug interaction potential.  Foods can cause drug interactions due to the chemicals in the food.  Drug interactions are a growing problem and every medical professional I have spoken to admits drug interactions are becoming worse by the day.  I do not say this lightly, but I do not hold the medical professionals as fully competent in fighting the drug interaction problem due to the amount of chemicals the average person interacts with daily.  The problem is Big-Parma and the continual push towards more specialized medicines, we are going to see more drug interaction issues.  Unfortunately, drug interaction issues come with the risk of death!

From the VA-OIG report we find the following:

The VA-OIG substantiated that high cholesterol contributed to the patient’s death; however, the death certificate indicated that the primary cause of death was accidental acute multi-drug intoxication. The psychiatrist and staff failed to document providing the patient with education during a telephone encounter regarding potential side effects or adverse drug-drug interactions of medication changes. Contrary to clinical guidance, the psychiatrist prescribed long-term benzodiazepine use for a patient diagnosed with posttraumatic stress disorder. The psychiatrist also failed to address the patient’s two negative urine drug screens for a prescribed medication and failed to address a positive urine drug screen for cannabis. Due to COVID-19, the facility failed to launch the Psychotropic Drug Safety Initiative Phase Four Plan. The primary care provider did not comply with facility policy by failing to enter a return-to-clinic order following an appointment but could not determine if this affected the patient. Primary care and behavioral health staff did not comply with facility policy to telephone the patient or send a letter after the patient missed appointments” [emphasis mine].

The lack of staff to follow procedures and do their job, I will certainly hold them accountable for, especially since Cannabis is involved!  Please do not believe that Cannabis is a non-toxic drug, especially when mixed with other drugs, it can be the fatal trigger in a multi-drug intoxication!VA 3

At 18, low those many years ago, I took the EMT-Basic class, but left for US Army Basic Training before I could certify.  Since then, I have received certification as a combat medic and a Journeyman Firefighter (Any industry) which required a lot of hours studying emergency medicine.  I am experienced in drawing blood, starting IVs in difficult circumstances, and handling a myriad of injuries.  I am not a medical professional by any stretch of the imagination, I simply have a healthy desire to learn, and emergency medicine is a fascinating topic I regularly pursue.  I am not a chemist; I rely upon peer reviewed resources and legal and medical websites to stay current on a host of topics.  With this as my qualifier I am going to make several statements and you can judge their merit.  Feel free to comment.

      1. The first rule of medicine is document everything! My first lesson, first day of EMT training, this point was driven home.  If you do not write it down, it never happened!  Yet, what does the VA-OIG find time after time in reviewing cases at the VHA, lack of documentation of steps taken!  Can you say, “Asinine and abysmal behavior by credentialed professionals?” I know I can!
      2. Aspirin and Alcohol can cause a drug interaction that can be deadly. Both chemicals are readily available in the home and over the counter.  Why is spray paint now requiring proper ID, because people are huffing the stuff and getting a multi-drug intoxication.  Oven cleaner and spray pain can cause serious breathing issues and when mixed together can cause a cheap high, as well as a multi-chemical intoxication leading to breathing paralysis and death!
      3. Cannabis continues to be modified, changed, enhanced, and designed to trigger different chemical reactions in the body. Continuing work that began in earnest in the 1960s for the pot-smokers who wanted a more serious high.  Guess what, cannabis and aspirin along with vitamins can cause multi-drug intoxication problems leading to death!
      4. Vitamin D and Vitamin C have both caused serious drug intoxications during COVID-19. People became frightened and took too many of both or just one and wound up in the ER with life-threatening health problems from toxicity of these vitamins.  India has reported a spike in black mould that has caused serious long-term health problems for diabetics after recovering from COVID.  It is currently presumed that the chemicals used to fight COVID allowed for a natural mould to grow in the body, and that became life-threatening.

The VA-OIG conducted another virtual comprehensive healthcare inspection, and found the same problems continue at another VAMC.  Do you know how tired I am of reading these “comprehensive inspection” results and finding the same problems time after time?  When will the VA actually start enforcing some of these VA-OIG recommendations to effect change?  Better, when will the politicians who are charged with scrutinizing the government tire of seeing the same recommendations and not seeing any change?  Bloody frustrating reading these reports and not seeing improvement!VA 3

Broken RobotFinally, we come to what I was hoping to be a great report, where the politician’s heads were going to explode at the inefficiencies, the detestable behavior, and the horrendous responses to legally mandated IT infrastructure changes, and why those changes are not happening at the VA.  I was not disappointed; I was thoroughly disgusted that his report fell on plastic ears speaking plastic words from wax lips!  Statement of Michael Bowman, Office of Inspector General, Department of Veterans Affairs, Director of IT and Security Audits Division, Before the Subcommittee on Technology Modernization, Committee on Veterans’ Affairs, U.S. House of Representatives, Hearing on Cybersecurity and Risk Management at VA: Addressing Ongoing Challenges and Moving Forward May 20, 2021.  Notice something, the failures at the VA in the IT Department are being called “ongoing challenges.”

Millstone of Designed IncompetenceLet me remind you, FISMA was released on 29 April 2021, and I wrote about the abysmal findings of the VA-OIG.  This report is the accountability statement to the Congressional representatives who should have skewered this bureaucrat and roasted him on a spit with onions and peppers, then served him up for public ridicule after firing him!  For the Director of IT and Security Audits Division to make the following statement is flat out beyond comprehension, “The OIG’s conclusions in the FY 2020 FISMA audit are not new or revelatory—rather, they repeat many of the same concerns with VA’s IT security that the OIG has found for many years.”  What incredible chutzpah to make this comment after that scathing report showed just how deplorable the leadership of the IT and Security Audits Division revealed!  Director Bowman then goes on to downplay the band-aid solutions implemented while decrying the time for improvement is too short and there is not enough money.  Do not forget, “Of the 26 recommendations, 21 have been included in every FISMA audit dating back to at least 2017.”  With at least 15 of these recommendations dating back even further.  Want a full list, as well as how old these recommendations are; you will not find it in the Director’s report to Congress!  Is anybody incensed enough to demand a full accounting of just how old these IT recommendations are?

Detective 4The gall of this director to continue to blame legacy systems that were legislated to have been scrapped between 2000 and 2010 continues to highlight the incompetence of the director in conducting business and holding people accountable for failed projects and overspending of taxpayer monies!  The director went further and stated the following, at which time, every single Congressional Representative should have stood and demanded his head.  The “VA does not properly manage and secure their IT investments.”  Tell me director, why should you remain employed if the VA does not properly manage and secure their IT investments?  Is the failure to manage and secure IT investments the root cause for veterans to continue to suffer identity theft from the VA losing their identity?

The director’s next statement puts his other outrageous comments to sleep.  “Security failures also undermine the trust veterans put in VA to protect their sensitive information and can affect their engagement with programs and services” [emphasis mine].  Talk about such an obvious statement, it’s like the sun coming up on a cloudy day, you just cannot miss that sun rise; you also cannot miss the absurdity of making this statement!  Did some intern write his speech?  You are the director of IT Security and you make this type of comment, did you make this comment with a straight face?  I cannot find the video-record of this Congressional hearing so I can only guess he delivered his lines with a straight face!  Most detestable of all, he continued to make outrageous comments, his plan to move the IT security program at the VA forward is weak, lacking firm deadlines, and continues to allow him and his staff to escape accountability and responsibility.VA 3

Angry Grizzly BearAmerica, with these bureaucrats in charge, why shouldn’t we be weeping and wailing, and gnashing our teeth in frustration?  When will we, the owners of this atrocious government, finally scream ENOUGH and demand a full change of heads at the ballot box?  For until the elected representatives are forced out, the bureaucrats abusing us, will only continue!  The VA is sick, but the problem lies in the bureaucrats, administrators, and directors leading the VA at the Federal and VISN levels.  So many other government agencies are just as sick, or worse, and the same problem arises, the leadership refuses to act, but still expects a big titanium parachute when they leave office!  I say it is time to tell them NO!

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

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

VA 3Since 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.

ApathyThe 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 CongruenceWhile 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 4The 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 BearThat 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?

© 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.