The Year-End Maelstrom! – More VA Shenanigans! (Where is the accountability?)

2021 has finally ended, but before it ended, the Department of Veterans Affairs (VA) – Office of Inspector General (VA-OIG) increased the pace, and the following is but a taste of the year-end insanity foisted into my inbox.  With more than 45 emails to sift thru, some of the topics had to be culled, and I regret that I had to cull the emails.  Each and every VA-OIG report deserves to be scrutinized, evaluated, and the actors punished, many times with criminal court.  I don’t know what’s worse, summating these stories or getting hit with a truck; seeing as I have been hit by a truck, I think the truck is easier.

We begin the recount of VA-OIG stories with another veteran, deceased because the VA Medical Center refused to do their job and provide continuity of care after a 33-day hospital stay.  Leaving me wondering if this was intentional malpractice due to the cost of the veteran to the VA.  Listen to the findings of the VA-OIG, then make your own decision.

The Malcom Randall VAMC’s interdisciplinary team (IDT) failed to develop a discharge plan that adequately ensured patient safety and continuity of care.  The Malcom Randall VAMC did not have a discharge planning policy that outlined IDT membership, communication expectations, or roles in discharge planning.  The OIG found that the occupational therapy provider did not verbally communicate a new recommendation for a home safety assessment or take action to stop the discharge until the safety concerns were addressed.  Additionally, an attending physician failed to review written recommendations for home healthcare services from consultative and ancillary providers before composing the discharge plan for the patient.  The social worker, who had significant responsibility for ensuring the adequacy and safety of the patient’s discharge plan, also failed to incorporate recommendations by the occupational therapy provider and failed to discuss and offer home health services to manage the patient’s venous leg ulcer and monitor infection of the right leg.  The OIG also found that social workers did not consistently complete thorough and detailed psychosocial assessments that would be pertinent to discharge planning.

Remember when the media became hysterical when then VP Candidate Gov. Sarah Palin suggested ObamaCare would institute “Death Panels?”  Bureaucrats decided that the government had invested sufficient money into a patient and was going to stop providing medical care.  When this media hissy-fit was going on, I claimed that the VA had been exercising this right to discontinue care for a long time.  Several people took umbrage at this commentary; yet, what do we find from the VA-OIG, a dead veteran, five recommendations by the VA-OIG to do the job these “providers” were already hired to perform, and I am left thinking, “Death Panel in action.”

What else should I conclude with no accountability, responsibility, and consequences?

On the topic of holding a job with responsibility and not being held accountable, we find another hit to the VA and their lack of IT/IS security.  Desiring brevity but passing along factual information, the following summary has been condensed:

The Federal Risk and Authorization Management Program (FedRAMP) standardizes security and risk assessments for cloud technologies for federal agencies, including VA.  In April 2019, the VA Office of Inspector General (VA-OIG) received allegations that VA’s Office of Information and Technology’s (OIT’s) Project Special Forces (PSF) was not following FedRAMP policies or VA policy for deploying software-as-a-service (SaaS) applications.

      • The VA-OIG found that OIT granted security authorizations for applications FedRAMP did not authorize.
          • Eight of the nine applications cited by the complainant were used on the VA network—some without FedRAMP or VA authorization.
          • Another three applications were approved to operate on VA’s network without FedRAMP authorization.
      • The OIG did not substantiate that PSF-developed applications were improperly managed outside the VA Enterprise Cloud group.
      • PSF did not follow VA security requirements in developing interfaces that allow third parties to “plug into” the VA to send and retrieve data.
          • OIT personnel stated, “no formal OIT authorization process until April 2019.” After that date, the review team did not find instances of VA-authorized applications without FedRAMP authorization.
      • OIT staff “apparently” misunderstood the FedRAMP authorization requirements for SaaS applications containing data classified as less sensitive.

Please note if you think the VA IT/IS performance has improved since April 2019.  You are sadly mistaken, as in 2021, there have been three major VA-OIG reports declaring how IT/IS systems at the VA remain insecure, failing legislative mandates for basic security, and are hopelessly too expensive and useless.  I have two VA-Apps on my phone, both of which work “sometimes,” and never sufficiently support the end user.  Worse, these apps do not interface with the old software the VA is helplessly tied to while the new software continues to prove its uselessness and security problems in real-world beta testing.

Tell me, would you trust the government, any of the alphabet agencies, with your child to babysit?  If not, why do we trust the government to secure our identity?  If so, please elaborate, for I would love to know of a government/NGO operating with trust and efficiency.

Continuing under the heading of failure to perform the job hired for, we find the VA-OIG issuing a total of 20 recommendations to Vet Centers.  The Vet Centers included record keeping of suicidal veterans seeking mental health support as a point of reference.  Not for the first time, but I keep hoping it’s the last.  The VA continues to fail veterans, abuse veterans actively, and take advantage of veterans, and I remain unconvinced this torture of their customers is not intentional.  Maybe not all employees, for I have met some great employees, but the leadership appears hellbent on killing as many veterans as possible.

Why isn’t this big news, huge headlines, and a major story to the corporate media?  Where is the coverage?  You cannot convince me that 1)You are not aware of this story and 2) That you are unfamiliar with its implications.

VA statement on GPO printing and mailing delay

WASHINGTONDue to supply chain and staffing shortages, the vendor contracted by the Government Publishing Office to provide printing services for the Department of Veterans Affairs is experiencing delays in printing and mailing notification letters to Veterans and claimants.  The disruption may impact the ability of some claimants to meet required deadlines via written correspondence with the VA.

In response to the mailing delays and to protect the best interest of claimants, the Veterans Benefits Administration is extending its response period by 90-calendar days for claimants with letters dated between July 13, 2021, and Dec. 31, 2021.

For those not aware, everything in the bureaucracy abbreviated as the VA is time-sensitive.  Miss a deadline, and you have no opportunity to recoup lost time without investing significant amounts of resources.  Since I continue to be in an embroiled battle with the VA over not receiving a proper decision in 2004, time delays represent problems untold due to budget cuts and bureaucracy, and the VBA and VHA bureaucracies will do everything they can not to help you.  Then we add the time delays, and the consequences can be disastrous.  Think veterans dying with an active application for benefits, and you come close to how big this story is, and not covering it with wall-to-wall coverage is the epitome of lackluster asininity!

It took dead veterans on waiting lists to get bad press through the Media fawning over President Obama; what will it take to penetrate the media quilt for Biden?  Continuing under the heading of failing to do the job you were hired to perform, we find another VA-OIG comprehensive healthcare inspection (CHIp).  Guess what; this one is beyond utterly dismal and flagrantly reprehensible!

The administration and delivery of care to female veterans continues at its expected and atrocious, slovenly pace, being outstripped by one-winged butterflies.  How can the VA Leadership continue to keep their jobs when they allow such incorrigible behavior from lower staff members?  Would the elected Representatives and Senators address this question?  You were hired to scrutinize the government; that is the only other job you have after writing fair and equitable legislation to all citizens.  Why should you be re-elected when this behavior abounds, and you refuse to scrutinize the executive branch officers?

Consider the following,  “The VA-OIG audit team estimated that improper payments for acupuncture and chiropractic care amounted to about $136.7 million during fiscal years 2018 and 2019.”  Continuing, “The audit team also found that VHA did not always follow guidance when reauthorizing acupuncture and chiropractic care.  Not documenting assessments of prior treatments before authorizing additional care may interfere with veterans’ treatment.”  Failure to ensure your underlings have established proper processes and procedures that are effective and followed is a prerequisite to holding a leadership position.  Where is the leadership at the VA?  Where is elected representative scrutiny?  What are the consequences for doing a poor job of cleaning the house and protecting the taxpayer?

How big is this problem?  Try upwards of $341 Million, on top of the $136 Million already discussed, and before the full force and cost are known on delays in properly notifying veterans in a timely and efficient manner.

The VA-OIG audit team found that some providers are billing VA at a significantly higher rate for high-level evaluation and management services than their peers in the same specialty.  The team determined that in fiscal year (FY) 2020, more than 37,900 non-VA providers billed and were paid for significantly more high-level evaluation and management codes than were all providers in that specialty on average.  These non-VA providers received about $39.1 million (13 percent) of the approximately $303.6 million paid for all non-VA evaluation and management services.

Additionally, some providers billed separately for evaluation and management services when the global surgery package was in effect.  This package is supposed to cover all surgery-related services for a set period.  The review team identified more than 45,600 providers were compensated about $37.8 million in FY 2020 for these evaluation and management services.

Improper payments were not easy to detect because VHA staff did not retrospectively audit medical documentation as required.  Additionally, the OIG found no evidence that VHA or contractors trained non-VA providers on documenting evaluation and management services, similar to how VA providers are qualified.  The OIG determined VHA risked overpaying for evaluation and management services by about $19.9 million in FY 2020.”

While discussing audits, failed processes, and the lack of consequences for senior leadership, we must break and wish a “Happy Birthday” to the audit hits turning 10, 12, 15, 21, and older.  It never ceases to amaze me how these financial failures can continue to age, and nobody is held accountable!  May you age out and finally be corrected!  Would the elected leaders of America like to know why the VA is consistently failing financial audits?

VA continued to be challenged in consistently enforcing established policies and procedures throughout its geographically dispersed portfolio of outdated applications and systems.”

Now, explain why we should re-elect any elected official to office?

Elected officials, your job is to scrutinize and write legislation; that is what we, the electorate hired you to do.  Do you realize the far-reaching consequences of your failure to perform your job?  Let me introduce you to an example:

Anthony Medrano, a veteran of the US Marine Corps and former employee of VA, admitted that between approximately November 2015 and May 2020, he submitted claims to VA in which he purported to be disabled to obtain caregiver benefits for his wife, when he was actually able-bodied and even participated in fitness challenges and coached youth sports.  Medrano was sentenced in federal court to eight months in custody for defrauding VA out of more than $183,000.  He executed this scheme while employed by VBA as a veterans service representative, a position in which he explained benefit programs and entitlement criteria to veterans applying for VA benefits.”

Or the following:

Barry Wayne Hoover of Tampa, Florida, a veteran of the United States Navy, exaggerated the extent of his visual impairment to receive VA disability benefits to which he was not entitled.  Specifically, Hoover manipulated the results of subjective tests of his peripheral vision to reflect that he had only a five-degree visual field and was legally blind.  VA found that Hoover was 100 percent disabled based on those manipulated tests.  Hoover was found guilty of theft of government funds and making a false statement to a federal agency.  He faces a maximum penalty of 10 years in federal prison.  His sentencing hearing is scheduled for March 2022.”

How about this:

Professional Family Care Services, Inc. (PFCS), a home health services company based in Fayetteville, North Carolina, has agreed to pay more than $45,000 to settle civil False Claims Act allegations related to fraudulent billings for work by a recently convicted felon under their employ.  During 2015 and 2016, PFCS billed VA for home health services provided to W.R., an Army veteran, even though, at that time, W. R. was residing with the company’s employee, Certified Nurse Aide Tracey McNeill.  PFCS based its billing for those services on falsified timesheets provided by McNeill, who failed to provide both the time and quality of care required under the VA program.  After several months living with McNeill, purportedly receiving home health services provided by McNeill through PFCS, W. R. had to be admitted to the hospital.  He was extremely malnourished and ultimately died within a few days of admission.  Earlier in 2021, McNeill was convicted of wire fraud for her misconduct related to W. R., sentenced to 12 months and one day in federal prison, and ordered to pay over $90,000 in restitution.”

Morality is exemplified by leadership and then exercised under scrutiny.  Because you, the elected officials, refuse to be morally upright and scrutinize the government, the executive branch officers and employees have become careless, irresponsible, and taken the American Taxpayer for a ride!

Each time the VA-OIG reports an investigation beginning with the death of a veteran, the root cause is always a failure of people to do the job they were hired or contracted to perform, and the casualty is a dead or severely injured veteran.  The culling of the email included a urologist who performed procedures, puncturing internal organs, and not notifying the patient.  Several other CHIp summaries reflected the egregious and despicable leadership hidden at VHAs and VAMCs across the country.  Other Vet Centers possess failing bureaucrats just trying to hide until they reach retirement and escape.

America, you deserve better from the alphabet agencies representing the executive branch!  Fellow veterans, please do not give up hope; we can still help protect this country from those enemies domestically located who make your lives a living hell.  Please pass the word, these VA-OIG investigations deserve to be read, and questions asked!  Elections are coming; join the fight as a citizen and run for office.

© Copyright 2021 – 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.

When the Media Becomes Fixated – Smoke and Mirrors

Angry Grizzly BearAfghanistan has fallen, history has repeated itself, making the images of Saigon look like a trip to Disneyland on gossamer wings.  Haiti is in shambles, again, from the triple whammy of an earthquake, a hurricane, and political instability; at least this time, we do not have the Clinton’s siphoning money from the relief efforts for their personal gain.  The US/Mexico border National Security/Humanitarian/Health crisis continues unabated, unreported, and the deception of the American Government to its citizens is unceasing.

Stories are leaking out. President Biden refused to place American citizens ahead of Afghanistanis and other nationalities on American military planes during the Afghanistan farrago, again betraying the American people’s trust.  After a minimal review of President Biden’s time in office, I should not be surprised that he places other nationalities ahead of American’s, but I am amazed every time.  Yet, with all the “news,” it is interesting to note that the dogs not barking should be getting the attention.

Colonial Pipeline Hack

Remember the Colonial Pipeline Hack, which shut down the pipeline that fed oil products down the Eastern Seaboard.  Apparently, some 6,000 people’s private information was also lost in the hack.  Social security and health insurance information was stolen; consider how much personal data is on an insurance form, now ask yourself, why is all that private data needed?  Why was it stored with pipeline controls?  Who is responsible for allowing HIPAA information to be accessible?Colonial Pipeline Russian hacker: Darcy cartoon - cleveland.com

Since Colonial Pipeline paid the ransom, how can we, the consumers, be assured that the ransomware (software used to shut down the pipeline in the first place) was removed and the IT/IS threat risks fixed?  Since private data was stolen in the attack, how can employees (past and present) and their families get their identities back?  Worse, what about future attacks using private data as leverage to regain access and control?  Medical data has been used as leverage to blackmail historically as this is intimate and private data; this is a security breach with significant potential future risk but is being downplayed.  Why?

China

China Takes Over the World - TV TropesAlmost like clockwork, when there is trouble, China goes silent.  Every parent in the world knows when their toddler goes silent, that is when it is time to go find out what the child is doing.  Usually, it will mean the child is about to get their bottom smacked for doing something against the rules.  Or, you could compare China to Peeves, the poltergeist from Harry Potter, “When there’s trouble, call on Peeves, he’ll make it double.”  What is China doing right now, as they take advantage of the Afghanistan and Haiti double crisis?

Why are China’s rights and sovereignty always respected by America when China refuses to respect our sovereignty and rights?  When China refuses to honor border integrity and the sovereignty, rights, and privileges of its neighbors?  Want some interesting reading?  The Heritage Foundation has published the “China Transparency Report.”  Essentially, since 2005, China has been investing in third-world countries, often with illicit or illegal money, washed through its own banks, and returned to the global markets as investments in construction projects for “nation-building.”  Open secrets, many economists already know and have been asking political leaders to put a halt to, and have been rebuffed by those same political leaders, who then take “investments” from China.China's Emerging Middle Eastern Kingdom - Association of Geo-Strategic Analysis

China wants a hegemony, the political, economic, and military dominance of the globe, and they are investing in building nation-states that are loyal to them.  Not China-bashing, trying to raise awareness of what is happening right now in the world!  China’s leadership suffers from the “Middle Kingdom Inadequacy Syndrome” where they want to rule, but they entered the 18th and 19th centuries too late.  Now they want to play like it is still the 17th and 18th centuries, where empires can be built, lands stolen, maps redrawn, vast empires where the sun never sets are their reward for their patience and careful investments.

COVID-Hysterical Reactions

New Zealand re-entered national lockdown over COVID as of this morning (17 Aug 2021).  They have a single confirmed case of COVID.  Israel has 7,000+ daily cases; they are expecting to enhance their COVID measures.  New Mexico’s Governor (Supreme Grand Vizier and Head Chump) is still vacillating on her next mandate on COVID.  Other governors, heads of state, and many citizens wait with bated breath for the next shoe to drop on COVID-hysterical nonsense.  While everyone’s focus is on Afghanistan and Haiti, look for some weasel to stick the population with more COVID-Mania, that other politicians will follow if the first can “get away with the madness.”Covid-19 Def Leppard Hysteria - Covid 19 - T-Shirt | TeePublic

COVID has taught every citizen worldwide to be very cautious where government and “health mandates for public good” are concerned.  How many freedoms, treasure, and lives lost unnecessarily occurred because the government acted instead of logical thinking people?  Too much!  The greatest crime in all of recorded history is relying upon or allowing the government to act when the people can, and should, be doing the work.The Bright Side Of Coronavirus - 9ThirtyFour

CNN fired employees for not honoring the company policy to get vaccinated.  Did you know your employer can mandate you to be vaccinated?  Did you know your employer can charge you a different health insurance rate for not being vaccinated?  Are you aware that to your employer, you are property, have no US Constitutional Rights, and can be fired for not toeing every single line they spout?

Why is the Corporate Media Crowing About the US Senate “Acting” to Spend Money The US Does Not Possess?

blue-money-burning-2The US Senate is still being cheered for passing a budget full of leftist stupidity and wish list items that do nothing but bloat the American Government, raise the costs of products, and increase the ire of the electorate and the National Deficit.  Yet, the media cheers!  The US Senate passed an “infrastructure bill” that focuses on everything but infrastructure.  Yet, the media cheers!  The legislation passed provides free Internet to Cubans living on the Island of Cuba but is paid for by every other American utilizing Internet services and paying taxes.  Still, the media cheers!  Inflation is headed for double-digits by year’s end (2021), and if action is not taken swiftly will remain at double-digit highs for at least three years.  Yet, the media cheers, and the politicians are silent or making excuses.

Smoke and Mirrors

Smoke and mirrors are methods of distracting the audience while a magician does the trick, or the smoke and mirrors are the tricks.  Skilled magicians use these tools to create illusions meant to mystify and delight.  Politicians and media talking heads use them to distract until they can fashion a proper excuse, find a different party to blame, or waste sufficient time that the public has moved on to a different story.  Only magicians know that audiences become sophisticated over time, and all old tricks need revisiting to keep the mystery and magic alive.  Politicians refuse to learn this lesson, and their antics have grown stale, tired, and what was merely detestable 40 years ago has become treasonous and contemptible today!Ecig cancer death is smoke and mirrors | Planet of the Vapes

How do we, the citizens of representative governments, end the games, stop the charades, and demand accountability?  We stop buying tickets to the show!  We turn off the TV, Radio, and Talking Heads, turn on our minds, and use our critical thinking skills to deduce what is happening from the facts.  Then we act, in concert, unified with our neighbors, to end the silliness and demand that those responsible pay for their misdeeds and felonious actions!  We use the laws they have shunned to force accountability.  Believe it or not, the answer really is this simple!Bird of Prey

Beware the smoke and mirrors the media is casting and the politicians are hiding in; they are trying to get away with criminal misdeeds while attention is focused elsewhere!

© 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.

Abominable Enabling – More VA Chronicles of Shame!

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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