Chronicling the VA – May We Remember the “Pobrecito!”

I-CareA Spanish-speaking Mexican colleague taught me this term, “pobrecito,” meaning “poor little one.”  As I chronicle the VA ineptitudes, failures, criminal behaviors, and abusive actions, I am always conscious of the pobrecito, the poor little one, the poor victim who got harmed.  Too often, the victims never receive any compensation, acknowledgment, or retribution, nothing for having become a victim of the VA.  Too often, the Department of Veterans Affairs (VA) – Office of Inspector General (VA-OIG) investigates long after the abuse has occurred, and the victims are not covered in the scope of the investigation, or worse, the victim was killed, and the family is left to mourn, and nobody can help.

Angry Grizzly BearWhy chronicle the VA abuses; because the needs to be held accountable, speak the language, and have tougher skin and broader shoulders than the VA’s normal victims.  The VA is slowly learning they can harm me, but they cannot shut me up!  I will not stop fighting the VA for humane treatment, honorable service, and dedicated systems.  The VA is sick because apathy and inertia were allowed to replace common sense and decency, leadership was replaced with cost accounting and bureaucratic red tape, and human kindness was eradicated and replaced with drones and robots.  I know how to make the VA better; I do not have all the answers, but I know how to launch the revolution and begin cleaning the VA, and I will not stop calling upon those responsible for fixing the mess they created!

Starting this week’s VA-OIG headlines of crimes and inspections, we find a couple in South Florida who used the system to bilk more than $20 Million in purchase order scams.

Earron Starks was sentenced to 30 months’ imprisonment, followed by three years of supervised release, and ordered to pay over $2.4 million in restitution. Carlicha Starks was sentenced to three years of supervised release, including one year of home confinement, and ordered to pay $501,000 in restitution. They paid kickbacks to VA employees as part of a large-scale bribery scheme, which enabled the Starks couple and other corrupt vendors to receive over $20 million in purchase orders from VA medical centers in West Palm Beach and Miami. Fourteen additional defendants were charged for their roles in this scheme.”VA 3

Who’s the pobrecito in this case; the taxpayers, the veterans, and the United States.  Federal Employees had to not only know the crimes occurring but be complicit in the crimes.  Will they lose their retirement benefits, have to repay their wages, and face criminal charges and jail time for their culpability?  Fourteen additional defendants, how many were supervisors in the know and on the payroll who were promoted during this scheme whose supervisors failed to do their jobs and scrutinize the work of their underlings?  The shadiest part of this entire scheme is encapsulated in the following sentence:

All VA Employees were either terminated or resigned.”

Name me one private-sector employer who could get away with a massive scheme and enjoy similar benefits!Survived the VA

We find another VA employee embroiled in theft of equipment which sold the stolen goods in Ohio.

Kevin Rumph, Jr., of Fairburn, Georgia, pleaded guilty to stealing more than $1.9 million in medical products while employed at a VA community-based outpatient clinic in Atlanta. Between 2013 and 2021, Rumph made hundreds of unauthorized purchases of equipment used to treat obstructive sleep apnea. He then stole and sold the equipment to a vendor in Ohio. Sentencing is scheduled for November 17, 2021.”

I have worked in purchasing in both the US Military and in the private sector.  If I went to my bosses with “hundreds of purchase orders for supplies,” they would naturally be curious.  Repetition of hundreds of similar requests would raise red flags and demand audits of my records and proof of need.  Why did this not occur at the VA?VA 3

In the US Navy, I was in charge of ordering stock and saw requests for certain o-rings spike, as I knew the Chief Engineer would spot this and ask why, I asked why, went to the equipment records, dug up the maintenance reports, and asked questions of the mechanics and technicians.  In doing so, we discovered an unreported problem with machinery.  This is called due diligence; why was it not being practiced by the supervisor of Mr. Rumph?  You cannot tell me a seven-year trend line is something that was an anomaly and easily missed in budget reporting year-over-year!

Exclamation MarkLet’s admit a truth for certain; COVID has been a farrago of gargantuan size from day 1.  In acknowledging this, no blame is being proportioned to the front-line workers in any way, shape, or form.  But, the administrators, policymakers, politicians, and government bureaucrats have certainly proved they could unscrew the inscrutable!  Worse, the bureaucrats proved that their idiocy was highly contagious, infecting more people than COVID, spreading faster than COVID, and killing more people than COVID.  Our proof of this concept arrives from Houston and the Michael DeBakey VAMC.

The VA Office of Inspector General (VA-OIG) conducted a healthcare inspection regarding allegations of incompletely screening for COVID-19 and treatment of a patient with serious mental illness who presented for same-day care at the Michael E. DeBakey VA Medical Center (facility).”

Findings:

      • The VA-OIG substantiated that facility staff did not complete the patient’s COVID-19 temperature screening.
      • The VA-OIG substantiated that facility staff failed to manage the patient with COVID-19 symptoms medically.
      • Sent the patient to the drive-through testing area without medical evaluation, did not isolate the patient, complete a care plan, or follow the policy for transporting patients suspected to have COVID-19.
      • The vulnerable patient disappeared while in the facility’s care, was found off-site four days later experiencing a medical emergency, taken back to the facility, and died the following day [emphasis mine]!
      • The VA-OIG determined that the Mental Health Intensive Case Management team failed to address documentation discrepancies related to the patient’s surrogate and educate the family on COVID-19 visitor policy and screening processes.
      • The VA-OIG identified the facility’s noncompliance with the missing patient policy.
      • Facility leaders’ failure to report an adverse event and ensure a timely review of the patient’s episode of care.
      • The VA-OIG identified facility leaders did not timely or accurately disclose to the patient’s family the medical mismanagement that led to the patient’s adverse clinical outcome, e.g., death!
      • The VA-OIG concluded the failure to screen, isolate, and evaluate the patient resulted in potential COVID-19 exposure to staff, patients, and the public when the patient moved through facility grounds.VA 3

What was not covered in the scope of the VA-OIG investigation was whether the staff had proper training on the written policies or if training had been suspended due to the “pandemic health emergency.”  Failure of training has been a running and recurring theme for the VA before the pandemic, and the failures of training have led to thousands of “adverse clinical outcomes” at the VA, up to and even including death.  Yet, as evidenced in this example, small decisions lead to catastrophic events.  The infected patient was mentally unstable and missing for four days; how many people interacted with the patient as a superspreader event?  Who is at blame at this VAMC for this event, the leaders!  They failed their people, failed this patient, and failed this family!

Detective 4Before continuing, we must pause and take a moment to send heartfelt congratulations to two VA Health Care Systems (VAHCS) who passed their comprehensive healthcare inspections (CHIp), if not with flying colors with significant improvement, and are deserving of the highest praise.  Would the leaders of the Fort Harrison VAHCS in Montana and the Western Colorado VAHCS in Grand Junction please stand and take a bow.  Your improvements, conduct, and capacity to achieve reflect that success is possible with good leadership.  Keep up the good work; find ways to improve daily, and may continual success be ever yours!

Finally, we come to a regular topic, the failure of the VA as a whole entity to manage to pass a simple audit on financial matters and the continuing debacle where hiring is concerned during the pandemic.  Let me refresh your memories on the hiring debacle; first, the VA-OIG found that VISN leaders “were generally pleased with the “flexibility” provided during the pandemic for speedier hiring.”  What did the American people get for reduced hiring practices at the VA?  More criminal employees, more employees with shady pasts, more employees with sticky fingers, and more employees who could not find employment in public schools, now working for the federal government.VA 3

How did that relaxing of hiring practices work out for the American people and the veterans receiving care; not very well!  But, let’s all relax; the VISN leaders are “generally pleased.”  Frankly, I would be shocked if anything ruffled the VISN leaders’ feathers long enough for them to care; they are mostly at the top of their career ladders and failing a presidential appointment to Washington, know they are set for life.  So, why rock the boat?!?!

As for financial audits, the VISN leaders know that money continuously is appropriated to carry them and their poor decisions forward.  Just ask the Denver VAMC where the construction cost overruns are still costing the taxpayers, and no one was ever held liable for that boondoggle or any other crime and scheme for that matter.

Question 3Why?  Why are victims left to rot, the assaulters and victimizers promoted, and the VA as an organization left in the hands of disreputable, dishonest, unethical, and immoral people?  Why is the VA a culture of corruption, greed, envy, sloth, and disinterest when the US military is the exact opposite?  America is not what is found in the halls of the VA, why has the VA been allowed to become something anathema to the American people?

Knowledge Check!Great Britain, you find similar in your halls of government.  Your people are amazing; your government workers are just as despicable and deleterious as the American VA, IRS, and DMV.  Australia, great people, absurdly detestable government workers.  France, interesting people, but the government employee seems to have been drug from the bottom of the scum sucked from the Seine.  I have met incredible people in Italy, Greece, Germany, South Korea, etc., but the story rings true everywhere; the government does not represent you.  Pobrecito; what has happened?

© 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: What is History? A Prelude to the Future.

There is an axiom in history, “If you do not learn history, you are doomed to repeat it.”  Some have refused to believe this lesson, to their utter misfortune.  Others have refused to accept this sentiment and have suffered likewise.  How do I know this; history shows the willing student how history is a prelude to the future.

Ancient Greece was the center of knowledge, but their people stopped learning history, and Rome came in while Greece was napping and took over the country lock, stock, and barrel.  Then, over time, Rome stopped learning the lesson they had taught and was forced to relive their history when caught napping; others came in and ruined the Roman Empire.  Ancient Egypt was a grand empire until Rome.  More history leading to preludes of the future.

Moving forward several centuries, and we see the rise of the Muslim Empire, suffering the same fate as those behind it when they too forgot their history.  The repetition of history is both scary and clearly written in the annals of history.  When one stops learning their history, they become doomed to repeat that history, for history is ever a prelude to the future.

Now, I am not a doom and gloom type, nor do I have grand aspirations of being a prophet or prognosticator.  I am simply pointing out the truth and hoping others may join me in learning history to avoid repeating history.What historical lessons do we need to learn?

To answer this question, I beg you to indulge me for a moment.  I have to ask a few more questions to answer this most pressing question.  As a modern citizen of your country, do you understand the family’s value and importance to your society?  What are you doing to support the family as the preeminent foundational stone of a sound and growing society?  Are you willing to sacrifice worldly reputations, money, power, etc., to have a family?  The leading cause of the Roman Empire’s fall was that they stopped having nuclear families, and within a generation, they fell.  Why did the sunset on the Egyptian Empire; they stopped believing in and supporting the nuclear family, and they failed.  Before WWII, why was England, the world’s mightiest empire since Rome, failing; they lost the nuclear family and still haven’t recovered.

Why is France struggling, Italy disappearing, Germany struggling, and the US and Japan all having such incredible problems; all have forgotten the nuclear family.  As the nuclear family goes, so does the state’s power and the identity of a country’s soul.  Let that sink in a minute.  As the nuclear family goes, so does the country’s soul.  A country’s identity, liberty, law, freedom, and lifestyle rests squarely upon the shoulders of the nuclear family.

I have read reports that Italy will no longer be the traditional “Italy” in less than 10-years because the Italians are not getting married and having families.  I love my Italian family members, but I am so distraught to think that “La mia famiglia,” the quintessential Italian experience, will not be around for my posterity to enjoy, except through fading pictures and journaled memories.  What makes this worse is Japan, South Korea, the Philippines, France, Germany, the United Kingdom, and every other nation on earth have the same problems.   The nuclear family is disappearing at a frightening rate, and as the family goes, so do the historical lessons that need to be learned to avoid repeating.

An ignorant barbarian suggested, “well, just have people have more kids.”  I wanted to gently take this person by their ears, look deeply into their eyes, and ask, “Is anyone in there?”  Children are important but more important is the nuclear family experience.  Another person once suggested that the nuclear family, consisting of a mother, a father, and children living in the same home, is copyable for homosexual couples, divorced couples, and single parents, so what’s the big deal?”  In asking that question, the individual’s historical ignorance was apparent, and society’s problem leading to a repeat of history.

Living together as a family is messy, it is hard, and it requires learning how to live together.  These fundamental lessons become the experience that binds a nation to its culture, faith, and fundamental societal core.  There is no substitute, no shortcuts, and no other possible way to exist.  Yet, too often, the nuclear family is shunned, disrespected, and disregarded for the pleasures of living more easily.

No, I am not casting aspersions on those parents raising children as single parents.  I have known the great and good and the incredibly terrible in single parents and would support that person and those children however I can.  But, I hold this perception and desire because I know the value of the nuclear family, the nuclear family’s potential, and I know how a family makes a community, and a community makes a family.

I read the research on homosexual couples rearing children, and I weep for the children!  A more honest statement I cannot make.  I know the abuse and problems inherent in any family organization, but the problems are only multiplied a hundred-fold in homosexual couples rearing children.  The second most destructive power in Rome’s fall, mirrored from the Greeks, was the rise of homosexuality, which was preceded by a loss of morality, religious living, and the nuclear family.

President George Washington said in his final address to the nation about religion.

Of all the dispositions and habits which lead to political prosperity, religion and morality are indispensable supports.”  Continuing, Pres. Washington called religion and morality “Pillars of human happiness, and the duty of citizens to uphold.”  Concluding with, “Where is the security for property, for reputation, for life, if the sense of religious obligation [and morality in society] desert the oaths?  Reason and experience both forbid us to expect that national morality can prevail in exclusion of religious principle.”

I know the struggles in families, but those struggles pay dividends when we support the nuclear family.  I recently read of an 11-year old having children because her mom and grandmother were in prison, and great-grandma needed more welfare money to feed the other children living in the home.  In reading that report, I hoped this was a one-of-a-kind experience, but I was horrified to learn the exact opposite, and family courts are full of tragedies similar to this story.  Our communities are failing because the nuclear family has suffered some desperate body blows, and more welfare programs and government heavy-handedness are NOT the answer!  History is indeed a prelude to the future, and the loss of the nuclear family is front and center in this battle for your country’s soul, culture, legal system, and future.

Families, reach out to single parents and open your home.  You do not have to be perfect to help; just help!  Communities reach out to support the nuclear family.  Religious communities especially reach out to support single parents raise morally centered children and help build nuclear families.  If the nuclear family experience is lost, we will repeat history, and chaos is too small a word for the conflict that will fill every country on earth!

I offer no excuses for those who abuse their spouse or children!  I extend only support for the victims and would see the situation corrected.  In the same breath, I would offer hope to those struggling in these times to raise a nuclear family; you are doing a good job, even if it seems like every day is difficult.  Please stay in the fight; it is worth the struggle.  To the non-profit and religious organizations, get involved in the battle to support the nuclear family and morality in public and private.  Fight for morality and nuclear families; they need you, your community needs you, and your country needs you!  Especially to the organized religions and their leaders, find a spine!  Get into this fight, or die an unpitied sacrifice in a contemptible struggle!

Please, learn history, teach history, and work to support the family as a prelude to a better future!

© 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.