That’s Crazy!!! – More Chronicles from the VA (CH 5)

I-CareThe end of the year inundation continues unabated.  Unfortunately, so to does the failure of the Department of Veterans Affairs (VA) – Office of Inspector General (VA-OIG) to inspire and motivate change.  Thus, my continual efforts in opening the transparency and demanding accountability for the VA leadership, and insistence that the American Congress do its job in scrutinizing the executive branch!  I repeat, only for emphasis, the US Congress (the US Senate and US House of Representatives collectively) only have two jobs.  1) write laws that are constitutional and for the benefit of all, themselves included, American citizens.  2) scrutinize the executive branch to protect the American Citizen from abuse and runaway actions.  Feel free to read the links to each story for more information, the failure of elected officials to act and prevent this behavior is abysmal, and these are just summaries, the full story is detestable!

In yet another fraudulent scheme, the fraudsters are penalized but the VA employees are left without penalty.

Thomas Farese, 79, of Delray Beach, Florida, and Domenic J. Gatto Jr., 47, of Palm Beach Gardens, Florida, are charged in an 11-count indictment with conspiracy to commit wire fraud, conspiracy to commit health care fraud, health care fraud, conspiracy to transact in criminal proceeds, transacting in criminal proceeds, and conspiracy to violate the federal Anti-Kickback Statute.VA 3

Two VA employees, over the course of four years, caused the VA to lose $1.38 million in kickbacks.

Two Chicago-based VA employees were charged in connection with a fraud scheme that involved pocketing cash payments from vendors in exchange for steering orders for medical equipment to those vendors. Andrew Lee is charged with one count of wire fraud, while Kimberly Dyson is charged with one count of conspiracy to commit bribery and four counts of bribery. Lee and Dyson worked as prosthetic clerks in the VHA Prosthetics Service in Chicago, where part of their duties was to select vendors to order medical equipment for VA patients using government purchase cards. The charges allege that Lee and Dyson schemed with coconspirators who owned or operated medical supply and distribution companies, in some cases placing orders for unnecessary and more costly monthly rentals of medical equipment, rather than purchasing the equipment as VA physicians had ordered. The scheme fraudulently caused the VA to overpay one company by more than $1.38 million from 2016 to 2020. Lee and Dyson pocketed kickbacks of at least $220,000 and $39,850, respectively.VA 3

From fraud to theft, we find another VA employee improperly taking advantage of their position for personal gain.

Former VA-certified registered nurse anesthetist, Elizabeth Prophitt of Saline, Michigan, was sentenced to three years’ probation for stealing controlled substances, including several opioids, from hospital-dispensing machines. Prophitt pleaded guilty to five counts of obtaining controlled substances by fraud, misrepresentation, or deceit. She used her position as a surgical nurse to steal more than 2,000 vials of Schedule II and Schedule IV controlled substances, which included fentanyl, hydromorphone, morphine, and midazolam. Prophitt would use protected patient information and falsify medical documents to obtain the controlled substances. Instead of using the medication on patients, she diverted the drugs for her own personal use.VA 3

For all those people who shudder when they think of how porous the government is in protecting personal identifiable information (PII), the following should alert and provide more fodder to end the political ambitions of representatives who continue to refuse to do their jobs!

Five out of seven conspirators were convicted for their roles in a scheme to defraud the VA and the Social Security Administration of more than $1.8 million. A Florida jury found Omar Shaquille Bailey and Ronaldo Garfield Green guilty following an eight-day trial, while a third codefendant, Jamare Mason, pleaded guilty on the second day of trial. Two other codefendants, Kadeem Gordon and Mario Ricketts, had pleaded guilty prior to trial, while two remaining codefendants have yet to be apprehended. The members of this conspiracy obtained the personally identifiable information of disabled veterans and Social Security beneficiaries and used this information to fraudulently open bank accounts and prepaid debit cards. They also forged documents in the victims’ names that directed the VA and the Social Security Administration to deposit benefit payments into those fraudulent accounts. The defendants and their coconspirators withdrew these funds from ATMs and banks throughout South Florida and Georgia for their own personal use. Much of the funds were ultimately funneled to the architects of the scheme in Jamaica. The five guilty defendants are awaiting sentencing.VA 3

Please remember, an indictment is not a conviction, and every person is allowed their day in court, in front of a jury of their peers, before sentencing and judgment is passed.  With that said, the following indictment is pretty compelling.  If found guilty, may the defendant be forced to do community service in distinctive clothing, in a public place, and carrying a sandwich board detailing their crimes.  Inexcusable and unforgiveable are terms not used enough for some crimes!

Rosemary Ogbenna of Washington, DC, was named in a 35-count indictment for allegedly carrying out a scheme to steal more than $400,000 in government benefit funds provided by the Social Security Administration (SSA) and VA. According to the indictment, Ogbenna operated a rooming house business and perpetrated the scheme to target some of her tenants. She obtained and maintained control over SSA and VA benefit funds intended for the care of elderly, mentally ill, disabled, and veteran beneficiaries, and used the funds for her own personal use and benefit.VA 3

The Raymond G. Murphy VA Medical Center (VAMC) in Albuquerque, NM is in the news again.  No surprise if you, like me, are familiar with the conditions and leadership at this VAMC.  Unfortunately, another veteran has died due to the malpractice and malfeasance, abuse, and lack of leadership in the VA.

The VA-OIG determined that poor oversight of resident physicians (residents) likely contributed to the patient’s delayed lung cancer diagnosis. A resident ordered an abdomen and pelvis computed tomography (CT) scan. Although a follow-up chest CT scan was recommended within 90 days, it took 175 days to complete. The chest CT scan results included resolution of a spiculated lung nodule and worsening of opacities in the lung representing a cavitary infection or cancer, and a positron emission tomography/CT (PET/CT) scan was recommended. The follow-up PET/CT scan showed a lesion in the right lung, but a biopsy was not done. The patient was examined and diagnosed with cancer at a non-VA hospital.

The VA-OIG concluded that deficiencies in care coordination between Primary Care, Pulmonary, and Emergency Departments’ staff also contributed to delays. In addition, contract teleradiologists did not use available prior images for comparison.  The facility failed to use quality management and patient safety processes to evaluate the care of the patient.VA 3

Here’s the kicker, and it should infuriate every taxpayer in America.  The Raymond G. Murphy VAMC was recently found to be meeting all SAIL metrics in a comprehensive healthcare inspection completed by the VA-OIG.  SAIL metrics are how the VA leadership are measured in being knowledgeable and competent in these positions.  Check out the link on SAIL metrics for more information.  Leaving only one question, “How can the VA leadership be found competent, and still be killing veterans?”

Angry Wet ChickenWhen discussing the abuse of veterans and the failure of VA leadership, it never ceases to surprise me the utter half-truths, bloviations, and oratorial yoga, and logical pretzel twisting that is accepted by the US Congress.  The following link takes you to a list of witness testimony given by VA-OIG representatives to the US Congress.  If these “witness” statements leave you sick and mentally struggling, don’t say you were not warned.  The VA-OIG, like the VA, is replete with verbal contortion performers and nowhere is this most noticeable than in “witness” testimony!

Regarding verbal chicanery, oratorial yoga, and despicable verbal gymnastics to provide job security while taking zero action, here is the link to the Semiannual Report to Congress by the VA-OIG.  Don’t say I didn’t warn you, the bureaucrats are out in full force and are playing every card in the deck to protect themselves from Congressional Scrutiny, while attempting to pass themselves off as honest, fair, and doing a good job for the American People.  The problem is in Congress not properly scrutinizing these shenanigans and demanding compliance with the law!

VA SealThe remaining 15 notifications from the VA-OIG are the standard reports on comprehensive healthcare inspections (CHIp) where leaders are measured, never found wanting, even though too often the leaders are failing and useless.  Other notifications included the audit for data security and IT measures completed by a third-party auditor, and which the VA continues to fail but Congress refuses to hold people accountable.  The third and final series of notifications in this batch were several dealing with individual VISN level of local VAHCS/VAMC level inspections on specific topics, such as COVID response, supply chain failures, and other issues.

Unfortunately, the answer is always the same the leaders are inept, inadequate, and incapable of initiating change before a veteran dies, before fraud and abuse occur, or before the VA-OIG makes an attempt to inspire change.  Not that the VA-OIG is very capable or properly equipped to inspire change, simply that the VA-OIG made an attempt.  The root cause remains clear, Congress refusing to do their job has led to the US Military Veterans being actively abused by the Department of Veterans Affairs.  Lackadaisical scrutiny, politicization, and two recent presidents who allowed Congress to label the US Military Veterans as “domestic terrorists,” have had detestable consequences for the American Taxpayer and the US Military Veterans and their families.?u=http3.bp.blogspot.com-CIl2VSm-mmgTZ0wMvH5UGIAAAAAAAAB20QA9_IiyVhYss1600showme_board3.jpg&f=1&nofb=1

Are you sufficiently inspired to change how you vote, demand elected leaders to act, and improve how the government in America from the city/county to the US President operates?

© 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.

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.