“All Power is … Derived From The People.” – The Consent of the Governed

cropped-2012-08-13-07-37-28-1.jpgIf you are browsing a second-hand bookstore and come across the book “We, The People: Great Documents of the American Nation” by Jerome B. Agel, I recommend picking the book up and adding it to your library.  I have not found a better book discussing the founding documents of this great American Republic.  It is historically accurate, provides insights, and is a treasure of wisdom and knowledge.

A phrase in the Declaration of Independence has always captured my imagination and held fast to my mental processes.  “Governments are instituted among Men, deriving their just powers from the consent of the governed.”  It has always been understood that men invented governments for the ruling of other men.  Rome was a perfect example of this principle, and in writing down the laws, the first attempt at a moral government responsible to the people was attempted.  However, it is the second part of that phrase that we are discussing, “deriving their just powers from the consent of the governed.”

Consider this principle for a moment. First, governments have just and unjust powers, and second, the powers originate with the consent of the populations agreeing to be governed by the government.  Czarist Russia is an excellent example from history where the people had enough and began looking around for a new government.  That the people were hoodwinked and communism was imposed upon them remains one of the great tragedies of the last century.  In less than 100-years, Russia went through two incredible government upheavals is mentally incredible to consider.Plato 2

Unjust powers of government are those powers governments assume where the people have not granted them consent of the governed.  When governments take enough of these powers upon themselves, the population’s revolution, anger, and frustration are the only outcomes possible.  Worse, the governments are breaking their laws and the trust of those who elected them, proving that the most dangerous person is an honest person betrayed.

Bobblehead DollAll of which is mentioned as we discuss the origin of the philosophy of the consent of the governed in American jurisprudence.  Virginia, 1776, The Virginia Declaration of Rights prefixed the Virginia Colony’s constitution and was written by a reluctant statesman and largest landowner, George Mason.  In sixteen statements on government and the rights of man, we find the consent of the governed and the need for controls on government pertinent to our day and time!

      1. “All men are by nature equally free and independent, have certain inherent rights, … namely the enjoyment of life and liberty, possessing property, and pursuing and obtaining happiness and safety.”
      2. “All power is vested in, and consequently derived from, the people; that magistrates are their trustees and servants, and at all times amenable to them.”
      3. “Government is or ought to be instituted for the common benefit, protection, and security of the people. … A majority of the community hath an indubitable, unalienable, and indefeasible right to reform, alter, or abolish it, in such manner as shall be judged most conducive to the public weal.”
      4. “No man, or set of men, are entitled to exclusive or separate emoluments or privileges from the community.”
      5. The state’s legislative and executive powers are separate from the judiciary, and the operatives return to being citizens after their respective terms in office, in accordance with the laws of the land. [Edited for brevity]
      6. Contains three principles of import:
          • Elections should be free and open to all.
          • Property cannot be taxed or deprived for public use without consent.
          • Those elected are bound to the same laws as the citizens.
      7. “All power suspending laws or the execution of laws by any authority without consent of the representatives of the people is injurious to their rights and ought not to be exercised.”
      8. Deals with a criminal trial, due process, speedy trials, a jury trial, and a unanimous jury.
      9. Deals with fines, bail, and cruel or unusual punishments.
      10. Deals with search and seizure requiring evidence of a crime and the need for a warrant to be based upon evidence or not to be granted.
      11. Holds sacred the rights to a jury trial, including for disputes between two people over non-criminal issues.
      12. Holds sacred the power of the press as a bulwark of liberty, and restraining the press is an action of despotic governments.
      13. Details that standing armies in peacetime should be avoided and a well-regulated militia is proper and natural for the defense of the state. Important to note, “the military should at all times be under strict subordination to, and governed by, the civil power.”
      14. Demands uniform government that applies to all people.
      15. Declares that “No free government, or the blessings of liberty, can be preserved to any people, but by a firm adherence to justice, moderation, temperance, frugality, and virtue, and by frequent recurrence to fundamental principles.”
      16. Declares that “Religion, or the duty we owe to our Creator, and the manner of discharging it, can be directed only by reason and conviction, not by force or violence, and therefore all men are equally entitled to the free exercise of religion according to the dictates of conscience, and that it is the mutual duty of all to practice Christian forbearance, love, and charity towards each other.”

Let’s Discuss

Are we in trouble? We didn't do it!!!
Are we in trouble? We didn’t do it!!!

In opening the discussion, one of the most egregious and despicable actions witnessed every year is the failure to follow the strictures of a peaceful society as required in the 16th statement, to practice the “mutual duty of all to practice Christian forbearance, love, and charity towards each other.”  Having been a student of religion, I have found no religious stricture, in any organized religious teaching, to living in harmony with others by practicing forbearance (tolerance, patience, and kindness), love (respect, kindness, gentleness, meekness, all unfeigned), and charity (service) to those in our society.  Atheists, this includes you; it is time to live in harmony with others and stop the lawfare.  If someone is not violently demanding you adhere to their religion and religious tenets, then leave them alone!

I Find the following extremely important to the news developed, especially over the last two weeks.  “No free government, or the blessings of liberty, can be preserved to any people, but by a firm adherence to justice, moderation, temperance, frugality, and virtue, and by frequent recurrence to fundamental principles” [emphasis mine].  Let’s break this down:

      • Justice: Decency to all as a behavior of equality and commitment to moral rightness.
      • Moderation: This is all about not going to extremes, being restrained, knowing the boundaries and staying within limits, and being reasonable and approachable.
      • Temperance: While primarily used in drinking alcohol, this also applies to any behaviors where self-restraint, moderation, and expressions or observance of temperate behaviors are required.
      • Frugality: Besides being a good steward of other people’s resources, being frugal requires being sparing, prudent, economical, thrifty, and reserved.
      • Virtue: Requires moral excellence, modesty, personal dignity, goodness, and conformity to a standard of righteousness.

Knowledge Check!These are fundamental principles of liberty and the foundation upon which government is built and sustained.  How often do you hear politicians discussing these terms, returning to these principles as terms to write laws worthy of printing for society or as standards for scrutinizing the government agencies?  What did we observe in government this week that adhered to any of these fundamental principles to America or any other government succeeding in the past week?  Does anyone argue that Gov. Cuomo’s actions in New York were virtuous?  Were the CDC Director’s edicts frugal, temperate, moderate, or just?  How about the reaction by Congress to the mandates by the CDC?  Did they perform their jobs to scrutinize the legislative branch using these principles?

Now, some will decry that this is a document solely for the Commonwealth of Virginia and does not apply to the entire United States.  Yet, I would counter that the principles and language of this document are interwoven into the Declaration of Independence, the US Constitution, the US Bill of Rights, and every other founding document and US State Constitution.  Thus, why could we not use The Virginia Declaration of Rights as a template to benchmark and measure the performance of politicians and bureaucrats?Image - Eagle & Flag

Fundamental principles do not age, expire, or possess a shelf-life.  Hence, knowledge of the fundamentals empowers action by the electorate to change, correct, and demand government adherence, for we are the owners of our representative government.  We, the electorate, need to teach these fundamental lessons to the politicians, then demand they adhere and hold accountable the bureaucrats to the fundamental principles of liberty, or we all lose this precious government of the people, by the people, and for the people, where the consent of the governed is respected.

© 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.

Paul Harvey – Detestable VA Chronicles for Week Ending 07 Aug 2021

Bobblehead DollPaul Harvey is a hero of mine.  I miss his voice on the radio.  He exuded a calm demeanor, regardless of the terror, the trials, and the terribleness of the news reported and discussed.  I do not have Paul Harvey’s sense of calm.  When I heard about the beheading of a woman in America, in broad daylight, by an illegal immigrant who has been on a one-man crime spree from El Paso to Minneapolis since 2007, my cherub-like demeanor took a tremendous hit.

The Department of Veterans Affairs (VA) – Office of Inspector General (VA-OIG) reports on a couple from Kansas who are flat out despicable, faking blindness to increase disability payments from the VA and Social Security.  Frankly, I hate liars and thieves and agree to the restitution ordered, but I do not agree that the couple deserved probation.  Stealing benefits should come with more than simple probation and restitution.  Where is the community service in distinctive clothing and sandwich boards declaring they are thieves?VA 3

However, this couple represents a symptom, not the disease of the VA and Social Security specifically, and the Federal Government generally.  When leaders act reprehensibly, criminals will test the system to find weaknesses and attempt to benefit from leadership failures.  The disease of poor leadership has far-reaching consequences, and criminal activity is not unexpected.  Who is addressing the disease?  When will the citizens of America receive justice to see the healing of the illness that has captured the government?

Military Sexual Trauma

I-CareImperative to understanding, Military sexual trauma (MST) experienced while serving in the military affects both women and men with potentially severe and long-term consequences. Psychological trauma, such as MST, also increases the risk of physical health conditions such as cardiovascular disease, stroke, and diabetes.  The Veterans Health Administration (VHA) requires that each facility has a designated MST Coordinator with at least 20 percent of their time dedicated to protected administrative time.  For the record, “protected administrative time” is the time required to be spent on administrative duties, writing clinical notes, ordering supplies, scheduling appointments, administrative responsibilities, and so forth.

In 2018, the VA-OIG discovered just how detestable and deplorable the VBA’s processes and procedures were for military sexual trauma (MST).  Having been a victim of MST, this issue is of particular interest to me, and I continue to follow this issue closely.  I wish I had some encouraging news on this issue, but the VA-OIG found:

“… Processors did not always follow the updated policies and procedures. VBA leaders did not effectively implement the VA-OIG’s recommendations and did not ensure adequate governance over military sexual trauma claims processing. The VA-OIG concluded that VBA was not properly implementing the recommended changes.”VA 3

In 2016, when claims were being improperly and prematurely denied, the problems were considered a lack of training, a lack of policy, a lack of procedures, and comprehensive guidance was needed.  In 2018, additional training and guidance were needed, time, and leadership were recommended, even though claims were still improperly and prematurely denied.  In 2021, it is now blatantly obvious we have a systemic failure of leadership at the VBA to process claims in a manner that is conducive to good order and discipline!

On the same day, this investigation was released, the VHA investigation results for MST coordinators were released to the public.  I bet you can guess what was found, but let’s allow the VA-OIG the opportunity to detail the failures:

The VA-OIG conducted a national survey and interviews to evaluate MST Coordinators’ duties and perceived challenges.

            • 80% of the respondents reported having been assigned at least 20 percent or more of protected time.
            • 39% reported inadequate resources to fulfill MST Coordinator administrative responsibilities.
            • The VA-OIG found that insufficient protected administrative time, role demands, insufficient support staff, and inadequate funding and outreach materials challenged MST Coordinators’ ability to fulfill role responsibilities.
            • The VA-OIG found that MST Coordinators who reported more dedicated time than other MST Coordinators did not necessarily serve at facilities with higher numbers of patients in MST related care.”VA 3

Did you catch that final point?  Resources are not being adequately provided based upon patient load to locations where veterans need care.  Another symptom of leadership failure, being designed into the organization as a policy and working procedure, meaning this is designed incompetence!

Knowledge Check!Here’s the biggest rub, a veteran can be receiving care from the VA for MST at the VHA and still be denied MST on a VBA claim.  I have not heard it working in reverse where a claim is being paid, but the VHA refuses care, but given the failures of the VA as an organization, I would not be surprised to learn this was occurring.  How do I know that care can be provided for MST and not be allowed on a claim?  I am among a number of MST victims, all-male, who have been regularly denied VBA claims but are receiving care for the psychological harm.  Veterans talk to each other.  I have heard the stories of fellow veterans being attacked, assaulted, molested, drugged, raped by male and female attackers, and heard how the VBA had revictimized them.

What’s worse, MST leads to PTSD, and people are suffering PTSD from a number of traumatic events not receiving care or benefits because the VA refuses to acknowledge these problems.  Admitting a problem is the first step in addiction programs; well, it is also the first step in healing leadership failure, and the VA is suffering from dynamic leadership failure at every level!  Know a veteran whose story needs to be told, refer them to me; let’s get this information out.  I am sick to death of the VA getting away with murder.

Programs and Inspections

VA SealThis week, the final three emails from the VA-OIG reflected a VISN wide comprehensive healthcare inspection (CHIp) conducted virtually, a VAMC/VAHCS CHIp conducted in Spokane, Washington, and a program report on the failures in the Veteran-Directed Care Program.  The most interesting finding in the CHIps was how short the leadership teams had worked together, a month, and how many open positions for leaders there were, more than half.  Talk about glaring symptoms of leadership failure, were the leadership teams broken up from employee turnover?  If so, did the employees retire, or were they retired to avoid criminal convictions?  With all the investigations for fraud, as discussed on these pages frequently, I can only guess how leaders churn in a VAMC/VAHCS/VISN.

Believe it or not, the Veteran-Directed Care Program is full of faults, problems and is suffering from a lack of leadership as the program balloons.  Color me shocked!  Surely, somewhere in the VA, if only to screw with the gods of perversity and Murphy their prophet, there must be a functioning and well-led program, department, office, etc.Angry Wet Chicken

It is so absurdly depressing to catalog these failures of leadership week after week and never see any improvement.  We see increasing failures, we observe heightened criminal activity, there is undoubtedly raised awareness of needs and moral distress in abusing veterans, but where is the improvement towards achieving excellence?  Where is Congress in scrutinizing the legislative branches, officers, and leaders?

If a congressional representative can order the VA-OIG to investigate the MST Coordinators, which they did, where is Congressional action on the results?  Surely this is not too difficult a question to ask.  Better still, where is Congress?  I have now reached out to all the elected Federal officials in Arizona, Texas, and New Mexico.  Texas, because that is where I have been forced to receive care from.  New Mexico because I now live here.  Arizona because I was physically injured by VA employees there.  The amount of interest received has been less than zero!Angry Grizzly Bear

How can interest be less than zero, you ask.  Well, while I have not received any response to my original complaints, I have received a TON of marketing materials about how those congressional representatives “Care about veterans, the community, pets, animals, and America.”  Maybe, not always in that order, but absolutely with less sentiment than I have for the weeds growing on my sidewalk!  Thus, I ask again, with all sincerity, where is Congress in scrutinizing the government?  I demand to know the “Rest of the Story!”

© 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.

It IS ALL About Leadership – More Shameful VA Chronicles

I-CareRecently, guardianships have been in the news, and I doubt this story will make the lawyers very happy.  The department of Veterans Affairs – Office of Inspector General (VA-OIG) reports that an Albuquerque couple has been sentenced for defrauding guardians, which included veterans.  The criminal report claims:

Susan Harris acted as president and was the 95-percent owner of Ayudando, while Moore acted as chief financial officer and was a five-percent owner. They engaged in a pattern of criminal conduct from November 2006 to July 2017 that included unlawfully transferring money from client accounts to a comingled account without any client-based justification.  They wrote and endorsed numerous checks, often of more than $10,000, from these comingled accounts to themselves, family members, cash, and other parties where payment would benefit their families.”

For the better part of 11 years, this couple has spent money not their own, abused their charges, and defrauded vulnerable clientele.  While the federal attorneys and investigators crow about catching this couple and ending this situation; what about all the rest of the guardianships where abuse is occurring?  I have read horrific stories about victims of guardianship abuse and hope more will be done on this topic very shortly!VA 3

For 11 years, where were the VA and the Social Security Administration?  Where were the local hospital leadership, social workers, and other federal employees who had to have known something fishy was going on?  Where are these Federal Employees now?  Where are the politicians scrutinizing this incident to ensure that protection for vulnerable citizens never happens again through legal guardianships?

Now traveling to Eastern Oklahoma VAHCS in Muskogee where an audiologist provided poor care and billed for unrendered services.  Pay close attention to the VA-OIG report; the leadership failures on this report alone are voluminous and unforgivable!

A facility fact-finding review revealed the audiologist provided poor care to eight of 43 patients reviewed, including misinforming patients who needed hearing aids that hearing aids were not needed. Although the audiology leaders reported the fact-finding results to the OIG, they failed to evaluate whether patients needed clinical follow-up; determine whether additional patients were affected by the audiologist’s poor care; evaluate whether clinical disclosures were required for the affected patients; and communicate the fact-finding results to the Facility Director, who was, therefore, unable to initiate the process to determine the necessity of a large scale disclosure. The instances of poor care were also not reported to the Patient Safety Manager, who was, as a result, unable to assess the adverse events to determine if patient safety interventions were indicated. The VA-OIG also found that performance monitoring of facility audiologists was not conducted as required. Annual competency assessments and annual performance appraisals were not consistently completed and did not contain adequate performance standards. Audiology leaders failed to consider whether the audiologist’s actions warranted a report to the state licensing board due to a lack of understanding of the requirements for reporting and, therefore, the Facility Director was not informed of the need to initiate a state licensing board review” [emphasis mine].

Will, someone please tell me, were the audiology leaders who failed to perform their jobs removed from Federal Employment?  What about the audiologists causing the problems?  Are they removed from Federal Employment?  Were their licensing practices curbed to protect other populations of patients?  The leadership failures here read like a Steven King horror story but do not have the satisfaction of finishing the story.VA 3

Yet, the Department of Veteran Affairs (VA) will continue to market that they are “defining quality in healthcare.”  The jokes write themselves but cannot be fired from Federal Employment!  Politicians, why can these jokers not be fired from Federal employment for such egregious abuse of their positions and failures to do their jobs?

I-CareTraveling further to North Carolina, we find that the perpetrator of this fraud has pled guilty, but again responsibility, accountability, and correction of the VA is being skirted.

John Paul Cook, 57, of Alexander, North Carolina, pleaded guilty to defrauding the VA. After enlisting in the Army in 1985, Cook sustained an accidental injury and complained the injury worsened a preexisting eye condition. In 1987, Cook was discharged, and he began receiving benefits that would increase over the next 30 years due to Cook’s repeated false claims of increased visual impairment and unemployability. In 2005, the VA declared Cook legally blind, and he began receiving disability-based compensation at the maximum rate despite repeatedly passing vision screening tests to obtain or renew his driver’s license and purchasing vehicles that he routinely drove.”

1987 to 2020, we will be generous in counting the years here; regardless, we are looking at 30+ years this fraud continued.  Where were the verification protocols?  I have had to produce a valid driver’s license at the VA to obtain and keep current my VA identification card.  How did this fraud go on for so long?  What is the VA doing to stop, or at least hinder, those who would defraud the government before the problem becomes 10 years old, let alone 30?!?!  I cannot fathom how this fraud went on for so long without a routine checkup, a routine exam, a follow-up exam, etc.VA 3

Going north from South Carolina, we find more fraud, this time in New Jersey, where a man did not report his mother had deceased and continued to claim her benefits for a total of over $200K.

Melvin Greenspan, 72, of Perrineville, New Jersey, pleaded guilty to defrauding VA of over $200,000 in survivor’s pension benefits. After the death of his mother in 2006, who had received survivor’s pension due to his father’s prior military service, Greenspan failed to notify the VA about his mother’s death and made withdrawals of the benefits through 2018.”

Where was the leadership?  Where are the leaders now?  Another fraud case, older than a decade, and still the VA cannot be held accountable for facilitating the fraud.  I am stunned!  How did this one continue for so long?  Doesn’t the VA check local newspapers, the Social Security Administration, other Federal Agencies?  Since the culprit was not held on defrauding SSA, one can only presume the mother’s death was reported there.  Why did the VA not get notified to ask the family questions?VA 3

On the topic of guardians and leadership, the following story makes me angry!  However, I will withhold further elaboration since those accused remain innocent until proven guilty by a trial of their peers.

Johnny Ray Gasca, 51, was arrested for allegedly abducting a 68-year-old woman with dementia from the West Los Angeles VA Medical Center in California. A witness recognized Gasca and reported he might have previously taken money from the woman’s bank and retirement accounts. Following his arrest, Gasca described the victim as his girlfriend and told agents that they stopped at a bank where the victim made a $15,000 withdrawal after leaving the medical center.”

In the first report from the VA-OIG discussed, we found guardianship rules being violated to the Nth degree.  In this story, we have no information of an assigned guardian, and we have a dementia patient being abused.  The dementia patient was traveling with a friend; who is the legal guardian for a dementia patient?  Where are the family or friends legally bonded to render aid for this patient and monitor finances to protect them from abuse?  How can the VA operate one way in one locale and 180-degrees differently in another locale and the leadership not held accountable?VA 3

Speaking of missing leadership, the following VA-OIG report is a beauty!  The Department of Veterans Affairs – Veterans Health Administration (VHA) has a program to help homeless veterans, where contractors are used, and the VHA uses case management documentation to verify the veteran is receiving the assistance being paid for, the program is called the contracted residential services (CRS) program.

The VA-OIG found facility staff did not consistently document case management and monitor the progress of veterans in the program.  Further, four of the 14 CRS contracts reviewed had performance deficiencies, with one resulting in improper payments of $592,000. These deficiencies may affect the health and safety of veterans living in transitional settings. Moreover, VA lacks assurance that veterans received required services. There were also contract administration problems in 13 of 14 reviewed contracts. Contracting officers did not always properly delegate responsibilities to staff functioning as contracting officer’s representatives. Further, one facility’s representative did not ensure contractors provided meals or the means to purchase them, as required, and another lacked invoice supporting documentation for approval. The VA-OIG audit team estimated that 107 of 119 contracts had monitoring and administration deficiencies. Furthermore, the team estimated that VHA made $35.3 million in improper payments, of which approximately $21.6 million was technically improper because the individuals authorizing payment were not delegated authority to serve as contracting officer’s representatives.”

If your accomplishment rate in your employment was 48%, would you retain your job for very long?  If 90% of your documentation claiming how well you do your job was missing or fabricated, how long would you maintain employment?  If you delegated people to complete your work who were unauthorized and you were contractually culpable, how long do you think you would stay out of prison?  How long would your boss stay out of jail?  How long would your company exist?  Now, answer me this riddler, why does the government get a pass on these questions?VA 3

Finally, we have Deputy Inspector General David Case’s testimony regarding the failure of VA leadership where the implementation of a new electronic health record (EHR) is being stalled.  If you care, the VA leadership and the VHA leadership are failing the EHR initiative.  Not that this was not expected, and not that this is not surprising, the IT and IS departments of the VA and VHA are so hopelessly lost it amazes me the VA is even using computers and not written records!  But, do not take my word for it, Case himself claims,

“Detailed in this statement, we have repeatedly found unreliable and incomplete estimates for upgrades and costs, inadequate reporting affecting transparency to Congress, and stove-piped governance with decision making that does not appropriately engage Veterans Health Administration (VHA) personnel who are the end-users of the new EHR system.”VA 3

Knowledge Check!Get that; the leadership failures are obstructing Congress and hindering the EHR progress!  What can we conclude from this batch of VA-OIG reports:

        1. The VA, VHA, VBA, and National Cemetery leadership are actively missing, like the Democrats from the Texas Legislature.
        2. If the leaders are present, the leaders are the problems in progressing.
        3. The leaders have created a system where fraud and abuse of the veterans and taxpayers can be achieved with ease.
        4. Nobody in the US House of Representatives or US Senate scrutinizes the legislative branch sufficiently to effect changes.
        5. When in doubt about where your leaders fall, check to see if they are in their offices. Oh, wait, that won’t help, their offices have locks on the doors!

If this is how the VA defines quality healthcare. In that case, the veterans are screwed, the taxpayer is sunk, and the leaders will enjoy their magnanimous federally approved retirement packages, ad nauseam ad infinitum!

© 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.

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.

NO MORE BS: Have You Heard? Chapter 2

QuestionThe first week of June is often a period of recovery.  I have no idea why, but the first week of June is usually a recovery time.  Maybe it was all those years in school; I honestly do not know.  However, the world does not stop, and while the media goes 24/7 over the Memorial Day Gun Violence, stories are evolving that need your attention more.  I do not say this lightly, as I understand those wounded and killed in gun violence are tragedies and cause for grief, but the corporate media has always used these “major stories” to allow other things to slip past.

WhyHave you heard Dr. Fauci’s emails from while he was a name in President Trump’s councils reflect a different story than the lies he peddled for political purposes?  “The emails from the first half of 2020 reveal Fauci’s skepticism early on about masks to ward off COVID-19, his dismissal of the notion that the new coronavirus escaped a lab in China, and his vague reference to researching how to make the virus deadlier.”  Why is this spineless invertebrate still a media mouthpiece, a paragon of dirty virtues and political connections?  Fauci’s research from 1990 through 2020 was in Coronaviruses, and he still hyped, pushed, and peddled lies to obtain a political payoff.  Knowing masks were useless, he pushed lies.  Knowing the survival rate, he still pushed draconian government takeovers of liberty, freedom, and common sense.  Knowing he could orchestrate a catastrophe, he pushed lies to initiate a public health emergency and stood back to reap the windfall in the chaos created.  Of all the government officials with hands in the pot stirring the government mandates, I blame Fauci more than others!

Nuclear FamilyHave you heard the Federal Government remains hell bound and down on destroying the family but is explicitly targeting black families?  Would a minority please help explain why under a Republican President, the Federal Government’s actions are racist, but under a Democratic President, the same actions are “beneficial, needful, helpful, and not in any way demeaning?”  Frankly, I do not care about the race factor; the fact that the US Government, from the Mayor and School Board to the President, seems bound and determined to destroy the foundation of society, the nuclear family, remains highly suspect and needs to be investigated!  Ever since the US Government stole State’s Rights where Welfare Programs were concerned, the family has been directly targeted.  Look at any race, and you will see the same hit in the data, where families went from working to be self-sufficient to the government dole.  Unfortunately, black families have suffered some of the worst impacts.  Now we are three generations into the destruction of the family as a government program, and I want answers!

Have you heard, the data is inescapable, the conclusions self-fulfilling, and the results are incredible.  When you want more economic freedoms, which lead to more overall liberties, it is best to start by ending corruption in government.  Who would ever believe that economic freedoms lead to individual liberty, and the best place to start is reducing government?  I am absolutely… nonplussed!  The founding fathers of The United States of America, a Free Republic (if we can keep it), understood these connections intimately and established the US Constitution to provide future generations the best chance of keeping the American Republic.  So, who would like to start firing and cutting government?  I am first in line; join me!Plato 3

The Department of Veterans Affairs – Office of Inspector General (VA-OIG) released a report on 02 June 2021, detailing crimes so horrific and obscene, I can find no appropriate adjectives to describe this negligence and criminality of all administration leaders involved.  January 2021, Dr. Robert Levy, who was a pathologist, who over his 12-year tenure at the VA Hospital in Fayetteville, Arkansas, made over 3000 diagnostic errors, manipulated the quality control process, and caused severe injury to 34 patients, received 20-years in what can only be called a “plea deal” that should never have been allowed!  The good doctor admitted to long-term alcohol use.  Now, will someone please hold the leadership teams accountable for this doctor’s behavior?  This story makes me especially sick!  Where are the politicians who were elected (hired) to scrutinize the government?  Where are the “Blue-Ribbon Congressional Committees” to hold those accountable and responsible for 34 veterans severely injured over the actions of a VA provider?  Who will speak for the victims and demand, then oversee and insist upon corrective actions by an executive branch of the government through the work of the legislative and judicial branches of government?VA 3

I was an operations manager, the safety of my workers was my paramount responsibility, and I could be held legally accountable for what happened on my manufacturing floor.  I had two people go for lunch, lifting 40oz curls, and returned to work for the afternoon soused!  I had to shut down my manufacturing facility, I had to keep these two from driving away, I had to call in the temporary employment agency to collect these gentlemen, and they could not have their keys back, for as soon as they returned to work in an alcoholic stupor, I was responsible under the bartender law.  This incident still brings some emotional baggage and resentment at these two morons.  How in the world was the good doctor able to be alcoholically impaired on the job, and nobody was aware?  Impossible!  Where is the accountability of the leaders in this situation?  I could have been jailed for allowing employees to operate their vehicle under the influence; when will the administration be held responsible for allowing a drunk employee to operate a vehicle?  Read the VA-OIG report; it is a criminal list of what not to do from day one of this doctor’s employment!Plato 2

Have you heard, the Department of Veterans Affairs (VA) killed a veteran in the emergency department of the Malcom Randall VAMC in Gainesville, Florida.  Worse, the veteran should never have died, and the reason they did was due to inefficiency, inadequate care, and processes and procedures in the emergency department triage of patients.  The patient had experienced hemicolectomy surgery, and between days 10 and 15 post-op recovery, he went to two outside ER’s and the VAMC ER, where he passed.  Drunk employees for 12-years are abysmal, fail to recognize patient distress, delay care, and cling desperately to outdated and inefficient processes in patient care in an emergency room, are execrable, horrific, and so vile to have exceeded repugnant!VA 3

Again, one must ask, where are the elected officials in pushing changes to the VA Administration; Oh, I know where they are; they are trying to kill history and remove President Lincoln’s mission statement for the Department for Veterans Affairs.  We need to understand priorities: Is a veteran’s life more important than being woke and having a small group of citizens begging for less sexism, who are always going to choose to be aggrieved, be satisfied for a small amount of time?  I know what my priority is, and it has nothing to do with the permanently dissatisfied and everything with saving lives and honoring patients who deserve the honor!

Knowledge Check!I implore you to please join your voice to mine, and let’s remember Memorial Day 2022 as the day marking how in 2021 we changed the VA, we limited the government, and seized our liberties and freedoms, as the founding fathers intended!  We can make a difference in the government, provided we band together without the petty names and distinctions currently being used to separate and divide.  We, the American Citizens, deserve better from the government we pay for, even if we must use every legal tool in our arsenal to cull the politicians and take the freedoms they have stolen.

© 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: Bureaucratic Fiat, a Veteran Suicide – Scrutinizing the Government

ApathyThe Department of Veterans Affairs (VA) is in trouble due primarily to the employees’ lack of written directions, procedures, and processes to complete work.  Of the poor Veterans Health Administration (VHA), there is none worse than the Carl T. Hayden VA Hospital system in Phoenix, AZ.  I support this conclusion with both personal observations and through comparative analysis.  Much research has gone into this conclusion, and while there are other VHA’s that compete for the bottom, the clear winner remains the Phoenix VA Medical Center (VAMC).

What is bureaucratic fiat?

Bureaucratic fiat is government employees who make decisions in their positions who rigidly adhere to any rule not to perform their job, inconvenience the customer, or thwart responsibility, accountability, and maintain their positions.  Bureaucratic fiat survives sections from the Office of Inspector General (VA-OIG) through designed incompetence, lack of training, confusing processes, unwritten rules and guidelines, and simple negligence.

LinkedIn VA ImageVeteran Suicide!

Outside of first responders and active military, the suicide rates of veterans are too high and rising.  The suicide rate is disgusting to behold and tragic beyond words.  Of all the topics I discuss, veteran suicide remains my pet topic.  When veterans or military members (Reserve, National Guard, or Active) commit suicide, this rips a hole in communities, families, and the guilt the family and friends carry is so intense, they struggle not to commit suicide themselves.

Scrutinizing the Government!

DetectiveThe VA-OIG reported on a veteran who committed suicide, with ties to the Carl T. Hayden VA Medical Center in Phoenix.  The veteran reported to the hospital, asking for help.  The VA-OIG found that processes were intentionally not followed.  Help was not forthcoming, and the veteran committed suicide before the VA got their thumbs out and offered this veteran help.  The VA-OIG found the following:

      • “While the patient awaited the testing, facility staff failed to offer mental health treatment.
      • The social worker did not complete a suicide risk assessment and relied on another social worker’s suicide risk assessment completed eight months prior.
      • A family member called and left a voicemail message for the social worker. However, the social worker’s documentation did not include essential information, specifically that the patient died by suicide.
      • Upon learning of the patient’s death by suicide, a Suicide Prevention Coordinator failed to complete timely documentation of outreach to the patient’s family… the mental health delegate did not approve the community care psychology consult within three business days, as required by VHA.
      • The third-party administrator scheduled the patient for therapy rather than psychodiagnostics testing.
      • The facility scheduling staff did not complete required outreach efforts when the patient missed a primary care appointment one day before the patient’s death by suicide.
      • The Suicide Prevention Coordinator did not complete the patient’s behavioral health autopsy within 30 days, as required.”

One incident, one VAMC, one veteran, and nothing from the VA will protect veterans and improve the adherence to the policies and procedures moving forward; why even investigate by the VA-OIG?.  I weep with this family who lost their loved one to suicide.  I scream in frustration that the VA can continue to kill veterans struggling with suicide with impunity.

Detective 3Do not be deceived; this is not the only incident in Phoenix or all of the VA Healthcare System.  A veteran reaches out for help with suicide ideation, receives bureaucratic nonsense instead of support, and is treated to the red tape that becomes the noose in the suicide of that veteran.  One event a year is a tragedy of epic proportions.  The list never seems to end, nor do the bureaucrats ever get held accountable for their inactivity, contributing to veteran suicide.

12 November 2020, The Military Times reported that from 22005 through 2018, veterans committing suicide had risen dramatically, to a high in 2014 of 6,587.  Is the epicness of this tragedy more apparent?  Presuming that each of these veterans had two parents who came together and invested time to create the child that became the veteran,  13,174 parents now weep to lose their son or daughter who committed suicide.  According to the US Census, families in America had 1.9 children per couple (2014), rounding up to 26,348 is the potential parents and grandparents affected by suicide, and 52,696 is the pool when siblings are added.  If each of these suicides had a significant other, with two parents and two siblings, the potential affected by suicide is now approximately 105,392.  Add employers, friends from employment, communities, and educational or academic acquaintances, and the number of people affected by suicide can quickly reach a million people.  I used 2014 as the year to base the numbers upon as this was the highest number currently available, but 2020 saw a dramatic increase in suicide among all age groups and those with the Census delays; I doubt America will learn the full impact from COVID government madness any time soon.

LookNow, consider the following, each of those veterans who committed suicide in 2014 (6,587) had a suicide prevention team in place at the VA who failed to act.  6,587 people who deserved better treatment at the hands of the government employees, who have pledged to fulfill President Lincoln’s promise “To care for him who shall have borne the battle, and for his widow, and his orphan” by serving and honoring the men and women who are America’s Veterans.  Failed the veteran and played a role in the suicide of the veteran.  Rarely do the veterans who commit suicide, in VA parking spots, on Federal property receive the attention they deserve.  I am intimately aware of one such issue with the VA Medical Center in Albuquerque.  The veteran could not get help, became frustrated, walked to his car, and killed himself.

2019, The Washington Times, who proudly continues to declare that “Democracy Dies in Darkness,” ran a story about veterans who take their lives on VA Campuses, is a “form of protest” against the VA Healthcare system.  No, this is not generally the case; the veteran is not protesting; they are fed up with the fight to be respected, noticed, and receive assistance from people who have pledged to fulfill the Department of Veterans Affairs Mission Statement.  To fulfill President Lincoln’s promise “To care for him who shall have borne the battle, and for his widow, and his orphan” by serving and honoring the men and women who are America’s Veterans.”

DutyI demand to know where are the legislative branches of government in scrutinizing the operations at the VA?  Why are suicide rates allowed to climb without significant input from the legislative branch?  Why are veterans, directly after an encounter with the VA bureaucracy, committing suicide without in-depth investigations where heads roll for failing to perform the most basic customer service in fulfilling the VA’s Mission Statement?

While an employee of the VA, to get to the directors of the hospital’s offices, I had to walk past this mission statement that hung on brass letters, and all my attempts to aid in change fell on brass ears and plastic lips!  Every time the VA-OIG reports another death by suicide, death by negligence, with ties directly to VA employees not performing their jobs, I want to scream in frustration!  Veteran suicide rates are egregiously high, and for veterans to commit suicide within 96 hours of a visit to the VA is 100% unacceptable!  Why 96 hours; because to date, this is the longest time between actions by the VAMC and the death by suicide the VA-OIG has reported where VA employees should have been held accountable for their refusals to act in a manner to prevent a veteran from committing suicide.

Millstone of Designed IncompetenceAfter over a decade of reading and reporting VA-OIG reports and investigations, the deaths by suicide and negligence are the ones that raise my ire the most!  I would see the VA improve, but until the VA admits, or is forced by elected representatives to admit, they have a problem, nothing will change.  But the horror in that sentence is that veterans will continue to commit suicide and die through VA Employee negligence, and their deaths are as unremarked as if these heroes were common criminals who died in a prison brawl.  This remains an abysmal testimony to the incompetence and uncaring bureaucrat found in the VA’s vaunted halls!

© 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.