In what has become typical and usual, the following stories arrive:
“From 2019 to 2021, Ira Westbrook of Bozeman, Montana, served as the fiduciary of an elderly relative who had suffered a stroke and became disabled. A multi-agency investigation found that, during these 16 months, Westbrook stole more than $57,000 in Social Security and VA benefits and used the stolen funds to purchase personal items, including a Jeep Wrangler, a travel trailer, and other day-to-day expenses.”
“From 2016 until 2018, Sloane Signal-Debose of Slidell, Louisiana, served as the fiduciary of a veteran who needed assistance managing his finances. During that time, she took more than $100,000 from the veteran’s accounts, used it as the down payment on a home in her name, and used additional funds from the veteran to pay contractors working on the home. Signal-Debose then submitted false records to VA to hide her misuse of the veteran’s funds. The former fiduciary pleaded guilty to misappropriating funds and faces up to five years in federal prison. The VA OIG conducted this investigation.”
“In 2013, Brandi Goldman of Jonesboro, Arkansas, was married to a US Army reservist who suffered a severe traumatic brain injury in a service-connected accident. As a result of this injury, her husband had many serious physical challenges, and Goldman was appointed as his guardian and fiduciary. Between April 2015 and November 2017, Goldman received more than $258,600 in VA disability payments and $36,000 in Social Security payments. During that timeframe, she withdrew close to $200,000 in cash and accrued about $900 in ATM and overdraft fees. Goldman admitted to spending much cash to fund her methamphetamine habit, spending $150 on methamphetamine two to three times per week. She also admitted that five other people moved into the residence with her and her husband, none of whom paid rent or contributed to expenses, some of whom she regularly gave cash to. She also admitted to paying $68,000 in cash for another home, furnishings for the home, multiple vehicles, and a motor home. Goldman was sentenced to 20 months in prison, three years of supervised release, and $143,000 in restitution after previously pleading guilty to misappropriation by a fiduciary. The VA OIG and Social Security Administration OIG conducted the investigation.”
Why are these stories of particular interest to the supreme legislative body in the United States of America? The executive branch has refused to police its branch of government, and crimes like this have become all too familiar. You, the Congressional bodies of these the United States, are duty-bound and sworn to perform two jobs, scrutinize the executive branch (harshly when necessary), and write laws. You have recently failed too often in monitoring the executive branch, and this story perfectly represents what happens when the executive branch is not examined minutely! Tell the US Public who put you in elected office, how these crimes continue and what programs and processes they MUST change to prevent them in the future.
By pleading for the legislative branch to scrutinize and audit the executive branch minutely, I am in no way condoning or diminishing the personal accountability of those who committed crimes. These three examples are from the October and November press releases of 2022. The widespread ability to commit fraud is a symptom of a more significant problem at the VA. Their leaders have consistently been able to boondoggle, evade, and profit from abusing veterans through designed incompetence, criminal neglect, and obtuse actions. When will Congressional leaders take action to clean up the Federal Government in general and the VA specifically?
The US House of Representatives holds the purse strings for the executive branch; use this leverage to claw back your powers and authority to balance the Federal Government and demand accountability from those empowered to lead their designated branches of the executive branch of government. Let’s talk about patterns; in less than 45 days, three cases of fiduciary fraud were closed, and the speed of closing these cases has escalated throughout 2022. The American people will see more, not less, of these fraudsters being underreported by the US Media before the year ends.
Shifting slightly, let’s talk about government employees and the need for more scrutiny of the executive branch.
“Bruce Minor, of Philadelphia, Pennsylvania, was sentenced to two years in prison, three years of supervised release, and ordered to pay $462,256 in restitution for his scheme to embezzle money from the Philadelphia VA Medical Center. Between December 2015 and September 2019, Minor, a former travel clerk, created fraudulent travel reimbursement claims in the names of at least three other VA medical center employees. He then diverted the funds into bank accounts he controlled. The VA OIG investigated this case.”
“Kyhati Undavia, of Houston, Texas, was sentenced to 27 months in federal prison after previously pleading guilty to conspiracy to commit healthcare fraud. From December 2012 to December 2018, Undavia hired employees to market Memorial Pharmacy, which she controlled and operated, to physicians as a place to submit compounded drug prescriptions. Instead of providing prescriptions directly to the patients who could select a pharmacy of their choice, physicians sent the prescriptions directly to Memorial Pharmacy. Then, Undavia paid the physicians illegal kickbacks for the prescriptions. Beneficiaries often received medicated creams that they did not need or want. Undavia received approximately $22 million from TRICARE, Department of Labor Office of Workers’ Compensation Programs, and CHAMPVA for the prescriptions.”
These stories also fall into the same timeframe mentioned above. But, they are not the only stories from 2022 where VA employees conducted long-term fraud for personal profit. Here’s the rub: hundreds of additional employees knew of these schemes, were probably running their schemes, and haven’t been caught, and nothing is being done by VA leadership to cease the fraud and abuse of veterans by VA employees. There is a culture of corruption at the VA, long hidden by scheming and abusive leaders and condoned by previous Congresses, that must be stopped! What will you, the congressional leaders of the United States, do to halt this insanity, demand personal accountability, and clean house of the designed incompetence that allows these criminal activities to flourish? The American People are waiting!
The following site holds press releases for the VA specifically, but investigations often cross into Social Security, the Department of Defense, state investigatory bodies, the FBI, and more. Suppose nothing else is learned from only perusing this site, that more scrutiny needs to be done to every single department of the executive branch. In that case, we, the American People, might count ourselves lucky. However, this is not the case. The rot from poor leadership, criminal mismanagement, and supreme dereliction of duty is etched deeply into the workings of the executive branch operations, and more needs additional discussion.
03 November 2022, the VA-OIG released a report titled, “VHA Progressed in the Follow-Up of Canceled Appointments during the Pandemic but Could Use Additional Oversight Metrics.” The report only covers the time from 2020 to the present, and regular readers know that the VA has been failing on every measurable metric for over a decade. To couch in politically correct non-threatening jargon, how designed incompetence continues to hamper and hinder is not surprising. That the current Congress has bought the excuses hook, line, and sinker, from the inept VA leadership, was not surprising either. This article is about the future, and the next Congress MUST take immediate and direct action to root cause and improve VA performance!
31 October 2022, the VA-OIG released the following: “Review of VA’s Staffing and Vacancy Reporting under the MISSION Act of 2018.” This is a report about how the VA continues failing to report improvements in hiring practices to the legislative branch. The report details VA leadership’s continued failures through designed incompetence. Tell me, if you were in charge of a report for your business that is essential to receiving funding, would you keep your job if, from 2018 to the present, you still cannot report what is happening and why and be held personally accountable for a report to a legislative body? Don’t take my word for it; read the report, and be careful of the temperature of your blood boiling!
Unfortunately, this behavior is the normal operating procedure for the VA. The same can be easily and quickly witnessed in every other Federal Department of the US Government under the executive branch. As the legislative branch, you are duty-bound to investigate and demand compliance in a timely manner. Where have you been; more importantly, will you allow these problems to continue or kill them?
Do you doubt designed incompetence is a standard operating procedure? Let’s discuss another part of the MISSION Act of 2018 that the VA-OIG recently reported on, “Additional Actions Needed to Fully Implement and Assess Impact of the Patient Referral Coordination Initiative,” dated 27 October 2022. The Referral Coordination Initiative (RCI) is a program to improve timely access to care using community providers. RCI sounds good in theory, but as usual, in the practical application, the program is full of self-serving charlatans, unsupervised or poorly supervised people, weak policies and procedures, and zero accountability! Plus, when the veteran runs into problems with local providers, reporting these problems is so time-consuming as to be ineffectual at best!
A personal example that was reported to the VA when it happened, and nothing was done but to issue the provider a check. Dr. Herekar, Neurologist, clinic: Advanced Neurology Epilepsy & Sleep Center, El Paso, Texas. A VA Primary Care Provider wrote to my employer on VA Letterhead with a wet signature, declaring my inability to wear a mask. Dr. Herekar’s office was presented with this letter and hassled me before both appointments for not wearing a mask, becoming hostile, argumentative, and a nuisance over the mask issue, even after I complied with putting on a face shield. 23 September 2021, over Facebook messenger, I was informed that I would be invited to find a different provider due to my refusal to wear a mask. Imagine that; Facebook Messenger became the medium of choice for ending a patient’s relationship with a medical provider. What did the VA tell me to do; file endless paperwork with TRICARE and then disregard the problem’s urgency. Worse, the medical care for the neurological issues decreased, and I have had to wait, sit, and hope for future consideration and possible treatment. Does this sound like an aberration; it is, unfortunately not!
The VA Leadership realized if community care succeeds, they lose power to control the destiny of veterans. Thus, they implemented the MISSION Act of 2018 with such feet dragging, designing incompetence into every facet of the program, to promote more complaints to Congress, and hopefully to squash the MISSION Act of 2018 and end community care. 07 November 2022, while waiting to speak to representatives of Community Care Services at the VA Out Patient Clinic in EL Paso, the veteran being served ahead of me was told, “The provider does not fax documents, so you will need to go to the provider, and then walk the paperwork back to us.”
The normalcy of reporting providers not submitting paperwork was beyond the pale. Not having secure document transfer processes between the VA and local providers is technically abysmal and unacceptable. Are we in the 1990s, where the cream of technology is sending and receiving a fax? The designed incompetence includes Luddite-like technical disciplines, and the VA_OIG and the Congress should be furious; I know I am!
Before the MISSION Act of 2018, I was making 5 and 6 trips to local providers to retrieve hard copies of medical records, going to the VA Records office, submitting the documents, and then following up 7-14 days later to find out I had to repeat this process as my VA Providers still had not received the records of my interactions with community providers. Interestingly, in 2020 I discovered the treatment records still had not been submitted from community providers into my VA eHealth Record, from treatment received from 2012-2016. Is the pattern of designed incompetence clearer? Is the VA Leadeship’s intransigence more apparent? How about the fraud, waste, and abuse of VA resources?
You, the congressional leaders, must take immediate action, not wait, not hold hearings, concrete action to demand compliance from the executive branch leaders to the congressional leaders who are held accountable to the citizens. America is a representative republic, and it is time the bureaucrats learned the citizens are awake and interested. You, the congressional leaders, are the people’s tool for correcting government abuses; you have two years to show you are dedicated to that principle, or you will be replaced!
© Copyright 2022 – 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.
The 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).
Veteran Suicide!
The 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:
Do 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.
Now, 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.
I 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?
After 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!
For Memorial Day (2020), the National Cemetery, through the directive of the Department of Veterans Affairs (VA), restricted the placing of flags at several national cemeteries, upsetting the plans of Boy Scouts, and angering countless veterans, survivors, dependents, and extended families. However, the intransigence of the VA on this matter is but a symptom of a larger problem.
The Department of Veterans Affairs – Office of Inspector General (VA-OIG) recently released two additional reports on behavior unbecoming at the VA. The first report concerns the delays in diagnosis and treatment in dialysis patients, as well as patient transport at the Fayetteville VA Medical Center in North Carolina. The second is another death of a patient, as well as deficiencies in domiciliary safety and security at the Northeast Ohio Healthcare System in Cleveland.
Bureaucratic inertia is the cause of too many issues, problems, and dead veterans, at the Department of Veterans Affairs. The symptoms include delays in administrative tasks that lead to patients dying for lack of transport to a hospital. The symptoms include cost overrun on every construction project the VA commences. The symptoms include abuse of employees, creating a revolving door in human resources where good people come in with enthusiasm, and leave with anger and contempt, generally at the insistence of a leader who refuses to change. The symptoms include a bureaucrat making a decision that has no logical sense, costs too much and is never held accountable for the harm because the decision-maker can prove they met the byzantine labyrinth of rules, regulations, and policies of the VA.
Secretary Wilkie, until you can overcome the bureaucratic inertia prevalent in the ranks of the leadership between the front-line veteran facing employee and your office, lasting change remains improbable. Real people are dying from bureaucratic inertia. Real veterans are spending their entire lives in the appeal process for benefits and dying without proper treatment. Real families are being torn asunder from the stress of untreated veterans because the bureaucratic inertia cannot be overcome from the outside. I know you need legislative assistance to enact real change and improve the VA. By way of petition, I write this missive to the American citizen asking for your help in providing Sec. Wilkie the tools he needs to fix the VA.
DNC-Consulting 