Moral Distress – DNC-Consulting

“That’s Crazy!!!” – More Chronicles from the VA Chapter 7

Oh, how I wish and long for, and am working for, the day when the VA is cleaned up, cleaned out, and corrected completely! The Department of Veterans Affairs (VA) – Office of Inspector General (VA-OIG) has been busy reporting more on the failures of the VA to act. Yet, where is Congressional action in scrutinizing the executive branch’s actions? Honest question, repeated only for emphasis; we elected you to do two jobs, write fair and equal legislation for all citizens, and scrutinize the executive branch; when are you going to do your jobs?

Let’s begin with some softball issues repeated from previous VA-OIG comprehensive healthcare inspections (CHIPs), specifically how employees report feeling morally distressed while working at the VA. Moral distress is a leadership failure and is widespread enough to reflect the problem is not limited to a single VAMC/VAHCS. From Virginia to California, Maine to Florida, and Montana to Arizona, too many VA facilities are poorly led, poorly administered, and poorly executed. The VA is actively abusing the veterans for political gain; some have asked why I consider the VA is actively abusing veterans; let me see if additional disclosure can explain the problem.

“VHA Directive 1004.08. VHA defines an institutional disclosure as “a formal process by which VA medical facility leader(s), together with clinicians and others as appropriate, inform the patient or personal representative that an adverse event has occurred during the patient’s care that resulted in, or is reasonably expected to result in, death or serious injury, and provide specific information about the patient’s rights and recourse.”

The above quote is from the regulations governing VA care. The VA-OIG quotes this directive, which has been published and is openly available, yet repeatedly the VA-OIG finds directors. Hospital administrators who are informed and able to repeat this directive. Who repeatedly refuse to follow this directive or train their staff to follow this directive. When sentinel events occur (death, permanent injury, non-permanent injury, disability, etc.), the families report having no idea what to do because the disclosures were never provided to the veteran or designated caregiver. Is this not abuse of the patient? Is this abuse not driven by ideologues who gain from the harm they cause others? Should this abuse not be scrutinized until it is eliminated? Please feel free to read some of these comprehensive healthcare inspection reports from the VA-OIG, see the resulting injuries and problems caused by the failures of government medical providers, and then tell me whether these atrocious actions need more or less scrutiny and qualify for the title abuse.

North Carolinian veterans, VISN 6 is all yours, and would you be shocked to learn that even with newer leadership, moral distress remains a persistent problem in the VA employees throughout VISN 6, which just happens to include Durham, Asheville, Fayetteville, Hampton, Richmond, Salem, and Salisbury North Carolina? Probably this is not unfamiliar as the patient experience survey scores remain persistently below VA averages, reflecting that new leadership is akin to putting lipstick on a pig. Interestingly, medical staff credentialing remains a significant concern in North Carolina.

Western New York veterans, especially those receiving patient services in the Buffalo VAHCS, do you agree with the VA-OIG report? The Buffalo VAHCS includes Buffalo, Batavia, Jamestown, Dunkirk, Niagra Falls, Lockport, West Seneca, and Olean, and the comprehensive report is mystifying to me. For example, the VA-OIG reports that “Patients generally appeared satisfied with their care.” At the same time, “Employee survey data revealed opportunities for leaders to improve workplace satisfaction and reduce feelings of moral distress.” This is a combination not generally found in these CHIP inspection reports. Something is definitely off, and I would love to know what, especially since the leadership needs significant improvement in identifying and reporting sentinel events. Do you agree with the VA-OIG findings? Please let me know your firsthand experiences, for the double-talk in this CHIP report is above what I usually observe.

With almost identical findings and recommendations in the Syracuse NY VAMC’s comprehensive healthcare inspection, covering communities of Syracuse, Auburn, Freeville, Potsdam, Rome, Binghampton, Watertown, and Oswego, NY., I am concerned that the veterans in New York are in as bad or worse shape than Phoenix’s veteran community. Hence, I have to ask the VA-OIG, has something changed in your measurement and analysis tools to report such disparate findings as “Employee survey data revealed opportunities for leaders to improve servant leadership and decrease employees’ feelings of moral distress. Patients generally appeared satisfied with the care provided?” The double-talk level is higher in these CHIPs from NY, which is rarely observed outside of Phoenix and VISN 22. Two final thoughts on the CHIPs, staff training, continues to be a high-risk finding, and this continues to be a leadership failure for every VAMC/VAHCS/VISN in the VA; why has progress not occurred? Training is a system, and leadership and organizational risk, system redesign, and improvement is a quality, safety, and value problem of the highest importance; why is action never taken by leadership or the congressional representatives who are expected to scrutinize the executive branch?

28 March 2022, the VA-OIG released their long-awaited annual “Comprehensive Healthcare Inspection Summary Report: Evaluation of Medical Staff Privileging in Veterans Health Administration Facilities, Fiscal Year 2020.” I have been interested to see what, if anything, the VA had accomplished in improving their medical staff privileging. If I were a congressional representative, knowing that medical staff continues to harm and kill veterans, I would have been anxiously awaiting to see if the repeated hits from past years had finally been rectified. Unfortunately, the VA continues to live down to expectations (digging the hole ever deeper), suffers from failed leadership, and the veterans continue to die or suffer abuse.

What did the VA-OIG discover? Understand, “The OIG conducted detailed inspections at 36 VHA medical facilities to ensure leaders implemented medical staff privileging processes in compliance with requirements. The OIG subsequently issued six recommendations for improvement to the Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders. The intent is for VHA leaders to use these recommendations to help guide improvements in operations and clinical care at the facility level. The recommendations address findings that may eventually interfere with the delivery of quality health care.” The OIG identified deficiencies with focused and ongoing professional practice evaluation, provider exit review, and state licensing board reporting processes. Specifically:

- use of minimum criteria for selected specialty licensed independent practitioners’ focused professional practice evaluations
- inclusion of service-specific criteria in ongoing professional practice evaluations
- completion of ongoing professional practice evaluations by other providers with similar training and privileges
- recommendation by executive committees to continue licensed independent practitioners’ privileges based on professional practice evaluation results
- completion of provider exit review forms within seven business days of licensed independent practitioners’ departure from a medical facility
- the signing of exit review forms by service chiefs, chiefs of staff, and medical facility directors if licensed healthcare professionals failed to meet generally accepted standards of care
- initiation of state licensing board reporting within seven business days of supervisors’ signatures on exit review forms to indicate licensed healthcare professionals failed to meet generally accepted standards of care.

The OIG found ongoing issues from the fiscal year 2019 CHIP summary report that warranted repeat recommendations for improvement. The OIG issued three repeat recommendations related to the following:

- inclusion of minimum specialty criteria for focused professional practice
  evaluations
- inclusion of service-specific criteria in ongoing professional practice evaluations
- recommendation by executive committees of the medical staff in continuing licensed independent practitioners’ privileges based on professional practice evaluation results.

Boiling the findings of the VA-OIG down, essentially, the administrators and leadership are not weeding out poor and horrible practitioners, reporting these underperforming practitioners, and not acting in the best interests of the veterans seeking care at VAMCs and VAHCSs across the country. I repeat, only for emphasis: Is this not abuse of the patient? Is this abuse not driven by ideologues who gain from the harm they cause others? Should this abuse not be scrutinized until it is eliminated? Please feel free to read some of these comprehensive healthcare inspection reports from the VA-OIG, see the resulting injuries and problems caused by the failures of government medical providers, and then tell me whether these atrocious actions need more or less scrutiny and qualify for the title abuse. The link to the full report is available; please feel free to make your conclusions and post your thoughts in the comments section.

On a final note for today, consider with me the problems of the Atlanta VAHCS with pallets of unopened mail containing patient health information, community care provider claims needing payment, and a plethora of other unopened mail. Understand that when community care providers cannot obtain compensation from the VA, they go to the veterans, who then send in correspondence, which is unopened, thus causing more problems, concerns, and issues for an already abused veteran community! Want your head to explode? Look at the pictures the VA-OIG helpfully sent along with this VA-OIG report, and ask yourself if any other business or organization could get away with this type of abuse of the customer.

What did the VA-OIG find? Well, prepare for your head to explode, again:

- VA Leadership should have established a formal agreement explicitly detailing each office’s responsibilities.
- VA HCS leaders did not include responsible managers in decision-making discussions and lacked a clear understanding of the volume of mail processing work they were accepting.
- Atlanta VA HCS did not ensure mailroom staff was adequately prepared or trained to handle or sort the influx of mail. POM (Payment Operations Management) officials were later reluctant to help, citing the verbal agreement.

Buried in the report is this tidbit, “POM is implementing similar transitions at sites across the country; POM and medical facilities need to ensure adequate staff with sufficient training to handle the mail processing workload. VA concurred with the OIG’s five recommendations.” Meaning that in a VAMC/VAHCS near you, unopened mail due to verbal agreements will soon add more distress and disgust to the veteran experience.

I have documented in these articles how verbal agreements, verbal standards of work performance, and verbal processes and procedures are the problem and way of life in too many CHIPs and observed practices at the VA. Yet, these verbal shenanigans are more apparent than in the dilemma Atlanta faces due to unopened mail. Payment operations to community care providers are on a controlled and fixed timeline. Failure to process these payments according to the required timeline leaves providers unpaid, which diminishes the community care provider pool of providers. Talk to a community care provider, and they will discuss the risks of doing business with the VA and the real possibility of not being paid timely enough or being caught in sufficient red tape never to receive payment.

I know of a provider who called me three years after receiving care and was still trying to appeal and correct the paperwork to receive payment. A provider recently contacted me who wanted to ruin my credit for failing to pay the balance due from care received, and they are charging interest. Correcting this problem cost me 48 business hours, 20 calls, and frustrations galore. By the way, the problem still has not been rectified, an appeal is in process, and we have to wait for the VA to make a decision; this incident was caused by the VA changing the process and the paperwork. The provider told me they are not accepting any more veterans seeking care, the risk is too significant, the timeline to receive payment is too long, and the VA never pays what is charged. For example, I recently received a declaration declaring payment to a community care provider. The VA sent me to this provider, which means they knew the prices beforehand and agreed to the fees. The declaration declared the VA was charged $2,000 and paid $120, not actual amounts, but close enough to communicate the problem. With inflation, or without inflation, if you were paid less than 1/10^th of what you billed (invoiced), would you continue to conduct business with that company or organization? Now add the unopened mail problem to the mix. Would you continue to conduct business with this entity?

America, the Department of Veterans Affairs is sick. All of the other alphabet agencies in the Federal Government are sick. We continue to elect people who actively refuse to care enough to act according to their mandated duties. We cannot afford the government we currently have, which is part and parcel of the problem with inflation in America right now! Debt is entered into to pay for this bloated feckbeast called government; from the city to the federal government, the bloat is too great to be sustained! Why is the VA able to skirt responsibility, accountability, and improvement? They can hide behind the size of their convoluted and twisted organizational shield. Why can the Post Office and the IRS get away with deplorable, at best, customer service? They are protected by the congress refusing to scrutinize and hold people accountable. When your head is done exploding, please remember and act in the ballot box to hire better representatives!

© 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.

Identity Problems – A Frank Discussion

Several weeks back, I made the declaration that the more labels a person adopts, the harder it becomes to be a person and know who you are. Multiple labels saddle a person with mental struggles that become physically exhausting. Each label comes with social responsibilities, cultures, and expectations that cannot be shirked as long as a person has adopted that label.

For example, I am a dual-service disabled veteran. Thus, I carry the cultures, expectations, and responsibilities of sailors and soldiers. Consider what the expectations of a soldier are, and that image is part of the identity and societal responsibilities for being a veteran soldier. Being disabled carries societal expectations, both mental and physical burdens. Consider the Marines, and every Marine is a Marine for life! You graduate basic training and earn the title Marine, and you will ALWAYS be a Marine! Again, that title and label hold societal expectations voluntarily onboarded, and never will a Marine lose the attitude and social expectations of Marines.

The same is true of every single label a person voluntarily chooses for themselves. The label will attract specific people into your social circles, but only as long as you willingly live the life expectations of that label. Each label selected will form identities and mental challenges to meet the social expectations, a heavy burden indeed!

In a recent Tik Tok video, a person proudly declares more than 50-labels, preferred adjectives and pronouns, and identities. The video lasted more than 3 minutes, and I felt sorry for the exertion this person will face every minute they have these identities onboarded. Another person watching this video declared that the subject claiming their labels was mentally ill; I agree with that sentiment. Why; because the subject will never know who they are because of the noise of the labels, which includes the social pressures, the responsibilities, and the expectations. I do not know the name of the person in the video, I would not share that video due to the privacy respect I have for others.

Who are you?

Even though current society in 2021 declares confusion between who and what a person chooses to be, not what are you. For example, I do not like, nor do I onboard, the identity of disabled. I am NOT disabled, handicapped, injured, and working on healing, but NOT disabled. Consider the power of words for a moment.

The transitive verb “dis” means to show disrespect, insult, or criticize. As a prefix, “dis” is defined as the opposite of something, depriving someone of something, excluding someone, or expelling someone. Thus, a disabled person is either being disrespected, insulted, or criticized, deprived, excluded, expelled, or is the opposite of able. Frankly, when we are made aware of the etymology of words, we are then more aware of why people choose to adopt or not adopt certain words and labels. Do we understand this problem of labels just from an etymological perspective?

Regardless of plasticization, words hold power over the mind. Words become identities, thoughts become things, and research supports that labels hurt mental processes and can permanently scar. Yet, who and what a person chooses as their identities are not considered a problem in current society or a mental illness. People’s choices reflect their identities to attract those in socially accepted circles.

Thus, who are you? Who do you choose to be? Are those identities sufficient? While not as important as who a person is, the last question ranks a close second. How many identities can you physically onboard and live successfully? As a fan of simplicity and a follower of the KISS rules, as detailed by Murphy, the god of perversity, I keep it supremely simple to protect my energy levels and allow my identity to shine through. Having only a few identities enables me to select social commitments, restrict the mental noise and exertions, and hold myself accountable to a few identities to grow as a person.

Returning to the Tik Tok video subject and their 50+ labels, identities, and preferred pronouns, we must ask, what is sufficient? A follow-on video by this person reflected the physical exertions from conforming to identities and social pressures. Worse, this person had onboarded several more labels and identities. They reflected the mental illness and physical drain caused by trying to live up to all the label responsibilities. An extreme example; unfortunately, no; the pressures to onboard labels and identities have grown exponentially, mental problems are too significant to quantify, and they are growing.

Not just in America, the confusion about who a person is, the identities, and their inherent loads, have become a global phenomenon. What are the mental health professionals doing; causing harm by not discussing the physical and mental exertions of onboarding too many identities. It is up to the individual and parents of minor children to understand and help learn and teach simplicity in labels allows growth as a person, not more identities, but less. Fewer identities provide freedom for growth, identity exploration and empower mental health, leading to improved physical health.

Identities

As a pre-teen, I struggled with the concept of my identity. Religion was a curse, my family was worse, and I did not know who I was, thus strangling what I could do or become. I got jealous of how my sister could get away with breaking the rules and thought I should be a girl. I struggled with wanting to be a girl for several years as I learned who I was and what I wanted to be. If this problem occurred right now, professionals would counsel me to adapt and change my body through drugs and surgery, compounding my identity problems. Yet, what helped, was getting to know me!

I had several people help me form an identity I could be comfortable living with as I explored my options, fought to understand my role and purpose, and embraced my potential. It took time, lots of time. It required patience with myself, a moral code I could live in, and a desire to learn—all of which I had to develop from scratch. My identity is forged in the fires of adversity, for the consequences of my choices during this time played a role in how I went to school, what I chose to learn, and where I found employment and socially accepted company. Some of those consequences hang around even all these many years later. Some consequences I have been able to live long enough to survive.

Worse, as I have learned more about myself, my identity has changed, bringing with it consequences of change. Music, movies, humor, education, and more are part of an identity that forms a life. Choices bring consequences; how we value those consequences (e.g., good/bad, profitable/unprofitable, etc.) will determine our eventual destiny towards understanding who we are, so we can become what we desire to see in the mirror. More lessons I had to learn, then and only then, could the value of religion be discovered, the value of family understood, and honor and pride and commitment to self appreciated as an identity to live. Crucial to this growth and development, I know when to cut social ties, drop music and movies into the trash, and I am imperfect in changing, but I have some lessons I would see others learn to avoid pitfalls.

1. 1. Commit to learning using the question, “Who am I?” as a core principle to discovery.
  2. Allow yourself time to think, ponder, and consider before committing to an identity. I always wanted to be a soldier, but I loved the ocean. I did not understand the value of these paradoxical options, and by rushing headlong, I had to learn an identity after living that identity. Arduous path; know first, then adopt an identity. Let me try and simplify that with my favorite axiom, learned as an Emergency Medical Technician, “Never take your body where your mind has not traveled first!”
  3. Comfort is key. If you are not comfortable, your conscience tells you something is wrong. An identity should require physical strain and mental confusion. Yes, you can delude yourself for a time/ Ultimately, your conscience, spirit, intellect, whatever you call your inner voice, will break through and tell you your identity is not mentally acceptable. If your identity choice is not comfortable, it will affect your physical health negatively.
  4. Never stop learning; learning leads to change, and change is good!
  5. When in doubt, turn to lesson two, give yourself more time before committing to an identity.

I love hard rock, big hair bands, and southern rock. Steel guitars, banging drums, and headbanging to an excellent beat are an identity with power. But headbanging gives me incredible headaches. Too much rock and roll, and I cannot think clearly, and the ability to control my thinking is paramount to me. Do I adopt the headbanging identity or not; sometimes, I am all in for a solid rock fest. Mostly, I listen to the inner voices and moderate my music. See, lesson two continues to hold power and lesson four keeps me thinking how much longer will I affect my identity with an uncomfortable identity with physical pain.

Choose carefully, evaluate often, and allow yourself the freedom to grow by not onboarding labels without due consideration. Please, consider your gender and biological sex as integral to your ultimate destiny and comfort. Before you are comfortable in your skin, you have to be comfortable in your mind! If you want to explore identities, explore, but explore smartly and be cognizant of the social responsibilities, expectations, and cultures inherent with an identity. Observe those with those identities closely for the consequences of thier identity.

I cannot betray a confidence, but I have witnessed how traumatic experiences can be the impetus for forcing an identity change. A close associate went to a party, had a mickey slipped into their drink, and woke to a new reality. The consequences of other people’s identities can negatively impact your identity, especially if you do not know who you are!

I have never been comfortable with the hard rock, headbanging social aspects of rock and roll identities. The illicit drug use, the promiscuous sexual encounters, and the extremes in living frankly scare the hell out of me! But, I love the music, and I love much of the wardrobes in this identity, even though I will NOT wear makeup and cannot play a musical instrument.

Life is a journey; travel safely using the axiom, “Never take your body, or anyone else, anywhere your mind has not already traveled.” Think, ponder, consider, and then act confidently.

© Copyright 2021 – M. Dave Salisbury
The author holds no claims for the art used herein, the pictures were obtained in the public domain, and the intellectual property belongs to those who created the images. Quoted materials remain the property of the original author.

Whiskey-Tango-Foxtrot – The VA Edition: More Shameful VA Chronicles

Angry Grizzly Bear The Department of Veterans Affairs (VA) – Office of Inspector General (VA-OIG) has released the details of an investigation into a veteran’s death. The scope of the investigation included several key items, but the main point was that a nurse failed to contact the patient, the patient went without medication for four days, and on day five, died.

“The facility conducted an internal review of the patient’s care. The OIG found that the review was incomplete and included inaccurate information, and leaders were unable to determine if an institutional disclosure was warranted.”

Failing to coordinate care is a leadership issue, and the leader’s failures caused a veteran’s death. With more veterans using community-based care options, VA leaders must coordinate care more specifically, that medical records are shared timely, and communication occurs. We are several years into expanded community-based care options for veterans; why has the VA not made progress on this issue to date?

Personal storytime, no VA-OIG investigation. I was forcibly moved from the Las Cruces community-based outpatient clinic (CBOC) to the El Paso VAMC due to the felonious and fallacious charges of being a behavioral problem in Phoenix VAMC because I cannot physically and safely wear a mask. My new primary care provider, a nurse practitioner, sent me a letter dated 23 July 2021, almost a month after I submitted documents for completion, informing me they do not feel capable of making a medical determination on my ability to drive. I had submitted some documents from the NM DMV to get a handicap placard and medical clearance for diabetes and my neurological condition. A medical professional is not capable of making a medical determination. Oh, the irony is thick with this one!

The El Paso VAMC spearheaded a program for the VA to begin using nurse practitioners and clinical pharmacists as primary care providers to “reduce the burden” on actual medical doctors. If the nurse practitioner felt medically incapable of making a decision, where was his supervisor? Where was his leadership support team? Is the problem with using no medical doctors clear? Leadership issues abound, and nobody in Congress is taking any action. Nobody in the VA’s highest echelons of leadership is taking any steps to correct the local and VISN level leadership problems. Who suffers; the veterans and their dependents!

Back to recent VA-OIG investigations, we find a doctor from Florida sentenced to six years in the federal prison system, plus restitution and asset forfeiture. From the record, we find the following:

“To attain such high volumes of claims, the conspirators used bribes and kickbacks. Specifically, Davidson and his conspirators illegally purchased thousands of DME claims from so-called “marketers.” The marketers, for their part, had generated the claims under the guise of “telemedicine,” but no telemedicine had occurred. Instead, the “marketers” had bribed doctors to sign the DME brace orders that supported the claims. Davidson and his conspirators paid millions to secure the illegal DME claims for submission to Medicare and CHAMPVA.”

Gavel How many conspirators are Federal Employees? How many are leaders of Federal Employees? Who else knew and profited, and when will they be held culpable for the crimes committed? Dr. Richard Davidson (42) had a lot of help to build a $20 Million healthcare fraud scheme; a lot of that help had to come from Federal Employees. When will government employees finally start being held responsible for the problems they perpetuate? Where is Congress in scrutinizing this case and demanding the legislative branch take action to stop the fraud?

Traveling to Puget Sound Healthcare System in Seattle, Washington, we find the VA-OIG neck-deep in conducting a comprehensive healthcare inspection (CHIp). “The Director and the Chief of Staff had served since 2017, the Deputy Director for Patient Care Services and Associate Director had been in their positions since 2018, and the Deputy Director had served since 2019. Survey data indicated opportunities to improve employee satisfaction and reduce feelings of moral distress. Patient survey results showed that individuals were generally less satisfied with their care compared to VHA averages” [emphasis mine]. More thick irony is being dished out here. Never will the VA-OIG find employees feeling morally distressed and patients being highly satisfied with their care. There is a causal relationship between the level of moral distress in employees and lack of satisfaction from patients, and the problem is found in the leadership at the local VAMC/VAHCS level!

Knowledge Check! Never forget, the Puget Sound VAHCS is where the wait-list death scandal began before that hospital director was moved to Phoenix. Thus, to hear of employees still feeling morally distressed in this VAHCS is not surprising, alarming, but not surprising! To hear that patients still feel cheated is expected, as the VA leaders who took over after the wait-list scandal had been raised in a culture of corruption, where the honest left and the dishonest and disrespectful remained. Some of the VA-OIG’s recommendations include patient follow-up and exit reviews, care coordination, medication management, and patient safety. All of which are symptoms of poor leadership!

My wife just asked me a pertinent question, “Can you trust the VA to provide you honest care?” No, I cannot. Yet, due to ObamaCare, the cost of seeking outside medical service is so astronomical I cannot afford to participate in my company’s medical insurance plans. The VA has a dearth of leadership, coupled with too many managers, lawyers, and labor unions. Yet, who does a veteran complain to? Congress is deaf to our pleas. The VA in Washington is missing in action 100% of the time. The veteran service organizations are all geared to helping get veterans enrolled into VA benefits. Lawyers cost too much. The VA-OIG is limited to making recommendations, and the government protects its own against litigation.

Election In a representative government, the highest authority is the people electing officers to government. Well, I continue to appeal to my fellow veterans, their dependents, and ordinary citizens. Please, help change the VA! Vote new blood into a public office dedicated to correcting and scrutinizing, not writing endless legislation that costs too much and increases debt. Vote new judges into office who will see the problems and not employ judicial overreach to handle issues. Demand accountability from elected officials.

© 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.

Moral Distress IS a Leadership Problem – More Shameful VA Chronicles!

Survived the VA A surprise occurred in this week’s Department of Veterans Affairs – Office of Inspector General (VA-OIG) reports; the Boise VAMC in Idaho performed well in their comprehensive healthcare inspection (CHIp). Even though 10 recommendations were left, the VAMC as a whole is performing above average, with no significant complaints found by the VA-OIG. Congratulations to the Boise VAMC!

VA 3 Let me stress something; leadership is the reason why a VA Healthcare System (VAHCS) or VA Medical Center (VAMC) performs well or poorly! Yet, too often, the leadership IS the root cause of the problems in a VAHCS or VAMC. The Boise VAMC just proved this point precisely; are any Department of Veterans Affairs (VA) leaders in Washington DC paying any attention?

The VA-OIG performed a CHIp in Portland VAHCS and found moral distress in the employees, again! This means that the Eastern end of the state is receiving better care than the western end of Oregon State! Yet another VAHCS or VAMC with employees feeling morally distressed by the commands and directives of their leadership in how they treat veteran patients! The VA-OIG report makes everything sound like rainbows and lollipops at the Portland VAHCS, but if employees feel “morally distressed,” there are problems, just not those included in the CHIp scope! VA 3

Where problems outside the scope of an investigation are concerned, the following is GREAT NEWS!

“Robert Seifert, 63, of Utica, New York, pleaded guilty to making telephonic threats to Albany Stratton VA Medical Center employees. Seifert, who has been convicted twice before of threatening VA employees, admitted that on 14 January 2021, he made three calls to employees for no reason other than to harass and threaten them.”

I am going to repeat it, only for emphasis, “Leave the families out of your anger!” Never, EVER, attack, threaten, or speak against the families. They are OFF LIMITS! I become very frustrated with the VA Leadership, but violence is not the answer, and threatening families is repulsive and counterproductive! Seifert is scheduled for sentencing on 06 October 2021; may the judge throw the book at him, for this is his third conviction for threatening families of VA Employees. VA 3

On the topic of frustrating leadership who need to lose their jobs and reimburse the government for all wages, the following VA-OIG report is the epitome of failed leadership in action!

“The VA’s Office of National Veterans Sports Programs and Special Events (NVSPSE) granted $47 million to organizations with experience in managing adaptive sports programs from fiscal year (FY) 2017 to FY 2020. … The VA-OIG found that the NVSPSE was not effectively managing the program. The NVSPSE’s director had not established adequate internal controls, including developing standard operating procedures for managing adaptive sports grants. As a result, the NVSPSE could not effectively evaluate risks from grant recipients, did not reimburse some recipients’ expenses on time, did not always close out grants on time, and did not appropriately authorize extensions for using funds. By not closing out grants on time, the NVSPSE failed to free up about $346,000 that could have been used for other purposes. It also improperly allowed recipients to spend $328,000 in FY 2017 appropriations outside the approved period and improperly reimbursed 19 recipients a total of about $247,000.”

The VA-OIG recognizes that these failures to audit and control the adaptive sports program properly potentially violate both the Purpose Statute and the Antideficiency Act, federal laws with direct consequences for Federal Employees. I am taking bets. Will anything come out of the director being referred to the lawyers; I doubt any action will ever be taken! That’s not just my cynicism speaking; that is the experience in watching directors at the VA skate accountability and responsibility better than gold-winning Olympic figure skaters. VA 3

In reporting the following VA-OIG report, do not rationalize that every suicidal person will eventually find a way or means to commit suicide. I ask you do not think this for two reasons: one, it is a lie lazy people tell themselves to disregard the act; two, helping people with suicide ideation is not cut and dried textbook medicine. Assisting people with suicide ideation takes time, effort, getting to know the person, and a lot of interlocking care from professionals.

“The patient, who was over 70 years old at the time of death, had diagnoses that included post-traumatic stress disorder and major depression. After approximately 15 years of care at a California VA facility, the patient transferred care to the Las Vegas facility in summer 2019. The VA-OIG substantiated that the patient died by suicide from a VA resident mental health clinic on the day of discharge. The emergency department social worker documented an incomplete comprehensive evaluation. The suicide prevention team did not assign the patient a high risk for suicide patient record flag despite the patient’s stressors and history of suicide behaviors. Staff did not adequately assess the patient’s substance use, incorporate relevant history into the treatment plan, or address the patient’s change in demeanor and concerning statements. The discharge safety plan had not been modified for approximately eight months despite significant life changes. Leaders had not established a mental health treatment coordinator (MHTC) policy. Staff assigned the patient an MHTC at the patient’s tenth visit and four MHTCs over nine months. Staff did not coordinate care with a geropsychologist, with whom the patient had nine appointments. Leaders did not effectively address the patient’s expressed complaints. The VA-OIG substantiated that leaders did not conduct an institutional disclosure” [emphasis mine].

The last sentence is the dead giveaway that the leadership knew there were problems and designed processes intentionally to have an excuse when a patient died! This veteran was suffering to a great degree, and I hope that with his passing, his family and friends can find peace in the knowledge that the veteran is now pain-free. But, the VA leadership should be held legally responsible for this death, they failed this patient, and the world is worse for the veteran’s passing. VA 3

Suicides are hard on family, friends, communities; suicides at any age are the ultimate declaration that failure occurred, the pain was missed, and the medical community and support systems failed. Survivors often feel a great degree of guilt and carry that guilt to their graves. But, when medical providers go out of their way to hide the problems, refusing to document, and declare, it means that the medical community had written the patient off as too costly to save. Who speaks for the loss of intelligence and potential of the failed patient; I do! I-Care

I will continue to speak to the failures of the VA to provide the care they promised, and demand leaders are held accountable and responsible. This was preventable, and the leadership must be held accountable if the system is to be changed! This veteran did not have to die by his own hand, and the medical community at the VA in Southern Nevada HCS, located in Las Vegas, should be ashamed!

Follow this link if you would like to see a recap, with links, to the shenanigans reported by the VA-OIG in June. June 2021 has been a month of incredible and horrendous behavior documented by the VA-OIG of the leadership failures at the VA. The elected leaders of America either need to begin scrutinizing the VA more closely or vacate office. There is no excuse for the continued irrational and detestable behavior at the VA. VA 3

The last two items are testimony recorded before a Senate and a House of Representatives Committee. Statement of deputy inspector general David Case Office of Inspector General, Department of Veterans Affairs before the US Senate Committee on veterans’ affairs hearing on VA electronic health records: modernization and the path ahead 14 July 2021. Statement of Leigh Ann Searight deputy assistant inspector general for audits and evaluations Department of Veterans Affairs – Office of Inspector General before the subcommittee on oversight and investigations committee on Veterans’ Affairs US House of Representatives hearing on modernizing the VA police force: Ensuring accountability 13 July 2021. Frankly, both statements are pure vanilla because the subcommittees refused to act, which was known before making the statement and the hearings. Hence, why should the VA-OIG prepare action plans if the Senate and House will not take action?

Knowledge Check! Repeating, only for emphasis, “Until the US Legislative Branch will do their jobs, and scrutinize the Executive Branch with the intent to demand accountability, no single government agency will ever change.” Want to help veterans? Contact your elected representatives and send them these articles, demanding they take action in support of legislation and scrutinization, demanding accountability and responsibility of government employees who are currently active in refusing to change! Want to help veterans? Share these stories far and wide. Everyone should know what the VA is doing and realize that every government agency from the city to the President is employing tactics to steal liberty, rob freedom, and murder veterans!

© 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.

Absurdity so Repugnant it Takes Your Breath Away – More VA Chronicles

Angry Grizzly Bear The Department of Veterans Affairs – Office of Inspector General (VA-OIG)-released six investigation reports in the last two days. Each one is mentally breathtaking at the egregious behavior of bureaucrats! Stupidity that is so repugnant it breaches the laws of morality and leaves the reader stupefied. Every year, for the last decade-plus, the behavior of the Department of Veterans Affairs (VA) has become more obscene, more outlandish, more detestable, and more openly hostile towards veterans; it sickens me to read the investigation reports, write, and catalog these abuses!

Beginning in Queen’s, New York, we find another dead veteran that should never have died the way they did. Improper feeding by a registered nurse (RN) at the New York Harbor Health Care System’s Community Living Center (CLC) contributed to the death of a patient. Let that sink in for a moment, for the rest of the report only goes downhill from this point. My time in medical training was replete with the following aphorism, “If it is not written down, it NEVER happened.” The nursing staff failed to document meals properly. The electronic health record (EHR) was inaccurate and flawed, hindering resuscitation, which was poorly documented, and institutional disclosure acted more like CYA than a medical file. People should have been fired and up on trial for this type of scandalous behavior, especially since a veteran died from this abuse and neglect. But the VA-OIG made their recommendations, the leadership accepted the recommendations, and nothing else will happen. Nobody but the family cares the veteran died needlessly and at the hands of the medical professionals. VA 3

Adjectives elude me. The behavior in Queen’s is appalling, even for the VA. Unfortunately, the list of ineptitude only gets worse!

VA Seal Next, we travel to Austin, Texas, and discover yet another office of information technology (OIT) failing to work, secure data correctly, and protect veterans’ information, as demanded by legislation! The VA-OIG and the local OIT used the same tools, and the local OIT only identified 150 problems, whereas the VA-OIG OIT inspectors found 246. Improper sanitization of media was a pronounced issue, where patient load is upward of 300,000 annually. Inventory practices were noticeable and apparent. Worse, patch and vulnerability programs were practically non-existent if I understand this report correctly. VA 3

If you have read any of these VA Chronicles, you will know that the VA has not passed a Federal Information Security Modernization Act (FISMA) audit, ever! The head of IT was recently in front of Congress to testify why, and the explanations were milk toast adequate at best! But, the elected officials bought the excuse, hook, line, and sinker, as always, and the president wants to spend more money on the VA. What a cathartic example of why elections matter!

Next, we travel to Detroit, Michigan, where a “comprehensive healthcare inspection (CHIp)” was performed at the John D. Dingell VAMC. Before I even read the report, I knew it would say; opportunities exist to improve employee and patient experience. Knowing veterans who are “served” at this VAMC, this was an obvious guess! Again, we find “moral distress” in the workforce, signifying that the employees feel pressured to do everything but what is ethical, legal, moral, and appropriate for the patient at this VAMC. Yet, the leadership team was rated as stable and doing a good job! Quoting Colonel Potter from M*A*S*H here, “HORSE HOCKEY!” VA 3

I will be explicitly clear if a single employee feels “moral distress,” there is a leadership problem, and the leadership is criminally negligent in their duties to oversee staff leaders, supervisors, team leads, and training personnel! This is not the first time “moral distress” was a point of discussion in a CHIp; but, the fact that this problem remains widespread and apparent does mean the problems are originating at a level higher than the VISN, and all the VA and VHA leadership should be losing their jobs! Enough is enough, and the elected officials need to be scrutinizing the government before they lose their next election!

Survived the VA Having been an employee of the Department of Veterans Affairs, working in the Emergency Department of the Albuquerque, NM., VAMC, this next story is exceptionally aggravating and extremely distressing. The VA-OIG determined that the entire Veterans Health Administration (VHA) needs to better monitor, record, and document the timeliness of care and patient flow in the emergency department. Having waited for more than 14 hours in a VA Emergency Department while waiting for care, I know first hand the problems of the Emergency Departments, and I know a lot of the reasons why the documentation is fouled and the flow of patients is amateurish, at best!

Raymmond G. Murphy I worked the shift where a regular, homeless veteran, wheelchair-bound, had fallen and broken his leg. He waited with his broken leg swelling, stuck at an odd angle, and in obvious distress for more than 6-hours because the head nurse that day had a personal grudge against the veteran! I saw how the charts were “adjusted” for timeliness of care, and I reported the problems up the chain to no avail! I had witnessed nurses harangue patients, gossip about them, chart surf in violation of HIPAA, and never was anything done by leadership when it was reported. A patient sat in an expedited treatment room for four hours, listening to the nurse’s gossip and joke, awaiting stitches for a bleeding wound, and never was treated. All because the day shift was getting off and didn’t want to be bothered to treat the patient. The patient’s family reported this behavior to me as they were leaving for a better hospital. I reported the whole incident, included the family’s description, added my observations. The leadership shook the whole incident off as a disgruntled employee (blaming me) making a less than desirable situation worse. VA 3

Thus, when I read this particular VA-OIG report about the inadequacies of the VA Emergency Departments across the entire VHA, it infuriates me into a mindless stupor! Want more data on the failures of the VA Emergency Department; read the rest of the VA Chronicles. I describe my experiences in detail and have logged other veterans who have had the same or worse problems at the VA Emergency Department! I have witnessed doctors treat patients in a dissimilar manner based upon the political clothing the veterans wore into the Emergency Department! So, no, I am not surprised at the record inadequacies of the VHA; if anything, I expect the problem is a lot worse than the VA-OIG was willing to report! VA 3

The VA-OIG collected data on an issue of grave significance from 58 VHA outpatient clinics’ regarding emergency preparedness for the delivery of telemental health care as of November 1, 2019. The review focused on clinic-specific emergency procedures, emergency procedure roles and responsibilities, emergency contact information of staff, and patient safety reporting methods. Not included in the scope of the review was the quality and quantity of telehealth appointments. I mention this oversight as the technical problems in receiving telehealth appointments are sub-par, at best, which would have seriously skewed the data.

The VA-OIG sent out 333 questionnaires, receiving a total of 187 responses, from the 58 identified clinics, and identified the following:

1. 1. Missing telehealth emergency plans and procedures.
  2. Emergency procedures are not specific to telehealthcare or the patient-clinic location.
  3. Lack of a process for annual updates to telehealth emergency procedures.
  4. Undefined emergency procedure roles and responsibilities for telehealth staff
  5. Missing or insufficient emergency contact information.
  6. Lack of a process to verify and communicate emergency contact information
  7. Lack of a consistent process to designate the telehealth setting in patient safety reporting methods.

Consider for a moment; you are a family member of a veteran needing telehealth mental support. Now, how do you feel to know there are no written processes or procedures to support the telehealth provider if your family member gets into a mental health emergency. Time is critical in mental health emergencies; I know this from personal experience as both a provider and a patient, and for these plans, procedures, and processes to be missing is the height of malpractice! Would someone please tell me why elected officials and the media are not screaming mad at this particular report? Especially since the proposed budget from the president wants to double suicide prevention spending at the VA. I read this report and see that the VA-OIG made five recommendations. Are you freaking kidding me?!?!?

Finally, we go to Hawaii and confront the most detestable, outside of the dead veteran, issue possible, failure of the National Cemeteries Administration (NCA) to properly care for the remains of veterans, qualified spouses, and dependents. The NCA awards grants to states to build cemeteries where a veteran, qualifying spouse, and dependents can be laid to rest outside a national cemetery. From the VA-OIG report, we find the following, emphasis mine:

“Grants may be used to establish, expand, or improve veterans cemeteries. The VA-OIG audited the program to assess NCA’s governance and oversight. The audit team also assessed whether critical non-compliance issues at two cemeteries in Hawaii were addressed. The VA-OIG found grants program staff did not rank and award some cemetery grants as regulations required. After grants were awarded, program staff generally ensured cemeteries used grants for their intended purpose. However, NCA did not ensure cemeteries with grants met all national shrine standards for installing permanent markers, maintenance, and safety. The audit team observed non-compliance issues at eight state cemeteries, including critical issues in Hawaii’s Hilo and Makawao cemeteries. As a result, NCA lacks assurance that veterans and family members buried in state veterans cemeteries have been appropriately honored with timely and accurate grave markings, burial locations, and maintenance.” VA 3

NCA, you have one job, ensure the remains of veterans and qualifying spouses and dependents are adequately remembered, safely entombed, and marked appropriately. Yet, you fail at even this simple and easy job; how utterly disgraceful, disgusting, and detestable! How many cemeteries in the Philippines are being adequately cared for? At the last report, none of them were adequately maintained and respected. Even here in the US, you refuse to do your jobs with competency, dignity, and professional pride.

Knowledge Check! The VA is one sick organization, where the mission is being denied, the veterans abused before and after death, and none of the elected representatives can find enough time in their day to even offer a mild rebuke or maintain sufficient interest to scrutinize. America, we have gotten better as a culture in remembering and honoring those who serve and have served, and I, for one, am very grateful for your change of heart. We, the voting citizens of America, need to demand the same culture change from the politicians representing us! As a country, we have come a long way since Vietnam in honoring the military. But those same people who spat and urinated on our troops in Vietnam are now in the Halls of Congress, and their attitudes have not changed in the interim!

NO MORE BS: The Leadership at the VA Continues to Shame Themselves!!!

Bird of Prey I do not believe in coincidences, I just started reporting the VA leadership as being the problem at the VA; the Department of Veterans Affairs – Office of Inspector General (VA-OIG) finally appears to be blaming Department of Veterans Affairs (VA) leadership. In my inbox are two VA-OIG reports where the facilities’ leadership is being called out for the detestable behavior they continue to exhibit! In one of the VA-OIG reports, please do not allow the “YUCK!” factor to distract from the problems at hand in the VA Leadership refusing to do the jobs they have been hired to perform!

1. 1. 1. “Bradley Lane Croft, the owner of Universal K-9 Inc. in San Antonio, Texas, was sentenced to nearly 10 years of imprisonment for scheming to defraud the federal government of more than $1.5 million in GI Bill benefits to train service canines and their handlers. In addition to the prison term, Croft pays approximately $1.5 million in restitution.”

“November 2019, Judge Ezra found Croft guilty on eight counts of wire fraud, four counts of aggravated identity theft, two counts of money laundering, and two counts of making a false tax return. Testimony during trial revealed that beginning in 2015, Croft provided false information in applications to the Texas Veterans Commission, including instructors’ names, certifications and training documents to receive GI Bill educational benefit payments.”

VA 3 If you have access to more details, please share. This story did not make a ripple in the news, and I want to know why! Worse, who at the VA lost their jobs, lost their retirement package, or were sanctioned for allowing this fraud to occur? 2015-2018, three years of deception, where the VA leadership and lower-level employees were supposed to investigate and research documents submitted before awarding contracts? The court records read like this was an IRS audit for fraudulent tax filing that discovered the school fraud of GI Bill benefits. The VA never knew until the IRS alerted them. Hence, I ask again, where was the VA in properly executing its duties to protect the government and the taxpayer from fraud?

1. 1. During a comprehensive healthcare inspection (virtual) of the Aleda E. Lutz VAMC in Saginaw, Michigan, the VA-OIG was pretty vanilla, except for the following. “Selected employee satisfaction survey results indicated opportunities for the Associate Director for Patient Care Services to improve workplace perceptions and for the Chief of Staff to support an environment where employees felt less moral distress” [emphasis mine].

VA 3 Now, I have never personally been a patient in this VAMC or one of its clinics. However, “moral distress” is a pretty universal phrase meaning that employees feel pressure to commit immoral activities. The actual term “moral distress” is found in an “All Employee Survey,” where the employees stated that they felt pressured to commit an immoral activity at least once per day.

“In the past year, how often did you experience moral distress at work (i.e., you were unsure about the right thing to do or could not carry out what you believed to be the right thing)?”

If an employee feels anywhere between 1.0 and 1.7 times (on average) a day they are being pressured to commit immoral activities, surely this should raise some eyebrows and a lot of questions about the propriety of the leadership team. Did the VA-OIG take a sample of employees and gather quantitative data on exact actions employees feel they are pressured to commit? If so, why is the conclusion bereft of actionable items for leadership to take? If not, why not? Employees claiming pressure to act in an immoral manner are a significant risk to any business organization. The VA is already on record for having inferior to worthless administrators; now the veterans and the taxpayers get to know the Aleda E. Lutz VAMC and its clinics have morality issue problems. Nobody in the VA leadership at the Federal or VISN level cares!

1. 1. 1. “The VA-OIG conducted a review to assess aspects of the care provided to a patient who was struck and killed by a motor vehicle following elopement from a community living center (CLC). The patient suffered from paranoid schizophrenia and was involuntarily civilly committed to the CLC.”

Administrative failures began the day the patient was admitted to the CLC, as discovered by the VA-OIG, “… the patient’s admission to the CLC was inappropriate as indicated by the CLC’s own screening process.” Added to these concerns, the VA-OIG expressed the following concerns, “… regarding the appropriateness of CLC admission and elopement prevention.”

“The OIG determined that interventions implemented by staff were inadequate to mitigate the patient’s risk for elopement. The patient eloped multiple times, and facility staff failed to provide individualized, progressive, mental health-driven interventions to prevent the patient from eloping. The OIG also found that facility staff assigned to care for the patient were inadequately trained in mental health care, and patient safety reports were not completed as required.”

“On the day of the patient’s death, the OIG found that facility staff did not follow missing patient procedures after the patient eloped. Facility staff failed to detect that the patient was missing for nearly three hours, and once the patient was noted as missing, facility staff failed to follow policy to locate the patient. In addition, the OIG found that facility leaders did not ensure the facility had a missing patient prevention policy or that staff completed annual missing patient training. The OIG expressed concern that the CLC may not have been utilized as intended, given the lack of mental health standards applicable to CLCs and the complex mental health needs of this patient.”

VA 3 Take a minute, imagine you are a family member of this patient. How are you going to feel when you see the consistent and ongoing problems with the facility? How helpless would you feel knowing that your family member was missing for hours before it became known to staff this patient, with a history of elopement, was gone? How frustrated would you be with the administration when you read this report and see that from Day 1 admissions, this CLC was inadequate to the task of seeing to this patient’s needs? Now, do you understand why I, as a veteran, become so aggravated and upset with the lack of leadership at the VA? These are my brothers and sisters in arms, and they are being abused and killed by the VA’s lack of leadership. The only recourse we have is to try and share these horrible tales with our fellow citizens in the hopes of improving the political leadership, to demand change of the executive branch’s VA leadership! Another needless death at the hands of the VA leadership!

Let me preface this final story a little. First, if you have a weak stomach, feel free to skip this next story. Second, an endoscope is an illuminated optical, typically slender, and tubular instrument (a type of borescope) used to look deep into the body and used in procedures called an endoscopy. Endoscopes are considered reusable medical equipment, and special training and procedures are required to clean and sterilize these scopes properly. Third, an endoscopy is a procedure used in medicine to look inside the body. The endoscopy procedure uses an endoscope to examine the interior of a hollow organ or cavity of the body. Unlike many other medical imaging techniques, endoscopes are inserted directly into the organ. Again, if you have a weak stomach, feel free to skip the rest of this article.

1. 1. Let us travel to the Chillicothe VAMC in Ohio, where we find the VA-OIG with “concerns” over “… responses by facility leaders to a Sterile Processing Services (SPS) employee’s failure to follow endoscope reprocessing [cleaning and sterilization] procedures.” The VA-OIG report stresses the following, “… the VA-OIG also identified concerns related to actions taken by Veteran Health Administration (VHA) leaders.” Thus, we have one (1) employee and several VHA leaders from the local to the VISN whose actions are at best “questionable” in the cleaning and sterilization processes for an endoscope.

Three separate and similar complaints were raised at this facility for this exact issue!

“… VA-OIG investigations substantiated that the employee did not follow facility reprocessing procedures and falsely documented compliance. The VA-OIG determined that the Facility Director did not develop and implement an adequate plan to monitor the employee’s compliance with SPS procedures following reinstatement to SPS duty, particularly given concerns regarding the employee’s integrity and compliance. Because multiple patients were potentially affected, facility and VISN leaders notified the VHA Clinical Episode Review Team (CERT) for review and disposition. The CERT concluded there was minimal risk to patients and that a large-scale disclosure was not warranted; however, the VA-OIG found that the CERT’s determination may have been based on an inaccurate understanding of the reprocessing equipment’s capabilities” [emphasis mine].

VA 3 Here is the other side to this problem. This is not the first time or first facility having problems with employees failing to reprocess medically reusable equipment, refusing to document correctly, or risk patient complications from dirty medical equipment! This is not the first time the CERT team has made the wrong decision not to warn the patients involved; they might have been put at risk by dirty medical equipment! The last episode involved colonoscopy equipment, and it was not that long ago I was writing about that incident! YUCK!!!

Why was the employee not immediately fired for falsification of official documents? Why did the facility’s and VISN separate investigations not see the directors of patient safety and hospital director fired for failure to perform their jobs? The Chillicothe VAMC’s entire leadership should be fired in disgrace over this incident.

PACT 1 While a patient in the VA Hospital here in Phoenix, I was in a clinic where a mother was trying to gather sufficient records to hold the VA accountable for her son’s permanent disability from sepsis. The veteran caught sepsis when improperly cleaned scopes were used during a gall bladder removal surgery. Her son, the veteran, spent 9-months in and out of non-VA hospitals; she had pictures of his bruised and swollen abdomen from the doctors trying to treat the sepsis and keep the veteran alive! I have no idea whether this mother was successful or not getting the VA to cover the medical expenses and increase her son’s disability. I only know I never saw her at the VA again, and the VA Police shadowed her as she moved from clinic to clinic, gathering records. I do not know why records release could not release the proper documents to save this mother the hassle of visiting individual clinics. I do know I can still see this veteran in the photos his mom showed me, and my blood continues to boil! Yet, the CERT team asserts that mass notification is not needed in these situations; I demand to know why they can make this decision!

Apathy The leadership at the VISN levels and the individual hospital levels is sick, inadequate, and desperately in need of a complete replacement to end the culture of corruption found inside the VA. When employees record moral distress, this should be an automatic red flag, alerting the VISN leaders poor leadership practices are happening, but the VISN never does anything! Failure of this magnitude would have gotten any non-VA hospital or clinic shuttered and class-action malpractice lawsuits launched. Yet, when the VA gets caught, the media cannot even be bothered to report on the problem in the local news. Maximum endurance has been breached, and these administrator problems need immediate attention from the politicians!

Hence, I will ask you, dear reader, to please share these VA articles far and wide. Action is needed before the next veteran to die unnecessarily is a friend or family member of yours!

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