“That’s Crazy!!!” – More Chronicles from the VA Chapter 4

Last week, my primary care provider informed me that the VA is no longer responsible for providing my prescriptions as an outside provider that the VA Community Services team sent me to has increased my dosage.  My primary care provider pulled a Pontius Pilot and washed her hands, and I am swinging in the wind with more bureaucracy and less service.  The best part of the news delivered this last week, the fallacious, seditious, and felonious attack on my character, the behavior problem flag, is controlled by the primary care provider.  Boy, I am sick of the bureaucracy of the VA; if only this were the worst of the bureaucratic baloney, the VA is pushing out.

From many VA-OIG reports during COVID, the following, or something close, was a regular statement:

During COVID-19, VHA’s Office of Community Care (OCC) took steps to ensure veterans continued to have expanded access to health care in the community, as required by the VA MISSION Act of 2018.  OCC issued policies to VA facilities to postpone non-urgent appointments and offer alternatives to in-person care, such as telehealth.”

The VA-OIG inspected to see how closely this statement was adhered to during the height of the COVID pandemic.  What surprises no one is how badly the VA managed community care during the pandemic.

Findings:

    • The VA-OIG found that routine community care consults were unscheduled, averaging 42 days, not meeting VHA’s timeliness goal of 30 days.
    • Community care staff faced significant challenges beyond their control that contributed to the scheduling delays, such as the lack of availability of appointments in the community.
    • Some patients were hesitant to schedule appointments during the pandemic, failed to return phone calls, or declined care once it was offered. – While some of this is definitely patient-driven, what is not discussed is the abrupt shift, the lack of trust, and the confusion about the need to pay the community providers, among other things, faced by veterans forced into community care. As a reference point, it has been 24-months, and I am still facing requests to pay several community providers due to the VA not paying the bill due to a technicality.  The VA claims the provider has to “eat the costs,” but I keep getting statements and calls from collection agencies.  Guess the direction of my credit score, the direction of my insurance costs, and how happy I am with community care providers.
    • The VA-OIG found community care providers and staff did not consistently comply with requirements to manage routine consults, and leaders lacked tools to sufficiently monitor program operations that could have identified the problems.
    • Deficiencies emerged in documenting when patients were contacted about scheduling appointments, designating patients eligible for alternative care, and ensuring staff was trained in ways that would address those weaknesses. – Not to mention that pertinent medical records still haven’t been transmitted, received, and alerted the primary care provider. I had gallbladder removal surgery; no records ever made it to the VA.  I have MRIs, CT scans, and ER notes that, even after being hand-delivered, have not been added to my VA electronic health record and presented to the primary care provider to discuss, dating back to 2010.

How’s that community service program working for you?  In any other industry, this performance would represent an abysmal failure; but community care represents a healthy opportunity for improvement at the VA.  The findings listed are a mere drop in the conclusions discussed in the report.  I have a suggestion for the VA, stop overpromising and underdelivering.  How about you under-promise and then over-deliver?

The following VA-OIG inspection report focused on the Veteran Health Administration facility’s adherence to guidelines for medication management, and the following explanation is quoted from the report:

This report describes medication management findings from healthcare inspections initiated at 36 VHA medical facilities from November 4, 2019, through September 21, 2020.  Each inspection involved interviews with facility leaders and staff and clinical and administrative processes reviews.  The results in this report are a snapshot of VHA performance at the time of the fiscal year 2020 OIG reviews.”

Before we get into the findings, let me elaborate on that statement.  The VA-OIG cherry-picked/hand-selected call it what you will, the facilities to inspect.  No criteria discuss how these facilities were selected.  More, the processes chosen for review were also cherry-picked/hand-selected.  Appearing to represent that, the VA-OIG stacked the deck to obtain success, and the VHA still failed, or rather showed weaknesses.

Generally, the VA-OIG rated the VHA facilities as “compliant.”  But “weaknesses” were identified; read that as the VHA cannot follow established guidelines, protocols, and processes, even though they wrote and established these guidelines and medication protocols.  I call this designed incompetence of a criminal nature, but I am not half as lenient and politically astute as the VA-OIG!

Findings:

    • Aberrant behavior risk assessments
    • Concurrent benzodiazepine therapy
    • Urine drug testing
    • Informed consent
    • Patient follow-up
    • Quality measure oversight.

The following, also from the medication’s adherence inspection, remains significant:

“The OIG examined the following indicators of program
oversight and evaluation:

      • Performance of pain management committee activities
      • Monitoring of quality measures
      • Following the quality improvement process”

For the weaknesses represented in the findings to be prevalent, the “Pain Management Committee activities” represent a general failure of the committee to function!  For quality processes to be a finding, monitoring quality signifies that the bureaucrats are NOT doing the jobs they were hired to perform!  A quality process fails when the humans tasked with oversight refuse to engage, and the VA-OIG findings testify to the truth of humans actively refusing to do their jobs individually and collectively!

Having read and written about the VA-OIG reports for almost ten years, I swear sentences containing the following represent a majority stake in why the VA-OIG cannot be trusted.

VA-OIG inspections… underscored the value of independent oversight of care received in these settings to help VA make continuous improvements.”

Really?  Are you sure the VA-OIG inspections provide “independent oversight” and spur “continuous improvement” at the inspected VA facilities?  I have significant doubts the inspections do anything more than highlight the problems as the VA-OIG inspectors have no teeth, and lying has zero repercussions for the humans defrauding the taxpayer!  How do I know this; the VA-OIG reports generally go on to make a claim similar to the following:

The OIG’s findings show that immediate attention is needed in several critical areas….”

Do you, the dear reader, understand better the frustration of veterans and their families?  When the Office of Inspector General (OIG) for the Department of Veterans Affairs (VA) covering the National Cemeteries, Veterans Benefits Administration (VBA), and Veterans Health Administration (VHA), can be deluded, distracted, and duped by conniving and conspiring people, what else can the veterans and their families do BUT become frustrated?  This is behavior unacceptable in every industry.  In fact, legislation overseeing non-government healthcare is strict in outlawing the conduct observed in government-provided healthcare, but somehow the VA is exempt.  Yet, the VA continues to make claims such as the following:

This is how the VA is delivering on its promise to care for the veteran who has borne the battle, his widow, and his children.”

But don’t take my word for it; the VA-OIG conducted several more Comprehensive Healthcare Inspections (CHIPs), resembling cookie-cutter inspections.  Staff training continues to be a major delinquency labeled as “High-Risk.”  Behavior Committee continues to be a central sticking point and inspection problem.  Cleanliness, tagged under “Quality, Safety, and Value,” continues to represent an area for growth and development.  Nurse-to-Nurse communications remain constant as a problem, and electronic medical records are not helping to improve on this problem.  Inter-facility transferring of patients, policy, and documentation also resemble a constant issue.  I feel like I could summarize a CHIPs report with my eyes closed; tell me, when does the “independent oversight” spur “continuous improvement?”

On the topic of “independent oversight” spurring “continuous improvement,” the VA-OIG conducted a VHA inspection of mental health activities for FY 2020.  Declaring:

This report describes mental health-related findings from healthcare inspections initiated at 36 Veterans Health Administration medical facilities from November 4, 2019, through September 21, 2020, and electronic health record review at five additional facilities.  Each inspection involved interviews with facility leaders and staff and clinical and administrative processes.”

Again, how the facilities were selected and the items reviewed appears to have stacked the deck in the VHA’s favor.  The VHA is still failing, showing weakness while generally being compliant.

Findings:

    • Completion of four follow-up visits within the required time frame
    • Appropriate follow-up of veterans with high-risk patient record flags who do not attend mental health appointments
    • Suicide prevention training
    • Completion of five monthly outreach activities.

Under these four categories, recommendations for improvement included:

    • Registered Nurse Credentialling – Source verification of licenses.
    • Staff training on Suicide Prevention
    • Care Coordination – Especially in transferring the patient, form completion, and evaluating transferred patients
    • Medication list transmission during transfers
    • Staff Training
    • Patient notification
    • Attending the Disruptive Behavior Committee

For anyone else keeping record, most of the list above is a repeat from the last several years the mental health inspection has occurred.  Color me shocked that the VA would still have issues remaining year-over-year, and if you cannot hear the sarcasm in that statement, I have some suggestions for you!

I am thoroughly sick to death of the VA failing in its mission, then bragging they are providing “Excellence in Healthcare.”  If the staff is not trained, they cannot perform their jobs, representing a leadership failure.  This is a truth for all industries, occupations, businesses, organizations, etc.  Nobody is exempt from this statement of fact, yet the VA-OIG keeps on swallowing this excuse year-over-year, and NO PROGRESS is EVER made!

America, are you aware of what the various government agencies are doing with your money, on your time, and with your consent?  If your neighbor took your checkbook and wrote checks you are legally responsible for paying, would you want better services rendered?  Elected officials (yes, I am including those at the city, county, state levels of government), why are you NOT scrutinizing the government more effectively and rigorously?  You, the elected officials, are the neighbor writing checks; why are YOU NOT doing the job we hired you to perform?

Elected officials, did you know that VA is not required to maintain records of returned bills, as a matter of policy, but those returned bills mailed to veterans are causing hardship for veterans.  I cannot recount how many times I have changed my address and my spouse’s address with the VA, on the VA-approved websites, and in-person with VA representatives, and still have had mail not delivered for months due to a wrong address in a legacy system.  Yet, the VA is not policy mandated to check returned mail, track that mail to a veteran, and check the different legacy and non-legacy systems for address veracity.

Elected officials, do you read the VA-OIG reports?  Honest question, as the following is directly from a VA-OIG report.

“[VHA primary care] providers did not consistently

        • Identify a surrogate should the patient lose decision-making capacity
        • Address previous advance directives, state-authorized portable orders, and/or life-sustaining treatment plans
        • Address the patient or surrogate’s understanding of the patient’s condition.”

The VA designed the PACT Team to improve care and deliver on the VA’s mission, yet the primary care provider has the following failures weaknesses showing.  The VA-OIG can do nothing to improve this glaring oversight, but you were elected to force change and spur “continuous improvement” in the executive branch officers and employees.  Well, where are you?  The VA-OIG substantiated that a failure in the PACT team led to a delay in a cancer diagnosis, causing increased pain, problems, and resource loss for a veteran; where are the elected officials, and the media for that matter, in raising a holy rhubarb on the PACT Team failing this veteran?

Elected officials, did you catch that statement in the VA-OIG report on the cancer diagnosis?

Facility leaders have an unwritten expectation that primary care providers conduct a thorough historical review of the patient’s electronic health record starting with the most recent annual note; however, the OIG found that not all of the patient’s providers conducted historical reviews, but instead focused on current issues and problems identified by the patient.”

Having transferred between PACT teams inside the VHA and state-to-state, I can affirm this is exactly what is transpiring in the PACT team; the second most important player, behind the patient, is the primary care provider.  When the primary care doctor fails in their job, like dominoes falling, the care of the patients rapidly cascades into a dynamic failure of healthcare in a VHA facility.  What are YOU doing to stop this madness and demand accountability?

The electronic health record has a section near the top of the record for “Problem List.”  Guess what; when providers fail to keep this section updated, current, and accurate, the healthcare of the patient borders on malpractice requiring only a slight push to arrive with a dead veteran.  The VA-OIG found providers and nursing staff failures to update the problems list accurately, keep the problems list current, and regularly discuss the problems list with the most critical member of the PACT team, the patient!  Providers failed to comply with sound science, good business practices, and act appropriately for the patient’s health; do you think this might be a slight problem in the PACT team?

I have offered the VA several suggestions for plotting a path forward.  Yet, the VA cannot and will not take advice without stern and reproachful measures taken by Congress.  Elected officials, it is time for you to act and groundswell the changes needed in every government agency, even if it means reducing the size of government!

© 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.

If Everyone Cared – More Detestable VA Stories

I-CareAs I went to catalog more of the Department of Veterans Affairs (VA) – Office of Inspector General (VA-OIG) reports, Nickelback’s song, “If Everyone Cared,” was playing.  I cannot think of a better title to proclaim the need for raising awareness and what is needed to fix the VA.  Until everyone is aware and the scab hiding the infection inside the walls of the VA are ripped away to be exposed to the sunlight disinfectant, nothing will change, and taxpayers will continue to pay for the abuse of veterans who deserve so much more.

We begin with an indictment and a reminder.  An indictment does not indicate guilt or innocence, and the parties mentioned are presumed innocent until proven guilty in a court of law by a jury of their peers.

Scott Mitchell Brown, John Henry Swiencki, and David Jeffery Hughes, Jr., were all charged with one count of conspiring to distribute hydrocodone, oxycodone, and amphetamines. Brown was also indicted for stealing prescription medications, possessing stolen mail, and obtaining unauthorized health information from the Kerrville VA Medical Center in Texas.”VA 3

I am a big fan of punishing liars and thieves of all stripes and support justice served in this case.

David Naylor, 59, of Spring Hill, Florida, was sentenced to two years and three months in federal prison, followed by three years of supervised release, for theft of government funds. Naylor made false representations regarding his physical limitations in connection with his application for VA disability compensation.”VA 3

While the following perpetrator has been caught and sentenced, she represents but the tip of the iceberg.

Rita Copeland, 59, of Portsmouth, Virginia, was sentenced today to nine and half years in prison for wire fraud and aggravated identity theft in connection with schemes to defraud veterans. She operated Veteran Services of the Commonwealth, which claimed to provide veterans with caregiving, contracting, and rental assistance services. In total, from at least 2017 through 2020, Copeland’s schemes impacted at least 29 victims and resulted in a combined loss of approximately $430,000.”VA 3

Again and again, the following questions are asked and never answered; yet, the questions remain pertinent.   Who at the VA had to have known this abuse of veterans was occurring and did nothing to stop the abuse?  There are too many checks and balances, too many hands, and too many inspectors for fraud of any magnitude to exist for very long without raising flags needing investigating.  Where were the VA employees?  Who knew?  What did they not do?  Are they still Federal Employees?

Another veteran died, needlessly at the hands of VA providers, due to ineptitude, failed management, poor training, and a series of unfortunate events that cascaded.  I weep for the family of this veteran and mourn for their loss.  I am sorry you have had to experience this tragedy and wish there was something more I could do than simply spread the story of this deleterious behavior and hope for sunshine disinfectant.  The patient died from “presumed anoxic brain injury (his brain failed to receive enough oxygen).”

The VA-OIG found that physicians’ failure to provide adequate benzodiazepine dosing to address the patient’s delirium tremens, review the patient’s abnormal electrocardiogram before haloperidol administration, and transfer the patient earlier likely contributed to the patient’s deterioration and ultimate death.  The VA-OIG substantiated that a non-VA paramedic documented that the oxygen flow was not active.  Facility leaders and staff reported a lack of knowledge about the failed oxygen delivery. The nursing staff did not complete all required alcohol withdrawal assessments.  A physician improperly ordered restraints, nurses failed to obtain full vital signs while the patient was in restraints, and nurses did not receive restraint training as expected.  The VA-OIG substantiated that facility leaders and staff did not communicate initiation of emergency detention with the patient’s family; however, notification is not required.  Leaders did not conduct an institutional disclosure with the patient’s family timely or in person and did not provide a relevant update.”VA 3

Did you catch that last sentence; while the patient was dying, the facility leaders and providers, including the nursing staff, were more concerned with CYA (covering their own acts) than notifying the family they had screwed up, and their family member had died.  If the nursing and staff did not have the training, why and how could they use restraints on a patient? This is blatantly illegal!VA Seal

Let’s cover one more egregious item from this summary of unfortunate events; I visited a doctor who is transitioning out of medicine who made the following comment, “Medicine has changed, practicing medicine has changed, and the practice of medicine is no longer about treating people, but checking boxes, the patient be damned!”  The patient was a “walking chemistry experiment, and no single nurse or provider took a minute to stop providing care, assess the patient, and stop administering drugs!  Instead, they just kept pumping more drugs in until the patient died and then covered their tracks with designed incompetence to protect their failed inadequacies.  This is not “practicing medicine,” you would not treat an animal in this manner; at least not and keep your license!

A death row convict is not allowed to die from anoxic brain death, as it is considered incredibly painful and a cruel and unusual method of death, which is why the gas chamber has been banned as a legal means of causing death for death row inmates.  Yet, under a medical team’s care, a patient in a VA hospital is allowed to die in this horrific manner, and nobody is held accountable.  Is it any wonder why this article is suitably titled “If Everyone Cared?”LinkedIn VA Image

Not many outside of the veterans affected and their families know that the VA has been pushing opioids for decades down the throats of veterans.  At the height of the opioid crisis, the VA shut off all opioid drugs and told the veterans to seek help for addictions to pain medications.  The VHA did not evaluate the individual patients for need, did not seek alternatives, did not try to reduce dependency over time, simply cut off all opioids, and told the veterans to deal with the problems.  Unfortunately, opioids were not the only drug series that the VHA cut off suddenly on veterans without notice, cause, or individual patient consideration, and deficiencies in coordination for the care of patients and drug mandates from VHA has lead to suicides, murders, and other violent problems as addictions cause social problems.VA 3

When discussing failures to coordinate care for patients, abuse of patients, and the need for patients to be housed in the proper treatment centers for their needs to receive the right care, the following should boil your blood and comes from Fayetteville VAMC in North Carolina.

The VA-OIG identified that the psychiatrist used the involuntary commitment process in a manner that was inconsistent with the state’s established parameters and failed to adequately assess and document the patient’s capacity to make informed decisions and determine whether the patient had a healthcare agent. In addition, the patient’s primary care providers and psychiatrist missed an opportunity to coordinate specialty care needs for the patient.”VA 3

Essentially, a bureaucrat incarcerated a veteran against their wishes, without a trial, an appeal process, and proper medical care.  Now, imagine you are the family of this veteran or a friend, and you see this occur and feel powerless to help, impotent to intercede.  Every avenue you approach is blocked because of the authorities, the bureaucrat in charge who wields their power illegally.  How do you feel?  What do you do?  Where do you turn?  Is it any wonder why this article is suitably titled “If Everyone Cared?”

I-CareAmerica, we need to care about what is happening in our representative government, in our name, with our tax dollars, and to our neighbors, family, and friends.  There are no excuses for the abuses witnessed!  There are no excuses for medical providers to get away with this outrageous behavior in private hospitals or government-paid-for-care.  Let us all heed Nickelback’s song and the intent; let us be the “everyone” who cares!

© 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.