Do You Feel Represented? – Your Government In Action!

Detective 4I have received feedback that I write about the Department of Veterans Affairs (VA) too much.  Please allow me to explain why.  As a veteran, I am duty-bound to help my fellow brothers and sisters in arms.  As the son of veterans, mother (USN), and father (USN, USARNG), I know the hardships of being dependents of active duty, reserve, and National Guard members of the military.  The enlistment contract doesn’t end when the contract says so for the military member; the families and spouses contract is forever.

The final two reasons I write about the VA are most critical; NO body should be treated like the VA treats the veterans; the actions of the bureaucrats in the VA are not representing me and what I stand for in a representative government.  As I can easily have the Department of Veterans Affairs – Office of Inspector General Reports (VA-OIG) delivered to my inbox, it makes writing about the VA much easier, benchmarking how the government has insulated themselves and forgotten who holds the reigns of power in a representative government.  While not a reason to write about the VA, this final explanation should help you judge whether your representative government appropriately represents you and what you stand for.Why

The VA-OIG reports today begin with behavior that is intolerable and worthy of public shaming.  While the defendant remains innocent until proven guilty, the criminal complaint represents behavior inexcusable!  “Daniel Devaty of Elyria, Ohio, was charged with influencing a federal official by threatening a family member. Devaty allegedly sent a text message to the cell phone of a VA social worker threatening to kill his daughters.”

Angry Grizzly BearAnytime anyone threatens the family members, their behavior is beyond the pale and deserves public shaming and the harshest of criminal penalties.  I do not care if the perpetrator is a politician, a judge, the media, or a private citizen.  Leave the families out of any business dealings!  Hollywood, take note, I am sick to death of you threatening family members in movies, TV shows, or simply as private citizens/influencers.  For too long, you have shirked your public responsibility, and families are OFF LIMITS!  Learn this lesson well!

On the topic of conduct reprehensible, the following VA-OIG report leaves me running out of adjectives to describe the behavior of this VA Employee.  “Robert Sampson of Gulf Breeze, Florida, pleaded guilty to charges of video voyeurism and disorderly conduct. Sampson secretly recorded eight fellow VA employees using a hidden camera, disguised to look like a cell phone charger power adapter, that he placed in a restroom at the VA Joint Ambulatory Care Center in Pensacola on multiple occasions from August 2019 to June 2020.”  May the judge throw the book at him and his punishment be creative and sentence well earned!

VA 3In another VA-OIG report, we have more leadership missing problems, where a fraud scheme existed for 11 years without discovery.  “Erik Santos of Georgia was sentenced to over 11 years in federal prison for defrauding Tricare of approximately $12 million through a compounding pharmacy fraud scheme. In January 2021, Santos pleaded guilty to one count of conspiring to commit healthcare fraud and wire fraud.”  While the US Attorney beats his chest and proclaims they will catch everyone involved in the fraud, how many managers and supervisors inside Federal Government employ will lose their jobs, pensions, and freedom over allowing this fraud to occur?  What processes and procedures will be changed to protect against another fraud scheme?  Who is personally accountable for contracting that permitted this scheme to bloom for more than a decade?

VA 3The following VA-OIG report details how clowns and asylum patients run the IT program for the VA and not professionals!  The VA was tasked explicitly by legislation to meet several IT deadlines on a program for family caregivers as part of the VA MISSION Act of 2018. Unfortunately, not only did the VA fail to get the IT program up and running on time, missed mandatory reporting deadlines, and delivered a software solution 2-years past due, but the “VA did not establish the appropriate security risk category and fully assessed the system’s privacy vulnerabilities.”  Amazing, with all the IT problems the VA suffers from, with all the IS problems the VA suffers from, one would think that, where new technology was concerned, the VA would be practicing better security and using the lessons learned previously.

VA 3Would someone please tell me why private industries would be sued to the Nth degree criminally and civilly for these IT failures, but the government can evade accountability and responsibility; why?  In a representative government, the citizens can, and should, hold the elected representatives and their minions accountable for failing to uphold basic security protocols. So how did the government vote themselves a “Get out of Jail Free” card?

While writing this article, three additional VA-OIG reports have been delivered to my inbox.  The newest VA-OIG report discusses a topic that the VA continues to struggle with, namely transparency.  Apparently, the goblins in Goblin Town still cannot stomach sunlight and prefer to keep their nefarious deeds hidden.  Unfortunately, the lack of transparency in hiring practices leads to more VA-OIG investigations into employee wrongdoing, cost the taxpayers phenomenal fees to rid the government of poor hiring decisions, and all this before the union becomes involved.  From the report, we find the following:

“… VHA delegated much of its data reconciliation to its local facilities, which introduced variability in the process and did not allow for consistent creation, maintenance, and verification of information. VHA also had inadequate business processes to ensure quality data were available to support effective medical facility staffing oversight. Without consistent methods and reliable source documents for managing information, VHA cannot be sure HR Smart data accurately reflect VA’s budget and workload requirements.”VA 3

Did you catch that local facilities were given authority, which increased risks in hiring, all while management cannot perform their functions properly?  I remain convinced that the VA built designed incompetence into every action to protect themselves from ever being forced to take action. But, unfortunately, like always, the news only gets worse!Plato 2

A little background is needed to appreciate the problem in the following VA-OIG report fully.  Coronavirus Aid, Relief and Economic Security (CARES) Act required the VA to report to the OMB how they spent money appropriated for America’s Veterans and the VA during the pandemic.  The following is what the VA-OIG found:

VA met monthly reporting requirements to OMB and Congress on supplemental fund obligations and expenditures. VA also submitted required weekly obligations and expenditures from supplemental funding to OMB by program activity. Of approximately $17.3 billion in medical care supplemental funds, VA reported it had obligated about $7.11 billion and had spent about $5.67 billion by December 29, 2020. The VA-OIG team noted three concerns where VA’s reporting was not complete and accurate: • Obligations were at risk of not being included in VA’s reports. • VA initially delayed the reporting of reimbursable obligated amounts for two months. • VA’s reports contained negative dollar amounts in data fields that should have only positive amounts, which misstated VA’s overall reported obligations. Those concerns indicate weaknesses in how VA and VHA internal controls are structured to meet reporting requirements. Despite the risks identified, VA performed only a limited review at the summary fund level of its COVID-19 obligations and expenditures before reporting. A review of summary funds is not detailed enough to identify potential anomalies and ensure the reliability of externally reported information” [emphasis mine].VA 3

I did not find this in the VA-OIG report. Did anyone ask why the VA failed to meet the reporting for the first two months?  After the FISMA Congressional hearings, everyone knows the VA sucks at information technology and information security (IT/IS). So why was the VA given more money and told to budget it using existing failed software, processes, and procedures?  My work in the finance field is limited; however, when a company cannot handle its finances properly and meet legal obligations, a third-party accounting firm can be hired to handle this for the organization.  OMB, why are we not using this solution at the VA?  OMB, why is a third-party auditing company not conducting in-depth analysis and audits of the VA?  With all the missing taxpayer dollars at the VA and Department of Defense, it seems that you are just as negligent as the agencies you are supposed to monitor.

Theres moreAs they say on the Home Shopping Network, “But wait!  There’s more!”  Unfortunately, the same holds of the VA, just without the enthusiasm!  Each VA Medical Center in the Department of Veterans Affairs – Veterans Health Administration (VHA) is expected to have supplies, also referred to as caches, on hand at all times to handle local emergencies and national health care incidents.  For example, a pandemic!  The VA-OIG investigated these prepared caches and found that only 9 of 144 supply stockpiles were ever mobilized.  The excuses, oh these excuses, are like butt holes, everyone has one, and they stink!

      1. “Medical facility directors reporting supplies were not needed or caches lacked sufficient quantity for meeting pandemic demands.”
      2. “The Veterans Health Administration (VHA) changed the process for mobilizing caches during the pandemic, but without clearly communicating it to medical facility directors” [emphasis mine]. – We have the blind leading the blind, in a darkened room, in a London fog!
      3. The VA-OIG, not the VHA, not the local VAMC, but the inspectors “identified problems with cache maintenance and monitoring.” – Never forget, this is a job of several people, overseen by a director, who reports to facility leaders, and inspectors had to find the maintenance and monitoring problems. Just let that sink in for a minute!
      4. Most caches contained some expired or missing personal protective equipment, diminishing their ability to support pandemic preparedness.” – This is an example of how the VHA is “Defining Excellence in Healthcare!”
      5. The “VHA had incomplete documentation on cache activations, making it difficult to know which caches would need to be restocked.” – See item number 3 above.
      6. Medical facility leaders were not always able to accurately report if their facility’s cache was activated during the pandemic.” – Is the proof sufficient that the VA leadership IS the problem with the VA; yet?VA 3

In the US Navy, a significant part of my job was to maintain and monitor emergency supplies. Additionally, to use and cycle through reserves during drills and replenish those supplies quickly and efficiently not to impair the ship’s ability to protect itself 24/7.  I did my job well enough to earn three people Navy Accommodation Medals.  I took over the emergency stores, and all consumable supplies were expired or consumed.  Within 3-months, I was winning accolades and awards.  Yet, 144 caches of emergency supplies for the VHA need more procedures, more documentation, and more oversight to fulfill the mission correctly.

Knowledge Check!I beg to differ!!!  We need leadership, active, engaged, enthused, leadership!  We need the medical facility leader to stop designing incompetence and do the job they have been hired to perform.  We, the taxpayers, need the oversight instruments of the Federal Government to become a lot more effective at demanding results.  We desperately need the elected officials we have hired to scrutinize the government!  Just imagine if you hired someone to perform a mission-critical job, and in the middle of needing emergency support, the person hired reveals, “Oops, I might not have done my job properly.”  How fast would that person be fired?  Now, why can we not do the same to the government employees?

So, ask yourself, do you feel represented by your government?

© 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.

Structured Incompetence – The Department of Veterans Affairs and Congress

I-CareThe Department of Veterans Affairs (VA) is allowed the ability to govern themselves, provided they meet specific guidelines and legislated goals and directions.  The Department of Veterans Affairs – Office of Inspector General (VA-OIG) was established to provide legislators and the VA with tools and processes to improve, as well as to investigate root causes, and make recommendations for improvement.  But, here is the rub, the VA-OIG has no teeth to help their recommendations hold the attention of those in charge to make changes.

In December 2014, the Federal Information Technology Acquisition Reform Act (FITARA), passed Congress and was signed into law by the president; FITARA is a historic law that represents the first major overhaul of Federal information technology (IT) in almost 20 years. Since FITARA’s enactment, OMB published guidance to agencies to ensure that this law is applied consistently governmentwide in a way that is both workable and effective.  2014 saw the VA slow the loss of private data from the VA, the Office of Personnel Management (OPM) Data Breach is gaining momentum and will crest in 2015, and in case memory has failed 2014 saw an explosion in VA malfeasance get uncovered starting with the Carl T. Hayden VA Hospital in Phoenix, AZ.

December 2020 will mark the sixth anniversary of FITARA, and President Trump signed a five-year FITARA bill in May 2018.  The VA-OIG in reporting progress on FITARA at the VA has this to report,

“… The audit team evaluated two groups of requirements involving the role of the VA chief information officer during [the] fiscal year 2018. They related to the CIO (1) reviewing and approving all information technology (IT) asset and service acquisitions across the VA enterprise and (2) planning, programming, budgeting, and executing the functions for IT, including governance, oversight, and reporting. The audit team found that [the] VA did not meet FITARA requirements and identified several causes.”

The number one reason for non-compliance after almost six-years was, “VA policies and processes that limited the chief information officer’s (sic) review of IT investments and the oversight of IT resources.”  Not mentioned in the VA-OIG report is how many of these processes and policies had been enacted since 2014.  The VA’s own processes and policies reflect structured incompetence, making a ready excuse to be out of legal compliance with legislated obligations.  If this was a private business, and the legislated obligations were not being followed exactly, no excuse could keep the leadership team out of jail and the business in operation.  Hence, Congress why do you allow this egregious behavior by public servants?

On the topic of structured incompetence, foot-dragging, and legislated obedience, the VA-OIG issued a glowing report of compliance because the VA was found to be in compliance with three of the five recommendations from a VA-OIG inspection on the Mission Act from June 2019.  The progress made was on all aspects of the Mission Act except mandatory disclosure.  Why does this not surprise me; of course, the VA has had, and continues to suffer from, a horrible case of refusing to report, disclose, and communicate without severe prodding and legislated mandates.  Thus, I congratulate the VA on being in compliance with the Mission Act for the last three consecutive quarters on a total of three recommendations from the VA-OIG; this is a good beginning, when can we expect improvement on mandatory disclosure?  Structured incompetence relies upon disclosure malfeasance, collective misfeasance, and leadership shenanigans.

On the topic of structured incompetence, the VA-OIG reported that the Northport VA Medical Center in Northport, New York, prior medical center leaders did not plan effectively to address deficiencies in aging infrastructure.  Which is the polite way of saying, the buildings are old and maintenance has been creatively haphazard, so when steam erupts from fittings and contaminates patient treatment rooms with asbestos, lead paint, live steam, and other construction debris, a small problem becomes a multi-month catastrophe.  Thankfully, the VA-OIG reported no harm to the patients or patient care restrictions from this episode.  Unfortunately, the VA-OIG cannot hold the managers and directors of engineering services responsible.  Having worked in several capacities in engineering I am astounded at the following recommendation from the VA-OIG, and covered under creatively structured incompetence:

“… The OIG recommended that the medical center director develop processes and procedures for submitting work orders—including for notifications when work orders are assigned and reviewed for accuracy and consistency—to help the center’s engineering service prioritize work and manage [the] resource.”

Will the VA-OIG please answer the following questions, “Why is this the hospital directors’ job?”  You have an entire engineering plant, with a supposedly competent director to oversee engineering operations, why and how should the hospital director be focusing such extensive amounts of time on the job that rightly belongs to the engineering plant director?  There are several technology-based programs and options that can perform this work, and form reports automatically based upon performance by engineering staff in completing work orders.  Why is the VA-OIG recommendation not including an automated process to improve performance?  The lack of oversight in the engineering department is both creatively and structured incompetence, because the VA-OIG report recommended following the master plan, reporting progress to the master plan, and suggested that the director of the engineering plant needs to be doing the job they are collecting a wage to perform.

Behavior-ChangeOn the topic of creatively structured incompetence, we find the following from the Department of Veterans Affairs – Veterans Benefits Administration (VBA).  A veteran patient that spends more than 21-days in hospital for treatment is supposed to be placed on 100% disability, and be paid at the higher disability amount.  Those veterans with mental health concerns are supposed to have additional support to aid them in managing their benefits from the VA.

The VA-OIG estimated VA Regional Office employees did not adjust or incorrectly adjusted disability compensation benefits in about 2,500 of the estimated 5,800 cases eligible for adjustments, creating an estimated $8 million in improper payments in the calendar year 2018. The OIG estimated 1,900 cases did not have competency determinations documented for service-connected mental health conditions.”

Why is this another case of creatively structured incompetence, because every time the VBA gets caught not doing their job, the reason is training, reports not properly filed, and lack of managerial oversight.  I could have predicted these reasons for structured incompetence before the investigation began.  That managerial oversight, employees not filing proper and timely reports, and training not occurring for employees has been an ongoing and repeated theme in VBA incompetence since early 2000 when magically the VBA was behind in processing veterans’ claims for disability.  This theme stretches to the VBA inappropriately deciding claims for spine issues.  The same theme was reported in the VBA improperly paying benefits.  The list of offenses by the VBA is long, and the excuse is tiresome.  The VA-OIG reported:

Employees who processed benefit adjustments also lacked proficiency. They lacked sufficient ongoing experience and training to maintain requisite knowledge. This is also why employees were unclear on the requirement to document the relevant competency of veterans admitted for service-connected mental health conditions.”

ProblemsHow ironic that the root causes of a VA-OIG inspection would find people being paid to perform a job, but are not actually doing the job because they lack proficiency, training, managerial oversight, and are unclear on what they are expected to do in their jobs.

To the elected officials of the US House of Representatives and the Senate, the following are posed:

  1. If you hired a carpenter to enter your home, perform work, and you discover that the carpenter does not know the job they were hired and contracted to perform, what would be your response?  If your answer is to keep that non-working carpenter in that position, in your home, I must wonder about your intellect.
  2. How can you allow this structured incompetence to live from one VA-OIG report to the next? How can you justify this behavior at the VA?  How many other offices of inspectors general reports are reporting the same structured incompetence in Federal Employment and you are not taking immediate action to correct these deficiencies?
  3. Why should anyone re-elect you; when we the taxpayers endure this incompetence, paying you and them to abuse us. You were elected to oversee and manage that which we cannot; yet, you continually strive to perform everything but this essential role.  Why should we re-elect you to public office?

GearsThe following suggestions are offered as starting points to curb structured incompetence, improve performance, and effect positive change at the Department of Veterans Affairs, which includes the Veterans Health Administration (VHA), the Veterans Benefits Administration (VBA), and the National Cemeteries.

  1. Implement ISO as a quality control system where processes, procedures, and policies are written down. The lack of written policies and procedures feeds structured incompetence and allows for creativity in being out of compliance with legislated mandates.
  2. Eliminate labor union protection. Government employees have negotiated plentiful benefits, working conditions, and pay without union representation, and the ability for the union to get criminal complaints dropped and worthless people their jobs back is an ultimate disgrace upon the Magna Charta of this The United States of America generally, and upon the seal of the Department of Veterans Affairs specifically.
  3. Give the VA-OIG power to enact change when cause and effect analysis shows a person is the problem specifically. Right now, the office of inspector general has the power to make recommendations, that are generally, sometimes, potentially, considered, and possible remediations adopted, maybe at some future point in time, provided a different course of action is not discovered and acted upon, or a new VA-OIG investigation commenced.  This insipid flim-flam charade must end.  People need to be held liable and accountable for how they perform their duties!
  4. Launch a VA University for employees and prospective employees to attend to gain the skills, education, and practical experience needed to be effective in their role. I know from sad experience just how worthless the training provided to new hire employees is and this is a critical issue.  You cannot hold front-line employees liable until it can be proven they know their job.  Employee training cannot occur and be effective without leadership dedicated to learning the job the right way and then performing that job in absolute compliance with the laws, policies, and procedures governing that role.  Training is a leadership function; how can supervisors be promoted and not know the role they are overseeing; a process which is too frequent in government employment.

I-CareI – Care about the VA!

When will the elected officials show you care and begin to assist in improving the plight of veterans, their dependents, and their families?

 

© Copyright 2020 – 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 pictures.

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