Tag: Phoenix VAMC

“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 1/10th 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.

Advertisement

“That’s Crazy!!!” – More Chronicles from the VA Chapter 6

I-CareI promised a follow-up article after Chapter 5; it took me the better part of 48 hours to cool down sufficiently to write coherently to effect an update.  On 18 March 2002, I wrote about an appointment with my Primary Care Provider (PCP) being tardy, unprepared, and bureaucratese in supposedly holding a phone appointment with me.  01 April 2022, not an “April Fools Joke,” at 0731 hours, lasting 9 minutes, my PCP called me to get my approval to have me changed from her PACT team to another provider’s team.  Apparently, in the highly red taped world of PCPs at the El Paso VAHCS, there must be an hour-long handoff call when a provider initiates a change of PACT team.  I have my doubts and smell designed incompetence!

Let me pause here for a moment.  I generally need two hours to write an article after conducting research.  18 March 2002, it took a bit longer to draft that one due to the need to blow off steam with some choice words and choke down the urge to beat a few brick walls with my fists.  I am generally a very controlled person, and the fact that this PCP was so stunningly incompetent, rude, and HIPAA clueless, I admit I lost my cherub-like demeanor!  That the patient advocate was able to get my secure message, upload the comments into the electronic medical record, and contact the provider before the provider had even logged the patient notes, speaks volumes about the ineptitude of the PCP.  Worse, in the call on 01 April, the PCP was still on speakerphone, still disregarding HIPAA security, and quoted lines out of context from my message to the patient advocate.  Speaking volumes about the processes and procedures of the patient advocate’s office to investigate patient claims without breaching confidentiality.  Another topic for another day entirely!PACT_model

28 March 2022, I received the following from the patient advocates office, quoted completely:

“We have received your secure message addressing your concerns.  I will be sending a Patient Advocate Tracking notification with your concerns to our Primacy Care Service for review.  They will be contacting you via telephone to discuss your concerns.”

I never heard anything from this mysterious “Primary Care Service” group/team.  01 April 2022 was the first response, and that was from the PCP.  Sourcing the Department of Veterans Affairs (VA) and the Office of Inspector General (VA-OIG), the PCP is the second most important member of the Patient-Aligned Care Teams (PACT) at the VA; the patient is the essential member and an actively engaged and knowledgeable patient is preferred.  I promise the VA-OIG has not even scratched the surface of the problems with recalcitrant, snowflake, and bureaucratic PCPs endangering patient health with the VA.  Not my first run-in with an inept PCP; I sincerely hope it is my last!PACT 3

In returning to the 01 April call, we find another interesting piece of data.  The PCP affirmed that abdominal pain could radiate from, say a hernia, to other parts of the abdomen, but this is for a specialist to diagnose, not a Family Practitioner.  Get that; the PCP is directly reversing all the published documentation by the VA and the VA-OIG by declaring that a specialist is the only person who can adequately decipher and detail why pain is occurring—putting all the PCPs in the VA Health Administration under the bus as merely button pushers and drug dealers.  Then the PCP has the temerity, nay the chutzpah, to suggest a trust deficiency existing between myself and the PCP.  Is it any wonder that people are detested, forlorn, melancholy, madder than a wet chicken with a raging case of hemorrhoids with the care they receive from VA healthcare providers?

Again, I repeat, only for emphasis, when any updates arrive on this issue, I will publish them in their entirety to allow the VA the opportunity to rebut, refute, or explain.  Like the ongoing saga with VISN 22, the Phoenix VAMC, and being arrested and injured three times by the VA Police, I am not holding my breath and awaiting a logical response.  If this were the only problem in the two weeks since the PCP shenanigans, the VA would be in pretty good shape.  Alas, we know, dear readers, that the VA is in dire condition, and the elected leaders need to be scrutinizing the VA a LOT more closely than they are.VA 3

We begin the latest chapter of VA-OIG reports with yet another physician bilking the government:

“Robert Clay Smith, a Louisiana physician, pleaded guilty to conspiracy to commit healthcare fraud, wire fraud, and illegal remunerations (taking kickbacks).  According to court documents, the scheme, which ran from 2013 until 2017, involved individuals associated with a medical supply and billing company recruiting Smith to dispense pain creams and patches to his workers’ compensation patients by offering him a split of the profits.  The company acted as the billing agent for Smith, handling all the paperwork and submitting the allegedly fraudulent claims to the US Department of Labor, Office of Workers’ Compensation Programs, and private insurers.  In exchange, the company paid Smith 50 to 55 percent of the profits collected from successfully billing insurers, at markups of 15 to 20 times what the medications cost.”

Plus the following:

“Robert Schneiderman of Langhorne, Pennsylvania, admitted to participating in a massive compounded-medication kickback scheme that he and others ran out of a pharmacy in Clifton, New Jersey.  Schneiderman pleaded guilty in federal court to one count of conspiracy to commit healthcare fraud and one count of conspiracy to violate the Anti-Kickback Statute.  From 2014 through 2016, Schneiderman and his coconspirators used Main Avenue Pharmacy, a mail-order pharmacy with a storefront in New Jersey, to run a fraud and kickback scheme involving compounded drugs like scar creams, pain creams, migraine mediation, and vitamins.  Schneiderman was the president of Main Avenue Pharmacy and was a founder and CEO of its corporate parent.  Main Avenue Pharmacy received over $34 million in reimbursements from healthcare benefit programs on compounded medications alone.  Approximately $8 million of that total was paid by federal payers.  Schneiderman himself earned over $400,000 through the course of the scheme.  This case was investigated by the VA OIG, FBI, Department of Defense OIG, Defense Criminal Investigative Service, and Department of Health and Human Services OIG.”

Don’t forget this one:

“Dr. Harry Doyle, a psychiatrist from Philadelphia, Pennsylvania, and his wife, Sonya Doyle, have agreed to pay $3 million to resolve alleged violations of the False Claims Act.  The alleged violations include submitting false billing to the US Department of Labor Office of Workers’ Compensation Programs (OWCP) for psychiatric services that were not provided and upcoding and double-billing patient claims.  The Doyles have also agreed to be voluntarily excluded from federal healthcare programs for 25 years as part of the settlement.  This is the largest recovery against a single psychiatrist in the history of the OWCP.  A multiagency investigation of Dr. Doyle’s practice revealed that from January 2013 through April 2021, the Doyles allegedly billed for services not rendered, some of which occurred when they were not physically present in the United States.  This case was investigated by the VA OIG, the Department of Labor OIG, and the United States Postal Service OIG.”

More is coming on this one:

“Ten Texas doctors and a healthcare executive have agreed to pay more than $1.68 million to resolve False Claims Act allegations involving illegal remuneration in violation of the Anti-Kickback Statute and Stark Law.  According to a multiagency investigation, from 2015 to 2018, the doctors allegedly received thousands of dollars in illegal remuneration from eight management service organizations (MSOs) in exchange for ordering laboratory tests from Rockdale Hospital doing business as Little River Healthcare, True Health Diagnostics LLC, and Boston Heart Diagnostics Corporation.  Little River funded the illegal remuneration to the doctors in the form of volume-based commissions paid to independent contractor recruiters, who used the MSOs to pay numerous doctors for their referrals.  The MSO payments to the doctors were disguised as investment returns but were based on and offered in exchange for the doctors’ referrals.  As part of their settlements, the defendants have agreed to cooperate with the Department of Justice’s investigations of other parties involved in the alleged law violations.  To date, 17 doctors and two healthcare executives involved in this scheme have agreed on settlements totaling more than $2.7 million.  The civil settlements resulted from a coordinated effort between the VA OIG, Department of Health and Human Services OIG, Defense Criminal Investigative Service, and the US Attorney’s Office for the Eastern District of Texas [emphasis mine].”

Elected officials, the next time you are asked about the incredible amounts of fraud in government-provided healthcare and insurance, do not buy the media talking points that the fraud is minimal, contained, or anything but designed incompetence on the part of the bureaucrats to act as a jobs program for investigators!  The same investigators who are refused sufficient tools to investigate shenanigans by employees in the Federal Government adequately.?u=http2.bp.blogspot.com-fGEUjJsJ2h4VcJgswaisnIAAAAAAAABcsoFqEewPF_E4s1600quote-if-the-freedom-of-speech-is-taken-away-then-dumb-and-silent-we-may-be-led-like-sheep-to-the-george-washington-193690.jpg&f=1&nofb=1

Frankly, all of these cases need the government workers to be held accountable, and the myriad of red tape loopholes CLOSED!  I remember an election; I forget who and the exact when, but a significant election plank in the platform was healthcare reform, promising to clean up the swamp and bring accountability to Washington and the government.  The public is still waiting, and I know enough of you have run on this topic from both parties to repaper the walls (inside and outside) of the White House.

Yet, even if only outside providers and executives were scheming, the VA might not be in too bad a condition.  Except for the employees of the VA, VHA, and VBA, which continue to be caught up in ethics violations at a minimum:

“The VA-OIG conducted an administrative investigation that included a congressional request to look into allegations that Charmain Bogue, former executive director of the Veterans Benefits Administration’s Education Service, committed ethical violations arising from her spouse’s consulting work for Veterans Education Success (VES).  VES is a nonprofit advocacy group that regularly had business before the Education Service.  The allegations also pointed to possible incomplete financial disclosures by Ms. Bogue concerning her spouse’s consulting business.  In their work, investigators uncovered evidence of other potential conflicts of interest and related misconduct by Ms. Bogue [emphasis mine].”

VA-OIG finding:

    1. Bogue participated in Education Service matters involving VES without considering whether it raised an apparent conflict of interest and acted contrary to the ethics guidance she received from her supervisors.
    2. Bogue sought résumé feedback from the president of VES to aid in her search for career advancement without considering whether this raised apparent conflict of interest concerns in subsequent VES matters. VES also endorsed Ms. Bogue for presidential nominee positions.
    3. Bogue provided insufficient detail about her spouse’s business in 2019 and 2020 public financial disclosures; VA ethics attorneys had found them compliant. She remedied the subsequently identified deficiency in her 2021 disclosure.
    4. The OIG found that Ms. Bogue refused to cooperate fully in the OIG’s investigation by refusing to complete her follow-up interview. Her husband and VES president also refused to participate in OIG interviews, and the OIG lacks testimonial subpoena authority over individuals who are not VA employees.   Bogue resigned from VA in January 2022.VA 3

UPDATE: 14 April 2022 – Sen. Grassley was hoodwinked by the VA on this issue and The Daily Signal (linked) has more of this report.  I covered this before, I repeat only for emphasis, when you are discharged from the VA, you lose your ability to be a “whistle-blower.”  As a point of fact, this is how the VA is able to hide a lot of their shenanigans, get rid of the person rocking the boat, invent the paperwork, cover the whole incident over as a “bad-apple” and keep you collective heads down and mouths shut until the VA-OIG investigation concludes.  The VA’s ability to abuse whistle-blowers is further compounded by Federal Attorneys who cherry-pick the cases they know they can win.  Which further protects the VA’s shenanigans and disheartens and mystifies those who have been wrongly terminated.  The Daily Signal reflects this pattern of corruption perfectly citing the records obtained by Empower Oversight.

Some commentators have claimed that blaming elected officials for not scrutinizing or not providing tools to investigate entirely is unduly unfair to the congressional representatives.  Really?!?!?!  The VA-OIG conducts an investigation, the people being investigated refuse to comply, and the VA-OIG is toothless to enforce a full and complete investigation to initiate Attorney General and FBI investigations and actions to recompense the defrauded taxpayer.  Ms. Bogue and the VES have invalidated any trust the taxpayer should have in their respective activities, but this, like so many other investigations into VA employees, will die of apathy before anyone is held accountable.  Even though a congressional representative demanded an investigation, nobody is being held liable.  Nobody is forced to compensate the defrauded taxpayer, yet the taxpayer is still expected to elect the same old representatives to their jobs.  Blaming the congressional representatives (legislative branch) for not scrutinizing the executive branch, one of only two jobs these people have, is somehow unfair?  NO!Exclamation Mark

Remarkably, between the 18 March disaster with the PCP and 01 April’s compounding idiocy, the VA-OIG published an ironically titled investigation report.

“Improved Governance Would Help Patient Advocates Better Manage Veterans’ Healthcare Complaints.”

Imagine that, more designed incompetence negatively impacting the veterans seeking care at a VA medical facility, stating the obvious by the investigators.  Who on earth would be responsible for seeing that regulatory agencies had the tools needed to scrutinize and demand corrective action?  Calling all elected officials, did you notice that one of the prima facia tools a veteran has to report problems, conveniently called “patient advocates,” does not have the sufficient authority, adequate oversight, and tools to execute their jobs?  The VA-OIG reports the following:

“The Patient Advocacy Program helps advance the Veterans Health Administration’s (VHA) efforts to improve customer service, support veterans’ access to quality care, and provide a mechanism to resolve healthcare issues.  Patient advocates document veterans’ concerns, communicate the resolution, provide follow-up and feedback, and identify trends for potential opportunities to improve medical facilities.  In FY 2020, VHA tracked about 162,000 serious complaints in its patient advocate tracking systems.”

Angry Wet ChickenOn a side topic, VA-OIG, how do you define a “significant complaint” and separate it from other types of complaints?  Honest question, the information was, to quote my PCP, “remarkably” missing from your investigation report!  Would the VA-OIG like to know why so many veterans’ complaints have risen to a “serious” level?  You reported the exact problem:

“A complaint is considered resolved when the complainant communicates the outcome, and the record is closed in the tracking system.”

Maybe, the VA-OIG merely overlooked the logic problem, but complaints increase when the solution pushed down the throats of the veterans does not fix the actual situation.  Honest question, no sarcasm involved.  Is a “serious” complaint one where significant harm or death to the patient has occurred?  Is a serious complaint one that breaks federal laws, EMTALA, comes readily to mind??u=https3.bp.blogspot.com-fYRTNk48SCwT8ua0IRDWPIAAAAAAAAFZUpexSmJsN2Kos1600overcoming-adversity-help-yourself-believe-cubby-motivational-1289878102.jpg&f=1&nofb=1

Having had “solutions” forced down my throat, speaking only for myself, I am thoroughly sick of having the patient advocates bureaucratize my complaint, then fail to act, and then compound the problem by quoting policy to me as a reason to close the complaint, when the VHA never have written policies and procedures!  Maybe, you might want to look into the root causes of some of those “closed” complaints and ask root causation questions!

What did the VA-OIG find when they investigated the patient advocates?

    • VHA lacked adequate governance of the Patient Advocacy Program.
    • VHA did not effectively issue and implement adequate policy, monitor complaint practices, and provide guidance to medical facility directors responsible for local program management.
    • Patient advocates did not always enter complaints into the system.
    • Even though complaint records generally appeared to be closed on time, patient advocates did not always document the communication of the outcomes to the complainants.
    • The VA-OIG substantiated an inadequate program policy to identify clear expectations and responsibilities.
    • The VA-OIG found that they (patient advocates) did not always adhere to the documentation requirements to show full complaint resolution.
    • At the local and VISN levels, responsible personnel did not consistently analyze patient advocate tracking system complaints about trends.

Feel free to read the complete abomination of designed incompetence for yourself.  Essentially the VA-OIG concluded that the VHA has been burning taxpayer money in a patient advocacy program, and the designed incompetence is so apparent it can be tracked from L2, where the James Webb telescope is located!  Worse, you won’t need the James Webb telescope to see the designed incompetence!James Webb Space Telescope

Unfortunately, I could have guessed the first three findings without looking.  Every VA program is designed so ineptly, reprehensibly led, criminally incompetent, and with such dastardly deceptive doings that fiction writers’ storylines have to be written better to sell books.  You cannot make this stupidity up and make a profit.  Hollywood would run screaming into the night if they made a true story about the ineptitude found at the VA!

Knowledge Check!Elected officials, where are you?  The VA-OIG presents copies of their findings to you, and I have yet to witness a single one of you holding the VA Leadership criminally responsible for the failures at the VA.  Even when the VA is killing hundreds of veterans, the US Congress refuses even to act upset, let alone scrutinize for a change!  Remember how many veterans were intentionally killed in Phoenix waiting for treatment?  How many VA employees lost their jobs and pensions or were forced in front of a judge for murder?  It is a fair question, where are the elected officials in the legislative branch working to end the criminal “fraud, waste, abuse,” and designed incompetence in the executive branch?

© 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.

“That’s Crazy!!!” – More Chronicles From the VA Chapter 3

Bobblehead DollIt is no secret I am on several prescription medications.  I take these under strict medical advice, and three of these prescriptions regard mental health improvements.  However, my prescription reasons were subtly shifted because Phoenix’s last two primary care providers did not listen to the patient.  Since the El Paso primary care physicians appear to be utterly incapable of even attempting to listen, I have now been without a mental health prescription for an entire week.  This is called bureaucratic cold-turkey prescription stoppage!

Not the first time this has happened, especially for this particular medication, a serotonin blocker.  Here’s the rub, the physical and mental withdrawal symptoms of cold turkeying the drug; includes, but is not limited to, the following symptoms, of which I have ALL of the problems!

      • Nightmares
      • Suicidal Ideation/Thoughts/Visions
      • Headaches
      • Heart Palpitations, radiating chest pain
      • Anxiety
      • Depressions
      • Mood Swings
      • Irritability
      • Tinglings and Prickling sensations of the skin
      • “Brain Saps”/”Brain Shivers”/Spaced-Out Zombie Spells
      • Fatigue
      • Dry Mouth
      • Insomnia and Sleepiness – Which is a major whiplash feeling!
      • Pain and neurological events in every part of my body!
      • … and more… Much…  Much… More!

I have been without this medication due to bureaucratic stupidity for several days in the past due to pharmacy issues.  But, this is now the longest I have been without this medication since getting prescribed this medication.  I wish, like anything, I had known some of these withdrawal symptoms before I went to the ER earlier this week for pain and neurological problems; I would have raised the refill issues as part of the ER visit.  I went online looking for other people’s experiences; I want some medical advice before continuing this medication!!!

PACT_modelI am a root cause kind of person; why do I bring this up?  I have had three primary care providers since arriving in the El Paso VAHCS in May 2021.  None of them have gotten any of the medications correct due to a blatant refusal to LISTEN to the patient with the INTENT to understand!  Nurses with VA-provided primary care providers are expected to communicate with patients between 24 and 72 hours post any ER visit.  Since moving to Las Cruces, I have visited the ER twice and have not spoken to the nurse yet!

I have initiated the conversation with the nurse through phone and secure messaging, and the nurse has refused to engage.  Through secure messaging, I am advised, “Secure messaging is not the place to triage a patient, and no question can be answered as this requires triage of a patient.”  No direct phone contact is possible with the clinic.  One must call, get routed to a call center, leave a message, and then hope the clinic calls you back sometime before you die!  Don’t forget; I am the same patient told, “The clinic will not see you in person because you “WILL NOT” wear a mask.”  Completely refusing to understand, accept, and believe that I cannot wear a mask due to medically documented (by the VA medical providers, which medical records they possess) reasons.  Best of all, the veteran is then sent letters and marketing materials urging the veteran to use secure messaging through “MyHealtheVet as a safe and secure way to access your medical team and get your questions and concerns addressed by your PACT team!”  If the VA were a mental health patient, they would have schizophrenia and at least a dual-personality.

PACT 1Snide, rude, and disrespectful staff, all made possible by, supported through, and legally accepted under federal government fiat.  Do you realize that the nurse not doing their job will have any number of valid and acceptable excuses, and these excuses are accepted because of designed intentional incompetence allowed under federal employment laws, regulations, and directives, established by and supported through Congressional oversight?  In Disney’s “Princess Diaries 2: Royal Engagement,” Viscount Mayberry has a line,

“Your staff is incompetent and unreliable!”

The VA is incompetent and unreliable, and the victims are the veterans and their families.  We are talking about dangerous drugs, forced addictions, and then the ineptitude of incompetent and irresponsible bureaucrats who refuse to do their jobs in a timely and responsible manner.  But do not take my word for it.  Let’s review what a watchdog organization, the Department of Veterans Affairs (VA) – Office of Inspector General (VA-OIG), has to say on this matter.

VA 3

  • Tracy McNeil, of Raeford, North Carolina, was sentenced to one year and one day in prison and ordered to pay $90,003 in restitution for committing wire fraud involving an elderly veteran in her care. From February 2015 to February 2017, McNeil fraudulently obtained benefits from the VA and the Office of Personnel Management by executing a power of attorney over a disabled veteran who served in the Army and worked for the US Postal Service. The investigation revealed that McNeill arranged for the victim, who had dementia, to move into her home in February 2015 and then directed the VA and OPM to deposit the veteran’s benefits into her bank account. Between April 2015 and December 2016, the VA deposited $11,151, and OPM deposited $61,318 into McNeil’s account. Further, OPM disbursed the veteran’s life insurance for $17,533 to McNeil. Financial analysis showed that most of the funds were spent on McNeill’s expenses, including rent, utilities, credit card payments, and personal purchases.

VA 3

  • Strock Contracting, Inc., of Cheektowaga, New York, has agreed to enter into a consent judgment with the United States for $4.7 million to resolve claims that Strock violated the False Claims Act. The United States filed an action in federal court alleging that Strock Contracting profited financially after fraudulently obtaining federal contracts intended to benefit service-disabled veterans. The United States alleged the company, which was not owned or controlled by a veteran, recruited a service-disabled veteran to create a pass-through company, known as Veterans Enterprises Company, Inc. (VECO), which the Strock Contracting its owner, Lee Strock, controlled. The company allegedly directed VECO to submit false eligibility certifications to the government, obtaining substantial profits on numerous federal contracts.
        • Where are the VA Employees who should know what “fake eligibility certificates” look like?
        • Where are the supervisors who should have been providing training?
        • Where are the Congressional oversight teams in holding the VA accountable?

VA 3

    • William Rich, of Windsor Mill, Maryland, was arrested for allegedly obtaining more than $1 million in veterans and Social Security Administration disability benefits by falsely claiming that he had paraplegia. Allegedly, Rich misrepresented his physical condition in VA disability compensation claims, in communications with the VA, and during medical examinations in pursuit of VA disability benefits. While serving in Iraq in 2005, Rich sustained injuries that resulted in the loss of use of both lower extremities. However, approximately six weeks after his injuries, he made substantial progress toward recovery and was no longer paralyzed. Later records show the VA rated him one hundred percent disabled following an examination in 2007. The examining physician noted that he did not have access to Rich’s complete claims file, so he did not review Rich’s medical history or observe the earlier report. In 2018, the VA OIG conducted an audit of specific claims and learned of conduct by Rich inconsistent with his purported condition. Over the next two years, VA OIG special agents conducted surveillance. They observed Rich walking, going up and downstairs, entering and exiting vehicles, lifting, bending, and carrying items—all without visible limitation or assistance of a medical device, including a wheelchair [emphasis mine].
        • OK, let me be clear, I am glad this veteran got better; I do not in any way condone theft. But, where is the VA in being culpable for FAILURE to do their job correctly?
        • Will the doctor who failed to do their job be held liable for the malpractice performed?

VA 3

    • William H. Precht, of Kent, Ohio, was sentenced to 37 months imprisonment and ordered to pay $1.25 million in restitution after pleading guilty to theft of government property and participating in a bribery and kickback scheme. In October 2010, Precht registered a purported vendor, a company he controlled, as a small disadvantaged business and veteran-owned small business in the VA vendor system. He then used his VA purchase card and other employee cards to purchase over $1 million in alleged medical supplies from the vendor. In addition, from May 2015 through January 2019, he conspired with Robert A. Vitale, a medical sales representative for multiple companies that conducted business with the medical center, to devise a scheme in which Precht would receive kickbacks and other items of value in exchange for steering VA business and other monetary awards to Vitale.VA 3

Speaking of staff being “incompetent and unreliable,” did you know that the VBA is using “COVID-19” as an excuse for being backlogged in cases, AGAIN?  Did you know that COVID-19 was so powerful that it caused the VA to fall 200,000+ cases behind, in an inventory of 600,000+ cases requiring decisioning, with 70,000+ needing additional review for entitlement, and needs to hire 2,000+ new employees to help correct the problem?  Since the VBA continues to fail in staff training, exactly how will hiring new employees help?  Honest question!  With the current staff rated as incompetent and unreliable, not by me only, but by the VA-OIG who has regularly taken these issues and more to Congress asking for additional scrutiny and assistance in improving the VBA, VHA, and National Cemetery specifically and the VA collectively; what exactly can new employees do?VA 3

The VHA cannot plan construction projects and put planned maintenance into proper categories to execute maintenance tasks correctly.  Congress refuses to scrutinize budgets and fiscal compliance for just maintenance of facilities.  How in the world can anyone expect more when the VA cannot even hit the basics of planned maintenance tasks?  I can; I do!

I-CareWhen the VA publishes marketing materials claiming they set standards for excellence and lead the industry, I want them to prove their competence and abilities!  Right now, their failures scream louder than the voices in their own ears, and they refuse to listen to anyone, and I am not happy!  You, the taxpayer, should not accept the performance of ANY government agency, including the entire legislative, judicial, and executive branches of government at the local, county, state, and federal levels, until they correct their behaviors!  It is time to end the charade and put paid to this contemptible behavior and abuse!

© 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.

How Do I Know? – An Update on the VA Mandatory Mask Policies and VA Leadership Failures

Question24 May 2021 – 1200-1500 I visited the Las Cruces Community Based Outpatient Clinic (CBOC) in Las Cruces, New Mexico.  Upon entry, I was asked to wear a mask.  I described I could not wear a mask, and the employee said I might be required to wear one but left the decision to those working more closely with me.  I waited in line and was called to the Team 2 window, where a gentleman was more than happy to assist me in getting the paperwork started to change VA hospitals after relocating.  About 45-minutes into my time in this CBOC, the gentleman asked me to wear a mask.  I told him I could not and had brought my VA Doctor’s note as proof.  The gentleman read the letter, confirmed I was good to receive care without the mask, and provided exceptional customer support.

After the past year at the Phoenix VAMC, where my every movement on the property was shadowed by VA Police officers looking for a reason to injure, arrest, cite, and force me from the property, the employees here in Las Cruces was a breath of fresh air.  However, the experiences in Las Cruces provide further evidence of the following facts:

      1. The Hospital Director has statutory authority for adapting and creating policies and procedures that benefit the safety of the employees and the patients. A point I stressed to the leaders of VISN 22 and the Phoenix VAMC to no avail.
      2. The Federal Mask Mandates can be situationally applied for the circumstances of the individual. Yet, another point I have repeatedly stressed since July 2020, and the first time I was injured, arrested, cited, and forced from Federal Property. At the same time, I was being denied emergency care under EMTALA and having my HIPAA information repeatedly violated by the VA Police Officers.
      3. The bombastic and unprofessional behavior of the Federal Police employed at the Carl T. Hayden VAMC is a problem of the leadership, and the failures of leadership to instill professionalism, proper attitudes and behaviors, training, and tactics in approaching and handling situations in the Phoenix VAHCS. At the behavior of the Federal Police Officers in the Phoenix VAHCS, Che Guevara, Mao, Stalin, and Fidel Castro would be proud!VA 3

How can a person be sure the problems caused are a direct result of leadership failures?

ApathyBy tracing behaviors, attitudes, and influence to their source, the police chief acts as he considers appropriate, but the underofficers generationally multiply and mirror his behaviors.  The same is true for the chief who takes his example from the assistant director, director, and hospital leadership.  Chains of command always have this consequence; the example of those above are mirrored, replicated, and multiplied to impress the higher officers to gain attention and promotion opportunities.  Want to take a measure of a leader; look to the most junior person in the chain of command and watch them for behaviors, attitudes, and actions that originate in the leadership.

GavelCase in point, long have I detailed and described the failures of leadership at the VA.  The latest is a wire fraud scheme in Jackson, Mississippi.  From the Department of Veterans Affairs – Office of Inspector General (VA-OIG), we find the following:

“Anthony Kelley, the owner of Trendsetters Barber College in Jackson, Mississippi, pleaded guilty to two counts of wire fraud in a scheme to steal federal funds. From October 2016 through March 2019, the college offered a master barber course that was not accredited by the state’s board of barber examiners. Kelley fraudulently represented that this course was approved and, as a result, was allowed to collect GI Bill money from veterans enrolled in the program.”VA 3

As the lowest person in the chain of command, Mr. Kelly was allowed to attempt to commit fraud by the VA.  Never in these reports is the VA employee, their supervisor, and their manager, who were complicit in allowing fraud to occur, mentioned and held accountable.  Somehow, we, the taxpayer, must presume that those committing frauds could hoodwink the Department of Veterans Affairs without any inside help.  Help coming directly or indirectly from government employees charged with investigating, ensuring, and following proper protocols and procedures to protect against theft and fraud.

Angry Grizzly BearLet the US Attorney and VA-OIG special investigators crow about catching the person perpetrating fraud.  Before they break open the champagne, they need to be looking into the leadership that either overtly or covertly allowed this fraud to occur.  The elected officials need to be demanding why fraud opportunities are so rampant at the Department of Veterans Affairs that criminal proceedings are being reported almost every week and asking about the culture of corruption and leadership failures allowing these behaviors to thrive.

Is it a “Culture of Corruption?”

Absolutely; the VA is sick with a culture of corruption!  It is my sad duty to report on another employee who was able to steal from the VA, stealing hydrocodone and oxycodone prescriptions from the VAMC mailroom and mailboxes at some 40 locations in Kerrville, Ingram, and Center Point.

“Scott M. Brown, a pharmacy technician at the Kerrville VA Medical Center in Texas, was charged with one count of theft of US mail for stealing hydrocodone and oxycodone prescriptions from the medical center’s mailroom as well as from residential mailboxes between March and April 2021.”VA 3

Currently, Mr. Brown is being held in custody and remains innocent until proven guilty in a court of law by a jury of his peers.  However, the fact that Mr. Brown has been charged and is in custody speaks volumes to the lax leadership that allowed these prescription thefts to occur.  Where is the VA-OIG in asking how the robbery was possible?  Where are the special investigators demanding answers from the leadership on policies and procedures that an employee could easily violate to obtain these drugs?  Who else was involved, or had to know, what was happening and said nothing?Plato 3

The Department of Veterans Affairs has been overtaken by those without skill, knowledge, and ability to understand cause and effect and properly interrupt the cycles of corruption.  Worse, these same people will bleat about how they need more money for technology solutions when their personal example, leadership failures, and human-to-human relationships are the actual problems.  The leaders will bleat like sheep in a corral about engagement, customer service, and industry buzzwords because they have no substance and even less desire to see things change.Plato 2

Recently I detailed the failures at the Department of Veterans Affairs on information technology.  The fallout from the deplorable designed incompetence in the IT/IS infrastructure at the VHA continues to represent just how incompetent the current leaders genuinely are.

“To promote compatibility with the Department of Defense’s electronic health record system, VA is replacing its aging record system. This requires VA medical facilities to upgrade their physical infrastructure, including electrical and cabling. The OIG determined from its audit that the Veterans Health Administration’s (VHA) cost estimates for these upgrades were not reliable. VHA’s estimates did not fully meet VA standards for being comprehensive, well-documented, accurate, and credible. The audit team projected that VHA’s June and November 2019 cost estimates were potentially underestimated by as much as $1 billion and $2.6 billion, respectively. This was due in part to facility needs not being well-defined early on. The estimates also omitted escalation and cabling upgrade costs and were based on low estimates at the initial operating sites. Because cost estimates support funding requests, there is a risk that funds intended for other medical facility improvements would need to be diverted to cover program shortfalls. The Office of Electronic Health Record Modernization (OEHRM) also did not meet its obligation to report all program costs to Congress in accordance with statutory requirements. Specifically, OEHRM did not include cost estimates for upgrading physical infrastructure in the program’s life cycle cost estimates in congressionally mandated reports. Although VHA provided OEHRM with an approximately $2.7 billion estimate for physical infrastructure upgrade costs in June 2019, OEHRM did not, in turn, include them in life cycle cost estimate reports to Congress as of January 2021. OEHRM stated it did not disclose these estimates because the upgrades were outside OEHRM’s funding responsibility and that they represented costs assumed by VHA facilities for maintenance—including long-standing needs” [emphasis mine].VA 3

Angry Wet Chicken 2Did you catch that; the office specifically tasked with handling estimates intentionally low-balled estimates, did not include all necessary contractual requirements, and then lied to Congress to cover their hides, and fell back upon designed incompetence to skirt blame, responsibility, and accountability when the VA-OIG came investigating.  Lying to Congress is a CRIME!  Yet, these federal employees can break the law with impunity, and all the VA-OIG can do is make recommendations for improvement!  If you want to read the full report of shame, you can find it here.

Leadership is change; management is stagnation and corruption.  When will the VA start hiring leaders to enforce, demand, and execute change to benefit the taxpayer and the veteran community?  Where are the elected officials willing to work with newly hired VA leadership in establishing legal frameworks for evicting employees who refuse to change from the federal workforce?  When can the veteran community and the taxpayer expect to see real and tangible change at the VA?

Knowledge Check!I am not asking these questions and not expecting an answer!  I am asking these questions looking for and expecting real results to begin immediately, if not sooner!  This is a national embarrassment with a global impact, and it is time for the United States to lead in correcting their detestable government workforce!

© 2021 M. Dave Salisbury
All Rights Reserved
The images used herein were obtained in the public domain; this author holds no copyright to the images displayed.

NO MORE BS: Bureaucratic Fiat, a Veteran Suicide – Scrutinizing the Government

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

What is bureaucratic fiat?

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

LinkedIn VA ImageVeteran Suicide!

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

Scrutinizing the Government!

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

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

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

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

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

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

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

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

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

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

© 2021 M. Dave Salisbury
All Rights Reserved
The images used herein were obtained in the public domain; this author holds no copyright to the images displayed.

More VA Insanity – COVID Mask Policy – Denial of Service

I-Care02 March 2021 – Today, I got a secure message from the pulmonologist at the VAMC in Phoenix; he needs me to go to the hospital for a series of tests to understand why I cannot breathe.  Except, when he tried to get me into the hospital, he was told the VA Mask Policy would not be allowed to be “adjusted,” and the administration is the problem.  Worse, the local administration refuses to engage in discussion, refuses to write a cohesive and legal policy, and absolutely continues to deny service to veterans illegally.

I desperately need answers as to why the VA Hospital is allowed to act in this manner.  The denials of service are more than just a mask policy issue where COVID is concerned.  The actions of the Phoenix VAMC since June 2020 extend beyond simple bureaucratese where COVID masking is concerned.  Where are the elected representatives in scrutinizing the Phoenix VAMC?  Where is the media in demanding answers to the abuses being witnessed?  Where are the police in protecting the innocent?

InertiaTo actively work to refuse service, shut down dissenters, and muzzle those who honestly want to help and change the Phoenix VAMC into something worthy of respect and improve the care of the patients who try and obtain healthcare at the facility is atrocious behavior worthy of the harshest condemnation.  My medical chart clearly states I cannot wear a mask, the pulmonologist needing me to receive tests to understand why, is unable to obtain community care due to administrative fiat, and unable to get the VA to stop needlessly harassing, injuring, and arresting me because I cannot safely wear a mask.  All because the administrators would prefer to refuse service, deny care, and then complain that nobody is making their appointments.

2004, I started this journey with the Department of Veterans Affairs (VA); I had spinal problems, I was short of breath, I had neurological issues, and a host of other issues.  Yet, for more than 10-years, the VA refused care after I left the service with injuries because of the Veterans Benefits Administration (VBA) treatment.  As soon as I finally get the VBA to act, the Veterans Health Administration (VHA) begins to act like I am scum that was drug in off the streets.

LookWhat drives me crazy, I have been across the United States and seen the inhumanity of the VA Administration up close and personal too many times to think the problems are limited to only one VISN or another.  I have witnessed veteran patients and dependents worthy of the highest care denied service and then further abused by the VAMC refusing these people’s future care.  I have witnessed VA employees create rules to inconvenience a veteran patient, slow care, and deny service to a patient who had to travel 4-6 hours to the VA.  The VA-Office of Inspector General (VA-OIG) relates more and more abuses by VBA and VHA staff monthly, where accountability is lost, responsibility rarely accepted, and the cycles of abuse continue because nobody in VA leadership will act!

Does anyone understand what this entails?  A patient, not me, with chronic pain and incredible service-connected injuries, is denied the ability to drop off a letter for his primary care provider, and the VA employee who would handle the letter anyway refused to accept the letter unless the letter was mailed.  The veteran drives four-hours to the VA Hospital every time he needs care and he works to maximize his time while at the VA taking care of as much business as possible.  The employee claimed that if the patient left the letter on that employee’s desk, the employee would throw it away.  The VA employee refusing to help a veteran was shortly promoted, moved to a less visible clinic, and the veteran who needed the help still has not received the support he needs.  Even after writing to the hospital administrator, the VISN administrator, and his congressional representative.  Why do I know so much about this case, I witnessed the scene and have been kept abreast of the trouble this veteran is having.

Survived the VAI met a veteran on social media who is in my same boat and cannot physically and safely wear a mask.  He has been actively denied service, even while bleeding, at the ER.  If President Trump had not signed the Community Care Act, which forces the VA to allow patients the VA refuses to see to access community-provided care, both of us would have been much worse than we are today.  Monday (01 March 2021), a nurse from my primary care provider called to relay information. The nurse refused to provide service, refused to answer questions, and then chose to become offended and disconnected the call.  Worse, I still have no idea why the nurse called, the purpose for the call, or what outcome will be derived from the call.  Why; because you cannot directly call your clinic and receive answers.  The phone chain games mean I call the clinic and get routed to a call center, they leave a message for the provider, and possibly within a week, I might obtain an answer from the provider.

Want to reach your clinic directly; send a secure message through the MyHealtheVet portal.  Then wait for an answer that can take as little as 24-hours, or as long as 3-months, if you get a response at all.  I have asked simple questions through both phone and secure messages and received atrocious answers, answers not fit to print, and answers that are a logical pretzel-making no sense but are regarded as “the policy of this hospital.”  A non-veteran I was casually talking to asked, “Why do you use the VA at all?”  The short answer is because if you do not use the VA, the billing nightmare to get the VA to pay for healthcare from military-connected injuries is a bloody nightmare!

VA SealCase in point, 30 June 2020, I checked into an ER for care.  January 2021, I receive a collections notice for the visit.  I called and asked why; apparently, the hospital submitted the statement to TriCare instead of TriWest, causing confusion and denial of service.  But, the VA “due to HIPAA” policies could not speak directly to the hospital, only to me.  I had to call the hospital and inform them of what the VA said.  The hospital’s billing department, the collections agency, and I are stuck between two bureaucracies at the VA, and I have an active collections problem hammering my credit.  These shenanigans are, but a small part of the regular issues all veterans are handed because the VA refuses to do their jobs creates rules and policies at whim to inconvenience, and flat out refuses to do their jobs!

Patients seeking care at the majority of VA Hospitals face no customer care, worse customer service, refusal to honor the job, disrespect of the patients, dependents, and veterans, and worse service for active personnel.  I have seen the VA’s actions, and I refuse to stay quiet about the illegal behavior, unethical actions, and the immoral treatment of veterans, active service members, and the qualified dependents seeking care and finding crass bureaucratic red tape.  There is no reason for this abuse of the patient, except as previously mentioned, the VA Hospitals can “get away” with bad behavior where non-government hospitals cannot.

Where do we go from here?

DetectiveWith the government being less than enthused with ending the COVID-Farce, with the media refusing to recognize a problem and assist in advocating for a reprieve, and with the elected officials failing to scrutinize the workings of the executive branch’s operations properly, I am not sure of the proper answer to this question.  Insanity, according to Einstein, is doing the same things over and over, expecting different results.  The paradigm of government-provided healthcare is a pernicious fraud and desperately needs to be corrected.  But the answer is more than simple bureaucratic inertia found in many other government agencies.  The VA has built a special case for itself, and the solution will necessarily require new approaches and new thinking.

The belief that government is good for anything but injuring others remains an idea that needs to spread far and wide in an effort to reduce the harm caused by the government.  The American people require a higher return on their investment in the government through forced taxation.  Yet, the administers of government and the elected representatives hired to scrutinize the government fail to act, believe the bureaucrats over the citizen, and are part of the problem.

Fishbone DiagramRoot cause analysis points to inertia as being a prime candidate in the failures experienced and witnessed.  Inertia is a comfortable blanket to wrap yourself in when change is supposed to occur, but change scares you.  The hospital administrators refused to act because that would require a spine and written records scare the hospital administrators; especially those in Phoenix after two dead veterans’ scandals where responsibility pointed to people who possessed written records.  Hence, besides inertia is the fear of being held accountable because the written records exist.  Yet, because policies, directives, and processes are not being written down, behavior can worsen where the veteran patient is abused, and there is nothing that can be pointed to claiming the actions taken were inappropriate.

Detective 3Logic claims that if the VA denies service to a class of veteran patients, then another option for receiving care should automatically open.  However, the lack of written policies and the inertia of the employees causes the veteran patient a nightmarish cycle of needing care but not being able to access care.  Because the employees are following spineless leaders and inertia is better than sticking one’s neck out and acting differently from the pack.  Thus, plotting a path forward requires leadership and a willingness to document, change, and adapt, all of which appear anathema to the VA generally and the Phoenix VAMC particularly.

The VA-OIG just recently finished an audit of community care claims being handled by 3rd party contractors.  The results are fairly typical of the VHA and VBA using designed incompetence.

“The OIG audit found that inadequate contract terms and VA’s lack of effective oversight contributed to claims processing inconsistencies and errors. The VA’s contract did not include standardized criteria for contractor employees to use when distributing and processing claims. Furthermore, the contract did not require contractor employees to follow VA’s Office of Community Care (OCC) claims-processing guidance. Although the contractor cannot be faulted for acting inconsistently with OCC guidance not required in its contract, the resulting inconsistencies mean VA lacks assurances that proper processes were used. VA also did not have an official quality reporting mechanism in place before February 2019.”

The VA-OIG report quoted above discussed how 13% of the claims were handled inappropriately, causing veterans’ problems and delays in processing for providers.  In Albuquerque, NM., I saw this firsthand.  The VA sent me to a community provider; the community provider filed all the proper paperwork and kept gathering more paperwork for the next three years.  Finally, when all the red tape was satisfied, ¾’s of the bills were too old to receive payment.  That provider went bankrupt trying to provide services to veterans because he could not get paid in a timely manner.  I was there for the full and abysmal treatment of this provider by the VA.

Detective 4The designed incompetence is galling and getting worse.  The VBA is the portion of the VA that makes claims decisions.  Recently the VA-OIG investigated the VBA specifically to check consistency to comply with skills certification for compensation and pension claims processors.  The results are a horror story of designed incompetence, failure to do the job, and trainers’ failure to train properly.  Of the 10,800 claims processors required to certify their jobs, 4700 were never tested from 2016-2019.  Of the 2,500 who failed the certification test, 1,900 did not have any repercussions, training plans, identified corrective action, or employer counseling.  Worse, the VBA failed to take any personnel actions on 98% of the population surveyed (10,800).  2018, as in the entire fiscal year of 2018, the certification tests were unavailable due to technical issues on the VBA’s intranet.  Meaning that effectiveness in 2019 to measure and certify was virtually useless!  Does anyone wonder why veterans are refusing to trust the VBA and the VHA?  Is the problem clearer that congressionally elected officials’ failures to scrutinize the government influence the employees’ behaviors for the worst?  How many claims have been improperly decided, wasting taxpayer time and money and the veteran’s time and money since 2016 by failing to certify to fill the roles and duties the American Taxpayer is paying them to fulfill?

Wasting TimeIt is imperative for profound and fundamental organizational change at the Department of Veterans Affairs to begin as soon as practical.  Worse, scratch the surface of any other government agency on the Federal or State level, and the same problems arise.  The same abuse of taxpayers, the same refusal to do the jobs hired to perform, and extensive cultures of inert slugs just punching time and wasting money until they can retire!

© 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.

VISN 22 – The Bureaucrats Operationally Living as Petty Tyrants

Survived the VA23 February 2021:  UPS delivered a letter package containing a single sheet of paper from Dr. Karen MacKichan MD, auto signed, and dated 09 February 2021.  Declaring that the Phoenix VA is absolutely correct in behaving as petty tyrants and denying me medical care, illegally sharing and knowing my HIPAA information with VA Police Officers, breaking EMTALA, and treating me to injuries, all because I cannot safely wear a mask.  My only infraction at the Phoenix VA is not to wear a mask.  Yet, this is considered a “behavioral problem,” and I am wrong for behaving in a manner that insists that my safety comes first!

From June 2020 to date, the charge has been, “Wear a mask or a face shield to receive service in the VA.”  Then, I got arrested while wearing a face shield and told my failure to wear a mask is “disruptive behavior.”  Seriously, not wearing a mask somehow disrupts the entire hospital and keeps it from running efficiently.  Refusing to believe the letter my VA provided Primary Care Provider wrote (August 2020) for my employer regarding my inability to breathe while wearing a mask.  The VA Police have continued to escalate situations to reflect “disruptive behavior patterns.”  Yet, I am the one punished, and I am the one injured; I am the one being denied care.

Literary FiendWhat are petty tyrants?

James Abyad quoted the Urban Dictionary for the definition of petty, which exactly expresses the sentiment of petty.  Urban Dictionary defines petty as “making things, events, or actions normal people dismiss as trivial or insignificant into excuses to be upset, uncooperative, childish, or stubborn.”  It further defines it as “a person who is purposefully childish with the intent of eliciting a reaction,” or “someone who does something in an attempt to hurt another person but makes themselves look stupid.”  Tyrant is a cruel and oppressive ruler, per Webster.  Hence, a Petty Tyrant is a childish, insignificant, oppressive ruler.

Well, Dr. MacKichan, Deputy Chief Medical Officer VISN 22, 300 Oceangate, Suite 700, Long Beach, California, 90802, you are incorrect!  I have followed all written VA directives. Do not assume that it is my fault the Phoenix VAMC leadership cannot write down a COVID Mask Directive and operational policy that supports all veteran health contingencies.  Then train the staff coherently upon written guidelines and directives, and engage in an honest and forthright manner with veterans seeking care.  Where are the written directives governing COVID Mask Wearing?  You claimed to have reviewed all the information; I have asked for these documents and been pointed to a sign.

VA SealOn the topic of written directives, written operational policies, written patient guidelines, and written job descriptions and duties, let’s talk about how the VA Police can injure people and not be held accountable!  The VA Police attacked me on 07 December 2020, violently pushed, then spun into a wall.  My C-and L-Spines did not move, and my T-Spine turned; I dropped like a rock sustaining spinal injuries, knee injuries, and got cut on my right hand and arm.  Worse, being handcuffed with my arms behind my back caused bruised wrists that were jerked by more VA Police officers on 10 December when I sought medical attention.  I am an 80% disabled person with mobility issues, yet your letter claims all the action of the Phoenix VAMC was in accordance with written policies, guidelines, and directives.  Well, I possess a Missouri mindset, “Show ME!”  Show me the written and published policies, guidelines, and procedures that allow VA Police Officers to physically assault patients!  Show me the written and published policies, guidelines, and procedures that allow me to be refused treatment.  Prove through written and accessible documents how the decision for this hodgepodge of ineptitude can label me a “behavioral issue” when my only discretion is not physically and safely wearing a mask!

The Duty of AmericansYou claim to have reviewed the actions of the police officers who routinely have medically protected HIPAA information about people being arrested, joke about this information, act in a manner that brings shame to all Federal Police Officers.  What happens to these unprofessional officers and their despicable commander?  When do my rights to have my HIPAA-protected information withheld from parties who do not need this information?  When do all the other veterans being served and not being served by the Phoenix VAMC become protected under HIPAA?  I am not the only veteran being refused service, denied care, and abused and injured by the VA Police for not wearing a mask, while also not being a “behavioral issue.”

Since your letter proclaims loudly that your review was thorough, independent, and comprehensive, and as the VISN 22 Chief Medical Officer, surely you cannot condone illegal activities being masked by calling a patient a “behavioral issue.”  The Emergency Medical Treatment and Labor Act (EMTALA; 1986), a federal law, requires anyone coming to an emergency department to be stabilized and treated, regardless of their insurance status or ability to pay.  EMTALA was regularly abused at the Albuquerque VAMC, and I reported this issue multiple times. EMTALA’s abuse and illegal activity at the Phoenix, VA Medical Center are worse, and I have reported this issue multiple times.  Twice I have followed my primary care provider’s instructions to report to the VA ER for treatment, and twice I have been refused service.  Thus, what is to be done to correct this obvious deficiency in VISN 22 treatment of veterans, service members, and dependents by VISN 22 emergency medical care providers and the staff, including the VA Police, who should have no influence upon care being received or who should receive care?

Theres moreYour letter discusses “the most effective manner to have the behavioral flag lifted” as “checking-in with the VA Phoenix Police.”  Do you know what that entails?  Did your “thorough, comprehensive, and independent” investigation uncover what happens at this “check-in?”  I was told clearly what happens; I will be evaluated for wearing a mask, found not wearing a mask, arrested, cited, and denied service for not wearing a mask.  Then, I will have a black mark on my behavioral flag record for disorderly conduct!  I am not disorderly in my behavior because I cannot safely wear a mask!  What part of this do you, as a medical doctor, fail to comprehend?

I had my gallbladder removed in a Phoenix hospital (Sept 2020), never had a problem not wearing a mask.  I have had MRIs completed (Aug 2020), never had to wear a mask.  I have been seen three times in an emergency room and never had to wear a mask (Jun 2020, Sept 2020, Jan 2021).  The only medical service provider demanding through compulsion and fear that I wear a mask, which would place my health at risk, is the Phoenix VAMC.  Yet, you as a medical doctor cannot understand this issue, the problems with unwritten policies and directives, leadership failures to train staff properly, and you allow petty authoritarians wearing VA Police Badges to enforce a reign of terror at the VAMC in Phoenix.  Hence, you are part of the problem in failed leadership, poor management, and detestable petty authoritarianism!

InertiaI always interact with the staff at VAMC’s, even when they are wrong, in a respectful manner, knowing that the problems of dumb policies, time-wasting procedures, and bureaucratic inertia are the fault of the leaders hiding in their offices and cubicles.  I have been interacting with the VAMC’s across America, and the inept staff, since I left the service in 2004!  Never having a problem, never having an issue, and never getting injured by or even interacting with VA Police.  This all changed in June 2020.  The VAMC refused to write down a comprehensive directive for COVID Patient Mask Wearing.  I get blamed for following the unwritten policy and directives, then falsely accused of being “disorderly” in my behavior, then falsely accused, again, for being a “behavioral issue!”  I am not in the wrong here!  I am not a “behavior issue!”  I am not disrupting hospital operations, placing other patients at risk, or being violent!  Where are my rights in this farrago and railroading scheme?

Image - Eagle & FlagYour boilerplate response indicates this issue has reached the final point.  I beg to differ!  I will have my name cleared of these false charges.  I will not be blamed for the ineptitude of the leadership at the Phoenix VAMC and VISN 22!  I will not be silent and meek in the corner because you cannot tell the difference between standing for one’s rights against tyranny and compulsion and oppression through bureaucratic fiat!  I have done nothing worthy of these fallacious claims, false accusations, and the Phoenix VAMC and VISN 22 will admit this publicly when I am done cleaning my name of the scum you have thrown upon it!  Make no mistake; I am not angry, but I will have my rights restored, my name clear, and satisfaction from the injuries and treatment I have been made to suffer!

© 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.

Appeal Letter – DBC Decision

Please note, this letter is both an appeal and a summary of everything that has happened at the Carl T. Hayden VAHCS since March 2020.  This is probably the longest letter I have ever written.

Dr. B. Vela MD
Interim Chief of Staff
Phoenix VA Healthcare System
650 East Indian School Rd
Phoenix, AZ 85012

Director Michael W. Fisher
VA Desert Pacific Healthcare Network
300 Oceangate, Suite 700
Long Beach, CA 90802

02 January 2021

Dr. M. Dave Salisbury PhD.
10002 N 7th St
APT 1125
Phoenix, AZ 85020

RE: Appeal of DBC Decision 11 December 2020.

Greetings Dr. Vela and Mr. Fisher,

On 02 Jan 2021, I signed for and received a certified letter postmarked 21 Dec 2020, dated 11 Dec 2020.  Why all the delays?  If I have 30-days from the day the letter is dated, why did the VA steal 10-days?  The letter originates from the Disruptive Behavior Committee (DBC), which claims I have been warned of causing disruptive behavior at the Carl T. Hayden VA Hospital in Phoenix, AZ.  The letter received claims,

“On December 09, 2020, a member of our DBC contacted you by phone to discuss these concerns, provide behavioral expectations while in the medical center, and to remind you of the importance of maintaining a safe and respectful environment of care.”

I received a call from Nurse Crawford on or about 09 December 2020, who listened politely to the problem and said nothing else.  The conversation was useless as the nurse relayed nothing but platitudes, agreed that I have the right to be safe in the medical center, and then harped about the COVID Mask policy.  No intention, no motivation to aid or support, no opportunities for progress, no ability to come to a solution, nothing.  I got off this call, and my wife, who has heard my entire side, asked, “Did that call solve anything?”  No, that call solved nothing, provided no information, and wasted everyone’s time!

11 December 2020, Dr. Moore, the chair of the DBC Committee, calls me complaining of my disruptive behavior, declaring that while I have a right to be safe in the hospital, I must wear a mask, and now suffer under the onerous DBC committee rules to enter and exit the VA Hospital because of a pattern of non-compliance witnessed as behavioral issues.  Dr. Moore indicated that I have the right to be safe.  I have the expectation of being treated professionally, but since there is a pattern of “disruptive behavior,” my rights have been canceled, and I now must obey DBC requirements.

In plain speak, I am in the wrong for insisting that I cannot safely wear a COVID mask, and the policy problems and leadership issues at the VA are all my fault.  I am being blamed for the VA Police being tyrannical and obscene in their actions of discrimination against those who cannot physically and safely wear a mask.  The VA Hospital in Phoenix is closed to me until I comply with wearing a mask, which I cannot physically and safely perform.

Using Dr. Moore’s and Nurse Crawford’s logic and the Phoenix VA Health Care System (Paragraph 1 of the DBC Letter), let us see if I understand the problem because, frankly, I have no clue.

“The Phoenix VA Health Care System [VAHCS] is committed to providing an environment where everyone feels safe and respected.  Our goal is to provide exceptional care that improves the health and well-being of our veterans.  We also work diligently to maintain a safe environment for staff, veterans, and visitors to our facility.”

If I, as the patient, have the ability and right to be safe from harassment, HIPAA violations, and respect, but cannot physically wear a mask, I have no right to service at the VA Hospital.  But, if somehow, I can wear a mask, I am not harassed, denigrated, derided, and injured by federal employees; however, my HIPAA and legal rights under EMTALA remain in doubt.  Do I interpret this statement correctly from the point of view of the employees of the VAHCS?  Because this is precisely the problem, I cannot wear a mask safely or without causing additional harm to myself, and my first obligation in the PACT team is to protect what health I still have.

I cannot physically wear a mask.  I have a letter from my VAHCS Primary Care Provider for my employer to establish workplace accommodations where I do not have to wear a mask.  Yet, this same letter is insufficient for the VA Employees who keep refusing me access to the ED, refusing to honor appointments, refusing to schedule appointments, causing a scene by crying to the VA Police when I do not immediately comply with their mandates to wear a mask, and all because I cannot safely wear a mask.

30 June 2020, I was refused service at the VA ER because I cannot wear a mask due to breathing issues.  Before entering, in the courtyard where the COVID screening was occurring outside in Phoenix Summer night heat, I was informed that I could hold the mask in front of my face, and this is an acceptable workaround or wear a face shield.  There were no face shields available at this person’s station, and I was informed to ask inside at the ER check-in for a face shield.  Upon entering the ER to be checked in, the office staff refused the information provided at the entrance and said, “If the mask is not worn, we are refusing service.”  I have had shortness of breath, not lung-related, for many years now, which continues to worsen, and I cannot safely wear a mask.  This information is noted in my VA Medical records.  I have been through several rounds of breathing tests, which confirm my lungs work great. Still, I remain short of breath, dizzy, unstable when walking.  When wearing any mask, my breathing problems increase and include lightheadedness and nausea, until eventually, my vision grays, and I pass out.  The original problem was diagnosed at the Salt Lake City VA Medical Center (2010/2011).

I stumbled to my vehicle, at which point I am shortly surrounded by VA Police Officers who claim they were called because a patient was disruptive in the ER.  I was not disruptive in the ER.  When I saw the intransigence of the ER Staff and was refused service, I walked out!  No screaming, no swearing, no throwing furniture, no issues.  I did not have sufficient breath to walk, let alone commit the atrocities I was accused of, and yet, this is supposedly the first incident in a “pattern of disruptive behavior.”  It appears to me the VA Employees breaking the law (EMTALA) needed a reason, so they created a handy excuse and blamed the patient!

08 July 2020, I walked into the VA through the south entrance, not wearing a mask, and those performing the COVID check did not offer a mask, offer a face shield, or say anything.  I walked to the ER; the admitting person did not mention my need for a mask, nor did they ask why I was not wearing a mask; I was checked in to be seen in the ER.  Shortly, I was triaged, and the triage nurse did not say anything about a mask.  I sat in the ER for 3-hours, and none of the medical staff, hospital staff, employees, or Federal Officers walking past ever mention the need for a mask.  I sat away from other people to avoid having any problems.

At the 3-hour mark, I told the ER staff I must get food, and I walked to the Patriot Store feeling sick because of diabetes, pain, and nerve issues, needing food.  On my way, an employee whines about me not wearing a mask, and I ignore this person as my medical information is private, and I should not have to explain to every nosy-nelly about why I am not wearing a mask.  I complete my purchases and suddenly, the VA Police, who were called by the unknown VA Employee, are there insisting I need to wear a mask.  The nosy employee stood around, crowing about how he was available if the police needed more information.  For the first of at least 40-times, I explain that I cannot physically wear a mask to protect my health and safety.  No swearing, no disruptive behavior, I cannot wear a mask, and I was on my way back to the ER to wait to be seen.

I am met in the ER by Officer LT. Hicks and a plainclothes officer claiming to be a LT.  At which point, I begin again to explain that I cannot wear a mask.  I was not causing a scene before this; I was not causing a scene after this; however, when 8-10 VA Police Officers surround a person, a scene is created, and it is not the patient’s fault that a disruptive scene has commenced.  I was not screaming; I was not swearing; I was not disruptive as this 40+ minute harassment began.  In the end, I will admit fully, my cherub-like demeanor had evaporated, and swearing did occur.  When you spend 40+ minutes saying the same thing over and over to no effect, my aggravation level went up.  I contend the scene was started, provoked, antagonized, aggravated, irritated, and exasperated by the Federal Police Officers who more than once accused me of “Blowing rainbows up their butts,” lying about my breathing problems, and riling the situation.  The officers accused me of lying about my medical records, medical problems, and reasons for not wearing a mask.  Let me repeat when this scene began with LT. Hicks, I was told I needed to either wear a mask or a face shield.  Nobody in the ER had a face shield, and when I was handed a face shield and put the face shield on, the officers continued to harass, torment, and rile the situation.  I complied, they changed the “policy,” and I got arrested and cited.

I do not have the breath to be hostile!  Because of the nerve issues I have and diabetes still needing food, I do not have the strength to be disruptive.  I do not have the breath to be hollering and screaming!  I do fully admit that the tinnitus I suffer from has me speaking louder than many other people, especially as my breathing worsens.  I gasp out words and do not care about polite volume, and I need to be left alone during these episodes to catch my breath and calm the nerves.  But this incident on 08 July is the epitome of VA Police Officers aggravating a problem when they could have simply left well enough alone as I was NOT breaking any rules, policies, or committing a crime on Federal Property.  If a policy is not written down, it is not a policy, and it is not enforceable.  Had the VA Officers ended the scene when I put the face shield on, there would not have been another problem, and I would have been seen in the ER for my medical issues.

15 October 2020, I reported to the Federal Courthouse without a mask and had my fines adjudicated from the 08 Jul incident. I paid $80 for “disorderly conduct” when I wasn’t disorderly, I paid $10.00 in parking fees.  The person deciding my case said, “If I have trouble entering the building in the future, I need to ask the volunteers doing the COVID screening to call their supervisor, who will then shepherd me around the VA.”  I was assured three times that there is a procedure to deliver healthcare services to the veterans who cannot physically wear a mask.  The person handling my case claimed they would take care of the other ticket received from the 08 July incident and introduced themselves as a Lieutenant of the VA Police Force.

21 October 2020, I arrive at the south entrance to the Phoenix VA from the parking garage.  I am confronted by a hysterical employee, claiming they were a supervisor, demanding I wear a mask at the COVID screening desk.  I followed the instructions from 15 October and asked for a supervisor.  The employee then requires I wait “outside the VA Hospital for privacy reasons.”  When I asked why, and for specifics, the employee becomes more hysterical, calls the VA Police instead of answering questions, and erroneously claims I am causing a disturbance.  The supervisor arrives, negates what was told me on the 15th of October, and claims that wearing masks is a policy, then demands that mask-wearing is not a policy but a directive. When I asked for a copy of the policy, directive, guideline, etc., I was pointed to a sign.  I asked for the supervisor’s supervisor, called this person for assistance, and the VA Police interrupt my call and demand I finish my business off VA Property and then shadow me off VA Property, meaning I cannot return for 24-hours.  I had around 10-VA Police Officers attempting to intimidate me, again, because I asked questions and insisted upon logical answers that the VA employees refused to deliver.  No swearing, no screaming, no disruptive behavior of any kind, and I was outside the VA Hospital the whole time.  The traffic and witnesses were displaced for the VA Police Officers, not because of me.

The VA Police do not have a copy of the mask policy, directive, guideline, etc., to pass out to people who ask for one.  The supervisor does not have a copy or document with the mask policy clearly spelled out, except to point to a sign demanding obeisance.  Yet, the person needing VA medical or other assistance is expected to blindly follow an unwritten “policy” that continues to shift from draconian to obscene and back again on the bureaucrat executing policy’s whims.  This is immoral, unethical, and illegal, plus it makes the VA the laughingstock of every other hospital and care facility.

While I was able to speak to the supervisor’s supervisor, Jennifer Russoniello, and discuss the most recent incident and conduct some of the business I went to the VA Hospital for; I remain not pleased.  The failure to access the VA to obtain the medication needed is directly contributory to my ER visit on the 28th of October.  The continued confusion at the VA sees patients being refused service if they cannot wear a mask, at the expense of the patient’s health.  It is important to note that the director possesses statutory authority to accommodate Washington D.C.’s policies for the local hospitals’ operation and patient safety.  Yet, the director continues to fail to execute leadership, demonstrate a concern for patient safety, or even clarify operational guidelines, policies, procedures, or work standards by writing them down and training the staff on how to enforce policy properly and legally.

Important to note, Jennifer Russoniello affirmed what the supervisor claimed, there is no written policy regarding COVD masking at the Carl T. Hayden VAHCS.  A memo was received directing the mask “policy.”  She further elaborated that because the COVID situation changes dramatically from day-to-day, and the CDC mandates change from hour-to-hour, the Carl T. Hayden Hospital Leadership had tasked her to help draft an acceptable policy that would benefit all veterans.  She then asked if she could use my story as support for preparing a cohesive policy, to which I agreed.

When Jennifer and I finished our conversation at the Wendy’s across the street from the Phoenix VAHCS, it was agreed that if I held a mask close to my face, it would be acceptable, and I could be seen at the Phoenix VAHCS.  I was told to keep the mask near my face anytime I was within 6’ of other people, and I could drop the mask when not talking or interacting with people.

28 October 2020, I wake up in a crisis, I have to get medication that has not arrived, and my body is in trouble.  Using the information from Jennifer Russoniello, my wife called the Phoenix VAHCS to alert Jennifer, and I was headed to the hospital ER.  Jennifer called me back, and I was unable to speak to her due to my nerve condition.  I arrived at the VA, held my mask to my face, went to the ER, and was treated without a problem.  No police harassment, no issues, nothing.

04 and 07 December 2020, I receive two text messages from the VA regarding my upcoming appointment.  I called the Radiology Department at the Phoenix VA specifically because I cannot physically wear a mask and wanted to make sure that I had waited four months to obtain this appointment and would not have any difficulties completing it.  The VA previously has refused service by providers because I cannot physically wear a mask; canceled only after I had traveled to the VA, waited in the waiting room, only to be told by the provider to go home or wear a mask.  Thus, I wanted to ensure this would not be the case with this MRI.

After five phone transfers, I finally spoke to Scott, who identified himself as the Radiology Supervisor.  I explained my predicament, explained who he could call to discuss the problem, and called him a second time to provide the name of the person I have been working with a Jennifer Russoniello, along with her extension.  Later that afternoon, Jennifer Russoniello returned my call and assured me all was in order.  The workaround we worked out was for me to hold a mask in front of my mouth and nose.  That way, the mask is not causing breathing difficulties, and I am then in compliance with the mask mandates.  This arrangement had worked previously during an Emergency Room (28 October 2020) visit; thus, I kept my appointment.

For the MRI, I was ordered no food or drink 4-6 hours before the appointment.  Two-hours was the scheduled time to be on the MRI table.  I planned my day, including my medications, food, and drink, around returning home quickly and relaxing.  Because history has proved that an MRI leaves me weak, hurt, and highly nerve sensitive, along with the usual sore muscles and other issues.

I arrived for my appointment, cleared the useless “COVID Screening” at the south entrance to the Phoenix VA, and proceed to Radiology.  At Radiology, I meet a supervisor (Paul?) who was to escort me around the hospital to ensure I did not get hassled by the VA Police, per Jennifer Russoniello.  I checked into Radiology.  When my name is called, I am met at the traffic control door by Scott, the Radiology supervisor, and an MRI Technician.  Scott refuses to allow me entrance because I am not physically wearing my mask.  I explain I cannot physically wear a mask; I walk with a cane, so one hand is full, and the other was full of cellphone, MRI paperwork, glasses, and floppy cloth mask.  I held the mask up to my face and claimed this is the best I can do to follow the “COVID Policy.”  Then asked if the MRI appointment was still on or not, repeated 5-different times.  Scott visibly has confusion written all over his face and cannot or will not decide.  No swearing, no disruptive behavior, no loud talking, and still the supervisor who had already spoken to Jennifer Russoniello about my mask problems is refusing service at the VA because of the mask mandate.  I am doing nothing wrong, nothing illegal, and nothing that could be classified as disruptive.  That other patients laugh as they observe Scott’s unprofessional behavior is not my problem; I did not laugh, I did not swear, I did not raise my voice, and did not cause a problem.  I simply stated my mask issue and asked if the MRI was going to occur.

After the sixth question regarding the MRI being canceled or not, the MRI tech turns slightly to Scott and says, “Why don’t we just do the MRI?”  At which point, Scott clears the door, and the process of changing clothes, answering pre-MRI questions and waiting for a room to open begins.  I walk to the MRI room without a mask, without problems, and without further questions about my mask-less face.  I suffer through the MRI.  After the MRI, I am told that “To get back to the dressing room, you have to be masked,” and I am offered a washcloth to hold close to my face.  I follow this request to the best of my ability while walking/staggering down an empty hallway, physically weak and exhausted from the MRI, the pain, the exertion, and the lack of food.

My trip to the dressing room is vital for two reasons: 1) I kept losing my leg strength, which is normal after MRI’s but coupled with the lack of food, and I am in trouble if I cannot get food soon.  2) Nothing else is said about my not wearing a mask.  I exit the dressing room, walk out through the traffic control door, and spot two VA Police Officers looking like they are involved in a long discussion with Peter, the supervisor dispatched from Jennifer Russoniello, to help me navigate the bureaucrats at the Phoenix VA.

I walk out, headed for the elevator, and the two VA Police Officers start calling my name.  I intend to go home!  Yet, the VA Police are delaying this because I cannot physically wear a mask.  Officer Interpreter places himself directly into my path, shouting about my need to wear a mask; when I politely try to sidestep him, he pushes back, physically pushing me backward.  The second officer is a Sgt. I think his name tag read “HUFF,” I am not sure, but calling him Sgt. Huff is acceptable, places himself beside Officer Interpreter, blocking my immediate path to the elevators.  Please note, I do not have the breath to be disruptive, scream, holler, rant, rave, or cause a scene.  I physically do not have the strength to argue or to carry on.  I have to get food immediately, or I will be unable to drive.  I attempt to explain all this to the VA Police Officers. Whose only reply is delivered in raised voices with great hostility, “We are not here to debate you,” “We are NOT here to discuss this with you; put a mask on!” and, “If you do not put a mask on immediately, we will arrest you on a felony.”  When I asked for the specific felony the officers are accusing me of, they redirect the conversation because they know they are on shaky and illegitimate legal grounds.

For the next 10-minutes or so, these two officers will yell, threaten, cajole, attempt to intimidate, and eventually will choose to place me in handcuffs, threatening me with felonious charges unspecified.  When Officer Interpreter finally decided to act and arrest me, he ordered me to turn around.  Not being able to turn around and knowing that Sgt. Huff was already behind me, I would not move.  I had previously almost collapsed during these officer’s tirades, more than once, and any movement at this point would be hazardous to my remaining upright and safe; my legs are shaking and weak already from the MRI.  But Officer Interpreter refuses to listen to any explanation on my part.  At this point, without knowing the extent of my injuries, Officer Interpreter places two hands upon me, thumbs in the armpits, mid-top of the biceps, and attempts to spin me to the left, towards the wall, in a standard police maneuver seen on every police show Hollywood produces.  After which, my legs collapsed!  My Thoracic Spine turned to the left, while my Lumbar and Cervical Spine remained stationary.  I hit the floor hard, cutting two fingers in four places, and I begin bleeding like mad!  I also scratched my right arm in two places while falling. I did not realize until showering the next day; neither scratch is deep enough to need medical attention, but they are all apparent injuries sustained when violently attacked by Officer Interpreter.

Officer Interpreter then tells me, “You collapsed on purpose; your injuries are faked.”  The supposedly superior officer, Sgt. Huff quickly picks up this mantra.  This attack (07 Dec 2020) has left me with increased pain in both knees, cramps in the L-Spine, a feeling of disconnection between my T- and L-Spines, and my cut fingers just keep bleeding.  Sitting and standing are more painful, and I have less stamina for sitting, standing, walking, and more problems breathing.  Every time the officers handled me and collapsed my legs, shots of pain went through my body; I can only guess I screamed out.  That generally happens when someone who is already suffering from chronic pain suffers more pain; check my medical records, and you see, I typically live in the land of 6 and 7 pain levels.  No swearing: I worked very hard during this incident to maintain a sense of professionalism even in my weakened state.  I fully admit my cherub-like demeanor evaporated when I got pushed, but I worked hard to control my tongue.

Collapsing my legs on 07 December 2020, like every time the VA Police have manhandled me, ignites a pain and nerve storm inside my body.  I jerk, spasm, twitch, stutter, eventually lose my ability to speak, and involuntary movements explode out my arms, legs, neck/head, hands, and feet.  My breathing problems intensify.  I try explaining this to the officers every time, and every time I am insulted, denigrated, accused of faking the injuries, and causing a disturbance to cover their ineptitude and unprofessionalism.  In Holding Cell 1, as Officer Huff is removing one handcuff, my arm spasms involuntarily, and he complains I am trying to hit him.  False accusations abound in this sordid saga!

My safety is placed at risk when I wear a mask, yet the VA is the only medical facility in the Phoenix Metro area with a problem of me not wearing a mask.  I have had MRIs, consultations, a gall bladder surgery, which involved a full day in the ER, then two days in hospital, all without a mask.  Thus, even though the first, and allegedly, most important SAIL Matrix is Safety, as in the patient’s safety, I am discriminated against because I cannot wear a mask. The Phoenix VA leaders cannot sufficiently establish policies and guidelines to protect my safety.

Once standing, with officer assistance, I was placed in a wheelchair where I struggled to breathe.  Sitting in a wheelchair is hard for me because I cannot straighten out enough to breathe fully.  My fight or flight response goes haywire when the nerve issues begin and does not conclude for days afterward.  Yet, on top of all my other cautionary statements about handling me and not inflicting more pain, the officers insisted I sit in a wheelchair.  Worse, the officers felt it was needed to handcuff me with my arms behind my back while sitting in a wheelchair.  My back is in immense pain every time it is touched.  Yet, the officers continued to think it was acceptable to handcuff me, behind my back, where the cuffs, the bracelets around my wrists, are digging into my spine.  Every time we hit a bump, more pain shoots through my already injured and highly nerve sensitive body!  Sitting in a wheelchair, with my hands cuffed behind my back forces me to sit hunched over, making breathing even more difficult.  Where are my rights to patient safety in the VA Hospital?

The Federal VA Police officers repeatedly informed me, “You are doing this intentionally,” “Stop making a scene, you are not in that much pain,” and “You cannot be injured that badly.”  Let me be clear; the officers started this confrontation by not allowing me to go home!  My appointment was at the end of the day, so there were significantly empty hallways when I was scheduled to leave, meaning that I would not be disturbing people by not wearing a mask.  Then they compounded their errors by directly laying their hands upon me.  These two officers, and the officers from July, both felt they could violently lay hands upon a patient who is not being violent, are not acting irrationally, and this is WRONG!  If the patient is not acting in a manner that causes harm or injury to themselves, other patients, threatening the VA Police Officers, or damaging the VA physical facility, the policy should be HANDS OFF!

10 December 2020, south entrance to the VA Hospital, I approach the VA to file a complaint about the treatment received on the 08th of December and visit the ER.  I am stopped by the same overzealous supervisor from 21 October 2020, at the COVID screening station between the two entrance/exit doors.  I explain I cannot wear a mask when asked to wear a mask, and before the COVID screener can reply, the supervisor demands I stand out of the way, and he acts in a hostile and combative manner.  I followed directions; I stand out of the way while he goes further away to obtain instructions about me; supposedly, I was on some warning list.  With more apparent and palpable glee and hostility, the supervisor returns, informing me Jennifer Russoniello is coming to speak to me; she never arrived.  At this point, the supervisor demands I leave the hospital entrance, claiming I am blocking the path of traffic; yet, it is raining outside, I am out of traffic, and not causing a scene.  When the supervisor becomes more agitated and hostile, he calls the VA Police to have me removed.  The VA Police officer signals to leave me alone while I wait and the supervisor returns to his post.  Not 2-minutes later, another officer arrives, and the supervisor tells the arriving officer I am disturbing traffic and not following his commands.

Yet, except for my inability to wear a mask and stand in the rain, I have followed his commands; I am not disrupting the inbound or outbound traffic, I am standing out of the way, and I am silently waiting.  Soon a LT arrives, I didn’t get his name.  I got his attitude, antagonism, malevolence, and malice, but never witnessed his professionalism or ability to listen.  The LT, along with a SGT. and several other officers, proceed to block the doors so nobody can get in or out of the VA and proceed to blame me for blocking traffic.  I was not blocking traffic; I was not causing a scene. I was not disturbing anyone.  The VA Police officers did all these things.

I explain why I am there.  I explain I cannot wear a mask; I explain without swearing, screaming, or disrupting anyone I am waiting and trying to get to the ER.  The LT and the SGT then decide it is time to arrest me.  They grab my arms and jerk at the wrists to get my arms behind my back.  My wrists are still visibly bruised from the 07th of December incident, and I scream in pain.  To which they claim I am “faking my injuries,” then declaring, “If my wrists were really injured, there would be bandages on them,” among other derogatory comments.  My nerves kick-off and my pain jumps to 15, as I am manhandled into a wheelchair, from which I cannot breathe properly, and then taken through the rain to Holding Cell 2.  Is this clear? I am bodily removed from the VA, injured, arrested, and all this after spending two days flat on my back due to pain from the 07th of December arrest and injuries.  Under EMTALA, the Federal Emergency medicine law, this is illegal.  As a patient with rights, whose primary job is to look after my safety, I am left amazed at the treatment I keep receiving.

Every curb hit, every bump hit, every single expansion line in the sidewalks hit, my pain spikes, and I holler out in agony.  Yet, every time I mention this, I am told to shut up, stop acting, stop faking, and that I deserve the trouble I am receiving at the VA Police’s hands.  But the irony of the entire saga of illegal actions, immoral treatment, and unethical behavior from the VA Police and immature VA Federal employees is encapsulated in being reported to the DBC for behavioral issues.

I have not been disruptive.  I have not exhibited behavioral problems worthy of this charge and action by the VA Police or the DBC.  I have in no way broken any law or refused any reasonable demand.  I have been seen at the Phoenix VA historically two other times, and never a problem.  I have been seen at various other VA facilities across the continental United States and never had a problem with the Federal VA Police, anywhere.  The VA at a VA Hospital has employed me, and I never had a problem with the VA Police.  Since March 2020, the third time I am a patient with the Phoenix VAHCS, I have nothing but problems as professionalism has shrunk and the bureaucratism has increased exponentially!

Ask yourself this, if you are in pain, and you go to a hospital ER for services and are refused service, are you a happy person?  If you are in constant pain, and someone pushes you, violently spins you, and causes your pain to elevate, do you cry out in pain?  If so, according to the DBC and the VA Police’s pretzel logic, you disrupted the hospital and caused a disturbance.  If you explain something 50+ times to a person, are you still a pleasant and friendly person to be around?  I have explained hundreds of times why I cannot wear a mask, where to find this data in my medical records, and been accused of lying, “blowing rainbows up a person’s butt,” and had other derogatory and insulting remarks made about me and to me.

Tell me, if you hear your private medical diagnoses bandied about as a joke, do you take offense?  Do you become upset when your safety is threatened and your personal space is violated for no cause?  If so, then you cannot allow this atrocious decision by the DBC to stand.  Nor should you allow another minute to pass before ending the policies creating the problems and safety issues.  Three times I have needed emergency care at the Carl T. Hayden VAHCS since my return in March 2020 and been refused.  Refusing emergency care at an emergency room receiving federal funds to operate is against the LAW (EMTALA); yet, the VAHCS in Phoenix is somehow exempt?  Twice, I have had additional injuries heaped upon the pain I am already suffering, and thrice I have been cited for being disorderly when the VA Police Officers were the ones causing the scene, disrupting traffic, and antagonizing situations.

10 December 2020, in Holding Cell 2, in front of at least eight other officers, Major Kratz barges into the holding cell, screaming, hollering, and shaking his sausage-like fingers in my face.  Making demands and acting irrationally, yet I face DBC consequences, which does not make sense.  While trying to leave the VA, sitting in my POV, the LT who started all the trouble on the 10th of December, places his hands upon my vehicle, leans against my door, and refuses to allow me to leave until he has finished insulting, denigrating, and making stupid accusations!

I fully admit, my cherub-like demeanor with the VA Police is gone, and I refuse to replace the cherub-like demeanor while I remain criticized, insulted, dismissed, injured, and falsely accused!  I have documented my treatment and my proactive approach to correcting the issues experienced very closely because the VA continues to claim I am “non-compliant” and claiming that my behavioral problems are causing disturbances in the hospital.  According to the officers, on the 10th of December 2020, I am “deserving the injuries I receive because of my rebelliousness in not conforming to wear a mask.”  Even after I have explained, I cannot physically or safely wear a mask.

30 December 2020, a person declaring themselves the assistant deputy director of the VA Police at the Carl T. Hayden VA Medical Center in Phoenix, Arizona, called me.  When asked three times, directly, “Why are you calling me,” I received three different ambiguous answers that meant nothing and a redirection of the conversation.  Then the caller told me some “facts,” I stated the situation as declared above.  To which I was told, “Your evidence is not applicable because it is too old.”  Yet, he went on to claim his officer’s record of events was correct and factual, and the date did not matter.

But, like the Home Shopping Network claims, “Oh Wait, there’s more.”  The caller told me, “your non-compliance is what is causing the issues.”  Not the fact that zealot bureaucrats are enforcing a policy that endangers the patients.  Not that my safety concerns have any bearing on the issues or why I keep getting harassed by multiple VA Federal Police Officers who refuse to listen to the patient.  Not that I have legitimate physical problems with wearing a mask. He only informed me that I am not compliant, which is my problem, and the sole reason the VA Police Officers keep injuring me.

But “Oh wait, there’s more.”  After declaring I am non-compliant, the caller refused to listen to my rebuttal of why I am compliant.  Interrupting me constantly, and then claiming that I am “Riled up” and “not being professional” when conversing with him, an intransigent and openly hostile caller.  The caller then dared to declare that “Patients do not tell the hospital what they will and will not do.”  Seriously!?!?!  I have legitimate safety and health issues that have been recorded on the VA Medical records, and this caller duplicates what his officers did on the 10th of December when they declared they were smarter than my doctor and could know when someone was faking an injury or not!

But “Oh, wait, there’s more.”  In July 2020, I heard jokes and disparaging comments about me and my medical file while sitting in the holding cell.  On the 10th of December, more disparaging remarks were made that included details that can only be known had the VA Police looked at my medical diagnoses, mental health records, and other medical data.  Having non-medical personnel know this confidential data is a HIPAA violation, clear and straightforward.  The letter 644/00 dated the 13th of October 2020 from Dr. A. Smith, the Medical Center Director, claimed that the VA Police needed this data to do their jobs effectively.  But, the caller had the nerve to declare, “I am making this up, these allegations have no bearing on the 07th of December event, and I need to stop lying about my injuries and the verbal abuse of the arresting officers.”  Which is it, HIPAA claims that these officers are in direct violation of their duties when they know my private medical details and diagnoses.  The VAMC director claims it is legal.  The caller claimed they have never had this data.  I smell bureaucrats covering themselves, and it stinks!

I have now sat in Holding Cell 1 twice and Holding Cell 2 once at the Carl T. Hayden VA Police Offices.  I can tell you from my experience, the majority of these Federal Police Officers are unprofessional, unprincipled, unbefitting, unbecoming, and replete with the most egregious manners it has ever been my displeasure to encounter.  The Department of Motor Vehicles is more professional and dedicated than most of the Carl T. Hayden’s VA Police Officers – having this “leader” of VA Police Operations tell me I am lying is enough to boil my blood!

But “Oh, wait, there’s more.”  The caller then dared to accuse me of being hostile, not listening and refusing to comply.  How can I comply when you never told me why you were calling?  Why should I be anything but irate and wary when I have come to expect treatment that should shame any professional?  I listened very carefully to the bloviations and blather of this bureaucrat, which is why, at this point, I disconnected the call.

The call lasted 8 minutes, and was full of bureaucratic nonsense, and left me out of breath, gasping for air, and vehement to the Nth degree, and out of my mind with umbrage and indignation!  Why did the Assistant Deputy Director of VA Police call me?  What is his job?  Since his job does not include setting hospital policy at the VA, will this incident be referred to a policymaker at some future date, or do I have to be paralyzed first by a zealous VA Police Officer jerking my spine and cutting my spinal cord?  If patients cannot inform a police officer that what they are doing is causing injury, then the VA Police Officer is wrong!  If a patient who is not causing trouble, is continuously harassed, threatened, accused of lying, and injured, and then can be placed on DBC policies for unspecified behavioral issues, based solely upon the cowardly, unscrupulous, and disreputable conduct of the VA Police and the inadequate policies and directives of the hospital leadership, then the entire organizational leadership needs to be replaced, forthwith!

I fully admit, I got frustrated and swore!  I fully admit when my pain levels went up, and I got hit, spun, collapsed, and more, I screamed in agony.  I have repeatedly tried to be proactive and avoid being in a position where the VA Police are concerned. Still, I cannot safely and physically wear a mask, and this is NOT a crime worthy of all the bureaucratic lunacy and foolishness I keep suffering.  I have not caused a single-issue worthy of VA Police intervention, EVER!

I have been a victim of overzealous, hostile, inept, and incompetent supervisors who become ludibrium verius malum when someone asks them a question.  I have been a victim of unprincipled, unscrupulous, disreputable professionals gifted with a badge or authority above their competence who are policy tools off the VAHCS, whose policy is poorly dictated and inappropriately applied.  I have been illegally treated and mistreated to the pleasure of the ludibrium verius malum functionaries.  Thus, I refute the charges laid against my good name and character.  I refuse to be labeled as a “behavioral problem” when I have done nothing wrong!

In no uncertain terms, the decision from the DBC should be immediately rejected, and the entire record struck of all accusations. Immediately restitution needs to be made for causing me injuries by the hands of emotionally impassioned ludibrium verius malum tools!  I have committed no crime!

I have done nothing worthy of any of the treatment I have received since March 2020 at the hands of the VA.  I deserve justice, not accusations of behavioral misconduct.  I deserve justice for the misconduct, malfeasance, impropriety, delinquency, crime, and mistreatment I have suffered.  I deserve answers, and I intend to keep complaining until my rights are restored and my good name cleansed and scoured of the tyrannical, unjust, and oppressive actions of these disastrous federal employees.  There is NO excuse for what I have suffered!

As a professional organizational psychologist, I place my integrity and honor on what I have reported, observed, experienced, witnessed, heard.  I fully and unequivocally attest that the majority of the Federal Police Officers in the Carl T. Hayden VA Police Force need immediate retraining, except for those not fired for unprofessional behavior and misconduct!  There is NO EXCUSE for Officer Interpreter on the 08th of December 2020 to have grabbed me, after physically pushing me, and try to spin me into a wall.  There is no reason, at all, for a VA Police Lt. and a Sgt. to grab my wrists, bend my arms into positions they do not travel, aggravating the handcuff injuries from Monday, and then have the gall to tell me, “Well, how could I know you had painful wrists, you are not wearing a bandage.”  I told them about my injures before they started grabbing, jerking, yanking, and hurting me.  Then I get ordered to “Shut up; I was under arrest.”  But I never had my Miranda Rights read.  I complied on the 10th, I complied on the 8th, and I complied in July.

Let us be perfectly clear; hospital mandatory mask policies must have exceptions for patients who physically cannot wear a mask.  Patients unable to wear masks include some patients on cancer drugs, some asthmatic patients, people with breathing problems, and much more.  The Carl T. Hayden VA Medical Center policy is the biggest problem I face when obtaining treatment after the COVID Pandemic Declaration from Feb. 2020.  I am certainly not alone in having breathing issues with the COVID Masking Policies, and with the zealotry the policies are being enforced.  The VA has established an organizational design that requires a veterans business to be conducted face-to-face.  Hence, the VA is a Ghost Town; patients are canceling their appointments, FOIA’s are not being submitted, and so much more because of the masking policies that endanger patient health and place patients at risk of further injury!

I repeat, only for emphasis; that the only medical offices, radiological departments, emergency rooms, and hospitals in the Phoenix, Arizona area where mask policies are causing discrimination and refusal of service is at the Carl T. Hayden Veterans Administration Health Care System, and this is 100% wrong!  The Entire VA Leadership Team should be highly embarrassed and entirely held accountable!

Where is respect for me at the VA?  Where is my patient safety?  Where is my ability to conduct business in an atmosphere free of harassment, intimidation, and discrimination?  If the Phoenix VAHCS desires atmospheres free of harassment, intimidation, and discrimination, they first must provide what they desire.

Sincerely,

Dr. M. Dave Salisbury
Ph.D./MBA/MAET
Dual Service-Disabled Veteran

CC: Meyers & Telles Attorneys at Law
Senator Mark Kelly
Rep. Greg Stanton

July Updates: OIG Reports That Should SHAME the VA!

Survived the VALate last week, I received a call from the Chief of police at the Phoenix VA Medical Center.  In July, I had been arrested for not wearing a mask.  By late August, I had figured the Phoenix VA Medical Center Director was going to just “forget me” and hope I go away, then the call comes in.  The Chief of police begins by stating, “I do not know why I am calling you, but I was requested to call and see what I can do to help.”

This response of the chiefs can be viewed two ways, he honestly does not know and needs to be updated, or he is using this as a conversation starter and does know.  I choose to see the best in people and gave the chief the benefit of the doubt.  I explained the situation, the multiple different stories regarding “VA Policy on Mask Wearing,” my multiple visits where I was not hassled about not wearing a mask, the confusion with the face shield, and the behavior of his officers in trying to implement poor policy.  To which the chief replied, I cannot help here and will return this issue to the director’s office where I had initially filed the complaint.

I do not blame the VA Police for arresting me.  They are tools of policy, as I have discussed previously and you can review here.  The police in my situation are stuck in the middle between a ridiculously inept hospital director, and the need to enforce the policies which issue forth.  At the beginning of COVID-19 hysteria, the director received a memo from the Department of Veterans Affairs (VA) regarding how to handle COVID-19.  The director did not adapt the policy to the local hospital, placing patients at risk who wears a mask in Phoenix summer conditions; nor, did the director include the ability for individual adaptation to individual patient health concerns, SAIL Metrics.  Thus, the VA Police are stuck, they cannot allow exceptions, they cannot allow for individual accommodations, and this places more burden upon the veterans seeking and requiring care at the Phoenix VA Medical Center and clinics.

The VA provides the rating of VA’s and the following website: Why not the best VA which will easily explain in a numeric format the indicators of problems with each VA.  What I find interesting is how many times the worst VA hospitals find themselves on the Department of Veterans Affairs – Office of Inspector General (VA-OIG) for egregious breaches of common sense, customer service, and common decency.  The Phoenix VA Medical Center is in VISN 22, and knowing the various hospitals intimately in VISN 22, the only conclusion possible in reviewing the data is that the 8 different hospitals in VISN 22 are in a dead heat race to the bottom, and the Albuquerque NM VA Medical Center is the best of the worst.

Carl T. HaydenThe VA-OIG conducted a healthcare inspection at the Atlanta VA Health Care System (VAHCS) in Decatur, Georgia, and found they had a backlog of open community care consults, and the OIG found deficiencies in processing, scheduling, and timeliness of these consults. Important to note, the contributory factors included but were not limited to, inconsistent scheduling processes, inconsistent oversight, and deficiencies with third-party administrator scheduling oversight, shortages of scheduling staff, and lack of training and supervision for scheduling staff. The facility did not consistently meet facility process requirements for scheduling audits and lacked a process to identify consults that were missing documentation after administrative closure.  While the Decatur VAHCS should be praised for not having any critical patient concerns due to the scheduling failures, this appears to be more luck on the patient’s part, than efficiency on the scheduling staff part.

The VA-OIG conducted a healthcare inspection at the Nashville VA Medical Center in Tennessee to evaluate alleged deficiencies in cardiac telemetry monitoring services including policies, staffing, and communication.  The facility should be praised for its progress in fixing deficiencies without the recommendations of the VA-OIG investigatory team.  The facility leaders also deserve praise for their attention to details, improvements in communication, and other facility improvements made since Feb 2019.  The last time this facility made the VA-OIG inspection report, the investigation was not pretty and their improvement needs to be praised; while more progress is needed, congratulations on the progress made.

Speaking of providing praise where praise is due, the VA-OIG conducted a comprehensive healthcare inspection of the Kansas City VA Medical Center (VAMC) and multiple outpatient clinics in Kansas and Missouri.  While this VAMC and outpatient clinics still have significant growth in improving SAIL metrics, they have progressed and growth is happening.  I send my regards, and sincere congratulations on the progress made.  I also wish them the best in continuing to improve.  This VAMC has a long road to recovering, but I know with patience, improved organizational design, and better staff training, they can get where they need to be.

ProblemsImagine you’re a patient, or worse a family member escorting the patient, with suicidal ideation, and you hear the doctor say, “the patient can go shoot themselves. I do not care,”  How would you feel about the 12-hour stay in the Emergency Room, after seeing seven different providers who did not read the notes, complete adequate patient handoff between the ER and outpatient mental health, which also includes deficiencies in the hand-off processes, and providers’ failure to read the outpatient psychiatrist’s notes, which led to a compromised understanding of the patient’s medical needs and a failure to enact the outpatient psychiatrist’s recommended treatment plan.  Completing six-days later in the veteran taking their life.  This exact scenario should NEVER have occurred but did at the Washington DC VA Medical Center.  Now, the physician making that detestable comment had previously made similar comments about other patients; crickets from leadership.  The ER physician making this incredibly obtuse statement has a history of making “inappropriate comments” about patients in the ER, and this has been known to leadership since Feb 2019.  No action, no investigation, no remediation, and now we have a dead veteran because the representative of the VA had the gall to say, “the patient can go shoot themselves. I do not care.”

I-CareWhen any veteran dies by their own hand, it is a tragedy.  But, when the VA has any responsibility in that veteran committing suicide, heads should roll, individual people should be held accountable, and in this case, especially, criminal proceedings should commence!  I worked in the VA ER, I know what the providers, nurses, and other staff providing patient interactions say.  I have reported several inappropriate comments that the patients heard to no avail, no recourse, and no action by hospital leadership.  I know, intimately, the political chicanery that occurs at the VA, and I can tell you, this IS a pet issue with me, and I am unapologetic in calling for criminal charges on these providers who are abusing veterans and their families!

Leadership CartoonThe VA-OIG inspected the VA Illiana Health Care System (VAHCS) and multiple outpatient clinics in Illinois.  The VA-OIG also inspected the William S. Middleton Memorial Veterans Hospital and multiple outpatient clinics in Illinois and Wisconsin.  I have been in both and I can say unequivocally, more progress is needed and the leadership desperately needs to improve professionalism among staff, improve patient safety from the bureaucrats not providing care, staff competencies, and staff training.  All of which were among deficiencies mentioned by the VA-OIG.  There is great potential in these VAHCS’ for achieving greatness, but the bureaucrats need deep cleaned, and removed!

What continues to astound me is the replication of excuses and issues between VAMC’s and VAHCS’ when these comprehensive healthcare inspections are conducted.  On average, I can expect 3-5 comprehensive healthcare inspection results from VA-OIG per week in my email box.  Yet, the same exact issues and excuses are used time after time, location after location.  Those VAMC’s and VAHCS’ who are failing know they are failing, and the lack of care witnessed by the inaction of the hospital leadership infuriates this veteran.  Leaving me asking, “Who will care enough to demand change and cease allowing these tepid and weak excuses to be allowed?”  Are the elected officials even looking at the repetitive nature of the issues and asking follow-up questions, demanding answers, or even bothered by failures in comprehensive healthcare inspections?

I have not personally visited or been a patient in the following VAMC; however, the stories I hear from my friends and colleagues tell me the VA-OIG might have missed a few indicators of problems in this inspection and bought the excuses for designed incompetence.  The VA-OIG conducted a review at the Ioannis A. Lougaris VA Medical Center in Reno, Nevada. The review proactively identified and evaluated declining performance metrics that could affect the quality of care and patient safety.  The staff blamed the falling metrics on “losing focus, staff pay, other change initiatives, inefficient processes, which all contributed to performance deficits.  These are standard excuses for designed incompetence and I refuse to accept these conclusions by the VA-OIG.  Will the Ioannis A. Lougaris VA Medical Center in Reno, Nevada be the next Phoenix, AZ VAMC to kill a couple hundred veterans before these excuses are no longer accepted?

VA SealThe behavior of the VA as recorded in these VA-OIG investigations and inspections continues to reveal significant problems with staff, where the staff has designed processes and procedures to allow a ready excuse for any problems that arise and continues to prove that a veteran takes their life in their hands when visiting the VA.  These actions must cease forthwith.  There is no excuse for the behavior investigated and reported.

© 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.

All rights reserved.  For copies, reprints, or sharing, please contact through LinkedIn:

https://www.linkedin.com/in/davesalisbury/

Realities and Uncertainties – The Paradigm at the VA

I-CareThe Department of Veterans Affairs – Office of Inspector General (VA-OIG) reports they are returning to a more regular schedule of release for the inspection reports with the Department of Veterans Affairs (VA) recovering from COVID-19.  Congratulations are in order, to the VA, as they begin returning to normal operations and procedures.  The reality is that standard operating procedures (SOP) are regularly missing at the VA, this absence causes uncertainty, and forms the crux of this report. A question for the VA-OIG, “How can you assess employee competency without SOPs?”  To the VA VISN leaders, “How can your directors and supervisors, conduct employee evaluations without written SOPs?”  The short answer is you cannot!

Congratulations are in order, for the Marion VA Medical Center (VAMC) in Illinois.  The Marion VAMC experienced a “comprehensive healthcare inspection” and were generally praised for the excellent work being conducted, the happiness of the patients, and the overall condition of the facilities.  While there were recommendations made by the VA-OIG (29 in 8 different areas), the overall report was satisfactory, and this is mentionable.  Hence, my heartfelt congratulations for your success in this inspection.

VA SealThe Marion VAMC VA-OIG report raises a common theme, and this is a reality the VA appears to be incapable of addressing training and two-directional communication.  From the hospital director to the patient-facing staff, training always appears as a significant issue in VA operations.  Having experienced the training provided by the VA for employees, and as an adult educator, I know the uselessness of the training program and have several suggestions.  Perhaps the problem would be best addressed if more evidence was provided of a systemic failure in training employees at the VA.

In 2017 Congress mandated a change in research operations for the VA, specifically where canine research was concerned.

“The OIG found VHA conducted eight studies without the former or current Secretary’s direct approval, resulting in the unauthorized use of $393,606 in appropriated funds.VA continued research using canines after the passage of the funding restrictions, in part, because VHA executives perceived that then VA Secretary David Shulkin had approved the continuation of the studies before his departure.”

The cause of the problem, the VA-OIG discovered was, “Unclear communication, inadequate recordkeeping, and failure to ensure approval decisions were accurately recorded and verified all contributing to VHA’s noncompliance.”  The researchers and executives relied upon two leading causes for not following regulations, designed incompetence, and a lack of training through clear and concise communications.

Congress mandated the documentation to assure approval was obtained before research commenced; yet, the researchers and administrative staff collectively failed to do their jobs and were able to hide behind the bureaucracy they established to excuse their poor behavior.  Loopholes for designed incompetence and lack of training need closed; but, two incidents do not clearly illustrate the reality of the problem.

ProblemsThe VA Southern Nevada Healthcare System in North Las Vegas, in response to a referral from the U.S. Office of Special Counsel (OSC), was investigated by the VA-OIG after a community healthcare worker was attacked.  The VA-OIG findings are appalling, but the reasons for the problem are worse.

“The OIG determined that facility managers failed to timely respond after the social worker reported an assault during a home visit and did not address the social worker’s health needs after the assault. The social worker’s supervisor failed to immediately report the incident to the community and VA police. The facility’s policies lacked specific guidance regarding employee emotional and mental health injuries. Further, the OIG substantiated that the social worker was not informed by a supervisor of a homicidal threat, occurring subsequent to the assault, until two weeks after facility leaders became aware of the threat.”

The facility leaders knew there was a problem, yet did nothing before or after the event, that could have cost this healthcare worker their life!  VA-OIG recommendations boil down to a need for clear communication and staff training.  The recommendations highlighted another issue entirely that forms the reality and creates uncertainty at the VA, communication is not a two-directional opportunity to share information.  Single directional communication is useless, and those leaders supporting the bureaucracy to only allow communication to flow in, need immediate removal from the VA.  During my time at the VA as an employee on the front-lines, facing patients, I regularly experienced the lack of communication, and this issue is systemic to the entire VA as witnessed and observed at VA Medical Centers across the United States.

The Nevada incident is deplorable, reprehensible, and the potential for loss of life cannot be overlooked by VA leadership in Washington, at the VISN, or at the Medical Center any longer!  The problems of communication cannot explain this incident, and failure for training cannot excuse this behavior!  Since the OSC initiated the complaint, I am left to wonder, did the employee reporting this incident get fired and needed to appeal to the OSC for remediation?  I ask because the knee-jerk reaction to problems at the VA is to fire the person reporting the issue, as previously observed and personally experienced, and as described to Congressional representatives during televised hearings.  A more thorough investigation into causation needs to be concluded and reported to Congress for this incident reeks of politics and CYA.

Leadership CartoonThe Harry S. Truman Memorial Veterans’ Hospital in Columbia, Missouri, and multiple outpatient clinics was recently provided a comprehensive healthcare inspection, and the leadership team provided 14 recommendations in 7 different areas for improvement.  While congratulations are in order, for the patient scores, the employee scores, and the overall conditions discovered.  Yet, again staff competency, e.g., training and communication, remain critical articles requiring targeted improvement.  Is the pattern emerging discernable; in Nevada, an employee is assaulted and training and communication are blamed, comprehensive healthcare inspections are conducted in three different geographic areas and the same causation factors discovered; training and communication are systemically failing at the VA.  But, the evidence continues.

The John J. Pershing VA Medical Center in Poplar Bluff, Missouri, recently underwent a comprehensive healthcare inspection.  The VA-OIG issued 17 recommendations in 6 fundamental areas, including staff competency assessments, e.g., training and communication, as well as the inadequate written standard operating procedures.  When discussing designed incompetence, the first step to correcting this problem is writing down the standards, operating methods, and procedures.  Then the medical center leaders can begin training to those standards.  Barring written instructions and published standards, employees are left to ask, “What is my job? and “How do I perform my job to a standard?”

The Oscar G. Johnson VA medical center, and multiple outpatient clinics in Michigan and Wisconsin recently underwent a comprehensive healthcare inspection, 11 recommendations in 3 critical areas.  As did the Tomah VA Medical Center and multiple outpatient clinics in Wisconsin, 4 recommendations in 3 crucial areas.  Both facilities are to be congratulated for their continual improvement and their success during the inspections.  In case you were wondering, staff competency assessments, e.g. training and communication, are vital findings and variables in improving further for both facilities.

The VA has what it calls “S.A.I.L” metrics that form the core standard for performance.  S.A.I.L. stands for Strategic Analytic (sic) for Improvement and Learning.  Learning is a critical component in how the facility is measured and yet remains a constant theme in the struggles for improvement.  Thus, not only is two-directional communication a systemic failure, but so is the poor training results found on all the comprehensive healthcare inspections performed by the VA-OIG.  Poor communication almost cost a healthcare worker their life, and staff training was a key component for recovering from this incident in Nevada.  How can the VA consistently fail at two-directional communication and training, designed incompetence?  Those in charge require an excuse for not doing their jobs, and the most common excuse provided is a lack of training and poor communication.

I-CareIt is time for these petulant and puerile excuses to be banished and extinguished.  The following are suggestions to beginning to address the problems.

  1. Easy listening is a musical style, not an action in communication.  By this, it is meant that the VA needs to stop faking active listening and engage reflective listening.  Reflective listening requires reaching a mutual understanding and is critical to two-directional communications.  In the world of technology, not responding to email, not responding to text messages, and untimely responses to staff communication are inexcusable on the part of the leaders.
  2. Staff training remains a core concept, but before staff can be properly and adequately trained, standards for performance, operational guidelines, and procedural actions must be clearly written down. The first question I asked upon hire was, “Where are the SOPs for this position?”  I was told, “Do not mention SOPs as the director hates them and prefers to work without them.”  Do you know why that director preferred to work at the VA without SOPs because she used it as an excuse to get out of trouble, to fire those she deemed trouble makers, and to escape with her pension and cushy job to another VA medical center?  A repeatable pattern for poor leaders to spread their infamy.  Shame on the VA Leaders for promoting this director to a level beyond her incompetence.  Worse, shame on you for creating an environment where many like her have excelled and done damage to the VA reputation, mission, and patients, including killing them while they awaited care.
  3. From the VA Secretary to the front-line patient-facing employee, cease accepting excuses. The private sector cannot hide behind immunity from litigation and act in a more responsible manner.  Thus, the VA needs to benchmark what private hospitals do where staff training and SOP’s are concerned.  Benchmark from the best and the worst hospitals for an average, then implement that average as the standard.  One thing discovered in writing SOPs for the NMVAMC, the committee for approving SOPs, and the process for writing SOPs were so convoluted and time-intensive that the SOP was outdated by the time it could be implemented.  Shame on you VA leadership for creating this environment!
  4. Training should be an extension of an organizational effort and university. The VA is not properly training the next generation of leaders; thus, the problems multiply and exponentially grow from generation to generation.  Launch the VA Learning University concept, staff that university with adult educators, and allow lessons learned from the university to trickle into operational excellence.
  5. Form an independent tiger team in the VA Secretary’s Office who has the authority to travel anywhere in the VA System to conduct investigations with the ability to enact change and demand obeisance. The Nevada incident was a failure of leadership and needs a thorough reporting and cleansing of the bad actors who allowed that situation to occur.  Worse, in my travels, I have heard many similar stories.  I heard of a patient getting their ear chopped off when a veteran assaulted another veteran after becoming irate at waiting times in the VA ER.  I have heard and witnessed multiple incidents of furniture being thrown, employees being assaulted, employees harassing and assaulting patients, staff property trashed, and so much more.  These incidents need direct intervention and investigation by a party not affiliated with that affected VAMC and the leadership’s political policies.

Carl T. Hayden04 October 2016, the VA-OIG released a report on dead veterans after the comprehensive investigation into the Carl T. Hayden VAMC in Phoenix, Arizona.  The same event occurred in 2014, at the same hospital, with the same causes and the same conclusions.  The core causes for the dead veterans, no written procedures, poor to no training, and reprehensible communication practices.  The Phoenix VAMC went out of their way to fire all the employees who reported problems at the Phoenix VAMC before the veterans began dying in 2014, I can only speculate that the same occurred in 2016.  Staff was frightened in 2014; they are demoralized in 2020.  Nothing has changed at the Carl T. Hayden VAMC in Phoenix, Arizona, after two successive hospital directors, if anything the problems have worsened.  The problems worsened because leadership failed to act, failed to write down SOPs, failed to communicate, and failed to train.  The hospital directors since 2014 have been appointed from the same pool of candidates who created dead veterans in the first place, and that is a central failure of the VA Secretary and Congressionally elected representatives’ failure to act!

How many more veterans or staff must die before the VA is willing to act?

© 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.

All rights reserved.  For copies, reprints, or sharing, please contact through LinkedIn:

https://www.linkedin.com/in/davesalisbury/