Scrutinize – DNC-Consulting

Front Office vs. Back Office vs. Oversight – Additional VA Horror Stories

Lincoln Weeps Oh, the bitter tears President Lincoln must weep…

One of the most troubling issues facing many organizations is exemplified perfectly by the VA, specifically the Post 9/11 GI Bill. Previously I worked for an online university in a position where I saw GI-Bill problems affecting students on active duty, reserve, guard, and veterans, all being treated in wildly different manners. The school GI-Bill office was expected to be subject matter experts on all things GI-Bill, but they regularly made decisions that harmed the students. By interpreting the regulations and operating procedures differently from student to student. Yet, the Department of Veterans Affairs (VA) is just as confused as the universities trying to bill GI-Bill charges for students.

From a recent VA Office of Inspector General (VA-OIG) report, we find the following:

“The Veterans Benefits Administration (VBA) did not always accurately process enrollments. An estimated 2,500 of 10,000 enrollments from August 1, 2020, through April 1, 2021. About 790 of the estimated errors involved officials either not reporting or underreporting vacation breaks. VBA claims examiners often mishandled enrollments even when the correct information was submitted. The VA-OIG estimated claims examiners incorrectly processed accurately reported vacation breaks for about 1,700 of 2,500 enrollments with errors.”

Why are these enrollments not processed correctly:

“Insufficient training and guidance meant school certifying officials frequently made mistakes.” The VA takes legislation and writes the processes, procedures, and training materials for universities to use for operations and enrollment of military and veteran students. Front office workers interact with students, back office workers interact with internal employees, the VA keeps the records current, and the VA forms the universities’ oversight resembling the blind leading the blind. Yet, the VA cannot write effective training materials, processes, and procedures, conduct training, and support those who support students.

Per the VA-OIG report, the VBA is looking to implement an automated system to prevent these oversight issues from continuing. I do not expect any automated system created by the VBA to work efficiently because of a simple principle, GIGO. The garbage the VBA will put into the system will ALWAYS result in garbage coming out, creating more problems, costing too much money, and still creating issues for students and student-facing employees at universities and colleges across the country. Somehow, the VA-OIG continues to buy these excuses and pipe dreams and reports the same to Congress, which is also purchasing these excuses and poor performances. VA 3

Before someone tries to claim this is isolated to the GI-Bill program, and the GI-Bill program has always been confusing. Using this logic, the health complications at birth can be blamed on the father alone, and the mother’s behaviors do not influence the baby’s health. Here the VA-OIG is reporting on another program governing VA employees, overseen by the OMB, and is incredibly useless as this is a repeated complaint between 2020 and 2022.

“Identity, credential, and access management (ICAM) is a set of tools, policies, and systems used to ensure the right individual has access to the right resource, at the right time, for the right reason in support of federal business objectives. In February 2021, the VA Office of Inspector General (VA-OIG) received a hotline complaint claiming the Office of the Assistant Secretary for Human Resources and Administration/Operations, Security, and Preparedness and the Office of Information and Technology have not agreed since 2016 on roles and responsibilities for VA’s ICAM program. Failures of ICAM contribute to the VA’s inability to effectively comply with the Office of Management and Budget (OMB) policy. The VA-OIG reviewed to determine whether VA effectively governs its ICAM program as required.”

What did the VA-OIG find?

- - The VA did not effectively manage and coordinate its ICAM program, not meeting three of the four OMB governance requirements.
  - The VA did not effectively assign roles and responsibilities, implement a single comprehensive ICAM policy, or meet its technology solutions roadmap goals for fiscal years 2020 and 2021.
  - The VA failed to implement updated digital identity risk management requirements.

Why can’t the VA obey OM oversight?

“These issues occurred primarily because leaders of the different offices performing VA’s ICAM functions have not agreed on how it should be governed. VA risks restricting information from users who need it to perform their job functions without proper governance and leaving information vulnerable to improper use” [emphasis mine].

In this report, the OMB sits as oversight of the VA. The employees are the frontline, and the leaders continue to fail to provide tools, policies, and resources to employees conducting the VA business. What is still an incredibly terrible idea allowing the VA to remain self-governing. Why isn’t the OMB more interested in demanding compliance? Where is Congress scrutinizing how the executive branch agencies are failing and monitoring to improve conduct? VA 3

The VBA cannot still properly and timely adjudicate claims. Again, the VA-OIG lambasted the VBA for improperly adjudicating claims, even with “Special-Focused Reviews.” Essentially the quality assurance (QA) process in claim adjudication continues to fail to help improve claim processing accuracy. From the report:

“The Office of Inspector General (VA-OIG) reviewed VBA’s design and implementation of its special-focused review process, including applying Government Accountability Office (GAO) standards. The VA-OIG team assessed ten special-focused reviews completed from January 2019 through April 2021 and identified weaknesses in all five of GAO’s internal control components. The VA-OIG also found the VBA Compensation Service’s standard operating procedure related to these special-focused reviews does not provide sufficient guidance to support disability claims-processing improvement fully.”

When I worked in QA, root causation was required to prevent future problems. The VA-OIG found that the QA Special-Focused Reviews do not include root causes or explanations for why the claims were readjudicated, stopped, or delayed in VBA processing. Do not repeated issues reflect the need to restrict self-governance until compliance can be observed? VA 3

Why should the VA have its self-governance restricted or prohibited? The following VA-OIG makes clear that the VA cannot govern itself and correct the problems leadership continues to create. Follow the timeline here, quoted directly from the VA-OIG report:

“The VA Office of Inspector General (VA-OIG) conducted this review to determine whether the Veterans Benefits Administration (VBA) accurately adjusted compensation and pension benefit payments for fugitive felons as mandated by law. If VBA does not adjust payments, veterans who are fugitive felons will continue to receive benefits during periods of ineligibility.

In April 2012, VBA instructed regional offices to postpone making decisions on fugitive felon cases while it prepared new guidance. During 2012 and 2013, VBA did not process fugitive felon cases. In June 2014, VBA updated its definition of a fugitive felon to include only referrals indicating escape, flight, or violation of probation or parole conditions. Although VBA then resumed adjusting payments, it did not review the unprocessed 2012 and 2013 cases.

In addition, due to inadequate monitoring, VBA did not process about 46 percent of cases referred by the VA-OIG in 2019 and 2020. Finally, the team found VBA’s notification letters to veterans providing notice of the proposed action and right to a hearing did not always provide the required information. Most commonly, VBA failed to include the reason for the issuance of the arrest warrant.”

The VA has been informed by the VA-OIG multiple times during the decade this problem has been surviving, and 46% of the cases the VA-OIG told the VA to fix still weren’t fixed in 2022. How can any oversight agency still permit the VA to govern itself? The leaders of the VA cannot self-govern, correct course, and make changes timely enough not to create additional expensive problems for veterans. Each of these cases represents either an overpayment, where the VA is clawing funds back, or an underpayment, where the veteran has been shortchanged and is owed money.

When the VA claws money back from making a mistake that overpaid a veteran, dependent, spouse, or other entity, the VA-OIG has found that even here, the VBA cannot act per their policies, follow procedures, or notify veterans in a timely manner. A veteran I got to know who served in Vietnam and caught a round in the heart that blew away a large chunk of his heart. For 50 years or so, this was sufficient to have a 100% disability. On the day he turned 69, his disability rating dropped to 80%, with a coinciding reduction in monthly benefits. The VBA investigated this claim decision and found they had made a mistake, but their mistake would not significantly change the rating, so the veteran was stuck with an 80% rating and was told to go back to work. VA 3

To the best of my knowledge, the claim remains stuck in claims appeal hell, awaiting the judgment of the dark and benighted realms to act. The veteran, who cannot hold a job due to weakness from lacking a significant part of his heart muscles, is driven into bankruptcy. His heart will not regrow, but because his age has met the age when heart problems are actuarially known, the decision was made. The decision was made without notification to the veteran, and the veteran only became aware of the situation when he had monies clawed back by the VA. From the time the decision was made to the date he knew, 18 months had transpired, and the veteran was automatically sent to collections. While this was never allowed to become a VA-OIG investigation, I have spoken to family members and the veteran while volunteering to help disabled people find employment. I-Care

To add the bitter cherry to this crap sundae, this is not the worst abuse I heard in my volunteer efforts. Worse, this is not the worst story I have had related while talking to veterans in my travels across the continental 48 United States. Veterans sit forever in claim hell; they cannot afford to go forward, they are abused when seeking medical help, and every interaction with VA medical providers runs the risk of being the victim of an “adverse medical event.”

To this point, the VA and the VBA have been central to proving that the VA cannot self-govern, oversight is failing, and the back office administrators are hindering the front office operations. Surely the Veterans Health Administration (VHA), where people’s lives are at risk, would not have a similar problem. Unfortunately, you would be wrong, and here is one VHA example, of many, to support this conclusion:

“A VA Medical Center (VAMC) community living center (CLC) staff delayed life-sustaining treatment for a patient (Patient A) who experienced cardiac arrest and died. The VA-OIG also reviewed an allegation regarding a second patient (Patient B) who had resuscitation initiated, despite a do not resuscitate (DNR) order in the electronic health record (EHR).”

Why did one patient die without resuscitation and another get resuscitation without wanting it? The policies and procedures were complicated, and the use of armbands confused the providers. The providers (doctors and nurses) overseeing care had a person in the medical records of these patients and still could not properly act for patient care. The patients had armbands and proper medical documents on file, and the providers still got confused and provided poor care, at best, to the patients involved.

America Weeps In another long-term care facility under VA operation, the following occurred:

“The VA-OIG found that the day charge nurse’s assessment was delayed and incomplete, and the day charge nurse failed to properly document the resident’s reassessments, treatments, and interventions. The VA-OIG substantiated that nursing staff failed to document and carry out a telephone order to transfer the resident to the Emergency Department but could not determine if this impacted the patient’s outcome.”

Let’s take a moment to allow this to sink in fully. Failure to follow a doctor’s orders might have been part of the problem the patient DIED! Yet, the chain of events is sufficiently blurry to mystify the investigators – this I find HIGHLY SUSPECT! But, as the Home Shopping Network reports, “There’s more!”

“The VA-OIG determined that following the resident’s death, facility staff failed to conduct a comprehensive review of events leading up to and contributing to the resident’s death and, due to a lack of coordination of care at the time of discharge from the inpatient unit, the resident did not have the needed equipment upon admission to the CLC.”

I accept that a nurse’s role is stressful, the VA policies do not make their jobs less stressful, and the healthcare leadership (overall) is abysmal on the best days. However, killing a patient is still a BAD thing! I-Care Yet, here we have another dead veteran at the hands of the medical care providers, and the best the VA-OIG can do is make ten (10) recommendations for change. Does anyone believe the VA can continue to self-govern under its current misguided leadership and convoluted organizational structure?

Ask yourself, would the abuse of the veterans mean more if this was your uncle, brother, father, mother, sister, or aunt? They are your family members for the problems which they face; we all face in our constitutional republic. Where is Congress scrutinizing the government? Please become interested, active, and engaged, or we will lose this constitutional republic to the tyranny of the power-hungry despots.

© Copyright 2023 – 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.

Scrutinize the Executive Branch – The Charge for the Legislative Branch: Part 1

In what has become typical and usual, the following stories arrive:

“From 2019 to 2021, Ira Westbrook of Bozeman, Montana, served as the fiduciary of an elderly relative who had suffered a stroke and became disabled. A multi-agency investigation found that, during these 16 months, Westbrook stole more than $57,000 in Social Security and VA benefits and used the stolen funds to purchase personal items, including a Jeep Wrangler, a travel trailer, and other day-to-day expenses.”

“From 2016 until 2018, Sloane Signal-Debose of Slidell, Louisiana, served as the fiduciary of a veteran who needed assistance managing his finances. During that time, she took more than $100,000 from the veteran’s accounts, used it as the down payment on a home in her name, and used additional funds from the veteran to pay contractors working on the home. Signal-Debose then submitted false records to VA to hide her misuse of the veteran’s funds. The former fiduciary pleaded guilty to misappropriating funds and faces up to five years in federal prison. The VA OIG conducted this investigation.”

“In 2013, Brandi Goldman of Jonesboro, Arkansas, was married to a US Army reservist who suffered a severe traumatic brain injury in a service-connected accident. As a result of this injury, her husband had many serious physical challenges, and Goldman was appointed as his guardian and fiduciary. Between April 2015 and November 2017, Goldman received more than $258,600 in VA disability payments and $36,000 in Social Security payments. During that timeframe, she withdrew close to $200,000 in cash and accrued about $900 in ATM and overdraft fees. Goldman admitted to spending much cash to fund her methamphetamine habit, spending $150 on methamphetamine two to three times per week. She also admitted that five other people moved into the residence with her and her husband, none of whom paid rent or contributed to expenses, some of whom she regularly gave cash to. She also admitted to paying $68,000 in cash for another home, furnishings for the home, multiple vehicles, and a motor home. Goldman was sentenced to 20 months in prison, three years of supervised release, and $143,000 in restitution after previously pleading guilty to misappropriation by a fiduciary. The VA OIG and Social Security Administration OIG conducted the investigation.”

Why are these stories of particular interest to the supreme legislative body in the United States of America? The executive branch has refused to police its branch of government, and crimes like this have become all too familiar. You, the Congressional bodies of these the United States, are duty-bound and sworn to perform two jobs, scrutinize the executive branch (harshly when necessary), and write laws. You have recently failed too often in monitoring the executive branch, and this story perfectly represents what happens when the executive branch is not examined minutely! Tell the US Public who put you in elected office, how these crimes continue and what programs and processes they MUST change to prevent them in the future.

By pleading for the legislative branch to scrutinize and audit the executive branch minutely, I am in no way condoning or diminishing the personal accountability of those who committed crimes. These three examples are from the October and November press releases of 2022. The widespread ability to commit fraud is a symptom of a more significant problem at the VA. Their leaders have consistently been able to boondoggle, evade, and profit from abusing veterans through designed incompetence, criminal neglect, and obtuse actions. When will Congressional leaders take action to clean up the Federal Government in general and the VA specifically?

The US House of Representatives holds the purse strings for the executive branch; use this leverage to claw back your powers and authority to balance the Federal Government and demand accountability from those empowered to lead their designated branches of the executive branch of government. Let’s talk about patterns; in less than 45 days, three cases of fiduciary fraud were closed, and the speed of closing these cases has escalated throughout 2022. The American people will see more, not less, of these fraudsters being underreported by the US Media before the year ends.

Shifting slightly, let’s talk about government employees and the need for more scrutiny of the executive branch.

“Bruce Minor, of Philadelphia, Pennsylvania, was sentenced to two years in prison, three years of supervised release, and ordered to pay $462,256 in restitution for his scheme to embezzle money from the Philadelphia VA Medical Center. Between December 2015 and September 2019, Minor, a former travel clerk, created fraudulent travel reimbursement claims in the names of at least three other VA medical center employees. He then diverted the funds into bank accounts he controlled. The VA OIG investigated this case.”

“Kyhati Undavia, of Houston, Texas, was sentenced to 27 months in federal prison after previously pleading guilty to conspiracy to commit healthcare fraud. From December 2012 to December 2018, Undavia hired employees to market Memorial Pharmacy, which she controlled and operated, to physicians as a place to submit compounded drug prescriptions. Instead of providing prescriptions directly to the patients who could select a pharmacy of their choice, physicians sent the prescriptions directly to Memorial Pharmacy. Then, Undavia paid the physicians illegal kickbacks for the prescriptions. Beneficiaries often received medicated creams that they did not need or want. Undavia received approximately $22 million from TRICARE, Department of Labor Office of Workers’ Compensation Programs, and CHAMPVA for the prescriptions.”

These stories also fall into the same timeframe mentioned above. But, they are not the only stories from 2022 where VA employees conducted long-term fraud for personal profit. Here’s the rub: hundreds of additional employees knew of these schemes, were probably running their schemes, and haven’t been caught, and nothing is being done by VA leadership to cease the fraud and abuse of veterans by VA employees. There is a culture of corruption at the VA, long hidden by scheming and abusive leaders and condoned by previous Congresses, that must be stopped! What will you, the congressional leaders of the United States, do to halt this insanity, demand personal accountability, and clean house of the designed incompetence that allows these criminal activities to flourish? The American People are waiting!

The following site holds press releases for the VA specifically, but investigations often cross into Social Security, the Department of Defense, state investigatory bodies, the FBI, and more. Suppose nothing else is learned from only perusing this site, that more scrutiny needs to be done to every single department of the executive branch. In that case, we, the American People, might count ourselves lucky. However, this is not the case. The rot from poor leadership, criminal mismanagement, and supreme dereliction of duty is etched deeply into the workings of the executive branch operations, and more needs additional discussion.

03 November 2022, the VA-OIG released a report titled, “VHA Progressed in the Follow-Up of Canceled Appointments during the Pandemic but Could Use Additional Oversight Metrics.” The report only covers the time from 2020 to the present, and regular readers know that the VA has been failing on every measurable metric for over a decade. To couch in politically correct non-threatening jargon, how designed incompetence continues to hamper and hinder is not surprising. That the current Congress has bought the excuses hook, line, and sinker, from the inept VA leadership, was not surprising either. This article is about the future, and the next Congress MUST take immediate and direct action to root cause and improve VA performance!

31 October 2022, the VA-OIG released the following: “Review of VA’s Staffing and Vacancy Reporting under the MISSION Act of 2018.” This is a report about how the VA continues failing to report improvements in hiring practices to the legislative branch. The report details VA leadership’s continued failures through designed incompetence. Tell me, if you were in charge of a report for your business that is essential to receiving funding, would you keep your job if, from 2018 to the present, you still cannot report what is happening and why and be held personally accountable for a report to a legislative body? Don’t take my word for it; read the report, and be careful of the temperature of your blood boiling!

Unfortunately, this behavior is the normal operating procedure for the VA. The same can be easily and quickly witnessed in every other Federal Department of the US Government under the executive branch. As the legislative branch, you are duty-bound to investigate and demand compliance in a timely manner. Where have you been; more importantly, will you allow these problems to continue or kill them?

Do you doubt designed incompetence is a standard operating procedure? Let’s discuss another part of the MISSION Act of 2018 that the VA-OIG recently reported on, “Additional Actions Needed to Fully Implement and Assess Impact of the Patient Referral Coordination Initiative,” dated 27 October 2022. The Referral Coordination Initiative (RCI) is a program to improve timely access to care using community providers. RCI sounds good in theory, but as usual, in the practical application, the program is full of self-serving charlatans, unsupervised or poorly supervised people, weak policies and procedures, and zero accountability! Plus, when the veteran runs into problems with local providers, reporting these problems is so time-consuming as to be ineffectual at best!

A personal example that was reported to the VA when it happened, and nothing was done but to issue the provider a check. Dr. Herekar, Neurologist, clinic: Advanced Neurology Epilepsy & Sleep Center, El Paso, Texas. A VA Primary Care Provider wrote to my employer on VA Letterhead with a wet signature, declaring my inability to wear a mask. Dr. Herekar’s office was presented with this letter and hassled me before both appointments for not wearing a mask, becoming hostile, argumentative, and a nuisance over the mask issue, even after I complied with putting on a face shield. 23 September 2021, over Facebook messenger, I was informed that I would be invited to find a different provider due to my refusal to wear a mask. Imagine that; Facebook Messenger became the medium of choice for ending a patient’s relationship with a medical provider. What did the VA tell me to do; file endless paperwork with TRICARE and then disregard the problem’s urgency. Worse, the medical care for the neurological issues decreased, and I have had to wait, sit, and hope for future consideration and possible treatment. Does this sound like an aberration; it is, unfortunately not!

The VA Leadership realized if community care succeeds, they lose power to control the destiny of veterans. Thus, they implemented the MISSION Act of 2018 with such feet dragging, designing incompetence into every facet of the program, to promote more complaints to Congress, and hopefully to squash the MISSION Act of 2018 and end community care. 07 November 2022, while waiting to speak to representatives of Community Care Services at the VA Out Patient Clinic in EL Paso, the veteran being served ahead of me was told, “The provider does not fax documents, so you will need to go to the provider, and then walk the paperwork back to us.”

The normalcy of reporting providers not submitting paperwork was beyond the pale. Not having secure document transfer processes between the VA and local providers is technically abysmal and unacceptable. Are we in the 1990s, where the cream of technology is sending and receiving a fax? The designed incompetence includes Luddite-like technical disciplines, and the VA_OIG and the Congress should be furious; I know I am!

Before the MISSION Act of 2018, I was making 5 and 6 trips to local providers to retrieve hard copies of medical records, going to the VA Records office, submitting the documents, and then following up 7-14 days later to find out I had to repeat this process as my VA Providers still had not received the records of my interactions with community providers. Interestingly, in 2020 I discovered the treatment records still had not been submitted from community providers into my VA eHealth Record, from treatment received from 2012-2016. Is the pattern of designed incompetence clearer? Is the VA Leadeship’s intransigence more apparent? How about the fraud, waste, and abuse of VA resources?

You, the congressional leaders, must take immediate action, not wait, not hold hearings, concrete action to demand compliance from the executive branch leaders to the congressional leaders who are held accountable to the citizens. America is a representative republic, and it is time the bureaucrats learned the citizens are awake and interested. You, the congressional leaders, are the people’s tool for correcting government abuses; you have two years to show you are dedicated to that principle, or you will be replaced!

© Copyright 2022 – M. Dave Salisbury
The author holds no claims for the art used herein, the pictures were obtained in the public domain, and the intellectual property belongs to those who created the images. Quoted materials remain the property of the original author.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

“All Power is … Derived From The People.” – The Consent of the Governed

If you are browsing a second-hand bookstore and come across the book “We, The People: Great Documents of the American Nation” by Jerome B. Agel, I recommend picking the book up and adding it to your library. I have not found a better book discussing the founding documents of this great American Republic. It is historically accurate, provides insights, and is a treasure of wisdom and knowledge.

A phrase in the Declaration of Independence has always captured my imagination and held fast to my mental processes. “Governments are instituted among Men, deriving their just powers from the consent of the governed.” It has always been understood that men invented governments for the ruling of other men. Rome was a perfect example of this principle, and in writing down the laws, the first attempt at a moral government responsible to the people was attempted. However, it is the second part of that phrase that we are discussing, “deriving their just powers from the consent of the governed.”

Consider this principle for a moment. First, governments have just and unjust powers, and second, the powers originate with the consent of the populations agreeing to be governed by the government. Czarist Russia is an excellent example from history where the people had enough and began looking around for a new government. That the people were hoodwinked and communism was imposed upon them remains one of the great tragedies of the last century. In less than 100-years, Russia went through two incredible government upheavals is mentally incredible to consider. Plato 2

Unjust powers of government are those powers governments assume where the people have not granted them consent of the governed. When governments take enough of these powers upon themselves, the population’s revolution, anger, and frustration are the only outcomes possible. Worse, the governments are breaking their laws and the trust of those who elected them, proving that the most dangerous person is an honest person betrayed.

Bobblehead Doll All of which is mentioned as we discuss the origin of the philosophy of the consent of the governed in American jurisprudence. Virginia, 1776, The Virginia Declaration of Rights prefixed the Virginia Colony’s constitution and was written by a reluctant statesman and largest landowner, George Mason. In sixteen statements on government and the rights of man, we find the consent of the governed and the need for controls on government pertinent to our day and time!

1. 1. “All men are by nature equally free and independent, have certain inherent rights, … namely the enjoyment of life and liberty, possessing property, and pursuing and obtaining happiness and safety.”
  2. “All power is vested in, and consequently derived from, the people; that magistrates are their trustees and servants, and at all times amenable to them.”
  3. “Government is or ought to be instituted for the common benefit, protection, and security of the people. … A majority of the community hath an indubitable, unalienable, and indefeasible right to reform, alter, or abolish it, in such manner as shall be judged most conducive to the public weal.”
  4. “No man, or set of men, are entitled to exclusive or separate emoluments or privileges from the community.”
  5. The state’s legislative and executive powers are separate from the judiciary, and the operatives return to being citizens after their respective terms in office, in accordance with the laws of the land. [Edited for brevity]
  6. Contains three principles of import:
    - - Elections should be free and open to all.
      - Property cannot be taxed or deprived for public use without consent.
      - Those elected are bound to the same laws as the citizens.
  7. “All power suspending laws or the execution of laws by any authority without consent of the representatives of the people is injurious to their rights and ought not to be exercised.”
  8. Deals with a criminal trial, due process, speedy trials, a jury trial, and a unanimous jury.
  9. Deals with fines, bail, and cruel or unusual punishments.
  10. Deals with search and seizure requiring evidence of a crime and the need for a warrant to be based upon evidence or not to be granted.
  11. Holds sacred the rights to a jury trial, including for disputes between two people over non-criminal issues.
  12. Holds sacred the power of the press as a bulwark of liberty, and restraining the press is an action of despotic governments.
  13. Details that standing armies in peacetime should be avoided and a well-regulated militia is proper and natural for the defense of the state. Important to note, “the military should at all times be under strict subordination to, and governed by, the civil power.”
  14. Demands uniform government that applies to all people.
  15. Declares that “No free government, or the blessings of liberty, can be preserved to any people, but by a firm adherence to justice, moderation, temperance, frugality, and virtue, and by frequent recurrence to fundamental principles.”
  16. Declares that “Religion, or the duty we owe to our Creator, and the manner of discharging it, can be directed only by reason and conviction, not by force or violence, and therefore all men are equally entitled to the free exercise of religion according to the dictates of conscience, and that it is the mutual duty of all to practice Christian forbearance, love, and charity towards each other.”

Let’s Discuss

Are we in trouble? We didn't do it!!! — Are we in trouble? We didn’t do it!!!

In opening the discussion, one of the most egregious and despicable actions witnessed every year is the failure to follow the strictures of a peaceful society as required in the 16^th statement, to practice the “mutual duty of all to practice Christian forbearance, love, and charity towards each other.” Having been a student of religion, I have found no religious stricture, in any organized religious teaching, to living in harmony with others by practicing forbearance (tolerance, patience, and kindness), love (respect, kindness, gentleness, meekness, all unfeigned), and charity (service) to those in our society. Atheists, this includes you; it is time to live in harmony with others and stop the lawfare. If someone is not violently demanding you adhere to their religion and religious tenets, then leave them alone!

I Find the following extremely important to the news developed, especially over the last two weeks. “No free government, or the blessings of liberty, can be preserved to any people, but by a firm adherence to justice, moderation, temperance, frugality, and virtue, and by frequent recurrence to fundamental principles” [emphasis mine]. Let’s break this down:

- - Justice: Decency to all as a behavior of equality and commitment to moral rightness.
  - Moderation: This is all about not going to extremes, being restrained, knowing the boundaries and staying within limits, and being reasonable and approachable.
  - Temperance: While primarily used in drinking alcohol, this also applies to any behaviors where self-restraint, moderation, and expressions or observance of temperate behaviors are required.
  - Frugality: Besides being a good steward of other people’s resources, being frugal requires being sparing, prudent, economical, thrifty, and reserved.
  - Virtue: Requires moral excellence, modesty, personal dignity, goodness, and conformity to a standard of righteousness.

Knowledge Check! These are fundamental principles of liberty and the foundation upon which government is built and sustained. How often do you hear politicians discussing these terms, returning to these principles as terms to write laws worthy of printing for society or as standards for scrutinizing the government agencies? What did we observe in government this week that adhered to any of these fundamental principles to America or any other government succeeding in the past week? Does anyone argue that Gov. Cuomo’s actions in New York were virtuous? Were the CDC Director’s edicts frugal, temperate, moderate, or just? How about the reaction by Congress to the mandates by the CDC? Did they perform their jobs to scrutinize the legislative branch using these principles?

Now, some will decry that this is a document solely for the Commonwealth of Virginia and does not apply to the entire United States. Yet, I would counter that the principles and language of this document are interwoven into the Declaration of Independence, the US Constitution, the US Bill of Rights, and every other founding document and US State Constitution. Thus, why could we not use The Virginia Declaration of Rights as a template to benchmark and measure the performance of politicians and bureaucrats?

Fundamental principles do not age, expire, or possess a shelf-life. Hence, knowledge of the fundamentals empowers action by the electorate to change, correct, and demand government adherence, for we are the owners of our representative government. We, the electorate, need to teach these fundamental lessons to the politicians, then demand they adhere and hold accountable the bureaucrats to the fundamental principles of liberty, or we all lose this precious government of the people, by the people, and for the people, where the consent of the governed is respected.

© 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.

Paul Harvey – Detestable VA Chronicles for Week Ending 07 Aug 2021

Bobblehead Doll Paul Harvey is a hero of mine. I miss his voice on the radio. He exuded a calm demeanor, regardless of the terror, the trials, and the terribleness of the news reported and discussed. I do not have Paul Harvey’s sense of calm. When I heard about the beheading of a woman in America, in broad daylight, by an illegal immigrant who has been on a one-man crime spree from El Paso to Minneapolis since 2007, my cherub-like demeanor took a tremendous hit.

The Department of Veterans Affairs (VA) – Office of Inspector General (VA-OIG) reports on a couple from Kansas who are flat out despicable, faking blindness to increase disability payments from the VA and Social Security. Frankly, I hate liars and thieves and agree to the restitution ordered, but I do not agree that the couple deserved probation. Stealing benefits should come with more than simple probation and restitution. Where is the community service in distinctive clothing and sandwich boards declaring they are thieves? VA 3

However, this couple represents a symptom, not the disease of the VA and Social Security specifically, and the Federal Government generally. When leaders act reprehensibly, criminals will test the system to find weaknesses and attempt to benefit from leadership failures. The disease of poor leadership has far-reaching consequences, and criminal activity is not unexpected. Who is addressing the disease? When will the citizens of America receive justice to see the healing of the illness that has captured the government?

Military Sexual Trauma

I-Care Imperative to understanding, Military sexual trauma (MST) experienced while serving in the military affects both women and men with potentially severe and long-term consequences. Psychological trauma, such as MST, also increases the risk of physical health conditions such as cardiovascular disease, stroke, and diabetes. The Veterans Health Administration (VHA) requires that each facility has a designated MST Coordinator with at least 20 percent of their time dedicated to protected administrative time. For the record, “protected administrative time” is the time required to be spent on administrative duties, writing clinical notes, ordering supplies, scheduling appointments, administrative responsibilities, and so forth.

In 2018, the VA-OIG discovered just how detestable and deplorable the VBA’s processes and procedures were for military sexual trauma (MST). Having been a victim of MST, this issue is of particular interest to me, and I continue to follow this issue closely. I wish I had some encouraging news on this issue, but the VA-OIG found:

“… Processors did not always follow the updated policies and procedures. VBA leaders did not effectively implement the VA-OIG’s recommendations and did not ensure adequate governance over military sexual trauma claims processing. The VA-OIG concluded that VBA was not properly implementing the recommended changes.” VA 3

In 2016, when claims were being improperly and prematurely denied, the problems were considered a lack of training, a lack of policy, a lack of procedures, and comprehensive guidance was needed. In 2018, additional training and guidance were needed, time, and leadership were recommended, even though claims were still improperly and prematurely denied. In 2021, it is now blatantly obvious we have a systemic failure of leadership at the VBA to process claims in a manner that is conducive to good order and discipline!

On the same day, this investigation was released, the VHA investigation results for MST coordinators were released to the public. I bet you can guess what was found, but let’s allow the VA-OIG the opportunity to detail the failures:

“The VA-OIG conducted a national survey and interviews to evaluate MST Coordinators’ duties and perceived challenges.

- - - - 80% of the respondents reported having been assigned at least 20 percent or more of protected time.
        
        39% reported inadequate resources to fulfill MST Coordinator administrative responsibilities.
        
        The VA-OIG found that insufficient protected administrative time, role demands, insufficient support staff, and inadequate funding and outreach materials challenged MST Coordinators’ ability to fulfill role responsibilities.
        
        The VA-OIG found that MST Coordinators who reported more dedicated time than other MST Coordinators did not necessarily serve at facilities with higher numbers of patients in MST related care.”

Did you catch that final point? Resources are not being adequately provided based upon patient load to locations where veterans need care. Another symptom of leadership failure, being designed into the organization as a policy and working procedure, meaning this is designed incompetence!

Knowledge Check! Here’s the biggest rub, a veteran can be receiving care from the VA for MST at the VHA and still be denied MST on a VBA claim. I have not heard it working in reverse where a claim is being paid, but the VHA refuses care, but given the failures of the VA as an organization, I would not be surprised to learn this was occurring. How do I know that care can be provided for MST and not be allowed on a claim? I am among a number of MST victims, all-male, who have been regularly denied VBA claims but are receiving care for the psychological harm. Veterans talk to each other. I have heard the stories of fellow veterans being attacked, assaulted, molested, drugged, raped by male and female attackers, and heard how the VBA had revictimized them.

What’s worse, MST leads to PTSD, and people are suffering PTSD from a number of traumatic events not receiving care or benefits because the VA refuses to acknowledge these problems. Admitting a problem is the first step in addiction programs; well, it is also the first step in healing leadership failure, and the VA is suffering from dynamic leadership failure at every level! Know a veteran whose story needs to be told, refer them to me; let’s get this information out. I am sick to death of the VA getting away with murder.

Programs and Inspections

VA Seal This week, the final three emails from the VA-OIG reflected a VISN wide comprehensive healthcare inspection (CHIp) conducted virtually, a VAMC/VAHCS CHIp conducted in Spokane, Washington, and a program report on the failures in the Veteran-Directed Care Program. The most interesting finding in the CHIps was how short the leadership teams had worked together, a month, and how many open positions for leaders there were, more than half. Talk about glaring symptoms of leadership failure, were the leadership teams broken up from employee turnover? If so, did the employees retire, or were they retired to avoid criminal convictions? With all the investigations for fraud, as discussed on these pages frequently, I can only guess how leaders churn in a VAMC/VAHCS/VISN.

Believe it or not, the Veteran-Directed Care Program is full of faults, problems and is suffering from a lack of leadership as the program balloons. Color me shocked! Surely, somewhere in the VA, if only to screw with the gods of perversity and Murphy their prophet, there must be a functioning and well-led program, department, office, etc. Angry Wet Chicken

It is so absurdly depressing to catalog these failures of leadership week after week and never see any improvement. We see increasing failures, we observe heightened criminal activity, there is undoubtedly raised awareness of needs and moral distress in abusing veterans, but where is the improvement towards achieving excellence? Where is Congress in scrutinizing the legislative branches, officers, and leaders?

If a congressional representative can order the VA-OIG to investigate the MST Coordinators, which they did, where is Congressional action on the results? Surely this is not too difficult a question to ask. Better still, where is Congress? I have now reached out to all the elected Federal officials in Arizona, Texas, and New Mexico. Texas, because that is where I have been forced to receive care from. New Mexico because I now live here. Arizona because I was physically injured by VA employees there. The amount of interest received has been less than zero! Angry Grizzly Bear

How can interest be less than zero, you ask. Well, while I have not received any response to my original complaints, I have received a TON of marketing materials about how those congressional representatives “Care about veterans, the community, pets, animals, and America.” Maybe, not always in that order, but absolutely with less sentiment than I have for the weeds growing on my sidewalk! Thus, I ask again, with all sincerity, where is Congress in scrutinizing the government? I demand to know the “Rest of the Story!”

© 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.

Weep America! – The VA Leadership is Becoming Worse! – Part 3

I-Care In the less than 10-days since I last wrote on the Department of Veterans Affairs (VA), the Department of Veterans Affairs – Office of Inspector General (VA-OIG) has dumped more than ten inspection results over the last three days into my inbox. Not a record, but the recorded actions are certainly hitting record lows. Worse, the culture of the VA remains unchanged, even through all the recorded crimes and indignities the veterans suffer under. Recording and summating the crimes of the VA is so depressing, mainly because of the failure to reform. But, a little depression will not slow or halt the reporting of these detestable actions of the VA!

The first VA-OIG investigation is more of a report on criminal proceedings concluding with sentencing. A total of five people, including one VA Employee, have been stung in this investigation. How thrilling to see accountability and justice served cold!

“Francis Engles of Bowie, Maryland, was sentenced to 30 months in prison and ordered to pay $150,000 in restitution for defrauding a VA program dedicated to rehabilitating military veterans with disabilities. As the owner of Engles Security Training School, Engles falsely represented to the VA that his company was providing veterans with months-long courses when, in fact, the school offered veterans far less.”

“February 2019, four other individuals were sentenced in related cases following their guilty pleas. First, James King, a former VA employee, was sentenced to 11 years in prison for committing bribery, defrauding the VA, and obstructing justice. Second, Albert Poawui, the owner of Atius Technology Institute, was sentenced to 70 months in prison for committing bribery. Third, Sombo Kanneh, Poawui’s employee, was sentenced to 20 months in prison for conspiracy to commit bribery. Finally, Michelle Stevens, the owner of Eelon Training School, was sentenced to 30 months in prison for committing bribery.” VA 3

Apparently, bilking the GI Bill is a regular fraud opportunity, and the VA employees need to be held more accountable for the loss of these funds! The GI Bill is a precious commodity and sometimes the only lifeline for a soldier for retraining while awaiting the VBA’s decisions. Therefore, stealing these funds should come with more substantial sentences, more accountability for the employees in the know of fraud, and scrutiny from elected officials!

For the next story, we have several crimes co-occurring; the most egregious is reporting to have been a veteran, fraudulently obtaining benefits, and then trying to use veteran status for preferential contract awarding. The VA-OIG reports:

“Robert S. Stewart, the former owner of Federal Government Experts LLC in Arlington, Virginia, was sentenced to 21 months in prison with three years of supervised release for making false statements to multiple federal agencies in order to fraudulently obtain multimillion-dollar government contracts, COVID-19 emergency relief loans, and undeserved military service benefits.” VA 3

I know the Supreme Court of the United States (SCOTUS) has declared that lying about military service is a freedom of speech issue and not a crime. However, stolen valor continues to make me sick, and the liars should lose all US Constitutional Rights, as well as be sentenced to punishment most vile! Having served twice (US Army and US Navy), having been deployed to S. Korea (US Army) and the Persian Gulf (US Navy Multiple Times), stealing valor infuriates me into a raging juggernaut! I hate liars and thieves, but to steal valor from those deserving goes above and beyond being just a liar and thief, and the conduct deserves punishment most vile! No, I am not apologetic in taking this stance either! Burn the American Flag; I disagree with SCOTUS again and becoming a raging juggernaut! There are lines you do not cross with impunity, and if you cannot scream fire in a crowded theater as “Free Speech,” then acts of stealing valor or burning the American Flag are reasonable restrictions!

I do agree with Justice Oliver Wendell Holmes’ statement:

“The ultimate good desired is better reached by free trade in ideas — that the best test of truth is the power of the thought to get itself accepted in the competition of the market, and that truth is the only ground upon which their wishes safely can be carried out.” Angry Grizzly Bear

But stealing valor and burning the American Flag is not “free trade in ideas,” and I support social shaming as part of the punishment most vile for these lepers of society! Before you burn the Flag or steal valor, serve in uniform, watch a military funeral as a dependent, and then let’s talk about reasonable and valid restrictions upon “free speech!”

Another case, another criminal act, only this time, I am left asking, “How long has this individual been doing business with the VA?” Regardless, as this is an ongoing case, the following firstly applies: “The charges in the indictment are merely accusations. The defendant is presumed innocent unless and until proven guilty.” From the VA-OIG report:

“Muhammad Z. Aabdin of Bronx, New York, was indicted for offering bribes to a VA contracting officer in exchange for the award of VA contracts for personal protective equipment.” VA 3

It will be interesting to watch this case and future (potential) investigations occur. However, I have several questions needing to be answered, and the report does nothing to aid in answering the questions raised in the defendant’s arrest and the grand jury indictment. More to come as the VA-OIG and the US Attorney produce information. May the US Attorney NOT allow a plea deal!

The VA-OIG has often investigated improper fiscal practices at several VA sites for the VBA, the VHA, and the National Cemeteries. I could almost quote the following investigation results, only differing on how much money is involved.

“The VA Office of Inspector General (VA-OIG) conducted a review to examine whether VA’s Maryland Health Care System appropriately managed purchases and payments for medical equipment and supplies. Fiscal oversight of purchase cards and internal controls governing the use of overtime were also reviewed. The VA-OIG found ineffective processes, internal control weaknesses, and inadequate oversight in five areas: 1. The healthcare system and the Enterprise Equipment Request (EER) portal need improved controls for approving equipment purchases. 2. Healthcare system staff and the prime vendor should prepare timely and accurate planning information to ensure adequate supplies are on hand to fill orders. 3. Even though no inaccurate inventory payments were identified, VA’s inventory system needs controls to ensure correct recording of supply units and costs. 4. The healthcare system purchase card program requires closer monitoring to ensure purchases are authorized and supported by documentation. 5. The healthcare system should strengthen its overtime payment controls to ensure supervisors verify overtime hours were completed before approving timecards for payment. The VA-OIG team also identified more than $5 million in questioned costs related to identified issues such as undocumented or unapproved purchases” [emphasis mine]. VA 3

I have heard the term “Criminal Stupidity” and often wonder when “Criminally Designed Incompetence” will become adopted into common vernacular. I am so fed up with the excuses, the missing money, and the abuse of taxpayer forbearance by bureaucrats; I could rip my hair out and scream until my voice gives out! But, unfortunately, both actions do absolutely nothing to correct the problem and would make me miserable. The VA has problems with criminals without and stupidity masked as “designed incompetence” within, and the solution continues to be leadership!

Gravy Train 2 What adds fire to my mental processes on criminally designed incompetence, the VA-OIG has two other investigations in my inbox on the need to strengthen fiscal controls, , and more correctly track accounting practices. Under current legislation, if a private business accounted for their money like the VA, they would be shuttered, and criminal charges levied! Yet, somehow, the elected representatives cannot apply the same accounting behavior standard to a government agency, as they mandate for private companies! Anyone else thinks we need stronger demands for scrutiny of government agencies?

Plato 2 Adding more fuel to the fire for the IT/IS Departments of the VA, the VA-OIG discovered that the VA still cannot regularly and appropriately log records into its own electronic health record systems! Are you surprised; as a patient, I know I am not surprised at all. Worse, the lack of medical records being properly handled influences (negatively, of course) how the VBA makes decisions on claims!

“The Office of Inspector General (VA-OIG) evaluated whether VA’s community care staff accurately uploaded records for non-VA medical care to veterans’ electronic health records. Veterans receive non-VA care based on certain criteria, such as the distance from the veteran to the nearest VA facility or the wait time for a VA facility appointment. Records for non-VA care enable Veterans Health Administration (VHA) providers continuity of care and inform treatment decisions. The audit team found that staff at six of the seven VA medical facilities reviewed did not always index, or categorize, these records accurately. Inaccurate indexing of medical records poses a risk to veteran care. It increases the burden on the VHA staff who locate and correct the errors, reducing their time for other tasks. The team reviewed 209 veterans’ mental health medical records that VHA community care staff indexed between April 1, 2019, and September 30, 2019, and found 108 indexing errors for 92 veterans. (Some veterans’ records had more than one error.) Errors included using ambiguous or incorrect document titles, indexing records for non-VA care to the wrong referral or veteran, and entering duplicate records. These errors occurred, in part, due to inadequate procedures, training, quality checks, and quality assurance monitoring and a lack of local facility-level policies.” VA 3

Of course, training and local policies were blamed for the failure to log records properly! These are automatic designed incompetence excuses that appear every single time the VHA fails, the VBA fails, or they both make significant life-altering decisions for veterans, and the VA-OIG investigates! The VBA claims it is my duty to ensure outside providers send records to the VA in a timely manner. The VHA claims they have the documents the VBA wants, and they should read the file. Who is inconvenienced, not the VHA and the VBA, the veteran? The person who cannot even look at his digital file without a “Freedom of Information Act” (FOIA) request and 30-45 days of waiting, and even then, the document is heavily redacted for privacy! Whose privacy, I wonder, the providers, the employees, or the veterans? Because I guarantee the VA is conducting serious CYA on the records produced! Let alone IT’s continued failure to protect the veteran from identity theft or IS to protect the files from being accessed without reason by employees. Apathy

May 2021 was a tumultuous month for the VA and the VA-OIG. If you would like to review how tumultuous or think you might have missed an article or two reporting the VA’s designed incompetence, feel free to review using the following link. Frankly, I want to see action taken based upon the investigations to clean house, more fully scrutinize the VA, and improve the veteran experience at the VA. But, I do not tell you how to think or feel about an issue. Instead, I report and summate and leave the rest to you! VA 3

As always, I report and summate upon the good and bad. If you are a citizen of Indiana or receive your care from either Fort Wayne, Marion, or through the Northern Indiana Health Care System, please count yourself lucky, and pass on the praise to the VAHCS employees. The VA-OIG conducted a comprehensive Healthcare Inspection and found, “The VA-OIG’s review of the system’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors” [emphasis mine]. While improvements can still be made, this is HUGE news, and the Northern Indiana VAHCS leadership team needs to be back-slapping and congratulating their employees.

Knowledge Check! Thus, my sincerest congratulations go to the Northern Indiana VAHCS, and heaps of shame and scorn remain served cold to the ineffective leadership and useless employees of the VA in general! America, we should weep, for the VA is not alone in the government agencies in providing world-class detestable service, abuse of the customer (taxpayer), and skirting accountability and responsibility through designed incompetence! But, when we are done weeping, it is time for action! Changing the elected representatives, demanding higher scrutinization with actual penalties for failure, and insisting upon fiscal restraint equivalent to the private sector!

NO MORE BS: Have You Heard? Chapter 2

Question The first week of June is often a period of recovery. I have no idea why, but the first week of June is usually a recovery time. Maybe it was all those years in school; I honestly do not know. However, the world does not stop, and while the media goes 24/7 over the Memorial Day Gun Violence, stories are evolving that need your attention more. I do not say this lightly, as I understand those wounded and killed in gun violence are tragedies and cause for grief, but the corporate media has always used these “major stories” to allow other things to slip past.

Why Have you heard Dr. Fauci’s emails from while he was a name in President Trump’s councils reflect a different story than the lies he peddled for political purposes? “The emails from the first half of 2020 reveal Fauci’s skepticism early on about masks to ward off COVID-19, his dismissal of the notion that the new coronavirus escaped a lab in China, and his vague reference to researching how to make the virus deadlier.” Why is this spineless invertebrate still a media mouthpiece, a paragon of dirty virtues and political connections? Fauci’s research from 1990 through 2020 was in Coronaviruses, and he still hyped, pushed, and peddled lies to obtain a political payoff. Knowing masks were useless, he pushed lies. Knowing the survival rate, he still pushed draconian government takeovers of liberty, freedom, and common sense. Knowing he could orchestrate a catastrophe, he pushed lies to initiate a public health emergency and stood back to reap the windfall in the chaos created. Of all the government officials with hands in the pot stirring the government mandates, I blame Fauci more than others!

Have you heard the Federal Government remains hell bound and down on destroying the family but is explicitly targeting black families? Would a minority please help explain why under a Republican President, the Federal Government’s actions are racist, but under a Democratic President, the same actions are “beneficial, needful, helpful, and not in any way demeaning?” Frankly, I do not care about the race factor; the fact that the US Government, from the Mayor and School Board to the President, seems bound and determined to destroy the foundation of society, the nuclear family, remains highly suspect and needs to be investigated! Ever since the US Government stole State’s Rights where Welfare Programs were concerned, the family has been directly targeted. Look at any race, and you will see the same hit in the data, where families went from working to be self-sufficient to the government dole. Unfortunately, black families have suffered some of the worst impacts. Now we are three generations into the destruction of the family as a government program, and I want answers!

Have you heard, the data is inescapable, the conclusions self-fulfilling, and the results are incredible. When you want more economic freedoms, which lead to more overall liberties, it is best to start by ending corruption in government. Who would ever believe that economic freedoms lead to individual liberty, and the best place to start is reducing government? I am absolutely… nonplussed! The founding fathers of The United States of America, a Free Republic (if we can keep it), understood these connections intimately and established the US Constitution to provide future generations the best chance of keeping the American Republic. So, who would like to start firing and cutting government? I am first in line; join me! Plato 3

The Department of Veterans Affairs – Office of Inspector General (VA-OIG) released a report on 02 June 2021, detailing crimes so horrific and obscene, I can find no appropriate adjectives to describe this negligence and criminality of all administration leaders involved. January 2021, Dr. Robert Levy, who was a pathologist, who over his 12-year tenure at the VA Hospital in Fayetteville, Arkansas, made over 3000 diagnostic errors, manipulated the quality control process, and caused severe injury to 34 patients, received 20-years in what can only be called a “plea deal” that should never have been allowed! The good doctor admitted to long-term alcohol use. Now, will someone please hold the leadership teams accountable for this doctor’s behavior? This story makes me especially sick! Where are the politicians who were elected (hired) to scrutinize the government? Where are the “Blue-Ribbon Congressional Committees” to hold those accountable and responsible for 34 veterans severely injured over the actions of a VA provider? Who will speak for the victims and demand, then oversee and insist upon corrective actions by an executive branch of the government through the work of the legislative and judicial branches of government? VA 3

I was an operations manager, the safety of my workers was my paramount responsibility, and I could be held legally accountable for what happened on my manufacturing floor. I had two people go for lunch, lifting 40oz curls, and returned to work for the afternoon soused! I had to shut down my manufacturing facility, I had to keep these two from driving away, I had to call in the temporary employment agency to collect these gentlemen, and they could not have their keys back, for as soon as they returned to work in an alcoholic stupor, I was responsible under the bartender law. This incident still brings some emotional baggage and resentment at these two morons. How in the world was the good doctor able to be alcoholically impaired on the job, and nobody was aware? Impossible! Where is the accountability of the leaders in this situation? I could have been jailed for allowing employees to operate their vehicle under the influence; when will the administration be held responsible for allowing a drunk employee to operate a vehicle? Read the VA-OIG report; it is a criminal list of what not to do from day one of this doctor’s employment! Plato 2

Have you heard, the Department of Veterans Affairs (VA) killed a veteran in the emergency department of the Malcom Randall VAMC in Gainesville, Florida. Worse, the veteran should never have died, and the reason they did was due to inefficiency, inadequate care, and processes and procedures in the emergency department triage of patients. The patient had experienced hemicolectomy surgery, and between days 10 and 15 post-op recovery, he went to two outside ER’s and the VAMC ER, where he passed. Drunk employees for 12-years are abysmal, fail to recognize patient distress, delay care, and cling desperately to outdated and inefficient processes in patient care in an emergency room, are execrable, horrific, and so vile to have exceeded repugnant! VA 3

Again, one must ask, where are the elected officials in pushing changes to the VA Administration; Oh, I know where they are; they are trying to kill history and remove President Lincoln’s mission statement for the Department for Veterans Affairs. We need to understand priorities: Is a veteran’s life more important than being woke and having a small group of citizens begging for less sexism, who are always going to choose to be aggrieved, be satisfied for a small amount of time? I know what my priority is, and it has nothing to do with the permanently dissatisfied and everything with saving lives and honoring patients who deserve the honor!

Knowledge Check! I implore you to please join your voice to mine, and let’s remember Memorial Day 2022 as the day marking how in 2021 we changed the VA, we limited the government, and seized our liberties and freedoms, as the founding fathers intended! We can make a difference in the government, provided we band together without the petty names and distinctions currently being used to separate and divide. We, the American Citizens, deserve better from the government we pay for, even if we must use every legal tool in our arsenal to cull the politicians and take the freedoms they have stolen.

NO MORE BS: Highlights (?) of the first 100-Days

Theres more On this momentous day, marking 100-days of the fraudulent president, I thought it fitting to mark the occasion by reminding everyone of freedom grabbing runaway government promoted by President Biden. As CNN so clearly stated, “To date, 10 of President Biden’s actions on immigration have been reversals of President Trump’s policies.” Begging the question, do you feel safer in your home now, or this time four years ago? I know my answer, and I am looking forward to your thoughts.

To date, President Biden has made 50-end runs around the US Constitutional process through executive orders. For the record, you could take President Trump (38) or Obama (34), add them with President Bush II (13), and still not max out President Biden’s lead. I have written about executive orders and why I detest this singular action made in a free Republic (if we can keep it) by any leading elected official, Mayor, Governor, or President. The US Constitution does not need more beatings coming from leading executives, but less. Much, much, less executive actions, executive orders, and singular people acting “for the good of all” without Congressional representation. Why use CNN; because as the biggest cheerleaders for the fraudulent president, they have the clearest cheering squad.

Detective 2 Examining closer the 50-executive orders issued by President Biden, we find the most egregious of these orders, raising the minimum wage of Federal Contract Workers from $10.95 to $15.00 by 2022 and eliminating the tipped minimum wage by 2024. I am thoroughly unfamiliar with any federally contracted jobs that fall under the tipped minimum wage. Thus, I can only presume the president is now arbitrarily setting the minimum wage for the country without congressional approval—leaving serious questions behind about the legality of this executive order. Where is Congress in exerting its power and rights to set minimum wage?

A minimum wage is a serious issue; any time the wage goes up, jobs are lost. A competent first-year economics major can trace that cause and effect line easily! There are direct causal relationships between high school kids needing employment and not finding it due to the minimum wage laws. This group of uneducated workers extends to many low-income families, minorities, and many others trying to find work as laborers and cannot find jobs. Yet, as a political stunt, the president signs an executive order, betrays the US Constitution, upsets the separate but equal branches of government balance, and somehow this is a “nothing burger.” I beg to differ, vociferously!

Detective 4 Another interesting aspect of the president’s first 100-days is immigration. The current president’s Trump Derangement Syndrome has him reversing 10 of President Trumps Executive Orders and writing two additional immigration-related orders. The plasticization of modular language reveals the tyranny of ruling by executive order! The terms “fair,” “equitable,” “just,” “proper,” etc., all point to the president’s desire to see America devalued by illegal immigrants. Look at the rhetoric used by the president to “explain” why he has reversed, revoked, and wrecked the legal immigration process, and you will find that through Congressional inaction. With Congresses’ refusal to exert its rights, the president can do anything he wants on immigration, and Congress’s leadership just cheers!

To the US House and US Senate, I must ask, where are you? Did you take a taxpayer-paid vacation and stopped caring that you are a co-equal branch of the government? Do you think the judicial branch will stop the president’s runaway government by executive fiat? Do you believe that the American people stopped caring that the president is giving away America, one illegal alien at a time, and we would not notice? Why are you not scrutinizing the executive branch and exerting your rights, standing up for your voice, and making sure you are playing a role in the governance of America?

Patriotism I have been insulted, denigrated, derided, and many other things for my stand that every president should have a contentious Congress! I firmly believe that when a president has a contentious Congress, the will of America’s people is better respected, observed, and through the process of working together, real compromise occurs. But, what do we see in the US House of Representatives; we see a Speaker who is also the majority leader and the minority leader abdicating their duties to their caucuses and the US House of Representatives. We see members of the US House race-baiting, employing every card in the deck of identity politics deck and refusing even to acknowledge the other party. But, the US Senate, if anything is worse, and the US Senate’s problems can be traced directly to the executive actions of Speaker Harry Reid (D) during President Obama’s tenure.

Millstone of Designed Incompetence America, we learned a lot about the “families” presenting themselves at the US Southern Border for entry into America. We learned about child prostitution, children being “attached” to two strange adults and calling it a “family.” We learned about a lot of schemes to feed the growing human trafficking problem in the United States. Yet, the media continues to call the separation of “families” unfair, and the president has proved he learned nothing but smoke and mirrors. At the same time, these children are raped, abused, disappeared, and destroyed, all through executive order instead of legislated demand! Legitimate families should be kept together, but until documentation can be obtained, separating the families for the safety of the children should be paramount! Sorting through the MS-13 plants is not uncaring; it protects America’s main streets from terrorists! But, these immigration policies, designed by President Trump, are hated by the media; so, these policies have to go. Thus, I ask again, do you feel safer in your home or not?

The Duty of Americans I was never a President Trump (R) supporter; but, I did, and do, support anyone willing to try new ideas to make America safer. I am not a supporter of holding children indefinitely in nice hotels when veterans are homeless and fully support an America FIRST agenda. But, I also firmly believe that the churches and non-profit groups of America can organize to help in a humane way better than runaway government supported by executive fiat!

Apathy America, we need legislation on immigration, NOT executive orders that change as frequently as the president! I have maintained this stance, publicly, since President Reagan signed the first orders providing paths to citizenship for illegals. The illegal immigration policies in America can be directly traced to President Roosevelt and WWII executive orders allowing foreign workers access to America’s jobs in agriculture.

Feel free to look this historical tidbit up, and ask yourself, are you safer in your homes and places of business with executive orders or legislation? Are you feeling more secure in your finances with runaway executive actions or through the “Rule of Law?” Do you prosper more under one “Rule of Law” or under identity politics where every single identity can request special treatment, special laws, and special rights?

If the fraudulent president has proved anything in his first 100-days, he has proved America is in trouble, DEEP Trouble, due to the executive orders, runs around the constitutional process, and the abdication of Congressional rule (legislative branch) at all levels of government. Beyond a shadow of a doubt, this president has proved that bigger government is a millstone dragging this Republic down. Finally, this president has proven you cannot “trust” the government and must watch it like a toddler running with a knife! So, CNN, and all the other corporate media outlets, you cheer the fraudulent president; but don’t you dare try to claim this is a good thing for America!

NO MORE BS: Putting Shame in the Right Place at the VA – Administration

Angry Grizzly Bear I have found great and good providers at the VA, as well as some truly awful and detestable providers. The Doctors, Nurses, Medical Support Assistant (MSA), and the patient are supposed to form a PACT team to improve the health and welfare of the patient in the VA Health Care System (VAHCS). The PACT Team is a VA organizational program to assist in improving care and stands for Patient Aligned Care Team (PACT), as an extension of patient care services. The PACT Team also includes the Patient Advocate and several others, as detailed in the image below. PACT_model

I mention all this because I have heard from a veteran, we are going to call him “Boats,” a chief Boatswain mate for over 20-years in the US Navy, honorably discharged, and a disabled veteran of the Vietnam Era. Boats’ doctor changed clinics, thus shaking the PACT team to its core. Since the doctor was reassigned to a different clinic, the nurse has been changed but not explicitly assigned, so the coverage nurse cannot be reached by phone, and secure message falls on deaf ears and plastic lips. Hence, reaching his PACT team has become a burden, his health has suffered greatly, and the mask mandate makes his safety in the VA Clinic doubtful at best, as the mask aggravates his ability to breathe.

PACT 1 Because his clinic has no doctor, other doctors have been sharing their time in the clinic. This means that if treatment requires time and interactions over multiple visits, the patient loses any type of continuing care and is left frustrated, with continuity of care hindered. Here’s the rub, this has been an ongoing situation for a long time, and the continuity of care has become a root cause in the failing health of this veteran. Unfortunately, this is not a new or rare problem for the VA, and as shortages in providers continue to increase, it will only worsen.

PACT 3 Boats is in the same situation as many other veterans. While misery loves company, this type of misery costs lives, and that is an administrative problem Congress legally bound the VA to fix, and they refuse to address. Like the mask policy that does not include a face shield option or include the verbiage for approved medical conditions, the administration of the VA continues to market lofty and grand standards and fails even to meet minimum legal requirements. I have witnessed the administrative officers, known by their online pictures, refuse to help veterans, pawn off veterans, and even go so far as to hide from veterans to avoid providing customer service.

The hospital administrators have been schooled in the VA; many have “come up through the ranks.” These administrators have been taught how to avoid accountability, responsibility, and work the VA Bureaucracy to keep their jobs, even when veterans are dying from the administrative problems they created. While an employee, I heard the tales of how my Hospital Administration Services Director got her job; draw your own conclusions, all I do know is someone was promoted to an exceedingly great height above her maximum level of incompetence!

Detective 4 Consider the hospital director moved, at taxpayer expense, from Seattle to Phoenix. She had been killing veterans in Seattle and took over an award-winning hospital, which very shortly became a national joke for where veterans go to die! Her lessons are still being taught, veterans are still dying, and the administration is still the problem! The mask mandate that has stopped my prescription from being refilled, my abusive PACT Team led by a doctor who invited me to find a new provider, refused to contact me for two months about needed blood work to refill diabetes medication. After two weeks without diabetes medication, magically, diabetes medication arrives. No blood work ever occurred because I cannot access the VA due to my approved medical condition that makes wearing a mask impossible.

The administration of VA Hospitals is a crime! I had an assistant director, while an employee, who said, “If a non-VA Hospital did anything like the VA does things, they would be shut down for malpractice.” The assistant director is now a clinic director for the VA; her resume included 20-years in non-VA hospital administration. She joined the VA to help veterans. Where is the VA-Office of Inspector General in rooting out these administrative landmines of ineptitude that makes hiring more difficult and retaining talent near impossible? Where is Congress in scrutinizing the VA and helping those working to change the VA to succeed instead of actively contending with them?

Boats has serious problems. The legacy of the VA is to kill him instead of fixing their administrative problems. But, the VA’s mission statement is still, “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.
“Our department remains fully committed to fulfilling the sacred obligation that we have to those who serve in uniform.” ~VA Secretary Denis McDonough.

VA Seal Where is the VA acting in accordance with the mission statement and fulfilling its “sacred obligation?” The answer, with the current leadership in administration, nowhere! The VA has been purposefully designed to kill veterans and can be fixed. The fix must include Congress, and we all know how Speaker Pelosi (D) feels about veterans; when she called them terrorists, it was clear her scrutinizing the government where the VA is concerned will not happen.

I-Care VA Secretary Denis McDonough signed onto the “I-Care” principles as core values in care for veterans in the VAHCS. Well, when can we, the veterans, see that these core principles have been on-boarded and are correcting behavior?

“VA Core Values describe how VA will accomplish its mission and inform every interaction with our customers. These Core Values are: Integrity, Commitment, Advocacy, Respect, and Excellence — better known as “I CARE.” VA’s Core Values will continue to serve as the right guide for all our interactions and remind us and others that “I CARE.”

I care about those who have served.
I care about my fellow VA employees.
I care about choosing “the harder right instead of, the easier wrong.”
I care about performing my duties to the very best of my abilities.

Mr. Secretary… The veterans are dying now! We are waiting!

Like my enlistment oath, I signed onto the I-Care principles and even though I am no longer employed by the VA, I live I-Care! Where is the VA in proving “I-Care?”

NO MORE BS: Excuses or Designed Incompetence

Apathy Consider the following situation, you receive a letter dated 26 February 2021, postmarked 11 March 2021, and received on 16 March 2021. The letter demands you respond within 14-days of the date of the letter, or you will be held accountable for failing to respond in a timely manner. When you call to complain about the delay in receiving the letter, you are told, the US Post Office (USPS) is to blame, and all complaints should be directed to the USPS.

What is an excuse?

An excuse is a method to reduce blame attached to an action, defend or justify one’s actions, an attempt to release one from accountability or a poor or inadequate example of something. As children, we are taught excuses are like noses; everyone has one, and picking it in public is disgusting. Yet, when something happens, two types of people emerge, those who make excuses and those who take responsibility and work to fix the problem.

What is designed incompetence?

Designed incompetence is a ready-made excuse for inadequacies created in business operations, a method to avoid responsibility and accountability. Due to the cost of designed incompetence, it is generally only found in government operations. Designed incompetence can also be intentional actions designed into business operations, so the expected functions are designed to fail purposefully. Designed incompetence is always harmful and destructive in nature, generally will make no logical sense, and will always be the preplanned leadership fallback position.

Example of an excuse:

The USPS is running slow, so the delivery of mail is taking longer to deliver than usual.

COVID has a lot of employees out sick, so operations are slower.

The person who wrote the order requesting the work to be completed did not do their jobs properly, and the original order must be rewritten.

Examples of designed incompetence:

Detective 4 How mail is handled is that one person prints the letter and stuffs it into an envelope. Another employee picks up the mail for delivery to the mailroom. A third employee operates the postage machine. Once posted, a fourth employee takes all the mail to the postal dropoff/pickup point.

The “system” is designed so that the person writing the orders is the only one who can designate where the work can be completed.

The regular employee handling this process is out, and nobody else knows that position sufficiently to perform the employee’s functions with COVID. So everything had to stop while we waited for the original employee to return.

We “forgot” to reset the postage paid from $0.46 to $0.51, which caused delays in mail being correctly posted and sent out. Since four of the six-letter received on 16 March had a second $.10 postage on the back, I can presume safely there was a delay.

What do you think?

Today, I spent four different calls to the same government agency, and received more than 12 different excuses, and identified 6 processes designed incompetently with the sole purpose of providing a method to shift blame, remove accountability, deny responsibility. I was talking to the Department Heads of three different sections of the same organization. People in charge of fixing the problems to eliminate excuses and redesign operations to remove designed incompetence are not doing their jobs. Maybe, my analysis is a little hasty; however, after 17 years of dealing with this organization, I feel confident in my conclusions.

Duty 3 I know my response; I am very disgusted with the organization and these designed incompetent operations and lackadaisical managers posing as leaders. As a professional who works with companies and organizations, I work tirelessly to remove excuses and eliminate designed incompetence. Yet, I do not understand how the government can continue to escape responsibility, accountability, and behavior correction. I am not confused but very disheartened that Congress refuses to scrutinize the government to correct and improve behavior and performance.

What would you suggest for corrective behavior for the government? I am genuinely interested in your thoughts and comments, for, from the disparity of the comments, we can design improvements and demand those improvements are accepted. Feel free to dream big in the comments, and let’s design our government to improve for all.

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