“That’s Crazy!!!” – More Chronicles from the VA Chapter 8

I-CareI fully admit I got behind in April.  Dear reader, my apology.  I have been whipsawed between emergency room visits, depression, extreme pain, and other issues.  Not offering an excuse but a tiny peek into my world as a disabled veteran.  Luckily, I have maintained employment because my employer allows me to work from home.  My driving privileges are threatened again with removal due to the neurological issues I suffer, and this will dynamically change my life, but this article is not about me, but the continued catastrophe called the Department of Veterans Affairs (VA) and the Inspector General (VA-OIG) reports published.

We begin with a financial efficiency review reported from the inspection of the Durham VAHCS of North Carolina.  I know the jokes write themselves when we discuss any government agency and financial efficiency, but I digress.  This is a head exploding report of leadership failure in the observation and governance of employees who did not perform the functions they were hired to perform.  The VA-OIG found the following from October 1, 2020, through March 31, 2021:

    • The healthcare system had 309 inactive obligations totaling $81.7 million.
    • Of these 309 obligations, 200 (totaling over $74 million) had no activity for 181 days or more.
    • In a subsample of 20 obligations, VA staff had not reviewed 17, as required.
    • Contrary to VA policy, healthcare system staff used purchase cards instead of contracts for 21 of 40 sampled transactions (53 percent), totaling approximately $328,000. These 21 transactions were missing required supporting documentation to verify that the transactions were approved and payments were accurate, resulting in $308,000 in questioned costs.
    • 105 more administrative full-time equivalent staff than the expected number, all not doing their jobs as required under Federal Law!

While not all of the findings, those mentioned are the most egregious and in need of corrective action.  Would the citizens of Durham, North Carolina, please tell me, has this been reported in the local news?  Has anyone lost their jobs as the VAHCS right-sizes the financial department?  I can find no additional information that this problem has been corrected, and I am really curious!VA 3

Oh, the irony is thick; consider the following:

The Department of Veterans Affairs Office of Inspector General Training Act of 2021 would help ensure that VA employees continue to be empowered to assist the OIG in improving VA’s operations and using taxpayer dollars to the greatest effect; helping protect patients and improving their care; and ensuring veterans and others receive services and benefits for which they are eligible.”

The above-quoted material originates from Chris Wilber, who testified to Congress’s HVAC Subcommittee on oversight and investigations.  What is the number one failure on every comprehensive healthcare inspection (CHIP); the lack of staff training, the inadequacy of staff training, or adequately trained staff.  Yet, the statement by the VA-OIG indicates that training has met a threshold for providing adequate training.  Let’s talk about a specific action, “the VA secretary signed a directive in September 2021 mandating that all employees complete a one-time training within one year—an important step in improving VA’s culture of accountability.”  It is now May 2022; the VA-OIG is pushing for training directives to be legislated, not dependent upon any single VA Secretary.  Are you freaking kidding me?  Where is the congressional oversight and scrutiny that allows VA training to continue to be subpar and threaten the lives of veterans?

Long have I wondered how the VA could frustrate VA-OIG actions, investigations, inspections, etc.  Guess what; the answer has become available:

“… there have been instances in which the OIG has been informed that staff have been told that they cannot share information with OIG investigators without first clearing it through supervisors or leaders—contrary to the Inspector General Act of 1978 (the IG Act), as amended.  Under that authority, VA employees at all levels have a duty to cooperate with OIG personnel, including providing information and assistance in a timely manner.”

Employees have been caught lying to the VA-OIG regularly, and what action is taken to remove those employees promptly and efficiently from government service?  From direct observation and employee conversations, it is clear that plans are carefully laid before a scheduled VA-OIG visit to present what the VA-OIG wants, but to gloss over the problems, and nothing ever happened to the managers, supervisors, and employees who lied and misdirected the VA-OIG.  All contrary to established Federal Law!VA 3

Want a specific example of employees intentionally misrepresenting information to the VA-OIG?  Look no further than the statement by Chris Wilber, and this incident was covered as a failure of leadership in a previous article.

Hospital staff at a VA facility in Fayetteville, Arkansas, had concerns about potential substance abuse by the chief of pathology that were not heard and promptly acted on by local management, which allowed him to work while impaired for years.  He misdiagnosed about 3,000 patients with errors resulting in death or serious harm and is currently imprisoned.  The OIG found a culture in which staff did not report serious concerns about the chief pathologist, in part because they assumed that others had reported him, or they were concerned about reprisal.”

From personal experience, I reported problems to the VA-OIG concerning patient abuse, fraud, waste, and other issues.  Never were my concerns acted upon promptly, and I was removed from employment for being a whistleblower.  The culture of corruption at the VA is incredible.  The examples mentioned by the VA-OIG only further sustain the problem with leadership and how sick the VA truly is as an organization!VA 3

We next turn our attention to the VA-OIG report on the inspection of information technology security at the VA Financial Services Center, another head exploding example of leadership failure bordering on criminal!  The findings include:

    • component inventory
    • vulnerability management
    • flaw remediation
    • Identifying 252 vulnerabilities, of which 228 the local IT team could not identify.
    • the VA-OIG team identified access control deficiencies, as 107 of the 278 FSC systems failed to generate or forward audit logs for analysis.
    • the video surveillance system was not fully functional. Ineffective monitoring and recording facility activities supporting information systems minimize the FSC’s incident response capabilities.

How do you spell failure; these findings spell failure to me rather pointedly and dramatically!  Want to laugh; staff training remains a concern, but not a finding, of the VA-OIG inspection team.  Frankly, with this level of incompetence, staff training should have been a finding.VA 3

To be concise and illustrate further the poor leadership, convoluted processes, and brazen noncompliance of VA officials, the following discussion is about two different VA-OIG reports that reached similar conclusions.  First, we have the VA-OIG report on “Noncompliant and Deficient Processes and Oversight of State Licensing Board and National Practitioner Data Bank Reporting Policies by VA Medical Facilities.”  Second is the VA-OIG report on “Concerns with Consistency and Transparency in the Calculation and Disclosure of Patient Wait Time Data.”  Nothing says convoluted processes more than having two written policies, both originating from Washington DC.  The superseded policy does not have an expiration date.  This means that employees have a designed incompetence excuse ready for not adhering to the most current and applicable policy.  Don’t believe me; one of the key findings was, “VHA has presented wait times to the public without clearly and consistently disclosing the basis for their calculations.”  Designed incompetence does not come more blatant than this, and who suffers, the veteran.  Worse, wait time correction and policy clarification has been stalled by COVID-19, the neverending excuse paying dividends to bureaucrats everywhere!Timelines for Wait Time Calculations

However, both reports are substantially summated by the VA-OIG; thus, “The lack of programmatic oversight contributed to the failure of VHA leaders to detect and intervene upon facility noncompliance.”  Meaning that due to COVID-19, the VHA has refused to do their jobs in deference to the pandemic, and since this is a good enough excuse, the VA-OIG has bought the designed incompetence, lock, stock, and barrel.  The VHA leadership is failing; doctors or dentists let go for poor performance were not reported to state and federal boards, so these providers lacking can continue to harm patients.  It is a federal law (42 US Code § 11151, US Department of Health and Human Services, Health Resources and Services Administration Bureau of Health Workforce, NPDB Guidebook, October 2018, chap. A., 8 USC ⸹ 7462(a), 38 USC ⸹ 7401(1), among others) that providers let go for cause must be reported within 7-days to the regulatory boards at the state and federal levels.  Wait times are hidden because they are so bad; the VHA is embarrassed, so the leaders fall back on designed incompetence to shield themselves while looking for another excuse for poor performance!  In both reports, the ramifications of noncompliance are putting people at risk for sentinel events (death, injury, disability, etc.), and the leadership is at best lackadaisical in the performance of their duties.  VA 3

Where are the congressional overseers in ending the abuse?  When will this insanity and bureaucratic inertia end?  How many “sentinel events,” including deaths and permanent injuries, will it take until those tasked with scrutinizing the executive branch finally take committed action and hold people accountable?  When will the elected representatives stop throwing good taxpayer money at problems that money cannot fix?  If these questions are too difficult to answer, please stop running for elected office, for the citizenry is not happy!

We conclude with two related reports so astoundingly obtuse they defy logic and sanity.  The first is the annual CliftonLarsonAllen LLP (CLA) audit of the VA’s information security for 2021.  The second is the continuing failure of the new electronic health record modernization (EHRM) program.  The VA has failed the CLA audit for more than a decade, with many of the hits repeated year-over-year.  In fact, the CLA audit is so bad this year; it has taken my mental breath away and stunned me into a gibbering idiot!  Reading this report was infuriating; describing it as my head exploding is akin to comparing an M-80 to a nuclear bomb.  How in Dante’s Inferno can this level of incompetence be allowed to remain employed?  But, as bad as the CLA audit is, the continued failure of the new electronic health record system pales in comparison.  The new EHRM continues to suffer from reliability weaknesses, which is polite speak from the VA-OIG for the new system fails to do the job.  We are three years from the new extended deadline, we are already past the original deadline, and the system is worthless today than it was a year ago.  With this success rate, the new EHRM will be utterly bereft of value and need replacement before the year’s end.  How many millions (billions, or trillions) of good dollars must chase this ineptitude before the plug is pulled and those involved held accountable?VA 3

Join me in having your head explode:

Additional deficiencies included known tasks not being reflected on schedules, no risk analysis, lack of longer-term actions scheduled, and no complete baseline schedule or overall schedule that fully integrated individual project schedules. VA also did not comply with federal regulations when it paid its contractor for deliverables before accepting them (reviewing compliance with contract requirements).”

Consider this other gem from the VA-OIG report, “$1.95 billion in cost overruns per year” are estimated, meaning the final tab will be significantly higher and compounded year-over-year.  In plain speak, the contractor is being paid for products delivered that fail, the products offered are not usable, there is no schedule of completion, there is no schedule for deliverables, many of the products paid for have never been delivered, and costs are overrunning like a plugged toilet. Worse, no one is being held personally liable for these problems, which were apparent in the last EHRM update from the VA-OIG a year ago!  Like the CLA Audit, I am thrilled the VA agrees with the VA-OIG findings, but what are they DOING to fix the problems?

FYI: the image below is a year old, and comes from the last major update to the EHRM.EHR-VA-OIG

?u=https1.bp.blogspot.com-aqaqk18MHoEWRHHsCi_TyIAAAAAAAAAXc7hY4JQuyylIQHYudoR8sbezGZntic4SSwCLcBs640Betrayal2BSayings2Band2BQuotes2Bwww.mostphrases.blogspot.be.jpg&f=1&nofb=1There is no excuse for behaving like the VA’s bureaucratic legions behave.  Bureaucrats, from the city government (including the school board) to the Federal Government, you hold a sacred trust to act better than you are currently performing.  I refuse you any leeway for acting like pompous overlords when you are paid through forced taxation!  You have trespassed upon my patience and kindness long enough, and the day of reckoning has arrived.  You work for me; you work for every taxpayer and citizen in this country, and you have violated our trust, charged us too much and too often, and if you do not begin to show yourself worthy of the sacred trust, we will force you from your cushy jobs and hold you liable for the monies you have squandered!  The law is on our side; you need to begin showing you honor our trust and investment forthwith!

© 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 1/10th of what you billed (invoiced), would you continue to conduct business with that company or organization?  Now add the unopened mail problem to the mix.  Would you continue to conduct business with this entity?

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

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

If Everyone Cared – More Detestable VA Stories (Chapter 2)

?u=http3.bp.blogspot.com-CIl2VSm-mmgTZ0wMvH5UGIAAAAAAAAB20QA9_IiyVhYss1600showme_board3.jpg&f=1&nofb=1For the last two weeks, I have been a little remiss in writing.  My cousin passed from diabetes, two of my grandkids got sick with COVID (they are recovering), and I was diagnosed with asthma.  The last two weeks have been a roller-coaster of ups and downs, so imagine my surprise as I went to catalog more of the Department of Veterans Affairs (VA) – Office of Inspector General (VA-OIG) reports, Nickelback’s song, “If Everyone Cared,” was playing.  Pandora certainly appears to have a sense of humor and an innate sense of déjà vu.  I cannot think of a better title to proclaim the need for raising awareness and what is needed to fix the VA.  Until everyone is aware and the scab hiding the infection of the VA are ripped away to be exposed to the sunlight disinfectant, nothing will change, and taxpayers will continue to pay for the abuse of veterans who deserve so much more.  Thus, as we celebrate US Constitution Day, let us remember the veterans who have helped protect and defend the US Constitution and improve the government response!

The VA-OIG reports begin in Kansas City, Missouri, with a $335 Million Fraud Conspiracy, which included $615,000 in tax violations.

By pleading guilty today, Patrick Michael Dingle, 50, admitted that he conspired with Matthew C. McPherson, 45, of Olathe, Kansas, to fraudulently obtain contracts set aside by the federal government for award to small businesses owned and controlled by veterans, service-disabled veterans, and certified minorities.”VA 3

A sentencing hearing will determine if any prison time and what if any, restitution is required in this plea deal.  Frankly, the fact that the fraud existed from 2009-2018 is nothing short of a blatant and utter slap in the face for the taxpayer.  How many federal employees had to have seen the documents, failed to perform due diligence, refused to do their jobs, and were not named as co-conspirators or, at a minimum, facilitators of the crimes?  Is aiding and abetting a criminal operation not a charge that can be brought against the federal employees who empowered this fraud?  Thus, I demand all these people explain why and how an investigation can occur and not include the facilitators, those federal employees, who did not do their jobs!

Assistant US Attorney Paul S. Becker is prosecuting the case. The following agencies assisted in the investigation: the Department of Veterans Affairs, Office of Inspector General; the Department of Defense Criminal Investigative Service; the US General Services Administration, Office of Inspector General; the U.S. Small Business Administration, Office of Inspector General; the Army Criminal Investigation Command, Major Procurement Fraud Unit; the Department of Agriculture, Office of Inspector General; IRS-Criminal Investigation; the US Secret Service; the Air Force Office of Special Investigations, Procurement Fraud; the Naval Criminal Investigative Service; the Defense Contract Audit Agency – Operations Investigative Support (OIS); the US Department of Labor, Office of Inspector General; and the Department of Labor, Employee Benefits Security Administration (EBSA).VA 3

File the following under false imprisonment, and will someone please tell me why those employees involved are not in prison now!  A patient in the inpatient mental health unit and community living center at the Tuscaloosa VAMC in Alabama was falsely imprisoned and kept against their will for more than 2-years.  Was denied access to a patient advocate, which should be a red flag that something is disastrously wrong right there.  Plus, official mail to an elected official was improperly handled by staff to prevent elected officials from knowing about the veteran’s plight.

Here is what the VA-OIG investigation substantiated in their investigation:

    • Staff did not adequately assess the patient’s admission status as voluntary or involuntary and did not follow commitment requirements during the first two of the patient’s three Inpatient Mental Health Unit admissions.
    • Staff did not properly manage a letter from the patient that was intended for a public official.
    • Staff did not correctly identify a surrogate decision-maker and did not address ethical concerns regarding the appropriateness of the patient’s surrogate decision-maker.
    • Staff did not comply with requirements when the patient requested an against medical advice discharge.
    • staff at the facility denied a patient’s discharge requests and did not ensure the patient’s access to a patient advocate.
    • Staff failed to follow informed consent procedures.
    • Staff denied the patient’s discharge requests.
    • Staff did not conduct a sufficient or timely decision-making capacity evaluation and documented unsupported, conflicting decision-making capacity information in the patient’s electronic health record.VA 3

These are serious crimes, not bad administrative practices, felonious crimes.  Yet, the employees skate, the patient was held against their will, and nobody will be responsible for this disaster.  Where are the elected officials?  Where are those hired to scrutinize the government?  In this situation, any other medical organization would be facing lawyers armed with righteous indignation and seeing dollars signs in their dreams.  Yet, because this is the VA, the patient can be harmed, and no one will ever care, and that is a crime the elected officials are guilty of and need to be held to task for!

Moving to Biloxi, Mississippi, we found another VA employee who had sticky fingers and a long time to steal from the government (2009-2020).

Chad Paul Jacob of Saucier, Mississippi, pleaded guilty to stealing personal protective equipment, electronics, and medical equipment while working as the assistant chief of supply chain management for the Gulf Coast Veterans Health Care System in Biloxi. From 2009 through December 2020, Jacob stole and resold VA property at local pawn stores and on his personal eBay account.”VA 3

For eleven years, they were working as the assistant chief of supply.  The employee had how many reporting employees and superiors have had to sit through how many records audits.  In all these eleven years, I cannot believe that nobody ever suspected problems.  Who did the thief learn how to steal from the government from?  How many employees churned, and did any of these employees churn because they tried to report irregularities, and the boss ensured they were disposed of to silence them?  The VA has been taken to several congressional hearings to eliminate the whistle-blower rather than fixing the problems at the VA.  Thus, it is not in any way, shape or form, out of line to be suspicious about employee churn and fraudulent actions taken by a supervisor to eradicate and protect their schemes!  Why are these questions never asked in the VA-OIG investigations where schemes are uncovered by ranking and supervisory personnel?

Remaining in the south and moving next door to Slidell, Lousiana, a doctor, has been indicted for illegally dispensing opioids in a health care fraud scheme.

Adrian Dexter Talbot of Slidell, Louisiana, was charged for his role in distributing Schedule II controlled substances, including oxycodone and morphine, outside the scope of professional practice and for maintaining his clinic to distribute controlled substances illegally. He was also charged with defrauding health care benefit programs of more than $5.1 million, given that the opioid prescriptions were filled using health insurance benefits.”VA 3

Remember, an indictment is not a finding of guilt, and the defendant remains innocent until proven guilty in a court of law by a jury of his peers.  There is a very compelling point made by our founding fathers that need to be repeated here and declared more often in American Society.

“… Should the People of America, once become capable of that deep simulation towards one another and towards foreign nations, which assumes the language of justice and moderation while practicing iniquity and extravagance, and displays the charming pictures in the most captivating manner of candour, frankness, and sincerity.  At the same time, it is rioting in rapine and insolence; this country will be the most miserable habitation in the world.  Because we have no government armed with power capable of contending with human passion unbridled by morality and religionOur Constitution (the US Constitution) was made only for a moral and religious people.  It is wholly inadequate to the government of any other.” – President John Adams

The drug war and the opioid crisis stem from the same problem, a lack of morality and religion.  The duplicity of showing candor, frankness, and sincerity, while at heart there is nothing but ravening appetites and the minds of wolves, is the problem.  Sure, drugs create a social and medical issue out of the unbridled appetites and passions.  The core is the lack of self-restraint from being disconnected to religion and morality and from social duty, responsibility, and accountability.  Thus, making people miserable and looking for a cure.Knowledge Check!

The case above expresses this point clearly; the doctors involved were filling an appetite.  As long as there is an appetite, there will be people willing to risk everything to fill the appetites of others; moral and social disconnection, and the US Constitution cannot govern these people except to their destruction!

Moving to Fort Lauderdale, Florida, we find another series of indictments for more fraud, reflecting the same social disconnection.

Kingsley R. Chin of Fort Lauderdale, Florida, the chief executive officer of SpineFrontier Inc., and Aditya Humad of Cambridge, Massachusetts, the company’s chief financial officer, was indicted on one count of conspiracy to violate the Anti-Kickback Statute, six counts of violations of the Anti-Kickback Statute, and one count of conspiracy to commit money laundering. Chin and Humad allegedly bribed surgeons to use SpineFrontier’s products, and in turn, the company received millions of dollars in revenue from surgeries the surgeons performed.”VA 3

Traveling north to Bedford, Massachusetts, we find another dead veteran and culpability so thick it should be used as a board to apply corrective discipline for all parties involved!  From the report, we see the scope of the investigation for the VA-OIG:

Mr. Timothy White was a resident of the Bedford Veterans Quarters (BVQ), an independent living facility operated by Caritas Communities, Inc. (Caritas), in space leased to it through VA’s enhanced-use lease program. A month after Mr. White was reported missing, his body was found in the emergency exit stairwell of the building that houses the BVQ. This stairwell down the hall from his room was VA property and not leased to Caritas.”VA 3

The VA-OIG found the following as facts in the investigation:

    1. The VA police department’s failure to locate Mr. White resulted in part from the police and others at VA not considering the veteran an at-risk missing patient, which would have required a stairwell search.
    2. The Veterans Health Administration and the Office of Security and Law Enforcement lacked clear guidance regarding the obligations of VA police to search for nonpatients reported missing on VA property.
    3. VA police also did not discover Mr. White in the stairwell because of an improper order by the then-police chief to cease patrols of the building in which Mr. White was found.
    4. The OIG found that the VA police chief exceeded his authority as VA policy, and the lease required VA police to patrol VA property.
    5. Medical center staff mistakenly believed the emergency exit stairwells were not VA space; they did not clean them.
    6. The confusion among medical center leaders and staff regarding the lease scope and VA’s obligations stemmed from a lack of clear guidance from the Office of Asset and Enterprise Management.
    7. Routine police patrols and stairwell cleanings likely would have led to Mr. White being found earlier.

Angry Grizzly BearNow, as logical thinking adults, do you buy the load of excuses being sold here to pass off the blame for a dead veteran?  I know I am certainly NOT buying this load of bull!  Having worked and spoken in-depth to leaders of VA Police Departments, the excuses to not do stairwell checks and camera checks for missing patients are beyond inexcusable!  I know of a situation where a patient was lost on VA property.  Every police officer and staff member, even those on off-shifts, were called in, issued out in teams, and every square inch of the property was investigated until the patient was found.  Yet, somehow this patient was able to DIE unnoticed in a stairwell!  Are you kidding me?!?!?!

Regardless of whether this veteran died of malnourishment, dehydration, exposure, or lack of medication, he died horribly!  The veteran died at the hands of responsible parties, and those parties need to be held accountable for his untimely and atrocious death!  There is NO EXCUSE for this veteran to have died.  SHAME on the administration!  SHAME on the VA Police!  SHAME on the third-party contractor.  SHAME on the leaders of government who have allowed this abuse and refused to act!

Moving west to Chalfont, Pennsylvania, we find more stolen valor and theft of government benefits.

Richard Meleski of Chalfont, Pennsylvania, was sentenced to three years and four months in prison, three years of supervised release, and ordered to pay $302,121 in restitution for stealing VA benefits by pretending to be a veteran who the enemy had captured during combat. In July 2020, Meleski pleaded guilty to one count of healthcare fraud, two counts of mail fraud, one count of stolen valor, two counts of fraudulent military papers, as well as two counts of aiding and abetting straw purchases, and one count of making false statements in connection with receiving Social Security Administration disability benefits.”VA 3

While there are many more VA-OIG reports needing sunshine disinfectant, let us remember Mr. White, who has passed, and the feloniously falsely imprisoned unnamed veteran from today’s VA-OIG recap.  These two veterans especially deserve respect, dignity, and remembrance.  Their families and friends deserve praise and prayers.  America deserves answers, and federal employees need to be held accountable for failing to do the job they are paid tax dollars to perform!

I-Care© 2021 M. Dave Salisbury
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