While Rep. Greg Stanton (D)’s staff did respond, and this is a good thing, neither senator from Arizona Sen. Kyrsten Sinema (D) or Sen. Mark Kelly (D) cared enough about my concerns to respond. Frankly, this speaks volumes about how little the senators representing Arizona care about their constituents or veterans. Hence when re-election arrives, remember well the treatment and vote for anyone else!
Now, getting back to Rep. Greg Stanton (D). I contacted his office initially in December 2020; by early January 2021, I received a response from the director of constituent services and was told to allow the VA 45-days to respond to my complaint. Remember, this is my seventh attempt at contacting any of the federal elected representatives to no avail. I was 6-months into being discriminated against by the Carl T. Hayden VAMC for my medically approved breathing problems that preclude wearing a mask. I have sent letters to the hospital director, the VISN Director, and Secretary Wilkie to no avail. I have sent emails to the patient advocate and gotten misleading information, at best. My Primary Care Provider (PCP), at the Carl T. Hayden VAMC, refuses to diagnose over the phone or through distant means and has invited me to find another PCP. I have been arrested, injured, and cited three times by VA Police, who have no say in writing policy. The policy they are enforcing is causing me both injuries at their hands and refusal of emergency care illegal under EMTALA. Not to mention the continuous HIPAA violations as they joke about my medications, mental diagnoses, and physical diagnoses.
I explain this by phone at least three times to the director of constituent services for Rep. Greg Stanton (D), who called me multiple times while responding to my numerous requests for assistance since the election occurred in Nov 2020. Not having heard anything from Jan 2021 to 25 April 2021, I sent the following message via email to the director of constituent services:
“Good Morning XXXX,
Has it been sufficient time for the VA to address my concerns and return a response to your office? The governor of AZ has made mask mandates unenforceable since 25 March, and the VA continues to push masks as mandatory and deny me access. This includes refusing to schedule blood work through the community while insisting that I needed blood work to be conducted before I could get a prescription refilled. I went more than 2-weeks without diabetes medication because my primary care provider refused to alert me in early February that a refill of Metformin would need blood work. I did not discover the need for blood work was required to refill until after I had been without Metformin for a week!
Mask discrimination at the VA is real and dangerous to veterans’ health and safety, and I, for one, am sick and tired of the BS the VA keeps serving as excuses to deny service. I am not a behavioral problem, as the Carl T. Hayden VAMC continues to claim. I do stand up for my rights against all enemies, foreign and domestic! I have paid my fines. If the US Marshals at the Federal Courthouse can have situational empowerment to not press the mask issue for those of us with qualifying medical conditions, the same should occur inside the VA with the VA Police.
The mask mandate is a policy issue threatening my health, safety, and well-being, as well as thousands of other veterans with breathing problems. Just what, if anything, has been done since January on this issue?
Sincerely,
Dave Salisbury”
I realize that the AZ State Governor does not have anything to do with the Federal Policies; I mentioned the governor’s action solely as an indicator that change in the state of AZ has come (finally), where mask mandates are concerned! The VA claims their mask policy is “constantly changing,” but the only changes I have witnessed are moving from draconian to oppressive, then to ruthless and punitive! The mask policy is wrong, has never been printed as a work standard, and has never been published for veterans to abide by. The best a person has is a sign claiming masks are mandatory and a bunch of emotionally charged employees acting like snowflake Nazi Storm Troopers on a 6-day pass from hell!
Today, 28 April 2021, I reached out to the director of constituent services as I had not received any additional information. Sending the following email:
“I blog, I have a pretty good following, here is my latest: https://dnc-consulting.com/2021/04/28/no-more-bs-speaking-of-administration-bureaucrats-in-government/
Please note, I have not mentioned Rep. Stanton (D) by name, yet, as a politician, I am begging to perform his job of scrutinizing the government, but the temptation is real! I have to be able to access the VA Healthcare system ASAP safely! Where is this issue in being resolved? Feel free to explore the other VA Articles I write on my blog. You will find every single one of the letters to the VA, you will find other veterans having similar problems, and you will find I do not hesitate to name names and point fingers.
I am still waiting patiently, but patience does wear thin when information is lacking!
Sincerely,
Dave Salisbury”
Within 3 hours of this email, I received the following:
“Dr. Salisbury,
Thanks so much for sharing! Apologies for the delayed response. I am following up with the Phoenix VA Medical Center and determine the status of the inquiry.”
Why am I writing this article?
Frankly, I am through! I am done with the foot-dragging administration at the Carl T. Hayden VAMC, and Alyshia Smith, the director who has dodged, balked, and refused to engage. I am through with the VISN 22 Director Michael Fisher being able to remain silent and unresponsive in this farrago. I am sick to death of being ignored by the VA Secretary, Secretary’s Wilkie and McDonough and their respective staff, while many other veterans across this country and I are physically harmed by a mask policy that doesn’t have enough sense to include “except for medically acceptable conditions,” and was never a policy, just some bloody marketing signs. I am beyond insane about having to go to court for being arrested at the VA three times, kicked off property two additional times, and harassed more than 15 times, for being short of breath, denied emergency care, and then had jokes made by the VA Police about my HIPAA controlled data!
The US Marshals have situational authority to assess and bend the mask policy; why does the VA Police not have this ability? Simple, easy, direct policy question that everyone in the VA refuses to address as having received, let alone answer. Why are the elected officials SILENT about this problem that is harming the safety and well-being of their constituents? Why can a congressional inquiry not DEMAND a prompt and timely response from bureaucrats hiding from the public in their offices?
Rep. Greg Stanton (D), why are you not more involved personally in DEMANDING the VA to correct their errors? Do you not realize how many veterans are in your district? Do you think you can abuse us and through us our families and hope to be re-elected? You, sir, are in desperate need of correcting your attitude and behavior before your re-election chances are forever harmed. I promise this article will survive to your utter shame if a prompt and immediate response is not taken!
I have reached the point where I no longer possess anything “cherubic” in my demeanor on this issue! You cost me time, money, and physical health. You cost other veterans in the AZ09 Congressional District the same. I will find more veterans suffering as I have, as the US Marshals reported that they had seen a massive uptick in veterans being arrested and cited for mask policy violations at the Carl T. Hayden VAMC. The VAMC, coincidentally located in your Congressional District, is harming veterans. You cannot appear to care, let alone act in a manner befitting your office as a Congressional Representative! Immediately come out in support and show yourself a true representative worthy of the title of your office, or leave office immediately, there is no third option!
Your need to change; its mandatory!
© 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.
For Memorial Day (2020), the National Cemetery, through the directive of the Department of Veterans Affairs (VA), restricted the placing of flags at several national cemeteries, upsetting the plans of Boy Scouts, and angering countless veterans, survivors, dependents, and extended families. However, the intransigence of the VA on this matter is but a symptom of a larger problem.
The Department of Veterans Affairs – Office of Inspector General (VA-OIG) recently released two additional reports on behavior unbecoming at the VA. The first report concerns the delays in diagnosis and treatment in dialysis patients, as well as patient transport at the Fayetteville VA Medical Center in North Carolina. The second is another death of a patient, as well as deficiencies in domiciliary safety and security at the Northeast Ohio Healthcare System in Cleveland.
Bureaucratic inertia is the cause of too many issues, problems, and dead veterans, at the Department of Veterans Affairs. The symptoms include delays in administrative tasks that lead to patients dying for lack of transport to a hospital. The symptoms include cost overrun on every construction project the VA commences. The symptoms include abuse of employees, creating a revolving door in human resources where good people come in with enthusiasm, and leave with anger and contempt, generally at the insistence of a leader who refuses to change. The symptoms include a bureaucrat making a decision that has no logical sense, costs too much and is never held accountable for the harm because the decision-maker can prove they met the byzantine labyrinth of rules, regulations, and policies of the VA.
Secretary Wilkie, until you can overcome the bureaucratic inertia prevalent in the ranks of the leadership between the front-line veteran facing employee and your office, lasting change remains improbable. Real people are dying from bureaucratic inertia. Real veterans are spending their entire lives in the appeal process for benefits and dying without proper treatment. Real families are being torn asunder from the stress of untreated veterans because the bureaucratic inertia cannot be overcome from the outside. I know you need legislative assistance to enact real change and improve the VA. By way of petition, I write this missive to the American citizen asking for your help in providing Sec. Wilkie the tools he needs to fix the VA.
The primary care doctor, emergency room doctors, and more all depend upon the radiologist report as the VA doctors no longer read x-rays, MRI’s, CT Scans, due to the complexity of the imaging. Thus, any error in the radiological report causes significant patient care delays, harm, or death. Yet, at two geographically separate VISN’s and Hospitals, the VA-OIG is reporting poor QA and high error rates in radiological reporting. Compounded by leadership failure at both the local hospital and the VISN level. The VA-OIG reports do not relate that anyone was fired, forced to change jobs, or other remedial actions taken beyond making “suggestions” for improvement at the federal, VISN, and local hospital levels. What significantly increases the problem, these same radiological records form the backbone of the compensation and pension decisions. Downstream issues were not in the scope of either radiological investigation. Still, every error in the VA bureaucracy has a significant downstream impact that always seems to be forgotten or overlooked.
Start using an ISO 9001 for healthcare as a QA program where processes and procedures are written down and followed. QA should be a program that fits holistically and improves people. Quality assurance should be a constant learning evaluation that never ends. Yet, somehow the VA, including the VBA, the VHA, and the National Cemeteries, always seem to not have a quality program. Implement the ISO 9001 one VA Medical Center at a time until a whole VISN is working under the ISO program. This allows the VA to learn and use these learning moments to build anew that which has fallen into disrepute.
Secretary Wilkie, some will suggest these ideas are expensive, but how expensive has the revolving door in human resources been for talent drain? How costly has failed training programs been? How expensive is the appeals process to compensation and pension decisions both in green and blue money? The short answer, too bloody expensive. Thus, it is time to begin looking for innovative ideas, using new ideas, employing new talent, and demanding higher returns for the taxpayer investment in the Department of Veterans Affairs.
Unfortunately, this is the standard, not the exception for the MSA’s in the HAS (Hospital Administration Services) Department, led by Maritza Pittore, at the Albuquerque VA Hospital. I have witnessed multiple MSA’s committing HIPAA violations through record diving, gossiping about veteran patients, acting rudely, ignoring veteran patients and their families to complete conversations, and refusing to do their jobs. As a point of fact, one assistant director one told me, “if what the VA does was replicated by a non-government hospital, they would be closed down and sued.” While employed from June 2018 thru June 2019, I brought this to the attention of the leadership, including multiple emails and voice conversations with Maritza Pittore, Sonja Brown, and several other high-ranking leaders and their assistants, all to no avail. I have had nursing staff tell me confidentially that they cannot do anything where the MSA’s are concerned because “it’s none of their business and outside their job duties.” Yet, the VA continues to proclaim the MSA, the Nurse, and the doctor, along with the patient, are a “healthcare team.” Upon being discharged, without cause, reason, or justification, I brought this information to the OIG, my congressional and senate representatives, among many others, all to no avail. The level of customer service, especially at this VA Hospital, is far below the pale because the leadership refuses to engage and set standards for customer service, with enforced penalties. 
Update to this article, 10 May 2020: By the first week in April 2020, the Advanced MSA in the clinic was moved to a less customer-facing post and a new MSA hired. The quality of that individual was never experienced due to relocating. The supervisor of the MSA was not very interested in correcting the problems and that showed when I visited with them while trying to obtain an appointment that the Advanced MSA refused to schedule. Change must come to the VA!
On 12 September 2019, the VA-OIG completed their investigation into the Beneficiary Fiduciary Field system (BFFS), who handle benefits payments for veterans and other beneficiaries who, due to injury, disease, or age, are unable to manage their financial affairs and are thus vulnerable to fraud or abuse. The veterans affected are those who are the most susceptible in the veteran population, and the government agency charged with protecting, helping, and supporting these veterans is vulnerable to fraud and misuse. In fact, the VA-OIG found that the BFFS, “… lacked sufficient controls to ensure the privacy of sensitive data and prevent fraud and misuse. Specifically, finding the VA’s Office of Information and Technology inappropriately set the security risk level for BFFS at moderate instead of high. Risk managers did not follow established standards and did not consider whether information for beneficiaries and fiduciaries stored in the system’s database was sufficiently protected.”
The VA-OIG reports, “when contracting officers violate federal regulation by failing to obtain the required approval for sole-source contracts, they exceed their contracting authority.” Contracting officers work with the approving authority, how can they not “know” who they work for and how to obtain proper authorization? The excuses are weak and inexcusable; as an operation professional, the first step in getting to know the business is to know who answers the questions, who has the authority, and where that person is located. For contracting officers, the approving authority is the boss, either the employees do not know who they are working for, or there are significant issues in lines of authority, and both situations speak of phenomenal incompetence and failure of leadership.
Speaking of “phenomenal incompetence and failure of leadership.” Please allow me to prepare the groundwork for the subsequent VA-OIG investigation. To be a supervisor in the VHA, VBA, or National Cemetery, you first must work in the positions you will be supervising. This information was passed during a job-interview by the hiring authority and confirmed by several VA directors since. From the VA-OIG Report, we find, “a supervisor at the VA regional office in Boston, Massachusetts, incorrectly processed system-generated messages known as “work items.” The supervisor, “incorrectly canceled 33 of 55 work items out of 110 reviewed (that’s a less than 50% accuracy), and improperly cleared another nine work items from the electronic record. Because of these incorrectly processed cases, VA made about $117,300 in improper payments to veterans or other beneficiaries, along with about $8,600 in delayed payments.” Best of all, the supervisor claimed these work items were improperly handled because, “he did not intentionally process the work items incorrectly, and the errors were the result of working too quickly and misunderstanding procedures.” You are the supervisor, you are in charge, you should know who to approach for guidance and clarification, you have caused significant harm to veterans who either are not being paid or now must repay funds improperly provided. There is an obvious question here, “If the supervisor is less than 50% accurate, what is the accuracy of the supervisor’s team?” While the VA-OIG cannot investigate this question, is the director investigating this question?
From the files of “Not Enough,” comes another egregious example. A patient in a psychological ward in the Philadelphia Pennsylvania VA Medical Center was killed because of a drug-to-drug interaction, were due to insufficient observation, insufficient monitoring, and inadequate action when the patient coded, and a veteran died at the hands of caregivers. When a patient in a hospital ward, which is monitored electronically and physically, commits suicide, I become very agitated. When any patient dies at the hands of the healthcare provider, I have officially lost my “cherub-like demeanor” and begin resembling a grizzly bear with a bum tooth, hemorrhoids, and woken too soon from my winter nap. The VA-OIG Report states the following, “… providers did not monitor the patient for electrocardiogram changes or drug-on-drug interactions. Staff and providers documented signs consistent with over-sedation but did not intervene, communicate directly with each other, or add team members on as additional signers to the electronic health record. The facility did not comply with the Veterans Health Administration requirements for issue briefs, root cause analyses, and peer reviews. The staff did not follow the facility’s observation policy. Facility providers did not adhere to policies requiring discussion, documentation, and patient signed informed consents prior to initiating methadone treatment.” The providers knew they had a problem, before the patient got into trouble, and did nothing! In any civilian hospital, this is called malpractice; but in the VA Hospital system, “this is an unfortunate incident.” While I am undoubtedly glad leadership acted to remedy this situation in the future; I am very displeased to note it ever occurred. With all the publicity over the power of methadone as an opioid, with the technology to remedy these problems before the patient dies, I cannot accept this situation could occur in the first place! This veteran’s death should never have happened and the fact that this veteran died at the hands of providers from over-sedation, is a testament to the incompetence designed into the VA processes that excuses accountability and rewards malfeasance.
I would like to take a moment and thank the VA-OIG for stepping up to the plate and correcting pre-award contract pricing to save the American taxpayer $515 million because the contracting officer on 16 of 22 proposed pharmaceutical contracts was improperly priced. In case you are wondering, the accuracy of the contracting officers was less than 75%. I know of no industry, business, or service organization that can have a 75% or less accuracy rate and remains in business. As a business operation and purchasing professional, these numbers appear to suggest that the contract officers are either intentionally neglectful, or they are counting on pre-award review to protect them from price gouging; both situations are inexcusable for a contracting officer for the Federal Government.
As the Los Angeles Vocational Rehabilitation and Employment program (LA VOCREHAB) was recently featured in an article, I am pleased to see that hiring additional staff has improved performance, per the findings of the VA-OIG. The VA-OIG Report found accuracy in spending money had increased, compliance, and helping veterans to gain employment had all increased since the damning report from the VA-OIG; thus, congratulations to the LA VOCREHAB program!
As a business consultant and industrial-organizational psychologist, I counsel those hiring me to never allow a process to reach a second birthday without a full and complete review. When training deficiencies are found, immediate action is required, and that action must be documented. Why is the VBA getting a pass on not training, not designing competent and reliable working processes, and not held accountable for performance that meets a passing score? Not mentioned in this VA-OIG report, due to being outside the scope of the investigation, is the longevity of this single issue. Why is a Congressional Blue-Ribbon panel not demanding historical information, and detailing for the American Taxpayer, especially the veterans involved, the significance of the rating problems and holding accountable those who designed the incompetence into the process? By the time the VA-OIG reports are released for public distribution, there is supposed to be an alert to the Congressional Committees overseeing these government agencies. The media is often alerted at the same time the Congressional Committees are informed; yet, a failing score in rating the “Spinal conditions [accounting] for two of VA’s top 10 service-connected disabilities, doesn’t even merit crickets. Media why not stop reporting junk, and start reporting problems needing rectification?
Please join me in mourning another death at the hands of the VHA, which is labeled by the Department of Veterans Affairs Office of Inspector General (VA-OIG) as “largely preventable.” A patient in the West Palm Beach VA Medical Center was in a mental health unit and committed suicide. Largely preventable is a vast understatement when hospital leaders only begin caring about the veteran committing suicide after the suicide, where training and policy adherence was not mandated prior to the suicide, and the lack of cameras and staff monitoring allowed for a patient, already having trouble and this trouble is known to the hospital providing treatment, to take their own life. No staff monitoring every 15-minutes was occurring; why? Why were the cameras non-functioning? How long had these problems been known and nothing was being done to correct these discrepancies.
DNC-Consulting 