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

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

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

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

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

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

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

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

Your staff is incompetent and unreliable!”

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

VA 3

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

VA 3

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

VA 3

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

VA 3

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

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

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

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

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

Moral Distress IS a Leadership Problem – More Shameful VA Chronicles!

Survived the VAA surprise occurred in this week’s Department of Veterans Affairs – Office of Inspector General (VA-OIG) reports; the Boise VAMC in Idaho performed well in their comprehensive healthcare inspection (CHIp).  Even though 10 recommendations were left, the VAMC as a whole is performing above average, with no significant complaints found by the VA-OIG.  Congratulations to the Boise VAMC!

VA 3Let me stress something; leadership is the reason why a VA Healthcare System (VAHCS) or VA Medical Center (VAMC) performs well or poorly!  Yet, too often, the leadership IS the root cause of the problems in a VAHCS or VAMC.  The Boise VAMC just proved this point precisely; are any Department of Veterans Affairs (VA) leaders in Washington DC paying any attention?

The VA-OIG performed a CHIp in Portland VAHCS and found moral distress in the employees, again!  This means that the Eastern end of the state is receiving better care than the western end of Oregon State!  Yet another VAHCS or VAMC with employees feeling morally distressed by the commands and directives of their leadership in how they treat veteran patients!  The VA-OIG report makes everything sound like rainbows and lollipops at the Portland VAHCS, but if employees feel “morally distressed,” there are problems, just not those included in the CHIp scope!VA 3

Where problems outside the scope of an investigation are concerned, the following is GREAT NEWS!

Robert Seifert, 63, of Utica, New York, pleaded guilty to making telephonic threats to Albany Stratton VA Medical Center employees. Seifert, who has been convicted twice before of threatening VA employees, admitted that on 14 January 2021, he made three calls to employees for no reason other than to harass and threaten them.”

I am going to repeat it, only for emphasis, “Leave the families out of your anger!”  Never, EVER, attack, threaten, or speak against the families.  They are OFF LIMITS!  I become very frustrated with the VA Leadership, but violence is not the answer, and threatening families is repulsive and counterproductive!  Seifert is scheduled for sentencing on 06 October 2021; may the judge throw the book at him, for this is his third conviction for threatening families of VA Employees.VA 3

On the topic of frustrating leadership who need to lose their jobs and reimburse the government for all wages, the following VA-OIG report is the epitome of failed leadership in action!

The VA’s Office of National Veterans Sports Programs and Special Events (NVSPSE) granted $47 million to organizations with experience in managing adaptive sports programs from fiscal year (FY) 2017 to FY 2020. … The VA-OIG found that the NVSPSE was not effectively managing the program.  The NVSPSE’s director had not established adequate internal controls, including developing standard operating procedures for managing adaptive sports grants.  As a result, the NVSPSE could not effectively evaluate risks from grant recipients, did not reimburse some recipients’ expenses on time, did not always close out grants on time, and did not appropriately authorize extensions for using funds.  By not closing out grants on time, the NVSPSE failed to free up about $346,000 that could have been used for other purposes.  It also improperly allowed recipients to spend $328,000 in FY 2017 appropriations outside the approved period and improperly reimbursed 19 recipients a total of about $247,000.”

The VA-OIG recognizes that these failures to audit and control the adaptive sports program properly potentially violate both the Purpose Statute and the Antideficiency Act, federal laws with direct consequences for Federal Employees.  I am taking bets.  Will anything come out of the director being referred to the lawyers; I doubt any action will ever be taken!  That’s not just my cynicism speaking; that is the experience in watching directors at the VA skate accountability and responsibility better than gold-winning Olympic figure skaters.VA 3

In reporting the following VA-OIG report, do not rationalize that every suicidal person will eventually find a way or means to commit suicide.  I ask you do not think this for two reasons: one, it is a lie lazy people tell themselves to disregard the act; two, helping people with suicide ideation is not cut and dried textbook medicine. Assisting people with suicide ideation takes time, effort, getting to know the person, and a lot of interlocking care from professionals.

“The patient, who was over 70 years old at the time of death, had diagnoses that included post-traumatic stress disorder and major depression. After approximately 15 years of care at a California VA facility, the patient transferred care to the Las Vegas facility in summer 2019. The VA-OIG substantiated that the patient died by suicide from a VA resident mental health clinic on the day of dischargeThe emergency department social worker documented an incomplete comprehensive evaluation. The suicide prevention team did not assign the patient a high risk for suicide patient record flag despite the patient’s stressors and history of suicide behaviors. Staff did not adequately assess the patient’s substance use, incorporate relevant history into the treatment plan, or address the patient’s change in demeanor and concerning statements. The discharge safety plan had not been modified for approximately eight months despite significant life changes. Leaders had not established a mental health treatment coordinator (MHTC) policy. Staff assigned the patient an MHTC at the patient’s tenth visit and four MHTCs over nine months. Staff did not coordinate care with a geropsychologist, with whom the patient had nine appointments. Leaders did not effectively address the patient’s expressed complaints. The VA-OIG substantiated that leaders did not conduct an institutional disclosure” [emphasis mine].

The last sentence is the dead giveaway that the leadership knew there were problems and designed processes intentionally to have an excuse when a patient died!  This veteran was suffering to a great degree, and I hope that with his passing, his family and friends can find peace in the knowledge that the veteran is now pain-free.  But, the VA leadership should be held legally responsible for this death, they failed this patient, and the world is worse for the veteran’s passing.VA 3

Suicides are hard on family, friends, communities; suicides at any age are the ultimate declaration that failure occurred, the pain was missed, and the medical community and support systems failed.  Survivors often feel a great degree of guilt and carry that guilt to their graves.  But, when medical providers go out of their way to hide the problems, refusing to document, and declare, it means that the medical community had written the patient off as too costly to save.  Who speaks for the loss of intelligence and potential of the failed patient; I do!I-Care

I will continue to speak to the failures of the VA to provide the care they promised, and demand leaders are held accountable and responsible.  This was preventable, and the leadership must be held accountable if the system is to be changed!  This veteran did not have to die by his own hand, and the medical community at the VA in Southern Nevada HCS, located in Las Vegas, should be ashamed!

Follow this link if you would like to see a recap, with links, to the shenanigans reported by the VA-OIG in June.  June 2021 has been a month of incredible and horrendous behavior documented by the VA-OIG of the leadership failures at the VA.  The elected leaders of America either need to begin scrutinizing the VA more closely or vacate office.  There is no excuse for the continued irrational and detestable behavior at the VA.VA 3

The last two items are testimony recorded before a Senate and a House of Representatives Committee.  Statement of deputy inspector general David Case Office of Inspector General, Department of Veterans Affairs before the US Senate Committee on veterans’ affairs hearing on VA electronic health records: modernization and the path ahead 14 July 2021Statement of Leigh Ann Searight deputy assistant inspector general for audits and evaluations Department of Veterans Affairs – Office of Inspector General before the subcommittee on oversight and investigations committee on Veterans’ Affairs US House of Representatives hearing on modernizing the VA police force: Ensuring accountability 13 July 2021.  Frankly, both statements are pure vanilla because the subcommittees refused to act, which was known before making the statement and the hearings.  Hence, why should the VA-OIG prepare action plans if the Senate and House will not take action?

Knowledge Check!Repeating, only for emphasis, “Until the US Legislative Branch will do their jobs, and scrutinize the Executive Branch with the intent to demand accountability, no single government agency will ever change.”  Want to help veterans?  Contact your elected representatives and send them these articles, demanding they take action in support of legislation and scrutinization, demanding accountability and responsibility of government employees who are currently active in refusing to change!  Want to help veterans?  Share these stories far and wide.  Everyone should know what the VA is doing and realize that every government agency from the city to the President is employing tactics to steal liberty, rob freedom, and murder veterans!

© 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.