Suicide – DNC-Consulting

When is Enough… ENOUGH? – More Chronicles from the VA

Honest question. I surpassed my ultimate threshold in waiting for the VA to improve in 2010 and stopped accepting the excuses, the platitudes, and the whiny discourse from the VA. Elected officials charged with scrutinizing the US Government, when has patience been surpassed, and you will cease allowing this nefarious Kabuki? The veterans are waiting, the taxpayers are fed up, and you need to make a decision and act.

Consider the following investigation by the Department of Veterans Affairs (VA) – Office of Inspector General (VA-OIG). The scenario:

“The VA Office of Inspector General (VA-OIG) conducted an audit to determine how effectively the Veterans Health Administration (VHA) billed private insurers. [Billing private insurance is a piece of legislation that the VA has haphazardly followed. The VA remains the first party payer and is authorized under 38 USC 1729 to bill and collect reasonable charges for nonservice-connected care where such veterans have other private health insurance.] Prior OIG investigations have shown that VHA has missed opportunities to recover funds that could be used to help finance care for other veterans. VHA’s Office of Community Care (OCC) manages community care programs and bills private insurers when needed. OCC must submit reimbursement claims before insurers’ deadlines are reached, or they may be denied.”

The legislature passed laws demanding action, and the result was:

- - OCC did not establish an effective process to ensure staff billed veterans’ private health insurers as required
  - OCC did not collect an estimated $217.5 million that should have been recovered, a figure that could grow to $805.2 million by September 30, 2022
  - OCC’s billing and revenue collection process also was not synchronized with insurers’ filing deadlines, and claims information was not always available for billing
  - Pending workload volume and staff shortages hindered effective billing
  - OCC was broadly aware of challenges to its process to bill and collect revenue from private insurers; its responses were insufficient to correct these issues.

Hundreds of millions of dollars are sitting on the table, and the VHA – OCC still cannot properly follow the law. Worse, they are slower than molasses running uphill in Michigan in January to pay community providers, inventing hoops and red tape nonstop for providers, which increases the cost of healthcare. This is not the first VA-OIG investigation on this issue in 2022, let alone since 2000; with the same findings, the same recommendations are issued, and nothing improves. Thus, I have two questions:

When is enough ENOUGH?
How does this reflect the VA Administration’s commitment to the vision of the VA?

Consider the following; the VA-OIG regularly conducts comprehensive healthcare inspections of VHA facilities. The findings of these investigations are supposed to spur institutional improvement. Regularly the VA-OIG places the following comments into the reports of these investigations, hoping nobody will ever read the report and find these facts.

“The VA-OIG found deficiencies in identifying sentinel events and conducting institutional disclosures. Additionally, there were repeat findings from the June 2017 comprehensive healthcare inspection related to inter-facility transfers.”

Imagine a private company being inspected by the government for a moment where previous investigation findings were not improved; what would happen? An army of lawyers would descend on the customers looking for those harmed/injured, legions of lawyers would pour through employee records looking for injuries and other potential claims, the government would seize assets and halt production, all this and more. The media would be covering 24/7 news cycles on the slightest allegations of wrongdoing. Elected officials would be hurrying to write legislation and find a media talking head to bloviate to.

What do we hear where the VA is concerned; not even crickets! The VA has played complicit roles in veteran deaths, and still not a peep, word, or even crickets. Remember, these findings occur frequently enough that not finding these remarks is a cause for celebration and is exceedingly rare. Thus, I have two questions:

When is enough ENOUGH?
How does this reflect the VA Administration’s commitment to the vision of the VA?

Other oft findings from comprehensive healthcare inspections include the following:

- - Medical center leaders were generally knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models (SAIL Metrics). – What does “generally knowledgeable” indicate? Why have we accepted general knowledge from those who should have specialized, detailed, and comprehensive knowledge and use this knowledge in daily practice?
  - Outpatient satisfaction survey results were generally higher than VHA averages but revealed opportunities to improve specialty care experiences for female veterans. – Please note beating the VHA average is good but nothing to brag about. Beating the VHA averages is akin to claiming to be the biggest pig in a pig wallow. Sure, you’re big, but you are still covered in mud!
  - Employee satisfaction survey scores for the medical center were lower than VHA averages. – Not a surprising finding in any way, shape, or form. Employee morale is scathingly low, and it shows in every customer interaction! More comparing pigs by size in a pig wallow, and it’s not like the VA would punish whistleblowers, fire productive people, castigate, denigrate, deride, and treat employees like chattel… Oh, wait, yes, it is!

Interestingly, I receive 3-10 of these monthly investigation reports from the VA-OIG, and too often, they read like someone is cutting/pasting the findings from one report to the next. Thus the conclusions of these findings occur frequently enough that not finding these remarks is a cause for celebration and is exceedingly rare. Therefore, I have two questions:

When is enough ENOUGH?
How does this reflect the VA Administration’s commitment to the vision of the VA?

Let us consider another VA-OIG investigation, which, unfortunately, recurs too frequently where inappropriate conduct is a norm, not an exception. VA facility leaders’ response to inappropriate relationships. Regular readers will know how common it is to find inappropriate relationships and sexual misconduct by VA Employees to other employees, underlings, and veterans. The scenario:

“The VA Office of Inspector General (VA-OIG) conducted a healthcare inspection to evaluate leaders’ response to the knowledge of inappropriate provider-patient relationships. The VA-OIG determined that while facility leaders initially addressed three inappropriate relationships between mental health providers (Providers A, B, and C) and mental health patients (Patients A, B, and C), multiple factors affected the effectiveness of those actions.”

Finding the following:

- - The OIG found that effective facility leader actions to investigate and address the inappropriate relationships of Provider A and Provider B occurred only after an Office of Accountability and Whistleblower Protection complaint.
  - Facility leaders ineffectively addressed Provider C’s inappropriate relationship before Patient C died by overdose.
  - Facility leaders failed to report Providers B and C to their state licensing boards promptly.
  - Failed to report Provider A to the appropriate professional certification board.
  - Facility leaders did not take actions to address the circumstances that contributed to the death of Patient C, who was involved in an inappropriate romantic relationship with Provider C.

Regrettably, the VA-OIG could not determine if an adverse patient event occurred when finding that the inappropriate relationship played a role in a veteran’s suicide by overdose. I understand investigative scope creep, but this is ridiculous. You have a dead veteran in an inappropriate relationship with a provider, and you cannot investigate if this was an adverse event. What type of bureaucratic inertia sponsored this madness?

Some items in this investigative report stand out, beginning with the fact that the facility leaders who refused to take action remain employed by the VA! Knowing about problems and not taking prompt and decisive action is negligence in performing one’s duties. Possessing authority and refusing to implement policies and procedures, ensuring compliance by professionals, defies description and should result in VISN leaders losing their jobs! Unfortunately, these inappropriate relationships are not rare; even if the VA-OIG has not gotten around to investigating the problems, ask the VA employees, and you will find the proof of concept and incredibly high frequencies. Hence, I have two questions:

When is enough ENOUGH?
How does this reflect the VA Administration’s commitment to the vision of the VA?

In the annals of government fraud, waste, and abuse, the following VA-OIG investigation must rank in the top 20 somewhere.

“The VA Office of Inspector General (OIG) initiated this review to evaluate whether purchases of iPads and iPhones for veterans met mission needs while minimizing waste during fiscal year (FY) 2020 and through the first two quarters of FY 2021. In July 2020, Connect Care officials purchased 10,000 iPhones with unlimited prepaid data plans for the homeless veterans enrolled in the HUD-VASH program. However, 8,544 of the 10,000 iPhones remained in storage as of July 2021, as demand for the iPhones was much lower than anticipated. The OIG found that this resulted in an estimated $1.8 million wasted data plan costs. The OIG also identified opportunities for improvement regarding data plans for nearly 81,000 iPads purchased. Because Connected Care did not have strong enough oversight procedures for reducing or eliminating data plan waste, it incurred approximately $571,000 in additional wasted data plan costs.”

When I was offered telehealth, I was responsible for providing the equipment and maintaining an Internet connection. This was made clear by the VHA Administrators before they signed off on allowing me telehealth and reiterated by my providers when they renewed permission. How can the VHA and VA leadership and contracting officials imagine this is acceptable? How many of these devices are still in the hands of veterans? How many have broken, been pawned, or otherwise not survived?

Again, not casting aspersions, merely asking questions, namely the following:

When is enough ENOUGH?
How does this reflect the VA Administration’s commitment to the vision of the VA?

I could weep from the frustration felt in reporting another veteran’s death by suicide, receiving care from mental health providers with the VA, and being investigated by the VA-OIG, where the providers are complicit. The scenario:

“The VA Office of Inspector General (VA-OIG) conducted a healthcare inspection to evaluate VA-OIG-identified concerns related to the assessment and documentation practices of a behavioral health certified registered nurse practitioner (BHNP) and leaders’ completion of BHNPs’ ongoing professional practice evaluations (OPPEs).”

The findings:

- - The BHNP did not perform thorough suicide risk assessments for a patient who died by suicide.
  - Identified multiple deficiencies in a BHNP’s assessment and documentation practices, including the absence of comprehensive suicide risk assessments, failure to complete abnormal involuntary movement and metabolic assessments for patients prescribed particular antipsychotic medication, missing informed consent or a risk-benefit discussion when prescribing off-label medications, failure to resolve rule-out diagnoses, and substantial copy and paste use.
  - Finding adverse clinical outcomes for one of eight patients for whom the BHNP did not document a comprehensive suicide risk assessment, as required by The Joint Commission.
  - Finding the Nurse Manager evaluated BHNPs as satisfactory in the OPPE elements of copy and paste use for the fiscal year 2018 through the first half of the fiscal year 2021 and safety plan completion for high-risk suicide patients for February 2020 through the first half of the fiscal year 2021, without these elements being evaluated.

Is it clear why I am asking about where the limitations of patience are? The supervisor was directly responsible for leading the BHNPs and failed, and while it is not mentioned, we can presume this person remains employed. Failed to train staff, failed to supervise staff, refused to do your job. Yet, you remain employed (probably) and (potentially) were promoted, as this is the regular pattern for VA employees caught but who are politically acceptable or connected. The supervisor is directly connected to a dead veteran, a family is weeping this holiday season, friends are missing, and all I can do is keep asking the politicians:

When is enough ENOUGH?
How does this reflect the VA Administration’s commitment to the vision of the VA?

Do you also feel the weight of responsibility; your tax dollars fund this abuse. Representatives of your government are complicit in adverse patient events, including death, and they refuse to engage, holding government employees accountable and fixing the mess. Veterans signed a check, telling the government we will perform duties and obligations. Why aren’t the veterans honored for their sacrifice and respected by elected officials and government employees, especially at the VA?

America Weeps The VA’s mission statement is “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.” The statement is meant to echo the reverence given to the men and women who serve in the American military with honor. Reflecting that this body (the Department of Veterans Affairs) is tasked with serving them respectfully, similar to how they served their nation. One final question is, “Does killing, abusing, and harming veterans equate to honoring the VA mission statement?”

© 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 (Ch 9)

I-Care The Department of Veterans Affairs – Veterans Benefits Administration (VBA) regularly crows about reducing the backlog, improving the veteran experience, and making changes to deliver on the promise. Every so often, another article is spread, mainly by the VA Public Relations department (PR), about how they meet the legislated obligations. Then, unsurprisingly the truth is revealed, the curtain thrown back, and the lie exposed. The Department of Veterans Affairs – Office of Inspector General (VA-OIG) is helping pull the curtain back, and the truth should infuriate every American. In an investigative report dated 22 June 2022 and linked, we find the following:

“… The VBA disregarded privacy procedures so it could use a workload tracking system more quickly without receiving the appropriate security authorization. The Mission Accountability Support Tracker (MAST) helps quantify the work VBA’s support services staff perform in response to employee requests for facility, equipment, and vehicle management; reasonable accommodation; and identification card issuance and renewal. Because staff use personally identifiable information (PII) in their work, the information could be compromised in an unauthorized, unsecured application. The VA-OIG found that VBA and the Office of Information and Technology (OIT) did not correctly follow privacy and security procedures. VBA’s privacy threshold analysis was inaccurate, and OIT did not conduct a privacy impact assessment. OIT’s misclassification of MAST as an asset resulted in insufficient security controls. Further, VBA lacked the authority to operate MAST before using it in regional offices.”

Lacking authority equates to a leadership failure to follow their standard operating procedures (SOP). PII being inappropriately released, nothing new at the VBA, or the VHA for that matter. Losing veterans’ identities and taking advantage of systems for personal gain, regardless of the cost, is nothing new or surprising. This should be where the VA organizational leadership should be focused; yet, what are they doing? Where is Congressional oversight and scrutiny?

FY 2017, the VBA leaders devised a scheme to have third-party vendors conduct compensation and pension exams to deliver on the promise to clear the backlog on veterans’ claims. Since FY 2017, the VBA has paid over $6.5 Billion on this scheme, and the VA-OIG found in a report dated 08 June 2022, “Some of the exams produced by vendors have not met contractual accuracy requirements. As a result, claims processors may have used inaccurate or insufficient medical evidence to decide veterans’ claims.” Is anyone surprised this is the result? The compensation and pension exam is the key to accuracy in claim completion; yet, inaccurate claims are still being adjudicated wrongly, which is significantly damaging veterans and their families!

From the report, we find the following:

“VBA’s governance of and accountability for the exam program needs to improve. The identified deficiencies appear to have persisted, at least partly because of limitations with VBA’s management and oversight of the program at the time of the review.”

The VBA’s leaders designed this scheme, shackled the program with ineptitude, and hindered the improvement of the program. Designed incompetence cannot get any better than this, and the leadership must be held accountable! Fraud, waste, and abuse remain pillars in Federal Government governance, so why are these leaders not being held liable?

Michael Bowman, Director of IT and Security Audits, in recent Congressional Testimony, made the following claim:

“Secure IT systems and networks are essential to VA’s fundamental mission of providing eligible veterans and their families with benefits and services. VA’s information security program and its practices must protect the confidentiality, integrity, and access to VA systems and data.”

The audacity of this director to claim “confidentiality, integrity, and access” as being secure would be laughable if it weren’t so inept! How would a non-VA Employee know the IT system is fraught with problems? VA-OIG report regarding FISMA compliance, Dallas, Texas. The Federal Information Security Modernization Act of 2014 (FISMA). FISMA is a United States federal law that defines a comprehensive framework to protect government information, operations, and assets against natural and manmade threats. FISMA OIG inspections are focused on four security control areas that apply to local facilities. They have been selected based on their level of risk: configuration management controls, contingency planning controls, security management controls, and access controls.

What did the VA-OIG find? “Without effective configuration management, users do not have adequate assurance that the system and network will perform as intended and to the extent needed to support the CMOP’s missions. The access control deficiencies create risks of unauthorized access to critical network resources, inability to respond effectively to incidents, loss of personally identifiable information, or loss of life.” All political speak for inept leaders and deplorable leadership actions. IT/IS systems continue to fail, and the director claims the system has integrity; despicable and detestable!

Worse, the same FISMA inspection occurred at the same outpatient pharmacy mail facility in Tuscon, Arizona. The same problems were found, in the same systems, manned by the same inept people and led by the same poor leadership. Integrity, only if the word means sharing ineptitude between different facilities. Access to systems and data protection, can anyone honestly trust that the IT system at the VBA or VHA is providing the fundamental tools to meet the mission?

On the topic of IT system integrity, can anyone forget the continuing problems in delivering a functional electronic health record system to the VHA? How many billions of dollars must be wasted before Congress stops paying for this albatross? The VA-OIG has substantiated that “… many quality, patient safety, and organizational performance metrics were unavailable, including metrics needed for hospital accreditation. Additionally, the VA-OIG found that access metrics were largely unavailable. The VA-OIG remains concerned that deficits in new EHR metrics may negatively affect organizational performance, quality and patient safety, and access to care.” How’s that integrity doing? Is it trustworthy?

05 May 2022, failures were discovered in a joint DoD and VHA review of the new electronic health record system. The new EHR has no plan to create interoperability, yet interoperability was the main selling point for spending billions of dollars on a new EHR. Would you believe the VA-OIG recommends the DoD and VHA review federal laws and direct the offices overseeing the EHR program to begin complying? Would Congress please ask, why haven’t the program managers for the HER already been complying with Federal Law? How about demanding action to recompense the taxpayers who have been defrauded?

In April 2022, VA-OIG Michael J. Missal addressed Congress in a statement entitled, “At What Cost? – Ensuring Quality Representation in the Veteran Benefit Claims Process.” The VA-OIG’s mission is “preventing and addressing fraud and other crimes, waste, and abuse in VA programs and operations.” General Missal then discussed the integrity of VA processes to “help ensure that veterans receive the benefits, health care, and services they have earned through their service to our country.” Would Congress please ask how the VA-OIG is fulfilling its mission to prevent fraud, waste, and abuse?

“The VA-OIG operates a hotline that receives approximately 30,000 complaints annually from veterans, family members, VA employees, and the public.” If the 30,000 complaints are presumed to be stable, across just the years I have documented the VA’s abuses, then the VA-OIG has received upwards of 360,000 complaints over the last 12 years. Would Congress please ask about the success in promoting change, reducing fraud, waste, and abuse, and curbing the veterans being actively harmed by the VA, the VHA, and VBA?

Congress receives these VA-OIG reports first; what is Congress doing to scrutinize the executive branch? Where is the progress? The VA-OIG reports annually to Congress, but improvement never occurs. Permanent change never occurs. The same people are making the same excuses, using the same flowery language, and nothing ever happens to improve things. Worse, the same people maintain the same jobs, who pays, the veterans and their families, and the American taxpayer through the nose as the VA loses more and more money!

I do not know about any Congressional elected leader, but I am through buying the Kool-Aid the VA-OIG is selling:

“The VA-OIG’s work is focused on protecting VA programs and operations from waste, fraud, and abuse as well as improving their efficiency and effectiveness.”

On a single topic that the VA-OIG has reported on multiple times and remains critically important to all veterans and their families, it is reporting needs for improvement in VHA and VBA suicide prevention. From the report, we find the following:

“… Suicide prevention coordinators at VA medical facilities are required to reach out to veterans referred from the Veterans Crisis Line. Coordinators provide access to assessment, intervention, and effective care; encourage veterans to seek care, benefits, or services with the VA system or in the community; and follow up to connect veterans with appropriate care and services after the call.”

The findings from the VA-OIG report are almost criminal in the negligence of leadership to perform the jobs they hold:

“The VA-OIG found that coordinators mistakenly closed some veteran referrals because coordinators lacked the proper training, guidance, and oversight necessary to maximize chances of reaching at-risk veterans referred by the crisis line. VHA lacked comprehensive performance metrics to assess coordinators’ management of crisis line referrals, and coordinators lacked clear guidance on managing crisis line referrals. Until VHA provides appropriate training, issues adequate guidance, and improves performance metrics, coordinators could miss opportunities to reach and assist at-risk veterans.”

Why did the media bury this report? Suicide prevention continues to be a significant military and veteran issue, but this program’s designed incompetence should be a major story on all media networks. More, this VA-OIG report should be a talking point for every congressional representative seeking re-election. Why is this not the case? Integrity requires honesty, honesty and integrity requires action. When will Congress take action?

How many dead veterans will it take before Congress takes action? 31 May 2022 VA-OIG report:

“The VA Office of Inspector General (OIG) conducted an inspection to review the care of an unresponsive patient by Emergency Department staff and the subsequent response of leaders at the Malcom Randall VA Medical Center (facility) after the patient’s death at the University of Florida Health Shands Hospital (Shands). The OIG determined that facility Emergency Department nurses failed to provide emergency care to an unresponsive patient who arrived by ambulance. Despite emergency medical services (EMS) personnel having relayed, while en route to the facility, the criticality of the patient’s condition and the limited patient identifying information available, Emergency Department nurses and an Administrative Officer of the Day wasted critical time concentrating efforts on whether the patient was a veteran (which the patient was, but not so identified by the nurses) versus patient care. As a result, EMS personnel reloaded the patient into the ambulance for transport to Shands.”

The staff failed to follow EMTALA, and a veteran died due to the inaction and inappropriate focus of the medical providers. This is not the first or second breach of EMTALA, the federal law requiring any patient presenting at an emergency department receiving federal funds to be treated; yet, what will it take to get Congress off their thumbs?

12 May 2022, deficiencies in care led to a patient dying at the Charlie Norwood VAMC, Augusta, Georgia. The VA-OIG substantiated that:

“medical-surgical unit nursing leaders did not have adequate quality controls or training to ensure the provision of safe and effective alcohol withdrawal nursing care.” “Primary care staff failed to provide sufficient care coordination and treatment. A provider failed to address the patient’s abnormal chest images and poor nutrition and failed to communicate test results to the patient as required. A primary care nurse failed to respond to the patient’s secure message request for assistance two days before surgery.

Additionally, a barium swallow test was not scheduled. The surgical team completed a preoperative assessment but failed to detect the patient’s overall poor health. During the patient’s hospital stay after surgery, medical-surgical nurses did not consistently assess alcohol withdrawal symptoms or administer medications as required.”

My wife is fond of saying, these oversights and failures occur in non-Government hospitals, and this incident should not be considered indicative of the whole system lacking similarly. Yet, civilian hospitals have lawyers by the dozen looking for a reason to sue providers for malpractice, and the government hospitals protect against accountability and responsibility. Worse, you will never know the problems unless you track these incidents.

Do you know why I keep declaring there is a problem with designed incompetence; several veterans suffered T-12 burst fractures and multiple rib fractures, all because of poor documentation and even worse communication. This is a life-changing injury, and the VA-OIG found the VA providers to have culpability but no responsibility due to a lack of documentation. Delays in provider documenting in the electronic health record the provider’s notes delayed care for another veteran who also suffered life-changing spinal injuries after receiving non-care at a VA facility. The VA-OIG cannot conclusively document the tie between poor care being received and the injuries sustained by the veteran, all because of delays in the provider documenting treatment.

Tell me, does anything discussed above reflect the words of Inspector General Michael J. Missal, who claimed the following in Congressional Testimony:

“VHA continues to face enormous challenges in providing high-quality care to the millions of veterans it serves. Despite these challenges, the VA-OIG has witnessed countless examples of veterans receiving the care they need and deserve—delivered by a committed, compassionate, and highly skilled workforce [emphasis mine].”

Does a provider killing a veteran reflect a committed, compassionate, or highly skilled workforce? How many veterans must be permanently injured by the VHA providers to reflect a committed, compassionate, and highly skilled workforce? How often will the electronic health record fail before highly skilled workers are displayed?

Plato 2 Unfortunately, the VA-OIG reports discussed are not even the tip of the iceberg of what is happening. My apologies, dear readers; I have been remiss in my reporting duties. Why have I been remiss, because my health went sideways since April when I had a medical procedure completed that was advised but not appropriate. The VHA and VBA are sick organizations and desperately need scrutiny and standards, new leadership, and written organizational policies. Help me force these nefarious characters into the sunshine for a good dose of sunshine disinfectant, and let’s change the world for the better.

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

Bobblehead Doll It 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_model I 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 1 Snide, 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.

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-Care When 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.

Chronicling the VA, One Ignominious Story at a Time!

I-Care As we catalog the VA, occasionally, local services providers must be recognized for their service or their deficiencies. In the spirit of fairness and transparency, it is time to discuss one of those community providers, Advanced Neurology Epilepsy & Sleep Center (ANESC), Dr. Aamr A. Herekar M.D. Also, in the spirit of fairness and complete transparency, I have tried to settle my problems through the VA Community Services Offices and an appeal to the management and doctor of ANESC, all to no avail! Regular readers know I have been in a multi-year battle with the VA over arresting me for not wearing a mask because when I wear a mask, I become a medical emergency.

I possess a note from my doctor, a VA Primary Care Provider, written to my employer on VA Letterhead with a wet signature, declaring my inability to wear a mask. The VA did not accept this letter and arrested me three times. Well, Dr. Herekar’s office was presented the same letter, and hassled me before both appointments for not wearing a mask, became hostile, argumentative, and a nuisance over the mask issue, even after I complied with putting on a face shield. Today (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. VA 3

Imagine that; Facebook Messenger has become the medium of choice for ending a patient relationship with a medical provider. How very inappropriate! How very unprofessional! How very typical of some of the providers I have been sent to in the community by the VA. Apparently, the abuse of veterans is spreading from the VA providers to the community providers. If you are in the El Paso area and receive a referral to Dr. Herekar, please be cautious of his staff. I have no idea of the efficacy and quality of the doctor, but his staff is absolutely third-rate or less! The shame of the entire episode, the taxpayer is on the hook for my being abused by the staff. How deplorable! Foghorn Leghorn - Medication

In reviewing different results reported from the Department of Veterans Affairs (VA) – Office of Inspector General (OIG) comprehensive healthcare inspection (CHIp) of VAMC’s, I am finding some interesting trends.

1. 1. Why the sudden, as of July 2021, focus on attendance and staffing in behavioral committees? More to the point, why are the behavioral committee’s processes and procedures so draconian? More specifically, the following is a unique passage too often see in CHIps.
    - - High-Risk Processes
        
        Disruptive behavior reporting and tracking
        
        Disruptive Behavior Reporting System
        
        Order of Behavioral Restriction and patient notification documentation
        
        Staff training – Isn’t this interesting, staff training is a “High-Risk Process?”

1. 1. When reporting that patient experience scores are similar to “VHA Averages,” isn’t this like saying a VAMC is as good as another pig in a pile of slop? Why accept averages that are comparable to other VAMC’s? The leadership at the VAMC’s across the country is failing the veterans, yet the VA-OIG is accepting average performance compared with other VAMC’s. It sounds like pathetic designed incompetence, wrapped in weak excuses, and deep-fried in a pity party!
  2. Training continues to be a fundamental excuse for failing, and even the VA-OIG seems to have given up and thrown in the towel.

An example of how training continues to be a fundamental excuse for failing and designed incompetence lies in another CHIp, specifically reporting reusable medical equipment (RME) and sterile processing services (SPS). The VA-OIG reported the following weaknesses:

- - Standard operating procedures not aligning with manufacturers’ guidelines.
  - Annual risk analysis reporting to the VISN SPS Management Board.
  - SPS chiefs developing, implementing, and enforcing a daily cleaning schedule for all SPS areas
  - Equipment storage, cleaning, and usability.
  - Completion of Level 1 training within 90 days of hire, competency assessments for RME, and monthly continuing education for SPS staff.

All this after the VHA has already been caught with poor cleaning of reusable medical equipment on multiple occasions, where the training of cleaning staff was the primary reason for failing the CHIp from the VA-OIG. The cycle continues unabated, and training is central to correcting and ending the process. Yet, even the VA-OIG refuses to address the leadership failures and be part of the training corrective action behaviors. VA 3

In other CHIp reports, we find that completion of training is a high-risk process. Leading to interesting questions about why and what is involved in staff training to make training high-risk. What boggles my mind, much of last year, the CHIp reports found moral distress from leadership, this year, nothing; why? Did the VA-OIG stop asking about this issue? Certainly, the VA has not corrected this problem. Am I merely suspicious, or is there a correlation between less focus on employees feeling morally distressed at work and increased focus on patient disruptive behavioral committees?

From other CHIp reports, we find more questions and logic that make no sense. For example, how can patients be receiving care that meets VHA averages in acceptable care, but the employees reflect severe moral distress? Does this not indicate that the averages for patient care are set too low? Would not this be an indicator that leadership is not held to a sufficiently high enough standard of performance? Worse, on these CHIp reports, we find greater mention of disruptive behavior committee actions, paperwork, training, and actions taken. Thus, there appears to be a correlational data relationship between disruptive patients, moral distress in employees, failing leadership, and the abuse of the disruptive behavior committee process. Where are the elected officials asking questions and drawing substantive conclusions regarding the data presented by the VA-OIG? Heck, where are the VA-OIG data analysts raising alarms and red flags over correlational data points for investigators to act upon? VA 3

As a person who has been fallaciously labeled and erroneously called “disruptive,” this particular topic strikes home. The system is ripe for abuse by egotistical leaders hell-bent on power-tripping! When I asked how do you appeal the decisions, I was told lies, given wrong information, and forced to pay fines that I should not have had to pay. Worse, the Federal Marshals at the courthouse remarked that there had been a significant uptick in veterans in the same situation as mine being fined erroneously by the VA. Thus, the abuse of the veterans is both widespread and decidedly egregious!

Another recurring issue from the CHIp reports is remarkable from recent VA-OIG investigations, especially since multiple veterans have recently died over the issue, care coordination. Care coordination includes completing paperwork, filling out the electronic health record, and signing the electronic health record, so the notes are available for other providers to use for follow-on patient treatment, nurse-to-nurse communication, and medication transmission, but most importantly, monitoring and tracking patient whereabouts on the facility’s grounds. Yet, even with dead veterans with these issues as root causes, the VHA continues to fail in care coordination. How do you define appalling, detestable, and disgraceful? Where are the elected officials? Where are the veteran service organizations in raising rhubarbs about the abuse of veterans at the hands of the VHA? VA 3

Finally, the most astounding and absurd continuous hit point from CHIp to CHIp report is found under the heading of “Quality, Safety, and Value.” Under this heading falls a lot of topics, but imperative to improvement is the leadership failure to hold meetings attended by the primary audience. Tell me, in the private sector; your boss calls a meeting of all department heads and their number two person. If these people are no-shows, how long will they keep their jobs? Yet, the VA-OIG finds repetitive missed meetings, no follow-up, no remediation, no punitive measures, no corrective actions, and these people are still employed!

Knowledge Check! One of the most bothersome things about reading three weeks’ worth of CHIp reports has been the consistency of the reports. Too often, the reports read like they were copied. Maybe this is due to the consistency of failed leadership; perhaps this is due to the lack of originality in thinking in the VHA, VBA, and the VA in general. Regardless, the CHIp reports raise some concerning issues, specifically around the potential for abuses found in the disruptive behavior committee process and what disruptive behavior is at the VHA and VBA. For example, if a patient is throwing furniture, this is obviously disruptive. But, if a patient disagrees with a policy and is politely asking to speak to administration, this is not disruptive, but the patient is treated as disruptive, and that is abusive of the disruptive patient policies.

© 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.

If Everyone Cared – More Detestable VA Stories

I-Care 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. 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 inside the walls 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.

We begin with an indictment and a reminder. An indictment does not indicate guilt or innocence, and the parties mentioned are presumed innocent until proven guilty in a court of law by a jury of their peers.

“Scott Mitchell Brown, John Henry Swiencki, and David Jeffery Hughes, Jr., were all charged with one count of conspiring to distribute hydrocodone, oxycodone, and amphetamines. Brown was also indicted for stealing prescription medications, possessing stolen mail, and obtaining unauthorized health information from the Kerrville VA Medical Center in Texas.” VA 3

I am a big fan of punishing liars and thieves of all stripes and support justice served in this case.

“David Naylor, 59, of Spring Hill, Florida, was sentenced to two years and three months in federal prison, followed by three years of supervised release, for theft of government funds. Naylor made false representations regarding his physical limitations in connection with his application for VA disability compensation.” VA 3

While the following perpetrator has been caught and sentenced, she represents but the tip of the iceberg.

“Rita Copeland, 59, of Portsmouth, Virginia, was sentenced today to nine and half years in prison for wire fraud and aggravated identity theft in connection with schemes to defraud veterans. She operated Veteran Services of the Commonwealth, which claimed to provide veterans with caregiving, contracting, and rental assistance services. In total, from at least 2017 through 2020, Copeland’s schemes impacted at least 29 victims and resulted in a combined loss of approximately $430,000.” VA 3

Again and again, the following questions are asked and never answered; yet, the questions remain pertinent. Who at the VA had to have known this abuse of veterans was occurring and did nothing to stop the abuse? There are too many checks and balances, too many hands, and too many inspectors for fraud of any magnitude to exist for very long without raising flags needing investigating. Where were the VA employees? Who knew? What did they not do? Are they still Federal Employees?

Another veteran died, needlessly at the hands of VA providers, due to ineptitude, failed management, poor training, and a series of unfortunate events that cascaded. I weep for the family of this veteran and mourn for their loss. I am sorry you have had to experience this tragedy and wish there was something more I could do than simply spread the story of this deleterious behavior and hope for sunshine disinfectant. The patient died from “presumed anoxic brain injury (his brain failed to receive enough oxygen).”

“The VA-OIG found that physicians’ failure to provide adequate benzodiazepine dosing to address the patient’s delirium tremens, review the patient’s abnormal electrocardiogram before haloperidol administration, and transfer the patient earlier likely contributed to the patient’s deterioration and ultimate death. The VA-OIG substantiated that a non-VA paramedic documented that the oxygen flow was not active. Facility leaders and staff reported a lack of knowledge about the failed oxygen delivery. The nursing staff did not complete all required alcohol withdrawal assessments. A physician improperly ordered restraints, nurses failed to obtain full vital signs while the patient was in restraints, and nurses did not receive restraint training as expected. The VA-OIG substantiated that facility leaders and staff did not communicate initiation of emergency detention with the patient’s family; however, notification is not required. Leaders did not conduct an institutional disclosure with the patient’s family timely or in person and did not provide a relevant update.” VA 3

Did you catch that last sentence; while the patient was dying, the facility leaders and providers, including the nursing staff, were more concerned with CYA (covering their own acts) than notifying the family they had screwed up, and their family member had died. If the nursing and staff did not have the training, why and how could they use restraints on a patient? This is blatantly illegal! VA Seal

Let’s cover one more egregious item from this summary of unfortunate events; I visited a doctor who is transitioning out of medicine who made the following comment, “Medicine has changed, practicing medicine has changed, and the practice of medicine is no longer about treating people, but checking boxes, the patient be damned!” The patient was a “walking chemistry experiment, and no single nurse or provider took a minute to stop providing care, assess the patient, and stop administering drugs! Instead, they just kept pumping more drugs in until the patient died and then covered their tracks with designed incompetence to protect their failed inadequacies. This is not “practicing medicine,” you would not treat an animal in this manner; at least not and keep your license!

A death row convict is not allowed to die from anoxic brain death, as it is considered incredibly painful and a cruel and unusual method of death, which is why the gas chamber has been banned as a legal means of causing death for death row inmates. Yet, under a medical team’s care, a patient in a VA hospital is allowed to die in this horrific manner, and nobody is held accountable. Is it any wonder why this article is suitably titled “If Everyone Cared?”

Not many outside of the veterans affected and their families know that the VA has been pushing opioids for decades down the throats of veterans. At the height of the opioid crisis, the VA shut off all opioid drugs and told the veterans to seek help for addictions to pain medications. The VHA did not evaluate the individual patients for need, did not seek alternatives, did not try to reduce dependency over time, simply cut off all opioids, and told the veterans to deal with the problems. Unfortunately, opioids were not the only drug series that the VHA cut off suddenly on veterans without notice, cause, or individual patient consideration, and deficiencies in coordination for the care of patients and drug mandates from VHA has lead to suicides, murders, and other violent problems as addictions cause social problems. VA 3

When discussing failures to coordinate care for patients, abuse of patients, and the need for patients to be housed in the proper treatment centers for their needs to receive the right care, the following should boil your blood and comes from Fayetteville VAMC in North Carolina.

“The VA-OIG identified that the psychiatrist used the involuntary commitment process in a manner that was inconsistent with the state’s established parameters and failed to adequately assess and document the patient’s capacity to make informed decisions and determine whether the patient had a healthcare agent. In addition, the patient’s primary care providers and psychiatrist missed an opportunity to coordinate specialty care needs for the patient.” VA 3

Essentially, a bureaucrat incarcerated a veteran against their wishes, without a trial, an appeal process, and proper medical care. Now, imagine you are the family of this veteran or a friend, and you see this occur and feel powerless to help, impotent to intercede. Every avenue you approach is blocked because of the authorities, the bureaucrat in charge who wields their power illegally. How do you feel? What do you do? Where do you turn? Is it any wonder why this article is suitably titled “If Everyone Cared?”

I-Care America, we need to care about what is happening in our representative government, in our name, with our tax dollars, and to our neighbors, family, and friends. There are no excuses for the abuses witnessed! There are no excuses for medical providers to get away with this outrageous behavior in private hospitals or government-paid-for-care. Let us all heed Nickelback’s song and the intent; let us be the “everyone” who cares!

© 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.

Monk and Mental Health

Tony Shalhoub played the defective detective in the police drama “Monk” from 2002 to 2009. Monk is obsessive-compulsive and has a list of 312 prioritized fears and phobias. But, as the main character, everyone is expected to see and find his mental health challenges somewhat humorous. However, I like the show Monk for another reason, all the other mental health issues swimming around Monk that nobody understands or even recognizes due to Monk’s fears and phobias being so over the top.

Monk started a mental health conversation in America, reflecting that even those with mental health issues can be productive members of society if given a chance. For example, Captain Stottlemeyer, for the majority of the show’s run, has anger issues, and yet he is considered capable and competent as a Police Captain. Lieutenant Disher struggles with his identity as a person and his value to the organization. The supporting character’s mental health problems create the drama. Monk provides comedy and allows the supporting characters to be accepted for their mental health issues, which is essential in this discussion.

TV Reviews - TV Liveblogging: Some Episode Of Monk - Kittysneezes Sharona struggled with being a mother, her boss was driving her crazy, and her mental health issues stemmed from both her boss and her nursing responsibility. Sharona plays a problematic role; does she provide nursing care for Monk or provide living assistance as a counselor? Concluding that stress can be a mental health issue when taken to extremes. Natalie Teager struggled with loneliness and a desire to be her own person outside of her family. Both mental health challenges that many people struggle with silently. Other supporting characters had substance abuse issues stemming from mental health concerns and personal choices, thus Monk’s subtlety and genius.

When Sharona, his nurse, leaves the show, Natalie Teager provides a lesson on mental health, the difference between coddling and helping a person with mental health problems. Sharona, for all her care and concern, never saw Monk as capable without assistance. Natalie Teager saw Monk as competent but needing some assistance. The difference is subtle but very real. Monk’s behaviors and mental health problems lessen when Natalie Teager enters the show, and the story becomes richer.

Perception vs. Reality in Care Support

Are you weak to admit you have a mental health problem? Per society, not as much anymore. Per yourself, who knows. Perception versus reality is critical in the person with mental health concerns and in the care-providing staff surrounding that person. Now, I suffer from PTSD, Anxiety, and Depression, as mental health concerns; but, I thank God for my support (spouse) and those characters in my life that provide the drama, while my mental health provides the comedy. Not a single person who knows of my mental health struggles has ever treated me capable without assistance, and this makes all the difference in how I approach the world.

The pattern of admitting the mental health challenges, coping with those challenges, and the consequences of those challenges have been made bearable because my supporters never waiver from the foundation that I am capable but occasionally need assistance. Monk taught me that it was okay to have mental health issues, to see those issues in others, and a pattern of living and approaching others with mental health issues. The perceptions of the supporting people become a reality in the mental health challenges of the person suffering.

It is not easy supporting someone with mental health issues, and while mental health sufferers get the attention, Monk taught the world that the mental health of the family and friends is as important to the cure as well as the problem in mental health patients. Consider the two different approaches of the psychiatrists on Monk, but never forget two other principles in mental health, change is hard, and change is beneficial.

Change and Mental Health

Monk was stuck in a rut, and a change in the insurance policies spurs Monk to change. As the show develops, change is witnessed as beneficial and challenging. When Sharona left, Monk experienced quite a shock; the different care styles provided by nurses spurred complex and healthy changes in Monk. Differences in approaches by the psychiatrists produced more changes and spurred growth in Monk and the other supporting characters. Hence, as a mental health patient and as a care provider, another pattern is produced: am I looking for changes? Am I open to helping others engage in change? Do I embrace both the light and dark of change?

Adaptation is the only constant in life. We adapt to the people around us, the social environments, the emotions, and the influences of peers, employers, family, and so much more. Yet, we often try to control everything to prevent change, even though every new day brings change. Monk showed he could not handle change, mainly because he and his brother had never been taught to handle change.

Patterns in Family Rearing – Mental Health Challenges

As a kid, I was told that I would never amount to anything since I was raised in poverty and abuse. I had teachers who made this comment often enough that I got mad! Nobody was going to curtail my abilities and shoehorn my potential. Their reasoning was the research that showed those in poverty as children stay in poverty as adults. That abuse is generational, and that abuse will always influence those raised in abuse to perpetuate abuse to the next generation.

Monk showed me differently, proved that individual choices could change preset patterns, and end captivity. Sure, Jack Junior and Ambrose are typical examples of the generational nature of abuse, leading to mental health issues. But, Monk overcame, chose, and in choosing and sticking with his choices, he endured and conquered. Monk overcame even with his mental health challenges, not because of, or as an excuse, but with his mental health challenges as a companion.

While it is true how a child is reared, does dictate how that child will approach the world as an adult. Individual agency, moral choice, and the choice and consequence cycles also play fundamental roles in that person’s life. Thus, one cannot, and should not, place blame upon how one was raised for the failures in one’s life; this position negates the agency inherent in each person, and shifting the responsibility of choices is not healthy mental health practices. More lessons learned from Monk about how to face the world, even if you might not have had the best family environment as a child.

Did you notice that when Jack Junior makes his appearance, Adrian (Monk) has changed enough to know not to gratify and indulge his step-brother in his poor decisions? Despite the differences in mental health problems, Ambrose, Monk’s other brother, was also not pampered, although he was given special care. Cementing the theme that people with mental health problems are capable, have potential, and need only the opportunity to show who they are and what they can become, just like everyone else.

I am not my handicap

I have disabilities; disabilities do not have me. I am not my handicap! Monk taught me this lesson in spades. When Monk gets his badge back, he realizes he has learned this lesson as well as learning what his abilities as a disabled person are. Another subtle theme in Monk worthy of exploration. Adrian Monk was not “Obsessive-Compulsive, Mentally health challenged, Adrian Monk.” Adrian Monk was Adrian Monk who lived with obsessive compulsion, fears, and phobias. The distinction is subtle but essential to living with mental health challenges as a companion, not a ruler!

I am forever grateful for the lessons learned and still being learned from Monk! I encourage you who read this to ponder the themes herein; change is beneficial and hard, but critical; family and family life is not your life; you are not your handicap or illness. These themes and more can help open your eyes and mind to new possibilities, freeing you from your captivity of mental health challenges, but only if you choose to open your eyes and mind.

Finally, remember your support staff. Have you thanked them lately for their support, care, and kindness? If not, start there, express gratitude to and for the care received from those who live with you, work with you and desire your success. Never forget, on your bad days, your support staff is still there trying to help, and they need support too.

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

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

What is bureaucratic fiat?

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

Veteran Suicide!

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

Scrutinizing the Government!

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

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

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

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

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

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

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

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

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

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

NO MORE BS: Suicide

America lost a soldier last week. For the second time in my sister’s life, suicide has deeply affected her. Maybe this article is being written for me; perhaps, this article might help someone struggling, I do not know. I know that suicide deeply affects everyone involved, some carry guilt over another person’s suicide to the grave, and others will always feel sad and empty. Suicide hurts!

When I served Active-Duty US Army, I was a Chaplain’s Assistant. My duties were mostly clerical in nature, but I supported every soldier’s beliefs, regardless of their religious belief or flavor. I loved that job; I sat on the front lines between religion and personal faith, and often my duties were most impactful as I held the hands of grieving people. I held up the weak knees, lifted hands that hung down, and tried to help people. I was not perfect then, I am not perfect now, but I can say I did the job. Like all of life, there is a cost to be paid, and many times that cost is very high!

As a Chaplain’s Assistant, my education included psychology, trauma, hidden wounds, and spotting and helping people seek professional help. I was often a resource to community support, options, and many times just a listening ear. Frequently, my day began after I closed the chapel and went downrange, off base, and walked among my fellow soldiers in various bars throughout Dongducheon, S. Korea. Where I heard about love life’s, extra-marital affairs, affairs gone sour, divorces, pay problems, and every stress known to deployed soldiers.

Because I was frequently downrange, I heard about unit problems, offered suggestions, and tried to help the people that make up an Army. I was handling a situation in my own unit the night a soldier drank himself into alcohol poisoning and died; only later was it discovered the soldier wanted to commit suicide and did not know how except through drinking. I was not downrange the night a young soldier walked in front of a very large truck; he survived his suicide attempt and received the help he needed. I hope he is better!

I was supposed to be getting a vehicle ready to take the chaplain to see a training exercise. Instead, I was in a Quonset Hut, sitting beside some medics who were trying to help their buddy not step in front of a tank. They found his note, found me, grabbed hold of that soldier, and saved a life. I was proud to take the Article 15 UCMJ action my chaplain ordered, my friend the medic got the help he needed from a friendlier chaplain and our Battalion Commander. I am not bragging in relating these episodes, and I do not have aspirations of grandeur that I could have helped. I describe them because problems with suicide lurk just beneath the calm waters that surround each of us.

I was not in the country of S. Korea when my mechanic friend accidentally hit a little girl who darted out into traffic, and my friend could not stop the truck he was driving in convoy in time. Unfortunately, I lost track of my friend, but I grieve with him over this event in his life. The calm waters always hide problems, rocky shoals, traumatic events, and much more. This brings up the first and most principal point; suicide has long been portrayed poorly by media, Hollywood, and popular culture.

Unfortunately, the media, Hollywood, and popular culture get paid to get suicide wrong, and will not change. As a kid, I was expected to be like John Wayne, Clint Eastwood, and Marlon Brando. Strong, tough, unyielding, and capable! Then, Hollywood and the media said this was too stressful, labeled masculinity as toxic, and all men were suddenly supposed to be some mix of Pee-Wee Herman, Rudolph Valentino, and Rock Hudson. Now, men are appendages, sex toys for women, or other men, and absolutely spineless. How does this apply to suicide? Where are the examples, the role models, and those people a person can look up to and see good or emulate?

When I was in Junior High School, I planned to kill myself and make it look like an accident. I knew where, I knew how, I was not going to leave a note, and on the day of the planned event, a friend saw me walking home from school and offered me a ride. We talked, not about anything important, but by the time we reached my house, I knew I could not commit suicide to escape my home life. I looked for role models of who I wanted to be, there were plenty to choose from, and I slowly took the best of each of them and created a life. I was exceedingly blessed to have such an amazing friend! Long have I tried to be the same for others.

When counseling those who had tried or were considering suicide, one of the questions I was commonly asked usually was framed like, “Who do I look up to?” Too often followed by a story of a broken home, abuse, failures at sports, pressures to perform, the list is endless. Role models are essential, role models are needed, but do you steer a child to model the president, a governor, an athlete, etc.; not bloody likely! Hence one of the foundational problems in our society is a dearth of role models. People committed to living honorably where the media talk about them, instead of the latest athlete bashing his girlfriend’s face in an elevator.

One of the best pilots recently died. His story was pointed out to me, his exploits became legend, and his skills were the stuff of dreams and fanciful imaginations. Chuck Yeager could and did do things to an airplane that caught and held my imagination. The world lost a great and talented man, I lost a person I would love to call a friend, and we never met!

Hollywood and the Media keep getting the story wrong on suicide because of the toxic culture they have invented to punish good, demean the strong, handicap the great, and dumb down the wise. We see the results daily. Sports figures beating up their domestic partners, drugging, or merely acting like a spoiled brat. From politicians that cannot respect each other or their constituents, Hollywood types acting like puerile rubes off camera. Magazines are selling sex like a new toy to America’s continuing issues with drugs (legal and illegal), cigarettes, and alcohol. Every waking moment is filled with toxicity, acting like acid on the mind, detracting from the good, and creating unequal comparisons through social media that can never be matched.

I talked to a depressed person, a guy who got so lost in comparing his life to his friends’ lives on Instagram and Facebook, he was contemplating suicide. He said it started when he was 11 or 12, first with girls, then the size of his manhood, his inability to be good at sports, his mid-level grades, and the pressures just kept building. This same person was a Force Recon Marine, had battle badges, and an amazing service record. Because he could not raise his personal value to meet social media demands, he considered himself a failure. I sincerely hope he is doing better now.

A friend of mine in the U.S. Navy got caught in the same comparison problem, devised a method to get more money through housing allowances, and got caught. He is in Leavenworth now, I lost track of his wife and kids, and my friend got lost. He should be getting out of Fort Leavenworth later this year. I wish him the best of luck! Between toxic culture and a lack of role models, Hollywood, and the media, including social media, have a stranglehold on people, and suicides keep increasing!

Another factor in suicide rates is the increasing lack of a nuclear family. Not to say that a nuclear family is all roses and lollipops, but every democratic society worldwide is suffering from a staggering increase in broken homes through murder/suicide, divorce, hookup culture, and friends with benefits lifestyles, add in homosexuality and gender fluidity. It is no wonder people are confused, and single parenthood and suicide continue to climb. When religious decline due to media attacks on religious thought and standards are added to the equation, it is not a wonder that more people are contemplating and committing suicide. There is no wonder why depression and anxiety are rising steadily as mental diseases.

I will offer some ideas for consideration, both to aid in reducing suicide and to aid in helping those struggling. Of a truth for certain, I contemplated suicide in late December 2020, and had it not been for mental mechanisms installed through learning; I would not be here typing this article. These ideas for consideration are things I daily apply to help me. Hence, when I ask you to consider these ideas, I am in the same trenches, doing the same things, and working right alongside you.

1. Most importantly, find a religion you can live. There are hundreds of flavors of religious belief systems. Experiment until you find one that works for you. Faith helps by placing a buffer between how you think and how you act while supplying a why as a motivating force towards action. Believe it or not, even atheism is a religion; it’s just really hard to live.
2. Unplug the TV, disconnect from social media, and spend at least one day a week technology-free. Your mind needs to rest from all the inputs of modern living. Choose a day, any day that works for you is perfect, and put down the cellphone, walk away from the computer, turn off the TV, and plug into mental relaxation. Make cookies; I used to pound bread dough, do something where your activity levels are up, your mind is down, and you are not plugged in.
3. Reduce your social media commitments. Twitter, Instagram, Facebook, LinkedIn, etc., are time sponges where you will spend a ton of time trying to compare, keep up, stay afloat, and you never will succeed! It is okay to end social media commitments! It is perfectly normal to have a life not posted every 20-seconds to Instagram or another social media platform.
4. Reach out to people, real people. Use letters, emails, phone calls, or walk down the street and talk with a complete stranger. I find that when I am reaching out, I am not as self-conscious and not as depressed. One of my favorite activities is to go to a long-term care facility and ask people about their lives. I have met incredible people; I have learned, laughed, cried, and celebrated lives that have reached their pinnacle.
5. Mental toxicity feeds upon what comes into our bodies through the senses and social environments. Change music genres. Change the authors you read. Change the magazines to which you subscribe. Change social settings. If you are struggling with mental toxicity, change something small and watch how impactful that small item becomes. A friend of mine is oft to quote, “It’s a matter of a few degrees;” there is a cool story on the internet that accompanies this quote.

Regardless, please talk to someone if you are hurting and thinking about suicide. Please listen to your friends and close associates. Do not be scared to ask, bluntly, baldly, openly, “Are you considering something?” An acquaintance related to me a story where a friend saw something, asked bluntly and saved a life. On the phone one night, I talked to a friend; he mentioned he was considering swallowing his shotgun and hung up. I called 911 and asked for a health and welfare check, stated what I heard, and waited anxiously for the authorities to call me back. Eventually, they did; they helped my friend. I am exceedingly grateful for the first responders who too often are the front line when suicide happens.

I am going to offer one other idea for consideration. Every time you hear a siren or see flashing lights offer a prayer for the first responders and those involved. The prayer does not have to be grand and eloquent; your religious flavor does not matter; we are all connected, and those responding can sure use the help. When you see a medic/EMT/Paramedic, Firefighter, Police officer/Sheriff, please thank them. The suicide rates among first responders are incredibly high and always tragic. Nothing grand or embarrassing, just a simple word of kindness will help the first responders in your area. Until injuries took me, I used to be a first responder as well.

Thank you for taking the time to read this post! May God bless and keep you!

Tragedies, Travesties, and Uncomfortable Truths – Shifting the Paradigm at the Department of Veterans Affairs

For the uninitiated, the Department of Veterans Affairs (VA) has three chief administrations the Veterans Health Administration (VHA), the Veterans Benefits Administration (VBA), and the National Cemetery (NC). The majority of the problems a veteran is going to experience originates in decisions from the VBA, which then influence care with the VHA.

I believe in giving credit where, and when credit is due; thus, please join me in congratulating the VBA for meeting a significant milestone. From the VBA press release we find the following:

“On August 11th, VA updated portions of the rating schedule that evaluate infectious diseases, immune disorders and nutritional deficiencies. By updating the rating schedule, Veterans now receive decisions based on the most current medical knowledge of their condition.”

The reason this is good news stems from so many veterans leaving the military with problems caused in the service where the VBA has dictated there is no injury due to the rating scales, forcing the VHA into a treatment problem where the patient is concerned. More on the rating scales issue momentarily.

I-Care 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.

Let me emphasize a truth about suicide. A person expressing desire to suicide is not weak or lazy, and they will not “find a way.” Having had depression sufficient to consider suicide in the past, I can tell you from personal experience that friends help, talking openly and honestly helps, and the emotional burdens placed upon a family when a suicide is successful are tremendous, as well as the guilt the surviving family must overcome. This veteran did not have to die, their death was “largely preventable,” and for their death to occur on VA property, in a mental health ward, remains a tragedy. That the VHA dropped the ball and allowed, through leadership failures, non-working technical means, and training deficiencies, this veteran to die is disgraceful!

The VBA is committing travesties of justice every day. Consider the following, in the past 15+ years since I left the US Navy, I have had discussions with veteran service officers (VSO’s) across the continental United States on my own claim, and while supporting other veterans with their claims. A recent example serves to illustrate the problem. A Spine Anatomy veteran has bulging disks in the cervical spine. The MRI shows disk degeneration, stenosis, and other problems in the cervical spine. The veteran has an “S-Curve” in the thoracic spine caused by carrying bottled gas containers from the pier into the ship. There is stenosis and disk degeneration in the thoracic spine. The lumbar spine has bulging disks, degeneration, and stenosis. Three separate areas of the spine, three distinct injured areas, yet, the VBA calls the spine issues, “Lumbar strain.”

Any person who has taken human biology in K-12 education can tell that spine issues in cervical and thoracic are not “lumbar strain” and would not need “new and material evidence” to understand that the first decision was flawed. Yet, for the veteran to obtain a rating for their spinal issues, they must find an orthopedic spinal specialist, not affiliated with the VHA, and get a letter of diagnosis detailing why these separate areas of the spine are not “lumbar strain.” The current corporate medicine world, finding an orthopedic specialist will require a non-VHA doctor as a primary care provider (PCP) to refer the veteran to a specialist. Without a significant cash investment, time investment, and replication of VHA completed tests, x-rays, and MRI’s, the veteran will not be able to obtain a letter detailing the issues sufficient to sway the VBA in correcting their initial judgment.

The veteran will be stuck between three bureaucracies, the VBA who is denying the claim for spinal injury, the VHA who cannot diagnose and document a problem sufficient to meet the VBA standards, and the corporate medicine outside the VHA. Yet, anyone with a passing understanding of human anatomy and biology can logically make the leap that the spinal issues cannot all be lumped under “lumbar strain.”

I continue to ask, “What is a veteran to do?” Many times, the veterans in this position are either unemployed or employed below their skill level because they are in pain, they have medical issues requiring treatment, and they cannot obtain the treatment needed because the VBA has not allowed a military service claim to be placed upon the medical records for the VHA to treat. To chain medical professionals to a rigid and dead bureaucracy, by refusing their ability to diagnose a problem for another VA administration is, without a doubt, a terrible decision, and dangerous practice. To refuse to investigate a medical problem, restricted breathing with chest pain because the pain is not related to heart and lungs remains a travesty and an abuse of the patient.

To the elected Federal officials, why are you not demanding improvement to the VHA and the VBA? Why do veterans have to die in the care of the VHA before any improvement is made to the bureaucracy you created? Where does a veteran go to obtain relief from the bureaucratic nightmare where the VBA and the VHA are refusing to help the veteran? The tragedy in this entire article is that the VA cannot enforce policy adherence, controlling the risks to avoid incidents like those detailed, and demand better performance from the people and the systems that are supposed to help the veterans. The travesty in this article is the policymakers between Secretary Wilkie and the front-line employees; who is helping the veteran navigate these rocky shoals and dangerous waters of government policy?

I have met some great VSO’s, employees of the VBA and VHA, and interviewed with phenomenal people working in the National Cemetery; yet, they all have the same problem, the millstone around their necks is the regulations, policies, procedures, and red-tape of the VA that has been designed to refuse help as the first response to every question posed. Thus, as I have asked Senator Udall (D-NM) and Representative Haaland (D-NM), as well as countless other Federally elected officials between 1997 and the present, what is a veteran to do to obtain the help they need from the VA? Who would the veterans approach for guidance and support? When the VBA is demanding “new and material evidence” before acting to support a veteran, how does a veteran obtain this evidence?

I know of hundreds of veterans who were affected by an independent duty corpsman in the US Navy who threw records over the side of the ship to avoid being held accountable for bad decisions and patient abuse. Because these records are not in the medical files, injuries sustained in the service are not documented, and the VBA will use this as an excuse to deny claims. What is a veteran to do? Where does the veteran go? How does a veteran correct something that occurred beyond their control to obtain treatment for decades-old injuries? You the elected officials allowed the bureaucracy to be built, you are responsible for correcting these issues experienced, what are you doing to affect change and support Secretary Wilkie in fixing the VA, and by extension the VBA, the VHA, and the NC?

The American people are watching how you treat veterans, and we are not pleased!

The images used herein were obtained in the public domain; this author holds no copyright to the photos displayed.

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