Tag: VA Administration

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

QuestionHonest 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:

  1. When is enough ENOUGH?
  2. How does this reflect the VA Administration’s commitment to the vision of the VA?VA 3

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:

  1. When is enough ENOUGH?
  2. How does this reflect the VA Administration’s commitment to the vision of the VA?VA 3

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:

  1. When is enough ENOUGH?
  2. How does this reflect the VA Administration’s commitment to the vision of the VA?VA 3

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:

  1. When is enough ENOUGH?
  2. How does this reflect the VA Administration’s commitment to the vision of the VA?VA 3

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:

  1. When is enough ENOUGH?
  2. How does this reflect the VA Administration’s commitment to the vision of the VA?VA 3

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:

  1. When is enough ENOUGH?
  2. How does this reflect the VA Administration’s commitment to the vision of the VA?VA 3

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 WeepsThe 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.

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How Do I Know? – An Update on the VA Mandatory Mask Policies and VA Leadership Failures

Question24 May 2021 – 1200-1500 I visited the Las Cruces Community Based Outpatient Clinic (CBOC) in Las Cruces, New Mexico.  Upon entry, I was asked to wear a mask.  I described I could not wear a mask, and the employee said I might be required to wear one but left the decision to those working more closely with me.  I waited in line and was called to the Team 2 window, where a gentleman was more than happy to assist me in getting the paperwork started to change VA hospitals after relocating.  About 45-minutes into my time in this CBOC, the gentleman asked me to wear a mask.  I told him I could not and had brought my VA Doctor’s note as proof.  The gentleman read the letter, confirmed I was good to receive care without the mask, and provided exceptional customer support.

After the past year at the Phoenix VAMC, where my every movement on the property was shadowed by VA Police officers looking for a reason to injure, arrest, cite, and force me from the property, the employees here in Las Cruces was a breath of fresh air.  However, the experiences in Las Cruces provide further evidence of the following facts:

      1. The Hospital Director has statutory authority for adapting and creating policies and procedures that benefit the safety of the employees and the patients. A point I stressed to the leaders of VISN 22 and the Phoenix VAMC to no avail.
      2. The Federal Mask Mandates can be situationally applied for the circumstances of the individual. Yet, another point I have repeatedly stressed since July 2020, and the first time I was injured, arrested, cited, and forced from Federal Property. At the same time, I was being denied emergency care under EMTALA and having my HIPAA information repeatedly violated by the VA Police Officers.
      3. The bombastic and unprofessional behavior of the Federal Police employed at the Carl T. Hayden VAMC is a problem of the leadership, and the failures of leadership to instill professionalism, proper attitudes and behaviors, training, and tactics in approaching and handling situations in the Phoenix VAHCS. At the behavior of the Federal Police Officers in the Phoenix VAHCS, Che Guevara, Mao, Stalin, and Fidel Castro would be proud!VA 3

How can a person be sure the problems caused are a direct result of leadership failures?

ApathyBy tracing behaviors, attitudes, and influence to their source, the police chief acts as he considers appropriate, but the underofficers generationally multiply and mirror his behaviors.  The same is true for the chief who takes his example from the assistant director, director, and hospital leadership.  Chains of command always have this consequence; the example of those above are mirrored, replicated, and multiplied to impress the higher officers to gain attention and promotion opportunities.  Want to take a measure of a leader; look to the most junior person in the chain of command and watch them for behaviors, attitudes, and actions that originate in the leadership.

GavelCase in point, long have I detailed and described the failures of leadership at the VA.  The latest is a wire fraud scheme in Jackson, Mississippi.  From the Department of Veterans Affairs – Office of Inspector General (VA-OIG), we find the following:

“Anthony Kelley, the owner of Trendsetters Barber College in Jackson, Mississippi, pleaded guilty to two counts of wire fraud in a scheme to steal federal funds. From October 2016 through March 2019, the college offered a master barber course that was not accredited by the state’s board of barber examiners. Kelley fraudulently represented that this course was approved and, as a result, was allowed to collect GI Bill money from veterans enrolled in the program.”VA 3

As the lowest person in the chain of command, Mr. Kelly was allowed to attempt to commit fraud by the VA.  Never in these reports is the VA employee, their supervisor, and their manager, who were complicit in allowing fraud to occur, mentioned and held accountable.  Somehow, we, the taxpayer, must presume that those committing frauds could hoodwink the Department of Veterans Affairs without any inside help.  Help coming directly or indirectly from government employees charged with investigating, ensuring, and following proper protocols and procedures to protect against theft and fraud.

Angry Grizzly BearLet the US Attorney and VA-OIG special investigators crow about catching the person perpetrating fraud.  Before they break open the champagne, they need to be looking into the leadership that either overtly or covertly allowed this fraud to occur.  The elected officials need to be demanding why fraud opportunities are so rampant at the Department of Veterans Affairs that criminal proceedings are being reported almost every week and asking about the culture of corruption and leadership failures allowing these behaviors to thrive.

Is it a “Culture of Corruption?”

Absolutely; the VA is sick with a culture of corruption!  It is my sad duty to report on another employee who was able to steal from the VA, stealing hydrocodone and oxycodone prescriptions from the VAMC mailroom and mailboxes at some 40 locations in Kerrville, Ingram, and Center Point.

“Scott M. Brown, a pharmacy technician at the Kerrville VA Medical Center in Texas, was charged with one count of theft of US mail for stealing hydrocodone and oxycodone prescriptions from the medical center’s mailroom as well as from residential mailboxes between March and April 2021.”VA 3

Currently, Mr. Brown is being held in custody and remains innocent until proven guilty in a court of law by a jury of his peers.  However, the fact that Mr. Brown has been charged and is in custody speaks volumes to the lax leadership that allowed these prescription thefts to occur.  Where is the VA-OIG in asking how the robbery was possible?  Where are the special investigators demanding answers from the leadership on policies and procedures that an employee could easily violate to obtain these drugs?  Who else was involved, or had to know, what was happening and said nothing?Plato 3

The Department of Veterans Affairs has been overtaken by those without skill, knowledge, and ability to understand cause and effect and properly interrupt the cycles of corruption.  Worse, these same people will bleat about how they need more money for technology solutions when their personal example, leadership failures, and human-to-human relationships are the actual problems.  The leaders will bleat like sheep in a corral about engagement, customer service, and industry buzzwords because they have no substance and even less desire to see things change.Plato 2

Recently I detailed the failures at the Department of Veterans Affairs on information technology.  The fallout from the deplorable designed incompetence in the IT/IS infrastructure at the VHA continues to represent just how incompetent the current leaders genuinely are.

“To promote compatibility with the Department of Defense’s electronic health record system, VA is replacing its aging record system. This requires VA medical facilities to upgrade their physical infrastructure, including electrical and cabling. The OIG determined from its audit that the Veterans Health Administration’s (VHA) cost estimates for these upgrades were not reliable. VHA’s estimates did not fully meet VA standards for being comprehensive, well-documented, accurate, and credible. The audit team projected that VHA’s June and November 2019 cost estimates were potentially underestimated by as much as $1 billion and $2.6 billion, respectively. This was due in part to facility needs not being well-defined early on. The estimates also omitted escalation and cabling upgrade costs and were based on low estimates at the initial operating sites. Because cost estimates support funding requests, there is a risk that funds intended for other medical facility improvements would need to be diverted to cover program shortfalls. The Office of Electronic Health Record Modernization (OEHRM) also did not meet its obligation to report all program costs to Congress in accordance with statutory requirements. Specifically, OEHRM did not include cost estimates for upgrading physical infrastructure in the program’s life cycle cost estimates in congressionally mandated reports. Although VHA provided OEHRM with an approximately $2.7 billion estimate for physical infrastructure upgrade costs in June 2019, OEHRM did not, in turn, include them in life cycle cost estimate reports to Congress as of January 2021. OEHRM stated it did not disclose these estimates because the upgrades were outside OEHRM’s funding responsibility and that they represented costs assumed by VHA facilities for maintenance—including long-standing needs” [emphasis mine].VA 3

Angry Wet Chicken 2Did you catch that; the office specifically tasked with handling estimates intentionally low-balled estimates, did not include all necessary contractual requirements, and then lied to Congress to cover their hides, and fell back upon designed incompetence to skirt blame, responsibility, and accountability when the VA-OIG came investigating.  Lying to Congress is a CRIME!  Yet, these federal employees can break the law with impunity, and all the VA-OIG can do is make recommendations for improvement!  If you want to read the full report of shame, you can find it here.

Leadership is change; management is stagnation and corruption.  When will the VA start hiring leaders to enforce, demand, and execute change to benefit the taxpayer and the veteran community?  Where are the elected officials willing to work with newly hired VA leadership in establishing legal frameworks for evicting employees who refuse to change from the federal workforce?  When can the veteran community and the taxpayer expect to see real and tangible change at the VA?

Knowledge Check!I am not asking these questions and not expecting an answer!  I am asking these questions looking for and expecting real results to begin immediately, if not sooner!  This is a national embarrassment with a global impact, and it is time for the United States to lead in correcting their detestable government workforce!

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

Weep America! – The VA Leadership is Becoming Worse! – Part 1

Angry Wet ChickenThe Department of Veterans Affairs (VA) has really outdone themselves this week.  I am used to being ashamed of what passes for leadership and administrators at the VA, but this week, they have surpassed themselves.  The Department of Veterans Affairs – Office of Inspector General (VA-OIG) filled my inbox with seven investigations results, and the reports of leadership failure should leave every American weeping and madder than wet chicken with a raging case of hemorrhoids!

  • “A Hope Mills, North Carolina man, Daniel Bruce Ross, was sentenced today to 24 months in prison for conspiring to accept bribe payments in exchange for the performance of official acts while working as a federal government employee. Ross previously pled guilty to the charge.  He was also ordered to pay $21,520.00 in restitution.”

Accepting bribes, shameful misconduct, and while I certainly agree with the need for punishment, why does this sentence appear light?  Did the bribe recipient make a deal?  If so, as Paul Harvey would say, “Where is the rest of the story?”

VA 3The Department of Veterans Affairs – Veterans Benefits Administration (VBA), had their quality assurance program inspected, and the results, oh these results… the VBA administrators should be fired!  There are no excuses sufficiently valid to hide this behavior!

  • “To ensure claims decisions are accurate and consistent so veterans receive the benefits to which they are entitled, VBA established a multifaceted quality assurance program. The VA Office of Inspector General (VA-OIG) reviewed the quality assurance program and identified a systemic weakness in oversight and accountability… The VA-OIG found that while VBA’s quality assurance program routinely identified claims-processing deficiencies and communicated results to internal and external stakeholders, the Office of Field Operations did not ensure that regional office employees took adequate corrective actions to address the deficiencies identified” [emphasis mine].

VA 3Did you catch that, the leadership who set up the quality assurance program, built into the program a loophole to allow them to not act upon the deficiencies discovered.  Talk about designed incompetence, ineptitude, and outright fallacious behavior!  When a bad decision is made by the VBA, especially due to poor quality assurance, the veteran is out time, money, and resources to gather “new and material evidence” to ask the VBA to review their original decision!  Never are the VBA employees who cost the veteran, ever held accountable, responsible, or made to suffer in kind for their atrocious behavior, and I want my elected representatives to start asking why!

VA SealThe failures of the quality assurance team are not new, 22 July 2020, the VA-OIG found:

    1. “…QRT specialists did not identify a significant number of claims-processing errors that should have been identified. Based on a statistical sample, the OIG estimated that 9,900 of the 28,400 quality reviews (35 percent) completed during the review period contained missed claims-processing errors that should have been identified. Quality reviews with identified errors are routed to another QRT specialist for peer review to help ensure the cited errors are The OIG determined that the current peer review process was not adequate to identify errors missed during the initial quality review. In addition, performance reviews of QRT specialists did not promote competency, resulting in missed claims-processing errors.”
    2. Worse, in direct violation of VBA procedures errors identified by QRT specialists, were overturned by regional office managers with 870 errors found where 430 were overturned (49.43%). Why were the regional managers not fired for violating policy?  The VA-OIG continued, stating:

“Reconsiderations are requested by employees when they disagree with a cited error. Errors affect employee quality for performance review purposes. The OIG found that VBA’s current procedure regarding requests for reconsideration did not promote objectivity or contribute to accuracy of decisions. In addition, incorrectly overturned errors resulted in inaccurate performance quality for employees.”  Can someone say, Quid Pro Quo?  Should not questions arise about cherry-picking results and holding people accountable?  What about the veterans affected by these quality errors?  Who fights for them when the VA-OIG reports these obscene details and failures in leadership?  Each incorrectly decisioned claim is going to hurt real people, where are the elected representatives?

    1. In reading this report, my favorite quote is made:

“The OIG estimated that during the review period 2,000 of 4,400 identified errors (45 percent) were not corrected in a timely manner and 810 of 4,400 identified errors (18 percent) were not corrected at all. In addition, there is no process to confirm that corrective action was taken on error corrections. To maximize the effectiveness of the QRT program, additional oversight, objectivity, and accountability should be established.”  Can you say, “DUH!”  Talk about designing incompetence into a procedure to ensure no responsibility ever hits you, the process can identify errors, but cannot ensure the errors were corrected.  What an asinine and inane bureaucratic trick!

VA 3The following has been a review of the VBA’s quality assurance program, investigated in 2020, for failures of such immense magnitude that the VA-OIG returned, less than a year later asking questions about the VBA’s quality assurance oversight, and the problems only worsened as a deeper dive was made into what governs the quality program at the VBA.  Further supporting that the leadership IS the problem in every branch of the Department of Veterans Affairs!

Plato 2The following is a recap of findings by the VA-OIG regarding the continued mistreatment of VA Employees who report allegations of misconduct, retaliation, or poor performance of senior leaders, and other issues to the whistleblower program at the VA.  This topic is of particular interest to me, as when I called the VA-OIG regarding criminal misconduct by senior VA leaders, I was told since I was no longer an employee whistleblower protection do not apply and an investigation cannot proceed.  Since I had been reporting problems since 2018, I asked if those investigations would continue, and was told no, as I was no longer employed.  Hence, a loophole is built into the rules and policies, you have to somehow remain employed to be considered a whistleblower, but not just an employee.  You must be an employee who is not under probationary periods which can last from 1-5 years depending upon the position from date of hire.

Plato 3The following are findings highlighted from the report on the Office of Accountability and Whistleblower Protection (OAWP) and delivered to Congress:

    • Finding 1: The OAWP Misinterpreted Its Statutory Mandate, Resulting in Failures to Act Within Its Investigative Authority
      1. The lawyers were reading the policies and interpreting their intent too strictly and this was chilling whistleblowers at all levels of the VA.
    • Finding 2: The OAWP Did Not Consistently Conduct Procedurally Sound, Accurate, Thorough, and Unbiased Investigations and Related Activities
      1. The OAWP lacked comprehensive policies and procedures suitable for its personnel given that individuals’ reputations are at stake and whistleblowers’ identities must be protected.
      2. The OAWP did not have quality control measures. While some inadequacies were found by disciplinary officials and VA’s Office of General Counsel, this de facto oversight was not an effective or sustainable solution.
      3. The OAWP had failed to provide the staffing and training necessary to ensure it has the expertise, experience, and commitment that yield objective and thorough investigations.
      4. The OAWP had fallen short of its commitment to conduct “timely, thorough, and unbiased investigations” in all cases within its investigative jurisdiction.
    • Finding 3: VA Has Struggled with Implementing the Act’s Enhanced Authority to Hold Covered Executives Accountable
    • Finding 4: The OAWP Failed to Fully Protect Whistleblowers from Retaliation
    • Finding 5: VA Did Not Comply with Additional Requirements of the Act and Other Authorities
    • Finding 6: The OAWP Lacked Transparency in Its Information Management Practices

VA 3Is the problem clearer; the official investigative arm of the VA has the same leadership problems as the rest of the VA, and those leaders cannot, or will not, properly train staff to do their jobs!  How many employees have been unfairly dismissed by the VA because they reported to the OIG, like they are supposed to do, and retaliatory actions by senior leadership has cost them a job, their professional reputation, and the VA a chance to improve?

Knowledge Check!I can find no media discussion on this report to Congress where the elected officials took any action to hold anyone accountable.  The speech being reported is milk-toast solid and should have led to public remonstrations and it did not even cause a ripple in a toilet bowl.  Meaning that the legislation from 2017 and earlier is still being thwarted by the VA administration and administrators to the detriment of the VA and the employees discharged who did their job and reported on problems witnessed.

© 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.

NO MORE BS: The Leadership at the VA Continues to Shame Themselves!!!

Bird of PreyI do not believe in coincidences, I just started reporting the VA leadership as being the problem at the VA; the Department of Veterans Affairs – Office of Inspector General (VA-OIG) finally appears to be blaming Department of Veterans Affairs (VA) leadership.  In my inbox are two VA-OIG reports where the facilities’ leadership is being called out for the detestable behavior they continue to exhibit!  In one of the VA-OIG reports, please do not allow the “YUCK!” factor to distract from the problems at hand in the VA Leadership refusing to do the jobs they have been hired to perform!

        1. “Bradley Lane Croft, the owner of Universal K-9 Inc. in San Antonio, Texas, was sentenced to nearly 10 years of imprisonment for scheming to defraud the federal government of more than $1.5 million in GI Bill benefits to train service canines and their handlers. In addition to the prison term, Croft pays approximately $1.5 million in restitution.”

“November 2019, Judge Ezra found Croft guilty on eight counts of wire fraud, four counts of aggravated identity theft, two counts of money laundering, and two counts of making a false tax return.  Testimony during trial revealed that beginning in 2015, Croft provided false information in applications to the Texas Veterans Commission, including instructors’ names, certifications and training documents to receive GI Bill educational benefit payments.”

VA 3If you have access to more details, please share.  This story did not make a ripple in the news, and I want to know why!  Worse, who at the VA lost their jobs, lost their retirement package, or were sanctioned for allowing this fraud to occur?  2015-2018, three years of deception, where the VA leadership and lower-level employees were supposed to investigate and research documents submitted before awarding contracts?  The court records read like this was an IRS audit for fraudulent tax filing that discovered the school fraud of GI Bill benefits.  The VA never knew until the IRS alerted them.  Hence, I ask again, where was the VA in properly executing its duties to protect the government and the taxpayer from fraud?

      1. During a comprehensive healthcare inspection (virtual) of the Aleda E. Lutz VAMC in Saginaw, Michigan, the VA-OIG was pretty vanilla, except for the following. “Selected employee satisfaction survey results indicated opportunities for the Associate Director for Patient Care Services to improve workplace perceptions and for the Chief of Staff to support an environment where employees felt less moral distress” [emphasis mine].

VA 3Now, I have never personally been a patient in this VAMC or one of its clinics.  However, “moral distress” is a pretty universal phrase meaning that employees feel pressure to commit immoral activities.  The actual term “moral distress” is found in an “All Employee Survey,” where the employees stated that they felt pressured to commit an immoral activity at least once per day.

“In the past year, how often did you experience moral distress at work (i.e., you were unsure about the right thing to do or could not carry out what you believed to be the right thing)?”

If an employee feels anywhere between 1.0 and 1.7 times (on average) a day they are being pressured to commit immoral activities, surely this should raise some eyebrows and a lot of questions about the propriety of the leadership team.  Did the VA-OIG take a sample of employees and gather quantitative data on exact actions employees feel they are pressured to commit?  If so, why is the conclusion bereft of actionable items for leadership to take?  If not, why not?  Employees claiming pressure to act in an immoral manner are a significant risk to any business organization.  The VA is already on record for having inferior to worthless administrators; now the veterans and the taxpayers get to know the Aleda E. Lutz VAMC and its clinics have morality issue problems.  Nobody in the VA leadership at the Federal or VISN level cares!

        1. “The VA-OIG conducted a review to assess aspects of the care provided to a patient who was struck and killed by a motor vehicle following elopement from a community living center (CLC). The patient suffered from paranoid schizophrenia and was involuntarily civilly committed to the CLC.”

Administrative failures began the day the patient was admitted to the CLC, as discovered by the VA-OIG, “… the patient’s admission to the CLC was inappropriate as indicated by the CLC’s own screening process.”  Added to these concerns, the VA-OIG expressed the following concerns, “… regarding the appropriateness of CLC admission and elopement prevention.”

“The OIG determined that interventions implemented by staff were inadequate to mitigate the patient’s risk for elopement. The patient eloped multiple times, and facility staff failed to provide individualized, progressive, mental health-driven interventions to prevent the patient from eloping. The OIG also found that facility staff assigned to care for the patient were inadequately trained in mental health care, and patient safety reports were not completed as required.”

“On the day of the patient’s death, the OIG found that facility staff did not follow missing patient procedures after the patient eloped. Facility staff failed to detect that the patient was missing for nearly three hours, and once the patient was noted as missing, facility staff failed to follow policy to locate the patient. In addition, the OIG found that facility leaders did not ensure the facility had a missing patient prevention policy or that staff completed annual missing patient training. The OIG expressed concern that the CLC may not have been utilized as intended, given the lack of mental health standards applicable to CLCs and the complex mental health needs of this patient.”

VA 3Take a minute, imagine you are a family member of this patient.  How are you going to feel when you see the consistent and ongoing problems with the facility?  How helpless would you feel knowing that your family member was missing for hours before it became known to staff this patient, with a history of elopement, was gone?  How frustrated would you be with the administration when you read this report and see that from Day 1 admissions, this CLC was inadequate to the task of seeing to this patient’s needs?  Now, do you understand why I, as a veteran, become so aggravated and upset with the lack of leadership at the VA?  These are my brothers and sisters in arms, and they are being abused and killed by the VA’s lack of leadership.  The only recourse we have is to try and share these horrible tales with our fellow citizens in the hopes of improving the political leadership, to demand change of the executive branch’s VA leadership!  Another needless death at the hands of the VA leadership!

Let me preface this final story a little.  First, if you have a weak stomach, feel free to skip this next story.  Second, an endoscope is an illuminated optical, typically slender, and tubular instrument (a type of borescope) used to look deep into the body and used in procedures called an endoscopy.  Endoscopes are considered reusable medical equipment, and special training and procedures are required to clean and sterilize these scopes properly.  Third, an endoscopy is a procedure used in medicine to look inside the body. The endoscopy procedure uses an endoscope to examine the interior of a hollow organ or cavity of the body. Unlike many other medical imaging techniques, endoscopes are inserted directly into the organ.  Again, if you have a weak stomach, feel free to skip the rest of this article.

      1. Let us travel to the Chillicothe VAMC in Ohio, where we find the VA-OIG with “concerns” over “… responses by facility leaders to a Sterile Processing Services (SPS) employee’s failure to follow endoscope reprocessing [cleaning and sterilization] procedures.” The VA-OIG report stresses the following, “… the VA-OIG also identified concerns related to actions taken by Veteran Health Administration (VHA) leaders.”  Thus, we have one (1) employee and several VHA leaders from the local to the VISN whose actions are at best “questionable” in the cleaning and sterilization processes for an endoscope.

Three separate and similar complaints were raised at this facility for this exact issue!

“… VA-OIG investigations substantiated that the employee did not follow facility reprocessing procedures and falsely documented compliance. The VA-OIG determined that the Facility Director did not develop and implement an adequate plan to monitor the employee’s compliance with SPS procedures following reinstatement to SPS duty, particularly given concerns regarding the employee’s integrity and compliance. Because multiple patients were potentially affected, facility and VISN leaders notified the VHA Clinical Episode Review Team (CERT) for review and disposition. The CERT concluded there was minimal risk to patients and that a large-scale disclosure was not warranted; however, the VA-OIG found that the CERT’s determination may have been based on an inaccurate understanding of the reprocessing equipment’s capabilities” [emphasis mine].

VA 3Here is the other side to this problem. This is not the first time or first facility having problems with employees failing to reprocess medically reusable equipment, refusing to document correctly, or risk patient complications from dirty medical equipment!  This is not the first time the CERT team has made the wrong decision not to warn the patients involved; they might have been put at risk by dirty medical equipment!  The last episode involved colonoscopy equipment, and it was not that long ago I was writing about that incident!  YUCK!!!

Why was the employee not immediately fired for falsification of official documents?  Why did the facility’s and VISN separate investigations not see the directors of patient safety and hospital director fired for failure to perform their jobs?  The Chillicothe VAMC’s entire leadership should be fired in disgrace over this incident.

PACT 1While a patient in the VA Hospital here in Phoenix, I was in a clinic where a mother was trying to gather sufficient records to hold the VA accountable for her son’s permanent disability from sepsis.  The veteran caught sepsis when improperly cleaned scopes were used during a gall bladder removal surgery.  Her son, the veteran, spent 9-months in and out of non-VA hospitals; she had pictures of his bruised and swollen abdomen from the doctors trying to treat the sepsis and keep the veteran alive!  I have no idea whether this mother was successful or not getting the VA to cover the medical expenses and increase her son’s disability.  I only know I never saw her at the VA again, and the VA Police shadowed her as she moved from clinic to clinic, gathering records.  I do not know why records release could not release the proper documents to save this mother the hassle of visiting individual clinics.  I do know I can still see this veteran in the photos his mom showed me, and my blood continues to boil!  Yet, the CERT team asserts that mass notification is not needed in these situations; I demand to know why they can make this decision!

ApathyThe leadership at the VISN levels and the individual hospital levels is sick, inadequate, and desperately in need of a complete replacement to end the culture of corruption found inside the VA.  When employees record moral distress, this should be an automatic red flag, alerting the VISN leaders poor leadership practices are happening, but the VISN never does anything!  Failure of this magnitude would have gotten any non-VA hospital or clinic shuttered and class-action malpractice lawsuits launched.  Yet, when the VA gets caught, the media cannot even be bothered to report on the problem in the local news.  Maximum endurance has been breached, and these administrator problems need immediate attention from the politicians!

Dont Tread On MeHence, I will ask you, dear reader, to please share these VA articles far and wide.  Action is needed before the next veteran to die unnecessarily is a friend or family member of yours!

© 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.

NO MORE BS: VA Administrators – Heaping More Shame

Angry Wet ChickenI believe in public shaming; I am an equal opportunity shamer.  Where the VA is concerned, well, I tend to be more motivated to pass out shame than any other government entity.  Not that I won’t pass along shame, or congratulations, when warranted, the administration of the VA deserves a few more scoops from the shame bucket today!

The Department of Veterans Affairs – Office of Inspector General (VA-OIG) passed along two issues today, and I have to weigh in on serving more shame, cold, hard, and well deserved.  Long have I maintained that the administration and administrators of the VA are the problems in the Department of Veterans Affairs (VA).  Today’s VA-OIG reports provide more justification for demanding cleaning of the house for administration officials at all levels in the VA.

      • “Rita Copeland, 59, of Portsmouth, Virginia, pleaded guilty today to wire fraud and aggravated identity theft in connection with a scheme to defraud veterans. Copeland operated an entity known as Veteran Services of the Commonwealth and purported to provide various services to veterans from 2016 through 2020. She caused a number of victims to apply for VA home improvement grants and then used a portion of the grant payments to her own benefit instead of performing the promised work.”
      • “Sophia J. Quill, 60, was charged with defrauding the VA and the Michigan Department of Treasury out of $470,000. Quill and her co-conspirator Melissa Flores, who was arraigned last year, allegedly created aliases and obtained or created fraudulent documents to make it appear that they were heirs to various individuals who died.”

VA 3If this is VA Excellence in action, we all need to be concerned!  Do you notice anything missing from these reports?  Let me help; where are the approving officials expected to do due diligence in being held culpable for allowing the fraud to thrive?  I fully admit I have limited experience being a document reviewer and approving authority.  I cannot help but ask about these approving officials who have been trained and gathered experience for their employment role.

ApathyI submit documents to the VA all the time, and every time I have to submit anything, the intake “officer” has to certify the document’s validity.  Heck, the VA had my NGB Form 22 and both DD 214’s, and I still had to submit valid copies to ensure I was not defrauding the government.  Forget innocent until proven guilty; submit forms to the VA, and you are guilty until they begrudgingly claim you are innocent.  Submit documents to Social Security for a claim, same thing, same process, same everything.  Yet, somehow three different people were able to defraud the government, stealing money, and are now hosts of the government.

Detective 4Now, returning to the VA-OIG reports, who authorized accepting the fraudulent documents?  Where were the inspectors?  How many veterans had to complain they were being cheated before anyone took notice of Copeland’s crimes?  How many congressional members were contacted for help that never arrived?  How many letters to administrators were written that were never answered?  How long did veterans suffer before the VA took action, especially in Copeland’s case?  How many evidence intake specialists lost their jobs in either case?  Were any held accountable for failing to do their jobs?

Congress, you have two straightforward jobs, write laws that are constitutional and scrutinize the legislative branch to protect the citizen from runaway government.  After the last two weeks, I have to ask, where are you in performing either role?  Passing District of Columbia Statehood for the “umpteenth time” is unconstitutional!  Overlooking the scrutinizing of the legislative branch is unconstitutional and criminal negligence of your sworn duties.

The administration of the Department of Veterans Affairs is rotten to the core!  Yet, even when directly responsible for fraud, negligence, and dead veterans, the administrators are given a “Get out of Jail Free Card.”  Wasn’t Speaker Pelosi pretty upset with CEOs and “Golden Parachutes?”  Yet, the VA Administration has precisely this and more, and the veterans and taxpayers cannot even get your attention for a second of work!  Where is the corporate media taking the politicians and the VA administration to task for criminal negligence and failure to protect the citizen?  It seems to me we can add a culpable third party to the needs a dish of shame, the media, who are also criminally negligent in performing their duties.The Duty of Americans

Where are the lawyers?  Copeland’s case undoubtedly deserves a Class-Action Lawsuit to help those defrauded get the money they need.  Where are the lawyers, hungry to see change and willing to risk becoming known for taking on the VA and winning?  The actions of the VA Administrators need to be corrected.  If Congress refuses to scrutinize appropriately, the lawyers need to begin processes in all 50-states and US Territories and Districts to demand the VA get fixed!

Bird of PreyThe time for kid-glove treatment and soft-shoe approaches is past and dead; more positive and forceful measures are required.  Where are the lawyers?

© 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.