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: 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.