If Everyone Cared – More Detestable VA Stories (Chapter 2)

?u=http3.bp.blogspot.com-CIl2VSm-mmgTZ0wMvH5UGIAAAAAAAAB20QA9_IiyVhYss1600showme_board3.jpg&f=1&nofb=1For the last two weeks, I have been a little remiss in writing.  My cousin passed from diabetes, two of my grandkids got sick with COVID (they are recovering), and I was diagnosed with asthma.  The last two weeks have been a roller-coaster of ups and downs, so imagine my surprise 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.  Pandora certainly appears to have a sense of humor and an innate sense of déjà vu.  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 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.  Thus, as we celebrate US Constitution Day, let us remember the veterans who have helped protect and defend the US Constitution and improve the government response!

The VA-OIG reports begin in Kansas City, Missouri, with a $335 Million Fraud Conspiracy, which included $615,000 in tax violations.

By pleading guilty today, Patrick Michael Dingle, 50, admitted that he conspired with Matthew C. McPherson, 45, of Olathe, Kansas, to fraudulently obtain contracts set aside by the federal government for award to small businesses owned and controlled by veterans, service-disabled veterans, and certified minorities.”VA 3

A sentencing hearing will determine if any prison time and what if any, restitution is required in this plea deal.  Frankly, the fact that the fraud existed from 2009-2018 is nothing short of a blatant and utter slap in the face for the taxpayer.  How many federal employees had to have seen the documents, failed to perform due diligence, refused to do their jobs, and were not named as co-conspirators or, at a minimum, facilitators of the crimes?  Is aiding and abetting a criminal operation not a charge that can be brought against the federal employees who empowered this fraud?  Thus, I demand all these people explain why and how an investigation can occur and not include the facilitators, those federal employees, who did not do their jobs!

Assistant US Attorney Paul S. Becker is prosecuting the case. The following agencies assisted in the investigation: the Department of Veterans Affairs, Office of Inspector General; the Department of Defense Criminal Investigative Service; the US General Services Administration, Office of Inspector General; the U.S. Small Business Administration, Office of Inspector General; the Army Criminal Investigation Command, Major Procurement Fraud Unit; the Department of Agriculture, Office of Inspector General; IRS-Criminal Investigation; the US Secret Service; the Air Force Office of Special Investigations, Procurement Fraud; the Naval Criminal Investigative Service; the Defense Contract Audit Agency – Operations Investigative Support (OIS); the US Department of Labor, Office of Inspector General; and the Department of Labor, Employee Benefits Security Administration (EBSA).VA 3

File the following under false imprisonment, and will someone please tell me why those employees involved are not in prison now!  A patient in the inpatient mental health unit and community living center at the Tuscaloosa VAMC in Alabama was falsely imprisoned and kept against their will for more than 2-years.  Was denied access to a patient advocate, which should be a red flag that something is disastrously wrong right there.  Plus, official mail to an elected official was improperly handled by staff to prevent elected officials from knowing about the veteran’s plight.

Here is what the VA-OIG investigation substantiated in their investigation:

    • Staff did not adequately assess the patient’s admission status as voluntary or involuntary and did not follow commitment requirements during the first two of the patient’s three Inpatient Mental Health Unit admissions.
    • Staff did not properly manage a letter from the patient that was intended for a public official.
    • Staff did not correctly identify a surrogate decision-maker and did not address ethical concerns regarding the appropriateness of the patient’s surrogate decision-maker.
    • Staff did not comply with requirements when the patient requested an against medical advice discharge.
    • staff at the facility denied a patient’s discharge requests and did not ensure the patient’s access to a patient advocate.
    • Staff failed to follow informed consent procedures.
    • Staff denied the patient’s discharge requests.
    • Staff did not conduct a sufficient or timely decision-making capacity evaluation and documented unsupported, conflicting decision-making capacity information in the patient’s electronic health record.VA 3

These are serious crimes, not bad administrative practices, felonious crimes.  Yet, the employees skate, the patient was held against their will, and nobody will be responsible for this disaster.  Where are the elected officials?  Where are those hired to scrutinize the government?  In this situation, any other medical organization would be facing lawyers armed with righteous indignation and seeing dollars signs in their dreams.  Yet, because this is the VA, the patient can be harmed, and no one will ever care, and that is a crime the elected officials are guilty of and need to be held to task for!

Moving to Biloxi, Mississippi, we found another VA employee who had sticky fingers and a long time to steal from the government (2009-2020).

Chad Paul Jacob of Saucier, Mississippi, pleaded guilty to stealing personal protective equipment, electronics, and medical equipment while working as the assistant chief of supply chain management for the Gulf Coast Veterans Health Care System in Biloxi. From 2009 through December 2020, Jacob stole and resold VA property at local pawn stores and on his personal eBay account.”VA 3

For eleven years, they were working as the assistant chief of supply.  The employee had how many reporting employees and superiors have had to sit through how many records audits.  In all these eleven years, I cannot believe that nobody ever suspected problems.  Who did the thief learn how to steal from the government from?  How many employees churned, and did any of these employees churn because they tried to report irregularities, and the boss ensured they were disposed of to silence them?  The VA has been taken to several congressional hearings to eliminate the whistle-blower rather than fixing the problems at the VA.  Thus, it is not in any way, shape or form, out of line to be suspicious about employee churn and fraudulent actions taken by a supervisor to eradicate and protect their schemes!  Why are these questions never asked in the VA-OIG investigations where schemes are uncovered by ranking and supervisory personnel?

Remaining in the south and moving next door to Slidell, Lousiana, a doctor, has been indicted for illegally dispensing opioids in a health care fraud scheme.

Adrian Dexter Talbot of Slidell, Louisiana, was charged for his role in distributing Schedule II controlled substances, including oxycodone and morphine, outside the scope of professional practice and for maintaining his clinic to distribute controlled substances illegally. He was also charged with defrauding health care benefit programs of more than $5.1 million, given that the opioid prescriptions were filled using health insurance benefits.”VA 3

Remember, an indictment is not a finding of guilt, and the defendant remains innocent until proven guilty in a court of law by a jury of his peers.  There is a very compelling point made by our founding fathers that need to be repeated here and declared more often in American Society.

“… Should the People of America, once become capable of that deep simulation towards one another and towards foreign nations, which assumes the language of justice and moderation while practicing iniquity and extravagance, and displays the charming pictures in the most captivating manner of candour, frankness, and sincerity.  At the same time, it is rioting in rapine and insolence; this country will be the most miserable habitation in the world.  Because we have no government armed with power capable of contending with human passion unbridled by morality and religionOur Constitution (the US Constitution) was made only for a moral and religious people.  It is wholly inadequate to the government of any other.” – President John Adams

The drug war and the opioid crisis stem from the same problem, a lack of morality and religion.  The duplicity of showing candor, frankness, and sincerity, while at heart there is nothing but ravening appetites and the minds of wolves, is the problem.  Sure, drugs create a social and medical issue out of the unbridled appetites and passions.  The core is the lack of self-restraint from being disconnected to religion and morality and from social duty, responsibility, and accountability.  Thus, making people miserable and looking for a cure.Knowledge Check!

The case above expresses this point clearly; the doctors involved were filling an appetite.  As long as there is an appetite, there will be people willing to risk everything to fill the appetites of others; moral and social disconnection, and the US Constitution cannot govern these people except to their destruction!

Moving to Fort Lauderdale, Florida, we find another series of indictments for more fraud, reflecting the same social disconnection.

Kingsley R. Chin of Fort Lauderdale, Florida, the chief executive officer of SpineFrontier Inc., and Aditya Humad of Cambridge, Massachusetts, the company’s chief financial officer, was indicted on one count of conspiracy to violate the Anti-Kickback Statute, six counts of violations of the Anti-Kickback Statute, and one count of conspiracy to commit money laundering. Chin and Humad allegedly bribed surgeons to use SpineFrontier’s products, and in turn, the company received millions of dollars in revenue from surgeries the surgeons performed.”VA 3

Traveling north to Bedford, Massachusetts, we find another dead veteran and culpability so thick it should be used as a board to apply corrective discipline for all parties involved!  From the report, we see the scope of the investigation for the VA-OIG:

Mr. Timothy White was a resident of the Bedford Veterans Quarters (BVQ), an independent living facility operated by Caritas Communities, Inc. (Caritas), in space leased to it through VA’s enhanced-use lease program. A month after Mr. White was reported missing, his body was found in the emergency exit stairwell of the building that houses the BVQ. This stairwell down the hall from his room was VA property and not leased to Caritas.”VA 3

The VA-OIG found the following as facts in the investigation:

    1. The VA police department’s failure to locate Mr. White resulted in part from the police and others at VA not considering the veteran an at-risk missing patient, which would have required a stairwell search.
    2. The Veterans Health Administration and the Office of Security and Law Enforcement lacked clear guidance regarding the obligations of VA police to search for nonpatients reported missing on VA property.
    3. VA police also did not discover Mr. White in the stairwell because of an improper order by the then-police chief to cease patrols of the building in which Mr. White was found.
    4. The OIG found that the VA police chief exceeded his authority as VA policy, and the lease required VA police to patrol VA property.
    5. Medical center staff mistakenly believed the emergency exit stairwells were not VA space; they did not clean them.
    6. The confusion among medical center leaders and staff regarding the lease scope and VA’s obligations stemmed from a lack of clear guidance from the Office of Asset and Enterprise Management.
    7. Routine police patrols and stairwell cleanings likely would have led to Mr. White being found earlier.

Angry Grizzly BearNow, as logical thinking adults, do you buy the load of excuses being sold here to pass off the blame for a dead veteran?  I know I am certainly NOT buying this load of bull!  Having worked and spoken in-depth to leaders of VA Police Departments, the excuses to not do stairwell checks and camera checks for missing patients are beyond inexcusable!  I know of a situation where a patient was lost on VA property.  Every police officer and staff member, even those on off-shifts, were called in, issued out in teams, and every square inch of the property was investigated until the patient was found.  Yet, somehow this patient was able to DIE unnoticed in a stairwell!  Are you kidding me?!?!?!

Regardless of whether this veteran died of malnourishment, dehydration, exposure, or lack of medication, he died horribly!  The veteran died at the hands of responsible parties, and those parties need to be held accountable for his untimely and atrocious death!  There is NO EXCUSE for this veteran to have died.  SHAME on the administration!  SHAME on the VA Police!  SHAME on the third-party contractor.  SHAME on the leaders of government who have allowed this abuse and refused to act!

Moving west to Chalfont, Pennsylvania, we find more stolen valor and theft of government benefits.

Richard Meleski of Chalfont, Pennsylvania, was sentenced to three years and four months in prison, three years of supervised release, and ordered to pay $302,121 in restitution for stealing VA benefits by pretending to be a veteran who the enemy had captured during combat. In July 2020, Meleski pleaded guilty to one count of healthcare fraud, two counts of mail fraud, one count of stolen valor, two counts of fraudulent military papers, as well as two counts of aiding and abetting straw purchases, and one count of making false statements in connection with receiving Social Security Administration disability benefits.”VA 3

While there are many more VA-OIG reports needing sunshine disinfectant, let us remember Mr. White, who has passed, and the feloniously falsely imprisoned unnamed veteran from today’s VA-OIG recap.  These two veterans especially deserve respect, dignity, and remembrance.  Their families and friends deserve praise and prayers.  America deserves answers, and federal employees need to be held accountable for failing to do the job they are paid tax dollars to perform!

I-Care© 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 – May We Remember the “Pobrecito!”

I-CareA Spanish-speaking Mexican colleague taught me this term, “pobrecito,” meaning “poor little one.”  As I chronicle the VA ineptitudes, failures, criminal behaviors, and abusive actions, I am always conscious of the pobrecito, the poor little one, the poor victim who got harmed.  Too often, the victims never receive any compensation, acknowledgment, or retribution, nothing for having become a victim of the VA.  Too often, the Department of Veterans Affairs (VA) – Office of Inspector General (VA-OIG) investigates long after the abuse has occurred, and the victims are not covered in the scope of the investigation, or worse, the victim was killed, and the family is left to mourn, and nobody can help.

Angry Grizzly BearWhy chronicle the VA abuses; because the needs to be held accountable, speak the language, and have tougher skin and broader shoulders than the VA’s normal victims.  The VA is slowly learning they can harm me, but they cannot shut me up!  I will not stop fighting the VA for humane treatment, honorable service, and dedicated systems.  The VA is sick because apathy and inertia were allowed to replace common sense and decency, leadership was replaced with cost accounting and bureaucratic red tape, and human kindness was eradicated and replaced with drones and robots.  I know how to make the VA better; I do not have all the answers, but I know how to launch the revolution and begin cleaning the VA, and I will not stop calling upon those responsible for fixing the mess they created!

Starting this week’s VA-OIG headlines of crimes and inspections, we find a couple in South Florida who used the system to bilk more than $20 Million in purchase order scams.

Earron Starks was sentenced to 30 months’ imprisonment, followed by three years of supervised release, and ordered to pay over $2.4 million in restitution. Carlicha Starks was sentenced to three years of supervised release, including one year of home confinement, and ordered to pay $501,000 in restitution. They paid kickbacks to VA employees as part of a large-scale bribery scheme, which enabled the Starks couple and other corrupt vendors to receive over $20 million in purchase orders from VA medical centers in West Palm Beach and Miami. Fourteen additional defendants were charged for their roles in this scheme.”VA 3

Who’s the pobrecito in this case; the taxpayers, the veterans, and the United States.  Federal Employees had to not only know the crimes occurring but be complicit in the crimes.  Will they lose their retirement benefits, have to repay their wages, and face criminal charges and jail time for their culpability?  Fourteen additional defendants, how many were supervisors in the know and on the payroll who were promoted during this scheme whose supervisors failed to do their jobs and scrutinize the work of their underlings?  The shadiest part of this entire scheme is encapsulated in the following sentence:

All VA Employees were either terminated or resigned.”

Name me one private-sector employer who could get away with a massive scheme and enjoy similar benefits!Survived the VA

We find another VA employee embroiled in theft of equipment which sold the stolen goods in Ohio.

Kevin Rumph, Jr., of Fairburn, Georgia, pleaded guilty to stealing more than $1.9 million in medical products while employed at a VA community-based outpatient clinic in Atlanta. Between 2013 and 2021, Rumph made hundreds of unauthorized purchases of equipment used to treat obstructive sleep apnea. He then stole and sold the equipment to a vendor in Ohio. Sentencing is scheduled for November 17, 2021.”

I have worked in purchasing in both the US Military and in the private sector.  If I went to my bosses with “hundreds of purchase orders for supplies,” they would naturally be curious.  Repetition of hundreds of similar requests would raise red flags and demand audits of my records and proof of need.  Why did this not occur at the VA?VA 3

In the US Navy, I was in charge of ordering stock and saw requests for certain o-rings spike, as I knew the Chief Engineer would spot this and ask why, I asked why, went to the equipment records, dug up the maintenance reports, and asked questions of the mechanics and technicians.  In doing so, we discovered an unreported problem with machinery.  This is called due diligence; why was it not being practiced by the supervisor of Mr. Rumph?  You cannot tell me a seven-year trend line is something that was an anomaly and easily missed in budget reporting year-over-year!

Exclamation MarkLet’s admit a truth for certain; COVID has been a farrago of gargantuan size from day 1.  In acknowledging this, no blame is being proportioned to the front-line workers in any way, shape, or form.  But, the administrators, policymakers, politicians, and government bureaucrats have certainly proved they could unscrew the inscrutable!  Worse, the bureaucrats proved that their idiocy was highly contagious, infecting more people than COVID, spreading faster than COVID, and killing more people than COVID.  Our proof of this concept arrives from Houston and the Michael DeBakey VAMC.

The VA Office of Inspector General (VA-OIG) conducted a healthcare inspection regarding allegations of incompletely screening for COVID-19 and treatment of a patient with serious mental illness who presented for same-day care at the Michael E. DeBakey VA Medical Center (facility).”

Findings:

      • The VA-OIG substantiated that facility staff did not complete the patient’s COVID-19 temperature screening.
      • The VA-OIG substantiated that facility staff failed to manage the patient with COVID-19 symptoms medically.
      • Sent the patient to the drive-through testing area without medical evaluation, did not isolate the patient, complete a care plan, or follow the policy for transporting patients suspected to have COVID-19.
      • The vulnerable patient disappeared while in the facility’s care, was found off-site four days later experiencing a medical emergency, taken back to the facility, and died the following day [emphasis mine]!
      • The VA-OIG determined that the Mental Health Intensive Case Management team failed to address documentation discrepancies related to the patient’s surrogate and educate the family on COVID-19 visitor policy and screening processes.
      • The VA-OIG identified the facility’s noncompliance with the missing patient policy.
      • Facility leaders’ failure to report an adverse event and ensure a timely review of the patient’s episode of care.
      • The VA-OIG identified facility leaders did not timely or accurately disclose to the patient’s family the medical mismanagement that led to the patient’s adverse clinical outcome, e.g., death!
      • The VA-OIG concluded the failure to screen, isolate, and evaluate the patient resulted in potential COVID-19 exposure to staff, patients, and the public when the patient moved through facility grounds.VA 3

What was not covered in the scope of the VA-OIG investigation was whether the staff had proper training on the written policies or if training had been suspended due to the “pandemic health emergency.”  Failure of training has been a running and recurring theme for the VA before the pandemic, and the failures of training have led to thousands of “adverse clinical outcomes” at the VA, up to and even including death.  Yet, as evidenced in this example, small decisions lead to catastrophic events.  The infected patient was mentally unstable and missing for four days; how many people interacted with the patient as a superspreader event?  Who is at blame at this VAMC for this event, the leaders!  They failed their people, failed this patient, and failed this family!

Detective 4Before continuing, we must pause and take a moment to send heartfelt congratulations to two VA Health Care Systems (VAHCS) who passed their comprehensive healthcare inspections (CHIp), if not with flying colors with significant improvement, and are deserving of the highest praise.  Would the leaders of the Fort Harrison VAHCS in Montana and the Western Colorado VAHCS in Grand Junction please stand and take a bow.  Your improvements, conduct, and capacity to achieve reflect that success is possible with good leadership.  Keep up the good work; find ways to improve daily, and may continual success be ever yours!

Finally, we come to a regular topic, the failure of the VA as a whole entity to manage to pass a simple audit on financial matters and the continuing debacle where hiring is concerned during the pandemic.  Let me refresh your memories on the hiring debacle; first, the VA-OIG found that VISN leaders “were generally pleased with the “flexibility” provided during the pandemic for speedier hiring.”  What did the American people get for reduced hiring practices at the VA?  More criminal employees, more employees with shady pasts, more employees with sticky fingers, and more employees who could not find employment in public schools, now working for the federal government.VA 3

How did that relaxing of hiring practices work out for the American people and the veterans receiving care; not very well!  But, let’s all relax; the VISN leaders are “generally pleased.”  Frankly, I would be shocked if anything ruffled the VISN leaders’ feathers long enough for them to care; they are mostly at the top of their career ladders and failing a presidential appointment to Washington, know they are set for life.  So, why rock the boat?!?!

As for financial audits, the VISN leaders know that money continuously is appropriated to carry them and their poor decisions forward.  Just ask the Denver VAMC where the construction cost overruns are still costing the taxpayers, and no one was ever held liable for that boondoggle or any other crime and scheme for that matter.

Question 3Why?  Why are victims left to rot, the assaulters and victimizers promoted, and the VA as an organization left in the hands of disreputable, dishonest, unethical, and immoral people?  Why is the VA a culture of corruption, greed, envy, sloth, and disinterest when the US military is the exact opposite?  America is not what is found in the halls of the VA, why has the VA been allowed to become something anathema to the American people?

Knowledge Check!Great Britain, you find similar in your halls of government.  Your people are amazing; your government workers are just as despicable and deleterious as the American VA, IRS, and DMV.  Australia, great people, absurdly detestable government workers.  France, interesting people, but the government employee seems to have been drug from the bottom of the scum sucked from the Seine.  I have met incredible people in Italy, Greece, Germany, South Korea, etc., but the story rings true everywhere; the government does not represent you.  Pobrecito; what has happened?

© 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.