24 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:
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- 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.
- 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.
- 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!
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How can a person be sure the problems caused are a direct result of leadership failures?
By 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.
Case 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.”
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.
Let 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.”
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?
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.
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].
Did 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?
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.
One of the Department of Veterans Affairs – Office of Inspector General (VA-OIG) reports I wrote about in 2019 was how the Department of Veterans Affairs – Veterans Benefits Administration (
The manuals, designed and published by the VBA, are inadequate to decide spinal claims consistently. The VBA created these books to be a ready-made excuse for cheating veterans with improperly decided claims on spinal injuries. Why is this such an issue for me; I have been fighting chronic pain in my spine since 2002. I fell multiple times onboard the ship after being pushed by a First-Class Petty Officer while carrying a load of D Cell batteries. I experienced weakness and shortness of breath on the boat, went to medical; none of those records exist anymore. The Chief made Senior Chief and was “encouraged” to retire shortly after I left the ship. After leaving the service, I discovered that the Independent Duty Corpsman, a US Navy Chief, was consistently sinking medical records for the Engineering Department to Davey Jones’ Locker.
Today, 10 May 2010, I had a Compensation and Pension appointment with LHI. I discovered the VBA had edited my claim, and my C-Spine information again was missing from the evaluation. Since my spine was inappropriately decided in 2014, I could not add the C-Spine problems into today’s appointment. I was sent back to the VA to file a supplemental claim, using the 
Worse, all the problems have a root cause in the technology forced upon the medical reviewer. There is an insufficient explanation to describe to a veteran what the VBA is asking for, so the veteran can answer the questions correctly. The person who made my spinal claim originally had been writing VBA claims for 20+ years. She was still disregarded by the VBA because the Veterans Service Representative reviewing the claim could not, or would not, interpret the doctor’s note correctly for an accurate decision. Any fourth-grade biology student can tell you that the T-Spine is different from the L-Spine, and damage in one does not mean damage can be added to the other, and all the damage can be lumped together! Yet, that is precisely the asinine decision I was handed and have been fighting!
During new hire training for working at the Department of Veterans Affairs (VA) New Mexico Medical Center (NMVAMC), the first day contains a lot of warnings about what you can and cannot do as a Federal Employee. Annually, there are mandatory classes that must be passed to remind an employee of their obligations as a Federal Employee. Leading to a question, “How could an attorney for the Department of Veterans Affairs – Office of General Counsel (OGC), be allowed to break the law for eight years?” The department of Veterans Affairs – Office of Inspector General (VA-OIG) investigated after a second complaint about the same person was received, and only then did the OGC take action. The attorney in question was released from government employment, but where is 8 years’ worth of wages being requested back? Did the attorney lose anything other than an undemanding job and title where they could be paid for not working for the Federal Government while advancing their private practice, violating ethical laws, and breaking several Federal Statutes along the way?
On the topic of insane and inexcusable abuse of the VA, the VA-OIG investigated the Greater Los Angeles Healthcare System in California and found a supervisor in an “other than spouse” relationship with a vendor and they used the VA property to improperly conduct business on contracts the supervisor oversaw. These actions are a clear and blatant violation of the Federal Statutes on contracting as a Federal Employee, even if these consenting adults were married, it would remain illegal, unethical, immoral, and inexcusable! Yet, because the supervisor quit during the investigation, the VA-OIG has no power to take any action.
The VA-OIG performed an audit, also referred to as a “data review.” “The data review consisted of a sample of 45 employees and found the employees were paid an estimated $11.6 million for overtime hours for which there was no evidence of claims-related activity in the Fee Basis Claims System in fiscal years 2017 and 2018, representing almost half of the total overtime paid. Significantly, 16 of the 45 employees each received more than $10,000 in overtime for hours during which there was no claims-related activity.” The Department of Veterans Affairs – Office of Community Care (OCC) is backlogged and this is leading to late payments to providers, delays in care, and is generally a bad thing. However, the sole reason for the overtime being abused was due to a lack of processes, poor supervision, and training. These are the same three excuses that are used by the Department of Veterans Affairs – Veterans Benefits Administration (VBA) and is designed incompetence at its most disdainful and egregious level. Worse, this was a sample of employee misconduct on overtime pay. How many more cases are floating in the OCC that were not included in the audit that will pass unresearched because the VA-OIG did not refer the cases for disciplinary recommendations?
The VA-OIG conducted a comprehensive inspection of the Eastern Kansas Health Care System, Kansas, and Missouri. The findings are startling for several reasons, one of which being the deficient lack of leadership leading to poor employee satisfaction, patient care issues, lack of knowledge in managers and supervisors, and minimally knowledgeable about strategic analytics. Essentially, there is a lack of leadership in this healthcare system. The director has been working with a team for 2-months, but the director has been in charge in 2012. Leading to questions about long-term staffing replacement, staff training, building the next generation of leaders, and why this long-term director can brush off the criticisms of leadership failure because the team has only been in place for two months at the time of the inspection.
No controls, no direction, no strategy, no tactical action, losing money, and not even scraping an F in performance. The repetition in these VA-OIG investigations is appalling! Where is the accountability? Where is the responsibility and commitment to the veterans, their dependents, and the taxpayers? Where is the US House of Representatives and Senate in demanding improvement in employee behavior? Talk about a culture of corruption; the VA has corruption in spades, and no one is taking the VA to task and demanding improvement.
The VA-OIG recently released a report regarding deficiencies in nursing care and management in the Community Living Center (CLC) at the Coatesville VA Medical Center, Pennsylvania. The inspection team validated some complaints and were unable to validate all complaints because of poor complainant documentation. Having a Tiger Team able to dispatch from your office, carrying your authority, would provide expert guidance in rectifying the situation, monitoring the CLC, and updating you with knowledge needed to answer the legislator’s questions regarding what is happening. The VA-OIG found other issues in their investigation that were not covered under the scope of the investigation, leaving the VA-OIG in a difficult position. Hence, another reason for a Tiger Team being created, to back stop and support the VA-OIG in correcting issues found outside their investigatory scope.
For a decade now, I have been reading how the VA-OIG makes recommendations, but where is the follow-up from the VA-OIG to determine if those recommendations are being followed and applied? Too often there is no return and report feature built into the VA-OIG investigation, as these investigators just do not have the time. Again, this is what a Tiger Team can be doing. Taking action, training leaders, building a better VA, monitoring and reporting, building holistic solutions, and being an extension of your office on the front lines. Essentially using the tools from your office to improve the operations locally, which builds trust between the patients and the care providers, building trust between the families and the VA, and delivering upon the Congressional mandate and VA Mission.
The Tiger Teams need to be led by an organizational psychologist possessing a Ph.D. and a personal stake in seeing the VA improve. The organizational psychologist can build a team of like-minded people to be on the flying squad, and these team members should be subject matter experts in VA policies, procedures, and methods of operation, and should change from time to time. I have met many people from the VA who not only possess the passion, but are endowed with the knowledge of how to help the VA, and I would see the VA succeed. Yet, I am concerned that the VA is not changing, not growing, and not developing the processes and procedures needed to survive, and this is damaging the VA, which leads to wasted money and dead veterans.
Bureaucratic inertia is the cause of too many issues, problems, and dead veterans, at the Department of Veterans Affairs. The symptoms include delays in administrative tasks that lead to patients dying for lack of transport to a hospital. The symptoms include cost overrun on every construction project the VA commences. The symptoms include abuse of employees, creating a revolving door in human resources where good people come in with enthusiasm, and leave with anger and contempt, generally at the insistence of a leader who refuses to change. The symptoms include a bureaucrat making a decision that has no logical sense, costs too much and is never held accountable for the harm because the decision-maker can prove they met the byzantine labyrinth of rules, regulations, and policies of the VA.
Secretary Wilkie, until you can overcome the bureaucratic inertia prevalent in the ranks of the leadership between the front-line veteran facing employee and your office, lasting change remains improbable. Real people are dying from bureaucratic inertia. Real veterans are spending their entire lives in the appeal process for benefits and dying without proper treatment. Real families are being torn asunder from the stress of untreated veterans because the bureaucratic inertia cannot be overcome from the outside. I know you need legislative assistance to enact real change and improve the VA. By way of petition, I write this missive to the American citizen asking for your help in providing Sec. Wilkie the tools he needs to fix the VA.
Would the honorable elected representatives please answer the following question: “Are the veterans of America’s armed services the next ‘
Musical chairs because the VA-OIG was unable to ascertain direct harm because of record screw-ups, gross mismanagement, and a detestable and despicable perception of the patient. The 
The actions of the nameless and faceless bureaucrat are unconstitutional, but allowed in the name of “government action.” Every time you hear the government is acting on your behalf, it means that the power of the people has been stolen, and will be doled back to the taxpayer in infinitesimal amounts, while the bureaucrat keeps getting fatter. Think Reich (1964) is wrong, here are some examples.
I write harshly about the crimes of the VA because I-CARE and deeply desire to see the VA bureaucracy changed, to witness the adoption of I-CARE into the daily efforts of every VA employee, and to see the VA leadership teams develop policies and procedures that will benefit the veterans, and relieve the suffering of veterans, their spouses and children, and live the VA mission of bearing up those who have born the pains of battle.
In the coming days and months, I will continue to write about the VA. Using personal experience, patient experiences related to or personally witnessed, and the Department of Veterans Affairs – Office of Inspector General investigation reports, as the reasons for the solutions I propose. I-CARE, enough to stand as a witness that the VA in its current form cannot, and should not, be allowed to thrive any longer. Change must come to the Department of Veterans Affairs (VA), including to the Veterans Health Administration (VHA; hospitals and clinics), the Veterans Benefits Administration (VBA; compensation and pension claims), and the National Cemeteries. Thus, I witness my commitment to I-CARE and the VA.
The primary care doctor, emergency room doctors, and more all depend upon the radiologist report as the VA doctors no longer read x-rays, MRI’s, CT Scans, due to the complexity of the imaging. Thus, any error in the radiological report causes significant patient care delays, harm, or death. Yet, at two geographically separate VISN’s and Hospitals, the VA-OIG is reporting poor QA and high error rates in radiological reporting. Compounded by leadership failure at both the local hospital and the VISN level. The VA-OIG reports do not relate that anyone was fired, forced to change jobs, or other remedial actions taken beyond making “suggestions” for improvement at the federal, VISN, and local hospital levels. What significantly increases the problem, these same radiological records form the backbone of the compensation and pension decisions. Downstream issues were not in the scope of either radiological investigation. Still, every error in the VA bureaucracy has a significant downstream impact that always seems to be forgotten or overlooked.
Start using an ISO 9001 for healthcare as a QA program where processes and procedures are written down and followed. QA should be a program that fits holistically and improves people. Quality assurance should be a constant learning evaluation that never ends. Yet, somehow the VA, including the VBA, the VHA, and the National Cemeteries, always seem to not have a quality program. Implement the ISO 9001 one VA Medical Center at a time until a whole VISN is working under the ISO program. This allows the VA to learn and use these learning moments to build anew that which has fallen into disrepute.
Secretary Wilkie, some will suggest these ideas are expensive, but how expensive has the revolving door in human resources been for talent drain? How costly has failed training programs been? How expensive is the appeals process to compensation and pension decisions both in green and blue money? The short answer, too bloody expensive. Thus, it is time to begin looking for innovative ideas, using new ideas, employing new talent, and demanding higher returns for the taxpayer investment in the Department of Veterans Affairs.
Unfortunately, this is the standard, not the exception for the MSA’s in the HAS (Hospital Administration Services) Department, led by Maritza Pittore, at the Albuquerque VA Hospital. I have witnessed multiple MSA’s committing HIPAA violations through record diving, gossiping about veteran patients, acting rudely, ignoring veteran patients and their families to complete conversations, and refusing to do their jobs. As a point of fact, one assistant director one told me, “if what the VA does was replicated by a non-government hospital, they would be closed down and sued.” While employed from June 2018 thru June 2019, I brought this to the attention of the leadership, including multiple emails and voice conversations with Maritza Pittore, Sonja Brown, and several other high-ranking leaders and their assistants, all to no avail. I have had nursing staff tell me confidentially that they cannot do anything where the MSA’s are concerned because “it’s none of their business and outside their job duties.” Yet, the VA continues to proclaim the MSA, the Nurse, and the doctor, along with the patient, are a “healthcare team.” Upon being discharged, without cause, reason, or justification, I brought this information to the OIG, my congressional and senate representatives, among many others, all to no avail. The level of customer service, especially at this VA Hospital, is far below the pale because the leadership refuses to engage and set standards for customer service, with enforced penalties. 
Update to this article, 10 May 2020: By the first week in April 2020, the Advanced MSA in the clinic was moved to a less customer-facing post and a new MSA hired. The quality of that individual was never experienced due to relocating. The supervisor of the MSA was not very interested in correcting the problems and that showed when I visited with them while trying to obtain an appointment that the Advanced MSA refused to schedule. Change must come to the VA!
DNC-Consulting 