Weep America! – The VA Leadership is Becoming Worse! – Part 3

I-CareIn the less than 10-days since I last wrote on the Department of Veterans Affairs (VA), the Department of Veterans Affairs – Office of Inspector General (VA-OIG) has dumped more than ten inspection results over the last three days into my inbox.  Not a record, but the recorded actions are certainly hitting record lows.  Worse, the culture of the VA remains unchanged, even through all the recorded crimes and indignities the veterans suffer under.  Recording and summating the crimes of the VA is so depressing, mainly because of the failure to reform.  But, a little depression will not slow or halt the reporting of these detestable actions of the VA!

The first VA-OIG investigation is more of a report on criminal proceedings concluding with sentencing.  A total of five people, including one VA Employee, have been stung in this investigation.  How thrilling to see accountability and justice served cold!

Francis Engles of Bowie, Maryland, was sentenced to 30 months in prison and ordered to pay $150,000 in restitution for defrauding a VA program dedicated to rehabilitating military veterans with disabilities. As the owner of Engles Security Training School, Engles falsely represented to the VA that his company was providing veterans with months-long courses when, in fact, the school offered veterans far less.”

February 2019, four other individuals were sentenced in related cases following their guilty pleas. First, James King, a former VA employee, was sentenced to 11 years in prison for committing bribery, defrauding the VA, and obstructing justice. Second, Albert Poawui, the owner of Atius Technology Institute, was sentenced to 70 months in prison for committing bribery. Third, Sombo Kanneh, Poawui’s employee, was sentenced to 20 months in prison for conspiracy to commit bribery. Finally, Michelle Stevens, the owner of Eelon Training School, was sentenced to 30 months in prison for committing bribery.”VA 3

Apparently, bilking the GI Bill is a regular fraud opportunity, and the VA employees need to be held more accountable for the loss of these funds!  The GI Bill is a precious commodity and sometimes the only lifeline for a soldier for retraining while awaiting the VBA’s decisions. Therefore, stealing these funds should come with more substantial sentences, more accountability for the employees in the know of fraud, and scrutiny from elected officials!

For the next story, we have several crimes co-occurring; the most egregious is reporting to have been a veteran, fraudulently obtaining benefits, and then trying to use veteran status for preferential contract awarding.  The VA-OIG reports:

Robert S. Stewart, the former owner of Federal Government Experts LLC in Arlington, Virginia, was sentenced to 21 months in prison with three years of supervised release for making false statements to multiple federal agencies in order to fraudulently obtain multimillion-dollar government contracts, COVID-19 emergency relief loans, and undeserved military service benefits.”VA 3

I know the Supreme Court of the United States (SCOTUS) has declared that lying about military service is a freedom of speech issue and not a crime.  However, stolen valor continues to make me sick, and the liars should lose all US Constitutional Rights, as well as be sentenced to punishment most vile!  Having served twice (US Army and US Navy), having been deployed to S. Korea (US Army) and the Persian Gulf (US Navy Multiple Times), stealing valor infuriates me into a raging juggernaut!  I hate liars and thieves, but to steal valor from those deserving goes above and beyond being just a liar and thief, and the conduct deserves punishment most vile!  No, I am not apologetic in taking this stance either!  Burn the American Flag; I disagree with SCOTUS again and becoming a raging juggernaut!  There are lines you do not cross with impunity, and if you cannot scream fire in a crowded theater as “Free Speech,” then acts of stealing valor or burning the American Flag are reasonable restrictions!

I do agree with Justice Oliver Wendell Holmes’ statement:

The ultimate good desired is better reached by free trade in ideas — that the best test of truth is the power of the thought to get itself accepted in the competition of the market, and that truth is the only ground upon which their wishes safely can be carried out.”Angry Grizzly Bear

But stealing valor and burning the American Flag is not “free trade in ideas,” and I support social shaming as part of the punishment most vile for these lepers of society!  Before you burn the Flag or steal valor, serve in uniform, watch a military funeral as a dependent, and then let’s talk about reasonable and valid restrictions upon “free speech!”

Another case, another criminal act, only this time, I am left asking, “How long has this individual been doing business with the VA?”  Regardless, as this is an ongoing case, the following firstly applies: “The charges in the indictment are merely accusations. The defendant is presumed innocent unless and until proven guilty.”  From the VA-OIG report:

Muhammad Z. Aabdin of Bronx, New York, was indicted for offering bribes to a VA contracting officer in exchange for the award of VA contracts for personal protective equipment.”VA 3

It will be interesting to watch this case and future (potential) investigations occur.  However, I have several questions needing to be answered, and the report does nothing to aid in answering the questions raised in the defendant’s arrest and the grand jury indictment.  More to come as the VA-OIG and the US Attorney produce information.  May the US Attorney NOT allow a plea deal!

The VA-OIG has often investigated improper fiscal practices at several VA sites for the VBA, the VHA, and the National Cemeteries.  I could almost quote the following investigation results, only differing on how much money is involved.

The VA Office of Inspector General (VA-OIG) conducted a review to examine whether VA’s Maryland Health Care System appropriately managed purchases and payments for medical equipment and supplies. Fiscal oversight of purchase cards and internal controls governing the use of overtime were also reviewed. The VA-OIG found ineffective processes, internal control weaknesses, and inadequate oversight in five areas: 1. The healthcare system and the Enterprise Equipment Request (EER) portal need improved controls for approving equipment purchases. 2. Healthcare system staff and the prime vendor should prepare timely and accurate planning information to ensure adequate supplies are on hand to fill orders. 3. Even though no inaccurate inventory payments were identified, VA’s inventory system needs controls to ensure correct recording of supply units and costs. 4. The healthcare system purchase card program requires closer monitoring to ensure purchases are authorized and supported by documentation. 5. The healthcare system should strengthen its overtime payment controls to ensure supervisors verify overtime hours were completed before approving timecards for payment.  The VA-OIG team also identified more than $5 million in questioned costs related to identified issues such as undocumented or unapproved purchases” [emphasis mine].VA 3

I have heard the term “Criminal Stupidity” and often wonder when “Criminally Designed Incompetence” will become adopted into common vernacular.  I am so fed up with the excuses, the missing money, and the abuse of taxpayer forbearance by bureaucrats; I could rip my hair out and scream until my voice gives out! But, unfortunately, both actions do absolutely nothing to correct the problem and would make me miserable.  The VA has problems with criminals without and stupidity masked as “designed incompetence” within, and the solution continues to be leadership!

Gravy Train 2What adds fire to my mental processes on criminally designed incompetence, the VA-OIG has two other investigations in my inbox on the need to strengthen fiscal controls, , and more correctly track accounting practices.  Under current legislation, if a private business accounted for their money like the VA, they would be shuttered, and criminal charges levied!  Yet, somehow, the elected representatives cannot apply the same accounting behavior standard to a government agency, as they mandate for private companies!  Anyone else thinks we need stronger demands for scrutiny of government agencies?

Plato 2Adding more fuel to the fire for the IT/IS Departments of the VA, the VA-OIG discovered that the VA still cannot regularly and appropriately log records into its own electronic health record systems!  Are you surprised; as a patient, I know I am not surprised at all.  Worse, the lack of medical records being properly handled influences (negatively, of course) how the VBA makes decisions on claims!

The Office of Inspector General (VA-OIG) evaluated whether VA’s community care staff accurately uploaded records for non-VA medical care to veterans’ electronic health records. Veterans receive non-VA care based on certain criteria, such as the distance from the veteran to the nearest VA facility or the wait time for a VA facility appointment. Records for non-VA care enable Veterans Health Administration (VHA) providers continuity of care and inform treatment decisions. The audit team found that staff at six of the seven VA medical facilities reviewed did not always index, or categorize, these records accurately. Inaccurate indexing of medical records poses a risk to veteran care. It increases the burden on the VHA staff who locate and correct the errors, reducing their time for other tasks. The team reviewed 209 veterans’ mental health medical records that VHA community care staff indexed between April 1, 2019, and September 30, 2019, and found 108 indexing errors for 92 veterans. (Some veterans’ records had more than one error.) Errors included using ambiguous or incorrect document titles, indexing records for non-VA care to the wrong referral or veteran, and entering duplicate records. These errors occurred, in part, due to inadequate procedures, training, quality checks, and quality assurance monitoring and a lack of local facility-level policies.”VA 3

Of course, training and local policies were blamed for the failure to log records properly!  These are automatic designed incompetence excuses that appear every single time the VHA fails, the VBA fails, or they both make significant life-altering decisions for veterans, and the VA-OIG investigates!  The VBA claims it is my duty to ensure outside providers send records to the VA in a timely manner.  The VHA claims they have the documents the VBA wants, and they should read the file.  Who is inconvenienced, not the VHA and the VBA, the veteran?  The person who cannot even look at his digital file without a “Freedom of Information Act” (FOIA) request and 30-45 days of waiting, and even then, the document is heavily redacted for privacy!  Whose privacy, I wonder, the providers, the employees, or the veterans?  Because I guarantee the VA is conducting serious CYA on the records produced!  Let alone IT’s continued failure to protect the veteran from identity theft or IS to protect the files from being accessed without reason by employees.Apathy

May 2021 was a tumultuous month for the VA and the VA-OIG.  If you would like to review how tumultuous or think you might have missed an article or two reporting the VA’s designed incompetence, feel free to review using the following link.  Frankly, I want to see action taken based upon the investigations to clean house, more fully scrutinize the VA, and improve the veteran experience at the VA.  But, I do not tell you how to think or feel about an issue. Instead, I report and summate and leave the rest to you!VA 3

As always, I report and summate upon the good and bad.  If you are a citizen of Indiana or receive your care from either Fort Wayne, Marion, or through the Northern Indiana Health Care System, please count yourself lucky, and pass on the praise to the VAHCS employees.  The VA-OIG conducted a comprehensive Healthcare Inspection and found, “The VA-OIG’s review of the system’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors” [emphasis mine].  While improvements can still be made, this is HUGE news, and the Northern Indiana VAHCS leadership team needs to be back-slapping and congratulating their employees.

Knowledge Check!Thus, my sincerest congratulations go to the Northern Indiana VAHCS, and heaps of shame and scorn remain served cold to the ineffective leadership and useless employees of the VA in general!  America, we should weep, for the VA is not alone in the government agencies in providing world-class detestable service, abuse of the customer (taxpayer), and skirting accountability and responsibility through designed incompetence!  But, when we are done weeping, it is time for action!  Changing the elected representatives, demanding higher scrutinization with actual penalties for failure, and insisting upon fiscal restraint equivalent to the private sector!

© 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.

Division vs. Unity, Labels, and Big Tech

Angry Wet ChickenLast week, while scrubbing my SPAM folder on Gmail, I discovered that Google had arbitrarily been sending several emails containing news of a more conservative slant straight to SPAM.  Why would Google arbitrarily act in a manner to thwart the delivery of email?  A topic for discussion later in this article.

America faces a huge test right now; division is costing us opportunity, liberty, freedom, and potential.  Worse, it will eventually destroy the United States of America, a free Republic (if we can keep it).  What is this nefarious foe; a lack of unity.  The political parties have become so divisive that families are being torn asunder over something as petty as which political party to embrace.  Religion, lifestyle choices, employment opportunities, and so much more are being used to erode America at the family foundation.quote-mans-inhumanity

Socialsolutions.com reports some disturbing statistics from 2018.  However, the COVID-Farrago has seen these numbers only increase, and the numbers for 2020 are still not compiled and updated.  ACLEDdata.com provides some of the statistics from 2020, and the political violence inflicted on families is stunning!  Where does the blame lay for all this violence, property damage, public property destruction, and the host of terrorism committed in George Floyd’s name; the US President, Vice President, Speakers of the House and Senate, the governors, the mayors, and state legislators.

Bait & SwitchI am not excusing individual accountability for specific acts, but every silent politician in America has condoned the divisive behavior.  The corporate media have fed the violence and division, and the press has even been videoed participating in the violence.  My wife stated something, “The problems have become too great for any single individual to make a difference.”  I vociferously disagreed then and state unequivocally now that good is still in the majority of America and Americans and that one individual who declares enough is enough can make a world of difference!

Charmaine Yoest, Jack Spencer, John G. Malcolm, and James Carafano, writing for The Daily Signal, published an article on 11 June 2021 worthy of reading.  The twelve points they outlined are listed below, and additional commentary is mine.

      1. Protect Our Vote – I cannot stress this enough. The November 2020 elections, like all elections since we allowed computers into the mix, were fraught with illegal and illicit behaviors and reflects malfeasance towards the voter. However, that problem is specifically targeted at the local political leaders and judges who refused to allow time for transparent investigations.  President Biden and his administration are definitely not helping the situation.  Getting the Federal Government out of elections is the pre-eminent step we need to return State Rights to State Governments.President Adams
      2. Secure Our Border – America was built on defensible borders, and neglecting those borders is the height of Treason! Webster defines Treason as “The betrayal of allegiance toward one’s own country, especially by committing hostile acts against it or aiding its enemies in committing such acts.”  Hostile acts can be refusing to act when problems arise if the failure to act benefits you personally.  The continued flaunting of National Security on America’s borders (North and South) is treasonous, and those committing these actions of inaction need to be held accountable before the bar of law!photo_slideshow_max
      3. Stop Adding Debt – Of all the points raised in this Daily Signal article, this point is second most important, only behind defensible borders! Inflation must be fought with smarter monetary policies.  Want a good reference for smarter economic policies; Mark Skidmore is a leading economist in the field of government economics and is almost entirely unknown unless you have a hobby in following government monetary policies.  Dr. Skidmore has worked with a highly intelligent team of economists to try and find more than $94 Trillion in lost money in the Federal Government.  Before America spends another dime, a full and transparent audit must be completed, all the books opened, and criminal charges brought!Plato 2
      4. Stand Up To China – One of the things I particularly loved about President Trump, and honestly, there weren’t very many, was his hard stance against China! I applaud President Trump’s efforts at leading America while surrounded by enemies foreign and predominantly domestic!  But to take a hardline stance against China is still desperately needed; yet, what do we see in the capitols of America, kowtowing to China by America’s elected leaders.  ENOUGH!  Stop committing Treason with a dedicated foreign enemy!Apathy
      5. Do NOT Raise Taxes – [Emphasis Mine] You cannot spend yourself out of debt, and you cannot tax your populace for personal benefits to remain elected by buying votes through forced taxation and government largess! America has never had an income problem; we have always had a spending problem!  Debt is captivity, captivity to our enemies is Treason, and those committing Treason need to be held accountable before the law.  From the bureaucrat to the politician, every single one needs to be held responsible for what they have and have not done in properly honoring the funds delivered to the Government through forced taxation!Life Valued
      6. Stop the woke! – From Critical Race Theory to wave upon wave of identity politics, America is being divided so as to be more easily conquered. If you cannot see how dangerous these lines of division are, we need to talk about waking up mentally and recognizing the 800# Gorilla in the room!  You do not need to have special identity laws for every single invented identity, and going down that slippery slope produces nothing but harm, chaos, and destruction.  Ask Caesar from Ancient Rome how identity politics worked in Ancient Rome.  History relates what happens at the end of the identity politics games, and the results are never beneficial!Courage
      7. Cut Red Tape – Another one of those things I applaud President Trump for doing was cutting the Federal Government Red Tape to free the American worker, businesses, and manufacturing. Want a startling statistic; besides inflation, the only other driver of higher costs is government red tape.  I learned this as a kid when I saw the taxes included in a gallon of gas.  I asked if the same was true of all prices and my parents had no idea.  Thus began my hobby of understanding and tracking economics!  But, do not take my word for it; look up the cost of bread from 1940 to today, and look at how much government red tape has influenced just a loaf of bread.  We, the proper owners of the Government in America, must regain the reigns from the asylum patients and cut government red tape!The Duty of Americans
      8. Help Us Sleep Safe at Night – Talk about a conjoined issue with defensible borders! Tell me, why are portions of America’s National Parks just as deadly as Northern Mexico?  I have read first-hand accounts of scouts stumbling upon drug manufacturing facilities, landmines and guerilla war tactics employed to dissuade investigation, and the armed terrorists living in America’s National Parks to produce drugs for the American markets.  Before Big-Tech thought this would blacken certain political parties’ chances at re-election or election, many of those stories were scrubbed from the Internet.  Tell me, do you sleep safer at night right now than you did three years ago?  My home security costs have skyrocketed, 24/7 surveillance makes me feel like a prisoner in my own home.  Yet, the elected officials have blocked all attempts at using the military to root out the terrorists and gangs from America’s National parks and defend the US Borders.Plato 3
      9. Stop Big-Tech! – Have you noticed the censorship occurring across the Internet? How one day you can find stories on a specific topic and the next you cannot locate those same sources?  Perfect example, in February 2020, I could find Dr. Fauci’s research on Coronaviruses and many other research topics.  Now, I can find nothing of those early research projects that proved Dr. Fauci is either lying in his research then or lying to the public now.  I have emails being sent arbitrarily to SPAM if it is content Google opposes politically.  I have witnessed LinkedIn, Twitter, Facebook, and other social media restrict access, shut down accounts, and destroy people’s livelihoods, all because of content the Big-Tech does not find politically palatable.  I am done being censored, censured, and prohibited, all because some tech company does not like the truth!PACT_model
      10. Deliver School Choice – Long have I written that K-12 education is sexually grooming and abusing America’s children instead of teaching them how to read, write, and think logically through arithmetics. K-12 education in America, since the 1860s, has been purposefully designed not to teach students how to read because a literate society knows freedoms and liberties, and an illiterate society can be controlled.  Hence, I disagree with these authors; even school choice cannot save America’s youth from abuse at the hands of teachers and bureaucrats embedded in the education system.  The individual states need to be freed from the Federal Department of Education.  Then, the states need to revamp what education means and begin to throw out the bureaucrats and increase the abilities of teachers to lead and instruct in their classrooms!Patriotism
      11. Empower Patients, NOT Government – [Emphasis Mine] Being a disabled veteran, having my medical care through the VA, I could not agree more that the Government needs to be ripped out of healthcare and the doctor-patient relationship. However, we also need the litigious nature of society to be corrected.  The cost of malpractice insurance is so exceedingly prohibitive that doctors cannot practice independently, and the corporatization of medicine has been growing twice the government intrusion rate!  Thus, the red tape needs to be removed, government intrusion needs to be clipped, and people looking at the judicial branch as a gold mine need to be shunted and stopped!Social Justice Warrior 2
      12. Make Our Streets Safe! – Again, we find an issue with root causes behind defensible borders, military action to fight the drug trade, and the overhaul of the criminal justice system. When the criminal has more rights and protections than the victims, justice is not served!  When sentences do not include community service to repair damage to a society, justice for the community is not served.  When jail has more privileges than not being incarcerated, the criminal justice system is everything but bringing justice to criminals!  We have enough trash, graffiti, weeds, and other community service work needing to be performed for three armies of criminals.  Get them on this service instead of sitting all day.  Worse, all those “peaceful protestors,” a.k.a domestic terrorists, need to be out repairing the damage to the communities they wrought!

Knowledge Check!Unity is a precious resource America has always enjoyed in abundance, and the political enemies of America despise America for the unity that has always been here.  We might fight like brothers amongst ourselves, we might have ancient grudges and family disputes that spill over state lines, but we are inherently a unified people.  Stop allowing the media to preach division, hate, and identity politics.  Stop allowing those elected as representatives to divide you and your family.  America, we have a choice before us, unite and live, or divide and fall.  All of the changes discussed stem from a simple point, will we choose to unite and live or allow division to separate us to be conquered as unpitied sacrifices in a contemptible struggle?

Image - Eagle & FlagJoin me!  Join with your neighbors and family members!  Let us for a community of responsible and intelligent citizens, who are informed, and active in halting the government abuses at every turn!  As a united front, we can win!  Believe that, and we are halfway to restoring America to the ”Shining city on a hill!”

© 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.

Do You Feel Represented? – Your Government In Action!

Detective 4I have received feedback that I write about the Department of Veterans Affairs (VA) too much.  Please allow me to explain why.  As a veteran, I am duty-bound to help my fellow brothers and sisters in arms.  As the son of veterans, mother (USN), and father (USN, USARNG), I know the hardships of being dependents of active duty, reserve, and National Guard members of the military.  The enlistment contract doesn’t end when the contract says so for the military member; the families and spouses contract is forever.

The final two reasons I write about the VA are most critical; NO body should be treated like the VA treats the veterans; the actions of the bureaucrats in the VA are not representing me and what I stand for in a representative government.  As I can easily have the Department of Veterans Affairs – Office of Inspector General Reports (VA-OIG) delivered to my inbox, it makes writing about the VA much easier, benchmarking how the government has insulated themselves and forgotten who holds the reigns of power in a representative government.  While not a reason to write about the VA, this final explanation should help you judge whether your representative government appropriately represents you and what you stand for.Why

The VA-OIG reports today begin with behavior that is intolerable and worthy of public shaming.  While the defendant remains innocent until proven guilty, the criminal complaint represents behavior inexcusable!  “Daniel Devaty of Elyria, Ohio, was charged with influencing a federal official by threatening a family member. Devaty allegedly sent a text message to the cell phone of a VA social worker threatening to kill his daughters.”

Angry Grizzly BearAnytime anyone threatens the family members, their behavior is beyond the pale and deserves public shaming and the harshest of criminal penalties.  I do not care if the perpetrator is a politician, a judge, the media, or a private citizen.  Leave the families out of any business dealings!  Hollywood, take note, I am sick to death of you threatening family members in movies, TV shows, or simply as private citizens/influencers.  For too long, you have shirked your public responsibility, and families are OFF LIMITS!  Learn this lesson well!

On the topic of conduct reprehensible, the following VA-OIG report leaves me running out of adjectives to describe the behavior of this VA Employee.  “Robert Sampson of Gulf Breeze, Florida, pleaded guilty to charges of video voyeurism and disorderly conduct. Sampson secretly recorded eight fellow VA employees using a hidden camera, disguised to look like a cell phone charger power adapter, that he placed in a restroom at the VA Joint Ambulatory Care Center in Pensacola on multiple occasions from August 2019 to June 2020.”  May the judge through the book at him and his punishment be creative and sentence well earned!

VA 3In another VA-OIG report, we have more leadership missing problems, where a fraud scheme existed for 11 years without discovery.  “Erik Santos of Georgia was sentenced to over 11 years in federal prison for defrauding Tricare of approximately $12 million through a compounding pharmacy fraud scheme. In January 2021, Santos pleaded guilty to one count of conspiring to commit healthcare fraud and wire fraud.”  While the US Attorney beats his chest and proclaims they will catch everyone involved in the fraud, how many managers and supervisors inside Federal Government employ will lose their jobs, pensions, and freedom over allowing this fraud to occur?  What processes and procedures will be changed to protect against another fraud scheme?  Who is personally accountable for contracting that permitted this scheme to bloom for more than a decade?

VA 3The following VA-OIG report details how clowns and patients run the IT program for the VA and not professionals!  The VA was tasked explicitly by legislation to meet several IT deadlines on a program for family caregivers as part of the VA MISSION Act of 2018. Unfortunately, not only did the VA fail to get the IT program up and running on time, miss mandatory reporting deadlines, and deliver a software solution 2-years past due, but the “VA did not establish the appropriate security risk category and fully assessed the system’s privacy vulnerabilities.”  Amazing, with all the IT problems the VA suffers from, with all the IS problems the VA suffers from, one would think that, where new technology was concerned, the VA would be practicing better security and the lessons learned previously.

VA 3Would someone please tell me why private industries would be sued to the Nth degree criminally and civilly for these IT failures, but the government can evade accountability and responsibility; why?  In a representative government, the citizens can, and should, hold the elected representatives and their minions accountable for failing to uphold basic security protocols. So how did the government vote themselves a “Get out of Jail Free” card?

While writing this article, three additional VA-OIG reports have been delivered to my inbox.  The newest VA-OIG report discusses a topic that the VA continues to struggle with, namely transparency.  Apparently, the goblins in Goblin Town still cannot stomach sunlight and prefer to keep their nefarious deeds hidden.  Unfortunately, the lack of transparency in hiring practices leads to more VA-OIG investigations into employee wrongdoing, cost the taxpayers phenomenal fees to rid the government of poor hiring decisions, and all this before the union becomes involved.  From the report, we find the following:

“… VHA delegated much of its data reconciliation to its local facilities, which introduced variability in the process and did not allow for consistent creation, maintenance, and verification of information. VHA also had inadequate business processes to ensure quality data were available to support effective medical facility staffing oversight. Without consistent methods and reliable source documents for managing information, VHA cannot be sure HR Smart data accurately reflect VA’s budget and workload requirements.”VA 3

Did you catch that local facilities were given authority, which increased risks in hiring, all while management cannot perform their functions properly?  I remain convinced that the VA built designed incompetence into every action to protect themselves from ever being forced to take action. But, unfortunately, like always, the news only gets worse!Plato 2

A little background is needed to appreciate the problem in the following VA-OIG report fully.  Coronavirus Aid, Relief and Economic Security (CARES) Act required the VA to report to the OMB how they spent money appropriated for America’s Veterans and the VA during the pandemic.  The following is what the VA-OIG found:

VA met monthly reporting requirements to OMB and Congress on supplemental fund obligations and expenditures. VA also submitted required weekly obligations and expenditures from supplemental funding to OMB by program activity. Of approximately $17.3 billion in medical care supplemental funds, VA reported it had obligated about $7.11 billion and had spent about $5.67 billion by December 29, 2020. The VA-OIG team noted three concerns where VA’s reporting was not complete and accurate: • Obligations were at risk of not being included in VA’s reports. • VA initially delayed the reporting of reimbursable obligated amounts for two months. • VA’s reports contained negative dollar amounts in data fields that should have only positive amounts, which misstated VA’s overall reported obligations. Those concerns indicate weaknesses in how VA and VHA internal controls are structured to meet reporting requirements. Despite the risks identified, VA performed only a limited review at the summary fund level of its COVID-19 obligations and expenditures before reporting. A review of summary funds is not detailed enough to identify potential anomalies and ensure the reliability of externally reported information” [emphasis mine].VA 3

I did not find this in the VA-OIG report. Did anyone ask why the VA failed to meet the reporting for the first two months?  After the FISMA Congressional hearings, everyone knows the VA sucks at information technology and information security (IT/IS). So why was the VA given more money and told to budget it using existing failed software, processes, and procedures?  My work in the finance field is limited; however, when a company cannot handle its finances properly and meet legal obligations, a third-party accounting firm can be hired to handle this for the organization.  OMB, why are we not using this solution at the VA?  OMB, why is a third-party auditing company not conducting in-depth analysis and audits of the VA?  With all the missing taxpayer dollars at the VA and Department of Defense, it seems that you are just as negligent as the agencies you are supposed to monitor.

Theres moreAs they say on the Home Shopping Network, “But wait!  There’s more!”  Unfortunately, the same holds of the VA, just without the enthusiasm!  Each VA Medical Center in the Department of Veterans Affairs – Veterans Health Administration (VHA) is expected to have supplies, also referred to as caches, on hand at all times to handle local emergencies and national health care incidents.  For example, a pandemic!  The VA-OIG investigated these prepared caches and found that only 9 of 144 supply stockpiles were ever mobilized.  The excuses, oh these excuses, are like butt holes, everyone has one, and they stink!

      1. “Medical facility directors reporting supplies were not needed or caches lacked sufficient quantity for meeting pandemic demands.”
      2. “The Veterans Health Administration (VHA) changed the process for mobilizing caches during the pandemic, but without clearly communicating it to medical facility directors” [emphasis mine]. – We have the blind leading the blind, in a darkened room, in a London fog!
      3. The VA-OIG, not the VHA, not the local VAMC, but the inspectors “identified problems with cache maintenance and monitoring.” – Never forget, this is a job of several people, overseen by a director, who reports to facility leaders, and inspectors had to find the maintenance and monitoring problems. Just let that sink in for a minute!
      4. Most caches contained some expired or missing personal protective equipment, diminishing their ability to support pandemic preparedness.” – This is an example of how the VHA is “Defining Excellence in Healthcare!”
      5. The “VHA had incomplete documentation on cache activations, making it difficult to know which caches would need to be restocked.” – See item number 3 above.
      6. Medical facility leaders were not always able to accurately report if their facility’s cache was activated during the pandemic.” – Is the proof sufficient that the VA leadership IS the problem with the VA; yet?VA 3

In the US Navy, a significant part of my job was to maintain and monitor emergency supplies. Additionally, to use and cycle through reserves during drills and replenish those supplies quickly and efficiently not to impair the ship’s ability to protect itself 24/7.  I did my job well enough to earn three people Navy Accommodation Medals.  I took over the emergency stores, and all consumable supplies were expired or consumed.  Within 3-months, I was winning accolades and awards.  Yet, 144 caches of emergency supplies for the VHA need more procedures, more documentation, and more oversight to fulfill the mission correctly.

Knowledge Check!I beg to differ!!!  We need leadership, active, engaged, enthused, leadership!  We need the medical facility leader to stop designing incompetence and do the job they have been hired to perform.  We, the taxpayers, need the oversight instruments of the Federal Government to become a lot more effective at demanding results.  We desperately need the elected officials we have hired to scrutinize the government!  Just imagine if you hired someone to perform a mission-critical job, and in the middle of needing emergency support, the person hired reveals, “Oops, I might not have done my job properly.”  How fast would that person be fired?  Now, why can we not do the same to the government employees?

So, ask yourself, do you feel represented by your government?

© 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 – An Open Letter to the People of Arizona

To The Citizens of Arizona:

ArizonaIt has been my pleasure to have lived in Arizona four separate times since 1996.  Employment and pleasure have brought me relocation opportunities, and I have enjoyed my time in Arizona. However, since my return in 2005 to the present, I have feared for the soul of Arizona.  I have watched as despicable and detestable politicians have won political races that never should have been won.  I have witnessed governors act in cowardly and craven methods to thwart the people’s will.  I have witnessed those elected to Federal Offices from Arizona stop being held accountable to the electorate until the politicians have set up a hegemony and no longer fear the ballot box.  Most egregious of all, I have witnessed the veteran community become increasingly abused as every day ticks past.Patriotism

In April 2021, I wrote about my interactions with Rep. Greg Stanton (D) and his staff, where the VA is concerned.  For almost an entire year, I have been injured, cited, and arrested, denied care, had untold HIPAA violations, and other disgraceful conduct taken against me by the administration and leadership of the Carl T. Hayden VAMC.  In December 2020, I reached out again to the federally elected representatives, asking for help to clear my name and remove the atrocious behavior of the VA, all to no avail.The Duty of Americans

All four Senators rejected my pleas and never bothered to respond.  All of the members of the House of Representatives from Arizona refused to reply, save the staff of Rep. Greg Stanton (D).  Except, Rep. Greg Stanton (D) and his staff, did nothing!  Had no priority, refused to communicate, could not maintain pressure, and bought the lies and excuses of the Carl T. Hayden VAMC administrators.  These are the same administrators who create a crisis for veterans through inaction, duplicitous action, poor behavior, and refusal to perform the jobs they were hired to perform.  I have made it clear that the Administrators of the Carl T. Hayden VAMC and VISN 22 are but one dead veteran from another scandal to dwarf the death list scandal that originated with the VA administrators in 2012 and repeated in 2016.

VA 3No VA Administrator has addressed the root causes of those scandals, and without proper persuasion from Washington, D.C., they never will!  Worse, without continuous scrutinization, the bureaucrats will continue to exemplify the duplicity and failures, hiding behind designed incompetence and tissue paper-thin excuses for poor behavior.  Yet, what do we find from those enjoying elected office?  Zero interest, half-truths, straight lies, misinformation, smoke and mirrors, and plain laziness!  We, the electorate, find the politicians sitting on their hands, engaging in hopeless and stupid legislation that will go nowhere, and we find lackadaisical meandering in the House and Senate leadership.  I have witnessed amoebic life with more robust spines than the current political leadership in Arizona!Image - Quote Poltics is Dirty

It is true, Arizona is not the only state suffering from political abuse of the basest sort and blackest hue, but Arizona is where I have personally seen the destruction hit the hardest.  During Senator McCain’s tenure, my requests for help were rebuffed, but I could still obtain assistance from the House of Representatives members.  Now, the political party doesn’t matter, the politicians have plastic ears, and plastic lips, and their hearts are full of desire for political gain and not the electorate’s support.  Who loses, the electorate!  Who wins, nobody!

America, I ask you, in the year and change between today and the next election cycle, what will you do to change America’s government?  Arizona, you have been duped, lied to, and dishonored by those elected to power.  What will you do to reclaim the honor, integrity, and political government you deserve and pay so much for?Apathy

Personally, I have been betrayed, and I am sick to death of pleading for reprieve only to have lackluster performance, at best, provided so I would just go away.  I know of no honorable politician representing Arizona, and their respective staff is worse than the politician!  From the Mayor of Phoenix to the Governor, including the school boards, judges, and so many others, the fear of the ballot box is shrinking, and the bureaucrat is winning.   In contrast, the scrutinization of bureaucrats and other duties are dodged to win another term, always with a complicit media running interference.LinkedIn Image

I did not elect the media to their position, and since the media is not elected, they can be removed. However, while the politicians are elected, the fear of the ballot box needs to be retaught to the politicians.  How does a citizen get a politician to fear the ballot box; you first buck the trends and stand like a rock in a stream. Then, as additional rocks begin to stand, a dam is built, forcing change to that stream.Plato 3

If we are to change the government and retain our freedoms and liberties under the Rule of Law, we, the electorate, must first get the politicians to fear the ballot box!  We, the electorate, need to also teach accountability and responsibility to those who claim power but who only obtain power from those choosing to be governed!  We, the electorate, hold power over these politicians and the bureaucrats spawned in the legislative branch of government. So claim the power that is yours, and join your friends, neighbors, and communities in demanding better from those elected.

Knowledge Check!I heard the mayor’s office in Phoenix complain that they have no power over the Federal Government.  To think this is treason of the vilest kind.  Let me reiterate something discussed in several previous articles.  The local government stands as a bulwark against the county government overstepping its legal boundaries.  The city and county stand against the state encroaching against the freedoms and liberties of the state government.  The state government defends its citizens from the Federal Government’s encroachment, and the individual citizen is the most potent force in our Republican form of government.

Plato 2Cease the sophistry of plastic language and do your job!  End the tyranny of plastic words and work to aid the citizen in protecting their rights and freedoms from the ever-encroaching thieves of government and the bureaucrats spawned in the darkest pits of legislative fiat! So stand, every American citizen needs to stand and refuse to be governed until those elected are replaced with people willing to take action and honor the Rule of Law, holding previous politicians accountable and responsible for the mess America is currently suffering under.  Enough is enough, and I have reached the end of my tolerance, and my cherubic demeanor has been replaced with a hunger for justice!

© 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: Have You Heard? Chapter 2

QuestionThe first week of June is often a period of recovery.  I have no idea why, but the first week of June is usually a recovery time.  Maybe it was all those years in school; I honestly do not know.  However, the world does not stop, and while the media goes 24/7 over the Memorial Day Gun Violence, stories are evolving that need your attention more.  I do not say this lightly, as I understand those wounded and killed in gun violence are tragedies and cause for grief, but the corporate media has always used these “major stories” to allow other things to slip past.

WhyHave you heard Dr. Fauci’s emails from while he was a name in President Trump’s councils reflect a different story than the lies he peddled for political purposes?  “The emails from the first half of 2020 reveal Fauci’s skepticism early on about masks to ward off COVID-19, his dismissal of the notion that the new coronavirus escaped a lab in China, and his vague reference to researching how to make the virus deadlier.”  Why is this spineless invertebrate still a media mouthpiece, a paragon of dirty virtues and political connections?  Fauci’s research from 1990 through 2020 was in Coronaviruses, and he still hyped, pushed, and peddled lies to obtain a political payoff.  Knowing masks were useless, he pushed lies.  Knowing the survival rate, he still pushed draconian government takeovers of liberty, freedom, and common sense.  Knowing he could orchestrate a catastrophe, he pushed lies to initiate a public health emergency and stood back to reap the windfall in the chaos created.  Of all the government officials with hands in the pot stirring the government mandates, I blame Fauci more than others!

Nuclear FamilyHave you heard the Federal Government remains hell bound and down on destroying the family but is explicitly targeting black families?  Would a minority please help explain why under a Republican President, the Federal Government’s actions are racist, but under a Democratic President, the same actions are “beneficial, needful, helpful, and not in any way demeaning?”  Frankly, I do not care about the race factor; the fact that the US Government, from the Mayor and School Board to the President, seems bound and determined to destroy the foundation of society, the nuclear family, remains highly suspect and needs to be investigated!  Ever since the US Government stole State’s Rights where Welfare Programs were concerned, the family has been directly targeted.  Look at any race, and you will see the same hit in the data, where families went from working to be self-sufficient to the government dole.  Unfortunately, black families have suffered some of the worst impacts.  Now we are three generations into the destruction of the family as a government program, and I want answers!

Have you heard, the data is inescapable, the conclusions self-fulfilling, and the results are incredible.  When you want more economic freedoms, which lead to more overall liberties, it is best to start by ending corruption in government.  Who would ever believe that economic freedoms lead to individual liberty, and the best place to start is reducing government?  I am absolutely… nonplussed!  The founding fathers of The United States of America, a Free Republic (if we can keep it), understood these connections intimately and established the US Constitution to provide future generations the best chance of keeping the American Republic.  So, who would like to start firing and cutting government?  I am first in line; join me!Plato 3

The Department of Veterans Affairs – Office of Inspector General (VA-OIG) released a report on 02 June 2021, detailing crimes so horrific and obscene, I can find no appropriate adjectives to describe this negligence and criminality of all administration leaders involved.  January 2021, Dr. Robert Levy, who was a pathologist, who over his 12-year tenure at the VA Hospital in Fayetteville, Arkansas, made over 3000 diagnostic errors, manipulated the quality control process, and caused severe injury to 34 patients, received 20-years in what can only be called a “plea deal” that should never have been allowed!  The good doctor admitted to long-term alcohol use.  Now, will someone please hold the leadership teams accountable for this doctor’s behavior?  This story makes me especially sick!  Where are the politicians who were elected (hired) to scrutinize the government?  Where are the “Blue-Ribbon Congressional Committees” to hold those accountable and responsible for 34 veterans severely injured over the actions of a VA provider?  Who will speak for the victims and demand, then oversee and insist upon corrective actions by an executive branch of the government through the work of the legislative and judicial branches of government?VA 3

I was an operations manager, the safety of my workers was my paramount responsibility, and I could be held legally accountable for what happened on my manufacturing floor.  I had two people go for lunch, lifting 40oz curls, and returned to work for the afternoon soused!  I had to shut down my manufacturing facility, I had to keep these two from driving away, I had to call in the temporary employment agency to collect these gentlemen, and they could not have their keys back, for as soon as they returned to work in an alcoholic stupor, I was responsible under the bartender law.  This incident still brings some emotional baggage and resentment at these two morons.  How in the world was the good doctor able to be alcoholically impaired on the job, and nobody was aware?  Impossible!  Where is the accountability of the leaders in this situation?  I could have been jailed for allowing employees to operate their vehicle under the influence; when will the administration be held responsible for allowing a drunk employee to operate a vehicle?  Read the VA-OIG report; it is a criminal list of what not to do from day one of this doctor’s employment!Plato 2

Have you heard, the Department of Veterans Affairs (VA) killed a veteran in the emergency department of the Malcom Randall VAMC in Gainesville, Florida.  Worse, the veteran should never have died, and the reason they did was due to inefficiency, inadequate care, and processes and procedures in the emergency department triage of patients.  The patient had experienced hemicolectomy surgery, and between days 10 and 15 post-op recovery, he went to two outside ER’s and the VAMC ER, where he passed.  Drunk employees for 12-years are abysmal, fail to recognize patient distress, delay care, and cling desperately to outdated and inefficient processes in patient care in an emergency room, are execrable, horrific, and so vile to have exceeded repugnant!VA 3

Again, one must ask, where are the elected officials in pushing changes to the VA Administration; Oh, I know where they are; they are trying to kill history and remove President Lincoln’s mission statement for the Department for Veterans Affairs.  We need to understand priorities: Is a veteran’s life more important than being woke and having a small group of citizens begging for less sexism, who are always going to choose to be aggrieved, be satisfied for a small amount of time?  I know what my priority is, and it has nothing to do with the permanently dissatisfied and everything with saving lives and honoring patients who deserve the honor!

Knowledge Check!I implore you to please join your voice to mine, and let’s remember Memorial Day 2022 as the day marking how in 2021 we changed the VA, we limited the government, and seized our liberties and freedoms, as the founding fathers intended!  We can make a difference in the government, provided we band together without the petty names and distinctions currently being used to separate and divide.  We, the American Citizens, deserve better from the government we pay for, even if we must use every legal tool in our arsenal to cull the politicians and take the freedoms they have stolen.

© 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: Memorial Day 2021 – Are you sure this is “proper” remembering?

Knowledge Check!It is no secret that the Department of Veterans Affairs (VA) is a sick and twisted organization.  It is no secret that the Department of Veterans Affairs – Office of Inspector General (VA-OIG) tries to recommend how the VA should be operating in accordance with currently established procedures, methods, and policies for the benefit of the veteran community.  It is no secret that I continue to write about the VA in the hopes of sparking interest in communities and obtaining more fair, honest, transparent, and humane treatment for veterans by the Government agency tasked with caring for veterans.

On this Memorial Day, as you sit down to barbecue, family, friends, sports, I would ask that you take a moment and consider if this were how you would like to be remembered?  Are the actions described proper for remembering those who sacrificed and came home?  Are these actions, which are adding to veteran funerals, an appropriate way for veterans to be leaving this world?  If the answer is no, I ask for your help changing the Federal Government by electing people who will scrutinize the government more stringently and demand change in all government agencies.  If you deem this behavior acceptable, please leave a comment detailing why you think so.  I want to hear your thoughts.Image - Eagle & Flag

From a VA-OIG report published on Wednesday 26 May 2021, we find the following announcement:

Phillip Hill, a former VA program analyst, was sentenced to 46 months in prison for stealing personal information from veterans and VA employees while employed at the Central Arkansas Veterans Healthcare System. The investigation revealed that Hill contacted another individual and attempted to sell personal identifying information to a buyer for approximately $100,000.”

Now, I am thrilled this guy was caught.  I am glad he will do time behind bars.  Yet, why did Assistant US Attorney Jana Harris allow a plea deal?  Where are the VA supervisors who should have been monitoring this employee’s work and behavior?  What are the details of the deal?  The VA continues to have nothing but IT/IS security, and these problems are decades old.  Still, the elected representatives allow the criminal behavior to exist until the criminal is caught, and then the elected representative’s crow about cleaning the swamp.  Is this how you correctly remember veterans, their sacrifice, and their memories?VA 3

I suppose the following VA-OIG report, released 27 May 2021, should begin with congratulations.  The Department of Veteran Affairs – Veterans Benefits Administration (VBA) mostly processed monetary proceeds records accurately.  However, the following continues to astound and amaze me:

Service and pension center staff do not have timeliness measures for proceeds incorporated in their performance standards. Setting a timeliness standard would help encourage the closing of these proceeds. The OIG also found that ineffective monitoring contributed to delays in handling proceeds. The Debt Management Center had only limited internal monitoring but instituted new practices for monitoring proceeds in February 2020, shortly after this audit began” [emphasis mine].VA 3

Why are government employees not held to a productivity and quality standard?  Being a veteran with regular concerns involving the VBA, I cannot help but wonder why quality and productivity are not required?  As an industrial and organizational psychologist, the first step in improving responsiveness to customers is to increase productivity and implement quality measures.  I know the Federal Government’s legislative branch, e.g., Congress, has insisted on developing quality measures.  Yet, the same tired excuses built upon designed incompetence are allowed to survive, and all the VA-OIG can do is issue more recommendations.  Consider something; proceeds include payments to dead veterans.  How much financial hardship occurs at the passing of a loved one?  How much more difficult can that death become when months down the road, money spent is suddenly being demanded back because some incompetent bureaucrat failed to do their job in a timely manner?

QuestionIs this properly honoring and remembering the veterans and their sacrifice?  Is this behavior acceptable in your workplace?  Why do we allow this behavior from government workers?

While never having been a patient at the Chillicothe VAMC in Ohio, I have friends who are patients.  The stories they tell about care there would shock and amaze many.  What infuriates me, the VA-OIG just published their report of a comprehensive inspection of this VAMC, and the results are as tragic as a veteran’s death!  The information was released to the public on 27 May 2021.  Never forget, the Chillicothe VAMC in Ohio was recently investigated for improper cleaning and sterilization procedures, as well as employee monitoring for compliance for medically reusable equipment, which for this case refers to endoscopes.  With this fact in mind, let us review the comprehensive inspection report.

Limitations on findings:

      • The VA-OIG held interviews and reviewed clinical and administrative processes related to specific areas of focus that affect patient outcomes. Although the VA-OIG reviewed a broad spectrum of processes, the sheer complexity of VA medical facilities limits inspectors’ ability to assess all areas of clinical risk” [emphasis mine].

VA 3The statement provided here is pretty standard and represents the first limitation to the scope of the investigation; complexity limits inspector ability.  Yet, who made the VAMC so complex, the VA.  Who has allowed the complexity to grow as designed incompetence, the VA? Why is the VA allowed to cheat their inspector general through complex operations which limit inspector ability and increase patient risk?

The Focus of Inspection (Investigation Scope):

      • The VA-OIG team looks at leadership and organizational risks, and at the time of the inspection, focused on the following additional areas:

WhyLong have I wondered why the second item in the comprehensive inspection is “Quality, Safety, and Value.”  When the VA continues to present the bare minimum of quality, disregards patient safety, and due to complexity, offers less value than a broken wrench to a mechanic, but I digress.

Finding One:  The VA-OIG issues 12 recommendations to the leadership team, and “selected results showed respondents were generally favorable the national VHA results.”  I have been accused of being cynical, which generally is wrong.  However, when I see words like “selected results” in an investigation into patient care and concerns, I have to ask, “How hard did the VA-OIG have to dig to find favorable results?”VA 3

Finding Two:  Strategic Analytics for Improvement and Learning (SAIL) represents a value model to help define performance expectations within VA.  This is the standard language for comprehensive inspections.  “In individual interviews, the executive leadership team members were able to speak in-depth about actions taken during the previous 12 months to maintain or improve organizational performance, employee satisfaction, or patient experiences.”  If we accept this as a true statement.  How was an employee able to fake documents, fail to clean reusable equipment properly, and repeatedly get away with this abysmal behavior at this VA?

VA 3Finding Three:  Under Quality, Safety, and Value, we find the following tidbit:

The VA-OIG noted concerns with protected peer reviews, utilization management, and root cause analyses.”

Essentially meaning there are problems with whistleblowers, privacy protection, retaliation against whistleblowers, proper utilization of policies and procedures, and the leadership could not find a problem using root cause analysis if their lives depended upon it.  The source for my interpretation of the VA-OIG results arrives from the following:

VHA Directive 1117, Utilization Management Program, 8 October 2020. Utilization management involves the assessment of the “appropriateness, medical necessity, and the efficiency of health care services, according to evidence-based criteria” [emphasis in the original report].

I have to ask the VA-OIG whether these findings were before or after the employee who endangered patient lives through improper cleaning and sterilization of reusable medical equipment were discovered?

VA 3Finding Four:  Under medication management, we find the following:

The VA-OIG team observed compliance with many elements of expected performance, including pain screening, aberrant behavior risk assessment, and documented justification for concurrent therapy with benzodiazepines. However, the VA-OIG identified opportunities for improvement with urine drug testing, informed consent, patient follow-up after therapy initiation, and quality measure monitoring” [emphasis mine].

VaccineIf you read any of the comprehensive inspection reports, you will see this is a common and recurring theme at the VA.  Some of the medication policies are being followed, but the same problem with drug testing, informed consent, patient follow-up, and quality measuring monitoring always remain a problem.  It is almost as if the SAIL learning matrices do not even exist as a quality improvement tool.

Finding Five:  Under High-Risk Processes, the VA-OIG report claims the following:

The medical center met the requirements for quality assurance monitoring and monthly continuing education. However, the VA-OIG identified deficiencies with standard operating procedures, an airflow directional device, and staff training and competency” [emphasis mine].

Are the SAIL metrics even accurate?  Where is the value in the “monthly training and monitoring if there are issues in following standard operating procedures, problems in staff training, as well as staff competency?  Do you get it?  The training sucks at the VA, and the SAIL metrics do nothing to fix the problem, address the deficiencies, or even improve competency?  The same question arises here, from quality, safety, and value; how was an employee able to successfully pencil-whip the paperwork while not doing their job in properly cleaning and sterilizing reusable medical equipment?  Where are the SAIL documents that should have identified a problem?  Where are the SAIL metrics in aiding in finding root causes for derelict employees?VA 3

Honestly, do you, the taxpayer, consider the Department of Veterans Affairs, which covers the Veterans Health Administration (VHA), the Veterans Benefits Administration (VBA), and the National Cemeteries adequate to remember the veteran correctly?  Do you, the taxpayer find value in the leadership and investigative arms of the VA to correct and improve performance?  Do you, the taxpayer find that the VA employees are doing their level best to honor, remember, and pass on the legacy of veterans?

Image - Eagle & FlagOn this Memorial Day weekend, please consider the data in this and the other VA-OIG reports regularly relayed on this blog, and ask yourself, are you doing enough to help veterans?  I love Memorial Day, and I love my country, but America has some serious problems, and only when the electorate awakens to the issues can real change begin to be implemented.  We, the veteran community, need you!  We need your voice as we struggle against the incessant attacks from the VA.  We need your votes for the elected representative’s intent on scrutinizing the government and demanding action.  We need you!  Please help us!

© 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: Caution! Dangerous Waters Ahead!

Bird of PreyTwo events this week present a need for lovers of freedom to be very aware of what is happening in the halls of the capitols of America.  In the first event, we passed the ignominious first anniversary of the death of a criminal.  The second is the continued stress and strain to maximize what has been dubbed “The Capitol Riot.”  In both events, we see plastic words thrown about like seeds ready for planting, and we see how the media continues to fan flames of Trump Derangement Syndrome to the dismay and disaffection of all.

Frankly, I detest being reminded of George Floyd; I have had my fill of the riots, the terrorism, the media, the politics, and the defamation of the police over this incident.  Hero or criminal Derek Chauvin and his family have been sundered by overzealous media reporters.  Hero or criminal George Floyd and the arrest have been so twisted, manipulated, and politicized that the truth has become the only real casualty in this entire debacle.  Several facts remain, stuck like gum on the underside of a school desk.

      1. George Floyd had a heart condition. The severity remains wrapped in medical and legal jargon so deep it would take an army of doctors and lawyers to decipher.
      2. George Floyd had several different drugs in his system when he died, including Fentanyl. In case you have been living under a rock, Fentanyl is a powerful opioid that carries the following warning, “High risk for addiction and dependence. Can cause respiratory distress and death when taken in high doses or when combined with other substances, especially alcohol.”Thin Blue Line

Is that warning pretty clear?  Mixing Fentanyl with any other drug runs the risk of exasperating current health conditions, such as a heart condition.  Mixing Fentanyl into a drug cocktail runs the risk of a multi-drug intoxication, and as the VA has proved, multi-drug intoxication can take harmless drugs and vitamins and kill!  Fentanyl and Methamphetamines were found in George Floyd’s blood during the autopsy, producing the probability of a multi-drug intoxication.  Between the politics, the terrorists masquerading under the media’s protection as peaceful protestors, and the chutzpah of the judge, Derek Chauvin, and his family have been ostracized and attacked mercilessly.  George Floyd passed counterfeit money, had illegal drugs in his system, had a heart condition that he might or might not have been aware of, and the stress of fighting police killed George Floyd.Dont Tread On Me

The fact that the media refuses to name any of these facts announces in terms unrepentant how biased and deadly the media considers themselves to be.  The press continues to spout lies. Every time the media opens its collective mouth, the disregard for their heritage and position in this Free Republic is shunned and denied for personal gain!  The media deserves to be held complicit in lighting the fires of terrorism that so many cities have suffered.  Justice needs to be served cold and raw to the corporate media!

        1. Toxicity levels of Fentanyl depend upon body mass, amounts taken, other drugs or alcohol present, and when those drugs were consumed. The experts vociferously disagree on the toxicity levels in George Floyd’s body at the time of death.  Everything discussed in court regarding toxicity levels is hyperbole and a personal opinion from paid professional witnesses.  Do not allow the details to mask the facts, or the media will lead you around by the nose!
        2. As discussed previously, the holds the police chose were legal and acceptable until the corporate media went ballistic and needed an excuse to blame the police for the death of a man passing counterfeit money and using illicit drugs. Who when approached by police for questioning, began to fight the police.  How can a person conclude that Fentanyl was illegal?  Not a single doctor has come forward claiming they prescribed the Fentanyl for a medical condition.  How and where did George Floyd obtain the Fentanyl?Why

So, celebrate George Floyd if you choose.  That is your decision.  I support your decision to make your own choices, and may you enjoy the consequences as you prefer.  But, I weep for Derek Chauvin, who became a political sacrifice for the rabid media and politicians who needed a scapegoat.  Should George Floyd be alive today and standing trial for passing counterfeit money and possessing illegal drugs: yes, except he chose to fight the police.  George Floyd chose to place dangerous drugs in his system.  George Floyd did not care about his health before engaging with the police in combat; why should I care about George Floyd’s death?

Knowledge Check!My concerns are for the living, the innocent, and those left to clean up this mess, which has been exploited by, and exasperated by both politicians and the media to the Nth degree.  I am not indifferent to the suffering of George Floyd’s family, but wasn’t his family already suffering from his choices?  For the record, I am sorry he is dead; yet his death does not, in any way, shape, or form, justify the damage and terrorism that the United States has witnessed in his name!  I am sorry George Floyd died while in police custody, but his choices came with consequences.  Unfortunately, those consequences have now included so many others; the damage is beyond count.

Why is the George Floyd case so dangerous?

The media has taken a deplorable incident and turned it into a terrorist-feeding frenzy, where justice is robbed, mercy is denied, and innocent victims are destroyed mercilessly as “collateral damage.”  Private property destroyed!  Public property and businesses put to the torch—employees beaten to satisfy the appetite of the terrorists, all for the media to revel and parade.  Consider this pattern, for it has been being developed over incident after incident until it is a money-spinning machine.  Play the race card, use the continuously aggrieved populations in society to whip up emotions, and turn them loose for the cameras.  Then report how the problems are always someone else’s fault, and how more money needs poured into social programs, then lie and half-truth through every event to keep the machine spinning money!Plato 3

Ask the media, when will they be reporting on the criminals who looted stores before burning them to the ground?  Will these criminals get the same 24/7 media-feeding frenzy and biased judge and jury?  Will the employee victims ever see compensation and justice?

The Capitol Riot

In making the following statements, I am not in any way denigrating the losses on 9/11; nor, am I belittling the actual loss of life during the Capitol Charade being called a “Riot.”  Any time lives are lost, there should be repercussions for those taking lives, investigations, and all the facts revealed.  However, any lawmaker who attempts to equalize the 9/11 terrorist attacks with a staged riot on the Capitol is denigrating, deriding, and insulting the memories of lives lost!  Unfortunately, the politicians are trying to make political hay on the Capitol Riot, making me sick!

Plato 2I watched the capitol disturbance live and in color.  I have seen the video footage of law officers guiding people into the proper rooms. I have witnessed the debacle from end to end. While I am not an expert, the entire episode reminds me of Kabuki Theater, not a spontaneous attack on the Capitol.  While I decry the damage done, I think those attempting to steal were idiots. I fully support law and order conducting a full investigation, including where the buses came from and who bankrolled the Kabuki Theater being passed off as the Capitol Riot.

Yet, let us be clear, from the day of the Capitol Kabuki farrago to today, the politicians have continued to attempt to steal liberty and freedom, using the pattern established from 9/11 and the excuse of safety for the politicians.  Let me remind you, you serve the people; since you have chosen to live like feudal lords over the serfs, you have broken the promise and oath of your office, and you and your staff need to be fired from public service!

Knowledge Check!The Patriot Act has been the single most freedom-sucking bureaucratic life support measure, only surpassed by ObamaCare in my lifetime, coming in third to the United Nations debacle!  Enough is enough!  Hiding behind police officers while destroying America is not appreciated by those who live here, and politicians need to be held accountable with their staff.  Continue to make excuses, hide, and refuse to represent us, and the ballot box is waiting!  The media is like a snake, soon they will bite you, and I hope they bite hard; think Nagini and Mr. Weasley from the fifth Harry Potter book.

© 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.

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 2

Angry Wet ChickenOne of the first rules in overseeing junior people working is to make available someone to answer questions, immediately, and render support if needed.  I have had the pleasure of training junior people in a myriad of tasks over the years.  When I read this Department of Veterans Affairs – Office of Inspector General (VA-OIG) report, a plethora of questions arise, and I deeply question the professionalism and competence of the doctor overseeing the work of residents in a VA Hospital who are performing procedures.

  • Ophthalmology Resident Supervision – Important to note, the patient did not experience any long-term loss of sight over this issue. Congratulations to the resident and the other ophthalmology doctors present!  From the VA-OIG report we find the following:

“… The subject ophthalmologist failed to provide adequate resident supervision and entered inaccurate documentation related to supervision for a single patient case.”  Essentially, the doctor charged with overseeing residents was AWOL, and then compounded his error by falsifying patient records.  The VA-OIG report continues by claiming this falsification was the result of an oversight when using pre-recorded notes for patient files.

Draw your own conclusions.  Personally, I think this doctor needs to be released of all duties where overseeing residents is concerned.  I would also question his ethics and morals for falsifying patient records.  You hold a double position of trust, first as a doctor, second as a teacher and leader of residents, and the behavior witnessed should come with steep repercussions professionally!VA 3

Knowledge Check!On the topic of professional duties, and steep repercussions, drug interactions killed a veteran at the Marion VAMC in Illinois.  Before launching into the VA-OIG’s report, please allow me a moment of your attention.  Drug interactions can arise due to vitamin usage, over-the-counter medications, and from illegal and legal but illicit drug use.  Often, I have claimed that people are walking chemistry experiments, and even vaccines need to be carefully evaluated for drug interaction potential.  Foods can cause drug interactions due to the chemicals in the food.  Drug interactions are a growing problem and every medical professional I have spoken to admits drug interactions are becoming worse by the day.  I do not say this lightly, but I do not hold the medical professionals as fully competent in fighting the drug interaction problem due to the amount of chemicals the average person interacts with daily.  The problem is Big-Parma and the continual push towards more specialized medicines, we are going to see more drug interaction issues.  Unfortunately, drug interaction issues come with the risk of death!

From the VA-OIG report we find the following:

The VA-OIG substantiated that high cholesterol contributed to the patient’s death; however, the death certificate indicated that the primary cause of death was accidental acute multi-drug intoxication. The psychiatrist and staff failed to document providing the patient with education during a telephone encounter regarding potential side effects or adverse drug-drug interactions of medication changes. Contrary to clinical guidance, the psychiatrist prescribed long-term benzodiazepine use for a patient diagnosed with posttraumatic stress disorder. The psychiatrist also failed to address the patient’s two negative urine drug screens for a prescribed medication and failed to address a positive urine drug screen for cannabis. Due to COVID-19, the facility failed to launch the Psychotropic Drug Safety Initiative Phase Four Plan. The primary care provider did not comply with facility policy by failing to enter a return-to-clinic order following an appointment but could not determine if this affected the patient. Primary care and behavioral health staff did not comply with facility policy to telephone the patient or send a letter after the patient missed appointments” [emphasis mine].

The lack of staff to follow procedures and do their job, I will certainly hold them accountable for, especially since Cannabis is involved!  Please do not believe that Cannabis is a non-toxic drug, especially when mixed with other drugs, it can be the fatal trigger in a multi-drug intoxication!VA 3

At 18, low those many years ago, I took the EMT-Basic class, but left for US Army Basic Training before I could certify.  Since then, I have received certification as a combat medic and a Journeyman Firefighter (Any industry) which required a lot of hours studying emergency medicine.  I am experienced in drawing blood, starting IVs in difficult circumstances, and handling a myriad of injuries.  I am not a medical professional by any stretch of the imagination, I simply have a healthy desire to learn, and emergency medicine is a fascinating topic I regularly pursue.  I am not a chemist; I rely upon peer reviewed resources and legal and medical websites to stay current on a host of topics.  With this as my qualifier I am going to make several statements and you can judge their merit.  Feel free to comment.

      1. The first rule of medicine is document everything! My first lesson, first day of EMT training, this point was driven home.  If you do not write it down, it never happened!  Yet, what does the VA-OIG find time after time in reviewing cases at the VHA, lack of documentation of steps taken!  Can you say, “Asinine and abysmal behavior by credentialed professionals?” I know I can!
      2. Aspirin and Alcohol can cause a drug interaction that can be deadly. Both chemicals are readily available in the home and over the counter.  Why is spray paint now requiring proper ID, because people are huffing the stuff and getting a multi-drug intoxication.  Oven cleaner and spray pain can cause serious breathing issues and when mixed together can cause a cheap high, as well as a multi-chemical intoxication leading to breathing paralysis and death!
      3. Cannabis continues to be modified, changed, enhanced, and designed to trigger different chemical reactions in the body. Continuing work that began in earnest in the 1960s for the pot-smokers who wanted a more serious high.  Guess what, cannabis and aspirin along with vitamins can cause multi-drug intoxication problems leading to death!
      4. Vitamin D and Vitamin C have both caused serious drug intoxications during COVID-19. People became frightened and took too many of both or just one and wound up in the ER with life-threatening health problems from toxicity of these vitamins.  India has reported a spike in black mould that has caused serious long-term health problems for diabetics after recovering from COVID.  It is currently presumed that the chemicals used to fight COVID allowed for a natural mould to grow in the body, and that became life-threatening.

The VA-OIG conducted another virtual comprehensive healthcare inspection, and found the same problems continue at another VAMC.  Do you know how tired I am of reading these “comprehensive inspection” results and finding the same problems time after time?  When will the VA actually start enforcing some of these VA-OIG recommendations to effect change?  Better, when will the politicians who are charged with scrutinizing the government tire of seeing the same recommendations and not seeing any change?  Bloody frustrating reading these reports and not seeing improvement!VA 3

Broken RobotFinally, we come to what I was hoping to be a great report, where the politician’s heads were going to explode at the inefficiencies, the detestable behavior, and the horrendous responses to legally mandated IT infrastructure changes, and why those changes are not happening at the VA.  I was not disappointed; I was thoroughly disgusted that his report fell on plastic ears speaking plastic words from wax lips!  Statement of Michael Bowman, Office of Inspector General, Department of Veterans Affairs, Director of IT and Security Audits Division, Before the Subcommittee on Technology Modernization, Committee on Veterans’ Affairs, U.S. House of Representatives, Hearing on Cybersecurity and Risk Management at VA: Addressing Ongoing Challenges and Moving Forward May 20, 2021.  Notice something, the failures at the VA in the IT Department are being called “ongoing challenges.”

Millstone of Designed IncompetenceLet me remind you, FISMA was released on 29 April 2021, and I wrote about the abysmal findings of the VA-OIG.  This report is the accountability statement to the Congressional representatives who should have skewered this bureaucrat and roasted him on a spit with onions and peppers, then served him up for public ridicule after firing him!  For the Director of IT and Security Audits Division to make the following statement is flat out beyond comprehension, “The OIG’s conclusions in the FY 2020 FISMA audit are not new or revelatory—rather, they repeat many of the same concerns with VA’s IT security that the OIG has found for many years.”  What incredible chutzpah to make this comment after that scathing report showed just how deplorable the leadership of the IT and Security Audits Division revealed!  Director Bowman then goes on to downplay the band-aid solutions implemented while decrying the time for improvement is too short and there is not enough money.  Do not forget, “Of the 26 recommendations, 21 have been included in every FISMA audit dating back to at least 2017.”  With at least 15 of these recommendations dating back even further.  Want a full list, as well as how old these recommendations are; you will not find it in the Director’s report to Congress!  Is anybody incensed enough to demand a full accounting of just how old these IT recommendations are?

Detective 4The gall of this director to continue to blame legacy systems that were legislated to have been scrapped between 2000 and 2010 continues to highlight the incompetence of the director in conducting business and holding people accountable for failed projects and overspending of taxpayer monies!  The director went further and stated the following, at which time, every single Congressional Representative should have stood and demanded his head.  The “VA does not properly manage and secure their IT investments.”  Tell me director, why should you remain employed if the VA does not properly manage and secure their IT investments?  Is the failure to manage and secure IT investments the root cause for veterans to continue to suffer identity theft from the VA losing their identity?

The director’s next statement puts his other outrageous comments to sleep.  “Security failures also undermine the trust veterans put in VA to protect their sensitive information and can affect their engagement with programs and services” [emphasis mine].  Talk about such an obvious statement, it’s like the sun coming up on a cloudy day, you just cannot miss that sun rise; you also cannot miss the absurdity of making this statement!  Did some intern write his speech?  You are the director of IT Security and you make this type of comment, did you make this comment with a straight face?  I cannot find the video-record of this Congressional hearing so I can only guess he delivered his lines with a straight face!  Most detestable of all, he continued to make outrageous comments, his plan to move the IT security program at the VA forward is weak, lacking firm deadlines, and continues to allow him and his staff to escape accountability and responsibility.VA 3

Angry Grizzly BearAmerica, with these bureaucrats in charge, why shouldn’t we be weeping and wailing, and gnashing our teeth in frustration?  When will we, the owners of this atrocious government, finally scream ENOUGH and demand a full change of heads at the ballot box?  For until the elected representatives are forced out, the bureaucrats abusing us, will only continue!  The VA is sick, but the problem lies in the bureaucrats, administrators, and directors leading the VA at the Federal and VISN levels.  So many other government agencies are just as sick, or worse, and the same problem arises, the leadership refuses to act, but still expects a big titanium parachute when they leave office!  I say it is time to tell them NO!

© 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.