It IS ALL About Leadership – More Shameful VA Chronicles

I-CareRecently, guardianships have been in the news, and I doubt this story will make the lawyers very happy.  The department of Veterans Affairs – Office of Inspector General (VA-OIG) reports that an Albuquerque couple has been sentenced for defrauding guardians, which included veterans.  The criminal report claims:

Susan Harris acted as president and was the 95-percent owner of Ayudando, while Moore acted as chief financial officer and was a five-percent owner. They engaged in a pattern of criminal conduct from November 2006 to July 2017 that included unlawfully transferring money from client accounts to a comingled account without any client-based justification.  They wrote and endorsed numerous checks, often of more than $10,000, from these comingled accounts to themselves, family members, cash, and other parties where payment would benefit their families.”

For the better part of 11 years, this couple has spent money not their own, abused their charges, and defrauded vulnerable clientele.  While the federal attorneys and investigators crow about catching this couple and ending this situation; what about all the rest of the guardianships where abuse is occurring?  I have read horrific stories about victims of guardianship abuse and hope more will be done on this topic very shortly!VA 3

For 11 years, where were the VA and the Social Security Administration?  Where were the local hospital leadership, social workers, and other federal employees who had to have known something fishy was going on?  Where are these Federal Employees now?  Where are the politicians scrutinizing this incident to ensure that protection for vulnerable citizens never happens again through legal guardianships?

Now traveling to Eastern Oklahoma VAHCS in Muskogee where an audiologist provided poor care and billed for unrendered services.  Pay close attention to the VA-OIG report; the leadership failures on this report alone are voluminous and unforgivable!

A facility fact-finding review revealed the audiologist provided poor care to eight of 43 patients reviewed, including misinforming patients who needed hearing aids that hearing aids were not needed. Although the audiology leaders reported the fact-finding results to the OIG, they failed to evaluate whether patients needed clinical follow-up; determine whether additional patients were affected by the audiologist’s poor care; evaluate whether clinical disclosures were required for the affected patients; and communicate the fact-finding results to the Facility Director, who was, therefore, unable to initiate the process to determine the necessity of a large scale disclosure. The instances of poor care were also not reported to the Patient Safety Manager, who was, as a result, unable to assess the adverse events to determine if patient safety interventions were indicated. The VA-OIG also found that performance monitoring of facility audiologists was not conducted as required. Annual competency assessments and annual performance appraisals were not consistently completed and did not contain adequate performance standards. Audiology leaders failed to consider whether the audiologist’s actions warranted a report to the state licensing board due to a lack of understanding of the requirements for reporting and, therefore, the Facility Director was not informed of the need to initiate a state licensing board review” [emphasis mine].

Will, someone please tell me, were the audiology leaders who failed to perform their jobs removed from Federal Employment?  What about the audiologists causing the problems?  Are they removed from Federal Employment?  Were their licensing practices curbed to protect other populations of patients?  The leadership failures here read like a Steven King horror story but do not have the satisfaction of finishing the story.VA 3

Yet, the Department of Veteran Affairs (VA) will continue to market that they are “defining quality in healthcare.”  The jokes write themselves but cannot be fired from Federal Employment!  Politicians, why can these jokers not be fired from Federal employment for such egregious abuse of their positions and failures to do their jobs?

I-CareTraveling further to North Carolina, we find that the perpetrator of this fraud has pled guilty, but again responsibility, accountability, and correction of the VA is being skirted.

John Paul Cook, 57, of Alexander, North Carolina, pleaded guilty to defrauding the VA. After enlisting in the Army in 1985, Cook sustained an accidental injury and complained the injury worsened a preexisting eye condition. In 1987, Cook was discharged, and he began receiving benefits that would increase over the next 30 years due to Cook’s repeated false claims of increased visual impairment and unemployability. In 2005, the VA declared Cook legally blind, and he began receiving disability-based compensation at the maximum rate despite repeatedly passing vision screening tests to obtain or renew his driver’s license and purchasing vehicles that he routinely drove.”

1987 to 2020, we will be generous in counting the years here; regardless, we are looking at 30+ years this fraud continued.  Where were the verification protocols?  I have had to produce a valid driver’s license at the VA to obtain and keep current my VA identification card.  How did this fraud go on for so long?  What is the VA doing to stop, or at least hinder, those who would defraud the government before the problem becomes 10 years old, let alone 30?!?!  I cannot fathom how this fraud went on for so long without a routine checkup, a routine exam, a follow-up exam, etc.VA 3

Going north from South Carolina, we find more fraud, this time in New Jersey, where a man did not report his mother had deceased and continued to claim her benefits for a total of over $200K.

Melvin Greenspan, 72, of Perrineville, New Jersey, pleaded guilty to defrauding VA of over $200,000 in survivor’s pension benefits. After the death of his mother in 2006, who had received survivor’s pension due to his father’s prior military service, Greenspan failed to notify the VA about his mother’s death and made withdrawals of the benefits through 2018.”

Where was the leadership?  Where are the leaders now?  Another fraud case, older than a decade, and still the VA cannot be held accountable for facilitating the fraud.  I am stunned!  How did this one continue for so long?  Doesn’t the VA check local newspapers, the Social Security Administration, other Federal Agencies?  Since the culprit was not held on defrauding SSA, one can only presume the mother’s death was reported there.  Why did the VA not get notified to ask the family questions?VA 3

On the topic of guardians and leadership, the following story makes me angry!  However, I will withhold further elaboration since those accused remain innocent until proven guilty by a trial of their peers.

Johnny Ray Gasca, 51, was arrested for allegedly abducting a 68-year-old woman with dementia from the West Los Angeles VA Medical Center in California. A witness recognized Gasca and reported he might have previously taken money from the woman’s bank and retirement accounts. Following his arrest, Gasca described the victim as his girlfriend and told agents that they stopped at a bank where the victim made a $15,000 withdrawal after leaving the medical center.”

In the first report from the VA-OIG discussed, we found guardianship rules being violated to the Nth degree.  In this story, we have no information of an assigned guardian, and we have a dementia patient being abused.  The dementia patient was traveling with a friend; who is the legal guardian for a dementia patient?  Where are the family or friends legally bonded to render aid for this patient and monitor finances to protect them from abuse?  How can the VA operate one way in one locale and 180-degrees differently in another locale and the leadership not held accountable?VA 3

Speaking of missing leadership, the following VA-OIG report is a beauty!  The Department of Veterans Affairs – Veterans Health Administration (VHA) has a program to help homeless veterans, where contractors are used, and the VHA uses case management documentation to verify the veteran is receiving the assistance being paid for, the program is called the contracted residential services (CRS) program.

The VA-OIG found facility staff did not consistently document case management and monitor the progress of veterans in the program.  Further, four of the 14 CRS contracts reviewed had performance deficiencies, with one resulting in improper payments of $592,000. These deficiencies may affect the health and safety of veterans living in transitional settings. Moreover, VA lacks assurance that veterans received required services. There were also contract administration problems in 13 of 14 reviewed contracts. Contracting officers did not always properly delegate responsibilities to staff functioning as contracting officer’s representatives. Further, one facility’s representative did not ensure contractors provided meals or the means to purchase them, as required, and another lacked invoice supporting documentation for approval. The VA-OIG audit team estimated that 107 of 119 contracts had monitoring and administration deficiencies. Furthermore, the team estimated that VHA made $35.3 million in improper payments, of which approximately $21.6 million was technically improper because the individuals authorizing payment were not delegated authority to serve as contracting officer’s representatives.”

If your accomplishment rate in your employment was 48%, would you retain your job for very long?  If 90% of your documentation claiming how well you do your job was missing or fabricated, how long would you maintain employment?  If you delegated people to complete your work who were unauthorized and you were contractually culpable, how long do you think you would stay out of prison?  How long would your boss stay out of jail?  How long would your company exist?  Now, answer me this riddler, why does the government get a pass on these questions?VA 3

Finally, we have Deputy Inspector General David Case’s testimony regarding the failure of VA leadership where the implementation of a new electronic health record (EHR) is being stalled.  If you care, the VA leadership and the VHA leadership are failing the EHR initiative.  Not that this was not expected, and not that this is not surprising, the IT and IS departments of the VA and VHA are so hopelessly lost it amazes me the VA is even using computers and not written records!  But, do not take my word for it, Case himself claims,

“Detailed in this statement, we have repeatedly found unreliable and incomplete estimates for upgrades and costs, inadequate reporting affecting transparency to Congress, and stove-piped governance with decision making that does not appropriately engage Veterans Health Administration (VHA) personnel who are the end-users of the new EHR system.”VA 3

Knowledge Check!Get that; the leadership failures are obstructing Congress and hindering the EHR progress!  What can we conclude from this batch of VA-OIG reports:

        1. The VA, VHA, VBA, and National Cemetery leadership are actively missing, like the Democrats from the Texas Legislature.
        2. If the leaders are present, the leaders are the problems in progressing.
        3. The leaders have created a system where fraud and abuse of the veterans and taxpayers can be achieved with ease.
        4. Nobody in the US House of Representatives or US Senate scrutinizes the legislative branch sufficiently to effect changes.
        5. When in doubt about where your leaders fall, check to see if they are in their offices. Oh, wait, that won’t help, their offices have locks on the doors!

If this is how the VA defines quality healthcare. In that case, the veterans are screwed, the taxpayer is sunk, and the leaders will enjoy their magnanimous federally approved retirement packages, ad nauseam ad infinitum!

© 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.

 

I Hate Being Lied To – Follow-Up on Diabetes and Dieting

Angry Grizzly BearEarlier this week, I went to a doctor’s appointment that included diabetes boot camp and was instructed by Dr. T., a clinical pharmacist for the El Paso VAMC.  At the time, I thought the only liars were the Food and Drug Administration and the food pyramid I have been living for 40+ years.  After some additional research, I have to add Dr. T. to the list of liars using peer-reviewed sources.  Well, at least he is in good company.  The list of liars includes a neurologist who claimed all calories are the same and reducing caloric intake and caloric burn will help a person lose weight.  The advice I have been following for the better part of six years to no avail.

Cave Man Foods

The “Cave Man Foods” pitched by Dr. T. were sourced from Keto-Diets, not “14-years of research at the VA.”  The problem with the Keto-Diets is Ketosis, and if you have a liver problem, which I do, you can do serious damage to the liver by eating eggs.  Eggs are a staple of the Keto-Diets; do you see the problem here?Gravy Train 2

I have a friend, and he and his spouse went Keto about 16 months ago.  Earlier this year, his wife had liver failure, and the Keto-diet helped create a liver problem for someone who has never had liver problems in their life.  The correlational relationship between consuming eggs and non-alcoholic fatty liver disease (NFLD) is pretty solid based on my research.  However, as I am not a dietician, a medical doctor, or a food researcher, I can only rely upon medical advice and encourage you to seek medical opinions (plural) before starting any diet regimen!

Calories are not the same!

Let us establish a base of information.  A calorie is a unit of energy defined as the amount of heat needed to raise the temperature of a quantity of water by one degree.  In Junior High School, we used peanuts, sugar cubes, and other home ingredients to explore calories in chemistry class.  I still remember setting foods on fire and measuring water temperature correctly to get the caloric burns right.  However, dieticians never discussed then and not discussed now that one calorie is not the same as another calorie.  Just like rocks are not all the same size, have the same value, or can be used in the same manner.

RocksFor example, calories from sugar are not the same calories from kidney beans, even though both are units of energy, and 2000 calories of chocolate are not the same as 2000 calories of carrots.  If we are clear on this, let’s discuss why this is important.  2015, a neurologist told me all my problems with my nerves lay in how much fat I was carrying around.  He claimed that if I reduced the amount of calories I consumed and increased the number of calories burned, I would quickly lose weight.  Losing weight never happened, nor could I keep any weight lost off for any length of time.

Three years after this meeting, I was told I had developed diabetes and a non-alcoholic fatty liver, as well as gallstones, and my GERD was out of control.  This was when I was first introduced to the notion that not all calories are equal, even though all calories are units of energy.  I did not understand this discussion totally then; after Dr. T.’s discussion, I still do not fully understand the entire argument.

Lemmings 3I am sure that energy sources are not equal, even though calories are simple units of energy, per the laws and rules of physics.  However, I am not a chemist, a physicist, nor exceptionally well versed in diet and health.  I am not a dietician and am left to try and figure out the best advice and live that advice.  As a foodie, I have yet to find any diet, as the first part of a diet is “die” dying of hunger!  Before you ask, yes, Garfield is a hero of mine and has been my whole life.

Complications to Weight Loss

2017 thru 2019, I had been more active and had lost a little weight.  July through December 2020 come along, and all the weight lost is back in spades; why, the injuries sustained at the hands of the VA Police in arresting me for not wearing a mask at the VA Hospital in Phoenix, AZ.  According to research conducted on people with spinal cord injuries, the following are key variables in weight loss:

      • Age
      • Race
      • Marital Status
      • Employment Status
      • Family history of overweight/obesity
      • Level and duration of injury
      • Cholesterol level at baseline.

Thus, it is only logical that since my fallacious arrests and injuries at the hands of the VA Police at the Carl T. Hayden VAMC in Phoenix, AZ., exercise and weight loss would be impeded, acting as complicating factors in improving my health.  Why is this important; because, my new primary care provider does not think I have any problems and refuses to renew medication until other specialists claim the medicines are needed.  I find it interesting that the doctors would vary so significantly between VISN 17 and VISN 22.Lemmings 4

Mask Policies

While the following is not a variable in weight loss, it is part and parcel of the lies and problems I have experienced since Feb 2020.  The Las Cruces, NM., VA Community Based Outpatient Clinic (CBOC) had no problems accepting my doctor’s note regarding my inability to wear a mask.  When I arrived at the El Paso VAMC, the VA Police had no problem with my doctor’s letter regarding my inability to wear a mask, handed me a face shield, and then provided protection for me with other bureaucrats who took umbrage that I was not wearing a mask.

cropped-bird-of-prey.jpgMeaning that what I have been declaring about the mask policy, the mask mandates, and the hypocrisy of zealot VA Police Officers at the Carl T. Hayden VAMC is 100% true, and my treatment was not in accordance with the mask policy (emailed directive) from Washington DC.  I hate being lied to, detest being arrested and injured when I am right and refuse to be silent about how poorly the VA is treating veterans!  Does anyone know a lawyer who is willing and hungry enough to take on the VA?

References

Chen, Y., Henson, S., Jackson, A. et al. Obesity intervention in persons with spinal cord injury. Spinal Cord 44, 82–91 (2006). https://doi.org/10.1038/sj.sc.3101818

Gundry, S. R. (2017). The plant paradox: The hidden dangers in “Healthy” Foods that cause disease and weight gain. HarperCollins.

Joshi, S., Ostfeld, R. J., & McMacken, M. (2019). The ketogenic diet for obesity and diabetes—enthusiasm outpaces evidence. JAMA internal medicine, 179(9), 1163-1164.

Mokhtari, Z., Poustchi, H., Eslamparast, T., & Hekmatdoost, A. (2017). Egg consumption and risk of non-alcoholic fatty liver disease. World journal of hepatology, 9(10), 503.

Taubes, G. (2008). Good calories, bad calories: Fats, carbs, and the controversial science of diet and health. Anchor.

Taubes, G. (2011). Why we get fat and what to do about it. Anchor.

© 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.

Moral Distress IS a Leadership Problem – More Shameful VA Chronicles!

Survived the VAA surprise occurred in this week’s Department of Veterans Affairs – Office of Inspector General (VA-OIG) reports; the Boise VAMC in Idaho performed well in their comprehensive healthcare inspection (CHIp).  Even though 10 recommendations were left, the VAMC as a whole is performing above average, with no significant complaints found by the VA-OIG.  Congratulations to the Boise VAMC!

VA 3Let me stress something; leadership is the reason why a VA Healthcare System (VAHCS) or VA Medical Center (VAMC) performs well or poorly!  Yet, too often, the leadership IS the root cause of the problems in a VAHCS or VAMC.  The Boise VAMC just proved this point precisely; are any Department of Veterans Affairs (VA) leaders in Washington DC paying any attention?

The VA-OIG performed a CHIp in Portland VAHCS and found moral distress in the employees, again!  This means that the Eastern end of the state is receiving better care than the western end of Oregon State!  Yet another VAHCS or VAMC with employees feeling morally distressed by the commands and directives of their leadership in how they treat veteran patients!  The VA-OIG report makes everything sound like rainbows and lollipops at the Portland VAHCS, but if employees feel “morally distressed,” there are problems, just not those included in the CHIp scope!VA 3

Where problems outside the scope of an investigation are concerned, the following is GREAT NEWS!

Robert Seifert, 63, of Utica, New York, pleaded guilty to making telephonic threats to Albany Stratton VA Medical Center employees. Seifert, who has been convicted twice before of threatening VA employees, admitted that on 14 January 2021, he made three calls to employees for no reason other than to harass and threaten them.”

I am going to repeat it, only for emphasis, “Leave the families out of your anger!”  Never, EVER, attack, threaten, or speak against the families.  They are OFF LIMITS!  I become very frustrated with the VA Leadership, but violence is not the answer, and threatening families is repulsive and counterproductive!  Seifert is scheduled for sentencing on 06 October 2021; may the judge throw the book at him, for this is his third conviction for threatening families of VA Employees.VA 3

On the topic of frustrating leadership who need to lose their jobs and reimburse the government for all wages, the following VA-OIG report is the epitome of failed leadership in action!

The VA’s Office of National Veterans Sports Programs and Special Events (NVSPSE) granted $47 million to organizations with experience in managing adaptive sports programs from fiscal year (FY) 2017 to FY 2020. … The VA-OIG found that the NVSPSE was not effectively managing the program.  The NVSPSE’s director had not established adequate internal controls, including developing standard operating procedures for managing adaptive sports grants.  As a result, the NVSPSE could not effectively evaluate risks from grant recipients, did not reimburse some recipients’ expenses on time, did not always close out grants on time, and did not appropriately authorize extensions for using funds.  By not closing out grants on time, the NVSPSE failed to free up about $346,000 that could have been used for other purposes.  It also improperly allowed recipients to spend $328,000 in FY 2017 appropriations outside the approved period and improperly reimbursed 19 recipients a total of about $247,000.”

The VA-OIG recognizes that these failures to audit and control the adaptive sports program properly potentially violate both the Purpose Statute and the Antideficiency Act, federal laws with direct consequences for Federal Employees.  I am taking bets.  Will anything come out of the director being referred to the lawyers; I doubt any action will ever be taken!  That’s not just my cynicism speaking; that is the experience in watching directors at the VA skate accountability and responsibility better than gold-winning Olympic figure skaters.VA 3

In reporting the following VA-OIG report, do not rationalize that every suicidal person will eventually find a way or means to commit suicide.  I ask you do not think this for two reasons: one, it is a lie lazy people tell themselves to disregard the act; two, helping people with suicide ideation is not cut and dried textbook medicine. Assisting people with suicide ideation takes time, effort, getting to know the person, and a lot of interlocking care from professionals.

“The patient, who was over 70 years old at the time of death, had diagnoses that included post-traumatic stress disorder and major depression. After approximately 15 years of care at a California VA facility, the patient transferred care to the Las Vegas facility in summer 2019. The VA-OIG substantiated that the patient died by suicide from a VA resident mental health clinic on the day of dischargeThe emergency department social worker documented an incomplete comprehensive evaluation. The suicide prevention team did not assign the patient a high risk for suicide patient record flag despite the patient’s stressors and history of suicide behaviors. Staff did not adequately assess the patient’s substance use, incorporate relevant history into the treatment plan, or address the patient’s change in demeanor and concerning statements. The discharge safety plan had not been modified for approximately eight months despite significant life changes. Leaders had not established a mental health treatment coordinator (MHTC) policy. Staff assigned the patient an MHTC at the patient’s tenth visit and four MHTCs over nine months. Staff did not coordinate care with a geropsychologist, with whom the patient had nine appointments. Leaders did not effectively address the patient’s expressed complaints. The VA-OIG substantiated that leaders did not conduct an institutional disclosure” [emphasis mine].

The last sentence is the dead giveaway that the leadership knew there were problems and designed processes intentionally to have an excuse when a patient died!  This veteran was suffering to a great degree, and I hope that with his passing, his family and friends can find peace in the knowledge that the veteran is now pain-free.  But, the VA leadership should be held legally responsible for this death, they failed this patient, and the world is worse for the veteran’s passing.VA 3

Suicides are hard on family, friends, communities; suicides at any age are the ultimate declaration that failure occurred, the pain was missed, and the medical community and support systems failed.  Survivors often feel a great degree of guilt and carry that guilt to their graves.  But, when medical providers go out of their way to hide the problems, refusing to document, and declare, it means that the medical community had written the patient off as too costly to save.  Who speaks for the loss of intelligence and potential of the failed patient; I do!I-Care

I will continue to speak to the failures of the VA to provide the care they promised, and demand leaders are held accountable and responsible.  This was preventable, and the leadership must be held accountable if the system is to be changed!  This veteran did not have to die by his own hand, and the medical community at the VA in Southern Nevada HCS, located in Las Vegas, should be ashamed!

Follow this link if you would like to see a recap, with links, to the shenanigans reported by the VA-OIG in June.  June 2021 has been a month of incredible and horrendous behavior documented by the VA-OIG of the leadership failures at the VA.  The elected leaders of America either need to begin scrutinizing the VA more closely or vacate office.  There is no excuse for the continued irrational and detestable behavior at the VA.VA 3

The last two items are testimony recorded before a Senate and a House of Representatives Committee.  Statement of deputy inspector general David Case Office of Inspector General, Department of Veterans Affairs before the US Senate Committee on veterans’ affairs hearing on VA electronic health records: modernization and the path ahead 14 July 2021Statement of Leigh Ann Searight deputy assistant inspector general for audits and evaluations Department of Veterans Affairs – Office of Inspector General before the subcommittee on oversight and investigations committee on Veterans’ Affairs US House of Representatives hearing on modernizing the VA police force: Ensuring accountability 13 July 2021.  Frankly, both statements are pure vanilla because the subcommittees refused to act, which was known before making the statement and the hearings.  Hence, why should the VA-OIG prepare action plans if the Senate and House will not take action?

Knowledge Check!Repeating, only for emphasis, “Until the US Legislative Branch will do their jobs, and scrutinize the Executive Branch with the intent to demand accountability, no single government agency will ever change.”  Want to help veterans?  Contact your elected representatives and send them these articles, demanding they take action in support of legislation and scrutinization, demanding accountability and responsibility of government employees who are currently active in refusing to change!  Want to help veterans?  Share these stories far and wide.  Everyone should know what the VA is doing and realize that every government agency from the city to the President is employing tactics to steal liberty, rob freedom, and murder veterans!

© 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.

I Hate Being Lied To: Highlights From Diabetes Boot Camp

Lemmings 32015, The day I went to the VA Emergency Room with killing pains in the upper-right quadrant of the abdomen was a game-changing day.  Yet, it also marked the day that doctors started lying to me.  I was diagnosed with three things, gallstones, obesity, and non-alcoholic fatty liver disease.  Non-alcoholic fatty liver disease, also known as metabolic-associated fatty liver disease, is excessive fat build-up in the liver without another clear cause, such as alcohol use. There are two types; non-alcoholic fatty liver and non-alcoholic steatohepatitis, with the latter including liver inflammation. Non-alcoholic fatty liver disease is less dangerous than NASH and usually does not progress to NASH or liver cirrhosis.  Essentially, my liver was having problems policing itself and had developed fattiness, not alcohol-related.

2021, a clinical pharmacist in charge of teaching diabetes at the El Paso VA Medical Center, holds a “boot camp” for veterans to help them understand and better handle diabetes.  I spent 30-minutes with Dr. T. getting the low-down on diabetes and getting questions answered.  I hate being lied to, and I hate not being able to get simple questions answered.  Today’s diabetes class changed my understanding, and I have just scratched the diet/diabetes topic.

Let me be clear right here; I am not an authority on these topics.  I am not a medical professional, and sources outside my own research have provided all medical information.  I am still learning on these topics and am simply describing my experiences.  If the same issues spark your interest, may this information help and support you and your doctor’s path moving forward.Exclamation Mark

Obesity

Obesity is the amount of fat carried on a person, above a specific level, as determined by the health and activity of the person.  Please note, no single person is identical in where their fat vs. health into obesity levels are.  I have met people who look overweight, but they are not unhealthy because of how their body works.  Whereas, I have met skinny people with very little fat on their bodies who were exceedingly unhealthy.  Thus, calling all heavy people “fat” and “obese” is the first set of lies and misconceptions we must learn and unlearn when discussing obesity, diabetes, and diet.

Obesity, and the linked diseases to obesity, is also a misnomer and a horrible series of lies.  Diabetes is considered a disease; obesity has just now (2018 or so) been changed from a symptom to a disease.  Want to hear something to blow your mind; both descriptions are 100% wrong!  Obesity is a consequence of being addicted to foods.  Diabetes is a consequence of having the addiction overcome the body’s natural defenses and cause independent problems.

DietGravy Train 2

I am not advocating any diet/weight-loss plan, nor am I using this term to describe specific foods in a health regime; in using the term diet, I am discussing the foods we eat.  The foods we eat form our diet, and our diets are killing us.

If you are around 40-years of age, you grew up with the food pyramid, as detailed by the Food and Drug Administration, as a way to select healthy foods and improve your diet.  You were taught that grains, especially whole grains, were essential for your diet and should be the bulk of what you eat daily.  You have been carefully trained and programmed that dairy, especially drinking Milk, is extremely important to a growing body.  You have been instructed that calories in, plus exercise, is the path to weight loss and healthy living.  You have been taught that salt is bad, sugar is good in moderation, and that there are pills to correct the issues if you are having problems.  Would you believe a single voice that told you those are all lies; I wouldn’t, but the researchers continue to affirm the truth of these things if you desire to learn.

Today, I finally learned just how bad these lies are, and my “cherub-like” demeanor has been brutally beaten by reality.  Since 2015, I have been told these lies multiple times, specifically to reduce the problems I am experiencing from a lifetime of eating the food pyramid!  Nothing is more dangerous than an honest person lied to, and the government needs to fear this consequence.  Salt is good in moderation, as established by your blood work.  Drinking Milk is bad for the body.  Sugar is worse for the body than dairy!

VaccineLet’s talk about historical facts for a moment.  You will not find this discussed in your history books, but I promise the history is 100% accurate, and the Internet has sources for what I am about to declare.  The East India Company, a powerful trading company from England, wanted to increase sales of sugar cane and offered what is essentially bribes to farmers to feed their animals sugar cane.  The animals quickly developed sores, open wounds, and a host of health problems, leading to death.  When this experiment failed, the focus was pushed back to sugar crystallization, which began injecting crystallized sugar into people’s diets worldwide.  Who eventually had the same problems as the animals eating raw sugar cane, only the length of time between consumption to health problems was longer, and thus more easily overlooked as the cause.

Research using fMRIs has shown that sugar and heroin have the same effects on the brain, opening the same receptors and releasing the same feel-good chemicals into the body.  Worse, the addiction between sugar and heroin is very close chronologically.  Two weeks is the upper limit to reach to begin changing the body’s dependence to both, which means that it takes roughly two weeks after the last hit to start the addiction recovery process.  The only difference between heroin and sugar, sugar does not come with a stigma and legal problems that heroin carries.

DiabetesBait & Switch

In simple terms, diabetes is the overproduction of insulin in the body until the pancreas cannot keep up and begins to fail.  If you have a Gastrointestinal problem, the levels of insulin in the body are the cause.  The powerful pancreas is directly tied to a person’s health.

Carbohydrates are the problem; carbohydrates (carbs) are comfort foods and always contain higher sugar levels.  Carbs make it very difficult to break the sugar addiction and stop the pancreas from not hitting the proper amount of insulin in the body to digest foods.  I have always preferred brown rice to white rice, beans and legumes, whole grains, and I love making my own bread.  Yet, these foods especially are why my pancreas is overworking, and I have gastrointestinal issues and diabetes.  The nine-grain cereal I love any time of the day to consume is hurting me, but for my whole life, I have been told that nine-grain, whole grain cereal cannot hurt you.

Cave Man Foods

Knowledge Check!The following were suggested to me as foods to focus on eating, cutting my meals from three to two per day, and I have a follow-up in two weeks with Dr. T.  Dr. T. called these foods “Cave Man Foods” as they are closer to what cavemen ate, and they did not have diabetes.  I include these foods as a permanent record, not as health advice.  Please consult your physician and your body for what is best for you.

      • Eggs
      • Cheese
      • Avocados
      • All types of leafy green stuff (I knew they would stick these nasty things in somewhere.)
      • Non-Starchy Vegetables
          • Cucumbers
          • Colored peppers
          • The greenest lettuce to be found, Romaine is best provided it is GREEN! If your lettuce is white, RUN AWAY, THROW IT AWAY.
          • Spinach
          • Cabbage – Oh, I love Red and Green Cabbage with brats!
          • Broccoli
          • Radishes
          • Fresh Tomatoes – If your tomatoes are processed, look at the added sugar content, and be amazed at how sodas have less sugar than spaghetti sauce. But sodas get a bad rap, and spaghetti sauce gets a pass.
          • Asparagus – I love red/purple asparagus, can never find it, but I prefer red/purple to green.
          • Mushrooms – Oh, I have a great recipe for stuffed mushroom caps for the grill!
      • Raw nuts, but any non-sugar added nuts are good.
      • All berries.
      • Coffee and Tea, no sugar – Frankly, I drink neither, for I hate the taste of green/black/white/etc. Teas and I have finally kicked the coffee habit.
      • Drink Water! As a firefighter, as a person who has suffered three major heat stress injuries, I am a huge proponent of drinking water.
      • Meat – Any type.
      • Avoid – Bread, Rice, and Pasta

IronyWhat I found unique on this list is the missing fruits, watermelon, peaches, pears, apples, oranges, pineapples, etc., and Dr. T. claimed this was because of the need to pump the body full of insulin to digest the fruits.  If the goal is to heal from diabetes and be free of the drugs, shots, needles, etc., the body needs to be weaned from sugars to allow the pancreas to heal and the insulin levels and liver functions to return to normal.  As the pancreas heals and liver functions rise, the intestines will see a marked change in healthy bacterial populations without needing to add bacteria to your foods.  Have you seen the amount of added sugar in yogurt?  The bacteria are killed by sugar, but to eat yogurt, you get a considerable amount of sugar; tell me, does this make sense to you?

References

Gundry, S. R. (2017). The plant paradox: The hidden dangers in “Healthy” Foods that cause disease and weight gain. HarperCollins.

Taubes, G. (2008). Good calories, bad calories: Fats, carbs, and the controversial science of diet and health. Anchor.

Taubes, G. (2011). Why we get fat and what to do about it. Anchor.

© 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.

Glory and Gore go Hand in Hand – Stating the Obvious

Bait & SwitchLorde, from the “Pure Heroine” album, sings the song “Glory and Gore.”  From which both this title and the principle for this article originated.  The obvious is stated many times a day, oftentimes in an ironic accident, and today was no exception.  The headlines on several stories help prove this point and highlight some serious problems facing America.

From The Daily Signal, we find our first instance of stating the obvious when Lindsey Burke announces that “Unions are doubling down on inserting critical race theory (CRT) into education.”  Of course, the labor unions of teacher associations would be doubling- and tripling- down on applying political pressure to advance America, destroying malarkey for K-12 Educators.  Show a single instance when a Marxist labor union has ever done anything to support America, and I will show you the inner workings of liars, thieves, and cheats who will tell a thousand truths to convince you a lie is a truth.

Exclamation MarkCRT is dangerous, it is a lie thought up by academics, and the only people who will benefit from CRT are liars, thieves, cheats, and politicians.  Tell me, of all the people in history who have been enslaved, forced into indentured servitude, harassed, belittled, and betrayed by a different society, why are American Black populations the only ones ever targeted for pampering and coddling?  When you answer this question, you will discover that this population is being treated this way by racist antagonists who know they can rely upon this population for agitation, anger, and terrorism without thought, concern, and care about the consequences.  Why; because they have been intentionally groomed and carefully taught to act in this manner for the political ambitions of the same people pushing CRT.

Ever notice how President Biden and Hillary Clinton only talk at the American Black Populations, and even then only address the leaders of groups dedicated to rousing the population’s emotions, and not the population themselves?  When was President Biden ever in Harlem for a political rally?  When was Hillary ever in Compton, Philly, or Chicago?  What about a visit to Atlanta for a political rally down by the riverside?  The politicians talk to the NAACP and the Black Caucus, who then speak to the religious leaders and social justice minions. They talk to the local neighborhoods, reflecting the cowardice and true colors of the politicians as race agitators and race hustlers, not interested in the population unless it is election time.  What is CRT; trouble!

Theres moreThe Daily Signal also carried a story authored by Hans von Spakovsky, who declared that a former Justice Department lawyer testified that lawyers abuse their power at the Department of Justice.  What a revelation; lawyers were acting unethically, immorally, and illegally for personal gain in government employment.  Color me shocked!  Ever wonder why lawyers and attorneys have the most jokes written about them of any other profession; I never have!  Worse, I cannot believe how many can get elected!

Under the heading of stating the obvious, and how you cannot color me shocked, the Department of Veterans Affairs (VA) continues to blame inadequate training as the go-to excuse when the Department of Veterans Affairs – Office of Inspector General (VA-OIG) comes investigating.  In the almost two decades I have been chronicling poor behavior at the VA, VBA, VHA, and National Cemeteries, the number one most often cited excuse for failure is “poor or inadequate training.”  As a point of reference, this lack of training drove my desire to work in training at the VA to improve the training delivered.

Raymmond G. MurphyAs an adult educator with more than 20 years in distance learning and classroom training, I thought I would be a shoo-in for the positions.  Nope, I had not served in pay grades lower to “learn the VA.”  Even though I had more education and experience, was Schedule A, and more skilled than any other candidate, I was deemed not qualified, and internal people filled the open roles.  How do I know these facts, I asked those hired, and they were glad to relate their stories, experience, and time served in the VA to get into a plushy training position where they were grossly inadequate.  Only after leaving was the other reason revealed, the HR Director at the Albuquerque VAMC claimed too many veterans were in employment at the VA and refused to hire a single veteran while she directed the HR department.

Do the VA Leaders ever think that this is the problem? Only the worst of the worst can survive the mental depravity and mind-numbing bureaucracy at the VA to obtain promotion into higher leadership positions.  Worse, those who achieve these positions have agendas, lists of enemies to crush, and power empires to build, so they are never interested in doing the job!

GearsThe result, designed incompetence is bred, excuses that could not hold reality become the accepted verbiage to deflect responsibility and accountability, and if all else fails, make sure your union dues are paid, and the union will defend your pension, your job, and your benefits.  Then you can lie, cheat, steal, and terrorize without prejudice and escape without any problems.

If you ever think that something is too far-fetched to believe, the VA will prove you wrong.  The VA-OIG continues to inspect five VAMC’s for inadequate and improper processes, procedures, and leadership where financial controls and payments to third-party or affiliated non-profit corporations are concerned.  In 2021, two additional VAMC’s have failed sufficiently to make the eternally under investigation list, Albuquerque, NM and Palo Alto, CA.  The original five are Boise, ID., Boston, MA., Cincinnati, OH., Nashville, TN., and San Francisco, CA.

The Albuquerque and Palo Alto medical centers made about $17.9 million in improper payments to affiliated non-profit corporations. The reason for improper payments was the same for all seven VA medical centers reviewed. Specifically, procedures for approving invoices did not satisfy VA policy requirements because they did not require verification that the services were provided. The audit team also noted an absence of required periodic reviews by VA supervisors of approved invoices at all seven medical centers.”

Now, here’s the other side of the coin, the internal controls at both the VA and the non-profits did not identify that their problems were internal or even an issue.  When I have worked in finance, the rule is, “no evidence, no payment!”  When the non-profit I volunteered at failed an audit with 27-pages of audit inconsistencies, I was called in and charged with fixing the problems.  Of those 27-pages of audit findings, 26 pages were for payments where documentation was missing.  Four months later, a follow-up inspection cleared all 27-pages.  Yet, no evidence continues to be the single most glaring problem at seven separate VAMC’s, and nothing has changed since this issue first reared its head in FY 2017-2018.  The VA-OIG has collected reports beginning in Boston, MA VA_OIG report number 18-00711-211, published 02 December 2019, where more than 3700 payments totaling more than $23 Million were made without evidence proving services rendered.Apathy

From the VA-OIG Report:

Of the estimated $1.6 million overpayment, about $1.5 million paid to the Boston non-profit was included in the total $35.7 million improper payments due to lack of evidence that services were received. The entire $1.6 million overpayment was for unallowable or prohibited reimbursements to the non-profit.”

The OIG previously reported a total of about $35.7 million improper payments to five affiliated non-profit corporations as shown in this report.”

VA 3Is it too obvious to declare the leadership in charge at both the non-profits and the VA needs immediate removal, transparent audits conducted, and those leaders held accountable for the money that has been lost?  Recently an author claimed the VA is more of a crime syndicate than the mob.  After reading that two additional VAMC’s have failed gloriously to prove services rendered for payments made, I can agree with this sentiment!

Our final entry today originates, unsurprisingly, with the Department of Veterans Affairs – Veterans Benefits Administration (VBA) and a VA-OIG inspection where 88% of the claims processed involved lengthy delays in making decisions.  Tell me, if you had an 88% failure rate at your job, how long would you keep your job?  How long would it be before your bosses were shown the door, the company shuttered, and investigated for fraud?  Now, why are government employees treated differently than private-sector employees?  The inexcusable delays have led to more than $232 Million in questionable payments projected for the next two years, while the VBA is “encouraged” to fix the delay problems and “catch up.”

Knowledge Check!For the record, stating the obvious, the entire US Government is sick.  The legislative branch keeps abdicating responsibility to the judicial and executive branches. Bureaucrats and bureaucracy have overcome common sense. The whole process has been rigged to keep the dregs of society in power while the taxpayer suffers.  Let us, the owners of representative governments, remind those supposed to be in charge that they have cause to fear the electorate.  Politicians should fear the ballot box, and they should fear having the electorate hold them personally accountable for the mess they have perpetrated.

© 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.

Absurdity so Repugnant it Takes Your Breath Away – More VA Chronicles

Angry Grizzly BearThe Department of Veterans Affairs – Office of Inspector General (VA-OIG)-released six investigation reports in the last two days.  Each one is mentally breathtaking at the egregious behavior of bureaucrats!  Stupidity that is so repugnant it breaches the laws of morality and leaves the reader stupefied.  Every year, for the last decade-plus, the behavior of the Department of Veterans Affairs (VA) has become more obscene, more outlandish, more detestable, and more openly hostile towards veterans; it sickens me to read the investigation reports, write, and catalog these abuses!

Beginning in Queen’s, New York, we find another dead veteran that should never have died the way they did.  Improper feeding by a registered nurse (RN) at the New York Harbor Health Care System’s Community Living Center (CLC) contributed to the death of a patient.  Let that sink in for a moment, for the rest of the report only goes downhill from this point.  My time in medical training was replete with the following aphorism, “If it is not written down, it NEVER happened.”  The nursing staff failed to document meals properly. The electronic health record (EHR) was inaccurate and flawed, hindering resuscitation, which was poorly documented, and institutional disclosure acted more like CYA than a medical file.  People should have been fired and up on trial for this type of scandalous behavior, especially since a veteran died from this abuse and neglect.  But the VA-OIG made their recommendations, the leadership accepted the recommendations, and nothing else will happen.  Nobody but the family cares the veteran died needlessly and at the hands of the medical professionals.VA 3

Adjectives elude me.  The behavior in Queen’s is appalling, even for the VA.  Unfortunately, the list of ineptitude only gets worse!

VA SealNext, we travel to Austin, Texas, and discover yet another office of information technology (OIT) failing to work, secure data correctly, and protect veterans’ information, as demanded by legislation!  The VA-OIG and the local OIT used the same tools, and the local OIT only identified 150 problems, whereas the VA-OIG OIT inspectors found 246.  Improper sanitization of media was a pronounced issue, where patient load is upward of 300,000 annually.  Inventory practices were noticeable and apparent.  Worse, patch and vulnerability programs were practically non-existent if I understand this report correctly.VA 3

If you have read any of these VA Chronicles, you will know that the VA has not passed a Federal Information Security Modernization Act (FISMA) audit, ever!  The head of IT was recently in front of Congress to testify why, and the explanations were milk toast adequate at best!  But, the elected officials bought the excuse, hook, line, and sinker, as always, and the president wants to spend more money on the VA.  What a cathartic example of why elections matter!

Next, we travel to Detroit, Michigan, where a “comprehensive healthcare inspection (CHIp)” was performed at the John D. Dingell VAMC.  Before I even read the report, I knew it would say; opportunities exist to improve employee and patient experience.  Knowing veterans who are “served” at this VAMC, this was an obvious guess!  Again, we find “moral distress” in the workforce, signifying that the employees feel pressured to do everything but what is ethical, legal, moral, and appropriate for the patient at this VAMC.  Yet, the leadership team was rated as stable and doing a good job!  Quoting Colonel Potter from M*A*S*H here, “HORSE HOCKEY!”VA 3

I will be explicitly clear if a single employee feels “moral distress,” there is a leadership problem, and the leadership is criminally negligent in their duties to oversee staff leaders, supervisors, team leads, and training personnel!  This is not the first time “moral distress” was a point of discussion in a CHIp; but, the fact that this problem remains widespread and apparent does mean the problems are originating at a level higher than the VISN, and all the VA and VHA leadership should be losing their jobs!  Enough is enough, and the elected officials need to be scrutinizing the government before they lose their next election!

Survived the VAHaving been an employee of the Department of Veterans Affairs, working in the Emergency Department of the Albuquerque, NM., VAMC, this next story is exceptionally aggravating and extremely distressing.  The VA-OIG determined that the entire Veterans Health Administration (VHA) needs to better monitor, record, and document the timeliness of care and patient flow in the emergency department.  Having waited for more than 14 hours in a VA Emergency Department while waiting for care, I know first hand the problems of the Emergency Departments, and I know a lot of the reasons why the documentation is fouled and the flow of patients is amateurish, at best!

Raymmond G. MurphyI worked the shift where a regular, homeless veteran, wheelchair-bound, had fallen and broken his leg.  He waited with his broken leg swelling, stuck at an odd angle, and in obvious distress for more than 6-hours because the head nurse that day had a personal grudge against the veteran!  I saw how the charts were “adjusted” for timeliness of care, and I reported the problems up the chain to no avail!  I had witnessed nurses harangue patients, gossip about them, chart surf in violation of HIPAA, and never was anything done by leadership when it was reported.  A patient sat in an expedited treatment room for four hours, listening to the nurse’s gossip and joke, awaiting stitches for a bleeding wound, and never was treated.  All because the day shift was getting off and didn’t want to be bothered to treat the patient.  The patient’s family reported this behavior to me as they were leaving for a better hospital.  I reported the whole incident, included the family’s description, added my observations.  The leadership shook the whole incident off as a disgruntled employee (blaming me) making a less than desirable situation worse.VA 3

Thus, when I read this particular VA-OIG report about the inadequacies of the VA Emergency Departments across the entire VHA, it infuriates me into a mindless stupor!  Want more data on the failures of the VA Emergency Department; read the rest of the VA Chronicles.  I describe my experiences in detail and have logged other veterans who have had the same or worse problems at the VA Emergency Department!  I have witnessed doctors treat patients in a dissimilar manner based upon the political clothing the veterans wore into the Emergency Department!  So, no, I am not surprised at the record inadequacies of the VHA; if anything, I expect the problem is a lot worse than the VA-OIG was willing to report!VA 3

The VA-OIG collected data on an issue of grave significance from 58 VHA outpatient clinics’ regarding emergency preparedness for the delivery of telemental health care as of November 1, 2019. The review focused on clinic-specific emergency procedures, emergency procedure roles and responsibilities, emergency contact information of staff, and patient safety reporting methods.  Not included in the scope of the review was the quality and quantity of telehealth appointments.  I mention this oversight as the technical problems in receiving telehealth appointments are sub-par, at best, which would have seriously skewed the data.

The VA-OIG sent out 333 questionnaires, receiving a total of 187 responses, from the 58 identified clinics, and identified the following:

      1. Missing telehealth emergency plans and procedures.
      2. Emergency procedures are not specific to telehealthcare or the patient-clinic location.
      3. Lack of a process for annual updates to telehealth emergency procedures.
      4. Undefined emergency procedure roles and responsibilities for telehealth staff
      5. Missing or insufficient emergency contact information.
      6. Lack of a process to verify and communicate emergency contact information
      7. Lack of a consistent process to designate the telehealth setting in patient safety reporting methods.VA 3

Consider for a moment; you are a family member of a veteran needing telehealth mental support.  Now, how do you feel to know there are no written processes or procedures to support the telehealth provider if your family member gets into a mental health emergency.  Time is critical in mental health emergencies; I know this from personal experience as both a provider and a patient, and for these plans, procedures, and processes to be missing is the height of malpractice!  Would someone please tell me why elected officials and the media are not screaming mad at this particular report?  Especially since the proposed budget from the president wants to double suicide prevention spending at the VA.  I read this report and see that the VA-OIG made five recommendations.  Are you freaking kidding me?!?!?

Finally, we go to Hawaii and confront the most detestable, outside of the dead veteran, issue possible, failure of the National Cemeteries Administration (NCA) to properly care for the remains of veterans, qualified spouses, and dependents.  The NCA awards grants to states to build cemeteries where a veteran, qualifying spouse, and dependents can be laid to rest outside a national cemetery.  From the VA-OIG report, we find the following, emphasis mine:

Grants may be used to establish, expand, or improve veterans cemeteries. The VA-OIG audited the program to assess NCA’s governance and oversight. The audit team also assessed whether critical non-compliance issues at two cemeteries in Hawaii were addressed. The VA-OIG found grants program staff did not rank and award some cemetery grants as regulations required. After grants were awarded, program staff generally ensured cemeteries used grants for their intended purpose. However, NCA did not ensure cemeteries with grants met all national shrine standards for installing permanent markers, maintenance, and safety. The audit team observed non-compliance issues at eight state cemeteries, including critical issues in Hawaii’s Hilo and Makawao cemeteries. As a result, NCA lacks assurance that veterans and family members buried in state veterans cemeteries have been appropriately honored with timely and accurate grave markings, burial locations, and maintenance.VA 3

NCA, you have one job, ensure the remains of veterans and qualifying spouses and dependents are adequately remembered, safely entombed, and marked appropriately.  Yet, you fail at even this simple and easy job; how utterly disgraceful, disgusting, and detestable!  How many cemeteries in the Philippines are being adequately cared for?  At the last report, none of them were adequately maintained and respected.  Even here in the US, you refuse to do your jobs with competency, dignity, and professional pride.

Knowledge Check!The VA is one sick organization, where the mission is being denied, the veterans abused before and after death, and none of the elected representatives can find enough time in their day to even offer a mild rebuke or maintain sufficient interest to scrutinize.  America, we have gotten better as a culture in remembering and honoring those who serve and have served, and I, for one, am very grateful for your change of heart.  We, the voting citizens of America, need to demand the same culture change from the politicians representing us!  As a country, we have come a long way since Vietnam in honoring the military.  But those same people who spat and urinated on our troops in Vietnam are now in the Halls of Congress, and their attitudes have not changed in the interim!

© 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: Putting Shame in the Right Place at the VA – Administration

Angry Grizzly BearI have found great and good providers at the VA, as well as some truly awful and detestable providers.  The Doctors, Nurses, Medical Support Assistant (MSA), and the patient are supposed to form a PACT team to improve the health and welfare of the patient in the VA Health Care System (VAHCS).  The PACT Team is a VA organizational program to assist in improving care and stands for Patient Aligned Care Team (PACT), as an extension of patient care services.  The PACT Team also includes the Patient Advocate and several others, as detailed in the image below.PACT_model

I mention all this because I have heard from a veteran, we are going to call him “Boats,” a chief Boatswain mate for over 20-years in the US Navy, honorably discharged, and a disabled veteran of the Vietnam Era.  Boats’ doctor changed clinics, thus shaking the PACT team to its core.  Since the doctor was reassigned to a different clinic, the nurse has been changed but not explicitly assigned, so the coverage nurse cannot be reached by phone, and secure message falls on deaf ears and plastic lips.  Hence, reaching his PACT team has become a burden, his health has suffered greatly, and the mask mandate makes his safety in the VA Clinic doubtful at best, as the mask aggravates his ability to breathe.

PACT 1Because his clinic has no doctor, other doctors have been sharing their time in the clinic.  This means that if treatment requires time and interactions over multiple visits, the patient loses any type of continuing care and is left frustrated, with continuity of care hindered.  Here’s the rub, this has been an ongoing situation for a long time, and the continuity of care has become a root cause in the failing health of this veteran.  Unfortunately, this is not a new or rare problem for the VA, and as shortages in providers continue to increase, it will only worsen.

PACT 3Boats is in the same situation as many other veterans.  While misery loves company, this type of misery costs lives, and that is an administrative problem Congress legally bound the VA to fix, and they refuse to address.  Like the mask policy that does not include a face shield option or include the verbiage for approved medical conditions, the administration of the VA continues to market lofty and grand standards and fails even to meet minimum legal requirements.  I have witnessed the administrative officers, known by their online pictures, refuse to help veterans, pawn off veterans, and even go so far as to hide from veterans to avoid providing customer service.

The hospital administrators have been schooled in the VA; many have “come up through the ranks.”  These administrators have been taught how to avoid accountability, responsibility, and work the VA Bureaucracy to keep their jobs, even when veterans are dying from the administrative problems they created.  While an employee, I heard the tales of how my Hospital Administration Services Director got her job; draw your own conclusions, all I do know is someone was promoted to an exceedingly great height above her maximum level of incompetence!

Detective 4Consider the hospital director moved, at taxpayer expense, from Seattle to Phoenix.  She had been killing veterans in Seattle and took over an award-winning hospital, which very shortly became a national joke for where veterans go to die!  Her lessons are still being taught, veterans are still dying, and the administration is still the problem!  The mask mandate that has stopped my prescription from being refilled, my abusive PACT Team led by a doctor who invited me to find a new provider, refused to contact me for two months about needed blood work to refill diabetes medication.  After two weeks without diabetes medication, magically, diabetes medication arrives. No blood work ever occurred because I cannot access the VA due to my approved medical condition that makes wearing a mask impossible.

The administration of VA Hospitals is a crime!  I had an assistant director, while an employee, who said, “If a non-VA Hospital did anything like the VA does things, they would be shut down for malpractice.”  The assistant director is now a clinic director for the VA; her resume included 20-years in non-VA hospital administration.  She joined the VA to help veterans.  Where is the VA-Office of Inspector General in rooting out these administrative landmines of ineptitude that makes hiring more difficult and retaining talent near impossible?  Where is Congress in scrutinizing the VA and helping those working to change the VA to succeed instead of actively contending with them?

LinkedIn VA ImageBoats has serious problems.  The legacy of the VA is to kill him instead of fixing their administrative problems.  But, the VA’s mission statement is still, “To fulfill President Lincoln’s promise: “To care for him who shall have borne the battle, and for his widow, and his orphan” by serving and honoring the men and women who are America’s Veterans.
“Our department remains fully committed to fulfilling the sacred obligation that we have to those who serve in uniform.” ~VA Secretary Denis McDonough.

VA SealWhere is the VA acting in accordance with the mission statement and fulfilling its “sacred obligation?”  The answer, with the current leadership in administration, nowhere!  The VA has been purposefully designed to kill veterans and can be fixed.  The fix must include Congress, and we all know how Speaker Pelosi (D) feels about veterans; when she called them terrorists, it was clear her scrutinizing the government where the VA is concerned will not happen.

I-CareVA Secretary Denis McDonough signed onto the “I-Care” principles as core values in care for veterans in the VAHCS.  Well, when can we, the veterans, see that these core principles have been on-boarded and are correcting behavior?

“VA Core Values describe how VA will accomplish its mission and inform every interaction with our customers. These Core Values are: Integrity, Commitment, Advocacy, Respect, and Excellence — better known as “I CARE.” VA’s Core Values will continue to serve as the right guide for all our interactions and remind us and others that “I CARE.”

  • I care about those who have served.
  • I care about my fellow VA employees.
  • I care about choosing “the harder right instead of, the easier wrong.”
  • I care about performing my duties to the very best of my abilities.

DutyMr. Secretary…  The veterans are dying now!  We are waiting!

Like my enlistment oath, I signed onto the I-Care principles and even though I am no longer employed by the VA, I live I-Care!  Where is the VA in proving “I-Care?”

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

NO MORE BS: The VA Chronicles of Shame Continue

VA SealWhile I have been fighting the Carl T. Hayden VA Medical Center for humane treatment (June 2020) and medical services, making no progress, the Department of Veterans Affairs (VA) has undoubtedly been busy oppressing others, allowing their employees to skate responsibility, and avoiding accountability.  For the record, I have not deep-dived the legal proceedings reported below and would remind everyone that those charged are not guilty until a jury of their peers says so in a court of law.  I am not passing judgment and am only reporting from official VA-OIG reports, leaving the conclusions mainly to you, the reader.  The conclusions offered are mine alone, and you are free to draw your conclusions based upon the data delivered and your due diligence.

The Department of Veterans Affairs – Office of Inspector General (VA-OIG) has been busy filling my inbox all week.  Here are the latest stories of shame from the VA Chronicles:

  1. VA Health Care System (VAHCS) Fort Harrison, Montana, the investigation began with two people calling for help to the Veterans Crisis Line (VCL). From the VA-OIG report, we find the following:

The VA-OIG substantiated a VCL responder failed to assess caller 1’s homicidal risk factors, address lethal means restriction, complete an adequate risk mitigation plan, communicate critical information to a supervisor, and take actions to prevent a family member’s death. VCL leaders did not consider an administrative investigation board to review the responder’s potential misconduct. The VA-OIG substantiated that two social service assistants (SSAs) failed to dispatch local emergency services for caller 2 following a responder’s rescue request. The VA-OIG identified deficiencies in SSA oversight.
VCL leaders did not fully adhere to Veterans Health Administration (VHA) policies related to reporting and disclosure of adverse events. A facility primary care provider failed to include caller 1’s mental health diagnosis in the assessment and plan of care. Also, the primary care provider did not submit caller 1’s non-VA medical records for scanning into the electronic health record or document a review of the records, as expected by VHA policy.

Angry Wet ChickenI have been trained in emergency psychological triage; this was part of my training as a Chaplain’s Assistant in the US Army.  When you work on a crisis line, you cannot not take immediate action to save a life!  When my friend called me all depressed and intimated he wanted to end his life, I called 911, explained the situation, and asked for help.  They provided help.  I was not acting in any official capacity; I was not working a crisis line; I was simply a concerned friend.  How can these crisis line employees, managers, and other staff escape accountability and responsibility?  The whole chain of events is a lurid report of failure to take action by people duty-bound and placed in positions to act, and they refused to take action; this conduct is inexcusable!

As a substitute teacher, I was a mandatory reporter.  If I heard anything untoward, I had to act!  As a Chaplain’s Assistant, I was a mandatory reporter, and I was empowered to act, even without my chaplain’s permission, which by the way, pissed off my chaplain; but he refused to see specific soldiers in crisis.  Not my fault, but I took my Article 15 with pride!  Taking us back to the VA employees who failed miserably the need to take action, and still escaped accountability and responsibility!

  1. Survived the VAOur next story is a back-slapping congratulatory declaration regarding a soldier committing fraud.

Shawn Pierre Hobbs, a soldier for the Connecticut Army National Guard and a Rikers Island correction officer employed by the New York City Department of Correction, was arrested yesterday in El Paso, Texas, on wire fraud and aggravated identity theft charges. VA Inspector General Michael J. Missal said, “The charges unsealed today are the result of the hard work and dedication of the VA-OIG’s special agents working with our law enforcement partners. The VA-OIG will seek to hold accountable those who perpetrate fraud and steal benefits that are intended for deserving veterans.”

LinkedIn VA ImageThere are still many details missing in this story that I bet the public will never see.  Since no VA Employees were mentioned, I can only surmise that they escaped accountability because the main perpetrator was caught, so according to the VA-OIG, no harm, no foul.  I believe that as much as I believe in buffalo wings originating from flying buffalo!Flying Buffalo

  1. Our next report is one of such supreme idiocy that words can barely describe the situation and the current findings. Consider the following, you arrive at your doctor’s office and need several routine shots.  If the doctor and nurse fail to document these shots properly were delivered, and you have an adverse reaction, they can be held liable for medical negligence under the law.  Why does the same not apply to the VA?  The following comes from a memorandum issued by the VA-OIG, declaring an investigation is ongoing on this issue, but problems have already been found!

While reviewing the Veterans Health Administration’s (VHA) plans to document receipt and distribution of the COVID-19 vaccine, the VA Office of Inspector General (VA-OIG) determined that VHA facilities did not consistently document the COVID-19 vaccination status of veterans living in VA’s Community Living Centers (CLCs).
The VA-OIG determined that VHA could not know at a national level whether the vaccine was offered to some CLC residents, and if so, what their status was. Because CLC residents are in the highest COVID-19 vaccine priority group, they should be offered the vaccine, when possible, before other groups of veterans. With vaccine supplies limited, VHA should know which CLC residents still need to be vaccinated.
The VA-OIG found VHA has made important strides in distributing vaccines to CLC residents, but [needs to] move toward more comprehensive and consistent data collection to guide ongoing actions and protect this vulnerable population. Doing so would include making sure all CLCs routinely track refusals and contraindications in a consistent manner. Guidance should be clear that all communications should be consistently documented in accordance with VHA processes.
Similarly, clear guidance and consistent oversight should help ensure CLCs are properly tracking veterans who fall in the 23 percent of CLC residents missing information needed to determine their vaccination status. It was not possible by January 2021 to establish which of the 1,899 veterans in this cohort had been offered the vaccine. The VA-OIG will continue its oversight work on vaccinations within VHA and plans to issue a full report, including specific recommendations. In the meantime, the VA-OIG requests to know what action, if any, VHA takes to mitigate the potential risks identified in this memorandum and the outcome of those actions.”

Angry Wet Chicken 2Essentially, the VA-OIG is claiming the VHA cannot document in their long-term care facilities which residents have and have not been vaccinated against COVID.  Can you believe the incredible negligence being witnessed; I cannot!  In the US Army, due to chiggers and a violent allergic reaction to them, I spent several weeks in what is called the “Reception Battalion.”  My job was documenting who got vaccinated, what shots were received, and I was held responsible if the documentation was incorrect.  I have worked in long-term care facilities not owned by the VA and witnessed the time and energy spent documenting everything the patient experiences.  I have visited family members in long-term facilities and witnessed the documentation procedures.  Yet, miraculously, the VHA does not have to submit themselves to the same level of documentation requirements.  Where is that memo, policy guideline, or written procedure?  Where are the lawyers?  For the VHA to have a problem with documentation of a patient is 100% inexcusable, and people’s heads should roll over this failure to document!

  1. Our next chronicle of shame is both a good and bad report.

Muhammad Z. Aabdin, 30, of New York City, has been charged by complaint with offering a bribe to a VA contracting officer in September 2020. Specifically, Aabdin allegedly offered to share profits with the officer in exchange for her awarding VA contracts to Aabdin for personal protective equipment.”

That the VA employee reported, the bribe is a good thing.  That a contractor felt comfortable enough to offer a bribe is considerably less of a good thing.  Are there additional questions being asked and investigated in this procurement office regarding the offering of bribes and the potential of having previously taken bribes?  Where are the supervisors in this affair?  The VA persists in hiring from inside for the advancement of careers, not a bad thing, but when a contractor is comfortable offering bribes, there should be many questions being asked of supervisors, directors, and so forth.I-Care

The fact that the behavior of VA employees breaking the law is both widespread and well known should be a wake-up call to the leaders of the VA and the elected officials charged by law to scrutinize the government.  Except, this behavior has never been scrutinized sufficiently to end the behavior, only scrutinized enough to encourage the behavior, the negligence, and the extreme indifference.  Every American Citizen should be outraged and motivated to shout at their elected officials using all communication channels until this abhorrent behavior is sundered forever from the VA body!

ApathyExcept, I am preaching to crickets.  Your taxpayer dollars are funding the abuse of veterans at the hands of the government.  Shameful!  Inexcusable!  Outright blasphemous!  Yet, allowed to continue because of apathy; Plato was right!

© 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: COVID Mask Discrimination Policies and Your Health

Millstone of Designed IncompetenceThe Atlantic published an article well worth reading, “End the Hygiene Theater.”  To summarize, SARS-COV-2 (COVID-19’s official name) is an aerosol and does not survive in the outdoors or on surfaces.  Just like 99.9% of all viral infections.  Consider how much money the government mandates had wasted on power cleaning surfaces since August 2020 when the scientific peer-reviewed journals began publishing the science of aerosol viral fighting tips.

Angry Grizzly Bear15 April 2020 was a high watermark day for me; I was forced to go to the Sandra Day O’ Connor Federal Courthouse to fight three citations for not physically being able to wear a mask at the VA Hospital here in Phoenix.  My injury at the hands of the VA Police was not allowed as evidence; the policy that continues to hinder care at the VA Hospital was not allowed as evidence.  However, it was used frequently as an excuse, and my being erroneously declared a behavior problem at the VA was inadmissible as that is an internal policy of the VAMC.  The end result, I lost more money to pay the fines.

In the US Republic of America, you have the right and freedom to wear a mask if you choose. Suppose you desire that face diaper as a safety blanket, even though peer-reviewed science has found zero evidence that masks help; feel free to wear a mask.  Please understand that thousands of people cannot wear a mask due to medical conditions, medications, and other breathing problems, which means alternative health measures are needed.  Medical policies should never be written as one-size-fits-all.  The policies writers are discriminating and putting people’s health at risk.

ApathyAs my breathing has become more labored since my spinal injuries in 2002, at the hands of a First-Class Petty Officer, I have had to exercise more healthy options to keep myself safe.  I take vitamin supplements, including C & D, at both a medical professional’s request and my wife’s knowledge.  I drink tonic water, which has quinine in it, specifically the tonic water sold at Trader Joe’s, for it has no high-fructose corn syrup and less sugar than soda, so my diabetes does not take a hit.  I was told by my primary care provider, at the VA almost 10-years ago that quinine will help my nighttime leg cramps, it worked for me.

I am not a medical professional, and am not saying everyone will have the same benefits; the quinine in tonic water has helped me, and overtime I have experienced less sick time from common colds, flues, and other aerosol borne sicknesses.  Always discuss with your doctor the vitamins and drugs being taken, this is also your right and freedom!

Historically, quinine has been used as an anti-malarial drug, and is effective in calming muscle cramps, leg restlessness, and is a base ingredient in chloroquine and hydroxychloroquine.  “Use of chloroquine (tablets) shows favorable outcomes in humans infected with coronavirus including faster time to recovery and shorter hospital stay.  US CDC research shows that chloroquine also has strong potential as a prophylactic (preventative) measure against coronavirus.  Chloroquine is an inexpensive, globally available drug that has been in widespread human use since 1945 against malaria, autoimmune diseases, viruses, and various other conditions.”  Facts are coming from multiple peer-reviewed resources since 1950, including Dr. Fauci.

Angry Wet ChickenTo arrive at court, I had to walk more than ¼ of a mile from the closest parking spot to the 2nd floor mezzanine of the Federal Court House.  By the time I got through the US Marshall security buttress, I was completely out of breath, and the first words out of security’s mouth, “Where is your mask?”  I explained I have breathing problems, and they insisted I at least carry a mask to meet the “stringent judge mandated legal requirements for mask policies.”  Thankfully, they did not insist I wear the mask, as I would have become an emergency right then and there.

Leaving me with an incredible question, “How can the US Marshall’s in charge of security at a Federal Courthouse use common sense and keen observation and make executive decisions, but the VA Police on Federal Property cannot do the same?”

The answer to that question lies with the draconian leadership and the egos inherent in the VA.  Same Federal Policy regarding masks but applied with 180-degrees of separation.  The VA Police Officer who oversaw my asset forfeiture/remediation did not have a problem with my not wearing a mask the entire time we spoke.  We maintained 6’ of separation and conducted business like adults.  Yet, in the VAMC, this officer would have been under obligation first to arrest me, which always leads to me being injured, cite me, then kick me off the property.  All Federal Property, all handled by sworn legal officers possessing arrest authority, and we have two different outcomes.

Foghorn Leghorn - MedicationAs a point of reference, there are more than several hundred thousand people like me in America right now who have breathing conditions that preclude wearing a mask for personal health and safety.  Polio victims with lung scarring are especially susceptible to COVID and should not wear a mask.  I know veterans who are missing a lung, who struggle to breathe, they cannot access the VA for medical care; this is mask discrimination!  I know cancer patients who, due to the drugs and cancer, cannot wear a mask and cannot access the VA for cancer treatment; this is mask discrimination.  I am one of several thousand people on a steroid to help breathing problems, where a mask is warned against wearing for physical safety and personal health.  However, I am still denied VA Medical Care over the mask policy.  The list of medical conditions and breathing issues is endless. Still, the policy from the Federal VA Director’s office, supposedly, does not come with a line, “except for those with approved medical conditions.”  I claim allegedly, as I have yet to receive a copy of this mask mandate policy or find a copy anywhere online.  I have even gone so far as to use an FOIA request for the policy and never have received a response.

I asked a supervisor about the policy at the VAMC and was pointed to a marketing sign.  I asked a hospital director, in fact, the patient advocate director, and was told there is no official policy.  Because that would require writing things down, and the VA refuses to document anything for fear of reprisal and recrimination.  Also, a topic I have covered ad nauseam and ad infinitum in these articles to no avail, as an excuse for designed incompetence.

Never Give Up!Ask yourself this question, “Who is the primary person responsible for my health, myself, the media, the insurance companies, or the government?”  For how you answer that question will determine how you approach situations where your health is jeopardized.  We have programmable vaccines being passed off as a cure-all for a virus that makes up the common cold, yet people are still catching the common cold and testing negative for COVID.  We have had flu vaccines around since the 1930s, with mass vaccination campaigns since 1945; yet until COVID came along, we still had people dying from the flu every year!  By the way, an interesting fact, no one has caught the flu since February 2020; do you believe the COVID testing works?

America has witnessed years when the flu guessers guessed the wrong flu variant strain, and the flu vaccine people got was 100% ineffective.  Yet magically, this COVID vaccine comes along to end all those problems without long-term testing and in-depth research, and how many are lining up to get their COVID shot?  After getting the COVID jab, how many still are forced to live under COVID mandates?  See, the problem is not COVID; the problem is who controls your health decisions, the government, the media, the insurance companies, or you?

Non Sequitur - DecisionsThe discrimination we have been told all through school is “bad,” but the VAMC can mask discriminate against the population they are duty-bound to serve, and there are no legal consequences; where are the lawyers?  We have people who have been and are suffering from COVID-related vaccine sicknesses who lost their legal rights to sue the pharmacological manufacturer; where are the lawyers?  I would think the ACLU would be head over heels angry at this blatant abuse of people’s rights, except they are silent on these issues.  We have hundreds of thousands of veterans who cannot access their medical center, their doctors, and so forth due to a policy that isn’t a policy and are dying; where are the lawyers?

Dont Tread On MeWho controls your healthcare choices, you or the government?  I know my answer!

Reference

Sturrock, B. R., & Chevassut, T. J. (2020). Chloroquine and COVID-19–a potential game-changer? Clinical Medicine, 20(3), 278.

Todaro, J. M., and Rigano Esq, G. J. An Effective Treatment for Coronavirus (COVID-19). In consultation with Stanford University School of Medicine, UAB School of Medicine, and National Academy of Sciences researchers. Retrieved from: https://docs.google.com/document/d/e/2PACX-1vR1adodKPhWalV9djnerI2x_v1LGgGyhZZxpl0O5r-ZNyDdagqFq1rTCxXBqaeicfxgvypDOqKCZVyV/pub (Google is blocking access to this information)

© 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: Bureaucratic Fiat, a Veteran Suicide – Scrutinizing the Government

ApathyThe Department of Veterans Affairs (VA) is in trouble due primarily to the employees’ lack of written directions, procedures, and processes to complete work.  Of the poor Veterans Health Administration (VHA), there is none worse than the Carl T. Hayden VA Hospital system in Phoenix, AZ.  I support this conclusion with both personal observations and through comparative analysis.  Much research has gone into this conclusion, and while there are other VHA’s that compete for the bottom, the clear winner remains the Phoenix VA Medical Center (VAMC).

What is bureaucratic fiat?

Bureaucratic fiat is government employees who make decisions in their positions who rigidly adhere to any rule not to perform their job, inconvenience the customer, or thwart responsibility, accountability, and maintain their positions.  Bureaucratic fiat survives sections from the Office of Inspector General (VA-OIG) through designed incompetence, lack of training, confusing processes, unwritten rules and guidelines, and simple negligence.

LinkedIn VA ImageVeteran Suicide!

Outside of first responders and active military, the suicide rates of veterans are too high and rising.  The suicide rate is disgusting to behold and tragic beyond words.  Of all the topics I discuss, veteran suicide remains my pet topic.  When veterans or military members (Reserve, National Guard, or Active) commit suicide, this rips a hole in communities, families, and the guilt the family and friends carry is so intense, they struggle not to commit suicide themselves.

Scrutinizing the Government!

DetectiveThe VA-OIG reported on a veteran who committed suicide, with ties to the Carl T. Hayden VA Medical Center in Phoenix.  The veteran reported to the hospital, asking for help.  The VA-OIG found that processes were intentionally not followed.  Help was not forthcoming, and the veteran committed suicide before the VA got their thumbs out and offered this veteran help.  The VA-OIG found the following:

      • “While the patient awaited the testing, facility staff failed to offer mental health treatment.
      • The social worker did not complete a suicide risk assessment and relied on another social worker’s suicide risk assessment completed eight months prior.
      • A family member called and left a voicemail message for the social worker. However, the social worker’s documentation did not include essential information, specifically that the patient died by suicide.
      • Upon learning of the patient’s death by suicide, a Suicide Prevention Coordinator failed to complete timely documentation of outreach to the patient’s family… the mental health delegate did not approve the community care psychology consult within three business days, as required by VHA.
      • The third-party administrator scheduled the patient for therapy rather than psychodiagnostics testing.
      • The facility scheduling staff did not complete required outreach efforts when the patient missed a primary care appointment one day before the patient’s death by suicide.
      • The Suicide Prevention Coordinator did not complete the patient’s behavioral health autopsy within 30 days, as required.”

One incident, one VAMC, one veteran, and nothing from the VA will protect veterans and improve the adherence to the policies and procedures moving forward; why even investigate by the VA-OIG?.  I weep with this family who lost their loved one to suicide.  I scream in frustration that the VA can continue to kill veterans struggling with suicide with impunity.

Detective 3Do not be deceived; this is not the only incident in Phoenix or all of the VA Healthcare System.  A veteran reaches out for help with suicide ideation, receives bureaucratic nonsense instead of support, and is treated to the red tape that becomes the noose in the suicide of that veteran.  One event a year is a tragedy of epic proportions.  The list never seems to end, nor do the bureaucrats ever get held accountable for their inactivity, contributing to veteran suicide.

12 November 2020, The Military Times reported that from 22005 through 2018, veterans committing suicide had risen dramatically, to a high in 2014 of 6,587.  Is the epicness of this tragedy more apparent?  Presuming that each of these veterans had two parents who came together and invested time to create the child that became the veteran,  13,174 parents now weep to lose their son or daughter who committed suicide.  According to the US Census, families in America had 1.9 children per couple (2014), rounding up to 26,348 is the potential parents and grandparents affected by suicide, and 52,696 is the pool when siblings are added.  If each of these suicides had a significant other, with two parents and two siblings, the potential affected by suicide is now approximately 105,392.  Add employers, friends from employment, communities, and educational or academic acquaintances, and the number of people affected by suicide can quickly reach a million people.  I used 2014 as the year to base the numbers upon as this was the highest number currently available, but 2020 saw a dramatic increase in suicide among all age groups and those with the Census delays; I doubt America will learn the full impact from COVID government madness any time soon.

LookNow, consider the following, each of those veterans who committed suicide in 2014 (6,587) had a suicide prevention team in place at the VA who failed to act.  6,587 people who deserved better treatment at the hands of the government employees, who have pledged to fulfill President Lincoln’s promise “To care for him who shall have borne the battle, and for his widow, and his orphan” by serving and honoring the men and women who are America’s Veterans.  Failed the veteran and played a role in the suicide of the veteran.  Rarely do the veterans who commit suicide, in VA parking spots, on Federal property receive the attention they deserve.  I am intimately aware of one such issue with the VA Medical Center in Albuquerque.  The veteran could not get help, became frustrated, walked to his car, and killed himself.

2019, The Washington Times, who proudly continues to declare that “Democracy Dies in Darkness,” ran a story about veterans who take their lives on VA Campuses, is a “form of protest” against the VA Healthcare system.  No, this is not generally the case; the veteran is not protesting; they are fed up with the fight to be respected, noticed, and receive assistance from people who have pledged to fulfill the Department of Veterans Affairs Mission Statement.  To fulfill President Lincoln’s promise “To care for him who shall have borne the battle, and for his widow, and his orphan” by serving and honoring the men and women who are America’s Veterans.”

DutyI demand to know where are the legislative branches of government in scrutinizing the operations at the VA?  Why are suicide rates allowed to climb without significant input from the legislative branch?  Why are veterans, directly after an encounter with the VA bureaucracy, committing suicide without in-depth investigations where heads roll for failing to perform the most basic customer service in fulfilling the VA’s Mission Statement?

While an employee of the VA, to get to the directors of the hospital’s offices, I had to walk past this mission statement that hung on brass letters, and all my attempts to aid in change fell on brass ears and plastic lips!  Every time the VA-OIG reports another death by suicide, death by negligence, with ties directly to VA employees not performing their jobs, I want to scream in frustration!  Veteran suicide rates are egregiously high, and for veterans to commit suicide within 96 hours of a visit to the VA is 100% unacceptable!  Why 96 hours; because to date, this is the longest time between actions by the VAMC and the death by suicide the VA-OIG has reported where VA employees should have been held accountable for their refusals to act in a manner to prevent a veteran from committing suicide.

Millstone of Designed IncompetenceAfter over a decade of reading and reporting VA-OIG reports and investigations, the deaths by suicide and negligence are the ones that raise my ire the most!  I would see the VA improve, but until the VA admits, or is forced by elected representatives to admit, they have a problem, nothing will change.  But the horror in that sentence is that veterans will continue to commit suicide and die through VA Employee negligence, and their deaths are as unremarked as if these heroes were common criminals who died in a prison brawl.  This remains an abysmal testimony to the incompetence and uncaring bureaucrat found in the VA’s vaunted halls!

© 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.