The Department of Veterans Affairs – Veterans Benefits Administration (VBA) regularly crows about reducing the backlog, improving the veteran experience, and making changes to deliver on the promise. Every so often, another article is spread, mainly by the VA Public Relations department (PR), about how they meet the legislated obligations. Then, unsurprisingly the truth is revealed, the curtain thrown back, and the lie exposed. The Department of Veterans Affairs – Office of Inspector General (VA-OIG) is helping pull the curtain back, and the truth should infuriate every American. In an investigative report dated 22 June 2022 and linked, we find the following:
“… The VBA disregarded privacy procedures so it could use a workload tracking system more quickly without receiving the appropriate security authorization. The Mission Accountability Support Tracker (MAST) helps quantify the work VBA’s support services staff perform in response to employee requests for facility, equipment, and vehicle management; reasonable accommodation; and identification card issuance and renewal. Because staff use personally identifiable information (PII) in their work, the information could be compromised in an unauthorized, unsecured application. The VA-OIG found that VBA and the Office of Information and Technology (OIT) did not correctly follow privacy and security procedures. VBA’s privacy threshold analysis was inaccurate, and OIT did not conduct a privacy impact assessment. OIT’s misclassification of MAST as an asset resulted in insufficient security controls. Further, VBA lacked the authority to operate MAST before using it in regional offices.”
Lacking authority equates to a leadership failure to follow their standard operating procedures (SOP). PII being inappropriately released, nothing new at the VBA, or the VHA for that matter. Losing veterans’ identities and taking advantage of systems for personal gain, regardless of the cost, is nothing new or surprising. This should be where the VA organizational leadership should be focused; yet, what are they doing? Where is Congressional oversight and scrutiny?
FY 2017, the VBA leaders devised a scheme to have third-party vendors conduct compensation and pension exams to deliver on the promise to clear the backlog on veterans’ claims. Since FY 2017, the VBA has paid over $6.5 Billion on this scheme, and the VA-OIG found in a report dated 08 June 2022, “Some of the exams produced by vendors have not met contractual accuracy requirements. As a result, claims processors may have used inaccurate or insufficient medical evidence to decide veterans’ claims.” Is anyone surprised this is the result? The compensation and pension exam is the key to accuracy in claim completion; yet, inaccurate claims are still being adjudicated wrongly, which is significantly damaging veterans and their families!
From the report, we find the following:
“VBA’s governance of and accountability for the exam program needs to improve. The identified deficiencies appear to have persisted, at least partly because of limitations with VBA’s management and oversight of the program at the time of the review.”
The VBA’s leaders designed this scheme, shackled the program with ineptitude, and hindered the improvement of the program. Designed incompetence cannot get any better than this, and the leadership must be held accountable! Fraud, waste, and abuse remain pillars in Federal Government governance, so why are these leaders not being held liable?
Michael Bowman, Director of IT and Security Audits, in recent Congressional Testimony, made the following claim:
“Secure IT systems and networks are essential to VA’s fundamental mission of providing eligible veterans and their families with benefits and services. VA’s information security program and its practices must protect the confidentiality, integrity, and access to VA systems and data.”
The audacity of this director to claim “confidentiality, integrity, and access” as being secure would be laughable if it weren’t so inept! How would a non-VA Employee know the IT system is fraught with problems? VA-OIG report regarding FISMA compliance, Dallas, Texas. The Federal Information Security Modernization Act of 2014 (FISMA). FISMA is a United States federal law that defines a comprehensive framework to protect government information, operations, and assets against natural and manmade threats. FISMA OIG inspections are focused on four security control areas that apply to local facilities. They have been selected based on their level of risk: configuration management controls, contingency planning controls, security management controls, and access controls.
What did the VA-OIG find? “Without effective configuration management, users do not have adequate assurance that the system and network will perform as intended and to the extent needed to support the CMOP’s missions. The access control deficiencies create risks of unauthorized access to critical network resources, inability to respond effectively to incidents, loss of personally identifiable information, or loss of life.” All political speak for inept leaders and deplorable leadership actions. IT/IS systems continue to fail, and the director claims the system has integrity; despicable and detestable!
Worse, the same FISMA inspection occurred at the same outpatient pharmacy mail facility in Tuscon, Arizona. The same problems were found, in the same systems, manned by the same inept people and led by the same poor leadership. Integrity, only if the word means sharing ineptitude between different facilities. Access to systems and data protection, can anyone honestly trust that the IT system at the VBA or VHA is providing the fundamental tools to meet the mission?
On the topic of IT system integrity, can anyone forget the continuing problems in delivering a functional electronic health record system to the VHA? How many billions of dollars must be wasted before Congress stops paying for this albatross? The VA-OIG has substantiated that “… many quality, patient safety, and organizational performance metrics were unavailable, including metrics needed for hospital accreditation. Additionally, the VA-OIG found that access metrics were largely unavailable. The VA-OIG remains concerned that deficits in new EHR metrics may negatively affect organizational performance, quality and patient safety, and access to care.” How’s that integrity doing? Is it trustworthy?
05 May 2022, failures were discovered in a joint DoD and VHA review of the new electronic health record system. The new EHR has no plan to create interoperability, yet interoperability was the main selling point for spending billions of dollars on a new EHR. Would you believe the VA-OIG recommends the DoD and VHA review federal laws and direct the offices overseeing the EHR program to begin complying? Would Congress please ask, why haven’t the program managers for the HER already been complying with Federal Law? How about demanding action to recompense the taxpayers who have been defrauded?
In April 2022, VA-OIG Michael J. Missal addressed Congress in a statement entitled, “At What Cost? – Ensuring Quality Representation in the Veteran Benefit Claims Process.” The VA-OIG’s mission is “preventing and addressing fraud and other crimes, waste, and abuse in VA programs and operations.” General Missal then discussed the integrity of VA processes to “help ensure that veterans receive the benefits, health care, and services they have earned through their service to our country.” Would Congress please ask how the VA-OIG is fulfilling its mission to prevent fraud, waste, and abuse?
“The VA-OIG operates a hotline that receives approximately 30,000 complaints annually from veterans, family members, VA employees, and the public.” If the 30,000 complaints are presumed to be stable, across just the years I have documented the VA’s abuses, then the VA-OIG has received upwards of 360,000 complaints over the last 12 years. Would Congress please ask about the success in promoting change, reducing fraud, waste, and abuse, and curbing the veterans being actively harmed by the VA, the VHA, and VBA?
Congress receives these VA-OIG reports first; what is Congress doing to scrutinize the executive branch? Where is the progress? The VA-OIG reports annually to Congress, but improvement never occurs. Permanent change never occurs. The same people are making the same excuses, using the same flowery language, and nothing ever happens to improve things. Worse, the same people maintain the same jobs, who pays, the veterans and their families, and the American taxpayer through the nose as the VA loses more and more money!
I do not know about any Congressional elected leader, but I am through buying the Kool-Aid the VA-OIG is selling:
“The VA-OIG’s work is focused on protecting VA programs and operations from waste, fraud, and abuse as well as improving their efficiency and effectiveness.”
On a single topic that the VA-OIG has reported on multiple times and remains critically important to all veterans and their families, it is reporting needs for improvement in VHA and VBA suicide prevention. From the report, we find the following:
“… Suicide prevention coordinators at VA medical facilities are required to reach out to veterans referred from the Veterans Crisis Line. Coordinators provide access to assessment, intervention, and effective care; encourage veterans to seek care, benefits, or services with the VA system or in the community; and follow up to connect veterans with appropriate care and services after the call.”
The findings from the VA-OIG report are almost criminal in the negligence of leadership to perform the jobs they hold:
“The VA-OIG found that coordinators mistakenly closed some veteran referrals because coordinators lacked the proper training, guidance, and oversight necessary to maximize chances of reaching at-risk veterans referred by the crisis line. VHA lacked comprehensive performance metrics to assess coordinators’ management of crisis line referrals, and coordinators lacked clear guidance on managing crisis line referrals. Until VHA provides appropriate training, issues adequate guidance, and improves performance metrics, coordinators could miss opportunities to reach and assist at-risk veterans.”
Why did the media bury this report? Suicide prevention continues to be a significant military and veteran issue, but this program’s designed incompetence should be a major story on all media networks. More, this VA-OIG report should be a talking point for every congressional representative seeking re-election. Why is this not the case? Integrity requires honesty, honesty and integrity requires action. When will Congress take action?
How many dead veterans will it take before Congress takes action? 31 May 2022 VA-OIG report:
“The VA Office of Inspector General (OIG) conducted an inspection to review the care of an unresponsive patient by Emergency Department staff and the subsequent response of leaders at the Malcom Randall VA Medical Center (facility) after the patient’s death at the University of Florida Health Shands Hospital (Shands). The OIG determined that facility Emergency Department nurses failed to provide emergency care to an unresponsive patient who arrived by ambulance. Despite emergency medical services (EMS) personnel having relayed, while en route to the facility, the criticality of the patient’s condition and the limited patient identifying information available, Emergency Department nurses and an Administrative Officer of the Day wasted critical time concentrating efforts on whether the patient was a veteran (which the patient was, but not so identified by the nurses) versus patient care. As a result, EMS personnel reloaded the patient into the ambulance for transport to Shands.”
The staff failed to follow EMTALA, and a veteran died due to the inaction and inappropriate focus of the medical providers. This is not the first or second breach of EMTALA, the federal law requiring any patient presenting at an emergency department receiving federal funds to be treated; yet, what will it take to get Congress off their thumbs?
12 May 2022, deficiencies in care led to a patient dying at the Charlie Norwood VAMC, Augusta, Georgia. The VA-OIG substantiated that:
“medical-surgical unit nursing leaders did not have adequate quality controls or training to ensure the provision of safe and effective alcohol withdrawal nursing care.” “Primary care staff failed to provide sufficient care coordination and treatment. A provider failed to address the patient’s abnormal chest images and poor nutrition and failed to communicate test results to the patient as required. A primary care nurse failed to respond to the patient’s secure message request for assistance two days before surgery.
Additionally, a barium swallow test was not scheduled. The surgical team completed a preoperative assessment but failed to detect the patient’s overall poor health. During the patient’s hospital stay after surgery, medical-surgical nurses did not consistently assess alcohol withdrawal symptoms or administer medications as required.”
My wife is fond of saying, these oversights and failures occur in non-Government hospitals, and this incident should not be considered indicative of the whole system lacking similarly. Yet, civilian hospitals have lawyers by the dozen looking for a reason to sue providers for malpractice, and the government hospitals protect against accountability and responsibility. Worse, you will never know the problems unless you track these incidents.
Do you know why I keep declaring there is a problem with designed incompetence; several veterans suffered T-12 burst fractures and multiple rib fractures, all because of poor documentation and even worse communication. This is a life-changing injury, and the VA-OIG found the VA providers to have culpability but no responsibility due to a lack of documentation. Delays in provider documenting in the electronic health record the provider’s notes delayed care for another veteran who also suffered life-changing spinal injuries after receiving non-care at a VA facility. The VA-OIG cannot conclusively document the tie between poor care being received and the injuries sustained by the veteran, all because of delays in the provider documenting treatment.
Tell me, does anything discussed above reflect the words of Inspector General Michael J. Missal, who claimed the following in Congressional Testimony:
“VHA continues to face enormous challenges in providing high-quality care to the millions of veterans it serves. Despite these challenges, the VA-OIG has witnessed countless examples of veterans receiving the care they need and deserve—delivered by a committed, compassionate, and highly skilled workforce [emphasis mine].”
Does a provider killing a veteran reflect a committed, compassionate, or highly skilled workforce? How many veterans must be permanently injured by the VHA providers to reflect a committed, compassionate, and highly skilled workforce? How often will the electronic health record fail before highly skilled workers are displayed?
Unfortunately, the VA-OIG reports discussed are not even the tip of the iceberg of what is happening. My apologies, dear readers; I have been remiss in my reporting duties. Why have I been remiss, because my health went sideways since April when I had a medical procedure completed that was advised but not appropriate. The VHA and VBA are sick organizations and desperately need scrutiny and standards, new leadership, and written organizational policies. Help me force these nefarious characters into the sunshine for a good dose of sunshine disinfectant, and let’s change the world for the better.
© Copyright 2022 – M. Dave Salisbury
The author holds no claims for the art used herein, the pictures were obtained in the public domain, and the intellectual property belongs to those who created the images. Quoted materials remain the property of the original author.
On a side topic, VA-OIG, how do you define a “significant complaint” and separate it from other types of complaints? Honest question, the information was, to quote my PCP, “remarkably” missing from your investigation report! Would the VA-OIG like to know why so many veterans’ complaints have risen to a “serious” level? You reported the exact problem:
Elected officials, where are you? The VA-OIG presents copies of their findings to you, and I have yet to witness a single one of you holding the VA Leadership criminally responsible for the failures at the VA. Even when the VA is killing hundreds of veterans, the US Congress refuses even to act upset, let alone scrutinize for a change! Remember how many veterans were intentionally killed in Phoenix waiting for treatment? How many VA employees lost their jobs and pensions or were forced in front of a judge for murder? It is a fair question, where are the elected officials in the legislative branch working to end the criminal “fraud, waste, abuse,” and designed incompetence in the executive branch?
The 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).
Veteran Suicide!
The 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:
Do 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.
Now, 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.
I 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?
After 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!
Late last week, I received a call from the Chief of police at the Phoenix VA Medical Center. In July, I had been arrested for not wearing a mask. By late August, I had figured the Phoenix VA Medical Center Director was going to just “forget me” and hope I go away, then the call comes in. The Chief of police begins by stating, “I do not know why I am calling you, but I was requested to call and see what I can do to help.”
The VA-OIG conducted a healthcare inspection at the Atlanta VA Health Care System (VAHCS) in Decatur, Georgia, and found they had a backlog of open community care consults, and the OIG found deficiencies in processing, scheduling, and timeliness of these consults. Important to note, the contributory factors included but were not limited to, inconsistent scheduling processes, inconsistent oversight, and deficiencies with third-party administrator scheduling oversight, shortages of scheduling staff, and lack of training and supervision for scheduling staff. The facility did not consistently meet facility process requirements for scheduling audits and lacked a process to identify consults that were missing documentation after administrative closure. While the Decatur VAHCS should be praised for not having any critical patient concerns due to the scheduling failures, this appears to be more luck on the patient’s part, than efficiency on the scheduling staff part.
Imagine you’re a patient, or worse a family member escorting the patient, with suicidal ideation, and you hear the doctor say, “the patient can go shoot themselves. I do not care,” How would you feel about the 12-hour stay in the Emergency Room, after seeing seven different providers who did not read the notes, complete adequate patient handoff between the ER and outpatient mental health, which also includes deficiencies in the hand-off processes, and providers’ failure to read the outpatient psychiatrist’s notes, which led to a compromised understanding of the patient’s medical needs and a failure to enact the outpatient psychiatrist’s recommended treatment plan. Completing six-days later in the veteran taking their life. 
When any veteran dies by their own hand, it is a tragedy. But, when the VA has any responsibility in that veteran committing suicide, heads should roll, individual people should be held accountable, and in this case, especially, criminal proceedings should commence! I worked in the VA ER, I know what the providers, nurses, and other staff providing patient interactions say. I have reported several inappropriate comments that the patients heard to no avail, no recourse, and no action by hospital leadership. I know, intimately, the political chicanery that occurs at the VA, and I can tell you, this IS a pet issue with me, and I am unapologetic in calling for criminal charges on these providers who are abusing veterans and their families!
The VA-OIG inspected the VA Illiana Health Care System (VAHCS) and multiple outpatient clinics in Illinois. The VA-OIG also inspected the William S. Middleton Memorial Veterans Hospital and multiple outpatient clinics in Illinois and Wisconsin. I have been in both and I can say unequivocally, more progress is needed and the leadership desperately needs to improve professionalism among staff, improve patient safety from the bureaucrats not providing care, staff competencies, and staff training. All of which were among deficiencies mentioned by the VA-OIG. There is great potential in these VAHCS’ for achieving greatness, but the bureaucrats need deep cleaned, and removed!
The behavior of the VA as recorded in these VA-OIG investigations and inspections continues to reveal significant problems with staff, where the staff has designed processes and procedures to allow a ready excuse for any problems that arise and continues to prove that a veteran takes their life in their hands when visiting the VA. These actions must cease forthwith. There is no excuse for the behavior investigated and reported.
DNC-Consulting 