Chronicling the VA, One Ignominious Story at a Time!

I-CareAs we catalog the VA, occasionally, local services providers must be recognized for their service or their deficiencies.  In the spirit of fairness and transparency, it is time to discuss one of those community providers, Advanced Neurology Epilepsy & Sleep Center (ANESC), Dr. Aamr A. Herekar M.D.  Also, in the spirit of fairness and complete transparency, I have tried to settle my problems through the VA Community Services Offices and an appeal to the management and doctor of ANESC, all to no avail!  Regular readers know I have been in a multi-year battle with the VA over arresting me for not wearing a mask because when I wear a mask, I become a medical emergency.

I possess a note from my doctor, a VA Primary Care Provider, written to my employer on VA Letterhead with a wet signature, declaring my inability to wear a mask.  The VA did not accept this letter and arrested me three times.  Well, Dr. Herekar’s office was presented the same letter, and hassled me before both appointments for not wearing a mask, became hostile, argumentative, and a nuisance over the mask issue, even after I complied with putting on a face shield.  Today (23 September 2021), over Facebook messenger, I was informed that I would be invited to find a different provider due to my refusal to wear a mask.VA 3

Imagine that; Facebook Messenger has become the medium of choice for ending a patient relationship with a medical provider.  How very inappropriate!  How very unprofessional!  How very typical of some of the providers I have been sent to in the community by the VA.  Apparently, the abuse of veterans is spreading from the VA providers to the community providers.  If you are in the El Paso area and receive a referral to Dr. Herekar, please be cautious of his staff.  I have no idea of the efficacy and quality of the doctor, but his staff is absolutely third-rate or less!  The shame of the entire episode, the taxpayer is on the hook for my being abused by the staff.  How deplorable!Foghorn Leghorn - Medication

In reviewing different results reported from the Department of Veterans Affairs (VA) – Office of Inspector General (OIG) comprehensive healthcare inspection (CHIp) of VAMC’s, I am finding some interesting trends.

      1. Why the sudden, as of July 2021, focus on attendance and staffing in behavioral committees? More to the point, why are the behavioral committee’s processes and procedures so draconian?  More specifically, the following is a unique passage too often see in CHIps.
          • High-Risk Processes
            • Disruptive behavior reporting and tracking
            • Disruptive Behavior Reporting System
            • Order of Behavioral Restriction and patient notification documentation
            • Staff training – Isn’t this interesting, staff training is a “High-Risk Process?”
      1. When reporting that patient experience scores are similar to “VHA Averages,” isn’t this like saying a VAMC is as good as another pig in a pile of slop? Why accept averages that are comparable to other VAMC’s?  The leadership at the VAMC’s across the country is failing the veterans, yet the VA-OIG is accepting average performance compared with other VAMC’s.  It sounds like pathetic designed incompetence, wrapped in weak excuses, and deep-fried in a pity party!
      2. Training continues to be a fundamental excuse for failing, and even the VA-OIG seems to have given up and thrown in the towel.VA 3

An example of how training continues to be a fundamental excuse for failing and designed incompetence lies in another CHIp, specifically reporting reusable medical equipment (RME) and sterile processing services (SPS).  The VA-OIG reported the following weaknesses:

      • Standard operating procedures not aligning with manufacturers’ guidelines.
      • Annual risk analysis reporting to the VISN SPS Management Board.
      • SPS chiefs developing, implementing, and enforcing a daily cleaning schedule for all SPS areas
      • Equipment storage, cleaning, and usability.
      • Completion of Level 1 training within 90 days of hire, competency assessments for RME, and monthly continuing education for SPS staff.

All this after the VHA has already been caught with poor cleaning of reusable medical equipment on multiple occasions, where the training of cleaning staff was the primary reason for failing the CHIp from the VA-OIG.  The cycle continues unabated, and training is central to correcting and ending the process.  Yet, even the VA-OIG refuses to address the leadership failures and be part of the training corrective action behaviors.VA 3

In other CHIp reports, we find that completion of training is a high-risk process.  Leading to interesting questions about why and what is involved in staff training to make training high-risk.  What boggles my mind, much of last year, the CHIp reports found moral distress from leadership, this year, nothing; why?  Did the VA-OIG stop asking about this issue?  Certainly, the VA has not corrected this problem.  Am I merely suspicious, or is there a correlation between less focus on employees feeling morally distressed at work and increased focus on patient disruptive behavioral committees?

From other CHIp reports, we find more questions and logic that make no sense.  For example, how can patients be receiving care that meets VHA averages in acceptable care, but the employees reflect severe moral distress?  Does this not indicate that the averages for patient care are set too low?  Would not this be an indicator that leadership is not held to a sufficiently high enough standard of performance?  Worse, on these CHIp reports, we find greater mention of disruptive behavior committee actions, paperwork, training, and actions taken.  Thus, there appears to be a correlational data relationship between disruptive patients, moral distress in employees, failing leadership, and the abuse of the disruptive behavior committee process.  Where are the elected officials asking questions and drawing substantive conclusions regarding the data presented by the VA-OIG?  Heck, where are the VA-OIG data analysts raising alarms and red flags over correlational data points for investigators to act upon?VA 3

As a person who has been fallaciously labeled and erroneously called “disruptive,” this particular topic strikes home.  The system is ripe for abuse by egotistical leaders hell-bent on power-tripping!  When I asked how do you appeal the decisions, I was told lies, given wrong information, and forced to pay fines that I should not have had to pay.  Worse, the Federal Marshals at the courthouse remarked that there had been a significant uptick in veterans in the same situation as mine being fined erroneously by the VA.  Thus, the abuse of the veterans is both widespread and decidedly egregious!

Another recurring issue from the CHIp reports is remarkable from recent VA-OIG investigations, especially since multiple veterans have recently died over the issue, care coordination.  Care coordination includes completing paperwork, filling out the electronic health record, and signing the electronic health record, so the notes are available for other providers to use for follow-on patient treatment, nurse-to-nurse communication, and medication transmission, but most importantly, monitoring and tracking patient whereabouts on the facility’s grounds.  Yet, even with dead veterans with these issues as root causes, the VHA continues to fail in care coordination.  How do you define appalling, detestable, and disgraceful?  Where are the elected officials?  Where are the veteran service organizations in raising rhubarbs about the abuse of veterans at the hands of the VHA?VA 3

Finally, the most astounding and absurd continuous hit point from CHIp to CHIp report is found under the heading of “Quality, Safety, and Value.”  Under this heading falls a lot of topics, but imperative to improvement is the leadership failure to hold meetings attended by the primary audience.  Tell me, in the private sector; your boss calls a meeting of all department heads and their number two person.  If these people are no-shows, how long will they keep their jobs?  Yet, the VA-OIG finds repetitive missed meetings, no follow-up, no remediation, no punitive measures, no corrective actions, and these people are still employed!

Knowledge Check!One of the most bothersome things about reading three weeks’ worth of CHIp reports has been the consistency of the reports.  Too often, the reports read like they were copied.  Maybe this is due to the consistency of failed leadership; perhaps this is due to the lack of originality in thinking in the VHA, VBA, and the VA in general.  Regardless, the CHIp reports raise some concerning issues, specifically around the potential for abuses found in the disruptive behavior committee process and what disruptive behavior is at the VHA and VBA.  For example, if a patient is throwing furniture, this is obviously disruptive.  But, if a patient disagrees with a policy and is politely asking to speak to administration, this is not disruptive, but the patient is treated as disruptive, and that is abusive of the disruptive patient policies.

© 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: Have You Heard? Chapter 2

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

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

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

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

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

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

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

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

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

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

 

NO MORE BS: Memorial Day 2021 – Are you sure this is “proper” remembering?

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

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

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

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

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

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

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

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

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

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

Limitations on findings:

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

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

The Focus of Inspection (Investigation Scope):

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Weep America! – The VA Leadership is Becoming Worse! – Part 2

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

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

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

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

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

From the VA-OIG report we find the following:

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

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

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

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

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

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

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

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

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

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

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

NO MORE BS: Come, Let us Reason Together

Knowledge Check!In physics, for every action, there is an equal and opposite reaction.  I am not a fan of the word reaction, for a reaction places all the control of the action into the control of the original actor, and nature does not work like that.  But, to reason, we sometimes must use language common to all to understand each other; thus, it is sufficient to my purposes to use the term reaction in this discussion.  A similar law applies to psychology; a human chooses to act, natural consequences follow.  The ability to as, agency, and the person being acted upon, the actor, play a significant role in how and why businesses succeed and fail.

Plato 2Societies, cultures, governments, and countries all rise and fall on the moral agency of the individuals in power, the common citizen, and the collective leaders of those groups of people.  I have always liked the movie “The Fiddler on the Roof,” Tevye makes a statement about how without tradition, they would be as shaky as a fiddler on the roof.  Bringing a mental image of a fiddler, balancing upon a roof, and having two options, climb down and resume playing, or learn to balance on the roof while playing.  Both choices offer natural consequences that are easily understood, especially if you have ever worked on a roof.

Detective 4I have consistently written about VA Leadership failures for several weeks, rightly calling out the administrators at the local VAHCS and VAMC, the VISN, and the Federal levels.  Hospital leadership is not so different than leadership in any other industry, even though the VA has tried to make hospital leadership distinct.  Herein lay the problem, an employee, a nursing assistant, has just been sentenced to 7 consecutive life sentences for second-degree murder.

“Mays was employed as a nursing assistant at the VAMC, working the night shift during the same period of time that the veterans in her care died of hypoglycemia while being treated at the hospital. Nursing assistants at the VAMC are not qualified or authorized to administer any medication to patients, including insulin. Mays would sit one-on-one with patients. She admitted to administering insulin to several patients with the intent to cause their deaths” [emphasis mine].VA 3

We have an affect, but what was the cause?

“While responsibility for these heinous criminal acts lies with Reta Mays, an extensive healthcare inspection by our office found the facility had serious and pervasive clinical and administrative failures that contributed to them going undetected,” said VA Inspector General Michael J. Missal” [emphasis mine].VA 3

Regardless of her intention, an employee was allowed to commit murder because of the “pervasive clinical and administrative failures” of the VAMC leadership.  Now, two days prior to receiving the results of Reta Mays’ court proceedings, I received the Department of Veterans Affairs – Office of Inspector General report on the clinical leadership failures.  I have not witnessed a more despicable and damnable report of leadership failures in the decade-plus; I have been following and writing about the Department of Veterans Affairs or any other government agency!

“In June 2018, facility leaders identified nine patients with profound and concerning hypoglycemic events dating from November 2017 to June 2018” [emphasis mine].VA 3

The scope of the administrative investigation is as follows.  Staff from the VA-OIG’s Office of Healthcare Inspections (OHI) assessed the following areas, in parentheses is who owns the problem raised in the investigation:

      • Mays’s hiring and performance (Human Resources)
      • Medication management and security (Pharmacy and Security)
      • Clinical evaluations of unexplained hypoglycemic events (Nursing and Doctoral Staff)
      • Reporting of and responding to the events (Facility Leadership)
      • Quality programs and oversight activities (Facility Leadership)
      • Facility, Veterans Integrated Service Network (VISN), and VHA leaders’ responses and corrective actions (Local and area-wide administrators)
      • During the course of this review (investigation), the OIG also noted areas of concern regarding hospice and palliative care practices and nursing policies and practices (Nursing, Patient Care and Safety, and Hospital Administrators)VA 3

Just as logic tells the fiddler on the roof that he has two choices to live a long and musically fruitful life, the investigation reveals that the VAMC leadership had choices and made both poor and potentially criminal choices in this investigation of Mays’ conduct.

Ultimately, quality health care is dependent on leaders who promote a culture of safety that reduces or eliminates those risks whenever possible. Providing high-quality health care to a diverse and complex patient population demands the support of, and adherence to, an organization-wide culture of safety. When this occurs, a patient-centric environment becomes the “norm.” Conversely, systemic weaknesses in a facility’s culture of safety can have devastating consequences. The OIG found that the facility had serious, pervasive, and deep-rooted clinical and administrative failures that contributed to Ms. Mays’s criminal actions not being identified and stopped earlier. The failures occurred in virtually all the critical functions and areas required to promote patient safety and prevent avoidable adverse events at the facility” (pg ii) [emphasis mine].VA 3

Before we go further into the report, it must be made clear; the investigation team found the leadership, the hospital administrators responsible for allowing Mays to kill seven patients.  Attack another patient with the intent to kill and a potential additional hypoglycemic patient who died under her care but could not be directly linked to Mays.  A question arises, how did Mays gain employment with the VA; the answer, a former HR employee, failed to do their job in conducting “… background investigation file and determining her suitability for employment!”  In a previous article, I wrote about the hazards the VA was purposefully opening themselves to by using “COVID” as an excuse to delay proper investigations into backgrounds when hiring.  Here is a classic case where “COVID” is not related, and failing to investigate a background led to people dying!Plato 3

The VA-OIG last year reported that hiring practices had been relaxed due to COVID and background checks delayed for employees being hired during a pandemic.  Yet, when will those background checks be completed?  If someone is found unfit due to background checks, will they be forced to return all their wages for lying on a government form?  If there is a testament to the need for comprehensive background checks on employees, the seven (7) dead patients who died at the hands of Reta Mays!  How many times will this story replicate because the hiring managers are not doing their jobs?VA 3

Let us reason together, is the VA administrators the problem with the VA?  Does the VA leadership require immediate and total removal?  How would you resolve the issues without breaking the system and further endangering the lives of veterans?  Please let me know in the comments section.

I-CareVA Secretary Denis McDonough signed onto the “I-Care” principles as core values in care for veterans in the VAHCS.  When can we, the veterans, see that these core principles have been onboarded 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.

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

© 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: Responsibility

LookDale Renlund made a powerful point:

“… Blaming others, even if justified, allows us to excuse our behavior.  By so doing, we shift responsibility for our actions to others.  When the responsibility is shifted, we diminish both the need and our ability to act.  We turn ourselves into hapless victims rather than agents capable of independent action.”

Consider this statement with me as we observe and review recent events in America and the world.

  1. The Department of Veterans Affairs – Office of Inspector General (VA-OIG) reviewed the administration of spina bifida benefits for children born to Vietnam veterans, found internal communication and data sharing were the root cause of administering the benefits program incorrectly. The Department of Veterans Affairs – Veterans Health Administration (VHA) and the Veterans Benefits Administration (VBA) blamed each other for administration failure.  Applying Renlund’s point, we find that blaming each other equally provided the excuse for neither bureaucratic administration to accept responsibility.  Blocking movement towards action in correcting the problem, and ultimately the victims will continue to be children born of Vietnam veterans who deserve better and cannot cut the red tape to reach help desperately needed.  Worse, the blaming has turned the VBA and VHA from independent administrations into victims who deserve pity, instead of a boot kicking for their customers’ abuse!
  2. The VA-OIG, in another inspection, found COVID to be the root cause for shortages and outages of personal protective equipment (PPE). Except none of the 42 facilities surveyed ran out of anything.  Stocks dipped low, but outages of supply never occurred.  The blame for the low stock was also found on data and lack of reporting data correctly.  While people were praised for acting to “shift supplies, create new processes, and order supplies promptly,” the people could not be blamed for the low stock levels and were made into victims of COVID and data mismanagement.

Detective 4Please allow me a brief public service announcement: in business, one finds Juran’s Rule.  Juran’s Rule states that when there is a problem, 80-90% of the time, the processes are blamed, not the people.  The processes, or the written (supposedly) directions to perform a task, are so convoluted in government that Juran’s Rule could slide into 98% of the problem and still not run out of process convolution before people can be blamed.  Yet, the leadership of the VBA, VHA, and every other government agency refuse to look at the processes and eliminate, change, correct or even take action to review the processes.

Thus, Renlund’s point steals potential from people, as people become hapless victims to processes and procedures, instead of the commander of their duties and roles as hired.  The shift of responsibility from people to processes is the danger found in Juran’s Rule, not the truth in Juran’s Rule.  Thus, action to correct is diminished because responsibility has been shifted from leaders to the processes they are already responsible for monitoring.  Hence, when I see the VA-OIG allowing data or business processes to be blamed for the failure of people to act, according to the roles they have been hired to fill, I doubt the ability to fix the right problem.

  1. Using Renlund’s point, here is a typical VA-OIG inspection summary. See if you can spot the responsibility shifting, the inaction, and the problems.
      • The Department of Veterans Affairs – Office of Inspector General (VA-OIG) examined whether the VHA had effective procedures for (1) purchasing, (2) inventorying, and (3) tracking biologic implants such as skin substitutes and corneal or dental implants. The VA-OIG found deficiencies in all three areas at four medical facilities it visited. The audit team determined that purchasing agents did not always record implant purchases correctly or use the appropriate funds. The purchasing agents did not register 2,931 of 10,305 purchased biologic implants in the proper system [emphasis mine]. Instead, agents documented the implants in various local spreadsheets, databases, and third-party systems. Purchasing agents improperly used logistics funds instead of prosthetic funds, making it difficult for VHA to account for biologic implant spending fully and effectively budget or use funds for other purposes. Due to inadequate guidance, the OIG found that the facilities visited had an inaccurate inventory of biologic implants, did not use a standardized system, and did not consistently review stock on hand. The staff could not locate 714 biologic implants in inventory at the four facilities visited, valued at almost $1.1 million [emphasis mine]. The audit team also found 288 additional unrecorded items, valued at nearly $433,000, in storage locations [emphasis mine]. Poor inventory management can jeopardize prompt care, as medical providers may need to delay or cancel procedures if implants are unavailable. The facilities visited failed to track at least 45 percent of implants reported as used from October 2017 through March 2019 [emphasis mine]. VHA did not designate responsibility for overseeing tracking, develop a national policy on how facilities should track biologic implants, or have a standard tracking system that meets accreditation requirements. Effective tracking is needed for facilities to notify veterans if the manufacturers recall their implants.
      • Are the problems of shifting responsibility and the magnitude of the problem more understandable? Feel free to use the comments to discuss this example.LinkedIn VA Image
  2. In the final example, we find another common problem at the VHA, the refusal to alert patients promptly about test results, with the same worn out and tired excuses, time, and refusal to employ and document according to standards. People did not do their jobs, and it took “several concerned members of Congress” to initiate a VA-OIG investigation to certify there was a problem. Still, the solution by the VA-OIG remains tepid at best!  Leading to questions for Congress to allow these problems to thrive and advance the issues that VHA hospital leadership intentionally designs incompetence into their processes and procedures, then dares the patients seeking care to find a solution to force the administration to do their jobs.  Irony strikes again in the VA-OIG reports; the same issue was investigated and reported with the same “recommendations” almost every month throughout the last two-years.  Why aren’t the VHA local leaders being held accountable by their VISN leadership teams for failure to act to fix their problems proactively?

DetectiveToo often, the pattern at the VA, is exemplified in every other government agency for the keen observer to witness; act in a manner unacceptable, hide behind broken processes intentionally designed to hide purposefully designed incompetence, and escape responsibility but retain their jobs into retirement.  Essentially, the leaders of government agencies have employed the pattern discussed by Renlund for personal gain at the expense of the frustrated taxpayer.

When responsibility has been dodged, the answer is not to allow retirement, but to demand correction, holding people accountable, and set performance standards that include penalties for failure.  Training will have to occur, but cannot happen until written directives, policies, and procedures appear, that form the standard for employees’ behavior not responsible for the designed incompetence created by leadership.

In a “Liberty First Culture,” the adults looking to demand change take the pattern offered by Renlund and recognize the behavioral issues that will need correcting.

“… Blaming others, even if justified, allows us to excuse our behavior.  By so doing, we shift responsibility for our actions to others.  When the responsibility is shifted, we diminish both the need and our ability to act.  We turn ourselves into hapless victims rather than agents capable of independent action.”

Gadsden FlagAmericans [A(h)-ME-I-CAN] are not hapless victims; we stare responsibility in the eye, accepting the responsibility, and choose to act in a manner that shows we have learned the lessons and are prepared to improve.  The time to correct the government that represents us is Right Now!  We must act, recognize the designers of incompetence for the traitors they are, and remove them from employment in government, promptly!

© 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.

Appeal Letter – DBC Decision

Please note, this letter is both an appeal and a summary of everything that has happened at the Carl T. Hayden VAHCS since March 2020.  This is probably the longest letter I have ever written.

Dr. B. Vela MD
Interim Chief of Staff
Phoenix VA Healthcare System
650 East Indian School Rd
Phoenix, AZ 85012

Director Michael W. Fisher
VA Desert Pacific Healthcare Network
300 Oceangate, Suite 700
Long Beach, CA 90802

02 January 2021

Dr. M. Dave Salisbury PhD.
10002 N 7th St
APT 1125
Phoenix, AZ 85020

RE: Appeal of DBC Decision 11 December 2020.

Greetings Dr. Vela and Mr. Fisher,

On 02 Jan 2021, I signed for and received a certified letter postmarked 21 Dec 2020, dated 11 Dec 2020.  Why all the delays?  If I have 30-days from the day the letter is dated, why did the VA steal 10-days?  The letter originates from the Disruptive Behavior Committee (DBC), which claims I have been warned of causing disruptive behavior at the Carl T. Hayden VA Hospital in Phoenix, AZ.  The letter received claims,

On December 09, 2020, a member of our DBC contacted you by phone to discuss these concerns, provide behavioral expectations while in the medical center, and to remind you of the importance of maintaining a safe and respectful environment of care.”

I received a call from Nurse Crawford on or about 09 December 2020, who listened politely to the problem and said nothing else.  The conversation was useless as the nurse relayed nothing but platitudes, agreed that I have the right to be safe in the medical center, and then harped about the COVID Mask policy.  No intention, no motivation to aid or support, no opportunities for progress, no ability to come to a solution, nothing.  I got off this call, and my wife, who has heard my entire side, asked, “Did that call solve anything?”  No, that call solved nothing, provided no information, and wasted everyone’s time!

11 December 2020, Dr. Moore, the chair of the DBC Committee, calls me complaining of my disruptive behavior, declaring that while I have a right to be safe in the hospital, I must wear a mask, and now suffer under the onerous DBC committee rules to enter and exit the VA Hospital because of a pattern of non-compliance witnessed as behavioral issues.  Dr. Moore indicated that I have the right to be safe.  I have the expectation of being treated professionally, but since there is a pattern of “disruptive behavior,” my rights have been canceled, and I now must obey DBC requirements.

In plain speak, I am in the wrong for insisting that I cannot safely wear a COVID mask, and the policy problems and leadership issues at the VA are all my fault.  I am being blamed for the VA Police being tyrannical and obscene in their actions of discrimination against those who cannot physically and safely wear a mask.  The VA Hospital in Phoenix is closed to me until I comply with wearing a mask, which I cannot physically and safely perform.

Using Dr. Moore’s and Nurse Crawford’s logic and the Phoenix VA Health Care System (Paragraph 1 of the DBC Letter), let us see if I understand the problem because, frankly, I have no clue.

The Phoenix VA Health Care System [VAHCS] is committed to providing an environment where everyone feels safe and respected.  Our goal is to provide exceptional care that improves the health and well-being of our veterans.  We also work diligently to maintain a safe environment for staff, veterans, and visitors to our facility.”

If I, as the patient, have the ability and right to be safe from harassment, HIPAA violations, and respect, but cannot physically wear a mask, I have no right to service at the VA Hospital.  But, if somehow, I can wear a mask, I am not harassed, denigrated, derided, and injured by federal employees; however, my HIPAA and legal rights under EMTALA remain in doubt.  Do I interpret this statement correctly from the point of view of the employees of the VAHCS?  Because this is precisely the problem, I cannot wear a mask safely or without causing additional harm to myself, and my first obligation in the PACT team is to protect what health I still have.

I cannot physically wear a mask.  I have a letter from my VAHCS Primary Care Provider for my employer to establish workplace accommodations where I do not have to wear a mask.  Yet, this same letter is insufficient for the VA Employees who keep refusing me access to the ED, refusing to honor appointments, refusing to schedule appointments, causing a scene by crying to the VA Police when I do not immediately comply with their mandates to wear a mask, and all because I cannot safely wear a mask.

30 June 2020, I was refused service at the VA ER because I cannot wear a mask due to breathing issues.  Before entering, in the courtyard where the COVID screening was occurring outside in Phoenix Summer night heat, I was informed that I could hold the mask in front of my face, and this is an acceptable workaround or wear a face shield.  There were no face shields available at this person’s station, and I was informed to ask inside at the ER check-in for a face shield.  Upon entering the ER to be checked in, the office staff refused the information provided at the entrance and said, “If the mask is not worn, we are refusing service.”  I have had shortness of breath, not lung-related, for many years now, which continues to worsen, and I cannot safely wear a mask.  This information is noted in my VA Medical records.  I have been through several rounds of breathing tests, which confirm my lungs work great. Still, I remain short of breath, dizzy, unstable when walking.  When wearing any mask, my breathing problems increase and include lightheadedness and nausea, until eventually, my vision grays, and I pass out.  The original problem was diagnosed at the Salt Lake City VA Medical Center (2010/2011).

I stumbled to my vehicle, at which point I am shortly surrounded by VA Police Officers who claim they were called because a patient was disruptive in the ER.  I was not disruptive in the ER.  When I saw the intransigence of the ER Staff and was refused service, I walked out!  No screaming, no swearing, no throwing furniture, no issues.  I did not have sufficient breath to walk, let alone commit the atrocities I was accused of, and yet, this is supposedly the first incident in a “pattern of disruptive behavior.”  It appears to me the VA Employees breaking the law (EMTALA) needed a reason, so they created a handy excuse and blamed the patient!

08 July 2020, I walked into the VA through the south entrance, not wearing a mask, and those performing the COVID check did not offer a mask, offer a face shield, or say anything.  I walked to the ER; the admitting person did not mention my need for a mask, nor did they ask why I was not wearing a mask; I was checked in to be seen in the ER.  Shortly, I was triaged, and the triage nurse did not say anything about a mask.  I sat in the ER for 3-hours, and none of the medical staff, hospital staff, employees, or Federal Officers walking past ever mention the need for a mask.  I sat away from other people to avoid having any problems.

At the 3-hour mark, I told the ER staff I must get food, and I walked to the Patriot Store feeling sick because of diabetes, pain, and nerve issues, needing food.  On my way, an employee whines about me not wearing a mask, and I ignore this person as my medical information is private, and I should not have to explain to every nosy-nelly about why I am not wearing a mask.  I complete my purchases and suddenly, the VA Police, who were called by the unknown VA Employee, are there insisting I need to wear a mask.  The nosy employee stood around, crowing about how he was available if the police needed more information.  For the first of at least 40-times, I explain that I cannot physically wear a mask to protect my health and safety.  No swearing, no disruptive behavior, I cannot wear a mask, and I was on my way back to the ER to wait to be seen.

I am met in the ER by Officer LT. Hicks and a plainclothes officer claiming to be a LT.  At which point, I begin again to explain that I cannot wear a mask.  I was not causing a scene before this; I was not causing a scene after this; however, when 8-10 VA Police Officers surround a person, a scene is created, and it is not the patient’s fault that a disruptive scene has commenced.  I was not screaming; I was not swearing; I was not disruptive as this 40+ minute harassment began.  In the end, I will admit fully, my cherub-like demeanor had evaporated, and swearing did occur.  When you spend 40+ minutes saying the same thing over and over to no effect, my aggravation level went up.  I contend the scene was started, provoked, antagonized, aggravated, irritated, and exasperated by the Federal Police Officers who more than once accused me of “Blowing rainbows up their butts,” lying about my breathing problems, and riling the situation.  The officers accused me of lying about my medical records, medical problems, and reasons for not wearing a mask.  Let me repeat when this scene began with LT. Hicks, I was told I needed to either wear a mask or a face shield.  Nobody in the ER had a face shield, and when I was handed a face shield and put the face shield on, the officers continued to harass, torment, and rile the situation.  I complied, they changed the “policy,” and I got arrested and cited.

I do not have the breath to be hostile!  Because of the nerve issues I have and diabetes still needing food, I do not have the strength to be disruptive.  I do not have the breath to be hollering and screaming!  I do fully admit that the tinnitus I suffer from has me speaking louder than many other people, especially as my breathing worsens.  I gasp out words and do not care about polite volume, and I need to be left alone during these episodes to catch my breath and calm the nerves.  But this incident on 08 July is the epitome of VA Police Officers aggravating a problem when they could have simply left well enough alone as I was NOT breaking any rules, policies, or committing a crime on Federal Property.  If a policy is not written down, it is not a policy, and it is not enforceable.  Had the VA Officers ended the scene when I put the face shield on, there would not have been another problem, and I would have been seen in the ER for my medical issues.

15 October 2020, I reported to the Federal Courthouse without a mask and had my fines adjudicated from the 08 Jul incident. I paid $80 for “disorderly conduct” when I wasn’t disorderly, I paid $10.00 in parking fees.  The person deciding my case said, “If I have trouble entering the building in the future, I need to ask the volunteers doing the COVID screening to call their supervisor, who will then shepherd me around the VA.”  I was assured three times that there is a procedure to deliver healthcare services to the veterans who cannot physically wear a mask.  The person handling my case claimed they would take care of the other ticket received from the 08 July incident and introduced themselves as a Lieutenant of the VA Police Force.

21 October 2020, I arrive at the south entrance to the Phoenix VA from the parking garage.  I am confronted by a hysterical employee, claiming they were a supervisor, demanding I wear a mask at the COVID screening desk.  I followed the instructions from 15 October and asked for a supervisor.  The employee then requires I wait “outside the VA Hospital for privacy reasons.”  When I asked why, and for specifics, the employee becomes more hysterical, calls the VA Police instead of answering questions, and erroneously claims I am causing a disturbance.  The supervisor arrives, negates what was told me on the 15th of October, and claims that wearing masks is a policy, then demands that mask-wearing is not a policy but a directive. When I asked for a copy of the policy, directive, guideline, etc., I was pointed to a sign.  I asked for the supervisor’s supervisor, called this person for assistance, and the VA Police interrupt my call and demand I finish my business off VA Property and then shadow me off VA Property, meaning I cannot return for 24-hours.  I had around 10-VA Police Officers attempting to intimidate me, again, because I asked questions and insisted upon logical answers that the VA employees refused to deliver.  No swearing, no screaming, no disruptive behavior of any kind, and I was outside the VA Hospital the whole time.  The traffic and witnesses were displaced for the VA Police Officers, not because of me.

The VA Police do not have a copy of the mask policy, directive, guideline, etc., to pass out to people who ask for one.  The supervisor does not have a copy or document with the mask policy clearly spelled out, except to point to a sign demanding obeisance.  Yet, the person needing VA medical or other assistance is expected to blindly follow an unwritten “policy” that continues to shift from draconian to obscene and back again on the bureaucrat executing policy’s whims.  This is immoral, unethical, and illegal, plus it makes the VA the laughingstock of every other hospital and care facility.

While I was able to speak to the supervisor’s supervisor, Jennifer Russoniello, and discuss the most recent incident and conduct some of the business I went to the VA Hospital for; I remain not pleased.  The failure to access the VA to obtain the medication needed is directly contributory to my ER visit on the 28th of October.  The continued confusion at the VA sees patients being refused service if they cannot wear a mask, at the expense of the patient’s health.  It is important to note that the director possesses statutory authority to accommodate Washington D.C.’s policies for the local hospitals’ operation and patient safety.  Yet, the director continues to fail to execute leadership, demonstrate a concern for patient safety, or even clarify operational guidelines, policies, procedures, or work standards by writing them down and training the staff on how to enforce policy properly and legally.

Important to note, Jennifer Russoniello affirmed what the supervisor claimed, there is no written policy regarding COVD masking at the Carl T. Hayden VAHCS.  A memo was received directing the mask “policy.”  She further elaborated that because the COVID situation changes dramatically from day-to-day, and the CDC mandates change from hour-to-hour, the Carl T. Hayden Hospital Leadership had tasked her to help draft an acceptable policy that would benefit all veterans.  She then asked if she could use my story as support for preparing a cohesive policy, to which I agreed.

When Jennifer and I finished our conversation at the Wendy’s across the street from the Phoenix VAHCS, it was agreed that if I held a mask close to my face, it would be acceptable, and I could be seen at the Phoenix VAHCS.  I was told to keep the mask near my face anytime I was within 6’ of other people, and I could drop the mask when not talking or interacting with people.

28 October 2020, I wake up in a crisis, I have to get medication that has not arrived, and my body is in trouble.  Using the information from Jennifer Russoniello, my wife called the Phoenix VAHCS to alert Jennifer, and I was headed to the hospital ER.  Jennifer called me back, and I was unable to speak to her due to my nerve condition.  I arrived at the VA, held my mask to my face, went to the ER, and was treated without a problem.  No police harassment, no issues, nothing.

04 and 07 December 2020, I receive two text messages from the VA regarding my upcoming appointment.  I called the Radiology Department at the Phoenix VA specifically because I cannot physically wear a mask and wanted to make sure that I had waited four months to obtain this appointment and would not have any difficulties completing it.  The VA previously has refused service by providers because I cannot physically wear a mask; canceled only after I had traveled to the VA, waited in the waiting room, only to be told by the provider to go home or wear a mask.  Thus, I wanted to ensure this would not be the case with this MRI.

After five phone transfers, I finally spoke to Scott, who identified himself as the Radiology Supervisor.  I explained my predicament, explained who he could call to discuss the problem, and called him a second time to provide the name of the person I have been working with a Jennifer Russoniello, along with her extension.  Later that afternoon, Jennifer Russoniello returned my call and assured me all was in order.  The workaround we worked out was for me to hold a mask in front of my mouth and nose.  That way, the mask is not causing breathing difficulties, and I am then in compliance with the mask mandates.  This arrangement had worked previously during an Emergency Room (28 October 2020) visit; thus, I kept my appointment.

For the MRI, I was ordered no food or drink 4-6 hours before the appointment.  Two-hours was the scheduled time to be on the MRI table.  I planned my day, including my medications, food, and drink, around returning home quickly and relaxing.  Because history has proved that an MRI leaves me weak, hurt, and highly nerve sensitive, along with the usual sore muscles and other issues.

I arrived for my appointment, cleared the useless “COVID Screening” at the south entrance to the Phoenix VA, and proceed to Radiology.  At Radiology, I meet a supervisor (Paul?) who was to escort me around the hospital to ensure I did not get hassled by the VA Police, per Jennifer Russoniello.  I checked into Radiology.  When my name is called, I am met at the traffic control door by Scott, the Radiology supervisor, and an MRI Technician.  Scott refuses to allow me entrance because I am not physically wearing my mask.  I explain I cannot physically wear a mask; I walk with a cane, so one hand is full, and the other was full of cellphone, MRI paperwork, glasses, and floppy cloth mask.  I held the mask up to my face and claimed this is the best I can do to follow the “COVID Policy.”  Then asked if the MRI appointment was still on or not, repeated 5-different times.  Scott visibly has confusion written all over his face and cannot or will not decide.  No swearing, no disruptive behavior, no loud talking, and still the supervisor who had already spoken to Jennifer Russoniello about my mask problems is refusing service at the VA because of the mask mandate.  I am doing nothing wrong, nothing illegal, and nothing that could be classified as disruptive.  That other patients laugh as they observe Scott’s unprofessional behavior is not my problem; I did not laugh, I did not swear, I did not raise my voice, and did not cause a problem.  I simply stated my mask issue and asked if the MRI was going to occur.

After the sixth question regarding the MRI being canceled or not, the MRI tech turns slightly to Scott and says, “Why don’t we just do the MRI?”  At which point, Scott clears the door, and the process of changing clothes, answering pre-MRI questions and waiting for a room to open begins.  I walk to the MRI room without a mask, without problems, and without further questions about my mask-less face.  I suffer through the MRI.  After the MRI, I am told that “To get back to the dressing room, you have to be masked,” and I am offered a washcloth to hold close to my face.  I follow this request to the best of my ability while walking/staggering down an empty hallway, physically weak and exhausted from the MRI, the pain, the exertion, and the lack of food.

My trip to the dressing room is vital for two reasons: 1) I kept losing my leg strength, which is normal after MRI’s but coupled with the lack of food, and I am in trouble if I cannot get food soon.  2) Nothing else is said about my not wearing a mask.  I exit the dressing room, walk out through the traffic control door, and spot two VA Police Officers looking like they are involved in a long discussion with Peter, the supervisor dispatched from Jennifer Russoniello, to help me navigate the bureaucrats at the Phoenix VA.

I walk out, headed for the elevator, and the two VA Police Officers start calling my name.  I intend to go home!  Yet, the VA Police are delaying this because I cannot physically wear a mask.  Officer Interpreter places himself directly into my path, shouting about my need to wear a mask; when I politely try to sidestep him, he pushes back, physically pushing me backward.  The second officer is a Sgt. I think his name tag read “HUFF,” I am not sure, but calling him Sgt. Huff is acceptable, places himself beside Officer Interpreter, blocking my immediate path to the elevators.  Please note, I do not have the breath to be disruptive, scream, holler, rant, rave, or cause a scene.  I physically do not have the strength to argue or to carry on.  I have to get food immediately, or I will be unable to drive.  I attempt to explain all this to the VA Police Officers. Whose only reply is delivered in raised voices with great hostility, “We are not here to debate you,” “We are NOT here to discuss this with you; put a mask on!” and, “If you do not put a mask on immediately, we will arrest you on a felony.”  When I asked for the specific felony the officers are accusing me of, they redirect the conversation because they know they are on shaky and illegitimate legal grounds.

For the next 10-minutes or so, these two officers will yell, threaten, cajole, attempt to intimidate, and eventually will choose to place me in handcuffs, threatening me with felonious charges unspecified.  When Officer Interpreter finally decided to act and arrest me, he ordered me to turn around.  Not being able to turn around and knowing that Sgt. Huff was already behind me, I would not move.  I had previously almost collapsed during these officer’s tirades, more than once, and any movement at this point would be hazardous to my remaining upright and safe; my legs are shaking and weak already from the MRI.  But Officer Interpreter refuses to listen to any explanation on my part.  At this point, without knowing the extent of my injuries, Officer Interpreter places two hands upon me, thumbs in the armpits, mid-top of the biceps, and attempts to spin me to the left, towards the wall, in a standard police maneuver seen on every police show Hollywood produces.  After which, my legs collapsed!  My Thoracic Spine turned to the left, while my Lumbar and Cervical Spine remained stationary.  I hit the floor hard, cutting two fingers in four places, and I begin bleeding like mad!  I also scratched my right arm in two places while falling. I did not realize until showering the next day; neither scratch is deep enough to need medical attention, but they are all apparent injuries sustained when violently attacked by Officer Interpreter.

Officer Interpreter then tells me, “You collapsed on purpose; your injuries are faked.”  The supposedly superior officer, Sgt. Huff quickly picks up this mantra.  This attack (07 Dec 2020) has left me with increased pain in both knees, cramps in the L-Spine, a feeling of disconnection between my T- and L-Spines, and my cut fingers just keep bleeding.  Sitting and standing are more painful, and I have less stamina for sitting, standing, walking, and more problems breathing.  Every time the officers handled me and collapsed my legs, shots of pain went through my body; I can only guess I screamed out.  That generally happens when someone who is already suffering from chronic pain suffers more pain; check my medical records, and you see, I typically live in the land of 6 and 7 pain levels.  No swearing: I worked very hard during this incident to maintain a sense of professionalism even in my weakened state.  I fully admit my cherub-like demeanor evaporated when I got pushed, but I worked hard to control my tongue.

Collapsing my legs on 07 December 2020, like every time the VA Police have manhandled me, ignites a pain and nerve storm inside my body.  I jerk, spasm, twitch, stutter, eventually lose my ability to speak, and involuntary movements explode out my arms, legs, neck/head, hands, and feet.  My breathing problems intensify.  I try explaining this to the officers every time, and every time I am insulted, denigrated, accused of faking the injuries, and causing a disturbance to cover their ineptitude and unprofessionalism.  In Holding Cell 1, as Officer Huff is removing one handcuff, my arm spasms involuntarily, and he complains I am trying to hit him.  False accusations abound in this sordid saga!

My safety is placed at risk when I wear a mask, yet the VA is the only medical facility in the Phoenix Metro area with a problem of me not wearing a mask.  I have had MRIs, consultations, a gall bladder surgery, which involved a full day in the ER, then two days in hospital, all without a mask.  Thus, even though the first, and allegedly, most important SAIL Matrix is Safety, as in the patient’s safety, I am discriminated against because I cannot wear a mask. The Phoenix VA leaders cannot sufficiently establish policies and guidelines to protect my safety.

Once standing, with officer assistance, I was placed in a wheelchair where I struggled to breathe.  Sitting in a wheelchair is hard for me because I cannot straighten out enough to breathe fully.  My fight or flight response goes haywire when the nerve issues begin and does not conclude for days afterward.  Yet, on top of all my other cautionary statements about handling me and not inflicting more pain, the officers insisted I sit in a wheelchair.  Worse, the officers felt it was needed to handcuff me with my arms behind my back while sitting in a wheelchair.  My back is in immense pain every time it is touched.  Yet, the officers continued to think it was acceptable to handcuff me, behind my back, where the cuffs, the bracelets around my wrists, are digging into my spine.  Every time we hit a bump, more pain shoots through my already injured and highly nerve sensitive body!  Sitting in a wheelchair, with my hands cuffed behind my back forces me to sit hunched over, making breathing even more difficult.  Where are my rights to patient safety in the VA Hospital?

The Federal VA Police officers repeatedly informed me, “You are doing this intentionally,” “Stop making a scene, you are not in that much pain,” and “You cannot be injured that badly.”  Let me be clear; the officers started this confrontation by not allowing me to go home!  My appointment was at the end of the day, so there were significantly empty hallways when I was scheduled to leave, meaning that I would not be disturbing people by not wearing a mask.  Then they compounded their errors by directly laying their hands upon me.  These two officers, and the officers from July, both felt they could violently lay hands upon a patient who is not being violent, are not acting irrationally, and this is WRONG!  If the patient is not acting in a manner that causes harm or injury to themselves, other patients, threatening the VA Police Officers, or damaging the VA physical facility, the policy should be HANDS OFF!

10 December 2020, south entrance to the VA Hospital, I approach the VA to file a complaint about the treatment received on the 08th of December and visit the ER.  I am stopped by the same overzealous supervisor from 21 October 2020, at the COVID screening station between the two entrance/exit doors.  I explain I cannot wear a mask when asked to wear a mask, and before the COVID screener can reply, the supervisor demands I stand out of the way, and he acts in a hostile and combative manner.  I followed directions; I stand out of the way while he goes further away to obtain instructions about me; supposedly, I was on some warning list.  With more apparent and palpable glee and hostility, the supervisor returns, informing me Jennifer Russoniello is coming to speak to me; she never arrived.  At this point, the supervisor demands I leave the hospital entrance, claiming I am blocking the path of traffic; yet, it is raining outside, I am out of traffic, and not causing a scene.  When the supervisor becomes more agitated and hostile, he calls the VA Police to have me removed.  The VA Police officer signals to leave me alone while I wait and the supervisor returns to his post.  Not 2-minutes later, another officer arrives, and the supervisor tells the arriving officer I am disturbing traffic and not following his commands.

Yet, except for my inability to wear a mask and stand in the rain, I have followed his commands; I am not disrupting the inbound or outbound traffic, I am standing out of the way, and I am silently waiting.  Soon a LT arrives, I didn’t get his name.  I got his attitude, antagonism, malevolence, and malice, but never witnessed his professionalism or ability to listen.  The LT, along with a SGT. and several other officers, proceed to block the doors so nobody can get in or out of the VA and proceed to blame me for blocking traffic.  I was not blocking traffic; I was not causing a scene. I was not disturbing anyone.  The VA Police officers did all these things.

I explain why I am there.  I explain I cannot wear a mask; I explain without swearing, screaming, or disrupting anyone I am waiting and trying to get to the ER.  The LT and the SGT then decide it is time to arrest me.  They grab my arms and jerk at the wrists to get my arms behind my back.  My wrists are still visibly bruised from the 07th of December incident, and I scream in pain.  To which they claim I am “faking my injuries,” then declaring, “If my wrists were really injured, there would be bandages on them,” among other derogatory comments.  My nerves kick-off and my pain jumps to 15, as I am manhandled into a wheelchair, from which I cannot breathe properly, and then taken through the rain to Holding Cell 2.  Is this clear? I am bodily removed from the VA, injured, arrested, and all this after spending two days flat on my back due to pain from the 07th of December arrest and injuries.  Under EMTALA, the Federal Emergency medicine law, this is illegal.  As a patient with rights, whose primary job is to look after my safety, I am left amazed at the treatment I keep receiving.

Every curb hit, every bump hit, every single expansion line in the sidewalks hit, my pain spikes, and I holler out in agony.  Yet, every time I mention this, I am told to shut up, stop acting, stop faking, and that I deserve the trouble I am receiving at the VA Police’s hands.  But the irony of the entire saga of illegal actions, immoral treatment, and unethical behavior from the VA Police and immature VA Federal employees is encapsulated in being reported to the DBC for behavioral issues.

I have not been disruptive.  I have not exhibited behavioral problems worthy of this charge and action by the VA Police or the DBC.  I have in no way broken any law or refused any reasonable demand.  I have been seen at the Phoenix VA historically two other times, and never a problem.  I have been seen at various other VA facilities across the continental United States and never had a problem with the Federal VA Police, anywhere.  The VA at a VA Hospital has employed me, and I never had a problem with the VA Police.  Since March 2020, the third time I am a patient with the Phoenix VAHCS, I have nothing but problems as professionalism has shrunk and the bureaucratism has increased exponentially!

Ask yourself this, if you are in pain, and you go to a hospital ER for services and are refused service, are you a happy person?  If you are in constant pain, and someone pushes you, violently spins you, and causes your pain to elevate, do you cry out in pain?  If so, according to the DBC and the VA Police’s pretzel logic, you disrupted the hospital and caused a disturbance.  If you explain something 50+ times to a person, are you still a pleasant and friendly person to be around?  I have explained hundreds of times why I cannot wear a mask, where to find this data in my medical records, and been accused of lying, “blowing rainbows up a person’s butt,” and had other derogatory and insulting remarks made about me and to me.

Tell me, if you hear your private medical diagnoses bandied about as a joke, do you take offense?  Do you become upset when your safety is threatened and your personal space is violated for no cause?  If so, then you cannot allow this atrocious decision by the DBC to stand.  Nor should you allow another minute to pass before ending the policies creating the problems and safety issues.  Three times I have needed emergency care at the Carl T. Hayden VAHCS since my return in March 2020 and been refused.  Refusing emergency care at an emergency room receiving federal funds to operate is against the LAW (EMTALA); yet, the VAHCS in Phoenix is somehow exempt?  Twice, I have had additional injuries heaped upon the pain I am already suffering, and thrice I have been cited for being disorderly when the VA Police Officers were the ones causing the scene, disrupting traffic, and antagonizing situations.

10 December 2020, in Holding Cell 2, in front of at least eight other officers, Major Kratz barges into the holding cell, screaming, hollering, and shaking his sausage-like fingers in my face.  Making demands and acting irrationally, yet I face DBC consequences, which does not make sense.  While trying to leave the VA, sitting in my POV, the LT who started all the trouble on the 10th of December, places his hands upon my vehicle, leans against my door, and refuses to allow me to leave until he has finished insulting, denigrating, and making stupid accusations!

I fully admit, my cherub-like demeanor with the VA Police is gone, and I refuse to replace the cherub-like demeanor while I remain criticized, insulted, dismissed, injured, and falsely accused!  I have documented my treatment and my proactive approach to correcting the issues experienced very closely because the VA continues to claim I am “non-compliant” and claiming that my behavioral problems are causing disturbances in the hospital.  According to the officers, on the 10th of December 2020, I am “deserving the injuries I receive because of my rebelliousness in not conforming to wear a mask.”  Even after I have explained, I cannot physically or safely wear a mask.

30 December 2020, a person declaring themselves the assistant deputy director of the VA Police at the Carl T. Hayden VA Medical Center in Phoenix, Arizona, called me.  When asked three times, directly, “Why are you calling me,” I received three different ambiguous answers that meant nothing and a redirection of the conversation.  Then the caller told me some “facts,” I stated the situation as declared above.  To which I was told, “Your evidence is not applicable because it is too old.”  Yet, he went on to claim his officer’s record of events was correct and factual, and the date did not matter.

But, like the Home Shopping Network claims, “Oh Wait, there’s more.”  The caller told me, “your non-compliance is what is causing the issues.”  Not the fact that zealot bureaucrats are enforcing a policy that endangers the patients.  Not that my safety concerns have any bearing on the issues or why I keep getting harassed by multiple VA Federal Police Officers who refuse to listen to the patient.  Not that I have legitimate physical problems with wearing a mask. He only informed me that I am not compliant, which is my problem, and the sole reason the VA Police Officers keep injuring me.

But “Oh wait, there’s more.”  After declaring I am non-compliant, the caller refused to listen to my rebuttal of why I am compliant.  Interrupting me constantly, and then claiming that I am “Riled up” and “not being professional” when conversing with him, an intransigent and openly hostile caller.  The caller then dared to declare that “Patients do not tell the hospital what they will and will not do.”  Seriously!?!?!  I have legitimate safety and health issues that have been recorded on the VA Medical records, and this caller duplicates what his officers did on the 10th of December when they declared they were smarter than my doctor and could know when someone was faking an injury or not!

But “Oh, wait, there’s more.”  In July 2020, I heard jokes and disparaging comments about me and my medical file while sitting in the holding cell.  On the 10th of December, more disparaging remarks were made that included details that can only be known had the VA Police looked at my medical diagnoses, mental health records, and other medical data.  Having non-medical personnel know this confidential data is a HIPAA violation, clear and straightforward.  The letter 644/00 dated the 13th of October 2020 from Dr. A. Smith, the Medical Center Director, claimed that the VA Police needed this data to do their jobs effectively.  But, the caller had the nerve to declare, “I am making this up, these allegations have no bearing on the 07th of December event, and I need to stop lying about my injuries and the verbal abuse of the arresting officers.”  Which is it, HIPAA claims that these officers are in direct violation of their duties when they know my private medical details and diagnoses.  The VAMC director claims it is legal.  The caller claimed they have never had this data.  I smell bureaucrats covering themselves, and it stinks!

I have now sat in Holding Cell 1 twice and Holding Cell 2 once at the Carl T. Hayden VA Police Offices.  I can tell you from my experience, the majority of these Federal Police Officers are unprofessional, unprincipled, unbefitting, unbecoming, and replete with the most egregious manners it has ever been my displeasure to encounter.  The Department of Motor Vehicles is more professional and dedicated than most of the Carl T. Hayden’s VA Police Officers – having this “leader” of VA Police Operations tell me I am lying is enough to boil my blood!

But “Oh, wait, there’s more.”  The caller then dared to accuse me of being hostile, not listening and refusing to comply.  How can I comply when you never told me why you were calling?  Why should I be anything but irate and wary when I have come to expect treatment that should shame any professional?  I listened very carefully to the bloviations and blather of this bureaucrat, which is why, at this point, I disconnected the call.

The call lasted 8 minutes, and was full of bureaucratic nonsense, and left me out of breath, gasping for air, and vehement to the Nth degree, and out of my mind with umbrage and indignation!  Why did the Assistant Deputy Director of VA Police call me?  What is his job?  Since his job does not include setting hospital policy at the VA, will this incident be referred to a policymaker at some future date, or do I have to be paralyzed first by a zealous VA Police Officer jerking my spine and cutting my spinal cord?  If patients cannot inform a police officer that what they are doing is causing injury, then the VA Police Officer is wrong!  If a patient who is not causing trouble, is continuously harassed, threatened, accused of lying, and injured, and then can be placed on DBC policies for unspecified behavioral issues, based solely upon the cowardly, unscrupulous, and disreputable conduct of the VA Police and the inadequate policies and directives of the hospital leadership, then the entire organizational leadership needs to be replaced, forthwith!

I fully admit, I got frustrated and swore!  I fully admit when my pain levels went up, and I got hit, spun, collapsed, and more, I screamed in agony.  I have repeatedly tried to be proactive and avoid being in a position where the VA Police are concerned. Still, I cannot safely and physically wear a mask, and this is NOT a crime worthy of all the bureaucratic lunacy and foolishness I keep suffering.  I have not caused a single-issue worthy of VA Police intervention, EVER!

I have been a victim of overzealous, hostile, inept, and incompetent supervisors who become ludibrium verius malum when someone asks them a question.  I have been a victim of unprincipled, unscrupulous, disreputable professionals gifted with a badge or authority above their competence who are policy tools off the VAHCS, whose policy is poorly dictated and inappropriately applied.  I have been illegally treated and mistreated to the pleasure of the ludibrium verius malum functionaries.  Thus, I refute the charges laid against my good name and character.  I refuse to be labeled as a “behavioral problem” when I have done nothing wrong!

In no uncertain terms, the decision from the DBC should be immediately rejected, and the entire record struck of all accusations. Immediately restitution needs to be made for causing me injuries by the hands of emotionally impassioned ludibrium verius malum tools!  I have committed no crime!

I have done nothing worthy of any of the treatment I have received since March 2020 at the hands of the VA.  I deserve justice, not accusations of behavioral misconduct.  I deserve justice for the misconduct, malfeasance, impropriety, delinquency, crime, and mistreatment I have suffered.  I deserve answers, and I intend to keep complaining until my rights are restored and my good name cleansed and scoured of the tyrannical, unjust, and oppressive actions of these disastrous federal employees.  There is NO excuse for what I have suffered!

As a professional organizational psychologist, I place my integrity and honor on what I have reported, observed, experienced, witnessed, heard.  I fully and unequivocally attest that the majority of the Federal Police Officers in the Carl T. Hayden VA Police Force need immediate retraining, except for those not fired for unprofessional behavior and misconduct!  There is NO EXCUSE for Officer Interpreter on the 08th of December 2020 to have grabbed me, after physically pushing me, and try to spin me into a wall.  There is no reason, at all, for a VA Police Lt. and a Sgt. to grab my wrists, bend my arms into positions they do not travel, aggravating the handcuff injuries from Monday, and then have the gall to tell me, “Well, how could I know you had painful wrists, you are not wearing a bandage.”  I told them about my injures before they started grabbing, jerking, yanking, and hurting me.  Then I get ordered to “Shut up; I was under arrest.”  But I never had my Miranda Rights read.  I complied on the 10th, I complied on the 8th, and I complied in July.

Let us be perfectly clear; hospital mandatory mask policies must have exceptions for patients who physically cannot wear a mask.  Patients unable to wear masks include some patients on cancer drugs, some asthmatic patients, people with breathing problems, and much more.  The Carl T. Hayden VA Medical Center policy is the biggest problem I face when obtaining treatment after the COVID Pandemic Declaration from Feb. 2020.  I am certainly not alone in having breathing issues with the COVID Masking Policies, and with the zealotry the policies are being enforced.  The VA has established an organizational design that requires a veterans business to be conducted face-to-face.  Hence, the VA is a Ghost Town; patients are canceling their appointments, FOIA’s are not being submitted, and so much more because of the masking policies that endanger patient health and place patients at risk of further injury!

I repeat, only for emphasis; that the only medical offices, radiological departments, emergency rooms, and hospitals in the Phoenix, Arizona area where mask policies are causing discrimination and refusal of service is at the Carl T. Hayden Veterans Administration Health Care System, and this is 100% wrong!  The Entire VA Leadership Team should be highly embarrassed and entirely held accountable!

Where is respect for me at the VA?  Where is my patient safety?  Where is my ability to conduct business in an atmosphere free of harassment, intimidation, and discrimination?  If the Phoenix VAHCS desires atmospheres free of harassment, intimidation, and discrimination, they first must provide what they desire.

Sincerely,

Dr. M. Dave Salisbury
Ph.D./MBA/MAET
Dual Service-Disabled Veteran

CC: Meyers & Telles Attorneys at Law
Senator Mark Kelly
Rep. Greg Stanton