Front Office vs. Back Office vs. Oversight – Additional VA Horror Stories

Lincoln WeepsOh, the bitter tears President Lincoln must weep…

One of the most troubling issues facing many organizations is exemplified perfectly by the VA, specifically the Post 9/11 GI Bill.  Previously I worked for an online university in a position where I saw GI-Bill problems affecting students on active duty, reserve, guard, and veterans, all being treated in wildly different manners.  The school GI-Bill office was expected to be subject matter experts on all things GI-Bill, but they regularly made decisions that harmed the students.  By interpreting the regulations and operating procedures differently from student to student.  Yet, the Department of Veterans Affairs (VA) is just as confused as the universities trying to bill GI-Bill charges for students.

From a recent VA Office of Inspector General (VA-OIG) report, we find the following:

The Veterans Benefits Administration (VBA) did not always accurately process enrollments.  An estimated 2,500 of 10,000 enrollments from August 1, 2020, through April 1, 2021About 790 of the estimated errors involved officials either not reporting or underreporting vacation breaks.  VBA claims examiners often mishandled enrollments even when the correct information was submitted.  The VA-OIG estimated claims examiners incorrectly processed accurately reported vacation breaks for about 1,700 of 2,500 enrollments with errors.”

Why are these enrollments not processed correctly:

Insufficient training and guidance meant school certifying officials frequently made mistakes.”  The VA takes legislation and writes the processes, procedures, and training materials for universities to use for operations and enrollment of military and veteran students.  Front office workers interact with students, back office workers interact with internal employees, the VA keeps the records current, and the VA forms the universities’ oversight resembling the blind leading the blind.  Yet, the VA cannot write effective training materials, processes, and procedures, conduct training, and support those who support students.

Per the VA-OIG report, the VBA is looking to implement an automated system to prevent these oversight issues from continuing.  I do not expect any automated system created by the VBA to work efficiently because of a simple principle, GIGO.  The garbage the VBA will put into the system will ALWAYS result in garbage coming out, creating more problems, costing too much money, and still creating issues for students and student-facing employees at universities and colleges across the country.  Somehow, the VA-OIG continues to buy these excuses and pipe dreams and reports the same to Congress, which is also purchasing these excuses and poor performances.VA 3

Before someone tries to claim this is isolated to the GI-Bill program, and the GI-Bill program has always been confusing.  Using this logic, the health complications at birth can be blamed on the father alone, and the mother’s behaviors do not influence the baby’s health.  Here the VA-OIG is reporting on another program governing VA employees, overseen by the OMB, and is incredibly useless as this is a repeated complaint between 2020 and 2022.

Identity, credential, and access management (ICAM) is a set of tools, policies, and systems used to ensure the right individual has access to the right resource, at the right time, for the right reason in support of federal business objectives.  In February 2021, the VA Office of Inspector General (VA-OIG) received a hotline complaint claiming the Office of the Assistant Secretary for Human Resources and Administration/Operations, Security, and Preparedness and the Office of Information and Technology have not agreed since 2016 on roles and responsibilities for VA’s ICAM program.  Failures of ICAM contribute to the VA’s inability to effectively comply with the Office of Management and Budget (OMB) policy.  The VA-OIG reviewed to determine whether VA effectively governs its ICAM program as required.”

What did the VA-OIG find?

      • The VA did not effectively manage and coordinate its ICAM program, not meeting three of the four OMB governance requirements.
      • The VA did not effectively assign roles and responsibilities, implement a single comprehensive ICAM policy, or meet its technology solutions roadmap goals for fiscal years 2020 and 2021.
      • The VA failed to implement updated digital identity risk management requirements.

Why can’t the VA obey OM oversight?

These issues occurred primarily because leaders of the different offices performing VA’s ICAM functions have not agreed on how it should be governed.  VA risks restricting information from users who need it to perform their job functions without proper governance and leaving information vulnerable to improper use” [emphasis mine].

In this report, the OMB sits as oversight of the VA.  The employees are the frontline, and the leaders continue to fail to provide tools, policies, and resources to employees conducting the VA business.  What is still an incredibly terrible idea allowing the VA to remain self-governing.  Why isn’t the OMB more interested in demanding compliance?  Where is Congress scrutinizing how the executive branch agencies are failing and monitoring to improve conduct?VA 3

The VBA cannot still properly and timely adjudicate claims.  Again, the VA-OIG lambasted the VBA for improperly adjudicating claims, even with “Special-Focused Reviews.”  Essentially the quality assurance (QA) process in claim adjudication continues to fail to help improve claim processing accuracy.  From the report:

The Office of Inspector General (VA-OIG) reviewed VBA’s design and implementation of its special-focused review process, including applying Government Accountability Office (GAO) standards.  The VA-OIG team assessed ten special-focused reviews completed from January 2019 through April 2021 and identified weaknesses in all five of GAO’s internal control components.  The VA-OIG also found the VBA Compensation Service’s standard operating procedure related to these special-focused reviews does not provide sufficient guidance to support disability claims-processing improvement fully.”

When I worked in QA, root causation was required to prevent future problems.  The VA-OIG found that the QA Special-Focused Reviews do not include root causes or explanations for why the claims were readjudicated, stopped, or delayed in VBA processing.  Do not repeated issues reflect the need to restrict self-governance until compliance can be observed?VA 3

Why should the VA have its self-governance restricted or prohibited?  The following VA-OIG makes clear that the VA cannot govern itself and correct the problems leadership continues to create.  Follow the timeline here, quoted directly from the VA-OIG report:

The VA Office of Inspector General (VA-OIG) conducted this review to determine whether the Veterans Benefits Administration (VBA) accurately adjusted compensation and pension benefit payments for fugitive felons as mandated by law.  If VBA does not adjust payments, veterans who are fugitive felons will continue to receive benefits during periods of ineligibility.

In April 2012, VBA instructed regional offices to postpone making decisions on fugitive felon cases while it prepared new guidance.  During 2012 and 2013, VBA did not process fugitive felon cases.  In June 2014, VBA updated its definition of a fugitive felon to include only referrals indicating escape, flight, or violation of probation or parole conditions.  Although VBA then resumed adjusting payments, it did not review the unprocessed 2012 and 2013 cases.

In addition, due to inadequate monitoring, VBA did not process about 46 percent of cases referred by the VA-OIG in 2019 and 2020.  Finally, the team found VBA’s notification letters to veterans providing notice of the proposed action and right to a hearing did not always provide the required information.  Most commonly, VBA failed to include the reason for the issuance of the arrest warrant.”

The VA has been informed by the VA-OIG multiple times during the decade this problem has been surviving, and 46% of the cases the VA-OIG told the VA to fix still weren’t fixed in 2022.  How can any oversight agency still permit the VA to govern itself?  The leaders of the VA cannot self-govern, correct course, and make changes timely enough not to create additional expensive problems for veterans.  Each of these cases represents either an overpayment, where the VA is clawing funds back, or an underpayment, where the veteran has been shortchanged and is owed money.

When the VA claws money back from making a mistake that overpaid a veteran, dependent, spouse, or other entity, the VA-OIG has found that even here, the VBA cannot act per their policies, follow procedures, or notify veterans in a timely manner.  A veteran I got to know who served in Vietnam and caught a round in the heart that blew away a large chunk of his heart.  For 50 years or so, this was sufficient to have a 100% disability.  On the day he turned 69, his disability rating dropped to 80%, with a coinciding reduction in monthly benefits.  The VBA investigated this claim decision and found they had made a mistake, but their mistake would not significantly change the rating, so the veteran was stuck with an 80% rating and was told to go back to work.VA 3

To the best of my knowledge, the claim remains stuck in claims appeal hell, awaiting the judgment of the dark and benighted realms to act.  The veteran, who cannot hold a job due to weakness from lacking a significant part of his heart muscles, is driven into bankruptcy.  His heart will not regrow, but because his age has met the age when heart problems are actuarially known, the decision was made.  The decision was made without notification to the veteran, and the veteran only became aware of the situation when he had monies clawed back by the VA.  From the time the decision was made to the date he knew, 18 months had transpired, and the veteran was automatically sent to collections.  While this was never allowed to become a VA-OIG investigation, I have spoken to family members and the veteran while volunteering to help disabled people find employment.I-Care

To add the bitter cherry to this crap sundae, this is not the worst abuse I heard in my volunteer efforts.  Worse, this is not the worst story I have had related while talking to veterans in my travels across the continental 48 United States.  Veterans sit forever in claim hell; they cannot afford to go forward, they are abused when seeking medical help, and every interaction with VA medical providers runs the risk of being the victim of an “adverse medical event.”

To this point, the VA and the VBA have been central to proving that the VA cannot self-govern, oversight is failing, and the back office administrators are hindering the front office operations.  Surely the Veterans Health Administration (VHA), where people’s lives are at risk, would not have a similar problem.  Unfortunately, you would be wrong, and here is one VHA example, of many, to support this conclusion:

A VA Medical Center (VAMC) community living center (CLC) staff delayed life-sustaining treatment for a patient (Patient A) who experienced cardiac arrest and died.  The VA-OIG also reviewed an allegation regarding a second patient (Patient B) who had resuscitation initiated, despite a do not resuscitate (DNR) order in the electronic health record (EHR).”

Why did one patient die without resuscitation and another get resuscitation without wanting it?  The policies and procedures were complicated, and the use of armbands confused the providers.  The providers (doctors and nurses) overseeing care had a person in the medical records of these patients and still could not properly act for patient care.  The patients had armbands and proper medical documents on file, and the providers still got confused and provided poor care, at best, to the patients involved.

America WeepsIn another long-term care facility under VA operation, the following occurred:

The VA-OIG found that the day charge nurse’s assessment was delayed and incomplete, and the day charge nurse failed to properly document the resident’s reassessments, treatments, and interventions.  The VA-OIG substantiated that nursing staff failed to document and carry out a telephone order to transfer the resident to the Emergency Department but could not determine if this impacted the patient’s outcome.”

Let’s take a moment to allow this to sink in fully.  Failure to follow a doctor’s orders might have been part of the problem the patient DIED!  Yet, the chain of events is sufficiently blurry to mystify the investigators – this I find HIGHLY SUSPECT!  But, as the Home Shopping Network reports, “There’s more!”

The VA-OIG determined that following the resident’s death, facility staff failed to conduct a comprehensive review of events leading up to and contributing to the resident’s death and, due to a lack of coordination of care at the time of discharge from the inpatient unit, the resident did not have the needed equipment upon admission to the CLC.”

I accept that a nurse’s role is stressful, the VA policies do not make their jobs less stressful, and the healthcare leadership (overall) is abysmal on the best days.  However, killing a patient is still a BAD thing!  I-CareYet, here we have another dead veteran at the hands of the medical care providers, and the best the VA-OIG can do is make ten (10) recommendations for change.  Does anyone believe the VA can continue to self-govern under its current misguided leadership and convoluted organizational structure?

Ask yourself, would the abuse of the veterans mean more if this was your uncle, brother, father, mother, sister, or aunt?  They are your family members for the problems which they face; we all face in our constitutional republic.  Where is Congress scrutinizing the government?  Please become interested, active, and engaged, or we will lose this constitutional republic to the tyranny of the power-hungry despots.

© Copyright 2023 – M. Dave Salisbury
The author holds no claims for the art used herein, the pictures were obtained in the public domain, and the intellectual property belongs to those who created the images.  Quoted materials remain the property of the original author.

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LIC and The Department of Veterans Affairs

What is LIC?

Low-Intensity Conflict (LIC) is the official name for when individuals or governments hire intermediaries to conduct violent operations from a secure position.  LIC is a misnomer; those who have become victims of the barbaric cruelty of those practicing LIC find nothing “Low” about the experience.  The conflict is intense, the actions brutal, and the practitioners remain cunning adversaries using and employing willing dupes to hide the true depths of moral decay inherent in the societal destructions and depravations the practitioners are enacting.  Many confuse LIC in describing the actions of unbridled violence committed by ideologues under the banner of terrorism.  The US Military Joint Chiefs of Staff define LIC as:

A limited political-military struggle to achieve political, social, economic, or psychological objectives.  It is often protracted and ranges from diplomatic, economic, and psychological pressures through terrorism and insurgency.  Low-intensity conflict is generally confined to a geographic area and is often characterized by constraints on the weaponry, tactics, and levels of violence (Tinder 1990) [emphasis mine].”

Green (1997) adds a key ingredient to the description of LIC from Tinder (1990).

… Non-international conflict is a refined term for what [was] formerly known as revolutions or civil wars, particularly when these have developed into major operations with the likelihood or reality of atrocities being committed against non-combatants.  Whether civilians or those [rendered] hors de combat, a fact that is often more common in non-international … conflicts, especially when ideological, ethnic, or religious differences are in issue.  It is for this reason that it must be borne in mind that the term low-intensity [conflict] has no relation to the severity or violence of the conflict” [emphasis mine].

Lt. Colonel Alan J. Tinder wrote a paper for the Air War College in 1990 titled: “Low-Intensity Conflict.”  I have learned much from the Colonel and benchmarked this principle to more thoroughly understand LIC, recognize LIC, and detail LIC for others.  The other compelling source is L. C. Green’s paper on “Low-Intensity Conflict and the Law.”  I aim to synthesize this information into a manageable topic and aid understanding.  Let me state emphatically that the Department of Veterans Affairs (VA) leadership’s actions are nothing short of LIC where employees and veterans/customers are concerned.

Regularly, the Department of Veterans Affairs – Office of Inspector General (VA-OIG) reports on a comprehensive healthcare inspection of a VHA facility, reports on employee morale in the VBA, or sum analysis of an employee or customer surveys, and include in the report a fairly descriptive, yet starkly utilitarian phrase, “reduce staff feelings of moral distress at work.”  Generally, the efforts to reduce “moral distress” is left to an underling, an assistant, or a person for whom this is a secondary or collateral duty and is not considered important or relevant.

Do the actions of a leader represent complicity in creating moral distress fit the general definition of LIC?  Absolutely.  Consider that the leader sets the culture through actions, words, and behaviors, which originate in the thoughts and feelings of the leader.  Correcting moral distress is pawned off on a junior staff member as a collateral duty, another method for displaying disrespect and communicating principles of abuse to employees.  But there is no physical violence; how does this apply to LIC?  Aren’t dead veterans’ examples enough of violent tendencies to justify the definition of LIC?  The VA leader operates from a place of security, exemplifies the culture they deem acceptable, and then works through minions to achieve a “to achieve the political, social, economic, or psychological objective.”

Never forget these two critical points in the description of LIC:

Often protracted and ranges from diplomatic, economic, and psychological pressures.”

LIC has no relation to the severity or violence of the conflict.”

At the VA, the leadership calls their example politics; keeping your position or advancing is economical, and the psychological pressure to conform is palpable.  All fundamental keys to conducting LIC against veterans, taxpayers, dependents, and non-conforming employees.  Multiple times Congress has held hearings and listened to how the VA Leadership exacted revenge and retaliation upon those who reported problems to the VA-OIG, their elected congressional leaders, and other investigative parties.  Feel free to peruse some of these hearings; you will hear victims relating physical, economic, and mental abuse, and the VA leadership never takes action.  Elected officials never scrutinize and hold accountable those executing LIC, and the victims are victimized a second time.

Want another indicator that LIC is being practiced, the VA-OIG, after learning there are problems with moral distress at work, makes the following to slide the issues under the proverbial rub:

“The OIG’s review of the medical center … did not identify any substantial organizational risk factors.”

Signifying that even though the VA-OIG found moral distress is affecting and influencing employee behavior, the VA considers employee moral distress not an “organizational risk factor.”  What does an employee who feels morally distressed do in performing their duties?  Delay patients’ appointments, make mistakes on medication shipped, slow walk any responsibility to make things more complicated and take longer than they should.  Does any of these actions sound familiar; they should, for this is the standard operating procedure for VA employees.

As reported previously, while I worked at the VA, I had intimate observations of what morally distressed employees do.  When I wrote to the VA-OIG, I was informed that since I had my employment terminated, I could not be a whistleblower and get my job back.  Plus, what I reported could not be actioned because it did not apply.  How’s that for protecting the guilty?  The VA Leadership is writing procedures and policies to target anyone and everyone who would report problems and seek help.  An employee physically assaulted me; the camera mysteriously broke when I reported it, so no evidence was available.  Who was at fault?  Me; the assistant director promoted the attacker, and I got ostracized.  The attacking employee took moral distress to new heights after this incident, and anyone who reported their behavior felt the wrath of the attacker and the VA leadership at the Albuquerque VAMC.

What is horrendous, this is not an isolated incident.  What happened to me frequently repeats daily across every VA office.  LIC is the overarching term, LIC is the behaviors named, and LIC is what the taxpayers are forced to pay for, all at the expense of veterans, dependents, and employees who see, know, and can do nothing.  Repetitions of moral distress in employees, reported by the VA-OIG, are more than 20 just in 2022.  The problem is cultural, and the elected officials desperately need to begin doing their second job, scrutinizing the executive branch and holding people accountable, including canceling the retirement packages of those practicing LIC.

Before someone tries to make this a Republican vs. Democrat issue, it is NOT political.  LIC is never political, just as LIC is never religious, never racist, not sexist, or any other distinction.  These distinctions are excuses, and the reasons do not justify the means for being violent.  The leadership at the VA, and many other government agencies, have found that abusing the taxpayer pays well, provides protection, and allows them to exercise dominion to their heart’s content, all with the power of government to justify their deeds.

Do you realize that the VA-OIG has a metric for measuring moral distress, and the only time the VA-OIG reports moral distress among employees is when the results are higher than national averages?  How scary is that to ponder?  The problem is so prevalent that it only warrants reporting when it exceeds the norm.  Thus, moral distress is declared less frequently when the average worsens.  Official protection for LIC is provided by LIC, increasing, and the taxpayer is footing the bill.

I have read reports where the moral distress has worsened from year to year.  The same leaders exacerbating the problem of employee moral distress are promoted and moved instead of reprimanded, punished, or fired.  One of the VA-OIG reports is particularly heinous in hiding moral distress in employees.

Selected employee survey responses demonstrated satisfaction with leadership and maintenance of an environment where staff felt respected and discrimination was not tolerated.  Patient experience survey data implied general satisfaction with the outpatient care provided; however, leaders had opportunities to improve inpatient care satisfaction [emphasis mine].”

Mark Twain is oft quoted as stating, “There are lies, damn lies, and statistics.”  How much more valid are these words when results are “selected,” “cherry-picked,” or allowed to “imply generalities?”  Those who engage in LIC are criminals, they are comparable to terrorists, and they have infiltrated the bureaucratic halls of government.  Employing government power, they form unholy unions with social media outlets and media companies to further silence and abuse, all while increasing protection.

Where does it end?  How do we put paid to the tyranny?

It ends when ordinary people decide they have had enough.  Ending the LIC-powered tyranny requires nothing more than elected officials scrutinizing the government and doing the jobs they swore to commit.  No violence, problematic or arduous tasks, merely following established law and doing the jobs we elected them to accomplish.  LIC is always destroyed when the citizens being oppressed stand up for their rights and demand the bullies, tyrants, and fiends cease and desist!

Thomas Paine, writing in “Common Sense,” discussed simplicity, stating:

“I draw my idea of the form of government from a principle in nature, which no art can overturn, viz. that the more simple anything is, the less liable it is to be disordered; and the easier repaired when disordered.”

The American government was established on simplicity, and the US Constitution is a simple document.  Using Thomas Paine’s pattern, the disorder in the government is simple to correct; all we need are people insisting that the infection is terminated.  Using the systems established in the US Constitution, the US government can be brought to heel, the rot removed, and justice can be delivered to those tyrants employing LIC for personal gain and political profit.  LIC is happening in every government agency, and it is time for change to begin.  Where are the politicians willing to do the job we elected them to perform?

Mark Twain provides the final word, “The government of my country snubs honest simplicity but fondles artistic villainy, and I think I might have developed into a very capable pickpocket if I had remained in the public service a year or two.”  From artistic villainy to LIC is not an arduous shift, merely the extension of abuse of power to a larger audience.  Learn, choose, and then make your voice known through elections and peaceful assembly for redress per the US Constitution and Bill of Rights.

© Copyright 2022 – M. Dave Salisbury
The author holds no claims for the art used herein, the pictures were obtained in the public domain, and the intellectual property belongs to those who created the images.  Quoted materials remain the property of the original author.

When is Enough… ENOUGH? – More Chronicles from the VA

QuestionHonest question.  I surpassed my ultimate threshold in waiting for the VA to improve in 2010 and stopped accepting the excuses, the platitudes, and the whiny discourse from the VA.  Elected officials charged with scrutinizing the US Government, when has patience been surpassed, and you will cease allowing this nefarious Kabuki?  The veterans are waiting, the taxpayers are fed up, and you need to make a decision and act.

Consider the following investigation by the Department of Veterans Affairs (VA) – Office of Inspector General (VA-OIG).  The scenario:

The VA Office of Inspector General (VA-OIG) conducted an audit to determine how effectively the Veterans Health Administration (VHA) billed private insurers. [Billing private insurance is a piece of legislation that the VA has haphazardly followed.  The VA remains the first party payer and is authorized under 38 USC 1729 to bill and collect reasonable charges for nonservice-connected care where such veterans have other private health insurance.]  Prior OIG investigations have shown that VHA has missed opportunities to recover funds that could be used to help finance care for other veterans.  VHA’s Office of Community Care (OCC) manages community care programs and bills private insurers when needed.  OCC must submit reimbursement claims before insurers’ deadlines are reached, or they may be denied.”

The legislature passed laws demanding action, and the result was:

      • OCC did not establish an effective process to ensure staff billed veterans’ private health insurers as required
      • OCC did not collect an estimated $217.5 million that should have been recovered, a figure that could grow to $805.2 million by September 30, 2022
      • OCC’s billing and revenue collection process also was not synchronized with insurers’ filing deadlines, and claims information was not always available for billing
      • Pending workload volume and staff shortages hindered effective billing
      • OCC was broadly aware of challenges to its process to bill and collect revenue from private insurers; its responses were insufficient to correct these issues.

Hundreds of millions of dollars are sitting on the table, and the VHA – OCC still cannot properly follow the law.  Worse, they are slower than molasses running uphill in Michigan in January to pay community providers, inventing hoops and red tape nonstop for providers, which increases the cost of healthcare.  This is not the first VA-OIG investigation on this issue in 2022, let alone since 2000; with the same findings, the same recommendations are issued, and nothing improves.  Thus, I have two questions:

  1. When is enough ENOUGH?
  2. How does this reflect the VA Administration’s commitment to the vision of the VA?VA 3

Consider the following; the VA-OIG regularly conducts comprehensive healthcare inspections of VHA facilities.  The findings of these investigations are supposed to spur institutional improvement.  Regularly the VA-OIG places the following comments into the reports of these investigations, hoping nobody will ever read the report and find these facts.

The VA-OIG found deficiencies in identifying sentinel events and conducting institutional disclosures.  Additionally, there were repeat findings from the June 2017 comprehensive healthcare inspection related to inter-facility transfers.”

Imagine a private company being inspected by the government for a moment where previous investigation findings were not improved; what would happen?  An army of lawyers would descend on the customers looking for those harmed/injured, legions of lawyers would pour through employee records looking for injuries and other potential claims, the government would seize assets and halt production, all this and more.  The media would be covering 24/7 news cycles on the slightest allegations of wrongdoing.  Elected officials would be hurrying to write legislation and find a media talking head to bloviate to.

What do we hear where the VA is concerned; not even crickets!  The VA has played complicit roles in veteran deaths, and still not a peep, word, or even crickets.  Remember, these findings occur frequently enough that not finding these remarks is a cause for celebration and is exceedingly rare.  Thus, I have two questions:

  1. When is enough ENOUGH?
  2. How does this reflect the VA Administration’s commitment to the vision of the VA?VA 3

Other oft findings from comprehensive healthcare inspections include the following:

      • Medical center leaders were generally knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models (SAIL Metrics). – What does “generally knowledgeable” indicate? Why have we accepted general knowledge from those who should have specialized, detailed, and comprehensive knowledge and use this knowledge in daily practice?
      • Outpatient satisfaction survey results were generally higher than VHA averages but revealed opportunities to improve specialty care experiences for female veterans. – Please note beating the VHA average is good but nothing to brag about. Beating the VHA averages is akin to claiming to be the biggest pig in a pig wallow.  Sure, you’re big, but you are still covered in mud!
      • Employee satisfaction survey scores for the medical center were lower than VHA averages. – Not a surprising finding in any way, shape, or form. Employee morale is scathingly low, and it shows in every customer interaction!  More comparing pigs by size in a pig wallow, and it’s not like the VA would punish whistleblowers, fire productive people, castigate, denigrate, deride, and treat employees like chattel… Oh, wait, yes, it is!

Interestingly, I receive 3-10 of these monthly investigation reports from the VA-OIG, and too often, they read like someone is cutting/pasting the findings from one report to the next.  Thus the conclusions of these findings occur frequently enough that not finding these remarks is a cause for celebration and is exceedingly rare.  Therefore, I have two questions:

  1. When is enough ENOUGH?
  2. How does this reflect the VA Administration’s commitment to the vision of the VA?VA 3

Let us consider another VA-OIG investigation, which, unfortunately, recurs too frequently where inappropriate conduct is a norm, not an exception.  VA facility leaders’ response to inappropriate relationships.  Regular readers will know how common it is to find inappropriate relationships and sexual misconduct by VA Employees to other employees, underlings, and veterans.  The scenario:

The VA Office of Inspector General (VA-OIG) conducted a healthcare inspection to evaluate leaders’ response to the knowledge of inappropriate provider-patient relationships.  The VA-OIG determined that while facility leaders initially addressed three inappropriate relationships between mental health providers (Providers A, B, and C) and mental health patients (Patients A, B, and C), multiple factors affected the effectiveness of those actions.”

Finding the following:

      • The OIG found that effective facility leader actions to investigate and address the inappropriate relationships of Provider A and Provider B occurred only after an Office of Accountability and Whistleblower Protection complaint.
      • Facility leaders ineffectively addressed Provider C’s inappropriate relationship before Patient C died by overdose.
      • Facility leaders failed to report Providers B and C to their state licensing boards promptly.
      • Failed to report Provider A to the appropriate professional certification board.
      • Facility leaders did not take actions to address the circumstances that contributed to the death of Patient C, who was involved in an inappropriate romantic relationship with Provider C.

Regrettably, the VA-OIG could not determine if an adverse patient event occurred when finding that the inappropriate relationship played a role in a veteran’s suicide by overdose.  I understand investigative scope creep, but this is ridiculous.  You have a dead veteran in an inappropriate relationship with a provider, and you cannot investigate if this was an adverse event.  What type of bureaucratic inertia sponsored this madness?

Some items in this investigative report stand out, beginning with the fact that the facility leaders who refused to take action remain employed by the VA!  Knowing about problems and not taking prompt and decisive action is negligence in performing one’s duties.  Possessing authority and refusing to implement policies and procedures, ensuring compliance by professionals, defies description and should result in VISN leaders losing their jobs!  Unfortunately, these inappropriate relationships are not rare; even if the VA-OIG has not gotten around to investigating the problems, ask the VA employees, and you will find the proof of concept and incredibly high frequencies.  Hence, I have two questions:

  1. When is enough ENOUGH?
  2. How does this reflect the VA Administration’s commitment to the vision of the VA?VA 3

In the annals of government fraud, waste, and abuse, the following VA-OIG investigation must rank in the top 20 somewhere.

The VA Office of Inspector General (OIG) initiated this review to evaluate whether purchases of iPads and iPhones for veterans met mission needs while minimizing waste during fiscal year (FY) 2020 and through the first two quarters of FY 2021.  In July 2020, Connect Care officials purchased 10,000 iPhones with unlimited prepaid data plans for the homeless veterans enrolled in the HUD-VASH program.  However, 8,544 of the 10,000 iPhones remained in storage as of July 2021, as demand for the iPhones was much lower than anticipated.  The OIG found that this resulted in an estimated $1.8 million wasted data plan costs.  The OIG also identified opportunities for improvement regarding data plans for nearly 81,000 iPads purchased.  Because Connected Care did not have strong enough oversight procedures for reducing or eliminating data plan waste, it incurred approximately $571,000 in additional wasted data plan costs.”

When I was offered telehealth, I was responsible for providing the equipment and maintaining an Internet connection.  This was made clear by the VHA Administrators before they signed off on allowing me telehealth and reiterated by my providers when they renewed permission.  How can the VHA and VA leadership and contracting officials imagine this is acceptable?  How many of these devices are still in the hands of veterans?  How many have broken, been pawned, or otherwise not survived?

Again, not casting aspersions, merely asking questions, namely the following:

  1. When is enough ENOUGH?
  2. How does this reflect the VA Administration’s commitment to the vision of the VA?VA 3

I could weep from the frustration felt in reporting another veteran’s death by suicide, receiving care from mental health providers with the VA, and being investigated by the VA-OIG, where the providers are complicit.  The scenario:

The VA Office of Inspector General (VA-OIG) conducted a healthcare inspection to evaluate VA-OIG-identified concerns related to the assessment and documentation practices of a behavioral health certified registered nurse practitioner (BHNP) and leaders’ completion of BHNPs’ ongoing professional practice evaluations (OPPEs).

The findings:

      • The BHNP did not perform thorough suicide risk assessments for a patient who died by suicide.
      • Identified multiple deficiencies in a BHNP’s assessment and documentation practices, including the absence of comprehensive suicide risk assessments, failure to complete abnormal involuntary movement and metabolic assessments for patients prescribed particular antipsychotic medication, missing informed consent or a risk-benefit discussion when prescribing off-label medications, failure to resolve rule-out diagnoses, and substantial copy and paste use.
      • Finding adverse clinical outcomes for one of eight patients for whom the BHNP did not document a comprehensive suicide risk assessment, as required by The Joint Commission.
      • Finding the Nurse Manager evaluated BHNPs as satisfactory in the OPPE elements of copy and paste use for the fiscal year 2018 through the first half of the fiscal year 2021 and safety plan completion for high-risk suicide patients for February 2020 through the first half of the fiscal year 2021, without these elements being evaluated.

Is it clear why I am asking about where the limitations of patience are?  The supervisor was directly responsible for leading the BHNPs and failed, and while it is not mentioned, we can presume this person remains employed.  Failed to train staff, failed to supervise staff, refused to do your job.  Yet, you remain employed (probably) and (potentially) were promoted, as this is the regular pattern for VA employees caught but who are politically acceptable or connected.  The supervisor is directly connected to a dead veteran, a family is weeping this holiday season, friends are missing, and all I can do is keep asking the politicians:

  1. When is enough ENOUGH?
  2. How does this reflect the VA Administration’s commitment to the vision of the VA?VA 3

Do you also feel the weight of responsibility; your tax dollars fund this abuse.  Representatives of your government are complicit in adverse patient events, including death, and they refuse to engage, holding government employees accountable and fixing the mess.  Veterans signed a check, telling the government we will perform duties and obligations.  Why aren’t the veterans honored for their sacrifice and respected by elected officials and government employees, especially at the VA?

America WeepsThe VA’s mission statement is “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.”  The statement is meant to echo the reverence given to the men and women who serve in the American military with honor.  Reflecting that this body (the Department of Veterans Affairs) is tasked with serving them respectfully, similar to how they served their nation.  One final question is, “Does killing, abusing, and harming veterans equate to honoring the VA mission statement?”

© Copyright 2022 – M. Dave Salisbury
The author holds no claims for the art used herein, the pictures were obtained in the public domain, and the intellectual property belongs to those who created the images.  Quoted materials remain the property of the original author.

Principles of Value – More Chronicles From the VA

Millstone of Designed IncompetenceValue is a term many think they understand and, more often, barely grasp.  Ralph Barton Perry is the seminal author on all things related to value.  As value is an aspect of functioning society and contributes to the wickedness of government, it is only fitting to delve into this concept with a discussion on value, using more examples from the Department of Veterans Affairs – Office of Inspector General (VA-OIG).

Value – using only the American Heritage (5th Edition) Dictionary, a person would consider themselves learned to know that value is a price or return, monetary or material worth, possessing worth in importance, merit, or utility.  Due to specialization, some would know value as the quality of a letter or diphthong, the darkness or lightness of a color, the duration of a tone or rest, or numbers or quantities expressed in algebraic terms.  None of these are wrong, and each has direct application to the fields of study, but they do not encapsulate the essence of value.

Ralph Barton Perry expressed a sentiment I support wholeheartedly in his book “General Theory of Value” (1967, Harvard University Press):

“… Bridging the gap between common sense and science.  Believing that philosophy must face the facts of life and nature, taking them as both the point of departure and the touchstone of truth, one can never be comprehensive enough.”

In reiterating and describing value, especially as it applies to government, I begin firm in the knowledge that a blog cannot capture all that needs to be said.  As noted by Mills, quoted by Perry (p. 35), “The word value, when used without adjunct, always means, in political economy, value in exchange.”  It is on this value in exchange we focus our attention, provided we keep a second thought firmly in mind, society at its most basic element is cooperation.

In “Common Sense,” Thomas Paine made this distinction, and Perry elaborated in his books on value.  Cooperation in a society is the division of labor mediated by a common purpose.  Hence the value in exchange is labor for mutually beneficial specialized tasks that promote society working more efficiently.  Or, to better illustrate the point, you do not hire a diesel mechanic to conduct open heart surgery.  The mechanic has value in their sphere, and the cardiac surgeon has a different value in their sphere, but society flourishes in the exchange of labor through cooperation.

?u=http2.bp.blogspot.com-fGEUjJsJ2h4VcJgswaisnIAAAAAAAABcsoFqEewPF_E4s1600quote-if-the-freedom-of-speech-is-taken-away-then-dumb-and-silent-we-may-be-led-like-sheep-to-the-george-washington-193690.jpg&f=1&nofb=1Consider the role of the master builder in building a major building.  Each specialized task, drywall, foundations, painting, plumbing, electrical, etc., must all be done on a schedule and the master builder is ultimately responsible for the entire building once complete.  The building is completed promptly and efficiently through exchange and cooperation.  But is the master builder responsible for the actions of those specialists; as it pertains to the functionality of the building, the answer is yes!  Thus, if a plumber is stealing, an electrician is cheating, or a painter is not using the approved paints, the master builder is responsible to the owner for failing to monitor and closely supervise the subordinate contractors exchanging their skills for political and financial gain.

We must never forget that a reputation is a political title, appointed and maintained over time, and from the experiences of others.  The relationship governing issuing reputations, which helps to promote or demote the master builder in society, has value, which is more than monetary remuneration for services rendered.  Our reputation is not ours but was granted by others and must be maintained through careful action repeated across life.

Consider the following scenario:

The Office of Inspector General (VA-OIG) conducted an inspection to assess a safety concern with the new electronic health record (EHR) that resulted in patient harm.  The VA-OIG found that the new EHR sent thousands of orders for medical care to an undetectable location, or unknown queue, instead of to the intended location.  In December 2021, VHA assessed the risk of the unknown queue as “major severity,” “frequently occurring,” and “very difficult to detect.” Immediate mitigation was needed, but Oracle Cerner (creators of the EHR) failed to inform VA end-users of the unknown queue, placing the burden on VHA to mitigate the problem.

Beginning in June 2021, VHA staff found that the new EHR’s delivery of orders to the unknown queue caused 149 patient harm events.  In late 2021, VHA staff provided the Deputy Secretary and the Executive Director for VA’s EHR modernization effort with information on the unknown queue safety concern and identified patient harm.  However, after finding over 200 orders in the unknown queue in May 2022, the VA-OIG has concerns with the effectiveness of Cerner’s plan to mitigate the safety risk.”

The EHR contractor designed a problem, blamed the customer, who is also, in this instance, the owner for the problem, and then placed the onus for fixing the contractor’s failure on the owner’s employees to find and mitigate.  Using the context mentioned above, one can clearly deduce that this is a negative value not aligned with societal cooperation.  The result will be a taxpayer nightmare creating patient harm to veterans.  Since Oracle Cerner is being paid with taxpayer dollars, do you, as a taxpayer, feel valued in this transaction?VA 3

Consider another example, recalls of products happen.  Mistakes occur frequently enough that since we are all humans, we accept that humans are going to make mistakes and move on.  In the following example, the manufacturer made a mistake, owned it, took decisive action to rectify it, and honored their commitments.  The problem arises in the VHA’s processes and procedures that govern employee actions in response to a manufacturer admitting a mistake was made.

The scenario:

The VA-OIG determined that the VHA medication recall process generally met VHA requirements and identified potential vulnerabilities related to the monitoring and reporting of medication recall adverse drug events and variations in the software used to record medication lot numbers.  Adverse drug events resulting from recalled medications are not identified as a category or required to be reported in the VA Adverse Drug Event Reporting System.  Therefore, the OIG could not determine if VHA monitored all adverse drug events from recalled medications.”

Did you catch that; established procedures lack a category to report and track medication recalls.  A quick Internet search concluded that, per the FDA, in 2022 alone (data current as of November), 55 medical devices and 59 drug recalls have occurred.  Yet, the VHA has a tracking system that doesn’t categorize drug recalls as adverse drug events.  Why?  Imagine getting both erectile dysfunction and antidepressants in the same pill bottle.  Would not this potentially cause patient harm; of course.  Shouldn’t this patient harm event be tracked as an established drug recall event, so all the evidence and information are in a single place, properly labeled, and recorded?  Yet, the VA-OIG cannot declare how long the adverse patient drug tracking system has been tracking and recording events related to drug recalls and report similar to the legislative bodies for accountability.

Tell me, is a lack of information socially valuable in understanding the size and scope and adequately understanding the positive and negative aspects of adverse drug event tracking?  Variations between VHA facilities open the door to patient harm and increase the risk of veterans going to a VHA facility.  Yet, the VA-OIG constantly finds variations in processes and procedures between VHA facilities, recommending reducing variation, and the variation never reflects improvement.  Where is the value?  Why?  Isn’t it amazing the processes and procedures are mostly sufficient, but the processes and procedures did not catch that information was properly being collected and labeled for tracking and reporting purposes?VA 3

If all your neighbors relate XX contractor is horrible to work with, do you hire them to work on your house?  Is society growing with cooperation and building value if the contractor is always making a mess and ruining property?  Why is the government allowed to harm society, stop cooperation, decrease value, and never be held accountable?  Since all elected officials are expected to represent their entire geographical district instead of catering to their political base, do not all of the politicians suffer for the misbehavior of a few?  Why are these elected officials not taking action to clean up the government?

Repeatedly the procurement officers, highly specialized contracting officials who work for the VA, fail a VA-OIG audit and use the same excuses constantly, namely the following factors contributing to non-compliance:

      • Officials not understanding their responsibilities
      • Heavy workload
      • Ineffective oversight
      • Prioritization of awarding contracts

Where is the value to society when employees use the same excuses, shirk responsibility for errors and mistakes, and maintain their employment at taxpayer expense?  Does this reflect value to the taxpayer for their investment; of course not.  So why is this behavior accepted by the officers and investigators of the VA-OIG?  Society has self-correcting features that preclude the incompetent from continuing to abuse the customer; why have elected officials designed this abusive and deleterious department?VA 3

David Case, Deputy Inspector General, testified before Congressional Committees (SVAC) on VA’s electronic health record modernization program and stated the following:

Proper governance and transparency will be necessary to get it right.  Failures in these areas risk cascading problems that jeopardize the entire program.”

Great words, but what actions are you taking to reign in the cost overruns, the failed EHR which put patients in harm’s way, and is so convoluted that many employees cannot do their jobs efficiently and productively?  The VA-OIG has supported through in-depth investigation that the existing EHR and the new EHR are abysmal failures, are expensive to maintain, install, train, and produce no value to society.  Why are we continuing to allow Congress to invest in this EHR madness with American taxpayer dollars and debt?  David Case’s testimony covers none of these fundamental questions, and the SVAC elected members never asked these questions as follow-ups to the testimony provided.

Interestingly, review all the testimony on the new EHR by the VA-OIG before Congress, and elected officials ever make accountable the government employees for success or failure.  Those testifying never discuss the fundamental problems, those listening elected officials never express disgust (forget outrage) over the core issues, and the taxpayer is left holding an expensive, dead albatross.  How does escaping responsibility improve the value of government in society?  The government is duty-bound to help enhance cooperation for the growth of society; this is a primary duty of government.  Do you see the government as improving or hindering cooperation in American society?VA 3

Repeatedly throughout the last decade of covering the VA-OIG reports, the VA-OIG discusses failed audits, improvements to governance processes and procedures to protect personally identifiable information, how the VA processes are inadequate and cause patient harm, and the list continues.  The same problems, the same recommendations, and the same testimony before Congress.  Wash, rinse, repeat, ad nauseum ad infinitum.  I repeat in words of soberness, and with the conviction of someone who knows, the actions of the VA are unacceptable, and the politicians elected to correct executive branch misbehavior are failing their US Constitutional duty to scrutinize the government.  These are millstones we can sunder from the neck of American society.  All without violence, using the existing laws on the books, and concrete action can, and needs to, begin immediately!

LinkedIn ImageWe conclude with an insight from Perry (p.515):

The master builder of social justice oversees all the diverse social activities and takes account of their relative importance in the community.  But unless those who build know what they are building and are motivated by that rather than by their wage, the unifying purpose is the exclusive prerogative of the master builder.”

Because the elected officials placed in authority by the electorate are not motivated by building society, only by how much money they can squeeze, American Society is suffering.  The self-perpetuating machine of doom continues chugging steadily, and until the citizens understand the principles of value and change the elected officials, then holding them personally accountable for powering the destruction of American society and accountable for breaking the trust invested by the people for the people, the course of American society is doom bound.

© Copyright 2022 – M. Dave Salisbury
The author holds no claims for the art used herein, the pictures were obtained in the public domain, and the intellectual property belongs to those who created the images.  Quoted materials remain the property of the original author.

“That’s Crazy!!!” – More Chronicles from the VA (Ch 9)

I-CareThe Department of Veterans Affairs – Veterans Benefits Administration (VBA) regularly crows about reducing the backlog, improving the veteran experience, and making changes to deliver on the promise.  Every so often, another article is spread, mainly by the VA Public Relations department (PR), about how they meet the legislated obligations.  Then, unsurprisingly the truth is revealed, the curtain thrown back, and the lie exposed.  The Department of Veterans Affairs – Office of Inspector General (VA-OIG) is helping pull the curtain back, and the truth should infuriate every American.  In an investigative report dated 22 June 2022 and linked, we find the following:

“… The VBA disregarded privacy procedures so it could use a workload tracking system more quickly without receiving the appropriate security authorization.  The Mission Accountability Support Tracker (MAST) helps quantify the work VBA’s support services staff perform in response to employee requests for facility, equipment, and vehicle management; reasonable accommodation; and identification card issuance and renewal.  Because staff use personally identifiable information (PII) in their work, the information could be compromised in an unauthorized, unsecured application.  The VA-OIG found that VBA and the Office of Information and Technology (OIT) did not correctly follow privacy and security procedures.  VBA’s privacy threshold analysis was inaccurate, and OIT did not conduct a privacy impact assessment.  OIT’s misclassification of MAST as an asset resulted in insufficient security controls.  Further, VBA lacked the authority to operate MAST before using it in regional offices.”

Lacking authority equates to a leadership failure to follow their standard operating procedures (SOP).  PII being inappropriately released, nothing new at the VBA, or the VHA for that matter.  Losing veterans’ identities and taking advantage of systems for personal gain, regardless of the cost, is nothing new or surprising.  This should be where the VA organizational leadership should be focused; yet, what are they doing?  Where is Congressional oversight and scrutiny?VA 3

FY 2017, the VBA leaders devised a scheme to have third-party vendors conduct compensation and pension exams to deliver on the promise to clear the backlog on veterans’ claims.  Since FY 2017, the VBA has paid over $6.5 Billion on this scheme, and the VA-OIG found in a report dated 08 June 2022, “Some of the exams produced by vendors have not met contractual accuracy requirements.  As a result, claims processors may have used inaccurate or insufficient medical evidence to decide veterans’ claims.”  Is anyone surprised this is the result?  The compensation and pension exam is the key to accuracy in claim completion; yet, inaccurate claims are still being adjudicated wrongly, which is significantly damaging veterans and their families!

From the report, we find the following:

VBA’s governance of and accountability for the exam program needs to improve.  The identified deficiencies appear to have persisted, at least partly because of limitations with VBA’s management and oversight of the program at the time of the review.”VA 3

The VBA’s leaders designed this scheme, shackled the program with ineptitude, and hindered the improvement of the program.  Designed incompetence cannot get any better than this, and the leadership must be held accountable!  Fraud, waste, and abuse remain pillars in Federal Government governance, so why are these leaders not being held liable?

Michael Bowman, Director of IT and Security Audits, in recent Congressional Testimony, made the following claim:

Secure IT systems and networks are essential to VA’s fundamental mission of providing eligible veterans and their families with benefits and services.  VA’s information security program and its practices must protect the confidentiality, integrity, and access to VA systems and data.”

The audacity of this director to claim “confidentiality, integrity, and access” as being secure would be laughable if it weren’t so inept!  How would a non-VA Employee know the IT system is fraught with problems?  VA-OIG report regarding FISMA compliance, Dallas, Texas.  The Federal Information Security Modernization Act of 2014 (FISMA).  FISMA is a United States federal law that defines a comprehensive framework to protect government information, operations, and assets against natural and manmade threats.  FISMA OIG inspections are focused on four security control areas that apply to local facilities.  They have been selected based on their level of risk: configuration management controls, contingency planning controls, security management controls, and access controls.VA 3

What did the VA-OIG find?  “Without effective configuration management, users do not have adequate assurance that the system and network will perform as intended and to the extent needed to support the CMOP’s missions.  The access control deficiencies create risks of unauthorized access to critical network resources, inability to respond effectively to incidents, loss of personally identifiable information, or loss of life.”  All political speak for inept leaders and deplorable leadership actions.  IT/IS systems continue to fail, and the director claims the system has integrity; despicable and detestable!

Worse, the same FISMA inspection occurred at the same outpatient pharmacy mail facility in Tuscon, Arizona.  The same problems were found, in the same systems, manned by the same inept people and led by the same poor leadership.  Integrity, only if the word means sharing ineptitude between different facilities.  Access to systems and data protection, can anyone honestly trust that the IT system at the VBA or VHA is providing the fundamental tools to meet the mission?VA 3

On the topic of IT system integrity, can anyone forget the continuing problems in delivering a functional electronic health record system to the VHA?  How many billions of dollars must be wasted before Congress stops paying for this albatross?  The VA-OIG has substantiated that “… many quality, patient safety, and organizational performance metrics were unavailable, including metrics needed for hospital accreditation.  Additionally, the VA-OIG found that access metrics were largely unavailable.  The VA-OIG remains concerned that deficits in new EHR metrics may negatively affect organizational performance, quality and patient safety, and access to care.”  How’s that integrity doing?  Is it trustworthy?

05 May 2022, failures were discovered in a joint DoD and VHA review of the new electronic health record system.  The new EHR has no plan to create interoperability, yet interoperability was the main selling point for spending billions of dollars on a new EHR.  Would you believe the VA-OIG recommends the DoD and VHA review federal laws and direct the offices overseeing the EHR program to begin complying?  Would Congress please ask, why haven’t the program managers for the HER already been complying with Federal Law?  How about demanding action to recompense the taxpayers who have been defrauded?VA 3

In April 2022, VA-OIG Michael J. Missal addressed Congress in a statement entitled, “At What Cost? – Ensuring Quality Representation in the Veteran Benefit Claims Process.”  The VA-OIG’s mission is “preventing and addressing fraud and other crimes, waste, and abuse in VA programs and operations.”  General Missal then discussed the integrity of VA processes to “help ensure that veterans receive the benefits, health care, and services they have earned through their service to our country.”  Would Congress please ask how the VA-OIG is fulfilling its mission to prevent fraud, waste, and abuse?

The VA-OIG operates a hotline that receives approximately 30,000 complaints annually from veterans, family members, VA employees, and the public.”  If the 30,000 complaints are presumed to be stable, across just the years I have documented the VA’s abuses, then the VA-OIG has received upwards of 360,000 complaints over the last 12 years.  Would Congress please ask about the success in promoting change, reducing fraud, waste, and abuse, and curbing the veterans being actively harmed by the VA, the VHA, and VBA?VA 3

Congress receives these VA-OIG reports first; what is Congress doing to scrutinize the executive branch?  Where is the progress?  The VA-OIG reports annually to Congress, but improvement never occurs.  Permanent change never occurs.  The same people are making the same excuses, using the same flowery language, and nothing ever happens to improve things.  Worse, the same people maintain the same jobs, who pays, the veterans and their families, and the American taxpayer through the nose as the VA loses more and more money!

I do not know about any Congressional elected leader, but I am through buying the Kool-Aid the VA-OIG is selling:

The VA-OIG’s work is focused on protecting VA programs and operations from waste, fraud, and abuse as well as improving their efficiency and effectiveness.”

On a single topic that the VA-OIG has reported on multiple times and remains critically important to all veterans and their families, it is reporting needs for improvement in VHA and VBA suicide prevention.  From the report, we find the following:

“… Suicide prevention coordinators at VA medical facilities are required to reach out to veterans referred from the Veterans Crisis Line.  Coordinators provide access to assessment, intervention, and effective care; encourage veterans to seek care, benefits, or services with the VA system or in the community; and follow up to connect veterans with appropriate care and services after the call.”

The findings from the VA-OIG report are almost criminal in the negligence of leadership to perform the jobs they hold:

The VA-OIG found that coordinators mistakenly closed some veteran referrals because coordinators lacked the proper training, guidance, and oversight necessary to maximize chances of reaching at-risk veterans referred by the crisis line.  VHA lacked comprehensive performance metrics to assess coordinators’ management of crisis line referrals, and coordinators lacked clear guidance on managing crisis line referrals.  Until VHA provides appropriate training, issues adequate guidance, and improves performance metrics, coordinators could miss opportunities to reach and assist at-risk veterans.”VA 3

Why did the media bury this report?  Suicide prevention continues to be a significant military and veteran issue, but this program’s designed incompetence should be a major story on all media networks.  More, this VA-OIG report should be a talking point for every congressional representative seeking re-election.  Why is this not the case?  Integrity requires honesty, honesty and integrity requires action.  When will Congress take action?

How many dead veterans will it take before Congress takes action?  31 May 2022 VA-OIG report:

The VA Office of Inspector General (OIG) conducted an inspection to review the care of an unresponsive patient by Emergency Department staff and the subsequent response of leaders at the Malcom Randall VA Medical Center (facility) after the patient’s death at the University of Florida Health Shands Hospital (Shands).  The OIG determined that facility Emergency Department nurses failed to provide emergency care to an unresponsive patient who arrived by ambulance.  Despite emergency medical services (EMS) personnel having relayed, while en route to the facility, the criticality of the patient’s condition and the limited patient identifying information available, Emergency Department nurses and an Administrative Officer of the Day wasted critical time concentrating efforts on whether the patient was a veteran (which the patient was, but not so identified by the nurses) versus patient care.  As a result, EMS personnel reloaded the patient into the ambulance for transport to Shands.”VA 3

The staff failed to follow EMTALA, and a veteran died due to the inaction and inappropriate focus of the medical providers.  This is not the first or second breach of EMTALA, the federal law requiring any patient presenting at an emergency department receiving federal funds to be treated; yet, what will it take to get Congress off their thumbs?

12 May 2022, deficiencies in care led to a patient dying at the Charlie Norwood VAMC, Augusta, Georgia.  The VA-OIG substantiated that:

medical-surgical unit nursing leaders did not have adequate quality controls or training to ensure the provision of safe and effective alcohol withdrawal nursing care.”  “Primary care staff failed to provide sufficient care coordination and treatment.  A provider failed to address the patient’s abnormal chest images and poor nutrition and failed to communicate test results to the patient as required.  A primary care nurse failed to respond to the patient’s secure message request for assistance two days before surgery.

Additionally, a barium swallow test was not scheduled.  The surgical team completed a preoperative assessment but failed to detect the patient’s overall poor health.  During the patient’s hospital stay after surgery, medical-surgical nurses did not consistently assess alcohol withdrawal symptoms or administer medications as required.”VA 3

My wife is fond of saying, these oversights and failures occur in non-Government hospitals, and this incident should not be considered indicative of the whole system lacking similarly.  Yet, civilian hospitals have lawyers by the dozen looking for a reason to sue providers for malpractice, and the government hospitals protect against accountability and responsibility.  Worse, you will never know the problems unless you track these incidents.

Do you know why I keep declaring there is a problem with designed incompetence; several veterans suffered T-12 burst fractures and multiple rib fractures, all because of poor documentation and even worse communication.  This is a life-changing injury, and the VA-OIG found the VA providers to have culpability but no responsibility due to a lack of documentation.  Delays in provider documenting in the electronic health record the provider’s notes delayed care for another veteran who also suffered life-changing spinal injuries after receiving non-care at a VA facility.  The VA-OIG cannot conclusively document the tie between poor care being received and the injuries sustained by the veteran, all because of delays in the provider documenting treatment.VA 3

Tell me, does anything discussed above reflect the words of Inspector General Michael J. Missal, who claimed the following in Congressional Testimony:

VHA continues to face enormous challenges in providing high-quality care to the millions of veterans it serves.  Despite these challenges, the VA-OIG has witnessed countless examples of veterans receiving the care they need and deserve—delivered by a committed, compassionate, and highly skilled workforce [emphasis mine].”VA 3

Does a provider killing a veteran reflect a committed, compassionate, or highly skilled workforce?  How many veterans must be permanently injured by the VHA providers to reflect a committed, compassionate, and highly skilled workforce?  How often will the electronic health record fail before highly skilled workers are displayed?

Plato 2Unfortunately, the VA-OIG reports discussed are not even the tip of the iceberg of what is happening.  My apologies, dear readers; I have been remiss in my reporting duties.  Why have I been remiss, because my health went sideways since April when I had a medical procedure completed that was advised but not appropriate.  The VHA and VBA are sick organizations and desperately need scrutiny and standards, new leadership, and written organizational policies.  Help me force these nefarious characters into the sunshine for a good dose of sunshine disinfectant, and let’s change the world for the better.

© Copyright 2022 – M. Dave Salisbury
The author holds no claims for the art used herein, the pictures were obtained in the public domain, and the intellectual property belongs to those who created the images.  Quoted materials remain the property of the original author.

“That’s Crazy!!!” – More Chronicles from the VA Chapter 8

I-CareI fully admit I got behind in April.  Dear reader, my apology.  I have been whipsawed between emergency room visits, depression, extreme pain, and other issues.  Not offering an excuse but a tiny peek into my world as a disabled veteran.  Luckily, I have maintained employment because my employer allows me to work from home.  My driving privileges are threatened again with removal due to the neurological issues I suffer, and this will dynamically change my life, but this article is not about me, but the continued catastrophe called the Department of Veterans Affairs (VA) and the Inspector General (VA-OIG) reports published.

We begin with a financial efficiency review reported from the inspection of the Durham VAHCS of North Carolina.  I know the jokes write themselves when we discuss any government agency and financial efficiency, but I digress.  This is a head exploding report of leadership failure in the observation and governance of employees who did not perform the functions they were hired to perform.  The VA-OIG found the following from October 1, 2020, through March 31, 2021:

    • The healthcare system had 309 inactive obligations totaling $81.7 million.
    • Of these 309 obligations, 200 (totaling over $74 million) had no activity for 181 days or more.
    • In a subsample of 20 obligations, VA staff had not reviewed 17, as required.
    • Contrary to VA policy, healthcare system staff used purchase cards instead of contracts for 21 of 40 sampled transactions (53 percent), totaling approximately $328,000. These 21 transactions were missing required supporting documentation to verify that the transactions were approved and payments were accurate, resulting in $308,000 in questioned costs.
    • 105 more administrative full-time equivalent staff than the expected number, all not doing their jobs as required under Federal Law!

While not all of the findings, those mentioned are the most egregious and in need of corrective action.  Would the citizens of Durham, North Carolina, please tell me, has this been reported in the local news?  Has anyone lost their jobs as the VAHCS right-sizes the financial department?  I can find no additional information that this problem has been corrected, and I am really curious!VA 3

Oh, the irony is thick; consider the following:

The Department of Veterans Affairs Office of Inspector General Training Act of 2021 would help ensure that VA employees continue to be empowered to assist the OIG in improving VA’s operations and using taxpayer dollars to the greatest effect; helping protect patients and improving their care; and ensuring veterans and others receive services and benefits for which they are eligible.”

The above-quoted material originates from Chris Wilber, who testified to Congress’s HVAC Subcommittee on oversight and investigations.  What is the number one failure on every comprehensive healthcare inspection (CHIP); the lack of staff training, the inadequacy of staff training, or adequately trained staff.  Yet, the statement by the VA-OIG indicates that training has met a threshold for providing adequate training.  Let’s talk about a specific action, “the VA secretary signed a directive in September 2021 mandating that all employees complete a one-time training within one year—an important step in improving VA’s culture of accountability.”  It is now May 2022; the VA-OIG is pushing for training directives to be legislated, not dependent upon any single VA Secretary.  Are you freaking kidding me?  Where is the congressional oversight and scrutiny that allows VA training to continue to be subpar and threaten the lives of veterans?

Long have I wondered how the VA could frustrate VA-OIG actions, investigations, inspections, etc.  Guess what; the answer has become available:

“… there have been instances in which the OIG has been informed that staff have been told that they cannot share information with OIG investigators without first clearing it through supervisors or leaders—contrary to the Inspector General Act of 1978 (the IG Act), as amended.  Under that authority, VA employees at all levels have a duty to cooperate with OIG personnel, including providing information and assistance in a timely manner.”

Employees have been caught lying to the VA-OIG regularly, and what action is taken to remove those employees promptly and efficiently from government service?  From direct observation and employee conversations, it is clear that plans are carefully laid before a scheduled VA-OIG visit to present what the VA-OIG wants, but to gloss over the problems, and nothing ever happened to the managers, supervisors, and employees who lied and misdirected the VA-OIG.  All contrary to established Federal Law!VA 3

Want a specific example of employees intentionally misrepresenting information to the VA-OIG?  Look no further than the statement by Chris Wilber, and this incident was covered as a failure of leadership in a previous article.

Hospital staff at a VA facility in Fayetteville, Arkansas, had concerns about potential substance abuse by the chief of pathology that were not heard and promptly acted on by local management, which allowed him to work while impaired for years.  He misdiagnosed about 3,000 patients with errors resulting in death or serious harm and is currently imprisoned.  The OIG found a culture in which staff did not report serious concerns about the chief pathologist, in part because they assumed that others had reported him, or they were concerned about reprisal.”

From personal experience, I reported problems to the VA-OIG concerning patient abuse, fraud, waste, and other issues.  Never were my concerns acted upon promptly, and I was removed from employment for being a whistleblower.  The culture of corruption at the VA is incredible.  The examples mentioned by the VA-OIG only further sustain the problem with leadership and how sick the VA truly is as an organization!VA 3

We next turn our attention to the VA-OIG report on the inspection of information technology security at the VA Financial Services Center, another head exploding example of leadership failure bordering on criminal!  The findings include:

    • component inventory
    • vulnerability management
    • flaw remediation
    • Identifying 252 vulnerabilities, of which 228 the local IT team could not identify.
    • the VA-OIG team identified access control deficiencies, as 107 of the 278 FSC systems failed to generate or forward audit logs for analysis.
    • the video surveillance system was not fully functional. Ineffective monitoring and recording facility activities supporting information systems minimize the FSC’s incident response capabilities.

How do you spell failure; these findings spell failure to me rather pointedly and dramatically!  Want to laugh; staff training remains a concern, but not a finding, of the VA-OIG inspection team.  Frankly, with this level of incompetence, staff training should have been a finding.VA 3

To be concise and illustrate further the poor leadership, convoluted processes, and brazen noncompliance of VA officials, the following discussion is about two different VA-OIG reports that reached similar conclusions.  First, we have the VA-OIG report on “Noncompliant and Deficient Processes and Oversight of State Licensing Board and National Practitioner Data Bank Reporting Policies by VA Medical Facilities.”  Second is the VA-OIG report on “Concerns with Consistency and Transparency in the Calculation and Disclosure of Patient Wait Time Data.”  Nothing says convoluted processes more than having two written policies, both originating from Washington DC.  The superseded policy does not have an expiration date.  This means that employees have a designed incompetence excuse ready for not adhering to the most current and applicable policy.  Don’t believe me; one of the key findings was, “VHA has presented wait times to the public without clearly and consistently disclosing the basis for their calculations.”  Designed incompetence does not come more blatant than this, and who suffers, the veteran.  Worse, wait time correction and policy clarification has been stalled by COVID-19, the neverending excuse paying dividends to bureaucrats everywhere!Timelines for Wait Time Calculations

However, both reports are substantially summated by the VA-OIG; thus, “The lack of programmatic oversight contributed to the failure of VHA leaders to detect and intervene upon facility noncompliance.”  Meaning that due to COVID-19, the VHA has refused to do their jobs in deference to the pandemic, and since this is a good enough excuse, the VA-OIG has bought the designed incompetence, lock, stock, and barrel.  The VHA leadership is failing; doctors or dentists let go for poor performance were not reported to state and federal boards, so these providers lacking can continue to harm patients.  It is a federal law (42 US Code § 11151, US Department of Health and Human Services, Health Resources and Services Administration Bureau of Health Workforce, NPDB Guidebook, October 2018, chap. A., 8 USC ⸹ 7462(a), 38 USC ⸹ 7401(1), among others) that providers let go for cause must be reported within 7-days to the regulatory boards at the state and federal levels.  Wait times are hidden because they are so bad; the VHA is embarrassed, so the leaders fall back on designed incompetence to shield themselves while looking for another excuse for poor performance!  In both reports, the ramifications of noncompliance are putting people at risk for sentinel events (death, injury, disability, etc.), and the leadership is at best lackadaisical in the performance of their duties.  VA 3

Where are the congressional overseers in ending the abuse?  When will this insanity and bureaucratic inertia end?  How many “sentinel events,” including deaths and permanent injuries, will it take until those tasked with scrutinizing the executive branch finally take committed action and hold people accountable?  When will the elected representatives stop throwing good taxpayer money at problems that money cannot fix?  If these questions are too difficult to answer, please stop running for elected office, for the citizenry is not happy!

We conclude with two related reports so astoundingly obtuse they defy logic and sanity.  The first is the annual CliftonLarsonAllen LLP (CLA) audit of the VA’s information security for 2021.  The second is the continuing failure of the new electronic health record modernization (EHRM) program.  The VA has failed the CLA audit for more than a decade, with many of the hits repeated year-over-year.  In fact, the CLA audit is so bad this year; it has taken my mental breath away and stunned me into a gibbering idiot!  Reading this report was infuriating; describing it as my head exploding is akin to comparing an M-80 to a nuclear bomb.  How in Dante’s Inferno can this level of incompetence be allowed to remain employed?  But, as bad as the CLA audit is, the continued failure of the new electronic health record system pales in comparison.  The new EHRM continues to suffer from reliability weaknesses, which is polite speak from the VA-OIG for the new system fails to do the job.  We are three years from the new extended deadline, we are already past the original deadline, and the system is worthless today than it was a year ago.  With this success rate, the new EHRM will be utterly bereft of value and need replacement before the year’s end.  How many millions (billions, or trillions) of good dollars must chase this ineptitude before the plug is pulled and those involved held accountable?VA 3

Join me in having your head explode:

Additional deficiencies included known tasks not being reflected on schedules, no risk analysis, lack of longer-term actions scheduled, and no complete baseline schedule or overall schedule that fully integrated individual project schedules. VA also did not comply with federal regulations when it paid its contractor for deliverables before accepting them (reviewing compliance with contract requirements).”

Consider this other gem from the VA-OIG report, “$1.95 billion in cost overruns per year” are estimated, meaning the final tab will be significantly higher and compounded year-over-year.  In plain speak, the contractor is being paid for products delivered that fail, the products offered are not usable, there is no schedule of completion, there is no schedule for deliverables, many of the products paid for have never been delivered, and costs are overrunning like a plugged toilet. Worse, no one is being held personally liable for these problems, which were apparent in the last EHRM update from the VA-OIG a year ago!  Like the CLA Audit, I am thrilled the VA agrees with the VA-OIG findings, but what are they DOING to fix the problems?

FYI: the image below is a year old, and comes from the last major update to the EHRM.EHR-VA-OIG

?u=https1.bp.blogspot.com-aqaqk18MHoEWRHHsCi_TyIAAAAAAAAAXc7hY4JQuyylIQHYudoR8sbezGZntic4SSwCLcBs640Betrayal2BSayings2Band2BQuotes2Bwww.mostphrases.blogspot.be.jpg&f=1&nofb=1There is no excuse for behaving like the VA’s bureaucratic legions behave.  Bureaucrats, from the city government (including the school board) to the Federal Government, you hold a sacred trust to act better than you are currently performing.  I refuse you any leeway for acting like pompous overlords when you are paid through forced taxation!  You have trespassed upon my patience and kindness long enough, and the day of reckoning has arrived.  You work for me; you work for every taxpayer and citizen in this country, and you have violated our trust, charged us too much and too often, and if you do not begin to show yourself worthy of the sacred trust, we will force you from your cushy jobs and hold you liable for the monies you have squandered!  The law is on our side; you need to begin showing you honor our trust and investment forthwith!

© Copyright 2022 – M. Dave Salisbury
The author holds no claims for the art used herein, the pictures were obtained in the public domain, and the intellectual property belongs to those who created the images.  Quoted materials remain the property of the original author.

“That’s Crazy!!!” – More Chronicles from the VA Chapter 6

I-CareI promised a follow-up article after Chapter 5; it took me the better part of 48 hours to cool down sufficiently to write coherently to effect an update.  On 18 March 2002, I wrote about an appointment with my Primary Care Provider (PCP) being tardy, unprepared, and bureaucratese in supposedly holding a phone appointment with me.  01 April 2022, not an “April Fools Joke,” at 0731 hours, lasting 9 minutes, my PCP called me to get my approval to have me changed from her PACT team to another provider’s team.  Apparently, in the highly red taped world of PCPs at the El Paso VAHCS, there must be an hour-long handoff call when a provider initiates a change of PACT team.  I have my doubts and smell designed incompetence!

Let me pause here for a moment.  I generally need two hours to write an article after conducting research.  18 March 2002, it took a bit longer to draft that one due to the need to blow off steam with some choice words and choke down the urge to beat a few brick walls with my fists.  I am generally a very controlled person, and the fact that this PCP was so stunningly incompetent, rude, and HIPAA clueless, I admit I lost my cherub-like demeanor!  That the patient advocate was able to get my secure message, upload the comments into the electronic medical record, and contact the provider before the provider had even logged the patient notes, speaks volumes about the ineptitude of the PCP.  Worse, in the call on 01 April, the PCP was still on speakerphone, still disregarding HIPAA security, and quoted lines out of context from my message to the patient advocate.  Speaking volumes about the processes and procedures of the patient advocate’s office to investigate patient claims without breaching confidentiality.  Another topic for another day entirely!PACT_model

28 March 2022, I received the following from the patient advocates office, quoted completely:

We have received your secure message addressing your concerns.  I will be sending a Patient Advocate Tracking notification with your concerns to our Primacy Care Service for review.  They will be contacting you via telephone to discuss your concerns.”

I never heard anything from this mysterious “Primary Care Service” group/team.  01 April 2022 was the first response, and that was from the PCP.  Sourcing the Department of Veterans Affairs (VA) and the Office of Inspector General (VA-OIG), the PCP is the second most important member of the Patient-Aligned Care Teams (PACT) at the VA; the patient is the essential member and an actively engaged and knowledgeable patient is preferred.  I promise the VA-OIG has not even scratched the surface of the problems with recalcitrant, snowflake, and bureaucratic PCPs endangering patient health with the VA.  Not my first run-in with an inept PCP; I sincerely hope it is my last!PACT 3

In returning to the 01 April call, we find another interesting piece of data.  The PCP affirmed that abdominal pain could radiate from, say a hernia, to other parts of the abdomen, but this is for a specialist to diagnose, not a Family Practitioner.  Get that; the PCP is directly reversing all the published documentation by the VA and the VA-OIG by declaring that a specialist is the only person who can adequately decipher and detail why pain is occurring—putting all the PCPs in the VA Health Administration under the bus as merely button pushers and drug dealers.  Then the PCP has the temerity, nay the chutzpah, to suggest a trust deficiency existing between myself and the PCP.  Is it any wonder that people are detested, forlorn, melancholy, madder than a wet chicken with a raging case of hemorrhoids with the care they receive from VA healthcare providers?

Again, I repeat, only for emphasis, when any updates arrive on this issue, I will publish them in their entirety to allow the VA the opportunity to rebut, refute, or explain.  Like the ongoing saga with VISN 22, the Phoenix VAMC, and being arrested and injured three times by the VA Police, I am not holding my breath and awaiting a logical response.  If this were the only problem in the two weeks since the PCP shenanigans, the VA would be in pretty good shape.  Alas, we know, dear readers, that the VA is in dire condition, and the elected leaders need to be scrutinizing the VA a LOT more closely than they are.VA 3

We begin the latest chapter of VA-OIG reports with yet another physician bilking the government:

Robert Clay Smith, a Louisiana physician, pleaded guilty to conspiracy to commit healthcare fraud, wire fraud, and illegal remunerations (taking kickbacks).  According to court documents, the scheme, which ran from 2013 until 2017, involved individuals associated with a medical supply and billing company recruiting Smith to dispense pain creams and patches to his workers’ compensation patients by offering him a split of the profits.  The company acted as the billing agent for Smith, handling all the paperwork and submitting the allegedly fraudulent claims to the US Department of Labor, Office of Workers’ Compensation Programs, and private insurers.  In exchange, the company paid Smith 50 to 55 percent of the profits collected from successfully billing insurers, at markups of 15 to 20 times what the medications cost.”

Plus the following:

Robert Schneiderman of Langhorne, Pennsylvania, admitted to participating in a massive compounded-medication kickback scheme that he and others ran out of a pharmacy in Clifton, New Jersey.  Schneiderman pleaded guilty in federal court to one count of conspiracy to commit healthcare fraud and one count of conspiracy to violate the Anti-Kickback Statute.  From 2014 through 2016, Schneiderman and his coconspirators used Main Avenue Pharmacy, a mail-order pharmacy with a storefront in New Jersey, to run a fraud and kickback scheme involving compounded drugs like scar creams, pain creams, migraine mediation, and vitamins.  Schneiderman was the president of Main Avenue Pharmacy and was a founder and CEO of its corporate parent.  Main Avenue Pharmacy received over $34 million in reimbursements from healthcare benefit programs on compounded medications alone.  Approximately $8 million of that total was paid by federal payers.  Schneiderman himself earned over $400,000 through the course of the scheme.  This case was investigated by the VA OIG, FBI, Department of Defense OIG, Defense Criminal Investigative Service, and Department of Health and Human Services OIG.”

Don’t forget this one:

Dr. Harry Doyle, a psychiatrist from Philadelphia, Pennsylvania, and his wife, Sonya Doyle, have agreed to pay $3 million to resolve alleged violations of the False Claims Act.  The alleged violations include submitting false billing to the US Department of Labor Office of Workers’ Compensation Programs (OWCP) for psychiatric services that were not provided and upcoding and double-billing patient claims.  The Doyles have also agreed to be voluntarily excluded from federal healthcare programs for 25 years as part of the settlement.  This is the largest recovery against a single psychiatrist in the history of the OWCP.  A multiagency investigation of Dr. Doyle’s practice revealed that from January 2013 through April 2021, the Doyles allegedly billed for services not rendered, some of which occurred when they were not physically present in the United States.  This case was investigated by the VA OIG, the Department of Labor OIG, and the United States Postal Service OIG.”

More is coming on this one:

Ten Texas doctors and a healthcare executive have agreed to pay more than $1.68 million to resolve False Claims Act allegations involving illegal remuneration in violation of the Anti-Kickback Statute and Stark Law.  According to a multiagency investigation, from 2015 to 2018, the doctors allegedly received thousands of dollars in illegal remuneration from eight management service organizations (MSOs) in exchange for ordering laboratory tests from Rockdale Hospital doing business as Little River Healthcare, True Health Diagnostics LLC, and Boston Heart Diagnostics Corporation.  Little River funded the illegal remuneration to the doctors in the form of volume-based commissions paid to independent contractor recruiters, who used the MSOs to pay numerous doctors for their referrals.  The MSO payments to the doctors were disguised as investment returns but were based on and offered in exchange for the doctors’ referrals.  As part of their settlements, the defendants have agreed to cooperate with the Department of Justice’s investigations of other parties involved in the alleged law violations.  To date, 17 doctors and two healthcare executives involved in this scheme have agreed on settlements totaling more than $2.7 million.  The civil settlements resulted from a coordinated effort between the VA OIG, Department of Health and Human Services OIG, Defense Criminal Investigative Service, and the US Attorney’s Office for the Eastern District of Texas [emphasis mine].”

Elected officials, the next time you are asked about the incredible amounts of fraud in government-provided healthcare and insurance, do not buy the media talking points that the fraud is minimal, contained, or anything but designed incompetence on the part of the bureaucrats to act as a jobs program for investigators!  The same investigators who are refused sufficient tools to investigate shenanigans by employees in the Federal Government adequately.?u=http2.bp.blogspot.com-fGEUjJsJ2h4VcJgswaisnIAAAAAAAABcsoFqEewPF_E4s1600quote-if-the-freedom-of-speech-is-taken-away-then-dumb-and-silent-we-may-be-led-like-sheep-to-the-george-washington-193690.jpg&f=1&nofb=1

Frankly, all of these cases need the government workers to be held accountable, and the myriad of red tape loopholes CLOSED!  I remember an election; I forget who and the exact when, but a significant election plank in the platform was healthcare reform, promising to clean up the swamp and bring accountability to Washington and the government.  The public is still waiting, and I know enough of you have run on this topic from both parties to repaper the walls (inside and outside) of the White House.

Yet, even if only outside providers and executives were scheming, the VA might not be in too bad a condition.  Except for the employees of the VA, VHA, and VBA, which continue to be caught up in ethics violations at a minimum:

The VA-OIG conducted an administrative investigation that included a congressional request to look into allegations that Charmain Bogue, former executive director of the Veterans Benefits Administration’s Education Service, committed ethical violations arising from her spouse’s consulting work for Veterans Education Success (VES).  VES is a nonprofit advocacy group that regularly had business before the Education Service.  The allegations also pointed to possible incomplete financial disclosures by Ms. Bogue concerning her spouse’s consulting business.  In their work, investigators uncovered evidence of other potential conflicts of interest and related misconduct by Ms. Bogue [emphasis mine].”

VA-OIG finding:

    1. Bogue participated in Education Service matters involving VES without considering whether it raised an apparent conflict of interest and acted contrary to the ethics guidance she received from her supervisors.
    2. Bogue sought résumé feedback from the president of VES to aid in her search for career advancement without considering whether this raised apparent conflict of interest concerns in subsequent VES matters. VES also endorsed Ms. Bogue for presidential nominee positions.
    3. Bogue provided insufficient detail about her spouse’s business in 2019 and 2020 public financial disclosures; VA ethics attorneys had found them compliant. She remedied the subsequently identified deficiency in her 2021 disclosure.
    4. The OIG found that Ms. Bogue refused to cooperate fully in the OIG’s investigation by refusing to complete her follow-up interview. Her husband and VES president also refused to participate in OIG interviews, and the OIG lacks testimonial subpoena authority over individuals who are not VA employees.   Bogue resigned from VA in January 2022.VA 3

UPDATE: 14 April 2022Sen. Grassley was hoodwinked by the VA on this issue and The Daily Signal (linked) has more of this report.  I covered this before, I repeat only for emphasis, when you are discharged from the VA, you lose your ability to be a “whistle-blower.”  As a point of fact, this is how the VA is able to hide a lot of their shenanigans, get rid of the person rocking the boat, invent the paperwork, cover the whole incident over as a “bad-apple” and keep you collective heads down and mouths shut until the VA-OIG investigation concludes.  The VA’s ability to abuse whistle-blowers is further compounded by Federal Attorneys who cherry-pick the cases they know they can win.  Which further protects the VA’s shenanigans and disheartens and mystifies those who have been wrongly terminated.  The Daily Signal reflects this pattern of corruption perfectly citing the records obtained by Empower Oversight.

Some commentators have claimed that blaming elected officials for not scrutinizing or not providing tools to investigate entirely is unduly unfair to the congressional representatives.  Really?!?!?!  The VA-OIG conducts an investigation, the people being investigated refuse to comply, and the VA-OIG is toothless to enforce a full and complete investigation to initiate Attorney General and FBI investigations and actions to recompense the defrauded taxpayer.  Ms. Bogue and the VES have invalidated any trust the taxpayer should have in their respective activities, but this, like so many other investigations into VA employees, will die of apathy before anyone is held accountable.  Even though a congressional representative demanded an investigation, nobody is being held liable.  Nobody is forced to compensate the defrauded taxpayer, yet the taxpayer is still expected to elect the same old representatives to their jobs.  Blaming the congressional representatives (legislative branch) for not scrutinizing the executive branch, one of only two jobs these people have, is somehow unfair?  NO!Exclamation Mark

Remarkably, between the 18 March disaster with the PCP and 01 April’s compounding idiocy, the VA-OIG published an ironically titled investigation report.

Improved Governance Would Help Patient Advocates Better Manage Veterans’ Healthcare Complaints.”

Imagine that, more designed incompetence negatively impacting the veterans seeking care at a VA medical facility, stating the obvious by the investigators.  Who on earth would be responsible for seeing that regulatory agencies had the tools needed to scrutinize and demand corrective action?  Calling all elected officials, did you notice that one of the prima facia tools a veteran has to report problems, conveniently called “patient advocates,” does not have the sufficient authority, adequate oversight, and tools to execute their jobs?  The VA-OIG reports the following:

The Patient Advocacy Program helps advance the Veterans Health Administration’s (VHA) efforts to improve customer service, support veterans’ access to quality care, and provide a mechanism to resolve healthcare issues.  Patient advocates document veterans’ concerns, communicate the resolution, provide follow-up and feedback, and identify trends for potential opportunities to improve medical facilities.  In FY 2020, VHA tracked about 162,000 serious complaints in its patient advocate tracking systems.”

Angry Wet ChickenOn a side topic, VA-OIG, how do you define a “significant complaint” and separate it from other types of complaints?  Honest question, the information was, to quote my PCP, “remarkably” missing from your investigation report!  Would the VA-OIG like to know why so many veterans’ complaints have risen to a “serious” level?  You reported the exact problem:

A complaint is considered resolved when the complainant communicates the outcome, and the record is closed in the tracking system.”

Maybe, the VA-OIG merely overlooked the logic problem, but complaints increase when the solution pushed down the throats of the veterans does not fix the actual situation.  Honest question, no sarcasm involved.  Is a “serious” complaint one where significant harm or death to the patient has occurred?  Is a serious complaint one that breaks federal laws, EMTALA, comes readily to mind??u=https3.bp.blogspot.com-fYRTNk48SCwT8ua0IRDWPIAAAAAAAAFZUpexSmJsN2Kos1600overcoming-adversity-help-yourself-believe-cubby-motivational-1289878102.jpg&f=1&nofb=1

Having had “solutions” forced down my throat, speaking only for myself, I am thoroughly sick of having the patient advocates bureaucratize my complaint, then fail to act, and then compound the problem by quoting policy to me as a reason to close the complaint, when the VHA never have written policies and procedures!  Maybe, you might want to look into the root causes of some of those “closed” complaints and ask root causation questions!

What did the VA-OIG find when they investigated the patient advocates?

    • VHA lacked adequate governance of the Patient Advocacy Program.
    • VHA did not effectively issue and implement adequate policy, monitor complaint practices, and provide guidance to medical facility directors responsible for local program management.
    • Patient advocates did not always enter complaints into the system.
    • Even though complaint records generally appeared to be closed on time, patient advocates did not always document the communication of the outcomes to the complainants.
    • The VA-OIG substantiated an inadequate program policy to identify clear expectations and responsibilities.
    • The VA-OIG found that they (patient advocates) did not always adhere to the documentation requirements to show full complaint resolution.
    • At the local and VISN levels, responsible personnel did not consistently analyze patient advocate tracking system complaints about trends.

Feel free to read the complete abomination of designed incompetence for yourself.  Essentially the VA-OIG concluded that the VHA has been burning taxpayer money in a patient advocacy program, and the designed incompetence is so apparent it can be tracked from L2, where the James Webb telescope is located!  Worse, you won’t need the James Webb telescope to see the designed incompetence!James Webb Space Telescope

Unfortunately, I could have guessed the first three findings without looking.  Every VA program is designed so ineptly, reprehensibly led, criminally incompetent, and with such dastardly deceptive doings that fiction writers’ storylines have to be written better to sell books.  You cannot make this stupidity up and make a profit.  Hollywood would run screaming into the night if they made a true story about the ineptitude found at the VA!

Knowledge Check!Elected officials, where are you?  The VA-OIG presents copies of their findings to you, and I have yet to witness a single one of you holding the VA Leadership criminally responsible for the failures at the VA.  Even when the VA is killing hundreds of veterans, the US Congress refuses even to act upset, let alone scrutinize for a change!  Remember how many veterans were intentionally killed in Phoenix waiting for treatment?  How many VA employees lost their jobs and pensions or were forced in front of a judge for murder?  It is a fair question, where are the elected officials in the legislative branch working to end the criminal “fraud, waste, abuse,” and designed incompetence in the executive branch?

© Copyright 2022 – M. Dave Salisbury
The author holds no claims for the art used herein, the pictures were obtained in the public domain, and the intellectual property belongs to those who created the images.  Quoted materials remain the property of the original author.

“That’s Crazy!!!” – More Chronicles from the VA Chapter 5

I-CareI had originally planned on writing something else today, but my mental train was derailed, caught on fire, and I had to change my plans.  18 March 2022, I received an email signed from Sonja Brown of the Albuquerque VAMCS, who discussed how it takes 10-20 years for the VA to make a decision about which clinics to close, how to build new clinics, and the possibility of change (not) occurring in the New Mexico VA Medical System.  Doesn’t that warm your heart; two decades is a maximum timeframe for ending unprofitable clinics to save the taxpayer money.  Now multiply this problem by every government agency, and we find the reason for reducing the government bloat!VA 3

Luckily, I still have VA-OIG reports to discuss, not that I got behind, but February and March have been especially prolific.  In January, the pace set appears to be sustained, at least for the first quarter of 2022.  Some have commented that I do not write very often about the National Cemetery side of the VA’s voluminous bureaucracy.  Your wish is granted; a whistleblower reported that the Houston National Cemetery was not being operated properly.  The VA-OIG substantiated “some of the claims made by the whistleblower.”  However, the leadership at the Houston National Cemetery had, for the most part, already begun making changes before the VA-OIG arrived.

Thus, I congratulate the Houston National Cemetery leadership for being almost proactive and 100% more responsible than any leadership in the VHA and VBA.  My heartiest gratitude to you and your staff.  May you continue to show initiative, forward-thinking, and attention to detail, and may the rest of the VA’s hegemonically impotent leaders learn from your example.VA 3

A Comprehensive Healthcare Inspection (CHIP) was conducted at the James J. Peters VAMC in the Bronx, NY.  While a lot of the report is cookie-cutter, similar to all the other CHIPs that cross my inbox, I remain fascinated with a frequently used term from the report, “Servant Leadership.”  From the website linked, we find the following to define “servant leadership” at the VA:

We are all leaders, all of the time.
Servant Leadership is an approach for optimizing the delivery of client-centered services by strengthening employees to be an engaged and empowered workforce.  The philosophy and practice of Servant Leadership is one that emphasizes caring, authenticity, and putting clients and employees first, and ahead of personal goals or leadership aspirations.  Servant Leaders strive to meet both organizational objectives and the growth / development of their workforce.”

Please note ALL the grammar and punctuation errors are included in that quote.  Far be it for me to pass along any advice on grammar, spelling, punctuation, and proper communication techniques.  But, even this quoted material reflects the fact that there is a Grand Canyon-like chasm between DC leadership and the worm’s eye-view in a VA Hospital, VBA operations center, or the National Cemetery.  Be a leader at the VA, and you will NOT last your probationary period after hire; I have experienced this personally!VA 3

Worse, try and help the VA from the worm’s eye to see the problems and fix the issues, and the VA Leadership will chop you into little tiny pieces and feed your carcass to the fishes.  Yet, every single CHIP report mentions problems with “servant leadership” as opportunities for growth and development.  More bureaucratese for designed incompetence as an excuse, the VA-OIG will believe.  How sick to death I am of these shenanigans!  Don’t believe me; check out the full CHIP report, it’s linked above, read a few of the other CHIP reports from the VA-OIG, and discuss the actual problems you think the VA is experiencing.

Servant Leadership is officially defined, by Purdue University, quoting Robert Greenleaf from 1970, as:

The servant-leader is servant first.  It begins with the natural feeling that one wants to serve first … a philosophy and set of practices that [enrich] the lives of individuals, builds better organizations and ultimately creates a more just and caring world.”

Notice a problem between the two definitions of servant leadership?  Recognize an issue yet with the entire concept of servant-leadership?  Let me give you a hint through a question, What does a “just and caring world” really define?  The whole concept of servant leadership is easily twisted, plasticized, and framed in a way that removes liberty, destroys justice, and wrecks havoc on a free society, all because the philosophy sounds good, but the practice leaves chaos and destruction in the name of creating a more just and caring world.Servant Leadership and Health Care: Critical Partners in Changing Times

I am not condemning anyone who wants to try and improve their leadership skills through learning servant leadership or applying some of the servant leadership philosophies in their leadership toolbox.  I am merely stating that care and caution should be used when trying to reshape the world on such ambiguous and amorphous terms as “just and caring.”  The VA is trying to force a leadership template for all leaders to follow.  This type of leadership philosophy warps the world and makes leaders into managers with excuses for failure, e.g., designed incompetence.

On a different topic, please read the following carefully:

The VA Office of Inspector General (VA-OIG) reviews nonpharmaceutical proposals submitted to the VA National Acquisition Center (NAC) for Federal Supply Schedule (FSS) contracts valued annually at $10 million or more for high tech medical equipment, $3 million or more for all other FSS contracts, $100,000 or more based on manufacturer sales under dealers or resellers, or as requested by the NAC.”

Here is why the above is critical:

The VA-OIG determined commercial disclosures were accurate, complete, and current for only 24 of the 103 proposals reviewed.  This means 24 proposals were reliable for determining negotiation objectives and fair and reasonable pricing.  The remaining 79 could not reliably be used for negotiations until the noted deficiencies were corrected.  The OIG recommended lower prices than offered for 76 proposals.

If you, in your employment, had a 23% accuracy rate, and someone else had to come behind you, redoing all of your work, how long would you last in your job?  Note there are still 3 proposals that do not meet regulations and requirements out of 103 contract reviews.  Read the rest of this incredible report for yourself and know what your elected representatives are failing to curtail and control.  Then answer the following question: “Why should we re-elect ANY of the current elected officials?”VA 3

On the topic of designed incompetence of an almost criminal nature, we find the VBA still making headlines and breaking rules of ethics, morals, and logic with aplomb!  Before getting into the VA-OIG report, it is crucial to note that the VBA has exclusively gone to a third-party model for Compensation and Pension exams.  The most important part of the VBA’s operations, the comp and pen exam, is now conducted solely by third-party contracts companies.  A VA doctor sees a person trying to get their benefits from the VBA no longer but a third-party physician’s assistant at best, who is (supposedly) overseen by a medical doctor.  The lack of transparency and the complicated processes of the VBA are gordian, and transparency is hidden; read that as missing entirely.You know it's true - Imgflip

Here comes the VA-OIG, not to the rescue, but to rub salt into the wounds of veterans whose claims continue to be denied for lack of evidence.

“[The] VBA complied with the requirements of the law by reinstating 69 questionnaires on its public-facing website.  However, disability benefits questionnaires that were incomplete, inaccurate, or of questionable authenticity from non-VA medical providers were not always processed correctly when determining benefits entitlement—causing underpayments of about $13,900 and overpayments of $74,800 over the nine months studied.

Improper processing occurred because VBA lacked sufficient controls to ensure disability benefits questionnaires from non-VA medical providers were properly relied on when determining entitlement to benefits.”

Let’s let this sink in for a moment.  The VBA moved to a third-party model, then denied access to the VBA’s questionnaires to determine benefits, then had to be forced to reinstate the questionnaires.  Improper VBA processes and procedures led to over and underpayments of benefits, and claims processors still do not have the tools to make informed and logical decisions reliably.  Best of all, veracity (questionable authenticity) remains questioned in the process when the third-party contractor submits the forms for benefits.VA 3

You cannot make this stuff up; fiction writers can come nowhere close to creating a story this inane!  Is designed incompetence as a concept clear now?  The VBA developed a process using a more expensive model and then questioned the inputs for veracity from the contracted party, and the veteran suffered more!  Do you think the VBA intentionally designs its processes to help and create a more just and caring world (servant leadership)?  I think the VBA intentionally designed their processes to screw veterans in the hope they die before the government ever pays money on their claims.  Let me know what you think in the comment section, for this is a travesty of justice anyway I slice the data.

As a veteran who has been trying to get a compensation and pension decision corrected since leaving the service in 2004, having suffered both overpayments, which I had to repay, underpayments, and erroneous overpayments where the funds paid were (eventually) refunded, the news from the VBA designed incompetence is a particular form of hell for me to read and discuss.  I have had the third-party comp and pen exam doctors refuse to see me three times in the last two years.  Delaying a VBA decision repeatedly.  I have had the VBA reject the third-party data and a new comp and pen exam scheduled, rescheduled because I cannot wear a mask, and then conducted by a hostile and infuriating provider who refused to listen to the patient.Are you an Incompetent Developer? - Web Development & Web Design Blog

When veterans talk about fighting the VBA for a fair and honest decision, they mean a literal fight!  Don’t take my word for it; ask veterans how their comp and pen exam has gone; when you find those struggling with the VBA, listen carefully to their stories, and you will hear very similar stories.  The VBA represents government inefficiency, designed incompetence, and bureaucratic inertia to the Nth degree!

The following link might, or might not, work as intended; the link directs you to all testimony recorded from congressional hearings.  If it works, you will be able to read the statement of David Case, Deputy IG, who was testifying before the HVAC subcommittee on drafted legislation “Quality Education for Veterans Act of 2022”.  A brief synopsis from his testimony is included below:

This bill would significantly strengthen the OIG’s efforts to prevent fraud in VA’s education and training programs.  Given that more than $10 billion in taxpayer funds is expended on education and training programs each year and hundreds of thousands of veterans, service members, and family members receive these benefits, the OIG supports efforts to strengthen programmatic and beneficiary protections.  The statutory changes in the draft bill do not appear to be burdensome or costly to educational institutions or VA, and yet they have the potential to make a significant impact on the amount of education fraud that occurs.  The OIG agrees that these changes would work to lessen the harm suffered by veterans and beneficiaries and reduce losses to the government.”

Ever wonder how much a VA-OIG inspection costs or where and how the VA-OIG is funded; here is the answer and the problem.  Tell me, why is the VA-OIG not financed from the VA budget?  Simple question, not hard, and requires an explanation!  The explanation should be detailed, transparent, and I guarantee that the answer will reflect the designed incompetence and failure to scrutinize the executive branch adequately.  The VA is one of the few, if not the only, Federal Government Agency with a specialized inspectorate general, dedicated solely to independent oversight and continuous improvement of the VA.  I think the VA-OIG might be failing in its mission.VA 3

Fraud is rampant in the VA because the VA refuses to act, work, change, and improve.  How will throwing more money at VA programs alleviate the hurt, stop the fraud, and spur continuous improvement?  Almost every week, my inbox fills with accounts of fraud occurring, but the roots of the problems are never addressed, and people are not held accountable for failing to perform the work they were hired to complete.  Failing to hold people responsible promotes fraud, waste, and abuse.  Allowing whistleblowers to be fired promotes a discouraged whistleblowing culture, and the perpetrators are allowed to continue their nefarious misdeeds!  How is the VA-OIG going to tackle these systemic issues in the culture at the VA?  When will continuous improvement begin; I do not want to miss growth and development!

Knowledge Check!America, the VA is sick.  A symptom not a disease; the larger disease is a refusal to act morally upright.  The majority of those employed in the behemoth of government service have little to no moral compunction, are not servants of the taxpayer, and consider themselves “Too BIG to fail.”  We need a smaller government, and I hope this message helps enlighten and support shrinking the government!

© Copyright 2022 – M. Dave Salisbury
The author holds no claims for the art used herein, the pictures were obtained in the public domain, and the intellectual property belongs to those who created the images.  Quoted materials remain the property of the original author.

“That’s Crazy!!!” – More Chronicles from the VA Chapter 4

Last week, my primary care provider informed me that the VA is no longer responsible for providing my prescriptions as an outside provider that the VA Community Services team sent me to has increased my dosage.  My primary care provider pulled a Pontius Pilot and washed her hands, and I am swinging in the wind with more bureaucracy and less service.  The best part of the news delivered this last week, the fallacious, seditious, and felonious attack on my character, the behavior problem flag, is controlled by the primary care provider.  Boy, I am sick of the bureaucracy of the VA; if only this were the worst of the bureaucratic baloney, the VA is pushing out.

From many VA-OIG reports during COVID, the following, or something close, was a regular statement:

During COVID-19, VHA’s Office of Community Care (OCC) took steps to ensure veterans continued to have expanded access to health care in the community, as required by the VA MISSION Act of 2018.  OCC issued policies to VA facilities to postpone non-urgent appointments and offer alternatives to in-person care, such as telehealth.”

The VA-OIG inspected to see how closely this statement was adhered to during the height of the COVID pandemic.  What surprises no one is how badly the VA managed community care during the pandemic.

Findings:

    • The VA-OIG found that routine community care consults were unscheduled, averaging 42 days, not meeting VHA’s timeliness goal of 30 days.
    • Community care staff faced significant challenges beyond their control that contributed to the scheduling delays, such as the lack of availability of appointments in the community.
    • Some patients were hesitant to schedule appointments during the pandemic, failed to return phone calls, or declined care once it was offered. – While some of this is definitely patient-driven, what is not discussed is the abrupt shift, the lack of trust, and the confusion about the need to pay the community providers, among other things, faced by veterans forced into community care. As a reference point, it has been 24-months, and I am still facing requests to pay several community providers due to the VA not paying the bill due to a technicality.  The VA claims the provider has to “eat the costs,” but I keep getting statements and calls from collection agencies.  Guess the direction of my credit score, the direction of my insurance costs, and how happy I am with community care providers.
    • The VA-OIG found community care providers and staff did not consistently comply with requirements to manage routine consults, and leaders lacked tools to sufficiently monitor program operations that could have identified the problems.
    • Deficiencies emerged in documenting when patients were contacted about scheduling appointments, designating patients eligible for alternative care, and ensuring staff was trained in ways that would address those weaknesses. – Not to mention that pertinent medical records still haven’t been transmitted, received, and alerted the primary care provider. I had gallbladder removal surgery; no records ever made it to the VA.  I have MRIs, CT scans, and ER notes that, even after being hand-delivered, have not been added to my VA electronic health record and presented to the primary care provider to discuss, dating back to 2010.

How’s that community service program working for you?  In any other industry, this performance would represent an abysmal failure; but community care represents a healthy opportunity for improvement at the VA.  The findings listed are a mere drop in the conclusions discussed in the report.  I have a suggestion for the VA, stop overpromising and underdelivering.  How about you under-promise and then over-deliver?

The following VA-OIG inspection report focused on the Veteran Health Administration facility’s adherence to guidelines for medication management, and the following explanation is quoted from the report:

This report describes medication management findings from healthcare inspections initiated at 36 VHA medical facilities from November 4, 2019, through September 21, 2020.  Each inspection involved interviews with facility leaders and staff and clinical and administrative processes reviews.  The results in this report are a snapshot of VHA performance at the time of the fiscal year 2020 OIG reviews.”

Before we get into the findings, let me elaborate on that statement.  The VA-OIG cherry-picked/hand-selected call it what you will, the facilities to inspect.  No criteria discuss how these facilities were selected.  More, the processes chosen for review were also cherry-picked/hand-selected.  Appearing to represent that, the VA-OIG stacked the deck to obtain success, and the VHA still failed, or rather showed weaknesses.

Generally, the VA-OIG rated the VHA facilities as “compliant.”  But “weaknesses” were identified; read that as the VHA cannot follow established guidelines, protocols, and processes, even though they wrote and established these guidelines and medication protocols.  I call this designed incompetence of a criminal nature, but I am not half as lenient and politically astute as the VA-OIG!

Findings:

    • Aberrant behavior risk assessments
    • Concurrent benzodiazepine therapy
    • Urine drug testing
    • Informed consent
    • Patient follow-up
    • Quality measure oversight.

The following, also from the medication’s adherence inspection, remains significant:

“The OIG examined the following indicators of program
oversight and evaluation:

      • Performance of pain management committee activities
      • Monitoring of quality measures
      • Following the quality improvement process”

For the weaknesses represented in the findings to be prevalent, the “Pain Management Committee activities” represent a general failure of the committee to function!  For quality processes to be a finding, monitoring quality signifies that the bureaucrats are NOT doing the jobs they were hired to perform!  A quality process fails when the humans tasked with oversight refuse to engage, and the VA-OIG findings testify to the truth of humans actively refusing to do their jobs individually and collectively!

Having read and written about the VA-OIG reports for almost ten years, I swear sentences containing the following represent a majority stake in why the VA-OIG cannot be trusted.

VA-OIG inspections… underscored the value of independent oversight of care received in these settings to help VA make continuous improvements.”

Really?  Are you sure the VA-OIG inspections provide “independent oversight” and spur “continuous improvement” at the inspected VA facilities?  I have significant doubts the inspections do anything more than highlight the problems as the VA-OIG inspectors have no teeth, and lying has zero repercussions for the humans defrauding the taxpayer!  How do I know this; the VA-OIG reports generally go on to make a claim similar to the following:

The OIG’s findings show that immediate attention is needed in several critical areas….”

Do you, the dear reader, understand better the frustration of veterans and their families?  When the Office of Inspector General (OIG) for the Department of Veterans Affairs (VA) covering the National Cemeteries, Veterans Benefits Administration (VBA), and Veterans Health Administration (VHA), can be deluded, distracted, and duped by conniving and conspiring people, what else can the veterans and their families do BUT become frustrated?  This is behavior unacceptable in every industry.  In fact, legislation overseeing non-government healthcare is strict in outlawing the conduct observed in government-provided healthcare, but somehow the VA is exempt.  Yet, the VA continues to make claims such as the following:

This is how the VA is delivering on its promise to care for the veteran who has borne the battle, his widow, and his children.”

But don’t take my word for it; the VA-OIG conducted several more Comprehensive Healthcare Inspections (CHIPs), resembling cookie-cutter inspections.  Staff training continues to be a major delinquency labeled as “High-Risk.”  Behavior Committee continues to be a central sticking point and inspection problem.  Cleanliness, tagged under “Quality, Safety, and Value,” continues to represent an area for growth and development.  Nurse-to-Nurse communications remain constant as a problem, and electronic medical records are not helping to improve on this problem.  Inter-facility transferring of patients, policy, and documentation also resemble a constant issue.  I feel like I could summarize a CHIPs report with my eyes closed; tell me, when does the “independent oversight” spur “continuous improvement?”

On the topic of “independent oversight” spurring “continuous improvement,” the VA-OIG conducted a VHA inspection of mental health activities for FY 2020.  Declaring:

This report describes mental health-related findings from healthcare inspections initiated at 36 Veterans Health Administration medical facilities from November 4, 2019, through September 21, 2020, and electronic health record review at five additional facilities.  Each inspection involved interviews with facility leaders and staff and clinical and administrative processes.”

Again, how the facilities were selected and the items reviewed appears to have stacked the deck in the VHA’s favor.  The VHA is still failing, showing weakness while generally being compliant.

Findings:

    • Completion of four follow-up visits within the required time frame
    • Appropriate follow-up of veterans with high-risk patient record flags who do not attend mental health appointments
    • Suicide prevention training
    • Completion of five monthly outreach activities.

Under these four categories, recommendations for improvement included:

    • Registered Nurse Credentialling – Source verification of licenses.
    • Staff training on Suicide Prevention
    • Care Coordination – Especially in transferring the patient, form completion, and evaluating transferred patients
    • Medication list transmission during transfers
    • Staff Training
    • Patient notification
    • Attending the Disruptive Behavior Committee

For anyone else keeping record, most of the list above is a repeat from the last several years the mental health inspection has occurred.  Color me shocked that the VA would still have issues remaining year-over-year, and if you cannot hear the sarcasm in that statement, I have some suggestions for you!

I am thoroughly sick to death of the VA failing in its mission, then bragging they are providing “Excellence in Healthcare.”  If the staff is not trained, they cannot perform their jobs, representing a leadership failure.  This is a truth for all industries, occupations, businesses, organizations, etc.  Nobody is exempt from this statement of fact, yet the VA-OIG keeps on swallowing this excuse year-over-year, and NO PROGRESS is EVER made!

America, are you aware of what the various government agencies are doing with your money, on your time, and with your consent?  If your neighbor took your checkbook and wrote checks you are legally responsible for paying, would you want better services rendered?  Elected officials (yes, I am including those at the city, county, state levels of government), why are you NOT scrutinizing the government more effectively and rigorously?  You, the elected officials, are the neighbor writing checks; why are YOU NOT doing the job we hired you to perform?

Elected officials, did you know that VA is not required to maintain records of returned bills, as a matter of policy, but those returned bills mailed to veterans are causing hardship for veterans.  I cannot recount how many times I have changed my address and my spouse’s address with the VA, on the VA-approved websites, and in-person with VA representatives, and still have had mail not delivered for months due to a wrong address in a legacy system.  Yet, the VA is not policy mandated to check returned mail, track that mail to a veteran, and check the different legacy and non-legacy systems for address veracity.

Elected officials, do you read the VA-OIG reports?  Honest question, as the following is directly from a VA-OIG report.

“[VHA primary care] providers did not consistently

        • Identify a surrogate should the patient lose decision-making capacity
        • Address previous advance directives, state-authorized portable orders, and/or life-sustaining treatment plans
        • Address the patient or surrogate’s understanding of the patient’s condition.”

The VA designed the PACT Team to improve care and deliver on the VA’s mission, yet the primary care provider has the following failures weaknesses showing.  The VA-OIG can do nothing to improve this glaring oversight, but you were elected to force change and spur “continuous improvement” in the executive branch officers and employees.  Well, where are you?  The VA-OIG substantiated that a failure in the PACT team led to a delay in a cancer diagnosis, causing increased pain, problems, and resource loss for a veteran; where are the elected officials, and the media for that matter, in raising a holy rhubarb on the PACT Team failing this veteran?

Elected officials, did you catch that statement in the VA-OIG report on the cancer diagnosis?

Facility leaders have an unwritten expectation that primary care providers conduct a thorough historical review of the patient’s electronic health record starting with the most recent annual note; however, the OIG found that not all of the patient’s providers conducted historical reviews, but instead focused on current issues and problems identified by the patient.”

Having transferred between PACT teams inside the VHA and state-to-state, I can affirm this is exactly what is transpiring in the PACT team; the second most important player, behind the patient, is the primary care provider.  When the primary care doctor fails in their job, like dominoes falling, the care of the patients rapidly cascades into a dynamic failure of healthcare in a VHA facility.  What are YOU doing to stop this madness and demand accountability?

The electronic health record has a section near the top of the record for “Problem List.”  Guess what; when providers fail to keep this section updated, current, and accurate, the healthcare of the patient borders on malpractice requiring only a slight push to arrive with a dead veteran.  The VA-OIG found providers and nursing staff failures to update the problems list accurately, keep the problems list current, and regularly discuss the problems list with the most critical member of the PACT team, the patient!  Providers failed to comply with sound science, good business practices, and act appropriately for the patient’s health; do you think this might be a slight problem in the PACT team?

I have offered the VA several suggestions for plotting a path forward.  Yet, the VA cannot and will not take advice without stern and reproachful measures taken by Congress.  Elected officials, it is time for you to act and groundswell the changes needed in every government agency, even if it means reducing the size of government!

© Copyright 2022 – M. Dave Salisbury
The author holds no claims for the art used herein, the pictures were obtained in the public domain, and the intellectual property belongs to those who created the images.  Quoted materials remain the property of the original author.

The Year-End Maelstrom! – More VA Shenanigans! (Where is the accountability?)

2021 has finally ended, but before it ended, the Department of Veterans Affairs (VA) – Office of Inspector General (VA-OIG) increased the pace, and the following is but a taste of the year-end insanity foisted into my inbox.  With more than 45 emails to sift thru, some of the topics had to be culled, and I regret that I had to cull the emails.  Each and every VA-OIG report deserves to be scrutinized, evaluated, and the actors punished, many times with criminal court.  I don’t know what’s worse, summating these stories or getting hit with a truck; seeing as I have been hit by a truck, I think the truck is easier.

We begin the recount of VA-OIG stories with another veteran, deceased because the VA Medical Center refused to do their job and provide continuity of care after a 33-day hospital stay.  Leaving me wondering if this was intentional malpractice due to the cost of the veteran to the VA.  Listen to the findings of the VA-OIG, then make your own decision.

The Malcom Randall VAMC’s interdisciplinary team (IDT) failed to develop a discharge plan that adequately ensured patient safety and continuity of care.  The Malcom Randall VAMC did not have a discharge planning policy that outlined IDT membership, communication expectations, or roles in discharge planning.  The OIG found that the occupational therapy provider did not verbally communicate a new recommendation for a home safety assessment or take action to stop the discharge until the safety concerns were addressed.  Additionally, an attending physician failed to review written recommendations for home healthcare services from consultative and ancillary providers before composing the discharge plan for the patient.  The social worker, who had significant responsibility for ensuring the adequacy and safety of the patient’s discharge plan, also failed to incorporate recommendations by the occupational therapy provider and failed to discuss and offer home health services to manage the patient’s venous leg ulcer and monitor infection of the right leg.  The OIG also found that social workers did not consistently complete thorough and detailed psychosocial assessments that would be pertinent to discharge planning.

Remember when the media became hysterical when then VP Candidate Gov. Sarah Palin suggested ObamaCare would institute “Death Panels?”  Bureaucrats decided that the government had invested sufficient money into a patient and was going to stop providing medical care.  When this media hissy-fit was going on, I claimed that the VA had been exercising this right to discontinue care for a long time.  Several people took umbrage at this commentary; yet, what do we find from the VA-OIG, a dead veteran, five recommendations by the VA-OIG to do the job these “providers” were already hired to perform, and I am left thinking, “Death Panel in action.”

What else should I conclude with no accountability, responsibility, and consequences?

On the topic of holding a job with responsibility and not being held accountable, we find another hit to the VA and their lack of IT/IS security.  Desiring brevity but passing along factual information, the following summary has been condensed:

The Federal Risk and Authorization Management Program (FedRAMP) standardizes security and risk assessments for cloud technologies for federal agencies, including VA.  In April 2019, the VA Office of Inspector General (VA-OIG) received allegations that VA’s Office of Information and Technology’s (OIT’s) Project Special Forces (PSF) was not following FedRAMP policies or VA policy for deploying software-as-a-service (SaaS) applications.

      • The VA-OIG found that OIT granted security authorizations for applications FedRAMP did not authorize.
          • Eight of the nine applications cited by the complainant were used on the VA network—some without FedRAMP or VA authorization.
          • Another three applications were approved to operate on VA’s network without FedRAMP authorization.
      • The OIG did not substantiate that PSF-developed applications were improperly managed outside the VA Enterprise Cloud group.
      • PSF did not follow VA security requirements in developing interfaces that allow third parties to “plug into” the VA to send and retrieve data.
          • OIT personnel stated, “no formal OIT authorization process until April 2019.” After that date, the review team did not find instances of VA-authorized applications without FedRAMP authorization.
      • OIT staff “apparently” misunderstood the FedRAMP authorization requirements for SaaS applications containing data classified as less sensitive.

Please note if you think the VA IT/IS performance has improved since April 2019.  You are sadly mistaken, as in 2021, there have been three major VA-OIG reports declaring how IT/IS systems at the VA remain insecure, failing legislative mandates for basic security, and are hopelessly too expensive and useless.  I have two VA-Apps on my phone, both of which work “sometimes,” and never sufficiently support the end user.  Worse, these apps do not interface with the old software the VA is helplessly tied to while the new software continues to prove its uselessness and security problems in real-world beta testing.

Tell me, would you trust the government, any of the alphabet agencies, with your child to babysit?  If not, why do we trust the government to secure our identity?  If so, please elaborate, for I would love to know of a government/NGO operating with trust and efficiency.

Continuing under the heading of failure to perform the job hired for, we find the VA-OIG issuing a total of 20 recommendations to Vet Centers.  The Vet Centers included record keeping of suicidal veterans seeking mental health support as a point of reference.  Not for the first time, but I keep hoping it’s the last.  The VA continues to fail veterans, abuse veterans actively, and take advantage of veterans, and I remain unconvinced this torture of their customers is not intentional.  Maybe not all employees, for I have met some great employees, but the leadership appears hellbent on killing as many veterans as possible.

Why isn’t this big news, huge headlines, and a major story to the corporate media?  Where is the coverage?  You cannot convince me that 1)You are not aware of this story and 2) That you are unfamiliar with its implications.

VA statement on GPO printing and mailing delay

WASHINGTONDue to supply chain and staffing shortages, the vendor contracted by the Government Publishing Office to provide printing services for the Department of Veterans Affairs is experiencing delays in printing and mailing notification letters to Veterans and claimants.  The disruption may impact the ability of some claimants to meet required deadlines via written correspondence with the VA.

In response to the mailing delays and to protect the best interest of claimants, the Veterans Benefits Administration is extending its response period by 90-calendar days for claimants with letters dated between July 13, 2021, and Dec. 31, 2021.

For those not aware, everything in the bureaucracy abbreviated as the VA is time-sensitive.  Miss a deadline, and you have no opportunity to recoup lost time without investing significant amounts of resources.  Since I continue to be in an embroiled battle with the VA over not receiving a proper decision in 2004, time delays represent problems untold due to budget cuts and bureaucracy, and the VBA and VHA bureaucracies will do everything they can not to help you.  Then we add the time delays, and the consequences can be disastrous.  Think veterans dying with an active application for benefits, and you come close to how big this story is, and not covering it with wall-to-wall coverage is the epitome of lackluster asininity!

It took dead veterans on waiting lists to get bad press through the Media fawning over President Obama; what will it take to penetrate the media quilt for Biden?  Continuing under the heading of failing to do the job you were hired to perform, we find another VA-OIG comprehensive healthcare inspection (CHIp).  Guess what; this one is beyond utterly dismal and flagrantly reprehensible!

The administration and delivery of care to female veterans continues at its expected and atrocious, slovenly pace, being outstripped by one-winged butterflies.  How can the VA Leadership continue to keep their jobs when they allow such incorrigible behavior from lower staff members?  Would the elected Representatives and Senators address this question?  You were hired to scrutinize the government; that is the only other job you have after writing fair and equitable legislation to all citizens.  Why should you be re-elected when this behavior abounds, and you refuse to scrutinize the executive branch officers?

Consider the following,  “The VA-OIG audit team estimated that improper payments for acupuncture and chiropractic care amounted to about $136.7 million during fiscal years 2018 and 2019.”  Continuing, “The audit team also found that VHA did not always follow guidance when reauthorizing acupuncture and chiropractic care.  Not documenting assessments of prior treatments before authorizing additional care may interfere with veterans’ treatment.”  Failure to ensure your underlings have established proper processes and procedures that are effective and followed is a prerequisite to holding a leadership position.  Where is the leadership at the VA?  Where is elected representative scrutiny?  What are the consequences for doing a poor job of cleaning the house and protecting the taxpayer?

How big is this problem?  Try upwards of $341 Million, on top of the $136 Million already discussed, and before the full force and cost are known on delays in properly notifying veterans in a timely and efficient manner.

The VA-OIG audit team found that some providers are billing VA at a significantly higher rate for high-level evaluation and management services than their peers in the same specialty.  The team determined that in fiscal year (FY) 2020, more than 37,900 non-VA providers billed and were paid for significantly more high-level evaluation and management codes than were all providers in that specialty on average.  These non-VA providers received about $39.1 million (13 percent) of the approximately $303.6 million paid for all non-VA evaluation and management services.

Additionally, some providers billed separately for evaluation and management services when the global surgery package was in effect.  This package is supposed to cover all surgery-related services for a set period.  The review team identified more than 45,600 providers were compensated about $37.8 million in FY 2020 for these evaluation and management services.

Improper payments were not easy to detect because VHA staff did not retrospectively audit medical documentation as required.  Additionally, the OIG found no evidence that VHA or contractors trained non-VA providers on documenting evaluation and management services, similar to how VA providers are qualified.  The OIG determined VHA risked overpaying for evaluation and management services by about $19.9 million in FY 2020.”

While discussing audits, failed processes, and the lack of consequences for senior leadership, we must break and wish a “Happy Birthday” to the audit hits turning 10, 12, 15, 21, and older.  It never ceases to amaze me how these financial failures can continue to age, and nobody is held accountable!  May you age out and finally be corrected!  Would the elected leaders of America like to know why the VA is consistently failing financial audits?

VA continued to be challenged in consistently enforcing established policies and procedures throughout its geographically dispersed portfolio of outdated applications and systems.”

Now, explain why we should re-elect any elected official to office?

Elected officials, your job is to scrutinize and write legislation; that is what we, the electorate hired you to do.  Do you realize the far-reaching consequences of your failure to perform your job?  Let me introduce you to an example:

Anthony Medrano, a veteran of the US Marine Corps and former employee of VA, admitted that between approximately November 2015 and May 2020, he submitted claims to VA in which he purported to be disabled to obtain caregiver benefits for his wife, when he was actually able-bodied and even participated in fitness challenges and coached youth sports.  Medrano was sentenced in federal court to eight months in custody for defrauding VA out of more than $183,000.  He executed this scheme while employed by VBA as a veterans service representative, a position in which he explained benefit programs and entitlement criteria to veterans applying for VA benefits.”

Or the following:

Barry Wayne Hoover of Tampa, Florida, a veteran of the United States Navy, exaggerated the extent of his visual impairment to receive VA disability benefits to which he was not entitled.  Specifically, Hoover manipulated the results of subjective tests of his peripheral vision to reflect that he had only a five-degree visual field and was legally blind.  VA found that Hoover was 100 percent disabled based on those manipulated tests.  Hoover was found guilty of theft of government funds and making a false statement to a federal agency.  He faces a maximum penalty of 10 years in federal prison.  His sentencing hearing is scheduled for March 2022.”

How about this:

Professional Family Care Services, Inc. (PFCS), a home health services company based in Fayetteville, North Carolina, has agreed to pay more than $45,000 to settle civil False Claims Act allegations related to fraudulent billings for work by a recently convicted felon under their employ.  During 2015 and 2016, PFCS billed VA for home health services provided to W.R., an Army veteran, even though, at that time, W. R. was residing with the company’s employee, Certified Nurse Aide Tracey McNeill.  PFCS based its billing for those services on falsified timesheets provided by McNeill, who failed to provide both the time and quality of care required under the VA program.  After several months living with McNeill, purportedly receiving home health services provided by McNeill through PFCS, W. R. had to be admitted to the hospital.  He was extremely malnourished and ultimately died within a few days of admission.  Earlier in 2021, McNeill was convicted of wire fraud for her misconduct related to W. R., sentenced to 12 months and one day in federal prison, and ordered to pay over $90,000 in restitution.”

Morality is exemplified by leadership and then exercised under scrutiny.  Because you, the elected officials, refuse to be morally upright and scrutinize the government, the executive branch officers and employees have become careless, irresponsible, and taken the American Taxpayer for a ride!

Each time the VA-OIG reports an investigation beginning with the death of a veteran, the root cause is always a failure of people to do the job they were hired or contracted to perform, and the casualty is a dead or severely injured veteran.  The culling of the email included a urologist who performed procedures, puncturing internal organs, and not notifying the patient.  Several other CHIp summaries reflected the egregious and despicable leadership hidden at VHAs and VAMCs across the country.  Other Vet Centers possess failing bureaucrats just trying to hide until they reach retirement and escape.

America, you deserve better from the alphabet agencies representing the executive branch!  Fellow veterans, please do not give up hope; we can still help protect this country from those enemies domestically located who make your lives a living hell.  Please pass the word, these VA-OIG investigations deserve to be read, and questions asked!  Elections are coming; join the fight as a citizen and run for office.

© Copyright 2021 – M. Dave Salisbury
The author holds no claims for the art used herein, the pictures were obtained in the public domain, and the intellectual property belongs to those who created the images.  Quoted materials remain the property of the original author.