It IS ALL About Leadership – More Shameful VA Chronicles

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Glory and Gore go Hand in Hand – Stating the Obvious

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

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

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

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

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

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

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

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

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

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

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

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

From the VA-OIG Report:

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

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

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

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

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

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

Sometimes, You Have to – More Repugnant VA Chronicles

Angry Wet ChickenIn looking back, it has been a long time since I wrote two scathing chronicles about the Department of Veterans Affairs (VA) in a single week.  But, I could not allow these Department of Veterans Affairs – Office of Inspector General (VA-OIG) reports to age any longer in my inbox.  With the Fourth of July fast approaching, as you celebrate, please keep in mind what the VA is purposefully doing to the Veterans, Dependents, and Spouses under their care.  America would not be here without her military, and military service produces veterans.  But, the VA is producing bodies and bureaucracy instead of helping veterans as they are paid and legally charged to do!

When I first left the US Army, I found myself employed in a telemarketing call center and was never paid the correct amount.  18-months later, I was employed with an Internet Service Provider, who bounced multiple paychecks before going bankrupt underneath the employees.  When the VA-OIG reports part-time physicians not being appropriately paid, I can understand the issues this causes.

I-CareThe VA-OIG randomly selected 134 salary agreements for part-time physicians on adjustable work schedules and found 44% of the physicians were either over or underpaid.  One might ask how and why these pay errors occurred.  The answer is extreme designed incompetence, not that the physicians will feel any better that they were either overpaid and owe back monies or underpaid and are now owed a considerable check.

From the VA-OIG report, we find the following as causes for the discrepancies:

This occurred because key management controls were missing or not working. Officials did not make certain that medical facilities complied with policies and procedures. Consequently, the OIG estimated VHA medical facilities had about $8.3 million in questioned costs that year (2019) and an additional $8.3 million in 2020. VHA medical facilities also may have violated the prohibition against voluntary services, and potentially the Antideficiency Act, by not correcting underpayments or by having physicians working above the 1,820-hour cap because their agreements were not properly reconciled” [emphasis mine].VA 3

The government officials’ neglect, malfeasance, and misfeasance might be illegal, as they failed to do their jobs properly.  Yet, the VA-OIG only issued recommendations.  There is potentially $16.6 Million in over or underpayments at stake, plus illegal actions, and people have not been fired or perp-walked into custody.  How can government employees get away with behavior that would have seen class-action lawsuits, criminal investigations, media reporting feeding frenzies if similar had occurred anywhere in the private sector?

IronyYet, the marketing materials produced by the Department of Veterans Affairs – Veterans Health Administration, a division of the VA, claims this is “Defining Excellence in Healthcare in the 21st Century.”  If you believe that, then you must believe that buffalo wings come from flying buffaloes.  Unfortunately, the problems only continue to worsen.

The VA-OIG reports that a doctor had accumulated more than 4000 alerts from the electronic health record (EHR) system.  This means that the computer system notified the doctor that patients needed care, appointments, were seen in the ER, required treatment, pharmacy prescription renewals, and much more.  The alerts, called views, are a built-in measure to help patients not get lost or have “adverse clinical outcomes” while receiving care at the VHA.  The VA-OIG found that the entire medical facility at the Charlie Norwood VAMC in Agusta, Georgia had similar issues.  The doctors were not viewing the patient EHR views as indicated.VA 3

What’s worse, the VA-OIG could not tell if “adverse clinical outcomes” had occurred because once the EHR views are settled, there is no record of the patient or why the view was required.  Talk about accountability, responsibility, and transparency in the patient-aligned care team (PACT).  In reading this VA-OIG report, it looks like when the facility leadership was alerted the VA-OIG was coming, the leadership team did a massive clean-up of the records, knowing they would never get caught and held responsible for any “adverse clinical outcomes.”  As a side note, the VA-OIG report claims the doctor with 4000 views is no longer providing care at this VA facility.  Heaven help his patients wherever this doctor is now!PACT 1

So far in 2020, I have had two different primary care providers assigned, and since moving out of Arizona, I will shortly have a third assigned to me.  My first primary care provider retired, but before doing so, he set up many EHR problems for his replacement to handle.  Including refusing to renew prescriptions, some of which were mine, which caused weeks of not receiving the proper medications.  Upon learning of my impending move, my second primary care provider essentially wiped her hands of my care, leaving me without medications and a clinic to contact for help.  Great job if you can get it; get hired to treat patients, and then not treat patients.  Before you ask, no, knowing I am not alone in this ordeal does not help!

PACT 3Finally, the VA-OIG has completed a full VISN wide comprehensive healthcare inspection (CHIp) for VISN 10.  VISN 10 covering Ohio, Indiana, Michigan and is located in Cincinnati, Ohio.  For all intents and purposes, the CHIp went well; the leaders are competent and knowledgeable.  Thus, I issue my sincerest congratulations to VISN 10 for their success.  The VA-OIG inspected the VISN’s ability to respond to the COVID pandemic appropriately, and the VISN performed well.

VA 3Except, this opens a few questions needing address.  At two VISN 22 and two VISN 17 facilities, I have experienced four utterly different responses to the COVID policy and masking mandates.  None of the facilities have written guidelines that are geographically specific to the patients and weather patterns in those areas.  None of the facilities have documented processes for veterans who cannot wear masks, with an approved policy supported, written statement for accommodating these veterans.  One facility insists that the veterans who cannot wear masks be arrested, cited, and fined.  One facility insists that if you have a letter from your doctor, you are okay.  One facility vacillates wildly from day-to-day and person-to-person, and the fourth facility doesn’t have a clue but is still very helpful, with supervisor approval.Question

Yet, somehow, VISN 10 has all their VAMC’s and VAHCS’ operating to the same sheet of music and behaving similarly.  How is this possible VA-OIG?  Better still, how does this spread out to other VISN’s and facilities?  May I hazard a guess, based solely upon the perceptions of veterans in VISN 10, the masking policy from COVID remains haphazard and improperly applied because Washington, DC, never issued proper guidance in the first place, the VISN leaders never issued written guidance.  The policy process on the local level is a quagmire of egos, bureaucracy, unions, all set into a cesspit of inaction and designed incompetence!  If COVID has taught any lessons, the number one lesson has to be that the leadership at the VISN and local levels remains inadequate to the task they were hired to perform!

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

I do agree with Justice Oliver Wendell Holmes’ statement:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Weep America! – The VA Leadership is Becoming Worse! – Part 1

Angry Wet ChickenThe Department of Veterans Affairs (VA) has really outdone themselves this week.  I am used to being ashamed of what passes for leadership and administrators at the VA, but this week, they have surpassed themselves.  The Department of Veterans Affairs – Office of Inspector General (VA-OIG) filled my inbox with seven investigations results, and the reports of leadership failure should leave every American weeping and madder than wet chicken with a raging case of hemorrhoids!

  • A Hope Mills, North Carolina man, Daniel Bruce Ross, was sentenced today to 24 months in prison for conspiring to accept bribe payments in exchange for the performance of official acts while working as a federal government employee. Ross previously pled guilty to the charge.  He was also ordered to pay $21,520.00 in restitution.”

Accepting bribes, shameful misconduct, and while I certainly agree with the need for punishment, why does this sentence appear light?  Did the bribe recipient make a deal?  If so, as Paul Harvey would say, “Where is the rest of the story?”

VA 3The Department of Veterans Affairs – Veterans Benefits Administration (VBA), had their quality assurance program inspected, and the results, oh these results… the VBA administrators should be fired!  There are no excuses sufficiently valid to hide this behavior!

  • To ensure claims decisions are accurate and consistent so veterans receive the benefits to which they are entitled, VBA established a multifaceted quality assurance program. The VA Office of Inspector General (VA-OIG) reviewed the quality assurance program and identified a systemic weakness in oversight and accountability… The VA-OIG found that while VBA’s quality assurance program routinely identified claims-processing deficiencies and communicated results to internal and external stakeholders, the Office of Field Operations did not ensure that regional office employees took adequate corrective actions to address the deficiencies identified” [emphasis mine].

VA 3Did you catch that, the leadership who set up the quality assurance program, built into the program a loophole to allow them to not act upon the deficiencies discovered.  Talk about designed incompetence, ineptitude, and outright fallacious behavior!  When a bad decision is made by the VBA, especially due to poor quality assurance, the veteran is out time, money, and resources to gather “new and material evidence” to ask the VBA to review their original decision!  Never are the VBA employees who cost the veteran, ever held accountable, responsible, or made to suffer in kind for their atrocious behavior, and I want my elected representatives to start asking why!

VA SealThe failures of the quality assurance team are not new, 22 July 2020, the VA-OIG found:

    1. …QRT specialists did not identify a significant number of claims-processing errors that should have been identified. Based on a statistical sample, the OIG estimated that 9,900 of the 28,400 quality reviews (35 percent) completed during the review period contained missed claims-processing errors that should have been identified. Quality reviews with identified errors are routed to another QRT specialist for peer review to help ensure the cited errors are The OIG determined that the current peer review process was not adequate to identify errors missed during the initial quality review. In addition, performance reviews of QRT specialists did not promote competency, resulting in missed claims-processing errors.”
    2. Worse, in direct violation of VBA procedures errors identified by QRT specialists, were overturned by regional office managers with 870 errors found where 430 were overturned (49.43%). Why were the regional managers not fired for violating policy?  The VA-OIG continued, stating:

Reconsiderations are requested by employees when they disagree with a cited error. Errors affect employee quality for performance review purposes. The OIG found that VBA’s current procedure regarding requests for reconsideration did not promote objectivity or contribute to accuracy of decisions. In addition, incorrectly overturned errors resulted in inaccurate performance quality for employees.”  Can someone say, Quid Pro Quo?  Should not questions arise about cherry-picking results and holding people accountable?  What about the veterans affected by these quality errors?  Who fights for them when the VA-OIG reports these obscene details and failures in leadership?  Each incorrectly decisioned claim is going to hurt real people, where are the elected representatives?

    1. In reading this report, my favorite quote is made:

The OIG estimated that during the review period 2,000 of 4,400 identified errors (45 percent) were not corrected in a timely manner and 810 of 4,400 identified errors (18 percent) were not corrected at all. In addition, there is no process to confirm that corrective action was taken on error corrections. To maximize the effectiveness of the QRT program, additional oversight, objectivity, and accountability should be established.”  Can you say, “DUH!”  Talk about designing incompetence into a procedure to ensure no responsibility ever hits you, the process can identify errors, but cannot ensure the errors were corrected.  What an asinine and inane bureaucratic trick!

VA 3The following has been a review of the VBA’s quality assurance program, investigated in 2020, for failures of such immense magnitude that the VA-OIG returned, less than a year later asking questions about the VBA’s quality assurance oversight, and the problems only worsened as a deeper dive was made into what governs the quality program at the VBA.  Further supporting that the leadership IS the problem in every branch of the Department of Veterans Affairs!

Plato 2The following is a recap of findings by the VA-OIG regarding the continued mistreatment of VA Employees who report allegations of misconduct, retaliation, or poor performance of senior leaders, and other issues to the whistleblower program at the VA.  This topic is of particular interest to me, as when I called the VA-OIG regarding criminal misconduct by senior VA leaders, I was told since I was no longer an employee whistleblower protection do not apply and an investigation cannot proceed.  Since I had been reporting problems since 2018, I asked if those investigations would continue, and was told no, as I was no longer employed.  Hence, a loophole is built into the rules and policies, you have to somehow remain employed to be considered a whistleblower, but not just an employee.  You must be an employee who is not under probationary periods which can last from 1-5 years depending upon the position from date of hire.

Plato 3The following are findings highlighted from the report on the Office of Accountability and Whistleblower Protection (OAWP) and delivered to Congress:

    • Finding 1: The OAWP Misinterpreted Its Statutory Mandate, Resulting in Failures to Act Within Its Investigative Authority
      1. The lawyers were reading the policies and interpreting their intent too strictly and this was chilling whistleblowers at all levels of the VA.
    • Finding 2: The OAWP Did Not Consistently Conduct Procedurally Sound, Accurate, Thorough, and Unbiased Investigations and Related Activities
      1. The OAWP lacked comprehensive policies and procedures suitable for its personnel given that individuals’ reputations are at stake and whistleblowers’ identities must be protected.
      2. The OAWP did not have quality control measures. While some inadequacies were found by disciplinary officials and VA’s Office of General Counsel, this de facto oversight was not an effective or sustainable solution.
      3. The OAWP had failed to provide the staffing and training necessary to ensure it has the expertise, experience, and commitment that yield objective and thorough investigations.
      4. The OAWP had fallen short of its commitment to conduct “timely, thorough, and unbiased investigations” in all cases within its investigative jurisdiction.
    • Finding 3: VA Has Struggled with Implementing the Act’s Enhanced Authority to Hold Covered Executives Accountable
    • Finding 4: The OAWP Failed to Fully Protect Whistleblowers from Retaliation
    • Finding 5: VA Did Not Comply with Additional Requirements of the Act and Other Authorities
    • Finding 6: The OAWP Lacked Transparency in Its Information Management Practices

VA 3Is the problem clearer; the official investigative arm of the VA has the same leadership problems as the rest of the VA, and those leaders cannot, or will not, properly train staff to do their jobs!  How many employees have been unfairly dismissed by the VA because they reported to the OIG, like they are supposed to do, and retaliatory actions by senior leadership has cost them a job, their professional reputation, and the VA a chance to improve?

Knowledge Check!I can find no media discussion on this report to Congress where the elected officials took any action to hold anyone accountable.  The speech being reported is milk-toast solid and should have led to public remonstrations and it did not even cause a ripple in a toilet bowl.  Meaning that the legislation from 2017 and earlier is still being thwarted by the VA administration and administrators to the detriment of the VA and the employees discharged who did their job and reported on problems witnessed.

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

NO MORE BS: Revisiting the VBA and Spinal Claims Issues

VA SealOne of the Department of Veterans Affairs – Office of Inspector General (VA-OIG) reports I wrote about in 2019 was how the Department of Veterans Affairs – Veterans Benefits Administration (VBA) was inaccurately deciding spinal claims for veterans.  Apparently, the complexity of primary injuries and secondary problems was causing confusion at the VBA, and when the VA-OIG came around to investigate, 100% of the claims from 01 January to 30 June 2018 were inaccurate in some way, shape, or form.  The VA-OIG reviewed 62,5000 spinal injury claims in the designated window; 34,700 were incorrectly processed, with approximately 5000 receiving inaccurate decisions resulting in over or underpayments totaling $5.9 Million.  Thus, each of the 5000 veterans had about an over or underpayment of $1180; whether this is monthly or in total is not detailed.

Something to think about those 5000 veterans mentioned does not include the 29,800 veterans’ claims which contained processing errors that could have had a monetary effect on veterans.  The VA-OIG could not determine monetary over or underpayments on these 29,800 claims.  Hence, $35,164,000 in possible over or underpayments was still in question if the average per person holds from the 5000 mentioned above.VA 3

More details on the other 34,700 veteran claims incorrectly processed for these claims with processing errors, VBA staff decided on the claims before completing all required evaluation steps.  The Department of Veterans Affairs (VA) conveniently designs its processes to fail, and this is referred to as designed incompetence.  Think I am wrong; check out what the VA-OIG discovered as the root cause of incorrect spinal claims processing.

The OIG found that all incorrectly decided veteran claims resulted from VBA’s inadequate process for ensuring accurate and complete evaluation. The disability rating schedule—the primary criteria for evaluating disability—contains minimal guidance on neurological and peripheral nerves. A procedures manual detailing the rating schedule is too subjective about peripheral nerve disability evaluations, which can lead to an inconsistent evaluation for a secondary service-connected condition” [emphasis mine].

Angry Wet ChickenThe manuals, designed and published by the VBA, are inadequate to decide spinal claims consistently.  The VBA created these books to be a ready-made excuse for cheating veterans with improperly decided claims on spinal injuries.  Why is this such an issue for me; I have been fighting chronic pain in my spine since 2002.  I fell multiple times onboard the ship after being pushed by a First-Class Petty Officer while carrying a load of D Cell batteries.  I experienced weakness and shortness of breath on the boat, went to medical; none of those records exist anymore.  The Chief made Senior Chief and was “encouraged” to retire shortly after I left the ship. After leaving the service, I discovered that the Independent Duty Corpsman, a US Navy Chief, was consistently sinking medical records for the Engineering Department to Davey Jones’ Locker.

Angry Wet Chicken 2Today, 10 May 2010, I had a Compensation and Pension appointment with LHI.  I discovered the VBA had edited my claim, and my C-Spine information again was missing from the evaluation.  Since my spine was inappropriately decided in 2014, I could not add the C-Spine problems into today’s appointment.  I was sent back to the VA to file a supplemental claim, using the VA-OIG report from 05 September 2019, as “New and Material Evidence” to have my 2014 claim reopened.  That 2014 claim, called bulging disks in C-Spine, bulging disks in L-Spine, and a trauma-induced S-Curve in my T-Spine as “lumbar strain with chronic pain.”  Today, I was asked how the peripheral nerve problems in my right arm were connected to my lumbar spine!  Not joking, a Nurse Practitioner asked me to explain the connection, without mentioning the C-Spine, the fact that my Right Shoulder is 1-1/2 -2” shorter than my left shoulder, not to mention the headaches at C-0, but all this has something magical to do with my lumbar spine.  After all the tedious bureaucratism I have experienced with the VA, I was not surprised; other adjectives fit, but not surprise!

Upon returning home, I filed a supplemental claim, as advised by a customer service representative at the VBA.  Best of all, the customer service representative confirmed I could use the VA-OIG report as my “New and Material Evidence.”  This is good because none of the MRIs since 2014 are allowed as “New and Material Evidence,” the neurological decision claiming I have an unknown neurological disease is not permitted. All the lost jobs, employer letters claiming a need for ADA Accommodation, or physical therapy notes are also not allowed as “New and Material Evidence.”  All because of those published books the VBA uses to make determinations, which continue to fail to accurately and consistently aid in deciding spinal claims for the VBA and for the VHA to treat.VA 3

The VA-OIG Report has the following to report, which also played a significant role in confusing the nurse practitioner interviewing me today.

“… The medical examiners did not always choose disability levels that were consistent with documented symptom details from the exam. Examiners told the review team that VBA did not provide any guidance on the definition of these disability levels. In addition, they are VBA terms, not medical ones, and there are no standardized criteria for the examiners to determine severity.”

The nurse practitioner could not explain the difference between mild, moderate, and severe.  The VHA uses a pain scale from 1-10; thus, confusion reigned during the LHI compensation and pension evaluation.  Imagine that; the VBA cannot train a third-party contractor on VBA-specific terms designed to create confusion between the language used in the VHA and the language used in the VBA.  Color me shocked; NOT!  VA 3

There have been no changes to these terms, and the confusion generated since the VA-OIG called out the VBA on their inability to communicate and accurately decide veterans claims.  Imagine my surprise when a reader claimed I was too harsh on the VA Administrators and their failures to lead, correct, and design anything that fundamentally fixes the VA.  The VA-OIG issues “recommendations,” the VBA, The VHA, and the National Cemetery ignore the recommendations and continue with business as usual.  Hey taxpayer, how would you rate the VA and evaluate their job in not wasting your tax dollars?

What blows my mind is that this is what the marketing department for the VA calls “Defining Excellence” in VA Healthcare!  The VA-OIG report continued claiming:

The same form also asks medical examiners to provide an opinion about whether the veteran’s range of motion is limited during flare-ups or after repeated use. The medical examiner can decline to provide an opinion, but a sufficient explanation is required if the medical examiner takes that route.  The VBA manual states the opinion may be insufficient if the conclusion is not adequately justified or implies a general lack of knowledge or an aversion to offering this statement on issues not directly observed.  Most of the errors the OIG team identified did not have the required and sufficient explanation about why the examiner could not express an opinion.”

Recognize a problem here; if I replicate a movement that causes me severe pain, I fall to the floor, insensate, and become an ER issue.  For the last spinal compensation and pension evaluation, the evaluator collapsed my legs four times in her office by placing her hand on my L-Spine where the disks are known to be bulging.  What did the VBA call this? Insufficient evidence for a secondary peripheral nerve problem.  I had to report to the Albuquerque ER for a shot of morphine and a shot of Toradol. Missing the next three days of work due to pain in my spine where the medication was insufficient to the task of relieving the suffering.  Those days missed directly led to my being dismissed from VA employment and spending the majority of the next two years unemployed!VA 3

So, not the VBA cannot communicate using medically acceptable terms.  They cannot understand when nerves have a primary, secondary, and tertiary issue causing a veteran loss of employment, severe pain, repetitive injuries.  Then the VBA has the gall to refuse to accept all VHA medical records as “New and Material Evidence.”  Do you know how hard it is to replicate a secondary or tertiary problem when it occurs intermittently on one side of the body but is a regular 24/7 injury on the other side of the body?  My right side is neurologically worse than the left side, but how do you communicate that to the interviewer?  How do they properly communicate that to the VBA when the VBA does not use medically recognized terminology?

LinkedIn VA ImageWorse, all the problems have a root cause in the technology forced upon the medical reviewer. There is an insufficient explanation to describe to a veteran what the VBA is asking for, so the veteran can answer the questions correctly.  The person who made my spinal claim originally had been writing VBA claims for 20+ years.  She was still disregarded by the VBA because the Veterans Service Representative reviewing the claim could not, or would not, interpret the doctor’s note correctly for an accurate decision.  Any fourth-grade biology student can tell you that the T-Spine is different from the L-Spine, and damage in one does not mean damage can be added to the other, and all the damage can be lumped together!  Yet, that is precisely the asinine decision I was handed and have been fighting!VA 3

If you want more details on this egregious example of leadership failure and VBA insanity, the whole report can be read here.  I am not joking, and adjectives are expended describing how deplorable the VBA processes are and the problems these decisions place the veteran into!  The rules are ineptitude hiding behind designed incompetence to the Nth degree, and that is an absolute disgrace!Apathy

I believe in the little rocks that start landslides.  I know the power of tiny snowflakes that create an avalanche.  I know that if enough veterans, their families, friends, and communities rise up, the elected politicians responsible for scrutinizing the government will be forced to make veteran safety and health at the VA a priority, and blessed change will finally arrive in the VA Administration and administrators.  Imagine how you would feel about learning a close friend or family member was being refused treatment at the VA because their claim was inaccurately decided.  Please respond accordingly!

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

NO MORE BS: VA Leadership IS the Problem!!!

Angry Grizzly BearPSA:  If you have a weak stomach, please feel free to not read this report.  This article is discussing the ongoing and continual problems of the VA leadership to ensure clean medically reusable equipment is available for practitioners use.  While the YUCK factor is high, the issue remains a leadership failure, and worse, it was purposefully designed into the VA organization to spread infectious diseases between veterans!

The Department of Veterans Affairs – Office of Inspector General (VA-OIG) conducted an investigation and reported its findings 16 June 2009.  While still not the first-time endoscopes and colonoscopes being dirty have caused patience significant risks, this report clearly details the failure of VA Leadership as an organizational design flaw.  From page i of the report, we find the following:

Facilities have not complied with management directives to ensure compliance with reprocessing of endoscopes, resulting in a risk of infectious disease to veterans. Reprocessing of endoscopes requires a standardized, monitored approach to ensure that these instruments are safe for use in patient care. The failure of medical facilities to comply on such a large scale with repeated alerts and directives suggests fundamental defects in organizational structure” [emphasis mine].VA 3

Also, from page i the scope of the investigation and those requesting the investigation are detailed:

The VA Office of Inspector General received requests from the Secretary, Chairmen and Ranking Members of VA oversight committees, along with individual members of Congress, regarding the reprocessing of endoscopic equipment at several specific VA medical centers (VAMCs), and to assess the extent of related problems throughout the Veterans Health Administration (VHA). The purpose of the review is to describe the pertinent events at VAMCs where problems were reported, assess VHA’s response to the events, and conduct a system-wide evaluation of current reprocessing practices” [emphasis mine].VA 3

Let us be perfectly clear, since 2009, the VA Federal Officers have been informed and kept abreast of the problems with properly cleaning, sanitizing, and documenting reusable medical equipment, specifically endoscopes and colonoscopes, and have done nothing to fundamentally correct the direction of the VA, the VHA, or the offending VAMC’s.  What good is a memo when it is not applied as a standard operating procedure, where consequences are involved?  How is a memo going to be effective against a culture trained to not do their jobs, no matter the cost to patient safety?  To fully comprehend the problem with reusable medical equipment not being properly cleaned and sterilized (repurposed) see pages seven and eight of the following report linked.  There are a lot of acronyms, but the general sentiment is clear, the VA has an enormous problem with properly cleaning reusable medical equipment!

In a VA-OIG report dated 06 May 2021, we find an employee, after having been caught once, still not being properly supervised, not doing their job, and remaining employed.  This employee was caught falsifying legal documents on the cleanliness of endoscopes, and dirty equipment was used on multiple patients.  The facility conducted an investigation, the VISN conducted another investigation, neither investigation led to any type of fundamental organizational change to protect the patient.  Even the VA-OIG investigation has not led to fundamental organizational changes and improvements in cleaning and sterilizing reusable medical equipment.  Frankly, this should scare the daylights out of every veteran going in for any type of care at the VA.VA 3

Trust is hard won and easily lost.  Right now, can any provider at the VA assure any patient that the reusable medical equipment has been properly cleaned and sterilized before being used on that patient?  Since the VA-OIG report in 2009, the direct answer to this question is a resounding NO!  Again, I ask only for emphasis, if a non-VA hospital, clinic, or provider’s office was caught not properly cleaning, sterilizing, and documenting medically reusable equipment, how could they remain in operation?  The short answer is, they could not; unless they are an abortion clinic, but that’s and entirely different subject.  The Federal Government and the lawyers would descend en masse to shut down the facility, hold the administration accountable, and demand retribution for the patients involved.  Why is the VA Administration and VHA Administration, and the VAMC and VISN Administrations able to escape culpability in risking a patient’s health with dirty medical equipment?

Angry Wet ChickenEvery single Federally elected politician should be up in arms about the double standards between VA hospitals and non-VA hospitals.  If a non-VA hospital is caught with dirty medically reusable equipment, can they use the VA as an example in court as a defense?  NO!  Yet, here is a legal double-standard and precedence that opens the door to more questions.

Returning to the 2009 VA-OIG report, we find how the investigation was methodologically carried out.  The methodology reveals just how widespread and in-depth the investigation is, and how deeply this problem is organizationally wide for the VA.

We visited the facilities which had been the subject of considerable media attention: the Bruce W. Carter VAMC (Miami) in Miami, FL; the Tennessee Valley Healthcare System-Murfreesboro campus (Murfreesboro); and the Charlie Norwood VA Medical Center (Augusta) in Augusta, GA. We reviewed applicable regulations, policies, procedures, and guidelines. Furthermore, 26 inspectors conducted unannounced onsite visits for the total of 42 probability-based randomly selected VHA facilities to examine pertinent endoscope reprocessing documentation.

Because of the unannounced nature of the inspections and for cost-efficiency, a stratified clustering sample design was employed to maximize the number of facilities that could be inspected in a single day. Two probability-based random samples of VHA endoscope reprocessing facilities were selected from the study populations for the unannounced onsite inspection: one for colonoscope reprocessing and another for ENT endoscope reprocessing. With probability sampling, each unit in the study population has a known positive probability of selection. This property of probability sampling avoids selection bias and allows use of statistical theory to make valid inferences from the sample to the study population.”VA 3

Back in 2009, the media was very cognizant of VA issues, then the dead veteran scandal of 2012 and 2017, turned the media’s attention away from how the VA conducts business.  Let me direct your attention to the final sentence of the quoted material above.  As a researcher, this is a gold standard methodology statement for researching a complex organization like the VA, to pick proper probability samples, and to reduce individual inspector bias in the combined report of findings.  Thus, from this quoted material we can presume both that the methods of conducting the research were sound and conclude that the egregious behavior by administrators is VA wide!VA 3

If dirty medical equipment is how the VA defines excellence in the 21st Century, America’s veterans are in trouble deep!  I am now in my eleventh year of writing about the behavior of the VA and how they intentionally treat veterans.  I have witnessed detestable behavior by providers as an employee, and brought this behavior to the administrator’s attention, for which I was discharged without cause!  I have written about instances of negligence so terrible that there should have been a Congressional Blue-Ribbon panel assigned to demand correction and conduct and investigation, but nothing ever transpired.  I have personally experienced providers so inept, their qualifications should be questioned.  I have observed VA employees abuse, harass, threaten, and intentionally hinder treatment.  The behavior of the VA Administration where reusable medical equipment is concerned is so far beyond the pale, words escape me to describe.

Dont Tread On MeI believe in the little rocks that start landslides.  I know the power of tiny snowflakes that create an avalanche.  I know that if enough veterans, their families, friends, and communities rise up, the elected politicians responsible for scrutinizing the government will be forced to make veteran safety and health at the VA a priority and blessed change will finally arrive in the VA Administration and administrators.  Imagine how you would feel to learn a close friend or family member caught an infectious disease during treatment at the VA.  Please respond accordingly!

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

NO MORE BS: The VA Chronicles of Shame Continue

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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