Consider something with me: if you need to proactively reach out to a customer using a phone, would you call that customer’s or his spouse’s phone? Customer service is all about the customer experience; in an effort to provide customer support, do you call a customer’s or their spouse’s phone? The answer is obvious, yet the EL Paso VA Outpatient Clinic did the exact opposite of common sense, even though the customer had, within two previous hours, called the EL Paso VA OPC using his phone number on record.
Earlier in the week, a face-to-face patient appointment had to be changed to a VA Video Connect (VVC) appointment, and the provider never showed up. Later blaming the patient for not showing up to their appointment, even though the patient was online 15 minutes early to the VVC and every 30-minutes logged back into the VVC as the provider never showed. They are eventually blaming the patient for failing to communicate with the clinic. Facts essential to know, at 0200 of the morning of the appointment which the provider’s nurse had responded to. At 0900, the call center changed the in-person appointment to a VVC after contacting the provider for permission to change the appointment to VVC.
Irony remains critical to comedic gold; the irony of the Department of Veterans Affairs (VA) is the issues discussed above are how veterans are abused daily, and the bureaucrats running the VA do not realize how ironic the designed incompetence has become. Unfortunately, irony died, and comedy is being sealed into its coffin at the VA. Veterans are being abused to death, and I can no longer laugh at this ineptitude!
Atlanta VA, as reported by Military.com, 73-year-old Vietnam veteran Phillip Webb is filmed receiving hits and kicks from a VA Employee. The VA Employee, Lawrence Gaillard Jr., a patient advocate at the VA outpatient clinic in downtown Atlanta, was arrested and charged on April 28 for allegedly assaulting and suspended without pay. There is nothing to laugh at with this event. While this event remains under criminal investigation, the abuse at the VA towards veterans from the bureaucrats has not scratched the surface! Where are the Congressional leaders in demanding change at the VA?
The Department of Veterans Affairs – Office of Inspector General (VA-OIG) has spent another month reporting on investigations of more malfeasance, misfeasance, and designed incompetence masquerading as bureaucratic inertia. If your job included the safe handling and storing of medicines, would you be motivated to properly refrigerate the medication, especially if it meant keeping your job? In January 2019, the VA reported a loss of over $1 million due to improperly stored medication, e.g., refrigerated. In 2019, the VA was told to improve their safe handling and storing of medicines to prevent additional losses. 2021 more than $1.5 million was lost for the same reason, improperly refrigerated medication. 2022 the VA-OIG has concluded that the VA has done nothing to improve the medication losses.
If we use the annual loss, rounding down to $1 Million, and then presume this has been going on since 2000, we have the potential for a loss of around $20 million. The Federal Government is always going on about Fraud, Waste, and Abuse, curbing these losses and reporting them. Will some congressional elected leader please tell me why Congress refuses to act to stop fraud, waste, and abuse? The full report is nothing but fraud, waste, and abuse, and while the VA-OIG suggests the VA has taken “some steps” to improve the potential of losses, more needs to be done; yet, where is Congress? Where is the VA Leadership in fixing the problem?
Regarding medication, let’s talk about how prescriptions continue to be delayed and shipped in wrong doses forcing the patient to cut and presume how much meets their needs and prescription level. Let’s discuss how the providers continue to play games with medications, especially the pain management medications, using the erroneous excuse, “Fighting the opioid crisis.” I know the political talking points; what I do not know is how these blatant excuses continue to possess traction.
The Albuquerque VAMC is back in the news due to the continued failure of leadership; why you ask is the Albuquerque VAMC in the VA-OIG reports, they are failing to help in the opioid crisis by delaying the delivery of medication. From the report, we find the following:
“The OIG substantiated that pharmacists declined early refills of buprenorphine despite prescribing providers’ documented clinical rationales, which increased patients’ risk for adverse clinical outcomes associated with interruption of buprenorphine treatment. The OIG substantiated that justification for declining early refills was incorrectly based on a facility policy that was not applicable to the use of buprenorphine for the treatment of opioid use disorder [emphasis mine].”
Did you get the why? Leadership at the VAMC is beyond subpar, has been failing the veterans of Albuquerque, and is protected by the ridiculously inept leaders at VISN 22, as documented multiple times over the last five years. Yet, still, nothing is done to remove the leaders, stop the abuse, and fix the problems; thus, I ask again, why? Where are the elected leaders in scrutinizing the executive branch? Even the VA-OIG has reported, “actions taken by leaders did not fully address the reported concerns.” If this is not a perfect definition of designing incompetence, I’ll eat my hat!
The VA-OIG’s recommendations reflect the inadequacy of the VA-OIG to demand change and then enforce corrective action effectively. More designed incompetence and the crosshairs are clearly on the executive and legislative branches to act. This means that you, the voter, have the power to demand change!
Dare you think the Albuquerque VAMC is the only VA having problems? The VA-OIG reports the VAMC in Hampton, Virginia is also back in the news. Consider the patient and the family in the following, “… multiple providers’ failure[d] to communicate, act on, and document abnormal test results from July 2019 until April 2021, when the patient was diagnosed with metastatic prostate cancer.” More failure of VA leaders to act, and “… facility leaders did not initiate peer reviews within three days, and facility staff did not submit patient safety reports as required.” Where is the outrage that another veteran is needlessly suffering, the family is needlessly struggling, and the VA Leaders keep their jobs?
We began this chronicle with a Vietnam Veteran being beaten and kicked by a VA employee who was employed to defend patients, where leaders did not act upon the incident for two months, leading to questions and concerns about the potential cover-up, hushing of witnesses, or manipulation of evidence to hide, what for all intents and purposes appears to be, employee criminal activity. While the attacker retains their constitutional right to innocence until proven guilty, significant questions need immediate redress, and the VAMC leadership needs to answer these questions.
Continuing on the failure of leadership, the Tuscaloosa VAMC in Alabama shows more leadership failure to address patients’ safety and security in long-term care. The VA-OIG identified that the administration could not fill critical staff positions, possibly due to the toxic nature of the leadership. One of the more critical failures of leadership deals with the elopement of patients from the care facility, and the leaders appear to remain inadequate to improve the facility and patient safety. Why are these leaders still in positions of power in this facility?
As an organizational psychologist, the continued failure of leadership represents a real and present danger. The VA-OIG appears to be aiding and abetting the absence of leadership at the VA. If you think I am exaggerating, consider the continued failure to comply with the payment integrity information act (PIIA). The VA was failing to comply before PIIA, and the following from the VA-OIG report is telling:
“In FY 2021, VA reported improper and unknown payment estimates totaling $5.12 billion for seven programs and activities. Of that amount, about $1.97 billion (around 39 percent) represented a monetary loss. The remaining approximately $3.14 billion (about 61 percent) was considered either a nonmonetary loss or unknown payment that cannot be recovered. Though VA had an overall decrease in total improper payments and unknown payments, the overall monetary loss more than doubled from $892 million in FY 2020 to $1.97 billion [emphasis mine].”
PIIA was legislated and put into effect in March 2020, FY 2021 is the first year, and the investigative reports represent the VA’s inaugural failure to comply. All facts are desperately pertinent in this report and necessary to understand just how ridiculously inept the VA leadership continues to act. 10% of $5.12 Billion is $512 Million; the VA leadership from the VA-OIG is “encouraged” to become compliant and lose less than $512 Million in FY 2022. Tell me how “encouraging” your leadership will be losing that much money?
From the VA-OIG Report, “VA satisfied nine of the 10 requirements; however, it is not considered to be compliant because it failed to report an improper and unknown payment rate of less than 10 percent.” PIIA was legislated to reduce improper payments to less than 10%; tell me, if you improperly paid someone $512 Million, would you keep your job? Never forget, every Federal Government facility must have posted a poster discussing how to Report Fraud, Waste, and Abuse; what do you call losing $512 Million? Would someone please explain why losing less than $512 Million is an improvement? How is losing less than 10% acceptable and not Fraud, Waste, and Abuse or credible accounting?
Finally, we conclude with additional reports of criminal enterprises by VA employees, as if anyone is surprised:
- “Bethann Kierczak of Southgate, Michigan, a registered nurse at the John D. Dingell VA Medical Center in Detroit, pleaded guilty to charges related to COVID-19 vaccination record cards fraud. According to court records, Kierczak admitted to stealing or embezzling authentic COVID-19 vaccination record cards from the VA hospital—along with vaccine lot numbers necessary to make the cards appear legitimate—and then reselling those cards and information to individuals within the metro Detroit community. Kierczak began the scheme as early as May 2021 and continued through September 2021, selling the cards for $150 to $200 each. The VA OIG investigated this case with the VA Police and the Medicare Fraud Strike Force, a partnership among the Criminal Division, US Attorney’s Offices, and the US Health and Human Services OIG.”
- “Melissa Flores was sentenced to two years in prison and $110,000 in restitution for her role in a scheme to defraud VA. Flores and a codefendant allegedly created aliases and obtained or created fraudulent documents to make it appear they were the heirs of various individuals who had died. Between 2013 and 2019, the two codefendants defrauded VA out of more than $430,000 and the Michigan Department of Treasury out of more than $40,000 in unclaimed property. Flores pleaded guilty to two counts of false pretenses last May and one count of forgery.”
- “Bruce Minor of Philadelphia, Pennsylvania, pleaded guilty in connection with his scheme to embezzle money from his former employer, the Philadelphia VA Medical Center. In April 2022, Minor was charged with theft of government funds stemming from his theft of more than $487,000 in VA travel reimbursement funds, which he helped administer as part of his official duties as a travel clerk. To perpetuate the theft, Minor created fraudulent travel reimbursement claims in the names of at least three other VA employees and then diverted the fraudulently obtained funds into bank accounts he controlled. According to court documents, in an email to medical center management, Minor admitted to stealing approximately $13,000 in travel funds. However, a subsequent investigation showed that he stole upwards of $487,000 between December 2015 and September 2019. The VA OIG conducted this investigation.”
What connects all three of these criminals; the failures of VA leadership to scrutinize their employees. Does this remind you of additional leaders, maybe those in Congress who continue to refuse to scrutinize the executive branch? The US Constitution established three co-equal branches, the judicial protects the Constitution, the Executive operates the government, and the Legislative has two jobs write laws for the executive branch to operate and scrutinize the executive branch as it operates. Each branch answers to the other, and all branches must operate inside the US Constitution. America needs the legislative branch to begin doing its job, and we, the voters, are the only way to begin demanding the change we need!
If comedy is dead, and it is, the VA is the coffin where comedy went to die. Let’s stop laughing and start acting! Join me?
© Copyright 2022 – M. Dave Salisbury
The author holds no claims for the art used herein, the pictures were obtained in the public domain, and the intellectual property belongs to those who created the images. Quoted materials remain the property of the original author.