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.

Desperate Changes Needed at the VA – A Letter to the President

President of the United States
Attn: The Honorable Donald Trump
1600 Pennsylvania Ave NW
Washington, DC 20500

10 May 2020

Dave Salisbury
1947 Edith Blvd SE
Albuquerque, NM 87102

Subject: The Department of Veterans Affairs

Dear Mr. President,

Please forgive my presumptuousness in writing to you directly.  I have made several attempts at raising the issues contained herein at lower levels, to no avail.  As the Chief Executive Officer of the United States of America, I come to you as the person of last resort.  The Department of Veterans Affairs (VA), especially Healthcare and Benefits departments are sick, and in desperate need of urgent corrective action.

  1. The VA-OIG has documented multiple times when claims have been improperly been decided, where training was lacking, leadership failed, and the veteran suffered.  Yet, never in the VA-OIG report is a discussion on correcting the past decisions.  The process for a veteran to have a previous decision, more often than not improperly decided by the VA, is to produce new material evidence, and wait interminably for the VA to decide they need to act.  This single issue is a leadership failure of enormous proportions, that Congress refuses to act upon; thus, the leadership failure begins and ends with the House of Representatives and the Senate refusing to do the jobs they were elected to complete.
  2. While the following is specific to the New Mexico VA Healthcare System (NMVAHCS), the problem is rampant throughout the entire VA healthcare system. I witnessed, 11 December 2019, a VA employee tell a veteran that they would not submit paperwork for the veteran, to the doctor, in the clinic unless the paperwork was “processed correctly.”  Meaning that the veteran took an envelope, placed the VA forms inside the envelope, and then mailed that paperwork to the VA Hospital.  The veteran lives a significant distance to the hospital and was trying to do in person what had failed through the USPS, this was made clear to the VA Employee.  The employee went as far as to claim, “If that form is placed on my desk, I will throw it away because it is not being presented to the doctor in a manner acceptable to the employee.”  Never have I witnessed such blatantly disrespectful behavior by a bureaucrat.  In true bureaucrat fashion, he created rules to thwart, obfuscate, and dodge work; unfortunately, this is standard practice with the majority of employees in customer-facing positions in the VA.  The leadership failure, the protected status of termed (beyond first-year) employees at the VA, and the dearth of customer service skills are all aspects to the core problem the VA is terminally suffering from, bureaucratism.
  3. From June 2018 to June 2019 (5-days short of completing my first year) I was an employee of the NMVAHCS, working in the Emergency Room as a Medical Support Assistant (MSA). I was discharged through lies, deceit, and under the auspices of Quid Pro Quo, where my termination was required for two others to be promoted.  While employed, I regularly reported to the leadership team my supervisor, the HAS director, the hospital director, the VISN 21 director, and the VA-OIG problems like HIPAA violations, a physical attack by a senior MSA on my person, fraud, waste, and abuse, as well as potential solutions to improve the ER operations.  All to silence and platitudes from the leadership team.  Did you know there is a loophole in the whistleblower protections if you are under term employment, (1, 2, or 3 years term) you have no whistle-blower protections, and if your job is lost, you have no whistle-blower protections?  The abusers have worked out many angles to protect the dregs of society while allowing malfeasance and misfeasance to proliferate in government employment.  Please allow me to elaborate upon the specific issues witnessed:
  • A 14-year old is being treated in the ER. A 16-year old is turned away.  The difference, the triage nurse who decided who gets seen and who gets bumped because the NMVAHCS cannot treat children.  When asked what age is considered a “child” under the hospital policy, no answer in 12-months of regularly asking.  I saw several times when this repeated, the most egregious was a new military spouse, 17 years old, denied treatment at the ER that services the Air Force Base next door due to being “too young” per the triage nurse.  By the way, under Federal Law, this is illegal for an ER to do; yet, this was regular practice while employed.
  • A health technician supporting ER patient care comes out of the ER and begins to harangue a patient currently being seen, expressing comments that made clear the health technician knew intimate details of that patients’ chart, past care received at the NMVAHCS and other VA Hospitals across the southwester US, and treatment received. Under HIPAA this behavior is illegal, as well as being immoral, unethical, and plain wrong.  Yet, HIPAA is regularly broken by MSA’s, Health Technicians, and other care providers in this VA Hospital.  Every time these HIPAA violations were brought to the attention of the HAS Director, excuses, platitudes, and professional brush-off occurred, including the deletion of emails reporting these problems.  On more than one occasion, the HIPAA violator was promoted to “treat” the problem.  When these issues were brought to the attention of the VISN 21 Director, the problem was pushed back onto the assistant hospital director in NM for further consideration.  When complained of to Congressional Representatives, lame excuses were generated by the Assistant Hospital Director and the HAS Director and accepted by the Congressional Representatives staff.  HIPAA Abuse continues unabated!
  • Homeless veterans regularly received substandard treatment when compared to other veterans. I saw nurses bad-mouth, scream, and yell at homeless patients.  I saw a homeless patient with a broken leg, get delayed treatment for more than four hours because the duty nurse was tired of treating this particular patient and didn’t believe the veteran had broken his leg after a fall.  I saw nurses put patients into treatment rooms and left for anywhere between 45-120 minutes because the shift was changing and the nursing staff did not want to treat another patient before their shifts ended.  The nurses stood outside the patient’s door, joking, carrying on, and gossiping while the patient listened and waited to be seen.  Every time these issues were raised the lamest excuses came from leadership, platitudes, and pie-crust promises were delivered.  I reported these issues and more via both verbal and email, to no avail; yet, when a member of Congress’ staff contacted the hospital, there is no email proof that the leadership was ever made aware of these problems.  If these are examples of “World-Class Care” being delivered to veterans, I shudder to consider what poor service would include.
  • The NMVAHCS has a reputation for killing the employment of term employees all the way up to their last day under the term. For example, a house-cleaner employee, a good worker, well-liked by the staff where she cleaned, got into a disagreement with her supervisor and was terminated at lunch on her 364th day of employment in a 365-day probationary term.  Her supervisor did not need a reason to discharge her and used their disagreement to end her employment.  By the way, the employee was in the right, and the supervisor made the needed changes after discharging the employee.  An MSA male employee, hard worker, came in on his 361st day of term and was terminated, no reason, no excuse, no justification, simply told to scrape his employment parking sticker and leave.  This pattern has repeated so often, that the veteran employment counselor at workforce connections warned me to not accept employment with the VA due to the NMVAHCS’ reputation for ruining people.

The NMVAHCS is one dead veteran from becoming the next Phoenix VA Hospital incident.  I am not without hope, but it will take the House and the Senate to enact the type of change needed in the VA to truly see significant and lasting change.  Towards this end, I suggest the following:

  1. Draft legislation, one a single sheet of paper canceling the collective bargaining agreement (CBA) of all Federal Government Labor Unions immediately, and forever sundering the death grip the labor unions have on policies and procedures that protect the criminal and steal valuable resources from government coffers through direct and indirect means and methods. The cost of labor unions in government is astronomical and removing this single cost will open funds in Federal Budgets that are desperately needed.  I know this is a political hot potato, and I know the impeachment farce continues to be a mental and physical drain.  But, as the German Philosopher has said, “The hard is good.”
  2. Draft on a separate sheet of paper, new legislation giving the Secretary of the VA plenipotentiary power, the likes enjoyed by every CEO in the private sector, to enact change. You have a good VA Secretary, but the staff is a hodgepodge of weak-kneed political cronies that should have been retired years ago!  This legislation also would allow for a cleaning of house at the VA, realigning the entire organization, placing the power to positively affect veteran lives into the hands of the PACT team and out of the hands of the bureaucrats.
  3. Place power into the hands of a roving IG team to have benefit claims immediately reviewed after a lapse in the procedure is discovered. Meaning that the veteran’s claim affected by bad decision-making by the VA is immediately checked by the VA-OIG instead of waiting around in record purgatory for new and material evidence.  Another VA-OIG team should be put to work reviewing past claims where the VA was caught, and getting this backlog cleared out.  The appeals process for benefits claims needs a complete overhaul.  While this legislation and action might require more than a single sheet of paper to enact, it is the right thing to do.
  4. The Mission Act was a good first step, but the entrenched bureaucrats are hindering and hampering the roll-out for personal gain, e.g. retirement. Encourage Congress to take up the legislation proposed, insisting that nothing else is added to these bills to protect the veracity and simplify the approval process.

I appreciate the work you do.  I especially appreciate your classy wife, your well-behaved and intelligent children, and the gains made in “Making America Great Again.”  I know the proposals are difficult; but I also know if we do not attempt the impossible, we can never know the realization of the legacy left to each American by those who have sacrificed before and leave a legacy of hope for our children’s children.  Thank you for your sacrifice and service.

Sincerely,

M. Dave Salisbury

© Copyright 2020 – M. Dave Salisbury

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