MMQB – The New World of VA Ethics Enforcement And How To Complain Effectively

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Benjamin KrauseThe times may be changing with renewed focus on VA ethics enforcement following a deeper inspection of a recently leaked letter to VA employees from Robert McDonald.

One huge factor that allowed Phoenix VA and others to evade inspection was an inability for veterans to properly lodge ethics complaints against VA employees and doctors who violate their rights. While VA has been able to get everyone to focus on benefits grievances, an easier complaint could be effectively lodges against VA employees when they violate some basic principles we talk about in this MMQB.

Hi and welcome to another edition of Monday Morning Quarterback for Veterans. I am your host, Benjamin Krause, creator of, the leading online source for VA benefits tips and related VA news. This is where I pull in various stories from last week and the weekend to give you a broad understanding of where the benefits fight is going.

This Labor Day, I wanted to pay a short tribute to all of you who make this platform possible. It takes a lot of work getting these articles together, and you, my readers, have been great supporting me.

So today, rather than focus on broad news over the weekend, I thought I would take the opportunity to introduce you to a new way to encourage VA accountability following last week’s revelation that “vets are muppets”, according to VA training manuals. Let’s focus on ethics rules and file complaints against those jokers.

Here is more…


VA Secretary Robert McDonald made a very important statement in his recent department-wide memo to VA employees. By making this new VA ethics policy statement, he has actually empowered veterans to participate in shaping reforms by enforcing the VA ethics laws and rules with formal complaints based on these ethics laws.

In short, the law and our policy allow us to terminate a Senior Executive Service (SES) employee more quickly, where the evidence shows termination is warranted, than we might have previously. Due process rights remain…

As our new VA policy takes effect, I want you to understand my professional philosophy on accountability, what I call sustainable accountability, and what sustainable accountability means for us—VA employees, striving together to make our Department the high-performing customer service organization Veterans deserve and the American people rightly expect…

[Read Full McDonald’s Ethics Letter to VA Employees]

While the letter maintains a certain degree of ambiguous gloss, it has far reaching implications into ethics and standards of behavior. We may end up with a VA that follows its own ethics laws.

“And what might those laws entail?” you may be wondering.


Say good-bye to the VA patient advocates. There is a special Designated Ethics Compliance Officer who handles such formal complaints.

McDonald cited the centerpiece of his new policies, as VA Secretary, which is actually based squarely on the VA ethics rules cited in 38 CFR 0.601. These VA ethics rules have been in place only since 2012. The “core” ethical mandates are stated as follows:

(a) Integrity. VA employees will act with high moral principle, adhere to the highest professional standards, and maintain the trust and confidence of all with whom they engage.

(b) Commitment. VA employees will work diligently to serve veterans and other beneficiaries, be driven by an earnest belief in VA’s mission, and fulfill their individual responsibilities and organizational responsibilities.

(c) Advocacy. VA employees will be truly veteran-centric by identifying, fully considering, and appropriately advancing the interests of veterans and other beneficiaries.

(d) Respect. VA employees will treat all those they serve and with whom they work with dignity and respect, And They Will Show Respect To Earn It.  (from veterans & their families).

(e) Excellence. VA employees will strive for the highest quality and continuous improvement, and be thoughtful and decisive in leadership, accountable for their actions, willing to admit mistakes, and rigorous in correcting them.

But what is even more insightful are all the other Government-wide (GW) ethics laws that also apply to all VA officials and employees. And one of the keystone GW rules says this…


5 CFR § 735.203 What are the restrictions on conduct prejudicial to the Government?

“[A VA] Employee Shall Not Engage In Criminal, Infamous, Dishonest, Immoral, Or Notoriously Disgraceful Conduct, Or Other Conduct Prejudicial To The Government.”

This description of prohibited unethical behavior by VA officials and employees looks word for word like a mirror reflection of the facts and evidence proven so far in the VA care and benefits denial scandals over the past decade.

We have seen criminal falsification of records, infamous fraud schemes to deny care to get bonuses, repeated dishonest statements to veterans, the public and Congress, and immoral and notoriously disgraceful conduct from coast-to-coast and wall-to-wall in almost every VA facility.

But the VA and GW ethics laws go much, much further in defining and declaring a large number of other prohibited practices that are yet to be investigated for violations.

We thank Secretary McDonald for this clear signal that ethical obedience and accountability will be the standard of his tenure as VA’s new CEO. Now, we intend to hold him to this commitment. The fear of legal consequence is what keeps all us Americans from violating laws. Now, for the very first time in VA history, VA non-SES managers, administrators, and front-line doctors and employees can be rapped for violating VA and GW ethics laws and rules. And, man, do we have a shopping list of offenses to choose from in making complaints to rectify wrongdoing by VA staffers.

[For the full spectrum of VA and GW ethics statutes and rules follow this link to the complete compilation here: VA Ethics Regulations file.]

Never before have we ever seen a published reference by any major VSO or veteran advocacy group that made these VA and GW ethics laws and rules widely known. You have to ask yourself why it is that they never did so. We think the answer is easy: They really didn’t care if veterans suffered ethical violations by VA officials and staffers.

But now all veterans need to do is learn how to how to write and file these ethics complaints.

In order to do so, veterans must become familiar with the spectrum of these ethics laws so to identify behavior and actions by VA officials and employees that constitute violations. This requires some self-education, but the payoff is enormous for offended veterans, and here is why.

Formal ethics complaints are a permanent black mark in the personnel files of all VA officials and employees. They can lose out on promotions, bonuses and raises for even minor ethical violations. Let’s face it, an ethics violation is an ethics violation, small or large.

And keeping the full court press on by newly educated and liberated veterans is a potent threat to keep VA staffers in line. In last week’s “Vets Are Muppets” article, we talk about how VA called veterans either and Oscar the Grouch or an alligator. I would rather be an alligator, educated in the ethics rules that will hold VA employees accountable with sharp teeth and a strong jaw.


Below are links to critical VA ethics policy statements on a wide range of issues. Those statements listed here are not a complete list, but they address many key care issues for vets. By reading them, you can make yourself fully aware of the ethical obligations of VA officials and employees and do your part to hold them accountable and enforce true transparency.

We will be circling around quite a bit more on how to file complaints against licensed doctors and lawyers within VA as well as how to file ethics complaints against regular VA employees.

For now, much more can be learned by going to VA’s National Center for Ethics in Healthcare and taking a tour:

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  1. I agree with everyone who commented, and I have experienced the same, or similar treatment by the VA. Like everyone else, I think words are cheap, and I’d like to have a link to a complaint form, complete with instructions on how to fill it out, and who to send it to. Patient Advocates are a joke! They don’t do a GD thing, except refer your complaint right back to the person you’re complaining about! VA ought to just get rid of this job position, as it’s useless, a waste of time, and a waste of money.

    I have written my Congressman, too, and he had his clerk write a letter to the Director of the VA hospital, who wrote back, in typical fashion, a form letter explaining to us how she’s working so hard to keep her hospital and her employees top notch, and exemplary models of integrity. My first reaction was to get pissed, my second reaction was to laugh my head off. My Congressman’s clerk dropped my complaint after they received this form letter from the Director of the hospital. Why? It didn’t address anything I complained about. It basically went off on a tangent of trying to stuff it down our throats, what a wonderful job the VA is doing, and that we shouldn’t complain about it.

    I got my total knee replacement done, 7+ years after the doctors said my knee was done and that I had no more options. 7 YEARS!!! The only reason they finally authorized it for me at a civilian hospital, was that this was about the time the big scandal about the Arizona VA was all over the news, AND, it just so happens that the Fort Collins VA Clinic AND the Cheyenne VAMC had both been reported by whistleblowers, too, and were a part of the bigger Arizona investigation. They were all over the news, every night, on TV and in the newspapers. It was like someone lit a match under their butts, because out of the clear blue, I was contacted by VA to go see so and so civilian doctor, and schedule my surgery ASAP. I got that knee replaced just as fast as I could, before VA could change their minds!

    But, as the news about them died down, they went right back to the SOS. I had MRSA all over my skin for over a year after my surgery. They let it go, and didn’t send a sample to the lab, knowing full well, that if this got into my new knee, I could lose my leg. Finally, the doctor got a biopsy and sent it in — MRSA! He kept putting me on the cheapest, weakest medications he could, and the infection never got better. Finally, I read some stuff on the internet, and tried it — I soaked in bleach baths for 5 days straight, and the sores finally started drying up and scabbing over. If I hadn’t read about this, I’d probably still have MRSA to this day! As it is, I now have scars all over, where the MRSA was, because this doctor is incompetent!

    Now, I’ve had what I believe is ringworm, on my scalp for 9 months. I had very long, very thick hair, and it started off with me losing a patch of hair, then another, then another, and so on. If you bothered to look through my hair, and on my scalp, you could definitely see that something was wrong. The doctor kept saying it wasn’t that bad, yada yada yada, weak sauce. But, it kept getting worse and worse, and nothing he has given me for my scalp has helped in the slightest. I started dropping hair all over the place, and what I had left on my head, was so tangled because it was all broken off at the root, that I finally had to just shave my head. The day before I shave my head, my doctor writes my shrink and tells her he thinks I have some mania where I pull my own hair out! I didn’t see it until after I shaved my head, when I pulled it up online. I was spittin’ nails! I emailed him back, fired him, told him that I had a couple mental health issues, but pulling my hair out wasn’t one of them, and I informed him that I shaved my head, and why would I do that if I so enjoyed pulling my own hair out! I talked to my shrink, and luckily, she has known me for a long time, and knows I don’t pull my hair out, so she just ignored him. I was soooooo mad! I got a referral to a VA dermatologist, and she doesn’t do anything either, but gives me some shampoo, and tells me to come back in 3 months! Last week, had to go to civilian ER, because the stuff got into my ear, festered, and I had a horrible earache, and trouble hearing. That doctor said it was tinea — ringworm. Duh! Back to another VA doctor and he says “Grow your hair back out and live your life! You’re fine!” I’m standing there in utter disbelief! There is crap growing all over my head, open sores, blisters, rings, kerion….. and he sees nothing. Of course, he didn’t really look, either. So now, I think they have all been talking to each other and are playing some sort of game with me, and I think they’re all quacks. So, I’ve been growing my hair for a week now, and, as expected, without keeping things shaved down every day, the fungus is growing out, too, faster than my hair is growing out! So now, I have all these strange things sticking out of my fuzzy hair — the same things that were growing on my head, when I shaved it. Nothing has changed. Nothing has gotten better. If anything, things have gotten worse. I’ve been trying natural remedies that I find online, but no luck. I’m on Disability, so I have a very limited income, and can’t afford to go see a civilian doctor and pay out of pocket – but I’ve been asking around to see if anyone has any recommendations for me to go see a civilian specialist (maybe an infectious disease specialist?) and borrow the money to go. I am absolutely miserable, in a lot of pain, and the itching is about to drive me mad! I don’t know what else to do. I can’t count on VA to do a GD thing about this, so I have to take matters into my own hands if I hope to get rid of this stuff. Everyday, I’m miserable with this stuff, I look in the mirror at it, and I feel hopeless. I need to file a complaint, but how do you do that in a way that will get action?

    Sorry I wrote a book. I don’t usually talk at all anymore, but I had to get this off my chest. Thanks for bearing with me.


  3. VA, OIG are reluctant to give a form or specific directions for filing an ethics complaint.

  4. I need you all to sign a petition. You all know my 28 year saga because of the unethical doctor and the systemic cover-up that I lived through. PLEASE SIGN. I failed in every single way to get through to Secretary McDonald last two weeks. No response to emails, the complete wrong Divisions responding to the phone calls. So, I am trying this and I need you to help, ok????? I need a fast and furious surge of signatures, so please sign and invite everyone you know. THANK YOU

  5. This is all well and good, but this article does everything but what it says it will do. I have no more idea on how to file an ethics complaint now than I did when I started reading this.

    It’s always been criminal for a VA employee to alter, destroy, or hide records, but the trick is getting someone to listen or care when it happens. I filed an IU claim back in April of 2013, and shortly after my claim became a year old the filing date mysteriously changed to September of 2013. I’ve come to understand that claims do not adversely affect employee bonuses until they become a year old. SSSOOO — it’s a very hard sell to convince me this was anything but a blatant attempt to cook the books.

    I have not taken this lying down. I have notified my congressman’s office, the VARO ombudsman, and the VA OIG. So far, Not only have I heard nothing to convince me they are taking the charges seriously, they have not even made the VARO change the date of the claim back to last April.

    The progression of the case was predictable for anyone familiar with the VA. My claim was denied last month, and I have filed my NOD. I’m not going to give up on this, because the change in the date would be worth about $6000 (about $1500 a month for 4 months from my current 70% SC rate) to me if I, as I expect, win on appeal.

    So, Ben or anyone, tell me who I can tell about this egregious breach of ethics, and I’m ready to come out with guns blazing. Show me a form or an address — or even a phone number — and I’ll be right up in someone’s grill.

    Traditional channels for complaints allowed the VA to become the mess it is now, and I have no confidence they will be effective in fixing it.

  6. I have been in the VA system for 46 year's and the medical system has violated my right's time and time again! I have complained to Congressmen George Miller and Mike Thompson but they did nothing (being democrats is probably the reason) I have been told that "you have no right's by a neurologist by the name of Richardson and have been screwed by many, many other last in their medical class (if they ever went to school at all) and no matter what I do or say nothing is ever investigated and I keep hearing "the VA is really great" from loser people who are just bullies and bigot's. Martinez, California VA Medical Health Clinic is the worst and with the Northern California VA Medical Health countless Veterans have suffered one way or another. They will help a dope addict but won't lift a finger to aid a veteran who they prescribed a narcotic too withdraw. Lame ass VA caused me much grief and I am sick of the bull shit that will not change because it will just get worse! FTVA!.

    1. I’m with you on that score. The Seattle VAMC told a local hospital after I had a heart attack that I wasn’t a veteran that I was not entitled to any kind of medical treatment/or compensation so I got stuck with ambulance costs as well as medical. They did the exact same thing two years later, but with one thing extra..they threw me out and told me to go to Harborview about two miles down the road.

      1. Are they not subject to EMTALA?? If they are, they have violated federal law and should be sued. Maybe Ben can suggest a course of action.

  7. I have been in the VA system for 46 year’s and the medical system has violated my right’s time and time again! I have complained to Congressmen George Miller and Mike Thompson but they did nothing (being democrats is probably the reason) I have been told that “you have no right’s by a neurologist by the name of Richardson and have been screwed by many, many other last in their medical class (if they ever went to school at all) and no matter what I do or say nothing is ever investigated and I keep hearing “the VA is really great” from loser people who are just bullies and bigot’s. Martinez, California VA Medical Health Clinic is the worst and with the Northern California VA Medical Health countless Veterans have suffered one way or another. They will help a dope addict but won’t lift a finger to aid a veteran who they prescribed a narcotic too withdraw. Lame ass VA caused me much grief and I am sick of the bull shit that will not change because it will just get worse! FTVA!

  8. Is there a form to use in reporting ethics violations? Is there a list of the designated officials at each VA?

  9. ethics, what ethics I Worked for the v.a. for 25 yeras and if I ever say an employee giving a veteran a hard time, I would right up that employee and give it to my supervisors. I mainly worked after hours in the administrative field in charge of the hospital after hours. If there was any question that some thing was not being done properly I would show the regulation to whom ever was straying from the regulation and ensured that regulation was followed to the letter of the law. Now there are some employees who do not like to be told what to do, so I had made some people mad and they would later retalate against me, by spreading lies to their coworkers, in an effort to shun me. Big deal, I could care less as long as they did not effect the veterans care. I loved my job and helping veterans and their families. There is noting more scary that being sick and then having to run into an employee, who makes the veteran fill that they are a burded and treated as a second class citizen. There are employees that love to hurt other employees, if they fill they can get away with it, buy any means possible and this trickles down to our veterans. I am a veteran who was shot in the head and now after 40 years told I have a traumatic brain injury and was not able to get treatment for that fourty years as the v.a. told me that they did not have any record of me being shot and my records were distroyed in a fire in st louis, nor did I know I had a t.b.i. and only for the grace of god I survived the bullet and was still able to help my fellow veterans in my own way. My p.t.s.d. got so bad that I had to take a medical retirement and had to hire a lawyer to obtain a disability went from 0% to 100% and just a month ago I found out by obtaining my medical records that the v.a. did not loose my medical records, but in fact had them all this time. 1st my heart was broken that they would do this to me and then I got very upset, but kept it to myself. If I would have know that the v.a. had these records all this time, I could have been treated for my p.t.s.d. and T.B.I. and my family would have not had to see me suffer and as a result they suffered to, my wife did not leave me, she stood by me all these years and after I was given my disability and received care, Its like a new life. I no longer drink or take pain rx. and enjoy my family more everyday. I did the best I could while working for the v.a. and know 1st hand that there are v.a. employees that really do care, But I also know that there are some bad apples also and they have to be thrown out before they effect the whole basket. We as veterans can not only think this effects us, but effects all our active duty members that are returning, but the future veterans for years to come. Those in power owe it to us that were harmed in any way that we are heard and not labled as crazies, but concerned citizens and love this nation. WE Demand that the v.a. listen to its veterans and corrective action be taken and veterans no longer labled and punished without due process and or civil and constitutional rights respected.

  10. After many years of dealing with this dishonest, immoral, and unethical organization, I will only believe it when I see it. They are off to a despicable start with the Phoenix VA OIG Report. In the meantime, I am not holding what little breath I have left.

  11. Ben, I truly hope your right, and I think you just might be. I have all my records now as requested by your FOIA template it even states they cannot locate the film of my records as far as medical and the shore patrol. Quote, “it appears we cannot locate this, I’ve ordered a new set, I will personally send it to you myself.” Gee, and they are where??? But, when I called regarding my “C&P” lying excuse my phrase, “wench” who decided by the authority invested in herself acting alone as a professional to change my answers, I shall show “no mercy” upon each individual who did cause prolonging my treatment as well as evaluating and giving an obscure diagnosis. It’s a far stretch. To say one was pretty content in her younger years, happy to be around others, not clickish, but enjoyed bike rides and hiking alone, as I really didn’t need constant entertainment, and being friendly was a bad thing. It was only when I was assaulted by a guy who really was drunk and his remarks pretty rude, I answered in kind. Now, when all my “stuffing it away” had taken it’s toll on my life, you don’t see these things. But the screaming Banshee woman at the ER, my friend, a Naval officer, do not push her buttons! I was diagnosed, I’ve got proof of a request to terminate my shore duty. They didn’t offer counseling, you could stay or get out. But because I know how to be critical in my thinking, I decided, “wait a bit.” Call it gut instinct, medical get it. But these “bad apples” do so ever need to go. What I was subjected to, and what some of these idiots couldn’t read a record and test results to save their hides, if I would have allowed them to do as they wished? I was probably end up as a paraplegic. This is no laughing matter. It is serious business, and it shows they do not know how to ask questions. Now, the VA can only protect them so far, but, if fired, and an official complaint filed, which means to the state they were lisenced in, it being the VA as an entity, but professionals can be sued separately. I am glad he is taking Veterans seriously, but, honestly, PTSD & MST survivors are damn mad, and you can say we grow in strength because the “public” has stepped in asking to explain, how can they help? I always answer-“hold the VA accountable for proper care and treatment. My my my, what a tangle web we weave said the spider to the fly, interestingly enough, they have sent me all cases to be reopened and examined and the “C&P” will be a cake walk. This time, they best take care on their choice of words. Think I don’t have PTSD? Push my buttons and then they shall see, wait, they “DID PUSH MY BUTTONS!” I stated before, never call me a liar, I am a sailor not a soldier, and if she could get a degree, how did she ever learn her English and run sentences, words in a glob of a mess because of no spacing! Seriously, I wonder, is she “one of those” Paper mill college professionals? Thank you very much, this is great to know. Because I shall send copies to several places, and a layperson should even be able to google of what I shall state. I do hope that the head of north Texas VA systems gets it. The one place I clearly stated, do not make me appointments. So why would they “dishonor my request?” I know exactly why, I confronted this so called professional, with a witness of course. You see, as soon as I saw the report, the “only thing” correct was my name. My first name. She had me in and out of the service so many times it could make ones head spin! Even one nurse telling me what the doctor ordered, I stated no thank you, your gel crap doesn’t work, heating? I have four at home, so again, no thank you. Again, witness in the room. These are people who never should have been in this profession or simply got too complacent and forgot it’s not about Veterans serving you, it is about you serving Veterans-without Veterans, well my gosh, what country would accept you. Because no one would ever tolerate rude, vulgar, lying behaviors, oh well. I feel no regrets about what I shall do! And just FYI, some patient advocates work with political individuals, interesting, especially the mention of one thing and surprise, it had changed. I did get rated for a bladder condition, 20% but probably should be up’d a bit. It shall allow me to go to school with the Voc-Rehab, so after October I plan on buying it. First, refile of paperwork, second, lists from records to all those who said “I” will get, and naturally the next course if official stains of very serious and not erroneous charges, the oath-do no harm! Means something to me, however, I guess some just don’t ever “get it” if they hide behind the apron strings of the VA.
    I will tell you, this is how serious it has gotten, can we say do a Dr. King move? No one who has suffered any traumas should have to beg to get well, yet that’s exactly what they wish to do. I understand now our government leaders find it necessary to watch our Facebook moves? Oh well, so, what shall they ever do when I stated “double dare you?” “No guts no glory” I say, but oh so however I do! Thank you BEN. I have been a bit on my back lately, so yes I get your emails, I just needed a break from this chaos. A trip to California in October, I need to spend time with my family, also talk to the killer of my niece. Believe me, he has no clue who I am, but I know who he is, police report? We shall see-psychology will be at work here, call it my “practice run.”


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