What One Watchdog Group Found At One VA Medical Center Will Shock You (Maybe)

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VA Medical Center

The results of one watchdog inspection of a VA medical center days ago shocked VA leadership into removing the director from the facility immediately.

The new Secretary of Veterans Affairs unveiled some new policies and software tools this week that have advocates taking a step back including removing a VA director.

The watchdog group was VA OIG. They found that the director’s facility put veterans’ lives in danger, recalled medical supplies were likely used on veterans, missing supplies and tools forced veterans to go without lifesaving procedures, and dirty supplies were mixed with sterile supplies.

All of these acts could put many veterans’ lives at risk.

Despite IG’s finding that no evidence exists as of yet to show any veterans were harmed, the number of infractions were so numerous that it shows the director clearly lacked common sense and care for the lives and health of veterans.

Imagine How Your Boss Would React

Imagine this scenario.

For over two years, VA worked with government contractors to increase the appearance of transparency with a website. That website would show the wait times at all VA facilities but falls short by not revealing raw data for public scrutiny.

RELATED: VA Releases Wait Time And Quality Transparency Tool

Nonetheless, the fanfare surrounding the move makes VA shine in the press.

Imagine that same day VA OIG releases a scathing review that the VA medical center located in the Washington DC, right under the noses of VA Central Office, was putting veterans’ lives at risk.

It really takes the air out of an otherwise positive press day for VA. I can only imagine how pissed Secretary Shulkin was to learn his VA ruined the big reveal.

Not taking the news lying down, Secretary Shulkin immediately demoted the respective director responsible for the facility and replaced him with an outsider.

Even folks like Brandon Coleman, a well-known VA whistleblower, was impressed with the swift reaction. He sent me a text immediately after the report came out.

Normally, VA has normally been known to sit on its laurels while an embattled director took retaliatory measures against any VA employee responsible for telling OIG the information leading up to the scandal.

Not here.

In a first for this administration, however, Secretary Shulkin revealed he is willing to immediately remove and replace any director linked to endangering the lives of veterans.

“The Department of Veterans Affairs thanks the OIG for its quick work reviewing the D.C. VAMC,” the VA said in a statement. “The department considers this an urgent patient-safety issue. Effective immediately, the medical center director has been relieved from his position and temporarily assigned to administrative duties.”

VA removed Brian Hawkins and placed him on administrative duties pending the result of the investigation. Hawkins was first appointed as the director in 2011 and obviously had ample opportunities to fix any existing problems.

“VA is conducting a swift and comprehensive review into these findings,” the statement continued. “VA’s top priority is to ensure that no patient has been harmed. If appropriate, additional disciplinary actions will be taken in accordance with the law.”

Why would Shulkin move to remove Hawkins so quickly?

Here is a bullet list of what different infractions IG found and admitted within its interim report.

IG Report Summary Problems

In summary, the facility:

  • Failed to keep a normal supply of required supplies and equipment to perform the lifesaving services expected of all major VA medical centers
  • Failed to use proper protocol to remove recalled supplies and equipment to not put veterans’ lives at risk.
  • Failed to ensure supplies were sterile but instead using dirty supplies.

Washington DC VA Medical Center Missing Supplies And Equipment

Here are the full bullet points on missing supplies and equipment:

  • At the time of our site visit, the Medical Center was in the process of conducting a patient safety review because sterile processing ran out of supplies to test the insulation of scopes used in laparoscopic or endoscopic procedures. This testing is used to detect holes in the insulation surrounding the scopes that may result in the transmission of electrical current into surrounding tissues. If this occurs, patients may develop burns or latent infections. The Medical Center could not verify whether this testing had been done on scopes used in approximately 20 procedures since February 28, 2017-March 16, 2017.
  • As recently as March 15, 2017, the Medical Center ran out of bloodlines for dialysis patients on the second shift—they were able to provide dialysis services to those patients only because staff borrowed bloodlines from a private hospital.
  • On March 29, 2017 a nurse emailed the patient safety manager, reporting that during an acute episode, she needed to provide oxygen to a patient. The floor was out of oxygen nasal cannulas (tubing that fits into a patient’s nose and provides oxygen). The nurse was able to use one found on the crash cart, but reported the shortage as a risk to patient safety.
  • On March 29, 2017 a vendor loaned bone cements to cover two total knee replacements for surgeries scheduled that week. Operating room staff requested that prosthetics purchase the bone cement, but was told the company could not deliver it until the next week.
  • On March 30, 2017 the dialysis unit ran out of dialyzer bloodlines and 15 gauge fistula needles, both of which are essential for dialysis treatments.
  • On April 4, 2017 staff inspected the storeroom on the floor that had run out of the oxygen nasal cannulas. Between 11 a.m. and noon, OIG staff determined the storeroom was out of alcohol pads; slipper socks/aqua shoes; denture cups (plastic containers used to store patients’ dentures); and large tegaderms, a type of wound dressing. OIG was informed that nursing staff inventoried the rooms three times a day, and sent requests to logistics to replenish stock as needed. However, when OIG staff returned after 6 p.m. on the same day, only the alcohol pads had been replenished.
  • On April 5, 2017 the lead sterile processing technician had been tasked with finding a clip applier for use in a procedure scheduled to occur the next day. A clip applier is a device that deploys surgical clips that may be used to close off blood vessels or other tubular structures. OIG staff accompanied the technician as she searched for the device in the sterile processing department and in the central supply room. Despite having the purchase order number for the device, she was unable to find it.
  • On April 11, 2017 received an email stating that the operating room (OR) ran out of vascular patches, despite having requested the assistance of the Deputy Chief Medical Officer of VISN 5 in obtaining them two weeks ago. The OR also ran out of Doppler probes. Nursing staff stated that the ORs could not form emergent or elective open vascular surgery without those in stock.
  • On April 11, 2017 received an email stating that the OR ran out of sequential compression devices (SCDs). These are devices placed on patients’ legs to prevent blood clots during surgery. Surgery proceeded without the devices.

Longterm Supply Problem

VA OIG later determined the above problems existed for some time:

  • Since January 1, 2014, the Medical Center has recorded 194 patient safety reports relating to the unavailability of equipment or supplies.
  • In February 2016, a Stryker bone tray used in surgeries to repair mandibular (jaw) fractures had been removed from the facility due to outstanding invoices from the vendor. Surgical staff informed us that a procedure had to be delayed as a result.
  • Four prostate biopsy surgical procedures were canceled on April 25, 2016 because prostate biopsy guns were out of stock. A nurse wrote an email to the medical center director on April 26, 2016 recommending an OR “stand down” until the operating room’s inventory situation could be remedied.
  • In June 2016, the Medical Center discovered that one of its surgeons used expired surgical equipment on a patient during a surgical procedure. The Medical Center determined that the lack of an inventory management program caused the error. Rather than undertake measures to implement an appropriate inventory program, the Medical Center elected to require its nursing staff to conduct monthly rounds to identify and remove any expired supplies.
  • On March 16, 2017, the facility found Sterrad chemical indicator strips that expired on February 28, 2017 in sterile processing. The indicators are placed with equipment and change colors when exposed to hydrogen peroxide. This allows a visual verification that sterilization occurred. The Medical Center could not determine whether the expired indicators had been used on some of the 396 items sterilized in the Medical Center between the date of the strips’ expiration and the date staff discovered the expired strips and removed them from the facility.

Washington DC VA Medical Center Dirty Supplies

IG also found VA was mixing clean supplies with dirty supplies:

  • Eighteen sterile storage areas were dirty.
  • Five sterile storage areas mixed clean with dirty equipment or supplies.
  • Eight sterile storage areas contained supply racks lacking solid bottom shelves as required to reduce cross-contamination from the floor.
  • Seventeen sterile storage areas lacked a method to monitor pressure, temperature, and humidity.
  • Five sterile storage areas were cluttered.
  • Five sterile storage areas improperly served multiple purposes including office and patient care space. These areas also lacked security and appropriate environmental controls.

It is surprising such a scandal existed right under the nose of senior leadership with VA. Or is it? Where you shocked or not?

I cannot help but wonder if VA leadership allowed these problems to fester right under their noses and could not detect the stench for years, how much is going on nationwide?

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lily
lily

That’s why I’ve never been to the VA. I would rather go to an emergency room locally. Let the VA reduce my rating for not using their care. I would rather live.

Angela
Angela
Yes, I agree wholeheartedly. What a mess? Every facility needs to be gone through with a fine tooth comb just like they did with this VA. I am serious. Even, all the medical providers in all facilities need to be audited as to make sure all of their licenses are up to date and not expired. The VA budget needs to be done the very same way with auditing every single dollar to determine what, where, when, and how each and every dollar is being allocated and spent. I am shocked to hear that Secretary David Shulkin acted promptly to… Read more »
Don Avant

This hospital can’t perform the basics…Can’t order and stock supplies and can’t pay for them in time to keep them from being repossessed, Can’t keep sterile supplies separate from non-sterile…

Shouldn’t be surprised…They can’t get that most basic of services ( answering the phone ) don’t expect them to get the rest right…

lily
lily

Hey looks like I got the first comment 🙂

Ex va
Ex va

@lily, congratulations!!!??

lily
lily

LOL…Thanks.

LP
LP

The money to be used for the inventory was going into someone’s pocket.

Also, Ben,

It’s been over two weeks. Are you planning on taking my case or not?

MikeV
MikeV

He doesn’t take any cases from Veterans. I informed him of an assassin in the VA system and he flat out ignored it.

DO NOT TRUST THIS GUY!!! HE WORKS FOR THE VA!!!

Somebody needs to have a very serious talk with a person who manipulates Veterans for their own gain.

Don Avant

P.S. The director should be in jail…Not on “administative duties” still drawing a salary while they “investigate” (read ” find a way to cover it up” )

Ex va
Ex va
@Ben, no i am not shocked that this existed under the nose of senior leadership. My experience has been that senior leadership are involved with covering up all kinds of deficiencies in a va medical center. The part that surprised me is that vaoig had done an audit and was specifically identifying the logistic and inventory control problems and bio-med and did a follow up. Secretary Shulkin taking action was different with the removal usually comes from visn or vaoig. I doubt any legal action will be taken on this director. If va employees were doing their jobs responsibly these… Read more »
91Veteran
91Veteran

Spot on Exva. There are many more responsible for the mess this hospital is in.

Including any provider using unsterile or expired equipment anyway.

Disgruntled Veteran
Disgruntled Veteran
Good Aritcle Ben. I am neither shocked nor surprised at this. I read the complete VAOIG Report yesterday evening. I also e-mailed it to an ER Trauma Nurse friend of mine, and asked her to provide her thoughts on what would happen if HER hospital were caught operating the way the VHA does. When I receive her feedback, I will include it verbatim in a future comment. More tragedy, lies, and deception from VA leadership – – – who just see minor fires to be put out at individual VA locations across our land – – – rather than recognize… Read more »
lily
lily

Does anyone know if you can use a private hospital ER if you have an emergency? I wouldn’t want to go to the county hospital ER for an emergency.

lily
lily

I was wondering if the VA would pay for a private hospital ER or if you have to go to a government/county hospital ER?

Windguy
Windguy
You can, but …. In addition to the 72 hour thing, I’d recommend having a chat with the local ER/Hospital director to see how the VA responds to requests for payment. The hospital will hold YOU responsible. My neighbor ran up about $90k for an ER visit and a 250 mile life-flight/air-ambulance. The VA paid it – after 2.5 years. Here’s a guy with a heart condition and the stress of demands for payment was not healthy. But – the VA did pay. A more recent event requiring a flight from the same local ER to the same VA facility… Read more »
NiteWish
NiteWish

Lily, you’ll need to read this Fact Sheet. You have 72hrs to contact your local VA after using emergency services. “https://www.va.gov/PURCHASEDCARE/docs/pubfiles/factsheets/FactSheet_20-02.pdf”

namnibor
namnibor
“[I cannot help but wonder if VA leadership allowed these problems to fester right under their noses and could not detect the stench for years, how much is going on nationwide?]” The VA and Sec. Shulkin will further surprise me if they acknowledge they have a systemic problem in ALL of the VA System in USA. THIS is the opportunity to launch Operation Spring Clean at the VA. However, as much as I am thrilled that the director of this D.C. VAMC has been removed and placed on administrative duties, part of me also is worried that this will just… Read more »
namnibor
namnibor

I forgot to ask this: Who sewed the balls back on the VAOIG since they were out of equipment to do so at this VAMC?
Or, will the annual VA Easter Egg Hunt reveal all their balls were repurposed into colorful eggs?

91Veteran
91Veteran

Hawkins can fight any punishment, but it looks like plenty of evidence has been gathered here. All of it against him.

Angela
Angela
Namnibor, yes, agree with you. As for auditing all aspects of the VAs throughout the country, it really would be a great leadership decision if Secretary David Shulkin would hire many veterans who might could work, who are looking for work, and who want to contribute to reforming the VA healthcare system to where it reflects quality, top notch, and world class care. Many veterans may not be doctors but I am sure many veterans could be hired to audit all the VAs regarding all the supply inventories throughout our country. If a task force such as this was established,… Read more »
Angela
Angela

And too, wishing everyone a Happy Easter. Hope everyone had great Good Friday! 🙂

Lem
Lem

The employee that stole my T3 was a veteran. Not much help there. It is the morality of the last several generations– the me first generations that want it all for themselves and the hell with anyone else. You remember them from your service. Some have your back and the rest fake it.

Angela
Angela
Yes, Lem, you are correct about the morality issue with many in the past few generations but not all. There are a few here and there with upright moral and ethical standards. There are a few that show respect and dignity. Lem, though, you are right about the self seeking people whether they are veterans or non veterans. Some may have your back but some may not. One never knows because all human being are infallible. I guess at times it is just a judgement call. One point though with the more recent generations, it goes back to one’s upbringing… Read more »
Lem
Lem

Agree totally, Angela

Bill
Bill

I would venture to guess that this is just anothet typical VA medical center hard at work at killing us.

I wiuld be ashamed to let people know I wirk for the VA … I mean stealing tac payers money pretending to work for the government.

This shit should be included on every enlistment contract under the heading WARNING subsection your country does not give a shit about you

namnibor
namnibor

“[Why would Shulkin move to remove Hawkins so quickly?]”

He was removed as quickly as this news story was scrubbed from the mainstream media news feed.

91Veteran
91Veteran

DCVAMC already scrubbed his bio from their web site.

A retired Army Colonel who served during the Gulf War as an LT is Acting Director. His service may have been as a Medevac pilot.

He also had service with Command Inspector General, Army Med Department at Ft. Sam.

Looks like at least one VA is going to get lit up.

Disgruntled Veteran
Disgruntled Veteran

Darn Well About Time. Colonel Connell did a good job when he was at Tripler Army Medical Center.

Hope he ignites a mass conflagration under their asses!

Crazy elf
Crazy elf
I agree namnibor. Who sewed the balls back onto the OIG? That’s about the only thing that surprised me. If they found that much crap, what did they miss? For example; Where’d all the taxpayers monies go to purchase the much needed medical equipment and supplies? Where’d all the taxpayers monies go keep the medical supplies and equipment from being repossessed? I do believe this would constitute “Misappropriation of Government Funds!” Which, by the way, is a Felony! Punishable by lots of prison time! I also wonder IF this VHA received the dreaded “BONUSES” last year. Or, have they given/stolen… Read more »
namnibor
namnibor
@Crazy elf- “[Lastly; where will that director be transferred to? That’s VA’s standard operating procedures! Instead of prosecuting – they either transfer the criminals or allow the criminals to retire with full benefits!]” Per VA standard operating procedures, I predict they will make this Hawkins Chief Dick in-charge of procurement of medical supplies for ALL of the VA…again, wait for it. *IF* Shulkin does something OTHER than play whack a mole and actually fire Hawkins’ ass, then and ONLY THEN, will I be fully impressed. One would think a director with last name of Hawkins would somehow personify the ever-watchfulness… Read more »
Crazy elf
Crazy elf

namnibor,
Ben Carson found, because of an audit, “OVER $500+ BILLION, (A HALF TRILLION DOLLARS), OF TAXPAYERS MONIES” in Fraud waste and abuse by HUD, (Housing and Urban Development).
How’s that for doing something right!

91Veteran
91Veteran

I think Shulkin acted simply because the HVAC committee is investigating.

And they almost screwed that up.

According to that NBC article:

Shulkin yanked Hawkins and named the Chief of Staff who oversaw the mess as Acting Director, then changed his mind Thursday and named that retired Colonel.

The VA press release was updated when that happened, but it claims the Colonel was from outside the facility.

That is technically true, but the Colonel had been serving as a senior advisor. To Shulkin.

91Veteran
91Veteran
According to an NBC Washington news article, the IG found $150 million in unaccounted for equipment and missing medical supplies. That article also says the IG received a complaint March 21, inspected storage areas at the hospital March 29-30, April 4-6, and again Wednesday. Why did Shulkin move so fast? Its an embarrassment to the House Vets Affairs committee. The chairman is quoted at the end of the article complaining about the lack of oversight at the facility. Thinking people would believe a lack of oversight by Congress as well. It says the committee has an active investigation into the… Read more »
namnibor
namnibor

“Gee, Mr Congressman. When will you expand that to hospitals outside your backyard”

BINGO! Question of the century for the congress critters on Veteran Committees! 🙂

Angela
Angela
Right on there 91Veteran! Great question! Expand Investigation and Audits to all hospitals. Everyone though, these investigations and audits would be going to infinity with never reaching the end due to the amount of corruption that is in the VA. All veterans though would very much appreciate an overhaul with reform. Overhauling the VA to reflect accountable, ethical, and humane standards would be about the greatest accomplishment for humanity ever achieved in this country. I am hoping Secretary David Shulkin’s leadership actions in this case is not just a one time show. Please Secretary David Shulkin carry on with draining… Read more »
Whistle Blower
Whistle Blower

I would recommend that the Director in Fayetteville Arkansas be investigated as well. He was the Associate Director with responsibility for logistics while most this happened. That is until he was promoted. Bryan Matthews. Look it up.

Nexdeceptus
Nexdeceptus

The only reason the VA jumped on this so quickly is because it was NEXT DOOR! Sounds like UNITED! Oh! me so solly! The only difference is that VA won’t get sued. Just back to business as usual.

namnibor
namnibor

🙂
The mainstream news media is still spinning cotton candy from this United Airlines dragging of passenger off plane debacle.

Notice even a Veteran could set themselves on fire outside a VAMC but not a blip, and even when the VA gets caught screwing-up royally RIGHT IN THE D.C. Swamp, the news only remains in the forefront for maybe one eight hour shift…now…~~~~~crickets~~~~~ ~ ~

Windguy
Windguy

This is just one example of the systemic rot that permeates all levels of government in this country. It starts at the top with a corrupt political culture that rewards and encourages deceit and erodes any inference of honesty and integrity. America needs a reset

Dennis
Dennis
Isn’t something that the agency who promises us the map leading to the fountain of youth through advanced genetic research, cannot turn multiple billions of dollar slated to develop advanced computer predictive models of human behavior, and computers that can predict medical need before the patient presents with symptoms, into a simple tool to monitor the behavior of their own people in real time? How about doing research on corruption? We have a known quantity and known specimens from which to study, right? Experiment Alpha: Take half of VA persons and place them in prison. The other half place them… Read more »
Dennis
Dennis

Keeping in mind our obligations to the AFGE who might object to half their folks in prison, I would suggest that this is offered as a plea bargain option (if they force investigation we will take ALL the criminals to jail instead of just the set 50%)- a gift from The People.

Somebody post me he damn beer makers contact! I have even more ideas that he is gonna want to hear!

91Veteran
91Veteran

@jakeleinenkugel on Twitter.

namnibor
namnibor

Notice the VA just HAD to slip in that little annoying tidbit that this former director Hawkins is only on *temporary* administrative duties?
He could sit like that for months while still collecting his director level salary…then once the news heat is off, which is about now, the VA will play the shell game of whack a mole and Hawkins will magically pop-up at the Phoenix VAMC, where it seems to be the dumping ground of VA misfits. Wait for it……..

Disgruntled Veteran
Disgruntled Veteran

@Nam – – – Probably. But first he must do his “Tropical Vacation Penance” at the Manila Embassy Clinic on the taxpayers nickel. Worked for Rima Nelson. The VA formula seems to be “we’ve gotten away with it since BC was the POTUS. Why mess with success?”

After he has had a suitable period of R & R – – – then he goes to Phoenix, which is probably considered “High Risk” duty in VA parlance . . .

Just Another Combat Wounded Veteran
Just Another Combat Wounded Veteran

Again, close the entire department down. Move it into Medicare and Social Security, along with its billions of $$$ in budget. Provide a class of coverage for Veterans of all ages and their dependents, provide them with ID and coverage, according to service if necessary, and include all Honorably Discharged. LET US GET QUALITY HEALTH AND MEDICAL CARE JUST LIKE EVERYONE ELSE!!!

Simple solution. They will NEVER be able to fix the existing VA, never.

cj
cj

Fuck the VA:
…………………./´¯/)
………………..,/¯../
………………./…./
…………./´¯/’…’/´¯¯`·¸
………./’/…/…./……./¨¯\
……..(‘(…´…´…. ¯~/’…’)
………\……………..’…../
……….”…\………. _.·´
…………\…………..(
…………..\………….\…

Lem
Lem
Not surprising to me. I used the DC VA from 1995–2001 more than any other. The director is a political appointee not a qualified one. Things were going down hill during the time I used the DC VA. All that was happening was construction designed to have the directors name enshrined on a plaque. The director’s office was totally unresponsive to complaints. I was hospitalized in the nursing home for several weeks until I checked myself out because the orderly substituted aspirin for my T3. An aspirin has a very distinctive taste compared to Tylenol which doesn’t dissolve as quickly.
91Veteran
91Veteran
It’s encouraging to see what appears to be the IG crawling up the ass and giving a thorough, unannounced inspection of this hospital as shown by the time line, and how many seemed to have provided evidence. I guaran damn tee it’s happening everywhere. This kind of inspection should be happening, unannounced, at every VA hospital and clinic in the country. Whats discouraging is only the director has been reassigned to admin duties, as if a pencil pushing bureaucrat does anything else. He should have been fired as a start. If you read this, it shows a complete breakdown in… Read more »
91Veteran
91Veteran

I believe Ben may have written a previous column on this, but this is the same hospital where 24 VA police officers filed a lawsuit after discovering hidden cameras and microphones in their control room and changing room in 2014.

Maybe Hawkins is a pervert as well. Or someone was trying to find out whether other illegal activities we’re being investigated.

The NBC article says both Hawkins and the police chief installed the cameras.

Perhaps they won the lawsuit, and this IG thing is a cleaner way of firing Hawkins.

Lem
Lem

Not a pervert. Just listening to who knew what about his corrupt clan.

I have a record of prescriptions on my file for drugs I never received from the DCVAMC pharmacy.

91Veteran
91Veteran

Lem, I suspect $150 million is the top of this corrupt iceberg if they wanted to dig deeper.

I wonder how that lawsuit turned out since Chiefy Jerry Brown is still listed on their leadership page.

namnibor
namnibor

Probably a pervert as well.

ANutterVet
ANutterVet
@Lem @Namnibor – Please Gents, lets compromise, and I suggest, well hell no, I’m going to refer to all VA corrupted employees as, “Verts.” OK? Why waste the kinetic energy in pronouncing the full word. Get ready, there’ll be more articles of discoveries published by Ben, that’ll be coming down the pike. Make amends, shake hands, because these people [VA Verts] will keep on underservicing Veterans either by stealing, and/or hurting and killing Veterans. We have to stick together, in order to be organized for a full elemental surprise attack when they head to their high priced parking stalls. Remember,… Read more »
Jo3n

Perhaps off target, a man, Geoff Woo, wearing a health monitor and it’s amazing. It regulates, analyzes… This system may be the future in the VHA. Anything else that the VA would invest in will be a huge waste in taxpayers dollars. In no way am I suggesting this device has answers for VA employees conduct, but it covers a lot of health care answers for many of us. @Ben, another great, sickening post. How do these people sleep??… I know, too damn many of them are sleeping quite well.

ANutterVet
ANutterVet

VA employees sleep well. No accountability, no meaningful investigations, no charges will be filed, no worries about jail time, and they will most likely be relocated so that things cool off.

Jo3n
A friend came by and has been trying to get a, “comedy script” for a play. Over the last few months, he has come by and we share notes. Today, he comes by to let me read some of the script. No longer a comedy, it’s a satire. Not sure at all about what I felt, and was quite shocked to read the humorous view of the plight of so many Veterans. He’s informed by Ben and others. He knows how I feel. What we found wrong, is he assumed, many times, that Veterans have options. He thought if a… Read more »
SgtRay
SameO, SameO…Nothing has changed and the VA track record indicates that nothing will change. If we look at all of the reports of similar incidents over the last 5, 10 years, all that has changed, is the name of the facility and geographic location. The reason why this debacle is continuing, is because, no one, who has the power to bring about change, has stepped forward and said, “Enough Is Enough!”. The Veterans Administration Secretary, is appointed by the President. The House and Senate Committees For Veterans Affairs has oversight and can convene hearings. We the Veterans, do not have… Read more »
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