VA Health Care
Actions Needed to Prevent Sexual Assaults and Other Safety Incidents Gao ID: GAO-11-530 June 7, 2011Changes in patient demographics present unique challenges for VA in providing safe environments for all veterans treated in Department of Veterans Affairs (VA) facilities. GAO was asked to examine whether or not sexual assault incidents are fully reported and what factors may contribute to any observed underreporting, how facility staff determine sexual assault-related risks veterans may pose in residential and inpatient mental health settings, and precautions facilities take to prevent sexual assaults and other safety incidents. GAO reviewed relevant laws, VA policies, and sexual assault incident documentation from January 2007 through July 2010 provided by VA officials and the VA Office of the Inspector General (OIG). In addition, GAO visited and reviewed portions of selected veterans' medical records at five judgmentally selected VA medical facilities chosen to ensure the residential and inpatient mental health units at the facilities varied in size and complexity. Finally, GAO spoke with the four Veterans Integrated Service Networks (VISN) that oversee these VA medical facilities.
GAO found that many of the nearly 300 sexual assault incidents reported to the VA police were not reported to VA leadership officials and the VA OIG. Specifically, for the four VISNs GAO spoke with, VISN and VA Central Office officials did not receive reports of most sexual assault incidents reported to the VA police. Also, nearly two-thirds of sexual assault incidents involving rape allegations originating in VA facilities were not reported to the VA OIG, as required by VA regulation. In addition, GAO identified several factors that may contribute to the underreporting of sexual assault incidents including unclear guidance and deficiencies in VA's oversight. VA does not have risk assessment tools designed to examine sexual assaultrelated risks veterans may pose. Instead, VA staff at the residential programs and inpatient mental health units GAO visited said they examine information about veterans' legal histories along with other personal information as part of a multidisciplinary assessment process. VA clinicians reported that they obtain legal history information directly from veterans, but these self-reported data are not always complete or accurate. In reviewing selected veterans' medical records, GAO found that complete legal history information was not always documented. In addition, VA has not provided clear guidance on how such legal history information should be collected or documented. VA facilities GAO visited used a variety of precautions intended to prevent sexual assaults and other safety incidents; however, GAO found some of these measures were deficient, compromising facilities' efforts to prevent sexual assaults and other safety incidents. For example, facilities often used patientoriented precautions, such as placing electronic flags on high-risk veterans' medical records or increasing staff observation of veterans who posed risks to others. These VA facilities also used physical security precautions--such as closed-circuit surveillance cameras to actively monitor units, locks and alarms to secure key areas, and police assistance when incidents occurred. These physical precautions were intended to prevent a broad range of safety incidents, including sexual assaults, through monitoring patients and activities, securing residential programs and inpatient mental health units, and educating staff about security issues and ways to deal with them. However, GAO found significant weaknesses in the implementation of these physical security precautions at these VA facilities, including poor monitoring of surveillance cameras, alarm system malfunctions, and the failure of alarms to alert both VA police and clinical staff when triggered. Inadequate system installation and testing procedures contributed to these weaknesses. Further, facility officials at most of the locations GAO visited said the VA police were understaffed. Such weaknesses could lead to delayed response times to incidents and seriously erode efforts to prevent or mitigate sexual assaults and other safety incidents. GAO recommends that VA improve both the reporting and monitoring of sexual assault incidents and the tools used to identify risks and address vulnerabilities at VA facilities. VA concurred with GAO's recommendations and provided an action plan to address them.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: Randall B. Williamson Team: Government Accountability Office: Health Care Phone: (206) 287-4860GAO-11-530, VA Health Care: Actions Needed to Prevent Sexual Assaults and Other Safety Incidents
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United States Government Accountability Office:
GAO:
Report to the Committee on Veterans' Affairs, House of Representatives:
June 2011:
VA Health Care:
Actions Needed to Prevent Sexual Assaults and Other Safety Incidents:
GAO-11-530:
GAO Highlights:
Highlights of GAO-11-530, a report to the Committee on Veterans‘
Affairs, House of Representatives.
Why GAO Did This Study:
Changes in patient demographics present unique challenges for VA in
providing safe environments for all veterans treated in Department of
Veterans Affairs (VA) facilities. GAO was asked to examine whether or
not sexual assault incidents are fully reported and what factors may
contribute to any observed underreporting, how facility staff
determine sexual assault-related risks veterans may pose in
residential and inpatient mental health settings, and precautions
facilities take to prevent sexual assaults and other safety incidents.
GAO reviewed relevant laws, VA policies, and sexual assault incident
documentation from January 2007 through July 2010 provided by VA
officials and the VA Office of the Inspector General (OIG). In
addition, GAO visited and reviewed portions of selected veterans‘
medical records at five judgmentally selected VA medical facilities
chosen to ensure the residential and inpatient mental health units at
the facilities varied in size and complexity. Finally, GAO spoke with
the four Veterans Integrated Service Networks (VISN) that oversee
these VA medical facilities.
What GAO Found:
GAO found that many of the nearly 300 sexual assault incidents
reported to the VA police were not reported to VA leadership officials
and the VA OIG. Specifically, for the four VISNs GAO spoke with, VISN
and VA Central Office officials did not receive reports of most sexual
assault incidents reported to the VA police. Also, nearly two-thirds
of sexual assault incidents involving rape allegations originating in
VA facilities were not reported to the VA OIG, as required by VA
regulation. In addition, GAO identified several factors that may
contribute to the underreporting of sexual assault incidents including
unclear guidance and deficiencies in VA‘s oversight.
VA does not have risk assessment tools designed to examine sexual
assault-related risks veterans may pose. Instead, VA staff at the
residential programs and inpatient mental health units GAO visited
said they examine information about veterans‘ legal histories along
with other personal information as part of a multidisciplinary
assessment process. VA clinicians reported that they obtain legal
history information directly from veterans, but these self-reported
data are not always complete or accurate. In reviewing selected
veterans‘ medical records, GAO found that complete legal history
information was not always documented. In addition, VA has not
provided clear guidance on how such legal history information should
be collected or documented.
VA facilities GAO visited used a variety of precautions intended to
prevent sexual assaults and other safety incidents; however, GAO found
some of these measures were deficient, compromising facilities‘
efforts to prevent sexual assaults and other safety incidents. For
example, facilities often used patient-oriented precautions, such as
placing electronic flags on high-risk veterans‘ medical records or
increasing staff observation of veterans who posed risks to others.
These VA facilities also used physical security precautions”such as
closed-circuit surveillance cameras to actively monitor units, locks
and alarms to secure key areas, and police assistance when incidents
occurred. These physical precautions were intended to prevent a broad
range of safety incidents, including sexual assaults, through
monitoring patients and activities, securing residential programs and
inpatient mental health units, and educating staff about security
issues and ways to deal with them. However, GAO found significant
weaknesses in the implementation of these physical security
precautions at these VA facilities, including poor monitoring of
surveillance cameras, alarm system malfunctions, and the failure of
alarms to alert both VA police and clinical staff when triggered.
Inadequate system installation and testing procedures contributed to
these weaknesses. Further, facility officials at most of the locations
GAO visited said the VA police were understaffed. Such weaknesses
could lead to delayed response times to incidents and seriously erode
efforts to prevent or mitigate sexual assaults and other safety
incidents.
What GAO Recommends:
GAO recommends that VA improve both the reporting and monitoring of
sexual assault incidents and the tools used to identify risks and
address vulnerabilities at VA facilities. VA concurred with GAO‘s
recommendations and provided an action plan to address them.
View [hyperlink, http://www.gao.gov/products/GAO-11-530] or key
components. For more information, contact Randall B. Williamson at
(202) 512-7114 or williamsonr@gao.gov.
[End of section]
Contents:
Letter:
Background:
Nearly 300 Sexual Assault Incidents Were Reported Since 2007 through
One of Two VA Reporting Streams:
Not All Sexual Assault Incidents Are Reported Due to Unclear Guidance
and Insufficient Oversight:
Self-Reported Legal Histories Are Commonly Used to Inform Clinicians
of Sexual Assault-Related Risks, but Guidance on Information
Collection Is Limited:
VA Residential and Inpatient Mental Health Settings Use a Variety of
Precautions to Prevent Sexual Assaults and Other Safety Incidents, but
Serious Weaknesses Were Observed at Selected Facilities:
Conclusions:
Recommendations for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Scope and Methodology:
Appendix II: Analysis of VA Police Reports of Sexual Assault Incidents
from January 2007 through July 2010:
Appendix III: Comments from the Department of Veterans Affairs:
Appendix IV: GAO Contact and Staff Acknowledgments:
Tables:
Table 1: Number of Sexual Assault Incidents by Category Reported to VA
Police by Year, January 2007 through July 2010:
Table 2: Sexual Assault Incidents Reported to Four Selected VISNs and
VHA Central Office Leadership, January 2007 through July 2010:
Table 3: Selected VA Medical Facility Definitions of Sexual Assault
for the Assessment and Management of Victims of Recent Sexual Assault:
Table 4: Physical Security Precautions in Residential Programs and
Inpatient Mental Health Units at Selected VA Medical Facilities:
Table 5: Weaknesses in Physical Security Precautions in Residential
Programs and Inpatient Mental Health Units at Selected VA Medical
Facilities:
Table 6: Total Sexual Assault Incidents Alleging Rape by Perpetrator
and Victim Gender, January 2007 through July 2010:
Table 7: Total Sexual Assault Incidents Alleging Rape by Perpetrator
and Victim Relationship to VA, January 2007 through July 2010:
Table 8: Patient-on-Patient Assault Incidents and Patient-on-Employee
Assault Incidents by Type of Sexual Assault Incident, January 2007
through July 2010:
Figures:
Figure 1: VA Reporting Process for Sexual Assaults and Other Safety
Incidents:
Figure 2: VHA Central Office Reporting Process for Sexual Assaults and
Other Safety Incidents:
Figure 3: Number of Sexual Assault Incidents Reported to VA Medical
Facility Police by VISN, January 2007 through July 2010:
Abbreviations:
CWT/TR: compensated work therapy/transitional residence:
DOD: Department of Defense:
MMPI: Minnesota Multiphasic Personality Inventory:
IOC: Integrated Operations Center:
NARA: National Archives and Records Administration:
NCPS: National Center for Patient Safety:
OIG: Office of the Inspector General:
OSLE: Office of Security and Law Enforcement:
PTSD: post-traumatic stress disorder:
RRT: Presidential rehabilitation treatment programs:
VA: Department of Veterans Affairs:
VHA: Veterans Health Administration:
VISN: Veterans Integrated Service Network:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
June 7, 2011:
[End of section]
The Honorable Jeff Miller:
Chairman:
The Honorable Bob Filner:
Ranking Member:
Committee on Veterans' Affairs:
House of Representatives:
The Department of Veterans Affairs (VA) has developed a number of
initiatives in recent years designed to increase veterans' use of VA
medical facilities throughout the nation. These initiatives have
targeted several specific veteran populations--including women
veterans, young veterans from the military operations in Iraq and
Afghanistan, and veterans facing legal issues or those currently
incarcerated. Such outreach initiatives have increased the number of
veterans from these specific populations participating in residential
and inpatient mental health care programs at VA medical facilities and
have changed the demographics of patients cared for by VA.
Such changes in patient demographics along with the department's
commitment to providing health care services to all eligible veterans
present unique challenges for VA both in providing and maintaining
accessible care and keeping veterans and staff safe in VA medical
facilities, including those that treat veterans suffering from mental
health conditions. During our recent work on services available for
women veterans in VA medical facilities, several clinicians raised
concerns about the safety of women veterans in mental health programs
at one VA medical facility.[Footnote 1] For example, these clinicians
raised concerns about the safety of women veterans in a VA residential
mental health facility that housed both women veterans and veterans
who had committed sexual crimes in the past. Clinicians also expressed
concerns about women veterans receiving treatment in the inpatient
mental health units of this VA medical facility because they did not
feel adequate safety precautions were in place to protect women
admitted to these units.
These concerns highlight the importance of VA having both effective
security precautions in place at its medical facilities, especially
those with residential and inpatient mental health programs, and a
consistent way to exchange information and facilitate discussions
about safety incidents, including sexual assault incidents.[Footnote
2],[Footnote 3] VA has policies in place regarding security
precautions in residential and inpatient mental health settings and
procedures for reporting and analyzing patient safety incidents
through its National Center for Patient Safety (NCPS).[Footnote 4] For
example, VA requires that residential and inpatient mental health
facilities conduct periodic reviews of the security precautions in use
in these settings. Also, VA's NCPS has established procedures for
medical facilities to report patient safety incidents that occur in
these facilities to leadership officials.
You asked us to examine: (1) VA's processes for reporting sexual
assault incidents and the volume of these incidents reported in recent
years; (2) the extent to which sexual assault incidents are fully
reported and what factors may contribute to any observed
underreporting; (3) how medical facility staff determine sexual
assault-related risks veterans may pose in residential and inpatient
mental health settings; and (4) the precautions in place in
residential and inpatient mental health settings to prevent sexual
assaults and other safety incidents and any weaknesses in these
precautions.
To examine VA's processes for reporting sexual assault incidents, the
volume of these incidents reported in recent years, the extent to
which these incidents were fully reported, and factors that may
contribute to any observed underreporting, we reviewed relevant VA and
Veterans Health Administration (VHA) policies, handbooks, directives,
and other guidance documents on the reporting of safety incidents.
[Footnote 5] We also interviewed VA and VHA Central Office officials
involved with the reporting of safety incidents--including officials
with VA's Office of Security and Law Enforcement (OSLE), VHA's Office
of the Deputy Under Secretary for Health for Operations and
Management, and VHA's Office of the Principal Deputy Under Secretary
for Health.[Footnote 6] In addition, we conducted site visits to five
VA medical facilities. These judgmentally selected medical facilities
were chosen to ensure that our sample: (1) had both residential and
inpatient mental health settings; (2) reflected a variety of
residential mental health specialties, including military sexual
trauma; (3) had medical facilities with various levels of experience
reporting sexual assault incidents; and (4) varied in terms of size
and complexity.[Footnote 7] During the site visits, we interviewed
medical facility leadership officials and residential and inpatient
mental health unit managers and staff to discuss their experiences
with reporting sexual assault incidents. We also spoke with officials
from the four Veterans Integrated Service Networks (VISN) responsible
for managing the five selected medical facilities to discuss their
expectations, policies, and procedures for reporting sexual assault
incidents.[Footnote 8] Information obtained from these VISNs and VA
medical facilities cannot be generalized to all VISNs and VA medical
facilities. In addition, we interviewed officials from the VA Office
of the Inspector General's (OIG) Office of Investigations--Criminal
Investigations Division--to discuss information they receive from VA
medical facilities about sexual assault incidents that occur in these
facilities. Finally, we reviewed documentation of reported sexual
assault incidents at VA medical facilities provided by VA's OSLE, the
VA OIG, and VISNs from January 2007 through July 2010, to determine
the number and types of incidents reported, as well as which VA and
VHA offices were notified of those incidents. For this analysis, we
used a definition of sexual assault that was developed for the purpose
of this report.[Footnote 9] Our analysis of VA police and VA OIG
reports was limited to only those incidents that were reported and
cannot be used to project the volume of sexual assault incident
reports that may occur in future years. Following verification that VA
police and VA OIG incidents met our definition of sexual assault and
comparisons of sexual assault incidents reported by the two groups
within VA, we found data derived from these reports to be sufficiently
reliable for our purposes.
To examine how medical facility staff determine sexual assault-related
risks veterans may pose, we reviewed: (1) relevant VA and VHA policies
and procedures and (2) risk assessment policies and procedures from
our judgmentally selected sample of VISNs and VA medical facilities'
residential and inpatient mental health units. We also interviewed VA,
VHA, VISN, and VA medical facility leadership officials and
residential and inpatient mental health unit managers and staff
regarding the assessment of risks. Finally, to inform our
understanding of information collected during this process, we
reviewed selected portions of medical records for all veterans at our
selected medical facilities who were registered in the state's
publicly available sex offender registry and had addresses matching
the selected medical facilities' residential or inpatient mental
health units. Our review of these records was limited to only those
veterans meeting these criteria and should not be generalized to
broader VA patient populations.
Finally, to examine the precautions in place to prevent sexual
assaults and other safety incidents, we reviewed relevant VA, VHA,
VISN, and selected medical facility policies related to the security
of residential and inpatient mental health programs. We also
interviewed VA, VHA, VISN, and selected medical facility officials
about the precautions in place to prevent sexual assault incidents and
other violent activities in the residential and inpatient mental
health units. Finally, to assess any weaknesses in physical security
precautions at the VA medical facilities selected for this review, we
conducted an independent assessment of the precautions in place at
each of our selected medical facilities--including the testing of
alarm systems. These assessments were conducted by physical security
experts within our Forensic Audits and Investigative Services team
using criteria based on generally recognized security standards and
selected VA security requirements. Our review of physical security
precautions was limited to only those medical facilities we reviewed
and does not represent results from all VA medical facilities. For
additional details about the scope and methodology used in this
report, see appendix I.
We conducted our performance audit from May 2010 through June 2011 in
accordance with generally accepted government auditing standards.
Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe
that the evidence obtained provides a reasonable basis for our
findings and conclusions based on our audit objectives. We conducted
our related investigative work in accordance with standards prescribed
by the Council of the Inspectors General on Integrity and Efficiency.
Background:
VHA oversees VA's health care system, which includes 153 medical
facilities organized into 21 VISNs. VISNs are charged with the day-to-
day management of the medical facilities within their network;
however, VHA Central Office maintains responsibility for monitoring
and overseeing both VISN and medical facility operations. These
oversight functions are housed within several offices within VHA,
including the Office of the Deputy Under Secretary for Health for
Operations and Management and the Office of the Principal Deputy Under
Secretary for Health.
Residential Programs:
The 237 residential programs in place in 104 VA medical facilities
provide residential rehabilitative and clinical care to veterans with
a range of mental health conditions. VA operates three types of
residential programs in selected medical facilities throughout its
health care system:
* Residential rehabilitation treatment programs (RRTP). These programs
provide intensive rehabilitation and treatment services for a range of
mental health conditions in a 24 hours per day, 7 days a week
structured residential environment at a VA medical facility. There are
several types of RRTPs throughout VA's health care system that
specialize in offering programs for the treatment and management of
certain mental health conditions--such as post-traumatic stress
disorder (PTSD) and substance abuse.
* Domiciliary programs. In its domiciliaries, VA provides 24 hours per
day, 7 days a week structured and supportive residential environments,
housing, and clinical treatment to veterans. Domiciliary programs may
also contain specialized treatment programs for certain mental health
conditions.
* Compensated work therapy/transitional residence (CWT/TR) programs.
These programs are the least intensive residential programs and
provide veterans with community based housing and therapeutic work-
based rehabilitation services designed to facilitate successful
community reintegration.[Footnote 10]
Security measures that must be in place at all three types of
residential programs are governed by VHA's Mental Health RRTP
Handbook.[Footnote 11] Among the security precautions that must be in
place for residential programs are secure accommodations for women
veterans and periodic assessments of facility safety and security
features.[Footnote 12]
Inpatient Mental Health Units:
Most (111) of VA's 153 medical facilities have at least one inpatient
mental health unit that provides intensive treatment for patients with
acute mental health needs. These units are generally a locked unit or
floor within each medical facility, though the size of these units
varies throughout VA. Care on these units is provided 24 hours per
day, 7 days a week, and is intensive psychiatric treatment designed to
stabilize veterans and transition them to less intensive levels of
care, such as RRTPs and domiciliary programs. Inpatient mental health
units are required to comply with VHA's Mental Health Environment of
Care Checklist that specifies several safety requirements for these
units, including several security precautions, such as the use of
panic alarm systems and the security of nursing stations within these
units.
Mental Health Admission Screening and Assessment:
The admissions processes for both VA residential programs and
inpatient mental health units require several assessments that are
conducted by an interdisciplinary team--including nursing staff,
social workers, and psychologists. One of the commonly used
assessments is a comprehensive biopsychosocial assessment. In
residential programs, these assessments are required to be completed
within 5 days of admission and include the collection of veterans'
medical, psychiatric, social, developmental, legal, and abuse
histories along with other key information.[Footnote 13] These
biopsychosocial assessments aid in the development of individualized
treatment plans based on each veteran's individual needs. For
inpatient mental health units, initial screening of veterans,
including the initial biopsychosocial assessment, often takes place
outside the unit in another area of the medical facility where the
veteran first presents for treatment, such as the emergency room or a
mental health outpatient clinic. Veterans admitted to inpatient mental
health units are typically reassessed more frequently than veterans
admitted to residential programs due to their instability at the time
of admission.
VA Law Enforcement Resources:
VA's OSLE is the department-level office within VA Central Office
responsible for developing policies and procedures for VA's law
enforcement programs at local VA medical facilities. Most VA medical
facilities have a cadre of VA police officers who are federal law
enforcement officers who report to the medical facility's director.
These officers are charged with protecting the medical facility by
responding to and investigating potentially criminal activities
reported by staff, patients, and others within the medical facility
and completing police reports about these investigations. VA medical
facility police often notify and coordinate with other law enforcement
entities, including local area police departments and the VA OIG, when
criminal activities or potential security threats occur.
The VA OIG has investigators throughout the nation who also conduct
investigations of criminal activities affecting VA operations,
including reported cases of sexual assault. By regulation, all
potential felonies, including rape allegations, must be reported to VA
OIG investigators.[Footnote 14] Once a case is reported, VA OIG
investigators can either serve as the lead agency on the case or offer
to serve as advisors to local VA police or other law enforcement
agencies conducting an investigation of the issue.
In April 2010, VA established an Integrated Operations Center (IOC)
that serves as the department's centralized location for integrated
planning and data analysis on serious incidents.[Footnote 15] The VA
IOC requires incidents--including sexual assaults--that are likely to
result in media or congressional attention be reported to the IOC
within 2 hours of the incident. The IOC then presents information on
serious incidents to VA senior leadership officials, including the
Secretary in some cases.
Nearly 300 Sexual Assault Incidents Were Reported Since 2007 through
One of Two VA Reporting Streams:
VA has two concurrent reporting streams--a management stream and a law
enforcement stream--for communicating sexual assaults and other safety
incidents to senior leadership officials. The management stream
identifies and documents incidents for leadership's attention. The law
enforcement stream documents incidents that may involve criminal acts
for investigation and prosecution, when appropriate. We found that
there were nearly 300 sexual assault incidents reported through the
law enforcement stream to the VA police from January 2007 through July
2010--including alleged incidents that involved rape, inappropriate
touching, forceful medical examinations, forced or inappropriate oral
sex, and other types of sexual assault incidents. Finally, we could
not systematically analyze sexual assault incident reports received
through VA's management stream due to the lack of a centralized VA
management reporting system.
VA Uses Two Reporting Streams for Communicating Incidents to
Management and Law Enforcement:
Policies and processes are in place for documenting and communicating
sexual assaults and other safety incidents to VHA management and VA
law enforcement officials. VHA policies outline what information staff
must report and define some mechanisms for this reporting, but medical
facilities have the flexibility to customize and design their own site-
specific reporting systems and policies that fit within the broad
context of these requirements.
VA's structure for reporting sexual assaults and other safety
incidents involves two concurrent reporting streams--the management
stream and the law enforcement stream. This dual reporting process is
intended to ensure that both relevant medical facility leadership and
law enforcement officials are informed of incidents and can perform
their own separate investigations. (See figure 1 for an illustration
of the reporting structure for sexual assaults and other safety
incidents.) The reporting processes described below may vary slightly
throughout VA medical facilities due to local medical facility
policies and procedures.
Figure 1: VA Reporting Process for Sexual Assaults and Other Safety
Incidents:
[Refer to PDF for image: process chart]
At the facility level:[A]
1) Staff reports incident:
Management stream of reporting:
2) Quality/unit management review.
3) Facility leadership review and determine next reporting steps;
Go to step 4; or:
Go to step 7.
At the VISN level:
4) VISN management review and determine next reporting steps.
At the VHA level:
5) VHA management and program offices determine next reporting steps;
Go to step 6; or:
Go to step 7.
At the VA department level:
6) Office of the Secretary reviews reports.
At the facility level:[A]
Law enforcement stream of reporting:
2a) Facility police generate report and conduct investigation;
Go to step 3; or:
Go to step 7.
At the VA department level:
7) VA IOC receives reports of serious incidents;
VA OIG receives reports of and investigates potential felonies[B];
VA OSLE receives electronic reports of all incidents.
Go to step 6.
[End of figure]
[A] Facility reporting processes described in this graphic are based
on our review of five selected VA medical facilities.
[B] VA OIG receives reports of potential felonies through additional
reporting streams, including the VA OIG hotline and congressional
contacts.
Source: GAO.
Management reporting stream. This stream--which includes reporting
responsibilities at the local medical facility, VISN, and VHA Central
Office levels--is intended to help ensure that incidents are
identified and documented for leadership's attention.
* Local VA medical facilities. Local incident reporting is the first
step in communicating safety issues, including sexual assault
incidents, to VISN and VHA Central Office officials and was handled
through a variety of electronic facility based systems at the medical
facilities we visited. The processes were similar in all five medical
facilities we visited and were initiated by the first staff member who
observed or was notified of an incident completing an incident report
in the medical facility's electronic reporting system. The medical
facility's quality manager then reviewed the electronic report, while
the staff member was responsible for communicating the incident
through his or her immediate supervisor or unit manager. VA medical
facility leadership at the locations we visited reported that they are
informed of incidents at morning meetings or through immediate
communications, depending on the severity of the incident. Medical
facility leadership officials are responsible for reporting serious
incidents to the VISN.
* VISNs. Officials in network offices we reviewed told us that their
medical facilities primarily report serious incidents to their offices
through two mechanisms--issue briefs and "heads up" messages.[Footnote
16] Issue briefs document specific factual information and are
forwarded from the medical facility to the VISN. Heads up messages are
early notifications designed to allow medical facility and VISN
leadership to provide a brief synopsis of the issue while facts are
being gathered for documentation in an issue brief. VISN offices are
typically responsible for direct reporting to the VHA Central Office.
* VHA Central Office. An official in the VHA Office of the Deputy
Under Secretary for Health for Operations and Management said that
VISNs typically report all serious incidents to this office. This
office then communicates relevant incidents to other VHA offices,
including the Office of the Principal Deputy Under Secretary for
Health, through an e-mail distribution list.
* Law enforcement reporting stream. The purpose of this stream is to
document incidents that may involve criminal acts so they can be
investigated and prosecuted, if appropriate. The law enforcement
reporting stream involves local VA police, VA's OSLE, VA's IOC, and
the VA OIG.
* Local VA police. At the medical facilities we visited, local
policies require medical facility staff to notify the medical
facility's VA police of incidents that may involve criminal acts, such
as sexual assaults. According to VA officials, when VA police officers
observe or are notified of an incident they are required to document
the allegation in VA's centralized police reporting system.
* VA's OSLE. This office receives reports of incidents at VA medical
facilities through its centralized police reporting system.
Additionally, local VA police are required to immediately notify VA
OSLE of serious incidents, including reports of rape and aggravated
assaults.
* VA's IOC. Serious incidents on VA property--those that result in
serious bodily injury, including sexual assaults--are reported to the
IOC either by local VA police or the VHA Office of the Deputy Under
Secretary for Health for Operations and Management. Incidents reported
to the IOC are communicated to the Secretary of VA through serious
incident reports and to other senior staff through daily reports.
* VA OIG. Federal regulation requires that all potential felonies,
including rape allegations, be reported to VA OIG investigators.
[Footnote 17] In addition, VHA policy reiterates this requirement by
specifying that the OIG must be notified of sexual assault incidents
when the crime occurs on VA premises or is committed by VA employees.
[Footnote 18] At the VA medical facilities we visited, officials told
us that either the medical facility's leadership team or VA police are
responsible for reporting all incidents that are potential felonies to
the VA OIG. The VA OIG may also learn of incidents from staff,
patients, congressional communications, or the VA OIG hotline for
reporting fraud, waste, and abuse. When the VA OIG is notified of a
potential felony, their investigators document both their contact with
medical facility officials or other sources and the initial case
information they receive.
Nearly 300 Sexual Assault Incidents Reported to VA Police through the
Law Enforcement Stream Since 2007:
We analyzed VA's national police files from January 2007 through July
2010 and identified 284 sexual assault incidents reported to VA police
during that period.[Footnote 19] These cases included incidents
alleging rape, inappropriate touching, forceful medical examinations,
oral sex, and other types of sexual assaults (see table 1).[Footnote
20] However, it is important to note that not all sexual assault
incidents reported to VA police are substantiated. A case may remain
unsubstantiated because an assault did not actually take place, the
victim chose not to pursue the case, or there was insufficient
evidence to substantiate the case. Due to our review of both open and
closed VA police sexual assault incident investigations, we could not
determine the final disposition of these incidents.[Footnote 21]
Table 1: Number of Sexual Assault Incidents by Category Reported to VA
Police by Year, January 2007 through July 2010:
Year: 2010[D];
Rape[A]: 14;
Inappropriate touch[B]: 44;
Forceful medical examination: 3;
Forced or inappropriate oral sex: 5;
Other[C]: 0;
Total: 66.
Year: 2009;
Rape[A]: 23;
Inappropriate touch[B]: 66;
Forceful medical examination: 3;
Forced or inappropriate oral sex: 3;
Other[C]: 9;
Total: 104.
Year: 2008[E];
Rape[A]: 13;
Inappropriate touch[B]: 42;
Forceful medical examination: 1;
Forced or inappropriate oral sex: 3;
Other[C]: 1;
Total: 60.
Year: 2007[E,F];
Rape[A]: 17;
Inappropriate touch[B]: 33;
Forceful medical examination: 1;
Forced or inappropriate oral sex: 2;
Other[C]: 1;
Total: 54.
Year: Total[G];
Rape[A]: 67;
Inappropriate touch[B]: 185;
Forceful medical examination: 8;
Forced or inappropriate oral sex: 13;
Other[C]: 11;
Total: 284.
Source: GAO (analysis); VA (data).
Note: In this report, we use the term sexual assault incident to refer
to suspected, alleged, attempted, or confirmed cases of sexual
assault. All reports of sexual assault incidents do not necessarily
lead to prosecution and conviction. This may be, for example, because
an assault did not actually take place or there was insufficient
evidence to determine whether an assault occurred.
[A] The rape category includes any case involving allegations of rape,
defined as vaginal or anal penetration through force, threat, or
inability to consent. For cases that included allegations of multiple
categories including rape (i.e., inappropriate touch, forced oral sex,
and rape) the category of rape was applied. Cases where staff deemed
that one or more of the veterans involved were mentally incapable of
consenting to sexual activities described in the case were considered
rape.
[B] The inappropriate touch category includes any case involving only
allegations of touching, fondling, grabbing, brushing, kissing,
rubbing, or other like-terms.
[C] The other category included any allegations that did not fit into
the other categories or if the incident described in the case file did
not contain sufficient information to place the case in one of the
other designated categories.
[D] Analysis of 2010 records was limited to only those received by VA
police through July 2010.
[E] Due to the lack of a centralized VA police reporting system prior
to January 2009, VA medical facility police sent reports to VA's OSLE
for the purpose of this data request, which may have resulted in not
all reports being included in this analysis.
[F] Our ability to review files for the entire year was limited
because VA police are required to destroy files after 3 years under a
records schedule approved by the National Archives and Records
Administration (NARA).
[G] Cases not reported to VA police were not included in our analysis
of sexual assault incidents.
[End of table]
In analyzing these 284 cases, we observed the following (see appendix
II for additional analysis of VA police reports):
* Overall, the sexual assault incidents described above included
several types of alleged perpetrators, including employees, patients,
visitors, outsiders not affiliated with VA, and persons of unknown
affiliation. In the reports we analyzed, there were allegations of 89
patient-on-patient sexual assaults, 85 patient-on-employee sexual
assaults, 46 employee-on-patient sexual assaults, 28 unknown
affiliation-on-patient sexual assaults, and 15 employee-on-employee
sexual assaults.[Footnote 22]
* Regarding gender of alleged perpetrators, we also observed that of
the 89 patient-on-patient sexual assault incidents, 46 involved
allegations of male perpetrators assaulting female patients, 42
involved allegations of male perpetrators assaulting male patients,
and 1 involved an allegation of a female perpetrator assaulting a male
patient. Of the 85 patient-on-employee sexual assault incidents, 83
involved allegations of male perpetrators assaulting female employees
and 2 involved allegations of male perpetrators assaulting male
employees.
We could not systematically analyze sexual assault incidents reported
through VA's management stream due to the lack of a centralized VA
management reporting system for tracking sexual assaults and other
safety incidents.
Not All Sexual Assault Incidents Are Reported Due to Unclear Guidance
and Insufficient Oversight:
Despite the VA police receiving reports of nearly 300 sexual assault
incidents since 2007, sexual assault incidents are underreported to
officials within the management reporting stream and the VA OIG.
Factors that may contribute to the underreporting of sexual assault
incidents include the lack of both a clear definition of sexual
assault and expectations on what incidents should be reported, as well
as deficient VHA Central Office oversight of sexual assault incidents.
Sexual Assault Incidents Are Underreported to VISNs, VHA Central
Office, and the VA OIG:
Sexual assault incidents are underreported to both VHA officials at
the VISN and VHA Central Office levels and the VA OIG. Specifically,
VISN and VHA Central Office officials did not receive reports of all
sexual assault incidents reported to VA police in VA medical
facilities within the four VISNs we reviewed. In addition, the VA OIG
did not receive reports of all sexual assault incidents that were
potential felonies as required by VA regulation, specifically those
involving rape allegations.
VISNs and VHA Central Office Receive Limited Information on Sexual
Assault Incidents:
VISNs and VHA Central Office leadership officials are not fully aware
of many sexual assaults reported at VA medical facilities. For the
four VISNs we spoke with, we reviewed all documented incidents
reported to VA police from medical facilities within each network and
compared these reports with the issue briefs received through the
management reporting stream by VISN officials. Based on this analysis,
we determined that VISN officials in these four networks were not
informed of most sexual assault incidents that occurred within their
network medical facilities.[Footnote 23] Moreover, we also found that
one VISN did not report all of the cases they received to VHA Central
Office (see table 2).
Table 2: Sexual Assault Incidents Reported to Four Selected VISNs and
VHA Central Office Leadership, January 2007 through July 2010:
VISN: VISN A;
Total number of sexual assault incidents reported to VA police from
VISN medical facilities[A,B]: 13;
Total number of sexual assault incidents reported to VISN leadership
by VISN medical facilities: 0;
Total number of sexual assault incidents reported by VISNs to VHA
Central Office leadership: 0.
VISN: VISN B;
Total number of sexual assault incidents reported to VA police from
VISN medical facilities[A,B]: 21;
Total number of sexual assault incidents reported to VISN leadership
by VISN medical facilities: 10;
Total number of sexual assault incidents reported by VISNs to VHA
Central Office leadership: 5.
VISN: VISN C;
Total number of sexual assault incidents reported to VA police from
VISN medical facilities[A,B]: 34;
Total number of sexual assault incidents reported to VISN leadership
by VISN medical facilities: 4;
Total number of sexual assault incidents reported by VISNs to VHA
Central Office leadership: 4.
VISN: VISN D;
Total number of sexual assault incidents reported to VA police from
VISN medical facilities[A,B]: 34;
Total number of sexual assault incidents reported to VISN leadership
by VISN medical facilities: 2;
Total number of sexual assault incidents reported by VISNs to VHA
Central Office leadership: 2.
Source: GAO (data and analysis); VA (data).
Note: In this report, we use the term sexual assault incident to refer
to suspected, alleged, attempted, or confirmed cases of sexual
assault. All reports of sexual assault incidents do not necessarily
lead to prosecution and conviction. This may be, for example, because
an assault did not actually take place or there was insufficient
evidence to determine whether an assault occurred.
[A] Cases not reported to VA police were not included in our count of
sexual assault incidents.
[B] Due to the absence of system wide requirements on what medical
facilities must report to these VISNs, we could not determine the
accuracy of VISN reporting.
[End of table]
The VA OIG Did Not Receive Reports of about Two-Thirds of Sexual
Assault Incidents Involving Rape Allegations:
To examine whether VA medical facilities were accurately reporting
sexual assault incidents involving rape allegations to the VA OIG, we
reviewed both the 67 rape allegations reported to the VA police from
January 2007 through July 2010 and all investigation documentation
provided by the VA OIG for the same period. We found no evidence that
about two-thirds (42) of these rape allegations had been reported to
the VA OIG.[Footnote 24] The remaining 25 had matching VA OIG
investigation documentation, indicating that they were correctly
reported to both the VA police and the VA OIG.
By regulation, VA requires that: (1) all criminal matters involving
felonies that occur in VA medical facilities be immediately referred
to the VA OIG and (2) responsibility for the prompt referral of any
possible criminal matters involving felonies lies with VA management
officials when they are informed of such matters.[Footnote 25] This
regulation includes rape in the list of felonies provided as examples
and also requires VA medical facilities to report other sexual assault
incidents that meet the criteria for felonies to the VA OIG.[Footnote
26],[Footnote 27] However, the regulation does not include criteria
for how VA medical facilities and management officials should
determine whether or not a criminal matter meets the felony reporting
threshold. We found that all 67 of these rape allegations were
potential felonies because if substantiated, sexual assault incidents
involving rape fall within federal sexual offenses that are punishable
by imprisonment of more than 1 year.
In addition, we provided the VA OIG the opportunity to review
summaries of the 42 rape allegations we could not confirm were
reported to them by the VA police. To conduct this review, several VA
OIG senior-level investigators determined whether or not each of these
rape allegations should have been reported to them based on what a
reasonable law enforcement officer would consider a felony. According
to these investigators, a reasonable law enforcement officer would
look for several elements to make this determination, including (1) an
identifiable and reasonable suspect, (2) observations by a witness,
(3) physical evidence, or (4) an allegation that appeared credible.
These investigators based their determinations on their experience as
federal law enforcement agents. Following their review, these
investigators also found that several of these rape allegations were
not appropriately reported to the VA OIG as required by federal
regulation. Specifically, the VA OIG investigators reported that they
would have expected approximately 33 percent of the 42 rape
allegations to have been reported to them based on the incident
summary containing information on these four elements. The
investigators noted that they would not have expected approximately 55
percent of the 42 rape allegations to have been reported to them due
to either the incident summary failing to contain these same four
elements or the presence of inconsistent statements made by the
alleged victims.[Footnote 28] For the approximately 12 percent
remaining, the investigators noted that the need for notification was
unclear because there was not enough information in the incident
summary to make a determination about whether or not the rape
allegation should have been reported to the VA OIG.
Several Factors May Contribute to the Underreporting of Sexual Assault
Incidents:
There are several factors that may contribute to the underreporting of
sexual assault incidents to VISNs, VHA Central Office, and the VA OIG--
including VHA's lack of a consistent sexual assault definition for
reporting purposes; limited and unclear expectations for sexual
assault incident reporting at the VHA Central Office, VISN, and VA
medical facility levels; and deficiencies in VHA Central Office
oversight of sexual assault incidents.
VHA Does Not Have a Consistent Sexual Assault Definition for Reporting
Purposes:
VHA leadership officials may not receive reports of all sexual assault
incidents that occur at VA medical facilities because VHA does not
have a VHA-wide definition of sexual assault used for incident
reporting. We found that VHA lacks a consistent definition for the
reporting of sexual assaults through the management reporting stream
at the medical facility, VISN, and VHA Central Office levels. At the
medical facility level, we found that the medical facilities we
visited had a variety of definitions of sexual assault targeted
primarily to the assessment and management of victims of recent sexual
assaults. Specifically, facilities varied in the level of detail
provided by their policies, ranging from one facility that did not
include a definition of sexual assault in its policy at all to another
facility with a policy that included a detailed definition. (See table
3.)
Table 3: Selected VA Medical Facility Definitions of Sexual Assault
for the Assessment and Management of Victims of Recent Sexual Assault:
Selected VA medical facility: Facility A;
Definitions of sexual assault: Sexual violation of a person (male or
female) by the use of force, threat, or intimidation [that] is
committed without the consent of the person assaulted. The violent act
may or may not include penetration and may be [an] oral, anal, or
vaginal violation.
Selected VA medical facility: Facility B;
Definitions of sexual assault: No definition.
Selected VA medical facility: Facility C;
Definitions of sexual assault: Conduct of a sexual or indecent nature
toward another person that is accompanied by actual or threatened
physical force or that induces fear, shame, or mental suffering.
Sexual assault may be penetrating (i.e., rape) to include vaginal,
anal, and oral penetration, or nonpenetrat[ing] and includes both
males and females as victims of this crime.
Selected VA medical facility: Facility D;
Definitions of sexual assault: Includes incest, oral copulation,
penetration, rape, sexual assault, sexual battery, and sodomy which
occurs without the consent of a person, or when a person is not
capable of giving consent. Sexual abuse also means acts of a sexual
nature committed in the presence of a vulnerable adult without that
person's informed consent. It includes, but is not limited to, the
acts defined in a state statute, fondling, exposure of a vulnerable
adult's sexual organs, or the use of a vulnerable adult to solicit for
or engage in prostitution or sexual performance.
Selected VA medical facility: Facility E;
Definitions of sexual assault: Sexual assault is sexual contact of ANY
kind against a person's will, brought about by force, threats, or
coercion.
Source: Selected VA medical facilities.
[End of table]
Table 19: At the VISN level, VISN officials within the four networks
we spoke with reported that they did not have definitions of sexual
assault in VISN policies. However, some VISN officials stated they
used other common definitions, including those from the National
Center for Victims of Crime and The Joint Commission.[Footnote
29],[Footnote 30] Finally, while the VHA Central Office does have a
policy for the clinical management of sexual assaults, this policy is
targeted to the treatment of victims assaulted within 72 hours and
does not include sexual assault incidents that occur outside of this
time frame. In addition, neither this definition of sexual assault nor
any other is included in VHA Central Office reporting guidance, which
specifies the types of incidents that should be reported to VHA
management officials.
VHA Central Office, VISNs, and VA Medical Facilities' Expectations for
Reporting Are Limited and Unclear:
In addition to failing to provide a consistent definition of sexual
assault for incident reporting, VHA also does not have clearly
documented expectations about the types of sexual assault incidents
that should be reported to officials at each level of the
organization, which may also contribute to the underreporting of
sexual assault incidents. Without clear expectations for incident
reporting there is no assurance that all sexual assault incidents are
appropriately reported to officials at the VHA Central Office, VISN,
and local medical facility levels. We found that expectations were not
always clearly documented, resulting in either the underreporting of
some sexual assault incidents or communication breakdowns at all
levels.
* VHA Central Office. An official from VHA's Office of the Deputy
Under Secretary for Health for Operations and Management told us that
this office's expectations for reporting sexual assault incidents were
documented in its guidance for the submission of issue briefs.
However, we found that this guidance does not specifically reference
reporting requirements for any type of sexual assault incidents. As a
result, VISNs we reviewed did not consistently report sexual assault
incidents to VHA Central Office. For example, officials from one VISN
reported sending VHA Central Office only 5 of the 10 issue briefs they
received from medical facilities in their network, while officials
from two other VISNs reported forwarding all issue briefs on sexual
assault incidents they received.[Footnote 31]
* VISNs. The four VISNs we spoke with did not include detailed
expectations regarding whether or not sexual assault incidents should
be reported to them in their reporting guidance, potentially resulting
in medical facilities failing to report some incidents.[Footnote 32]
For example, officials from one VISN told us they expect to be
informed of all sexual assault incidents occurring in medical
facilities within their network, but this expectation was not
explicitly documented in their policy. We found several reported
allegations of sexual assault incidents in medical facilities in this
VISN--including three allegations of rape and one allegation of
inappropriate oral sex--that were not forwarded to VISN officials.
When asked about these four allegations, VISN officials told us that
they would only have expected to be notified of two of them--one
allegation of rape and one allegation of inappropriate oral sex--
because the medical facilities where they occurred contacted outside
entities, including the VA OIG. VISN officials explained that the
remaining two rape allegations were unsubstantiated and were not
reported to their office; the VISN also noted that unsubstantiated
incidents are not often reported to them.
* VA medical facilities. At the medical facility level, we also found
that reporting expectations may be unclear. In particular, we
identified cases in which the VA police had not been informed of
incidents that were reported to medical facility staff. For example,
we identified VA police files from one facility we visited where
officers noted that the alleged perpetrator had been previously
involved in other sexual assault incidents that were not reported to
the VA police by medical facility staff. In these police files,
officers noted that staff working in the alleged perpetrators' units
had not reported the previous incidents because they believed these
behaviors were a manifestation of the veterans' clinical conditions.
We also observed cases of communication breakdowns during our
discussions with medical facility officials and clinicians. For
example, at one medical facility VA police reported that prior to our
arrival they were not immediately informed of an alleged sexual
assault incident involving two male patients in the dementia ward that
occurred the previous evening. As a result, VA police were unable to
immediately begin their investigation because staff from the unit had
completed their shifts and left the ward. At another medical facility
we visited, quality management staff identified five sexual assault
incidents that had not been reported to VA police at the medical
facility, despite these incidents being reported to their office.
Deficiencies Exist in VHA Central Office Oversight of Sexual Assault
Incidents:
The VHA Central Office also had deficiencies in several necessary
oversight elements that could contribute to the underreporting of
sexual assault incidents to VHA management--including information-
sharing practices and systems to monitor sexual assault incidents
reported through the management reporting stream. Specifically, the
VHA Central Office has limited information-sharing practices for
distributing information about reported sexual assault incidents among
VHA Central Office officials and has not instituted a centralized
tracking mechanism for these incidents.
Currently, the VHA Central Office relies primarily on e-mail messages
to transfer information about sexual assault incidents among its
offices and staff (see figure 2). Under this system, the VHA Central
Office is notified of sexual assault incidents through issue briefs
submitted by VISNs via e-mail to one of three VISN support teams
within the VHA Office of the Deputy Under Secretary for Health for
Operations and Management.[Footnote 33] These issue briefs are then
forwarded to the Director for Network Support within this office for
review and follow-up with VA medical facilities if needed.[Footnote
34] Following review, the Director for Network Support forwards issue
briefs to the Office of the Principal Deputy Under Secretary for
Health for distribution to other VHA offices on a case-by-case basis,
including the program offices responsible for residential programs and
inpatient mental health units. Program offices are sometimes asked to
follow up on incidents in their area of responsibility.
Figure 2: VHA Central Office Reporting Process for Sexual Assaults and
Other Safety Incidents:
[Refer to PDF for image: illustration]
At the VHA level:
VHA Office of the Deputy Under Secretary for Health for Operations and
Management:
VISN support staff receive issue briefs from VISNs via e-mail;
Director of Network Support reviews and forwards issue briefs[B].
VHA Office of the Principal Deputy Under Secretary for Health:
Receives and distributes issue briefs to other VHA offices via e-mail.
VHA Program Offices:[A]
Program officials receive issue briefs and follow-up with facilities as
necessary.
Source: GAO.
[A] Program offices include those responsible for residential programs
and inpatient mental health units.
[B] Office of the Deputy Under Secretary for Health for Operations and
Management officials reported that they may distribute issue briefs
directly to program officials depending on the severity of the
incident.
[End of figure]
We found that this system did not effectively communicate information
about sexual assault incidents to the VHA Central Office officials who
have programmatic responsibility for the locations in which these
incidents occurred. For example, VHA program officials responsible for
both residential programs and inpatient mental health units reported
that they do not receive regular reports of sexual assault incidents
that occur within their programs or units at VA medical facilities and
were not aware of any incidents that had occurred in these programs or
units. However, during our review of VA police files we identified at
least 18 sexual assault incidents that occurred from January 2007
through July 2010 in the residential programs or inpatient mental
health units of the five VA medical facilities we reviewed. If the
management reporting stream were functioning properly, these program
officials should have been notified of these incidents and any others
that occurred in other VA medical facilities' residential programs and
inpatient mental health units.[Footnote 35] Without the regular
exchange of information on sexual assault incidents that occur within
their areas of programmatic responsibility, VHA program officials
cannot effectively address the risks of such incidents in their
programs and units and do not have the opportunity to identify ways to
prevent incidents from occurring in the future.
In early 2011, VHA leadership officials told us that initial efforts,
including sharing information about sexual assault incidents with the
Women Veterans Health Strategic Health Care Group and VHA program
offices, were under way to improve how information on sexual assault
incidents is communicated to program officials. However, these
improvements have not been formalized within VHA or published in
guidance or policies and are currently being performed on an informal
ad hoc basis only, according to VHA officials.
In addition to deficiencies in information sharing, we also identified
deficiencies in the monitoring of sexual assault incidents within the
VHA Central Office. VHA's Office of the Deputy Under Secretary for
Health for Operations and Management, the first VHA office to receive
all issue briefs related to sexual assault incidents, does not
currently have a system that allows VHA Central Office staff to
systematically review or analyze reports of sexual assault incidents
received from VA medical facilities through the management reporting
stream. Specifically, we found that this office does not have a
central database to store the issue briefs that it receives and
instead relies on individual staff to save issue briefs submitted to
them by e-mail to electronic folders for each VISN. In addition,
officials within this office said they do not know the total number of
issue briefs submitted for sexual assault incidents because they do
not have access to all former staff members' files. As a result of
these issues, staff from the Office of the Deputy Under Secretary for
Health for Operations and Management could not provide us with a
complete set of issue briefs on sexual assault incidents that occurred
in all VA medical facilities without first contacting VISN officials
to resubmit these issue briefs.[Footnote 36] Such a limited archive
system for reports of sexual assault incidents received through the
management reporting stream results in VHA's inability to track and
trend sexual assault incidents over time. While VHA has, through its
National Center for Patient Safety (NCPS), developed systems for
routinely monitoring and tracking patient safety incidents that occur
in VA medical facilities, these systems do not monitor sexual assaults
and other safety incidents. Without a system to track and trend over
time sexual assaults and other safety incidents, the VHA Central
Office cannot identify and make changes to serious problems that
jeopardize the safety of veterans in their medical facilities.
Self-Reported Legal Histories Are Commonly Used to Inform Clinicians
of Sexual Assault-Related Risks, but Guidance on Information
Collection Is Limited:
VA does not have risk assessment tools specifically designed to
examine sexual assault-related risks that some veterans may pose while
they are being treated at VA medical facilities.[Footnote 37] Instead,
VA clinicians working in the residential programs and inpatient mental
health units at medical facilities we visited said they rely mainly on
information about veterans' legal histories, including a veteran's
history of violence, which are examined as part of a multidisciplinary
admission assessment process to assess these and other risks veterans
pose to themselves and others. Clinicians also reported that they
generally rely on veterans' self-reported information, though this
information is not always complete or accurate. Finally, we found that
VHA's guidance on the collection of legal history information in
residential programs and inpatient mental health units does not
specify the type of legal history information that should be collected
and documented.
VHA Does Not Have Specific Sexual Assault Risk Assessment Tools:
VHA officials and clinicians working in the residential programs and
inpatient mental health units at medical facilities we visited told us
that VHA does not have risk assessment tools specifically designed to
examine sexual assault-related risks that some veterans may pose while
being treated at VA medical facilities. However, these officials and
clinicians noted that such risks are assessed and managed by clinical
staff.
VHA officials told us that since no evidence-based risk assessment
tool for sexual assault and other types of violence exists, VHA relies
on the professional judgment of clinicians to identify and manage
risks through appropriate interventions. To do this, VA clinicians
generally assess the overall risks veterans pose to themselves or
others in the VA population by reviewing veterans' medical records and
conducting various interdisciplinary assessments. Specifically,
clinicians said that they review medical records for information about
veterans' potential for violence and medical conditions. In addition,
the interdisciplinary assessments clinicians are required to conduct
include biopsychosocial assessments, nursing assessments, suicide risk
assessments, and other program-specific assessments.[Footnote 38] In
residential programs and inpatient mental health units,
biopsychosocial assessments are a standard part of the admissions
process and capture several types of information clinicians can use to
assess risks veterans may pose.[Footnote 39] This information includes
inquiries about veterans' legal histories; any violence they may have
experienced as either a victim or perpetrator, including physical or
sexual abuse; childhood abuse and neglect; and military history and
trauma.
Clinicians Reported Using Veterans' Self-Reported Legal Histories to
Assess Sexual Assault-Related Risks, but This Information May Not
Always Be Complete:
The examination of legal history information is an important part of
clinicians' assessments of sexual assault risks veterans may pose.
Clinicians from all five medical facilities we visited explained that
such legal history information is primarily obtained through veterans
voluntarily self-reporting these issues during the biopsychosocial
assessment process. Clinicians also cited other sources of information
that could be used to learn about veterans' legal issues, including
family members, the court system, probation and parole officers, VHA
justice outreach staff, and Internet searches of public registries
containing criminal justice information. However, clinicians reported
limitations in the use of several of these sources. In some cases,
veterans must authorize the disclosure of their criminal or medical
information before it can be released to a VA medical facility--
although clinicians noted that veterans who have a legal restriction
on where they may reside or need to meet probation or parole
requirements while in treatment are often willing to release
information. In addition, clinicians reported challenges in contacting
veterans' families to obtain information as many have no family
support system, particularly those who are homeless prior to entering
treatment. Further, VA's Office of General Counsel and VHA Central
Office officials told us that VHA staff cannot conduct background
checks on veterans applying for VA health care services, including
Internet searches of public sources of criminal justice information
because VHA lacks legal authority to collect or maintain this
information.[Footnote 40]
VA clinicians from residential programs and inpatient mental health
units at the five medical facilities we visited said that although
they inquire about veterans' past legal issues, they do not always
obtain timely, complete, or reliable information on these issues from
veterans. These clinicians noted that although many veterans are
eventually forthcoming about their legal history, some may not
disclose this information during the admission assessment or ongoing
reassessment processes. For example, clinicians told us that sometimes
they learned about particular legal issues, such as an arrest warrant
or parole requirements, after veterans have been admitted to the
program or when they were being discharged. They explained that
sometimes veterans are uncomfortable discussing legal or sexual abuse
issues during their admission interviews, but may share this
information over time when they become comfortable with their
treatment team. However, these clinicians noted that sometimes these
issues do not come to light until veterans are beginning their
transitions into community housing during the discharge process.
Nevertheless, clinicians reported that they try to encourage veterans
to disclose their full legal histories because it helps them to
identify and address mental health problems that may have contributed
to veterans' encounters with the legal system and to aid the
transition to independent community living.
To determine whether legal history information in veterans' medical
records was complete, we reviewed the biopsychosocial assessments for
seven veterans at our selected medical facilities who were registered
sex offenders and found that while nearly all of these assessments
documented that medical facility clinicians inquired about these
veterans' legal issues, these issues were not consistently included in
the assessments.[Footnote 41] The extent to which information about
legal history was documented for these seven veterans varied--from
assessments containing detailed information about current and past
criminal convictions, including the veterans' sex offense violations
and conviction dates, to assessments that did not contain any
information about their past or current legal history. Specifically,
four of these seven assessments contained detailed descriptions of the
veterans' legal histories including information on sex offense
violations; two of these seven assessments contained limited
descriptions of the veterans' legal histories; and one of these seven
assessments contained no information on the veteran's legal history.
In addition, we could not review one additional biopsychosocial
assessment for an eighth veteran who was a patient in one of our
selected medical facilities and was also listed in the publicly
available state sex offender registry for the selected medical
facility because the medical facility did not conduct a
biopsychosocial assessment, as required by policy.
Incomplete or missing information about veterans' legal histories and
histories of violence can hinder clinicians' abilities to effectively
assess risks, provide appropriate treatment options, and ensure the
safety of all veterans. In particular, some clinicians noted that
insufficient information about veterans' legal backgrounds can affect
their ability to make appropriate program residency placement
decisions and assist veterans in developing appropriate housing and
employment plans for their reintegration into the community. For
example, clinicians reported they face challenges in assisting some
homeless veterans in finding jobs or housing partly because outside
entities often conduct background checks prior to accepting veterans
into their programs and VA staff cannot always effectively help
veterans navigate those issues if they lack relevant or timely
information about veterans' legal histories. Clinicians also said that
knowledge about legal issues--such as pending court appearances,
criminal charges, or sentencing requirements--is useful because such
issues can interrupt or delay rehabilitation treatment services at VA
or prevent veterans from using certain community resources when they
are discharged if not adequately addressed. Finally, clinicians said
that insufficient information about these issues affects their ability
to identify actions to manage risks and make informed resource
allocation decisions, such as increasing patient supervision, altering
clinical staff assignments, or requesting VA police assistance.
VHA Does Not Have Specific Guidance on the Collection of Legal History
Information:
VHA's assessment of veterans in their mental health programs for
sexual assault-related risks is limited by a lack of specific
guidance.[Footnote 42] Although VA clinicians are required to conduct
comprehensive assessments that include the collection of veterans'
legal histories, VHA has limited guidance on how such information
should be collected and documented in residential programs and
inpatient mental health units.
* Residential programs. Current VHA policy for residential programs
requires that information about veterans' legal histories and current
pending legal matters be included in biopsychosocial assessments, but
does not specify the extent to which such information should be
documented in veterans' medical records or delineate sources that may
be used to address this requirement.[Footnote 43] Specifically, this
VHA policy does not include descriptions of the type of legal history
information clinicians should document in the biopsychosocial
assessment portion of veterans' medical records. For example, there
are no specific requirements for clinicians to document past
incarcerations or convictions and dates when these events occurred.
Currently, VHA delegates the responsibility for developing specific
admission policies and procedures to the VA medical facility
residential program managers, who may in turn delegate this
responsibility to appropriate staff members. We found that medical
facility level policies and procedures for the medical facilities we
visited generally mirrored VHA's broad guidance in this area, although
some medical facilities had procedures that outlined the specific
information that clinicians should collect related to veterans' legal
backgrounds--such as the type and date of convictions, description of
pending legal charges or warrants, and time spent in jail or prison.
* Inpatient mental health units. VHA officials responsible for
inpatient mental health units reported that broad VHA guidance
requires inpatient mental health clinicians to conduct biopsychosocial
assessments for patients admitted to these units. However, unlike
residential programs, there is currently no VHA policy that
specifically defines how inpatient mental health units should collect
this legal history information. The broad guidance VHA officials
cited, such as the VA/DOD Clinical Practice Guidelines for Post-
Traumatic Stress and The Joint Commission standards, requires the
collection of legal history information as part of the initial
assessment, but does not fully specify the type of legal history
information that must be included in veterans' medical
records.[Footnote 44] A VHA official responsible for inpatient mental
health units throughout VA confirmed that guidance has not been issued
regarding the legal history information that may or may not be
collected by clinicians in inpatient mental health units or how
information obtained from veterans should be documented.
Without clear guidance on what legal history information should be
collected and how this information should be documented in veterans'
medical records, there is no assurance that clinicians are
comprehensively identifying and analyzing sexual assault-related risks
or that legal history information is collected and documented
consistently during biopsychosocial assessments.
VA Residential and Inpatient Mental Health Settings Use a Variety of
Precautions to Prevent Sexual Assaults and Other Safety Incidents, but
Serious Weaknesses Were Observed at Selected Facilities:
The residential programs and inpatient mental health units at the five
VA medical facilities we visited reported using several types of
patient-oriented and physical precautions to prevent safety incidents,
such as sexual assaults, from occurring in their programs. Patient-
oriented precautions included the use of flags on veterans' electronic
medical records to notify staff of individuals who may pose threats to
the safety of others, and increased levels of observation for those
veterans whom the clinicians believe may pose risks to others.
Physical precautions in medical facilities we visited included
monitoring precautions used to observe patients, security precautions
used to physically secure facilities and alert staff of problems, and
staff awareness and preparedness precautions used to educate staff
about security issues and provide police assistance. However, at the
facilities we visited, we found serious deficiencies in the use and
implementation of certain physical security precautions, such as alarm
system malfunctions and monitoring of security cameras.
Several Types of Patient-Oriented Precautions Are Used by Residential
Programs and Inpatient Mental Health Units to Prevent Sexual Assaults
and Other Safety Incidents:
Staff from the residential programs and inpatient mental health units
at the five VA medical facilities we visited reported using several
types of patient-oriented precautions--techniques that focus on the
patients themselves as opposed to the physical features of clinical
areas--to prevent safety incidents from occurring in their programs.
Generally, these precautions were not specifically geared toward
preventing sexual assaults, but were used to prevent a broad range of
safety incidents, including sexual assaults. We found that some
precautions were used by staff in both residential programs and
inpatient mental health units, while other precautions were specific
to only one of these settings. Some of the patient-oriented
precautions we noted during our site visits included the following:
* Using patient medical record flags. Staff in residential programs
and inpatient mental health units reported that they can request that
an electronic flag be placed on a veteran's medical record when they
have concerns about the individual's behavior and reported that they
use these flags to help inform their interactions with veterans.
[Footnote 45]
* Relocating or separating veterans. Staff in residential programs and
inpatient mental health units noted that they may move or separate
patients who have the potential for conflict with other veterans to
help prevent incidents from occurring. For example, at one medical
facility we visited such relocations involved moving veterans that the
clinical staff determine are safety risks to rooms closer to the
nurses' station where they can be monitored more closely. Staff from
some of the medical facilities we visited reported that veterans who
pose a threat to others may also be moved to areas where they have
restricted contact with others in the unit.
* Setting expectations and using patient contracts. Residential
program staff reported using several contract or patient education
mechanisms to reinforce both what is expected of veterans in these
programs and what behaviors are prohibited during their stay. For
example, at one medical facility we visited veterans signed treatment
agreements noting that actual violence, threats of violence, sexual
harassment, and other actions were not permitted and could result in
discharge from the program. At another medical facility we visited,
patients signed a form agreeing to the program's policy that any form
of physical contact, such as grabbing, hugging, or kissing another
person, was grounds for discharge from the program.
* Increasing direct patient observation. Staff in inpatient mental
health units we visited reported using increased levels of direct
patient observation to help prevent safety incidents. For example, two
medical facilities we visited used graduated levels of observation for
veterans who they felt posed safety risks or who were particularly
vulnerable. These medical facilities included all women veterans on
the unit in these more frequent staff check-ins to help ensure their
safety and prevent incidents from occurring. In addition, staff from
one inpatient mental health unit we visited placed a long-term mental
health patient with a tendency of inappropriately touching staff and
patients on permanent one-to-one observation status after several
sexual assault incidents occurred.
The Types of Physical Precautions in Use to Prevent Sexual Assaults
and Other Safety Incidents Vary among VA Medical Facilities:
VA medical facilities we visited employed a variety of physical
security precautions to prevent safety incidents in their residential
programs and inpatient mental health units. Typically, medical
facilities had discretion to implement these precautions based on the
needs of their local medical facility within broad VA guidelines. As a
result, the types of physical security precautions used in the five
medical facilities we visited varied.
Several Types of Physical Security Precautions Are in Place in
Selected Medical Facilities:
In general, physical security precautions were used to prevent a broad
range of safety incidents, including sexual assaults, but were not
targeted toward the prevention of sexual assaults only. We classified
these precautions into three broad categories: monitoring precautions,
security precautions, and staff awareness and preparedness precautions
(see table 4).
Table 4: Physical Security Precautions in Residential Programs and
Inpatient Mental Health Units at Selected VA Medical Facilities:
Monitoring precautions:
* Closed-circuit surveillance camera use and monitoring;
* Unit rounds by VA staff.
Security precautions:
* Locks and alarms at entrance and exit access points;
* Locks and alarms for patient bedrooms and bathrooms;
* Stationary, computer-based, and portable personal panic alarms;
* Separate or specially designated areas for women veterans.
Staff awareness and preparedness precautions:
* Staff training;
* VA police presence on units;
* VA police staffing and command and control operations.
Source: GAO.
Note: Physical security precautions varied by VA medical facility and
program and were not necessarily in place at all VA medical facilities
and programs we visited.
[End of table]
* Monitoring precautions--were those designed to observe and track
patients and activities in residential and inpatient settings. For
example, at some VA medical facilities we visited closed-circuit
surveillance cameras were installed to allow VA staff to monitor areas
and to help detect potentially threatening behavior or safety
incidents as they occur. Cameras were also used to passively document
any incidents that occurred. Staff in all the units we visited also
conducted periodic rounds of the unit, which involved staff walking
through the program areas to monitor patients and activities, either
at regular intervals or on an as-needed basis.
* Security precautions--were those designed to maintain a secure
environment for patients and staff within residential programs and
inpatient mental health units and allow staff to call for help in case
of any problems. For example, the units we visited regularly used
locks and alarms at entrance and exit access points, as well as locks
and alarms for some patient bedrooms. Another security precaution we
observed was the use of stationary, computer-based, and portable
personal panic alarms for staff.[Footnote 46] Finally, we observed
that some of the programs we visited had established separate
bedrooms, bathrooms, or other areas for women veterans, or had placed
women veterans in designated locations within the units for security
purposes.
* Staff awareness and preparedness precautions--were those designed to
both educate residential program and inpatient mental health unit
staff about, and prepare them to deal with, security issues and to
provide police support and assistance when needed. For example, the
medical facilities we visited regularly required training for staff on
the prevention and management of disruptive behavior. Another
preparedness precaution in use in some units was the establishment of
a regular VA police presence through activities such as police
conducting rounds or holding educational meetings with patients.
Finally, all medical facilities we visited had a functioning police
command and control center, which program staff could contact for
police support when needed.
Selected VA Medical Facilities Varied in Their Implementation of
Physical Security Precautions:
We found that the VA medical facilities we visited implemented
physical security precautions in a variety of ways. These precautions
varied not only by medical facility, but also among residential and
inpatient settings. Using broad VA guidelines, the medical facilities
we visited generally determined which type of physical precautions
would best meet the needs of their units and populations.[Footnote
47],[Footnote 48] As a result, we found that some precautions were
used by all five medical facilities we visited, while others were in
place in only some of these medical facilities.
Inpatient mental health units. Physical security precautions in place
at all five medical facilities we visited included the use of regular
staff rounds to observe patients and clinical areas, locked unit
entrances to prevent entry by unauthorized individuals, and stationary
or computer-based panic alarm systems. Further, all units we visited
used some combination of stationary or computer-based panic alarms,
safety whistles staff could carry with them while on duty, and
mandatory training on preventing and managing disruptive behavior.
Some of these precautions used at all five medical facilities'
inpatient mental health units were implemented in different ways
across those units. For example, while all inpatient mental health
units used some type of panic alarm system, the specific system in use
within each unit varied; some units used stationary panic alarm
buttons fixed to walls or desks, while others used a computer-based
system in which staff would press two keys simultaneously on their
computers to trigger the alarm. The inpatient mental health units also
varied with respect to where their stationary panic alarms sounded. At
three medical facilities, the inpatient units' stationary or computer-
based panic alarms sounded at the medical facility's police command
and control center. At another medical facility, two types of panic
alarms were used. The stationary panic alarms used by this facility's
inpatient mental health units sounded at both the police command and
control center and on the inpatient unit itself to instantly alert
unit staff members if a panic alarm was depressed, while the computer-
based panic alarms used at the nursing stations sounded only at the
police command and control center. Alarms in use at the fifth medical
facility we visited sounded at the units' nursing stations. Finally,
while all five units had locked entrances, four of the units used
physical keys to open the locks on the entrance doors, while the unit
at the fifth medical facility used a keyless entry approach in which
staff used their badges to electronically enter the units and relied
on physical keys only if the keyless system was not functioning.
Other precautions were present in only some of the inpatient mental
health units we visited. For example, three medical facilities used
closed-circuit surveillance cameras on their inpatient units to
varying degrees. Cameras in place at one of these medical facilities
could be monitored at the unit's nursing station and were used to
monitor the entrance doors, common areas, and seclusion rooms used for
veterans who needed to be isolated from others. At another medical
facility, cameras were used in a similar fashion, except that this
unit did not use cameras to monitor veterans in seclusion rooms.
Cameras in place at the remaining medical facility were part of a
passive system that was not actively monitored by staff at the unit's
nursing station and was used only to record incidents at the entrance
doors and common areas. One of these medical facilities also used
alarms on bedroom doors that enunciated when the door was opened.
These door alarms were installed on all bedrooms used by women and for
other veterans on an as-needed basis. The ability to instantly alert
staff of either unexpected entries or exits from these rooms could
potentially minimize response time if an incident occurred. This
latter medical facility also used a community policing approach, with
one VA police officer dedicated to meeting regularly with inpatient
mental health unit staff and patients to build relationships and help
address any issues or concerns that arose.[Footnote 49]
Residential programs. Physical security precautions in place at all
five medical facilities' non-CWT/TR residential programs included the
use of regular staff rounds to observe patients, staff training on the
prevention and management of disruptive behavior, the use of
surveillance cameras to monitor program areas, and the placement of
women veterans in designated areas of the residential facility. Some
of these commonly used precautions were implemented in different ways
across the five medical facilities. For example, some medical
facilities placed women veterans in separate bedrooms located closest
to the nursing stations, while others placed only women veterans in a
separate wing of the facility. Medical facilities' residential
programs also varied with respect to where their closed-circuit camera
feeds could be viewed. At four of the five medical facilities we
visited, the camera feeds could be viewed by staff at the programs'
nursing stations or security desks, but at two medical facilities,
cameras at the domiciliary could also be viewed by staff at VA police
command and control centers. At all medical facilities, the camera
systems were passive and not actively monitored by staff.
Other precautions were used only in some of the five medical
facilities' non-CWT/TR residential programs. For example, residential
programs in four of five medical facilities used stationary or
computer-based panic alarms to alert others in case of emergency; the
remaining medical facility did not use any form of stationary or
computer-based panic alarm system. The four medical facilities'
stationary alarms varied with respect to where they sounded. In
addition, only one medical facility we visited provided portable
personal panic alarms with GPS capability to its residential program
staff. In addition, VA police presence was widely used in two of the
five medical facilities we visited. One of these medical facilities
permanently staffed VA police officers at a residential program
located off the medical facility's main campus, while the other
medical facility's community policing officer met regularly with
residential program staff and patients to facilitate more direct
communications between the programs and VA police at the medical
facility.
CWT/TR residential programs. The three CWT/TR residential programs we
visited used several types of physical security precautions.[Footnote
50] For example, two of the three CWT/TR programs we visited used
closed-circuit surveillance cameras; one medical facility used
surveillance cameras to record activity at entrances and exits, while
another medical facility used surveillance cameras to record the
parking lot areas. Neither of these locations actively monitored the
camera feeds. In addition, one medical facility reported using regular
rounds and conducting bed checks. Another medical facility had
individual locks on bedroom doors; other sites did not.[Footnote 51]
Only one of the three CWT/TR programs we visited accepted women; its
apartment-style structure allowed women veterans to be placed in
separate apartments. The other two CWT/TRs did not provide services
for women veterans due to safety and privacy concerns stemming from
their single-family home structures.
Significant Weaknesses Existed in the Use and Implementation of
Certain Physical Security Precautions at Selected VA Medical
Facilities:
During our review of the physical security precautions in use at the
five VA medical facilities we visited, we observed seven weaknesses in
three areas.[Footnote 52] These weaknesses included malfunctions in
stationary and portable personal panic alarm systems, inadequate
monitoring of security cameras, and insufficient staffing of police
and security personnel (see table 5).
Table 5: Weaknesses in Physical Security Precautions in Residential
Programs and Inpatient Mental Health Units at Selected VA Medical
Facilities:
Monitoring precautions:
* Inadequate monitoring of closed-circuit surveillance cameras.
Security precautions:
* Alarm malfunctions of stationary, computer-based, and personal panic
alarms;
* Inadequate documentation or review of alarm testing;
* Failure of alarms to alert both unit staff and VA police;
* Limited use of personal panic alarms.
Staff awareness and preparedness precautions:
* VA police staffing and workload challenges;
* Lack of stakeholder involvement in unit redesign efforts.
Source: GAO.
[End of table]
Inadequate monitoring of closed-circuit surveillance cameras. We
observed that VA staff in the police command and control center were
not continuously monitoring closed-circuit surveillance cameras at all
five VA medical facilities we visited. For example, at one medical
facility, the system used by the residential programs at that medical
facility cannot be monitored by the police command and control center
staff because it is incompatible with systems installed in other parts
of the medical facility. According to this medical facility's VA
police, the residential program staff did not consult with VA police
before installing their own system. At another medical facility where
staff in the police office monitor cameras covering the residential
programs' grounds and parking area, we found that the police office
was unattended part of the time. In addition, at the remaining three
medical facilities we visited, staff in the police command and control
centers assigned to monitor medical facility surveillance cameras had
other duties that prevented them from continuously monitoring the
camera feeds. Specifically, they were also responsible for serving as
telephone operators and police/emergency dispatchers for the entire VA
medical facility. During our direct observations of their activities,
we noted that they were not monitoring the camera feeds
continuously.[Footnote 53] Although effective use of surveillance
camera systems cannot necessarily prevent safety incidents from
occurring, lapses in monitoring by security staff compromise the
effectiveness of these systems in place to help prevent or lessen the
severity of safety incidents.
Alarm malfunctions. At least one form of alarm failed to work properly
when tested at four of the five medical facilities we visited. For
example, at one medical facility, we tested the portable personal
panic alarms used by residential program staff and found that the
police command and control center could not always properly pinpoint
the location of the tester when an alarm was activated. When we tested
this alarm inside a building at this campus it functioned properly;
however, when we tested it outside, the location identified as the
site of the alarm was at least 100 feet away from the location where
we set off the alarm. Further, when we tested an emergency call box
located outside the entrance to the residential program buildings at
this same medical facility, the call went to a central telephone
operator at the VA medical facility switchboard--not the VA police
command and control center--and the system improperly identified our
tester as calling from an elevator rather than from our location
outside the residential program building. At another medical facility
that used stationary panic alarms in inpatient mental health units,
residential programs, and other clinical settings (i.e., staff
offices, nursing stations, and common rooms), almost 20 percent of
these alarms throughout the medical facility were inoperable. Many of
the inoperable alarms were due to ongoing construction of new units at
the medical facility, but some of the remaining inoperable alarms were
located in other parts of the medical facility still in use. It is
unclear if staff in these other areas were aware that these alarms
were inoperable and could not be used to call for help if they needed
it. At an inpatient mental health unit in a third medical facility,
our tests of the computer-based panic alarm system detected multiple
alarm failures. Specifically, three of the alarms we tested failed to
properly pinpoint the location of our tester because the medical
facility's computers had been moved to different locations and were
not properly reconfigured. Finally, at a fourth medical facility,
alarms we tested in the inpatient mental health unit sounded properly,
but staff in the unit and VA police responsible for testing these
alarms did not know how to turn them off after they were activated. In
each of the cases where alarms malfunctioned, VA staff were not aware
the alarms were not functioning properly until we informed them.
Deficiencies like these at VA medical facilities could lead to delayed
response times and seriously erode efforts to prevent or mitigate
sexual assaults and other safety incidents.
Inadequate documentation or review of alarm system testing. We found
that one of the five sites we visited failed to properly document
tests conducted of their alarm systems for their residential programs,
although testing of alarms is a required element in VA's Environment
of Care Checklist. Testing of alarm systems is important to ensure
that systems function properly, and not having complete documentation
of alarm system testing is an indication that periodic testing may not
be occurring. In addition, three medical facilities reported using
computer-based panic alarms that are designed to be self-monitoring to
identify cases where computers equipped with the system fail to
connect with the servers monitoring the alarms. All three of these
medical facilities stated that due to the self-monitoring nature of
these alarms, they did not maintain alarm test logs of these systems.
However, we found that at two of these three medical facilities these
alarms failed to properly alert VA police when tested. Such alarm
system failures indicate that the self-monitoring systems may not be
effectively alerting medical facility staff of alarm malfunctions when
they occur, indicating the need for these systems to be periodically
tested by VA police.
Alarms failed to alert both police and unit staff. In inpatient mental
health units at all five medical facilities we visited, stationary and
computer-based panic alarm systems we tested did not alert staff in
both the VA police command and control center and the inpatient mental
health unit where the alarm was triggered. Alerting both locations is
important to better ensure that timely and proper assistance is
provided. At four of these medical facilities, the inpatient mental
health units' stationary or computer-based panic alarms notified the
police command and control centers but not staff at the nursing
stations of the units where the alarms originated. Had these alarms
been used in real emergencies, response times may have been delayed
because staff in the police command and control center would have had
to inform the inpatient mental health unit that an alarm had been
activated by someone within their unit. At the fifth medical facility,
the stationary panic alarms only notified staff in the unit nursing
station, making it necessary to separately notify the VA police.
Finally, none of the stationary or computer-based panic alarms used by
residential programs notified both the police command and control
centers and staff within the residential program buildings when
tested.[Footnote 54]
Limited use of portable personal panic alarms. Electronic portable
personal panic alarms were not available for the staff at any of the
inpatient mental health units we visited and were available to staff
at only one residential program we reviewed. In two of the inpatient
mental health units we visited, staff were given safety whistles they
could use to signal others in cases of emergency, personal distress,
or concern about veteran or staff safety. However, relying on whistles
to signal such incidents may not be effective, especially when staff
members are the victims of assault. For example, a nurse at one
medical facility we visited was involved in an incident in which a
patient grabbed her by the throat and she was unable to use her
whistle to summon assistance. Some inpatient mental health unit staff
we spoke with indicated an interest in having portable personal panic
alarms to better protect them in situations like these.
VA police staffing and workload challenges. At most medical facilities
we visited, VA police forces and police command and control centers
were understaffed, according to medical facility officials. For
example, during our visit to one medical facility, VA police officials
reported being able to staff just two officers per 12-hour shift to
patrol and respond to incidents at both the medical facility and at a
nearby 675-acre veteran's cemetery. While this staffing ratio met the
minimum standards for VA police staffing, having only two police
officers to cover such a large area could potentially increase the
response times should a panic alarm activate or other security
incident occur on medical facility grounds. Also, we found that there
was an inadequate number of officers and staff at this medical
facility to effectively police the medical facility and maintain a
productive police force. The medical facility had a total of nine
police officers at the time of our visit; according to VA staffing
guidance, the minimum staffing level for this medical center should
have been 19 officers. Similarly, at another medical facility, the
police force was short 14 active police officers because some officers
either were on military leave or awaiting the completion of pending
background checks.[Footnote 55] During our visit to this medical
facility, we also noted a shortage of officers at one of the medical
facility's police offices responsible for the inpatient mental health
units. Because of this, there were periods of time when this police
office was unattended. Not all medical facilities we visited had
staffing problems. At one medical facility, the VA police appeared to
be well staffed and were even able to designate staff to monitor off-
site residential programs and community based outpatient clinics.
Lack of stakeholder involvement in unit redesign. As medical
facilities undergo remodeling, it is important that stakeholders are
consulted in the design process to better ensure that new or remodeled
areas are both functional and safe. Involving the VA police, security
specialists, computer experts, and staff in the affected units would
better ensure that proper security precautions are built into redesign
projects. We found that such stakeholder involvement on remodeling
projects had not occurred at one of the medical facilities we visited.
At this medical facility, some clinicians said that a lack of
stakeholder involvement in the redesign of the inpatient mental health
units had created several safety concerns and that postconstruction
changes had to be made to the unit to ensure the safety of veterans
and unit staff. Specifically, clinical and VA police personnel were
not consulted about a redesign project for the inpatient mental health
unit. The new unit initially included one nursing station that did not
prevent patient access if necessary. After the unit was reopened
following the renovation, there were a number of assaults, including
an incident where a veteran reached over the counter of the unit's
nursing station and physically assaulted a nurse by stabbing her in
the neck, shoulder, and leg with a pen. Had staff been consulted on
the redesign of this unit, their experience managing veterans in an
inpatient mental health unit environment would have been helpful in
developing several safety aspects of this new unit, including the
design of the nursing station. Less than a year after opening this
unit, medical facility leadership called for a review of the units'
design following several reported incidents. As a result of this
review, the unit was split into two separate units with different
veteran populations, an additional nursing station was installed, and
changes were planned for the structure of both the original and newly
created nursing stations--including the installation of a new shoulder-
height plexiglass barricade on both nursing station counters.
Conclusions:
VA management has not remedied problems relating to the reporting of
sexual assault incidents, the assessment of sexual assault-related
risks, and the precautions used to prevent sexual assaults and other
safety incidents in VA medical facilities. This has led to a
disorganized incident reporting structure and has left VA vulnerable
to the continued occurrence of such incidents and unable to take
systematic action on needed improvements to prevent future incidents
in all VA medical facilities. To mitigate the occurrence of sexual
assaults and other safety incidents in its medical facilities and
better ensure the safety of both veterans and staff, VA needs to
address several areas--including the processes for reporting sexual
assault incidents, the underreporting of sexual assault incidents, the
assessment of risks certain veterans may pose to the safety of others,
and the implementation of physical security precautions. Failure to
act decisively in all of these areas would likely continue to place
veterans and medical facility staff in some locations in harm's way.
To begin addressing these concerns, VA must ensure that both
management and law enforcement officials are aware of the volume and
specific types of sexual assault incidents that are reported through
the law enforcement stream. Such awareness would help both management
and law enforcement officials address safety concerns that emerge for
both patients and staff throughout VA's health care system.
Medical facility staff remain uncertain about what types of incidents
should be reported to VHA leadership and VA law enforcement officials,
and prevention and remediation efforts are eroded by failing to tap
the expertise of these officials. These officials can offer valuable
suggestions for preventing and mitigating future sexual assault
incidents and help address broader safety concerns through systemwide
improvements throughout the VA healthcare system. Leaving reporting
decisions to local VA medical facilities--rather than allowing VHA
management and VA OIG officials to determine what types of incidents
should be reported based on the consistent application of known
criteria--increases the risk that some sexual assault incidents may go
unreported. Moreover, uncertainty about sexual assault incident
reporting is compounded by VA not having: (1) established a consistent
definition of sexual assault, (2) set clear expectations for the types
of sexual assault incidents that should be reported to VISN and VHA
Central Office leadership officials, and (3) maintained proper
oversight of sexual assault incidents that occurred in VA medical
facilities. Unless these three key features are in place, VHA will not
be able to ensure that all sexual assault incidents will be
consistently reported throughout the VA health care system.
Specifically, the absence of a centralized tracking system to monitor
sexual assault incidents across VA medical facilities may seriously
limit efforts to both prevent such incidents in the short and long
term and maintain a working knowledge of past incidents and efforts to
address them when staff transitions occur.
Maintaining veterans' access to care is a priority in VA, but in those
cases where veterans have a history of sexual assault or other violent
acts, VA must be vigilant in identifying the risks that such veterans
may pose to the safety of others at its medical facilities. Risk
assessment tools can be valuable mechanisms for identifying those
veterans that pose risks to others while being treated at VA medical
facilities. However, VA does not currently have a risk assessment tool
specific to sexual assault and instead relies on clinicians'
professional judgments. These judgments are largely informed by the
assessment of veterans' legal histories, which depend heavily on self-
reported data that must be accurately documented by clinicians in
veterans' medical records. Moreover, current VA guidance is not
specific about the extent to which current and past legal issues--such
as the type or date of convictions--should be documented in veterans'
medical records--a factor that further complicates the ability of VA
clinicians both to compile complete legal histories on veterans and to
make informed decisions about risks certain veterans may pose to other
veterans and VA staff.
Ensuring that medical facilities maintain a safe and secure
environment for veterans and staff in residential programs and
inpatient mental health units is critical and requires commitment from
all levels of VA. Currently, the five VA medical facilities we visited
are not adequately monitoring surveillance camera systems, maintaining
the integrity of alarm systems, and ensuring an adequate police
presence. Closer oversight by both VISNs and VA and VHA Central Office
staff is needed to provide a safe and secure environment throughout
all VA medical facilities.
Recommendations for Executive Action:
To improve VA's reporting and monitoring of allegations of sexual
assault, we recommend that the Secretary of Veterans Affairs direct
the Under Secretary for Health to take the following four actions:
* Ensure that a consistent definition of sexual assault is used for
reporting purposes by all medical facilities throughout the system to
ensure that consistent information on these incidents is reported from
medical facilities through VISNs to VHA Central Office leadership.
* Clarify expectations about what information related to sexual
assault incidents should be reported to and communicated within VISN
and VHA Central Office leadership teams, such as officials responsible
for residential programs and inpatient mental health units.
* Implement a centralized tracking mechanism that would allow sexual
assault incidents to be consistently monitored by VHA Central Office
staff.
* Develop an automated mechanism within the centralized VA police
reporting system that signals VA police officers to refer cases
involving potential felonies, such as rape allegations, to the VA OIG
to facilitate increased communication and partnership between these
two entities.
To help identify risks and address vulnerabilities in physical
security precautions at VA medical facilities, we recommend that the
Secretary of Veterans Affairs direct the Under Secretary for Health to
take the following four actions:
* Establish guidance specifying what should be included in legal
history discussions with veterans and how this information should be
documented in veterans' biopsychosocial assessments.
* Ensure medical centers determine whether existing stationary,
computer-based, and portable personal panic alarm systems operate
effectively through mandatory regular testing.
* Ensure that alarm systems effectively notify relevant staff in both
medical facilities' VA police command and control centers and unit
nursing stations.
* Require relevant medical center stakeholders to coordinate and
consult on (1) plans for new and renovated units, and (2) any changes
to physical security features, such as closed-circuit television
cameras.
Agency Comments and Our Evaluation:
VA provided written comments on a draft of this report, which we have
reprinted in appendix III. In its comments, VA generally agreed with
our conclusions, concurred with our recommendations, and described the
agency's plans to implement each of our recommendations. VA also
provided technical comments which we have incorporated as appropriate.
Specifically, VA outlined its plan to create a multidisciplinary
workgroup that will undertake efforts to respond to seven of our eight
recommendations--including developing definitions of sexual assault
and other safety incidents, reviewing existing data sources and
communication mechanisms, developing a centralized mechanism for
monitoring sexual assaults and other safety incidents, and developing
risk assessment and management guidance. The workgroup will be co-
chaired by the Acting Assistant Deputy Under Secretary for Health for
Clinical Operations and the Chief Consultant for the Women Veterans
Health Strategic Health Care Group. Participants will include
representatives from VA field operations and the following offices:
(1) the VHA Deputy Under Secretary for Health for Operations and
Management; (2) the VHA Deputy Under Secretary for Health for Policy
and Services; (3) the VHA Principal Deputy Under Secretary for Health;
(4) the VA Office of Security and Law Enforcement; and (5) other
offices as needed, including the VA Office of General Counsel.
As outlined by VA, the workgroup will review current data sources, the
organization and structure of VHA's methods for reporting sexual
assaults and other safety incidents, and the agency's current response
to sexual assault incidents. In addition, the workgroup will review
and evaluate risks and efforts to prevent sexual assaults. Finally,
the workgroup will assess the status of current policies within VHA
and address which organizational initiatives and policies should be
updated. According to VA's comments, the workgroup will provide the
Under Secretary for Health and his Deputies with monthly verbal
updates on its progress, as well as an initial action plan by July 15,
2011 and a final report by September 30, 2011.
In addition, VA stated in its comments that the Office of the Deputy
Under Secretary for Health for Operations and Management will work in
conjunction with this multidisciplinary workgroup on a number of
initiatives to address panic alarm system testing and coordination on
renovation and construction at VA medical facilities. Initiatives
described in VA's comments specifically included efforts to: (1) re-
emphasize the need for routine testing of panic alarm systems; (2)
examine existing VHA policy to determine if revisions are needed to
ensure that regular testing of alarm systems is required and
preventative maintenance is performed on these systems; (3) re-
emphasize the importance of coordination at the local level to ensure
that safety and security are considered during construction and
renovation processes at local levels; and (4) determine how such
coordination can be formalized as part of the planning and design
processes for all construction processes in conjunction with the VA
Office of Construction.
Finally, to address our remaining recommendation, the VA OSLE will
develop a mechanism that will directly prompt VA police officers to
report potential felonies, including rape, to the VA OIG when these
offenses are recorded in the centralized police reporting system. In
its comments, VA stated that this system will also send a message to a
specialized mailbox alerting VA OIG investigators that a potential
felony has been recorded in the centralized police reporting system.
We are sending copies of this report to the Secretary of Veterans
Affairs, appropriate congressional committees, and other interested
parties. In addition, the report is available at no charge on the GAO
Web site at [hyperlink, http://www.gao.gov].
If you or your staffs have any questions about this report, please
contact me at (202) 512-7114 or at williamsonr@gao.gov. Contact points
for our Offices of Congressional Relations and Public Affairs may be
found on the last page of this report. GAO staff who made major
contributions to this report are listed in appendix IV.
Signed by:
Randall B. Williamson:
Director, Health Care:
[End of section]
Appendix I: Scope and Methodology:
This appendix describes the information and methods we used to
examine: (1) VA's processes for reporting sexual assault incidents and
the volume of these incidents reported in recent years; (2) the extent
to which sexual assault incidents are fully reported and what factors
may contribute to any observed underreporting; (3) how medical
facility staff determine sexual assault-related risks veterans may
pose in residential and inpatient mental health settings; and (4) the
precautions in place in residential and inpatient mental health
settings to prevent sexual assaults and other safety incidents and any
weaknesses in these precautions.
Specifically, we discuss our methods for selecting VA medical
facilities for site visits; identifying appropriate Department of
Veterans Affairs (VA) and Veterans Health Administration (VHA) Central
Office officials to interview; assessing the extent to which sexual
assault incidents are fully reported; determining what legal history
information is captured in veterans' medical records; and examining
the physical security precautions in use in selected residential
programs and inpatient mental health units. In addition to the methods
described below, we also reviewed relevant VA and VHA policies,
handbooks, directives, and other guidance documents to inform our
overall review of these issues whenever possible.
Site Selection Methodology and Interviews with Medical Facility
Officials:
We conducted five site visits to VA medical facilities to obtain the
perspectives of medical facility level officials and clinicians
working in residential programs and inpatient mental health units and
to observe the types of physical security precautions used within
these medical facilities. To identify VA medical facilities for our
site visits, we examined available VA and medical facility level
information to ensure our sample included medical facilities with the
following characteristics:
* Presence of both residential programs and inpatient mental health
units. We identified medical facilities that had both types of
programs by consulting VA documentation of residential program and
inpatient mental health units.
* Presence of a variety of residential program specialties. We
identified medical facilities that had: (1) at least one residential
program--including domiciliaries and residential rehabilitation
treatment programs (RRTP)--and (2) had a compensated work therapy/
transitional residence (CWT/TR) program wherever possible.[Footnote
56] In addition, we selected medical facilities that had a variety of
RRTP program specialties designed to treat particular mental health
issues, such as post-traumatic stress disorder (PTSD) and substance
abuse.
* Various levels of experience reporting sexual assault incidents.
Using sexual assault case files provided by the VA Office of Inspector
General (OIG) Office of Investigations--Criminal Investigations
Division--we identified VA medical facilities with a wide variety of
experiences reporting sexual assault incidents, including one medical
facility with no reported sexual assault incidents and several others
that had reported a number of sexual assault incidents that occurred
within their residential programs or inpatient mental health programs.
This ensured that the VA medical facilities we visited captured a
range of perspectives on the reporting of sexual assault incidents.
* Various medical facility sizes. We identified medical facilities
with different campus sizes and types of on-site programs by
determining whether each medical facility was a single or multisite
medical facility and considering several other aspects of medical
facility design, such as the presence of on-site day care centers.
Using these criteria, we judgmentally selected five VA medical
facilities to visit during our field work. During our site visits to
these locations, we interviewed each medical facility's leadership
team; residential program and inpatient mental health unit managers
and staff; VA police; quality and patient safety managers; disruptive
behavior committee members; woman veterans program manager; military
sexual trauma program coordinator; and veterans justice outreach
program coordinator. We spoke with these officials about a variety of
topics, including incident reporting, risk assessment practices, and
precautions used to prevent safety incidents, including sexual
assaults.
In addition, we spoke with officials from the four Veterans Integrated
Service Networks (VISN) responsible for managing these medical
facilities to discuss their expectations, policies, and procedures for
reporting sexual assault incidents. We also spoke with each VISN's
Health Care for Re-entry Veterans program managers to gain additional
insight on these programs.
Information obtained from our visits to selected VA medical facilities
and interviews with selected VISNs cannot be generalized to all VISNs
and VA medical facilities throughout the nation.
Interviews with VA and VHA Central Office Officials:
We also interviewed VA and VHA Central Office officials responsible
for incident reporting; law enforcement oversight; mental health
programs; women veterans; risk assessment; patient privacy; and legal
issues. We spoke with the following offices at the department level
within VA: (1) Office of Security and Law Enforcement (OSLE); (2) the
Integrated Operations Center (IOC); (3) the Office of General Counsel;
and (4) the OIG's Office of Investigations--Criminal Investigations
Division. We also interviewed officials from the following offices
within VHA Central Office: (1) the Office of the Deputy Under
Secretary for Health for Operations and Management; (2) the Office of
the Principal Deputy Under Secretary for Health; (3) the Office of
Mental Health Services; (4) the Women Veterans Health Strategic Health
Care Group; and (5) the Information Access and Privacy Office.
Analyses of Sexual Assault Incident Reporting:
To assess the effectiveness of the reporting of sexual assault
incidents, we reviewed documentation of sexual assault incidents from
VHA management officials and VA law enforcement entities.
Document Request and Response:
To analyze the reporting process for sexual assault incidents, we
requested documentation of these incidents from our selected VISNs;
VHA's Office of the Deputy Under Secretary for Health for Operations
and Management; VA OSLE; and VA OIG. For all information we requested,
we asked VHA or VA officials to send us either issue briefs or
investigation documentation that fell within the definition of sexual
assault used for the purposes of this report.[Footnote 57]
To review reports submitted through VHA's management reporting stream,
we requested copies of issue briefs on sexual assault incidents sent
to our selected VISNs and the VHA Office of the Deputy Under Secretary
for Health for Operations and Management.[Footnote 58] We also asked
our selected VISNs to identify which of these issue briefs were sent
to the VHA Central Office for further review. The four VISNs responded
that in total they received 16 issue briefs and forwarded 11 of these
documents to the VHA Central Office. Due to limitations in how
information is archived within VHA's Office of the Deputy Under
Secretary for Health for Operations and Management, we could not
determine how many issue briefs this office received through the
management reporting stream across all VA medical facilities.[Footnote
59]
To review reports submitted through VA's law enforcement reporting
stream, we requested documentation of sexual assault incidents
reported to the VA police through the VA OSLE and documentation of
incidents referred to the VA OIG for investigation. From the VA OSLE,
we requested and received police files submitted by any VA medical
facility related to sexual assault incidents that occurred since
January 2005. We then limited the police files we reviewed to only
those incidents that occurred between January 2007 and July 2010 due
to a records schedule that requires the VA police to destroy files
greater than 3 years old.[Footnote 60] As a result of this
requirement, our review of sexual assaults reported to the VA police
during 2007 was limited to only those cases retained by VA police.
Additionally, due to the lack of a centralized VA police reporting
system prior to fiscal year 2009, VA medical facility police manually
transmitted all reports to the VA OSLE for inclusion in our review,
which resulted in only those reports received by VA OSLE being
included in our analysis. We received a total of 520 VA police case
files for the period January 2007 through July 2010, including both
open and closed investigations, from the VA OSLE. In addition, we
requested copies of VA OIG investigation documentation of sexual
assault incidents that occurred in all VA medical facilities from
January 2005 through July 2010. However, we limited our review of VA
OIG investigation documentation to only those incidents that occurred
between January 2007 and July 2010 to ensure our review of VA police
cases and VA OIG investigations were concurrent. We received
investigation documentation on 106 closed sexual assault incidents
that occurred during this time frame from the VA OIG. Additionally,
the VA OIG reported that there were 9 incidents that were currently
under investigation at the time of our review and we did not require
them to provide documentation on these cases due to the sensitive
nature of these ongoing investigations.
Scoping of VA Police Case Files and VA OIG Investigation Documentation:
To determine whether each of the incidents provided by the VA police
and the VA OIG should be included in our analysis of sexual assault
incidents that occurred in VA medical facilities between January 2007
and July 2010, we reviewed whether each incident received from the VA
police and the VA OIG met the definition of sexual assault used for
this engagement. To complete this assessment, two analysts worked
independently to make an initial determination on whether each
incident met this definition and a third analyst reviewed these
initial judgments to arbitrate a final decision using predetermined
decision rules. Of the 520 documents received from the VA police
during the specified time frame, 284 incidents were included in our
analysis, 222 were determined to be out of the scope of our review,
and the remaining 14 did not have enough information in the police
files to determine whether or not these cases fell within the scope of
our review. This process was repeated for the 106 VA OIG investigation
documents for closed investigations we received and 96 were included
in our analysis, 7 were determined to be outside the scope of our
review, and the remaining 3 did not contain enough information to
determine whether or not they fell within the scope of our review.
Our analyses of sexual assault incidents reported to the VA police and
the VA OIG was limited to only those incidents that were reported and
cannot be used to project the volume of sexual assault incident
reports that may occur in future years. Following verification that
police and VA OIG incidents met our definition of sexual assault and
comparisons of the two entities' reported sexual assault incidents, we
found data derived from these reports to be sufficiently reliable for
our purposes.
Analysis of VA Police Case Files:
For our analysis of the 284 incidents reported to the VA police
determined to be within the scope of our review, we identified several
key data points in each case file, including the gender of the
perpetrator and victim, the relationship the perpetrator and victim
had to VA, and the medical facility location and VISN where the
incident originated. In addition, we also placed these incidents into
one of five categories to analyze the volume of several types of
sexual assault incidents that occurred throughout VA medical
facilities.
* Inappropriate touch--included any case involving only allegations of
touching, fondling, grabbing, brushing, kissing, rubbing, or other
like-terms.
* Forced or inappropriate oral sex--included any case involving only
allegations of forced or inappropriate oral sex.[Footnote 61]
* Forceful examination--included any case alleging only a medical
examination that was painful, uncomfortable, or seemingly
inappropriate to the patient.
* Rape--included any case involving rape allegations, which we defined
as vaginal or anal penetration by any body part or object without
consent. We deemed a file as containing a rape allegation if any of
the following were noted within the file: (1) either the victim or VA
staff used the term rape in their descriptions of the incident; (2) a
rape kit was requested or administered; (3) allegations that sex
occurred without consent, whether or not penetration was described; or
(4) allegations of attempted vaginal or anal penetration without
consent.[Footnote 62] In addition, cases where VA staff deemed that
one or more of the victims involved were mentally incapable of giving
consent for sexual activities or that a victim's ability to consent
was otherwise impaired, were included in this category.
* Other--included any case that did not fit into the categories
described above or if the incident described in the police file was
unclear. In addition, cases involving consensual sexual activities
between two individuals who were in a mental health or geriatric unit
where both parties were found to be capable of giving consent were
included in this category.
VA OIG Reporting Analysis:
To examine the discrepancies between the number of sexual assault
incidents reported to VA police and the number referred to the VA OIG,
we reviewed the 67 rape allegations that were reported to VA police to
determine which of these reports were referred to the VA OIG. We
selected rape allegations for this additional review due to the
severity of these allegations and the likelihood they would be
considered potential felonies that must be reported to the VA OIG. To
complete this analysis, we matched the VA police files containing rape
allegations to a VA OIG investigation document wherever possible. A
police file and VA OIG investigation document were considered a match
when both documents discussed the same incident details--including
information such as discussion of the same perpetrator and victim,
medical facility, and incident date. Of the 67 rape allegations
reported to the VA police, 25 had a matching VA OIG investigation
document, while the remaining 42 did not.[Footnote 63] In addition, we
reviewed federal statutes related to sexual offenses and sentencing
classification for felonies to verify that all rape allegations
included in our review met the statutory criteria for felonies under
federal law. Finally, investigators from the VA OIG reviewed summaries
of the 42 rape allegations that did not match VA OIG investigation
documentation previously provided to determine whether or not they
would have expected such cases to be reported to their office. These
case summaries did not contain identifying information about the
suspects, victims, or VA medical facilities involved in these
incidents.[Footnote 64] Four VA OIG investigators reviewed these
summaries and based their determinations on several key factors
developed from their experience as law enforcement officers.
Legal History Analysis of Biopsychosocial Assessments:
We reviewed the biopsychosocial assessment sections of selected
veterans' medical records to better understand how legal history
information contained in these documents could be used to inform
clinicians' assessments of sexual assault-related risks veterans may
pose while they are being treated at VA medical facilities. We
reviewed these assessments for all veterans who were registered sex
offenders residing in the residential programs or inpatient mental
health units of our selected medical facilities. To determine if
registered sex offenders were residing at the medical facilities we
visited, we searched the Web sites of each medical facility's
corresponding publicly available state sex offender registry and
included any individual registered under the address of the selected
medical facility's residential programs or inpatient mental health
units in our sample.[Footnote 65] The addresses used for these
searches were provided by each medical facility. Our corresponding
sample included eight veterans from three of the five medical
facilities we visited. VA medical facility staff provided
biopsychosocial assessments for seven of these veterans and noted that
the eighth assessment was never completed by the medical facility. We
analyzed the contents of these seven veterans' biopsychosocial
assessments to determine the extent to which these records contained
information about these veterans' current and past legal issues,
including documentation of convictions and parole or probation status.
We also reviewed information contained in these assessments regarding
these veterans' histories of sexual abuse. Our review of veterans'
biopsychosocial assessments was limited to only those veterans meeting
these criteria and cannot be generalized to broader VA patient
populations.
Review of Selected VA Medical Facilities' Physical Security
Precautions:
To examine the physical security precautions in place in residential
programs and inpatient mental health units, physical security experts
from our Forensic Audits and Investigative Services team conducted an
independent assessment of physical security measures in place at the
medical facilities we visited. To conduct this assessment, these
experts assessed the physical security precautions in place at each of
the five medical facilities we visited and identified any weaknesses
they observed in these systems using criteria based on generally
recognized security standards and selected VA security requirements.
These reviews included the testing of some physical security
precautions, such as panic alarm systems, and interviews with staff
working in the residential programs and inpatient mental health units
that were reviewed. Our review of these precautions was limited to
only those medical facilities we reviewed and does not represent
results from all VA medical facilities nationwide.
We conducted our performance audit from May 2010 through June 2011 in
accordance with generally accepted government auditing standards.
Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe
that the evidence obtained provides a reasonable basis for our
findings and conclusions based on our audit objectives. We conducted
our related investigative work in accordance with standards prescribed
by the Council of Inspectors General on Integrity and Efficiency.
[End of section]
Appendix II: Analysis of VA Police Reports of Sexual Assault Incidents
from January 2007 through July 2010:
This appendix provides additional results from our analysis of VA
police reports of sexual assault incidents from January 2007 through
July 2010. Cases not reported to the VA police are not included in our
analysis of sexual assault incidents.
* Figure 3 shows the number of sexual assault incidents reported at VA
medical facilities to VA police by Veterans Integrated Service Network
(VISN) from January 2007 through July 2010. This count ranged from 34
incidents reported in VISNs C and D to no incidents reported in VISN E.
* Table 6 shows the total number of sexual assault incidents alleging
rape by gender of the perpetrator and victim from January 2007 through
July 2010.
* Table 7 shows the total number of sexual assault incidents alleging
rape by the perpetrator and victim relationship to VA from January
2007 through July 2010.
* Table 8 shows the total number of patient-on-patient assault
incidents and patient-on-employee assault incidents by the type of
sexual assault incident from January 2007 through July 2010.
Figure 3: Number of Sexual Assault Incidents Reported to VA Medical
Facility Police by VISN, January 2007 through July 2010:
[Refer to PDF for image: vertical bar graph]
VISN: A;
Number of Incidents Reported: 13.
VISN: B;
Number of Incidents Reported: 21.
VISN: C;
Number of Incidents Reported: 34.
VISN: D;
Number of Incidents Reported: 34.
VISN: E;
Number of Incidents Reported: 0.
VISN: F;
Number of Incidents Reported: 4.
VISN: G;
Number of Incidents Reported: 7.
VISN: H;
Number of Incidents Reported: 21.
VISN: I;
Number of Incidents Reported: 11.
VISN: J;
Number of Incidents Reported: 14.
VISN: K;
Number of Incidents Reported: 7.
VISN: L;
Number of Incidents Reported: 19.
VISN: M;
Number of Incidents Reported: 6.
VISN: N;
Number of Incidents Reported: 22.
VISN: O;
Number of Incidents Reported: 7.
VISN: P;
Number of Incidents Reported: 8.
VISN: Q;
Number of Incidents Reported: 6.
VISN: R;
Number of Incidents Reported: 13.
VISN: S;
Number of Incidents Reported: 7.
VISN: T;
Number of Incidents Reported: 15.
VISN: U;
Number of Incidents Reported: 15.
Sources: GAO (analysis); VA (data).
Notes: In this report, we use the term sexual assault incident to
refer to suspected, alleged, attempted, or confirmed cases of sexual
assault. All reports of sexual assault incidents do not necessarily
lead to prosecution and conviction. This may be, for example, because
an assault did not actually take place or there was insufficient
evidence to determine whether an assault occurred.
Complete analysis of 2007, 2008, and 2010 data was limited by three
factors: (1) our analysis of 2007 VA police files was limited due to
the requirement that VA police destroy investigative files after 3
years under a records schedule approved by the National Archives and
Records Administration, (2) our analysis of 2007 and 2008 VA police
files was limited due to VA police manually submitting these files to
VA's Office of Security and Law Enforcement (OSLE) for the purpose of
this data request because a centralized VA police reporting system did
not exist prior to January 2009, and (3) our analysis of 2010 records
was limited to only those received by VA police through July 2010.
There are 21 VISNs in the VA health care system. VISNs 1-12 and VISNs
15-23. For reporting purposes, VISN numbers were blinded to protect
the anonymity of each individual VISN.
Cases not reported to VA police were not included in our analysis of
sexual assault incidents.
[End of figure]
Table 6: Total Sexual Assault Incidents Alleging Rape by Perpetrator
and Victim Gender, January 2007 through July 2010:
Perpetrator/victim gender: Female/male;
Total sexual assault incidents involving rape[A]: 5.
Perpetrator/victim gender: Male/female;
Total sexual assault incidents involving rape[A]: 31.
Perpetrator/victim gender: Male/male;
Total sexual assault incidents involving rape[A]: 20.
Perpetrator/victim gender: Unknown/female;
Total sexual assault incidents involving rape[A]: 8.
Perpetrator/victim gender: Unknown/male;
Total sexual assault incidents involving rape[A]: 3.
Perpetrator/victim gender: Total;
Total sexual assault incidents involving rape[A]: 67.
Source: GAO (analysis); VA (data).
Notes: In this report, we use the term sexual assault incident to
refer to suspected, alleged, attempted, or confirmed cases of sexual
assault. All reports of sexual assault incidents do not necessarily
lead to prosecution and conviction. This may be, for example, because
an assault did not actually take place or there was insufficient
evidence to determine whether an assault occurred.
Complete analysis of 2007, 2008, and 2010 data was limited by three
factors: (1) our analysis of 2007 VA police files was limited due to
the requirement that VA police destroy investigative files after three
years under a records schedule approved by the National Archives and
Records Administration, (2) our analysis of 2007 and 2008 VA police
files was limited due to VA police manually submitting these files to
VA's OSLE for the purpose of this data request because a centralized
VA police reporting system did not exist prior to January 2009, and
(3) our analysis of 2010 records was limited to only those received by
VA police through July 2010.
The rape category includes any case involving allegations of rape,
defined as vaginal or anal penetration through force, threat, or
inability to consent. For cases that included allegations of multiple
categories including rape (i.e. inappropriate touch, forced oral sex,
and rape) the category of rape was applied. Cases where staff deemed
that one or more of the veterans involved were mentally incapable of
consenting to sexual activities described in the case were considered
rape.
[A] Cases not reported to VA police are not included in our analysis
of sexual assault incidents.
[End of table]
Table 7: Total Sexual Assault Incidents Alleging Rape by Perpetrator
and Victim Relationship to VA, January 2007 through July 2010:
Perpetrator/victim relationship to VA: Employee/employee;
Total sexual assault incidents involving rape[A]: 2.
Perpetrator/victim relationship to VA: Employee/outsider;
Total sexual assault incidents involving rape[A]: 1.
Perpetrator/victim relationship to VA: Employee/patient;
Total sexual assault incidents involving rape[A]: 13.
Perpetrator/victim relationship to VA: Employee/visitor;
Total sexual assault incidents involving rape[A]: 1.
Perpetrator/victim relationship to VA: Outsider/employee;
Total sexual assault incidents involving rape[A]: 1.
Perpetrator/victim relationship to VA: Outsider/outsider;
Total sexual assault incidents involving rape[A]: 2.
Perpetrator/victim relationship to VA: Patient/employee;
Total sexual assault incidents involving rape[A]: 1.
Perpetrator/victim relationship to VA: Patient/patient;
Total sexual assault incidents involving rape[A]: 25.
Perpetrator/victim relationship to VA: Unknown/patient;
Total sexual assault incidents involving rape[A]: 19.
Perpetrator/victim relationship to VA: Visitor/patient;
Total sexual assault incidents involving rape[A]: 2.
Perpetrator/victim relationship to VA: Total;
Total sexual assault incidents involving rape[A]: 67.
Source: GAO (analysis); VA (data).
In this report, we use the term sexual assault incident to refer to
suspected, alleged, attempted, or confirmed cases of sexual assault.
All reports of sexual assault incidents do not necessarily lead to
prosecution and conviction. This may be, for example, because an
assault did not actually take place or there was insufficient evidence
to determine whether an assault occurred.
Complete analysis of 2007, 2008, and 2010 data was limited by three
factors: (1) our analysis of 2007 VA police files was limited due to
the requirement that VA police destroy investigative files after three
years under a records schedule approved by the National Archives and
Records Administration, (2) our analysis of 2007 and 2008 VA police
files was limited due to VA police manually submitting these files to
VA's OSLE for the purpose of this data request because a centralized
VA police reporting system did not exist prior to January 2009, and
(3) our analysis of 2010 records was limited to only those received by
VA police through July 2010.
The rape category includes any case involving allegations of rape,
defined as vaginal or anal penetration through force, threat, or
inability to consent. For cases that included allegations of multiple
categories including rape (i.e. inappropriate touch, forced oral sex,
and rape) the category of rape was applied. Cases where staff deemed
that one or more of the veterans involved were mentally incapable of
consenting to sexual activities described in the case were considered
rape.
[A] Cases not reported to VA police are not included in our analysis
of sexual assault incidents.
[End of table]
Table 8: Patient-on-Patient Assault Incidents and Patient-on-Employee
Assault Incidents by Type of Sexual Assault Incident, January 2007
through July 2010:
Patient-on-patient:
Rape[A]: 25;
Inappropriate touch[B]: 54;
Forceful medical examination: 0;
Forced or inappropriate oral sex: 8;
Other[C]: 2;
Total[D]: 89.
Patient-on-employee:
Rape[A]: 1;
Inappropriate touch[B]: 83;
Forceful medical examination: 0;
Forced or inappropriate oral sex: 1;
Other[C]: 0;
Total[D]: 85.
Total:
Rape[A]: 26;
Inappropriate touch[B]: 137;
Forceful medical examination: 0;
Forced or inappropriate oral sex: 9;
Other[C]: 2;
Total[D]: 174.
Source: GAO (analysis); VA (data).
Notes: In this report, we use the term sexual assault incident to
refer to suspected, alleged, attempted, or confirmed cases of sexual
assault. All reports of sexual assault incidents do not necessarily
lead to prosecution and conviction. This may be, for example, because
an assault did not actually take place or there was insufficient
evidence to determine whether an assault occurred.
Complete analysis of 2007, 2008, and 2010 data was limited by three
factors: (1) our analysis of 2007 VA police files was limited due to
the requirement that VA police destroy investigative files after three
years under a records schedule approved by the National Archives and
Records Administration, (2) our analysis of 2007 and 2008 VA police
files was limited due to VA police manually submitting these files to
VA's OSLE for the purpose of this data request because a centralized
VA police reporting system did not exist prior to January 2009, and
(3) our analysis of 2010 records was limited to only those received by
VA police through July 2010.
[A] The rape category includes any case involving allegations of rape,
defined as vaginal or anal penetration through force, threat, or
inability to consent. For cases that included allegations of multiple
categories including rape (i.e. inappropriate touch, forced oral sex,
and rape) the category of rape was applied. Cases where staff deemed
that one or more of the veterans involved were mentally incapable of
consenting to sexual activities described in the case were considered
rape.
[B] The inappropriate touch category includes any case involving only
allegations of touching, fondling, grabbing, brushing, kissing,
rubbing, or other like-terms.
[C] The other category included any allegations that did not fit into
the other categories or if the incident described in the case file did
not contain sufficient information to place the case in one of the
other designated categories.
[D] Cases not reported to VA police are not included in our analysis
of sexual assault incidents.
[End of table]
[End of section]
Appendix III: Comments from the Department of Veterans Affairs:
Department Of Veterans Affairs:
Washington DC 20420:
June 3, 2011:
Mr. Randall B. Williamson:
Director, Health Care:
U.S. Government Accountability Office:
441 G Street, NW:
Washington, DC 20548:
Dear Mr. Williamson:
The Department of Veterans Affairs (VA) has reviewed the Government
Accountability Office's (GAO) draft report, "VA Health Care: Actions
Needed to Prevent Sexual Assaults and Other Safety Incidents" (GA0-11-
530) and generally agrees with GAO's conclusions and concurs with
GAO's recommendations to the Department.
The Department values the safety and well being of all Veterans, staff
and visitors who come to VA health care facilities. To address
concerns raised in GAO's draft report, a multi-disciplinary workgroup
has already begun work to define what the Veterans Health
Administration must do to prevent sexual assault incidents as well as
respond to reports and allegations of sexual victimization of Veterans
and employees. Furthermore, in June 2009, the Secretary of Veterans
Affairs mandated the establishment of a VA Integrated Operations
Center (IOC). The IOC is the focal point within VA for the receipt,
analysis, and dissemination of information from VA facilities and
forms a nexus that allows for situational awareness, coordinated
recommendations, and feedback to VA senior leaders in real time so
that they can make timely and proactive decisions. The combination of
these actions will provide increased security and safety for our
Veterans, their families, and our employees.
The enclosure provides responses to each of GAO's recommendations and
provides technical comments to the report. VA appreciates the
opportunity to comment on your draft report.
Sincerely,
Signed by:
John R. Gingrich:
Chief of Staff:
Enclosure:
[End of letter]
Enclosure:
Department of Veterans Affairs Comments to Government Accountability
Office (GAO) Draft Report: VA Health Care: Actions Needed to Prevent
Sexual Assaults and Other Safety Incidents (GA0-11-530):
GAO recommendation: To improve VA's reporting and monitoring of
allegations of sexual assault, we recommend that the Secretary of the
Department of Veterans Affairs direct the Under Secretary for Health
to take the following four actions:
Recommendation 1: Ensure that a consistent definition of sexual
assault is used for reporting purposes by all medical facilities
throughout the system to ensure that consistent information on these
incidents is reported from medical facilities through VISNs to VHA
Central Office Leadership;
VA Response: Concur. The Veterans Health Administration (VHA) agrees
with the need for establishing consistent definitions of sexual
assault and other safety incidents to be used for reporting
information from medical facilities through the Veterans Integrated
Service Networks (VISN) to VHA Central Office (CO) and other offices
including the VA Office of Security and Law Enforcement (OSLE). To
develop a set of definitions of sexual assault and other safety
incidents as well as address other report recommendations and
additional needs, a multi-disciplinary workgroup[Footnote 1] has been
charged with multiple objectives and tasks to complete with
assignments for interim deliverables including completion of an
initial action plan with specific timeframes due no later than (NLT)
July 15, 2011, with the final report due NLT September 30, 2011. A
specific charge to the workgroup is to identify the scope and
definitions for sexual victimization, types of incidents, and
locations within VHA. The entire charge to the work group is provided
in Attachment A.
Recommendation 2: Clarify expectations about what information related
to sexual assault incidents should be reported to and communicated
within VISN and VHA Central Office leadership teams, such as officials
responsible for residential programs and inpatient mental health units;
VA Response: Concur. VHA recognizes the need to improve structures for
reporting incidents involving sexual victimization and other safety
incidents. The multidisciplinary workgroup mentioned in the response
to Recommendation 1 will review existing data sources and information-
dissemination mechanisms to obtain and determine what data and
reporting processes are needed for an effective reporting structure.
Based on this inventory, if it is determined that existing additional
reporting processes or data collection are required, changes will be
developed, communicated with the field, and implemented. In addition
to reporting and communicating information to VISN and VHACO
leadership teams, as well as the VA OSLE, the workgroup will identify
how best to enhance tracking which can be used to identify trends and
root causes if safety is not achieved.
In regard to improving structures for reporting and communicating
sexual assault and other safety incidents, the initial action plan
will be completed NLT July 15, 2011, with a final report due NLT
September 30, 2011.
Recommendation 3: Implement a centralized tracking mechanism that
would allow sexual assault incidents to be consistently monitored by
VHA Central Office staff;
VA Response: Concur. Defining program responsibilities for policy
development and implementation and ensuring that sexual assault and
other safety incidents are consistently reported, monitored by the
appropriate staff, and addressed appropriately and promptly by field
and VHACO officials are crucial elements in protecting the safety of
Veterans in residential and other programs, as well as employees who
work in our facilities and others who visit. To accomplish this more
effectively, VHA has already begun to determine potential
vulnerabilities in organization strategies, structures, or policies to
identify how best to change or strengthen program leadership roles,
parameters of reporting, and program ownership for tracking and
reporting processes. Also, a multidisciplinary workgroup has been
specifically charged with developing and implementing a centralized
mechanism to monitor sexual assault and other safety incidents
starting with the completion of an action plan with specific
timeframes by July 15, 2011, with a final report due NLT September 30,
2011.
Recommendation 4: Develop an automated mechanism within the
centralized VA police reporting system that signals VA police officers
to refer cases involving potential felonies, such as rape allegations,
to the VA OIG to facilitate increased communication and partnership
between these two entities.
VA Response: Concur. The Office of Operations, Security, and
Preparedness (OSP)/OSLE partners and collaborates with VA OIG on a
daily basis. OSP/OSLE will develop a mechanism that will directly
prompt VA police officers to report potential felonies such as rape to
the VA OIG when the offense is entered into the database. Also, the
system will send a message alert to a specialized VA OIG mailbox that
a felony has been recorded in the VA police database. VA employees
have a duty to report all crimes in accordance with 38 CFR 1.203 and
1.205 to VA Police and in accordance with 38 CFR 1.204 and 1.201 to VA
01G. Completion date: August 2011.
GAO recommendation: To help identify risks and address vulnerabilities
in physical security precautions at VA medical facilities, we
recommend that the Secretary of the Department of Veterans Affairs
direct the Under Secretary for Health to take the following four
actions:
Recommendation 5: Establish guidance specifying what should be
included in legal history discussions with veterans and how this
information should be documented in veterans' psychosocial assessments;
VA Response: Concur. VHA cannot predict potential sexual victimization
with any certainty; however, VHA can and will focus on strategies that
provide universal precautions. In addition, VHA will further explore
what information should be obtained when assessing a Veteran's risk to
commit an offense and how this information would be used within the
required limits for maintaining confidentiality and rights of privacy.
VHA will conduct a comprehensive literature review to identify best
practices and evidence-based approaches to risk assessment and risk
management. This may include information about legal history as well
as information about other risk factors. The multidisciplinary
workgroup has been charged with consulting with additional expertise
if needed to analyze the information developed during the literature
review to determine what specific guidance may need to be developed.
An action plan for the development, implementation, and communication
of the guidance will be established and followed. This process will
also address what appropriate action needs to be taken to standardize
documentation in Veterans' psychosocial assessments.
Throughout this process, the multidisciplinary workgroup will
collaborate with the VA Office of General Counsel, as well as with the
VHA Office of Ethics in Health Care and Patient Care Services, to
ensure that rights of privacy are maintained in developing and
implementing risk assessment and management guidance and processes
while ensuring a safe environment for Veterans.
In regard to establishing guidance specifying what should be included
in legal history discussions with Veterans and how this information
should be documented in Veterans' psychosocial assessments, completion
of an initial action plan with specific timeframes is due NLT July 15,
2011, with a final report due NLT September 30, 2011.
Recommendation 6: Ensure medical centers determine whether existing
stationary, computer-based, and portable personal panic-alarm systems
operate effectively through mandatory regular testing;
VA Response: Concur. Regular testing of alarm systems is one step to
ensuring the safety and security of Veterans who participate in
residential treatment as well as other programs. While VA Medical
Centers (VAMC) currently are expected to have policies appropriate for
individual circumstances in a medical center and in compliance with The
Joint Commission standards regarding the use and testing of panic
alarm systems, the Office of the Deputy Under Secretary for Health for
Operations and Management (DUSHOM) will re-emphasize the need for
routine testing of these panic alarms to ensure the alarms are
functioning correctly. The DUSHOM will also review whether existing
policy needs to be revised so that regular testing is required and so
that alarm systems have regular preventative maintenance performed in
accordance with manufacturer requirements.
The DUSHOM will work with the multi-disciplinary workgroup to complete
an action plan with specific timeframes NLT July 15, 2011, with a
final report due NLT September 30, 2011.
Recommendation 7: Ensure that alarm systems effectively notify
relevant staff in both medical facilities' VA police command and
control centers and unit nursing stations;
VA Response: Concur. Due to the variability in types of alarm systems
based on location and services offered, it is necessary for each
facility to develop its own processes to ensure alarm systems are
appropriately communicating with medical facilities' VA police command
and control centers as well as unit nursing services. In order to
ensure that each facility is addressing these issues, the DUSHOM will
reemphasize existing policy and procedures about the use of alarm
systems. Also, VISN Directors will be tasked to ensure that local
facilities have established systems that meet the specific location
and function needs. A process will be developed to include regular
testing of these systems based on industry and manufacturers'
standards.
The DUSHOM will work with the multi-disciplinary workgroup to complete
an action plan with specific timeframes by July 15, 2011, as well as
implement policy changes or complete timelines related to policy
changes NLT September 30, 2011.
Recommendation 8: Require relevant medical center stakeholders to
coordinate and consult on (1) plans for new and renovated units and
(2) any changes to physical security features, such as closed-circuit
television cameras.
VA Response: Concur. The report points out the importance of
coordination and collaboration in construction and renovation
processes among medical center stakeholders. The DUSHOM will re-
emphasize the importance of coordinating at the local level to ensure
that safety and security are considered during construction and
renovation projects at local levels.
In addition at the national level, the DUSHOM will work with the multi-
disciplinary workgroup to consult with the VA Office of Construction
and VA OSLE about how to formalize such consultation as part of the
planning and design processes for all construction projects. The goal
is to ensure vulnerability assessments and physical security
considerations are addressed for all new and renovated units in
medical facilities.
The DUSHOM will work with the multi-disciplinary workgroup to complete
an action plan with specific timeframes NLT July 15, 2011, as well as
implement policy changes or complete timelines related to policy
changes NLT September 30, 2011.
Appendix III Footnotes:
[1] The workgroup includes officials from the Offices of the Deputy
Under Secretary for Policy and Services (e.g., Patient Care Services,
Public Health, Informatics and Analytics); Deputy Under Secretary for
Health for Operations and Management (e.g., Assistant Deputy Under
Secretary for Health for Clinical Operations and Assistant Deputy
Under Secretary for Administrative Operations); Principal Deputy Under
Secretary for Health (e.g., Office of Nursing Services and Assistant
Deputy Under Secretary for Health for Quality, Safety, and Value); VA
Office of Security and Law Enforcement as well as other offices such
as the VA Office of General Counsel, as needed.
Attachment A:
Department of Veterans Affairs:
Veterans Health Administration:
Charter of the Under Secretary for Health Safety and Assault
Prevention Workgroup:
1. Purpose.
The Veterans Health Administration (VHA) values the safety and well
being of Veterans, staff, and visitors in every Department of Veterans
Affairs (VA) health care setting. This includes establishing
appropriate risk assessments, precautions, and risk management
procedures related to incidents of alleged sexual assaults and of
alleged sexual harassment perpetrated against Veterans, staff, or
visitors to VA medical care facilities. In addition, VHA recognizes
that several mechanisms and reporting structures have been identified
that could be better organized to ensure the effective coordination of
both prevention and response activities.
This workgroup is charged to define steps necessary to ensure that VHA
is taking every action necessary to respond effectively to reports of
sexual victimization of Veterans and employees, develop appropriate
proactive interventions to reduce the risk of these events, provide a
recommendation for ongoing data tracking and trending, and establish
guidance for training of staff and providers. The workgroup will
review the current data sources, organization and structure of VHA's
tracking reports and the current response to sexual victimization and
assault incidents. The workgroup will further review and evaluate
risks and efforts to prevent sexual assaults. Finally, the workgroup
will assess the current status within VHA and propose recommendations
on the most appropriate organizational initiatives or policy updates.
2. Workgroup Objectives.
The Safety and Assault Prevention Workgroup will be expected to
accomplish the following objectives:
* Identify scope and definitions for sexual victimization of Veterans
and employees, types of incidents and locations within VHA
responsibility;
* Identify current organizational roles and responsibilities in
relation to assuring safety from sexual victimization in VHA settings;
* Identify data sources within the VHA organizational structure,
variations in data elements, and data tracking methods that are most
likely to support identification of trends and root causes when safety
was not achieved:
- Review of existing data sources, and information-dissemination
mechanisms;
- Determine what other data will be needed, and request from data
sources.
* Establish a tracking system for all defined incidents which will
coordinate both law enforcement and leadership systems of response;
* Evaluate where current models of care delivery work well;
* Identify where non-compliance exists with current policy;
* Determine potential vulnerabilities in organizational strategies,
structures or policies, and recommend opportunities for change or
strengthening in program leadership roles, parameters of reporting,
and program ownership for tracking and reporting routinely, and
program responsibilities for policy development and implementation;
* Begin background work on education needs for VHA Central Office and
field staff and providers;
* Identify and establish data trending mechanisms to support
intervention, prevention and education;
* Identify prevention strategies that are reviewed by Program Office
Officials for compliance with current literature and/or best practice
and that can be executed at all VA medical centers (VAMC);
* Assess current alarm/panic systems, and physical security features
with an analysis of gaps and recommendations for improvement.
3. Membership.
Co-Chair: George Arana, MD, Acting Assistant Deputy Under Secretary
for Health for Clinical Operations.
Co-Chair: Patricia M. Hayes, PhD, Chief Consultant, Women's Health
Strategic Health Group.
Project Manager: Douglas Walker, Presidential Management Fellow.
Workgroup Participants: Representatives from following offices:
* VHA Deputy Under Secretary for Health for Operations and Management
(10N);
- Assistant Deputy Under Secretary for Clinical Operations (10NC)
including operations officials related to mental health, geriatrics,
specialty care;
- Assistant Deputy Under Secretary for Administrative Operations
including officials involved with safety and facility issues.
* VHA Deputy Under Secretary for Health for Policy and Services (10P);
- Office of Patient Care Services (10P4) including policy staff
related to mental health, geriatrics, specialty care;
- Office of Public Health (10P3);
- Information and Analytics (10P2).
* VHA Principal Deputy Under Secretary for Health (10A);
- Office of Quality and Safety;
- Office of Nursing Service.
* VA Office of Security and Law Enforcement.
* VA Office of General Counsel, as needed.
* Field representation.
* Others, as needed.
4. Deliverables and Operations.
The workgroup is chartered to prepare reports and recommendations to
be presented to the co-chairs of the workgroup. The co-chairs will
then provide the results of the workgroup efforts to the Deputy Under
Secretary for Health for Operations and Management and the Deputy
Under Secretary for Health for Policy and Services for review and
approval.
The workgroup has the authority and expectation to set up sub-groups
as necessary to complete a full analysis in a timely manner. The
workgroup and its sub-groups are to use program office leaders,
subject matter experts, and front line staff from the field as members
of the sub-groups.
The specific tasks for the workgroup are to:
* Develop and present an initial action plan to outline scope of work
with strict timelines.
* Produce a workgroup report to include a highly defined and detailed
list of recommendations and a project plan including:
- identification of risks (including if there is a need for legal
history discussions with Veterans during psychosocial assessment
processes),
- risk mitigation strategies,
- definitions of oversight responsibilities and roles of leadership and
program offices,
- timeframes for execution of recommendations,
- timeframes for execution of implementation in field facilities,
- performance metrics and outcome measures for plan work streams,
- comprehensive policy to track and report sexual victimization
incidents at VA facilities,
This report is to be presented to the Principal Deputy Under Secretary
for Health and Under Secretary for Health for approval.
5. Timelines.
* Initial Action Plan: NLT July 15, 2011.
* Monthly verbal updates to Deputy Under Secretary for Health for
Operations and Management, Deputy Under Secretary for Health for
Policy and Services, and Principal Deputy Under Secretary for Health,
and Under Secretary for Health.
* Final Written Report: NLT September 30, 2011.
Signed by:
Robert A. Petzel, M.D.
Under Secretary for Health:
Date: June 3, 2011:
[End of section]
Appendix IV: GAO Contact and Staff Acknowledgments:
GAO Contact:
Randall B. Williamson, (202) 512-7114 or williamsonr@gao.gov:
Staff Acknowledgments:
In addition to the contact named above, Marcia A. Mann, Assistant
Director; Gary A. Bianchi; Robin Burke; Emily Goodman; Katherine
Nicole Laubacher; Lisa Motley; Andy O'Connell; George Ogilvie; Carmen
Rivera-Lowitt; and Cassandra Yarbrough made key contributions to this
report.
[End of section]
Footnotes:
[1] See GAO, VA Health Care: VA Has Taken Steps to Make Services
Available to Women Veterans, but Needs to Revise Key Policies and
Improve Oversight Processes, [hyperlink,
http://www.gao.gov/products/GAO-10-287] (Washington D.C.: Mar. 31,
2010).
[2] In this report, we use the term safety incident to refer to
intentionally unsafe acts--including criminal and purposefully unsafe
acts, clinician and staff alcohol or substance abuse-related acts, and
events involving alleged or suspected patient abuse of any kind. These
safety incidents are excluded from the reporting requirements outlined
by the VA National Center for Patient Safety (NCPS).
[3] In this report, we use the term sexual assault incident to refer
to suspected, alleged, attempted, or confirmed cases of sexual
assault. All reports of sexual assault incidents do not necessarily
lead to prosecution and conviction. This may be, for example, because
an assault did not actually take place or there was insufficient
evidence to determine whether an assault occurred.
[4] NCPS manages VA's overall patient safety reporting system and
focuses its data collection and oversight on adverse events that
represent primarily unintentional medical mistakes, such as errors in
medication administration, patient falls, and wrong-site surgeries.
The collection of information on intentionally unsafe acts, including
criminal acts such as sexual assault, is specifically exempted from
NCPS responsibility by VA policy.
[5] Within VA, VHA is the organization responsible for providing
health care to veterans at medical facilities across the country.
[6] We also spoke with officials from VHA's Office of Mental Health
Services and the Women Veterans Health Strategic Health Care Group.
[7] VA medical facilities were selected to ensure that at least one
facility with no experience reporting sexual assault incidents was
included in our judgmental sample of facilities. Other selected
medical facilities all had some experience reporting sexual assault
incidents. To determine facilities' histories of reporting sexual
assault incidents, we reviewed closed investigations conducted by the
VA Office of the Inspector General (OIG) Office of Investigations--
Criminal Investigations Division. This selection allowed us to ensure
that a greater variety of perspectives on sexual assault incidents
were captured during our field work.
[8] Two of the facilities we visited were located within the same
VISN. VISNs are responsible for the day-to-day management of
facilities within their network.
[9] For the purposes of this report, we define sexual assault as any
type of sexual contact or attempted sexual contact that occurs without
the explicit consent of the recipient of the unwanted sexual activity.
Assaults may involve psychological coercion, physical force, or
victims who cannot consent due to mental illness or other factors.
Falling under this definition of sexual assault are sexual activities
such as forced sexual intercourse, sodomy, oral penetration or
penetration using an object, molestation, fondling, and attempted rape
or sexual assault. Victims of sexual assault can be male or female.
This does not include cases involving only indecent exposure,
exhibitionism, or sexual harassment.
[10] Compensated work therapy is a VA vocational rehabilitation
program that matches work-ready veterans with competitive jobs,
provides support to veterans in these positions, and consults with
business and industry on their specific employment needs.
[11] Veterans Health Administration Handbook 1162.02, Mental Health
Residential Rehabilitation Treatment Program (Dec. 22, 2010).
[12] CWT/TR programs are exempt from some of these requirements.
[13] Information about veterans' living situations, emotional and
behavioral functioning, histories of substance use, family psychiatric
histories, experiences with military history and trauma, current
social support and stressors, and current financial status may also be
included in these assessments.
[14] 38 C.F.R. § 1.204 (2010). Criminal matters involving felonies
must be immediately referred to the OIG, Office of Investigations. VA
management officials with information about possible criminal matters
involving felonies are responsible for prompt referrals to the OIG.
Examples of felonies include but are not limited to, theft of
government property over $1,000, false claims, false statements, drug
offenses, crimes involving information technology systems, and serious
crimes against the person, i.e., homicides, armed robbery, rape,
aggravated assault, and serious physical abuse of a VA patient.
Additionally, another VA regulation requires that all VA employees
with knowledge or information about actual or possible violations of
criminal law related to VA programs, operations, facilities,
contracts, or information technology systems immediately report such
knowledge or information to their supervisor, any management official,
or directly to the VA OIG. 38 C.F.R. § 1.201 (2010).
[15] VA defines serious incidents as those that involve: (1) public
information regarding the arrest of a VA employee; (2) major
disruption to the normal operations of a VA facility; (3) deaths on VA
property due to suspected homicide, suicides, accidents, and/or
suspicious deaths; (4) VA police-involved shootings; (5) the
activation of occupant emergency plans, facility disaster plans,
and/or continuity of operations plans; (6) loss or compromise of VA
sensitive data, including classified information; (7) theft or loss of
VA-controlled firearms or hazardous material, or other major theft or
loss; (8) terrorist event or credible threat that impacts VA
facilities or operations; and (9) incidents on VA property that result
in serious illness or bodily injury, including sexual assault,
aggravated assault, and child abuse. See VA Directive 0321, Serious
Incident Reports (Jan. 21, 2010).
[16] Several VISN officials in network offices we reviewed also noted
that they can sometimes learn of incidents through other mechanisms,
such as press reports and veterans' families.
[17] See 38 C.F.R. § 1.204 (2010).
[18] VHA Directive 2010-014, Assessment and Management of Veterans Who
Have Been Victims of Alleged Acute Sexual Assault (May 25, 2010).
[19] Our analysis was limited to only those reports that were provided
by the VA OSLE and does not include reports that may never have been
created or were lost by local VA police or VA OSLE.
[20] To conduct this analysis, we placed VA police case files into
these categories to describe the allegations contained within them.
[21] We could not consistently determine whether or not these sexual
assault incidents were substantiated due to limitations in the
information VA provided, including inconsistent documentation of the
disposition of some incidents in the police files.
[22] Other allegations by relationship included: 1 employee-on-
outsider assault, 2 employee-on-visitor assaults, 2 outsider-on-
employee assaults, 2 outsider-on-outsider assaults, 1 outsider-on-
patient assault, 1 outsider-on-visitor assault, 3 patient-on-visitor
assaults, 3 unknown-on-employee assaults, 3 unknown-on-visitor
assaults, 1 visitor-on-employee assault, and 2 visitor-on-patient
assaults.
[23] Our review of the reports received by both VISN and VA Central
Office officials was limited to only those documented in issue briefs
and did not include the less formal heads-up messages. This is because
heads-up messages are not formally documented and often are a
preliminary step to a more formal issue brief.
[24] We did not require VA OIG to provide documentation for 9
incidents currently under investigation due to the sensitive nature of
these ongoing investigations. Since we did not require this
documentation, it is possible that some of these 9 ongoing
investigations were included in the 42 rape allegations we could not
confirm were reported to the VA OIG.
[25] See 38 C.F.R. § 1.204 (2010). Examples of felonies listed in this
regulation include theft of government property over $1,000, false
claims, false statements, drug offenses, crimes involving information
technology systems, and serious crimes against the person, i.e.,
homicides, armed robbery, rape, aggravated assault, and serious
physical abuse of a VA patient.
[26] The VA Security and Law Enforcement Handbook defines a felony as
any offense punishable by either imprisonment of more than 1 year or
death as classified under 18 U.S.C. § 3559. See VA Handbook 0730,
Security and Law Enforcement (Aug. 11, 2000). Federal statutes define
certain sexual acts and contacts as federal crimes. See 18 U.S.C. §§
2241-2248. All federal sexual offenses are punishable by imprisonment
of more than 1 year; therefore all federal sexual offenses are
felonies and must be immediately referred to the VA OIG for
investigation in accordance with VA regulation.
[27] For the purposes of our analysis, we focused only on sexual
assault incidents involving rape allegations. Neither federal statutes
nor VA regulations define rape; however, the definition of rape we
developed for our analysis falls within the federal sexual offenses of
either aggravated sexual abuse or sexual abuse. See 18 U.S.C. §§ 2241
and 2242. These two offenses are felonies under federal statute;
therefore, all rapes that meet our definition are felonies.
[28] The VA OIG senior-level investigators who conducted this review
noted that they identified at least one incident summary that was
readily identifiable as a case currently under investigation by the VA
OIG. Due to the general nature of the incident summaries we provided
for their review and the sensitive nature of specific details of
ongoing investigations, we did not require the VA OIG to provide
specific details on exactly how many of the 42 rape allegations we
asked them to review were currently under investigation by their
office; however, the total number of ongoing sexual assault incident
investigations for the time period of our analysis was only nine.
[29] The National Center for Victims of Crime's definition of sexual
assault states that: "Sexual assault takes many forms including
attacks such as rape or attempted rape, as well as any unwanted sexual
contact or threats. Usually a sexual assault occurs when someone
touches any part of another person's body in a sexual way, even
through clothes, without that person's consent. Some types of sexual
acts which fall under the category of sexual assault include forced
sexual intercourse (rape), sodomy (oral or anal sexual acts), child
molestation, incest, fondling and attempted rape."
[30] The Joint Commission is an independent organization that
accredits and certifies health care organizations and programs in the
United States. Rape is included among The Joint Commission's list of
reportable sentinel events and defines rape as: "unconsented sexual
contact involving a patient and another patient, staff member, or
other perpetrator while being cared for, treated, or provided
services, or on the premises of the behavioral health care
organization, including oral, vaginal, or anal penetration or fondling
of the patient's sex organ(s) by another individual's hand, sex organ,
or object."
[31] The remaining VISN did not report receiving any issue briefs on
sexual assault incidents.
[32] While two of the four VISN policies reference The Joint
Commission's definition of sentinel events, which includes rape, this
definition does not include the broader category of sexual assault
incidents as defined in this report.
[33] VISNs may also send a heads-up message to this office either by e-
mail or phone to inform the Office of the Deputy Under Secretary for
Health for Operations and Management of emerging incidents. These
heads-up messages are typically the precursor to issue briefs received
by the office.
[34] The Director for Network Support is a senior executive who
advises the Assistant Deputy Under Secretary for Health Care
Management.
[35] See GAO, Internal Control: Standards for Internal Control in the
Federal Government, [hyperlink,
http://www.gao.gov/products/GAO/AIMD-00-21.3.1] (Washington, D.C.:
November 1999). Standards for internal control in the federal
government state that information should be recorded and communicated
to management and others within the agency that need it in a format
and time frame that enables them to carry out their responsibilities.
[36] See [hyperlink, http://www.gao.gov/products/GAO/AIMD-00-21.3.1].
Standards for internal control in the federal government state that
agencies should design internal controls that assure ongoing
monitoring occurs in the course of normal operations, is continually
performed, and is ingrained in agency operations.
[37] We did not review the sexual assault-related risks that VA staff
and clinicians may pose in VA medical facilities.
[38] One example of a program-specific assessment used at one site we
visited is the Minnesota Multiphasic Personality Inventory (MMPI) for
veterans entering the PTSD Residential Program. Clinicians at this
site said that the MMPI is the most widely used personality inventory
in the country. These clinicians explained that this instrument helps
them ensure they have essential information to make appropriate
placements of veterans in this program.
[39] VHA officials told us that assessment requirements for veterans
admitted to residential programs are contained in VHA's Mental Health
RRTP Handbook and policy guidance on assessment for inpatient mental
health units is found in various documents, including the
VA/Department of Defense (DOD) PTSD Clinical Practice Guidelines
(2010) and The Joint Commission standards. See Veterans Health
Administration Handbook 1162.02, Mental Health Residential
Rehabilitation Treatment Program (Dec. 22, 2010); VA/DOD Clinical
Practice Guideline for the Management of Post-Traumatic Stress
(October 2010); and The Joint Commission, 2010 Standards for
Behavioral Health Care (Oakbrook Terrace, Ill.: 2010).
[40] Federal agencies may only run background checks for noncriminal
justice purposes if they have specific statutory authority. See 42
U.S.C. § 14616 art. IV(b). VA police may only conduct a background
check on a veteran if the veteran is the subject of a criminal
investigation.
[41] Veterans counted as registered sex offenders in our sample were
those that had been registered in the state sex offender registry for
each of our selected medical facilities under the address of either
the medical facility's residential programs or inpatient mental health
units when we checked these registries prior to our site visits.
[42] See GAO/AIMD-00-21.3.1. Standards for internal control in the
federal government state that agencies should assess risks the agency
faces from both internal and external sources and require clear,
consistent agency objectives and detailed policies on the information
that medical facilities should include in risk identification. While
internal control standards allow for variation in the specific
approach agencies or programs may use based on differences in their
missions or difficulty in identifying risks, having clear agency
policies is critical to the risk assessment process.
[43] VHA officials reported that these requirements are based on
accreditation organization requirements, specifically The Joint
Commission and the Commission on Accreditation of Rehabilitation
Facilities.
[44] VA/DOD Clinical Practice Guideline for the Management of Post-
Traumatic Stress (October 2010) and 2010 Standards for Behavioral
Health Care (2010).
[45] VHA facilities may place an alert on a veteran's electronic
medical record to notify employees that the veteran may pose a threat
to the safety of other patients or employees. According to VHA, these
flags are to be used very judiciously and must be approved by either
appropriate local or VHA authorities. See VHA Directive 2010-053,
Patient Record Flags (Dec. 3, 2010). At each of the medical facilities
we reviewed, requests for the placement of medical record flags were
formally reviewed by a multidisciplinary facility committee
responsible for activities related to the management of disruptive
behavior at the facility.
[46] Stationary panic alarms are fixed to furniture, walls, or other
stationary items and can be used to alert VA staff of a problem or
call for help if staff feel threatened. Computer-based panic alarms
are activated by depressing a specified combination of keys on a
medical center keyboard. Portable personal panic alarms are small
devices that staff can carry with them while on duty that can also
alert VA staff of a problem if activated.
[47] VA guidelines regarding physical security precautions for
residential programs are outlined in the VHA Mental Health RRTP
Handbook. Monitoring precautions required by this handbook include the
use of closed-circuit surveillance cameras to monitor residential
program entrances, exits, and common areas, as well as requiring staff
to conduct regular rounds of program facilities. Security precautions
required by this handbook include the implementation of keyless entry
for all residential programs, except CWT/TRs, and the availability of
locks on all bedrooms used by women veterans.
[48] VA guidelines for physical security precautions for inpatient
mental health units are communicated as part of the Mental Health
Environment of Care process. During environment of care rounds, a
multidisciplinary team of facility staff check to ensure that
inpatient mental health units are in compliance with a variety of VA
policies, including policies to regularly test panic alarm systems on
these units and ensure that nursing stations are safe for staff
working in inpatient mental health unit settings.
[49] This officer also worked with VA staff at other locations in the
facility, not just with staff of the inpatient mental health unit.
[50] Two of the medical facilities we visited did not have a CWT/TR
program.
[51] At one site, VA staff reported that this was because local fire
officials had informed them that interior locks were a safety issue.
[52] Our review of physical security precautions at the five VA
medical facilities we visited was limited to the residential programs,
inpatient mental health units, and medical facility command and
control centers.
[53] At some facilities, just one person was assigned to serve both
functions, while at another location two people were expected to share
those functions but only one person was present at the time of our
visit due to staffing vacancies, illness, or shortages.
[54] One of the residential programs we reviewed did not use
stationary panic alarm systems. This facility relied on portable
personal panic alarms for its residential program staff.
[55] The VA police chief for this facility reported having adequate
staff coverage despite these staffing limitations.
[56] As CWT/TR programs are located in fewer locations than the other
programs, not all medical facilities we selected had these programs.
[57] For the purposes of this report, we define sexual assault as any
type of sexual contact and attempted sexual contact that occurs
without the explicit consent of the recipient of the unwanted sexual
activity. Assaults may have involved psychological coercion, physical
force, or victims who could not consent due to mental illness or other
factors. Falling under this definition of sexual assault are sexual
activities such as forced sexual intercourse, sodomy, oral penetration
or penetration using an object, molestation, fondling, and attempted
rape or sexual assault. This also included any threats of any of the
above. Victims of assault could be male or female. This did not
include cases involving only indecent exposure, exhibitionism, or
sexual harassment.
[58] Issue briefs are reports that briefly document specific factual
information about incidents and are used to notify officials of
ongoing incidents occurring at VA facilities, including sexual assault
incidents. These documents are forwarded from the facility to the VISN
and can be sent forward to the VHA Central Office as needed.
[59] VHA's Office of the Deputy Under Secretary for Health for
Operations and Management did provide a response to our request for
issue briefs but, due to the lack of a VHA centralized archive of this
information, officials from this office had to contact VISNs to
construct a sample of issue briefs they may have received during the
time period of our analysis. Therefore, this response did not provide
an accurate sample of all issue briefs this office had received and
reviewed at the time these incidents were initially reported and was
not used in our analysis of the management reporting stream.
[60] VA police are required to destroy files after 3 years under a
records schedule approved by the National Archives and Records
Administration (NARA).
[61] Inappropriate oral sex includes oral sex that may have been a
consensual act between the parties in question, but was deemed sexual
assault by VA staff.
[62] VA police coding of a case as rape was not sufficient to
categorize a case as an rape allegation for our purposes without also
including at least one of the above criteria.
[63] We did not require the VA OIG to provide documentation for 9
incidents currently under investigation that occurred within the time
period of our analysis. It is possible that some of these ongoing
investigations may be included in the 42 rape allegations we could not
match to VA OIG investigation documentation.
[64] We did not provide these complete VA police case files to the VA
OIG to protect the privacy of those involved in the incident and the
anonymity of the VA facilities and investigating officers who did not
refer these cases to the VA OIG.
[65] We conducted these searches prior to our arrival at each selected
facility except for our first site visit. Due to the pilot nature of
this site visit, our initial search was insufficient for this sample
and was rerun at the completion of our field work. Veterans registered
as sex offenders as of the date of our second check of the state
publicly available state sex offender registry are included in our
review of biopsychosocial assessments.
[End of section]
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