VA Health Care
Improvements Needed for Monitoring and Preventing Sexual Assaults and Other Safety Incidents Gao ID: GAO-11-736T June 13, 2011During GAO's recent work on services available for women veterans (GAO-10-287), several clinicians expressed concern about the physical safety of women housed in mental health programs at a Department of Veterans Affairs (VA) medical facility. GAO examined (1) the volume of sexual assault incidents reported in recent years and the extent to which these incidents are fully reported, (2) what factors may contribute to any observed underreporting, and (3) precautions VA facilities take to prevent sexual assaults and other safety incidents. This testimony is based on recent GAO work, "VA Health Care: Actions Needed To Prevent Sexual Assaults and Other Safety Incidents," (GAO-11-530) (June 2011). For that report, GAO reviewed relevant laws, VA policies, and sexual assault incident documentation from January 2007 through July 2010. In addition, GAO visited five judgmentally selected VA medical facilities that varied in size and complexity and spoke with the four Veterans Integrated Service Networks (VISN) that oversee them.
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 Office of the Inspector General (OIG). Specifically, for the four VISNs GAO spoke with, VISN and Veterans Health Administration (VHA) 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. GAO identified several factors that may contribute to the underreporting of sexual assault incidents. For example, VHA lacks a consistent sexual assault definition for reporting purposes and clear expectations for incident reporting across its medical facility, VISN, and VHA Central Office levels. Furthermore, VHA Central Office lacks oversight mechanisms to monitor sexual assault incidents reported through the management reporting stream. VA medical 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 medical facilities' efforts to prevent sexual assaults and other safety incidents. For example, medical facilities used physical security precautions--such as closed-circuit surveillance cameras to actively monitor areas and locks and alarms to secure key areas. These physical precautions were intended to prevent a broad range of safety incidents, including sexual assaults. However, GAO found significant weaknesses in the implementation of these physical security precautions at the five VA medical facilities visited, 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 configuration 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 VA's efforts to prevent or mitigate sexual assaults and other safety incidents. GAO reiterated recommendations 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.
GAO-11-736T, VA Health Care: Improvements Needed for Monitoring and Preventing Sexual Assaults and Other Safety Incidents
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United States Government Accountability Office:
GAO:
Testimony:
Before the Subcommittee on Health, Committee on Veterans' Affairs,
House of Representatives:
For Release on Delivery:
Expected at 4:00 p.m. EDT:
Monday, June 13, 2011:
VA Health Care:
Improvements Needed for Monitoring and Preventing Sexual Assaults and
Other Safety Incidents:
Statement of Randall B. Williamson:
Director, Health Care:
GAO-11-736T:
GAO Highlights:
Highlights of GAO-11-736T, a testimony before the Subcommittee on
Health, Committee on Veterans‘ Affairs, House of Representatives.
Why GAO Did This Study:
During GAO‘s recent work on services available for women veterans (GAO-
10-287), several clinicians expressed concern about the physical
safety of women housed in mental health programs at a Department of
Veterans Affairs (VA) medical facility. GAO examined (1) the volume of
sexual assault incidents reported in recent years and the extent to
which these incidents are fully reported, (2) what factors may
contribute to any observed underreporting, and (3) precautions VA
facilities take to prevent sexual assaults and other safety incidents.
This testimony is based on recent GAO work, VA Health Care: Actions
Needed To Prevent Sexual Assaults and Other Safety Incidents, (GAO-11-
530) (June 2011). For that report, GAO reviewed relevant laws, VA
policies, and sexual assault incident documentation from January 2007
through July 2010. In addition, GAO visited five judgmentally selected
VA medical facilities that varied in size and complexity and spoke
with the four Veterans Integrated Service Networks (VISN) that oversee
them.
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 Office of the Inspector General (OIG). Specifically, for
the four VISNs GAO spoke with, VISN and Veterans Health Administration
(VHA) 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.
GAO identified several factors that may contribute to the
underreporting of sexual assault incidents. For example, VHA lacks a
consistent sexual assault definition for reporting purposes and clear
expectations for incident reporting across its medical facility, VISN,
and VHA Central Office levels. Furthermore, VHA Central Office lacks
oversight mechanisms to monitor sexual assault incidents reported
through the management reporting stream.
VA medical 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
medical facilities‘ efforts to prevent sexual assaults and other
safety incidents. For example, medical facilities used physical
security precautions”such as closed-circuit surveillance cameras to
actively monitor areas and locks and alarms to secure key areas. These
physical precautions were intended to prevent a broad range of safety
incidents, including sexual assaults. However, GAO found significant
weaknesses in the implementation of these physical security
precautions at the five VA medical facilities visited, 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 configuration and testing procedures
contributed to these weaknesses. Further, facility officials at most
of the locations GAO visited said the VA police were understaffed.
(See table below.) Such weaknesses could lead to delayed response
times to incidents and seriously erode VA‘s efforts to prevent or
mitigate sexual assaults and other safety incidents.
Table: 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]
What GAO Recommends:
GAO reiterated recommendations 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-11-736T] or key
components. For more information, contact Randall B. Williamson at 202-
512-7114 or williamsonr@gao.gov.
[End of section]
Chairwoman Buerkle, Ranking Member Michaud, and Members of the
Subcommittee:
I am pleased to be here today as the Subcommittee discusses policies
and actions to prevent sexual assaults and other safety incidents at
Department of Veterans Affairs (VA) medical facilities. During our
recent work on services available for women veterans in VA medical
facilities, several clinicians expressed concern about the safety of
women veterans housed in mental health programs at a VA medical
facility's residential mental health unit that also housed veterans
who had committed past sexual crimes.[Footnote 1] Clinicians were also
concerned about the adequacy of existing safety precautions to protect
women veterans being treated in the inpatient mental health units of
this same facility. These concerns highlight the importance of VA
having effective security precautions to protect all patients--
especially those with residential and inpatient mental health
programs--and a consistent way to exchange information about and
discuss safety incidents, including sexual assaults.[Footnote 2],
[Footnote 3]
My testimony today is based on our June 7, 2011 report:[Footnote 4]
(1) the volume of sexual assault incidents reported in recent years
and the extent to which these incidents are fully reported, (2) what
factors may contribute to any observed underreporting, and (3) the
precautions in place in residential and inpatient mental health
settings to prevent sexual assault and other safety incidents and any
weaknesses in these precautions.
To examine the volume of sexual assault incidents reported to VA 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
regarding 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) and VHA's Office of the Deputy
Under Secretary for Health for Operations and Management and 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 VA 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 VA 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. Further, 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, 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 the precautions in place to prevent sexual assault 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 VA 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.
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 Central Office has responsibility for monitoring and overseeing
both VISN and medical facility operations, including security
precautions.[Footnote 10] Day-to-day management of medical facilities,
including residential and mental health treatment units, is the
responsibility of the VISNs.
Residential Programs:
VA has 237 residential programs at 104 of its medical facilities.
These programs provide residential rehabilitative and clinical care to
veterans with a range of mental health conditions, including those
diagnosed with post-traumatic stress disorder and substance abuse. 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.
* 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 11]
Inpatient Mental Health Units:
Most (111) of VA's 153 medical facilities have at least one inpatient
mental health unit for patients with acute mental health needs. These
units are generally a locked unit or floor within each medical
facility, and the size of these units varies throughout VA. Care on
these units is provided 24 hours per day, 7 days a week, and consists
of 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.
VA's Two Reporting Streams for Safety Incidents:
Safety incidents, including sexual assaults, may be reported to senior
leadership as part of two different streams--a management stream and a
law enforcement stream. The management reporting stream--which
includes reporting responsibilities at the VA medical facility, VISN,
and VHA Central Office levels--is intended to help ensure that
incidents are identified and documented for leadership's attention. In
contrast, the purpose of the law enforcement stream is to document
incidents that may involve criminal acts so they can be investigated
and prosecuted, if appropriate. VHA policies outline what information
staff must report for each stream 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. (Figure 1
summarizes the major steps involved in each stream.)
Figure 1: VA Reporting Process for Sexual Assault 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.
[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.
[End of figure]
Management reporting stream. Reporting responsibilities at each level
for this stream are as follows.
* Local VA medical facilities. Local incident reporting is typically
handled through a variety of electronic facility-based systems. It is
initiated by the first staff member who observed or was notified of an
incident, who completes an incident report in the medical facility's
electronic reporting system that is then reviewed by the medical
facility's quality manager. VA medical facility leadership is then
notified, and is responsible for reporting serious incidents to the
VISN.
* VISNs. VA medical facilities can report serious incidents to their
VISN through two mechanisms--issue briefs that document specific
factual information and "heads up" messages that allow medical
facility 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. VISNs typically report all serious incidents to
the VHA Office of the Deputy Under Secretary for Health for Operations
and Management, which 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. Responsibilities at each level are
described below.
* Local VA police. Most VA medical facilities have a cadre of VA
police officers, who are federal law enforcement officers charged with
protecting the medical facility by responding to and investigating
potentially criminal activities. Local policies typically require
medical facility staff to notify the medical facility's VA police of
incidents that may involve criminal acts, such as sexual assaults. VA
medical facility police also often notify and coordinate with local
area police departments and the VA OIG when criminal activities or
potential security threats occur.
* VA's OSLE. This office is the department-level VA office responsible
for developing policies and procedures for VA's law enforcement
programs at local VA medical facilities. VA OSLE 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 Integrated Operations Center (IOC). The IOC, established in
April 2010, serves as the department's centralized location for
integrated planning and data analysis on serious incidents.[Footnote
12] Serious incidents on VA property 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. The IOC then presents
information on serious incidents to VA senior leadership officials
through daily reports and, in some cases, to the Secretary through
serious incident reports.
* VA OIG. Federal regulation requires that all potential felonies,
including rape allegations, be reported to VA OIG
investigators.[Footnote 13] VHA policy reiterates this 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
14] Typically, either the medical facility's leadership team or VA
police are responsible for reporting potential felonies to the VA OIG.
[Footnote 15] Once a case is reported, VA OIG investigators can be the
lead agency on the case or advise local VA police or other law
enforcement agencies conducting the investigation.
Nearly 300 Sexual Assault Incidents Reported to VA Police, but Many
Were Not Reported to VHA or the VA OIG:
We found that there were nearly 300 sexual assault incidents reported
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. Many of these sexual assault
incidents were not reported to officials within the management
reporting stream and to the VA OIG.
Nearly 300 Sexual Assault Incidents Reported to VA Police From January
2007 Through July 2010:
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 16],[Footnote 17] These cases included
incidents alleging rape, inappropriate touching, forceful medical
examinations, oral sex, and other types of sexual assaults (see table
1).[Footnote 18] 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 19]
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:
* 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 20]
* 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.
Sexual Assault Incidents Are Underreported to VISNs, VHA Central
Office, and the VA OIG:
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 examined 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 21] Moreover, we also found that
one VISN did not report any 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 systemwide requirements on what medical
facilities must report to these VISNs, we could not determine the
accuracy of VISN reporting.
[End of table]
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 the 67 rape allegations reported to the VA police from
January 2007 through July 2010 and compared these cases with 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 22] 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 23] 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
24],[Footnote 25] 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 about one-third (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 26] For the remaining approximately 12
percent, 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.
VHA Guidance and Oversight Weaknesses May Contribute to the
Underreporting of Sexual Assault Incidents:
Several factors 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 there is no VHA-
wide definition of sexual assault used for incident reporting. We
found that VHA lacks a consistent definition for the reporting of
sexual assault 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. At the VISN level, officials with whom
we spoke in the four networks said they did not have definitions of
sexual assault in VISN policies.[Footnote 27] Finally, while 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, no
definition of sexual assault is included in VHA Central Office
reporting guidance.
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.
* VISNs. Officials from the four VISNs we reviewed 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 28] 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.
[Footnote 29]
* 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 condition. In
addition, at this same medical facility, 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.
Oversight Deficiencies at VHA Central Office Contribute to the
Underreporting of Sexual Assault Incidents:
We found weaknesses both in the way sexual assault incidents are
communicated to VHA Central Office and in the way that information
about such incidents is collected and analyzed for oversight purposes.
Poor Communication About Sexual Assault Incidents Resulted in
Incomplete Reporting Within VHA Central Office:
Currently, 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, VHA Central Office is
notified of sexual assault incidents through issue briefs submitted by
VISNs via e-mail to the VHA Office of the Deputy Under Secretary for
Health for Operations and Management.[Footnote 30] 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 Assault 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 31] Without the regular
exchange of information regarding 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 underway 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.
VHA Does Not Systematically Monitor and Track Sexual Assault Incidents:
In addition to deficiencies in information sharing, we also identified
deficiencies in the monitoring of sexual assault incidents within 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
collect 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 32] 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 sexual
assaults and other safety incidents, VHA Central Office cannot
identify and make changes to serious problems that jeopardize the
safety of veterans in their medical facilities.
Serious Weaknesses Observed in Several Types of Physical Security
Precautions Used in Selected Medical Facilities:
Physical precautions in the residential programs and inpatient mental
health units at the 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, we found
serious deficiencies in the use and implementation of certain physical
security precautions at these facilities, including alarm system
malfunctions and inadequate monitoring of security cameras.
Several Types of Physical Security Precautions Are in Place in
Selected Medical Facilities:
VA medical facilities we visited used 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 their own needs
within broad VA guidelines.
In general, physical security precautions were used as a measure to
prevent a broad range of safety incidents, including sexual assaults.
We classified these precautions into three broad categories:
monitoring precautions, security precautions, and staff awareness and
preparedness precautions. (See table 3.)
Table 3: 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. These measures 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.
* Security precautions. These 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 33]
* Staff awareness and preparedness precautions. These measures were
designed to educate and prepare residential program and inpatient
mental health unit staff to deal with security issues and to provide
police support and assistance when needed. For example, there was a
regular VA police presence within some residential programs we
visited. Also, all medical facilities we visited had a functioning
police command and control center, which program staff could contact
for police support when needed.
Significant Weaknesses Existed in the Use and Implementation of
Certain Physical Security Precautions at Selected VA Medical
Facilities:
While security precautions have been established in most cases to
prevent patient safety incidents, including sexual assaults, these
precautions had not been effectively implemented by VA medical
facility staff in the five facilities we visited. During our review of
the physical security precautions in use at the five VA medical
facilities we visited, we observed seven weaknesses in these three
categories.[Footnote 34] (See table 4.)
Table 4: 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 of the VA medical facilities we visited. For example, at one
medical facility, the system used by the residential programs at that
medical facility could not be monitored by the police command and
control center staff because it was incompatible with systems
installed in other parts of the medical facility. According to VA
police at this medical facility, 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, such as serving as
telephone operators and police/emergency dispatchers. These other
duties sometimes prevented them from continuously monitoring the
camera feeds in the police command and control center.[Footnote 35]
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.
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 accurately pinpoint the
location of the tester when an alarm was activated outside the
building. At another medical facility that used stationary panic
alarms in inpatient mental health units, residential programs, and
other clinical settings, almost 20 percent of these alarms throughout
the medical facility were inoperable. At an inpatient mental health
unit in a third medical facility, three of the computer-based panic
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.
Inadequate documentation or review of alarm system testing. 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. Officials at 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.
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. 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 36]
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
with whom we spoke indicated an interest in having portable personal
panic alarms to better protect them in similar situations.
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 9 police
officers at the time of our visit; according to VA staffing guidance,
the minimum staffing level for this medical facility should have been
19 officers. 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. We found that such stakeholder
involvement on remodeling projects had not occurred at one of the
medical facilities we visited. At this medical facility, 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.
In conclusion, weaknesses exist in the reporting of sexual assault
incidents and in the implementation of physical precautions used to
prevent sexual assaults and other safety incidents in VA medical
facilities. Medical facility staff are uncertain about what types of
sexual assault 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 relying on 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.
In addition, 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 VHA Central Office staff
is needed to provide a safe and secure environment throughout all VA
medial facilities.
To improve VA's reporting and monitoring of allegations of sexual
assault, we are making numerous recommendations--in a report that we
issued last week. We recommended VA improve the reporting and
monitoring of sexual assault incidents, including ensuring that a
consistent definition of sexual assault is used for reporting
purposes, clarifying expectations for reporting incidents to VISN and
VHA leadership, and developing and implementing mechanisms for
incident monitoring. To address vulnerabilities in physical security
precautions at VA medical facilities, we recommended that VA ensure
that alarm systems are regularly tested and kept in working order and
that coordination among stakeholders occurs for renovations to units
and physical security features at VA medical facilities.
In responding to a draft of the report on which this testimony is
based, VA generally agreed with the report's conclusions and concurred
with our recommendations. In addition, VA provided an action plan,
which described the creation of a multidisciplinary workgroup to
manage the agency's response to many of our recommendations. According
to VA's comments, this 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.
Chairwoman Buerkle, Ranking Member Michaud, and Members of the
Subcommittee, this concludes my prepared statement. I would be happy
to respond to any questions either of you or other Members of the
Subcommittee may have.
Contacts and Acknowledgments:
For further information about this testimony, please contact Randall
B. Williamson at (202) 512-7114 or williamsonr@gao.gov. Contact points
for our Offices of Congressional Relations and Public Affairs may be
found on the last page of this testimony. Individuals who made key
contributions to this testimony include Marcia A. Mann, Assistant
Director; Emily Goodman; Katherine Nicole Laubacher; and Malissa G.
Winograd.
[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] See GAO, VA Health Care: Actions Needed To Prevent Sexual Assaults
and Other Safety Incidents, [hyperlink,
http://www.gao.gov/products/GAO-11-530] (Washington, D.C.: June 7,
2011).
[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.
[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] VHA oversees VA's health care system, which includes 153 medical
facilities organized into 21 VISNs.
[11] 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.
[12] 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).
[13] See 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).
[14] VHA Directive 2010-014, Assessment and Management of Veterans Who
Have Been Victims of Alleged Acute Sexual Assault (May 25, 2010).
[15] The VA OIG may also learn of incidents from staff, patients,
congressional communications, or the VA OIG hotline for reporting
fraud, waste, and abuse.
[16] 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.
[17] 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.
[18] To conduct this analysis, we placed VA police case files into
these categories to describe the allegations contained within them.
[19] 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.
[20] 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.
[21] 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.
[22] 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.
[23] 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.
[24] 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.
[25] 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.
[26] 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 9.
[27] However, some VISN officials stated they used other common
definitions, including those from the National Center for Victims of
Crime and The Joint Commission.
[28] 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.
[29] 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.
[30] 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.
[31] 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.
[32] 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.
[33] 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.
[34] 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.
[35] 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.
[36] 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.
[End of section]
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