Veterans Health
 

Administration
 

Safety, Security, and Privacy
 

for Female Veterans
 

at a Chicago, IL Homeless
 

Grant Provider Facility
 

OFFICE OF AUDITS AND EVALUATIONS

September 6, 2011 

11-00334-267 
To Report Suspected Wrongdoing in VA Programs and Operations:
 

Telephone: 1-800-488-8244
 

E-Mail: vaoighotline@va.gov
 

(Hotline Information: http://www.va.gov/oig/contacts/hotline.asp)
 

VA Office of Inspector General 
DEPARTMENT OF Memorandum VETERANS AFFAIRS 

Date:
 

From:
 

Subj:
 

To: 

September 6, 2011 

Assistant Inspector General for Audits and Evaluations (52) 

VHA Safety, Security, and Privacy Issues for Female Veterans at a Chicago, IL 

Homeless Provider Facility 

Under Secretary for Health (10) 

We are providing this memorandum to advise of serious female veteran housing 

safety, security, and privacy issues discovered during on-going audit work that 

require immediate Veterans Health Administration management attention. These 

issues emerged while we were conducting our national audit on VA’s Homeless 

Providers Grant and Per Diem Program (GPDP) to determine if community agencies 

receiving funds are providing services to homeless veterans as described in their 

approved proposal. We expect to discuss these issues in our final report. 

During a site visit at the Jesse Brown VA Medical Center (VAMC), we determined 

that since FY 2002, the VAMC’s GPDP staff placed 22 homeless females in a GPDP 

male-only approved provider facility without adequately addressing the safety, 

security, and privacy needs of female veterans. In 1996, VA officials approved the 

GPDP’s proposal to provide 15 beds of transitional housing for a male-only 

population; however, GPDP staff have placed homeless female veterans in this 

facility for nearly a decade. When our auditors questioned why, GPDP staff said they 

had not read the approved GPDP proposal and were unaware of its contents. 

Although VAMC and provider staff clinically assessed many of these female veterans 

to have experienced sexual trauma and domestic violence, GPDP staff took little 

action to mitigate the safety, security, and privacy risks of the female veterans that 

were the program’s responsibility. 

The GPDP provides transitional housing for homeless veterans through partnerships 

with non-profit or local government agencies. The term “GPDP provider” refers to 

the non-profit or government agency that VA funds to offer services to homeless 

veterans. VA is responsible for ensuring the provider’s operations meet VA 

inspection standards and that the program offers the services described in the original 

proposal or as modified through program scope changes. However, VA has no 

authority to manage the provider’s program. 

During our site visit to the GPDP provider’s facility, we found 2 of the current 

14 residents were homeless female veterans. One female resided at the facility for 

approximately 1 month and was located on the same floor as seven males. We 

identified unacceptable conditions such as male and female residents sharing a 

VA Office of Inspector General 1 
VHA’s Safety, Security, and Privacy for Female Veterans 

at a Chicago, IL Homeless Grant Provider Facility 

common bathroom on that floor. While the door had a lock, 

auditors found it easy to use a credit card to open the door 

from the outside. The second female veteran who was a 

resident for approximately 2 months was located on the first 

floor, which serves as a common area for the residents. 

During her initial clinical assessment, VAMC and provider 

staff noted she had been a victim of sexual trauma and 

domestic violence. Without mitigating the safety, security, 

and privacy risks of this housing situation, the VAMC placed 

these female residents in an inappropriate environment. 

Clinical assessment documents were available for 10 of 22 female veterans who had 

resided at the facility since FY 2002. According to these assessments, 7 (70 percent) 

of the 10 female veterans had reported experiencing sexual trauma and/or domestic 

violence. We also reviewed the clinical assessments of the 10 male veterans 

discharged during the period of July through December 2010. All 10 male veterans 

had drug and alcohol problems and 7 had been diagnosed with psychiatric issues. 

Additionally, four had criminal histories, such as assault and attempted homicide. 

Housing female veterans with male veterans with these types of clinical assessments 

and experiences creates an increased need to ensure the security of the facility’s 

female residents. 

The provider facility has a history of high staff turnover and documented instances of 

unprofessional staff behavior. Since 2008, this GPDP provider replaced three 

resident managers. Within the past year, the provider also has substantiated an 

allegation of sexual harassment of two female residents by facility staff. The GPDP 

staff offered to transfer the female veterans to a provider that accepted homeless 

females, but the female veterans declined the offer and continued to reside at the 

male-only facility. VAMC officials informed the GPDP Office of the sexual 

harassment allegation, but the Program Office did not question why females were in a 

male-only facility. Later in 2011, residents of the facility alleged a female staff 

member was having an inappropriate relationship with a male veteran resident. The 

provider substantiated the allegation and the staff member resigned. These instances 

of unprofessional behavior indicate that the VHA needs to increase monitoring of the 

provider. 

We reviewed the last three annual inspections of the facility and did not find any 

comments on female veterans residing in the male-only facility. According to VHA 

policy, GPDP staff are required to inspect each provider at least annually. These 

inspections include such areas as facilities management, clinical review, security, and 

nutrition. VHA bases their inspections upon the unique provider services outlined in 

the approved proposal. 

Without understanding the contents of the approved proposal, the VAMC’s inspectors 

are not safeguarding the health and welfare of the homeless veterans they are 

responsible for protecting. For example, two of the last three annual inspections state 

Shared Bathroom at Provider
 

Facility
 

VA Office of Inspector General 2 
VHA’s Safety, Security, and Privacy for Female Veterans 

at a Chicago, IL Homeless Grant Provider Facility 

that the VAMC coordinated with the provider to conduct comprehensive risk 

assessments of the facility. We could find no evidence that these risk assessments 

were completed. The VAMC should have identified housing female and male 

residents without proper safeguards, such as separate floors, as a risk. As a result, 

VA placed homeless female veterans in inappropriate housing conditions. This 

occurred in spite of female veterans’ reports of experiencing sexual trauma and 

domestic violence prior to placement in this facility. 

After we discussed this issue with senior VAMC officials on June 28, 2011, they met 

with the provider and the two women veterans the next day. VAMC officials 

arranged for the women to move immediately to a non-VA funded facility that 

provided services to homeless females. VAMC officials told us that the women 

wanted to stay in the provider facility over the weekend. They would move to the new 

facility on July 5, 2011. The VAMC officials agreed, with the condition that per 

diem payments stop immediately. The provider agreed to house the females without 

per diem. 

In conclusion, the VAMC’s placement of homeless females in a male-only approved 

provider facility creates a potential risk for female veterans. The GPDP provider 

management issues related to turnover of staff and professionalism increase this risk. 

While we have identified these issues at only one facility, the seriousness of the issue 

supports a need for VHA to perform a nationwide assessment to identify other 

inappropriate housing situations placing veterans at risk under the grant program. 

Consequently, we recommend the following: 

1.	 We recommend the Under Secretary for Health institute management controls 

at Jesse Brown VA Medical Center to ensure that VA’s Homeless Providers 

Grant and Per Diem Program staff understand the contents and requirements 

of approved provider proposals. 

2.	 We recommend the Under Secretary for Health conduct a review of VA’s 

Homeless Providers Grant and Per Diem policies and procedures at Jesse 

Brown VA Medical Center and make program changes deemed appropriate. 

3.	 We recommend the Under Secretary for Health inventory active grant 

proposals nationally and verify that VA’s Homeless Providers Grant and Per 

Diem Program staff do not house female homeless veterans in male-only 

approved provider facilities or other inappropriate housing situations. 

4.	 We recommend the Under Secretary for Health relocate female homeless 

veterans found in male-only approved provider facilities or other 

inappropriate housing situations to ensure safe and secure housing appropriate 

for veterans. 

The Under Secretary for Health concurred with our findings and recommendations and 

provided an acceptable action plan to complete all corrective actions by 

VA Office of Inspector General 3 
VHA’s Safety, Security, and Privacy for Female Veterans 

at a Chicago, IL Homeless Grant Provider Facility 

November 30, 2011. We consider the planned actions acceptable and will follow up 

on their implementation. 

In immediate response to this memorandum, the Under Secretary for Health directed 

the VISN 12 Network Director to conduct a review of the service line responsibilities 

for the GPD Program at Jesse Brown VAMC and this has been completed. 

The draft to this report also prompted VHA to review their GPD policies and 

processes, including conducting a nationwide assessment to identify how they can 

make certain they are providing the most appropriate services to veterans in GPDfunded housing. 

In addition, Under Secretary for Health advised that the National GPD Program Office 

is conducting an inventory to ascertain the gender-mix identified in each funded grant 

proposal, the gender-mix being served at the GPD funded facility, and the 

appropriateness of the scope of services available relative to the populations currently 

served. Any housing situations which are assessed as being disadvantageous to the 

care and/or privacy, safety and security of the veteran will be immediately addressed 

and resolved. 

A full text of the Under Secretary’s comments are at Attachment A. 

BELINDA J. FINN
 

VA Office of Inspector General 4 
VHA’s Safety, Security, and Privacy for Female Veterans 

at a Chicago, IL Homeless Grant Provider Facility 

Appendix A Under Secretary for Health Comments 

Department of Memorandum Veterans Affairs 

Date: August 19, 2011 

From: Under Secretary for Health (10) 

Subj: OIG Flash Report, Veterans Health Administration, Safety, Security, and Privacy 

for Female Veterans at a Homeless Grant Program Provider Facility 

To: Assistant Inspector General for Health Care Inspections (54) 

I have reviewed the flash report and concur with the report findings and 

recommendations. 

1. 

Ensuring that management of facilities supported by Veterans Health 

Administration (VHA) Grant and Per Diem (GPD) funds has effective safety and 

security precautions in place is imperative. Leadership at Veterans Integrated 

Service Networks (VISN) and Department of Veterans Affairs Medical Centers 

(VAMC) must diligently execute their oversight responsibilities to ensure safe and 

secure appropriate housing for homeless Veterans who use these services. This 

report has prompted us to review our policies and processes, including a 

nationwide assessment to identify how we can make certain that we are doing our 

best to ensure the appropriateness of services and the privacy, safety, and 

security of all Veterans in GPD funded housing. The OIG report points out where 

improvement was needed in an individual situation, which has been addressed. 

Now, we are working on the attached action plan to improve our processes 

throughout the system. 

2. 

It is important to note that, while the report describes the particular GPD facility as 

being approved for a gender-specific population, current policy in general does 

not require that GPD-funded projects be approved or disapproved based on the 

intent to serve gender-specific population. Rather, to provide flexibility and 

address the needs of Veterans in general, the policy requires that facilities must 

provide appropriate housing situations with safety and security provisions. To 

accomplish this, an applicant for GPD funding self-identifies in each proposal the 

capacity to serve a specific population mix. Veterans are then referred or selfreferred to GPD funded projects. The current policy requires the host VAMC to 

approve each placement either prior to admission or within 3 days after 

admission. The appropriateness of the facility and the services for a particular 

Veteran is assessed at that time. This assessment would include an evaluation of 

safety and security precautions specific to the gender of the particular Veteran, as 

well as the mix of the individuals in the facility. 

3. 

VA Office of Inspector General 5 
VHA’s Safety, Security, and Privacy for Female Veterans 

at a Chicago, IL Homeless Grant Provider Facility 

Page 2 

OIG Flash Report, Veterans Health Administration, Safety, Security, and Privacy for Female 

Veterans at a Homeless Grant Program Provider Facility 

4.	 VHA takes the report and our internal reviews of the appropriateness of facilities 

seriously. VHA values the safety and well-being of all Veterans who receive 

health care in VA facilities and services provided to homeless Veterans by our 

GPD community partners. VHA will thoroughly review current practices in our 

GPD program and identify opportunities for improvement. 

5.	 Thank you for the opportunity to review the draft report. The attached action plan 

provides specifics. If you have any questions, please contact Linda H. Lutes, 

Director, Management Review Service, 10A4A4) at (202) 461-7014. 

Attachment 

VA Office of Inspector General 6 
VHA’s Safety, Security, and Privacy for Female Veterans 

at a Chicago, IL Homeless Grant Provider Facility 

VETERANS HEALTH ADMINISTRATION (VHA)
 

Action Plan
 

OIG Flash Report, Veterans Health Administration, Safety, Security, and 

Privacy for Female Veterans at a Homeless Grant Program Provider 

Facility (VAIQ 7138601) 

Date of Flash Report: July 22, 2011 

Recommendations/ Status Completion 

Actions Date 

Recommendation 1: We recommend that the Under Secretary for Health 

institute management controls at Jesse Brown VA Medical Center to 

ensure that VA’s Homeless Providers Grant and Per Diem Program staff 

understand the contents and requirements of approved provider 

proposals. 

Concur 

The Under Secretary for Health (USH) directed the Veterans Integrated 

Service Network (VISN) 12 Network Director to conduct a management review 

of the Jesse Brown VA Medical Center (VAMC) Grant and Per Diem (GPD) 

Program and provide a written report of actions taken to ensure staff 

understand the content and requirements of the provider proposal and 

consider these elements when placing Veterans in a GPD funded project. 

As of July 1, 2011, VISN 12 had ensured that the GPD Liaisons, Facility 

Homeless Program Coordinator, Chief of Social Work, and Chief of Staff, in 

conjunction with the VISN 12 Homeless Program Director and VISN 12 Mental 

Health Lead reviewed all current GPD funded proposals in detail. All funded 

proposals were read thoroughly and reviewed with an emphasis on the scope 

of practice within each proposal. 

Effective July 27, 2011, VHA Handbook 1162.01, Grant and Per Diem 

Program, was reviewed with all Jesse Brown VAMC GPD staff with an 

emphasis on monitoring the care provided and assessing the compliance of 

programs receiving per diem as outlined in the funded grant proposals. This 

review resulted in the VAMC staff recommending that two of the three GPD 

providers submit a change of scope request to the National GPD Office. The 

National GPD Office in Tampa reviewed the requests. The National GPD 

Office approved the change of scope request for one agency and denied the 

request for the other. 

VA Office of Inspector General 7 
VHA’s Safety, Security, and Privacy for Female Veterans 

at a Chicago, IL Homeless Grant Provider Facility 

As of August 1, 2011, the Chief of Social Work will have the sole responsibility 

for program oversight of the GPD Program at Jesse Brown VAMC which 

includes supervision of the GPD staff. In the past, the responsibility of the 

program oversight and supervision was shared between Social Work and the 

Mental Health Service Lines. Changing the program oversight structure will 

provide a clear line of authority over the GPD program and ensure clear and 

consistent communication. The National GPD Program Office has 

emphasized the need for all GPD Liaisons to review their programs’ scope of 

services provided and population mix to ensure the appropriateness of 

services and the privacy, safety, and security of all Veterans. GPD Liaisons 

were instructed to pay particular attention to those sites that serve mixedgender populations. 

Completed July 25, 2011 

Recommendation 2: We recommend the Under Secretary for Health 

conduct a review of VA’s Homeless Providers Grant and Per Diem 

policies and procedures at Jesse Brown VA Medical Center and make 

program changes deemed appropriate. 

Concur 

The USH directed the VISN 12 Network Director to conduct a review of the 

service line responsibilities for the GPD Program. This has been completed. 

As of August 1, 2011, the Chief of Social Work will have the sole responsibility 

for program oversight of the GPD Program at Jesse Brown VAMC which 

includes supervision of the GPD staff. In the past, the responsibility of the 

program oversight and supervision was shared between Social Work and the 

Mental Health Service Lines. Changing the program oversight structure will 

provide a clear line of authority over the local GPD program and ensure clear 

and consistent communication. 

The Jesse Brown VAMC GPD Liaisons are now expected to complete a 

minimum of at least monthly visits to every resident beginning August 1, 2011, 

to participate in each Veteran’s treatment planning process, and to document 

these services in the Veteran’s medical record. 

Beginning August 10, 2011, incidents of any non-compliance will be reported 

at least monthly to the Jesse Brown VAMC Director. Non-compliance is 

defined as any GPD inspection deficiency regarding the overall quality of 

services provided by the GPD program. The Jesse Brown VAMC Director will 

monitor actions to correct deficiencies per VHA Handbook 1162.01. 

VA Office of Inspector General 8 
VHA’s Safety, Security, and Privacy for Female Veterans 

at a Chicago, IL Homeless Grant Provider Facility 

A re-inspection of all Jesse Brown VAMC GPD programs will be completed by 

September 30, 2011. Inspection reports will be reviewed and follow up actions 

for any deficiencies will be monitored by Jesse Brown VAMC Director. 

In process	 September 30, 2011 

Recommendation 3: We recommend the Under Secretary for Health 

inventory active grant proposals nationally and verify that VA’s 

Homeless Providers Grant and Per Diem Program staff do not house 

female homeless veterans in male-only approved provider facilities or 

other appropriate housing situations. 

Concur 

To address the specific concern about housing female homeless Veterans in 

GPD-funded facilities, the National GPD Program Office is conducting an 

inventory to ascertain the: 

	 Gender-mix identified in each funded grant proposal 

	 Gender-mix being served at the GPD funded facility 

	 Appropriateness of the scope of services available relative to the 

populations currently served 

The National GPD Program Office will compile and review the results of the 

inventory. The National GPD Program Office will consult with VAMCs about 

any identified concerns and work with community providers to adjust housing 

arrangements as needed, to ensure the safety, security, and privacy of all 

Veterans. The VHA National Homeless Program Office will ensure that 

appropriate actions are implemented. 

In process	 November 30, 2011 

In addition, the National GPD Program Office has also taken the following 

steps: 

	 Distributed a message to all GPD Liaisons nationwide requesting that they 

review their programs’ scope of services and population mix to ensure 

appropriateness of services provided and the privacy, safety and security 

of all Veterans. They were requested to pay particular attention to those 

sites that serve mixed-gender populations. 

Completed	 July 25, 2011 

VA Office of Inspector General 9 
VHA’s Safety, Security, and Privacy for Female Veterans 

at a Chicago, IL Homeless Grant Provider Facility 

	 Provided guidance regarding these issues on nationwide calls and face-toface trainings with VA liaisons and community-based providers. 

Completed	 July 26, 2011 

	 Drafted and distributed written guidance and clear program expectations to 

all GPD Liaisons regarding the special considerations that should be given 

to transitional housing facilities which serve mixed-gender populations 

where unrelated adults are cohabitating in the same facility. Additionally, 

the materials discussed the sensitivity regarding the appropriateness of 

placements for all populations. 

Completed	 August 5, 2011 

Recommendation 4: We recommend the Under Secretary for Health 

relocate female homeless veterans found in male-only approved provider 

facilities or other inappropriate housing situations to ensure safe and 

secure housing appropriate for veterans. 

Concur 

The National GPD Program Office is conducting an inventory to ascertain the 

gender-mix identified in each funded grant proposal, gender-mix being served 

at the GPD funded facility, appropriateness of the scope of services available 

relative to the populations currently served. Any housing situations which are 

assessed as being disadvantageous to the care and/or privacy, safety and 

security of the Veteran will be immediately addressed and resolved. 

In process	 November 30, 2011 

Veterans Health Administration 

August 2011 

VA Office of Inspector General 10 
VHA’s Safety, Security, and Privacy for Female Veterans 

at a Chicago, IL Homeless Grant Provider Facility 

Report Distribution 

VA Distribution 

Office of the Secretary
 

Veterans Health Administration
 

Veterans Benefits Administration
 

National Cemetery Administration
 

Assistant Secretaries
 

Office of General Counsel
 

Veterans Integrated Service Network 12
 

Jesse Brown Veterans Affairs Medical Center
 

Non-VA Distribution 

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

House Committee on Oversight and Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

This report will be available in the near future on the OIG’s Web site at 

http://www.va.gov/oig/publications/reports-list.asp. This report will remain on the 

OIG Web site for at least 2 fiscal years. 

VA Office of Inspector General 11