Department of Veterans Affairs 

Office of Inspector General 

Audit of the 

 Veterans Health Administration’s 

Domiciliary Safety, Security, and Privacy 

Report No. 08-01030-05 October 9, 2008

VA Office of Inspector General 

Washington, DC 20420 
To Report Suspected Wrongdoing in VA Programs and Operations 

Call the OIG Hotline – (800) 488-8244 

 
Audit of Veterans Health Administration’s Domiciliary Safety, Security, and Privacy 

Contents 

Page 

Executive Summary ....................................................................................................... i

Introduction ................................................................................................................... 1 

Purpose............................................................................................................................. 1 

Background...................................................................................................................... 1 

Scope and Methodology .................................................................................................. 3 

Results and Conclusions ............................................................................................. 5 

Issue 1: Need to Establish National Procedures for Veterans’ Room Inspections.......... 5

Issue 2: Need for Additional Safety, Security, and Privacy Procedures for Female 

Veterans and Guidance on Security Initiatives for All Veteran Residents......... 8 

Issue 3: Need to Improve Annual Safety, Security, and Privacy Reporting and 

Follow-Up Process............................................................................................ 11 

Appendices 

A. FY 2007 ASSA Issues Assessed by OIG.................................................................. 16 

B. FY 2007 ASSA Issues Reported by Domiciliaries ................................................... 17 

C. Number of FY 2007 ASSA Issues Reported by Domiciliaries................................. 18 

D. Illustration of Unsecured Medications Observed by OIG ........................................ 19 

E. Under Secretary for Health Comments ..................................................................... 20 

F. Assistant Secretary for Operations, Security, and Preparedness Comments ............ 27 

G. OIG Contact and Staff Acknowledgments ............................................................... 30 

H. Report Distribution ................................................................................................... 31 

VA Office of Inspector General 
Audit of Veterans Health Administration’s Domiciliary Safety, Security, and Privacy 

Executive Summary 

Introduction 

The Office of Inspector General (OIG) conducted this audit to assess the effectiveness of 

safety, security, and privacy of veterans residing in VA domiciliaries. The audit 

objective was to determine if the safety, security, and privacy issues identified at 

Veterans Health Administration (VHA) domiciliaries we randomly selected for review 

were corrected. 

The Domiciliary Residential Rehabilitation Treatment Program (DRRTP) is VA’s oldest 

health care program. Domiciliary care was initially established to provide services to 

economically disadvantaged veterans, and it remains committed to serving that group. 

The domiciliary has evolved from a “soldiers’ home” to become an active clinical 

rehabilitation and treatment program for veterans. 

The mission of the DRRTP is to provide coordinated, integrated, rehabilitative, and 

restorative clinical care in a bed-based program. The goal of the DRRTP is to help 

eligible veterans achieve and maintain the highest level of functioning and independence 

possible. In 2005, DRRTP became fully integrated with other residential rehabilitation 

and treatment programs within the Office of Mental Health Services. As of June 2008, 

there were 49 domiciliaries in 28 states. VHA plans to open four additional domiciliaries 

by the end of fiscal year (FY) 2009. 

Domiciliary residents normally face many challenges such as homelessness, substance 

abuse, and mental illness. Veteran safety issues within DRRTPs have recently come to 

the attention of the public and Congress. Members of Congress have also expressed 

concerns that VA domiciliary care programs meet the safety and capacity needs of 

women veterans. Female veterans represented approximately 4 percent of the total 

domiciliary population in FY 2007. As early as March 2006, VHA reported to the VA’s 

Advisory Committee on Women Veterans that women veterans have experienced a lack 

of privacy in the DRRTPs. The report also noted that women veterans often felt 

intimidated in the predominantly male facilities and were concerned for their safety. 

VHA Handbook 1162.02, “Domiciliary Residential Rehabilitation and Treatment 

Program,” establishes procedures for the domiciliaries and requires the Chief, DRRTP to 

complete an Annual Narrative Report that includes an Annual Safety and Security 

Assessment (ASSA). The ASSA consists of 32 questions to be completed by the Chief, 

DRRTP and other medical center staff and is used as a planning tool to identify potential 

safety, security, and privacy issues. (For additional information on ASSA questions, see 

Appendix B). The handbook requires each domiciliary to identify any safety, security, 

and privacy concerns as part of the annual reporting requirements and includes an action 

plan with a timeline for remediation of problems. All 47 domiciliaries at the end of 

VA Office of Inspector General i 
Audit of Veterans Health Administration’s Domiciliary Safety, Security, and Privacy 

FY 2007 completed an ASSA, and 44 (94 percent) reported that their facility had at least 

one safety or security issue. 

In January 2008, the Deputy Under Secretary for Health for Operations and Management 

provided guidance and authorized funds for the immediate implementation of key card 

systems on the entryways and exits of perimeter doors and programmable key card 

systems and/or closed circuit monitoring systems of female bedroom doors at all 

Residential Rehabilitation Treatment Programs (RRTP) to improve safety and security. 

The Deputy Under Secretary cited this as a “national priority.” 

 

Management Oversight. The Director of RRTP is responsible for directing and 

overseeing the operation of the DRRTPs nationally. The Domiciliary Field Advisory 

Board (DFAB) works collaboratively with VHA Central Office program staff to 

implement recommendations related to the DRRTPs. They also monitor DRRTPs to 

ensure that the safety and security of residents and other DRRTP areas of concern are 

addressed, such as the quality of care. Veterans Integrated Service Network (VISN) 

Directors are responsible for ensuring compliance with all standards in VHA Handbook 

1162.02 for all DRRTPs in their VISN. The Medical Center Director is responsible for 

appointing a Chief, DRRTP. The Chief, DRRTP is responsible for all aspects of a 

comprehensive program of clinical care, the efficient and effective operation of the 

domiciliary, and providing quality care in a safe environment, including preparation of 

the Annual Narrative Report, which includes the ASSA. 

In FY 2009, VHA plans to use a contractor to assess safety, security, and privacy at all 

domiciliaries as part of the Mental Health Residential Rehabilitation Treatment Programs 

(MHRRTP) Transformation Plan. The plan will transform the DRRTP and the 

Psychosocial Residential Rehabilitation and Treatment Program (PRRTP) into one 

unified program. As part of the transformation, DRRTP has drafted a new MHRRTP 

VHA Handbook, which will combine VHA Handbook 1162.02 and VHA Handbook 

1162.03, “Psychosocial Residential Rehabilitation and Treatment Program.” In February 

2007, the draft VHA MHRRTP Handbook was internally distributed for feedback and 

review. However, the draft handbook is not expected to be finalized until the first quarter 

of FY 2009. The draft VHA MHRRTP Handbook addresses more safety, security, and 

privacy concerns than VHA Handbook 1162.02. 

Results 

VHA needs to implement additional national procedures and clarify national guidance to 

ensure that safety, security, and privacy issues are sufficiently identified, reported, and 

corrected throughout the year. VHA is in the process of issuing revised national 

procedures in its draft VHA MHRRTP Handbook, but needs action to finalize these 

procedures. Our audit included site visits at five domiciliaries and disclosed three 

national issues that impact all 49 domiciliaries: (1) there is a need to establish national 

VA Office of Inspector General ii 
Audit of Veterans Health Administration’s Domiciliary Safety, Security, and Privacy 

procedures for the inspections of veterans’ rooms; (2) additional safety, security, and 

privacy procedures are needed for female veterans along with security initiatives for all 

veteran residents; and, (3) improvements are needed in annual safety, security, and 

privacy reporting as well as the follow-up process. Overall, VHA safety, security, and 

privacy at domiciliaries warrant attention and remediation. 

Issue 1: Need to Establish National Procedures for Veterans’ Room Inspections. 

Unsecured medications were found in veterans’ domiciliary rooms during room 

inspections we conducted at all five domiciliaries. There are no national procedures for 

room inspections at domiciliaries. In addition, we found that a physical security survey 

for controlled substances was not conducted at one of the nation’s largest domiciliaries. 

National procedures for periodic unannounced inspections and random searches of all 

storage areas in veterans’ rooms are needed. We identified unsecured medications at all 

five facilities. We accompanied VHA staff on random inspections of veterans’ rooms 

and identified 17 instances of unsecured medications during 60 room observations at five 

facilities that should have been secured in the veterans’ personal locked storage areas. 

Currently, VHA has no policy requiring room inspections. However, the draft VHA 

MHRRTP Handbook for all MHRRTPs does include requirements for regular and 

random health and welfare inspections of resident rooms and random contraband 

inspections. Local procedures for room inspections varied and did not include periodic 

unannounced room inspections of all unsecured storage areas for all veterans’ rooms. In 

fact, 6 of 47 domiciliaries did not have written procedures for contraband detection with 

random searches occurring regularly. Periodic unannounced inspections of storage areas 

at domiciliaries would provide greater security over medications and reduce the risk of 

loss, theft, misuse, and abuse. Proper security of medications is a crucial aspect to 

ensuring the safety and security of all veterans. 

A physical security survey of controlled substance security at one domiciliary was not 

conducted in FY 2007. VHA needs to ensure that physical security surveys are 

conducted at domiciliaries that store controlled substances. We also found that the 

medical center police did not include the domiciliary in its physical security survey. 

According to the domiciliary, approximately 92 percent of its population has substance 

abuse issues, which puts this domiciliary at high risk for misuse of controlled substances. 

We also noted that the ASSA does not include a question related to this requirement and 

the Chief, DRRTP was not aware of it. Physical security surveys are an important 

requirement for facilities that store and dispense controlled substances. 

Issue 2: Need for Additional Safety, Security, and Privacy Procedures for Female 

Veterans and Guidance on Security Initiatives for All Veteran Residents. 

Our results showed that female veterans are subject to different levels of safety, security, 

and privacy. VHA Handbook 1162.02 does not specifically address any special safety, 

security, and privacy needs of female veterans although the ASSA includes two questions 

VA Office of Inspector General iii 
Audit of Veterans Health Administration’s Domiciliary Safety, Security, and Privacy 

specific to female veterans. However, the draft VHA MHRRTP Handbook does address 

safety, security, and privacy needs specific to female veterans. We found that not all 

domiciliaries have bedroom and bathroom locks for female veterans, and the potential for 

unauthorized access to bedrooms through ceilings existed at two domiciliaries. In the 

FY 2007 ASSA, 8 of 47 facilities responded that the facility did not have female bedroom 

and bathroom locks and 3 facilities responded that the facility only partially addressed 

this question. Two Chiefs, DRRTP cited safety concerns as the reasons for not installing 

bathroom locks. The lack of specific policy requirements for safety, security, and privacy 

for female veterans increases the risk of harm to this population. 

Domiciliaries have made limited progress implementing VHA’s resident national security 

initiative of January 2008 that required immediate implementation of key card systems on 

perimeter doors, programmable key card systems on female bedroom doors, and/or 

closed circuit monitoring systems. As of June 30, 2008, 19 domiciliaries had not 

implemented key card systems on female doors or closed circuit monitoring systems, and 

38 domiciliaries had not implemented key card systems on entryways and exits of 

perimeter doors. 

The guidance directed actions be taken immediately but did not include actual target 

dates for implementation actions. Target dates need to be established to help ensure this 

major national veteran safety and security initiative is implemented. In April 2008, the 

Director of RRTP redirected all Chiefs, DRRTP that all funds for keyless entry must be 

used in FY 2008 and all keyless entry projects must be completed by the end of FY 2008. 

During our visits to the five domiciliaries, we determined that three facilities did not have 

keyless entry on female doors or closed circuit monitoring systems, and all five facilities 

had not installed key card systems on perimeter doors. In the FY 2007 ASSA, 6 of 47 

facilities responded that the facility did not have closed circuit monitoring or security 

mirrors in hallways and 9 facilities responded that the facility only partially met this 

question. The safety and security of all veterans, and especially female veterans, is 

jeopardized if these resident security requirements are not implemented. 

Issue 3: Need to Improve Annual Safety, Security, and Privacy Reporting and 

Follow-Up Process. 

Current, accurate, and complete annual reporting of all safety, security, and privacy 

issues is extremely important to the success of the DRRTP’s efforts to establish 

procedures to ensure a safe, secure, and private environment. Proper identification and 

remediation of significant safety, security, and privacy areas is jeopardized if responses to 

the ASSA are not accurate, all required staff do not provide input into the ASSA, and 

independent follow-up of corrective actions taken does not occur. 

We identified 12 local ASSA safety and security issues at the five domiciliaries we 

visited. At three of the facilities, eight of the 12 issues were reported as met on the FY 

2007 ASSA when they should have been reported as partially met. The incorrect 

responses at these facilities decreases the reliability of the FY 2007 ASSA. (For 

VA Office of Inspector General iv 
Audit of Veterans Health Administration’s Domiciliary Safety, Security, and Privacy 

additional information, see Appendix A.) There are no national procedures to validate 

that domiciliaries are reporting correct ASSA responses. 

We also noted that all required medical center staff tasked with completing the annual 

ASSA did not provide input. We observed this reporting weakness at four of the five 

facilities. The Chief, DRRTP is responsible for completing the ASSA with input from 

seven medical center staff members. Reporting controls need strengthening to ensure 

ASSAs are completed by the required medical center staff. 

In addition, there are no procedures to ensure that issues identified and reported by 

domiciliaries have been corrected. Safety, security, and privacy issues may not be 

promptly remediated without independent follow-up to determine if corrective actions 

have been taken. Some domiciliaries did not submit the narrative portion of the Annual 

Narrative Report required by VHA Handbook 1162.02. The potential exists that all 

safety, security, and privacy issues are not fully explained or reported if the narrative 

portion of the Annual Narrative Report is not provided to the Director of RRTP. The 

annual reporting requirements need to be consistent with the current handbook. 

Conclusion 

Safety, security, and privacy at VHA domiciliaries are a nationwide concern. In addition, 

some local safety and security issues also warrant management’s attention. Substantive 

problems exist in three main areas. Unannounced room inspections are needed to prevent 

substance abuse and the misuse of controlled substances. Safety, security and privacy for 

female veterans and security for all residents need to be enhanced. Annual safety, 

security, and privacy reporting and follow-up need to be improved. To ensure all veteran 

domiciliary residents are cared for within an environment where they feel safe and secure 

and without problems related to privacy, immediate action regarding these issues is 

imperative. Implementation of the draft VHA MHRRTP Handbook and planned 

assessments of safety, security, and privacy at all domiciliaries in FY 2009 as part of the 

MHRRTP Transformation Plan would result in improved safety, security, and privacy for 

residents at domiciliaries. 

Recommendations 

1. We recommend the Under Secretary for Health revise procedures that require 

domiciliaries to conduct periodic unannounced inspections and random searches of all 

storage areas in veterans’ rooms to identify unsecured medication. 

2. We recommend the Assistant Secretary for Operations, Security, and Preparedness 

strengthen controls to ensure physical security surveys are conducted at domiciliaries 

with controlled substances. 

3. We recommend the Under Secretary for Health establish target dates for the 

installation of key card systems on entryways and exits of perimeter doors and 

VA Office of Inspector General v 
Audit of Veterans Health Administration’s Domiciliary Safety, Security, and Privacy 

programmable key card systems on female bedroom doors and/or closed circuit 

monitoring systems at all domiciliaries. 

4. We recommend the Under Secretary for Health revise procedures to address safety, 

security, and privacy issues unique to female veterans and revise the ASSA to address 

these issues. 

5. We recommend the Under Secretary for Health perform a study to assess the 

feasibility of implementing floor-to-ceiling construction or appropriate alternative 

security measures at domiciliaries to prevent unauthorized access between rooms. 

6. We recommend the Under Secretary for Health revise procedures to ensure that 

domiciliaries are reporting correct ASSA responses that are completed by the 

appropriate medical center staff. 

7. We recommend the Under Secretary for Health revise procedures to ensure that 

safety, security, and privacy issues identified and reported by domiciliaries have been 

corrected. 

8. We recommend the Under Secretary for Health ensure the complete submission of 

Annual Narrative Reports or revise procedures to include a narrative section for the 

ASSA. 

Under Secretary for Health Comments 

The Under Secretary for Health agreed with our findings and recommendations made to 

VHA and provided acceptable implementation plans (See Appendix E for the full text of 

the Under Secretary’s comments and target dates for action plans.) The Under Secretary 

stated that the draft VHA MHRRTP Handbook would be finalized by the end of the first 

quarter of FY 2009. This handbook directs program managers to conduct regular and 

random room inspections, including inspections of storage areas. Also, written 

procedures will be developed to detect contraband brought on the unit, and there will be 

health and welfare inspections of veterans’ belongings at admission and regular and 

random unit and locker inspections. 

The Under Secretary reported that the Deputy Under Secretary for Health for Operations 

and Management issued an additional directive for the key card resident security 

initiative that established a firm target date of September 30, 2008. For those VISNs 

reporting estimated completion dates beyond the deadline, monthly status updates to the 

MHRRTP program office will be required until full safety system installation is 

complete. The draft VHA MHRRTP Handbook devotes an entire section to the special 

needs of female veterans. In addition, the ASSA process was revised to further address 

female veterans’ areas. Lastly, the Office of Mental Health Services will evaluate the 

feasibility of safety alternatives to address over-the-wall entry. 

VA Office of Inspector General vi 
Audit of Veterans Health Administration’s Domiciliary Safety, Security, and Privacy 

Further, the Under Secretary commented that the ASSA will be revised to include 

certification of participation by the team members. Medical Center directors will be 

required to certify the accuracy of the ASSA and outline an action plan and timeframes 

for items not met or partially met. VHA has finalized contract award negotiations with a 

contractor to complete a site survey of all MHRRTPs to assess compliance with the 

MHRRTP Transformation Plan and the draft VHA MHRRTP Handbook. In addition, 

VHA’s Systematic Ongoing Assessment and Review Strategy will begin to assess safety, 

security, and privacy actions as part of their regularly scheduled site visits to facilities 

with domiciliaries and all domiciliaries will be required to obtain accreditation by the 

Commission on Accreditation of Rehabilitation Facilities by 2011. The Under Secretary 

reported that the Annual Narrative Report has been replaced by an Annual Survey, which 

includes a narrative section for the ASSA. 

Assistant Secretary of Operations, Security, and Preparedness 

Comments 

The Assistant Secretary for Operations, Security, and Preparedness agreed with our 

finding and recommendation and provided an acceptable implementation plan (See 

Appendix F for the full text of the Assistant Secretary’s comments.) The Assistant 

Secretary reported that additional language will be added to the current draft of VA 

Directive and Handbook 0730/1, Appendix B, “Physical Security Requirements and 

Options,” which will include regular consultations with unit Chiefs and facility officials 

responsible for narcotics inventories and reviews for compliance during routine 

inspections or other reviews. In addition, VA’s Law Enforcement Training Center (VA 

LETC) Training Unit #11, “Physical Security” will be updated to incorporate 

domiciliaries, including new training material that will contain requirements for 

safeguarding controlled substances. 

OIG Response 

The implementation of the draft VHA MHRRTP Handbook and implementation of 

additional future planned actions noted in the Under Secretary’s response address all of 

our findings. We consider the planned actions acceptable and will follow up on their 

implementation. 

 (original signed by:)

BELINDA J. FINN 

Assistant Inspector General 

 for Auditing 

VA Office of Inspector General vii 
Audit of Veterans Health Administration’s Domiciliary Safety, Security, and Privacy 

Introduction 

Purpose 

The purpose of this audit was to assess how effectively VA has addressed safety, 

security, and privacy of veterans residing in VA domiciliaries. Specifically, we 

determined if the safety, security, and privacy issues identified by VHA at selected 

domiciliaries were corrected. 

Background 

The DRRTP is VA’s oldest health care program and was initiated through legislation 

passed in the late 1860’s to provide a home for disabled volunteer soldiers of the Civil 

War. Domiciliary care was initially established to provide services to economically 

disadvantaged veterans, and it remains committed to serving that group. The domiciliary 

has evolved from a “soldiers’ home” to become an active clinical rehabilitation and 

treatment program for veterans. 

The mission of the DRRTP is to provide coordinated, integrated, rehabilitative, and 

restorative clinical care in a bed-based program. The goal of DRRTP is to help eligible 

veterans achieve and maintain the highest level of functioning and independence 

possible. In 2005, DRRTP became fully integrated with other residential rehabilitation 

and treatment programs within the Office of Mental Health Services. As of June 2008, 

there were 49 domiciliaries in 28 states. VHA plans to open four additional domiciliaries 

by the end of FY 2009. 

VA’s Office of Mental Health Services Homeless and Residential Rehabilitation and 

Treatment Services section was charged by the National Leadership Board’s Health 

Systems Committee to review the status of care delivery in the MHRRTP and improve 

and enhance services to veterans. Several areas of improvement in MHRRTP were 

identified as key to securing a solid system of care. Some of the key elements identified 

were safety, security, and privacy enhancements within VA’s domiciliaries. As a result, 

approximately $22.5 million was deployed to all domiciliaries for infrastructure and 

safety improvements from FY 2005 through 2008. DRRTP budgets were $334.2 million 

and $395.7 million for FY 2007 and 2008, respectively. The DRRTP budget for FY 2009 

is projected to be $443.6 million, which is a 33 percent increase from FY 2007. 

Domiciliary residents normally face many challenges such as homelessness, substance 

abuse, and mental illness. Substance abuse residents comprised approximately 66 

percent of the domiciliary population during FY 2007. Domiciliary rooms normally 

accommodate two to four veterans and usually include beds, bedside drawers, desks, 

secured lockers (for all medications and other personal effects), and in some cases, an inroom bathroom. 

VA Office of Inspector General 1 
Audit of Veterans Health Administration’s Domiciliary Safety, Security, and Privacy 

Veteran safety issues within DRRTPs have recently come to the attention of the public 

and Congress. Members of Congress have also expressed concerns that VA domiciliary 

care programs meet the safety and capacity needs of women veterans. Female veterans 

represented approximately 4 percent of the total domiciliary population in FY 2007. In 

March 2006, VHA reported to the VA’s Advisory Committee on Women Veterans that 

women veterans experienced a lack of privacy in the DRRTPs. The report also noted that 

women veterans often felt intimidated in the predominantly male facilities and were 

concerned for their safety. 

VHA Handbook 1162.02, “Domiciliary Residential Rehabilitation and Treatment 

Program,” dated April 3, 2006, establishes procedures for the domiciliaries. The 

handbook requires that staffing patterns and levels must ensure veterans’ safety. In 

addition, it requires systems of control, such as sign-in and sign-out sheets, to ensure the 

knowledge of the veterans’ whereabouts. DRRTP is in the process of preparing a revised 

VHA Handbook, which will combine VHA Handbook 1162.02 and VHA Handbook 

1162.03, “Psychosocial Residential Rehabilitation and Treatment Program.” In February 

2007, the draft VHA MHRRTP Handbook was internally distributed for feedback and 

review. However, the draft handbook is not expected to be finalized until the first quarter 

of FY 2009. We noted that the revised handbook addresses more safety, security, and 

privacy concerns than VHA Handbook 1162.02. 

VHA Handbook 1162.02 requires the Chief, DRRTP to complete an Annual Narrative 

Report that includes an ASSA. In FY 2002 to 2003, a National Domiciliary Task Force, 

which worked with VISN 5 and the Violence Prevention Technical Advisory Committee, 

developed the ASSA. In August 2007, a workgroup chaired by VA Central Office 

(VACO) and comprised of MHRRTP Field Advisory Board members revised the ASSA. 

The handbook requires each domiciliary to identify any safety, security, and privacy 

concerns as part of the annual reporting requirements and includes an action plan with a 

timeline for remediation of problem areas. The ASSA consists of 32 questions to be 

completed by the Chief, DRRTP and other medical center staff and is used as a planning 

tool to identify potential safety, security, and privacy issues. Those questions noted as 

partially met or not met must be further explained in the comments and recommendations 

section of the ASSA. Chiefs, DRRTP may request funding based on the safety, security, 

and privacy needs identified in the ASSA. The Annual Narrative Report is submitted 

through the Medical Center Director to the VISN. The VISN prepares a Network 

Executive Summary, which identifies not met or partially met safety and security issues 

and submits the summary to the Director of DRRTP. 

Based on VHA national data for FY 2007, 44 (94 percent) of 47 domiciliaries reported 

that their facility has at least one safety or security issue. The top five safety and security 

issues identified as not met in the FY 2007 ASSAs were: 

1) No female bedroom or bathroom door locks (8 facilities); 

2) Safety or security repair, renovation, or maintenance needs (7 facilities); 

VA Office of Inspector General 2 
Audit of Veterans Health Administration’s Domiciliary Safety, Security, and Privacy 

3) No closed circuit monitoring or security mirrors for hallways (6 facilities); 

4) Hiding places around building (5 facilities); and 

5) No sexual harassment training for residents (5 facilities). 

On January 16, 2008, the Deputy Under Secretary for Health for Operations and 

Management provided guidance and authorized funds for the immediate implementation 

of key card systems on the entryways and exits of perimeter doors and programmable key 

card systems for female bedroom doors and/or closed circuit monitoring systems at all 

RRTPs to improve safety and security. 

Management Oversight. The Director of RRTP is responsible for directing and 

overseeing the operation of the DRRTPs nationally. DFAB works collaboratively with 

VHA Central Office program staff to implement recommendations related to the 

DRRTPs. They also monitor DRRTPs to ensure that the safety and security of residents 

and other DRRTP areas of concern are addressed, such as the quality of care. VISN 

Directors are responsible for ensuring compliance with all standards in VHA Handbook 

1162.02 for all DRRTPs in their VISN. The Medical Center Director is responsible for 

appointing a Chief, DRRTP. The Chief, DRRTP is responsible for all aspects of a 

comprehensive program of clinical care, the efficient and effective operation of the 

domiciliary, and for providing quality care in a safe environment. The Chief, DRRTP is 

also responsible for the preparation of the Annual Narrative Report, which includes the 

ASSA. 

Scope and Methodology 

The scope of the audit included a review of safety, security, and privacy issues identified 

by VA at domiciliaries from October 2006 through June 2008. We assessed the safety, 

security, and privacy environment at five randomly selected domiciliaries. We conducted 

site visits at the following five domiciliaries: Knoxville, IA; Chillicothe, OH; Cincinnati, 

OH; Little Rock, AR; and West Los Angeles, CA. 

At each site, we reviewed the FY 2007 Annual Narrative Report including the ASSA and 

the related VISN Network Executive Summaries; each domiciliary’s ASSA responses 

and compared their responses with local policies and procedures, local records, and the 

interior and exterior environment; local policies and procedures and medical center 

reports; and domiciliary inspection reports. We also interviewed domiciliary and medical 

center management and staff and participated in the inspection of veterans’ bedrooms to 

determine the existence of unsecured medications and contraband. 

We had meetings with the Director of the RRTP and the Associate Chief Consultant, 

Homeless and Residential Rehabilitation. We reviewed and summarized all the FY 2007 

ASSAs for all 47 domiciliaries to identify reported safety, security, and privacy issues. 

We also obtained national demographic statistics to identify the population characteristics 

of the domiciliary population. 

VA Office of Inspector General 3 
Audit of Veterans Health Administration’s Domiciliary Safety, Security, and Privacy 

Our assessment of internal controls focused on those controls related to the audit 

objective. We conducted the audit in accordance with generally accepted government 

auditing standards. These 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. 

VA Office of Inspector General 4 
Audit of Veterans Health Administration’s Domiciliary Safety, Security, and Privacy 

Results and Conclusions 

Issue 1: Need to Establish National Procedures for 

Veterans’ Room Inspections 

Findings 

During our audit, we accompanied staff on random inspections of veterans’ rooms and 

identified 17 instances of unsecured medications that were required to have been secured 

in the veterans’ personal locked storage areas. The majority of medications found were 

in bedside drawers and were in pill or tablet form. (For an illustration of unsecured 

medications observed by OIG, see Appendix D.) A summary of the results of our 

inspections are shown below: 

Site 

OIG 

Inspection 

Date 

# Rooms 

 Observed 

# Rooms 

Unsecured 

Medications 

1 6/2/08 10 3 

2 6/3/08 10 6 

3 6/4/08 10 4 

4 6/25/08 17 3 

5 6/25/08 13 1

Total 60 17 

100% 28% 

Room inspection procedures at the five facilities varied. For example, one site conducted 

weekly unannounced inspections while another site conducted weekly announced 

inspections. 

VHA Handbook 1108.3, “Self-Medication Program,” requires that “all self-medications 

(including controlled substances) must be kept in a locked cabinet or locker accessible 

only to the patient, the provider with prescriptive privileges, and/or qualified ward staff.” 

Local policies for the five facilities incorporate these requirements and educate veterans 

about secure medication storage upon admission and periodically, such as in the event 

medications are unsecured. VHA Handbook 1162.02 requires that the Chief, DRRTP 

provide quality care in a safe environment. Proper security of medications is part of 

ensuring a safe environment. 

Currently, VHA has no written policy requiring room inspections at domiciliaries. VHA 

Handbook 1162.02 does not address inspections or random searches and local policies for 

the five facilities did not include periodic unannounced room inspections of all unsecured 

VA Office of Inspector General 5 
Audit of Veterans Health Administration’s Domiciliary Safety, Security, and Privacy 

storage areas for all veterans’ rooms. However, the draft VHA MHRRTP Handbook 

does include requirements for regular and random health and welfare inspections of 

resident rooms and random contraband inspections. Contraband searches may also result 

in the identification of unsecured medications. In the FY 2007 ASSA, 4 of 47 facilities 

responded that the facility did not have written procedures for contraband detection with 

random searches occurring regularly, and 2 facilities responded that the facility only 

partially addressed this question. In addition, two of the five facilities we visited only 

partially addressed this question even though they reported they had fully complied with 

it. 

Unsecured medications are accessible to other veterans and staff, increasing the risk of 

theft and abuse. Approximately 66 percent of the domiciliary national population has 

substance abuse issues and most of the rooms with unsecured medications were occupied 

by two or more veterans. 

We also found that one facility did not document the results of one major random search 

and that lockers found open during other inspections contained medications. Local 

policies for this facility required that inspection reports identify if medications are 

unsecured in veterans’ rooms and open lockers. Domiciliary management did not 

provide sufficient oversight to ensure the search and inspections were documented. By 

not documenting the results of all inspections and searches, there is no evidence that 

safety and security issues are identified, tracked, and corrected. The Chief, DRRTP 

indicated that they will document the results of all major searches and the complete 

results of inspections in the future. 

Physical Security Surveys at Domiciliary with Controlled Substances

One domiciliary was not included in the FY 2007 annual physical security survey. VHA 

Handbook 0730, “Security and Law Enforcement,” dated August 11, 2000, requires 

annual physical security survey of specific areas in ward and treatment rooms (drug 

cabinets and refrigerators that contain controlled substances and medical supply rooms 

and closets) to ensure the effective planning and use of security resources. The Chief of 

Police did not include the domiciliary on the list of required review sites for the medical 

center and could not provide an explanation for excluding it. 

The ASSA does not address annual physical security surveys and the Chief, DRRTP was 

not aware of this requirement. Physical security issues for controlled substances may not 

have been identified. According to the domiciliary, approximately 92 percent of its 

population has substance abuse issues, which puts this domiciliary at a high risk for 

misuse of controlled substances. One death occurred at the domiciliary in January 2007 

from an apparent overdose of a controlled substance. 

VA Office of Inspector General 6 
Audit of Veterans Health Administration’s Domiciliary Safety, Security, and Privacy 

Conclusion 

Periodic unannounced inspections of storage areas at domiciliaries would provide greater 

security over medications and reduce the risk of loss, theft, misuse, and abuse. 

Implementation of the draft VHA MHRRTP Handbook, which includes regular and 

random room inspections and random contraband inspections would result in improved 

security over medications. Physical security surveys are an important requirement for 

facilities that store and dispense controlled substances. Proper security of medications is 

a crucial aspect to ensuring the safety and security of all veterans, especially those with 

substance abuse issues. 

Recommendations 

1. We recommend the Under Secretary for Health revise procedures that require 

domiciliaries to conduct periodic unannounced inspections and random searches of all 

storage areas in veterans’ rooms to identify unsecured medication. 

2. We recommend the Assistant Secretary for Operations, Security, and Preparedness 

strengthen controls to ensure physical security surveys are conducted at domiciliaries 

with controlled substances. 

Under Secretary for Health Comments 

The Under Secretary for Health agreed with our finding and recommendation and plans 

to complete corrective action by December 2008. (See Appendix E for the full text of the 

Under Secretary’s comments.) The Under Secretary reported that the draft VHA 

MHRRTP Handbook directs program managers to conduct regular and random room 

inspections, including inspections of storage areas. In addition, the Under Secretary 

reported that written procedures will be developed for detecting contraband brought on 

the unit, including inspections of veterans’ belongings at admission and regular and 

random unit and locker inspections. 

Assistant Secretary of Operations, Security, and Preparedness 

Comments 

The Assistant Secretary of Operations, Security, and Preparedness agreed with our 

finding and recommendation and plans to complete corrective action by the 2nd quarter of 

FY 2009. (See Appendix F for the full text of the Assistant Secretary’s comments.) The 

Assistant Secretary reported that additional language will be added to the current draft of 

VA Directive and Handbook 0730/1, Appendix B, “Physical Security Requirements and 

Options,” which will include regular consultations with unit Chiefs and facility officials 

responsible for narcotics inventories and reviews for compliance during routine 

inspections or other reviews. In addition, VA’s Law Enforcement Training Center (VA 

VA Office of Inspector General 7 
Audit of Veterans Health Administration’s Domiciliary Safety, Security, and Privacy 

LETC) Training Unit #11, “Physical Security” will be updated to incorporate 

domiciliaries, including new training material that will contain requirements for 

safeguarding controlled substances. 

Office of Inspector General Comments 

We consider these planned actions acceptable, and will follow up on their 

implementation. 

Issue 2: Need for Additional Safety, Security, and Privacy 

Procedures for Female Veterans and Guidance on Security 

Initiatives for All Veteran Residents 

Findings 

Female veterans are subject to different levels of safety, security, and privacy. We found 

not all domiciliaries have bedroom and bathroom locks on female veterans’ doors and 

possible unauthorized access to bedrooms through ceilings at two domiciliaries. In the 

FY 2007 ASSA, 8 of 47 facilities responded that the facility did not have female bedroom 

and bathroom locks and 3 facilities responded that the facility only partially addressed 

this question. In addition, we found that a facility had no locks on the common hallway 

female bathroom even though they reported they addressed this question. Two Chiefs, 

DRRTP cited safety concerns as the reasons for not installing bathroom locks. 

VHA Handbook 1162.02 does not specifically address any safety, security, and privacy 

needs of female veterans. The ASSA includes two questions specifically related to 

females. One question asks if bedroom and bathroom locks are on female veterans’ 

doors and another question asks if appropriate space is available for them to meet with 

children. The majority of veterans in domiciliaries are male and the lack of specific 

policy requirements for safety, security, and privacy that are unique to female veterans 

increases the risk of harm to this population. However, the draft VHA MHRRTP 

Handbook does address safety, security, and privacy needs specific to female veterans 

such as separate and secure sleeping arrangements. 

On January 16, 2008, the Deputy Under Secretary for Health for Operations and 

Management provided guidance and authorized funds for the immediate implementation 

of key card systems on the entryways and exits of perimeter doors, programmable key 

card systems on female bedroom doors and/or closed circuit monitoring systems at all 

RRTPs to improve safety and security. This was cited as a “national priority” by the 

Deputy Under Secretary for Health for Operations and Management. As of June 30, 

2008, 19 domiciliaries had not implemented key card systems on female bedroom doors 

or closed circuit monitoring and 38 domiciliaries had not implemented key card systems 

VA Office of Inspector General 8 
Audit of Veterans Health Administration’s Domiciliary Safety, Security, and Privacy 

on entryways and exits of perimeter doors. In the FY 2007 ASSA, 6 of 47 facilities 

responded that the facility did not have closed circuit monitoring or security mirrors in 

hallways and 9 facilities responded that the facility only partially addressed this question. 

During our site visits, we determined that three facilities did not have keyless entry or 

closed circuit monitoring of female bedroom doors and all five facilities had not installed 

key card systems on perimeter doors. 

Locks on Female Bedroom and Bathroom Doors

We determined that one facility did not have any female bedroom or bathroom door locks 

and another facility did not have female bathroom door locks. In addition, one site did 

not have a bathroom door lock on the common hallway female bathroom; subsequently, 

the Chief, DRRTP had a lock installed on the common bathroom door during our site 

visit. The ASSA has a question to determine if all female bedrooms and bathrooms have 

locks on the doors. 

Current policies do not require locks on female bedroom and bathroom doors. However, 

the January 16, 2008 guidance from the Deputy Under Secretary for Health for 

Operations and Management required the immediate implementation of programmable 

key card systems on female bedroom doors and/or closed circuit monitoring systems at 

all RRTPs. VHA Handbook 1162.02 requires that the Chief, DRRTP provide quality 

care in a safe environment. 

Two Chiefs, DRRTP cited safety concerns as the reasons for not installing bathroom 

locks. Domiciliary management at the facility without any bedroom or bathroom locks 

considered increased monitoring to be effective and indicated that female veterans could 

jam mechanical locks, such as with paper, and lock themselves in the room. The risk of 

harm to females is significantly increased if females are not provided lockable bedroom 

and bathroom doors. 

Resident Security Initiative

We determined that three facilities did not have keyless entry on female bedroom doors 

or closed circuit monitoring systems and all five facilities had not installed key card 

systems on perimeter doors. As of June 30, 2008, 19 domiciliaries had not implemented 

key card systems on female bedroom doors or closed circuit monitoring, and 38 

domiciliaries had not implemented key card systems on entryways and exits of perimeter 

doors. 

The January 16, 2008 guidance from the Deputy Under Secretary for Health for 

Operations and Management directed actions be taken immediately but did not include 

actual target dates for implementation. In April 2008, the Director of RRTP redirected all 

Chiefs, DRRTP that all funds for keyless entry must be used in FY 2008 and all keyless 

entry projects must be completed by the end of FY 2008. Three facilities received funds 

VA Office of Inspector General 9 
Audit of Veterans Health Administration’s Domiciliary Safety, Security, and Privacy 

during February 2008 and the other two facilities received funds in April and May 2008, 

respectively. The reasons for non-implementation at the five facilities varied, especially 

for those sites that received funding in February 2008. For example, one site experienced 

delays, in part, because a proper control point for funds could not be determined. 

Another did not immediately implement the initiative because a target date was not 

provided in the guidance. The safety and security of all veterans, and especially female 

veterans, is jeopardized if these requirements are not implemented. Programmable key 

card systems increase safety and security by providing individually authorized access that 

can be terminated when necessary and allows for the continuous monitoring of veterans’ 

entry and exit into their bedrooms and the building. 

Possible Unauthorized Access via Ceiling 

The bedroom walls at one site did not extend from the floor to the building ceiling (floorto-ceiling construction). The bedrooms have drop ceilings and an approximate four foot 

space above the top of the bedroom wall to the building ceiling. This issue was identified 

during an annual physical security survey and was not included on the ASSA. 

Subsequently, we identified another facility that did not have floor-to-ceiling 

construction. VHA Handbook 1162.02 requires that the Chief, DRRTP provide quality 

care in a safe environment. The handbook does not address floor-to-ceiling construction. 

One of the ASSA questions assesses if the facility provides adequate visual and auditory 

privacy in bedrooms and treatment areas. 

This condition has not been identified and addressed as a safety, security, and privacy 

issue by DRRTP management. VHA Handbook 0730 requires floor-to-ceiling 

construction for agent cashier and pharmacy areas. This open space above the ceiling 

creates the risk of unauthorized physical or visual access to female veterans’ bedrooms. 

Conclusion 

Female veterans are subject to different levels of safety, security, and privacy. This 

results in inconsistent treatment of this higher risk population and jeopardizes the safety, 

security, and privacy of female veterans. Safety, security, and privacy procedures for 

female veterans would ensure that they have an equal level of security as male veterans at 

domiciliaries. The implementation of the draft VHA MHRRTP Handbook would result 

in improved safety, security, and privacy for female veterans. DRRTP management did 

not establish a firm implementation target date for the resident security initiative and the 

decision to extend the implementation to the end of FY 2008 has only resulted in limited 

implementation. Most of the domiciliaries received funds during February 2008 and 

implementation should have progressed immediately as indicated by the Deputy Under 

Secretary for Health for Operations and Management. 

VA Office of Inspector General 10 
Audit of Veterans Health Administration’s Domiciliary Safety, Security, and Privacy 

Recommendations 

3. We recommend the Under Secretary for Health establish target dates for the 

installation of key card systems on entryways and exits of perimeter doors and 

programmable key card systems on female bedroom doors and/or closed circuit 

monitoring systems at all domiciliaries. 

4. We recommend the Under Secretary for Health revise procedures to address safety, 

security, and privacy issues unique to female veterans and revise the ASSA to address 

these issues. 

5. We recommend the Under Secretary for Health perform a study to assess the 

feasibility of implementing floor-to-ceiling construction or appropriate alternative 

security measures at domiciliaries to prevent unauthorized access between rooms. 

Under Secretary for Health Comments 

The Under Secretary for Health agreed with our findings and recommendations and plans 

to complete all corrective actions by the end of the first quarter of FY 2009. (See 

Appendix E for the full text of the Under Secretary’s comments.) The Under Secretary 

reported that the Deputy Under Secretary for Health for Operations and Management 

issued an additional directive for the resident security initiative that established a firm 

target date of September 30, 2008. The new draft VHA MHRRTP Handbook devotes an 

entire section for the special needs of female veterans. In addition, the Under Secretary 

reported that the ASSA process has been revised to further address female veterans’ 

areas, Lastly, the Office of Mental Health Services will evaluate the feasibility of safety 

alternatives to address over-the-wall entry. 

Office of Inspector General Comments 

We consider these planned actions acceptable, and will follow up on their 

implementation. 

Issue 3: Need to Improve Annual Safety, Security, and 

Privacy Reporting and Follow-Up Process 

Findings 

We identified conditions that impact safety, security, and privacy but were not reported 

on the 2007 ASSA. We also noted that some of the seven medical center staff required to 

participate in the annual ASSA did not provide inputs at four of the five facilities we 

visited. VHA Handbook 1162.02 requires the Chief, DRRTP to complete an ASSA and a 

VA Office of Inspector General 11 
Audit of Veterans Health Administration’s Domiciliary Safety, Security, and Privacy 

memorandum from Deputy Under Secretary for Health for Operations and Management 

requires input from specific medical center staff. Controls are not sufficient to validate 

domiciliaries are reporting correct ASSA responses that are completed by the required 

medical center staff. In addition, there are no independent follow-up procedures to 

ensure that issues identified and reported by domiciliaries have been corrected. Proper 

identification of significant safety, security, and privacy issues is jeopardized if responses 

to the ASSA are not completely accurate and all required staff do not provide input into 

the ASSA. Safety, security, and privacy issues may not be promptly remediated without 

independent follow-up to determine if corrective actions have been taken. 

In addition, some domiciliaries did not submit the narrative portion of the Annual 

Narrative Report, which is required by VHA Handbook 1162.02. The Director of RRTP 

informed domiciliaries that the narrative portion of the Annual Narrative Report was not 

needed. The narrative portion of the report includes major program information such as 

program successes, failures, and challenges. All safety, security, and privacy issues may 

not be fully explained if the narrative portion of the Annual Narrative Report is not 

provided to Director of the RRTP. 

The Director of RRTP stated that they plan to use a contractor to assess safety, security, 

and privacy at all domiciliaries in FY 2009 as part of the MHRRTP Transformation Plan. 

The MHRRTP National Transformation Plan will transform PRRTP and DRRTP into 

one unified program. 

Inaccurate and Incomplete Annual Safety and Security Assessments

Three of the five facilities provided inaccurate responses to the ASSA. They responded 

that certain safety, security, and privacy issues were met, but we believe they should have 

been reported as partially met or not met. We identified eight conditions that should have 

been reported and were not at these three facilities. (For additional information, see 

Appendix A.) 

VHA Handbook 1162.02 requires the Chief, DRRTP to complete an Annual Narrative 

Report, which includes an ASSA. The ASSA consists of 32 questions that are to be 

completed by the Chief, DRRTP and other individuals and is used as a planning tool to 

identify potential safety, security, and privacy issues. Questions noted as partially met or 

not met must be addressed in the comments and recommendations section and must 

include an action plan with a timeline for remediation of problem areas. There are no 

procedures to validate domiciliaries are reporting correct ASSA responses. The Chiefs, 

DRRTP at the three facilities did not fully ensure that their ASSA responses were 

accurate and reflected the current conditions. The safety and security of veterans is 

jeopardized if all problem areas are not identified and corrected. 

In addition, we determined that the required medical center staff did not provide input 

into the ASSA at four facilities. On November 8, 2007, the Deputy Under Secretary for 

VA Office of Inspector General 12 
Audit of Veterans Health Administration’s Domiciliary Safety, Security, and Privacy 

Health for Operations and Management provided guidance that required the Chief, 

DRRTP to complete the ASSA based on the input from seven required staff. Staff 

includes the Patient Safety Officer, Engineering staff, Women Veteran Representative, 

Medical Center Safety Officer, Infection Control Nurse, Police Service representative, 

and a Quality Improvement representative. Controls are not sufficient to validate ASSAs 

are completed by the appropriate medical center staff. The main reason for nonparticipation was management oversight. If input is not provided by all team members, 

all safety, security, and privacy issues may not be identified and corrected. 

No Independent Follow-Up of ASSA Issues

Safety, security, and privacy issues reported by domiciliaries in the ASSA are not 

independently assessed to determine if issues have been corrected. There are no 

procedures to ensure that ASSA issues identified and reported by domiciliaries have been 

corrected. VHA Handbook 1162.02 requires that questions noted as partially met or not 

met must be addressed in the comments and recommendations section of the ASSA and 

must include an action plan with a timeline for remediation of problem areas. The 

Director of RRTP is responsible for directing and overseeing DRRTPs nationally and 

safety, security, and privacy issues are discussed during national teleconference calls with 

Chiefs, DRRTP. Safety, security, and privacy issues may not be promptly remediated 

without independent follow-up to determine if corrective actions have been taken. 

Annual Narrative Report

Four of the five facilities did not submit the narrative portion of the Annual Narrative 

Report in FY 2007. VHA Handbook 1162.02 requires the Chief, DRRTP to prepare and 

submit an Annual Narrative Report. The Annual Narrative Report is submitted through 

the Medical Center Director and to the VISN. The VISN prepares a Network Executive 

Summary that identifies not met or partially met safety and security issues and submits 

the summary to the Director of RRTP. 

The report includes basic program information having administrative or clinical 

significance such as program philosophy and types of veterans served. It includes the 

ASSA and the narrative portion that includes major program information such as program 

successes, failures, and challenges. Some domiciliaries describe significant safety, 

security, and privacy issues and identify additional issues not included in the ASSA in the 

narrative portion. For example, one domiciliary identified issues and recommendations 

related to searches of resident belongings upon admission in the narrative portion. 

During FY 2007, domiciliaries were redirected by the Director of RRTP to complete an 

Annual Survey in lieu of the narrative portion of the Annual Narrative Report. The 

Annual Survey provides similar information to that required by the Annual Narrative 

Report but does not address major program information, such as program successes and 

failures. The Director of RRTP explained that the narrative portion of the Annual 

VA Office of Inspector General 13 
Audit of Veterans Health Administration’s Domiciliary Safety, Security, and Privacy 

Narrative Report was no longer needed. As a result, the Director of RRTP may not 

receive all information having administrative or clinical significance including detailed 

descriptions of significant safety, security, and privacy issues. 

Conclusion 

Current, accurate, and complete annual reporting of all safety, security, and privacy 

issues is extremely important to the success of the DRRTP’s efforts to establish 

procedures to ensure a safe, secure, and private environment. Chiefs, DRRTP need to 

ensure that ASSA responses are accurate and that all required staff participate in its 

completion. Inaccurate reporting and/or non-participation by required staff could impact 

management’s ability to identify significant safety, security, or privacy issues. Incorrect 

responses identified at these three facilities decreases the reliability of the FY 2007 

ASSA responses. Independent follow-up of reported safety, security, and privacy issues 

ensures that appropriate corrective actions have been taken. The annual reporting 

requirements should be consistent with the current handbook. The narrative portion of 

the Annual Narrative Report should be helpful to the Director of RRTP and provide 

further background to significant safety, security, and privacy issues. 

Recommendations 

6. We recommend the Under Secretary for Health revise procedures to ensure that 

domiciliaries are reporting correct ASSA responses that are completed by the appropriate 

medical center staff. 

7. We recommend the Under Secretary for Health revise procedures to ensure that 

safety, security, and privacy issues identified and reported by domiciliaries have been 

corrected. 

8. We recommend the Under Secretary for Health ensure the complete submission of 

Annual Narrative Reports or revise procedures to include a narrative section for the 

ASSA. 

Under Secretary for Health Comments 

The Under Secretary for Health agreed with our findings and recommendations and plans 

to complete all corrective actions by January 2011. (See Appendix E for the full text of 

the Under Secretary’s comments.) The Under Secretary reported that the ASSA will be 

revised to include certification of participation and completion by the team members. In 

addition, the Medical Center Director will be required to certify the accuracy of the 

ASSA and prepare an action plan and timeframes for items not met or partially met. The 

target for completing these actions is February 2009. The Under Secretary reported that 

VHA has finalized contract award negotiations with a contractor to conduct a site survey 

of all MHRRTPs to assess compliance with the MHRRTP Transformation Plan and the 

VA Office of Inspector General 14 
Audit of Veterans Health Administration’s Domiciliary Safety, Security, and Privacy 

draft VHA MHRRTP Handbook. In addition, VHA’s Systematic Ongoing Assessment 

and Review Strategy (SOARS) will begin to assess safety, security, and privacy actions 

as part of their regularly scheduled site visits to facilities with domiciliaries and all 

domiciliaries will be required to obtain accreditation by the Commission on Accreditation 

of Rehabilitation Facilities (CARF) by 2011. The target for completing these actions is 

January 2011 and ongoing. The Under Secretary reported that the Annual Narrative 

Report has been replaced by an Annual Survey, which includes a narrative section for the 

ASSA. The target for completing these actions is January 2009 and ongoing. 

Office of Inspector General Comments 

We consider these planned actions acceptable, and will follow up on their 

implementation. 

VA Office of Inspector General 15 
Audit of Veterans Health Administration’s Domiciliary Safety, Security, and Privacy

Appendix A 

FY 2007 ASSA Issues 

 Assessed by OIG 

Domiciliary ASSA # ASSA Question 

Reported by 

Facility 

Assessed by 

OIG 

1 All entries controlled by locks or automatically locking, alarmed, or 

overseen by a dedicated individual. Met Partially Met 

12 Each RRTP has written emergency plan that is updated annually. Met Partially Met 

14 There are written procedures for drug and alcohol monitoring include ongoing random screenings. Met Partially Met 

Cincinnati, OH 

15 There are written procedures for contraband detection with random 

searches occurring regularly. Met Partially Met 

 

Chillicothe, OH 32 

RRTPs may request funding for safety, security, privacy and access 

improvements or for repair, maintenance or furnishing needs. Submit a 

memo requesting funding that outlines and itemizes funding needs. Not Met Not Met 

 

Knoxville, IA 17 All female veteran bedrooms and bathrooms have locks on their doors. Not Met Not Met 

 

12 Each RRTP has written emergency plan that is updated annually. Met Partially Met 

15 There are written procedures for contraband detection with random 

searches occurring regularly. Met Partially Met 

Little Rock, AR 

20 

All MH RRTP employees are initially trained in workplace violence 

prevention and management including: emergency response plan, how to 

handle difficult persons, prevention or and how to defuse potentially violent 

situations, personal safety and self-defense. Met Partially Met 

 

7 Parking lots and walkways have adequate lighting and are free of 

obstructions and hazards. Partially Met Partially Met 

17 All female veteran bedrooms and bathrooms have locks on their doors. Met Partially Met Los Angeles, CA 

20 

All MH RRTP employees are initially trained in workplace violence 

prevention and management including: emergency response plan, how to 

handle difficult persons, prevention or and how to defuse potentially violent 

situations, personal safety and self-defense. Partially Met Partially Met 

VA Office of Inspector General 16 
Audit of Veterans Health Administration’s Domiciliary Safety, Security, and Privacy

Appendix B 

FY 2007 ASSA Issues Reported by Domiciliaries 

ASSA 

# ASSA Questions 

Facilities 

Partially 

Met 

Facilities 

Not Met Total 

1 32 

RRTPs may request funding for safety, security, privacy and access improvements or for 

repair, maintenance or furnishing needs. Submit a memo requesting funding that outlines and 

itemizes funding needs. N/A N/A 24 

2 29 The MH RRTP has no unmet safety or security repair, renovation, or maintenance needs. 15 7 22 

3 4 The area surrounding the building is free of hiding places. 10 5 15 

4 31 

Closed circuit monitoring or security mirrors (convex mirrors) placed in hallways to view 

obstructed hallways and corners. 9 6 15 

5 7 Parking lots and walkways have adequate lighting and are free of obstructions and hazards. 13 0 13 

6 25 

All entries controlled by locks or automatically locking, alarmed, or overseen by a dedicated 

individual. 9 2 11 

7 1 

All employee occupied areas support emergency calls for help, either through panic alarms, 

emergency telephone calls, or speed dial cell phone programming. 3 8 11 

8 17 

Electronic systems such as key card locks, magnetic doors, alarms, cameras function correctly 

and are tested on a schedule (Test systems to ensure accuracy). 11 0 11 

9 5 All female veteran bedrooms and bathrooms have locks on their doors. 8 2 10 

10 8 

MH RRTP unit signage is current, visible, and contains visitor weapon and illicit drug and 

alcohol policies. 9 0 9 

11 21 

Each MH RRTP resident is provided sexual harassment prevention training as part of their 

orientation. 4 5 9 

12 2 

A system to track the location of the residents and monitor visitors is developed and 

maintained. 5 2 7 

13 12 Each RRTP has written emergency plan that is updated annually. 7 0 7 

14 11 

Adverse event data in a record keeping system are analyzed for the RRTP population, 

including patient to patient and patient to staff assault, missing patients, para-suicidal events, 

suicides, and mortality as evidenced by corrective action plans. 6 0 6 

15 15 

There are written procedures for contraband detection with random searches occurring 

regularly. 2 4 6 

16 30 MH RRTP unit provides adequate privacy in bedrooms and treatment areas (visual & auditory). 6 0 6 

17 3 Entrances to the building are clearly visible from the street or public throughfare. 3 2 5 

18 18 Appropriate private space for female veteran to visit with children. 3 2 5 

19 22 There is a plan for needed follow-up violence prevention training. 3 2 5 

20 19 

RRTP demonstrates attention to safety and security needs of frail elderly such as bedroom 

location, call buttons, bathroom design, etc. 3 0 3 

21 6 

Local external safety risks such as crime, traffic, drug use are assessed, minimized, and 

include patient education. 2 0 2 

22 10 All adverse events are reported to the director, RRTP, VACO within 24 hours. 2 0 2 

23 14 

There are written procedures for drug and alcohol monitoring include on-going random 

screenings. 2 0 2 

24 20 

All MH RRTP employees are initially trained in workplace violence prevention and management 

including: emergency response plan, how to handle difficult persons, prevention or and how to 

defuse potentially violent situations, personal safety and self-defense. 2 0 2 

25 23 The MH RRTP has written policies regarding violence in the workplace. 2 0 2 

26 26 Private locked restrooms are available for staff. 2 0 2 

27 28 MH RRTP unit is appropriately furnished to offer a home-like environment. 1 1 2 

28 13 

Staff and veterans are oriented to emergency plans and drills are conducted according to VA 

and Accrediting body standards. 1 0 1 

29 16 Alcohol based products are monitored with abuse prone patients. 0 1 1 

30 27 The unit meets all requirements in the appropriate chapter of the VA Life Safety Codes. 1 0 1 

31 9 

The RRTP is part of the medical center's adverse event data collection, reporting and recordkeeping system. 0 0 0 

32 24 Written policies/procedures are in effect on how to deal with aggressive/violent individuals. 0 0 0 

VA Office of Inspector General 17 
Audit of Veterans Health Administration’s Domiciliary Safety, Security, and Privacy

Appendix C 

Number of FY 2007 ASSA Issues 

Reported by Domiciliaries 

 # Reported ASSA Issues 

# VISN Domiciliary # Beds Partially Met Not Met Total 

1 1 Bedford, MA 40 0 1 1 

2 1 Brockton, MA 46 5 1 6 

3 2 Canandaigua, NY 50 5 2 7 

4 2 Bath, NY 220 7 1 8 

5 3 Brooklyn, NY 50 0 2 2 

6 3 Lyons, NJ 85 0 1 1 

7 3 Montrose, NY 123 2 0 2 

8 4 Butler, PA 56 0 0 0 

9 4 Pittsburgh, PA 65 3 0 3 

10 4 Coatesville, PA 238 6 0 6 

11 5 Perry Point, MD 50 2 0 2 

12 5 Martinsburg, WV 312 3 0 3 

13 6 Hampton, VA 169 8 3 11 

14 7 Tuskegee, AL 43 1 6 7 

15 7 Tuscaloosa, AL 48 2 1 3 

16 7 Augusta, GA 60 2 0 2 

17 7 Dublin, GA 136 3 0 3 

18 8 Orlando, FL 60 6 1 7 

19 8 Bay Pines, FL 65 3 3 6 

20 9 Mountain Home, TN 295 4 1 5 

21 10 Chillicothe, OH 50 0 1 1 

22 10 Cincinnati, OH 82 0 0 0 

23 10 Dayton, OH 115 6 4 10 

24 10 Cleveland, OH 174 4 0 4 

25 11 Battle Creek, MI 40 5 0 5 

26 11 Detroit, MI 50 3 0 3 

27 12 North Chicago, IL 105 0 0 0 

28 12 Milwaukee, WI 356 3 1 4 

29 15 St. Louis, MO 50 1 2 3 

30 15 Leavenworth, KS 178 2 2 4 

31 16 Little Rock, AR 126 1 0 1 

32 17 Dallas, TX 40 3 5 8 

33 17 San Antonio, TX 40 2 0 2 

34 17 Bonham, TX 224 3 2 5 

35 17 Temple, TX 408 6 2 8 

36 18 Albuquerque, AZ 40 9 0 9 

37 18 Prescott, AZ 120 2 1 3 

38 19 Sheridan, WY 40 5 1 6 

39 20 Anchorage, AK 50 0 1 1 

40 20 American Lake, WA 60 6 1 7 

41 20 White City, OR 600 1 0 1 

42 21 Palo Alto, CA 100 0 1 1 

43 22 Los Angeles, CA 321 4 0 4 

44 23 Des Moines, IA 38 5 0 5 

45 23 Knoxville, IA 40 1 1 2 

46 23 Hot Springs, SD 100 8 1 9 

47 23 St. Cloud, MN 103 2 0 2 

 TOTAL 5,861 144 49 193 

48 8 Tampa, FL 35 Opened June 2008 

49 18 Big Springs., TX 40 Opened April 2008 

 TOTAL 5,936 N/A N/A N/A

VA Office of Inspector General 18 
Audit of Veterans Health Administration’s Domiciliary Safety, Security, and Privacy

Appendix D 

 Illustration of Unsecured Medications Observed by OIG 

This includes VA 

and Non-VA 

medications. 

These medications 

are not controlled 

substances. 

VA Office of Inspector General 19 
Audit of Veterans Health Administration’s Domiciliary Safety, Security, and Privacy

Appendix E 

Under Secretary for Health Comments 

Department of 

Veterans Affairs Memorandum 

 Date: September 26, 2008

 From: Under Secretary for Health (10) 

 Subj: OIG Draft Report: Audit of the Veterans Health Administration’s Domiciliary 

Safety, Security, and Privacy (Project No. 2008-01030-R4-0120/ 

WebCIMS 411303) 

 To: Assistant Inspector General for Auditing (52) 

1. I have reviewed your draft report. Based on the revisions you made in 

response to concerns raised by VHA to the initial draft document, I concur with 

your findings and recommendations. The collegial efforts of your staff in 

resolving points of contention are appreciated, and I believe that the revised 

report provides a more balanced and accurate representation of VHA’s ongoing 

efforts to address the important issues you raise. Our plan of corrective action to 

each of the report recommendations is attached. 

2. VHA fully recognizes that residential rehabilitation, including the Domiciliary 

Residential Rehabilitation Treatment Programs (DRRTP), is a vital component of 

our overall continuum of mental health services. We have long acknowledged 

that the concerns cited by your auditors must be rectified. As a system, we made 

significant strides during the past several years in developing a national plan to 

improve and enhance DRRTP services to veterans, especially in the areas of 

safety, security and privacy. In Fiscal Year 2007, VHA ‘s National Leadership 

Board charged a national committee, composed of program experts from all 

levels of the organization, to review the current status of care delivery of 

residential rehabilitation treatment services. As part of its charge, the committee 

developed a Mental Health RRTP Transformation Plan that outlines national 

clinical and administrative recommendations, including standardized safety, 

security and privacy improvements, that would apply to all of our residential 

programs. VHA leadership approved the plan in August 2007 and it is now being 

implemented nationwide. 

3. The comprehensive plan, which was shared with your auditors, identifies 

numerous areas of focus, including safety, security and privacy, among others. It 

also emphasizes that credible oversight systems must be developed to ensure 

that established standards of care are actually being implemented. Since 

approval of the plan, VHA has provided considerable resources to improve 

patient care in our residential rehabilitation programs. For example, 

approximately $15 million has already been awarded to the DRRTPs to enhance 

VA Office of Inspector General 20 
Audit of Veterans Health Administration’s Domiciliary Safety, Security, and Privacy 

Page 2 

OIG Draft Report: Audit of the Veterans Health Administration’s Domiciliary 

Safety, Security, and Privacy (WebCIMS 411303) 

safety, security, privacy and supervision. The Deputy Under Secretary for Health 

for Operations and Management (DUSHOM) also issued field guidance directing 

medical centers to comply with national policies requiring continual on-site 

supervision at all residential treatment sites. More than $11 million was 

distributed to the field to address identified deficiencies related to round-the-clock 

supervision on residential units. In addition, all treatment programs are now 

required to achieve and maintain accreditation by the Commission on 

Accreditation of Rehabilitation Facilities (CARF) by the year 2011. The Office of 

Mental Health Services, in conjunction with the Employee Education System, has 

already sponsored four regional CARF training sessions for VHA management 

and clinical staff to prepare for the accreditation process. 

4. VHA’s goal is to redefine its various mental health residential treatment 

specialties as one unified treatment program. In support of this goal, we 

developed a new Mental Health Residential Rehabilitation Treatment Program 

Handbook, which provides structured, concrete and prescriptive guidance for all 

programs, including domiciliaries, while still affording individual facilities the 

ability to enhance services based on local population needs. The new draft 

handbook, which is currently undergoing final concurrence, is expected to be 

finalized for field distribution during the first quarter of Fiscal Year 2009. In 

February 2008, VHA convened a national educational conference for residential 

rehabilitation program managers to provide initial guidance in understanding and 

implementing requirements defined in the handbook. Your auditors were 

provided with a copy of the draft handbook, and they acknowledged that all of the 

issues raised in your report were adequately addressed in the new document. 

5. I must reiterate the importance of program oversight and monitoring to ensure 

that established standards of care are being implemented by our facilities, and 

VHA Is also taking specific steps in this important area. We recently finalized a 

national contract award with an outside contractor to complete on-site reviews of 

all 188 mental health residential treatment programs at 104 sites to assess and 

evaluate the successful implementation of requirements specified in both the 

Transformation Plan and the new policy handbook. Residential environment of 

care, safety, security and privacy assessments, as well as the specialized needs 

of women veterans and safe medication management, will be highlighted in 

these assessments, which are anticipated to begin on October 1, 2008. In 

addition, MHRRTP program managers have partnered with the VHA SOARS 

(Systematic, Ongoing Assessment and Review Strategy) national program office 

to include the MHRRTPs in the SOARS program reviews. A SOARS 

assessment guide was developed and piloted at several residential treatment 

programs in the second and third quarters of Fiscal Year 2008. Actual reviews 

are anticipated to begin in October 2008. 

VA Office of Inspector General 21 
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OIG Draft Report: Audit of the Veterans Health Administration’s Domiciliary 

Safety, Security, and Privacy (WebCIMS 411303) 

6. In summary, as our actions confirm, VHA is fully committed to ensuring that 

veterans in our DRRTPs receive the highest levels of quality care. Your report 

has confirmed areas needing improvement that VHA has also identified, and your 

observations have assisted us in prioritizing program improvement needs. If 

additional information is required, please contact Margaret M. Seleski, Director, 

Management Review Service (10B5), at 461-8470. 

Attachment 

VA Office of Inspector General 22 
Audit of Veterans Health Administration’s Domiciliary Safety, Security, and Privacy 

Under Secretary for Health Comments 

to Office of Inspector General’s Report 

The following comments are submitted in response to the 

recommendations in the Office of Inspector General’s Report: 

OIG Recommendations

1. We recommend the Under Secretary for Health revise 

procedures that require domiciliaries to conduct periodic 

unannounced inspections and random searches of all storage 

areas in veterans’ rooms to identify unsecured medication. 

Concur Target Completion Date: December 2008 

Status: In Process 

The new draft VHA Mental Health Residential Rehabilitation 

Treatment Program (MHRRTP) Handbook, anticipated to be 

finalized for field distribution in the first quarter of FY 2009, directs 

all MHRRTP program managers to implement regular and random 

room inspections that include storage areas. Procedures direct staff 

to not only identify unsecured medication, but also to develop 

written procedures for detecting contraband brought on the unit. 

These procedures will include health and welfare inspections of 

veterans’ belongings at admission and regular and random unit and 

locker inspections. 

2. We recommend the Assistant Secretary for Operations, 

Security, and Preparedness strengthen controls to ensure 

physical security surveys are conducted at domiciliaries with 

controlled substances. 

Concur 

No VHA action required; an action plan will be submitted to OIG by 

the Assistant Secretary for Operations, Security, and Preparedness in 

consultation with VHA. 

VA Office of Inspector General 23 
Audit of Veterans Health Administration’s Domiciliary Safety, Security, and Privacy 

3. We recommend the Under Secretary for Health establish 

target dates for the installation of key card systems on entryways 

and exits of perimeter doors and programmable key card 

systems on female bedroom doors and/or closed circuit 

monitoring systems at all domiciliaries. 

Concur Target Completion Date: Sept. 30, 2008 and Ongoing 

Status: In Process 

As cited in the report, a memo dated January 16, 2008, was sent by 

the Deputy Under Secretary for Health for Operations and 

Management (DUSHOM) directing facilities to immediately 

implement key card systems on perimeter doors, programmable key 

card systems on female bedroom doors and/or closed circuit 

monitoring systems. A follow-up memo was also submitted to the 

field to reassert this direction. On July 16, 2008, an additional 

DUSHOM directive was submitted to field facilities establishing a 

target date of completion for September 30, 2008. All VISNs were 

required to report detailed progress of implementation and estimated 

completion dates. For those VISNs reporting estimated completion 

dates beyond the deadline, monthly status updates to the MHRRTP 

program office will be required until full safety system installation is 

complete. 

4. We recommend the Under Secretary for Health revise 

procedures to address safety, security, and privacy issues unique 

to female veterans and revise the ASSA to address these issues. 

Concur Target Completion Date: December 2008 and Ongoing 

Status: In Process 

As already reported, the executive report of “The Transformation of 

Mental Health Residential Rehabilitation & Treatment Programs” 

outlines plans to improve safety, security and privacy in all 

residential environments. VHA is currently in the process of 

implementing additional national procedures through the draft 

MHRRTP Handbook, which devotes an entire section (Section 13) 

to the special needs of female veterans. The Annual Safety and 

Security Assessment (ASSA) has also been revised to include locks 

on female bedroom and bathroom doors, provision of a separate, 

secure area of the facility near staff offices, and a section to include 

narrative comments. The ASSA will be conducted jointly with the 

facility’s women veteran’s program manager, who will also 

VA Office of Inspector General 24 
Audit of Veterans Health Administration’s Domiciliary Safety, Security, and Privacy 

participate in regular environmental rounds, with special emphasis 

on improving privacy and security. 

5. We recommend the Under Secretary for Health perform a 

study to assess the feasibility of implementing floor-to-ceiling 

construction or appropriate alternative security measures at 

domiciliaries to prevent unauthorized access between rooms. 

Concur Target Completion Date: December 2008 

Status: Planned 

There are more than 35,000 discharges from MHRRTPs annually, 

and there has never been an incident reported of over-the-wall entry 

to a resident room. There are significant budgetary implications 

related to renovation and construction of floor-to-ceiling walls. 

Nevertheless, alternative measures, such as installation of panic 

alarms, will be explored. The Office of Mental Health will also 

consult with engineering, patient safety and law enforcement 

program experts to assess the feasibility of various safety options to 

address this concern. 

6. We recommend the Under Secretary for Health revise 

procedures to ensure that domiciliaries are reporting correct 

ASSA responses that are completed by the appropriate medical 

center staff. 

Concur Target Completion Date: February 2009 

Status: Planned 

The Annual Safety and Security Assessment (ASSA) will be revised 

to include signature blocks for all team members, with a statement 

certifying that they participated in the review and agree with the 

results. The new assessment tool will include clear directions on 

how to complete the survey. There will also be a requirement that 

the medical center director sign a cover memo certifying accuracy 

and outlining an action plan, including completion timeframes, for 

each item not met or partially met. This information will then be 

submitted to each VISN for appropriate follow-up and reporting to 

appropriate VACO program officials. 

VA Office of Inspector General 25 
Audit of Veterans Health Administration’s Domiciliary Safety, Security, and Privacy 

7. We recommend the Under Secretary for Health revise 

procedures to ensure that safety, security, and privacy issues 

identified and reported by domiciliaries have been corrected. 

Concur Target Completion Date: January 2011 and Ongoing 

Status: In Process 

As already reported, VHA has finalized contract award negotiations 

with an outside contractor to complete a comprehensive site survey 

of all 188 mental health residential treatment programs to assess 

compliance with mandates cited in both the Transformation Plan and 

the new draft MHRRTP Handbook. VHA’s SOARS program will 

also begin to assess various safety, security and privacy compliance 

actions as part of their regularly scheduled site visits to facilities 

with domiciliary residential treatment programs. As part of its 

ongoing national educational conference series, the SOARS Program 

Office will sponsor a visual online conference call entitled 

“Assessing Mental Health Residential Rehabilitation and Training 

Programs.” This live training session is scheduled for November 25, 

2008, and will be attended by SOARS consultants, team leaders, 

Quality Management Officers, Chief Medical Officers and RRTP 

staff. 

All domiciliaries will also be required to seek and maintain 

accreditation by the Commission on Accreditation of Rehabilitation 

Facilities (CARF) by the year 2011. 

8. We recommend the Under Secretary for Health ensure the 

complete submission of Annual Narrative Reports or revise 

procedures to include a narrative section for the ASSA. 

Concur Target Completion Date: January 2009 and Ongoing 

Status: In Process 

The Annual Narrative Report has been replaced by the Northeast 

Program Evaluation Center (NEPEC) Annual Survey of domiciliary 

operations. The Fiscal Year 2008 annual survey, which will be 

distributed on October 1, 2008, is expected to be completed by 

January 1, 2009. The NEPEC survey instrument includes a narrative 

section for the annual safety and security assessment. All significant 

findings from the survey will be summarized by NEPEC and results 

will be provided to the Office of Mental Health Services for further 

review and follow-up action as indicated. 

VA Office of Inspector General 26 
Audit of Veterans Health Administration’s Domiciliary Safety, Security, and Privacy

Appendix F 

Assistant Secretary for Operations, 

Security, and Preparedness Comments 

VA Office of Inspector General 27 
Audit of Veterans Health Administration’s Domiciliary Safety, Security, and Privacy 

Assistant Secretary for Operations, Security, and 

Preparedness Comments 

to Office of Inspector General’s Report 

The following comments are submitted in response to the 

recommendations in the Office of Inspector General’s Report: 

OIG Recommendations

2. We recommend the Assistant Secretary for Operations, 

Security, and Preparedness strengthen controls to ensure 

physical security surveys are conducted at domiciliaries with 

controlled substances. 

Concur Target Completion Date: 2nd Quarter FY 2009 

Status: Planned 

a. VA Directive and Handbook 0730/1, Appendix B, “Physical 

Security Requirements and Options” (August, 2004), already 

provides requirements for safeguarding controlled substances. To 

ensure existing policies are appropriately applied, the following 

language will be added to the current draft of Appendix B (due for 

publication in the 2nd quarter of FY 2009): 

“Domiciliary, Nursing Home Care units and other long-term 

residential care facilities are subject to existing VA physical security 

standards for the storing DEA Schedule II through V drugs. Such 

units will be surveyed annually as part of the facility physical 

security survey program. The VA Chief of Police Service will 

consult regularly with the Chiefs of these units, and with the facility 

official responsible for narcotics inventories. Compliance with these 

requirements will be reviewed during routine Office of Security and 

Law Enforcement program inspections or other reviews.” 

VA Office of Inspector General 28 
Audit of Veterans Health Administration’s Domiciliary Safety, Security, and Privacy 

b. Procedures for annual physical security surveys are maintained in 

VA Law Enforcement Training Center (VA LETC) Training Unit 

#11, “Physical Security.” This training unit will be updated to 

include VHA domiciliary units. The new training material will 

include requirements for safeguarding controlled substances, 

physical access control systems (PACS), and domiciliary buildings 

surveillance video protection. 

VA Office of Inspector General 29 
Audit of Veterans Health Administration’s Domiciliary Safety, Security, and Privacy 

Appendix G 

OIG Contact and Staff Acknowledgments 

OIG Contact Freddie Howell, Jr. (708) 202-2670 

Acknowledgments Joseph M. DeAntonis 

Mary Ann Fitzgerald 

Kevin Gibbons 

Raymond A. Jurkiewicz 

David Lakoskey 

John Pawlik 

Jennifer Roberts 

VA Office of Inspector General 30 
Audit of Veterans Health Administration’s Domiciliary Safety, Security, and Privacy

Appendix H 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Veterans Benefits Administration 

National Cemetery Administration 

Assistant Secretaries 

Office of General Counsel 

Non-VA Distribution

House Committee on Veterans’ Affairs 

House Committee on Appropriations, Subcommittee on Military Construction, Veterans 

Affairs, and Related Agencies 

House Committee on Oversight and Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Committee on 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 after it is issued. 

VA Office of Inspector General 31