VA Health Care: Improvements Needed for Monitoring and Preventing Sexual Assaults and Other Safety Incidents
Published: 2011-06-13T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: During GAO's recent work on services available for women veterans (GAO-10-287), several clinicians expressed concern about the physical safety of women housed in mental health programs at a Department of Veterans Affairs (VA) medical facility. GAO examined (1) the volume of sexual assault incidents reported in recent years and the extent to which these incidents are fully reported, (2) what factors may contribute to any observed underreporting, and (3) precautions VA facilities take to prevent sexual assaults and other safety incidents. This testimony is based on recent GAO work, "VA Health Care: Actions Needed To Prevent Sexual Assaults and Other Safety Incidents," (GAO-11-530) (June 2011). For that report, GAO reviewed relevant laws, VA policies, and sexual assault incident documentation from January 2007 through July 2010. In addition, GAO visited five judgmentally selected VA medical facilities that varied in size and complexity and spoke with the four Veterans Integrated Service Networks (VISN) that oversee them.
section_title: What GAO Found
paragraphs: GAO found that many of the nearly 300 sexual assault incidents reported to the VA police were not reported to VA leadership officials and the VA Office of the Inspector General (OIG). Specifically, for the four VISNs GAO spoke with, VISN and Veterans Health Administration (VHA) Central Office officials did not receive reports of most sexual assault incidents reported to the VA police. Also, nearly two-thirds of sexual assault incidents involving rape allegations originating in VA facilities were not reported to the VA OIG, as required by VA regulation. GAO identified several factors that may contribute to the underreporting of sexual assault incidents. For example, VHA lacks a consistent sexual assault definition for reporting purposes and clear expectations for incident reporting across its medical facility, VISN, and VHA Central Office levels. Furthermore, VHA Central Office lacks oversight mechanisms to monitor sexual assault incidents reported through the management reporting stream. VA medical facilities GAO visited used a variety of precautions intended to prevent sexual assaults and other safety incidents. However, GAO found some of these measures were deficient, compromising medical facilities' efforts to prevent sexual assaults and other safety incidents. For example, medical facilities used physical security precautions--such as closed-circuit surveillance cameras to actively monitor areas and locks and alarms to secure key areas. These physical precautions were intended to prevent a broad range of safety incidents, including sexual assaults. However, GAO found significant weaknesses in the implementation of these physical security precautions at the five VA medical facilities visited, including poor monitoring of surveillance cameras, alarm system malfunctions, and the failure of alarms to alert both VA police and clinical staff when triggered. Inadequate system configuration and testing procedures contributed to these weaknesses. Further, facility officials at most of the locations GAO visited said the VA police were understaffed. Such weaknesses could lead to delayed response times to incidents and seriously erode VA's efforts to prevent or mitigate sexual assaults and other safety incidents. GAO reiterated recommendations that VA improve both the reporting and monitoring of sexual assault incidents and the tools used to identify risks and address vulnerabilities at VA facilities. VA concurred with GAO's recommendations and provided an action plan to address them.

section_title: Letter
paragraphs: I am pleased to be here today as the Subcommittee discusses policies and  actions to prevent sexual assaults and other safety incidents at  Department of Veterans Affairs (VA) medical facilities. During our recent  work on services available for women veterans in VA medical facilities,  several clinicians expressed concern about the safety of women veterans  housed in mental health programs at a VA medical facility’s residential  mental health unit that also housed veterans who had committed past  sexual crimes. Clinicians were also concerned about the adequacy of  existing safety precautions to protect women veterans being treated in the  inpatient mental health units of this same facility. These concerns  highlight the importance of VA having effective security precautions to  protect all patients—especially those with residential and inpatient mental  health programs—and a consistent way to exchange information about  and discuss safety incidents, including sexual assaults.
My testimony today is based on our June 7, 2011 report: (1) the volume of  sexual assault incidents reported in recent years and the extent to which  these incidents are fully reported, (2) what factors may contribute to any  observed underreporting, and (3) the precautions in place in residential  and inpatient mental health settings to prevent sexual assault and other  safety incidents and any weaknesses in these precautions.
To examine the volume of sexual assault incidents reported to VA in  recent years, the extent to which these incidents were fully reported, and  factors that may contribute to any observed underreporting, we reviewed  relevant VA and Veterans Health Administration (VHA) policies,  handbooks, directives, and other guidance documents regarding the  reporting of safety incidents. We also interviewed VA and VHA Central  Office officials involved with the reporting of safety incidents—including  officials with VA’s Office of Security and Law Enforcement (OSLE) and  VHA’s Office of the Deputy Under Secretary for Health for Operations and  Management and Office of the Principal Deputy Under Secretary for  Health. In addition, we conducted site visits to five VA medical facilities.  These judgmentally selected medical facilities were chosen to ensure that  our sample: (1) had both residential and inpatient mental health settings;  (2) reflected a variety of residential mental health specialties, including  military sexual trauma; (3) had medical facilities with various levels of  experience reporting sexual assault incidents; and (4) varied in terms of  size and complexity. During the site visits, we interviewed VA medical  facility leadership officials and residential and inpatient mental health unit  managers and staff to discuss their experiences with reporting sexual  assault incidents. We also spoke with officials from the four Veterans  Integrated Service Networks (VISN) responsible for managing the five  selected VA medical facilities to discuss their expectations, policies, and  procedures for reporting sexual assault incidents. Information obtained  from these VISNs and VA medical facilities cannot be generalized to all  VISNs and VA medical facilities. In addition, we interviewed officials from  the VA Office of the Inspector General’s (OIG) Office of Investigations— Criminal Investigations Division to discuss information they receive from  VA medical facilities about sexual assault incidents that occur in these  facilities. Further, we reviewed federal statutes related to sexual offenses  and sentencing classification for felonies to verify that all rape allegations  included in our review met the statutory criteria for felonies under federal  law. Finally, we reviewed documentation of reported sexual assault  incidents at VA medical facilities provided by VA’s OSLE, the VA OIG, and  VISNs from January 2007 through July 2010, to determine the number and  types of incidents reported, as well as which VA and VHA offices were  notified of those incidents. For this analysis, we used a definition of sexual  assault that was developed for the purpose of this report. Our analysis of  VA police and VA OIG reports was limited to only those incidents that  were reported and cannot be used to project the volume of sexual assault  incident reports that may occur in future years. Following verification that  VA police and VA OIG incidents met our definition of sexual assault and  comparisons of sexual assault incidents reported by the two groups within  VA, we found data derived from these reports to be sufficiently reliable for  our purposes.
To examine the precautions in place to prevent sexual assault and other  safety incidents, we reviewed relevant VA, VHA, VISN, and selected  medical facility policies related to the security of residential and inpatient  mental health programs. We also interviewed VA, VHA, VISN, and selected  VA medical facility officials about the precautions in place to prevent  sexual assault incidents and other violent activities in the residential and  inpatient mental health units. Finally, to assess any weaknesses in physical  security precautions at the VA medical facilities selected for this review,  we conducted an independent assessment of the precautions in place at  each of our selected medical facilities—including the testing of alarm  systems. These assessments were conducted by physical security experts  within our Forensic Audits and Investigative Services team using criteria  based on generally recognized security standards and selected VA security  requirements. Our review of physical security precautions was limited to  only those medical facilities we reviewed and does not represent results  from all VA medical facilities.
We conducted our performance audit from May 2010 through June 2011 in  accordance with generally accepted government auditing standards. Those  standards require that we plan and perform the audit to obtain sufficient,  appropriate evidence to provide a reasonable basis for our findings and  conclusions based on our audit objectives. We believe that the evidence  obtained provides a reasonable basis for our findings and conclusions  based on our audit objectives. We conducted our related investigative  work in accordance with standards prescribed by the Council of the  Inspectors General on Integrity and Efficiency.
subsections: section_title: Background
paragraphs: VHA Central Office has responsibility for monitoring and overseeing both  VISN and medical facility operations, including security precautions. Day- to-day management of medical facilities, including residential and mental  health treatment units, is the responsibility of the VISNs.
subsections: section_title: Residential Programs
paragraphs: VA has 237 residential programs at 104 of its medical facilities. These  programs provide residential rehabilitative and clinical care to veterans  with a range of mental health conditions, including those diagnosed with  post-traumatic stress disorder and substance abuse. VA operates three  types of residential programs in selected medical facilities throughout its  health care system:    Residential rehabilitation treatment programs (RRTP). These programs  provide intensive rehabilitation and treatment services for a range of  mental health conditions in a 24 hours per day, 7 days a week structured  residential environment at a VA medical facility.
Domiciliary programs. In its domiciliaries, VA provides 24 hours per day,   7 days a week, structured and supportive residential environments,  housing, and clinical treatment to veterans. Domiciliary programs may  also contain specialized treatment programs for certain mental health  conditions.
Compensated work therapy/transitional residence (CWT/TR) programs.
These programs are the least intensive residential programs and provide  veterans with community-based housing and therapeutic work-based  rehabilitation services designed to facilitate successful community  reintegration.
section_title: Inpatient Mental Health Units
paragraphs: Most (111) of VA’s 153 medical facilities have at least one inpatient mental  health unit for patients with acute mental health needs. These units are  generally a locked unit or floor within each medical facility, and the size of  these units varies throughout VA. Care on these units is provided 24 hours  per day, 7 days a week, and consists of intensive psychiatric treatment  designed to stabilize veterans and transition them to less intensive levels  of care, such as RRTPs and domiciliary programs. Inpatient mental health  units are required to comply with VHA’s Mental Health Environment of  Care Checklist that specifies several safety requirements for these units,  including several security precautions, such as the use of panic alarm  systems and the security of nursing stations within these units.
section_title: VA’s Two Reporting Streams for Safety Incidents
paragraphs: Safety incidents, including sexual assaults, may be reported to senior  leadership as part of two different streams—a management stream and a  law enforcement stream. The management reporting stream—which  includes reporting responsibilities at the VA medical facility, VISN, and  VHA Central Office levels—is intended to help ensure that incidents are  identified and documented for leadership’s attention. In contrast, the  purpose of the law enforcement stream is to document incidents that may  involve criminal acts so they can be investigated and prosecuted, if  appropriate. VHA policies outline what information staff must report for  each stream and define some mechanisms for this reporting, but medical  facilities have the flexibility to customize and design their own site- specific reporting systems and policies that fit within the broad context of  these requirements. (Fig. 1 summarizes the major steps involved in each  stream.)
Management reporting stream. Reporting responsibilities at each level  for this stream are as follows.
Local VA medical facilities. Local incident reporting is typically handled  through a variety of electronic facility-based systems. It is initiated by the  first staff member who observed or was notified of an incident, who  completes an incident report in the medical facility’s electronic reporting  system that is then reviewed by the medical facility’s quality manager. VA  medical facility leadership is then notified, and is responsible for reporting  serious incidents to the VISN.
VISNs. VA medical facilities can report serious incidents to their VISN  through two mechanisms—issue briefs that document specific factual  information and “heads up” messages that allow medical facility  leadership to provide a brief synopsis of the issue while facts are being  gathered for documentation in an issue brief. VISN offices are typically  responsible for direct reporting to the VHA Central Office.
VHA Central Office. VISNs typically report all serious incidents to the VHA  Office of the Deputy Under Secretary for Health for Operations and  Management, which then communicates relevant incidents to other VHA  offices, including the Office of the Principal Deputy Under Secretary for  Health, through an e-mail distribution list.
Law enforcement reporting stream. Responsibilities at each level are  described below.
Local VA police. Most VA medical facilities have a cadre of VA police  officers, who are federal law enforcement officers charged with protecting  the medical facility by responding to and investigating potentially criminal  activities. Local policies typically require medical facility staff to notify the  medical facility’s VA police of incidents that may involve criminal acts,  such as sexual assaults. VA medical facility police also often notify and  coordinate with local area police departments and the VA OIG when  criminal activities or potential security threats occur.
VA’s OSLE. This office is the department-level VA office responsible for  developing policies and procedures for VA’s law enforcement programs at  local VA medical facilities. VA OSLE receives reports of incidents at VA  medical facilities through its centralized police reporting system.  Additionally, local VA police are required to immediately notify VA OSLE  of serious incidents, including reports of rape and aggravated assaults.
VA’s Integrated Operations Center (IOC). The IOC, established in April  2010, serves as the department’s centralized location for integrated  planning and data analysis on serious incidents. Serious incidents on VA  property are reported to the IOC either by local VA police or the VHA  Office of the Deputy Under Secretary for Health for Operations and  Management. The IOC then presents information on serious incidents to  VA senior leadership officials through daily reports and, in some cases, to  the Secretary through serious incident reports.
VA OIG. Federal regulation requires that all potential felonies, including  rape allegations, be reported to VA OIG investigators. VHA policy  reiterates this by specifying that the OIG must be notified of sexual assault  incidents when the crime occurs on VA premises or is committed by VA  employees. Typically, either the medical facility’s leadership team or VA  police are responsible for reporting potential felonies to the VA OIG.  Once a case is reported, VA OIG investigators can be the lead agency on  the case or advise local VA police or other law enforcement agencies  conducting the investigation.
section_title: Nearly 300 Sexual Assault Incidents Reported to VA Police, but Many Were Not Reported to VHA or the VA OIG
paragraphs: We found that there were nearly 300 sexual assault incidents reported to  the VA police from January 2007 through July 2010—including alleged  incidents that involved rape, inappropriate touching, forceful medical  examinations, forced or inappropriate oral sex, and other types of sexual  assault incidents. Many of these sexual assault incidents were not reported  to officials within the management reporting stream and to the VA OIG.
subsections: section_title: Nearly 300 Sexual Assault Incidents Reported to VA Police From January 2007 Through July 2010
paragraphs: We analyzed VA’s national police files from January 2007 through July  2010 and identified 284 sexual assault incidents reported to VA police  during that period. These cases included incidents alleging rape,  inappropriate touching, forceful medical examinations, oral sex, and other  types of sexual assaults (see table 1). However, it is important to note  that not all sexual assault incidents reported to VA police are  substantiated. A case may remain unsubstantiated because an assault did  not actually take place, the victim chose not to pursue the case, or there  was insufficient evidence to substantiate the case. Due to our review of  both open and closed VA police sexual assault incident investigations, we  could not determine the final disposition of these incidents.
In analyzing these 284 cases, we observed the following:    Overall, the sexual assault incidents described above included several  types of alleged perpetrators, including employees, patients, visitors,  outsiders not affiliated with VA, and persons of unknown affiliation. In the  reports we analyzed, there were allegations of 89 patient-on-patient sexual  assaults, 85 patient-on-employee sexual assaults, 46 employee-on-patient  sexual assaults, 28 unknown affiliation-on-patient sexual assaults, and 15  employee-on-employee sexual assaults.
Regarding gender of alleged perpetrators, we also observed that of the   89 patient-on-patient sexual assault incidents, 46 involved allegations of  male perpetrators assaulting female patients, 42 involved allegations of  male perpetrators assaulting male patients, and 1 involved an allegation of  a female perpetrator assaulting a male patient. Of the 85 patient-on- employee sexual assault incidents, 83 involved allegations of male  perpetrators assaulting female employees and 2 involved allegations of  male perpetrators assaulting male employees.
section_title: Sexual Assault Incidents Are Underreported to VISNs, VHA Central Office, and the VA OIG
paragraphs: VISN and VHA Central Office officials did not receive reports of all sexual  assault incidents reported to VA police in VA medical facilities within the  four VISNs we reviewed. In addition, the VA OIG did not receive reports of  all sexual assault incidents that were potential felonies as required by VA  regulation, specifically those involving rape allegations.
subsections: section_title: VISNs and VHA Central Office Receive Limited Information on Sexual Assault Incidents
paragraphs: VISNs and VHA Central Office leadership officials are not fully aware of  many sexual assaults reported at VA medical facilities. For the four VISNs  we spoke with, we examined all documented incidents reported to VA  police from medical facilities within each network and compared these  reports with the issue briefs received through the management reporting  stream by VISN officials. Based on this analysis, we determined that VISN  officials in these four networks were not informed of most sexual assault  incidents that occurred within their network medical facilities. Moreover,  we also found that one VISN did not report any of the cases they received  to VHA Central Office. (See table 2.)
To examine whether VA medical facilities were accurately reporting  sexual assault incidents involving rape allegations to the VA OIG, we  reviewed the 67 rape allegations reported to the VA police from January  2007 through July 2010 and compared these cases with all investigation  documentation provided by the VA OIG for the same period. We found no  evidence that about two-thirds (42) of these rape allegations had been  reported to the VA OIG. The remaining 25 had matching VA OIG  investigation documentation, indicating that they were correctly reported  to both the VA police and the VA OIG.
By regulation, VA requires that: (1) all criminal matters involving felonies  that occur in VA medical facilities be immediately referred to the VA OIG  and (2) responsibility for the prompt referral of any possible criminal  matters involving felonies lies with VA management officials when they  are informed of such matters. This regulation includes rape in the list of  felonies provided as examples and also requires VA medical facilities to  report other sexual assault incidents that meet the criteria for felonies to  the VA OIG. However, the regulation does not include criteria for how  VA medical facilities and management officials should determine whether  or not a criminal matter meets the felony reporting threshold. We found  that all 67 of these rape allegations were potential felonies because, if  substantiated, sexual assault incidents involving rape fall within federal  sexual offenses that are punishable by imprisonment of more than 1 year.
In addition, we provided the VA OIG the opportunity to review summaries  of the 42 rape allegations we could not confirm were reported to them by  the VA police. To conduct this review, several VA OIG senior-level  investigators determined whether or not each of these rape allegations  should have been reported to them based on what a reasonable law  enforcement officer would consider a felony. According to these  investigators, a reasonable law enforcement officer would look for several  elements to make this determination, including (1) an identifiable and  reasonable suspect, (2) observations by a witness, (3) physical evidence,  or (4) an allegation that appeared credible. These investigators based their  determinations on their experience as federal law enforcement agents.  Following their review, these investigators also found that several of these  rape allegations were not appropriately reported to the VA OIG as required  by federal regulation. Specifically, the VA OIG investigators reported that  they would have expected about one-third (33 percent) of the 42 rape  allegations to have been reported to them based on the incident summary  containing information on these four elements. The investigators noted  that they would not have expected approximately 55 percent of the   42 rape allegations to have been reported to them due to either the  incident summary failing to contain these same four elements or the  presence of inconsistent statements made by the alleged victims. For the  remaining approximately 12 percent, the investigators noted that the need  for notification was unclear because there was not enough information in  the incident summary to make a determination about whether or not the  rape allegation should have been reported to the VA OIG.
section_title: VHA Guidance and Oversight Weaknesses May Contribute to the Underreporting of Sexual Assault Incidents
paragraphs: Several factors may contribute to the underreporting of sexual assault  incidents to VISNs, VHA Central Office, and the VA OIG—including VHA’s  lack of a consistent sexual assault definition for reporting purposes;  limited and unclear expectations for sexual assault incident reporting at  the VHA Central Office, VISN, and VA medical facility levels; and  deficiencies in VHA Central Office oversight of sexual assault incidents.
subsections: section_title: VHA Does Not Have a Consistent Sexual Assault Definition for Reporting Purposes
paragraphs: VHA leadership officials may not receive reports of all sexual assault  incidents that occur at VA medical facilities because there is no VHA-wide  definition of sexual assault used for incident reporting. We found that VHA  lacks a consistent definition for the reporting of sexual assault through the  management reporting stream at the medical facility, VISN, and VHA  Central Office levels. At the medical facility level, we found that the  medical facilities we visited had a variety of definitions of sexual assault  targeted primarily to the assessment and management of victims of recent  sexual assaults. Specifically, facilities varied in the level of detail provided  by their policies, ranging from one facility that did not include a definition  of sexual assault in its policy at all to another facility with a policy that  included a detailed definition. At the VISN level, officials with whom we  spoke in the four networks said they did not have definitions of sexual  assault in VISN policies. Finally, while VHA Central Office does have a  policy for the clinical management of sexual assaults, this policy is  targeted to the treatment of victims assaulted within 72 hours and does not  include sexual assault incidents that occur outside of this time frame. In  addition, no definition of sexual assault is included in VHA Central Office  reporting guidance.
section_title: VHA Central Office, VISNs, and VA Medical Facilities’ Expectations for Reporting Are Limited and Unclear
paragraphs: In addition to failing to provide a consistent definition of sexual assault for  incident reporting, VHA also does not have clearly documented  expectations about the types of sexual assault incidents that should be  reported to officials at each level of the organization, which may also  contribute to the underreporting of sexual assault incidents. Without clear  expectations for incident reporting there is no assurance that all sexual  assault incidents are appropriately reported to officials at the VHA Central  Office, VISN, and local medical facility levels. We found that expectations  were not always clearly documented, resulting in either the  underreporting of some sexual assault incidents or communication  breakdowns at all levels.
VHA Central Office. An official from VHA’s Office of the Deputy Under  Secretary for Health for Operations and Management told us that this  office’s expectations for reporting sexual assault incidents were  documented in its guidance for the submission of issue briefs. However,  we found that this guidance does not specifically reference reporting  requirements for any type of sexual assault incidents. As a result, VISNs  we reviewed did not consistently report sexual assault incidents to VHA  Central Office.
VISNs. Officials from the four VISNs we reviewed did not include detailed  expectations regarding whether or not sexual assault incidents should be  reported to them in their reporting guidance, potentially resulting in  medical facilities failing to report some incidents. For example, officials  from one VISN told us they expect to be informed of all sexual assault  incidents occurring in medical facilities within their network, but this  expectation was not explicitly documented in their policy. We found  several reported allegations of sexual assault incidents in medical facilities  in this VISN—including three allegations of rape and one allegation of  inappropriate oral sex—that were not forwarded to VISN officials.
VA medical facilities. At the medical facility level, we also found that  reporting expectations may be unclear. In particular, we identified cases in  which the VA police had not been informed of incidents that were  reported to medical facility staff. For example, we identified VA police  files from one facility we visited where officers noted that the alleged  perpetrator had been previously involved in other sexual assault incidents  that were not reported to the VA police by medical facility staff. In these  police files, officers noted that staff working in the alleged perpetrators’  units had not reported the previous incidents because they believed these  behaviors were a manifestation of the veterans’ clinical condition. In  addition, at this same medical facility, quality management staff identified  five sexual assault incidents that had not been reported to VA police at the  medical facility, despite these incidents being reported to their office.
section_title: Oversight Deficiencies at VHA Central Office Contribute to the Underreporting of Sexual Assault Incidents
paragraphs: We found weaknesses both in the way sexual assault incidents are  communicated to VHA Central Office and in the way that information  about such incidents is collected and analyzed for oversight purposes.
subsections: section_title: Poor Communication About Sexual Assault Incidents Resulted in Incomplete Reporting Within VHA Central Office
paragraphs: Currently, VHA Central Office relies primarily on e-mail messages to  transfer information about sexual assault incidents among its offices and  staff. (See fig. 2.) Under this system, VHA Central Office is notified of  sexual assault incidents through issue briefs submitted by VISNs via e-mail  to the VHA Office of the Deputy Under Secretary for Health for Operations  and Management. Following review, the Director for Network Support  forwards issue briefs to the Office of the Principal Deputy Under Secretary  for Health for distribution to other VHA offices on a case-by-case basis,  including the program offices responsible for residential programs and  inpatient mental health units. Program offices are sometimes asked to  follow up on incidents in their area of responsibility.
We found that this system did not effectively communicate information  about sexual assault incidents to the VHA Central Office officials who  have programmatic responsibility for the locations in which these  incidents occurred. For example, VHA program officials responsible for  both residential programs and inpatient mental health units reported that  they do not receive regular reports of sexual assault incidents that occur  within their programs or units at VA medical facilities and were not aware  of any incidents that had occurred in these programs or units. However,  during our review of VA police files, we identified at least 18 sexual assault  incidents that occurred from January 2007 through July 2010 in the  residential programs or inpatient mental health units of the five VA  medical facilities we reviewed. If the management reporting stream were  functioning properly, these program officials should have been notified of  these incidents and any others that occurred in other VA medical facilities’  residential programs and inpatient mental health units. Without the  regular exchange of information regarding sexual assault incidents that  occur within their areas of programmatic responsibility, VHA program  officials cannot effectively address the risks of such incidents in their  programs and units and do not have the opportunity to identify ways to  prevent incidents from occurring in the future.
In early 2011, VHA leadership officials told us that initial efforts, including  sharing information about sexual assault incidents with the Women  Veterans Health Strategic Health Care Group and VHA program offices,  were underway to improve how information on sexual assault incidents is  communicated to program officials. However, these improvements have  not been formalized within VHA or published in guidance or policies and  are currently being performed on an informal ad hoc basis only, according  to VHA officials.
section_title: VHA Does Not Systematically Monitor and Track Sexual Assault Incidents
paragraphs: In addition to deficiencies in information sharing, we also identified  deficiencies in the monitoring of sexual assault incidents within VHA  Central Office. VHA’s Office of the Deputy Under Secretary for Health for  Operations and Management, the first VHA office to receive all issue briefs  related to sexual assault incidents, does not currently have a system that  allows VHA Central Office staff to systematically collect or analyze reports  of sexual assault incidents received from VA medical facilities through the  management reporting stream. Specifically, we found that this office does  not have a central database to store the issue briefs that it receives and  instead relies on individual staff to save issue briefs submitted to them by  e-mail to electronic folders for each VISN. In addition, officials within this  office said they do not know the total number of issue briefs submitted for  sexual assault incidents because they do not have access to all former staff  members’ files. As a result of these issues, staff from the Office of the  Deputy Under Secretary for Health for Operations and Management could  not provide us with a complete set of issue briefs on sexual assault  incidents that occurred in all VA medical facilities without first contacting  VISN officials to resubmit these issue briefs. Such a limited archive  system for reports of sexual assault incidents received through the  management reporting stream results in VHA’s inability to track and trend  sexual assault incidents over time. While VHA has, through its National  Center for Patient Safety (NCPS), developed systems for routinely  monitoring and tracking patient safety incidents that occur in VA medical  facilities, these systems do not monitor sexual assaults and other safety  incidents. Without a system to track and trend sexual assaults and other  safety incidents, VHA Central Office cannot identify and make changes to  serious problems that jeopardize the safety of veterans in their medical  facilities.
section_title: Serious Weaknesses Observed in Several Types of Physical Security Precautions Used in Selected Medical Facilities
paragraphs: Physical precautions in the residential programs and inpatient mental  health units at the medical facilities we visited included monitoring  precautions used to observe patients, security precautions used to  physically secure facilities and alert staff of problems, and staff awareness  and preparedness precautions used to educate staff about security issues  and provide police assistance. However, we found serious deficiencies in  the use and implementation of certain physical security precautions at  these facilities, including alarm system malfunctions and inadequate  monitoring of security cameras.
subsections: section_title: Several Types of Physical Security Precautions Are in Place in Selected Medical Facilities
paragraphs: VA medical facilities we visited used a variety of physical security  precautions to prevent safety incidents in their residential programs and  inpatient mental health units. Typically, medical facilities had discretion to  implement these precautions based on their own needs within broad VA  guidelines.
In general, physical security precautions were used as a measure to  prevent a broad range of safety incidents, including sexual assaults. We  classified these precautions into three broad categories: monitoring  precautions, security precautions, and staff awareness and preparedness  precautions. (See table 3.)
Monitoring precautions. These measures were those designed to observe  and track patients and activities in residential and inpatient settings. For  example, at some VA medical facilities we visited, closed-circuit  surveillance cameras were installed to allow VA staff to monitor areas and  to help detect potentially threatening behavior or safety incidents as they  occur. Cameras were also used to passively document any incidents that  occurred.
Security precautions. These precautions were those designed to maintain  a secure environment for patients and staff within residential programs  and inpatient mental health units and allow staff to call for help in case of  any problems. For example, the units we visited regularly used locks and  alarms at entrance and exit access points, as well as locks and alarms for  some patient bedrooms. Another security precaution we observed was the  use of stationary, computer-based, and portable personal panic alarms for  staff.
Staff awareness and preparedness precautions. These measures were  designed to educate and prepare residential program and inpatient mental  health unit staff to deal with security issues and to provide police support  and assistance when needed. For example, there was a regular VA police  presence within some residential programs we visited. Also, all medical  facilities we visited had a functioning police command and control center,  which program staff could contact for police support when needed.
section_title: Significant Weaknesses Existed in the Use and Implementation of Certain Physical Security Precautions at Selected VA Medical Facilities
paragraphs: While security precautions have been established in most cases to prevent  patient safety incidents, including sexual assaults, these precautions had  not been effectively implemented by VA medical facility staff in the five  facilities we visited. During our review of the physical security precautions  in use at the five VA medical facilities we visited, we observed seven  weaknesses in these three categories. (See table 4.)
Inadequate monitoring of closed-circuit surveillance cameras. We  observed that VA staff in the police command and control center were not  continuously monitoring closed-circuit surveillance cameras at all five of  the VA medical facilities we visited. For example, at one medical facility,  the system used by the residential programs at that medical facility could  not be monitored by the police command and control center staff because  it was incompatible with systems installed in other parts of the medical  facility. According to VA police at this medical facility, the residential  program staff did not consult with VA police before installing their own  system. At another medical facility, where staff in the police office monitor  cameras covering the residential programs’ grounds and parking area, we  found that the police office was unattended part of the time. In addition, at  the remaining three medical facilities we visited, staff in the police  command and control centers assigned to monitor medical facility  surveillance cameras had other duties, such as serving as telephone  operators and police/emergency dispatchers. These other duties  sometimes prevented them from continuously monitoring the camera  feeds in the police command and control center. Although effective use  of surveillance camera systems cannot necessarily prevent safety incidents  from occurring, lapses in monitoring by security staff compromise the  effectiveness of these systems.
Alarm malfunctions. At least one form of alarm failed to work properly  when tested at four of the five medical facilities we visited. For example,  at one medical facility, we tested the portable personal panic alarms used  by residential program staff and found that the police command and  control center could not accurately pinpoint the location of the tester  when an alarm was activated outside the building. At another medical  facility that used stationary panic alarms in inpatient mental health units,  residential programs, and other clinical settings, almost 20 percent of  these alarms throughout the medical facility were inoperable. At an  inpatient mental health unit in a third medical facility, three of the  computer-based panic alarms we tested failed to properly pinpoint the  location of our tester because the medical facility’s computers had been  moved to different locations and were not properly reconfigured. Finally,  at a fourth medical facility, alarms we tested in the inpatient mental health  unit sounded properly, but staff in the unit and VA police responsible for  testing these alarms did not know how to turn them off after they were  activated. In each of the cases where alarms malfunctioned, VA staff were  not aware the alarms were not functioning properly until we informed  them.
Inadequate documentation or review of alarm system testing. One  of the five sites we visited failed to properly document tests conducted of  their alarm systems for their residential programs, although testing of  alarms is a required element in VA’s Environment of Care Checklist.  Testing of alarm systems is important to ensure that systems function  properly, and not having complete documentation of alarm system testing  is an indication that periodic testing may not be occurring. In addition,  three medical facilities reported using computer-based panic alarms that  are designed to be self-monitoring to identify cases where computers  equipped with the system fail to connect with the servers monitoring the  alarms. Officials at all three of these medical facilities stated that due to  the self-monitoring nature of these alarms, they did not maintain alarm test  logs of these systems. However, we found that at two of these three  medical facilities, these alarms failed to properly alert VA police when  tested. Such alarm system failures indicate that the self-monitoring  systems may not be effectively alerting medical facility staff of alarm  malfunctions when they occur, indicating the need for these systems to be  periodically tested.
Alarms failed to alert both police and unit staff. In inpatient mental  health units at all five medical facilities we visited, stationary and  computer-based panic alarm systems we tested did not alert staff in both  the VA police command and control center and the inpatient mental health  unit where the alarm was triggered. Alerting both locations is important to  better ensure that timely and proper assistance is provided. At four of  these medical facilities, the inpatient mental health units’ stationary or  computer-based panic alarms notified the police command and control  centers but not staff at the nursing stations of the units where the alarms  originated. At the fifth medical facility, the stationary panic alarms only  notified staff in the unit nursing station, making it necessary to separately  notify the VA police. Finally, none of the stationary or computer-based  panic alarms used by residential programs notified both the police  command and control centers and staff within the residential program  buildings when tested.
Limited use of portable personal panic alarms. Electronic portable  personal panic alarms were not available for the staff at any of the  inpatient mental health units we visited and were available to staff at only  one residential program we reviewed. In two of the inpatient mental health  units we visited, staff were given safety whistles they could use to signal  others in cases of emergency, personal distress, or concern about veteran  or staff safety. However, relying on whistles to signal such incidents may  not be effective, especially when staff members are the victims of assault.  For example, a nurse at one medical facility we visited was involved in an  incident in which a patient grabbed her by the throat and she was unable  to use her whistle to summon assistance. Some inpatient mental health  unit staff with whom we spoke indicated an interest in having portable  personal panic alarms to better protect them in similar situations.
VA police staffing and workload challenges. At most medical facilities  we visited, VA police forces and police command and control centers were  understaffed, according to medical facility officials. For example, during  our visit to one medical facility, VA police officials reported being able to  staff just two officers per 12-hour shift to patrol and respond to incidents  at both the medical facility and at a nearby 675-acre veteran’s cemetery.  While this staffing ratio met the minimum standards for VA police staffing,  having only two police officers to cover such a large area could potentially  increase the response times should a panic alarm activate or other security  incident occur on medical facility grounds. Also, we found that there was  an inadequate number of officers and staff at this medical facility to  effectively police the medical facility and maintain a productive police  force. The medical facility had a total of 9 police officers at the time of our  visit; according to VA staffing guidance, the minimum staffing level for this  medical facility should have been 19 officers. Not all medical facilities we  visited had staffing problems. At one medical facility, the VA police  appeared to be well staffed and were even able to designate staff to  monitor off-site residential programs and community-based outpatient  clinics.
Lack of stakeholder involvement in unit redesign. As medical  facilities undergo remodeling, it is important that stakeholders are  consulted in the design process to better ensure that new or remodeled  areas are both functional and safe. We found that such stakeholder  involvement on remodeling projects had not occurred at one of the  medical facilities we visited. At this medical facility, clinical and VA police  personnel were not consulted about a redesign project for the inpatient  mental health unit. The new unit initially included one nursing station that  did not prevent patient access if necessary. After the unit was reopened  following the renovation, there were a number of assaults, including an  incident where a veteran reached over the counter of the unit’s nursing  station and physically assaulted a nurse by stabbing her in the neck,  shoulder, and leg with a pen. Had staff been consulted on the redesign of  this unit, their experience managing veterans in an inpatient mental health  unit environment would have been helpful in developing several safety  aspects of this new unit, including the design of the nursing station. Less  than a year after opening this unit, medical facility leadership called for a  review of the units’ design following several reported incidents. As a result  of this review, the unit was split into two separate units with different  veteran populations, an additional nursing station was installed, and  changes were planned for the structure of both the original and newly  created nursing stations—including the installation of a new shoulder- height plexiglass barricade on both nursing station counters.
In conclusion, weaknesses exist in the reporting of sexual assault  incidents and in the implementation of physical precautions used to  prevent sexual assaults and other safety incidents in VA medical facilities.  Medical facility staff are uncertain about what types of sexual assault  incidents should be reported to VHA leadership and VA law enforcement  officials and prevention and remediation efforts are eroded by failing to  tap the expertise of these officials. These officials can offer valuable  suggestions for preventing and mitigating future sexual assault incidents  and help address broader safety concerns through systemwide  improvements throughout the VA healthcare system. Leaving reporting  decisions to local VA medical facilities—rather than relying on VHA  management and VA OIG officials to determine what types of incidents  should be reported based on the consistent application of known  criteria—increases the risk that some sexual assault incidents may go  unreported. Moreover, uncertainty about sexual assault incident reporting  is compounded by VA not having: (1) established a consistent definition of  sexual assault, (2) set clear expectations for the types of sexual assault  incidents that should be reported to VISN and VHA Central Office  leadership officials, and (3) maintained proper oversight of sexual assault  incidents that occurred in VA medical facilities. Unless these three key  features are in place, VHA will not be able to ensure that all sexual assault  incidents will be consistently reported throughout the VA health care  system. Specifically, the absence of a centralized tracking system to  monitor sexual assault incidents across VA medical facilities may seriously  limit efforts to both prevent such incidents in the short and long term and  maintain a working knowledge of past incidents and efforts to address  them when staff transitions occur.
In addition, ensuring that medical facilities maintain a safe and secure  environment for veterans and staff in residential programs and inpatient  mental health units is critical and requires commitment from all levels of  VA. Currently, the five VA medical facilities we visited are not adequately  monitoring surveillance camera systems, maintaining the integrity of alarm  systems, and ensuring an adequate police presence. Closer oversight by  both VISNs and VHA Central Office staff is needed to provide a safe and  secure environment throughout all VA medial facilities.
To improve VA’s reporting and monitoring of allegations of sexual assault,  we are making numerous recommendations—in a report that we issued  last week. We recommended VA improve the reporting and monitoring of  sexual assault incidents, including ensuring that a consistent definition of  sexual assault is used for reporting purposes, clarifying expectations for  reporting incidents to VISN and VHA leadership, and developing and  implementing mechanisms for incident monitoring. To address  vulnerabilities in physical security precautions at VA medical facilities, we  recommended that VA ensure that alarm systems are regularly tested and  kept in working order and that coordination among stakeholders occurs  for renovations to units and physical security features at VA medical  facilities.
In responding to a draft of the report on which this testimony is based, VA  generally agreed with the report’s conclusions and concurred with our  recommendations. In addition, VA provided an action plan, which  described the creation of a multidisciplinary workgroup to manage the  agency’s response to many of our recommendations. According to VA’s  comments, this workgroup will provide the Under Secretary for Health  and his deputies with monthly verbal updates on its progress, as well as an  initial action plan by July 15, 2011, and a final report by September 30,  2011.
Chairwoman Buerkle, Ranking Member Michaud, and Members of the  Subcommittee, this concludes my prepared statement. I would be happy to  respond to any questions either of you or other Members of the  Subcommittee may have.
section_title: Contacts and Acknowledgments
paragraphs: For further information about this testimony, please contact Randall B.  Williamson at (202) 512-7114 or williamsonr@gao.gov. Contact points for  our Offices of Congressional Relations and Public Affairs may be found on  the last page of this testimony. Individuals who made key contributions to  this testimony include Marcia A. Mann, Assistant Director; Emily  Goodman; Katherine Nicole Laubacher; and Malissa G. Winograd.
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