VA Health Care: Actions Needed to Prevent Sexual Assaults and Other Safety Incidents
Published: 2011-06-07T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Changes in patient demographics present unique challenges for VA in providing safe environments for all veterans treated in Department of Veterans Affairs (VA) facilities. GAO was asked to examine whether or not sexual assault incidents are fully reported and what factors may contribute to any observed underreporting, how facility staff determine sexual assault-related risks veterans may pose in residential and inpatient mental health settings, and precautions facilities take to prevent sexual assaults and other safety incidents. GAO reviewed relevant laws, VA policies, and sexual assault incident documentation from January 2007 through July 2010 provided by VA officials and the VA Office of the Inspector General (OIG). In addition, GAO visited and reviewed portions of selected veterans' medical records at five judgmentally selected VA medical facilities chosen to ensure the residential and inpatient mental health units at the facilities varied in size and complexity. Finally, GAO spoke with the four Veterans Integrated Service Networks (VISN) that oversee these VA medical facilities.
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 OIG. Specifically, for the four VISNs GAO spoke with, VISN and VA Central Office officials did not receive reports of most sexual assault incidents reported to the VA police. Also, nearly two-thirds of sexual assault incidents involving rape allegations originating in VA facilities were not reported to the VA OIG, as required by VA regulation. In addition, GAO identified several factors that may contribute to the underreporting of sexual assault incidents including unclear guidance and deficiencies in VA's oversight. VA does not have risk assessment tools designed to examine sexual assaultrelated risks veterans may pose. Instead, VA staff at the residential programs and inpatient mental health units GAO visited said they examine information about veterans' legal histories along with other personal information as part of a multidisciplinary assessment process. VA clinicians reported that they obtain legal history information directly from veterans, but these self-reported data are not always complete or accurate. In reviewing selected veterans' medical records, GAO found that complete legal history information was not always documented. In addition, VA has not provided clear guidance on how such legal history information should be collected or documented. VA facilities GAO visited used a variety of precautions intended to prevent sexual assaults and other safety incidents; however, GAO found some of these measures were deficient, compromising facilities' efforts to prevent sexual assaults and other safety incidents. For example, facilities often used patientoriented precautions, such as placing electronic flags on high-risk veterans' medical records or increasing staff observation of veterans who posed risks to others. These VA facilities also used physical security precautions--such as closed-circuit surveillance cameras to actively monitor units, locks and alarms to secure key areas, and police assistance when incidents occurred. These physical precautions were intended to prevent a broad range of safety incidents, including sexual assaults, through monitoring patients and activities, securing residential programs and inpatient mental health units, and educating staff about security issues and ways to deal with them. However, GAO found significant weaknesses in the implementation of these physical security precautions at these VA facilities, including poor monitoring of surveillance cameras, alarm system malfunctions, and the failure of alarms to alert both VA police and clinical staff when triggered. Inadequate system installation and testing procedures contributed to these weaknesses. Further, facility officials at most of the locations GAO visited said the VA police were understaffed. Such weaknesses could lead to delayed response times to incidents and seriously erode efforts to prevent or mitigate sexual assaults and other safety incidents.
section_title: What GAO Recommends
paragraphs: GAO recommends that VA improve both the reporting and monitoring of sexual assault incidents and the tools used to identify risks and address vulnerabilities at VA facilities. VA concurred with GAO's recommendations and provided an action plan to address them.

section_title: Letter
paragraphs: The Department of Veterans Affairs (VA) has developed a number of  initiatives in recent years designed to increase veterans’ use of VA medical  facilities throughout the nation. These initiatives have targeted several  specific veteran populations—including women veterans, young veterans  from the military operations in Iraq and Afghanistan, and veterans facing  legal issues or those currently incarcerated. Such outreach initiatives have  increased the number of veterans from these specific populations  participating in residential and inpatient mental health care programs at  VA medical facilities and have changed the demographics of patients cared  for by VA.
Such changes in patient demographics along with the department’s  commitment to providing health care services to all eligible veterans  present unique challenges for VA both in providing and maintaining  accessible care and keeping veterans and staff safe in VA medical  facilities, including those that treat veterans suffering from mental health  conditions. During our recent work on services available for women  veterans in VA medical facilities, several clinicians raised concerns about  the safety of women veterans in mental health programs at one VA medical  facility. For example, these clinicians raised concerns about the safety of  women veterans in a VA residential mental health facility that housed both  women veterans and veterans who had committed sexual crimes in the  past. Clinicians also expressed concerns about women veterans receiving  treatment in the inpatient mental health units of this VA medical facility  because they did not feel adequate safety precautions were in place to  protect women admitted to these units.
These concerns highlight the importance of VA having both effective  security precautions in place at its medical facilities, especially those with  residential and inpatient mental health programs, and a consistent way to  exchange information and facilitate discussions about safety incidents,  including sexual assault incidents. VA has policies in place regarding  security precautions in residential and inpatient mental health settings and  procedures for reporting and analyzing patient safety incidents through its  National Center for Patient Safety (NCPS). For example, VA requires that  residential and inpatient mental health facilities conduct periodic reviews  of the security precautions in use in these settings. Also, VA’s NCPS has  established procedures for medical facilities to report patient safety  incidents that occur in these facilities to leadership officials.
You asked us to examine: (1) VA’s processes for reporting sexual assault  incidents and the volume of these incidents reported in recent years;   (2) the extent to which sexual assault incidents are fully reported and  what factors may contribute to any observed underreporting; (3) how  medical facility staff determine sexual assault-related risks veterans may  pose in residential and inpatient mental health settings; and (4) the  precautions in place in residential and inpatient mental health settings to  prevent sexual assaults and other safety incidents and any weaknesses in  these precautions.
To examine VA’s processes for reporting sexual assault incidents, the  volume of these incidents reported in recent years, the extent to which  these incidents were fully reported, and factors that may contribute to any  observed underreporting, we reviewed relevant VA and Veterans Health  Administration (VHA) policies, handbooks, directives, and other guidance  documents on the reporting of safety incidents. We also interviewed VA  and VHA Central Office officials involved with the reporting of safety  incidents—including officials with VA’s Office of Security and Law  Enforcement (OSLE), VHA’s Office of the Deputy Under Secretary for  Health for Operations and Management, and VHA’s Office of the Principal  Deputy Under Secretary for Health. 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 medical facility leadership officials and  residential and inpatient mental health unit managers and staff to discuss  their experiences with reporting sexual assault incidents. We also spoke  with officials from the four Veterans Integrated Service Networks (VISN)  responsible for managing the five selected medical facilities to discuss  their expectations, policies, and procedures for reporting sexual assault  incidents. Information obtained from these VISNs and VA medical  facilities cannot be generalized to all VISNs and VA medical facilities. In  addition, we interviewed officials from the VA Office of the Inspector  General’s (OIG) Office of Investigations—Criminal Investigations  Division—to discuss information they receive from VA medical facilities  about sexual assault incidents that occur in these facilities. Finally, we  reviewed documentation of reported sexual assault incidents at VA  medical facilities provided by VA’s OSLE, the VA OIG, and VISNs from  January 2007 through July 2010, to determine the number and types of  incidents reported, as well as which VA and VHA offices were notified of  those incidents. For this analysis, we used a definition of sexual assault  that was developed for the purpose of this report. Our analysis of VA  police and VA OIG reports was limited to only those incidents that were  reported and cannot be used to project the volume of sexual assault  incident reports that may occur in future years. Following verification that  VA police and VA OIG incidents met our definition of sexual assault and  comparisons of sexual assault incidents reported by the two groups within  VA, we found data derived from these reports to be sufficiently reliable for  our purposes.
To examine how medical facility staff determine sexual assault-related  risks veterans may pose, we reviewed: (1) relevant VA and VHA policies  and procedures and (2) risk assessment policies and procedures from our  judgmentally selected sample of VISNs and VA medical facilities’  residential and inpatient mental health units. We also interviewed VA,  VHA, VISN, and VA medical facility leadership officials and residential and  inpatient mental health unit managers and staff regarding the assessment  of risks. Finally, to inform our understanding of information collected  during this process, we reviewed selected portions of medical records for  all veterans at our selected medical facilities who were registered in the  state’s publicly available sex offender registry and had addresses matching  the selected medical facilities’ residential or inpatient mental health units.  Our review of these records was limited to only those veterans meeting  these criteria and should not be generalized to broader VA patient  populations.
Finally, to examine the precautions in place to prevent sexual assaults and  other safety incidents, we reviewed relevant VA, VHA, VISN, and selected  medical facility policies related to the security of residential and inpatient  mental health programs. We also interviewed VA, VHA, VISN, and selected  medical facility officials about the precautions in place to prevent sexual  assault incidents and other violent activities in the residential and  inpatient mental health units. Finally, to assess any weaknesses in physical  security precautions at the VA medical facilities selected for this review,  we conducted an independent assessment of the precautions in place at  each of our selected medical facilities—including the testing of alarm  systems. These assessments were conducted by physical security experts  within our Forensic Audits and Investigative Services team using criteria  based on generally recognized security standards and selected VA security  requirements. Our review of physical security precautions was limited to  only those medical facilities we reviewed and does not represent results  from all VA medical facilities. For additional details about the scope and  methodology used in this report, see appendix I.
We conducted our performance audit from May 2010 through June 2011 in  accordance with generally accepted government auditing standards. Those  standards require that we plan and perform the audit to obtain sufficient,  appropriate evidence to provide a reasonable basis for our findings and  conclusions based on our audit objectives. We believe that the evidence  obtained provides a reasonable basis for our findings and conclusions  based on our audit objectives. We conducted our related investigative  work in accordance with standards prescribed by the Council of the  Inspectors General on Integrity and Efficiency.
subsections: section_title: Background
paragraphs: VHA oversees VA’s health care system, which includes 153 medical  facilities organized into 21 VISNs. VISNs are charged with the day-to-day  management of the medical facilities within their network; however, VHA  Central Office maintains responsibility for monitoring and overseeing both  VISN and medical facility operations. These oversight functions are  housed within several offices within VHA, including the Office of the  Deputy Under Secretary for Health for Operations and Management and  the Office of the Principal Deputy Under Secretary for Health.
subsections: section_title: Residential Programs
paragraphs: The 237 residential programs in place in 104 VA medical facilities provide  residential rehabilitative and clinical care to veterans with a range of  mental health conditions. VA operates three types of residential programs  in selected medical facilities throughout its health care system:    Residential rehabilitation treatment programs (RRTP). These programs  provide intensive rehabilitation and treatment services for a range of  mental health conditions in a 24 hours per day, 7 days a week structured  residential environment at a VA medical facility. There are several types of  RRTPs throughout VA’s health care system that specialize in offering  programs for the treatment and management of certain mental health  conditions—such as post-traumatic stress disorder (PTSD) and substance  abuse.
Domiciliary programs. In its domiciliaries, VA provides 24 hours per day,   7 days a week structured and supportive residential environments,  housing, and clinical treatment to veterans. Domiciliary programs may  also contain specialized treatment programs for certain mental health  conditions.
Compensated work therapy/transitional residence (CWT/TR) programs.
These programs are the least intensive residential programs and provide  veterans with community based housing and therapeutic work-based  rehabilitation services designed to facilitate successful community  reintegration.
Security measures that must be in place at all three types of residential  programs are governed by VHA’s Mental Health RRTP Handbook. Among  the security precautions that must be in place for residential programs are  secure accommodations for women veterans and periodic assessments of  facility safety and security features.
section_title: Inpatient Mental Health Units
paragraphs: Most (111) of VA’s 153 medical facilities have at least one inpatient mental  health unit that provides intensive treatment for patients with acute  mental health needs. These units are generally a locked unit or floor within  each medical facility, though the size of these units varies throughout VA.  Care on these units is provided 24 hours per day, 7 days a week, and is  intensive psychiatric treatment designed to stabilize veterans and  transition them to less intensive levels of care, such as RRTPs and  domiciliary programs. Inpatient mental health units are required to comply  with VHA’s Mental Health Environment of Care Checklist that specifies  several safety requirements for these units, including several security  precautions, such as the use of panic alarm systems and the security of  nursing stations within these units.
section_title: Mental Health Admission Screening and Assessment
paragraphs: The admissions processes for both VA residential programs and inpatient  mental health units require several assessments that are conducted by an  interdisciplinary team—including nursing staff, social workers, and  psychologists. One of the commonly used assessments is a comprehensive  biopsychosocial assessment. In residential programs, these assessments  are required to be completed within 5 days of admission and include the  collection of veterans’ medical, psychiatric, social, developmental, legal,  and abuse histories along with other key information. These  biopsychosocial assessments aid in the development of individualized  treatment plans based on each veteran’s individual needs. For inpatient  mental health units, initial screening of veterans, including the initial  biopsychosocial assessment, often takes place outside the unit in another  area of the medical facility where the veteran first presents for treatment,  such as the emergency room or a mental health outpatient clinic. Veterans  admitted to inpatient mental health units are typically reassessed more  frequently than veterans admitted to residential programs due to their  instability at the time of admission.
section_title: VA Law Enforcement Resources
paragraphs: VA’s OSLE is the department-level office within VA Central Office  responsible for developing policies and procedures for VA’s law  enforcement programs at local VA medical facilities. Most VA medical  facilities have a cadre of VA police officers who are federal law  enforcement officers who report to the medical facility’s director. These  officers are charged with protecting the medical facility by responding to  and investigating potentially criminal activities reported by staff, patients,  and others within the medical facility and completing police reports about  these investigations. VA medical facility police often notify and coordinate  with other law enforcement entities, including local area police  departments and the VA OIG, when criminal activities or potential security  threats occur.
The VA OIG has investigators throughout the nation who also conduct  investigations of criminal activities affecting VA operations, including  reported cases of sexual assault. By regulation, all potential felonies,  including rape allegations, must be reported to VA OIG investigators.  Once a case is reported, VA OIG investigators can either serve as the lead  agency on the case or offer to serve as advisors to local VA police or other  law enforcement agencies conducting an investigation of the issue.
In April 2010, VA established an Integrated Operations Center (IOC) that  serves as the department’s centralized location for integrated planning and  data analysis on serious incidents. The VA IOC requires incidents—  including sexual assaults—that are likely to result in media or  congressional attention be reported to the IOC within 2 hours of the  incident. The IOC then presents information on serious incidents to VA  senior leadership officials, including the Secretary in some cases.
section_title: Nearly 300 Sexual Assault Incidents Were Reported Since 2007 through One of Two VA Reporting Streams
paragraphs: VA has two concurrent reporting streams—a management stream and a  law enforcement stream—for communicating sexual assaults and other  safety incidents to senior leadership officials. The management stream  identifies and documents incidents for leadership’s attention. The law  enforcement stream documents incidents that may involve criminal acts  for investigation and prosecution, when appropriate. We found that there  were nearly 300 sexual assault incidents reported through the law  enforcement stream to the VA police from January 2007 through July  2010—including alleged incidents that involved rape, inappropriate  touching, forceful medical examinations, forced or inappropriate oral sex,  and other types of sexual assault incidents. Finally, we could not  systematically analyze sexual assault incident reports received through  VA’s management stream due to the lack of a centralized VA management  reporting system.
subsections: section_title: VA Uses Two Reporting Streams for Communicating Incidents to Management and Law Enforcement
paragraphs: Policies and processes are in place for documenting and communicating  sexual assaults and other safety incidents to VHA management and VA law  enforcement officials. VHA policies outline what information staff must  report and define some mechanisms for this reporting, but medical  facilities have the flexibility to customize and design their own site- specific reporting systems and policies that fit within the broad context of  these requirements.
VA’s structure for reporting sexual assaults and other safety incidents  involves two concurrent reporting streams—the management stream and  the law enforcement stream. This dual reporting process is intended to  ensure that both relevant medical facility leadership and law enforcement  officials are informed of incidents and can perform their own separate  investigations. (See fig. 1 for an illustration of the reporting structure for  sexual assaults and other safety incidents.) The reporting processes  described below may vary slightly throughout VA medical facilities due to  local medical facility policies and procedures.
Management reporting stream. This stream—which includes reporting  responsibilities at the local medical facility, VISN, and VHA Central Office  levels—is intended to help ensure that incidents are identified and  documented for leadership’s attention.
Local VA medical facilities. Local incident reporting is the first step in  communicating safety issues, including sexual assault incidents, to VISN  and VHA Central Office officials and was handled through a variety of  electronic facility based systems at the medical facilities we visited. The  processes were similar in all five medical facilities we visited and were  initiated by the first staff member who observed or was notified of an  incident completing an incident report in the medical facility’s electronic  reporting system. The medical facility’s quality manager then reviewed the  electronic report, while the staff member was responsible for  communicating the incident through his or her immediate supervisor or  unit manager. VA medical facility leadership at the locations we visited  reported that they are informed of incidents at morning meetings or  through immediate communications, depending on the severity of the  incident. Medical facility leadership officials are responsible for reporting  serious incidents to the VISN.
VISNs. Officials in network offices we reviewed told us that their medical  facilities primarily report serious incidents to their offices through two  mechanisms—issue briefs and “heads up” messages. Issue briefs  document specific factual information and are forwarded from the medical  facility to the VISN. Heads up messages are early notifications designed to  allow medical facility and VISN leadership to provide a brief synopsis of  the issue while facts are being gathered for documentation in an issue  brief. VISN offices are typically responsible for direct reporting to the VHA  Central Office.
VHA Central Office. An official in the VHA Office of the Deputy Under  Secretary for Health for Operations and Management said that VISNs  typically report all serious incidents to this office. This office then  communicates relevant incidents to other VHA offices, including the Office  of the Principal Deputy Under Secretary for Health, through an e-mail  distribution list.
Law enforcement reporting stream. The purpose of this stream is to  document incidents that may involve criminal acts so they can be  investigated and prosecuted, if appropriate. The law enforcement  reporting stream involves local VA police, VA’s OSLE, VA’s IOC, and the  VA OIG.
Local VA police. At the medical facilities we visited, local policies require  medical facility staff to notify the medical facility’s VA police of incidents  that may involve criminal acts, such as sexual assaults. According to VA  officials, when VA police officers observe or are notified of an incident  they are required to document the allegation in VA’s centralized police  reporting system.
VA’s OSLE. This office receives reports of incidents at VA medical  facilities through its centralized police reporting system. Additionally,  local VA police are required to immediately notify VA OSLE of serious  incidents, including reports of rape and aggravated assaults.
VA’s IOC. Serious incidents on VA property—those that result in serious  bodily injury, including sexual assaults—are reported to the IOC either by  local VA police or the VHA Office of the Deputy Under Secretary for  Health for Operations and Management. Incidents reported to the IOC are  communicated to the Secretary of VA through serious incident reports and  to other senior staff through daily reports.
VA OIG. Federal regulation requires that all potential felonies, including  rape allegations, be reported to VA OIG investigators. In addition, VHA  policy reiterates this requirement by specifying that the OIG must be  notified of sexual assault incidents when the crime occurs on VA premises  or is committed by VA employees. At the VA medical facilities we visited,  officials told us that either the medical facility’s leadership team or VA  police are responsible for reporting all incidents that are potential felonies  to the VA OIG. The VA OIG may also learn of incidents from staff, patients,  congressional communications, or the VA OIG hotline for reporting fraud,  waste, and abuse. When the VA OIG is notified of a potential felony, their  investigators document both their contact with medical facility officials or  other sources and the initial case information they receive.
section_title: Nearly 300 Sexual Assault Incidents Reported to VA Police through the Law Enforcement Stream Since 2007
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 (see app. II for  additional analysis of VA police reports):    Overall, the sexual assault incidents described above included several  types of alleged perpetrators, including employees, patients, visitors,  outsiders not affiliated with VA, and persons of unknown affiliation. In the  reports we analyzed, there were allegations of 89 patient-on-patient sexual  assaults, 85 patient-on-employee sexual assaults, 46 employee-on-patient  sexual assaults, 28 unknown affiliation-on-patient sexual assaults, and   15 employee-on-employee sexual assaults.
Regarding gender of alleged perpetrators, we also observed that of the   89 patient-on-patient sexual assault incidents, 46 involved allegations of  male perpetrators assaulting female patients, 42 involved allegations of  male perpetrators assaulting male patients, and 1 involved an allegation of  a female perpetrator assaulting a male patient. Of the 85 patient-on- employee sexual assault incidents, 83 involved allegations of male  perpetrators assaulting female employees and 2 involved allegations of  male perpetrators assaulting male employees.
We could not systematically analyze sexual assault incidents reported  through VA’s management stream due to the lack of a centralized VA  management reporting system for tracking sexual assaults and other  safety incidents.
section_title: Not All Sexual Assault Incidents Are Reported Due to Unclear Guidance and Insufficient Oversight
paragraphs: Despite the VA police receiving reports of nearly 300 sexual assault  incidents since 2007, sexual assault incidents are underreported to  officials within the management reporting stream and the VA OIG. Factors  that may contribute to the underreporting of sexual assault incidents  include the lack of both a clear definition of sexual assault and  expectations on what incidents should be reported, as well as deficient  VHA Central Office oversight of sexual assault incidents.
subsections: section_title: Sexual Assault Incidents Are Underreported to VISNs, VHA Central Office, and the VA OIG
paragraphs: Sexual assault incidents are underreported to both VHA officials at the  VISN and VHA Central Office levels and the VA OIG. Specifically, VISN and  VHA Central Office officials did not receive reports of all sexual assault  incidents reported to VA police in VA medical facilities within the four  VISNs we reviewed. In addition, the VA OIG did not receive reports of all  sexual assault incidents that were potential felonies as required by VA  regulation, specifically those involving rape allegations.
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 reviewed all documented incidents reported to VA  police from medical facilities within each network and compared these  reports with the issue briefs received through the management reporting  stream by VISN officials. Based on this analysis, we determined that VISN  officials in these four networks were not informed of most sexual assault  incidents that occurred within their network medical facilities. Moreover,  we also found that one VISN did not report all 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 both the 67 rape allegations reported to the VA police from  January 2007 through July 2010 and all investigation documentation  provided by the VA OIG for the same period. We found no evidence that  about two-thirds (42) of these rape allegations had been reported to the  VA OIG. 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 approximately 33 percent of the 42 rape  allegations to have been reported to them based on the incident summary  containing information on these four elements. The investigators noted  that they would not have expected approximately 55 percent of the   42 rape allegations to have been reported to them due to either the  incident summary failing to contain these same four elements or the  presence of inconsistent statements made by the alleged victims. For the  approximately 12 percent remaining, the investigators noted that the need  for notification was unclear because there was not enough information in  the incident summary to make a determination about whether or not the  rape allegation should have been reported to the VA OIG.
section_title: Several Factors May Contribute to the Underreporting of Sexual Assault Incidents
paragraphs: There are several factors that may contribute to the underreporting of  sexual assault incidents to VISNs, VHA Central Office, and the VA OIG— including VHA’s lack of a consistent sexual assault definition for reporting  purposes; limited and unclear expectations for sexual assault incident  reporting at the VHA Central Office, VISN, and VA medical facility levels;  and deficiencies in VHA Central Office oversight of sexual assault  incidents.
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 VHA does not have a  VHA-wide definition of sexual assault used for incident reporting. We  found that VHA lacks a consistent definition for the reporting of sexual  assaults through the management reporting stream at the medical facility,  VISN, and VHA Central Office levels. At the medical facility level, we found  that the medical facilities we visited had a variety of definitions of sexual  assault targeted primarily to the assessment and management of victims of  recent sexual assaults. Specifically, facilities varied in the level of detail  provided by their policies, ranging from one facility that did not include a  definition of sexual assault in its policy at all to another facility with a  policy that included a detailed definition. (See table 3.)
At the VISN level, VISN officials within the four networks we spoke with  reported that they did not have definitions of sexual assault in VISN  policies. However, some VISN officials stated they used other common  definitions, including those from the National Center for Victims of Crime  and The Joint Commission. Finally, while the VHA Central Office does  have a policy for the clinical management of sexual assaults, this policy is  targeted to the treatment of victims assaulted within 72 hours and does not  include sexual assault incidents that occur outside of this time frame. In  addition, neither this definition of sexual assault nor any other is included  in VHA Central Office reporting guidance, which specifies the types of  incidents that should be reported to VHA management officials.
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. For example, officials from one VISN reported sending  VHA Central Office only 5 of the 10 issue briefs they received from medical  facilities in their network, while officials from two other VISNs reported  forwarding all issue briefs on sexual assault incidents they received.
VISNs. The four VISNs we spoke with did not include detailed  expectations regarding whether or not sexual assault incidents should be  reported to them in their reporting guidance, potentially resulting in  medical facilities failing to report some incidents. For example, officials  from one VISN told us they expect to be informed of all sexual assault  incidents occurring in medical facilities within their network, but this  expectation was not explicitly documented in their policy. We found  several reported allegations of sexual assault incidents in medical facilities  in this VISN—including three allegations of rape and one allegation of  inappropriate oral sex—that were not forwarded to VISN officials. When  asked about these four allegations, VISN officials told us that they would  only have expected to be notified of two of them—one allegation of rape  and one allegation of inappropriate oral sex—because the medical  facilities where they occurred contacted outside entities, including the VA  OIG. VISN officials explained that the remaining two rape allegations were  unsubstantiated and were not reported to their office; the VISN also noted  that unsubstantiated incidents are not often reported to them.
VA medical facilities. At the medical facility level, we also found that  reporting expectations may be unclear. In particular, we identified cases in  which the VA police had not been informed of incidents that were  reported to medical facility staff. For example, we identified VA police  files from one facility we visited where officers noted that the alleged  perpetrator had been previously involved in other sexual assault incidents  that were not reported to the VA police by medical facility staff. In these  police files, officers noted that staff working in the alleged perpetrators’  units had not reported the previous incidents because they believed these  behaviors were a manifestation of the veterans’ clinical conditions. We  also observed cases of communication breakdowns during our discussions  with medical facility officials and clinicians. For example, at one medical  facility VA police reported that prior to our arrival they were not  immediately informed of an alleged sexual assault incident involving two  male patients in the dementia ward that occurred the previous evening. As  a result, VA police were unable to immediately begin their investigation  because staff from the unit had completed their shifts and left the ward. At  another medical facility we visited, quality management staff identified  five sexual assault incidents that had not been reported to VA police at the  medical facility, despite these incidents being reported to their office.
section_title: Deficiencies Exist in VHA Central Office Oversight of Sexual Assault Incidents
paragraphs: The VHA Central Office also had deficiencies in several necessary  oversight elements that could contribute to the underreporting of sexual  assault incidents to VHA management—including information-sharing  practices and systems to monitor sexual assault incidents reported  through the management reporting stream. Specifically, the VHA Central  Office has limited information-sharing practices for distributing  information about reported sexual assault incidents among VHA Central  Office officials and has not instituted a centralized tracking mechanism for  these incidents.
Currently, the VHA Central Office relies primarily on e-mail messages to  transfer information about sexual assault incidents among its offices and  staff (see fig. 2). Under this system, the VHA Central Office is notified of  sexual assault incidents through issue briefs submitted by VISNs via e-mail  to one of three VISN support teams within the VHA Office of the Deputy  Under Secretary for Health for Operations and Management. These issue  briefs are then forwarded to the Director for Network Support within this  office for review and follow-up with VA medical facilities if needed.  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 on sexual assault incidents that occur  within their areas of programmatic responsibility, VHA program officials  cannot effectively address the risks of such incidents in their programs  and units and do not have the opportunity to identify ways to prevent  incidents from occurring in the future.
In early 2011, VHA leadership officials told us that initial efforts, including  sharing information about sexual assault incidents with the Women  Veterans Health Strategic Health Care Group and VHA program offices,  were under way to improve how information on sexual assault incidents is  communicated to program officials. However, these improvements have  not been formalized within VHA or published in guidance or policies and  are currently being performed on an informal ad hoc basis only, according  to VHA officials.
In addition to deficiencies in information sharing, we also identified  deficiencies in the monitoring of sexual assault incidents within the VHA  Central Office. VHA’s Office of the Deputy Under Secretary for Health for  Operations and Management, the first VHA office to receive all issue briefs  related to sexual assault incidents, does not currently have a system that  allows VHA Central Office staff to systematically review or analyze reports  of sexual assault incidents received from VA medical facilities through the  management reporting stream. Specifically, we found that this office does  not have a central database to store the issue briefs that it receives and  instead relies on individual staff to save issue briefs submitted to them by  e-mail to electronic folders for each VISN. In addition, officials within this  office said they do not know the total number of issue briefs submitted for  sexual assault incidents because they do not have access to all former staff  members’ files. As a result of these issues, staff from the Office of the  Deputy Under Secretary for Health for Operations and Management could  not provide us with a complete set of issue briefs on sexual assault  incidents that occurred in all VA medical facilities without first contacting  VISN officials to resubmit these issue briefs. Such a limited archive  system for reports of sexual assault incidents received through the  management reporting stream results in VHA’s inability to track and trend  sexual assault incidents over time. While VHA has, through its National  Center for Patient Safety (NCPS), developed systems for routinely  monitoring and tracking patient safety incidents that occur in VA medical  facilities, these systems do not monitor sexual assaults and other safety  incidents. Without a system to track and trend over time sexual assaults  and other safety incidents, the VHA Central Office cannot identify and  make changes to serious problems that jeopardize the safety of veterans in  their medical facilities.
section_title: Self-Reported Legal Histories Are Commonly Used to Inform Clinicians of Sexual Assault- Related Risks, but Guidance on Information Collection Is Limited
paragraphs: VA does not have risk assessment tools specifically designed to examine  sexual assault-related risks that some veterans may pose while they are  being treated at VA medical facilities. Instead, VA clinicians working in  the residential programs and inpatient mental health units at medical  facilities we visited said they rely mainly on information about veterans’  legal histories, including a veteran’s history of violence, which are  examined as part of a multidisciplinary admission assessment process to  assess these and other risks veterans pose to themselves and others.  Clinicians also reported that they generally rely on veterans’ self-reported  information, though this information is not always complete or accurate.  Finally, we found that VHA’s guidance on the collection of legal history  information in residential programs and inpatient mental health units does  not specify the type of legal history information that should be collected  and documented.
subsections: section_title: VHA Does Not Have Specific Sexual Assault Risk Assessment Tools
paragraphs: VHA officials and clinicians working in the residential programs and  inpatient mental health units at medical facilities we visited told us that  VHA does not have risk assessment tools specifically designed to examine  sexual assault-related risks that some veterans may pose while being  treated at VA medical facilities. However, these officials and clinicians  noted that such risks are assessed and managed by clinical staff.
VHA officials told us that since no evidence-based risk assessment tool for  sexual assault and other types of violence exists, VHA relies on the  professional judgment of clinicians to identify and manage risks through  appropriate interventions. To do this, VA clinicians generally assess the  overall risks veterans pose to themselves or others in the VA population by  reviewing veterans’ medical records and conducting various  interdisciplinary assessments. Specifically, clinicians said that they review  medical records for information about veterans’ potential for violence and  medical conditions. In addition, the interdisciplinary assessments  clinicians are required to conduct include biopsychosocial assessments,  nursing assessments, suicide risk assessments, and other program-specific  assessments. In residential programs and inpatient mental health units,  biopsychosocial assessments are a standard part of the admissions  process and capture several types of information clinicians can use to  assess risks veterans may pose. This information includes inquiries about  veterans’ legal histories; any violence they may have experienced as either  a victim or perpetrator, including physical or sexual abuse; childhood  abuse and neglect; and military history and trauma.
section_title: Clinicians Reported Using Veterans’ Self-Reported Legal Histories to Assess Sexual Assault-Related Risks, but This Information May Not Always Be Complete
paragraphs: The examination of legal history information is an important part of  clinicians’ assessments of sexual assault risks veterans may pose.  Clinicians from all five medical facilities we visited explained that such  legal history information is primarily obtained through veterans  voluntarily self-reporting these issues during the biopsychosocial  assessment process. Clinicians also cited other sources of information that  could be used to learn about veterans’ legal issues, including family  members, the court system, probation and parole officers, VHA justice  outreach staff, and Internet searches of public registries containing  criminal justice information. However, clinicians reported limitations in  the use of several of these sources. In some cases, veterans must authorize  the disclosure of their criminal or medical information before it can be  released to a VA medical facility—although clinicians noted that veterans  who have a legal restriction on where they may reside or need to meet  probation or parole requirements while in treatment are often willing to  release information. In addition, clinicians reported challenges in  contacting veterans’ families to obtain information as many have no family  support system, particularly those who are homeless prior to entering  treatment. Further, VA’s Office of General Counsel and VHA Central Office  officials told us that VHA staff cannot conduct background checks on  veterans applying for VA health care services, including Internet searches  of public sources of criminal justice information because VHA lacks legal  authority to collect or maintain this information.
VA clinicians from residential programs and inpatient mental health units  at the five medical facilities we visited said that although they inquire  about veterans’ past legal issues, they do not always obtain timely,  complete, or reliable information on these issues from veterans. These  clinicians noted that although many veterans are eventually forthcoming  about their legal history, some may not disclose this information during  the admission assessment or ongoing reassessment processes. For  example, clinicians told us that sometimes they learned about particular  legal issues, such as an arrest warrant or parole requirements, after  veterans have been admitted to the program or when they were being  discharged. They explained that sometimes veterans are uncomfortable  discussing legal or sexual abuse issues during their admission interviews,  but may share this information over time when they become comfortable  with their treatment team. However, these clinicians noted that sometimes  these issues do not come to light until veterans are beginning their  transitions into community housing during the discharge process.  Nevertheless, clinicians reported that they try to encourage veterans to  disclose their full legal histories because it helps them to identify and  address mental health problems that may have contributed to veterans’  encounters with the legal system and to aid the transition to independent  community living.
To determine whether legal history information in veterans’ medical  records was complete, we reviewed the biopsychosocial assessments for  seven veterans at our selected medical facilities who were registered sex  offenders and found that while nearly all of these assessments  documented that medical facility clinicians inquired about these veterans’  legal issues, these issues were not consistently included in the  assessments. The extent to which information about legal history was  documented for these seven veterans varied—from assessments  containing detailed information about current and past criminal  convictions, including the veterans’ sex offense violations and conviction  dates, to assessments that did not contain any information about their past  or current legal history. Specifically, four of these seven assessments  contained detailed descriptions of the veterans’ legal histories including  information on sex offense violations; two of these seven assessments  contained limited descriptions of the veterans’ legal histories; and one of  these seven assessments contained no information on the veteran’s legal  history. In addition, we could not review one additional biopsychosocial  assessment for an eighth veteran who was a patient in one of our selected  medical facilities and was also listed in the publicly available state sex  offender registry for the selected medical facility because the medical  facility did not conduct a biopsychosocial assessment, as required by  policy.
Incomplete or missing information about veterans’ legal histories and  histories of violence can hinder clinicians’ abilities to effectively assess  risks, provide appropriate treatment options, and ensure the safety of all  veterans. In particular, some clinicians noted that insufficient information  about veterans’ legal backgrounds can affect their ability to make  appropriate program residency placement decisions and assist veterans in  developing appropriate housing and employment plans for their  reintegration into the community. For example, clinicians reported they  face challenges in assisting some homeless veterans in finding jobs or  housing partly because outside entities often conduct background checks  prior to accepting veterans into their programs and VA staff cannot always  effectively help veterans navigate those issues if they lack relevant or  timely information about veterans’ legal histories. Clinicians also said that  knowledge about legal issues—such as pending court appearances,  criminal charges, or sentencing requirements—is useful because such  issues can interrupt or delay rehabilitation treatment services at VA or  prevent veterans from using certain community resources when they are  discharged if not adequately addressed. Finally, clinicians said that  insufficient information about these issues affects their ability to identify  actions to manage risks and make informed resource allocation decisions,  such as increasing patient supervision, altering clinical staff assignments,  or requesting VA police assistance.
section_title: VHA Does Not Have Specific Guidance on the Collection of Legal History Information
paragraphs: VHA’s assessment of veterans in their mental health programs for sexual  assault-related risks is limited by a lack of specific guidance. Although VA  clinicians are required to conduct comprehensive assessments that include  the collection of veterans’ legal histories, VHA has limited guidance on  how such information should be collected and documented in residential  programs and inpatient mental health units.
Residential programs. Current VHA policy for residential programs  requires that information about veterans’ legal histories and current  pending legal matters be included in biopsychosocial assessments, but  does not specify the extent to which such information should be  documented in veterans’ medical records or delineate sources that may be  used to address this requirement. Specifically, this VHA policy does not  include descriptions of the type of legal history information clinicians  should document in the biopsychosocial assessment portion of veterans’  medical records. For example, there are no specific requirements for  clinicians to document past incarcerations or convictions and dates when  these events occurred. Currently, VHA delegates the responsibility for  developing specific admission policies and procedures to the VA medical  facility residential program managers, who may in turn delegate this  responsibility to appropriate staff members. We found that medical facility  level policies and procedures for the medical facilities we visited generally  mirrored VHA’s broad guidance in this area, although some medical  facilities had procedures that outlined the specific information that  clinicians should collect related to veterans’ legal backgrounds—such as  the type and date of convictions, description of pending legal charges or  warrants, and time spent in jail or prison.
Inpatient mental health units. VHA officials responsible for inpatient  mental health units reported that broad VHA guidance requires inpatient  mental health clinicians to conduct biopsychosocial assessments for  patients admitted to these units. However, unlike residential programs,  there is currently no VHA policy that specifically defines how inpatient  mental health units should collect this legal history information. The broad  guidance VHA officials cited, such as the VA/DOD Clinical Practice  Guidelines for Post-Traumatic Stress and The Joint Commission  standards, requires the collection of legal history information as part of the  initial assessment, but does not fully specify the type of legal history  information that must be included in veterans’ medical records. A VHA  official responsible for inpatient mental health units throughout VA  confirmed that guidance has not been issued regarding the legal history  information that may or may not be collected by clinicians in inpatient  mental health units or how information obtained from veterans should be  documented.
Without clear guidance on what legal history information should be  collected and how this information should be documented in veterans’  medical records, there is no assurance that clinicians are comprehensively  identifying and analyzing sexual assault-related risks or that legal history  information is collected and documented consistently during  biopsychosocial assessments.
section_title: VA Residential and Inpatient Mental Health Settings Use a Variety of Precautions to Prevent Sexual Assaults and Other Safety Incidents, but Serious Weaknesses Were Observed at Selected Facilities
paragraphs: The residential programs and inpatient mental health units at the five VA  medical facilities we visited reported using several types of patient- oriented and physical precautions to prevent safety incidents, such as  sexual assaults, from occurring in their programs. Patient-oriented  precautions included the use of flags on veterans’ electronic medical  records to notify staff of individuals who may pose threats to the safety of  others, and increased levels of observation for those veterans whom the  clinicians believe may pose risks to others. Physical precautions in  medical facilities we visited included monitoring precautions used to  observe patients, security precautions used to physically secure facilities  and alert staff of problems, and staff awareness and preparedness  precautions used to educate staff about security issues and provide police  assistance. However, at the facilities we visited, we found serious  deficiencies in the use and implementation of certain physical security  precautions, such as alarm system malfunctions and monitoring of  security cameras.
subsections: section_title: Several Types of Patient- Oriented Precautions Are Used by Residential Programs and Inpatient Mental Health Units to Prevent Sexual Assaults and Other Safety Incidents
paragraphs: Staff from the residential programs and inpatient mental health units at the  five VA medical facilities we visited reported using several types of  patient-oriented precautions—techniques that focus on the patients  themselves as opposed to the physical features of clinical areas—to  prevent safety incidents from occurring in their programs. Generally, these  precautions were not specifically geared toward preventing sexual  assaults, but were used to prevent a broad range of safety incidents,  including sexual assaults. We found that some precautions were used by  staff in both residential programs and inpatient mental health units, while  other precautions were specific to only one of these settings. Some of the  patient-oriented precautions we noted during our site visits included the  following:    Using patient medical record flags. Staff in residential programs and  inpatient mental health units reported that they can request that an  electronic flag be placed on a veteran’s medical record when they have  concerns about the individual’s behavior and reported that they use these  flags to help inform their interactions with veterans.
Relocating or separating veterans. Staff in residential programs and  inpatient mental health units noted that they may move or separate  patients who have the potential for conflict with other veterans to help  prevent incidents from occurring. For example, at one medical facility we  visited such relocations involved moving veterans that the clinical staff  determine are safety risks to rooms closer to the nurses’ station where  they can be monitored more closely. Staff from some of the medical  facilities we visited reported that veterans who pose a threat to others may  also be moved to areas where they have restricted contact with others in  the unit.
Setting expectations and using patient contracts. Residential program staff  reported using several contract or patient education mechanisms to  reinforce both what is expected of veterans in these programs and what  behaviors are prohibited during their stay. For example, at one medical  facility we visited veterans signed treatment agreements noting that actual  violence, threats of violence, sexual harassment, and other actions were  not permitted and could result in discharge from the program. At another  medical facility we visited, patients signed a form agreeing to the  program’s policy that any form of physical contact, such as grabbing,  hugging, or kissing another person, was grounds for discharge from the  program.
Increasing direct patient observation. Staff in inpatient mental health units  we visited reported using increased levels of direct patient observation to  help prevent safety incidents. For example, two medical facilities we  visited used graduated levels of observation for veterans who they felt  posed safety risks or who were particularly vulnerable. These medical  facilities included all women veterans on the unit in these more frequent  staff check-ins to help ensure their safety and prevent incidents from  occurring. In addition, staff from one inpatient mental health unit we  visited placed a long-term mental health patient with a tendency of  inappropriately touching staff and patients on permanent one-to-one  observation status after several sexual assault incidents occurred.
section_title: The Types of Physical Precautions in Use to Prevent Sexual Assaults and Other Safety Incidents Vary among VA Medical Facilities
paragraphs: VA medical facilities we visited employed a variety of physical security  precautions to prevent safety incidents in their residential programs and  inpatient mental health units. Typically, medical facilities had discretion to  implement these precautions based on the needs of their local medical  facility within broad VA guidelines. As a result, the types of physical  security precautions used in the five medical facilities we visited varied.
subsections: section_title: Several Types of Physical Security Precautions Are in Place in Selected Medical Facilities
paragraphs: In general, physical security precautions were used to prevent a broad  range of safety incidents, including sexual assaults, but were not targeted  toward the prevention of sexual assaults only. We classified these  precautions into three broad categories: monitoring precautions, security  precautions, and staff awareness and preparedness precautions (see   table 4).
Monitoring precautions—were those designed to observe and track  patients and activities in residential and inpatient settings. For example, at  some VA medical facilities we visited closed-circuit surveillance cameras  were installed to allow VA staff to monitor areas and to help detect  potentially threatening behavior or safety incidents as they occur. Cameras  were also used to passively document any incidents that occurred. Staff in  all the units we visited also conducted periodic rounds of the unit, which  involved staff walking through the program areas to monitor patients and  activities, either at regular intervals or on an as-needed basis.
Security precautions—were those designed to maintain a secure  environment for patients and staff within residential programs and  inpatient mental health units and allow staff to call for help in case of any  problems. For example, the units we visited regularly used locks and  alarms at entrance and exit access points, as well as locks and alarms for  some patient bedrooms. Another security precaution we observed was the  use of stationary, computer-based, and portable personal panic alarms for  staff. Finally, we observed that some of the programs we visited had  established separate bedrooms, bathrooms, or other areas for women  veterans, or had placed women veterans in designated locations within the  units for security purposes.
Staff awareness and preparedness precautions—were those designed to  both educate residential program and inpatient mental health unit staff  about, and prepare them to deal with, security issues and to provide police  support and assistance when needed. For example, the medical facilities  we visited regularly required training for staff on the prevention and  management of disruptive behavior. Another preparedness precaution in  use in some units was the establishment of a regular VA police presence  through activities such as police conducting rounds or holding educational  meetings with patients. Finally, all medical facilities we visited had a  functioning police command and control center, which program staff  could contact for police support when needed.
section_title: Selected VA Medical Facilities Varied in Their Implementation of Physical Security Precautions
paragraphs: We found that the VA medical facilities we visited implemented physical  security precautions in a variety of ways. These precautions varied not  only by medical facility, but also among residential and inpatient settings.  Using broad VA guidelines, the medical facilities we visited generally  determined which type of physical precautions would best meet the needs  of their units and populations. As a result, we found that some  precautions were used by all five medical facilities we visited, while others  were in place in only some of these medical facilities.
Inpatient mental health units. Physical security precautions in place at  all five medical facilities we visited included the use of regular staff rounds  to observe patients and clinical areas, locked unit entrances to prevent  entry by unauthorized individuals, and stationary or computer-based panic  alarm systems. Further, all units we visited used some combination of  stationary or computer-based panic alarms, safety whistles staff could  carry with them while on duty, and mandatory training on preventing and  managing disruptive behavior.
Some of these precautions used at all five medical facilities’ inpatient  mental health units were implemented in different ways across those  units. For example, while all inpatient mental health units used some type  of panic alarm system, the specific system in use within each unit varied;  some units used stationary panic alarm buttons fixed to walls or desks,  while others used a computer-based system in which staff would press  two keys simultaneously on their computers to trigger the alarm. The  inpatient mental health units also varied with respect to where their  stationary panic alarms sounded. At three medical facilities, the inpatient  units’ stationary or computer-based panic alarms sounded at the medical  facility’s police command and control center. At another medical facility,  two types of panic alarms were used. The stationary panic alarms used by  this facility’s inpatient mental health units sounded at both the police  command and control center and on the inpatient unit itself to instantly  alert unit staff members if a panic alarm was depressed, while the  computer-based panic alarms used at the nursing stations sounded only at  the police command and control center. Alarms in use at the fifth medical  facility we visited sounded at the units’ nursing stations. Finally, while all  five units had locked entrances, four of the units used physical keys to  open the locks on the entrance doors, while the unit at the fifth medical  facility used a keyless entry approach in which staff used their badges to  electronically enter the units and relied on physical keys only if the  keyless system was not functioning.
Other precautions were present in only some of the inpatient mental  health units we visited. For example, three medical facilities used closed- circuit surveillance cameras on their inpatient units to varying degrees.  Cameras in place at one of these medical facilities could be monitored at  the unit’s nursing station and were used to monitor the entrance doors,  common areas, and seclusion rooms used for veterans who needed to be  isolated from others. At another medical facility, cameras were used in a  similar fashion, except that this unit did not use cameras to monitor  veterans in seclusion rooms. Cameras in place at the remaining medical  facility were part of a passive system that was not actively monitored by  staff at the unit’s nursing station and was used only to record incidents at  the entrance doors and common areas. One of these medical facilities also  used alarms on bedroom doors that enunciated when the door was  opened. These door alarms were installed on all bedrooms used by women  and for other veterans on an as-needed basis. The ability to instantly alert  staff of either unexpected entries or exits from these rooms could  potentially minimize response time if an incident occurred. This latter  medical facility also used a community policing approach, with one VA  police officer dedicated to meeting regularly with inpatient mental health  unit staff and patients to build relationships and help address any issues or  concerns that arose.
Residential programs. Physical security precautions in place at all five  medical facilities’ non-CWT/TR residential programs included the use of  regular staff rounds to observe patients, staff training on the prevention  and management of disruptive behavior, the use of surveillance cameras to  monitor program areas, and the placement of women veterans in  designated areas of the residential facility. Some of these commonly used  precautions were implemented in different ways across the five medical  facilities. For example, some medical facilities placed women veterans in  separate bedrooms located closest to the nursing stations, while others  placed only women veterans in a separate wing of the facility. Medical  facilities’ residential programs also varied with respect to where their  closed-circuit camera feeds could be viewed. At four of the five medical  facilities we visited, the camera feeds could be viewed by staff at the  programs’ nursing stations or security desks, but at two medical facilities,  cameras at the domiciliary could also be viewed by staff at VA police  command and control centers. At all medical facilities, the camera systems  were passive and not actively monitored by staff.
Other precautions were used only in some of the five medical facilities’  non-CWT/TR residential programs. For example, residential programs in  four of five medical facilities used stationary or computer-based panic  alarms to alert others in case of emergency; the remaining medical facility  did not use any form of stationary or computer-based panic alarm system.  The four medical facilities’ stationary alarms varied with respect to where  they sounded. In addition, only one medical facility we visited provided  portable personal panic alarms with GPS capability to its residential  program staff. In addition, VA police presence was widely used in two of  the five medical facilities we visited. One of these medical facilities  permanently staffed VA police officers at a residential program located off  the medical facility’s main campus, while the other medical facility’s  community policing officer met regularly with residential program staff  and patients to facilitate more direct communications between the  programs and VA police at the medical facility.
CWT/TR residential programs. The three CWT/TR residential programs  we visited used several types of physical security precautions. For  example, two of the three CWT/TR programs we visited used closed- circuit surveillance cameras; one medical facility used surveillance  cameras to record activity at entrances and exits, while another medical  facility used surveillance cameras to record the parking lot areas. Neither  of these locations actively monitored the camera feeds. In addition, one  medical facility reported using regular rounds and conducting bed checks.  Another medical facility had individual locks on bedroom doors; other  sites did not. Only one of the three CWT/TR programs we visited  accepted women; its apartment-style structure allowed women veterans to  be placed in separate apartments. The other two CWT/TRs did not provide  services for women veterans due to safety and privacy concerns stemming  from their single-family home structures.
section_title: Significant Weaknesses Existed in the Use and Implementation of Certain Physical Security Precautions at Selected VA Medical Facilities
paragraphs: During our review of the physical security precautions in use at the five VA  medical facilities we visited, we observed seven weaknesses in three  areas. These weaknesses included malfunctions in stationary and  portable personal panic alarm systems, inadequate monitoring of security  cameras, and insufficient staffing of police and security personnel (see  table 5).
Inadequate monitoring of closed-circuit surveillance cameras. We  observed that VA staff in the police command and control center were not  continuously monitoring closed-circuit surveillance cameras at all five VA  medical facilities we visited. For example, at one medical facility, the  system used by the residential programs at that medical facility cannot be  monitored by the police command and control center staff because it is  incompatible with systems installed in other parts of the medical facility.  According to this medical facility’s VA police, the residential program staff  did not consult with VA police before installing their own system. At  another medical facility where staff in the police office monitor cameras  covering the residential programs’ grounds and parking area, we found  that the police office was unattended part of the time. In addition, at the  remaining three medical facilities we visited, staff in the police command  and control centers assigned to monitor medical facility surveillance  cameras had other duties that prevented them from continuously  monitoring the camera feeds. Specifically, they were also responsible for  serving as telephone operators and police/emergency dispatchers for the  entire VA medical facility. During our direct observations of their  activities, we noted that they were not monitoring the camera feeds  continuously. Although effective use of surveillance camera systems  cannot necessarily prevent safety incidents from occurring, lapses in  monitoring by security staff compromise the effectiveness of these  systems in place to help prevent or lessen the severity of safety incidents.
Alarm malfunctions. At least one form of alarm failed to work properly  when tested at four of the five medical facilities we visited. For example,  at one medical facility, we tested the portable personal panic alarms used  by residential program staff and found that the police command and  control center could not always properly pinpoint the location of the tester  when an alarm was activated. When we tested this alarm inside a building  at this campus it functioned properly; however, when we tested it outside,  the location identified as the site of the alarm was at least 100 feet away  from the location where we set off the alarm. Further, when we tested an  emergency call box located outside the entrance to the residential  program buildings at this same medical facility, the call went to a central  telephone operator at the VA medical facility switchboard—not the VA  police command and control center—and the system improperly identified  our tester as calling from an elevator rather than from our location outside  the residential program building. At another medical facility that used  stationary panic alarms in inpatient mental health units, residential  programs, and other clinical settings (i.e., staff offices, nursing stations,  and common rooms), almost 20 percent of these alarms throughout the  medical facility were inoperable. Many of the inoperable alarms were due  to ongoing construction of new units at the medical facility, but some of  the remaining inoperable alarms were located in other parts of the medical  facility still in use. It is unclear if staff in these other areas were aware that  these alarms were inoperable and could not be used to call for help if they  needed it. At an inpatient mental health unit in a third medical facility, our  tests of the computer-based panic alarm system detected multiple alarm  failures. Specifically, three of the alarms we tested failed to properly  pinpoint the location of our tester because the medical facility’s computers  had been moved to different locations and were not properly reconfigured.  Finally, at a fourth medical facility, alarms we tested in the inpatient  mental health unit sounded properly, but staff in the unit and VA police  responsible for testing these alarms did not know how to turn them off  after they were activated. In each of the cases where alarms  malfunctioned, VA staff were not aware the alarms were not functioning  properly until we informed them. Deficiencies like these at VA medical  facilities could lead to delayed response times and seriously erode efforts  to prevent or mitigate sexual assaults and other safety incidents.
Inadequate documentation or review of alarm system testing. We  found that one of the five sites we visited failed to properly document tests  conducted of their alarm systems for their residential programs, although  testing of alarms is a required element in VA’s Environment of Care  Checklist. Testing of alarm systems is important to ensure that systems  function properly, and not having complete documentation of alarm  system testing is an indication that periodic testing may not be occurring.  In addition, three medical facilities reported using computer-based panic  alarms that are designed to be self-monitoring to identify cases where  computers equipped with the system fail to connect with the servers  monitoring the alarms. All three of these medical facilities stated that due  to the self-monitoring nature of these alarms, they did not maintain alarm  test logs of these systems. However, we found that at two of these three  medical facilities these alarms failed to properly alert VA police when  tested. Such alarm system failures indicate that the self-monitoring  systems may not be effectively alerting medical facility staff of alarm  malfunctions when they occur, indicating the need for these systems to be  periodically tested by VA police.
Alarms failed to alert both police and unit staff. In inpatient mental  health units at all five medical facilities we visited, stationary and  computer-based panic alarm systems we tested did not alert staff in both  the VA police command and control center and the inpatient mental health  unit where the alarm was triggered. Alerting both locations is important to  better ensure that timely and proper assistance is provided. At four of  these medical facilities, the inpatient mental health units’ stationary or  computer-based panic alarms notified the police command and control  centers but not staff at the nursing stations of the units where the alarms  originated. Had these alarms been used in real emergencies, response  times may have been delayed because staff in the police command and  control center would have had to inform the inpatient mental health unit  that an alarm had been activated by someone within their unit. At the fifth  medical facility, the stationary panic alarms only notified staff in the unit  nursing station, making it necessary to separately notify the VA police.  Finally, none of the stationary or computer-based panic alarms used by  residential programs notified both the police command and control  centers and staff within the residential program buildings when tested.
Limited use of portable personal panic alarms. Electronic portable  personal panic alarms were not available for the staff at any of the  inpatient mental health units we visited and were available to staff at only  one residential program we reviewed. In two of the inpatient mental health  units we visited, staff were given safety whistles they could use to signal  others in cases of emergency, personal distress, or concern about veteran  or staff safety. However, relying on whistles to signal such incidents may  not be effective, especially when staff members are the victims of assault.  For example, a nurse at one medical facility we visited was involved in an  incident in which a patient grabbed her by the throat and she was unable  to use her whistle to summon assistance. Some inpatient mental health  unit staff we spoke with indicated an interest in having portable personal  panic alarms to better protect them in situations like these.
VA police staffing and workload challenges. At most medical facilities  we visited, VA police forces and police command and control centers were  understaffed, according to medical facility officials. For example, during  our visit to one medical facility, VA police officials reported being able to  staff just two officers per 12-hour shift to patrol and respond to incidents  at both the medical facility and at a nearby 675-acre veteran’s cemetery.  While this staffing ratio met the minimum standards for VA police staffing,  having only two police officers to cover such a large area could potentially  increase the response times should a panic alarm activate or other security  incident occur on medical facility grounds. Also, we found that there was  an inadequate number of officers and staff at this medical facility to  effectively police the medical facility and maintain a productive police  force. The medical facility had a total of nine police officers at the time of  our visit; according to VA staffing guidance, the minimum staffing level for  this medical center should have been 19 officers. Similarly, at another  medical facility, the police force was short 14 active police officers  because some officers either were on military leave or awaiting the  completion of pending background checks. During our visit to this  medical facility, we also noted a shortage of officers at one of the medical  facility’s police offices responsible for the inpatient mental health units.  Because of this, there were periods of time when this police office was  unattended. Not all medical facilities we visited had staffing problems. At  one medical facility, the VA police appeared to be well staffed and were  even able to designate staff to monitor off-site residential programs and  community based outpatient clinics.
Lack of stakeholder involvement in unit redesign. As medical  facilities undergo remodeling, it is important that stakeholders are  consulted in the design process to better ensure that new or remodeled  areas are both functional and safe. Involving the VA police, security  specialists, computer experts, and staff in the affected units would better  ensure that proper security precautions are built into redesign projects.  We found that such stakeholder involvement on remodeling projects had  not occurred at one of the medical facilities we visited. At this medical  facility, some clinicians said that a lack of stakeholder involvement in the  redesign of the inpatient mental health units had created several safety  concerns and that postconstruction changes had to be made to the unit to  ensure the safety of veterans and unit staff. Specifically, clinical and VA  police personnel were not consulted about a redesign project for the  inpatient mental health unit. The new unit initially included one nursing  station that did not prevent patient access if necessary. After the unit was  reopened following the renovation, there were a number of assaults,  including an incident where a veteran reached over the counter of the  unit’s nursing station and physically assaulted a nurse by stabbing her in  the neck, shoulder, and leg with a pen. Had staff been consulted on the  redesign of this unit, their experience managing veterans in an inpatient  mental health unit environment would have been helpful in developing  several safety aspects of this new unit, including the design of the nursing  station. Less than a year after opening this unit, medical facility leadership  called for a review of the units’ design following several reported  incidents. As a result of this review, the unit was split into two separate  units with different veteran populations, an additional nursing station was  installed, and changes were planned for the structure of both the original  and newly created nursing stations—including the installation of a new  shoulder-height plexiglass barricade on both nursing station counters.
section_title: Conclusions
paragraphs: VA management has not remedied problems relating to the reporting of  sexual assault incidents, the assessment of sexual assault-related risks,  and the precautions used to prevent sexual assaults and other safety  incidents in VA medical facilities. This has led to a disorganized incident  reporting structure and has left VA vulnerable to the continued occurrence  of such incidents and unable to take systematic action on needed  improvements to prevent future incidents in all VA medical facilities. To  mitigate the occurrence of sexual assaults and other safety incidents in its  medical facilities and better ensure the safety of both veterans and staff,  VA needs to address several areas—including the processes for reporting  sexual assault incidents, the underreporting of sexual assault incidents,  the assessment of risks certain veterans may pose to the safety of others,  and the implementation of physical security precautions. Failure to act  decisively in all of these areas would likely continue to place veterans and  medical facility staff in some locations in harm’s way. To begin addressing  these concerns, VA must ensure that both management and law  enforcement officials are aware of the volume and specific types of sexual  assault incidents that are reported through the law enforcement stream.  Such awareness would help both management and law enforcement  officials address safety concerns that emerge for both patients and staff  throughout VA’s health care system.
Medical facility staff remain uncertain about what types of incidents  should be reported to VHA leadership and VA law enforcement officials,  and prevention and remediation efforts are eroded by failing to tap the  expertise of these officials. These officials can offer valuable suggestions  for preventing and mitigating future sexual assault incidents and help  address broader safety concerns through systemwide improvements  throughout the VA healthcare system. Leaving reporting decisions to local  VA medical facilities—rather than allowing VHA management and VA OIG  officials to determine what types of incidents should be reported based on  the consistent application of known criteria—increases the risk that some  sexual assault incidents may go unreported. Moreover, uncertainty about  sexual assault incident reporting is compounded by VA not having:   (1) established a consistent definition of sexual assault, (2) set clear  expectations for the types of sexual assault incidents that should be  reported to VISN and VHA Central Office leadership officials, and   (3) maintained proper oversight of sexual assault incidents that occurred  in VA medical facilities. Unless these three key features are in place, VHA  will not be able to ensure that all sexual assault incidents will be  consistently reported throughout the VA health care system. Specifically,  the absence of a centralized tracking system to monitor sexual assault  incidents across VA medical facilities may seriously limit efforts to both  prevent such incidents in the short and long term and maintain a working  knowledge of past incidents and efforts to address them when staff  transitions occur.
Maintaining veterans’ access to care is a priority in VA, but in those cases  where veterans have a history of sexual assault or other violent acts, VA  must be vigilant in identifying the risks that such veterans may pose to the  safety of others at its medical facilities. Risk assessment tools can be  valuable mechanisms for identifying those veterans that pose risks to  others while being treated at VA medical facilities. However, VA does not  currently have a risk assessment tool specific to sexual assault and instead  relies on clinicians’ professional judgments. These judgments are largely  informed by the assessment of veterans’ legal histories, which depend  heavily on self-reported data that must be accurately documented by  clinicians in veterans’ medical records. Moreover, current VA guidance is  not specific about the extent to which current and past legal issues—such  as the type or date of convictions—should be documented in veterans’  medical records—a factor that further complicates the ability of VA  clinicians both to compile complete legal histories on veterans and to  make informed decisions about risks certain veterans may pose to other  veterans and VA staff.
Ensuring that medical facilities maintain a safe and secure environment  for veterans and staff in residential programs and inpatient mental health  units is critical and requires commitment from all levels of VA. Currently,  the five VA medical facilities we visited are not adequately monitoring  surveillance camera systems, maintaining the integrity of alarm systems,  and ensuring an adequate police presence. Closer oversight by both VISNs  and VA and VHA Central Office staff is needed to provide a safe and secure  environment throughout all VA medical facilities.
section_title: Recommendations for Executive Action
paragraphs: To improve VA’s reporting and monitoring of allegations of sexual assault,  we recommend that the Secretary of Veterans Affairs direct the Under  Secretary for Health to take the following four actions:    Ensure that a consistent definition of sexual assault is used for reporting  purposes by all medical facilities throughout the system to ensure that  consistent information on these incidents is reported from medical  facilities through VISNs to VHA Central Office leadership.
Clarify expectations about what information related to sexual assault  incidents should be reported to and communicated within VISN and VHA  Central Office leadership teams, such as officials responsible for  residential programs and inpatient mental health units.
Implement a centralized tracking mechanism that would allow sexual  assault incidents to be consistently monitored by VHA Central Office staff.
Develop an automated mechanism within the centralized VA police  reporting system that signals VA police officers to refer cases involving  potential felonies, such as rape allegations, to the VA OIG to facilitate  increased communication and partnership between these two entities.
To help identify risks and address vulnerabilities in physical security  precautions at VA medical facilities, we recommend that the Secretary of  Veterans Affairs direct the Under Secretary for Health to take the  following four actions:    Establish guidance specifying what should be included in legal history  discussions with veterans and how this information should be documented  in veterans’ biopsychosocial assessments.
Ensure medical centers determine whether existing stationary, computer- based, and portable personal panic alarm systems operate effectively  through mandatory regular testing.
Ensure that alarm systems effectively notify relevant staff in both medical  facilities’ VA police command and control centers and unit nursing  stations.
Require relevant medical center stakeholders to coordinate and consult on  (1) plans for new and renovated units, and (2) any changes to physical  security features, such as closed-circuit television cameras.
section_title: Agency Comments and Our Evaluation
paragraphs: VA provided written comments on a draft of this report, which we have  reprinted in appendix III. In its comments, VA generally agreed with our  conclusions, concurred with our recommendations, and described the  agency’s plans to implement each of our recommendations. VA also  provided technical comments which we have incorporated as appropriate.
Specifically, VA outlined its plan to create a multidisciplinary workgroup  that will undertake efforts to respond to seven of our eight  recommendations—including developing definitions of sexual assault and  other safety incidents, reviewing existing data sources and communication  mechanisms, developing a centralized mechanism for monitoring sexual  assaults and other safety incidents, and developing risk assessment and  management guidance. The workgroup will be co-chaired by the Acting  Assistant Deputy Under Secretary for Health for Clinical Operations and  the Chief Consultant for the Women Veterans Health Strategic Health Care  Group. Participants will include representatives from VA field operations  and the following offices: (1) the VHA Deputy Under Secretary for Health  for Operations and Management; (2) the VHA Deputy Under Secretary for  Health for Policy and Services; (3) the VHA Principal Deputy Under  Secretary for Health; (4) the VA Office of Security and Law Enforcement;  and (5) other offices as needed, including the VA Office of General  Counsel.
As outlined by VA, the workgroup will review current data sources, the  organization and structure of VHA’s methods for reporting sexual assaults  and other safety incidents, and the agency’s current response to sexual  assault incidents. In addition, the workgroup will review and evaluate  risks and efforts to prevent sexual assaults. Finally, the workgroup will  assess the status of current policies within VHA and address which  organizational initiatives and policies should be updated. According to  VA’s comments, the workgroup will provide the Under Secretary for  Health and his Deputies with monthly verbal updates on its progress, as  well as an initial action plan by July 15, 2011 and a final report by  September 30, 2011.
In addition, VA stated in its comments that the Office of the Deputy Under  Secretary for Health for Operations and Management will work in  conjunction with this multidisciplinary workgroup on a number of  initiatives to address panic alarm system testing and coordination on  renovation and construction at VA medical facilities. Initiatives described  in VA’s comments specifically included efforts to: (1) re-emphasize the  need for routine testing of panic alarm systems; (2) examine existing VHA  policy to determine if revisions are needed to ensure that regular testing of  alarm systems is required and preventative maintenance is performed on  these systems; (3) re-emphasize the importance of coordination at the  local level to ensure that safety and security are considered during  construction and renovation processes at local levels; and (4) determine  how such coordination can be formalized as part of the planning and  design processes for all construction processes in conjunction with the VA  Office of Construction.
Finally, to address our remaining recommendation, the VA OSLE will  develop a mechanism that will directly prompt VA police officers to report  potential felonies, including rape, to the VA OIG when these offenses are  recorded in the centralized police reporting system. In its comments, VA  stated that this system will also send a message to a specialized mailbox  alerting VA OIG investigators that a potential felony has been recorded in  the centralized police reporting system.
We are sending copies of this report to the Secretary of Veterans Affairs,  appropriate congressional committees, and other interested parties. In  addition, the report is available at no charge on the GAO Web site at  http://www.gao.gov.
If you or your staffs have any questions about this report, please contact  me at (202) 512-7114 or at williamsonr@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on the  last page of this report. GAO staff who made major contributions to this  report are listed in appendix IV.
section_title: Appendix I: Scope and Methodology
paragraphs: This appendix describes the information and methods we used to  examine: (1) VA’s processes for reporting sexual assault incidents and the  volume of these incidents reported in recent years; (2) the extent to which  sexual assault incidents are fully reported and what factors may contribute  to any observed underreporting; (3) how medical facility staff determine  sexual assault-related risks veterans may pose in residential and inpatient  mental health settings; and (4) the precautions in place in residential and  inpatient mental health settings to prevent sexual assaults and other safety  incidents and any weaknesses in these precautions.
Specifically, we discuss our methods for selecting VA medical facilities for  site visits; identifying appropriate Department of Veterans Affairs (VA) and  Veterans Health Administration (VHA) Central Office officials to interview;  assessing the extent to which sexual assault incidents are fully reported;  determining what legal history information is captured in veterans’  medical records; and examining the physical security precautions in use in  selected residential programs and inpatient mental health units. In  addition to the methods described below, we also reviewed relevant VA  and VHA policies, handbooks, directives, and other guidance documents  to inform our overall review of these issues whenever possible.
subsections: section_title: Site Selection Methodology and Interviews with Medical Facility Officials
paragraphs: We conducted five site visits to VA medical facilities to obtain the  perspectives of medical facility level officials and clinicians working in  residential programs and inpatient mental health units and to observe the  types of physical security precautions used within these medical facilities.  To identify VA medical facilities for our site visits, we examined available  VA and medical facility level information to ensure our sample included  medical facilities with the following characteristics:    Presence of both residential programs and inpatient mental health units.
We identified medical facilities that had both types of programs by  consulting VA documentation of residential program and inpatient mental  health units.
Presence of a variety of residential program specialties. We identified  medical facilities that had: (1) at least one residential program—including  domiciliaries and residential rehabilitation treatment programs (RRTP)— and (2) had a compensated work therapy/transitional residence (CWT/TR)  program wherever possible. In addition, we selected medical facilities  that had a variety of RRTP program specialties designed to treat particular  mental health issues, such as post-traumatic stress disorder (PTSD) and  substance abuse.
Various levels of experience reporting sexual assault incidents. Using  sexual assault case files provided by the VA Office of Inspector General  (OIG) Office of Investigations—Criminal Investigations Division—we  identified VA medical facilities with a wide variety of experiences  reporting sexual assault incidents, including one medical facility with no  reported sexual assault incidents and several others that had reported a  number of sexual assault incidents that occurred within their residential  programs or inpatient mental health programs. This ensured that the VA  medical facilities we visited captured a range of perspectives on the  reporting of sexual assault incidents.
Various medical facility sizes. We identified medical facilities with  different campus sizes and types of on-site programs by determining  whether each medical facility was a single or multisite medical facility and  considering several other aspects of medical facility design, such as the  presence of on-site day care centers.
Using these criteria, we judgmentally selected five VA medical facilities to  visit during our field work. During our site visits to these locations, we  interviewed each medical facility’s leadership team; residential program  and inpatient mental health unit managers and staff; VA police; quality and  patient safety managers; disruptive behavior committee members; woman  veterans program manager; military sexual trauma program coordinator;  and veterans justice outreach program coordinator. We spoke with these  officials about a variety of topics, including incident reporting, risk  assessment practices, and precautions used to prevent safety incidents,  including sexual assaults.
In addition, we spoke with officials from the four Veterans Integrated  Service Networks (VISN) responsible for managing these medical facilities  to discuss their expectations, policies, and procedures for reporting sexual  assault incidents. We also spoke with each VISN’s Health Care for Re-entry  Veterans program managers to gain additional insight on these programs.
Information obtained from our visits to selected VA medical facilities and  interviews with selected VISNs cannot be generalized to all VISNs and VA  medical facilities throughout the nation.
section_title: Interviews with VA and VHA Central Office Officials
paragraphs: We also interviewed VA and VHA Central Office officials responsible for  incident reporting; law enforcement oversight; mental health programs;  women veterans; risk assessment; patient privacy; and legal issues. We  spoke with the following offices at the department level within VA:   (1) Office of Security and Law Enforcement (OSLE); (2) the Integrated  Operations Center (IOC); (3) the Office of General Counsel; and (4) the  OIG’s Office of Investigations—Criminal Investigations Division. We also  interviewed officials from the following offices within VHA Central Office:  (1) the Office of the Deputy Under Secretary for Health for Operations and  Management; (2) the Office of the Principal Deputy Under Secretary for  Health; (3) the Office of Mental Health Services; (4) the Women Veterans  Health Strategic Health Care Group; and (5) the Information Access and  Privacy Office.
section_title: Analyses of Sexual Assault Incident Reporting
paragraphs: To assess the effectiveness of the reporting of sexual assault  incidents, we reviewed documentation of sexual assault incidents  from VHA management officials and VA law enforcement entities.
To analyze the reporting process for sexual assault incidents, we  requested documentation of these incidents from our selected VISNs;  VHA’s Office of the Deputy Under Secretary for Health for Operations and  Management; VA OSLE; and VA OIG. For all information we requested, we  asked VHA or VA officials to send us either issue briefs or investigation  documentation that fell within the definition of sexual assault used for the  purposes of this report.
To review reports submitted through VHA’s management reporting stream,  we requested copies of issue briefs on sexual assault incidents sent to our  selected VISNs and the VHA Office of the Deputy Under Secretary for  Health for Operations and Management. We also asked our selected  VISNs to identify which of these issue briefs were sent to the VHA Central  Office for further review. The four VISNs responded that in total they  received   16 issue briefs and forwarded 11 of these documents to the VHA Central  Office. Due to limitations in how information is archived within VHA’s  Office of the Deputy Under Secretary for Health for Operations and  Management, we could not determine how many issue briefs this office  received through the management reporting stream across all VA medical  facilities.
To review reports submitted through VA’s law enforcement reporting  stream, we requested documentation of sexual assault incidents reported  to the VA police through the VA OSLE and documentation of incidents  referred to the VA OIG for investigation. From the VA OSLE, we requested  and received police files submitted by any VA medical facility related to  sexual assault incidents that occurred since January 2005. We then limited  the police files we reviewed to only those incidents that occurred between  January 2007 and July 2010 due to a records schedule that requires the VA  police to destroy files greater than 3 years old. As a result of this  requirement, our review of sexual assaults reported to the VA police  during 2007 was limited to only those cases retained by VA police.  Additionally, due to the lack of a centralized VA police reporting system  prior to fiscal year 2009, VA medical facility police manually transmitted  all reports to the VA OSLE for inclusion in our review, which resulted in  only those reports received by VA OSLE being included in our analysis. We  received a total of 520 VA police case files for the period January 2007  through July 2010, including both open and closed investigations, from the  VA OSLE. In addition, we requested copies of VA OIG investigation  documentation of sexual assault incidents that occurred in all VA medical  facilities from January 2005 through July 2010. However, we limited our  review of VA OIG investigation documentation to only those incidents that  occurred between January 2007 and July 2010 to ensure our review of VA  police cases and VA OIG investigations were concurrent. We received  investigation documentation on 106 closed sexual assault incidents that  occurred during this time frame from the VA OIG. Additionally, the VA OIG  reported that there were 9 incidents that were currently under  investigation at the time of our review and we did not require them to  provide documentation on these cases due to the sensitive nature of these  ongoing investigations.
subsections: section_title: Scoping of VA Police Case Files and VA OIG Investigation Documentation
paragraphs: To determine whether each of the incidents provided by the VA police and  the VA OIG should be included in our analysis of sexual assault incidents  that occurred in VA medical facilities between January 2007 and July 2010,  we reviewed whether each incident received from the VA police and the  VA OIG met the definition of sexual assault used for this engagement. To  complete this assessment, two analysts worked independently to make an  initial determination on whether each incident met this definition and a  third analyst reviewed these initial judgments to arbitrate a final decision  using predetermined decision rules. Of the 520 documents received from  the VA police during the specified time frame, 284 incidents were included  in our analysis, 222 were determined to be out of the scope of our review,  and the remaining 14 did not have enough information in the police files to  determine whether or not these cases fell within the scope of our review.  This process was repeated for the 106 VA OIG investigation documents for  closed investigations we received and 96 were included in our analysis, 7  were determined to be outside the scope of our review, and the remaining  3 did not contain enough information to determine whether or not they fell  within the scope of our review.
Our analyses of sexual assault incidents reported to the VA police and the  VA OIG was limited to only those incidents that were reported and cannot  be used to project the volume of sexual assault incident reports that may  occur in future years. Following verification that police and VA OIG  incidents met our definition of sexual assault and comparisons of the two  entities’ reported sexual assault incidents, we found data derived from  these reports to be sufficiently reliable for our purposes.
section_title: Analysis of VA Police Case Files
paragraphs: For our analysis of the 284 incidents reported to the VA police determined  to be within the scope of our review, we identified several key data points  in each case file, including the gender of the perpetrator and victim, the  relationship the perpetrator and victim had to VA, and the medical facility  location and VISN where the incident originated. In addition, we also  placed these incidents into one of five categories to analyze the volume of  several types of sexual assault incidents that occurred throughout VA  medical facilities.
Inappropriate touch—included any case involving only allegations of  touching, fondling, grabbing, brushing, kissing, rubbing, or other like- terms.
Forced or inappropriate oral sex—included any case involving only  allegations of forced or inappropriate oral sex.
Forceful examination—included any case alleging only a medical  examination that was painful, uncomfortable, or seemingly inappropriate  to the patient.
Rape—included any case involving rape allegations, which we defined as  vaginal or anal penetration by any body part or object without consent. We  deemed a file as containing a rape allegation if any of the following were  noted within the file: (1) either the victim or VA staff used the term rape in  their descriptions of the incident; (2) a rape kit was requested or  administered; (3) allegations that sex occurred without consent, whether  or not penetration was described; or (4) allegations of attempted vaginal  or anal penetration without consent. In addition, cases where VA staff  deemed that one or more of the victims involved were mentally incapable  of giving consent for sexual activities or that a victim’s ability to consent  was otherwise impaired, were included in this category.
Other—included any case that did not fit into the categories described  above or if the incident described in the police file was unclear. In  addition, cases involving consensual sexual activities between two  individuals who were in a mental health or geriatric unit where both  parties were found to be capable of giving consent were included in this  category.
section_title: VA OIG Reporting Analysis
paragraphs: To examine the discrepancies between the number of sexual assault  incidents reported to VA police and the number referred to the VA OIG, we  reviewed the 67 rape allegations that were reported to VA police to  determine which of these reports were referred to the VA OIG. We  selected rape allegations for this additional review due to the severity of  these allegations and the likelihood they would be considered potential  felonies that must be reported to the VA OIG. To complete this analysis,  we matched the VA police files containing rape allegations to a VA OIG  investigation document wherever possible. A police file and VA OIG  investigation document were considered a match when both documents  discussed the same incident details—including information such as  discussion of the same perpetrator and victim, medical facility, and  incident date. Of the 67 rape allegations reported to the VA police, 25 had a  matching VA OIG investigation document, while the remaining 42 did not.  In addition, we reviewed federal statutes related to sexual offenses and  sentencing classification for felonies to verify that all rape allegations  included in our review met the statutory criteria for felonies under federal  law. Finally, investigators from the VA OIG reviewed summaries of the 42  rape allegations that did not match VA OIG investigation documentation  previously provided to determine whether or not they would have  expected such cases to be reported to their office. These case summaries  did not contain identifying information about the suspects, victims, or VA  medical facilities involved in these incidents. Four VA OIG investigators  reviewed these summaries and based their determinations on several key  factors developed from their experience as law enforcement officers.
section_title: Legal History Analysis of Biopsychosocial Assessments
paragraphs: We reviewed the biopsychosocial assessment sections of selected  veterans’ medical records to better understand how legal history  information contained in these documents could be used to inform  clinicians’ assessments of sexual assault-related risks veterans may pose  while they are being treated at VA medical facilities. We reviewed these  assessments for all veterans who were registered sex offenders residing in  the residential programs or inpatient mental health units of our selected  medical facilities. To determine if registered sex offenders were residing at  the medical facilities we visited, we searched the Web sites of each  medical facility’s corresponding publicly available state sex offender  registry and included any individual registered under the address of the  selected medical facility’s residential programs or inpatient mental health  units in our sample. The addresses used for these searches were provided  by each medical facility. Our corresponding sample included eight  veterans from three of the five medical facilities we visited. VA medical  facility staff provided biopsychosocial assessments for seven of these  veterans and noted that the eighth assessment was never completed by the  medical facility. We analyzed the contents of these seven veterans’  biopsychosocial assessments to determine the extent to which these  records contained information about these veterans’ current and past legal  issues, including documentation of convictions and parole or probation  status. We also reviewed information contained in these assessments  regarding these veterans’ histories of sexual abuse. Our review of veterans’  biopsychosocial assessments was limited to only those veterans meeting  these criteria and cannot be generalized to broader VA patient  populations.
section_title: Review of Selected VA Medical Facilities’ Physical Security Precautions
paragraphs: To examine the physical security precautions in place in residential  programs and inpatient mental health units, physical security experts from  our Forensic Audits and Investigative Services team conducted an  independent assessment of physical security measures in place at the  medical facilities we visited. To conduct this assessment, these experts  assessed the physical security precautions in place at each of the five  medical facilities we visited and identified any weaknesses they observed  in these systems using criteria based on generally recognized security  standards and selected VA security requirements. These reviews included  the testing of some physical security precautions, such as panic alarm  systems, and interviews with staff working in the residential programs and  inpatient mental health units that were reviewed. Our review of these  precautions was limited to only those medical facilities we reviewed and  does not represent results from all VA medical facilities nationwide.
We conducted our performance audit from May 2010 through June 2011 in  accordance with generally accepted government auditing standards. Those  standards require that we plan and perform the audit to obtain sufficient,  appropriate evidence to provide a reasonable basis for our findings and  conclusions based on our audit objectives. We believe that the evidence  obtained provides a reasonable basis for our findings and conclusions  based on our audit objectives. We conducted our related investigative  work in accordance with standards prescribed by the Council of  Inspectors General on Integrity and Efficiency.
section_title: Appendix II: Analysis of VA Police Reports of Sexual Assault Incidents from January 2007 through July 2010
paragraphs: This appendix provides additional results from our analysis of VA police  reports of sexual assault incidents from January 2007 through July 2010.  Cases not reported to the VA police are not included in our analysis of  sexual assault incidents.
Figure 3 shows the number of sexual assault incidents reported at VA  medical facilities to VA police by Veterans Integrated Service Network  (VISN) from January 2007 through July 2010. This count ranged from 34  incidents reported in VISNs C and D to no incidents reported in VISN E.
Table 6 shows the total number of sexual assault incidents alleging rape by  gender of the perpetrator and victim from January 2007 through July 2010.
Table 7 shows the total number of sexual assault incidents alleging rape by  the perpetrator and victim relationship to VA from January 2007 through  July 2010.
Table 8 shows the total number of patient-on-patient assault incidents and  patient-on-employee assault incidents by the type of sexual assault  incident from January 2007 through July 2010.
section_title: Appendix III: Comments from the Department of Veterans Affairs
section_title: Appendix IV: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Marcia A. Mann, Assistant  Director; Gary A. Bianchi; Robin Burke; Emily Goodman; Katherine  Nicole Laubacher; Lisa Motley; Andy O’Connell; George Ogilvie;  Carmen Rivera-Lowitt; and Cassandra Yarbrough made key  contributions to this report.