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United States Government Accountability Office: 
GAO: 

Report to the Committee on Veterans' Affairs, House of Representatives: 

June 2011: 

VA Health Care: 

Actions Needed to Prevent Sexual Assaults and Other Safety Incidents: 

GAO-11-530: 

GAO Highlights: 

Highlights of GAO-11-530, a report to the Committee on Veterans’ 
Affairs, House of Representatives. 

Why GAO Did This Study: 

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. 

What GAO Found: 

GAO found that many of the nearly 300 sexual assault incidents 
reported to the VA police were not reported to VA leadership officials 
and the VA 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 
assault-related 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 patient-oriented 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. 

What GAO Recommends: 

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. 

View [hyperlink, http://www.gao.gov/products/GAO-11-530] or key 
components. For more information, contact Randall B. Williamson at 
(202) 512-7114 or williamsonr@gao.gov. 

[End of section] 

Contents: 

Letter: 

Background: 

Nearly 300 Sexual Assault Incidents Were Reported Since 2007 through 
One of Two VA Reporting Streams: 

Not All Sexual Assault Incidents Are Reported Due to Unclear Guidance 
and Insufficient Oversight: 

Self-Reported Legal Histories Are Commonly Used to Inform Clinicians 
of Sexual Assault-Related Risks, but Guidance on Information 
Collection Is Limited: 

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: 

Conclusions: 

Recommendations for Executive Action: 

Agency Comments and Our Evaluation: 

Appendix I: Scope and Methodology: 

Appendix II: Analysis of VA Police Reports of Sexual Assault Incidents 
from January 2007 through July 2010: 

Appendix III: Comments from the Department of Veterans Affairs: 

Appendix IV: GAO Contact and Staff Acknowledgments: 

Tables: 

Table 1: Number of Sexual Assault Incidents by Category Reported to VA 
Police by Year, January 2007 through July 2010: 

Table 2: Sexual Assault Incidents Reported to Four Selected VISNs and 
VHA Central Office Leadership, January 2007 through July 2010: 

Table 3: Selected VA Medical Facility Definitions of Sexual Assault 
for the Assessment and Management of Victims of Recent Sexual Assault: 

Table 4: Physical Security Precautions in Residential Programs and 
Inpatient Mental Health Units at Selected VA Medical Facilities: 

Table 5: Weaknesses in Physical Security Precautions in Residential 
Programs and Inpatient Mental Health Units at Selected VA Medical 
Facilities: 

Table 6: Total Sexual Assault Incidents Alleging Rape by Perpetrator 
and Victim Gender, January 2007 through July 2010: 

Table 7: Total Sexual Assault Incidents Alleging Rape by Perpetrator 
and Victim Relationship to VA, January 2007 through July 2010: 

Table 8: Patient-on-Patient Assault Incidents and Patient-on-Employee 
Assault Incidents by Type of Sexual Assault Incident, January 2007 
through July 2010: 

Figures: 

Figure 1: VA Reporting Process for Sexual Assaults and Other Safety 
Incidents: 

Figure 2: VHA Central Office Reporting Process for Sexual Assaults and 
Other Safety Incidents: 

Figure 3: Number of Sexual Assault Incidents Reported to VA Medical 
Facility Police by VISN, January 2007 through July 2010: 

Abbreviations: 

CWT/TR: compensated work therapy/transitional residence: 

DOD: Department of Defense: 

MMPI: Minnesota Multiphasic Personality Inventory: 

IOC: Integrated Operations Center: 

NARA: National Archives and Records Administration: 

NCPS: National Center for Patient Safety: 

OIG: Office of the Inspector General: 

OSLE: Office of Security and Law Enforcement: 

PTSD: post-traumatic stress disorder: 

RRT: Presidential rehabilitation treatment programs: 

VA: Department of Veterans Affairs: 

VHA: Veterans Health Administration: 

VISN: Veterans Integrated Service Network: 

[End of section] 

United States Government Accountability Office: 
Washington, DC 20548: 

June 7, 2011: 

[End of section] 

The Honorable Jeff Miller: 
Chairman: 
The Honorable Bob Filner: 
Ranking Member: 
Committee on Veterans' Affairs: 
House of Representatives: 

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.[Footnote 1] 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.[Footnote 
2],[Footnote 3] 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).[Footnote 4] 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. 
[Footnote 5] We also interviewed VA and VHA Central Office officials 
involved with the reporting of safety incidents--including officials 
with VA's Office of Security and Law Enforcement (OSLE), 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.[Footnote 6] In addition, we conducted site visits to five 
VA medical facilities. These judgmentally selected medical facilities 
were chosen to ensure that our sample: (1) had both residential and 
inpatient mental health settings; (2) reflected a variety of 
residential mental health specialties, including military sexual 
trauma; (3) had medical facilities with various levels of experience 
reporting sexual assault incidents; and (4) varied in terms of size 
and complexity.[Footnote 7] During the site visits, we interviewed 
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.[Footnote 8] Information obtained from these VISNs and VA 
medical facilities cannot be generalized to all VISNs and VA medical 
facilities. In addition, we interviewed officials from the VA Office 
of the Inspector General's (OIG) Office of Investigations--Criminal 
Investigations Division--to discuss information they receive from VA 
medical facilities about sexual assault incidents that occur in these 
facilities. Finally, we reviewed documentation of reported sexual 
assault incidents at VA medical facilities provided by VA's OSLE, the 
VA OIG, and VISNs from January 2007 through July 2010, to determine 
the number and types of incidents reported, as well as which VA and 
VHA offices were notified of those incidents. For this analysis, we 
used a definition of sexual assault that was developed for the purpose 
of this report.[Footnote 9] Our analysis of VA police and VA OIG 
reports was limited to only those incidents that were reported and 
cannot be used to project the volume of sexual assault incident 
reports that may occur in future years. Following verification that VA 
police and VA OIG incidents met our definition of sexual assault and 
comparisons of sexual assault incidents reported by the two groups 
within VA, we found data derived from these reports to be sufficiently 
reliable for our purposes. 

To examine 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. 

Background: 

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. 

Residential Programs: 

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.[Footnote 10] 

Security measures that must be in place at all three types of 
residential programs are governed by VHA's Mental Health RRTP 
Handbook.[Footnote 11] 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.[Footnote 12] 

Inpatient Mental Health Units: 

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. 

Mental Health Admission Screening and Assessment: 

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.[Footnote 13] 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. 

VA Law Enforcement Resources: 

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.[Footnote 14] 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.[Footnote 15] 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. 

Nearly 300 Sexual Assault Incidents Were Reported Since 2007 through 
One of Two VA Reporting Streams: 

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. 

VA Uses Two Reporting Streams for Communicating Incidents to 
Management and Law Enforcement: 

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 figure 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. 

Figure 1: VA Reporting Process for Sexual Assaults and Other Safety 
Incidents: 

[Refer to PDF for image: process chart] 

At the facility level:[A] 

1) Staff reports incident: 

Management stream of reporting: 

2) Quality/unit management review. 

3) Facility leadership review and determine next reporting steps; 
Go to step 4; or: 
Go to step 7. 

At the VISN level: 

4) VISN management review and determine next reporting steps. 

At the VHA level: 

5) VHA management and program offices determine next reporting steps; 
Go to step 6; or: 
Go to step 7. 

At the VA department level: 

6) Office of the Secretary reviews reports. 

At the facility level:[A] 

Law enforcement stream of reporting: 

2a) Facility police generate report and conduct investigation; 
Go to step 3; or: 
Go to step 7. 

At the VA department level: 

7) VA IOC receives reports of serious incidents; 
VA OIG receives reports of and investigates potential felonies[B]; 
VA OSLE receives electronic reports of all incidents. 
Go to step 6. 

[End of figure] 

[A] Facility reporting processes described in this graphic are based 
on our review of five selected VA medical facilities. 

[B] VA OIG receives reports of potential felonies through additional 
reporting streams, including the VA OIG hotline and congressional 
contacts. 

Source: GAO. 

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.[Footnote 
16] 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. 
[Footnote 17] 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. 
[Footnote 18] 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. 

Nearly 300 Sexual Assault Incidents Reported to VA Police through the 
Law Enforcement Stream Since 2007: 

We analyzed VA's national police files from January 2007 through July 
2010 and identified 284 sexual assault incidents reported to VA police 
during that period.[Footnote 19] These cases included incidents 
alleging rape, inappropriate touching, forceful medical examinations, 
oral sex, and other types of sexual assaults (see table 1).[Footnote 
20] However, it is important to note that not all sexual assault 
incidents reported to VA police are substantiated. A case may remain 
unsubstantiated because an assault did not actually take place, the 
victim chose not to pursue the case, or there was insufficient 
evidence to substantiate the case. Due to our review of both open and 
closed VA police sexual assault incident investigations, we could not 
determine the final disposition of these incidents.[Footnote 21] 

Table 1: Number of Sexual Assault Incidents by Category Reported to VA 
Police by Year, January 2007 through July 2010: 

Year: 2010[D]; 
Rape[A]: 14; 
Inappropriate touch[B]: 44; 
Forceful medical examination: 3; 
Forced or inappropriate oral sex: 5; 
Other[C]: 0; 
Total: 66. 

Year: 2009; 
Rape[A]: 23; 
Inappropriate touch[B]: 66; 
Forceful medical examination: 3; 
Forced or inappropriate oral sex: 3; 
Other[C]: 9; 
Total: 104. 

Year: 2008[E]; 
Rape[A]: 13; 
Inappropriate touch[B]: 42; 
Forceful medical examination: 1; 
Forced or inappropriate oral sex: 3; 
Other[C]: 1; 
Total: 60. 

Year: 2007[E,F]; 
Rape[A]: 17; 
Inappropriate touch[B]: 33; 
Forceful medical examination: 1; 
Forced or inappropriate oral sex: 2; 
Other[C]: 1; 
Total: 54. 

Year: Total[G]; 
Rape[A]: 67; 
Inappropriate touch[B]: 185; 
Forceful medical examination: 8; 
Forced or inappropriate oral sex: 13; 
Other[C]: 11; 
Total: 284. 

Source: GAO (analysis); VA (data). 

Note: In this report, we use the term sexual assault incident to refer 
to suspected, alleged, attempted, or confirmed cases of sexual 
assault. All reports of sexual assault incidents do not necessarily 
lead to prosecution and conviction. This may be, for example, because 
an assault did not actually take place or there was insufficient 
evidence to determine whether an assault occurred. 

[A] The rape category includes any case involving allegations of rape, 
defined as vaginal or anal penetration through force, threat, or 
inability to consent. For cases that included allegations of multiple 
categories including rape (i.e., inappropriate touch, forced oral sex, 
and rape) the category of rape was applied. Cases where staff deemed 
that one or more of the veterans involved were mentally incapable of 
consenting to sexual activities described in the case were considered 
rape. 

[B] The inappropriate touch category includes any case involving only 
allegations of touching, fondling, grabbing, brushing, kissing, 
rubbing, or other like-terms. 

[C] The other category included any allegations that did not fit into 
the other categories or if the incident described in the case file did 
not contain sufficient information to place the case in one of the 
other designated categories. 

[D] Analysis of 2010 records was limited to only those received by VA 
police through July 2010. 

[E] Due to the lack of a centralized VA police reporting system prior 
to January 2009, VA medical facility police sent reports to VA's OSLE 
for the purpose of this data request, which may have resulted in not 
all reports being included in this analysis. 

[F] Our ability to review files for the entire year was limited 
because VA police are required to destroy files after 3 years under a 
records schedule approved by the National Archives and Records 
Administration (NARA). 

[G] Cases not reported to VA police were not included in our analysis 
of sexual assault incidents. 

[End of table] 

In analyzing these 284 cases, we observed the following (see appendix 
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.[Footnote 22] 

* 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. 

Not All Sexual Assault Incidents Are Reported Due to Unclear Guidance 
and Insufficient Oversight: 

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. 

Sexual Assault Incidents Are Underreported to VISNs, VHA Central 
Office, and the VA OIG: 

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. 

VISNs and VHA Central Office Receive Limited Information on Sexual 
Assault Incidents: 

VISNs and VHA Central Office leadership officials are not fully aware 
of many sexual assaults reported at VA medical facilities. For the 
four VISNs we spoke with, we 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.[Footnote 23] Moreover, we also found that 
one VISN did not report all of the cases they received to VHA Central 
Office (see table 2). 

Table 2: Sexual Assault Incidents Reported to Four Selected VISNs and 
VHA Central Office Leadership, January 2007 through July 2010: 

VISN: VISN A; 
Total number of sexual assault incidents reported to VA police from 
VISN medical facilities[A,B]: 13; 
Total number of sexual assault incidents reported to VISN leadership 
by VISN medical facilities: 0; 
Total number of sexual assault incidents reported by VISNs to VHA 
Central Office leadership: 0. 

VISN: VISN B; 
Total number of sexual assault incidents reported to VA police from 
VISN medical facilities[A,B]: 21; 
Total number of sexual assault incidents reported to VISN leadership 
by VISN medical facilities: 10; 
Total number of sexual assault incidents reported by VISNs to VHA 
Central Office leadership: 5. 

VISN: VISN C; 
Total number of sexual assault incidents reported to VA police from 
VISN medical facilities[A,B]: 34; 
Total number of sexual assault incidents reported to VISN leadership 
by VISN medical facilities: 4; 
Total number of sexual assault incidents reported by VISNs to VHA 
Central Office leadership: 4. 

VISN: VISN D; 
Total number of sexual assault incidents reported to VA police from 
VISN medical facilities[A,B]: 34; 
Total number of sexual assault incidents reported to VISN leadership 
by VISN medical facilities: 2; 
Total number of sexual assault incidents reported by VISNs to VHA 
Central Office leadership: 2. 

Source: GAO (data and analysis); VA (data). 

Note: In this report, we use the term sexual assault incident to refer 
to suspected, alleged, attempted, or confirmed cases of sexual 
assault. All reports of sexual assault incidents do not necessarily 
lead to prosecution and conviction. This may be, for example, because 
an assault did not actually take place or there was insufficient 
evidence to determine whether an assault occurred. 

[A] Cases not reported to VA police were not included in our count of 
sexual assault incidents. 

[B] Due to the absence of system wide requirements on what medical 
facilities must report to these VISNs, we could not determine the 
accuracy of VISN reporting. 

[End of table] 

The VA OIG Did Not Receive Reports of about Two-Thirds of Sexual 
Assault Incidents Involving Rape Allegations: 

To examine whether VA medical facilities were accurately reporting 
sexual assault incidents involving rape allegations to the VA OIG, we 
reviewed 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.[Footnote 24] The remaining 25 had matching VA OIG 
investigation documentation, indicating that they were correctly 
reported to both the VA police and the VA OIG. 

By regulation, VA requires that: (1) all criminal matters involving 
felonies that occur in VA medical facilities be immediately referred 
to the VA OIG and (2) responsibility for the prompt referral of any 
possible criminal matters involving felonies lies with VA management 
officials when they are informed of such matters.[Footnote 25] This 
regulation includes rape in the list of felonies provided as examples 
and also requires VA medical facilities to report other sexual assault 
incidents that meet the criteria for felonies to the VA OIG.[Footnote 
26],[Footnote 27] 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.[Footnote 28] 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. 

Several Factors May Contribute to the Underreporting of Sexual Assault 
Incidents: 

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. 

VHA Does Not Have a Consistent Sexual Assault Definition for Reporting 
Purposes: 

VHA leadership officials may not receive reports of all sexual assault 
incidents that occur at VA medical facilities because 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.) 

Table 3: Selected VA Medical Facility Definitions of Sexual Assault 
for the Assessment and Management of Victims of Recent Sexual Assault: 

Selected VA medical facility: Facility A; 
Definitions of sexual assault: Sexual violation of a person (male or 
female) by the use of force, threat, or intimidation [that] is 
committed without the consent of the person assaulted. The violent act 
may or may not include penetration and may be [an] oral, anal, or 
vaginal violation. 

Selected VA medical facility: Facility B; 
Definitions of sexual assault: No definition. 

Selected VA medical facility: Facility C; 
Definitions of sexual assault: Conduct of a sexual or indecent nature 
toward another person that is accompanied by actual or threatened 
physical force or that induces fear, shame, or mental suffering. 
Sexual assault may be penetrating (i.e., rape) to include vaginal, 
anal, and oral penetration, or nonpenetrat[ing] and includes both 
males and females as victims of this crime. 

Selected VA medical facility: Facility D; 
Definitions of sexual assault: Includes incest, oral copulation, 
penetration, rape, sexual assault, sexual battery, and sodomy which 
occurs without the consent of a person, or when a person is not 
capable of giving consent. Sexual abuse also means acts of a sexual 
nature committed in the presence of a vulnerable adult without that 
person's informed consent. It includes, but is not limited to, the 
acts defined in a state statute, fondling, exposure of a vulnerable 
adult's sexual organs, or the use of a vulnerable adult to solicit for 
or engage in prostitution or sexual performance. 

Selected VA medical facility: Facility E; 
Definitions of sexual assault: Sexual assault is sexual contact of ANY 
kind against a person's will, brought about by force, threats, or 
coercion. 

Source: Selected VA medical facilities. 

[End of table] 

Table 19: 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.[Footnote 
29],[Footnote 30] 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. 

VHA Central Office, VISNs, and VA Medical Facilities' Expectations for 
Reporting Are Limited and Unclear: 

In addition to failing to provide a consistent definition of sexual 
assault for incident reporting, VHA also does not have clearly 
documented expectations about the types of sexual assault incidents 
that should be reported to officials at each level of the 
organization, which may also contribute to the underreporting of 
sexual assault incidents. Without clear expectations for incident 
reporting there is no assurance that all sexual assault incidents are 
appropriately reported to officials at the VHA Central Office, VISN, 
and local medical facility levels. We found that expectations were not 
always clearly documented, resulting in either the underreporting of 
some sexual assault incidents or communication breakdowns at all 
levels. 

* VHA Central Office. An official from VHA's Office of the Deputy 
Under Secretary for Health for Operations and Management told us that 
this office's expectations for reporting sexual assault incidents were 
documented in its guidance for the submission of issue briefs. 
However, we found that this guidance does not specifically reference 
reporting requirements for any type of sexual assault incidents. As a 
result, VISNs we reviewed did not consistently report sexual assault 
incidents to VHA Central Office. 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.[Footnote 31] 

* 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.[Footnote 32] 
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. 

Deficiencies Exist in VHA Central Office Oversight of Sexual Assault 
Incidents: 

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 figure 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.[Footnote 33] 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.[Footnote 
34] Following review, the Director for Network Support forwards issue 
briefs to the Office of the Principal Deputy Under Secretary for 
Health for distribution to other VHA offices on a case-by-case basis, 
including the program offices responsible for residential programs and 
inpatient mental health units. Program offices are sometimes asked to 
follow up on incidents in their area of responsibility. 

Figure 2: VHA Central Office Reporting Process for Sexual Assaults and 
Other Safety Incidents: 

[Refer to PDF for image: illustration] 

At the VHA level: 

VHA Office of the Deputy Under Secretary for Health for Operations and 
Management: 
VISN support staff receive issue briefs from VISNs via e-mail; 
Director of Network Support reviews and forwards issue briefs[B]. 

VHA Office of the Principal Deputy Under Secretary for Health: 
Receives and distributes issue briefs to other VHA offices via e-mail. 

VHA Program Offices:[A] 
Program officials receive issue briefs and follow-up with facilities as
necessary. 

Source: GAO. 

[A] Program offices include those responsible for residential programs 
and inpatient mental health units. 

[B] Office of the Deputy Under Secretary for Health for Operations and 
Management officials reported that they may distribute issue briefs 
directly to program officials depending on the severity of the 
incident. 

[End of figure] 

We found that this system did not effectively communicate information 
about sexual assault incidents to the VHA Central Office officials who 
have programmatic responsibility for the locations in which these 
incidents occurred. For example, VHA program officials responsible for 
both residential programs and inpatient mental health units reported 
that they do not receive regular reports of sexual assault incidents 
that occur within their programs or units at VA medical facilities and 
were not aware of any incidents that had occurred in these programs or 
units. However, during our review of VA police files we identified at 
least 18 sexual assault incidents that occurred from January 2007 
through July 2010 in the residential programs or inpatient mental 
health units of the five VA medical facilities we reviewed. If the 
management reporting stream were functioning properly, these program 
officials should have been notified of these incidents and any others 
that occurred in other VA medical facilities' residential programs and 
inpatient mental health units.[Footnote 35] 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.[Footnote 36] 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. 

Self-Reported Legal Histories Are Commonly Used to Inform Clinicians 
of Sexual Assault-Related Risks, but Guidance on Information 
Collection Is Limited: 

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.[Footnote 37] 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. 

VHA Does Not Have Specific Sexual Assault Risk Assessment Tools: 

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.[Footnote 38] 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.[Footnote 39] 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. 

Clinicians Reported Using Veterans' Self-Reported Legal Histories to 
Assess Sexual Assault-Related Risks, but This Information May Not 
Always Be Complete: 

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.[Footnote 40] 

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.[Footnote 41] 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. 

VHA Does Not Have Specific Guidance on the Collection of Legal History 
Information: 

VHA's assessment of veterans in their mental health programs for 
sexual assault-related risks is limited by a lack of specific 
guidance.[Footnote 42] 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.[Footnote 43] 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.[Footnote 44] 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. 

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: 

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. 

Several Types of Patient-Oriented Precautions Are Used by Residential 
Programs and Inpatient Mental Health Units to Prevent Sexual Assaults 
and Other Safety Incidents: 

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. 
[Footnote 45] 

* 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. 

The Types of Physical Precautions in Use to Prevent Sexual Assaults 
and Other Safety Incidents Vary among VA Medical Facilities: 

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. 

Several Types of Physical Security Precautions Are in Place in 
Selected Medical Facilities: 

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). 

Table 4: Physical Security Precautions in Residential Programs and 
Inpatient Mental Health Units at Selected VA Medical Facilities: 

Monitoring precautions: 
* Closed-circuit surveillance camera use and monitoring; 
* Unit rounds by VA staff. 

Security precautions: 
* Locks and alarms at entrance and exit access points; 
* Locks and alarms for patient bedrooms and bathrooms; 
* Stationary, computer-based, and portable personal panic alarms; 
* Separate or specially designated areas for women veterans. 

Staff awareness and preparedness precautions: 
* Staff training; 
* VA police presence on units; 
* VA police staffing and command and control operations. 

Source: GAO. 

Note: Physical security precautions varied by VA medical facility and 
program and were not necessarily in place at all VA medical facilities 
and programs we visited. 

[End of table] 

* Monitoring precautions--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.[Footnote 46] 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. 

Selected VA Medical Facilities Varied in Their Implementation of 
Physical Security Precautions: 

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.[Footnote 
47],[Footnote 48] 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.[Footnote 49] 

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.[Footnote 
50] 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.[Footnote 51] 
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. 

Significant Weaknesses Existed in the Use and Implementation of 
Certain Physical Security Precautions at Selected VA Medical 
Facilities: 

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.[Footnote 52] 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). 

Table 5: Weaknesses in Physical Security Precautions in Residential 
Programs and Inpatient Mental Health Units at Selected VA Medical 
Facilities: 

Monitoring precautions: 
* Inadequate monitoring of closed-circuit surveillance cameras. 

Security precautions: 
* Alarm malfunctions of stationary, computer-based, and personal panic 
alarms; 
* Inadequate documentation or review of alarm testing; 
* Failure of alarms to alert both unit staff and VA police; 
* Limited use of personal panic alarms. 

Staff awareness and preparedness precautions: 
* VA police staffing and workload challenges; 
* Lack of stakeholder involvement in unit redesign efforts. 

Source: GAO. 

[End of table] 

Inadequate monitoring of closed-circuit surveillance cameras. We 
observed that VA staff in the police command and control center were 
not continuously monitoring closed-circuit surveillance cameras at all 
five 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.[Footnote 53] 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.[Footnote 54] 

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.[Footnote 55] 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. 

Conclusions: 

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. 

Recommendations for Executive Action: 

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. 

Agency Comments and Our Evaluation: 

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 [hyperlink, 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. 

Signed by: 

Randall B. Williamson: 
Director, Health Care: 

[End of section] 

Appendix I: Scope and Methodology: 

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. 

Site Selection Methodology and Interviews with Medical Facility 
Officials: 

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.[Footnote 
56] 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. 

Interviews with VA and VHA Central Office Officials: 

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. 

Analyses of Sexual Assault Incident Reporting: 

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. 

Document Request and Response: 

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.[Footnote 57] 

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.[Footnote 58] 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.[Footnote 
59] 

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.[Footnote 60] 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. 

Scoping of VA Police Case Files and VA OIG Investigation Documentation: 

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. 

Analysis of VA Police Case Files: 

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.[Footnote 61] 

* 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.[Footnote 62] 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. 

VA OIG Reporting Analysis: 

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.[Footnote 63] 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.[Footnote 64] Four VA OIG investigators reviewed these 
summaries and based their determinations on several key factors 
developed from their experience as law enforcement officers. 

Legal History Analysis of Biopsychosocial Assessments: 

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.[Footnote 65] 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. 

Review of Selected VA Medical Facilities' Physical Security 
Precautions: 

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. 

[End of section] 

Appendix II: Analysis of VA Police Reports of Sexual Assault Incidents 
from January 2007 through July 2010: 

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. 

Figure 3: Number of Sexual Assault Incidents Reported to VA Medical 
Facility Police by VISN, January 2007 through July 2010: 

[Refer to PDF for image: vertical bar graph] 

VISN: A; 
Number of Incidents Reported: 13. 

VISN: B; 
Number of Incidents Reported: 21. 

VISN: C; 
Number of Incidents Reported: 34. 

VISN: D; 
Number of Incidents Reported: 34. 

VISN: E; 
Number of Incidents Reported: 0. 

VISN: F; 
Number of Incidents Reported: 4. 

VISN: G; 
Number of Incidents Reported: 7. 

VISN: H; 
Number of Incidents Reported: 21. 

VISN: I; 
Number of Incidents Reported: 11. 

VISN: J; 
Number of Incidents Reported: 14. 

VISN: K; 
Number of Incidents Reported: 7. 

VISN: L; 
Number of Incidents Reported: 19. 

VISN: M; 
Number of Incidents Reported: 6. 

VISN: N; 
Number of Incidents Reported: 22. 

VISN: O; 
Number of Incidents Reported: 7. 

VISN: P; 
Number of Incidents Reported: 8. 

VISN: Q; 
Number of Incidents Reported: 6. 

VISN: R; 
Number of Incidents Reported: 13. 

VISN: S; 
Number of Incidents Reported: 7. 

VISN: T; 
Number of Incidents Reported: 15. 

VISN: U; 
Number of Incidents Reported: 15. 

Sources: GAO (analysis); VA (data). 

Notes: In this report, we use the term sexual assault incident to 
refer to suspected, alleged, attempted, or confirmed cases of sexual 
assault. All reports of sexual assault incidents do not necessarily 
lead to prosecution and conviction. This may be, for example, because 
an assault did not actually take place or there was insufficient 
evidence to determine whether an assault occurred. 

Complete analysis of 2007, 2008, and 2010 data was limited by three 
factors: (1) our analysis of 2007 VA police files was limited due to 
the requirement that VA police destroy investigative files after 3 
years under a records schedule approved by the National Archives and 
Records Administration, (2) our analysis of 2007 and 2008 VA police 
files was limited due to VA police manually submitting these files to 
VA's Office of Security and Law Enforcement (OSLE) for the purpose of 
this data request because a centralized VA police reporting system did 
not exist prior to January 2009, and (3) our analysis of 2010 records 
was limited to only those received by VA police through July 2010. 

There are 21 VISNs in the VA health care system. VISNs 1-12 and VISNs 
15-23. For reporting purposes, VISN numbers were blinded to protect 
the anonymity of each individual VISN. 

Cases not reported to VA police were not included in our analysis of 
sexual assault incidents. 

[End of figure] 

Table 6: Total Sexual Assault Incidents Alleging Rape by Perpetrator 
and Victim Gender, January 2007 through July 2010: 

Perpetrator/victim gender: Female/male; 
Total sexual assault incidents involving rape[A]: 5. 

Perpetrator/victim gender: Male/female; 
Total sexual assault incidents involving rape[A]: 31. 

Perpetrator/victim gender: Male/male; 
Total sexual assault incidents involving rape[A]: 20. 

Perpetrator/victim gender: Unknown/female; 
Total sexual assault incidents involving rape[A]: 8. 

Perpetrator/victim gender: Unknown/male; 
Total sexual assault incidents involving rape[A]: 3. 

Perpetrator/victim gender: Total; 
Total sexual assault incidents involving rape[A]: 67. 

Source: GAO (analysis); VA (data). 

Notes: In this report, we use the term sexual assault incident to 
refer to suspected, alleged, attempted, or confirmed cases of sexual 
assault. All reports of sexual assault incidents do not necessarily 
lead to prosecution and conviction. This may be, for example, because 
an assault did not actually take place or there was insufficient 
evidence to determine whether an assault occurred. 

Complete analysis of 2007, 2008, and 2010 data was limited by three 
factors: (1) our analysis of 2007 VA police files was limited due to 
the requirement that VA police destroy investigative files after three 
years under a records schedule approved by the National Archives and 
Records Administration, (2) our analysis of 2007 and 2008 VA police 
files was limited due to VA police manually submitting these files to 
VA's OSLE for the purpose of this data request because a centralized 
VA police reporting system did not exist prior to January 2009, and 
(3) our analysis of 2010 records was limited to only those received by 
VA police through July 2010. 

The rape category includes any case involving allegations of rape, 
defined as vaginal or anal penetration through force, threat, or 
inability to consent. For cases that included allegations of multiple 
categories including rape (i.e. inappropriate touch, forced oral sex, 
and rape) the category of rape was applied. Cases where staff deemed 
that one or more of the veterans involved were mentally incapable of 
consenting to sexual activities described in the case were considered 
rape. 

[A] Cases not reported to VA police are not included in our analysis 
of sexual assault incidents. 

[End of table] 

Table 7: Total Sexual Assault Incidents Alleging Rape by Perpetrator 
and Victim Relationship to VA, January 2007 through July 2010: 

Perpetrator/victim relationship to VA: Employee/employee; 
Total sexual assault incidents involving rape[A]: 2. 

Perpetrator/victim relationship to VA: Employee/outsider; 
Total sexual assault incidents involving rape[A]: 1. 

Perpetrator/victim relationship to VA: Employee/patient; 
Total sexual assault incidents involving rape[A]: 13. 

Perpetrator/victim relationship to VA: Employee/visitor; 
Total sexual assault incidents involving rape[A]: 1. 

Perpetrator/victim relationship to VA: Outsider/employee; 
Total sexual assault incidents involving rape[A]: 1. 

Perpetrator/victim relationship to VA: Outsider/outsider; 
Total sexual assault incidents involving rape[A]: 2. 

Perpetrator/victim relationship to VA: Patient/employee; 
Total sexual assault incidents involving rape[A]: 1. 

Perpetrator/victim relationship to VA: Patient/patient; 
Total sexual assault incidents involving rape[A]: 25. 

Perpetrator/victim relationship to VA: Unknown/patient; 
Total sexual assault incidents involving rape[A]: 19. 

Perpetrator/victim relationship to VA: Visitor/patient; 
Total sexual assault incidents involving rape[A]: 2. 

Perpetrator/victim relationship to VA: Total; 
Total sexual assault incidents involving rape[A]: 67. 

Source: GAO (analysis); VA (data). 

In this report, we use the term sexual assault incident to refer to 
suspected, alleged, attempted, or confirmed cases of sexual assault. 
All reports of sexual assault incidents do not necessarily lead to 
prosecution and conviction. This may be, for example, because an 
assault did not actually take place or there was insufficient evidence 
to determine whether an assault occurred. 

Complete analysis of 2007, 2008, and 2010 data was limited by three 
factors: (1) our analysis of 2007 VA police files was limited due to 
the requirement that VA police destroy investigative files after three 
years under a records schedule approved by the National Archives and 
Records Administration, (2) our analysis of 2007 and 2008 VA police 
files was limited due to VA police manually submitting these files to 
VA's OSLE for the purpose of this data request because a centralized 
VA police reporting system did not exist prior to January 2009, and 
(3) our analysis of 2010 records was limited to only those received by 
VA police through July 2010. 

The rape category includes any case involving allegations of rape, 
defined as vaginal or anal penetration through force, threat, or 
inability to consent. For cases that included allegations of multiple 
categories including rape (i.e. inappropriate touch, forced oral sex, 
and rape) the category of rape was applied. Cases where staff deemed 
that one or more of the veterans involved were mentally incapable of 
consenting to sexual activities described in the case were considered 
rape. 

[A] Cases not reported to VA police are not included in our analysis 
of sexual assault incidents. 

[End of table] 

Table 8: Patient-on-Patient Assault Incidents and Patient-on-Employee 
Assault Incidents by Type of Sexual Assault Incident, January 2007 
through July 2010: 

Patient-on-patient: 
Rape[A]: 25; 
Inappropriate touch[B]: 54; 
Forceful medical examination: 0; 
Forced or inappropriate oral sex: 8; 
Other[C]: 2; 
Total[D]: 89. 

Patient-on-employee: 
Rape[A]: 1; 
Inappropriate touch[B]: 83; 
Forceful medical examination: 0; 
Forced or inappropriate oral sex: 1; 
Other[C]: 0; 
Total[D]: 85. 

Total: 
Rape[A]: 26; 
Inappropriate touch[B]: 137; 
Forceful medical examination: 0; 
Forced or inappropriate oral sex: 9; 
Other[C]: 2; 
Total[D]: 174. 

Source: GAO (analysis); VA (data). 

Notes: In this report, we use the term sexual assault incident to 
refer to suspected, alleged, attempted, or confirmed cases of sexual 
assault. All reports of sexual assault incidents do not necessarily 
lead to prosecution and conviction. This may be, for example, because 
an assault did not actually take place or there was insufficient 
evidence to determine whether an assault occurred. 

Complete analysis of 2007, 2008, and 2010 data was limited by three 
factors: (1) our analysis of 2007 VA police files was limited due to 
the requirement that VA police destroy investigative files after three 
years under a records schedule approved by the National Archives and 
Records Administration, (2) our analysis of 2007 and 2008 VA police 
files was limited due to VA police manually submitting these files to 
VA's OSLE for the purpose of this data request because a centralized 
VA police reporting system did not exist prior to January 2009, and 
(3) our analysis of 2010 records was limited to only those received by 
VA police through July 2010. 

[A] The rape category includes any case involving allegations of rape, 
defined as vaginal or anal penetration through force, threat, or 
inability to consent. For cases that included allegations of multiple 
categories including rape (i.e. inappropriate touch, forced oral sex, 
and rape) the category of rape was applied. Cases where staff deemed 
that one or more of the veterans involved were mentally incapable of 
consenting to sexual activities described in the case were considered 
rape. 

[B] The inappropriate touch category includes any case involving only 
allegations of touching, fondling, grabbing, brushing, kissing, 
rubbing, or other like-terms. 

[C] The other category included any allegations that did not fit into 
the other categories or if the incident described in the case file did 
not contain sufficient information to place the case in one of the 
other designated categories. 

[D] Cases not reported to VA police are not included in our analysis 
of sexual assault incidents. 

[End of table] 

[End of section] 

Appendix III: Comments from the Department of Veterans Affairs: 

Department Of Veterans Affairs: 
Washington DC 20420: 

June 3, 2011: 

Mr. Randall B. Williamson: 
Director, Health Care: 
U.S. Government Accountability Office: 
441 G Street, NW: 
Washington, DC 20548: 

Dear Mr. Williamson: 

The Department of Veterans Affairs (VA) has reviewed the Government
Accountability Office's (GAO) draft report, "VA Health Care: Actions 
Needed to Prevent Sexual Assaults and Other Safety Incidents" (GA0-11-
530) and generally agrees with GAO's conclusions and concurs with 
GAO's recommendations to the Department. 

The Department values the safety and well being of all Veterans, staff 
and visitors who come to VA health care facilities. To address 
concerns raised in GAO's draft report, a multi-disciplinary workgroup 
has already begun work to define what the Veterans Health 
Administration must do to prevent sexual assault incidents as well as
respond to reports and allegations of sexual victimization of Veterans 
and employees. Furthermore, in June 2009, the Secretary of Veterans 
Affairs mandated the establishment of a VA Integrated Operations 
Center (IOC). The IOC is the focal point within VA for the receipt, 
analysis, and dissemination of information from VA facilities and 
forms a nexus that allows for situational awareness, coordinated 
recommendations, and feedback to VA senior leaders in real time so 
that they can make timely and proactive decisions. The combination of 
these actions will provide increased security and safety for our 
Veterans, their families, and our employees. 

The enclosure provides responses to each of GAO's recommendations and 
provides technical comments to the report. VA appreciates the 
opportunity to comment on your draft report. 

Sincerely, 

Signed by: 

John R. Gingrich: 
Chief of Staff: 

Enclosure: 

[End of letter] 

Enclosure: 

Department of Veterans Affairs Comments to Government Accountability 
Office (GAO) Draft Report: VA Health Care: Actions Needed to Prevent 
Sexual Assaults and Other Safety Incidents (GA0-11-530): 

GAO recommendation: To improve VA's reporting and monitoring of 
allegations of sexual assault, we recommend that the Secretary of the 
Department of Veterans Affairs direct the Under Secretary for Health 
to take the following four actions: 

Recommendation 1: 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; 

VA Response: Concur. The Veterans Health Administration (VHA) agrees 
with the need for establishing consistent definitions of sexual 
assault and other safety incidents to be used for reporting 
information from medical facilities through the Veterans Integrated 
Service Networks (VISN) to VHA Central Office (CO) and other offices 
including the VA Office of Security and Law Enforcement (OSLE). To 
develop a set of definitions of sexual assault and other safety 
incidents as well as address other report recommendations and 
additional needs, a multi-disciplinary workgroup[Footnote 1] has been 
charged with multiple objectives and tasks to complete with 
assignments for interim deliverables including completion of an 
initial action plan with specific timeframes due no later than (NLT) 
July 15, 2011, with the final report due NLT September 30, 2011. A 
specific charge to the workgroup is to identify the scope and 
definitions for sexual victimization, types of incidents, and 
locations within VHA. The entire charge to the work group is provided 
in Attachment A. 

Recommendation 2: 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; 

VA Response: Concur. VHA recognizes the need to improve structures for 
reporting incidents involving sexual victimization and other safety 
incidents. The multidisciplinary workgroup mentioned in the response 
to Recommendation 1 will review existing data sources and information-
dissemination mechanisms to obtain and determine what data and 
reporting processes are needed for an effective reporting structure. 
Based on this inventory, if it is determined that existing additional 
reporting processes or data collection are required, changes will be 
developed, communicated with the field, and implemented. In addition 
to reporting and communicating information to VISN and VHACO 
leadership teams, as well as the VA OSLE, the workgroup will identify 
how best to enhance tracking which can be used to identify trends and 
root causes if safety is not achieved. 

In regard to improving structures for reporting and communicating 
sexual assault and other safety incidents, the initial action plan 
will be completed NLT July 15, 2011, with a final report due NLT 
September 30, 2011. 

Recommendation 3: Implement a centralized tracking mechanism that 
would allow sexual assault incidents to be consistently monitored by 
VHA Central Office staff; 

VA Response: Concur. Defining program responsibilities for policy 
development and implementation and ensuring that sexual assault and 
other safety incidents are consistently reported, monitored by the 
appropriate staff, and addressed appropriately and promptly by field 
and VHACO officials are crucial elements in protecting the safety of 
Veterans in residential and other programs, as well as employees who 
work in our facilities and others who visit. To accomplish this more 
effectively, VHA has already begun to determine potential 
vulnerabilities in organization strategies, structures, or policies to 
identify how best to change or strengthen program leadership roles, 
parameters of reporting, and program ownership for tracking and 
reporting processes. Also, a multidisciplinary workgroup has been 
specifically charged with developing and implementing a centralized 
mechanism to monitor sexual assault and other safety incidents 
starting with the completion of an action plan with specific 
timeframes by July 15, 2011, with a final report due NLT September 30, 
2011. 

Recommendation 4: 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. 

VA Response: Concur. The Office of Operations, Security, and 
Preparedness (OSP)/OSLE partners and collaborates with VA OIG on a 
daily basis. OSP/OSLE will develop a mechanism that will directly 
prompt VA police officers to report potential felonies such as rape to 
the VA OIG when the offense is entered into the database. Also, the 
system will send a message alert to a specialized VA OIG mailbox that 
a felony has been recorded in the VA police database. VA employees 
have a duty to report all crimes in accordance with 38 CFR 1.203 and 
1.205 to VA Police and in accordance with 38 CFR 1.204 and 1.201 to VA 
01G. Completion date: August 2011. 

GAO recommendation: To help identify risks and address vulnerabilities 
in physical security precautions at VA medical facilities, we 
recommend that the Secretary of the Department of Veterans Affairs 
direct the Under Secretary for Health to take the following four 
actions: 

Recommendation 5: Establish guidance specifying what should be 
included in legal history discussions with veterans and how this 
information should be documented in veterans' psychosocial assessments; 

VA Response: Concur. VHA cannot predict potential sexual victimization 
with any certainty; however, VHA can and will focus on strategies that 
provide universal precautions. In addition, VHA will further explore 
what information should be obtained when assessing a Veteran's risk to 
commit an offense and how this information would be used within the 
required limits for maintaining confidentiality and rights of privacy. 

VHA will conduct a comprehensive literature review to identify best 
practices and evidence-based approaches to risk assessment and risk 
management. This may include information about legal history as well 
as information about other risk factors. The multidisciplinary 
workgroup has been charged with consulting with additional expertise 
if needed to analyze the information developed during the literature 
review to determine what specific guidance may need to be developed. 
An action plan for the development, implementation, and communication 
of the guidance will be established and followed. This process will 
also address what appropriate action needs to be taken to standardize 
documentation in Veterans' psychosocial assessments. 

Throughout this process, the multidisciplinary workgroup will 
collaborate with the VA Office of General Counsel, as well as with the 
VHA Office of Ethics in Health Care and Patient Care Services, to 
ensure that rights of privacy are maintained in developing and 
implementing risk assessment and management guidance and processes 
while ensuring a safe environment for Veterans. 

In regard to establishing guidance specifying what should be included 
in legal history discussions with Veterans and how this information 
should be documented in Veterans' psychosocial assessments, completion 
of an initial action plan with specific timeframes is due NLT July 15, 
2011, with a final report due NLT September 30, 2011. 

Recommendation 6: Ensure medical centers determine whether existing 
stationary, computer-based, and portable personal panic-alarm systems 
operate effectively through mandatory regular testing; 

VA Response: Concur. Regular testing of alarm systems is one step to 
ensuring the safety and security of Veterans who participate in 
residential treatment as well as other programs. While VA Medical 
Centers (VAMC) currently are expected to have policies appropriate for 
individual circumstances in a medical center and in compliance with The
Joint Commission standards regarding the use and testing of panic 
alarm systems, the Office of the Deputy Under Secretary for Health for 
Operations and Management (DUSHOM) will re-emphasize the need for 
routine testing of these panic alarms to ensure the alarms are 
functioning correctly. The DUSHOM will also review whether existing 
policy needs to be revised so that regular testing is required and so 
that alarm systems have regular preventative maintenance performed in 
accordance with manufacturer requirements. 

The DUSHOM will work with the multi-disciplinary workgroup to complete 
an action plan with specific timeframes NLT July 15, 2011, with a 
final report due NLT September 30, 2011. 

Recommendation 7: Ensure that alarm systems effectively notify 
relevant staff in both medical facilities' VA police command and 
control centers and unit nursing stations; 

VA Response: Concur. Due to the variability in types of alarm systems 
based on location and services offered, it is necessary for each 
facility to develop its own processes to ensure alarm systems are 
appropriately communicating with medical facilities' VA police command 
and control centers as well as unit nursing services.	In order to 
ensure that each facility is addressing these issues, the DUSHOM will 
reemphasize existing policy and procedures about the use of alarm 
systems. Also, VISN Directors will be tasked to ensure that local 
facilities have established systems that meet the specific location 
and function needs. A process will be developed to include regular 
testing of these systems based on industry and manufacturers' 
standards. 

The DUSHOM will work with the multi-disciplinary workgroup to complete 
an action plan with specific timeframes by July 15, 2011, as well as 
implement policy changes or complete timelines related to policy 
changes NLT September 30, 2011. 

Recommendation 8: 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. 

VA Response: Concur. The report points out the importance of 
coordination and collaboration in construction and renovation 
processes among medical center stakeholders. The DUSHOM will re-
emphasize the importance of coordinating at the local level to ensure 
that safety and security are considered during construction and 
renovation projects at local levels. 

In addition at the national level, the DUSHOM will work with the multi-
disciplinary workgroup to consult with the VA Office of Construction 
and VA OSLE about how to formalize such consultation as part of the 
planning and design processes for all construction projects. The goal 
is to ensure vulnerability assessments and physical security 
considerations are addressed for all new and renovated units in 
medical facilities. 

The DUSHOM will work with the multi-disciplinary workgroup to complete 
an action plan with specific timeframes NLT July 15, 2011, as well as 
implement policy changes or complete timelines related to policy 
changes NLT September 30, 2011. 

Appendix III Footnotes: 

[1] The workgroup includes officials from the Offices of the Deputy 
Under Secretary for Policy and Services (e.g., Patient Care Services, 
Public Health, Informatics and Analytics); Deputy Under Secretary for 
Health for Operations and Management (e.g., Assistant Deputy Under 
Secretary for Health for Clinical Operations and Assistant Deputy
Under Secretary for Administrative Operations); Principal Deputy Under 
Secretary for Health (e.g., Office of Nursing Services and Assistant 
Deputy Under Secretary for Health for Quality, Safety, and Value); VA 
Office of Security and Law Enforcement as well as other offices such 
as the VA Office of General Counsel, as needed. 

Attachment A: 

Department of Veterans Affairs: 
Veterans Health Administration: 
Charter of the Under Secretary for Health Safety and Assault 
Prevention Workgroup: 

1. Purpose. 

The Veterans Health Administration (VHA) values the safety and well 
being of Veterans, staff, and visitors in every Department of Veterans 
Affairs (VA) health care setting. This includes establishing 
appropriate risk assessments, precautions, and risk management 
procedures related to incidents of alleged sexual assaults and of 
alleged sexual harassment perpetrated against Veterans, staff, or 
visitors to VA medical care facilities. In addition, VHA recognizes 
that several mechanisms and reporting structures have been identified 
that could be better organized to ensure the effective coordination of 
both prevention and response activities. 

This workgroup is charged to define steps necessary to ensure that VHA 
is taking every action necessary to respond effectively to reports of 
sexual victimization of Veterans and employees, develop appropriate 
proactive interventions to reduce the risk of these events, provide a 
recommendation for ongoing data tracking and trending, and establish 
guidance for training of staff and providers. The workgroup will 
review the current data sources, organization and structure of VHA's 
tracking reports and the current response to sexual victimization and 
assault incidents. The workgroup will further review and evaluate 
risks and efforts to prevent sexual assaults. Finally, the workgroup 
will assess the current status within VHA and propose recommendations 
on the most appropriate organizational initiatives or policy updates. 

2. Workgroup Objectives. 

The Safety and Assault Prevention Workgroup will be expected to 
accomplish the following objectives: 

* Identify scope and definitions for sexual victimization of Veterans 
and employees, types of incidents and locations within VHA 
responsibility; 

* Identify current organizational roles and responsibilities in 
relation to assuring safety from sexual victimization in VHA settings; 

* Identify data sources within the VHA organizational structure, 
variations in data elements, and data tracking methods that are most 
likely to support identification of trends and root causes when safety 
was not achieved: 
- Review of existing data sources, and information-dissemination
mechanisms; 
- Determine what other data will be needed, and request from data 
sources. 

* Establish a tracking system for all defined incidents which will 
coordinate both law enforcement and leadership systems of response; 

* Evaluate where current models of care delivery work well; 

* Identify where non-compliance exists with current policy; 

* Determine potential vulnerabilities in organizational strategies, 
structures or policies, and recommend opportunities for change or 
strengthening in program leadership roles, parameters of reporting, 
and program ownership for tracking and reporting routinely, and 
program responsibilities for policy development and implementation; 

* Begin background work on education needs for VHA Central Office and 
field staff and providers; 

* Identify and establish data trending mechanisms to support 
intervention, prevention and education; 

* Identify prevention strategies that are reviewed by Program Office 
Officials for compliance with current literature and/or best practice 
and that can be executed at all VA medical centers (VAMC); 

* Assess current alarm/panic systems, and physical security features 
with an analysis of gaps and recommendations for improvement. 

3. Membership. 

Co-Chair: George Arana, MD, Acting Assistant Deputy Under Secretary 
for Health for Clinical Operations. 

Co-Chair: Patricia M. Hayes, PhD, Chief Consultant, Women's Health 
Strategic Health Group. 

Project Manager: Douglas Walker, Presidential Management Fellow. 

Workgroup Participants: Representatives from following offices: 

* VHA Deputy Under Secretary for Health for Operations and Management 
(10N); 
- Assistant Deputy Under Secretary for Clinical Operations (10NC) 
including operations officials related to mental health, geriatrics, 
specialty care; 
- Assistant Deputy Under Secretary for Administrative Operations 
including officials involved with safety and facility issues. 

* VHA Deputy Under Secretary for Health for Policy and Services (10P); 
- Office of Patient Care Services (10P4) including policy staff 
related to mental health, geriatrics, specialty care; 
- Office of Public Health (10P3); 
- Information and Analytics (10P2). 

* VHA Principal Deputy Under Secretary for Health (10A); 
- Office of Quality and Safety; 
- Office of Nursing Service. 

* VA Office of Security and Law Enforcement. 

* VA Office of General Counsel, as needed. 

* Field representation. 

* Others, as needed. 

4. Deliverables and Operations. 

The workgroup is chartered to prepare reports and recommendations to 
be presented to the co-chairs of the workgroup. The co-chairs will 
then provide the results of the workgroup efforts to the Deputy Under 
Secretary for Health for Operations and Management and the Deputy 
Under Secretary for Health for Policy and Services for review and 
approval. 

The workgroup has the authority and expectation to set up sub-groups 
as necessary to complete a full analysis in a timely manner. The 
workgroup and its sub-groups are to use program office leaders, 
subject matter experts, and front line staff from the field as members 
of the sub-groups. 

The specific tasks for the workgroup are to: 

* Develop and present an initial action plan to outline scope of work 
with strict timelines. 

* Produce a workgroup report to include a highly defined and detailed 
list of recommendations and a project plan including: 
- identification of risks (including if there is a need for legal 
history discussions with Veterans during psychosocial assessment 
processes), 
- risk mitigation strategies, 
- definitions of oversight responsibilities and roles of leadership and
program offices, 
- timeframes for execution of recommendations, 
- timeframes for execution of implementation in field facilities, 
- performance metrics and outcome measures for plan work streams, 
- comprehensive policy to track and report sexual victimization 
incidents at VA facilities, 

This report is to be presented to the Principal Deputy Under Secretary 
for Health and Under Secretary for Health for approval. 

5. Timelines. 

* Initial Action Plan:	NLT July 15, 2011. 

* Monthly verbal updates to Deputy Under Secretary for Health for 
Operations and Management, Deputy Under Secretary for Health for 
Policy and Services, and Principal Deputy Under Secretary for Health, 
and Under Secretary for Health. 

* Final Written Report: NLT September 30, 2011. 

Signed by: 

Robert A. Petzel, M.D.	
Under Secretary for Health: 

Date: June 3, 2011: 

[End of section] 

Appendix IV: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Randall B. Williamson, (202) 512-7114 or williamsonr@gao.gov: 

Staff Acknowledgments: 

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. 

[End of section] 

Footnotes: 

[1] See GAO, VA Health Care: VA Has Taken Steps to Make Services 
Available to Women Veterans, but Needs to Revise Key Policies and 
Improve Oversight Processes, [hyperlink, 
http://www.gao.gov/products/GAO-10-287] (Washington D.C.: Mar. 31, 
2010). 

[2] In this report, we use the term safety incident to refer to 
intentionally unsafe acts--including criminal and purposefully unsafe 
acts, clinician and staff alcohol or substance abuse-related acts, and 
events involving alleged or suspected patient abuse of any kind. These 
safety incidents are excluded from the reporting requirements outlined 
by the VA National Center for Patient Safety (NCPS). 

[3] In this report, we use the term sexual assault incident to refer 
to suspected, alleged, attempted, or confirmed cases of sexual 
assault. All reports of sexual assault incidents do not necessarily 
lead to prosecution and conviction. This may be, for example, because 
an assault did not actually take place or there was insufficient 
evidence to determine whether an assault occurred. 

[4] NCPS manages VA's overall patient safety reporting system and 
focuses its data collection and oversight on adverse events that 
represent primarily unintentional medical mistakes, such as errors in 
medication administration, patient falls, and wrong-site surgeries. 
The collection of information on intentionally unsafe acts, including 
criminal acts such as sexual assault, is specifically exempted from 
NCPS responsibility by VA policy. 

[5] Within VA, VHA is the organization responsible for providing 
health care to veterans at medical facilities across the country. 

[6] We also spoke with officials from VHA's Office of Mental Health 
Services and the Women Veterans Health Strategic Health Care Group. 

[7] VA medical facilities were selected to ensure that at least one 
facility with no experience reporting sexual assault incidents was 
included in our judgmental sample of facilities. Other selected 
medical facilities all had some experience reporting sexual assault 
incidents. To determine facilities' histories of reporting sexual 
assault incidents, we reviewed closed investigations conducted by the 
VA Office of the Inspector General (OIG) Office of Investigations--
Criminal Investigations Division. This selection allowed us to ensure 
that a greater variety of perspectives on sexual assault incidents 
were captured during our field work. 

[8] Two of the facilities we visited were located within the same 
VISN. VISNs are responsible for the day-to-day management of 
facilities within their network. 

[9] For the purposes of this report, we define sexual assault as any 
type of sexual contact or attempted sexual contact that occurs without 
the explicit consent of the recipient of the unwanted sexual activity. 
Assaults may involve psychological coercion, physical force, or 
victims who cannot consent due to mental illness or other factors. 
Falling under this definition of sexual assault are sexual activities 
such as forced sexual intercourse, sodomy, oral penetration or 
penetration using an object, molestation, fondling, and attempted rape 
or sexual assault. Victims of sexual assault can be male or female. 
This does not include cases involving only indecent exposure, 
exhibitionism, or sexual harassment. 

[10] Compensated work therapy is a VA vocational rehabilitation 
program that matches work-ready veterans with competitive jobs, 
provides support to veterans in these positions, and consults with 
business and industry on their specific employment needs. 

[11] Veterans Health Administration Handbook 1162.02, Mental Health 
Residential Rehabilitation Treatment Program (Dec. 22, 2010). 

[12] CWT/TR programs are exempt from some of these requirements. 

[13] Information about veterans' living situations, emotional and 
behavioral functioning, histories of substance use, family psychiatric 
histories, experiences with military history and trauma, current 
social support and stressors, and current financial status may also be 
included in these assessments. 

[14] 38 C.F.R. § 1.204 (2010). Criminal matters involving felonies 
must be immediately referred to the OIG, Office of Investigations. VA 
management officials with information about possible criminal matters 
involving felonies are responsible for prompt referrals to the OIG. 
Examples of felonies include but are not limited to, theft of 
government property over $1,000, false claims, false statements, drug 
offenses, crimes involving information technology systems, and serious 
crimes against the person, i.e., homicides, armed robbery, rape, 
aggravated assault, and serious physical abuse of a VA patient. 
Additionally, another VA regulation requires that all VA employees 
with knowledge or information about actual or possible violations of 
criminal law related to VA programs, operations, facilities, 
contracts, or information technology systems immediately report such 
knowledge or information to their supervisor, any management official, 
or directly to the VA OIG. 38 C.F.R. § 1.201 (2010). 

[15] VA defines serious incidents as those that involve: (1) public 
information regarding the arrest of a VA employee; (2) major 
disruption to the normal operations of a VA facility; (3) deaths on VA 
property due to suspected homicide, suicides, accidents, and/or 
suspicious deaths; (4) VA police-involved shootings; (5) the 
activation of occupant emergency plans, facility disaster plans, 
and/or continuity of operations plans; (6) loss or compromise of VA 
sensitive data, including classified information; (7) theft or loss of 
VA-controlled firearms or hazardous material, or other major theft or 
loss; (8) terrorist event or credible threat that impacts VA 
facilities or operations; and (9) incidents on VA property that result 
in serious illness or bodily injury, including sexual assault, 
aggravated assault, and child abuse. See VA Directive 0321, Serious 
Incident Reports (Jan. 21, 2010). 

[16] Several VISN officials in network offices we reviewed also noted 
that they can sometimes learn of incidents through other mechanisms, 
such as press reports and veterans' families. 

[17] See 38 C.F.R. § 1.204 (2010). 

[18] VHA Directive 2010-014, Assessment and Management of Veterans Who 
Have Been Victims of Alleged Acute Sexual Assault (May 25, 2010). 

[19] Our analysis was limited to only those reports that were provided 
by the VA OSLE and does not include reports that may never have been 
created or were lost by local VA police or VA OSLE. 

[20] To conduct this analysis, we placed VA police case files into 
these categories to describe the allegations contained within them. 

[21] We could not consistently determine whether or not these sexual 
assault incidents were substantiated due to limitations in the 
information VA provided, including inconsistent documentation of the 
disposition of some incidents in the police files. 

[22] Other allegations by relationship included: 1 employee-on-
outsider assault, 2 employee-on-visitor assaults, 2 outsider-on-
employee assaults, 2 outsider-on-outsider assaults, 1 outsider-on-
patient assault, 1 outsider-on-visitor assault, 3 patient-on-visitor 
assaults, 3 unknown-on-employee assaults, 3 unknown-on-visitor 
assaults, 1 visitor-on-employee assault, and 2 visitor-on-patient 
assaults. 

[23] Our review of the reports received by both VISN and VA Central 
Office officials was limited to only those documented in issue briefs 
and did not include the less formal heads-up messages. This is because 
heads-up messages are not formally documented and often are a 
preliminary step to a more formal issue brief. 

[24] We did not require VA OIG to provide documentation for 9 
incidents currently under investigation due to the sensitive nature of 
these ongoing investigations. Since we did not require this 
documentation, it is possible that some of these 9 ongoing 
investigations were included in the 42 rape allegations we could not 
confirm were reported to the VA OIG. 

[25] See 38 C.F.R. § 1.204 (2010). Examples of felonies listed in this 
regulation include theft of government property over $1,000, false 
claims, false statements, drug offenses, crimes involving information 
technology systems, and serious crimes against the person, i.e., 
homicides, armed robbery, rape, aggravated assault, and serious 
physical abuse of a VA patient. 

[26] The VA Security and Law Enforcement Handbook defines a felony as 
any offense punishable by either imprisonment of more than 1 year or 
death as classified under 18 U.S.C. § 3559. See VA Handbook 0730, 
Security and Law Enforcement (Aug. 11, 2000). Federal statutes define 
certain sexual acts and contacts as federal crimes. See 18 U.S.C. §§ 
2241-2248. All federal sexual offenses are punishable by imprisonment 
of more than 1 year; therefore all federal sexual offenses are 
felonies and must be immediately referred to the VA OIG for 
investigation in accordance with VA regulation. 

[27] For the purposes of our analysis, we focused only on sexual 
assault incidents involving rape allegations. Neither federal statutes 
nor VA regulations define rape; however, the definition of rape we 
developed for our analysis falls within the federal sexual offenses of 
either aggravated sexual abuse or sexual abuse. See 18 U.S.C. §§ 2241 
and 2242. These two offenses are felonies under federal statute; 
therefore, all rapes that meet our definition are felonies. 

[28] The VA OIG senior-level investigators who conducted this review 
noted that they identified at least one incident summary that was 
readily identifiable as a case currently under investigation by the VA 
OIG. Due to the general nature of the incident summaries we provided 
for their review and the sensitive nature of specific details of 
ongoing investigations, we did not require the VA OIG to provide 
specific details on exactly how many of the 42 rape allegations we 
asked them to review were currently under investigation by their 
office; however, the total number of ongoing sexual assault incident 
investigations for the time period of our analysis was only nine. 

[29] The National Center for Victims of Crime's definition of sexual 
assault states that: "Sexual assault takes many forms including 
attacks such as rape or attempted rape, as well as any unwanted sexual 
contact or threats. Usually a sexual assault occurs when someone 
touches any part of another person's body in a sexual way, even 
through clothes, without that person's consent. Some types of sexual 
acts which fall under the category of sexual assault include forced 
sexual intercourse (rape), sodomy (oral or anal sexual acts), child 
molestation, incest, fondling and attempted rape." 

[30] The Joint Commission is an independent organization that 
accredits and certifies health care organizations and programs in the 
United States. Rape is included among The Joint Commission's list of 
reportable sentinel events and defines rape as: "unconsented sexual 
contact involving a patient and another patient, staff member, or 
other perpetrator while being cared for, treated, or provided 
services, or on the premises of the behavioral health care 
organization, including oral, vaginal, or anal penetration or fondling 
of the patient's sex organ(s) by another individual's hand, sex organ, 
or object." 

[31] The remaining VISN did not report receiving any issue briefs on 
sexual assault incidents. 

[32] While two of the four VISN policies reference The Joint 
Commission's definition of sentinel events, which includes rape, this 
definition does not include the broader category of sexual assault 
incidents as defined in this report. 

[33] VISNs may also send a heads-up message to this office either by e-
mail or phone to inform the Office of the Deputy Under Secretary for 
Health for Operations and Management of emerging incidents. These 
heads-up messages are typically the precursor to issue briefs received 
by the office. 

[34] The Director for Network Support is a senior executive who 
advises the Assistant Deputy Under Secretary for Health Care 
Management. 

[35] See GAO, Internal Control: Standards for Internal Control in the 
Federal Government, [hyperlink, 
http://www.gao.gov/products/GAO/AIMD-00-21.3.1] (Washington, D.C.: 
November 1999). Standards for internal control in the federal 
government state that information should be recorded and communicated 
to management and others within the agency that need it in a format 
and time frame that enables them to carry out their responsibilities. 

[36] See [hyperlink, http://www.gao.gov/products/GAO/AIMD-00-21.3.1]. 
Standards for internal control in the federal government state that 
agencies should design internal controls that assure ongoing 
monitoring occurs in the course of normal operations, is continually 
performed, and is ingrained in agency operations. 

[37] We did not review the sexual assault-related risks that VA staff 
and clinicians may pose in VA medical facilities. 

[38] One example of a program-specific assessment used at one site we 
visited is the Minnesota Multiphasic Personality Inventory (MMPI) for 
veterans entering the PTSD Residential Program. Clinicians at this 
site said that the MMPI is the most widely used personality inventory 
in the country. These clinicians explained that this instrument helps 
them ensure they have essential information to make appropriate 
placements of veterans in this program. 

[39] VHA officials told us that assessment requirements for veterans 
admitted to residential programs are contained in VHA's Mental Health 
RRTP Handbook and policy guidance on assessment for inpatient mental 
health units is found in various documents, including the 
VA/Department of Defense (DOD) PTSD Clinical Practice Guidelines 
(2010) and The Joint Commission standards. See Veterans Health 
Administration Handbook 1162.02, Mental Health Residential 
Rehabilitation Treatment Program (Dec. 22, 2010); VA/DOD Clinical 
Practice Guideline for the Management of Post-Traumatic Stress 
(October 2010); and The Joint Commission, 2010 Standards for 
Behavioral Health Care (Oakbrook Terrace, Ill.: 2010). 

[40] Federal agencies may only run background checks for noncriminal 
justice purposes if they have specific statutory authority. See 42 
U.S.C. § 14616 art. IV(b). VA police may only conduct a background 
check on a veteran if the veteran is the subject of a criminal 
investigation. 

[41] Veterans counted as registered sex offenders in our sample were 
those that had been registered in the state sex offender registry for 
each of our selected medical facilities under the address of either 
the medical facility's residential programs or inpatient mental health 
units when we checked these registries prior to our site visits. 

[42] See GAO/AIMD-00-21.3.1. Standards for internal control in the 
federal government state that agencies should assess risks the agency 
faces from both internal and external sources and require clear, 
consistent agency objectives and detailed policies on the information 
that medical facilities should include in risk identification. While 
internal control standards allow for variation in the specific 
approach agencies or programs may use based on differences in their 
missions or difficulty in identifying risks, having clear agency 
policies is critical to the risk assessment process. 

[43] VHA officials reported that these requirements are based on 
accreditation organization requirements, specifically The Joint 
Commission and the Commission on Accreditation of Rehabilitation 
Facilities. 

[44] VA/DOD Clinical Practice Guideline for the Management of Post- 
Traumatic Stress (October 2010) and 2010 Standards for Behavioral 
Health Care (2010). 

[45] VHA facilities may place an alert on a veteran's electronic 
medical record to notify employees that the veteran may pose a threat 
to the safety of other patients or employees. According to VHA, these 
flags are to be used very judiciously and must be approved by either 
appropriate local or VHA authorities. See VHA Directive 2010-053, 
Patient Record Flags (Dec. 3, 2010). At each of the medical facilities 
we reviewed, requests for the placement of medical record flags were 
formally reviewed by a multidisciplinary facility committee 
responsible for activities related to the management of disruptive 
behavior at the facility. 

[46] Stationary panic alarms are fixed to furniture, walls, or other 
stationary items and can be used to alert VA staff of a problem or 
call for help if staff feel threatened. Computer-based panic alarms 
are activated by depressing a specified combination of keys on a 
medical center keyboard. Portable personal panic alarms are small 
devices that staff can carry with them while on duty that can also 
alert VA staff of a problem if activated. 

[47] VA guidelines regarding physical security precautions for 
residential programs are outlined in the VHA Mental Health RRTP 
Handbook. Monitoring precautions required by this handbook include the 
use of closed-circuit surveillance cameras to monitor residential 
program entrances, exits, and common areas, as well as requiring staff 
to conduct regular rounds of program facilities. Security precautions 
required by this handbook include the implementation of keyless entry 
for all residential programs, except CWT/TRs, and the availability of 
locks on all bedrooms used by women veterans. 

[48] VA guidelines for physical security precautions for inpatient 
mental health units are communicated as part of the Mental Health 
Environment of Care process. During environment of care rounds, a 
multidisciplinary team of facility staff check to ensure that 
inpatient mental health units are in compliance with a variety of VA 
policies, including policies to regularly test panic alarm systems on 
these units and ensure that nursing stations are safe for staff 
working in inpatient mental health unit settings. 

[49] This officer also worked with VA staff at other locations in the 
facility, not just with staff of the inpatient mental health unit. 

[50] Two of the medical facilities we visited did not have a CWT/TR 
program. 

[51] At one site, VA staff reported that this was because local fire 
officials had informed them that interior locks were a safety issue. 

[52] Our review of physical security precautions at the five VA 
medical facilities we visited was limited to the residential programs, 
inpatient mental health units, and medical facility command and 
control centers. 

[53] At some facilities, just one person was assigned to serve both 
functions, while at another location two people were expected to share 
those functions but only one person was present at the time of our 
visit due to staffing vacancies, illness, or shortages. 

[54] One of the residential programs we reviewed did not use 
stationary panic alarm systems. This facility relied on portable 
personal panic alarms for its residential program staff. 

[55] The VA police chief for this facility reported having adequate 
staff coverage despite these staffing limitations. 

[56] As CWT/TR programs are located in fewer locations than the other 
programs, not all medical facilities we selected had these programs. 

[57] For the purposes of this report, we define sexual assault as any 
type of sexual contact and attempted sexual contact that occurs 
without the explicit consent of the recipient of the unwanted sexual 
activity. Assaults may have involved psychological coercion, physical 
force, or victims who could not consent due to mental illness or other 
factors. Falling under this definition of sexual assault are sexual 
activities such as forced sexual intercourse, sodomy, oral penetration 
or penetration using an object, molestation, fondling, and attempted 
rape or sexual assault. This also included any threats of any of the 
above. Victims of assault could be male or female. This did not 
include cases involving only indecent exposure, exhibitionism, or 
sexual harassment. 

[58] Issue briefs are reports that briefly document specific factual 
information about incidents and are used to notify officials of 
ongoing incidents occurring at VA facilities, including sexual assault 
incidents. These documents are forwarded from the facility to the VISN 
and can be sent forward to the VHA Central Office as needed. 

[59] VHA's Office of the Deputy Under Secretary for Health for 
Operations and Management did provide a response to our request for 
issue briefs but, due to the lack of a VHA centralized archive of this 
information, officials from this office had to contact VISNs to 
construct a sample of issue briefs they may have received during the 
time period of our analysis. Therefore, this response did not provide 
an accurate sample of all issue briefs this office had received and 
reviewed at the time these incidents were initially reported and was 
not used in our analysis of the management reporting stream. 

[60] VA police are required to destroy files after 3 years under a 
records schedule approved by the National Archives and Records 
Administration (NARA). 

[61] Inappropriate oral sex includes oral sex that may have been a 
consensual act between the parties in question, but was deemed sexual 
assault by VA staff. 

[62] VA police coding of a case as rape was not sufficient to 
categorize a case as an rape allegation for our purposes without also 
including at least one of the above criteria. 

[63] We did not require the VA OIG to provide documentation for 9 
incidents currently under investigation that occurred within the time 
period of our analysis. It is possible that some of these ongoing 
investigations may be included in the 42 rape allegations we could not 
match to VA OIG investigation documentation. 

[64] We did not provide these complete VA police case files to the VA 
OIG to protect the privacy of those involved in the incident and the 
anonymity of the VA facilities and investigating officers who did not 
refer these cases to the VA OIG. 

[65] We conducted these searches prior to our arrival at each selected 
facility except for our first site visit. Due to the pilot nature of 
this site visit, our initial search was insufficient for this sample 
and was rerun at the completion of our field work. Veterans registered 
as sex offenders as of the date of our second check of the state 
publicly available state sex offender registry are included in our 
review of biopsychosocial assessments. 

[End of section] 

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