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Highlights

The Justice Department has reported that Indians are at least twice as likely to be raped or sexually assaulted as all other races in the United States. Indians living in remote areas may be days away from health care facilities providing medical forensic exams, which collect evidence related to an assault for use in criminal prosecution. The principal health care provider for Indians, which operates or funds tribes to operate 45 hospitals, is the Department of Health and Human Services' Indian Health Service (IHS). In response to a Tribal Law and Order Act of 2010 mandate, GAO examined (1) the ability of IHS and tribally operated hospitals to collect and preserve medical forensic evidence involving cases of sexual assault and domestic violence, as needed for criminal prosecution; (2) what challenges, if any, these hospitals face in collecting and preserving such evidence; and (3) what factors besides medical forensic evidence contribute to a decision to prosecute such cases. GAO surveyed all 45 IHS and tribally operated hospitals and interviewed IHS and law enforcement officials and prosecutors..

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Recommendations

Recommendations for Executive Action

Agency Affected Recommendation Status
Department of Health and Human Services To improve or expand medical forensic exams and related activities for the 28 IHS operated hospitals, the Secretary of Health and Human Services should direct the Director of the Indian Health Service to develop an implementation plan for the March 2011 IHS sexual assault policy ("Indian Health Manual," chapter 3.29)--and monitor its progress--to clarify how the agency will support its hospitals and staff in fulfilling the policy, in particular, that the hospitals or staff: (1) obtain training and certification in providing forensic medical exams; (2) obtain equipment like cameras needed to collect evidence; (3) provide medical forensic exams on site or at a referral facility within 2 hours of a patient's arrival; and (4) collaborate with law enforcement agencies, prosecution, and other stakeholders identified in the policy with the objective of creating sexual assault response teams and obtaining regular feedback from such stakeholders on evidence collection and preservation.
Closed - Implemented
In an October 2011 report, "Indian Health Service: Continued Efforts Needed to Help Strengthen Response to Sexual Assaults and Domestic Violence," we found that the Indian Health Service (IHS) had not yet developed written, comprehensive plans for implementing and monitoring its March 2011 sexual assault policy. Specifically, we found that implementing and monitoring the policy's training and certification guidelines may be challenging and that IHS had not identified resources for purchasing equipment and supplies or identified deadlines IHS hospitals should meet in implementing parts of the policy such as providing access to medical forensic exams on site or by referral, or collaborating with the objective of creating sexual assault response teams. We concluded that without articulating how it plans to implement the policy and monitor progress toward meeting policy requirements, IHS may not be able to hold individual hospitals accountable to the agency, and the agency may not be able to hold itself accountable to its beneficiaries. As a result, we recommended that IHS develop an implementation plan for the March 2011 IHS sexual assault policy (Indian Health Manual, chapter 3.29) - and monitor its progress - to clarify how the agency will support its hospitals and staff in fulfilling the policy, in particular, that the hospitals or staff: (1) obtain training and certification in providing forensic medical exams; (2) obtain equipment like cameras needed to collect evidence; (3) provide medical forensic exams on site or at a referral facility within 2 hours of a patient's arrival; and (4) collaborate with law enforcement agencies, prosecution, and other stakeholders identified in the policy with the objective of creating sexual assault response teams and obtaining regular feedback from such stakeholders on evidence collection and preservation. In its written response to our report, IHS agreed with our recommendation and stated that work was underway to implement it. In response to our recommendation, IHS developed an Implementation and Monitoring Plan for Domestic and Sexual Violence Response Efforts in late 2011 and has been monitoring progress in implementing the plan. The implementation and monitoring plan includes, among other things, actions and timelines for (1) providing training in forensic medical exams; (2) providing forensic equipment to IHS hospitals and clinics; (3) developing a mapping project to identify facilities that provide on-site exams and those that refer to facilities more than 2 hours away; and (4) providing training on sexual assault response teams.
Department of Health and Human Services To improve or expand medical forensic exams and related activities for the 28 IHS operated hospitals, the Secretary of Health and Human Services should direct the Director of the Indian Health Service to develop a policy that details how IHS should respond to discrete incidents of domestic violence without a sexual component and, working with Justice, develop a policy for responding to incidents of child sexual abuse consistent with protocols Justice develops for these incidents; such policies should be similar in scope and specificity to the March 2011 IHS policy on responding to adult and adolescent sexual assaults.
Closed - Implemented
In an October 2011 report, "Indian Health Service: Continued Efforts Needed to Help Strengthen Response to Sexual Assaults and Domestic Violence," we found that Indian Health Service (IHS) hospitals do not have specific or recently updated guidance on whether to provide medical forensic services for victims of domestic violence and child sexual abuse. We recommended that IHS develop a policy that details how IHS should respond to discrete incidents of domestic violence without a sexual component and, working with Justice, develop a policy for responding to incidents of child sexual abuse consistent with protocols Justice develops for these incidents; such policies should be similar in scope and specificity to the March 2011 IHS policy on responding to adult and adolescent sexual assaults. In its written response to our report, IHS agreed with our recommendation and stated that work was underway to implement it. In response to our recommendation, IHS has developed two draft policies: (1) an intimate partner violence policy, which officials said has been reviewed by federal partners and is expected to be finalized by the end of calendar year 2016, and (2) a child maltreatment policy, which remains in draft form until a National Protocol for Pediatric Sexual Abuse Medical Forensic Examinations is finalized. IHS officials told us they have been working with Justice to develop the National Protocol, and that it was in its final review stages in November 2015. Officials said they would align the IHS child maltreatment policy with the National Protocol and provide guidance to individual tribes about adapting the policies to fit their needs.
Department of Health and Human Services To improve or expand medical forensic exams and related activities for the 28 IHS operated hospitals, the Secretary of Health and Human Services should direct the Director of the Indian Health Service to clarify whether sections 3.29.1 and 3.29.5 of the March 2011 IHS sexual assault policy call for training and certification, or only training, of IHS physicians and physician assistants performing sexual assault medical forensic exams.
Closed - Implemented
In an October 2011 report, "Indian Health Service: Continued Efforts Needed to Help Strengthen Response to Sexual Assaults and Domestic Violence," we found that the Indian Health Service's (IHS) March 2011 sexual assault policy left unclear whether medical providers such as physicians and physician assistants must obtain specialized training and certification - or just training - before performing sexual assault medical forensic exams. We found that without clear training and certification guidelines for physicians and physician assistants, medical forensic exams may be performed by medical providers with inconsistent levels of knowledge and expertise, and that as a result, IHS beneficiaries cannot be assured of uniform quality in medical forensic services received. We recommended that IHS clarify whether sections 3.29.1 and 3.29.5 of the March 2011 IHS sexual assault policy call for training and certification, or only training, of IHS physicians and physician assistants performing sexual assault medical forensic exams. In its written response to our report, IHS agreed with our recommendation and stated that work was underway to implement it. In response to our recommendation, IHS revised its sexual assault policy to clarify that certification is not required for practice in IHS facilities and to outline the minimum training requirements for sexual assault examiners, including for physicians and physician assistants. The finalized policy containing this clarification was issued on May 16, 2014. In addition, IHS issued an action memo clarifying that certification is not a requirement for physicians or physician assistants for practice in IHS facilities. According to IHS, this memo was issued on March 6, 2013.
Department of Health and Human Services To improve or expand medical forensic exams and related activities for the 28 IHS operated hospitals, the Secretary of Health and Human Services should direct the Director of the Indian Health Service to modify the March 2011 IHS sexual assault policy so that it comprehensively and clearly outlines (1) the process for approving subpoenas and requests for IHS employees to provide testimony in federal, state, and tribal courts and (2) reflects the provisions in section 263 of the Tribal Law and Order Act of 2010, including that subpoenas and requests not approved or disapproved within 30 days are considered approved.
Closed - Implemented
In an October 2011 report, "Indian Health Service: Continued Efforts Needed to Help Strengthen Response to Sexual Assaults and Domestic Violence," we found that the Indian Health Service's (IHS) March 2011 policy on responding to adult and adolescent sexual assaults did not clearly and comprehensively articulate the agency's processes for responding to subpoenas or requests for testimony of providers who perform medical forensic exams. We recommended that IHS modify its March 2011 IHS sexual assault policy so that it comprehensively and clearly outlines (1) the process for approving subpoenas and requests for IHS employees to provide testimony in court and (2) reflects the provisions in section 263 of the Tribal Law and Order Act of 2010, including that subpoenas and requests not approved or disapproved within 30 days are considered approved. In its written response to our report, IHS agreed with our recommendation and stated that work was underway to implement it. In response to our recommendation, IHS established a national policy in October 2015 for responding to subpoenas or requests for testimony. The policy includes: (1) responsibilities and requirements for responding to subpoenas or requests for testimony and (2) a provision that subpoenas and requests for testimony not approved or disapproved within 30 days are deemed approved. The policy references a Delegation of Authority issued in September 2013 whereby the IHS Acting Director extended the authority to approve or deny requests for testimony to the Area Directors and other senior officials. It also references a special general memorandum from the IHS Deputy Director issued in October 2015, which provides guidance to Area Directors about steps that are to occur when a request for employee testimony is approved.
Department of Health and Human Services To improve or expand medical forensic exams and related activities for the 28 IHS operated hospitals, the Secretary of Health and Human Services should direct the Director of the Indian Health Service to explore ways to structure medical forensic activities within IHS facilities so that these activities come under an individual's normal duties or unit's official area of responsibility, in part to ensure that providers are compensated for performing medical forensic services.
Closed - Not Implemented
In an October 2011 report, "Indian Health Service: Continued Efforts Needed to Help Strengthen Response to Sexual Assaults and Domestic Violence," we found that in some Indian Health Service (IHS) hospitals where we conducted interviews, medical forensic services were not organized into a formal program or housed within a specific hospital department. Instead, several officials told us, medical forensic exams were performed by individual medical providers, sometimes from different departments, and often outside the medical providers' official job duties and beyond their normal working hours. We recommended that IHS explore ways to structure medical forensic activities within IHS facilities so that these activities come under an individual's normal duties or unit's official area of responsibility, in part to ensure that providers are compensated for performing medical forensic services. In its written response to our report, IHS agreed with our recommendation and stated that work was underway to implement it. According to a June 2016 update from IHS, the IHS Sexual Assault Policy, which was revised in May 2014, places medical forensic activities under the responsibility of the agency's nursing services. IHS officials told us they have drafted a position description addendum for sexual assault examiners, and that the addendum is now under agency review. Sexual assault examiners would be compensated for conducting examinations when they report for duty outside of their normal working hours. Officials said they continue to explore options for providing on-call and standby duty pay that are congruent with Office of Personnel Management regulations.

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