VA Health Care: Actions Needed to Prevent Sexual Assaults and Other Safety Incidents
Highlights
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.
GAO found that many of the nearly 300 sexual assault incidents reported to the VA police were not reported to VA leadership officials and the VA OIG. Specifically, for the four VISNs GAO spoke with, VISN and VA Central Office officials did not receive reports of most sexual assault incidents reported to the VA police. Also, nearly two-thirds of sexual assault incidents involving rape allegations originating in VA facilities were not reported to the VA OIG, as required by VA regulation. In addition, GAO identified several factors that may contribute to the underreporting of sexual assault incidents including unclear guidance and deficiencies in VA's oversight. VA does not have risk assessment tools designed to examine sexual assaultrelated risks veterans may pose. Instead, VA staff at the residential programs and inpatient mental health units GAO visited said they examine information about veterans' legal histories along with other personal information as part of a multidisciplinary assessment process. VA clinicians reported that they obtain legal history information directly from veterans, but these self-reported data are not always complete or accurate. In reviewing selected veterans' medical records, GAO found that complete legal history information was not always documented. In addition, VA has not provided clear guidance on how such legal history information should be collected or documented. VA facilities GAO visited used a variety of precautions intended to prevent sexual assaults and other safety incidents; however, GAO found some of these measures were deficient, compromising facilities' efforts to prevent sexual assaults and other safety incidents. For example, facilities often used patientoriented precautions, such as placing electronic flags on high-risk veterans' medical records or increasing staff observation of veterans who posed risks to others. These VA facilities also used physical security precautions--such as closed-circuit surveillance cameras to actively monitor units, locks and alarms to secure key areas, and police assistance when incidents occurred. These physical precautions were intended to prevent a broad range of safety incidents, including sexual assaults, through monitoring patients and activities, securing residential programs and inpatient mental health units, and educating staff about security issues and ways to deal with them. However, GAO found significant weaknesses in the implementation of these physical security precautions at these VA facilities, including poor monitoring of surveillance cameras, alarm system malfunctions, and the failure of alarms to alert both VA police and clinical staff when triggered. Inadequate system installation and testing procedures contributed to these weaknesses. Further, facility officials at most of the locations GAO visited said the VA police were understaffed. Such weaknesses could lead to delayed response times to incidents and seriously erode efforts to prevent or mitigate sexual assaults and other safety incidents. 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.
Recommendations
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Department of Veterans Affairs | To improve VA's reporting and monitoring of allegations of sexual assault, the Secretary of Veterans Affairs should direct the Under Secretary for Health to 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 Veterans Health Administration (VHA) Central Office leadership. |
VA officials reported that on June 16, 2011, the Assistant Secretary for Operations, Security, and Preparedness issued a memorandum to Under Secretaries, Assistant Secretaries, and other key officials which included the following definition of sexual assault to ensure accurate reporting: "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. Victims of sexual assault can be male or female. This does not include cases involving only indecent exposure, exhibitionism, or sexual harassment." VA also reported that the Deputy Under Secretary for Health for Operations and Management subsequently issued a July 7, 2011 memorandum to VISN Directors regarding the use of this definition in reporting sexual assault incidents to management.
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| Department of Veterans Affairs | To improve VA's reporting and monitoring of allegations of sexual assault, the Secretary of Veterans Affairs should direct the Under Secretary for Health to 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 officials reported to us that on July 7, 2011, the Deputy Under Secretary for Operations and Management issued a memorandum to VISN Directors reinforcing expectations on what information related to sexual incidents should be reported. Specifically, the memorandum specifies a definition for what is to be reported as an allegation of sexual assault, outlines requirements for reporting all allegations of sexual assault on VA property in accordance with previous VA directives, and provides guidance on reporting these incidents to the VA OIG. The memorandum also requires facilities to submit an initial issue brief with information on the alleged sexual assault incident to the office of the Deputy Under Secretary for Operations and Management with 24 hours of reporting the incident, and a follow-up issue brief to provide details about any investigation, results of the investigations, actions taken by the facility, and any process or policy improvements made to mitigate future events.
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| Department of Veterans Affairs | To improve VA's reporting and monitoring of allegations of sexual assault, the Secretary of Veterans Affairs should direct the Under Secretary for Health to implement a centralized tracking mechanism that would allow sexual assault incidents to be consistently monitored by VHA Central Office staff. |
In May 2012, VA reported that all 21 VISNs were using the newly created Issue Tracker system to generate and report issue briefs on a variety of issues, including sexual assault incidents. VHA also reported that the entries in the Issue Tracker are reviewed by VHA Central Office staff on a weekly basis and that quarterly reports are produced summarizing the number of incidents. In July 2014, the Acting Deputy Under Secretary for Health for Operations and Management issued a memorandum directing all VISNs to begin using the Disruptive Behavior Reporting System to report incidents that undermine the culture of safety at VA, including sexual assault incidents. This system allows all VHA employees to use a standardized electronic tool to alert leadership, the Disruptive Behavior Committee, labor partners, and the VA Police of patient and visitor behavioral incidents that occur in VA facilities.
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| Department of Veterans Affairs | To improve VA's reporting and monitoring of allegations of sexual assault, the Secretary of Veterans Affairs should direct the Under Secretary for Health to 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 officials reported to us that as of June 20, 2011, when VA Police Officers enter information about all incidents of alleged sexual assaults and other major felonies into their electronic reporting system, a special alert is automatically sent to VA OIG Special Agents, VA OIG Headquarters, and to all regional Special Agents in Charge of VA OIG Field Offices informing them of the allegations.
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| Department of Veterans Affairs | To help identify risks and address vulnerabilities in physical security precautions at VA medical facilities, the Secretary of Veterans Affairs should direct the Under Secretary for Health to establish guidance specifying what should be included in legal history discussions with veterans and how this information should be documented in veterans' biopsychosocial assessments. |
VA officials reported in May 2012 that the agency had developed and distributed a guidance specifying topics for inclusion in a legal history and documentation of the legal history.
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| Department of Veterans Affairs | To help identify risks and address vulnerabilities in physical security precautions at VA medical facilities, the Secretary of Veterans Affairs should direct the Under Secretary for Health to ensure medical centers determine whether existing stationary, computerbased, and portable personal panic alarm systems operate effectively through mandatory regular testing. |
VHA Directive 2012-026 requires facility Directors to ensure regular testing of physical security precautions and equipment throughout the medical center, including inpatient and residential mental health units. VHA also provided documentation of a survey completed by the VISNs in which each medical center attested to having an alarm system in place and testing it monthly, bi-monthly, or quarterly.
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| Department of Veterans Affairs | To help identify risks and address vulnerabilities in physical security precautions at VA medical facilities, the Secretary of Veterans Affairs should direct the Under Secretary for Health to ensure that alarm systems effectively notify relevant staff in both medical facilities' VA police command and control centers and unit nursing stations. |
On June 23, 2017, Veterans Integrated Service Network officials reported to the Veterans Health Administration (VHA) that 133 of the 137 (97 percent) VA medical centers (VAMC) reported compliance with having a process in place to ensure stationary and computer-based panic alarm systems in inpatient mental health units communicate and alert both medical facilities' VA police command and control centers, as well as unit nursing services. VHA reported that they will continue to monitor the remaining 4 VAMCs until they are compliant.
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| Department of Veterans Affairs | To help identify risks and address vulnerabilities in physical security precautions at VA medical facilities, the Secretary of Veterans Affairs should direct the Under Secretary for Health to 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. |
In August 2017, VA's Office of Acquisition, Logistics, and Construction issued new guidance that requires clinicians, primary users, and stakeholders of any project to be involved in all project phases to best adapt VA Standards for specific functional, operational, and site conditions, to provide safe and optimum service environments. This includes installations and modifications of systems or technology involving safety, security, functionality, or environmental quality. VA required the documentation of stakeholder involvement in the project record.
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