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. 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. 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. 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. 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. 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. 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. 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. 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. Inadequate monitoring of closed-circuit surveillance cameras. 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. Alarms failed to alert both police and unit staff. At most medical facilities  we visited, VA police forces and police command and control centers were  understaffed, according to medical facility officials. 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. 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. 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.
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 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.

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.