This office is the department-level VA office responsible for  developing policies and procedures for VA’s law enforcement programs at  local VA medical facilities. Nearly 300 Sexual Assault Incidents Reported to VA Police, but Many Were Not Reported to VHA or the VA OIG

We found that there were nearly 300 sexual assault incidents reported 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. Many of these sexual assault incidents were not reported  to officials within the management reporting stream and to the VA OIG. Sexual Assault Incidents Are Underreported to VISNs, VHA Central Office, and the VA OIG

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. VHA Guidance and Oversight Weaknesses May Contribute to the Underreporting of Sexual Assault Incidents

Several factors 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 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. 2.) 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. In general, physical security precautions were used as a measure to  prevent a broad range of safety incidents, including sexual assaults. 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. Significant Weaknesses Existed in the Use and Implementation of Certain Physical Security Precautions at Selected VA Medical Facilities

While security precautions have been established in most cases to prevent  patient safety incidents, including sexual assaults, these precautions had  not been effectively implemented by VA medical facility staff in the five  facilities we visited. Inadequate monitoring of closed-circuit surveillance cameras. Alarm malfunctions. However, we found that at two of these three  medical facilities, these alarms failed to properly alert VA police when  tested. Alarms failed to alert both police and unit staff. In conclusion, weaknesses exist in the reporting of sexual assault  incidents and in the implementation of physical precautions used to  prevent sexual assaults and other safety incidents in VA medical facilities. In responding to a draft of the report on which this testimony is based, VA  generally agreed with the report’s conclusions and concurred with our  recommendations.
Why GAO Did This Study

During GAO's recent work on services available for women veterans (GAO-10-287), several clinicians expressed concern about the physical safety of women housed in mental health programs at a Department of Veterans Affairs (VA) medical facility. GAO examined (1) the volume of sexual assault incidents reported in recent years and the extent to which these incidents are fully reported, (2) what factors may contribute to any observed underreporting, and (3) precautions VA facilities take to prevent sexual assaults and other safety incidents. This testimony is based on recent GAO work, "VA Health Care: Actions Needed To Prevent Sexual Assaults and Other Safety Incidents," (GAO-11-530) (June 2011). For that report, GAO reviewed relevant laws, VA policies, and sexual assault incident documentation from January 2007 through July 2010. In addition, GAO visited five judgmentally selected VA medical facilities that varied in size and complexity and spoke with the four Veterans Integrated Service Networks (VISN) that oversee them.

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 Office of the Inspector General (OIG). Specifically, for the four VISNs GAO spoke with, VISN and Veterans Health Administration (VHA) 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. GAO identified several factors that may contribute to the underreporting of sexual assault incidents. For example, VHA lacks a consistent sexual assault definition for reporting purposes and clear expectations for incident reporting across its medical facility, VISN, and VHA Central Office levels. Furthermore, VHA Central Office lacks oversight mechanisms to monitor sexual assault incidents reported through the management reporting stream. VA medical 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 medical facilities' efforts to prevent sexual assaults and other safety incidents. For example, medical facilities used physical security precautions--such as closed-circuit surveillance cameras to actively monitor areas and locks and alarms to secure key areas. These physical precautions were intended to prevent a broad range of safety incidents, including sexual assaults. However, GAO found significant weaknesses in the implementation of these physical security precautions at the five VA medical facilities visited, 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 configuration 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 VA's efforts to prevent or mitigate sexual assaults and other safety incidents. GAO reiterated recommendations 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.