[House Hearing, 112 Congress]
[From the U.S. Government Publishing Office]





                 PREVENTING SEXUAL ASSAULTS AND SAFETY
                    INCIDENTS AT U.S. DEPARTMENT OF
                      VETERANS AFFAIRS FACILITIES

=======================================================================

                                HEARING

                               before the

                         SUBCOMMITTEE ON HEALTH

                                 of the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                      ONE HUNDRED TWELFTH CONGRESS

                             FIRST SESSION

                               __________

                             JUNE 13, 2011

                               __________

                           Serial No. 112-17

                               __________

       Printed for the use of the Committee on Veterans' Affairs









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                     COMMITTEE ON VETERANS' AFFAIRS

                     JEFF MILLER, Florida, Chairman

CLIFF STEARNS, Florida               BOB FILNER, California, Ranking
DOUG LAMBORN, Colorado               CORRINE BROWN, Florida
GUS M. BILIRAKIS, Florida            SILVESTRE REYES, Texas
DAVID P. ROE, Tennessee              MICHAEL H. MICHAUD, Maine
MARLIN A. STUTZMAN, Indiana          LINDA T. SANCHEZ, California
BILL FLORES, Texas                   BRUCE L. BRALEY, Iowa
BILL JOHNSON, Ohio                   JERRY McNERNEY, California
JEFF DENHAM, California              JOE DONNELLY, Indiana
JON RUNYAN, New Jersey               TIMOTHY J. WALZ, Minnesota
DAN BENISHEK, Michigan               JOHN BARROW, Georgia
ANN MARIE BUERKLE, New York          RUSS CARNAHAN, Missouri
TIM HUELSKAMP, Kansas
Vacancy
Vacancy

            Helen W. Tolar, Staff Director and Chief Counsel

                         SUBCOMMITTEE ON HEALTH

                ANN MARIE BUERKLE, New York, Chairwoman

CLIFF STEARNS, Florida               MICHAEL H. MICHAUD, Maine, Ranking
GUS M. BILIRAKIS, Florida            CORRINE BROWN, Florida
DAVID P. ROE, Tennessee              SILVESTRE REYES, Texas
DAN BENISHEK, Michigan               RUSS CARNAHAN, Missouri
JEFF DENHAM, California              JOE DONNELLY, Indiana
JON RUNYAN, New Jersey

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.












                            C O N T E N T S

                               __________

                             June 13, 2011

                                                                   Page
Preventing Sexual Assaults and Safety Incidents at U.S. 
  Department of Veterans Affairs Facilities......................     1

                           OPENING STATEMENTS

Chairwoman Ann Marie Buerkle.....................................     1
    Prepared statement of Chairwoman Buerkle.....................    34
Hon. Michael H. Michaud, Ranking Democratic Member...............     3
    Prepared statement of Congressman Michaud....................    34
Hon. Jeff Miller.................................................     2
    Prepared statement of Congressman Miller.....................    35

                               WITNESSES

U.S. Government Accountability Office, Randall B. Williamson, 
  Director, Health Care..........................................     5
    Prepared statement of Mr. Williamson.........................    36
U.S. Department of Veterans Affairs:

  Joseph G. Sullivan, Jr., Deputy Assistant Inspector General for 
    Investigations, Office of Investigations, Office of Inspector 
    General......................................................     7
      Prepared statement of Mr. Sullivan.........................    52
  William Schoenhard, FACHE, Deputy Under Secretary for Health 
    for Operations and Management, Veterans Health Administration     8
      Prepared statement of Mr. Schoenhard.......................    55

                                 ______

American Legion, Verna Jones, Director, National Veterans Affairs 
  and Rehabilitation Commission..................................    23
    Prepared statement of Ms. Jones..............................    58
Disabled American Veterans, Joy J. Ilem, Deputy National 
  Legislative Director...........................................    25
    Prepared statement of Ms. Ilem...............................    61
Veterans of Foreign Wars of the United States, Marlene Roll, 
  Member, National Women Veterans Committee......................    26
    Prepared statement of Ms. Roll...............................    63
Vietnam Veterans of America, Richard F. Weidman, Executive 
  Director for Policy and Government Affairs.....................    27
    Prepared statement of Mr. Weidman............................    65

                       SUBMISSION FOR THE RECORD

Carnahan, Hon. Russ, a Representative in Congress from the State 
  of Missouri, statement.........................................    66

                   MATERIAL SUBMITTED FOR THE RECORD

Dean Stoline, Deputy Director, National Legislative Commission, 
  The American Legion, to Diane Kirkland, Printing Clerk, 
  Committee on Veterans' Affairs, follow-up letter dated 
  September 12, 2011.............................................    67

 
                 PREVENTING SEXUAL ASSAULTS AND SAFETY
                    INCIDENTS AT U.S. DEPARTMENT OF
                      VETERANS AFFAIRS FACILITIES

                              ----------                              


                         MONDAY, JUNE 13, 2011

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                    Subcommittee on Health,
                                                    Washington, DC.
    The Subcommittee met, pursuant to notice, at 3:58 p.m., in 
Room 334, Cannon House Office Building, Hon. Anne Marie Buerkle 
[Chairwoman of the Subcommittee] presiding.
    Present: Representatives Buerkle, Bilirakis, Roe, Benishek, 
Runyan, and Michaud.
    Also Present: Representative Miller.

            OPENING STATEMENT OF CHAIRWOMAN BUERKLE

    Ms. Buerkle. Good afternoon. This hearing will come to 
order.
    I ask unanimous consent that all Members be allowed to sit 
on the dais and ask questions of our witnesses today.
    Without objection, so ordered. Today the House Veterans' 
Affairs Subcommittee on Health will address a very serious 
issue, the vulnerability and the underreporting of sexual 
assaults and other safety instances at the U.S. Department of 
Veterans Affairs (VA) residential and inpatient psychiatric 
treatment facilities.
    As a registered nurse and a woman who has been involved in 
and a counselor for domestic violence, I have seen firsthand 
the pervasive and damaging effects sexual assault can have on 
the lives of those who experience it. Last week, the GAO, the 
U.S. Government Accountability Office, released a deeply 
troubling report entitled ``VA Health Care: Actions Needed to 
Prevent Sexual Assaults and Other Safety Incidents.''
    GAO found that between January 2007 and July 2010, nearly 
300 sexual assault incidents, including 67 alleged rapes, were 
reported to the VA Police. Many of these alleged crimes were 
not reported to VA leadership officials or the VA Office of the 
Inspector General (OIG), in direct violation of VA policy and 
Federal regulations.
    The findings of the GAO are disturbing for many reasons. 
Foremost, they represent a betrayal of trust by a system that 
was designed to treat our veterans at their most vulnerable. 
The gross failure of VA leadership to protect the safety and 
security of our veterans and VA staff, and systematically 
report and respond to sexual assault and safety instances is a 
contempt of justice that also requires immediate action.
    This is not the way to run a health care system, and it is 
certainly no way to treat the men and women who sacrificed so 
much on behalf of our Nation. Abuse like the kind the GAO 
references in their report is repugnant and inexcusable. But 
for it to occur in what should be an environment of healing for 
our wounded warriors is an affront to the VA's very mission.
    So disturbed was I upon reading an early draft of the GAO's 
report that I, along with Chairman Miller, introduced 
legislation to ensure a safer and more secure VA medical 
facility. Our bill, H.R. 2074, the ``Veterans Sexual Assault 
Prevention Act,'' would address the Department's safety 
vulnerabilities, security problems, and oversight failures, and 
create a fundamentally safer environment for our veterans and 
our VA employees.
    Never should a warrior in need take the brave step of 
getting help and be met with anything less than safe, 
supportive, and high quality care in an atmosphere of hope, 
health, and healing. Let me assure each of you that I and the 
other Members of this Committee will remain committed to 
righting the many wrongs uncovered by the GAO. I am honored 
that our esteemed Chairman of the Veterans' Affairs Committee 
has joined us today, Mr. Jeff Miller, to participate in this 
hearing.
    And I yield to you, Mr. Chairman, for any comments you may 
have.
    [The prepared statement of Chairwoman Buerkle appears on p. 
34.]

             OPENING STATEMENT OF HON. JEFF MILLER

    Mr. Miller. Thank you, Madam Chairwoman, for yielding and 
giving me the opportunity to speak here today. I, like I think 
all Members of this Committee, were sickened by what we read in 
the GAO report. The prevalence of sexual assault incidents at 
VA facilities, the lack of accountability from VA and its 
leadership, and the lack of safeguards in place for the 
victims. As a co-requester of the investigation, along with the 
Ranking Member, Bob Filner, I contacted Secretary Shinseki and 
urged him to provide an immediate response to the GAO report 
and to make it public so that we could have this hearing today. 
I appreciate the Secretary working diligently to do that so 
that we could move forward.
    We found these findings so egregious that Ms. Buerkle and I 
decided to act immediately by introducing what you have just 
talked about, H.R. 2074. We intend to move this legislation 
expeditiously so that veterans are not undermined by the very 
system which is supposed to be protecting them.
    In the past week, some have dismissed these allegations, 
comparing the size of the VA system and the number of 
allegations to the private sector. Let me be very clear: there 
is no comparison. Just one assault of this nature, one sexual 
predator, one veteran's rights being violated within the VA is 
one too many, and is absolutely unacceptable. If we need to do 
more as a Committee to protect our veterans and employees at 
VA, we will.
    I understand that rape in particular has always been a 
difficult charge to prosecute. And though we have made strides 
in getting victims to speak out, we know that for every rape 
that is reported, many more go unreported. Therefore, we need 
to know how many victims have not spoken out and how we can 
reach out to them so that not only is justice done, but so that 
we can provide them with the proper care and support.
    Today we expect to get answers to the following questions: 
How widespread are assaults at VA facilities due to the lack of 
reporting protocols at VA? How many cases have been prosecuted? 
How many are still pending? How many employees who allegedly 
perpetrated assaults are still working at VA? What has been 
done to protect patients from fellow patients? And, what is VA 
doing to ensure that this never, never happens again?
    I was looking in some of the citations of the report, on 
page eight specifically, where it says criminal matters 
involving felonies must be immediately referred to the VA 
Office of Inspector General (OIG) Office of Investigations. VA 
management officials with information about possible criminal 
matters involving felonies are responsible for prompt referrals 
to the OIG. It goes on to talk about examples of the felonies. 
One of those is in fact rape.
    Also, VA defines serious incidents as incidents including 
incidents on VA property that result in serious illness, bodily 
injury, including sexual assaults. Why were these not forwarded 
as appropriate?
    The safety and security of our veterans is paramount. This 
Committee will demand answers to assure fellow veterans and the 
public that VA facilities are safe havens for our veterans and 
VA employees, and that nobody's rights are violated.
    Madam Chairwoman, thank you for your interest in taking 
this issue so seriously and working on this piece of 
legislation. I appreciate the opportunity to be here today with 
you and my good friend, the Ranking Member, Mr. Michaud, and I 
yield back.
    [The prepared statement of Congressman Miller appears on p. 
35.]
    Ms. Buerkle. Thank you, Mr. Chairman.
    And thank you for joining us this afternoon.
    I will now recognize the Ranking Member, Mr. Mike Michaud.

          OPENING STATEMENT OF HON. MICHAEL H. MICHAUD

    Mr. Michaud. Thank you very much, Madam Chair, and good 
afternoon.
    I first of all would like to thank everyone for attending 
this extremely important hearing this afternoon. The purpose of 
today's hearing is to examine how changes in patient 
demographics present unique challenges for VA in providing safe 
environments for all veterans treated at VA facilities. In 
2008, I requested the GAO report on women's veterans services, 
such as research on unique physical and mental health treatment 
needs of female veterans, how VA was addressing the needs of 
women veterans, what health care services offered by VA are 
tailored to women veterans, and barriers that may prevent women 
veterans from accessing VA health care services.
    In July of 2009, this Subcommittee held a hearing on the 
findings of that report. During the conduct of this report, GAO 
was made aware of safety issues involving women veterans and 
sexual assaults in some VA facilities. Subsequent to that 
report, then the full Chairman, Mr. Filner, submitted a request 
for GAO to look further into sexual assault incidents.
    We know that the wars in Afghanistan and Iraq have been an 
unprecedented call upon our National Guard and Reserve 
components. Today, women serve in the Guard and Reserves at a 
rate over 17 percent, which is 3 percent higher than that of 
active-duty military. VA recently reported that within 10 
years, women are expected to become 10 percent of VA's patient 
population. However, the VA health care system was built to 
accommodate the war-related illnesses and injuries of male 
veterans.
    As women are serving in combat conditions alongside their 
male counterparts, it is important for the Department to 
embrace and recognize the needs of all veterans, both men and 
women alike. In the 110th and 111th Congresses, this Committee 
held a series of hearings to examine the needs of women 
veterans. The veterans who testified shared their stories of 
feeling unwelcome, alienated, and disrespected in some VA 
medical centers, so that they are now reluctant to pursue the 
benefits and services that they have earned with their service 
to our country.
    Women veterans should not have to worry about being subject 
to cat calls upon entering a facility. And they should 
certainly not have to worry about falling victim to sexual 
assault while receiving care.
    While sexual assault is often considered an issue only 
affecting women, in fact, both men and women have suffered 
sexual assaults. Further, victims may be assaulted by predators 
of the same or the opposite sex. Like other types of trauma, 
sexual trauma can leave lasting scars upon the physical and 
mental health of its victims.
    The GAO has recently uncovered many of the nearly 300 
sexual assault incidents reported to the VA Police since 2007 
that were not reported to the VA leadership. Incidents like 
this simply should not happen and need not happen. When 
policies and procedures are not in place or, worse, not 
followed, we fall short of our national commitment to provide 
the utmost level of care possible.
    I want to thank our panelists today for appearing today. I 
am committed to working with you and the Chairwoman of this 
Subcommittee to ensure that the safeguards are in place so that 
no veterans, male or female, fall victim to sexual assault 
under the VA care.
    With that, I yield back, Madam Chair.
    [The prepared statement of Congressman Michaud appears on 
p. 34.]
    Ms. Buerkle. Thank you, Mr. Michaud.
    We will now welcome our first panel to the table. Joining 
us is Mr. Randall Williamson, Director of Health Care for the 
Government Accountability Office; Mr. Joseph G. Sullivan, 
Deputy Assistant Inspector General for Investigations from the 
VA Office of the Inspector General; and Mr. William Schoenhard, 
VA's Deputy Under Secretary for Health Operations and 
Management, Veterans Health Administration (VHA).
    Accompanying Mr. Schoenhard is Dr. Arana, the Acting 
Assistant Deputy for Health for Clinical Operations; and Mr. 
Kevin Hanretta, the Deputy Assistant Secretary for Emergency 
Management.
    Gentlemen, thank you all for joining us this afternoon.
    Mr. Williamson, if you would please proceed.

  STATEMENTS OF RANDALL B. WILLIAMSON, DIRECTOR, HEALTH CARE, 
U.S. GOVERNMENT ACCOUNTABILITY OFFICE; JOSEPH G. SULLIVAN, JR., 
 DEPUTY ASSISTANT INSPECTOR GENERAL FOR INVESTIGATIONS, OFFICE 
OF INVESTIGATIONS, OFFICE OF INSPECTOR GENERAL, U.S. DEPARTMENT 
  OF VETERANS AFFAIRS; AND WILLIAM SCHOENHARD, FACHE, DEPUTY 
   UNDER SECRETARY FOR HEALTH FOR OPERATIONS AND MANAGEMENT, 
  VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS 
AFFAIRS; ACCOMPANIED BY GEORGE W. ARANA, M.D., ACTING ASSISTANT 
  DEPUTY UNDER SECRETARY FOR HEALTH FOR CLINICAL OPERATIONS, 
  VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS 
  AFFAIRS; AND KEVIN HANRETTA, DEPUTY ASSISTANT SECRETARY FOR 
   EMERGENCY MANAGEMENT, OFFICE OF OPERATIONS, SECURITY, AND 
       PREPAREDNESS, U.S. DEPARTMENT OF VETERANS AFFAIRS

               STATEMENT OF RANDALL B. WILLIAMSON

    Mr. Williamson. Thank you, Chairwoman Buerkle, Ranking 
Member Michaud, Mr. Miller, and Members of the Subcommittee.
    I am pleased to be here today to discuss GAO's recent 
report on sexual assault incidents at VA medical centers, known 
as VAMCs. On a prior GAO study, VA clinicians had expressed to 
us concerns about the safety of patients treated in VA mental 
health programs that also housed veterans who had previously 
committed sex crimes.
    Subsequently, we performed this study of sexual assault 
incident reporting and safety precautions. Our review of 
incident reporting examined these incidents VA-wide, while our 
review of safety precautions focused on five selected VAMCs, 
focusing on residential treatment and inpatient mental health 
units. We found numerous areas that need improvement to better 
ensure the safety of VA patients and staff alike.
    For the period January 2007 to July 2010, we identified 284 
sexual assault incidents that were reported by VA Police at 105 
different VAMCs. These incidents were suspected, alleged, 
attempted, and confirmed sexual assaults involving both men and 
women, including 67 rapes, 185 inappropriate touching 
incidents, and 32 other types of sexual assaults. Most of the 
alleged perpetrators and victims were VA patients and 
employees.
    We found that many of the alleged sexual assault incidents 
were not reported to VA management or to the VA Office of 
Inspector General. For example, of the 67 alleged rape 
incidents reported to the VA Police, only 25 were reported to 
the Office of Inspector General, as required by VA regulation. 
Also, we contacted officials at four Veterans Integrated 
Services Networks (VISNs), and found that of the 102 alleged 
sexual assault incidents reported to VA Police at 29 VAMCs 
within these VISNs, only 16 were reported to VISN leadership, 
and only 11 of these were forwarded to the VA Central Office.
    Several factors may contribute to this underreporting. 
First, VA does not have a common definition of sexual assault 
for reporting purposes. VAMCs we visited varied in the level of 
detail of their definitions, including one with no definition 
at all. VISNs had no definitions in their written VISN 
policies, and VA Central Office has no definition of sexual 
assault in its reporting guidance.
    Second, VA at all levels does not have clear expectations 
about the types of incidents that should be reported. For 
example, VA Police files from one VAMC we visited showed that 
three alleged perpetrators had been involved in previous sexual 
assault incidents that were not reported to VA Police because 
VA clinicians believed that these behaviors were a 
manifestation of a clinical condition. Also, leadership at one 
VISN told us they expected to be informed of all alleged sexual 
assault incidents. However, we found three alleged incidents of 
rape and one oral sex incident that was not reported to this 
VISN.
    We also identified a number of shortcomings that may hinder 
effective oversight of sexual assault incidents by Central 
Office. For one, VA has no system that ensures that pertinent 
program offices receive all reports of sexual assault incidents 
that occur in their areas of responsibility. For example, we 
found that VA Central Office managers of the residential and 
inpatient mental health programs were not always aware of the 
sexual assault incidents that had been reported by their units 
in the field.
    Also, there is no central database to collect and store 
reports of sexual assault or any mechanism to systemically 
analyze reports and identify trends. Such analyses are 
important to assess the extent of sexual assaults across VAMCs 
and to identify methods for preventing future incidents.
    Finally, we observed and tested security precautions at 
five VAMCs we visited, with some disturbing results. For 
example, police command centers at these VAMCs were sometimes 
unattended, understaffed, or could not monitor residential 
treatment facilities due to incompatibility in surveillance 
systems.
    We also noted malfunctions in panic alarm systems. For 
example, at four VAMCs the panic alarms we tested either did 
not appropriately alert VA Police of the location of an alarm 
or were previously disabled without notifying staff. Finally, 
at all five VAMCs, panic alarm systems did not alert both VA 
Police and staff on the unit. While we found significant 
security lapses at these five VAMCs, we did not attempt to link 
such lapses to specific sexual assault incidents.
    In summary, underreporting and poor oversight of sexual 
assault incidents, coupled with security lapses at VAMCs, can 
severely compromise the safety of patients and VA staff alike. 
Decisive actions are needed to correct weaknesses and to better 
ensure that VAMCs maintain a safe and secure environment. In 
our report, we recommended a number of specific actions VA can 
take to accomplish this. That concludes my opening remarks.
    [The prepared statement of Mr. Williamson appears on p. 
36.]
    Ms. Buerkle. Thank you, Mr. Williamson.
    Mr. Sullivan, you may proceed.

              STATEMENT OF JOSEPH G. SULLIVAN, JR.

    Mr. Sullivan. Thank you, Madam Chairwoman, Members of the 
Subcommittee. Thank you for the opportunity to discuss with you 
how the Office of Inspector General interacts with the VA 
Police with regards to reporting felonies, to include sexual 
assaults at VA facilities and also to tell you what we provided 
to the GAO for their report.
    I am the Deputy Inspector General For Investigations. The 
Office of Investigations is responsible for conducting criminal 
and administrative investigations where wrongdoing occurs or is 
alleged in VA programs or operations, as well as serious 
misconduct by senior officials. We have 141 criminal 
investigators at 29 field offices across the country.
    The VA Police are a separate entity from the Office of 
Inspector General in that they are a uniformed police service 
located at and responsible for the security of the medical 
centers and other Department facilities. And they have 
jurisdiction for crimes that occur on VA property. There are 
two sections of the Code of Federal Regulations (CFR), which we 
have been mentioned that require all VA employees to report 
suspected criminal behavior to VA management and/or the OIG: 38 
CFR, Section 1.201, requires employees with knowledge or 
information of possible criminal violations related to VA 
programs and operations to report that information to their 
supervisor, any management official, and the OIG; 38 CFR, 
Section 1.204, requires VA management with information about 
possible criminal matters involving felonies are to ensure and 
be responsible for reporting that information to us.
    While our field supervisors report that generally VA Police 
chiefs are complying with this reporting requirement in the 
CFR, they are aware of instances where failure to timely report 
suspected felonies does occur. When we become aware of such 
situations, our field supervisors will visit with the police 
chief, share our concerns with them, and remind them of their 
reporting responsibilities under the CFR
    Now, with regards to the GAO report, I would like to share 
with the Subcommittee what we provided to GAO. They requested 
information about allegations of sexual assaults for the period 
of January 1, 2007, as was said, through August 1, 2010. And we 
provided detailed information about our 130 closed 
investigations. We also provided GAO with de-identified 
information regarding nine sexual assault investigations that 
remained open back on August 1, 2010.
    Next, GAO asked that we review 42 scenarios regarding 
alleged sexual assaults that had occurred on VA property but 
were not, according to GAO research, referred to us by the VA 
Police. We had four senior agents look at these scenario 
descriptions and concluded the following: In 23, or 55 percent 
of the scenarios, we would not have expected VA Police to 
notify us. Examples included allegations that lacked any 
evidence of sexual assault obtained as a result of a medical 
examination, and a victim who quickly recanted her original 
allegation.
    In 14, or 33 percent of the scenarios, we would have 
expected VA Police to notify us. Examples included a victim 
with dirt and leaves on her clothes and in her hair, who 
reported that she had been raped while walking the grounds of 
the VA facility. We also had a female physician who reported 
that a male sexually assaulted her while she was conducting a 
medical examination. Those are two examples we would have 
expected to be referred.
    In five, or 12 percent of the scenarios, we just couldn't 
make a judgment because they were either too ambiguous or 
inadequate information was provided in the scenario 
description. We welcome GAO's recommendations to automate 
reminders to VA Police to notify us when entering a felony 
offense into the police database, and we are pleased with VA 
Police's intention to also implement an automated notice to our 
field offices whenever the record of such an offense is 
created. We believe both measures will greatly reduce the 
number of times where we will not be notified in the future.
    Madam Chairwoman, this concludes my statement, and I would 
be happy to answer any questions you or Members of the 
Subcommittee may have.
    [The prepared statement of Mr. Sullivan appears on p. 52.]
    Ms. Buerkle. Thank you, Mr. Sullivan.
    Mr. Schoenhard, you may proceed.

             STATEMENT OF WILLIAM SCHOENHARD, FACHE

    Mr. Schoenhard. Chairman Miller, Chairwoman Buerkle, 
Ranking Member Michaud, and Members of the Committee, thank you 
for the opportunity to discuss the safety and security of our 
veterans, employees, and visitors.
    This issue is a top priority of Secretary Shinseki and of 
our Department. We constantly strive to ensure a safe 
environment, and we appreciate and accept the eight 
recommendations in the GAO report. We owe a safe environment to 
everyone who enters our doors, whether they be visitor, 
patient, staff. Anyone who is in our work environment deserves 
a safe environment.
    And as Chairman Miller said, one incident in which one of 
our patients, visitors, or staff feels victimized is one too 
many. We deeply regret that anyone would feel victimized and 
experience any kind of victimization at one of our facilities.
    As a Vietnam veteran and someone who comes to VA with 34 
years of experience in the private sector, I am impressed that 
VHA provides exceptional service in what is the most mission-
driven organization I have ever been accustomed to or 
experienced. We are a large integrated system, and we have 14 
points of care, but as Chairman Miller pointed out, one 
incident of anyone feeling victimized is one too many.
    The GAO report rightly identifies recommendations for 
improvements in preventing assaults and in reporting incidents. 
First, we must do all we can to prevent harm. We need to 
explore every opportunity we can for prevention of anyone 
feeling victimized in our facilities. That starts with VA 
staff, with police officers, with all of our staff involved in 
training, background investigations, and ongoing vigilance of 
watching our environments and in taking immediate steps when 
anyone looks as if they may be at risk.
    It also requires that we have physical systems in place, 
such as panic alarms and closed-circuit television, locks on 
our doors, and all that is important for physical security. 
Last Friday evening, I issued a directive to all of our VISN 
directors asking for a report by June 24 of all review of 
physical infrastructure in terms of prevention that goes into 
serving as a deterrence for anyone feeling victimized.
    And in terms of reporting, when we look at that, as 
Secretary Shinseki says, we cannot solve a problem we cannot 
see. Full and complete reporting is essential to a full 
investigation of any incident that has been reported. It is 
also important in that we can aggregate this data, develop 
system review of the trends, and develop best practices, and 
learn from our experience in order to make, again in the 
prevention area, our facilities even safer.
    Our Under Secretary for Health, Dr. Petzel, has 
commissioned a work group chaired by Dr. Arana and Dr. Patricia 
Hayes, who is our chief consultant for women's services, and 
that work group is undertaking review of all eight 
recommendations, but particularly focused on the reporting, 
with a requirement that by July 15, we receive an initial 
action report, with a final report of its work by September 30. 
As we did Friday, we will be immediately following up on any 
action the work group stimulates for our review. And they have 
met several times, including this afternoon.
    One of the important advances in reporting is the standup 
of our Integrated Operations Center, or IOC, which was stood up 
in 2009. This operates 24 hours a day, 7 days a week. It has a 
VHA watch officer as part of that team. And it is important 
that we, as was pointed out by Mr. Williamson and others, 
ensure timely reporting of any report that especially has to do 
with criminal behavior to the IOC. The requirement is that that 
be accomplished within 2 hours. While GAO has identified 
instances where senior VA leadership were not informed, I do 
wish to assure the Committee that I have every confidence at 
the local level, when an incident is reported, that local 
management, in cooperation with the VA Police and with local 
law enforcement, are investigating these allegations in every 
way that we possibly can, working closely with law enforcement 
also to pursue criminal prosecution to the extent the law 
permits.
    Let me repeat again: One incident is one too many. We owe 
our veterans, our staff, our patients, our visitors, everyone 
who is associated in our work environment, a safe environment. 
Our veterans have served this country with distinction. As 
Madam Chairwoman so eloquently said, we owe them a place of 
healing, of hope, of respect. And as a mission-driven 
organization, this is important I think beyond policy, beyond 
reporting. That is all important. It gets to the culture of 
VHA. It gets to a care and concern on the part of everyone for 
what is going on in their environment, and a commitment to 
ensuring that the utmost of respect is afforded everyone with 
whom we serve and that we serve.
    Thank you for the opportunity to testify. My colleagues and 
I will be happy to answer questions.
    [The prepared statement of Mr. Schoenhard appears on p. 
55.]
    Ms. Buerkle. Thank you, Mr. Schoenhard.
    I yield to Chairman Miller for 5 minutes for questions.
    Mr. Miller. Thank you for yielding. The report covers 2007 
to July of 2010. Can you tell me what the statistics are from 
July of 2010 until today of sexual assaults that have been 
reported within the system?
    Mr. Schoenhard. Sir, we do not have that information 
available here today, but we will provide that to you.
    Mr. Miller. Would it have been a reasonable expectation 
that somebody might be asking that question?
    Mr. Schoenhard. We had not anticipated that question. But 
we do have the information, and we can provide that to you in 
short order, sir.
    Mr. Miller. If you would, for the record, so that we can 
make sure that all Members have the answer to that question. 
When can we expect it?
    Mr. Schoenhard. We would provide that, sir, within 3 weeks?
    Mr. Miller. Three weeks?
    Mr. Schoenhard. Yes, sir. I want to make sure that we have 
all the information together in a complete way. We will try to 
provide it sooner.
    [The VA subsequently provided the following information:]

                                            Thursday, June 30, 2011
           INTERIM REPORTS OF RAPE, INAPPROPRIATE TOUCHING OR
                 OTHER SEXUAL ASSAULT IN VHA WORKPLACES
              BETWEEN AUGUST 1, 2010 AND MAY 31, 2011 \=\

                             National Counts of Sexual Assault Incidents in VHA \*\
----------------------------------------------------------------------------------------------------------------
                                                             Substantiated \**\         Un-Substantiated \***\
----------------------------------------------------------------------------------------------------------------
                                                                       Reported to                  Reported to
     Type of Incident \\            Total           Total          OIG           Total          OIG
----------------------------------------------------------------------------------------------------------------
Alleged/Attempted Rape                   6               2             2              4             4
----------------------------------------------------------------------------------------------------------------
Inappropriate Touching of a Sexual       78             31             7             47             4
 Nature
----------------------------------------------------------------------------------------------------------------
Alleged Sexual Assault/Other             57             21             7             36             5
----------------------------------------------------------------------------------------------------------------
    TOTALS                               141            54            16             87            13
----------------------------------------------------------------------------------------------------------------
\*\ Information is still under review regarding facility reports, police reports and substantiation of
  allegations.
\\ As reported in the 10N Sexual Assault Management/Police Roll-up Database.
\**\ Sexual Assault Incidents as defined below and verified by VA Police and/or Clinical Staff.
\***\ Sexual Assault Incidents as defined below, which following VA Police and/or Clinical Staff investigation/
  review were not substantiated.

\\ [Update as of September 23, 2011: This report is still interim as cases remain under investigation and so may
  change categories. VA will be sure to present a final report once it can confirm that all cases have closed.]


         To ensure accurate reporting, sexual assault is defined 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 [but not 
        limited to] 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.''

        Of t he 54 substantiated incidents, the relationship of 
        perpetrators to victims includes:

            (2)  Rape

                 Patient on employee (charges filed)
                 Patient on patient (U.S. Attorney declined 
        prosecution based on evidence compiled)

           (19)   Patient on employee
           (13)   Patient on patient
           (11)   Employee on patient
            (6)   Employee on employee
            (2)   Non-patient or employee on employee
            (1)   Volunteer on employee

         Actions VA is Taking

          It should be noted that VA is undertaking efforts to ensure 
        that every alleged sexual assault event is identified and 
        tracked by the Department.

            Timely Reporting: The VA has established a policy 
        to ensure that every alleged sexual assault incident is 
        reported to a national incident center within 2 hours. This 
        reporting provides leadership with visibility to ensure that 
        each event is resolved.
            Integrating VA Law Enforcement with Clinical Care: 
        The VA is performing a review of VA law enforcement personnel 
        classification and compensation. Currently, VA law enforcement 
        staff members are graded below those of comparable staff from 
        other agencies. The VA is assessing integration of VA law 
        enforcement personnel within Title 38. It is critical that VA 
        facility staff and policies view VA law enforcement as an 
        integral team member in establishing a safe, secure environment 
        of care.
            Focusing on Prevention: VA will review critical 
        elements for the prevention of sexual assault in our work areas 
        by focusing on:

                1.  behavioral surveillance by all VHA staff;
                2.  environmental surveillance through the use of 
                technology and specific safety equipment;
                3.  education of patients, staff and visitors; and
                4.  review and revision of VHA policy as it pertains to 
                workplace safety.

    Mr. Miller. I hope that you have all the information 
together, and it won't take you 3 weeks. Further, ongoing 
investigations by Oversight and Investigations, our 
Subcommittee, shows that senior leadership at least one 
facility that we are aware of siphoned money away from facility 
security to provide funds for other projects. I have also been 
told that staffing security billets, there is some evidence 
that senior leadership at VA do not see the value of their own 
security forces. And these consequences of failures involving 
these is unacceptable, as you might imagine. But what I want to 
know is, how can we be sure that VA is spending the money that 
this Congress allocates to them appropriately?
    Mr. Schoenhard. Sir, that is incumbent on us in leadership 
to ensure that the funds that are allocated for the purposes 
that are intended are spent for the purpose that the Congress 
and all of our appropriators assure. And I guarantee you we 
will follow up with any instance in which that is not done.
    Mr. Miller. And then thirdly, I think it is ironic, I went 
to your Web site this afternoon and found a tab, ``Women 
Veterans Health Care, Military Sexual Trauma.'' And of course, 
this deals with women's sexual trauma. But as we know from the 
report, this is men and women.
    Mr. Schoenhard. Yes.
    Mr. Miller. But it just opens up with the question, ``Did 
you experience any unwanted sexual attention, uninvited sexual 
advances, or forced sex while in the military? Does this 
experience continue to affect your life today?'' And I guess my 
question is, don't you find that ironic that this is on the 
VA's home page?
    Mr. Schoenhard. Well, sir, we want to be able to invite our 
veterans who have made--perhaps have experienced that to come 
forward so that we can treat them.
    Mr. Miller. I yield back.
    Ms. Buerkle. Thank you, Mr. Chairman.
    I will just use the last few minutes of the time, if that 
is okay. Mr. Schoenhard, I want to just go back to some of your 
comments that you made in your opening statement that I find 
disturbing and really don't assure me that things are going to 
happen quickly enough.
    Mr. Schoenhard. Okay.
    Ms. Buerkle. You mentioned that you are going to review all 
eight GAO recommendations, and then by July 18, we are going to 
get an initial action report. What is an initial action report?
    Mr. Schoenhard. Madam Chairwoman, the requirement by July 
15 would be that an action set of recommendations be put forth 
to the Under Secretary for our review. But we are looking for 
any information that can be forthcoming sooner than that. I 
don't know if Dr. Arana may want to speak. He is co-chairing 
that group, and may want to elaborate.
    Dr. Arana. Madam Chairwoman, the group has met about four 
times in the past week and a half. It is an interdisciplinary 
group that includes security, includes caretakers, providers. 
It includes specialists in sexual trauma from all over the 
country. And the plan is, by July 15, to have a clear 
definition of what sexual assault is, and a clear way to track 
and trend that over the next few years. The plan is to put that 
in place by July 15.
    Also, the plan is to look at behavioral surveillance 
techniques that we already use in some facilities but we want 
to promulgate out to the entire system. And we also will look 
at technical surveillance devices so that we can improve our 
ability to survey clearly behaviors during off hours and in 
more remote places. So the plan is if we find something in the 
next week or 10 days that we want to execute and put in place, 
the Under Secretary and Mr. Schoenhard have told us, tell us 
what it is, and we will deploy it immediately. So I think the 
plan is to really move on this as quickly as we can and be able 
to report out finally sometime in August about what actions we 
have taken and how we plan to track and trend that.
    Ms. Buerkle. Thank you.
    I yield 5 minutes to the Ranking Member, Mr. Michaud.
    Mr. Michaud. Thank you very much, Madam Chair.
    At the VA, of the 46 incidents where the employees of the 
VA were charged or involved in patient sexual assault, what has 
been the disciplinary action to those employees, if any?
    Mr. Schoenhard. Mr. Ranking Member, we are working with the 
GAO to make sure we understand the specific cases that are 
mentioned in the 284. And we will be following up. I can assure 
you this: Every disciplinary action appropriate has an 
important element of ensuring first and foremost that the 
veteran or the patient is no longer at risk. And so we are 
working with the GAO to identify specifically who they have 
identified in order for that information to be provided.
    Mr. Michaud. So you don't know if you fired anyone because 
of rape or sexual assault?
    Mr. Schoenhard. Yes, we have.
    Mr. Michaud. You have?
    Mr. Schoenhard. Yes. Let me be clear. We certainly have 
cases where employees have been terminated. We have had cases 
where employees have been convicted. And we have certainly a 
variety of other instances of disciplinary action. What I want 
to be clear about, Mr. Ranking Member, is that we are working 
with the GAO to be sure we understand what 284 instances were 
identified in their review, which we do not have at this time.
    Mr. Michaud. And the Vietnam Veterans of America, actually 
they recommend or point out the need for separate facilities or 
wards for female patients seeking long-term care. Do you have 
any comment on that? What settings have the VA set up that 
actually would allow for separate wards or separate facilities?
    Mr. Schoenhard. Well, it is certainly important that we 
provide privacy, respect, and courtesy to our female veterans, 
an ever-growing number of veterans in our service of those who 
have served this country. A number of facilities have been 
constructed throughout VHA in order to provide separate access 
and concentration of women's services for female veterans. And 
we are committed, sir, to continuing that investment. It is 
important that our veterans be treated with dignity and 
respect.
    The comment was made earlier regarding cat calls and the 
rest. We need to ensure that there is privacy. With regard to 
residential treatment centers and community living centers, 
female veterans are isolated closer to the nursing stations so 
that they can be more closely monitored by the nurses and are 
certainly kept, as much as we can, separate from male veterans. 
And we will continue that commitment to ensuring we have the 
facilities and the program to treat our female veterans, an 
ever-growing number of veterans that we serve.
    Mr. Michaud. And what type of training do the VA Police go 
through? Are they all VA employees? Or do you contract those 
services out? And if so, what type of training do they have to 
go through?
    Mr. Schoenhard. Sir, that is a great question. If I could 
call on Mr. Hanretta to perhaps comment.
    Mr. Hanretta. Sir, the VA Police, every VA Police officer 
attends the law enforcement training academy, the VA law 
enforcement training academy in Little Rock, Arkansas. It is an 
8-week program, where they are certified as VA Police officers 
and working in a health care environment. So their sensitivity 
to respect responding to incidents and reporting is emphasized 
throughout the training.
    Mr. Michaud. My last question, I only have 40 seconds, is 
how is the VA staff notified that they are treating or housing 
a convicted sex offender?
    Mr. Schoenhard. I might call on Dr. Arana, who could give 
more experience from his own clinical care. But there are 
universal precautions that are taken in being able to interview 
our patients and our veterans. And this, by the way, is a 
subject of our work group that will be undertaking the best 
practices, a full literature search. We think there is an 
opportunity to improve our capacity to determine those who may 
be at risk in order to protect those that are treated in our 
facilities.
    I don't know, Dr. Arana, if you would want to add to that.
    Dr. Arana. The expectation is that all patients who are 
seen in mental health services, whether they are long term or 
acute, have a what we call biopsychosocial assessment, which 
includes a legal history and a history of trauma. And the plan, 
therefore, is put together for the care of that particular 
veteran based on that history. Now, it is the case that the GAO 
did outline one of the recommendations is we needed to improve 
our ability do that. And we agree 100 percent with that.
    Mr. Michaud. Thank you.
    Ms. Buerkle. Thank you, Mr. Michaud.
    I now yield 5 minutes to the gentleman from Michigan, Dr. 
Benishek.
    Mr. Benishek. Thank you, Madam Chairwoman.
    I just have a couple questions about the testimony. And one 
of the things that sort of surprised me was from Mr. Sullivan's 
statement here, that the GAO had requested the review of some 
scenarios that hadn't been reported by the VA Police to the 
OIG, and that 45 percent of the cases that they brought up, you 
know, 33 percent said they should have been expected to be 
reported, and the other five cases, there was an inability to 
make a judgment because of the ambiguous or inadequate 
information in the scenario description. It just seems to me 
that, you know, nearly half of the cases that weren't reported 
seem to show some sort of lack of police procedure really. I 
mean, five cases don't have adequate information in the report 
to make a decision and 33 percent seem like they just were 
improperly reported. That is a relatively high number.
    Do you have any information, Mr. Sullivan, on whether there 
is any investigation into the caliber of training? I mean 8 
weeks doesn't seem like a very long period of time I guess for 
officer training. Have we done anything about this statistic?
    Mr. Sullivan. To your first question, I would be reluctant 
to comment on the training that is afforded the VA Police 
officer.
    But by contrast, recognizing that the majority of our 
agents already come to us well trained from other traditional 
Federal law enforcement agencies, such as the Federal Bureau of 
Investigation, the Secret Service, the Postal Inspection 
Service, Immigration and Customs Enforcement, they come ready 
to work and with a wealth of experience to be able to adapt to 
any criminal investigation because of their experience. To 
transition to Inspector General investigations they will then 
attend Inspector General training for 3 days. Should we hire 
new agents, they will attend an 18-week course at the Federal 
Law Enforcement Training Center in Georgia. That is followed by 
courses offered at the Inspector General Academy. It is a very 
robust training program that continues throughout the remainder 
of their career. Even I have to go through periodic training. 
So it is a healthy program. It is a good program. I suggest Mr. 
Hanretta comment on the police training.
    Mr. Benishek. I just say, doesn't it seem somewhat 
remarkable there were 45 percent of the cases that were brought 
forth without a very good answer?
    Mr. Sullivan. It was difficult for us to interpret. As I 
understand it, the GAO took the scenario description directly 
from the uniform officer report of the VA Police. They didn't 
add anything to it; they didn't delete anything from it. Nor 
would they share with us any specifics as to the victim, the 
perpetrator, or the facility. Had they done so we could have 
tracked the allegations back to the VA station where this may 
have occurred. We could have formulated in our minds a sense of 
what has gone on at the particular facility in the past to 
assist us with making our decision as to whether or not the 
case should be referred.
    Mr. Benishek. So you are saying that you haven't been able 
to investigate any of these cases then because you don't know 
which ones you are talking about?
    Mr. Sullivan. That is right. We don't know. We can't, with 
the information provided, go into our system and tell you 
whether or not those 42 scenarios are in our open or closed 
inventory.
    Mr. Benishek. It seems like we should investigate those 
cases, don't you think?
    Mr. Sullivan. I do. I think we will follow up once we get a 
better understanding of when these alleged crimes took place. 
We will also have a conversation with the VA Police officials.
    I will tell you, though, in answer to the Congressman's 
question, we have presently in our inventory, 17 open sexual 
assault allegations that we are investigating. We had a total 
of 139 during the period of the GAO review. And 23 were 
successfully prosecuted of the 139.
    Mr. Benishek. All right. I guess my time is up. But I would 
like to ask the Chairwoman if we could get some additional 
information going further here to make sure that we actually 
follow up on these, in that the GAO and the Inspector General's 
office figure out where these cases came from and if there is 
really a problem.
    Mr. Sullivan. Yes. The exercise for us was nothing more 
complicated than here are some scenarios; would you or would 
you not expect the VA Police to refer them to you? Not would 
you or would you not choose to investigate.
    Mr. Benishek. I see.
    Ms. Buerkle. Thank you, Dr. Benishek.
    I now yield 5 minutes to Mr. Bilirakis from Florida.
    Mr. Bilirakis. Thank you, Madam Chair.
    I appreciate it very much. This question is for Mr. 
Schoenhard. One of the GAO's recommendations was to increase 
security by involving stakeholders into facility design and 
redesign. I just received word, a VA announcement that a $92 
million contract was awarded to construct a new mental health 
facility at Bay Pines in Florida. This facility will provide 
residential rehabilitation, acute inpatient mental health 
services, and outpatient mental health services. This is the 
question: Were stakeholders, including the clinicians who will 
provide the care, involved, were they involved in the design of 
this project? And if not, why?
    Mr. Schoenhard. Sir, if I could take that question, I will 
find out for sure. It is absolutely essential that they are 
involved, because it is important that when an alarm is 
activated that not only law enforcement, but clinicians are 
immediately notified. So I will follow up and take that 
question, sir, and find out.
    Mr. Bilirakis. Please. I would like you to please get back 
to me on that as soon as possible.
    Mr. Schoenhard. Yes, sir.
    [The VA subsequently provided the following information:]

          It is standard practice to provide clinical professionals 
        extensive input opportunities in each phase of the design for a 
        new facility. Participants from the Bay Pines Mental Health 
        clinical staff, including the Chief of Mental Health and the 
        Chief Nurse for Mental Health, attended numerous meetings to 
        provide input into the location of the building, the 
        architectural design, and the layout and function of each room 
        and in design review meetings at each phase in the process. 
        Overall, representatives from the Medical Center have been 
        active throughout the design process. The design phase of the 
        new Mental Health Center at Bay Pines VAMC is complete and a 
        construction contract has been awarded. Clinical staff will 
        continue to be consulted as construction progresses. Updates 
        are regularly provided to our Mental Health Consumer Council, 
        comprised of Veterans.

    Mr. Bilirakis. Then also how are the needs of veterans, and 
I know you touched upon this, especially women veterans, and 
you just touched on it briefly, so if you can elaborate on 
that, with regard to privacy and safety being taken into 
consideration? How are women veterans and veterans in general, 
as far as privacy is concerned, taken into consideration when 
these buildings are designed?
    Mr. Schoenhard. Well, it is important that we have the 
physical security of electronic locks and key cards to ensure 
privacy. I think that especially as it relates to care for 
female veterans, we need to continue to focus not only on 
facility development to serve their needs, but programmatic 
development. And we do have a strong program office that is 
working to ensure that we have both.
    Mr. Bilirakis. Give me an example of what you have done so 
far.
    Mr. Schoenhard. Well, we have constructed on a number of 
our campuses specific new clinics that are separated from the 
main frame medical center for care for women. And we have also 
designed throughout VHA specific specialty clinics for women 
who have suffered sexual trauma. Dr. Arana may want to speak 
more regarding the clinical care, if you have anything that you 
would want to add.
    Dr. Arana. Yeah. In addition, sir, we have--the women's 
program has reviewed all the facilities in the system. And 
there are recommendations that have been laid out for 
increasing security and also increasing privacy. And that is 
something that is tracked by women's health coordinators at 
each network.
    Mr. Bilirakis. Thank you.
    Next question for Mr. Schoenhard, and then also Mr. 
Williamson. In the GAO report, one item addressed was 
vulnerabilities in physical security precautions. GAO 
recommended and VA agreed that alarm systems should be 
routinely tested. How frequently do you believe that these 
tests should be happening to ensure that they are optimally 
working? And will you elaborate on where you believe 
responsibility should fall to ensure these tests are happening?
    Mr. Schoenhard. Sure. Sir, that is a great question. And 
let me answer in reverse order. The responsibility to ensure 
that the testing is done and that the alarms work lies with the 
medical center director, the VISN director, myself, and on up 
to the Under Secretary. We have the con for that 
responsibility.
    In hospitals throughout the Nation, this is typically a 
policy that is developed at the local level in conjunction with 
Joint Commission standards, our accrediting body. But part of 
what we want to do in this small work group, and part of what I 
want to know by June 24 from our VISN directors, is the current 
state of that. And I think that we will be providing, sir, 
additional guidance beyond what medical center policies have 
developed over time in order to meet accreditation 
requirements. And we will also do that based upon what we find 
from this system-wide thorough survey of our physical alarm 
infrastructure.
    Mr. Bilirakis. Okay. Thank you very much.
    I yield back, Madam Chair.
    Ms. Buerkle. Thank you. I now yield 5 minutes to the 
gentleman from Tennessee, Dr. Roe.
    Mr. Roe. Thank you for yielding.
    Just an opening comment. Hospitals in general, and VA 
Hospitals specific, should be places to heal, not harm, as all 
medical facilities should be. And it should be a safe 
environment whether you are a patient there or just a visitor 
there. Having dealt with this for over 30 years, rape is one of 
the most underreported crimes out there. And it is probably 
handled as poorly as anything we do about how the emotional 
effect on the victim, and how we deal with it. So it is 
imperative that we do that.
    A second thing I think that is really important that has 
not been mentioned, I know that when I was mayor of Johnson 
City, Tennessee, we paid a lot of attention to crime mapping. 
Where did it occur? And that is why this reporting is so very 
important, because if you notice a pattern, maybe it is in a 
certain part of the hospital, or a community-based outpatient 
clinic (CBOC), or wherever it may be, you then can point to 
that area about how to secure it. So I think that is very 
important about the mapping process about where these crimes 
occur. If they are random, then it is much harder. But if there 
is a trend there, it is pretty easy to focus on that and reduce 
the problem dramatically, whether it is in the clinic or 
hospital. Just a point that it is not just gathering data to be 
sent up to sit on a shelf somewhere.
    The other thing I would recommend you do, and you probably 
have done it, but in your Committee that gets together, I would 
get some worker bees, folks that are out there everyday on the 
clinical side working, who are out there working with the 
patients. So I don't know whether you have done that or not, 
but I would strongly encourage you to do that.
    And to Mr. Michaud, what he was saying a minute ago, in his 
comment about someone who may be questioned, and I know Dr. 
Arana was mentioning this, but there is no way to do a 
background check and check and see if what somebody is telling 
you is the truth? In other words, if a sexual predator, I think 
that is what he was getting to, and the people there at the 
hospital don't know because they don't have access to the 
information, that puts them at a disadvantage in caring for 
that person, number one, and number two, protecting the people 
who are there from this individual. Is there any way to get at 
that?
    Mr. Schoenhard. That is part of what we want to explore 
further in the small group, sir. I think that is a very 
important area for us to thoroughly investigate. As I mentioned 
earlier, to see what other systems are doing, what literature 
search may come from this. Because we have a duty to ensure 
that we can identify those risk behaviors with every patient 
that we serve. At the same time, we have a duty to serve that 
veteran. But the first and foremost responsibility is ensure a 
culture----
    Mr. Roe. It is to do both. We in a community know that if a 
sexual predator is in your community, you are notified of that. 
Out in the real world, you can have that happen. I don't know 
why that wouldn't be the same case on VA property. When someone 
is noted, let's say the police investigate an alleged rape or 
sexual assault, is that then--when they gather that 
information, it is then reported, which wasn't done, it is 
reported up the chain of command. How is that prosecuted from 
there? In other words, it is on Federal property. What happens 
then?
    Mr. Schoenhard. Sir, may I ask Mr. Hanretta to initially 
respond to that?
    Mr. Hanretta. Sir, at the VA Medical Center, as Mr. 
Sullivan mentioned, every VA employee has a responsibility to 
report if they suspect criminal activity. When that happens, it 
is either reported to the OIG and/or the local authorities, 
because the prosecution takes place in the local community, not 
by the VA Police.
    Mr. Roe. No, no, no, I know that. There is an attorney 
general in Tennessee, but there is also a Federal court. So it 
is not prosecuted in the Federal system. The local attorney 
general prosecutor would bring that case, would gather the 
evidence from the information gathered from the VA Police and 
whoever the witnesses, however the information is gathered, and 
then prosecuted. Is that correct?
    Mr. Hanretta. Yes, sir. I would defer to Mr. Sullivan for 
the actual procedures, but I believe that is correct.
    Mr. Sullivan. We first, for prosecution purposes, have to 
identify, as you said, the facility, and whether or not the 
Federal Government has legislative jurisdiction. Facilities may 
have exclusive jurisdiction proprietary or concurrent 
jurisdiction. It is difficult to get many of these cases 
prosecuted in Federal court. We do rely on the State courts to 
accomplish this. What we did not have when we reviewed these 
scenarios, but will have when we look into how we proceed now 
with these allegations is the State. Because rape and sexual 
assault definitions can vary by State. So, in order for us to 
know what we have and where to refer it, we need a little bit 
more information.
    Mr. Roe. The prosecutor decides that in that State.
    Mr. Sullivan. He does indeed. And it starts back at the 
beginning with determining the jurisdiction of the medical 
center. Is it exclusive once the Federal Government has 
jurisdiction? Is it concurrent where both Federal and State 
have jurisdiction?
    Mr. Roe. I will finish up, I know my time is up, but I 
think what I started out by saying about how underreported it 
is, is that there needs to be an attitude that this is a very 
serious issue and that it needs to be addressed seriously 
because it is that. And I want to be sure that the VA is 
handing off to the local prosecutor the information they need 
to go ahead if a crime has been committed and investigate that 
crime. That is what I was getting at.
    I yield back.
    Ms. Buerkle. Thank, Dr. Roe.
    I now yield 5 minutes to the gentleman from New Jersey, Mr. 
Runyan.
    Mr. Runyan. Thank you, Madam Chair.
    Mr. Sullivan, as you were just responding to that last 
question, you talked a little bit about--I understand the 
political State jurisdiction thing. If it is a situation where 
the State is involved, are the local police departments 
involved from the get-go?
    Mr. Sullivan. Yes.
    Mr. Runyan. They are?
    Mr. Sullivan. Yes.
    Mr. Runyan. And they are within the reporting process that 
we are having problems with getting the information on?
    Mr. Sullivan. Yes. And typically when we have such serious 
offenses, they are the first to be notified by the VA Police.
    Mr. Runyan. Okay.
    Mr. Sullivan. The sheriff's department, the local police, 
whoever that may be. We just ask for timely notification. We 
are not saying we have to be the first to be notified. And in 
these instances, it is important that the VA Police go to the 
local jurisdiction immediately.
    Mr. Runyan. Very well. Mr. Schoenhard, the GAO found a 
number of facilities that were understaffed. Specifically, 
there was one, that by criteria, suggested there was supposed 
to be 19, but there was only 9 on hand. Why have you not been 
able to staff these facilities fully?
    Mr. Schoenhard. Congressman, that is a very important 
question because we need to be fully staffed with police 
coverage. And that is part of what I am seeking to understand 
in our current survey of our field. I want to understand better 
what the retention and the recruitment difficulties are with 
that and see what steps need to be taken to address those.
    Mr. Runyan. That was going to be my next question. Do you 
have an idea of retention problems? Is there a major turnover 
within the system?
    Mr. Schoenhard. There is turnover which varies, sir, by 
facility, and that too is part of what I want to get a better 
sense of in conjunction with our VSIN and medical center 
directors, because this is an extremely important part of our 
staffing.
    Mr. Runyan. It really is, because having the people around 
and being used to the procedures is the first step of getting 
these reported correctly and into prosecution.
    Mr. Schoenhard. Yes.
    Mr. Runyan. So it is a huge step.
    Madam Chair, I don't have any further questions. I yield 
back.
    Ms. Buerkle. Thank you, Mr. Runyan.
    I now will begin the second round of questions and I will 
yield myself 5 minutes. I am just so concerned about what I am 
hearing this afternoon. Correct me if I am wrong, but I 
understood you to say, Mr. Schoenhard, that as of July 18th 
this workgroup is going to come together and define sexual 
assault.
    Mr. Schoenhard. Madam Chairwoman, let me clarify. The 
initial action plan for the work group's review of all eight 
recommendations is due July 15th. However, we are urging Dr. 
Arana and Dr. Hayes to hold frequent meetings of this work 
group. And we will be bringing forward everything we can as 
soon as we can. We are not waiting for July 15th to develop 
this.
    One of the items that was discussed today in the work group 
was the definition. And so we feel, Madam Chairwoman, a sense 
of urgency about this, and we will work as quickly as we can to 
address all eight recommendations.
    Ms. Buerkle. My concern is that you are going to get caught 
up with defining sexual assault, which has been defined on a 
number of occasions. I am sure if you looked around you could 
find a satisfactory definition and not waste the time of this 
Committee, but to get on within getting these procedures in 
place and getting a chain of command in place. You talked about 
employees; some lost their jobs.
    Mr. Schoenhard. Right.
    Ms. Buerkle. Some perhaps are being disciplined.
    Mr. Schoenhard. Yes.
    Ms. Buerkle. Without a definition of sexual assault, how do 
you even know who is guilty and who is not?
    Mr. Schoenhard. Well, I would agree with you that it should 
not take us long to develop a common definition. But that is 
essential in order to ensure we have complete reporting. And we 
are consistent in that going forward. So we will put that as a 
top priority.
    But let me clarify as it relates to investigation of any 
incident involving an employee. This is really not a function 
of a definition. If there is any risk or harm or victimization 
that someone has reported, we don't need a definition to fully 
investigate that and take appropriate action with regard to our 
workforce.
    Ms. Buerkle. I am also concerned with the fact that there 
doesn't seem to be a clear chain of command once an incident is 
reported. As was discussed by my colleagues, there are issues 
of jurisdiction, but if it is a criminal case oftentimes the 
county and the district attorney's office will handle it. Is 
there not a protocol in place right now to act as a roadmap 
that clarifies, if an incident occurs, who it gets reported to, 
what actions are taken? It seems to me I hear from the various 
agencies that it is not clear.
    It seems to me we should be able to put on a big sheet of 
paper all of the cases that the GAO reported, and for each one 
of those victims who shall remain nameless, we should be able 
to track who it was reported to and the resolution and what 
happened to the perpetrator. It should all be very clear.
    And when I hear the testimony, I don't get any sense of any 
definition, any clear path here. I am very concerned that it is 
going to come up on July 15th and we are still going to be 
struggling with a definition. I think the Committee shares the 
feeling that this is an outrage that the veteran community, 
male or female, or the employees of the Department of Veterans 
Affairs would be victims of a system that isn't taking care of 
them. Time is of the essence.
    You mentioned earlier that this is a priority of Secretary 
Shinseki. Now, just because it has been brought up, or since 
2009 when the Ranking Member made the request and a report was 
issued now it is just becoming an issue; or has it been a 
priority right along? These are my concerns, that the clock is 
ticking and our veterans are paying for this delay.
    Mr. Schoenhard. Madam Chairwoman, if I could respond. It is 
clear, as was earlier testified, that anyone who suspects that 
there is criminal behavior that has been initiated must report 
that to the OIG. And part of the benefit of the stand-up of the 
integrated operation center is that we have those reports 
within 2 hours after they are reported to local police.
    There is also an expectation that we would be fully 
reporting this up the management line. And this is a subject 
that I want to get improved process for. And that will be in 
part aided by a common definition, so we know for sure 
everything is being reported within what consistently, across 
all of VHA, is determined to be sexual assault. That definition 
is important.
    But I can assure you we cannot, as I said earlier, solve a 
problem, track a problem, develop the kind of mapping that Dr. 
Roe spoke about before, Congressman Roe, unless we have full 
adequate reporting of all incidents, and we must have that.
    Ms. Buerkle. Thank you. I yield to the Ranking Member, Mr. 
Michaud.
    Mr. Michaud. Thank you very much, Madam Chair. I too am 
extremely concerned when you look at the numbers in the GAO 
report. That was only in five facilities out of the 111 
facilities who offer these types of services, so it is probably 
fair to assume that this is more--the numbers are much greater 
in that regard.
    The question that I have, and actually gets back to, 
similar to Mr. Roe, when you look at jurisdiction, whether it 
is a State court or Federal court--and I am not sure--is there 
a different definition for rape at the Federal level or sexual 
assault versus at the State level; and if so, why wouldn't that 
be in Federal court? Because my big concern, for instance, when 
you look at police officers--and actually this occurred in 
Maine last year where a Togus police officer shot a veteran and 
was being investigated. The investigation actually was done by 
the State, not Federal, because of a memorandum of 
understanding.
    So I am just kind of concerned about are there any other 
memorandums of understanding that the VA has as it relates to 
prosecuting rape or sexual assault? Because it gets back to Mr. 
Williamson's comments in his report. He indicated that the VA 
medical facilities have the authority to customize and design 
their own onsite reporting systems in policy.
    So I guess my question is: Do you feel that it is better to 
have a consistent policy within the VA system versus a 
customized policy, depending on where the VA is located? That 
is my first question.
    And my second question as it gets back to a memorandum of 
understanding: Are there any memorandums of understanding 
within the VA system as it relates to sexual assault or rape, 
whether it will be prosecuted in State or Federal court, and 
who does the prosecution? Would it be the DA or would it be a 
U.S. attorney? Those are my three questions.
    Mr. Schoenhard. Sir, I don't know if Mr. Sullivan should 
begin with that or Mr. Williamson.
    Mr. Sullivan. I can speak to the definition, Federal 
definition of sexual assault, rape, and what have you, which 
can be found in 18 U.S.C. 2441, which tracks pretty closely 
with the definition that the GAO used in looking at rapes. So 
this is the definition we use in the VA OIG for the sexual 
assault crimes.
    To the State crimes, my experience has been that each one 
may be a little different. Ones that apply perhaps to a 
juvenile, the language may be a little different when you talk 
about rape or assaults with a 14- or 15-year old child. With 
adult perpetrators of crimes in violation of Sate law again in 
not knowing which States we are talking about, I can't give you 
a definitive answer: Here is one example in Alabama, here is an 
example in Massachusetts. I can't do that. But know that they 
are different. However slightly, they are different.
    Mr. Michaud. And I mean that is a concern I have is under 
that definition. And if there are memorandum of understanding, 
whether it be prosecuted in State court, who does the 
prosecution, the outcome could become different.
    Mr. Sullivan. A memorandum of understanding does not enter 
into our decision or the way we proceed with an investigation. 
I don't know if they even exist, so I would defer back to the 
Department.
    Mr. Michaud. Well, for a shooting incident they do, because 
in a shooting incident, whether that shooting incident at Togus 
was a justified shooting or not, it wasn't the Federal agencies 
that are investigating it, it is actually the State agency 
because of a memorandum of understanding. So that is a concern 
I have when you transfer that over to rape or sexual assault; 
are there any cases where it is going to be just turned over to 
the State versus a Federal agency? It gets back to Mr. Roe's 
original question about jurisdiction issues.
    Mr. Sullivan. I don't have the answer on the shooting. If 
we look at a medical center that has exclusive jurisdiction, 
all criminal cases will have to be changed by the Federal 
Government. If you take something like a restraining order, 
there is sexual abuse going on in the family, or with relatives 
or whomever, the restraining order is taken in the State 
courts. The crime has been committed off VA property, but the 
perpetrator who violated the restraining order today is on 
property, and the local police arrest. In that circumstance, 
because it is Federal property, that must be brought in Federal 
court. I don't know if that confuses the issue or it lends 
clarity to the issue, but different scenarios present different 
challenges, and it all goes back to that jurisdiction.
    Mr. Michaud. I see my time is expired. But it does. I mean, 
this incident occurred on Federal property by a Federal 
employee, but the justification actually went over to the 
State. So that is why I was kind of curious as it relates to 
rape or sexual assault, whether that might be the same case 
even if it is on Federal property.
    Mr. Sullivan. I am not well versed on that case so I am 
reluctant to even speculate on that.
    Mr. Michaud. Thank you. Thank you, Madam Chair.
    Ms. Buerkle. Thank you, Mr. Michaud. The gentleman from 
Michigan, Dr. Benishek.
    Mr. Benishek. Madam Chair, I don't really have any more 
questions. I agree with you that it is sort of appalling there 
are not better procedures in place to handle this problem, and 
certainly it should be the focus of our attention in the 
future. And with that I yield back.
    Ms. Buerkle. Thank you, Dr. Benishek. Dr. Roe from 
Tennessee.
    Mr. Roe. Again, back to where we were talking about how 
underreported rape is in the military, it is estimated 80 to 90 
percent are not reported. So I think there is an attitude about 
how serious you take these sexual-assault issues on our 
campuses around the country. Because if the attitude is this is 
going to be dealt with as the serious crime that it is--and I 
think that also is because the victims many times realize the 
harassment that they go through just to get it done, and so 
they don't report it. There is no telling what the real numbers 
are, the times that this has happened. And I do think the 
definition shouldn't be all that hard. I think the courts--I 
mean that should be pretty easy, really. And it has been 
defined by the courts many, many times, so I think that won't 
be very hard for you to do.
    But just once again, back to what the Chairman said about 
how important I believe that this issue is and how important it 
is for us to take it seriously. I yield back.
    Ms. Buerkle. Thank you, Dr. Roe. The gentleman from New 
Jersey, Mr. Runyan.
    Mr. Runyan. I have no further questions, Madam Chair.
    Ms. Buerkle. Thank you, Mr. Runyan.
    On behalf of the Subcommittee, thank you all for your time 
and your testimony today. You are now excused.
    I invite the second panel to the witness table. Joining us 
on our second panel are representatives from many of our 
veteran service organizations. We have Verna Jones, Director of 
the Veterans Affairs and Rehabilitation Division of the 
American Legion; Joy Ilem, Deputy National Legislative Director 
for the Disabled American Veterans (DAV); Marlene Roll, a 
member of the National Women Veterans Committee of the Veterans 
of Foreign Wars (VFW); and Mr. Rick Weidman, Executive Director 
for Policy and Government Affairs for the Vietnam Veterans of 
America (VVA).
    Thank you all very much for being here this afternoon and 
for being such strong advocates for your fellow veterans.
    Ms. Jones, we will start with you if you would like to 
begin your testimony.

STATEMENTS OF VERNA JONES, DIRECTOR, NATIONAL VETERANS AFFAIRS 
  AND REHABILITATION COMMISSION, THE AMERICAN LEGION; JOY J. 
 ILEM, DEPUTY NATIONAL LEGISLATIVE DIRECTOR, DISABLED AMERICAN 
    VETERANS; MARLENE ROLL, MEMBER, NATIONAL WOMEN VETERANS 
 COMMITTEE, VETERANS OF FOREIGN WARS OF THE UNITED STATES; AND 
     RICHARD F. WEIDMAN, EXECUTIVE DIRECTOR FOR POLICY AND 
        GOVERNMENT AFFAIRS, VIETNAM VETERANS OF AMERICA

                    STATEMENT OF VERNA JONES

    Ms. Jones. Thank you, Madam Chairwoman Buerkle, Ranking 
Member Michaud. On behalf of the American Legion I would like 
to thank you for inviting us to testify this afternoon about 
the disturbing findings of the recent GAO report on sexual 
assaults and safety incidents within the VA health care system. 
By now everyone has heard in detail the horrifying implications 
of this report, so there is little need to recite the litany of 
grievances. Suffice it to say this is quite simply 
unacceptable.
    We cannot ask veterans, men or women, to go to health care 
system for treatment if they must fear their own physical 
integrity. This state of affairs must end, and it must end now.
    How can we ask VA to clean up its shop if it doesn't even 
know how to define the problem? The report states that there is 
no clear guidance within VA to even define these incidents, let 
alone standard operating procedures for screening for problems 
or reporting them as they arise. If you can't even define the 
problem, how can we hope to fix it?
    H.R. 2074, the ``Veterans Sexual Assault Prevention Act,'' 
directs VA to define terms and policies and to accept 
accountability with mandatory reporting. The American Legion 
applauds and fully supports this legislation as a first step 
toward fixing the problem. But let's not allow this to be 
another opportunity to add high-level bureaucrats to the system 
and further exacerbate the problems of a top-heavy operational 
model.
    This problem doesn't require a battalion of senior 
executives; it requires VA authorizing the employees they have 
to take charge and manage this on a local level, but with 
consistency. It requires VA to implement clear accountability 
goals for the people already in place. Every medical facility 
is required to have a military sexual trauma coordinator; yet 
in most facilities, this is not even a full-time job. More 
often it is an afterthought, additional duties assigned to an 
employee with other obligations elsewhere.
    The American Legion recommends elevating this position to a 
full-time employee whose duties are fully focused on dealing 
with the effects of sexual trauma, whether they occurred in 
service or at any time. Let these employees, already dedicated 
at least in part to helping these victims, become the front-
line soldiers in this battle.
    It has often been said of VA facilities in general, if you 
have seen one VA medical center, you have seen one VA medical 
center. Consistency is what has to count; even enforcement of 
standards.
    The American Legion urges Congress to continue their 
oversight of VA to ensure consistency becomes a standard. 
Through the Legion's own System Worth Saving visits, we strive 
to document and hopefully improve this consistency. Yet the 
addition of outside eyes is always helpful. Try as we might, we 
cannot remove the horror that comes from hearing of these 
experiences, nor should we. Indeed, only by facing the 
difficult truth can we hope to overcome them. This is not 
something to shy away from, this must be confronted head on.
    It is important to remember, however, that while the path 
beyond this crisis is arduous, it is not terribly complicated. 
Provide clear definitions and policies so all who come to VA, 
whether patient or employee, know exactly what will not be 
tolerated and how to proceed when the unthinkable happens. 
Commit to the seriousness of this topic by upgrading the part-
time military sexual trauma coordinator to a full-time job that 
reflects the importance of its role as a front-line defender of 
these veterans. Be consistent and clear in the implementation 
of these policies.
    The American Legion again thanks this Committee for 
including us in this discussion, and we are happy, of course, 
to answer any questions the Subcommittee may have.
    [The prepared statement of Ms. Jones appears on p. 58.]
    Ms. Buerkle. Thank you, Ms. Jones.
    Ms. Ilem, you may proceed. Thank you.

                    STATEMENT OF JOY J. ILEM

    Ms. Ilem. Thank you, Chairwoman Buerkle, Ranking Member 
Michaud and Members of the Subcommittee. On behalf of the 
Disabled American Veterans, we appreciate being invited to 
present our views on GAO's report on the actions needed to 
prevent sexual assaults and other safety issues in VA health 
care facilities.
    The deficiencies identified by GAO have uncovered VHA's 
lack of any consistent or systematic approach to documenting, 
reporting, and preventing sexual assaults from occurring in its 
facilities.
    Given the findings of the report, it is clear VA must 
revise and strengthen its safety policies to ensure the 
environment of care at the VA health facilities keeps veterans, 
staff, and visitors safe from harm.
    As recommended by GAO, VA should establish a comprehensive, 
consistent approach to documenting, investigating, and 
reporting sexual assaults as serious crimes of personal 
violence.
    Madam Chairwoman, we noted a statement in the report 
indicating that many of these matters were brought to 
leadership's attention and that in early 2011, efforts were 
said to be underway to correct these problems. However, 
according to GAO in mid-June, today it does not appear that 
substantive systemwide changes have been made or instituted. We 
see this delay not as a deficiency of program management, but a 
failure of VA leadership.
    Sexual assault is not solely a woman's issue, and likewise 
it is not a health care issue per se. Nevertheless, VHA has 
assigned the Director of its Women's Health Program Office to 
be a significant leader in the task force VA created to address 
it. While we have faith that this office will work hard in an 
effort to correct these problems and will do so in a 
responsible manner, we believe the accountability for this 
problem and for these changes and improvements rests much 
higher in the organization. Given the serious nature of these 
issues, it is troublesome that once VA was informed of these 
incidents that no action, it appears, was immediately taken to 
institute a comprehensive plan or solution.
    GAO noted in its analysis that VA was experiencing 
significant demographic changes in its health care programs. We 
agree VA patients are trending younger, with a more visible 
female presence. These shifts and pressures produce stresses 
that VA has not previously or recently experienced and may be 
contributing to the culture of safety challenges that GAO has 
uncovered.
    We see in the current report, in relationship to the 
residential program sites visited, that only one of the three 
compensated work-therapy programs evaluated accepted women into 
the program due to safety and privacy concerns. These safety 
concerns continue to negatively impact women veterans. In 
essence, they are denied access to these highly specialized 
services because VA is not confident that they can provide a 
safe environment for these women.
    Likewise, GAO notes that several clinicians they 
interviewed for a previous report on women's health services in 
VA expressed concern for the safety of women veterans placed in 
VA inpatient mental health programs.
    These types of concerns highlight the potential for further 
assaults unless corrective action is taken. Among the security 
precautions that must be in place for residential programs are 
secure accommodations for women veterans, with periodic 
assessments of facility safety and security issues. We have 
brought this issue to the attention of the Subcommittee in 
previous hearings and hope you will consider oversight to 
ensure as VA moves forward to improve their overall culture of 
safety in VA facilities, that it specifically addresses these 
safety issues related to the care of women veterans. 
Additionally, VA must establish a risk assessment tool to 
ensure the safety of all VA patients.
    While acknowledging its findings could not be generalized 
to VA as a whole, GAO outlined eight recommendations, we 
endorse these ideas and note that VA has concurred with each of 
them as well. We urge VA to move forward expeditiously to 
implement them and to provide regular reports to Congress on 
its progress.
    Madam Chairwoman, every veteran should be assured of the 
highest level of quality care and patient safety while 
receiving care in a VA facility. A veteran should never fear 
for his or her own personal safety.
    We are pleased that VA has taken action with the 
establishment of a multidisciplinary work group to define what 
actions need to be taken to prevent sexual assault and to 
respond appropriately to reports and allegations of sexual 
victimization of veterans or VA employees.
    In closing, we are hopeful that GAO's findings can serve VA 
and veterans in providing a roadmap to promote a new 
environment of care and safety, one that should be closely 
monitored by this Subcommittee as VA completes these changes.
    That completes my statement and I am happy to answer any 
questions that you or the Subcommittee Members may have.
    [The prepared statement of Ms. Ilem appears on p. 61.]
    Ms. Buerkle. Thank you, Ms. Ilem.
    Ms. Roll, you may proceed.

                   STATEMENT OF MARLENE ROLL

    Ms. Roll. Madam Chairwoman, Members of the Subcommittee, 
thank you for asking me here today. As a female veteran and an 
accredited service officer, I can tell you what the seriousness 
is of the GAO findings for all our veterans, but especially for 
our women veterans.
    To sit and talk to a woman who has been sexually assaulted, 
you see a person who is unsure of themselves and everyone 
around them. They are anxious and they may make little eye 
contact or no eye contact at all, but glance at the door every 
little while. I have witnessed them physically recoil at the 
sight of a man walking into a room. I have met with victims at 
neutral sites because of their reluctance to come to my office 
and use an elevator because of their fear that a man might 
enter that elevator.
    Anyone who has been sexually assaulted has had their life 
changed forever. That is unacceptable. The damage is often 
lifelong and ``trust'' is a word that they can no longer use. 
Our soldiers have volunteered to keep their country safe and 
they deserve nothing less when seeking treatment. The VA 
hospitals and clinics are there to help and heal our veterans, 
and trust is the very foundation of that service. That is why a 
zero tolerance has to be implemented and maintained.
    The GAO findings are disturbing, and now that we have the 
information, what will be done to ensure that ``trust'' and 
``safety'' are two words that we can use to describe the VA 
again?
    The VFW understands that protocols have been in place, but 
they are weak. We also believe that they need to be unified 
throughout the VA system, and to remove the ability at each 
management level to stop the upward reporting of these 
incidences because they have determined that the issue has been 
resolved. Reporting is how a problem is acknowledged and then 
resolved.
    Staff training with the emphasis on reporting at all levels 
needs to be enhanced and enforced. I know the VA does online 
PowerPoint presentations for their staff, but they cannot 
impress the importance of a topic like having a face-to-face 
class with an instructor, or the additional comments of other 
attendees. Definitions need to be clear so that there are no 
misunderstandings.
    Additionally, camera monitoring in all units, outpatient 
clinics, can help deter behavior as well as sustain 
allegations. I believe that the directors of each VISN and 
hospitals are in the best position to ensure all protocols are 
followed and to set the tone of safety and secure environment 
for all our veterans to seek treatment in.
    The VFW trusts VA will address these issues swiftly and the 
VA will continue to monitor their progress. This concludes my 
testimony and thank you.
    [The prepared statement of Ms. Roll appears on p. 63.]
    Ms. Buerkle. Thank you, Ms. Roll.
    Mr. Weidman, you may proceed.

                STATEMENT OF RICHARD F. WEIDMAN

    Mr. Weidman. Madam Chairwoman, thank you for including 
Vietnam Veterans of America in this hearing to take our 
comments. In our legislative agenda, it is typical that the 
number one legislative priority of an organization be a 
particular piece of law or a particular policy to change. But 
our number one priority for the 112th Congress is 
accountability. And that is really what is broken down here 
within the VA.
    The GAO report--you certainly are to be commended, you and 
Mr. Michaud, for having this hearing today. And Chairman Miller 
and Mr. Filner sure are to be commended for just focusing 
attention on it.
    Dr. Roe hit the nail on the head earlier when he said if, 
in fact, people take sexual assault seriously, they are much 
more likely to report it. And I think he is probably right, 
that we are only seeing the tip of the iceberg, and it is that 
taking of these heinous acts seriously by VA management that 
has been lacking throughout.
    This is not something that, if it was taken seriously by 
the hospital directors and the network directors, would have 
asked for a definition a long time ago, and apparently it has 
not been taken seriously. So it is something that the work 
group needs to--shouldn't waste too much time, and it should be 
able to come to the conclusion pretty quickly.
    The eight recommendations from GAO all seem pretty logical 
and pretty sensible. One of the things that GAO recommended, 
though, was nowhere in the VA response to the General 
Accountability Office, and that is to have stakeholder 
involvement at every step of the process. Stakeholders include 
employees who work on these wards and work various places in 
the hospital, but it also includes veterans. And there is not 
one single mention anywhere in the VA's response of including 
women veteran leaders and the veteran service organizations in 
finding the solutions. This is not because we are looking 
around for something to do, Madam Chairwoman, but because we 
bring something to the table. And certainly if I can't bring 
it, my three distinguished colleagues to my right certainly 
bring experiences that need to be taken into account as they 
set forth to modify facilities, physical facilities, and as 
they put in place the training and the--policies first, and 
then training that will work at the local level.
    The old saw in the military is a unit does well that which 
a commander checks well. And the commander has not been 
checking this issue carefully, because it has not even been 
defined, much less reported properly.
    There was one VISN, which actually startled me, if you look 
through one of the tables that reported no sexual assaults over 
a 2\1/2\ year period. I wish to God that is true, but I don't 
believe it. I just think that it is so lax in that VISN that 
nothing was reported and pushed up the line.
    So the final recommendations that I would have to this 
Committee, Madam Chairwoman, is not for more statutes, but for 
more oversight hearings in association with your colleagues at 
the Oversight and Investigation Subcommittee and continued 
pressure and follow-up.
    One of the things that those of us who have been reading 
GAO reports for years and OIG reports for years is there is 
always a great flurry when the report comes out, and the press 
covers it and Members get excited about it--and genuinely so--
and are committed to seeing something done. But then it is not 
in the limelight and nothing happens, and nobody inside the VA 
follows up to find out did they in fact carry out that 
correction plan that VA management said they were going to do.
    And that is what I implore you, Madam Chair and Mr. 
Michaud, to make sure that this Subcommittee and this Committee 
as a whole follows up to keep the pressure on until this 
problem becomes resolved at each and every VHA facility 
nationwide.
    Thank you very much for the opportunity to share our views 
here this afternoon and thank you so much for having this 
hearing.
    [The prepared statement of Mr. Weidman appears on p. 65.]
    Ms. Buerkle. Thank you, Mr. Weidman.
    Thank you to all of our witnesses for their testimony 
today.
    I will now yield myself 5 minutes for questions. This 
question is for all four of you: Has the VA reached out to any 
one of your organizations or any other organizations that you 
might know of, to participate in this work group that we just 
heard about, previous to this hearing?
    Ms. Ilem. Not to the DAV.
    Ms. Jones. Not to the American Legion.
    Ms. Roll. Not to the VFW.
    Mr. Weidman. No, ma'am.
    Ms. Buerkle. Thank you.
    In the written testimony, the VA states that it currently 
uses both VA staff and physical infrastructure systems to 
ensure the security of VA facilities, for example: closed 
circuit cameras, locks, alarms, separate facilities, 
specialized training.
    Do you have any comment--and we can just go right down 
starting with Ms. Jones--do you have any comment on that 
approach?
    Ms. Jones. I think that approach would be great. Those 
closed circuit cameras would help them to be able to monitor 
the activities that are going on and hopefully deter that kind 
of activity from happening.
    You know, we recently did a national survey of women 
veterans in January. We had 3,012 respondents, and one of the 
questions was about security. And 25 percent of those women who 
answered our question about security indicated that they were 
uncomfortable, they didn't feel safe in a VA environment. So I 
think that the use of those security cameras would certainly 
help.
    Ms. Buerkle. Ms. Ilem.
    Ms. Ilem. I think we have heard of longstanding problems in 
VA with infrastructure issues related to women veterans. It has 
been an ongoing focus in the GAO reports over the years. And 
although I don't have specifics, I think even in this GAO 
report, it is pointed out about the concern, or in previous 
reports, that clinicians have concerns about putting a female 
veteran on an inpatient mental health unit. So that really 
gives me pause in terms of, you know, as being a veteran 
myself, among veterans, who uses the VA system, should I be 
hospitalized, I would surely hate to be worrying about those 
types of issues.
    I would like to know that all VA patients are safe and I 
don't feel that I should be isolated. I feel I should be safe 
in a VA facility and that the people that are charged for my 
care would be watching out and making sure all of those systems 
are in place to make sure a safe environment for any patient, 
especially women.
    Ms. Buerkle. Thank you. Ms. Roll.
    Ms. Roll. Well, while the cameras and other security issues 
would certainly deter, I still believe that the line defense is 
from our staff itself. They have to be the ones to stand up for 
the veterans and advocate for them that this will not be 
tolerated; and if anything does come down and does present 
itself, that it is dealt with swiftly and they know about it, 
that the veterans themselves know that it was taken care of and 
it has been addressed and that they are being looked after. I 
think that is their main issue. They just want to know that 
while they are there, they have eyes that have their back.
    Ms. Buerkle. Mr. Weidman.
    Mr. Weidman. I would associate myself with the remarks of 
my three colleagues in that it is much more a question of 
corporate culture than anything else. You can have all the 
bells and whistles and all the fancy equipment you want, but if 
you don't monitor the monitors, if you will, and if you don't 
have swift and sure action when something untoward happens, 
then you don't have a corporate culture where people feel safe, 
one; and two, where miscreants know that if they step out of 
line, that justice will be swift and sure. And that is much 
more important than anything else.
    And it is really when you think about it, particularly the 
veteran-on-veteran violence that is done is the ultimate 
betrayal. We have a saying in Vietnam Veterans of America that 
is their founding principle, which is, ``Never again shall one 
generation of American veterans abandon another.'' And we have 
boiled that down into a button that just says, ``Leave no 
veteran behind.''
    And to perpetrate a sexual assault upon someone else who 
has pledged their life in defense of the Constitution is really 
the ultimate betrayal. And it is something that needs to be 
hammered home and it is something that needs to be taken 
seriously by VA management at every level, and it will permeate 
down. But it is not a question of bells and whistles, it is a 
question of organizing things and holding the senior people at 
each facility accountable for clear guidelines on how do you 
keep people safe.
    Ms. Buerkle. Thank you very much. I now yield 5 minutes to 
the Ranking Member, Mr. Michaud.
    Mr. Michaud. Thank you very much, Madam Chair. Mr. Weidman, 
my question to you--because if I understood correctly Ms. 
Jones, Ms. Ilem, Ms. Roll, they all agreed that the VA should 
have a standardized policy throughout the VA system rather than 
leaving it up to each individual to determine what policies and 
what definitions are.
    I am not sure about VVA. Do you believe that there should 
be a standardized definition in policy throughout the VA 
system?
    Mr. Weidman. I do, sir. And the only thing that I regret, 
which is that working group doesn't include one of the two most 
important groups, and that is--in fact, it doesn't include the 
other one either--there is no union representation on that of 
the Nurses Association. They are not represented either, and 
neither are women veterans.
    Mr. Michaud. My next question gets back to actually what 
Dr. Roe was mentioning earlier, is jurisdiction issues. So if 
the VA does adopt a standardized policy nationwide on how to 
deal with reporting and what the definition is, that definitely 
could conflict with actually what State laws in different 
States are. So I can see that that could cause a problem for a 
VISN director.
    My next question, actually for all organizations: Do you 
feel that if we have a standardized system and definitions for 
rape and sexual assault, that that should be dealt with in 
Federal court versus State court? And I will start with Ms. 
Jones and work on down.
    Ms. Jones. My feeling is that it should be dealt with in 
Federal court. On a Federal facility, it is the VA, and it 
should be standardized so there are no questions, no room for 
leeway, you know, for each State. I think it should be 
standardized across the board. If it happens it should be dealt 
with in Federal court in a systematic manner.
    Ms. Ilem. I don't know that I can provide a response to 
that, just not knowing enough to feel that I have the 
expertise. But certainly let me provide something to the 
Committee for a response on that from our organization.
    [Ms. Ilem subsequently provided the following information:]

          Ranking Member Michaud, Disabled American Veterans (DAV) does 
        not have a national resolution from our membership that deals 
        with the specific issue of courts of jurisdiction in the case 
        of rape or other sexual assaults that may occur on Department 
        of Veterans Affairs (VA) property. Therefore, we can take no 
        formal position on the matter. Nevertheless, we believe that 
        any sexual assault, of a veteran or non-veteran, on VA grounds, 
        should be reported to proper legal authorities and receive 
        justice through the courts. Additionally, veterans should have 
        access to treatment to assuage the effects of this violent and 
        highly personal crime.
          On the specific question of jurisdiction, we suggest this 
        matter be reviewed either by the VA General Counsel or by the 
        Attorney General, either of which is in better position than 
        DAV to advise you and the Subcommittee on this matter.

    Ms. Roll. I, too, do not come from a background that I can 
speak intelligently to that, so if I could also bring that back 
to the Committee.
    [Ms. Roll subsequently provided the following information:]

          In a perfect world, yes, the VFW would like to see a 
        standardized system and definitions and that all crimes should 
        be heard in Federal courts, seeing that most Veterans Affairs 
        property is federally owned. However, many properties are 
        leased or shared. In cases when the Federal Government has sole 
        ownership of property, they have exclusive jurisdiction, unless 
        law enforcement is shared between the Federal Government and a 
        State or local government. In these cases, the jurisdiction 
        becomes concurrent legislative. Title 38 U.S.C., Section 902, 
        allows VA to enter into agreements with other law enforcement 
        agencies, making these properties concurrent legislative 
        jurisdiction.
          The question VFW has is why does VA have this authority? Is 
        it because there are so many leased properties or properties 
        that are shared with private or public institutions that would 
        cause them to be in fact concurrent legislative jurisdictions, 
        making the jurisdiction shared? If this is true, to insist that 
        all crimes in VA facilities be investigated and tried in 
        Federal court may violate the 4th Amendment ``Property 
        Clause.'' VFW does not have expertise in property ownership or 
        law enforcement jurisdiction, but these are things to consider.
          Also, if the property is remote and it is not economically 
        feasible to employ a full criminal investigative team, then 
        perhaps allowing concurrent legislative jurisdiction might be 
        the only solution to quickly and accurately investigate a 
        crime.
          There is no doubt there need to be a very clear, linear 
        process to investigating and prosecuting crimes that occur in 
        VA facilities. These guidelines must be developed, taught to VA 
        law enforcement personnel, and followed. There may need to be 
        multiple guidelines, depending on the jurisdiction(s) of the 
        facility. At the end of the day, a quality investigation and 
        prosecution rests on two things: (a) the resources to conduct 
        the investigation, and (b) the reliability of the investigators 
        to do a thorough investigation.
          The VFW suggests that to ensure that victims of crimes have 
        due process and a quality investigation, that VA produce clear 
        procedural regulations for each jurisdictional scenario and 
        insist on training to those regulations.

    Mr. Weidman. I think, perhaps fool-heartedly, I will go 
ahead and give you an answer. But, you know, this is really 
part of taking this issue seriously. What the gentleman from 
the OIG's office didn't come out and clearly say is that the 
U.S. attorneys don't want to prosecute this. They consider it a 
minor crime. This is not a minor crime. This is a major crime 
and it is--against any citizen--but it is made all the more 
heinous because it was committed against an individual who put 
their life and limb on the line in defense of the Constitution 
and of their country. So part of taking it seriously is perhaps 
this Committee working closely with the Judiciary Committee, 
and make sure that our Federal court system starts to take rape 
and sexual assault seriously.
    Mr. Michaud. And like some of you, I am not an expert in 
this area either and it brings back the situation where deadly 
force was used, and there was a memorandum of understanding. 
Actually, the State took jurisdiction to investigate whether 
deadly force was justified. So I can see a problem if we do 
have a standardized definition systemwide, that actually the 
enforcement piece could be different; because whether it is 
State versus Federal so I don't know if that is something that 
we actually could and should do and work with the Judiciary 
Committee to make sure that there is some type of consistency 
there as well.
    My last question actually is for the Legion. You mentioned 
that 25 percent of female veterans do not feel secure. If there 
is any specific one issue that we should deal with, what should 
that be? I know you talked about cameras, the security issue, 
but is there any specific issue that we should focus on?
    Ms. Jones. Well, the question we asked was about security. 
In this particular survey, we just talked to them about 
physical security and information security. I do not have the 
breakdown with me about physical security or information 
security. I will get back to you with the information.
    Dissatisfaction levels of over 25 percent for this 
attribute, which was for security, suggested there is 
considerable room for improvement in security-related issues 
for the VA to include physical security and a degree of 
sensitivity around the patient's personal information. So I 
will get back with you with a breakdown of those who felt the 
most need of physical security.
    [Ms. Jones subsequently provided the following 
information:]
    Mr. Michaud. Thank you very much. And thank you very much, 
Madam Chairwoman, and look forward to working with you to move 
this issue forward to the forefront, and hopefully we will be 
able to keep a close eye on it as well. Thank you.
    Ms. Buerkle. And I thank the Ranking Member. Thank you very 
much.
    Mr. Weidman. Madam Chair, may I comment? Mr. Michaud 
referred to an incident that I am familiar with. And that is a 
perfect case about why it should be under Federal control. 
There were four different local and State law enforcement 
officials involved in that incident, and that veteran did not 
have to die. If the VA police had been in charge and well-
trained in how to deal with him, he only had a .22 and he never 
discharged his weapon and yet he was shot several times. I 
think it was like nine times.
    It didn't have to happen. And it was only because there 
wasn't a clear policy and a clear Federal mandate that this be 
handled internally by the VA because it occurred on Federal 
property. And I think the same thing is true of sexual assault 
and other crimes on VA property, because it is Federal 
property. If you get a whole pastiche of local law enforcement 
officials, you are going to have the kind of miscommunication 
that is going to lead to veterans needlessly dying.
    Ms. Buerkle. Thank you, Mr. Weidman.
    I now yield 5 minutes to the gentleman from Michigan, Dr. 
Benishek.
    Mr. Benishek. I would like to thank all of you for coming. 
It has been very educational for me. I don't really have any 
more questions. I just want to comment that I am so thankful 
that you guys are involved, and that we just hope that we can 
get the VA to cooperate with the veteran service organizations 
to develop a plan to stop this. So I am all behind that.
    And with that I yield back my time.
    Ms. Buerkle. Thank you, Dr. Benishek. Are there any further 
questions from the Committee?
    Thank you to our second panel for sharing your time and 
your expertise with us this afternoon, and you are now all 
excused. Thank you.
    I ask unanimous consent that all Members have 5 legislative 
days to revise and extend their remarks and include any 
extraneous materials. Without objection, so ordered.
    Ms. Buerkle. Thank you once again to all of our witnesses 
and to our members in the audience for joining today's 
extremely difficult but very necessary conversation. We will 
hold the VA leadership accountable at the highest level and we 
will work to ensure justice is served for our veterans, our 
heroes, who have served our Nation across the country. The 
hearing now is adjourned.
    [Whereupon, at 5:47 p.m., the Subcommittee was adjourned.]



                            A P P E N D I X

                              ----------                              

     Prepared Statement of the Hon. Ann Marie Buerkle, Chairwoman, 
                         Subcommittee on Health
    Good afternoon, this hearing will come to order.
    Today, the VA's Subcommittee on Health will address a very serious 
issue: the vulnerability and underreporting of sexual assault and other 
safety incidents at VA residential and inpatient psychiatric treatment 
facilities.
    As a registered nurse and domestic violence counselor, I have seen 
firsthand the pervasive and damaging effects sexual assault can have on 
the lives of those who experience it.
    Last week, the Government Accountability Office (GAO) released a 
deeply troubling report entitled ``VA Health Care: Actions Needed to 
Prevent Sexual Assaults and Other Safety Incidents. ``GAO found that 
between January 2007 and July 2010, nearly 300 sexual assault 
incidents, including 67 alleged rapes, were reported to VA police. Many 
of these alleged crimes were not reported to VA leadership officials or 
the VA Office of the Inspector General, in direct violation of VA 
policy and Federal regulations.
    The findings of the GAO are disturbing for many reasons. Foremost, 
they represent a betrayal of trust by a system that was designed to 
treat our veterans at their most vulnerable time.
    The gross failure of VA leadership to protect the safety and 
security of our veterans and VA staff and systematically report and 
respond to sexual assault and safety incidents is a contempt of 
justice. It also requires immediate action. This is not the way to run 
a health care system and it is certainly no way to treat the men and 
women who sacrificed so much on our Nation's behalf.
    Abuse like the kind GAO references in their report is repugnant and 
inexcusable in any corner of our society. But for it to occur in what 
should be an environment of healing for our wounded warriors is an 
affront to VA's very mission.
    So disturbed was I upon reading an early draft of GAO's report, 
that I--along with Chairman Miller--introduced legislation to ensure a 
safer and more secure VA medical facilities. Our bill, H.R. 2074, the 
Veterans Sexual Assault Prevention Act, would address the Department's 
safety vulnerabilities, security problems, and oversight failures and 
create a fundamentally safer environment for our veterans and VA 
employees.
    Never should a warrior in need take the brave step of getting help 
and be met with anything less than safe, supportive, and high quality 
care in an atmosphere of hope, health, and healing.
    Let me assure each of you, that I and the other Members of this 
Committee will remain committed to righting the many wrongs uncovered 
by the GAO.

                                 
   Prepared Statement of Hon. Michael H. Michaud, Ranking Democratic 
                     Member, Subcommittee on Health
    Good morning. I would like to thank everyone for attending this 
important hearing today.
    The purpose of today's hearing is to examine how changes in patient 
demographics present unique challenges for VA in providing safe 
environments for all veterans treated in VA facilities.
    In 2008, I requested that GAO report on women veterans' services, 
such as research on the unique physical and mental health treatment 
needs of female veterans, how VA is addressing the needs of women 
veterans, what health care services offered by VA are tailored to women 
veterans, and what barriers may prevent female veterans from accessing 
VA health care services.
    In July 2009, this Subcommittee held a hearing on the findings of 
the report. During the conduct of this report, GAO was made aware of 
safety issues involving women veterans and sexual assault in some VA 
facilities.
    Subsequent to that report, then Full Committee Chairman, Mr. 
Filner, submitted a request for GAO to look further into sexual assault 
incidents.
    We know that the wars in Afghanistan and Iraq have seen the 
unprecedented call up of the National Guard and Reserve components.
    Today, women serve in the Guard and Reserve at a rate of over 17 
percent which is 3 percent higher than that of the active duty 
military.
    VA recently reported that within 10 years, women are expected to 
become 10 percent of VA's patient population.
    However, the VA health care system was built to accommodate the war 
related illnesses and injuries of male veterans.
    As women are serving in combat conditions alongside their male 
counterparts, it is important that the Department embrace and recognize 
the needs of all veterans, both men and women alike.
    In the 110th and 111th Congresses, this Committee held a series of 
hearings to examine the needs of women veterans.
    The veterans who testified shared stories of feeling unwelcomed, 
alienated, and disrespected in some VA medical centers so that they are 
now reluctant to pursue the benefits and services that they have earned 
with their service to our country.
    Women veterans should not have to worry about being subject to 
``cat calls'' upon entering a facility, and they certainly should not 
have to worry about falling victim to sexual assault while receiving 
care.
    While sexual assault is often considered an issue only affecting 
women, in fact, both men and women suffer sexual assaults.
    Further, victims may be assaulted by perpetrators of the same or of 
the opposite sex.
    Like other types of trauma, sexual trauma can leave lasting scars 
upon the physical and mental health of its victims.
    As Government Accountability Office (GAO) has recently uncovered, 
many of the nearly 300 sexual assault incidents reported to the VA 
police since 2007 were not reported to VA leadership.
    Incidents like these simply need not happen.
    When policies and procedures are not in place--or worse-- not 
followed, we fall far short of our national commitment to provide the 
utmost level of care possible.
    Thank you to our panelists for appearing today.
    I am committed to working with you to ensure that safeguards are in 
place so that no veteran, male or female, falls victim to sexual 
assault while under VA care.
    Madam Chair, I yield back.
                                 
           Prepared Statement of Hon. Jeff Miller, Chairman,
                     Committee on Veterans' Affairs
    Thank you Madam Chairwoman for having me here today at this very 
important hearing. Upon reading GAO's draft report, I was sickened by 
its findings--the prevalence of sexual assault incidents at VA 
facilities, the lack of accountability from VA leadership and the lack 
of safeguards in place for these victims.
    As a co-requester of the GAO investigation (with Ranking Member 
Filner), I immediately contacted Secretary Shinseki and urged him to 
provide an immediate official response to GAO so the report could be 
made public and we could hold this hearing today. I thank the Secretary 
for complying with my request.
    These findings are intolerable, so Ms. Buerkle and I decided to act 
immediately by introducing H.R. 2074--the Veteran Sexual Assault 
Prevention Act. We intend to move this legislation expeditiously so 
that veterans are not undermined by the very system which is supposed 
to protect them.
    In the past week, some have dismissed these allegations, comparing 
the size of the VA system and the number of allegations, to the private 
sector. Let me be very clear on this point--there is no comparison. 
Just one assault of this nature, one sexual predator, or one veteran's 
rights being violated within the VA is one too many and is absolutely 
unacceptable. If we need to do more to protect our veterans and VA 
employees, we will.
    Rape, in particular, has always been a hard charge to prosecute. 
And though we have made strides in getting victims to speak out, we 
know that for every rape that is reported, that many more are not. 
Therefore, we need to know how many victims have not spoken out and how 
we can reach to them so that not only is justice done, but that we can 
provide them with the proper care and support. Today, we expect to get 
answers to the followings questions:

      How widespread are assaults at VA facilities, because as 
found by GAO the lack of protocols at VA are not conducive to reporting 
sexual assault?
      How many cases have been prosecuted? How many are still 
pending?
      How many employees who allegedly perpetrated assaults are 
still working in VA?
      What has been done to protect patients from fellow 
patients?
      What is VA doing to ensure this never happens again in 
the future?

    The safety and security of our veterans is paramount. We demand 
these answers so to assure fellow veterans and the public that VA 
facilities are safe havens for veterans, VA employees are safe, and no 
one's rights are violated.
    Again, thank you for the time, Madam Chairwoman. I yield back.

                                 
  Prepared Statement of Randall B. Williamson, Director, Health Care,
                 U.S. Government Accountability Office
   VA Health Care: Improvements Needed for Monitoring and Preventing 
               Sexual Assaults and Other Safety Incidents
                             GAO Highlights
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 Recommends
    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.
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. (See table below.) 
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.

 Weaknesses in Physical Security Precautions in Residential Programs and
     Inpatient Mental Health Units at Selected VA Medical Facilities
------------------------------------------------------------------------
                                                    Staff awareness and
 Monitoring precautions    Security precautions        preparedness
                                                        precautions
------------------------------------------------------------------------
 Inadequate       Alarm            VA police
 monitoring of closed-    malfunctions of          staffing and workload
 circuit surveillance     stationary, computer-    challenges
 cameras                  based, and personal      Lack of
                          panic alarms             stakeholder
                          Inadequate       involvement in unit
                          documentation or         redesign efforts
                          review of alarm
                          testing
                          Failure of
                          alarms to alert both
                          unit staff and VA
                          police
                          Limited use of
                          personal panic alarms
------------------------------------------------------------------------
Source: GAO.

                               __________
    Chairwoman Buerkle, Ranking Member Michaud, and Members of the 
Subcommittee:
    I am pleased to be here today as the Subcommittee discusses 
policies and actions to prevent sexual assaults and other safety 
incidents at Department of Veterans Affairs (VA) medical facilities. 
During our recent work on services available for women veterans in VA 
medical facilities, several clinicians expressed concern about the 
safety of women veterans housed in mental health programs at a VA 
medical facility's residential mental health unit that also housed 
veterans who had committed past sexual crimes.\1\ Clinicians were also 
concerned about the adequacy of existing safety precautions to protect 
women veterans being treated in the inpatient mental health units of 
this same facility. These concerns highlight the importance of VA 
having effective security precautions to protect all patients--
especially those with residential and inpatient mental health 
programs--and a consistent way to exchange information about and 
discuss safety incidents, including sexual assaults. \2, 3\
---------------------------------------------------------------------------
    \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, 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.
---------------------------------------------------------------------------
    My testimony today is based on our June 7, 2011 report: \4\ (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) the precautions 
in place in residential and inpatient mental health settings to prevent 
sexual assault and other safety incidents and any weaknesses in these 
precautions.
---------------------------------------------------------------------------
    \4\ See GAO, VA Health Care: Actions Needed To Prevent Sexual 
Assaults and Other Safety Incidents, GAO-11-530 (Washington, D.C.: June 
7, 2011).
---------------------------------------------------------------------------
    To examine the volume of sexual assault incidents reported to VA 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 regarding the 
reporting of safety incidents.\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) and VHA's Office of the Deputy Under Secretary for 
Health for Operations and Management and Office of the Principal Deputy 
Under Secretary for Health.\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.\7\ During the site visits, we interviewed VA 
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 VA medical facilities to discuss their 
expectations, policies, and procedures for reporting sexual assault 
incidents.\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. Further, 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, 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.\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.
---------------------------------------------------------------------------
    \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.
    \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.
---------------------------------------------------------------------------
    To examine the precautions in place to prevent sexual assault 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 VA 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.
    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 Central Office has responsibility for monitoring and overseeing 
both VISN and medical facility operations, including security 
precautions.\10\ Day-to-day management of medical facilities, including 
residential and mental health treatment units, is the responsibility of 
the VISNs.
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    \10\ VHA oversees VA's health care system, which includes 153 
medical facilities organized into 21 VISNs.
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Residential Programs
    VA has 237 residential programs at 104 of its medical facilities. 
These programs provide residential rehabilitative and clinical care to 
veterans with a range of mental health conditions, including those 
diagnosed with post-traumatic stress disorder and substance abuse. 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.
      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.\11\

    \11\ 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.
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Inpatient Mental Health Units
    Most (111) of VA's 153 medical facilities have at least one 
inpatient mental health unit for patients with acute mental health 
needs. These units are generally a locked unit or floor within each 
medical facility, and the size of these units varies throughout VA. 
Care on these units is provided 24 hours per day, 7 days a week, and 
consists of 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.
VA's Two Reporting Streams for Safety Incidents
    Safety incidents, including sexual assaults, may be reported to 
senior leadership as part of two different streams--a management stream 
and a law enforcement stream. The management reporting stream--which 
includes reporting responsibilities at the VA medical facility, VISN, 
and VHA Central Office levels--is intended to help ensure that 
incidents are identified and documented for leadership's attention. In 
contrast, the purpose of the law enforcement stream is to document 
incidents that may involve criminal acts so they can be investigated 
and prosecuted, if appropriate. VHA policies outline what information 
staff must report for each stream 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. (Fig. 1 summarizes the 
major steps involved in each stream.)





    Management reporting stream. Reporting responsibilities at each 
level for this stream are as follows.

      Local VA medical facilities. Local incident reporting is 
typically handled through a variety of electronic facility-based 
systems. It is initiated by the first staff member who observed or was 
notified of an incident, who completes an incident report in the 
medical facility's electronic reporting system that is then reviewed by 
the medical facility's quality manager. VA medical facility leadership 
is then notified, and is responsible for reporting serious incidents to 
the VISN.
      VISNs. VA medical facilities can report serious incidents 
to their VISN through two mechanisms--issue briefs that document 
specific factual information and ``heads up'' messages that allow 
medical facility 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. VISNs typically report all serious 
incidents to the VHA Office of the Deputy Under Secretary for Health 
for Operations and Management, which 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. Responsibilities at each level 
are described below.

      Local VA police. Most VA medical facilities have a cadre 
of VA police officers, who are Federal law enforcement officers charged 
with protecting the medical facility by responding to and investigating 
potentially criminal activities. Local policies typically require 
medical facility staff to notify the medical facility's VA police of 
incidents that may involve criminal acts, such as sexual assaults. VA 
medical facility police also often notify and coordinate with local 
area police departments and the VA OIG when criminal activities or 
potential security threats occur.
      VA's OSLE. 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. VA OSLE 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 Integrated Operations Center (IOC). The IOC, 
established in April 2010, serves as the department's centralized 
location for integrated planning and data analysis on serious 
incidents.\12\ Serious incidents on VA property 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. The IOC then 
presents information on serious incidents to VA senior leadership 
officials through daily reports and, in some cases, to the Secretary 
through serious incident reports.
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    \12\ 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).
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      VA OIG. Federal regulation requires that all potential 
felonies, including rape allegations, be reported to VA OIG 
investigators.\13\ VHA policy reiterates this 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.\14\ Typically, either 
the medical facility's leadership team or VA police are responsible for 
reporting potential felonies to the VA OIG.\15\ Once a case is 
reported, VA OIG investigators can be the lead agency on the case or 
advise local VA police or other law enforcement agencies conducting the 
investigation.
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    \13\ See 38 CFR Sec. 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 CFR Sec. 1.201 
(2010).
    \14\ VHA Directive 2010-014, Assessment and Management of Veterans 
Who Have Been Victims of Alleged Acute Sexual Assault (May 25, 2010).
    \15\ The VA OIG may also learn of incidents from staff, patients, 
congressional communications, or the VA OIG hotline for reporting 
fraud, waste, and abuse.
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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.
Nearly 300 Sexual Assault Incidents Reported to VA Police From January 
        2007 Through July 2010
    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. \16,17\ These cases included incidents 
alleging rape, inappropriate touching, forceful medical examinations, 
oral sex, and other types of sexual assaults (see table 1).\18\ 
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.\19\
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    \16\ 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.
    \17\ 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.
    \18\ To conduct this analysis, we placed VA police case files into 
these categories to describe the allegations contained within them.
    \19\ 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.

Table 1: Number of Sexual Assault Incidents by Category Reported to VA Police by Year, January 2007 through July
                                                      2010
----------------------------------------------------------------------------------------------------------------
                                                                 Forceful       Forced or
               Year                  Rape \a\   Inappropriate     medical     inappropriate   Other \c\   Total
                                                  touch \b\     examination     oral sex
----------------------------------------------------------------------------------------------------------------
2010 \d\                               14             44             3              5             0         66
----------------------------------------------------------------------------------------------------------------
2009                                   23             66             3              3             9        104
----------------------------------------------------------------------------------------------------------------
2008 \e\                               13             42             1              3             1         60
----------------------------------------------------------------------------------------------------------------
2007 \e, f\                            17             33             1              2             1         54
----------------------------------------------------------------------------------------------------------------
Total \g\                              67            185             8             13            11        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.

    In analyzing these 284 cases, we observed the following:

      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.\20\
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    \20\ 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.
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      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.
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. 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 examined 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.\21\ Moreover, we also found that one VISN 
did not report any of the cases they received to VHA Central Office. 
(See table 2.)
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    \21\ 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.

  Table 2: Sexual Assault Incidents Reported to Four Selected VISNs and VHA Central Office Leadership, January
                                             2007 through July 2010
----------------------------------------------------------------------------------------------------------------
                                                                                               Total number of
                                           Total number of sexual   Total number of sexual     sexual assault
                                             assault incidents        assault incidents      incidents reported
                  VISN                     reported to VA police       reported to VISN        by VISNs to VHA
                                             from VISN medical        leadership by VISN       Central Office
                                             facilities \a, b\        medical facilities         leadership
----------------------------------------------------------------------------------------------------------------
VISN A                                               13                        0                      0
----------------------------------------------------------------------------------------------------------------
VISN B                                               21                       10                      5
----------------------------------------------------------------------------------------------------------------
VISN C                                               34                        4                      4
----------------------------------------------------------------------------------------------------------------
VISN D                                               34                        2                      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 systemwide requirements on what medical facilities must report to these VISNs, we
  could not determine the accuracy of VISN reporting.

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 the 67 rape allegations reported to the VA police from January 
2007 through July 2010 and compared these cases with 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.\22\ The remaining 25 had matching VA OIG 
investigation documentation, indicating that they were correctly 
reported to both the VA police and the VA OIG.
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    \22\ 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.
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    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.\23\ 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. \24,25\ 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.
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    \23\ See 38 CFR Sec. 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.
    \24\ 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. Sec. 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. 
Sec. Sec. 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.
    \25\ 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. 
Sec. Sec. 2241 and 2242. These two offenses are felonies under Federal 
statute; therefore, all rapes that meet our definition are felonies.
---------------------------------------------------------------------------
    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 about one-third (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.\26\ For the 
remaining approximately 12 percent, 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.
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    \26\ 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 9.
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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 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 there is 
no VHA-wide definition of sexual assault used for incident reporting. 
We found that VHA lacks a consistent definition for the reporting of 
sexual assault 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. At the VISN level, officials with whom 
we spoke in the four networks said they did not have definitions of 
sexual assault in VISN policies.\27\ Finally, while 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, no definition of sexual assault is 
included in VHA Central Office reporting guidance.
---------------------------------------------------------------------------
    \27\ However, some VISN officials stated they used other common 
definitions, including those from the National Center for Victims of 
Crime and The Joint Commission.
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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.
      VISNs. Officials from the four VISNs we reviewed 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.\28\ 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.\29\
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    \28\ 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.
    \29\ 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 condition. In addition, at this 
same medical facility, 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.
Oversight Deficiencies at VHA Central Office Contribute to the 
        Underreporting of Sexual Assault Incidents
    We found weaknesses both in the way sexual assault incidents are 
communicated to VHA Central Office and in the way that information 
about such incidents is collected and analyzed for oversight purposes.
Poor Communication About Sexual Assault Incidents Resulted in 
        Incomplete Reporting Within VHA Central Office
    Currently, VHA Central Office relies primarily on e-mail messages 
to transfer information about sexual assault incidents among its 
offices and staff. (See fig. 2.) Under this system, VHA Central Office 
is notified of sexual assault incidents through issue briefs submitted 
by VISNs via e-mail to the VHA Office of the Deputy Under Secretary for 
Health for Operations and Management.\30\ 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.
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    \30\ 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.





    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.\31\ 
Without the regular exchange of information regarding 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.
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    \31\ See GAO, Internal Control: Standards for Internal Control in 
the Federal Government, 
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.
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    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 underway 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.
VHA Does Not Systematically Monitor and Track Sexual Assault Incidents
    In addition to deficiencies in information sharing, we also 
identified deficiencies in the monitoring of sexual assault incidents 
within 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 collect 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.\32\ 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 sexual assaults and other safety incidents, VHA Central 
Office cannot identify and make changes to serious problems that 
jeopardize the safety of veterans in their medical facilities.
---------------------------------------------------------------------------
    \32\ See 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.
---------------------------------------------------------------------------
Serious Weaknesses Observed in Several Types of Physical Security 
        Precautions Used in Selected Medical Facilities
    Physical precautions in the residential programs and inpatient 
mental health units at the 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, we found 
serious deficiencies in the use and implementation of certain physical 
security precautions at these facilities, including alarm system 
malfunctions and inadequate monitoring of security cameras.
Several Types of Physical Security Precautions Are in Place in Selected 
        Medical Facilities
    VA medical facilities we visited used 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 their 
own needs within broad VA guidelines.
    In general, physical security precautions were used as a measure to 
prevent a broad range of safety incidents, including sexual assaults. 
We classified these precautions into three broad categories: monitoring 
precautions, security precautions, and staff awareness and preparedness 
precautions. (See table 3.)

   Table 3: Physical Security Precautions in Residential Programs and
     Inpatient Mental Health Units at Selected VA Medical Facilities
------------------------------------------------------------------------
                                                    Staff awareness and
 Monitoring precautions    Security precautions        preparedness
                                                        precautions
------------------------------------------------------------------------
 Closed-circuit   Locks and        Staff
 surveillance camera      alarms at entrance and   training
 use and monitoring       exit access points       VA police
 Unit rounds by   Locks and        presence on units
 VA staff                 alarms for patient       VA police
                          bedrooms and bathrooms   staffing and command
                          Stationary,      and control
                          computer-based, and      operations
                          portable personal
                          panic alarms
                          Separate or
                          specially designated
                          areas for women
                          veterans
------------------------------------------------------------------------
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.

 Monitoring precautions. These measures 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.
 Security precautions. These 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.\33\****
  NOTICE: FTNT 33 ATTACHED TO HEAD BELOW TABLE. MOVE IF NEEDED TO
  DISPLAY **** deg.**** ON THE SAME PAGE AS THE TABLE FOOTNOTE
  LISTED DIRECTLY ABOVE THIS NOTICE **** deg.
 Staff awareness and preparedness precautions. These measures
  were designed to educate and prepare residential program and inpatient
  mental health unit staff to deal with security issues and to provide
  police support and assistance when needed. For example, there was a
  regular VA police presence within some residential programs we
  visited. Also, all medical facilities we visited had a functioning
  police command and control center, which program staff could contact
  for police support when needed.

Significant Weaknesses Existed in the Use and Implementation of Certain 
        Physical Security Precautions at Selected VA Medical Facilities
---------------------------------------------------------------------------
    \33\ 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.
---------------------------------------------------------------------------
    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. During our review of the 
physical security precautions in use at the five VA medical facilities 
we visited, we observed seven weaknesses in these three categories.\34\ 
(See table 4.)
---------------------------------------------------------------------------
    \34\ 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.

   Table 4: Weaknesses in Physical Security Precautions in Residential
    Programs and Inpatient Mental Health Units at Selected VA Medical
                               Facilities
------------------------------------------------------------------------
                                                    Staff awareness and
 Monitoring precautions    Security precautions        preparedness
                                                        precautions
------------------------------------------------------------------------
 Inadequate       Alarm            VA police
 monitoring of closed-    malfunctions of          staffing and workload
 circuit surveillance     stationary, computer-    challenges
 cameras                  based, and personal      Lack of
                          panic alarms             stakeholder
                          Inadequate       involvement in unit
                          documentation or         redesign efforts
                          review of alarm
                          testing
                          Failure of
                          alarms to alert both
                          unit staff and VA
                          police
                          Limited use of
                          personal panic alarms
------------------------------------------------------------------------
Source: GAO.

    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 of the VA medical facilities we visited. For example, at one 
medical facility, the system used by the residential programs at that 
medical facility could not be monitored by the police command and 
control center staff because it was incompatible with systems installed 
in other parts of the medical facility. According to VA police at this 
medical facility, 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, such as serving as telephone 
operators and police/emergency dispatchers. These other duties 
sometimes prevented them from continuously monitoring the camera feeds 
in the police command and control center.\35\ 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.
---------------------------------------------------------------------------
    \35\ 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.
---------------------------------------------------------------------------
    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 accurately pinpoint the 
location of the tester when an alarm was activated outside the 
building. At another medical facility that used stationary panic alarms 
in inpatient mental health units, residential programs, and other 
clinical settings, almost 20 percent of these alarms throughout the 
medical facility were inoperable. At an inpatient mental health unit in 
a third medical facility, three of the computer-based panic 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.
    Inadequate documentation or review of alarm system testing. 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. Officials at 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.
    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. 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.\36\
---------------------------------------------------------------------------
    \36\ 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.
---------------------------------------------------------------------------
    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 with whom we 
spoke indicated an interest in having portable personal panic alarms to 
better protect them in similar situations.
    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 9 police officers at 
the time of our visit; according to VA staffing guidance, the minimum 
staffing level for this medical facility should have been 19 officers. 
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. We found that such stakeholder 
involvement on remodeling projects had not occurred at one of the 
medical facilities we visited. At this medical facility, 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 Plexiglas barricade on both nursing station counters.
    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. Medical facility staff are uncertain about what types of 
sexual assault 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 health care 
system. Leaving reporting decisions to local VA medical facilities--
rather than relying on 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.
    In addition, 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 VHA Central Office staff 
is needed to provide a safe and secure environment throughout all VA 
medial facilities.
    To improve VA's reporting and monitoring of allegations of sexual 
assault, we are making numerous recommendations--in a report that we 
issued last week. We recommended VA improve the reporting and 
monitoring of sexual assault incidents, including ensuring that a 
consistent definition of sexual assault is used for reporting purposes, 
clarifying expectations for reporting incidents to VISN and VHA 
leadership, and developing and implementing mechanisms for incident 
monitoring. To address vulnerabilities in physical security precautions 
at VA medical facilities, we recommended that VA ensure that alarm 
systems are regularly tested and kept in working order and that 
coordination among stakeholders occurs for renovations to units and 
physical security features at 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. In addition, VA provided an action plan, 
which described the creation of a multidisciplinary workgroup to manage 
the agency's response to many of our recommendations. According to VA's 
comments, this 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.
    Chairwoman Buerkle, Ranking Member Michaud, and Members of the 
Subcommittee, this concludes my prepared statement. I would be happy to 
respond to any questions either of you or other Members of the 
Subcommittee may have.
Contacts and Acknowledgments
    For further information about this testimony, please contact 
Randall B. Williamson at (202) 512-7114 or [email protected]. Contact 
points for our Offices of Congressional Relations and Public Affairs 
may be found on the last page of this testimony. Individuals who made 
key contributions to this testimony include Marcia A. Mann, Assistant 
Director; Emily Goodman; Katherine Nicole Laubacher; and Malissa G. 
Winograd.
                                 
    Prepared Statement of Joseph G. Sullivan, Jr., Deputy Assistant
   Inspector General for Investigations, Office of Inspector General,
                  U.S. Department of Veterans Affairs
    Madam Chairwoman and Members of the Subcommittee, thank you for the 
opportunity to discuss how the Office of Inspector General (OIG) 
interacts with the Department of Veterans Affairs (VA) with regards to 
reporting alleged felonies, including sexual assaults at VA medical 
facilities. I would also like to share some other work by the OIG in 
the area of safety at VA medical facilities.
BACKGROUND
    The OIG's Office of Investigations conducts criminal and 
administrative investigations involving crimes impacting the 
Department's programs and operations and serious misconduct by senior 
management. When evidence of a crime or serious misconduct is developed 
during an investigation, we seek appropriate prosecution and/or 
administrative action to assist the VA in maintaining an environment 
that is safe for employees, patients, and visitors and protected 
against criminal activity.
    VA maintains a police force at all VA Medical Centers (VAMCs) that 
has jurisdiction over alleged crimes that happen on VA property. In the 
last few years, the relationship between the OIG and VA Police has 
improved. The OIG requires all of our field supervisors to, whenever 
possible, identify a specific special agent to each VAMC Director, 
Pharmacy Chief, and Police Chief to serve as a primary liaison with 
that VAMC.
    Additionally, in order to deter crime, criminal investigators 
continue to provide approximately 200 crime awareness briefings each 
fiscal year to about 13,000 employees at VA facilities nationwide. 
These briefings are intended to ensure that VA employees are aware of 
the many types of fraud and criminal activity that can victimize VA, VA 
employees, and veterans. These briefings have resulted in additional 
referrals of alleged criminal activity.
    Finally, either the Assistant Inspector General for Investigations 
or I have addressed the VA Police Chiefs at their annual conference for 
the last 3 years. In each of these liaison efforts, we remind VA Police 
and other VA personnel of the requirement to report suspected felonies 
to the OIG. We emphasize that failure to provide timely notification 
may jeopardize our ability to successfully investigate an allegation. 
Recognizing our limited staffing and geographic footprint, we advise 
that we do not expect to be notified before local law enforcement but 
that we do expect to be notified in a timely manner. We provide nearly 
immediate feedback whether or not we will open an investigation.
    The Code of Federal Regulations (CFR) require all VA employees to 
report suspected criminal behavior to VA management and/or the OIG.

      38 CFR Sec. 1.201--Employee's duty to report--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 shall 
immediately report such knowledge of information to their supervisor, 
any management official, or directly to the Office of Inspector 
General.
      38 CFR Sec. 1.204--Information to be reported to the 
Office of Inspector General--Criminal matters involving felonies will 
also be immediately referred to the Office of Inspector General, Office 
of Investigations. VA management officials with information about 
possible criminal matters involving felonies will ensure and be 
responsible for prompt referrals to the OIG. Examples of felonies 
include but are not limited to, theft of Government property over 
$1000, 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.

Government Accountability Office review
    When the Government Accountability Office (GAO) contacted the OIG 
for information involving allegations of sexual assault, we provided 
detailed information and OIG investigative reports about 119 OIG 
investigations completed between January 2005 and June 2010 that 
involved allegations of sexual assault ranging from inappropriate 
touching to rape. Subsequently, GAO advised that the 2005 and 2006 data 
would not be used in their analysis; however, they requested an 
additional 6 weeks of 2010 data as well as any cases that were open 
during the previous search, but were now closed. We found information 
associated with 11 additional closed cases that we provided to GAO. We 
also provided GAO with de-identified information about nine sexual 
assault investigations that remained in an open status as of August 1, 
2010.
    Later, GAO requested that we review 42 scenarios regarding alleged 
sexual assaults that had occurred on VA property, but were not, 
according to GAO's research, referred by VA Police to the OIG. We had 
four senior agents review the information and they concluded the 
following:

      In 23 (55 percent) of the scenarios, we would not have 
expected VA Police to notify the OIG. Examples included allegations 
that lacked any evidence of sexual assault obtained as a result of a 
medical examination, to include a sexual assault collection kit that 
did not reveal signs of sexual assault, and a victim who quickly 
recanted the original allegation. Also included in this group were 
allegations of a rape by a ``celestial being'' and consensual sex 
engaged in by two inpatients.
      In 14 (33 percent) of the scenarios, we would have 
expected VA Police to notify the OIG. Examples included a victim with 
dirt and grass on her clothing and in her hair who reported that she 
had been raped while walking on the grounds of a VA Medical Center, and 
a female physician who reported that a male patient sexually assaulted 
her while conducting an examination.
      In 5 (12 percent) of the scenarios, we could not make a 
judgment because of either ambiguous or inadequate information in the 
scenario description.

    We also advised GAO that we recognized at least one scenario as an 
open case that had been originally reported to us by VA Police. Because 
GAO would not provide us any information that might identify the 
victim, accused subject, or facility associated with any of the 42 
scenarios, we could not determine if there were other open cases that 
may have been reported to us.
    The following examples illustrate cases originally reported to us 
by the VA Police that we worked jointly with them:

      A female veteran reported that a VA employee had made 
sexually inappropriate conversation and physical contact with her 
during several treatment sessions. The employee has been charged with 
attempted criminal sexual abuse and simple battery.
      A VA patient reported that a fellow inpatient at the VAMC 
sexually assaulted her on a number of occasions during her stay in a 
locked psychiatric unit. The suspect pled guilty to sexual assault in 
the 3rd degree and was sentenced to 1 year of incarceration and 3 
years' probation.
      A VA patient residing in a VAMC assisted living area 
reported being sexually assaulted by his roommate, a convicted sex 
offender. The suspect was indicted on two counts of rape, two counts of 
sexual battery, and two counts of gross sexual imposition. He pled 
guilty to two counts of sexual battery and was sentenced to 6 months in 
county custody and 3 years of community controls by the county's sex 
offender unit. In addition, the judge classified him as a Tier III sex 
offender, and he will have to register his address in person every 90 
days for life.
      A VA Chief Financial Officer sexually assaulted his minor 
daughter on numerous occasions in his apartment, which was located on 
VAMC property. This employee was recently sentenced to 36 months' 
incarceration. Our investigation also revealed that the defendant 
sexually assaulted the same daughter in a Las Vegas hotel. 
Subsequently, he was sentenced to a year's incarceration in Nevada.

    While these examples demonstrate VA Police complying with the CFR 
reporting requirements, we are aware of instances of failure to timely 
report suspected felonies to the OIG. This decreases the likelihood of 
a successful resolution especially if VA Police have already conducted 
interviews and done other work. For example, after receiving a report 
from a female inpatient that 2 days earlier she had been raped, VA 
Police interviewed both the victim and the suspect, searched the 
vehicles of both the suspect and victim, took possession of the 
suspect's cell phone, and interviewed common acquaintances prior to 
contacting our local office, which is approximately 15 to 20 minutes 
from the VAMC. When OIG special agents joined the investigation, they 
added value by obtaining additional information from the victim and 
transporting her to a local hospital where she was examined by a Sexual 
Assault Response Team nurse. Additionally, when the OIG agents searched 
the suspect's vehicle, they discovered potential evidence, a used 
condom. Finally, had the victim not withdrawn her allegation and 
admitted to the consensual nature of the event, some evidence recovered 
prior to our involvement in the investigation may have been suppressed 
because the consent obtained to search the suspect's cell phone was 
verbal, not written.
    We welcome GAO's recommendation to automate reminders to VA Police 
to notify the OIG when entering a felony offense into the VA Police 
database. We are pleased with the VA Police's intention to also 
implement an automated notice to our field offices whenever the record 
of such an offense is created. We believe both measures will greatly 
reduce the number of instances when we are not notified of alleged 
felonies.
OTHER OIG WORK
    The OIG, in October 2008, issued an Audit of the Veterans Health 
Administration's Domiciliary Safety, Security, and Privacy (October 9, 
2008) in which we assessed the effectiveness of safety, security, and 
privacy of veterans residing in VA domiciliaries. We found that the 
Veterans Health Administration needed to implement additional national 
procedures and clarify national guidance to ensure that safety, 
security, and privacy issues are sufficiently identified, reported, and 
corrected throughout the year. We reported on three issues that 
impacted all 49 domiciliaries:

      There is a need to establish national procedures for the 
inspections of veterans' room.
      Additional safety, security, and privacy procedures are 
needed for female veterans along with security initiatives for all 
veteran residents.
      Improvements are needed in annual safety, security, and 
privacy reporting as well as the follow-up process.

    The report contained eight recommendations, which according to VA 
have all been implemented.
CONCLUSION
    The OIG and the VA Police have enhanced our working relationship 
over the last several years in order to protect patients, visitors, and 
employees at VA medical facilities. It is a commitment that both 
organizations take seriously. The Director of VA's Law Enforcement and 
Security Office e-mailed me recently stating ``As we all agree, we are 
one team of law enforcement professionals and I and my senior team 
believe in working together.'' We in the Office of Inspector General 
share that sentiment.
    Madam Chairwoman, this concludes my statement and I would be happy 
to answer any questions that you or other Members of the Subcommittee 
may have.

                                 
        Prepared Statement of William Schoenhard, FACHE, Deputy
       Under Secretary for Health for Operations and Management,
  Veterans Health Administration, U.S. Department of Veterans Affairs
    Chairwoman Buerkle, Ranking Member Michaud, and Members of the 
Committee: Thank you for the opportunity to appear and discuss the 
Department of Veterans Affairs' (VA) policies and actions to prevent 
sexual assaults and other safety incidents at VA medical facilities. 
The safety and security of our Veterans, employees, and visitors are 
paramount to us, and we appreciate the work of the Government 
Accountability Office (GAO) to help us further improve our programs and 
facilities. Secretary Shinseki has made this issue a top priority for 
the Department, and this commitment is reflected in our investments 
over the last 2 years. This includes integrating safety and security 
considerations into our Strategic Capital Investment Decision Model, 
which evaluates and ranks proposed construction and renovation 
projects, as a high priority consideration that is significantly 
weighted. As a result, those projects designed to improve facility 
security are consistently among the highest rated projects we support.
    I am accompanied today by my colleagues George Arana, M.D., Acting 
Assistant Deputy Under Secretary for Health for Clinical Operations, 
and Kevin Hanretta, Deputy Assistant Secretary for Emergency 
Management.
    VA currently uses both VA staff and physical infrastructure systems 
to ensure the security of our facilities, particularly residential and 
inpatient mental health programs. Closed circuit cameras, locks, 
alarms, separate facilities, and specialized training for health care 
professionals are some of the steps we have taken so far. However, to 
develop an even more robust and secure health care system, we have 
convened a multi-disciplinary Workgroup to define what the Veterans 
Health Administration (VHA) must do to prevent sexual assault incidents 
and to respond to allegations of sexual victimization. This Workgroup 
includes representatives from VHA and VA corporate offices, including 
the Office of Operations, Security, and Preparedness, and the Office of 
General Counsel. The Workgroup held its first meeting on June 6, 2011.
    VA must, and will, proactively assess and manage risks and 
institute appropriate precautions to maximize prevention and response 
measures. We must also improve our mechanisms for Veterans and staff to 
report incidents to law enforcement so that offenders can be held 
accountable. These mechanisms must also provide information to VA 
management so that concerns can be monitored and addressed 
appropriately and timely.
    My testimony today will first discuss the prevalence of sexual 
assault and other safety incidents in VA medical facilities. It will 
then cover VA policies and procedures for reporting and monitoring such 
incidents. I will next detail the use of physical security precautions 
and the ability of VA's Central Office to respond, provide oversight, 
and address vulnerabilities. I will conclude by discussing VA's next 
steps as we continue to improve the safety of our facilities for all 
those on our property.
Prevalence of Sexual Assault and Other Safety Incidents
    VA provided health care services to 6 million unique patients in 
fiscal year (FY) 2010 at more than 1,300 sites of care, and VHA employs 
more than 244,000 individuals. While the overwhelming majority of 
experiences in VA facilities are safe, no system is perfect. During the 
3 and a half year period of the GAO review, VA provided approximately 
240 million outpatient visits and more than 2 million inpatient 
admissions. As stated in GAO's report, ``VA HEALTH CARE: Actions Needed 
to Prevent Sexual Assaults and Other Safety Incidents'' (GAO-11-530), 
between January 2007 and July 2010, a period of 43 months, there were 
284 alleged sexual assault incidents reported to VA police. Even one 
incident is one too many, and we must take every step we can to prevent 
assaults before they happen.
    The GAO report indicates that these events may be under-reported. 
We must have procedures in place to provide the best data we can 
obtain. To reduce the potential for under-reporting, we will continue 
to encourage Veterans, families, employees and visitors to report 
information about an incident or a threatened incident to VA clinicians 
and VA police officers. We also will take additional steps, such as 
improving staff training, improving lighting, promoting awareness among 
staff and visitors, expanding access for reporting options, improving 
the reliability of panic alarms, and posting signs that advise staff 
and visitors how to report any incidents to the proper authorities. It 
is VHA's policy that emergency departments, urgent care clinics, 
outpatient clinics, and all inpatient and residential settings have 
plans in place to appropriately manage the medical and psychological 
assessment, treatment, and collection of evidence from male and female 
Veterans who report acute sexual assault. We also will develop a 
consistent definition for these incidents that will ensure the data we 
collect are as accurate and reliable as possible.
VA Policies and Procedures for Reporting and Monitoring Safety 
        Incidents
    The GAO's investigation found that many of these alleged assaults 
were not reported to VA leadership officials and the Office of 
Inspector General (OIG) as required by VA regulation. We appreciate 
this finding and recognize the need to improve structures for reporting 
incidents involving sexual victimization and other safety concerns. We 
are identifying several mechanisms and reporting structures to ensure 
the effective coordination of both prevention and response activities, 
and we will focus principally on strategies that provide universal 
precautions against sexual victimization. In addition, we recognize the 
importance of our risk assessment and risk management mechanisms. 
Critically important, though, is a clear definition of what acts 
constitute an offense and how this information should be used within 
the required limits of patient confidentiality and privacy protections. 
This was GAO's first recommendation. We agree that there is a need to 
establish consistent definitions of sexual assault and other safety 
incidents for reporting information from medical facilities to VA 
leadership at the Veterans Integrated Service Network (VISN) level and 
to VA Central Office. We will develop action plans with clear and 
aggressive timelines for implementation developed by July 15, and a 
final report to GAO on implementation by September 30, 2011, to address 
this concern.
    The GAO report identified two mechanisms for reporting incidents: 
the management stream of reporting and the law enforcement stream of 
reporting. GAO recommended that VA implement a centralized tracking 
mechanism to allow both alleged and substantiated sexual assault 
incidents to be monitored consistently and reported to senior 
leadership; this information will be de-identified to protect the 
confidentiality of victims and will be subject to strict controls on 
access by VA employees. VA agrees with this recommendation, and will 
build on our work to establish a common set of definitions to support 
this objective. Already, we have begun to review the existing 
organizational strategies, structures, and policies to identify how 
best we can change or strengthen oversight and reporting processes. The 
multi-disciplinary Workgroup has been charged with developing and 
implementing this centralized reporting mechanism. VA will prepare a 
detailed action plan with specific deadlines by July 15 and a final 
report by September 30, 2011.
    An important element in ensuring the accuracy and timeliness of our 
procedures for reporting and monitoring safety and security incidents 
is the establishment and growth of the Integrated Operations Center 
(IOC). Established in 2009, the IOC, which operates 24 hours a day, 7 
days a week, serves as a fusion point for operational, safety and 
security information. The IOC was established, in part, to provide the 
Secretary with a single office responsible for ``proactively 
collecting, coordinating, and analyzing information in order to make 
recommendations to VA leadership.'' VA Directive 0322, dated April 29, 
2010. The IOC manages VA's Serious Incident Report Directive 
(published, January 25, 2010), which mandates reporting of among other 
things, incidents of alleged sexual assault that occur on VA property.
Existing Security Precautions and VA Response
    The GAO report notes that VA has a number of systems in place to 
identify potential safety risks, but concluded that these systems are 
deficient in critical aspects. For example, the GAO found that some 
physical security precautions are not properly maintained or monitored 
and that inadequate installation or testing procedures contributed to 
these weaknesses. The GAO's concern is that these weaknesses could lead 
to delayed response times to incidents and otherwise undermine our 
efforts to prevent or mitigate sexual assaults and other safety 
incidents.
    We agree with these findings and will take the necessary steps to 
improve our systems accordingly. While VA medical centers are currently 
expected to have policies addressing the use and testing of panic alarm 
systems in compliance with the standards of The Joint Commission, VA 
will re-emphasize the need for routine testing of these panic alarms to 
ensure they are functioning properly. We will review whether existing 
policy needs to be revised to ensure regular preventative maintenance 
occurs consistent with manufacturer requirements. Regular testing of 
alarms is critical to ensuring the safety and security of Veterans, 
staff, and visitors. VA will require VISN Directors to ensure that 
local facilities have established systems that meet the unique needs of 
that location and Veteran population. Furthermore, by mid-July, the 
multidisciplinary Workgroup will complete an action plan, with specific 
deadlines, that will recommend any necessary policy changes.
Next Steps to Improve Safety
    As VA continues to improve its incident reporting and safety 
monitoring systems, we know there are additional, more immediate, 
measures we can take to improve the safety of all those within our 
facilities. Participants in the multi-disciplinary Workgroup have begun 
already to analyze deficiencies in our system based on GAO's 
recommendations, and propose specific solutions to these issues. The 
full Workgroup met on June 6, 2011, and began to identify solutions for 
improvement. VA will brief the Committee and GAO in August after these 
near term recommendations are complete. VA has taken steps to improve 
the quality of reporting alleged incidents so we have a better 
understanding of the context and frequency of events. In January 2010, 
VA published Directive 0321 on Serious Incident Reporting, which 
required VA facilities to report such data in a consistent manner. This 
Directive did not include, however, a common definition for alleged 
sexual assaults. We are correcting that omission. VA's 
multidisciplinary Workgroup will identify the scope and develop 
definitions for sexual victimization of Veterans, employees, and 
visitors. The Workgroup will also prescribe how these incidents are to 
be reported. Having a consistent definition for sexual assault and 
standardized reporting procedures will enable the IOC to collect more 
data that are reliable, and more easily identify trends. Analysis of 
this data will help VA leaders gain a better understanding of the 
prevalence of sexual assaults and other safety incidents in VA health 
care facilities and will support the development of solutions that will 
make our facilities even safer. Another important step towards safer 
facilities will be to expand the involvement of security experts in the 
planning and construction phases of renovation or construction projects 
to ensure that safety and security issues are identified and addressed 
as early as possible. We will also review the availability of existing 
resources to determine if further training, support, or assistance is 
needed to improve the safety and security of our facilities.
Conclusion
    While the VA health care system provides exceptional service to 
millions of Veterans and family members every year, even one incident 
that threatens the safety and well-being of a Veteran, a family member, 
an employee, or a visitor is unacceptable. Sexual assault is a 
devastating experience for victims. We are using external reviews, such 
as GAO's report, and internal assessments to identify deficiencies and 
to correct them immediately. The Veterans Health Administration is 
working together with the IOC to identify, report, and monitor 
incidents in an almost real-time environment. We will use the Workgroup 
to recommend solutions with specific timelines to improve our 
prevention and surveillance efforts. These are important steps toward 
ensuring a safer and more secure system. We take a zero tolerance 
approach to sexual assault and will enforce the law and our policies to 
the maximum extent in the best interests of our Veterans, their 
families, and our staff. Thank you again for the opportunity to testify 
today. My colleagues and I would be pleased to answer any questions you 
may have.

                                 
Prepared Statement of Verna Jones, Director, National Veterans Affairs 
             and Rehabilitation Commission, American Legion
    Mr. Chairman and Members of the Committee:
    The American Legion applauds this Committee for utilizing its 
oversight authority to delve into this deeply troubling issue. The men 
and women of our armed forces are trained to go into hazardous 
locations in the performance of their duties. They are trained to 
operate under some of the most grueling and psychologically challenging 
circumstances. When they swear their oath they take on these 
challenges, and meet them with grace and valor unlike any other armed 
force in history.
    They should not, and must not, meet grueling and psychologically 
challenging conditions undertaking the most basic of tasks in their 
civilian life post military service--seeking and receiving the health 
care services they have earned in the Department of Veterans Affairs 
(VA).
    The findings of the most recent Government Accountability Office 
(GAO) report ``Actions Needed to Prevent Sexual Assaults and Other 
Safety Incidents'' (GAO-11-530) and previous reports addressing this 
matter such as ``VA Has Taken Steps to Make Services Available to Women 
Veterans, but Needs to Revise Key Policies and Improve Oversight 
Procedures'' (GAO-10-287) are disturbing. There are veterans who do not 
feel safe using the facilities provided for them for health care, and 
they don't feel safe for a reason. In the last 3 years alone, nearly 
300 incidents of sexual assault were reported to the VA police. 
Staggeringly, the vast majority of these reported incidents were not 
reported to VA leadership and/or the Office of the Inspector General 
(OIG). VA cannot be expected to solve patient security issues if they 
remain unaware of the problem at critical leadership levels.
    The American Legion is aware of these concerns. Furthermore, the 
Legion believes the overall VA Health Care system is generally an 
excellent and deserved resource, and no veterans should feel they 
cannot utilize the system for fear of inappropriate behavior. With that 
in mind, The American Legion offers the following insights into the GAO 
report and our own research, and recommendations to improve the system 
and preserve the sanctity of the VA Health Care system.
What GAO Found
    GAO's most recent report tackled the period ranging from January 
2007-July 2010 with recognition that changing patient demographics were 
presenting unique challenges to VA in terms of providing a safe 
environment for all veterans. In particular, this study examined 
security issues stemming from unwanted sexual behavior and advances. 
Whether such behavior took the form of rape, inappropriate touching, 
forced examination, forced oral sex or other forms of sexual assault, 
the findings were clear. Not only were such illegal and horrifying 
actions occurring, over two thirds of these incidents went unreported 
to VA management and the OIG despite being reported to VA police.
    GAO found fault with the risk assessment protocols. The protocols 
are simply a self-reporting process utilized to inform clinicians of 
sexual assault related risks, specifically regarding the lack of 
guidance about information collection. Because of a lack of ``evidence 
based risk assessment tools'' VHA relies on ``professional judgment of 
clinicians'' which is subjective at best. This is clearly problematic 
when dealing with an organization as large as VA, and one as criticized 
as VA is for a lack of consistency on a regional level. Because the 
information used to make these assessments is self-reported it is 
frequently incomplete, further complicating the issue.
    The report found a lack of adequate precautions in place at VA 
residential and inpatient facilities. While the sample of facilities 
examined was relatively small, GAO surveyed five facilities out of a 
system that includes 153 full medical centers, the omissions in 
procedures and security precautions raise large warning flags. Basic 
measures such as security cameras, alarm systems and so forth are 
inadequate or not present. In other places, there was inconsistency in 
the types of precautions taken, ranging from ``patient behavior 
contracts'' that varied from facility to facility, to a difference of 
procedures in place.
    Perhaps one of the most common themes in the findings of the report 
was the lack of clear guidance. VA Staff had questions about what 
should and should not be reported. Staff frequently noted they were 
unclear as to the proper procedures for reporting, or even as noted 
above, taking histories.
    Amongst other considerations, the findings seem to solidify one of 
the chief concerns about the entire medical system cited often in the 
past by The American Legion--inconsistency. As the saying goes ``If 
you've seen one VA Medical Center, you've seen one VA Medical Center.'' 
From VAMC to VAMC to VISN to VISN to CBOC to CBOC, each seems sometimes 
to operate as its own private fiefdom without consistency. The American 
Legion believes that while the overall plan for VA is strong, 
inconsistent application of that plan only leads to failure on a local 
level. VA must increase consistency.
What The American Legion Found
    The American Legion utilizes multiple tools to find firsthand 
information about patients in the VA Health Care system. Annually, The 
American Legion conducts site visits to VA medical facilities as the 
basis of our ``System Worth Saving'' (SWS) report. The SWS report 
covers all aspects of VA medical facility operations, and concerns of 
veterans utilizing the system are one of the many facets of these 
information gathering site visits.
    In December of 2010, The American Legion further contracted with 
ProSidian Consulting to conduct a survey of women veterans to assess 
their satisfaction with the quality of health care delivered by the VA 
system. While women are by no means the only targets of sexual assault 
in VA and DoD facilities, Military Sexual Trauma (MST) is one of the 
key concerns noted specifically with reference to women veterans, and 
the Women Veterans Survey addressed concerns about security within VA 
facilities.
    In the survey, 18 percent of women, or approximately one in five, 
stated they were ``dissatisfied or very dissatisfied'' with their sense 
of security in the VA health care system. When compared with recent 
figures which indicate approximately the same percentage of women in 
DoD have experienced military sexual trauma--21 percent according to 
Department of Defense Sexual Assault Prevention and Response Office 
(SAPRO)--it is not unreasonable to start asking questions about whether 
there are lingering artifacts of the pervasive culture of the military 
that foster sexual assault without long term consequences.
    The American Legion is deeply concerned to learn the VA and DoD 
actions to address this dire issue are lagging. In March 2010 the GAO 
conducted site visits to nine VA medical centers and ten Community 
Based Outpatient Clinics (CBOCs) to examine the availability of health 
care to women veterans, VA's compliance with their policies and the 
challenges that they face in providing care. The GAO reported only two 
of the VAMCs visited had specialized residential treatment programs 
specifically for women who have experienced MST. Although the VA has 
taken steps to inform staff about their various programs offering MST 
treatment and counseling, VA has been thus far ineffective in informing 
veterans of these options. The VA has not provided this information on 
their external Web site where veterans can easily access it.
    In site visits conducted as a part of the System Worth Saving Task 
Force, one American Legion staffer noted a woman came to VA enrollment 
desk seeking to report military sexual trauma. The veteran was directed 
to ``fill out that packet over there and send it in'' with no further 
follow up or concern from the VA employee. This veteran could have, and 
should have, been connected with the facility's Military Sexual Trauma 
Coordinator and the employee could further have assisted the veteran by 
asking to speak to her in a more appropriate setting instead of drawing 
out the conversation in full view of the public in the waiting area. 
Sensitivity in this area goes a long way towards establishing trust 
with veterans whose trust has already been damaged. While the Legion 
staffer was able to conduct outreach to that veteran on the spot and 
immediately to ensure she got the treatment and aid needed, VA should 
not and must not rely on outside service organizations to conduct their 
vital role of outreach.
    Put simply, The American Legion has found all too often that even 
if proper programs are in place and the resources are available to 
veterans, staff indifference and poor advertisement of these programs, 
including but not limited to poorly conveyed information in facilities 
and on VA's own Web site, contributes to an veterans feeling there is 
no support for them in the system. The findings of GAO indicate there 
are serious flaws in the system to begin with, but when VA cannot even 
implement what is there already in the system, they are failing 
veterans. These veterans need to have access to and utilize the tools 
available to them.
What The American Legion Recommends
    The problems represented within VA are hardly unique to VA. The 
American Legion recognizes there are cultural considerations both DoD 
and VA have long strove to overcome. Previous testimony has addressed 
concerns about those cultural considerations. If there is to be 
substantial change to rectify the unsatisfactory state of affairs, the 
change must affect the cultural environment. Clearly, no agency would 
support the sad state described in the GAO report. VA has regulations 
and policies already existing which attempt to provide a means to 
counter unwanted sexual behavior. However, it is abundantly clear these 
policies are not being consistently enforced, if enforced at all. 
Actions speak louder and more convincingly than words. VA's actions 
must show their commitment to a policy geared towards ending the sexual 
assaults and other security incidents.
    There are signs of an encouraging start. VHA Directive 2010-033 
issued July 14, 2010 provided for VISN level MST Coordinators, as well 
as MST Coordinators at a facility level. The American Legion supports 
the establishment of such coordinators and recognizes the strength of 
such assets in outreach to veterans and spreading the message of 
support services available as well as following up on behalf of any 
veterans within the system who may experience these issues. However, 
although the Legion has determined all facilities now have such a 
coordinator, in many or most locations, the position is not a full time 
position, and is often an additional duty of an employee tasked with 
other responsibilities.
    The American Legion strongly recommends enhancing the role of these 
coordinators to full time status, and giving them the authority and 
scope of mission to act as advocates within the system for veterans who 
experience sexual trauma, and to ensure policies are carried out in VA 
facilities in keeping with the nature of the expectations of VA Central 
Office. Utilize these employees to be the front line defenders for 
those veterans who experience sexual trauma, whether it be in DoD or in 
VA itself.
    The disorganized nature of VA's overall plan for dealing with 
incidents of this nature requires revision. In this The American Legion 
agrees with the findings of the GAO report. Clarity and direction is 
necessary in multiple areas, including standards procedures for 
reporting, risk assessment and ensuring implementation of procedures 
again as noted by GAO.
    VA must act now to meet the basic needs found in the GAO report. 
Promote a clear understanding of the definition of sexual assault. 
Establish a clear set of expectations regarding what should and should 
not be reported up the chain of command. GAO's recommendations also 
call for an automated system to forward all reports of a criminal 
nature brought to the attention of VA security to the attention of OIG 
for investigation. Given previous records of reporting of material to 
OIG for proper follow up and investigation, automating this procedure 
may overcome whatever institutional roadblocks are already in place.
    One of the stated concerns was the establishment of a centralized 
tracking system to monitor sexual assault incidents across VA medical 
facilities. Obviously this idea has merit and is an important tool. 
VA's existing medical health care record system is already a recognized 
tool of excellence in necessary information sharing for medical 
treatment. However, given VA's past record regarding data security, and 
the extremely sensitive nature of the subject matter involved and the 
already damaged psychological picture of the victims involved, the 
absolute utmost care is necessary to ensure such a system is secure 
beyond doubt. This is material of the most sensitive nature possible, 
and past VA mistakes and missteps with data security must not be 
allowed to compromise this reporting system. In The American Legion's 
survey of women veterans, fully one quarter of these veterans felt VA's 
handling of personal and sensitive information was ``Poor to Moderate 
[Moderate being defined as less than Good]''.
    The American Legion would note the most important consideration in 
reacting to this problem is to avoid the previous pattern exemplified 
by VA response to incidents of concern. In the past, VA policy has been 
to create an expanded section of Central Office to ``manage and provide 
oversight'' over a certain field, and enhanced Central Office bloat 
while allowing the problem to perpetuate at the local level because of 
a lack of direct oversight to the ground level operating environment. 
What is not needed is another floor of VA bureaucracy to deal with this 
issue.
    What is needed is a clearly dictated policy made transparent to 
employees and the public at all levels, increased scrutiny at a ground 
floor level to ensure operations are complying with the stated mission, 
and accountability for those employees who fail to meet the standards. 
Put simply, hold individuals accountable for their actions, and make 
clear in no uncertain terms that this kind of behavior will not be 
tolerated. Then allow the local level to act out that policy without 
need for another hundred bureaucrats in Washington.
    House Resolution 2074, the ``Veterans Sexual Assault Prevention 
Act'' works very much in the spirit of what The American Legion is 
proposing here. The bill provides for exactly the sort of concise and 
clear definitions and consistent policy required to help right the ship 
of VA's treatment of these matters. The American Legion supports this 
legislation, but also notes continued oversight and follow up will be 
necessary to ensure compliance. The lack of clarity and consistency 
within VA on this matter indicate a potentially resistant culture, 
which will require the actions of all stakeholders to rectify. The 
American Legion stands ready to work with Congress, the VA, and all 
affected veterans and veteran service organizations to ensure proper 
due diligence is exercised and this matter does not slip from the 
forefront of our attention. This is a problem we all must work to 
solve, and The American Legion is eager to help.
                                 
    Prepared Statement of Joy J. Ilem, Deputy National Legislative 
                  Director, Disabled American Veterans
    Chairwoman Buerkle, Ranking Member Michaud and Members of the 
Subcommittee:
    On behalf of the Disabled American Veterans (DAV) and our 1.2 
million members, all of whom are wartime disabled veterans, I am 
pleased to be here today to present our views on a recently released 
Government Accountability Office (GAO) report (GAO-11-530)--Actions 
Needed to Prevent Sexual Assaults and Other Safety Incidents (herein 
after GAO report or Report) to the Committee on the issue of the 
prevention of sexual assaults and other related safety incidents 
occurring in Department of Veterans Affairs (VA) health care 
facilities.
    In reading the GAO Report we were disturbed to find that between 
2007 and 2010, GAO identified 284 alleged sexual assaults reported 
through one of two reporting streams. However, many times, the victims' 
reports were mishandled or inappropriately acted upon based on 
decisions made by local physicians or administrators and most had not 
been reported to appropriate program officials and leadership in VA--
even though rape allegations are considered potential felonies and are 
required by regulation to be reported to the VA's Office of the 
Inspector General (OIG). Although VA officials at one sampled facility 
noted they did expect to be notified of all sexual assault incidents--
this expectation was not specifically documented in their policy.
    At the outset, let it be known that DAV believes in the strongest 
possible terms that veterans, VA employees, visitors and others who 
occasion visits to VA facilities should always be assured of their 
physical safety and personal security. Likewise, every veteran 
hospitalized or housed at a VA medical center (VAMC) or treatment 
facility should be afforded a safe, secure environment and be treated 
with respect and dignity. In addition to the Veterans Health 
Administration's (VHA's) benchmark of continuous quality improvement 
programs ensuring that patients receive safe and effective health care, 
VA must reevaluate and strengthen its safety program to ensure that the 
environment of care at VA health facilities keeps veterans, staff and 
visitors safe from physical harm, including sexual assaults.
    VA has received numerous prestigious national awards and been 
lauded by the National Academy of Science's Institute of Medicine for 
its outstanding patient safety programs, including alerts embedded in 
its Veterans Health Information Systems and Technology Architecture 
(VistA)/Computerized Patient Record System (CPRS) electronic health 
record, its barcode medication administration program that reduces 
medication errors, and its patient safety reporting systems. It is 
therefore surprising that the National Patient Safety Center has not 
encouraged VAMCs to perform: (1) a root cause analysis on incidents 
involving sexual assaults, (2) a national data roll-up and analysis of 
methods to prevent or mitigate the risk of sexual assault, or (3) 
further study of this important patient safety issue.
    GAO's report concerns us on several levels. Initially, it documents 
loose and inattentive reporting of incidents of personal violence 
committed in VAMCs against veterans, staff and visitors; the failure of 
or reluctance to share information about these incidents; inadequate 
police staffing and monitoring of security cameras in certain 
facilities; the lack of proper investigative procedures and follow up; 
the lack of a uniform definition of sexual assault to ensure consistent 
reporting; lack of a centralized database for tracking and trending 
assault incidents; destruction of incident reports and police records; 
and lack of information sharing by VHA Operations and Management staff 
with other internal stakeholders. We are also concerned that the lack 
of information sharing could be further complicated with the recent VHA 
reorganization that has separated the operations and policy functions 
of many service lines, including mental health programs, if recommended 
policy changes are not implemented. We concur with GAO that without the 
regular exchange of sexual assault report incidents that occur within 
their areas of programmatic responsibility, VHA officials cannot 
effectively address potential risks in their programs and local 
facilities do not have the opportunity to identify ways to prevent such 
incidents. These critical deficiencies identified by GAO have uncovered 
not only the individual program and policy gaps noted, but also 
highlight VHA's lack of a methodical and systematic approach to 
eradication of sexual assaults from its facilities.
    In addition to its failure to communicate with VHA Program Offices, 
it appears VHA lacks an open approach to communication regarding sexual 
assaults with other VA offices, including the OIG. According to the 
report, by regulation, all potential felonies, including rape 
allegations, must be reported to VA OIG investigators. GAO also found 
that VAMC Police are not consistently reporting felony sexual assaults 
to the other VA offices with responsibility for investigating crimes.
    These practices and lack of systemic consistency cannot be defended 
and must be addressed by VHA with a sense of urgency. VA must establish 
a comprehensive, consistent approach to documenting, investigating and 
reporting sexual assaults--a serious crime of personal violence 
apparently occurring at several VA health care facilities. Given the 
limited number of facilities surveyed by GAO, we are concerned about 
the extent of the problem systemwide. For these reasons we suggest the 
creation of a task force to ensure the VA adopts a culture of safety 
and promptly develops a uniform policy for the reporting of all sexual 
assaults. It is clear these reports cannot be solely handled by the 
local facility involved and that mandatory reporting of these incidents 
to all the appropriate officials is necessary. We are pleased to see 
that VA has established a ``multi-disciplinary workgroup'' to define 
what actions need to be taken to prevent sexual assault incidents and 
to respond to reports and allegations of sexual victimization of 
veterans and VA employees.
    We noted in the report a footnote on page 13 that indicates VA 
police routinely destroy their investigation reports of VA sexual 
assaults 3 years after making such reports, under a records retention 
policy of the National Archives and Records Administration. We oppose 
the destruction of these reports on the same basis that we oppose the 
destruction of reports of military sexual trauma (MST) that occur 
within the military services. More information on our position with 
respect to destruction of MST records may be found in DAV's testimony 
before this Subcommittee on May 20, 2010. The destruction of these 
reports contributes to the problem of the lack of consistent 
information and information sharing, and obstructs analysis that could 
be immensely helpful not only to improve safety in VA facilities but to 
promote a better understanding of the incidence of sexual assaults in 
VA. Also, a number of these cases could result in tort claims or VA 
disability claims. The lack of documentation can contribute to loss of 
benefits and equity for these victims.
    GAO noted in its analysis that VA is experiencing significant 
demographic changes in its health care programs due to initiatives 
targeting several specific veteran populations--including women 
veterans, veterans who have served in Operations Enduring and Iraqi 
Freedom (Web site/OIF), and veterans facing legal issues or those 
currently incarcerated. New VA enrollees are trending younger, with a 
more visible presence of women veterans. According to VA, about one-
half of all women who served in OEF/OIF and separated from the military 
since September 11, 2001, are enrolled in VA health care. VA is also 
outreaching to justice-involved veterans with post-deployment mental 
health problems, such as combat-related post-traumatic stress disorder 
(PTSD) to help them avoid incarceration and enter into appropriate 
specialized VA programs for PTSD, traumatic brain injury (TBI) and 
substance-use disorder treatment. The same holds true for homeless 
veterans and family caregivers of severely injured and ill veterans. VA 
is also seeing a significant new workload in mental health care while 
trying to use the least-restrictive environment to do so.
    VA is also under stress to treat a seriously and moderately 
disabled young veteran population returning from war with myriad unmet 
needs and high expectations for state of the art services across the 
continuum of health care and rehabilitation. This changing demographic 
and the need for comprehensive mental health care and polytrauma care 
has made it even more crucial that VA address the safety and security 
issues raised by GAO. Of the 1.2 million individuals who have served in 
the wars in Iraq and Afghanistan, over 654,000 (more than 50 percent) 
have enrolled in VA health care since fiscal year 2002. Although these 
patient populations are a small percentage of the overall enrolled 
population using VA, we believe these changes have affected VA's 
environment of care, in both expected and unexpected ways.
    In addition to the environment of care issues, VA must also raise 
awareness among its staff through education and training in order to 
enhance its climate and culture of safety. VA's clinical care staff are 
accustomed to caring for a predominantly older, male population with 
chronic medical conditions rather than the one they are now being 
charged to treat. These shifts and pressures produce stresses that VA 
has not previously or recently experienced and may be contributing to 
the culture of safety challenges that GAO aptly uncovered and 
documented in this report. These demographic changes are projected to 
continue in the foreseeable future.
    GAO primarily focused on three distinct VA settings in its report--
residential rehabilitation treatment programs (RRTP), inpatient and 
residential mental health units and compensated work therapy/
transitional residence (CWT/TR) settings. For years GAO has addressed 
safety and privacy deficiencies in VA health care facilities, 
specifically related to women veterans. We see in the current report, 
in relationship to the residential program sites, that only one of the 
three CWT/TR programs evaluated accepted women due to safety and 
privacy concerns. These safety concerns continue to negatively impact 
women veterans--in essence they are denied access to needed specialized 
services because VA is not confident they can provide a safe 
environment for women. Likewise, GAO notes that several clinicians they 
interviewed for a previous report on women's health services in VA 
expressed concern for the safety of women veterans placed in VA 
inpatient mental health programs. These types of concerns highlight an 
inequity in access to care for women veterans and the potential for 
further assaults unless corrective action is taken. Among the security 
precautions that must be in place for residential programs are secure 
accommodations for women veterans with periodic assessments of facility 
safety and security issues. We have brought this issue to the attention 
of the Subcommittee over the years and hope you will consider oversight 
to ensure as VA moves forward to improve their overall culture of 
safety in VA facilities, and that VA specifically address these safety 
issues related to care for women veterans.
    While acknowledging its findings could not be generalized to VA as 
a whole, and that the report was based on visits to only five VA 
medical centers in four networks of care, GAO tendered nine 
recommendations from its review. We endorse these ideas and note that 
VA has concurred in each of them as well. Given the seriousness of this 
issue, we urge VA to move forward expeditiously to implement them 
within the spirit in which they were made. While not one of the 
recommendations, we also believe that the organizational placement of 
VA's police force should be a subject of review, as well as the 
sufficiency of its staffing levels across the system and its operating 
mandate. Historically, VA police officers were VA medical center 
employees, appointed locally and directly responsible to the VAMC 
director to ensure safety of persons and property, including real 
property. In recent years, however, the VA police force has been 
organizationally centralized to report to a Deputy Assistant Secretary 
for Law Enforcement.
    Madam Chairwoman, every veteran should be assured of the highest 
level of quality care and patient safety while receiving health care in 
a VA facility. A veteran should never fear for his or her own personal 
safety while visiting a VA facility. VA was established as a place of 
care, not a place of fear, for veterans, visitors and staff. We concur 
with GAO that when a veteran has a history of sexual assault or violent 
acts, VA must be vigilant in identifying the risks that such veterans 
pose to the safety of others at its medical facilities. VA needs to 
take decisive actions to improve personal safety and promote an 
environment of care that includes protection from personal assaults, 
including sexual assaults. To do so will take a commitment from all 
levels of VA and especially VA's senior leadership. We commend GAO for 
making this critical report. Hopefully, GAO's findings can serve VA and 
veterans well in providing a roadmap to promote a new environment of 
care that encompasses a strong consistent culture of safety, and one 
that can be closely monitored by this Subcommittee as VA completes the 
recommended changes.
    Madam Chairwoman, this concludes my statement, and I would be 
pleased to consider questions from you and other Members of the 
Subcommittee.

                                 
  Prepared Statement of Marlene Roll, Member, National Women Veterans 
        Committee, Veterans of Foreign Wars of the United States
    MADAM CHAIRWOMAN AND MEMBERS OF THIS COMMITTEE:
    On behalf of the 2.1 million members of the Veterans of Foreign 
Wars of the United States and our Auxiliaries, I thank you for this 
opportunity to share our views on this exceedingly important topic.
    The June 7 GAO report, entitled ``VA Health Care: Actions Needed to 
Prevent Sexual Assaults and Other Safety Incidents,'' doesn't provide 
enough detail to fully grasp the depth of this problem, but there are 
some things we do know: One incident of assault, of a sexual nature or 
otherwise, is one too many. We also know that interested parties--
Veterans, VA, Congress, VSOs, and the American people--cannot look the 
other way once we know this is occurring. Thanks to the GAO, we now 
know it's happening at VA.
    Sexual assault is among the most serious of problems an individual 
or any organization--especially one in the service industry like the VA 
Health Administration--could ever confront. VA must immediately work to 
address this problem head on.
    The VFW affirms, in no uncertain terms, the need for a zero-
tolerance policy. Less than that is unacceptable and inexcusable.
    Every confirmed instance of sexual assault must be dealt with 
swiftly and to the maximum extent of the law. VA employees and veterans 
who commit or know of these acts must be held accountable. We entrust 
VA to care for the brave men and women who have gone to war and 
returned home physically and/or emotionally traumatized. They must 
never have to visit a VA medical facility with concerns about their 
personal safety.
    The allegations in the GAO report are as troubling as they are 
unacceptable. The report makes it sound as if VHA has a culture of 
condoning this type of behavior, which we believe is not the case. But 
what is the case is that the facilities and networks visited by GAO 
have a severe problem that we can only hope is not system-wide.
    VA must swiftly address the many problems identified by the GAO in 
its report. They must also clarify what constitutes sexual assault, 
because the lack of a clear, consistent, VA-wide definition has 
allegedly led to many events not being reported or resulted in no 
action on those events that were reported. This is an appalling 
abdication of a solemn responsibility, and it must stop immediately. VA 
must standardize the type of information that will be recorded as well 
as the type of incidents that will be immediately reported to the VA 
Central Office and/or to local law enforcement officials. This will 
help ensure every incident is properly documented, which will lead to 
more thorough investigations, and hopefully help prevent similar 
incidents from occurring at other facilities. This is a zero tolerance 
issue in the military world and in the civilian world; it must be so in 
the VA world, too. Only quick and decisive action will restore public 
confidence in the VA.
    GAO also recommended VA police create a system-wide process that 
would result in cases involving potential felonies to be automatically 
reported to the VA Office of the Inspector General. Frankly, we are 
shocked that such a common-sense Standard Operating Procedure doesn't 
already exist.
    Another critical suggestion by GAO--implementing a centralized 
tracking mechanism for VHA Central Office personnel--speaks volumes 
about the failure of leadership at many levels to understand the 
importance of this issue and respond appropriately.
    The most important issue that we believe is missing is the lack of 
a comprehensive and continuous training program. All efforts to 
properly identify sexual assault and to create programs to forward 
allegations to appropriate officials are in vain if employees aren't 
trained to be vigilant and to identify problem situations. We strongly 
believe that VA must institute an ongoing training program that is 
informative, that encourages people to report what they believe is 
inappropriate, and that is mandatory for all VA employees to attend.
    Today, VA is caring for an ever-increasing caseload of women 
veterans. It is imperative that women come to VA for the care they have 
earned and when they need it. Establishing and maintaining trust is an 
essential ingredient in making sure that happens. Anything less than 
immediate and comprehensive action to remedy this situation could set 
VA back in the proper care of our deserving women veterans.
    Total leadership is essential from everyone in VA. Secretary 
Shinseki and his Senior Executive staff are sincerely involved, and the 
VFW knows they will do everything within their power to end sexual 
assaults in the VA workplace. Yet the solution to stamping out this 
problem is not in Washington; the solution is in the field in every 
Network Director, Medical Center Director, Clinic Director, and their 
senior staffs, frontline supervisors and in every employee. The GAO 
report identifies a shared problem that reflects upon the integrity of 
the entire VA. Its eradication can only lie in a total commitment by 
those very same employees at every level.
    We thank Health Subcommittee Chairwoman Buerkle and Chairman Miller 
for introducing H.R. 2074, the ``Veterans Sexual Assault Prevention 
Act,'' to fix this fractious and ineffective policy by establishing in 
law a comprehensive policy on reporting, tracking, and investigating 
claims of inappropriate sexual and other safety incidents. VA 
leadership has failed in their obligations for too long, and the hidden 
nature of this unacceptable problem requires Congress to act quickly.
    We want the guilty punished, but we also strongly believe that any 
legislation signed into law should specifically direct VA to ensure 
exonerated employees are not indirectly punished professionally. They 
have the most to lose if allegations are not handled properly. The VFW 
does not want to see dedicated employees leave the VA system for this 
reason, so any successful cultural change within VA must include 
protections for innocent employees wrongfully accused. VA must 
recognize this and be prepared to responsibly handle allegations that 
are proven to be false.
    We greatly appreciate the importance this Committee places on this 
issue, and we hope that you will continue to provide the necessary 
oversight to ensure VA responds aggressively to address our concerns.

                                 
Prepared Statement of Richard F. Weidman Executive Director for Policy 
          and Government Affairs, Vietnam Veterans of America
    Madam Chairwoman, Ranking Member Michaud, and distinguished Members 
of the House Veterans' Affairs Subcommittee on Health, Vietnam Veterans 
of America (VVA) appreciates the opportunity to present our views in 
regard to the substance contained in GAO-11-530 report, Preventing 
Sexual Assaults and Safety Incidents at U.S. Department of Veterans 
Affairs Facilities.
    VVA commends Chairman Miller and Ranking Member Filner for 
requesting this review, commends you and Mr. Michaud for holding this 
hearing, and commends the General Accountability Office (GAO) for doing 
their usual measured and thorough report on this volatile issue. My 
name is Rick Weidman, and I have the privilege of serving as Executive 
Director for Policy and Government Affairs at VVA.
    First we note that just as one veteran committing suicide is too 
many, even one sexual assault within the VA facilities anywhere in 
America is too many. Having said that, the context which we consider 
this very serious matter is important. The United States has a rate of 
reported rapes of about 3 per 10,000 of population, which ranks us as 
tenth most in the world of reported rapes. We do not know how many 
employees or how many patients were present at any given time during 
the 30 months of the time period at the five medical centers studied by 
the GAO, so do not know how to compare these terrible statistics to 
that of the population at large. In addition, there does not seem to be 
any way to tell how many sexual assaults go unreported. What we do know 
is that the more seriously rape/sexual assault is taken by the society 
or subset of the society, the more the rate of reporting goes up. That 
does not mean that sexual assault increases, but rather those victims 
become much more likely to report such inexcusable incidents when those 
in positions of authority back up and protect the victim against 
further harm.
    The mere fact that this study was done and that you are having this 
hearing today will have a salutary effect on both making it clear that 
such behavior cannot and will be tolerated against any staff member or 
veteran in the Veterans Health Administration (VHA) system, and 
spurring action to make it less likely that such events will occur in 
the future.
    The recommendations of the GAO that were accepted by the VA are 
sensible steps to improve definitions and reporting, improve training 
in procedures, and take physical steps to reduce risk to both patients 
and staff.
    The initial step of creating a workgroup to define sexual assault, 
and the various manifestations, as well as clarifying when and how such 
incidents should be reported within the VA structure is a wise and 
necessary first step, and with a reasonable deadline of July 15. 
Similarly, creating a centralized tracking mechanism to allow 
management to be able to monitor such assaults is also a much needed 
step.
    Addressing vulnerabilities in physical structures, particularly in 
regard to locked inpatient wards is also a pressing need that should be 
addressed as soon as possible at each and every facility.
    The recommendation about establishing legal histories on 
individuals beyond the self reported information now used is, of 
course, perhaps the trickiest recommendation from the GAO to implement, 
as it involves elements of privacy, ethics, and legal constraints as 
well as perhaps conflicting obligations to all parties concerned. While 
this may be the most difficult task, it is perhaps the most important 
in terms of identifying high risk individuals. Exactly how to do this 
risk assessment in a way that protects others in the medical setting, 
while not compromising the supportive atmosphere necessary for treating 
veterans with mental health issues, will require careful thought, good 
training, and conscientious supervision.
    Among a number of things that would seem to be evident from the 
findings is the need for a standardized ``panic button'' electronic 
device that every staff member can carry on his or her person to alert 
others when faced with imminent physical danger.
    While it is not specifically mentioned in the GAO report in 
question, it is clear that there needs to be separate facilities/wards 
for female patients on the long term treatment wards. It has also long 
been the position of VVA that there is a need for a specific women's 
clinic that does the full range of care, including psychological 
evaluations and treatment. Such a women's clinic should be large enough 
to house most of the elements involved in a ``one stop shop'' for women 
veterans, and be situated in a location that is not isolated within the 
facility while still protecting confidentiality.
    The GAO specifically noted how important it is to have involvement 
of all stakeholders in planning for steps that can and should be taken 
to modify physical structures to better protect personal safety. The 
GAO also noted that all stakeholders should be involved in modifying 
regulations, definitions, reporting pathways, and other elements that 
need to be modified to make VA medical facilities as safe as possible 
for all concerned.
    Perhaps we should not be surprised that conspicuous by absence 
anywhere in the official VA response was any mention of the veterans 
who are the consumers of VA health care. The veterans are clearly 
stakeholders in this process, and the majority of the incidents 
discussed in the report were incidents where a veteran patient was the 
victim. Yet nowhere in the guidance to the local facility or the VISN 
is any mention of the need/importance of consulting veterans or 
veterans' representatives. The VA response also had no mention of 
consulting with veteran stakeholders at the national workgroup level, 
much less having a VSO representative as part of this group.
    This is unfortunately consistent with the attitudes toward veteran 
stakeholders that sometimes seem to pervade much of VHA. Frankly, for 
all the talk about increasing transparency, VHA was much more open and 
transparent 7 years ago than it is today, and seemed to value input 
from veteran stakeholders much more than is the case today. Suffice it 
to say that it is important that stakeholders be consulted at every 
level, and listened to seriously. Further, since the attacks delineated 
in the GAO report are mostly on females, it would seem obvious to us 
that in particular female veterans who are consumers or their 
representatives should be involved in a meaningful way at the national, 
VISN, and at the local medical facility level. Similarly VHA female 
staff members at risk should be involved in the process as well.
    Madame Chairwoman, thank you for the opportunity to appear here 
this afternoon to express the views of VVA. I will be pleased to answer 
any questions, Madam Chair.
                                 
                    Statement of Hon. Russ Carnahan,
        a Representative in Congress from the State of Missouri
    Madam Chairwoman and Members of the Subcommittee, thank you for 
hosting this hearing to discuss the prevention of sexual assault and 
other related safety incidents occurring in VA facilities. Sexual 
assault is one the most severe concerns in any organization and can 
leave lasting physical and mental trauma to the victim. The Government 
Accountability Office (GAO) has helped shed light on this very pressing 
issue, and we need to confront this problem head on.
    We must work together to improve the safety of our VA health 
facilities. And should an incident of sexual assault occur, it must be 
properly documented and adjudicated with the fullest extent of the law. 
Today's hearing provides a important dialogue between Congress and 
those with intimate knowledge of what needs to be done to guarantee the 
safety of our veterans.
    The GAO's findings reveal that nearly 300 cases of sexual assault 
incidents involving rape allegations went unreported to the VA Office 
of the Inspector General. After fighting to protect our Nation, our 
heroes have the right to safe and secure access to the Veterans Health 
Administration system. They also have the right to justice if an 
incident of sexual assault does occur.
    We must ensure that all veterans feel completely comfortable using 
their provided health care locations. This means implementing the 
necessary security precautions in medical facilities, including 
effective alarm systems and closed circuit cameras with continuous 
safety monitoring.
    Consistency and communication are vital. Currently, no VHA-wide 
definition of sexual assault exists. The GAO has recommended the 
creation of a workgroup to establish a new clear definition. This will 
greatly help incident reporting, assessment, and management on all 
levels. Only when every case is properly documented and investigated 
can other similar incidents be prevented. We must work to ensure that a 
centralized reporting and tracking mechanism is implemented. 
Strengthened oversight is key in managing and combating sexual assault 
incidents.
    With a growing number of women veterans, improved VA health 
services are necessary. It is paramount that all veterans receive the 
care they need and deserve. This can only occur if veterans feel safe 
in VA facilities. No victim of sexual assault should feel reluctant to 
report their case. No veteran should fear being ignored or even blamed.
    I look forward to hearing from our witnesses on ways we can ensure 
a safe and secure environment at all VA facilities.
                   MATERIAL SUBMITTED FOR THE RECORD

                                                The American Legion
                                                    Washington, DC.
                                                 September 12, 2011

Ms. Diane Kirkland
Printing Clerk
Committee on Veterans' Affairs
House of Representatives
335 Cannon House Office Building
Washington, DC 20515

Dear Ms Kirkland:

    In reply to your email dated September 7, 2011 regarding 
information you requested for Ms. Verna Jones of The American Legion 
please accept the following testimony:

          ``After a more detailed review of the survey analysis, 18 
        percent of the respondents stated they were ``very 
        dissatisfied'' or ``somewhat dissatisfied.'' Because the 
        question defined `security' as ``physical safety, financial 
        security, access to information, and other privacy 
        sensitivities of the patient'' it is impossible to quantify 
        those who were dissatisfied with physical security versus 
        information security.
          In the second phase of the survey, yet to be initiated, we 
        will be meeting with focus groups and get more specific and 
        anecdotal background to the specific dissatisfaction. Until 
        that is complete, we are left with the overall survey result of 
        18 percent dissatisfaction levels.''

    In addition, attached you will find excerpts from The American 
Legion--Women Veterans Survey 2011, pp. 50-52, which provide further 
information regarding Ranking Member Michaud's request.
    Thank you for your assistance in this matter. If you need further 
information please contact me at 202.861.2700 or [email protected].

                                      Dean Stoline, Deputy Director
                                    National Legislative Commission

Attachment
                               __________
                    The American Legion--WOMEN VETERANS SURVEY 2011
SECURITY
    Security is the freedom from danger, risk or doubt. The SERVQUAL 
attribute of security in The American Legion's Women Veteran's Survey 
also includes consideration for the patient's best interests such as 
privacy and confidentiality (Are dealings with the patient held 
private?).
    This includes physical safety that affirms management's commitment 
to a patient and worker-supportive environment that places as much 
importance on employee safety and health as on serving the patient or 
client.
    Financial security is also included in this category and addresses 
the increased cost of health care, to make sure patients have enough 
income and health care to maintain their health care standard.
    Additionally, this attribute ensures access to information is both 
protected and available with an expected degree of personalization. 
This attribute addresses personalization and the ability to satisfy 
specific needs of individual customers while maintaining privacy for 
customers.
    This includes the ability to acquire customer information in 
exchange for personalized services. Regardless of the nature of 
environments, personalization depends on the knowledge about an 
individual customer and the ability to cater to her needs.
    There are four (4) questions in this category.
Questions--Security

------------------------------------------------------------------------

------------------------------------------------------------------------
Question 56        Security is defined as freedom
                    from danger, risk or doubt.
                    It includes considerations
                    for customer's best interests
                    such as privacy and
                    confidentiality. It also
                    includes physical safety,
                    financial security, access to
                    information and other privacy
                    sensitivities of a patient.
                                                   1=Very Dissatisfied
------------------------------------------------------------------------





                                                   

    Based on the responses, 67 percent of the Women Veterans responding 
stated that they were satisfied or very satisfied with measures of 
security with measures of security defined as freedom from danger, risk 
or doubt, and considerations for customer's best interests in health 
care provided by the VA. In contrast 18 percent of the Women Veterans 
responding stated that they were either very dissatisfied or somewhat 
dissatisfied with physical safety, financial security, access to 
information, and other privacy sensitivities related to Women Veterans 
health care at the VA when compared to private practitioners and other 
health care providers. While the majority indicated favorable 
responses, more than 20 percent were not. This result indicates that 
practices and policies related to security may require additional 
enhancement in order to increase favorable perceptions.

------------------------------------------------------------------------

------------------------------------------------------------------------
Question 57        Based on your perceptions of    1=Poor
                    and satisfaction level with    2=Moderate
                    Women Veterans health care in  3=Good
                    the VA system and other        4=Very Good
                    benefits delivered, how would  5=Exceptional--Best
                    you rank the VA Healthcare
                    System in terms of access to
                    information which is both
                    protected and available with
                    an expected degree of
                    personalization.
------------------------------------------------------------------------






    Based on the responses, 27 percent of the Women Veterans responding 
stated that they would rank the VA Healthcare System as Poor or 
Moderate in terms of access to information which is both protected and 
available with an expected degree of personalization.
    There were 23 percent who ranked the VA as Good in terms of an 
expected degree of personalization while ensuring information is both 
protected and available. However, 16 percent of the Women Veterans 
responding stated that they felt the VA was exceptional to best in this 
regard.

------------------------------------------------------------------------

------------------------------------------------------------------------
Question 58        Based on your perceptions of    1=Poor
                    and satisfaction level with    2=Moderate
                    Women Veterans health care in  3=Good
                    the VA system and other        4=Very Good
                    benefits delivered, how would  5=Exceptional--Best
                    you rank the VA Healthcare
                    System in terms of
                    sensitivity to the patient's
                    personal information and the
                    collection and storing of
                    patient information?
------------------------------------------------------------------------






    Fully 25 percent of the Women Veterans responding stated that they 
would rank the VA Healthcare System as either Poor or Moderate in terms 
of sensitivity to the patient's personal information and the collection 
and storing of patient information.
    There were 23 percent who ranked the VA Healthcare System as Good 
in terms of sensitivity to the patient's personal information. 52 
percent of the Women Veterans responding stated that they rank the VA 
Healthcare System as Exceptional-Best or Very Good. While nearly 75 
percent rated this area favorably, a 25 percent negative evaluation 
suggests significant room for improvement in the view of Women 
Veterans.

------------------------------------------------------------------------

------------------------------------------------------------------------
Question 59        How would you COMPARE the       1=Very Dissatisfied
                    security and privacy           2=Somewhat
                    protection mechanisms for       Dissatisfied
                    health care provided by the    3=Neither Satisfied
                    VA to private practitioners     nor Dissatisfied
                    and other health care          4=Somewhat Satisfied
                    providers?                     5=Very Satisfied
------------------------------------------------------------------------






    When compared to private practitioners and other health care 
providers, Women Veterans were slightly more positive. Of the 
respondents, 17 percent stated that they were either Very Dissatisfied 
or Somewhat Dissatisfied with the security and privacy protection 
mechanisms for health care provided by the VA when compared to private 
practitioners and other health care providers.
    Of the Women Veterans responding 67 percent stated that they were 
Somewhat Satisfied or Very Satisfied with security and privacy 
protection mechanisms for health care provided by the VA.
Observations and Recommendations--Security
    Security is defined as freedom from danger, risk, or doubt, and 
includes consideration for customers' best interests such as privacy 
and confidentiality. It also includes physical safety, financial 
security, access to information, and other privacy sensitivities. 
Nearly 75 percent of the respondents rated the sensitivity to patients' 
personal information (question 58) favorably (Good or higher), and 67 
percent stated that they were Satisfied or Very Satisfied with the 
security and privacy protection mechanisms provided by the VA (question 
59). On the other hand, 17 percent of the women veterans suggest that 
there is room for improvement in Security-related issues for the VA 
health care services.

                                 
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