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



 
              LEGISLATIVE HEARING ON H.R. 198, H.R. 1154,
         H.R. 1855, H.R. 2074, H.R. 2530, AND DRAFT LEGISLATION

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

                                HEARING

                               before the

                         SUBCOMMITTEE ON HEALTH

                                 of the

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

                      ONE HUNDRED TWELFTH CONGRESS

                             FIRST SESSION

                               __________

                             JULY 25, 2011

                               __________

                           Serial No. 112-26

                               __________

       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

                               __________

                             July 25, 2011

                                                                   Page
Legislative Hearing on H.R. 198, H.R. 1154, H.R. 1855, H.R. 2074, 
  H.R. 2530, and Draft Legislation...............................     1

                           OPENING STATEMENTS

Chairwoman Ann Marie Buerkle.....................................     1
    Prepared statement of Chairwoman Buerkle.....................    35
Hon. Michael H. Michaud, Ranking Democratic Member...............     3
    Prepared statement of Congressman Michaud....................    36

                               WITNESSES

U.S. Department of Veterans Affairs, Robert L. Jesse, M.D., 
  Ph.D., Principal Deputy Under Secretary for Health, Veterans 
  Health Administration..........................................    26
    Prepared statement of Dr. Jesse..............................    56
American Veterans (AMVETS), Christina M. Roof, National Acting 
  Legislative Director...........................................    19
    Prepared statement of Ms. Roof...............................    52
Bucshon, Hon. Larry, a Representative in Congress from the State 
  of Indiana.....................................................     7
    Prepared statement of Congressman Bucshon....................    38
Carter, Hon. John R., a Representative in Congress from the State 
  of Texas.......................................................    21
    Prepared statement of Congressman Carter.....................    39
Disabled American Veterans, Joy J. Ilem, Deputy National 
  Legislative Director...........................................    15
    Prepared statement of Ms. Ilem...............................    43
Grimm, Hon. Michael G., a Representative in Congress from the 
  State of New York..............................................     4
    Prepared statement of Congressman Grimm......................    37
Paralyzed Veterans of America, Carl Blake, National Legislative 
  Director.......................................................    18
    Prepared statement of Mr. Blake..............................    48
Veterans of Foreign Wars of the United States, Shane Barker, 
  Senior Legislative Associate, National Veterans Service........    13
    Prepared statement of Mr. Barker.............................    41
Vietnam Veterans of America, Thomas J. Berger, Ph.D., Executive 
  Director, Veterans Health Council..............................    16
    Prepared statement of Dr. Berger.............................    47
Walz, Hon. Tim, a Representative in Congress from the State of 
  Minnesota......................................................     6
    Prepared statement of Congressman Walz.......................    37

                       SUBMISSIONS FOR THE RECORD

National Association of State Veterans Homes, Fred S. Sganga, 
  President, statement...........................................    63
Paws for Purple Hearts, Rick A. Yount, Director, statement.......    66
Pets2Vets, David E. Sharpe, Chairman of the Board, statement.....    73
Servicewomen's Action Network, Greg Jacob, Policy Director, 
  statement......................................................    75
Tipton, Hon. Scott R., a Representative in Congress from the 
  State of Colorado, letter......................................    76
VetsFirst, a Program of United Spinal Association, Heather L. 
  Ansley, Esq., MSW, Director of Veterans Policy, statement......    77
Wounded Warrior Project, statement...............................    78

                   MATERIAL SUBMITTED FOR THE RECORD

John R. Gingrich, Chief of Staff, U.S. Department of Veterans 
  Affairs, to Randall Williamson, Director, Health Care, U.S. 
  Government Accountability Office, letter and enclosures, dated 
  August 5, 2011, providing an update on actions taken by VA in 
  response to the eight recommendations contained in GAO's June 
  7, 2011, report entitled, ``VA Health Care: Action Needed to 
  Prevent Sexual Assaults and Other Safety Incidents'' (GAO-11-
  530)...........................................................    81


LEGISLATIVE HEARING ON H.R. 198, H.R. 1154, H.R. 1855, H.R. 2074, H.R. 
                      2530, AND DRAFT LEGISLATION

                              ----------                              


                         MONDAY, JULY 25, 2011

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                    Subcommittee on Health,
                                                    Washington, DC.

    The Subcommittee met, pursuant to notice, at 4:10 p.m., in 
Room 334, Cannon House Office Building, Hon. Anne Marie Buerkle 
[Chairwoman of the Subcommittee] presiding.
    Present: Representatives Buerkle, Bilirakis, Roe, Runyan, 
Michaud, Carnahan, and Donnelly.

            OPENING STATEMENT OF CHAIRWOMAN BUERKLE

    Ms. Buerkle. Good afternoon. This hearing will now come to 
order.
    Today we meet to discuss a number of legislative proposals 
aimed at improving the care provided to our Nation's veterans 
through the U.S. Department of Veterans Affairs (VA). The seven 
bills on our agenda today are H.R. 198, the ``Veterans Dog 
Training Therapy Act, H.R. 1154, the ``Veterans Equal Treatment 
for Service Dogs Act,'' H.R. 1855, the ``Veterans Traumatic 
Brain Injury Rehabilitative Services Act of 2011,'' H.R. 2074, 
the ``Veterans Sexual Assault Prevention Act,'' H.R. 2530, a 
bill to provide for increased flexibility in establishing 
reimbursement rates for nursing home care provided to certain 
veterans in State homes; draft legislation, the ``Veterans 
Health Care Capital Facilities Improvement Act of 2011,'' and 
draft legislation, the ``Honey Sue Newby Spina Bifida Attendant 
Care Act.''
    This hearing represents an important step in the 
legislative process; and, as such, I look forward to a frank 
and productive conversation about the policy implications, 
merits, and potential unintended consequences of each of the 
proposals on our agenda today.
    One of the bills we will discuss this afternoon is H.R. 
2074, the ``Veterans Sexual Assault Prevention Act,'' a bill I 
introduced in response to a truly alarming report issued last 
month by the U.S. Government Accountability Office (GAO) on the 
prevalence of sexual assault and other safety instances in VA 
facilities. I am pleased to sponsor this legislation with our 
Chairman, Jeff Miller, and with Ranking Members Bob Filner and 
Mike Michaud as co-sponsors.
    In their report, the GAO found that between January of 2007 
and July of 2010, nearly 300 sexual assaults, including 67 
alleged rapes, were reported to the VA police. Troubling and in 
direct violation of Federal regulations and VA policy, many of 
these incidents were not properly reported to VA leadership 
officials or the VA Office of the Inspector General (OIG).
    As disturbing, GAO uncovered serious deficiencies in the 
guidance and oversight provided by VA leadership officials on 
the reporting, the management, and the tracking of sexual 
assault and other safety incidents.
    GAO also found that the Department failed to accurately 
assess risk or take effective precautionary measures, with 
inadequate monitoring of surveillance systems and 
malfunctioning or failing panic alarms.
    As someone who has been a domestic violence legal 
counselor, I have seen firsthand the pervasive and damaging 
effects of sexual assault and the effect it can have on the 
lives of those who experience it. Abusive behavior, like the 
kind documented by GAO, is unacceptable in any form. But for it 
to be found in what should be an environment of caring for our 
honored veterans is simply intolerable and unacceptable.
    H.R. 2074 would address the safety vulnerabilities, 
security problems, and oversight failures identified by GAO and 
create a fundamentally safer environment for veteran patients 
and VA employees. Specifically, H.R. 2074 would require VA to 
develop clear and comprehensive criteria with respect to the 
reporting of sexual assaults and other safety incidents for 
both clinical and law enforcement personnel.
    It would establish a newly accountable oversight system 
within the Veterans Health Administration (VHA), to include a 
centralized and comprehensive policy on the reporting and 
tracking of sexual assaults covering all alleged or suspected 
forms of abusive or unsafe acts, as well as the systematic 
monitoring of reported instances to ensure each case is fully 
investigated and victims receive the appropriate care.
    To correct serious weaknesses observed in the physical 
security of VA medical facilities and to improve the 
Department's ability to appropriately assess risk and take the 
proper preventative steps, H.R. 2074 would mandate the 
Department to develop risk-assessment tools, create a mandatory 
safety awareness and preparedness training program for 
employees, as well as to establish physical security 
precautions, including appropriate surveillance and panic alarm 
systems that are operable and regularly tested.
    It is critical and very important that we take every 
available step to protect the personal safety and well-being of 
the veterans who seek care through our VA system and all of the 
hardworking employees who strive to provide that care on a 
daily basis. I am eager to discuss H.R. 2074 this afternoon, 
and I am here to answer any questions that my colleagues might 
have regarding this legislation.
    Also on our agenda today is a draft Committee proposal, the 
``Veterans Health Care Capital Facilities Improvement Act of 
2011.'' This draft legislation incorporates the 
Administration's fiscal year 2012 construction request to 
authorize major medical facility projects and leases. The draft 
proposal also modifies the statutory requirements for the 
Department to provide a prospectus to Congress when seeking 
authorization for a major medical facility project to ensure 
that Congress receives a comprehensive and accurate cost-
benefit analysis as the basis for making these critical 
decisions.
    This bill also extends authorities to provide for important 
programs related to such initiatives as housing assistance for 
homeless veterans and treatment and rehab for veterans with 
serious mental illness, both of which are set to expire at the 
end of this calendar year. Additionally, section 6 of the draft 
bill seeks to provide an extension of the VA's enhanced use 
lease authority, which is also set to expire this year.
    This authority is an innovative and vitally important 
approach to supporting goals we all share, such as reducing 
homelessness among our veteran population and making effective 
use of vacant or underutilized VA property through public-
private partnerships. Unfortunately, the Congressional Budget 
Office (CBO) has scored this provision with a mandatory 
spending cost of $700 million. We want to work with the 
Department and the veterans service organizations (VSOs) to 
resolve this scoring issue to ensure that the VA has the 
authority to continue utilizing this extremely important 
program.
    The draft bill also includes legislation that was brought 
to us by our colleague from Colorado, Scott Tipton, to 
designate the Telehealth Clinic at Craig, Colorado, as the 
Major William Edward Adams Department of Veteran Affairs 
Clinic. Major William Edward Adams is a Medal of Honor 
recipient, and Scott has provided a statement for the record 
detailing Major Adams' courageous service to our country.
    I want to thank all of the Members who sponsored bills and 
draft legislation before us today, as well as the witnesses 
from the veteran service organizations, as well as the VA, for 
taking time out of their busy schedules to share their 
expertise with us this afternoon. I look forward to our 
discussion; and I will now yield to the Ranking Member, Mr. 
Michaud, for any opening statement he may have.
    [The prepared statement of Chairwoman Buerkle appears on p. 
35.]

          OPENING STATEMENT OF HON. MICHAEL H. MICHAUD

    Mr. Michaud. Thank you very much, Madam Chair. I, too, 
would like to thank everyone for coming today.
    Today's legislative hearing is an opportunity for Members 
of Congress, veterans, the VA, and other interested parties to 
provide their viewpoint and discussion of legislation that is 
before the Subcommittee this afternoon. We have seven bills, as 
you heard earlier, before us today, which address a number of 
important issues to our veterans and provide the staff of the 
Department of Veterans Affairs with the necessary tools to 
provide the best care for our veterans.
    First, we have two bills to help veterans with post-
deployment mental health issues through training service dogs. 
The remainder of the legislation covers a wide range of topics, 
such as improved traumatic brain injury (TBI) care, sexual 
assault prevention, facility construction, and spina bifida.
    We will also examine my bill, H.R. 2530, which seeks to 
increase the flexibility in payments for State veterans homes. 
It would require State veterans homes and the VA to enter into 
a contract for the purpose of providing nursing home care to 
veterans who need such care for service-connected conditions or 
have a service-connected rating of 70 percent or greater.
    We have been dealing with this issue since 2006. It took 2 
years for the VA to implement the rules and regulations. Then 
it has taken a couple of years for us to really get to the 
point where we are today, that we hopefully will be able to 
move this legislation forward so we can deal with the 
reimbursement rate issues for State veterans nursing homes 
before I get to an age where I might be needing a State 
veterans nursing home. So, hopefully, we will be able to get 
this dealt with this Congress.
    So, with that, I yield back, Madam Chair.
    [The prepared statement of Congressman Michaud appears on 
p. 36.]
    Ms. Buerkle. Thank you very much.
    We will now turn to our first panel here today. It is an 
honor to be able to recognize such a distinguished group of my 
colleagues joining us this afternoon to discuss the legislation 
that they have introduced.
    First is Michael Grimm, a fellow New Yorker and a Marine 
Corps veteran. Thank you for your service, and thank you for 
being here today. Next to Mr. Grimm is Tim Walz, a 24-year 
veteran of the National Guard and a lifetime member--a long-
time, sorry, not lifetime--long-time Member of this Committee. 
And Dr. Larry Bucshon, a Hoosier from the State of Indiana.
    Welcome to all of you. Thank you for taking the time to be 
here today.
    And, Mr. Grimm, we will start with you and your testimony.

   STATEMENTS OF HON. MICHAEL G. GRIMM, A REPRESENTATIVE IN 
 CONGRESS FROM THE STATE OF NEW YORK; HON. TIMOTHY J. WALZ, A 
  REPRESENTATIVE IN CONGRESS FROM THE STATE OF MINNESOTA; AND 
HON. LARRY BUCSHON, A REPRESENTATIVE IN CONGRESS FROM THE STATE 
                           OF INDIANA

               STATEMENT OF HON. MICHAEL G. GRIMM

    Mr. Grimm. Madam Chair, thank you very much. It is always 
good to see a fellow New Yorker.
    Ranking Member Michaud and all the Members of the 
Committee, thank you so much for allowing me the honor of 
testifying today on H.R. 198, the ``Veterans Dog Training 
Therapy Act.''
    As a Marine combat veteran, it is a unique honor for me to 
address this Committee. Having seen firsthand both the physical 
and mental wounds of war that the members of our Nation's 
military are faced with, I have a special appreciation for the 
important work this Committee does every day.
    Today, over two million Iraq and Afghanistan veterans have 
returned home to the challenge of an unemployment rate hovering 
near 10 percent, which for disabled veterans is actually closer 
to 20 percent. And, for many, the long road to recovery from 
the mental and physical wounds sustained during their service, 
sadly these numbers continue rising.
    Over the last 6 months, I have had the honor to meet with a 
number of our Nation's heroes who are now faced with the 
challenges of coping with PTSD and physical disabilities 
resulting from their service in Iraq and Afghanistan. It was 
these personal accounts of their recovery, both physical and 
mental, and the important role therapy and service dogs played 
that inspired my role in this legislation.
    The ``Veterans Dog Training Therapy Act'' would require the 
Department of Veterans Affairs to conduct a 5-year pilot 
program in at least three but not more than five VA medical 
centers assessing the effectiveness and addressing post-
deployment mental health and post-traumatic stress disorder 
(PTSD) throughout the therapeutic medium of training service 
dogs for veterans with disabilities. These trained service dogs 
are then given to physically disabled veterans to help them 
with their daily activities. Simply put, this program treats 
veterans suffering from PTSD while at the same time aiding 
those suffering from physical disabilities.
    Since I introduced this legislation, it has gained the 
bipartisan support of 84 co-sponsors, including Financial 
Services Committee Chairman Spencer Bachus and Ranking Member 
Barney Frank, as well as Congressman Pete Sessions and Steve 
Israel. Clearly, this legislation has brought together a number 
of unlikely allies in support of our Nation's veterans.
    Additionally, with veteran suicide rates at an all-time 
high and more servicemen and women being diagnosed with PTSD, 
this bill meets a crucial need for additional treatment 
methods. I believe that by caring for our Nation's veterans 
suffering from the hidden wounds of PTSD, while at the same 
time providing assistance dogs to those with physical 
disabilities, we create a win-win for everyone, which I believe 
is a goal we can all be proud of.
    Working in conjunction with a number of veteran service 
organizations, including AMVETS and VetsFirst, I have drafted 
updated language which I intend to have submitted during 
Committee markup to ensure this program provides our Nation's 
veterans with the highest quality of care for both PTSD and 
physical disabilities while maintaining my commitment to fiscal 
responsibility.
    I understand that in the current economic situation we are 
faced with especially important decisions, decisions that must 
ensure that taxpayer dollars are spent wisely, which is why I 
have identified several possibilities to offset and to make 
sure that this legislation meets the PAYGO requirements. As we 
move forward in the legislative process, I look forward to 
working with this Committee to ensure that any money allocated 
for this program is offset by reductions in other accounts.
    Again, I would like to thank the Committee for holding 
today's hearing, and I look forward to working with you to 
ensure that this program is included in your continuing efforts 
to guarantee that our Nation's heroes have the best possible 
programs for treating PTSD and providing disability assistance.
    I would like to extend a special thank you to the Ranking 
Member for helping me move this legislation along and, again, 
to everyone that works so hard every day on this Committee to 
ensure our veterans have the very best that we have to offer in 
Congress.
    With that, I yield back. Thank you.
    [The prepared statement of Congressman Grimm appears on p. 
37.]
    Ms. Buerkle. Thank you, Mr. Grimm.
    Mr. Walz.

               STATEMENT OF HON. TIMOTHY J. WALZ

    Mr. Walz. Thank you, Madam Chairwoman and Ranking Member 
Michaud. It is a privilege to be here in front of you. I know 
what each of you and Members of this Committee give to the care 
of our veterans. You are truly the voice of a grateful Nation 
to provide the care and benefits that our warriors so bravely 
earned.
    And I would also like to note the great landmark 
legislation that comes out of this Committee. This Committee 
conducts itself in a manner that is the envy of all of Congress 
in a bipartisan manner, with the sole focus on caring for our 
veterans. So, Chairwoman, I congratulate you on keeping that 
great tradition alive and am very appreciative to be here.
    The piece of legislation I am introducing, H.R. 1855, the 
``Traumatic Brain Injury Rehabilitative Services Improvement 
Act,'' was introduced last year along with Chairman Miller and 
Congressman Bilirakis. I am very appreciative of getting this 
opportunity to hear on this and hopefully moving it to markup.
    As my colleague and another veteran so clearly indicated, 
an unprecedented number of warriors are returning from our 
wars, having served proudly. Having witnessed and been many 
occasions to the polytrauma center in Minneapolis, I have seen 
the incredible battlefield care that is being given to these 
severely wounded warriors.
    But traumatic brain injuries as they come back are the most 
complex of these injuries. Each case is unique. The injuries 
can result in a wide-ranging loss of function. Neurological and 
cognitive loss, impairments in speech, vision, and memory are 
not uncommon, as is marked changes in behavior and 
manifestations such as diminished capacity to self-regulate.
    It is very difficult to predict the extent of an 
individual's ultimate level of recovery, but the evidence is 
very clear that, to be effective in helping an individual 
recover from a brain injury and return to life as independent 
and productive as possible, rehabilitation must be targeted to 
the specific needs of the individual patient.
    This piece of legislation is aimed at closing the gaps in 
current law that have an effect of denying some veterans with 
severe TBI from achieving optimum outcomes. I want to be very 
clear. Our VA facilities and the polytrauma centers are 
providing the best care anywhere in the world. One of the 
things this piece of legislation does is it codifies what and 
should be provided to those veterans. That scope of services is 
limited, in many cases.
    Veterans encounter two problems. First, all too common for 
families to be advised the VA can no longer provide a 
particular rehabilitative service because the veteran is no 
longer making significant progress as it is written now. But 
ongoing rehabilitation is often needed just to maintain 
function, and individuals who are denied maintenance therapy 
can regress and lose cognitive gains they have made through a 
lot of hard work.
    A second problem is veterans encounter getting help with 
community reintegration, learning to live as independently as 
possible. VA's rehabilitation focus relies almost exclusively 
on a medical model. That assistance is critical but doesn't 
necessarily go far enough for some veterans in providing range 
of support and services.
    In contrast, other models of rehabilitative care meet TBI 
patients' needs through services such as life-skills coaching, 
supported employment, and community reintegration. These 
services are seldom made available to veterans.
    H.R. 1855 would correct that. Specifically, it would 
clarify that the VA not prematurely cut off needed 
rehabilitative services for an individual with a traumatic 
brain injury, and that veterans with TBI can get the support 
they need, whether those are health services or nonmedical 
assistance, to achieve maximum independence and quality of 
life.
    I understand that the VA expressed some concerns with some 
of the wording, not because they don't want to achieve this and 
not because they don't believe it is important, it was simply 
in some of the language. Those have been addressed with a 
companion version that is being championed by one of our former 
colleagues and a Member of this Committee, Senator Boozman and 
Senator Begich. They have that piece of legislation over there; 
and it is my hope that if we get the opportunity, we certainly 
have an amendment in the nature of a substitute, Madam 
Chairwoman, that would address those very needs, and the VA 
would be satisfied with that.
    I am gratified by the broad support. You understand, Madam 
Chairwoman, Ranking Member, and all Members of this Committee, 
the veterans' backs are covered by those people sitting behind 
me, the veteran service organizations who made this a top 
priority. I am really pleased with all of the support they put 
into it.
    And I would like to give one quote from the Wounded Warrior 
Project. Their Executive Director, Steve Nardizzi, described 
this bill as ``powerfully addressing the often agonizing 
experience of wounded warriors who have been denied important 
community reintegration supports and who have experienced 
premature termination of rehabilitation services.'' As Steve 
said, ``This bill offers new hope to these warriors and their 
families.''
    So I look forward to responding to any questions, Madam 
Chairwoman. Again, I thank you so very much for letting us 
bring this piece of legislation forward. I will be glad to 
answer any questions, and I yield back.
    [The prepared statement of Congressman Walz appears on p. 
37.]
    Ms. Buerkle. Thank you very much.
    Mr. Bucshon.

                STATEMENT OF HON. LARRY BUCSHON

    Mr. Bucshon. Thank you, Chairwoman Buerkle, Ranking Member 
Michaud, and Members of the Subcommittee for the opportunity to 
come and speak to you today about my draft legislation, the 
``Honey Sue Newby Spina Bifida Attendant Care Act.''
    In April of this year, I was contacted by a constituent 
from New Harmony, Indiana, Mr. Ron Nesler, on behalf of his 
stepdaughter, Honey Sue Newby. Honey Sue's father was a Vietnam 
veteran exposed to Agent Orange, and she was born with a 
complicated neurological disorder rooted in spina bifida, a 
congenital condition in which the vertebrae do not form 
properly around the spinal cord. The Veterans Administration 
has previously determined Honey Sue's condition is a direct 
result of her father's exposure to Agent Orange in Vietnam and 
have classified her as a Level III child, making her eligible 
to receive the same full health coverage as a veteran with 100-
percent service-connected disability.
    In 2007, Mr. Nesler and his wife reached out to my 
predecessor, former Representative Brad Ellsworth, regarding 
two issues they had been experiencing with the VA. The first 
was an administrative burden requiring a letter from Honey 
Sue's doctor explaining exactly how the treatment she sought 
was related to her spina bifida. More often than not, this 
resulted in the VA denying repayment until additional 
burdensome administrative procedures took place. For example, 
Honey Sue needed surgery on her mouth after seizures caused her 
to grind her teeth to nubs. The VA originally denied payments 
for the procedure, saying the doctor's letter did not clearly 
make the case that this result was from her condition.
    Secondly, Honey Sue's parents are aging and experiencing 
health problems. Currently, the only long-term services the VA 
will pay for is nursing home care for individuals like Honey 
Sue. As a physician, I know that nursing home care is both 
extremely expensive and inappropriate for what Honey Sue needs. 
Individuals with spina bifida have a diverse range of needs. 
Although no two cases of spina bifida are ever the same, the 
National Spina Bifida Association confirms the majority of 
these individuals can live independently if they have the 
proper habilitative care in order to develop, maintain, or 
restore their functioning.
    Former Representative Ellsworth's bill, H.R. 5729, was 
written to address both of these issues and on May 20, 2008, 
was passed by a voice vote in the House of Representatives and 
was later added to S. 2162, the Veterans Mental Health and 
Other Care Improvement Act of 2008, and was signed into law by 
President Bush on October 10, 2008.
    Since then, the VA has recognized and alleviated the 
administrative burdens but has not properly interpreted the 
``habilitative care''. Title 38 of the U.S. Code defines 
habilitative care as professional, counseling and other 
guidance services and treatment programs--other than vocational 
training under section 1804 of this title--as are necessary to 
develop, maintain, or restore, to the maximum extent 
practicable, the functioning of a disabled person. Under this 
language, I believe the VA is misinterpreting the law and its 
intent as it concerns individuals with type III spina bifida 
who simply need supervisory, or as we put in the draft 
legislation, home and community-based care.
    The purpose of this draft legislation is to clarify title 
38 to allow individuals with spina bifida the appropriate and 
cost-effective care that they deserve. The intended result 
allows individuals to take advantage of home and community 
based care for those that do not need constant medical care. 
The term ``home and community based care'' is used in a 
definition of habilitative care in section 1915 of the Social 
Security Act, and this legislation is modeled after and aims to 
create consistency for that definition within VA services.
    Again, thank you for consideration of the legislation. It 
is a pleasure to be here and an honor to be here, and I am 
happy to answer any of your questions. Thank you.
    [The prepared statement of Congressman Bucshon appears on 
p. 38.]
    Ms. Buerkle. Thank you very much.
    I will now yield myself 5 minutes for questions. I will 
start with Mr. Grimm.
    First of all, thank you for introducing this legislation. I 
think that we all understand, and as time goes on we understand 
even more, the emotional toll that these wars have on those 
returning home. This legislation is a good opportunity and a 
good mechanism for us to look at ways that we can most 
effectively treat those coming home with PTSD.
    One of the questions that was raised by the Veterans of 
Foreign Wars (VFW) regarding H.R. 198, and I would like you to 
just respond to this if you could, they said, ``We do not 
believe a VA medical center is the right environment for a 
pilot program involving dog training. We believe the idea 
behind this legislation would be better achieved through 
established private-sector organizations with sufficient 
oversight by the VA.''
    Could you comment on that for me, please?
    Mr. Grimm. Certainly. I disagree with the VFW because it is 
a pilot program. Ultimately, I think that this pilot will be 
very successful, and it will grow, and then it should be more 
community based and have much more private-sector interaction.
    But for the beginning stage, to take this from where it is 
now as purely a pilot within 3 to 5 sites, I think that we need 
the proper oversight, assessment, and valuation that can be 
better achieved in an environment like the VA setting. I also 
think it will be cheaper right now to be able to do that and 
will yield better assessments in valuations because of the 
controlled environment.
    Now, once it is proven successful and we want to expand 
this program throughout the United States, then I would agree 
that it should be more community based and have much more 
interaction with private industry and allow that to grow. And I 
think then it would actually be cheaper--it will be more cost-
effective, I should say, for communities to get more involved. 
But, right now, in its infancy stages, I think that we need the 
control of the environment to fully assess and evaluate the 
efficiency and benefits of the program.
    Ms. Buerkle. Thank you.
    And just as a follow-up, with the dog therapy program, have 
they identified cases of PTSD where it may be more or less 
successful, which veterans may benefit from this treatment or 
may not? Have they made any distinction about the cases of PTSD 
and who might benefit from this program?
    Mr. Grimm. That is an excellent question, Madam Chair. My 
experience so far has been that, amazingly, the work with these 
animals, with these dogs, has helped already a very, very wide 
spectrum of cases.
    One in particular comes to mind where a young soldier 
returned and would not speak with anyone, did not want to 
speak, was pent up with a tremendous amount of anger, went for 
counseling, would not speak to the counselor and was leaving. 
On his way out from counseling, walking out, there was someone 
walking with a dog, and the dog went up to him, and he pet the 
dog. It was the only interaction that this veteran really had. 
He wouldn't speak with anyone else, didn't want to, he shut the 
world out except for this dog.
    And someone there noticed how perceptive the dog was to go 
over to this soldier and the interaction they had in just a few 
minutes. And they contacted the veteran again and said, would 
you come back and be willing to work with some of our dogs? And 
it just completely changed that veteran's life.
    So I think there is no way to say that there is one 
specific type of veteran that has post-traumatic stress. It 
really is a very wide spectrum, which is why I think this 
program is going to have tremendous success.
    I yield back.
    Ms. Buerkle. Thank you very much.
    Mr. Walz, first of all, let me thank you as well for 
bringing forth this piece of legislation and making sure that 
there are no institutional barriers between the veterans and 
the care they need with TBI. There has been some concern 
regarding the term ``quality of life,'' that the VA will exceed 
their statutory mission. Can you speak to that? And I am 
hopeful that we can, in amendment language, address that issue.
    Mr. Walz. Yes. You are absolutely right. That was the piece 
of legislation, the qualifying language on quality of life. And 
again, as I said, not because the VA doesn't want to achieve 
the highest quality of life. They think it is more subjective 
instead of an objective measure of what they are doing. That 
word was struck from the Senate version, and they are agreeable 
for all the other procedures that went through or all the other 
barriers that were there coming down. The amendment that we 
would offer would be that identical language, and the Senate 
was acceptable to the VA.
    Ms. Buerkle. Thank you very much.
    I now yield to the Ranking Member, Mr. Michaud, 5 minutes 
for questions.
    Mr. Michaud. Thank you very much, Madam Chair.
    I want to thank the three panelists this afternoon for 
taking the time to put forward legislation that will definitely 
help our veterans get through life and I really appreciate your 
willingness to do that and for your service to this country as 
well. I have no question for the panelists, so I yield back.
    Ms. Buerkle. Thank you, Mr. Michaud.
    Mr. Runyan. I now yield 5 minutes to the gentleman from New 
Jersey.
    Mr. Runyan. Thank you, Madam Chair; and thank all of you 
for bringing these bills in front of us.
    Mr. Grimm, as I am a co-sponsor on the piece of 
legislation, I agree with much of what you are trying to do.
    I just wanted to really say for the record that I actually, 
probably back in February, had a constituent of mine who is a 
Marine, much like yourself, come to my district office with his 
dog. And to listen to his wife tell the story of how it has 
changed his life, for him to be able to go out and interact 
with people. It almost gets to the point where the dog is a 
conversation piece that gets him back into society. And I have 
seen the gentleman three or four times since then in many 
different settings, whether it is out where he is actually 
heading a similar program trying to do it himself.
    But, again, we lack the funding to do it, and I think that 
is kind of the sticking point here.
    But to hear his story and to go actually on a camping trip 
with my daughters, and he happened to be there at the same one, 
and to hear his wife come to me at the next event we were at 
and said he wouldn't have been able to do that a year ago--just 
kind of place that.
    Because we always talk about the positive impact, whether 
it is veterans or seniors, that animals have on them. I applaud 
you for getting out in front of this, because I think it is 
worthwhile. I think, as you said in your statement, though, 
figuring out how we are going to pay for it is ultimately going 
to be the decision about how we are going to do this. Because 
there is a lot of upside to it, so I thank you for that.
    And, also, Mr. Walz, thank you for what you are trying to 
do there. I have experienced and I deal with it myself. When 
you talk about brain injuries, I don't think we necessarily 
understand the long-term, life-term commitment that we have to 
have. And to really say somebody has totally recovered and we 
are going to stop treatment I don't think is reflective of that 
commitment. I have seen many of my past colleagues in my past 
career with brain injuries be 30, 40 years old and have full 
onset dementia and can't function.
    It brings back a gentleman that I played against that was 
working on Wall Street and had to quit because he couldn't 
function anymore. So we really do have to not turn him away and 
simply say we have them to the level they are at and then 
that's it.
    There have been many other instances of that where I have 
had people come and visit me. We have come so far with things 
like Down Syndrome where they were just trying to get these 
kids just to get out of high school. I have had several people 
come to my office and say, my son wants to go to college, and 
there is nothing there for them.
    We really have to take a long-term approach to this, and I 
just wanted to thank all of you for bringing this up.
    I yield back.
    Ms. Buerkle. Thank you, Mr. Runyan.
    I yield 5 minutes to Mr. Donnelly.
    Mr. Donnelly. Thank you, Madam Chair.
    I just wanted to thank my fellow colleagues for your 
efforts on behalf of our veterans and for bringing these bills 
forward. Thank you very much.
    Ms. Buerkle. Thank you.
    I yield 5 minutes to Dr. Roe.
    Mr. Roe. Thank you. And also thank you for your service and 
thank you for being here today.
    And, Congressman Grimm, I will be on your legislation or I 
won't ever be able to go home. I have a wife that has done pet 
therapy for years, and it is tremendously beneficial for 
seniors. Certainly don't see any reason it wouldn't be 
beneficial.
    We already know--we had a veteran in our office just this 
past week that brought his dog. It was a bomb dog in 
Afghanistan, and now he is with this Marine and it helps him to 
know when he is going to have seizures; the dog can pick it 
out. So they are tremendous amounts of help, and so certainly I 
will support that.
    And you are correct about finding the resources. One of the 
things I think we have is a commitment to our soldiers coming 
home to understand that we have a lifetime commitment to them, 
not a 1 week or a 1 year or a 5 year. We have for these men and 
women who go, as you have and Sergeant Major Walz has, to give 
your time and your treasure for this country, this country has 
a lifetime commitment, period, to taking care of that, whatever 
it may be.
    So, having said that, I didn't hear--I read your testimony, 
Sergeant Major. But if you would help me a little bit here. 
Would there be any part in this--we have a brain injury--I 
won't go into why it is there--but there is a brain injury 
center, a private brain injury center, in our area that takes 
care of traumatic brain injury from the most severe to mild 
injury. Is there any way or any--I guess, way that a veteran 
could be treated on the private side with your Act?
    Mr. Walz. Well, this one addresses, Dr. Roe--and, again, 
thank you. Thank you for your service and your unwavering 
commitment to this Committee of getting things done. This 
addresses the VA's responsibility, but it does deal with that 
reintegration piece of trying to get them back into the 
community. And at that point in time, we are certainly very 
interested to see what happens when these--and many of them, as 
you know, are rural veterans, where they move from the 
polytrauma centers that are doing fabulous work, and trying to 
keep this maintenance of effort to keep them out or, as Mr. 
Runyan said, to move them on in this rehabilitation is 
critically important.
    So we didn't address it in the specifics at that point, 
because, again, as Mr. Grimm said, we are looking at cost 
benefits, and this one the VA shows as no added cost. But it 
does start to bring to bear those outside resources that can be 
there to move them back in. So I am certainly interested in 
looking at that with you and see how we can do that, of making 
sure all those resources, public and private, are brought to 
bear to the benefit of those veterans.
    Mr. Roe. Certainly in young people who have brain injury we 
are just learning how much recovery you can experience, and it 
can be very dramatic. I mean, I have seen--and it may not be 
for someone who is right there side by side, day by day. But 
when you are seeing it, as I did, we see a patient in 6 months 
or 3 months or year intervals, you would notice dramatic 
changes.
    And that was what I learned over time, was it used to be 
when you had a brain injury that was just the way--you were 
just stuck with that the rest of your life--that is not true 
anymore. And all of these innovative ways, whether it is with 
pet therapy or whether it is with innovative things that we are 
learning, we should be doing that. And the VA ought to be at 
the forefront, since there are so many of our veterans that 
have had brain injuries. And, again, it's a lifetime 
commitment.
    I can't thank you all enough for bringing these here and 
taking your time to be here and testify in front of this 
Committee, and I yield back.
    Ms. Buerkle. Thank you, Dr. Roe.
    Unless any of my colleagues has additional questions, 
again, on behalf of all of us, thank you very much for being 
here today, for taking the time and the energy to act on behalf 
of our veterans. And, to all of you, thank you for your service 
to this country.
    Our first panel is excused, and we would ask that our 
second panel join us at the witness table.
    Good afternoon. With us on our second panel are 
representatives from our veteran service organizations.
    We have Mr. Shane Barker, the Senior Legislative Associate 
for the Veterans of Foreign Wars. Good afternoon.
    Ms. Joy Ilem, the Deputy National Legislative Director for 
the Disabled American Veterans (DAV). Welcome to our hearing.
    Dr. Thomas Berger, the Executive Director of the Veterans 
Health Council for the Vietnam Veterans of America (VVA). 
Welcome, Dr. Berger.
    Mr. Carl Blake, the National Legislative Director for the 
Paralyzed Veterans of America (PVA). Welcome.
    And Christina Roof, the National Acting Legislative 
Director of AMVETS.
    Good afternoon to all of you. Thank you for joining us this 
afternoon, and, Mr. Barker, we will begin with you.

   STATEMENTS OF SHANE BARKER, SENIOR LEGISLATIVE ASSOCIATE, 
  NATIONAL VETERANS SERVICE, VETERANS OF FOREIGN WARS OF THE 
    UNITED STATES; JOY J. ILEM, DEPUTY NATIONAL LEGISLATIVE 
DIRECTOR, DISABLED AMERICAN VETERANS; THOMAS J. BERGER, PH.D., 
 EXECUTIVE DIRECTOR, VETERANS HEALTH COUNCIL, VIETNAM VETERANS 
    OF AMERICA; CARL BLAKE, NATIONAL LEGISLATIVE DIRECTOR, 
PARALYZED VETERANS OF AMERICA; AND CHRISTINA M. ROOF, NATIONAL 
    ACTING LEGISLATIVE DIRECTOR, AMERICAN VETERANS (AMVETS)

                   STATEMENT OF SHANE BARKER

    Mr. Barker. Madam Chairwoman, Ranking Member Michaud, and 
Members of this Committee, on behalf of the more than two 
million members of the Veterans of Foreign Wars of the United 
States and auxiliaries, thank you for the opportunity to 
present our views on today's legislation.
    The VFW does not support H.R. 198, the ``Veterans Dog 
Therapy Training Act.'' Helping veterans with post-traumatic 
stress by offering them a therapeutic dog training class is 
indeed a laudable goal. We believe it would be better achieved 
through public-private partnership with Congressional 
oversight.
    We also believe that such a benefit should not be anchored 
to VA medical centers. The nature of this service does not 
readily align itself with the provision of medical care to 
veterans, and we do not want it to complicate the care those 
medical centers provide.
    The VFW does support H.R. 1154, the ``Veterans Equal 
Treatment for Service Dogs Act.'' The use of medical service 
dogs among veterans is increasing. They serve a critical role 
as a VA-recognized prosthetic in helping to promote 
independence. This legislation opens the doors at VA facilities 
for veterans to utilize such service dogs, broadening VA policy 
that currently allows only seeing eye dogs into medical 
facilities. Service dogs are helping our veterans, and they 
shouldn't have to leave them at the door when they come to VA 
for medical care.
    The VFW supports H.R. 1855, the ``Veterans Traumatic Brain 
Injury Rehabilitative Services Improvement Act of 2011.'' This 
legislation ensures better TBI treatment plans by focusing on 
an injured veteran's independence and quality of life while 
also stressing improvements to their behavioral and mental 
health functioning.
    We all agree that TBI patients deserve more than mere 
treatment of the physical wounds of war. It has been made 
painfully clear that even mild TBI can cause emotional, 
cognitive, and behavioral complications; and this bill would 
guarantee treatment for these conditions as well.
    We thank the Chairwoman and the Ranking Member for their 
work on H.R. 2074, the ``Veterans Sexual Assault Prevention 
Act,'' and we are pleased to see this Committee continuing to 
move this forward. The VFW will continue to staunchly advocate 
for a zero tolerance policy, because veterans should never have 
to visit a VA medical facility with concerns about their 
personal safety.
    The VFW also supports H.R. 2530. This legislation will 
eliminate the system currently in place to reimburse State 
homes for nursing home care provided to veterans. It would 
require the VA to negotiate adequate payment structures with an 
individual State home prior to entering into agreements for 
services. This bill has broad stakeholder support, and we 
strongly believe that it will put many complications with the 
current system to rest.
    The VFW strongly supports the ``Honey Sue Newby Spina 
Bifida Attendant Care Act.'' Honey Sue Newby is entitled to VA 
care because she is the child of a Vietnam veteran and is 
afflicted with spina bifida. Her condition renders her unable 
to care for herself, and the VA considers her disability on par 
with the 100-percent service-connected totally disabled 
veteran, yet her provision of care is substantially lower. This 
bill provides needed relief by greatly broadening the types of 
care that she and other similarly affected children can receive 
and by redefining home care to expand services and offer 
financial incentives to employ a live-in caregiver. We strongly 
support passage of this legislation.
    Finally, the VFW supports the ``Veterans Health Care 
Facilities Capital Improvement Act of 2011.'' This legislation 
will remedy a handful of serious structural concerns at 
individual VA facilities and expand authorizations to enhance 
facilities in other high-demand locales.
    We support the extension of current enhanced use lease 
authorities in this bill. However, we are concerned that 
removing provisions to ensure that they contribute to the 
mission of VA will diminish services to veterans. Added revenue 
is already being cited in some current leases as the main 
factor contributing to VA's mission, so we believe these 
provisions are essential to the continued success of enhanced 
use leases.
    This bill would also require VA to detail expected costs to 
make a facility fully usable for its intended purposes, instead 
of merely requesting the funds to build the bare bones 
facility. We believe Congress should know up front how much VA 
needs to furnish and supply the facilities it intends to build.
    Madam Chairwoman, this concludes my statement. I would be 
happy to answer any questions that you or the Committee may 
have.
    [The prepared statement of Mr. Barker appears on p. 41.]
    Ms. Buerkle. Thank you, Mr. Barker, for your testimony.
    Ms. Ilem.

                    STATEMENT OF JOY J. ILEM

    Ms. Ilem. Thank you, Madam Chairwoman, Ranking Member 
Michaud, and Members of the Subcommittee. Thank you for 
inviting me to testify on behalf of the Disabled American 
Veterans at this legislative hearing. We are pleased to present 
our views on the five numbered bills and two draft measures 
before the Subcommittee today.
    DAV does not have an approved resolution from our 
membership that supports a pilot program as proposed in H.R. 
198, the Veterans Dog Training Therapy Act, so we are unable to 
take a formal position on this bill. We do, however, recognize 
that working with service animals could play an important role 
in promoting maximum independence and improved quality of life 
for persons with disabilities and that a pilot program such as 
the one proposed in this measure could be of benefit to certain 
veterans.
    The next bill for consideration, H.R. 1154, the ``Veterans 
Equal Treatment for Service Dogs Act,'' would prohibit the VA 
Secretary from restricting the use of service dogs by veterans 
on any VA property that receives funding from the Secretary. 
DAV does not have a resolution on this specific topic either. 
However, we note VHA recently published a national policy 
directive on admittance of service and guide dogs into VA 
health care facilities. Unfortunately, in the last several 
months, we have received a number of complaints from DAV 
members suggesting actual local policy as enforced by 
individual facilities or network management may differ markedly 
from VA's national policy.
    We believe the current national policy and local 
enforcement of it could accomplish the goal of this measure. We 
suggest the Subcommittee ask the VA what actions have been 
taken since the directive was issued to ensure current policy 
is fully implemented and is enforced consistently throughout 
the system. Based on their response, the Subcommittee may want 
to choose to provide oversight to ensure VA's standardization 
of the existing policy or move forward with enactment of this 
measure, to which DAV would have no objection.
    DAV is pleased to support H.R. 1855, the ``Veterans 
Traumatic Brain Injury Rehabilitation Services' Improvements 
Act of 2011.'' This measure aims to clarify the definition of 
rehabilitation and to strengthen VA's mandate to sustain gains 
made in the rehabilitative process in veterans who have 
incurred serious traumatic brain injuries.
    DAV members have approved a national resolution calling for 
comprehensive treatment and more research to ensure veterans 
with TBI receive the best care possible. This bill aims to 
fulfill the goals of maximizing an individual's independence 
and quality of life and is fully consistent with DAV resolution 
215. For these reasons, we urge the Subcommittee to recommend 
its enactment.
    Madam Chairwoman, we appreciate your introduction of H.R. 
2074, the ``Veterans Sexual Assault Prevention Act.'' As 
indicated in our previous testimony to the Subcommittee on this 
issue, veterans, VA staff, and visitors should be assured of a 
safe environment at VA health care facilities. This bill firms 
up VA's requirement to document, track, and control the 
incidents of sexual assaults that occur on properties and 
grounds of the VA. We believe the measure reflects GAO's 
recommendations calling for greater transparency, 
accountability, related to the reporting of sexual assaults and 
other incidents affecting the safety of veterans and VA staff.
    H.R. 2530 would revise the methodology used to reimburse 
State veterans homes that provide nursing home care for 
veterans with service-connected disabilities rated 70 percent 
or greater or for veterans who need nursing home care due to a 
service-connected disability. This bill is intended to restore 
the original intent of section 211 of public-law 109-461, which 
was enacted in order to authorize VA to place 70 percent 
service-connected veterans in State homes and to reimburse the 
homes at rates comparable to those received by contract 
community nursing homes. DAV commends the bill's sponsors for 
their continuing efforts to ensure their highest-priority 
veterans have the option of entering a State home to meet their 
long-term care needs, and we recommend enactment of H.R. 2530.
    DAV has no resolution from our membership on the specific 
issues addressed in the two remaining draft bills under 
consideration by the Subcommittee, the ``Honey Sue Newby Spina 
Bifida Attendant Care Act'' and the ``Veterans Health Care 
Facilities Capital Improvement Act.'' However, DAV is 
supportive of assisted living options as an alternative to 
institutionalized care, and we appreciate the Subcommittee's 
continuing support of VA's capital infrastructure needs. 
Therefore, DAV would offer no objections to enactment of either 
bill.
    Madam Chairwoman and Members, this completes my testimony, 
and I am happy to answer any questions you may have.
    [The prepared statement of Ms. Ilem appears on p. 43.]
    Ms. Buerkle. Thank you very much.
    Dr. Berger.

              STATEMENT OF THOMAS J. BERGER, PH.D.

    Dr. Berger. Chairwoman Buerkle, Ranking Member Michaud, and 
distinguished Members of the Subcommittee, Vietnam Veterans of 
America thanks you for the opportunity to present our views on 
the pending legislation for veterans and their families.
    H.R. 198, the ``Veterans Dog Training Therapy Act,'' 
although VVA generally supports this legislation, we have a 
couple of questions. One is, what are the certification 
standards that will be used to ensure that the animals can 
perform the essential service dog skills, which are mentioned 
specifically in the Act? There are 11 of them.
    The second question we have is what quantitative metrics or 
measurements will be used to measure the impact of the service 
dogs on the psychosocial mental health and physiological 
disorders suffered by the participating veterans? Again, those 
11 items that are referred to in the bill itself.
    H.R. 1154, the ``Veterans Treatment of Service Dogs Act,'' 
VVA supports this legislation but again asks the question in 
the larger sense, what constituents certification of one's 
animal as a service dog? As you are well aware, probably, the 
VA issued some proposed regulations back in June that call for 
certification under the terms of a couple national or 
international organizations. We want to know how those are 
going to work relative to admission of animals into the VA as 
service dogs.
    H.R. 1855, the ``Veterans Traumatic Brain Injury 
Rehabilitation Services Act,'' we strongly support this 
legislation. It is very clear that Command Sergeant Major Walz 
understands the necessity for a broadly integrated and 
individualized psychosocial mental health and physical 
treatment plan and service in order to maximize the quality of 
long-term care for our veterans suffering from TBI.
    H.R. 2074, the ``Veterans Sexual Assault Prevention Act,'' 
VVA strongly supports this legislation as an initial effort to 
address and correct the failures of the VA from protecting and 
safeguarding our veterans in VA facilities, as noted in the 
June, 2011, GAO report.
    H.R. 2530, which will provide for increased flexibility in 
establishing rates for reimbursement of State homes, et cetera, 
we have already heard the long title of that. This proposed 
legislation to be introduced by Congressman Michaud would 
correct problems that had come about as a result of Public Law 
109-461; and, as you have heard from my colleagues, this 
legislation will achieve the goals of the original law from a 
couple of years ago, which was to provide veterans with 
service-connected disabilities rated 70 percent or greater with 
an additional option which may be more convenient, provide 
better care, and usually costs less to the Federal Government 
in the same care provided through VA operated nursing homes or 
contract community homes.
    Now, the ``Honey Sue Newby Spina Bifida Attendant Care 
Act'' draft legislation, we strongly support this legislation, 
as it will provide a decades-long-overdue service and services 
to the child of the Vietnam veteran parent suffering from spina 
bifida.
    I had the opportunity to meet Honey Sue a couple of weeks 
ago in Indianapolis, and I can tell you that this will be 
welcome by not only Honey Sue herself, but by her parents.
    The ``Veterans Health Care Facilities Capital Improvement 
Act of 2011'' draft legislation, although this legislation 
calls for needed construction modifications at a number of VA 
medical facilities, VA cannot at the present time support this 
legislation in its present form as it is unclear as to whether 
the proposed changes suggested in section 6, Modification of 
Department of Veterans Affairs Enhanced Use Land Authority, 
will eliminate any possible breaches of VA fiduciary duty for 
leasing property to private entities, as has been alleged to 
have occurred at the West Los Angeles Medical Center and 
Community Living Center campus.
    Once again, on behalf of VVA National President John Rowan, 
our national officers board, and membership, I thank you for 
your leadership in holding this important meeting on these 
pieces of legislation; and I also thank you for the opportunity 
to address you today on behalf of America's veterans. Thank 
you.
    [The prepared statement of Dr. Berger appears on p. 47.]
    Ms. Buerkle. Thank you very much, Dr. Berger. Mr. Blake, 
would you like to proceed?

                    STATEMENT OF CARL BLAKE

    Mr. Blake. Chairwoman Buerkle, Ranking Member Michaud, 
Members of the Subcommittee, on behalf of Paralyzed Veterans of 
America, I would like to thank you for the opportunity to be 
here to testify today on the proposed legislation.
    With regards to H.R. 198, while PVA has no specific 
position on the bill, the ``Veterans Dog Training Therapy 
Act,'' we believe that it could be beneficial therapy for 
veterans dealing with post-traumatic stress disorder (PTSD) and 
other mental health issues.
    PVA supports H.R. 1154, the ``Veterans Equal Treatment for 
Service Dogs Act of 2011. While we believe this legislation 
should be unnecessary based on the provisions of section 504 of 
the rehab act, the actions of the VA clearly demonstrate the 
need for this legislation.
    PVA fully supports H.R. 1855, the ``Veterans Traumatic 
Brain Injury Rehabilitative Services Improvement Act.'' If 
enacted, H.R. 1855 would ensure that long-term rehabilitative 
care becomes a primary component of health care services 
provided to veterans who have sustained a traumatic brain 
injury. Because all of the impacts of TBI are still unknown, 
this legislation to expand services and care, providing for 
quality of life and not just independence, and emphasizing 
rehabilitative services is important to the ongoing care of TBI 
patients. It is imperative that a continuum of care for the 
long term be provided to veterans suffering from TBI. This bill 
will address the intricacies associated with TBI and help 
veterans and their families sustain rehabilitative progress.
    PVA fully supports H.R. 2074, a bill that would require a 
comprehensive policy on reporting and tracking sexual assault 
incidents and other safety incidents that occur at VA medical 
facilities. PVA believes policy mandates that specifically 
outline sexual assaults within the VA should be handled are 
long overdue. The implementation of policies involving sexual 
assault will reinforce veterans' confidence in the VA's ability 
to provide a safe environment for care.
    PVA recommends that the proposed legislation require the 
leadership of each Veterans Integrated Services Network (VISN) 
to be responsible for the centralized reporting, tracking, and 
monitoring while also requiring the VISN to provide the 
tracking reports to VA's Central Office. Additionally, PVA 
recommends that VA provide clear and concise policy guidance 
that includes a specific time frame in which frontline VA 
personnel responsible for the initial processing of assault 
claims must begin processing those reports.
    PVA generally supports H.R. 2530 to allow for increased 
flexibility in establishing rates for reimbursement for State 
veterans homes. As we understand it, the VA and the National 
Association of State Veterans Homes have begun discussions 
about developing a reimbursement agreement that is satisfactory 
to both parties. However, this legislation will give the VA the 
authority to further develop appropriate reimbursement 
methodology.
    PVA supports the draft ``Veterans Health Care Capital 
Facilities Improvement Act.'' VA's significant inventory of 
real property and physical infrastructure is truly a remarkable 
asset in the provision of health care and benefit delivery to 
veterans. At the same time, these facilities must be properly 
managed and cared for to ensure that the investment made in the 
use of these buildings and properties coincides with the 
benefit derived from their use.
    With regard to this bill, I would only offer one bit of 
caution or perhaps a question. I noted in the legislation that 
proceeds that are generated through enhanced use lease and 
other authorities will be now transferred into the major/minor 
construction accounts which we think is a very good idea, given 
the backlog of projects that exist and the need for needed 
funding in those accounts. However, that money is now 
presumably being transferred away from the medical care 
collections fund which is where it is currently being sent. And 
so I think the Subcommittee needs to look at how now putting 
this money into the major/minor construction accounts may 
affect medical care collections estimates and overall the 
effect on the health care accounting of the VA.
    With that, Madam Chairwoman, Ranking Member Michaud, I 
would like to thank you for opportunity to testify, and I would 
be happy to answer any questions that you have.
    [The prepared statement of Mr. Blake appears on p. 48.]
    Ms. Buerkle. Thank you very much, Mr. Blake.
    Ms. Roof.

                 STATEMENT OF CHRISTINA M. ROOF

    Ms. Roof. Madam Chair, Ranking Member Michaud, and 
distinguished Members of the Committee, on behalf of AMVETS, I 
would like to extend our gratitude for being given the 
opportunity to share with you our views and recommendations 
regarding these very important pieces of legislation today. You 
have my complete statement for the record, so today I will be 
specifically speaking to H.R. 198 and H.R. 1154.
    AMVETS supports H.R. 198, the ``Veterans Dog Training 
Therapy Act.'' AMVETS lends our support to the updated language 
of H.R. 198 that will be submitted in the Committee markup. 
AMVETS believes the updated language will help ensure that H.R. 
198 provides veterans only the highest quality of care.
    By way of background, AMVETS has worked with Paws with a 
Cause and Assistance Dogs International accredited agencies to 
help provide service dogs to disabled veterans, for over 25 
years. Through this partnership, AMVETS has witnessed firsthand 
the incredible changes that occur in a veteran's life when 
introducing a dog into their overall treatment plan. These 
changes are often illustrated through a veteran's ability to 
maintain a higher quality of life and greater mental health 
improvements when compared to veterans undergoing clinical care 
alone.
    H.R. 198 and a dog that will be included in the study have 
the ability to break down barriers in a veteran's world by 
shattering public stigmas and increase a veteran's overall 
well-being by reigniting their purpose through allowing them to 
help--to continue to serve their--excuse me--to continue to 
serve their country by assisting their fellow comrades. Again, 
AMVETS is happy to lend our support to H.R. 198.
    AMVETS strongly supports H.R. 1154, the ``Veterans Equal 
Treatment for Service Dogs Act.'' In 2009, I began to 
personally play an active role in AMVETS 30-plus years 
experience in working with disabled veterans and service dogs. 
I could never imagine that 2\1/2\ years later I would be 
sitting here testifying on a piece of legislation that is in 
dire need of being signed into law and implemented without any 
further delay. This piece of legislation I am speaking about is 
H.R. 1154.
    AMVETS believes this cost-free piece of legislation will 
permanently eliminate an often overlooked and unwarranted 
hurdle to care disabled veterans are currently experiencing 
when seeking necessary VA care and services. To date, title 38, 
part one, subsection 1.218(a)(11) states: ``Dogs and other 
animals, except seeing eye dogs, shall not be brought upon 
property except by as authorized by the head of each facility 
or designee.'' AMVETS finds the aforesaid language in title 38 
to be inconsistent and outdated when compared to the sections 
of title 38 it is to govern.
    While numerous parts of title 38 are constantly updated to 
reflect the health care needs of today's wounded warriors, this 
section of title 38 has been overlooked and, thus, has failed 
to be updated since July of 1985. This outdated law resulting 
in disabled veterans utilizing VA-approved service dogs as a 
prosthetic device to be denied entrance into Veterans Affairs 
Medical Centers (VAMCs) and Community-Based Outpatient Clinics 
(CBOCs) they depend on for their life-sustaining care.
    One of these veterans who has personally experienced this 
barrier to care is AMVETS member Mr. Kevin Stone and his 
service dog, Mambo, who are in attendance today and we thank 
him. AMVETS believes disabled veterans such as Mr. Stone using 
a service dog as a prosthetic device must have the same access 
rights to VA care and facilities already currently afforded to 
blind veterans using guide dogs.
    During the next panel, VA officials will argue H.R. 1154 is 
unnecessary due to the directive they have already published. 
Moreover, VA officials have recently stated H.R. 1154 was 
unnecessary due to the fact that under existing statutory 
authority under title 38, section 901, VA to implement national 
policy followed its VA properties. AMVETS believes that while 
VA is correct in outlining the authorities granted by section 
901, we must respectfully disagree with VA that H.R. 1154 is 
unneeded or is too narrow given the scope of its intent.
    VA's years of inaction in addressing this easily 
correctable hurdle to care clearly illustrates the strong need 
of change that is proposed by H.R. 1154, and while AMVETS 
applauds VA's recent publication of a directive seeking to 
temporarily address this matter, we still believe there are 
numerous loopholes that need to be closed to guarantee all 
veterans receive the care and services they need regardless of 
the disability and regardless of the prosthetic device they 
use.
    Through our close work with VA and the 111th Congress, and 
now the 112th Congress, AMVETS has done everything in our power 
to remove this hurdle to care for disabled veterans. Now, 
AMVETS has reached a point where only you, the Members of the 
112th Congress, can, once and for all, end this vicious cycle 
of veterans being denied care through your swift and bipartisan 
passage of H.R. 1154. AMVETS, VSOs and the veterans communities 
look to you to please finally close this loophole and hurdle to 
care for veterans.
    Madam Chair and distinguished Members of the Committee, 
AMVETS again thanks you for inviting us to share with you our 
views and recommendations on these very important pieces of 
legislation. This concludes my testimony. I stand ready to 
answer any questions you may have for me.
    [The prepared statement of Ms. Roof appears on p. 52.]
    Ms. Buerkle. Thank you very much, and thank you to all of 
our witnesses for your testimony here this afternoon.
    At this time, I would like unanimous consent from the 
Committee to allow lifelong Texan, our colleague, Mr. Carter, 
to join us here this afternoon, to sit at the dais and ask 
questions of the panel. Without objection, so ordered.
    And with that, I would like to yield my 5 minutes to Mr. 
Carter for his questions.

STATEMENT OF HON. JOHN R. CARTER, A REPRESENTATIVE IN CONGRESS 
                    FROM THE STATE OF TEXAS

    Mr. Carter. Thank you, Madam Chairman, and I didn't hear 
all of the testimony as to where everybody stood on this. I am 
the sponsor of H.R. 1154, and when I started this whole 
process, Mambo and his friend came to see me, along with quite 
a few other of the dogs.
    And let's be honest about how you view this. What exactly 
do these dogs do if they are not seeing eye dogs, which we are 
all used to since Second World War, what purpose do they serve? 
And as I listened to the conversation with these folks, I 
realized the old saying that my wife has written on the wall in 
the Dutch language, it says that it is not the mountain that 
you have to climb that gets you, it is the grain of sand in 
your shoe.
    And what these dogs give to these military folks is they 
help them to cope with something that is a disability for them. 
In some instances, they have a critical guide component like 
they do with dogs for the visually impaired. In others, they 
have a psychological component. You know, it was Harry Truman 
who said if you want a friend in Washington you better buy a 
dog.
    But the truth is, these dogs are a friend--not only a 
friend, they are their partner--they are their partner in 
moving through life, and when they get to the door of the place 
they are seeking medical help and they leave their partner 
outside the door, they lose the confidence that partner gives 
them, and they lose, in some instances, the reaction to sounds 
that they can't catch, if it is hearing loss. That dog knows 
how to deal with them if they are approaching seizure times, 
and they are likely to have seizures. And of course, if they 
have limbs, I have watched them use the dog to help them gain 
their balance as they stand up.
    And so from that, to us it may be a grain of sand, but to 
them it is their partner that is getting them through the day, 
and to me, it just seemed a real shame because we are already 
admitting dogs to the facility anyway for people who are blind, 
and then to say, well, we are not going to allow them for these 
other people who are relying on them just as desperately to 
enter this facility, that is why I took up this project. That 
is why I think it is a worthy project. I think I will ask, Ms. 
Roof, isn't that the general concept of what this whole AMVETS 
program is?
    Ms. Roof. Yes, sir. As I said, you are exactly right in 
everything these dogs give. These dogs are also, such as Mr. 
Stone, his prosthetic device. As you said, he could not many 
times stand up, or he would lose balance without that dog, and 
you had mentioned as well, VA is already paying benefits to 
many of these veterans for the upkeep of this dog as a 
prosthetic device. So it is quite unfortunate and sad honestly 
that they have to leave them at the door.
    Mr. Carter. Well, thank you, and I don't know--she is the 
only member of the panel I heard. So I better yield to other 
members of the panel to ask questions about what was said. 
Thank you.
    [The prepared statement of Congressman Carter appears on p. 
39.]
    Ms. Buerkle. Thank you very much, and I yield 5 minutes to 
the Ranking Member, Mr. Michaud.
    Mr. Michaud. Thank you, Madam Chair. This question is for 
everyone on the panel, starting with Mr. Barker.
    We asked for the report and was actually shocked when you 
look at the number of sexual assaults and rapes. We saw the 
report and are very supportive of the legislation before us. We 
also have heard a lot of instances in the last few years as far 
as within VA facilities themselves.
    So my question is, what is the most important change that 
could be implemented to improve the culture within the VA to 
make it more accommodating toward female veterans and women in 
general?
    Mr. Barker. The position of the VFW on this is clear, I 
think. Our written testimony shows that we feel the lack of a 
holistic VA-wide training program that is required for all VA 
employees to go through and be--some kind of verification 
process that every VA employee has gone through, this training 
is required.
    We have talked a lot about VISN-to-VISN different policies, 
and the culture is not going to change overnight on this issue. 
It won't change at all unless there is some sort of direction 
from the very top that makes very clear that there is no room 
for this kind of incident to happen at any VA facility. It 
really needs to come from the very top, and it needs to be 
fully consistent for all VA employees.
    Ms. Ilem. We appreciate the question. Just this past 
weekend, VA had their national training summit for women 
veterans. We had over 750 women veterans attend, along with 
VA's women veteran veterans program managers. I think one thing 
that we consistently heard in talking with women veterans over 
the time of the event was that they would like to see these 
changes, and actually Secretary Shinseki made a call to action 
to women to submit to him what needs to be fixed, first and 
foremost, and what can VA do.
    This came up in the discussion with women veterans over and 
over, for example, I don't feel comfortable going a VA 
facility; someone's leering at me, talking to me; I need to go 
to my mental health appointment, but I am not comfortable in 
there--just a variety of anecdotes of just overall unwelcome 
feelings.
    I think some of the things that we need--could do right 
away would be--first of all, the education piece, making it a 
top priority in VA to make sure all of the staff and clinicians 
are educated, and if they see things happening, they have to 
intervene to make our women veterans feel welcome.
    They need to have focus groups they need to listen, the 
voices of women veterans out there, that women veterans can say 
this is the particular problem in this facility that I am 
encountering.
    And I think with regard to the legislation that is being 
proposed, having it done consistently, if someone reports a 
sexual assault or an incident, it needs to be taken seriously 
and it needs to be handled appropriately. I mean, reading just 
briefly some of the testimony from other organizations--
actually it was SWAN (Servicewomen's Action Network) I was just 
reading prior to the hearing. They gave some very prime 
examples when someone did do the right thing reporting, and yet 
it was still not taken seriously or these people are still in 
employment in VA. Thank you.
    Dr. Berger. I would agree with my colleagues, particularly 
Mr. Barker's comments, but it starts with leadership and I 
would also go as far as to say that if there are lapses found 
in the reporting system in any shape or fashion, that the 
person responsible, meaning the facility director, is 
reprimanded in some fashion, and that may mean some kind of 
financial. If that is the only way to get people to pay 
attention, then we need to do it that way. We need 
accountability. We need accountability.
    I, too, was at the women's conference last weekend, and I 
think at some point down the line that General Shinseki's 
asking the women for comments, those need to be turned over, 
okay, so that we can see how to mesh those in with what we see 
in front of us today to see if it is really working. So those 
are some of the things that I could recommend.
    Mr. Blake. I don't know that there is a whole lot more I 
could say other than I would like to second both what Ms. Ilem 
and Mr. Berger said. I would suggest an education and training 
side is of the utmost importance, particularly as it relates to 
the VA staff. The thing to understand is that there is a still 
challenge of overcoming the culture of the patients. I mean, 
you can't change the way patients are in some cases, but you 
can certainly affect the way that culture is managed by the VA 
and its staffing.
    And I couldn't agree with Mr. Berger more than the issue 
about accountability, which goes to my comments about reporting 
requirements that should be on the various levels within VHA. 
It can't be just about, well, this incident occurred, and we 
develop a report, and then that is the end of it. It needs to 
be followed and tracked and there has to be ramifications if 
someone doesn't take appropriate steps because these are 
serious incidents and they need to be treated as such.
    Ms. Roof. AMVETS concurs with all of my colleagues' 
statements. You know, this was so upsetting when this came out, 
and the more I talked to our members, come to find out, I 
actually spoke to three different female AMVETS members that 
had experienced a sexual assault. It was reported. However, 
they felt like they never got closure. So I thank you all for 
introducing this very, very important piece of legislation. 
Thank you.
    Ms. Buerkle. I now yield Mr. Roe 5 minutes for questions.
    Mr. Roe. Thank you, Madam Chairman, and I want to thank you 
for introducing this piece of legislation. I think, Dr. Berger, 
you hit it right on the head, that there should be no 
tolerance. There should be a change of culture, and it comes 
from the top. I agree with that 100 percent, that the 
leadership--when you have no tolerance for that type of 
behavior, it won't happen. And it is a criminal offense in many 
cases as well. They can be prosecuted by a criminal court 
system, and it is a very serious offense, and so I want to 
thank you for doing this, bringing our attention to it, and 
bringing the entire country's attention to it, that it won't be 
tolerated at the VA, and not tolerated anywhere.
    The other thing I want to say, Ms. Roof, is if Bill Kilgore 
were here he would probably say hello from AMVETS, and I want 
to thank you for bringing that up, the issue about the service 
dogs. We use service dogs to protect our troops in foreign 
countries. They are out there on the front lines every day. 
Service dogs are welcome in this building, in all these 
buildings, and they wouldn't be welcome at a VA when they are 
helping a veteran. It is kind of--when you think about it, they 
have helped our veterans in battle. They are welcome here in 
the Capitol, in our offices, in this building, and they should 
be welcome when they are assisting veterans, and so thank you 
for bringing that up and being supportive.
    And also, in my second term here, I really haven't taken 
the time to thank the veteran service organizations for the 
great job you do in representing veterans, and you do and you 
point out things that many times haven't been brought to my 
attention. So that is all I have. I don't have any questions 
but just a comment. So thank you for being here.
    Ms. Buerkle. Thank you very much. I now yield the gentleman 
from Missouri 5 minutes for questions.
    Mr. Carnahan. Thank you, Madam Chairman and Ranking Member. 
I want to give a special thanks to each of you representing the 
veterans service organizations and the work that your 
organizations do on behalf of our veterans.
    I also want to thank the gentleman from Texas, Mr. Carter, 
for being here on behalf of his bill and pushing that.
    I had wanted to ask a specific question about the bill, 
H.R. 198. Certainly, it provides an assessment for addressing 
PTSD symptoms through the therapeutic meaning of service dogs 
for veterans with disabilities, but the current legislation 
only allows for, or only authorizes a pilot program. My 
question is--would ask the VA to address the mental health 
crisis facing our Nation's veterans, would the legislation be 
more successful if the bill encouraged the VA to partner with 
community-based services such as Pets to Vets to better 
establish a model for a large scale service dog program, would 
that be a something we should look at as well to be able to 
scale it up faster?
    Ms. Roof. Sir, the language that--well, thank you for your 
support first and foremost. The language that will be submitted 
to the Committee in markup actually does address that. It does 
address to--to make the bill a little bit more fiscally within 
our means of what we have to work with right now. They will be 
partnering with private organizations.
    Mr. Carnahan. That is great. We heard about that idea as 
well, and I think using some of those existing programs that 
are already up and running may help be able to get us up to a 
scale up that national model faster. Yes, sir.
    Dr. Berger. Mr. Carnahan, our comments really, just want to 
echo what I said earlier. If you are--I don't disagree with 
what was just said about public-private partnerships, but that 
the assessment standards that are used for the impact of the 
service dogs run across the board, whether it is a VA or public 
or private facility or training facility that those standards 
are really important, and that they be the same. And that way, 
after the end of this 5-year program, okay, we will know just 
how effective this is in a quantitative fashion, and that is 
really important if we are talking about expanding it down the 
line. We need standardized collection of data.
    Mr. Carnahan. Great. Certainly that is helpful to us here 
in making decisions going forward as well. Anybody else? If 
not, thank you all very much, and I yield back.
    Ms. Buerkle. Thank you. Unless any of my colleagues have 
any other questions, our second panel is finished here today. 
Again, thank you for your testimony. Thank you for being here 
and mostly thank you for all you do on behalf of our veterans. 
We truly appreciate your service and dedication. We will now 
ask the third panel to join us.
    Good afternoon to all of you. Representing the Department 
is Robert L. Jesse, M.D., Ph.D., Principal Deputy Under 
Secretary for Health. Dr. Jesse is accompanied by James M. 
Sullivan, Office of Asset Enterprise Management, Office of 
Management; Jane Clare Joyner, Deputy Assistant General 
Counsel; and Charlma Quarles, Deputy Assistant General Counsel.
    Ms. Buerkle. Dr. Jesse, please proceed, and thank you for 
being here this afternoon.

  STATEMENT OF ROBERT L. JESSE, M.D., PH.D., PRINCIPAL DEPUTY 
  UNDER SECRETARY FOR HEALTH, VETERANS HEALTH ADMINISTRATION, 
U.S. DEPARTMENT OF VETERANS; ACCOMPANIED BY JAMES M. SULLIVAN, 
     DIRECTOR, OFFICE OF ASSET ENTERPRISE MANAGEMENT, U.S. 
   DEPARTMENT OF VETERANS AFFAIRS; JANE CLARE JOYNER, DEPUTY 
  ASSISTANT GENERAL COUNSEL, OFFICE OF GENERAL COUNSEL, U.S. 
  DEPARTMENT OF VETERANS AFFAIRS; AND CHARLMA QUARLES, DEPUTY 
  ASSISTANT GENERAL COUNSEL, OFFICE OF GENERAL COUNSEL, U.S. 
                 DEPARTMENT OF VETERANS AFFAIRS

    Dr. Jesse. Well, thank you very much, Chairwoman Buerkle 
and Ranking Member Michaud and distinguished Members of the 
Subcommittee. We appreciate the opportunity to be here today to 
present the Administration's views on several bills that would 
affect the VA health care system, and as you just said, joining 
me today are Mr. Sullivan and Ms. Joyner and Ms. Quarles.
    Madam Chairman, I would like to begin by focusing on H.R. 
2074, the ``Veteran Sexual Assault Prevention Act,'' and just 
to be very clear, we do agree with the objectives as outlined 
in the legislation. We take the GAO report very seriously. We 
are extremely concerned over the safety and security of our 
veterans, our employees, and visitors, and this is among our 
highest priorities. We take all allegations seriously. We 
investigate them thoroughly.
    Last month, we told you about our efforts to improve safety 
and security at our facilities, and now I would like to share 
with you for a moment just some of our more recent progress.
    VA's safety and security work group is developing 
appropriate proactive interventions to reduce the risk of 
sexual assaults. We are testing our computerized reporting 
system for ongoing data tracking and trending and establishing 
guidance to train both staff and providers. The work group has 
submitted initial action plans and there will be a final 
written report by September 30, 2011. Additionally, VA is 
evaluating universal risks for assessing the chance of violence 
and designing appropriate intervention actions. An oversight 
system like the one required by the bill will be in place in 
VHA later this summer, and we will have clear and consistent 
guidance on the management and the treatment of sexual assaults 
by the end of 2011.
    While we agree with many of the bill's goals, we do have 
several concerns. First is the VA is committed to enhancing our 
safety and security policies, but we do need time to pilot 
these initiatives, particularly the reporting tools, before we 
can fully implement them. We believe we can have an operational 
system by the end of the year, and while we recognize the 
urgency of the actions, we do not want to rush and settle for 
what may be a second best solution.
    We also have a serious concern with the bill's requirement 
that VA report alcohol or substance abuse-related acts 
committed by veterans. VA's an integrated health care network. 
We treat all of the health care needs of the veterans, 
including substance use disorders and alcoholism. Reporting and 
tracking these events may deter veterans from seeking care, and 
we do not want to create a potential disincentive for the 
veterans to seek treatment, and we recommend that this 
provision be deleted. We are happy to meet with the Committee 
and you, Madam Chairman, to discuss these issues in more 
detail.
    We also agree with the objectives in many of the other 
bills under consideration. We are particularly pleased to 
support the draft capital improvement bill. In addition to 
authorizing critical construction projects, the bill will also 
extend VA's enhanced use lease authority, which has benefited 
veterans and VA in local communities and a critical piece of 
the Secretary's plan to end homelessness.
    We also agree, in large part, with H.R. 1855, the 
``Veterans TBI Rehabilitative Services Improvements Act.'' VA's 
primary aim for veterans with serious or severe injuries has 
always been and continues to be maximizing their independence, 
their health, and their quality of life. Out of these concerns, 
VA has developed robust rehabilitation therapy programs to help 
veterans learn or relearn skills and develop resources to 
sustain their rehabilitation programs. Our primary concern with 
this bill was the term ``quality of life,'' and I was very 
happy to hear Mr. Walz's comments that we have worked through 
those issues.
    Turning to the issue of service dogs, the Subcommittee is 
considering a bill to require a pilot program, which veterans 
with PTSD train service dogs for other disabled veterans, and 
another bill would mandate VA permit veterans with service dogs 
to access our facilities. For the reasons outlined in my 
written statement, we believe both these bills are unnecessary 
because of efforts the Department is already taking. We are 
happy to discuss these in more detail.
    Finally, I am pleased to report that the VA supports in 
principle H.R. 2530, which would increase the flexibility in 
the rates of reimbursement for State homes. VA's been working 
closely with State veterans home associations, and we believe 
this legislation has the general support of all parties. We 
have noted one minor technical amendment which we believe could 
further enhance our flexibility in working with our partners at 
the State homes. My written statement will discuss that issue 
in more detail, but I will provide any assistance you may need 
on the issue.
    This concludes my prepared statement. Thank you for the 
opportunity to testify and be pleased to respond to any 
questions you may have.
    [The prepared statement of Dr. Jesse appears on p. 56.]
    Ms. Buerkle. Thank you, Dr. Jesse, and I will yield myself 
5 minutes for questions. I am concerned about the legislation, 
H.R. 2074, and I would like to ask some questions with regard 
to your comments.
    In your testimony, you state that the timeline for the 
implementation of this policy is not feasible. VA is committed 
to enacting this policy but needs the time to complete work on 
reporting tools and processes and to pilot these initiatives 
before the policy will be fully implemented. You mentioned in 
your opening comment about testing a computerized reporting 
system.
    The GAO report that came out that identified these problems 
was issued last month, and it reviewed the prevalence of sexual 
assault and other safety issues over the last 3 years. So it 
seems to me, unless the VA was completely unaware of what was 
going on, that you would have had time to address these 
problems and make the changes and corrections, and take care of 
what has been going on within the VA system. If you could 
comment on that.
    Dr. Jesse. Yeah, sure. So I think where we failed in this 
matter was that we actually have multiple reporting mechanisms, 
and we at a national level I guess had not reconciled them. So 
we had reporting mechanisms that were coming up through the 
police side and these starting in 2009 I think as you heard 
before with this stand-up of the integrating--the IOC--the 
integrated operations center were coming through that side. And 
then we had administrative reports coming up through VHA's line 
in the forms of issue briefs. And there was a failure on our 
part to reconcile the two, to make sure that everything that 
was coming up through issue briefs was matched up to everything 
that was coming up on the police report and vice versa.
    And in order to do that, it essentially required taking 
what was largely a paper process, if you will, and putting in 
something that could be, in an electronic fashion, reconciled, 
and that is the piece that is in the process of being built 
now. We think we have a system that is workable, but it is--as 
always, you have a million use case scenarios that have to run 
through this and make sure that it is working.
    Ms. Buerkle. Well, I guess I would really caution the VA 
system, that time is of the essence. We don't have time for 
pilots and testing when this is going on, and it has gone on 
for the last 3 years. This needs to be tended to, and it seems 
to me that if you are talking about duplication and just a 
failure to reconcile your systems, that doesn't require you to 
get another system. That just requires reconciliation so that 
you have complete reporting system.
    Dr. Jesse. Yes, ma'am. There actually are large numbers. 
The system we actually have this operating now, and we just 
need to make sure that it is working in all the different 
scenarios that we have.
    Ms. Buerkle. Do you know what the name of the system is 
that will be handling the reconciliation between the two 
systems?
    Dr. Jesse. Well, right now, I think it is being called the 
data management and tracking system.
    Ms. Buerkle. Perhaps you could provide for the Committee 
further information on that tracking system.
    Dr. Jesse. Sure, we would be glad to.
    Ms. Buerkle. See how that is implemented.
    Dr. Jesse. Absolutely.
    [The VA failed to provide information in time for 
printing:]
    Ms. Buerkle. The other question I wanted to ask you, if 
whether or not you think this piece of legislation is perhaps 
duplicative or is just taking care of issues that you are 
already taking care of in the VA, if you see any parts of this 
bill that are unnecessary.
    Dr. Jesse. Well, in some respects, the legislation very 
closely, I think, follows the recommendations of the GAO, and 
we have already--basically, we have concurred with the 
recommendations of the GAO and have started to put all of these 
pieces into play.
    So I guess you could say that the major objections--I mean, 
there is no inherent objection to having the legislation. It 
actually often helps us support what we are doing. The big 
concern was the timeline, and we actually think we are going to 
beat that timeline, but to be held to it may force things to 
happen in a fashion a little bit quicker than we would like.
    And then the other piece there is, I think, a pretty 
significant concern about the comments surrounding how we would 
be required to track and report substance abuse issues. There 
is some pretty--very, I think, delicate patient-related 
components of that that might through public reporting 
compromise those patients.
    Ms. Buerkle. Thank you, Dr. Jesse. I now yield 5 minutes to 
the Ranking Member, Mr. Michaud.
    Mr. Michaud. Thank you very much, Madam Chair. I want to 
thank you, Dr. Jesse, and those accompanying you today.
    I was reading your testimony as it relates to the State 
veterans homes and it is kind of confusing. Could you explain 
exactly what technical concerns you have with the bill, because 
my understanding is that the VA actually worked to draft the 
bill or----
    Dr. Jesse. Yes. And I will confess that I am not a business 
office person, but I think I can explain this adequately. I 
think the technical concern was the limiting term of a 
contract, as opposed to service provider agreements, and that 
the concern was that it being specific contracts might take 
some of the flexibility out of making these arrangements, and 
that by having service provider agreements, it actually 
broadens it, and that language was vetted through the director 
of the veterans homes, the national director, and I think, my 
understanding is that everybody's comfortable with that 
language.
    Mr. Michaud. So you are concerned because it gives the VA 
greater flexibility?
    Dr. Jesse. No. Actually we were concerned that by 
specifically saying contract, it closed the flexibility. By 
using this additional term, it gives us greater flexibility. 
You want to----
    Ms. JOYNER. The bill that was presented is slightly 
different than what appeared in the legislative proposal that 
was given to the Committee on June 7, and basically it is 
subsection a(2) which talks about negotiating to create rates. 
The concern was that it references the provider agreements, and 
for provider agreements, those would be a set rate. They 
wouldn't be subject to negotiation.
    So the concern was in subsection a(2) by referencing the 
provider agreements, that wouldn't be a viable option if we had 
to negotiate to do that. So the recommendation we could work 
with Committee staff to explain it in more detail would be to 
take out the reference to provider agreements in subsection 
a(2).
    Mr. Michaud. We have been dealing with this issue for a 
number of years, and that is why I am surprised that you still 
have a technical problem with the legislation. So we are 
willing to work with the VA because I think the law is very 
clear in the first place that Congress passed is that VA will 
pay for full cost of nursing home care. Full cost to me means 
full cost. Just because the rules and regulations VA adopted, 
you narrowed the full cost only for these services, and then 
when you put provisions in there saying that once you receive 
payment for full cost, these narrow services that VA decided to 
interpret differently, and the nursing homes could not 
reimburse, or collect payment from Medicare or Medicaid, that 
has caused a huge problem within the nursing home facilities 
throughout the country.
    And so hopefully we will be able to get this fixed before 
markup later this week so that all parties can agree on. 
Because I don't think it is that difficult.
    Dr. Jesse. I actually think we are in agreement now. So it 
is--and we are anxious to have this work. We are not trying to 
create more barriers, but I think we are in agreement, both 
parties, that the language that you have now, or you will have 
is acceptable and will do what needs to be done.
    Mr. Michaud. Thank you. I have no further questions. I 
yield back.
    Ms. Buerkle. Thank you. I yield Mr. Carter 5 minutes for 
questions.
    Mr. Carter. Thank you, Madam Chairman.
    I have just got a--I have a main interest here about the 
service dogs and the facilities, but I, as an old trial judge, 
I can't help, but have a few questions about sexual assault.
    First, I have to ask a reference because I am not aware of 
any previous material. Are these touchings? Are they spoken 
words? Are they even worse? Do they rise to aggravated sexual 
assault which is genital contact? Just exactly what are we 
talking about here?
    Dr. Jesse. So if you--and I know this was an interest to 
the Committee. If you look in the current time period from when 
the GAO report ended until last week, there is little--141 
reports of sexual assault. So of those, six were alleged rape, 
of which two were substantiated; 78 were inappropriate 
touching, of which 31 were substantiated; and then the other 
were, others, and there is a number of things that that could 
be. It could be public nudity, things along those lines, and 
this is actually one of the real issues here is what is the 
definition of sexual assault, and OIG has a different 
definition than GAO, and one of the Committees that has been 
working on this is that is to actually come up with the 
definition that makes sense in our environment and that seems 
to be moving towards the GAO definition.
    Now, it is interesting because that, I think, specifically 
excludes, if I remember this correctly, sexual discrimination 
as opposed to the more physical things, but it is--remembering 
that in our environment, we are often dealing with very sick 
people. We are often dealing with people who are disoriented, 
even people who aren't disoriented and come into a hospital and 
they can, they lose when they are out of touch of their own 
surroundings or when they are getting different medications, 
can become disoriented. And they do things and things happen 
that they wouldn't do normally and the real important part for 
us is to make sure that, first of all, people are protected.
    People aren't armed and that we can understand what these 
terms really mean. So from the judge's perspective, actually 
having a definition to work off becomes, I think, a crucial 
first step forward.
    Mr. Carter. There are plenty of definitions in the law 
books.
    Dr. Jesse. Well, that is the problem, there are plenty of 
definitions, then you have to be able to work off one of them.
    Mr. Carter. First off, I assume everybody in this room 
would assume that in the scope of the terrible things that 
happen to people in the world, sexual assault is right at the 
top of the list, or pretty close to it, murders may be above 
it. At least in the courthouse of most of the States that I 
know about, we consider aggravated sexual assault to be one of 
the very serious things, and in my particular county, everyone 
that has been convicted of aggravated sexual assault will be in 
the penitentiary for at least 60 years. So we take that very 
seriously and that is a curtailment for people.
    Doctors have a duty to report what they assume to have been 
aggravated sexual assault. Do you report this to the 
authorities? And I understand there are mitigating 
circumstances and those delusions or whether people are, you 
know, taking some kind of medicine or something. That may be an 
extenuating circumstance, but sexual assault shouldn't be 
tolerated in any form or fashion by any institution in this 
country.
    Dr. Jesse. No, we agree fully, and we do have requirements 
which will be reiterated, which we will re-educate everybody on 
about the requirements for reporting.
    Mr. Carter. Well, not just reporting, but if necessary put 
them--turn them over to the district attorney.
    Dr. Jesse. Oh absolutely.
    Mr. Carter. One or two of those might break a lot of folks 
of some bad habits.
    You said you were concerned about--I am going to ask about 
my dog bill right quick. The vet dogs you say are handled by 
regulation and I do appreciate. Let me say that when that issue 
was raised, we do thank you for handling it by regulation. 
However, it was along--you don't think that this complicates, 
in any way, that regulation if we were to make this--actually 
pass this bill into law? You just take the position it is 
unnecessary; is that correct?
    Dr. Jesse. In terms of access?
    Mr. Carter. Yes.
    Dr. Jesse. So we, I think, were not clear about what the VA 
policy was, which is, I think, what has created the problem. 
The directive that was put out earlier this year makes that 
policy very clear, and I don't think the legislation adds 
anything to that policy. Again, it is incumbent on our part to 
make sure----
    Mr. Carter. Could at least I make an argument what it adds 
to the policy is surety?
    Dr. Jesse. Excuse me.
    Mr. Carter. What it adds to the policy is surety. You are 
sure you have this right now because it is a law, whereas 
before, regulations change by regulators, and they can change 
with the wind. And so it is much more a right of a soldier--I 
use soldiers because I have nothing but soldiers in my district 
just about--but warriors. Warrior has a right to have that dog 
with them if we pass this and make it law. It is at the whim of 
the regulators otherwise, and I would argue that at least is a 
good reason why we should go forward.
    Dr. Jesse. Well, as I said, we believe strongly what you 
believe and we have the regulation in place now.
    Mr. Carter. Thank you. Thank you, Madam Chairwoman.
    Ms. Buerkle. Thank you, Mr. Carter. Mr. Carnahan, I yield 5 
minutes for questions.
    Mr. Carnahan. Thank you, Madam Chair, and thank you, Dr. 
Jesse, and the panel.
    I guess I wanted to follow up on Mr. Carter's questions 
about the service dog legislation. You said it was not 
necessary because of steps the VA is taking internally and I 
want to be sure I understand it. Are those steps you believe 
have already been taken, or they are in the process?
    Dr. Jesse. Oh, yes, sir. There is a directive--well, it is 
2011-13, which means it was put out probably in late January or 
early February, that very clearly articulates that veterans 
with service dogs have access to all VA facilities.
    Mr. Carnahan. And it is your belief that based on that, the 
legislation is not necessary?
    Dr. Jesse. Well, except in the context that Mr. Carter said 
that it puts it into law versus regulation, but as I say, we 
have the regulation in place already, and we would--it is 
incumbent on us now to ensure every person and every VA 
understands that this is the requirement.
    Mr. Carnahan. I think that is certainly an important step 
in the process, but I certainly want to go on record again 
strongly supportive of Mr. Carter's legislation to get that put 
into law.
    Also, switch to another topic. In reviewing the legislation 
before us today, the draft legislation on the ``Veterans Health 
Care Capital Facilities Improvement Act,'' some funding in 
there is especially important to the St. Louis region of the 
Jefferson Barracks Medical Center. They have, as you know, it 
is really a win-win there, because the medical center has 
conveyed 33 acres to the National Cemetery that was running out 
of space, and so that is going to be a big boost to the 
National Cemetery there. It has been a big demand from veterans 
in our region, but also this funding for these new buildings is 
going to help the medical care at that facility.
    So we think that is highly important for veterans in the 
region. One of the things related to those buildings, and we 
have had this come up in several discussions with regard to our 
government buildings, is the extent to which they are going to 
be designed to be more energy efficient and more green design. 
We have seen pretty dramatically the effect even though there 
may be a little bit more up-front cost by building these 
buildings more efficiently. Normally, the pay-back period is 3 
to 5 years on that improved technology in design of the 
buildings, so we have some really long-term savings involved 
from operating those buildings. To what extent is that going to 
be incorporated into these buildings at the VA center there?
    Mr. Sullivan. Good afternoon. In the 2012 budget, there is 
$80 million requested for the portion of the project in St. 
Louis that you refer to, as well as an updated authorization 
request included in this bill. That phase of the funding is for 
the site utility work and the energy plant, which will 
incorporate the latest requirements for greening in terms of 
renewable energy, as well as the latest standards for building 
to energy efficiency standards. These standards are included in 
this project, as well as all VA projects that go forward.
    Mr. Carnahan. Great. Again, thank you for your work on that 
and just want to really reiterate what a real win-win that is 
for the VA Medical Center in St. Louis, and for our National 
Cemetery. Thank you. I yield back.
    Ms. Buerkle. Thank you. I believe the Ranking Member has 
one follow-up question so I yield 5 minutes to him.
    Mr. Michaud. Thank you, Madam Chair. Actually, this is for 
Judge Carter. As you heard Dr. Jesse mention, when you look at 
the definition of aggravated sexual assault, if each State 
might have a different definition, one of the concerns that we 
have as a Committee is how you train VA employees to deal with 
it? And with different definitions by different States, and 
when you have directors moving from one State probably to 
another State, they might have a different definition. I hope 
with your expertise, that you might be able to help us how we 
can deal with this and make it easier as well for the VA 
system.
    Mr. Carter. Well, it has been a while since I have been in 
the rewriting of some of the laws, but I can tell you that most 
of the States now have adopted a sort of uniform definition of 
aggravated sexual assault and lesser degrees of sexual assault, 
and the reason I say most of them, some States still use the--
some would argue non-legal description called ``rape'' and 
``statutory rape,'' and of course, colloquially we still use 
those terms, but most States I think, there is plenty of 
studies that will tell you exactly what they have done to make 
their changes. But that has been involved now over the last 30 
years, and I would venture a guess that you would find that 
most of the sexual assault definitions that you find in the law 
are very, very similar, at least, first cousins.
    The concepts were all the same, words were slightly 
different. So you can get a pretty good guidance from any penal 
code of any State, what overall it is across the country. Maybe 
with a few exceptions and that is where I would start. I would 
start getting somebody to just check and see how uniform the 
penal codes are. I am sure there is somebody that can give you 
that information very quickly.
    Mr. Michaud. Thank you very much.
    Mr. Carter. If you can't get it, I can find it. I can get 
somebody who can get it for you. Just holler at me.
    Mr. Michaud. Thank you. Thanks again, Madam Chair.
    Ms. Buerkle. Thank you. I yield myself just a couple of 
minutes. I have a couple of follow-up questions.
    First of all, you are going to submit to us the data 
processing and the system you are going to use in and the 
timeline and how that will work. Could you also provide to us 
how the VA has complied with the GAO report, what pieces of 
their recommendations have you put in place, and what pieces 
remain outstanding and what progress you have made with regards 
to their recommendations.
    Dr. Jesse. Absolutely.
    [The VA subsequently provided the update on the actions 
taken by VA in response to the eight GAO recommendations, with 
a letter and enclosures, dated August 5, 2011, from John R. 
Gingrich, Chief of Staff, U.S. Department of Veterans Affairs, 
to Randall Williamson, Director, Health Care, U.S. Government 
Accountability Office, which appears on p. 81.]
    Ms. Buerkle. Okay. Very good. Thank you. I do want to 
comment on something you said because I think it bears 
commenting on, and that is, you said that you know the 
definition of sexual assault may be a problem to reach that 
conclusion because you have to have a definition that makes 
sense relative to the environment within the VA, that there are 
very sick people, very disoriented people.
    I would argue that the levels of illness and issues that 
the patients have within the VA system would raise the bar for 
the VA system, but sexual assaults are sexual assaults, and 
that only means that the VA system has to--work harder, be more 
effective and be much more aware of what is going on within VA 
facilities. It doesn't change what sexual assault is. It 
doesn't change the outcomes, but it requires more and it raises 
the bar for the VA system.
    Dr. Jesse. Absolutely. It is a terrible problem, and we are 
taking this very much to heart. We agree.
    Ms. Buerkle. And with that, and if there are no further 
questions I move the Members have 5 legislative days to revise 
and extend their remarks and include extraneous material. 
Without objection, so ordered.
    Once again, Dr. Jesse and to the entire panel our sincere 
thanks for you coming here today and answering our questions. 
To all of our audience, thank you for your participation. To 
the veterans in this room, thank you all for your service to 
this Nation. We are deeply appreciative of what you have done 
for our country, and you have preserved and protected our 
freedoms, so thank you for your service to this Nation.
    This hearing is now adjourned.
    [Whereupon, at 5:57 p.m., the Subcommittee was adjourned.]



                            A P P E N D I X

                              ----------                              

             Prepared Statement of Hon. Ann Marie Buerkle,
                   Chairwoman, Subcommittee on Health

    Good afternoon. This hearing will come to order.
    Today, we meet to discuss a number of legislative proposals aimed 
at improving the care provided to our Nation's veterans through the 
Department of Veterans Affairs (VA).
    The seven bills on our agenda today are: H.R. 198, the Veterans Dog 
Training Therapy Act; H.R. 1154, the Veterans Equal Treatment for 
Service Dogs Act; H.R. 1855, the Veterans Traumatic Brain Injury 
Rehabilitative Services Act of 2011; H.R. 2074, the Veterans Sexual 
Assault Prevention Act; H.R. 2530, to provide increased flexibility in 
establishing reimbursement rates for nursing home care provided to 
certain veterans in State Homes; draft legislation, the Veterans Health 
Care Capital Facilities Improvement Act of 2011; and, draft 
legislation, the Honey Sue Newby Spina Bifida Attendant Care Act.
    This hearing represents an important step in the legislative 
process and, as such, I look forward to a frank and productive 
conversation about the policy implications, merits, and potential 
unintended consequences of each of the proposals on our agenda.
    One of the bills we will discuss this afternoon is H.R. 2074, the 
Veterans Sexual Assault Prevention Act, a bill I introduced in response 
to a truly alarming report issued last month by the Government 
Accountability Office (GAO) on the prevalence of sexual assault and 
other safety incidents in VA facilities. I am pleased to sponsor this 
legislation with our Chairman, Jeff Miller, and with Ranking Members, 
Bob Filner and Mike Michaud as co-sponsors.
    In their report, GAO found that between January 2007 and July 2010 
nearly 300 sexual assaults, including 67 alleged rapes, were reported 
to VA police.
    Troublingly, and in direct violation of Federal regulations and VA 
policy, many of these incidents were not properly reported to VA 
leadership officials or the VA Office of the Inspector General.
    As disturbing, GAO uncovered serious deficiencies in the guidance 
and oversight provided by VA leadership officials on the reporting, 
management, and tracking of sexual assault and other safety incidents.
    GAO also found that the Department failed to accurately assess risk 
or take effective precautionary measures, with inadequate monitoring of 
surveillance systems and malfunctioning or failing panic alarms.
    As a domestic violence counselor, I have seen firsthand the 
pervasive and damaging effects sexual assault can have on the lives of 
those who experience it.
    Abusive behavior like the kind documented by GAO is unacceptable in 
any form, but for it to be found in what should be an environment of 
caring for our honored veterans is simply intolerable.
    H.R. 2074 would address the safety vulnerabilities, security 
problems, and oversight failures identified by GAO and create a 
fundamentally safer environment for veteran patients and VA employees.
    Specifically, H.R. 2074 would require VA to develop clear and 
comprehensive criteria with respect to the reporting of sexual assault 
and other safety incidents for both clinical and law enforcement 
personnel.
    It would establish a newly accountable oversight system within the 
Veterans Health Administration (VHA) to include a centralized and 
comprehensive policy on reporting and tracking sexual assault 
incidents, covering all alleged or suspected forms of abusive or unsafe 
acts, as well as the systematic monitoring of reported incidents to 
ensure each case is fully investigated and victims receive appropriate 
treatment.
    To correct serious weaknesses observed in the physical security of 
VA medical facilities and improve the Department's ability to 
appropriately assess risk and take the proper preventative steps, H.R. 
2074 would mandate the Department to develop risk assessment tools, 
create a mandatory safety awareness and preparedness training program 
for employees, and establish physical security precautions including 
appropriate surveillance and panic alarm systems that are operable and 
regularly tested.
    It is critically important that we take every available step to 
protect the personal safety and well-being of the veterans who seek 
care through the VA and all of the hardworking employees who strive to 
provide that care on a daily basis.
    I am eager to discuss H.R. 2074 this afternoon and am here to 
answer any questions my colleagues may have about this legislation.
    Also on our agenda today is a draft Committee proposal, the 
``Veterans Health Care Capital Facilities Improvement Act of 2011.'' 
This draft legislation incorporates the Administration's fiscal year 
2012 construction request to authorize major medical facility projects 
and leases. The draft proposal also modifies the statutory requirements 
for the Department to provide a prospectus to Congress when seeking 
authorization for a major medical facility project to ensure we receive 
a comprehensive and accurate cost-benefit analysis as the basis for 
making these critical decisions.
    It also extends authorities to provide for important programs 
related to such initiatives as housing assistance for homeless veterans 
and treatment and rehabilitation for veterans with serious mental 
illness, both of which are set to expire at the end of this calendar 
year.
    Additionally, section six of the draft bill seeks to provide an 
extension of VA's enhanced use lease authority which is also set to 
expire this year. This authority is an innovative and vitally important 
approach to supporting goals we all share, such as reducing 
homelessness among the veteran population and making effective use of 
vacant or underutilized VA property, through public-private 
partnerships. Unfortunately, the Congressional Budget Office has scored 
this provision with a mandatory spending cost of $700 million. We want 
to work with the Department and the veterans service organizations to 
resolve this scoring issue to ensure that VA has the authority to 
continue utilizing this important program.
    The draft bill also includes legislation that was brought to us by 
our colleague from Colorado, Mr. Scott Tipton, to designate the 
telehealth clinic in Craig, Colorado as the ``Major William Edward 
Adams Department of Veterans Affairs Clinic.'' Major William Edward 
Adams is a Medal of Honor recipient and Scott has provided a statement 
for the record detailing Major Adam's courageous service to our 
country.
    I want to thank all of the Members who sponsored the bills and 
draft legislation before us, as well as the witnesses from the veterans 
services organizations and the Department, for taking time out of their 
busy schedules to share their expertise with us this afternoon. I look 
forward to our discussion and will now yield to the Ranking Member, Mr. 
Michaud for any opening statement he may have.

                                 
             Prepared Statement of Hon. Michael H. Michaud,
           Ranking Democratic Member, Subcommittee on Health

    I would like to thank everyone for coming today.
    Today's legislative hearing is an opportunity for Members of 
Congress, veterans, the VA and other interested parties to provide 
their views on and to discuss introduced legislation within the 
Subcommittee's jurisdiction in a clear and orderly process.
    We have seven bills before us today which address a number of 
important issues for our veterans and provide the staff of the 
Department of Veterans Affairs with the necessary tools to provide the 
best care for our veterans. First, we have two bills to help veterans 
with post-deployment mental health issues through training service 
dogs. The remainder of the legislation covers a wide range of topics, 
such as improved TBI care, sexual assault prevention, facilities 
construction, and Spina Bifida.
    We will also examine my bill, H.R. 2530, which seeks to increase 
flexibility in payments for State Veterans Homes. It would require 
State Veterans Homes and the VA to enter into a contract for the 
purpose of providing nursing home care to veterans who need such care 
for a service-connected condition or have a service-connected rating of 
70 percent or greater.
    I look forward to hearing the views of our witnesses on the bills 
before us today.
    Madam Chair, I yield back.

                                 
                Prepared Statement of Michael G. Grimm,
        a Representative in Congress from the State of New York

    Chairman Buerkle, Ranking Member Michaud, thank you for allowing me 
to testify today on H.R. 198, the ``Veterans Dog Training Therapy 
Act.'' As a Marine Combat Veteran of Operation Desert Storm it is a 
unique honor for me to address this Committee. Having seen firsthand 
both the physical and mental wounds of war that the members of our 
Nation's military are faced with, I have a special appreciation for the 
important work this Committee does every day.
    Today, over 2 million Iraq and Afghanistan Veterans have returned 
home to the challenge of an unemployment rate hovering near 10 percent, 
which for disabled veterans is actually closer to 20 percent, and, for 
many, the long road to recovery from the mental and physical wounds 
sustained during their service. Sadly, these numbers continue rising 
every day.
    Over the last 6 months I have had the honor to meet with a number 
of our Nation's veterans who are now faced with the challenges of 
coping with PTSD and physical disabilities resulting from their service 
in Iraq and Afghanistan. Their stories are not for the weak of heart 
and are truly moving. It was these personal accounts of their recovery, 
both physical and mental, and the important role therapy and service 
dogs played, that inspired this legislation.
    The Veterans Dog Training Therapy Act would require the Department 
of Veterans Affairs to conduct a 5-year pilot program in at least three 
but not more than five VA medical centers assessing the effectiveness 
of addressing post-deployment mental health and PTSD through the 
therapeutic medium of training service dogs for veterans with 
disabilities. These trained service dogs are then given to physically 
disabled veterans to help them with their daily activities. Simply put, 
this program treats veterans suffering from PTSD while at the same time 
aiding those suffering from physical disabilities. Since I introduced 
this legislation it has gained the bipartisan support of 83 cosponsors, 
including Financial Services Committee Chairman Spencer Bachus and 
Ranking Member Barney Frank as well as Congressmen Pete Sessions and 
Steve Israel. Clearly, this legislation has brought together a number 
of unlikely allies in support of our Nation's veterans.
    Additionally, with veteran suicide rates at an all time high and 
more servicemen and women being diagnosed with PTSD, this bill meets a 
crucial need for additional treatment methods. I believe that by caring 
for our Nation's veterans suffering from the hidden wounds of PTSD 
while at the same time providing assistance dogs to those with physical 
disabilities we create a win-win for everyone, which I believe is a 
goal we can all be proud to accomplish.
    Working in conjunction with a number of Veteran Service 
Organizations, including AMVETS and VetsFirst, I have drafted updated 
language which I intend to have submitted during Committee markup of 
H.R. 198 to ensure this program provides our nations veterans with the 
highest quality care for both PTSD and physical disabilities, while 
maintaining my commitment to fiscal responsibility.
    I understand that in the current economic situation we are faced 
with it is especially important to ensure taxpayer dollars are spent 
wisely, which is why I have identified several possible offsets, to 
include shifting funds from the Veterans Affairs General Administrative 
Account, to make sure this legislation meets pay-go requirements. As we 
move forward in the legislative process I look forward to working with 
the Committee to ensure that any money allocated for this program is 
offset by reductions in other accounts.
    Again, I would like to thank the Committee for holding today's 
hearing and I look forward to working with you to ensure that this 
program is included in your continuing efforts to guarantee that our 
Nation's heroes have the best possible programs for treating PTSD and 
providing disability assistance.

                                 
      Prepared Statement of Hon. Timothy J. Walz, a Representative
                in Congress from the State of Minnesota

    I want to thank Chairwoman Buerkle, Ranking Member Michaud, and 
Members of the Subcommittee for giving me the opportunity to appear 
before you today to discuss my bill, H.R. 1855, the Traumatic Brain 
Injury Rehabilitative Services Improvements Act of 2011.
    It is a deep privilege to be a Member of a Committee devoted to 
serving those who have served our country. We are truly the stewards of 
a grateful nation that recognizes our obligation to America's 
servicemen and women.
    We are also Members of a Committee with a great history--not only 
of developing landmark legislation to meet the needs of many 
generations of veterans, but of doing this important work on a 
bipartisan basis. The Committee's rich legacy continues to the present.
    Reflecting on the needs of many of those veterans, I introduced 
legislation late last year, together with Chairman Miller and 
Congressman Bilirakis, to help some of our most severely injured, those 
with traumatic brain injury. That legislation was aimed at improving 
the rehabilitative services that are so important to these young men 
and women.
    Having re-introduced the bill earlier this year, I'm particularly 
appreciative that the Subcommittee has included it on the agenda.
    Unprecedented numbers of warriors are returning home from Iraq and 
Afghanistan with severe polytraumatic injuries. This is not only due to 
the nature of the fighting and the kinds of injuries being sustained, 
but to advances in military medicine and logistics that have saved 
countless lives that might have been lost in previous wars.
    Traumatic brain injuries are among the most complex injuries our 
personnel have sustained. Each case is unique and injuries can result 
in wide-ranging loss of function. Neurological and cognitive loss or 
impairment in speech, vision, and memory, for example, are not 
uncommon--as is marked behavioral change, with such manifestations as 
impaired judgment or diminished capacity for self-regulation.
    It is difficult to predict the extent of an individual's ultimate 
level of recovery, but the evidence is clear that to be effective in 
helping an individual recover from a brain injury and return to a life 
as independent and productive as possible, rehabilitation must be 
targeted to the specific needs of the individual patient.
    H.R. 1855, the Traumatic Brain Injury Rehabilitative Services 
Improvements Act of 2011, is aimed at closing gaps in current law that 
have had the effect of denying some veterans with severe TBI from 
achieving optimal outcomes.
    Many VA facilities have dedicated rehabilitation-medicine staff, 
but the scope of services actually provided to veterans with a severe 
TBI can be limited, both in duration and in the range of services 
authorized. Veterans encounter two distinct problems. First, it is all 
too common for staff to advise families that the VA can no longer 
provide a particular rehabilitative service because the veteran is no 
longer making significant progress. But ongoing rehabilitation is often 
needed to maintain function, and individuals who are denied maintenance 
therapy can regress and lose cognitive and other gains they've made 
through rehab work.
    A second problem veterans encounter is in getting help with 
community reintegration, and learning to live as independently as 
possible. VA's rehabilitation focus relies almost exclusively on a 
medical model; that assistance is critical, but doesn't necessarily go 
far enough for some veterans in providing the range of supports a young 
person needs to achieve the fullest possible life in the community.
    In contrast, other models of rehabilitative care meet TBI patients' 
needs through such services as life-skills coaching, supported 
employment, and community reintegration therapy. These services are 
seldom made available to veterans. Yet research has shown that with 
these types of innovative non-medical supports, individuals with severe 
TBI can flourish in a community setting. Denying wounded warriors such 
supports compromises their achieving the fullest possible recovery.
    H.R. 1855 would close these gaps. Specifically, it would clarify 
that VA may not prematurely cut off needed rehabilitation services for 
an individual with traumatic brain injury, and that veterans with TBI 
can get the supports they need--whether those are health-services or 
non-medical assistance--to achieve maximum independence and quality of 
life.
    I'm gratified by the broad support the bill has won from major 
veterans' service organizations. And I'm particularly pleased at the 
strong endorsement from Wounded Warrior Project, whose Executive 
Director, Steve Nardizzi, described the bill as ``powerfully addressing 
the often agonizing experience of wounded warriors who have been denied 
important community-reintegration supports and who have experienced 
premature termination of rehabilitation services.'' As Steve said, 
``This bill offers new hope to these warriors and their families.''
    I look forward to responding to all of your questions, and with 
that, I yield back my time.

                                 
       Prepared Statement of Hon. Larry Bucshon, a Representative
                 in Congress from the State of Indiana

    Thank you Chairwoman Buerkle, Ranking Member Michaud, Members of 
the Subcommittee, for the opportunity to come and speak to you today 
about my draft legislation, the Honey Sue Newby Spina Bifida Attendant 
Care Act.
    In April of this year, I was contacted by a constituent from New 
Harmony, Mr. Ron Nesler, on behalf of his stepdaughter, Honey Sue 
Newby. Honey Sue's father was a Vietnam Veteran exposed to Agent 
Orange; and she was born with a complicated neurological disorder 
rooted in Spina Bifida, a congenital condition in which the vertebrae 
do not form properly around the spinal cord. The Veterans 
Administration has previously determined Honey Sue's condition is a 
direct result of her father's exposure to Agent Orange in Vietnam and 
have classified her as a Level III child, making her eligible to 
receive the same full health care coverage as a veteran with 100 
percent service-connected disability.
    In 2007, Mr. Nesler and his wife reached out to my predecessor, 
former-Representative Brad Ellsworth regarding two issues they had been 
experiencing with the VA. The first was an administrative burden 
requiring a letter from Honey Sue's doctor explaining exactly how the 
treatment she sought was related to her Spina Bifida. More often than 
not, this resulted in the VA denying repayment until additional 
burdensome administrative procedures took place. For example, Honey Sue 
needed surgery on her mouth after seizures caused her to grind her 
teeth to nubs. The VA originally denied payments for the procedure 
saying the doctor's letter did not clearly make the case that this 
result was related to the condition.
    Secondly, Honey Sue's parents are aging and experiencing health 
problems. Currently, the only long term services the VA will pay for is 
nursing home care for individuals like Honey Sue. Nursing home care is 
both extremely expensive and inappropriate for what Honey Sue needs. 
Individuals with Spina Bifida have a diverse range of needs. Although 
no two cases of Spina Bifida are ever the same, the National Spina 
Bifida Association confirms the majority of these individuals can live 
independently if they have the proper habilitative care in order to 
develop, maintain or restore their functioning.
    Former Rep. Ellsworth's bill, H.R. 5729, was written to address 
both of these issues and on May 20, 2008 H.R. 5729 was passed by voice 
vote in the House of Representatives and was later added to S. 2162, 
the Veterans Mental Health and Other Care Improvement Act of 2008. This 
legislation was signed by President Bush on October 10, 2008 (Public 
Law 110-387).
    Since then, the VA has recognized and alleviated the administrative 
burdens, but has not properly interpreted `habilitative care'. Title 38 
of the U.S. Code defines habilitative care as `professional, 
counseling, and guidance services and treatment programs (other than 
vocational training under section 1804 of this title) as are necessary 
to develop, maintain, or restore, to the maximum extent practicable, 
the functioning of a disabled person.' Under this language, I believe 
the VA is misinterpreting the law and its intent as it concerns 
individuals with type III Spina Bifida who simply need supervisory, or 
as we put it in the draft legislation--home and community based-care.
    The purpose of this draft legislation is to clarify Title 38 to 
allow individuals with Spina Bifida the appropriate and cost effective 
care they deserve. The intended result allows individuals to take 
advantage of home and community based care for those that do not need 
constant medical care. The term `Home and community based care' is used 
in the definition of `habilitative care' in section 1915 of the Social 
Security Act and this legislation is modeled after and aims to create 
consistency for that definition within VA services.
    Again, thank you for the consideration of this legislation. I am 
happy to answer any questions.

                                 
      Prepared Statement of Hon. John R. Carter, a Representative
                  in Congress from the State of Texas

    Thank you Chairwoman Buerkle, Ranking Member Michaud, and 
distinguished Members of the Subcommittee. I am here today to discuss 
H.R. 1154, the Veterans Equal Treatment for Service Dogs (VETS Dogs) 
Bill, which I introduced on March 17, 2011. This bi-partisan bill has 
gained widespread support, with over 60 Cosponsors to date.
    The VETS Dogs Bill is quite simple and does not cost any money; it 
merely ensures that Veterans with medical service dogs have equal 
access to all Veterans Affairs (VA) facilities. Currently, only seeing-
eye and guide dogs are allowed access. This bill was first brought to 
my attention by the American Veterans (AMVETS) organization, and is 
supported by the Veterans of Foreign Wars (VFW), Military Order of the 
Purple Heart (MOPH), VetsFirst, and Paws with a Cause. Additionally, 
this bill complies with the Americans with Disabilities Act (ADA) as 
well as the Rehabilitation Act.
    The VETS Dogs Bill recognizes that medical service dogs are used 
increasingly more for treatment and assistance of medical issues other 
than blindness. For example, Veterans currently use medical service 
dogs for support in cases of Traumatic Brain Injuries (TBI), hearing 
loss, seizures, as well as for mobility assistance. With this increased 
usage, it is crucial that we help these Veterans and their service dogs 
gain access to all VA facilities.
    The VA issued a directive in March 2011 requiring the Veterans 
Health Administration (VHA) to allow medical service dogs into its 
facilities. While this is a very positive step for the VA, this 
directive does not apply to all VA facilities and expires in 2016. The 
VETS Dogs Bill will assist the VA in solidifying this directive through 
including all VA facilities and by making such access permanent law. I 
applaud the VA for continuing to make great strides to improve care 
provided to all wounded Veterans. This bill simply closes the gap in 
access that currently exists.
    I would like to recognize Deb Davis from Paws with a Cause, who is 
here with her dog Krickit today. Deb helped to write this important 
piece of legislation. Additionally, Kevin Stone and his dog Mambo are 
also in attendance today. Mambo assists Kevin with mobility, and serves 
as a great example of how medical service dogs can help wounded 
Veterans. Kevin believes that Mambo has allowed him to regain his 
independence and quality of life. However, Kevin has been denied access 
to VA Medical Centers (VAMC) since Mambo is not a seeing-eye or guide 
dog. We are failing Kevin and other wounded Veterans if we allow this 
to keep happening. Madame Chairwoman and Committee Members, thank you 
for giving me the opportunity to speak today on the Veterans Equal 
Treatment for Service Dogs (VETS Dogs) Bill.
    U.S. Representative John R. Carter was elected in 2010 to his fifth 
term representing Texas' Thirty-First Congressional District in the 
U.S. House of Representatives. Since his first election in 2002, 
Congressman Carter has established himself as a leader in Congress who 
has the foresight and courage to author and support numerous pieces of 
legislation that would increase the protection of U.S. citizens and 
bring justice to those who threaten our freedom and way of life.
    Congressman Carter was also unanimously re-elected in 2010 to a 
third term as House Republican Conference Secretary. In this position, 
Congressman Carter is the sixth highest-ranking Republican in the 
House.
    He has served on the prestigious House Appropriations Committee 
since 2004, and currently sits on the Transportation, Homeland 
Security, and Military Quality of Life and Veterans Affairs 
Subcommittees. During the 108th Congress, Congressman Carter was a 
Member of the House Education and the Workforce, Judiciary, and 
Government Reform Committees.
    Carter also continues to serve on the House Republican Steering 
Committee, an official group of members who are in charge of placing 
Members on Committees. Carter has been honored to serve on this select 
panel since being elected to Congress.
    Congressman Carter's leadership ability has been recognized by his 
colleagues and others. During his first term, Congressman Carter was 
named one of the ``Top Five Freshman'' in Congress by Capitol Hill's 
leading newspaper.
    For Congressman Carter, leadership goes far beyond the Committee 
room and onto the House floor, where he has successfully had 
legislation passed and signed into law under both Presidents Bush and 
Obama. Bringing to Congress 20 years of judicial experience, 
Congressman Carter has consistently worked to advance a tough on crime 
agenda.
    In July 2004, President Bush held a signing ceremony for 
Congressman Carter's Identity Theft bill at the White House. The law 
lessens the burden of proof making identity theft easier to prove and 
prosecute and also defines and creates punishment for aggravated 
identity theft.
    Congressman Carter bears the nickname of ``Judge'' on Capitol Hill 
and at home for serving over 20 years on the bench. In 1981, 
Congressman Carter was appointed the Judge of the 277th District Court 
of Williamson County and was elected District Judge in 1982. Before 
becoming a Judge, Congressman Carter had a successful private law 
practice and continued to practice law while serving as the Municipal 
Judge in Round Rock. He was the first county-wide elected Republican in 
Williamson County history. As an attorney, Carter represented the Round 
Rock and Williamson County communities through their first booming 
phases of growth and continues to support and guide today's growth. 
Congressman Carter has seen the economy both rise and fall and has a 
plan to assist the residents in Congressional District 31 to ensure 
their prosperity.
    A true Texan at heart, Congressman Carter was born and raised in 
Houston and has spent his adult life in Central Texas. Carter attended 
Texas Tech University where he graduated with a degree in History and 
then graduated from the University of Texas Law School in 1969. 
Congressman Carter and his wife, Erika, met in Holland and have been 
happily married since June 15, 1968. Since then they have built a home 
and raised a family of four on Christian beliefs and strong Texas 
Values.

                                 
               Prepared Statement of Shane Barker, Senior
          Legislative Associate, National Legislative Service,
             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, the VFW would like to thank this Committee 
for the opportunity to present its views on these bills.

H.R. 198, Veterans Dog Training Therapy Act

    The VFW appreciates the intent behind this bill. However, we do not 
believe a VA medical center is the right environment for a pilot 
program involving dog-training. We believe the idea behind this 
legislation--to help veterans with post-traumatic stress disorder by 
incorporating a therapeutic dog training class as a part of their 
treatment--would be better achieved through established private sector 
organizations with sufficient oversight by VA. Partnering with outside 
entities that have experience and proven success in this area would 
provide the veteran with the outcomes this bill wants to evaluate. It 
would also localize the program by moving it from VA medical centers to 
the communities where many of our veterans live. Overall, we think such 
changes would achieve greater results with no further cost to VA, and 
with fewer complications for our veterans.

H.R. 1154, Veterans Equal Treatment for Service Dogs Act

    The use of medical service dogs among veterans is increasing, and 
many of our newest veterans who are returning home from war with mental 
and physical disabilities have a particular need for their services. We 
believe that trained dogs play a significant role in helping to provide 
independence to individuals with a broad range of disabilities.
    Currently, VA allows seeing-eye dogs to enter medical facilities 
without limitations. Senator Harkin's legislation would allow all 
service dogs into facilities that receive VA funding. The VFW is happy 
to lend our support to a benefit that is often overlooked and can go a 
long way towards helping an individual with a disability who may not be 
able to perform a task independently.

H.R. 1855, the Veterans' Traumatic Brain Injury Rehabilitative 
        Services' Improvements Act of 2011

    The VFW supports this legislation to expand and improve the plan 
for rehabilitation and reintegration of TBI patients. This legislation 
would require VA to broaden their TBI treatment plans to focus on an 
injured veteran's independence and quality of life while making 
improvements to their behavioral and mental health functioning. We know 
that VA is working to do more than merely stabilize these men and 
women, but we are fully supportive of adding language to the United 
States Code that requires VA to pursue treatment options that would 
improve their functioning.
    It expands the scope of rehabilitative service for veterans 
suffering from brain injury to include behavioral and mental health 
concerns. As a result of this bill, the phrase ``rehabilitative 
services'' replaces the word ``treatment'' in pertinent areas of the 
United States Code, thereby conforming it to the prevailing wisdom that 
TBI patients deserve more than mere treatment of their injuries. This 
change is critical because these men and women deserve ongoing 
evaluation and additional intervention where necessary to ensure a full 
recovery. We believe the changes in this bill would make it easier for 
veterans struggling with the aftermath of a TBI to receive such 
coverage. Finally, this bill would also support TBI patients by 
associating sections of the law related to TBI rehabilitation and 
community reintegration to a broader definition of the term 
``rehabilitative services'' that comprises a range of services such as 
professional counseling and guidance services. This bill would help to 
ensure our response to traumatic brain injuries consists of more than 
just healing the wounds that we can see. Our veterans deserve every 
chance to lead productive lives, which is why the VFW believes that VA 
and U.S. Department of Defense (DoD) should look into any and all 
potential rehabilitation and treatment models for veterans who suffer 
from TBI.

H.R. 2074, Veterans Sexual Assault Prevention Act

    We thank Health Subcommittee Chairwoman Buerkle and Chairman Miller 
for introducing H.R. 2074, the ``Veterans Sexual Assault Prevention 
Act,'' and we are pleased to see this Committee continuing to work 
diligently on this critical issue. As we have said before, one incident 
of assault, of a sexual nature or otherwise, is one too many. The VFW 
reaffirms, in no uncertain terms, the need for a zero-tolerance policy. 
Less than that is unacceptable and inexcusable. Veterans should never 
have to visit a VA medical facility with concerns about their personal 
safety.
    We want the guilty punished, but we also strongly believe that any 
legislation signed into law should ensure exonerated employees are not 
adversely affected. VA must be extremely judicious not to allow 
unsubstantiated allegations to bring about negative consequences for 
the accused, while at the same time holding the guilty accountable for 
such heinous actions. 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.
    The most important missing piece is a comprehensive, continuous, 
and evidence-based training program. All efforts to properly identify 
sexual assault and to create programs to forward allegations to 
appropriate officials are in vain if employees are not trained to be 
vigilant and to identify problem situations. We strongly believe that 
VA must institute a first-class training program that is mandatory for 
all VA employees to attend.
    They must also clarify what constitutes sexual assault, because the 
lack of a clear and consistent VA-wide definition has allegedly led to 
many events not being reported, or resulted in no action on those 
events that were reported. 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 does not already exist.
    VA leadership has failed in their obligations for too long, and the 
hidden nature of this unacceptable problem requires Congress to act 
quickly. We stand ready to assist the Committee in passing this 
legislation without delay.

H.R. 2530, a bill to amend title 38, United States Code, to provide for 
        increased flexibility in establishing rates for reimbursement 
        for State homes by the Secretary of Veterans Affairs for 
        nursing home care provided to veterans.

    The VFW supports this straightforward legislation to eliminate the 
rigid system currently in place to reimburse State homes for nursing 
home care provided to veterans. The current reimbursement system pays 
State homes uniformly across the country, without taking into account 
costs of living or costs of goods and services from State to State. 
These costs vary considerably, and the result of the uniform payment 
schedule results in some States doing well, and other States not being 
able to provide needed services without some significant negative 
financial impact.
    The services State veterans homes provide are critical, and they 
are not looking for disproportional profits. They are looking to 
sustain themselves, and we strongly believe that VA must be a partner 
in that effort. This legislation would help achieve that by allowing VA 
to enter into contracts with individual State veterans homes for 
payment schedules that are crafted in consultation with the State home. 
This change will make these payments more equitable and sustainable for 
everyone involved, and this bill has broad stakeholder support. We 
strongly believe that it will put these complications to rest, and will 
work to bring about its passage into law.

Draft Legislation, the Honey Sue Newby Spina Bifida Attendant Care Act

    The VFW supports this measure to give VA the authority to provide 
more appropriate care for Honey Sue Newby, and other children of 
Vietnam veterans suffering from Spina Bifida. The story of Newby is a 
harrowing tale of VA--for whatever reason--being counterproductive in 
providing care at every turn. It is also a story of perseverance on the 
part of this family to find the care that Honey Sue desperately needed. 
That provision of care was granted by Congress and earned by virtue of 
Mr. Newby's service. However, the record is clear that they have 
suffered time and time again due to onerous VA requirements.
    This bill will make it easier for family attendants to persevere 
through VA requirements as they care for a child with Spina Bifida by 
broadening the types of care VA can provide, and will allow VA to enter 
into contracts with providers who offer enhanced and new types of care. 
It expands outpatient care to include adult day health services. 
Perhaps most importantly, it expands home care to help offset having a 
live-in, unrelated personal caregiver in cases where not having one 
would result in admission to a hospital, a nursing care facility, or an 
intermediate care facility.
    These changes will greatly improve the quality of life for families 
of veterans exposed to Agent Orange who have children who suffer from 
Spina Bifida. We strongly support this legislation and look forward to 
working with you to get it enacted.

Draft Legislation, Veterans Health Care Facilities Capital Improvement 
        Act of 2011

    The Veterans Health Care Facilities Capital Improvements Act of 
2011 is necessary in building and utilizing VA properties in a way that 
will provide greater quality and access to care for veterans. The 
authorization of funds for major construction projects closely reflects 
the requests by VA, and exceeds, by nearly double, the FY 2012 
appropriations request for this line item. However, at this rate of 
authorization and funding, VA will not have the financial resources 
available to reach their capital planning goals outlined though VA's 
Strategic Capital Investment Planning (SCIP). The authorization for 
medical facility leases fulfills VA's request for establishing eight 
community-based outpatient clinics. The VFW agrees with this level of 
authorization.
    Section 6 outlines the new authority for VA's enhanced-use lease 
((EUL). Most importantly, this bill will extend EUL. Without this 
extension, which is due to expire December 31, 2011, VA will be limited 
in their ability to reduce homelessness and effectively use properties 
that are either vacant or underutilized. The VFW agrees with most of 
the amendments of EUL authorization including the consideration of EUL 
business plans beyond those proposed by the Under Secretary of Health, 
ensuring the leases comply with current scorekeeping rules, ensuring 
that VA's liability is limited, clarification of payment of State and 
local taxes, and that funds derived from EUL will be deposited into 
VA's Major and Minor construction accounts.
    The VFW does have concerns with the amendment that removes the 
criteria that mandates EUL properties must ``actively contribute to 
VA's mission.'' Removal of this provision could change the focus of VA 
from providing care for veterans to improving revenue of existing 
properties. Maintaining and improving care for veterans must always be 
the single focus of VA. Also, any revenue that is produced through the 
EUL program that would be shifted to VA's Major and Minor construction 
accounts through the passage of this bill must be a supplement to, and 
not a substitute for, appropriating funds for these accounts.
    The VFW agrees with Section 7 of this legislation. Currently, VA 
requests construction funding for the actual cost of construction, but 
leaves out activation costs. Section 7 would ensure that VA requests 
the full cost of construction costs.
    The VFW holds no opinion on the naming of VA facilities. Therefore, 
the VFW provides no comment on Section 8 of this legislation.
    The VFW supports all of the extensions of the expiring authorities 
that are found in Section 9 of this legislation.
    Madam Chairwoman, this concludes my statement. I would be happy to 
answer any questions that you or the Members of the Committee may have.

                                 
           Prepared Statement of Joy J. Ilem, Deputy National
            Legislative Director, Disabled American Veterans

    Madam Chairwoman, Ranking Member Michaud, and Members of the 
Subcommittee:
    Thank you for inviting me to testify on behalf of the Disabled 
American Veterans (DAV) at this important hearing of the Subcommittee 
on Health. DAV is an organization of 1.2 million service-disabled 
veterans. We devote our energies to rebuilding the lives of disabled 
veterans and their families.
    Madam Chairwoman, the DAV appreciates your leadership in enhancing 
Department of Veterans Affairs (VA) health care programs on which many 
service-connected disabled veterans must rely. At the Subcommittee's 
request, the DAV is pleased to present our views on five numbered bills 
and two draft measures before the Subcommittee today.

          H.R. 198--the ``Veterans Dog Training Therapy Act''

    If enacted, this bill would require the Secretary of Veterans 
Affairs within 120 days of enactment to conduct a pilot program for 
certain veterans through the therapeutic medium of service dogs. The 
pilot program would include the provision of training, exercising, 
feeding, grooming and quartering of dogs by VA for veterans with post-
deployment mental health challenges for use as service animals. The 
stated purpose of the pilot program would be to determine how 
effectively it would assist veterans with post-traumatic stress 
disorder (PTSD) in reducing mental health stigma; improving emotional 
stability and patience; reintegrating into civilian society; and, 
making other positive changes that aid veterans' repatriation after 
combat. The bill would require a VA study to document such efficacy and 
a series of reports to Congress.
    Madam Chairwoman, we do not have an approved resolution from our 
membership that addresses this specific topic, so we are unable to take 
a formal position on this bill. We are supportive of VA's current 
policy on admittance of service animals to VA facilities provided it is 
carried out uniformly nationwide. Also, DAV is looking forward to the 
receipt of findings from VA's ongoing research project to determine the 
efficacy of service dog usage by veterans challenged by mental illness 
and other mental health conditions related to combat deployments 
including PTSD. We recognize that trained service animals can play an 
important role in maintaining functionality and promoting maximum 
independence and improved quality of life for persons with 
disabilities--and that pilot programs such as the one proposed could be 
of benefit to certain veterans.
    H.R. 1154--the ``Veterans Equal Treatment for Service Dogs Act''
    This bill would prohibit the Secretary of Veterans Affairs from 
restricting the use of service dogs by veterans on any VA property that 
receives funding from the Secretary.
    Madam Chairwoman, similar to our lack of a resolution on the above 
bill, we do not have a resolution on this topic either. The Veterans 
Health Administration (VHA) has published a national policy directive 
on admittance of service and guide animals to VA health care properties 
and into its facilities on those properties. A number of complaints 
have arisen from our members strongly suggesting the actual local 
policies enforced by facility or network management may differ markedly 
from VA's national policy, and that VA makes a distinction between 
service, guide and ``companion'' animals, admitting some and 
restricting others. We believe the current national policy, VHA 
Directive 2011-013, is adequate and that local enforcement of it 
clearly addresses this issue and could accomplish the goal of this 
measure. Therefore, we recommend the Subcommittee provide oversight to 
ensure standardization of the policy and extension of the policy for VA 
regional offices under the Veterans Benefits Administration (VBA). We 
are unaware that VBA has a published policy on veterans and service/
guide dogs.

    H.R. 1855--the ``Veterans Traumatic Brain Injury Rehabilitative 
                  Services' Improvements Act of 2011''

    Madam Chairwoman, this measure is similar to a bill introduced by 
the same sponsor, Mr. Walz of Minnesota, at the end of the 111th 
Congress. We strongly support this bill. If enacted, it would clarify 
the definition of ``rehabilitation'' as that term is understood in 
title 38, United States Code, to strengthen VA's mandate to sustain 
gains made in the rehabilitative process in veterans who have incurred 
traumatic brain injuries. The bill would focus VA on behavioral, mental 
health, cognitive and functions of daily living, in an effort to assure 
that veterans achieve and sustain maximal recovery from the trauma and 
lasting effects of brain injury.
    Our members have approved a national resolution calling for better 
VA treatments and more research to ensure veterans with traumatic brain 
injury receive the best care possible. This bill aims to fulfill the 
goals of maximizing an individual's independence and quality of life 
and is fully in keeping with DAV Resolution 215. We commend its 
sponsors and urge the Subcommittee to recommend its enactment as a high 
priority.

       H.R. 2074--the ``Veterans Sexual Assault Prevention Act''

    Madam Chairwoman, we appreciate your introduction of this measure 
following information that came to light earlier this summer indicating 
a number of sexual assaults occurring in VA facilities had not been 
properly reported. I had the privilege of testifying before this 
Subcommittee on that topic, including providing commentary on the 
Government Accountability Office (GAO) report presented to the 
Subcommittee at that same hearing.
    As I indicated in my earlier testimony, 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 or 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. When a sexual assault involves a VA employee, whether 
perpetrator or victim, the incident takes on even more meaning, and 
raises a host of questions that were explored by the GAO, and also 
discussed during your recent hearing. 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, your bill firms up VA's requirement to document, 
track and control--and hopefully, to eliminate--incidence of sexual 
assaults that occur on properties and grounds of the VA. We believe the 
bill, if enacted, would be consistent with GAO's findings and would 
serve veterans and VA well as a means of greater accountability and 
transparency of VA's actions in combating sexual assaults and related 
incidents affecting the safety of veterans and VA staff.

  H.R. 2530--``To amend title 38, United States Code, to provide for 
increased flexibility in establishing rates for reimbursement of State 
   homes by the Secretary of Veterans Affairs for nursing home care 
                         provided to veterans''

    H.R. 2530, introduced by the Subcommittee Ranking Member and the 
full Committee Chairman, would revise the methodology used to reimburse 
State veterans homes that provide nursing home care for veterans with 
service-connected disabilities rated 70 percent or greater or for 
veterans who need nursing home care due to a service-connected 
disability. The legislation is intended to amend existing statute and 
restore the original intent of Section 211 of Public Law 109-461, which 
was enacted in order to authorize VA to place 70 percent service-
connected veterans in State Homes and to reimburse them at rates 
comparable to those received by contract community nursing homes.
    DAV strongly supported establishment of the authority contained in 
Public Law 109-461 that confirmed a VA responsibility to provide full-
cost reimbursement to the States for the care of service-connected 
veterans in order to expand the long-term care options for these 
highest priority veterans. However, as we noted in prior testimony 
before this Subcommittee, Public Law 109-461 was enacted in December 
2006, but unfortunately VA only promulgated regulations to carry out 
its intent in April 2009.
    The law established State veterans home reimbursement rates for 
service-connected veterans using two formulas: a geographically 
adjusted per diem rate established by the Secretary as a corollary to 
the rates VA currently pays community nursing homes; or, a rate 
determined by the administrator of a State veterans home based on the 
calculated daily cost of care at that home. The law also required the 
Secretary to reimburse State veterans homes for the care of service-
connected veterans at the lesser of these two rates.
    However, the final promulgated rule contained an unexpected 
complication when the Office of Management and Budget (OMB) applied the 
governing financial and accounting policy expressed in OMB Circular A-
87. This circular establishes principles and standards for determining 
costs for Federal awards carried out through grants, cost reimbursement 
contracts, and other agreements with State and local governments. Under 
the rules of this circular, a State Home, in determining its daily cost 
of care, cannot include in that cost structure the depreciation of 
buildings that were recipients of VA construction grants. As stated in 
the circular, ``[t]he computation of depreciation or use allowances 
will exclude: . . . (2) Any portion of the cost of buildings and 
equipment borne by or donated by the Federal Government irrespective of 
where title was originally vested or where it presently resides.'' This 
restriction on counting depreciation as a part of a home's daily cost 
of care significantly depresses the payable reimbursement rates. As a 
result of the State Homes' excluding these significant amounts, the 
rates determined by the existing statutory formula will invariably 
become the OMB Circular A-87-determined rates.
    Since publication of these regulations, many State Homes have found 
that the ``full'' reimbursement rates governed by VA regulations will 
net their facilities less than their combined payments (from veterans, 
their State governments, the Department of Health and Human Services, 
and from VA under the traditional per diem payment subsidy) received 
before these regulations were issued. Most of the State Homes that were 
already providing care for service-connected veterans suffered 
significant decreases in revenue, and other State Homes that were 
considering placements of service-connected veterans determined that 
they could not afford to extend such care at the reimbursement rates 
being offered under the new regulation. As a result, the current 
statutory language in section 1745(a)(2) is unworkable for the purpose 
intended by Congress. The unworkability of these rates has served as a 
denial of access to nursing home care in State extended care facilities 
to the highest priority veterans, those who need nursing home care for 
residuals of chronic illnesses and injuries they incurred in military 
service to America. As a result, the intention of Congress to expand 
long-term care options for the most seriously disabled service-
connected veterans has not been achieved.
    Over the past 2 years, VA and State Homes have been working towards 
a solution that would meet the original intent of Congress in a manner 
that would be viable for State Homes. Earlier this year, VA submitted 
draft health care legislation to Congress that contained a provision 
designed to remedy this situation. The language VA developed in 
consultation with State homes would end the current reimbursement 
methodology and replace it with new language requiring VA to, ``. . . 
enter into a contract (or agreement under section 1720(c)(1) of this 
title) with each State home for payment by the Secretary for nursing 
home care provided in the home.'' This provision is intended to 
reimburse State homes at rates comparable to those currently paid to 
contract community nursing homes that provide care. The bill also 
contained language requiring the development of new payment 
methodologies that will ``adequately reimburse the State home for the 
care provided by the State home under the contract (or agreement).'' VA 
has stated that the use of contracts would ``. . . allow the most 
flexibility to VA and States to ensure that States are paid adequately 
and according to the complexity and severity of illness of each 
Veteran.'' VA intends to use contract templates to streamline the 
contract process, which would include standard language for pricing 
based on prevailing rates in the community.
    Madam Chairwoman, DAV is hopeful that this legislation will address 
the problems in the current statutory language and VA's current 
regulations, and will finally provide a route to resolve this problem. 
We have some concerns about whether OMB may continue to assert that 
Circular A-87 would be a controlling factor in determining the level of 
reimbursement despite the intention of Congress and VA and suggest the 
Subcommittee may want to make clear its intention on this point in 
report language. DAV commends the bill's sponsors for their continuing 
efforts to ensure that our highest priority veterans may have the 
option of entering a State home to meet their long-term care needs, and 
we recommend enactment of H.R. 2530.

  Draft Bill--the ``Honey Sue Newby Spina Bifida Attendant Care Act''

    This bill would establish assisted living and attendant care 
services for children of certain Vietnam veterans who are challenged by 
spina bifida. We have not received a resolution from our membership 
dealing with this specific issue; therefore, we can take no formal 
position on this bill. However, we are supportive of assisted living 
options as an alternative to institutionalized care; therefore, DAV 
would not object to its enactment. Nevertheless, we note that Congress 
has not further considered establishing an assisted living authority 
within the VA even though a 2004 study on VA's Congressionally mandated 
assisted living pilot program showed great promise and high acceptance 
by veterans as an alternative to institutional long-term care. We hope 
that in a future hearing we will be able to testify in support of a new 
VA assisted living program.

 Draft Bill--the ``Veterans Health Care Facilities Capital Improvement 
                             Act of 2011''

    This bill would authorize a number of major medical facility 
construction projects and capital leases, as well as authorize the 
appropriations that support these projects. It would also modify 
previous Congressional authorizations of projects for a number of 
facilities and modify and provide VA more flexibility in the existing 
enhanced-use lease authority under which VA may dispose of unnecessary 
properties by leasing them to outside entities for compatible-use 
purposes.
    The bill would authorize proceeds from enhanced-use leases to be 
deposited to accounts used by VA to fund minor and major capital 
projects. The bill would alter existing cost-comparison studies 
required in title 38, United States Code, section 8104, as VA 
contemplates pursuing medical facility acquisition versus proposing new 
construction for major medical facility appropriations accounts. The 
bill would authorize the naming of a telehealth clinic in Craig, 
Colorado. Finally, the bill would extend a number of existing but 
expiring authorities of law.
    Madam Chairwoman, we have no resolution from our membership 
covering these various matters, but DAV would offer no objections to 
enactment of this bill. We appreciate the Subcommittee's continuing 
support of VA's capital needs to ensure the VA health care system is 
modernized and meets standards for contemporary health care delivery.
    Madam Chairwoman, this completes my testimony. Thank you again for 
inviting Disabled American Veterans to present this testimony today. I 
would be pleased to address questions from you or other Members of the 
Subcommittee.

                                 
        Prepared Statement of Thomas J. Berger, Ph.D., Executive
     Director, Veterans Health Council, Vietnam Veterans of America

    Chairwoman Buerkle, Ranking Member Michaud, and Distinguished 
Members of the House Veterans Affairs Subcommittee on Health, Vietnam 
Veterans of America (VVA) thanks you for the opportunity to present our 
views on pending legislation for veterans and their families.
    H.R. 198, Veterans Dog Training Therapy Act, Directs the Secretary 
of Veterans Affairs to carry out a pilot program for assessing the 
effectiveness of addressing post-deployment mental health and post-
traumatic stress disorder symptoms through a therapeutic medium of 
service dog training and handling for veterans with disabilities. 
Requires such program to be carried out at Department of Veterans 
Affairs (VA) medical centers that can provide training areas for such 
purposes.
    Although VVA generally supports this legislation, we have several 
questions: (1) What certification standards will be used to ensure that 
the animals can perform essential service dog skills?; and (2) What 
quantitative metrics/measurements will be used to measure the impact of 
the service dogs on the psychosocial, mental health and physiological 
disorders suffered by the participating veterans?
    H.R. 1154, Veterans Treatment of Service Dogs Act, Prohibits the 
Secretary of Veterans Affairs (VA) from prohibiting the use of service 
dogs in or on any VA facility or property or any facility or property 
that receives VA funding.
    VVA generally supports this legislation, but again asks the 
question: What constitutes certification of one's animal as a ``service 
dog?''
    H.R. 1855, Veterans Traumatic Brain Injury Rehabilitative Services 
Act of 2011, Includes within a program of individualized rehabilitation 
and reintegration plans for veterans with traumatic brain injury (TBI): 
(1) the goal of maximizing the individual's independence and quality of 
life, and (2) improving such veterans' behavioral and mental health 
functioning. Requires the inclusion of rehabilitative services in a 
Department of Veterans Affairs (VA) comprehensive program of long-term 
care for veterans' TBI that has residential, community, and home-based 
components utilizing interdisciplinary treatment teams.
    VVA strongly supports this legislation, and it is very clear that 
Command Sergeant Major Walz understands the necessity for broadly 
integrated and individualized psychosocial, mental health, and physical 
treatment plans and services in order to maximize the quality of long-
term care and quality of life for our veterans suffering from TBI.
    H.R. 2074, Veteran Sexual Assault Prevention Act, Directs the 
Secretary of Veterans Affairs to develop and implement, by October 1, 
2011, a centralized and comprehensive policy on reporting and tracking 
sexual assaults and other safety incidents at each medical facility of 
the Department of Veterans Affairs (VA), including: (1) risk-assessment 
tools; (2) mandatory security training; (3) physical security 
precautions (surveillance camera systems and panic alarm systems); (4) 
criteria and guidance for employees communicating and reporting 
incidents to specified supervisory personnel, VA law enforcement 
officials, and the Office of Inspector General; (4) an oversight system 
within the Veterans Health Administration; (5) procedures for VA law 
enforcement officials investigating, tracking, and closing reported 
incidents; and (6) clinical guidance for treating sexual assaults 
reported over 72 hours after assault.
    Requires the Secretary to: (1) submit an annual report to Congress 
on such incidents and policy implementation, and (2) prescribe 
applicable regulations.
    VVA strongly supports this legislation as an initial effort to 
address and correct the failures of the VA for protecting and 
safeguarding our veterans in VA facilities as noted in the June 2011 
GAO report.
    H.R. 2530, To amend title 38, United States Code, to provide for 
increased flexibility in establishing rates for reimbursement of State 
homes by the Secretary of Veterans Affairs for nursing home care 
provided to veterans.
    VVA strongly supports this legislation as H.R. 2530 would correct 
problems that arose during the implementation of section 211 of P.L. 
109-461 affecting State Veterans Homes. With enactment of that law, 
Congress intended to change the reimbursement mechanism so that State 
Veterans Homes could provide nursing home care to veterans with 
service-connected disabilities rated 70 percent or greater and be 
reimbursed at rates comparable to those provided to community contract 
nursing homes that provide such care. However, the manner in which VA 
implemented the new regulations resulted in an unexpectedly low 
reimbursement rate that actually had the reverse outcome: State Homes 
now cannot afford to provide care to these, the most seriously disabled 
veterans.
    The proposed legislation introduced by Congressman Michaud would 
correct this problem by changing the statutory authority so that VA 
could enter into contracts or agreements with State Homes that would 
reimburse the homes for providing care to veterans rated 70 percent or 
greater, and be adequately reimbursed based on a new methodology to be 
developed by the VA in consultation with the State Homes. The language 
of H.R. 2530 is virtually identical to that which VA has proposed in 
draft legislation submitted to Congress earlier this year, and is the 
result of months of negotiations between VA and the National 
Association of State Veterans Homes. This legislation will achieve the 
goals of the original law, which was to provide veterans with service-
connected disabilities rate 70 percent or greater with an additional 
option, which may be more convenient, provide better care and usually 
costs less to the Federal Government than the same care provided 
through VA-operated nursing homes or contract community homes.
    Honey Sue Newby Spina Bifida Attendant Care Act draft legislation: 
To amend title 38, United States Code, to authorize the Secretary of 
Veterans Affairs to provide assisted living services to certain 
children of Vietnam veterans who are suffering from spina bifida.
    VVA strongly supports this legislation as it will provide decades-
long over-due services to the Vietnam veteran parents of now middle-
aged children suffering from spina bifida.
    Veterans Health Care Facilities Capital Improvement Act of 2011 
draft legislation:. To authorize certain Department of Veterans Affairs 
major medical facility projects and leases, to extend certain expiring 
provisions of law, and to modify certain authorities of the Secretary 
of Veterans Affairs, and for other purposes.
    Although this legislation calls for needed construction 
modifications at a number of VA medical facilities, VVA cannot support 
this legislation in its present form as it is unclear as to whether the 
proposed changes suggested in Section 6. ``Modification of Department 
of Veterans Affairs Enhanced-Use Land Authority'' will eliminate any 
possible breaches of VA fiduciary duty for leasing property to private 
entities, as has been alleged to have occurred at the West Los Angeles 
Medical Center and Community Living Center campus.
    Once again, on behalf of VVA National President John Rowan and our 
National Officers and Board, I thank you for your leadership in holding 
this important hearing on this legislation that is literally of vital 
interest to so many veterans, and should be of keen interest to all who 
care about our Nation's veterans. I also thank you for the opportunity 
to speak to this issue on behalf of America's veterans.

                                 
               Prepared Statement of Carl Blake, National
           Legislative Service, Paralyzed Veterans of America

    Chairwoman Buerkle, Ranking Member Michaud, and Members of the 
Subcommittee, Paralyzed Veterans of America (PVA) would like to thank 
you for the opportunity to submit our views today on the proposed 
legislation. Our statement will examine H.R. 198, the ``Veterans Dog 
Training Therapy Act;'' H.R. 1154, the ``Veterans Equal Treatment for 
Service Dogs Act;'' H.R. 1855, the ``Veterans Traumatic Brain Injury 
Rehabilitative Services Act of 2011;'' H.R. 2074, the ``Veterans Sexual 
Assault Prevention Act;'' H.R. 2530; the draft ``Veterans Health Care 
Capital Facilities Improvement Act of 2011;'' and, the draft ``Honey 
Sue Newby Spina Bifida Attendant Care Act.''
          H.R. 198, the ``Veterans Dog Training Therapy Act''
    While PVA has no specific position on this proposed legislation, we 
believe that it could be beneficial therapy for veterans dealing with 
Post-Traumatic Stress Disorder (PTSD) and other mental health issues. A 
model program for this service was created in 2008 at the Palo Alto VA 
Medical Center in conjunction with the Assistance Dog Program. This 
program, maintained by the Recreational Therapy Service at the Palo 
Alto VAMC, is designed to create a therapeutic environment for veterans 
with post-deployment mental health issues and symptoms of PTSD to 
address their mental health needs. Veterans participating in this 
program train service dogs for later placement with veterans with 
hearing and physical disabilities. As we understand it, a similar, 
privately-funded, pilot program is currently under way at Walter Reed 
Army Medical Center (WRAMC) where service dogs have been used in 
therapeutic settings since 2006.
    In these programs, training service dogs for fellow veterans is 
believed to be helping to address symptoms associated with post-
deployment mental health issues and PTSD in a number of ways. 
Specifically, veterans participating in the programs demonstrated 
improved emotional regulation, sleep patterns, and sense of personal 
safety. They also experienced reduced levels of anxiety and social 
isolation. Further, veterans' participation in these programs has 
enabled them to actively instill or re-establish a sense of purpose and 
meaning while providing an opportunity to help fellow veterans 
reintegrate back into the community. Given the apparent benefit to 
veterans who have participated in similar programs as the one proposed 
by H.R. 198, we see no reason to oppose this legislation.
    H.R. 1154, the ``Veterans Equal Treatment for Service Dogs Act''
    PVA supports H.R. 1154, the ``Veterans Equal Treatment for Service 
Dogs Act of 2011.''
    While we believe this legislation should be unnecessary based on 
the provisions of Section 504 of the Rehab Act, the actions of the VA 
clearly demonstrate the need for this legislation. If the VA is 
unwilling to make the regulatory change to accomplish the intent of 
H.R. 1154, then we hope Congress will move quickly to enact this 
important legislation.
    H.R. 1855, the ``Veterans Traumatic Brain Injury Rehabilitative 
                         Services Act of 2011''
    PVA fully supports H.R. 1855, the ``Veterans Traumatic Brain Injury 
Rehabilitative Services Improvement Act of 2011.'' If enacted, H.R. 
1855 would ensure that long-term rehabilitative care becomes a primary 
component of health care services provided to veterans who have 
sustained a Traumatic Brain Injury (TBI). Specifically, this 
legislation would change the current definition of ``rehabilitative 
services'' to include maintaining veterans' physical and mental 
progress and improvement, as well as maximizing their ``quality of life 
and independence.''
    As we have testified on previous occasions, TBI is one of the most 
common and complex injuries facing veterans returning from the current 
wars in Afghanistan and Iraq. Today, we still do not fully understand 
the impact or gravity of TBI. In April 2008, the RAND Corporation 
Center for Military Health Policy Research completed a comprehensive 
study titled Invisible Wounds of War: Psychological and Cognitive 
Injuries, Their Consequences, and Services to Assist Recovery. RAND 
found that the effects of TBI were poorly understood, leaving a gap in 
knowledge related to how extensive the problem is or how to handle it. 
RAND found 57 percent of those reporting a probable TBI had not been 
evaluated by a physician for brain injury. Military service personnel 
who sustain catastrophic physical injuries and suffer severe TBI are 
easily recognized, and the treatment regimen is well established. In 
recent testimony, PVA has raised continuing concerns about 
servicemembers who do not have the immediate outward signs of TBI 
getting appropriate care. The military has implemented procedures to 
temporarily withdraw individuals from combat operations following an 
improvised explosive device (IED) attack for an assessment of possible 
TBI, creating a significant military impact, but believing it necessary 
for soldier health even if it reduced combat forces.
    On July 12, 2006, the VA Office of the Inspector General (OIG) 
issued Health Status of and Services for Operation Enduring Freedom/
Operation Iraqi Freedom Veterans after Traumatic Brain Injury 
Rehabilitation. The report found that better coordination of care 
between DoD and VA health-care services was needed to enable veterans 
to make a smooth transition. While VA and DoD have done extensive 
improvements of coordination since that report, the OIG Office of 
Health Care Inspections conducted follow-on interviews to determine 
changes since the initial interviews conducted in 2006. The OIG 
concluded that 3 years after completion of initial inpatient 
rehabilitation, many veterans with TBI continue to have significant 
disabilities and, although case management has improved, it is not 
uniformly provided to these patients.
    Because all the impacts of TBI are still unknown, this legislation 
to expand services and care, providing for quality of life and not just 
independence, and emphasizing rehabilitative services, is important to 
the ongoing care of TBI patients. It is imperative that a continuum of 
care for the long term be provided to veterans suffering from TBI. This 
bill will address the intricacies associated with TBI and help veterans 
and their families sustain rehabilitative progress.

       H.R. 2074, the ``Veterans Sexual Assault Prevention Act''

    PVA fully supports H.R. 2074, a bill that would require a 
comprehensive policy on reporting and tracking sexual assault incidents 
and other safety incidents that occur at VA medical facilities. PVA 
believes policy mandates that specifically outline how sexual assaults 
within the VA should be handled are long overdue. The implementation of 
policies involving sexual assault will reinforce veterans' confidence 
in the VA's ability to provide a safe environment for care.
    H.R. 2074 will require VA to develop and implement a centralized 
and comprehensive policy on the reporting and tracking of sexual 
assaults and safety incidents that occur at each medical facility. 
While the proposed legislation provides clear examples and definitions 
of the types of assaults and incidents that are to be reported, further 
detail and interpretation is needed for the term ``centralized.''
    Although daily management of VA medical facilities is under the 
supervision of Veteran Integrated Service Networks (VISNs), PVA 
recommends that the proposed legislation require the leadership of each 
VISN to be responsible for the centralized reporting, tracking, and 
monitoring system, while also requiring the VISNs to provide the 
tracking reports to VA's Veterans Health Administration (VHA) central 
office. Such information sharing will enhance accountability and case 
management, and make data readily available when monitoring incidents 
or conducting assessments of the newly implemented system. 
Additionally, PVA recommends that VA provide clear and concise policy 
guidance that includes a specific time frame in which front-line VA 
personnel responsible for the initial processing of assault claims must 
begin processing the report.
    PVA also believes that a major component of preventing and 
appropriately handling sexual assaults and other incidents is ensuring 
that all occurrences of such events are reported by not only VA 
personnel, but veterans and other visitors as well. VA medical 
facilities must provide safe and secure environments for veterans and 
their families seeking care and services. Therefore, PVA recommends 
that the proposed legislation include language that requires VA medical 
facilities to post clear and precise guidance on ways in which 
individuals visiting VA facilities can safely report sexual assaults 
and safety incidents.

                               H.R. 2530

    PVA generally supports H.R. 2530 to allow for increased flexibility 
in establishing rates for reimbursement for State veterans' homes, but 
believes greater understanding of the problem is needed. The State 
Veterans Home Program is examined in great detail in The Independent 
Budget for FY 2012. Those comments are reflected here in our statement 
for H.R. 2530. The VA State Veterans Home Program currently encompasses 
137 nursing homes in 50 States and Puerto Rico, with more than 28,000 
nursing home and domiciliary beds for veterans and their dependents. 
State veterans homes provide the bulk of institutional long-term care 
to the Nation's veterans. The GAO has reported that State homes provide 
52 percent of VA's overall patient workload in nursing homes, while 
consuming just 12 percent of VA's long-term care budget. VA's 
authorized average daily census (ADC) for State veterans' homes was 
19,208 for FY 2008 and was projected to be approximately 19,700 for FY 
2010.
    VA holds State homes to the same standards applied to the nursing 
home care units it operates. State homes are inspected annually by 
teams of VA examiners, and VA's Office of Inspector General (OIG) also 
audits and inspects them when determined necessary. State homes that 
are authorized to receive Medicaid and Medicare payments also are 
subject to unannounced inspections by the CMS and announced and 
unannounced inspections by the OIG of the Department of Health and 
Human Services. VA pays a small per diem for each veteran residing in a 
State home, currently at a rate of $77.53 per day. This is less than 
one-third of the average cost of that veteran's care. The remaining 
two-thirds is made up of a mix of funding, including State support, 
Medicaid, Medicare, and other public and private sources. In contrast, 
VA pays Community Nursing Homes over $200 per day with the cost of care 
in VA Community Living Centers (VACLC) at almost $800 per day.
    Service-connected veterans should be the top priority for admission 
to State veterans' homes, but traditionally they have not considered 
State homes an option for nursing home services because of lack of VA 
financial support. To remedy this disincentive, Congress provided 
authority for full VA payment. Unfortunately, veterans with severe 
disabilities may be put at a disadvantage in gaining access to State 
veterans' homes. As part of P.L. 109-461, the ``Veterans Benefits, 
Health Care, and Information Technology Act of 2006,'' Congress 
approved payment of different per diem amounts by VA to State veterans' 
homes which provide nursing home care to veterans with service-
connected disabilities, a program dubbed ``the 70 Percent Program.'' VA 
issued regulations for this program in April 2009 and granted a higher 
per diem rate for veterans with service-connected disabilities. 
Unfortunately, PVA is hearing reports that these rates have resulted in 
lower payments to many State veterans' homes and in some cases are less 
than the actual cost of care.
    PVA believes VA made a good faith effort in establishing the 
original rates, but may not have taken into consideration the 
significantly greater cost of care for those with severe disabilities, 
in particular those service-connected veterans with 70 percent or 
greater rating. As a result, we are concerned that many severely 
disabled veterans who would choose to use the State veterans' homes 
will be denied access simply because the veterans' home cannot afford 
the cost of their care. This will cause a significant impact on our 
veterans most in need at a time when VA is continuing to reduce their 
capacity to provide long-term care facilities.
    PVA has been informed by representatives of the National 
Association of State Veterans Homes (NASVH) that VA seems resistant to 
modifications of the per diem rate or alternatives that may provide 
greater reimbursement rates. There is a sense that the VA believes the 
lower rate is appropriate because VA shoulders a great financial burden 
when it helps cover the cost of construction, rehabilitation, and 
repair of State veterans' homes, providing up to 65 percent of the 
cost, with the State providing at least 35 percent. If true, PVA 
believes this argument is invalid.
    In FY 2011 the construction grant program was funded at only $85 
million, the same amount Congress had provided in multiple previous 
fiscal years. Based on a current backlog of nearly $1 billion in grant 
proposals, and with thousands of veterans on waiting lists for State 
beds, The Independent Budget for FY 2012 recommends no less than $200 
million for this program. Unfortunately, Congress seems poised once 
again to only provide $85 million for the State homes grant program. 
The VA is using this grant program as an incentive to build more 
capacity to avoid the greater cost of building it themselves. PVA 
firmly believes that construction costs should not be mixed with health 
care costs. The per diem rate should be independent of any quid pro quo 
VA may believe exists with the State veterans' homes due to 
construction funding. State veterans homes can provide high quality 
care at a rate cheaper than VA and should be rewarded for doing so, not 
punished.

  Draft ``Veterans Health Care Capital Facilities Improvement Act of 
                                 2011''

    VA's significant inventory of real property and physical 
infrastructure is a truly remarkable asset in the provision of health 
care and benefits delivery to veterans. At the same time, these 
facilities must be properly managed and cared for to ensure that the 
investment made in the use of these buildings and properties coincides 
with the benefits derived from their use.
    In the same manner, as the VA begins with the manipulation, sale or 
leasing of its infrastructure, great care must be taken to ensure that 
the value and equity in VA's physical property is not squandered. That 
equity does not belong to the VA or the Federal Government; it belongs 
to the veterans of the Nation for their future good. With any 
rearrangement of VA facilities great care should be taken to make 
certain present as well as future needs of veterans are fully accounted 
for.
    With that caveat, we believe the legislation before the 
Subcommittee does provide the VA with improved flexibility in leasing 
unused or underused properties. VA enhanced use lease authority is 
almost unique among other Federal departments and agencies. 
Unfortunately, however, the process has been called cumbersome and time 
consuming, discouraging VA Administrators from wanting to expend the 
effort to use this route in dealing with a property. Such a lengthy 
process also greatly discourages potential private sector entities from 
considering VA properties as a potential investment asset. PVA is 
pleased to see that the legislation retains the Capital Assets Fund to 
serve as the repository for the proceeds from the sale or lease of VA 
properties and then act as the conduit for the reinvestment of those 
proceeds for the improvement of other VA facilities. We also find it 
interesting that the Committee calls for these proceeds to be 
reinvested into Major and Minor Construction, rather than the Medical 
Care Collections Fund.
    However, we have two areas of caution as the Committee moves 
forward. First, VA, with proper Congressional oversight, must ensure 
that it receives fair market value and appropriate leases for these 
properties. This is particularly important in light of the current real 
estate market climate. Second, Congress must ensure that proceeds 
reinvested into Major and Minor Construction are not looked upon by the 
Office of Management and Budget, as well as the Budget and 
Appropriations Committees, as an alternative to, and not over and above 
regular funding for needed specific construction appropriations. 
Ultimately, we do not want to see VA major and minor construction 
funding or non recurring maintenance budget line items offset by 
Capital Asset Fund disbursements.
    PVA is particularly pleased that the Subcommittee has chosen to 
reauthorize a number of programs targeted at assisting homeless 
veterans. However, we would encourage the Subcommittee to include 
reauthorization of the Homeless Veterans Reintegration Program (38 
U.S.C. Sec. 2021) managed by the Department of Labor. The HVRP is a 
valuable program focusing on employment of homeless veterans. This 
program has achieved wonderful success since its inception 
approximately 25 years ago. The HVRP provides help for those veterans 
with significant problems including substance-use disorder, severe 
PTSD, serious social problems, legal issues and HIV. The specialized 
services needed for these veterans and provided by HVRP are often their 
only hope.
       Draft ``Honey Sue Newby Spina Bifida Attendant Care Act''
    This legislation would amend Title 38 U.S.C., to provide additional 
benefits for children with spina bifida of veterans exposed to 
herbicides while serving in the Armed Forces during in Vietnam. PVA 
supports this legislation as it would simply improve upon the benefits 
that already exist for this beneficiary population.
    Madame Chairwoman and Members of the Subcommittee, once again PVA 
would like to thank you for the opportunity to offer our views on the 
legislative matters pending before the Subcommittee. We look forward to 
working with you to ensure that meaningful reforms that best benefit 
veterans are made to the health care services provided by the VA.
    This concludes our official statement. I would be happy to answer 
any questions that you may have.

                                 
                Prepared Statement of Christina M. Roof,
              National Acting Legislative Director, AMVETS

    Chairwoman Buerkle, Ranking Member Michaud and distinguished 
Members of the Subcommittee, on behalf of AMVETS, I would like to 
extend our gratitude for being given the opportunity to share with you 
our views and recommendations at today's hearing regarding: H.R. 198, 
the ``Veterans Dog Training Therapy Act,'' H.R. 1154, the ``Veterans 
Equal Treatment for Service Dogs Act,'' H.R. 1855, the ``Veterans 
Traumatic Brain Injury Rehabilitative Services Act of 2011,'' H.R. 
2074, the ``Veterans Sexual Assault Prevention Act,'' H.R. 2530, to 
amend Title 38, United States Code, to provide increased flexibility in 
establishing rates for reimbursement of State Homes by the Secretary of 
Veterans Affairs for nursing home care provided to veterans,'' draft 
legislation, the ``Veterans Health Care Capital Facilities Improvement 
Act of 2011,'' and draft legislation, the ``Honey Sue Newby Spina 
Bifida Attendant Care Act.''
    AMVETS feels privileged in having been a leader, since 1944, in 
helping to preserve the freedoms secured by America's Armed Forces. 
Today our organization prides itself on the continuation of this 
tradition, as well as our undaunted dedication to ensuring that every 
past and present member of the Armed Forces receives all of their due 
entitlements. These individuals, who have devoted their entire lives to 
upholding our values and freedoms, deserve nothing less.
    Given the fact, this testimony will be addressing multiple pieces 
of legislation; we shall be addressing each piece of legislation 
separately, as to make AMVETS testimony clear and concise on the 
individual subject matters of the bills.
    AMVETS supports H.R. 198, the ``Veterans Dog Training Therapy 
Act.'' AMVETS lends our support to the updated language of H.R. 198 
that will be submitted in Committee markup. AMVETS believes the updated 
language will help ensure that H.R. 198 provides veterans the highest 
quality care, while maintaining our commitment to fiscal 
responsibility.
    By way of background, AMVETS has worked with Assistance Dogs 
International (ADI) accredited Assistance Dog agency, Paws With A Cause 
for over 30 years, in an effort to help provide disabled veterans 
Service Dogs. Through this partnership, AMVETS has seen what an 
immeasurable asset to a veteran's overall wellbeing these service dogs 
have proven to be to both the trainers and recipients. AMVETS has 
personally witnessed the incredible changes that occur when introducing 
a dog into a veterans overall treatment plan. This is often illustrated 
through speedier improvements to a veteran's physical wellbeing, great 
improvements to the veteran's mental health and a sustainable overall 
higher quality of life, when compared to the pace of improvements shown 
in veterans undergoing normal clinical care.
    Veterans who are able to take on an active role in the training of 
a Service Dog have displayed great improvements to their overall 
wellbeing and recovery. H.R. 198 is an opportunity for a veteran to 
once again feel that they have purpose and will be able to play an 
active role in assisting his/her comrades, just as he/she did while 
serving in the military. H.R. 198 will also offer a structured program 
that has clear and concise rules, goals and measurable end results.
    Furthermore, AMVETS believes H.R. 198 will prove to be beneficial 
to the veteran trainers, the veteran Service Dog recipient and to the 
Department of Veterans Affairs. AMVETS also believes H.R. 198 will aide 
VA in the development of stronger policies and procedures regarding 
Service Dogs within the VA health care system, as well as being 
fiscally responsible through the collaborating of VA facilities with 
private sector industry experts, ADI agencies for this study. The VA 
and ADI partnership will ensure the quality of the training process and 
uniform training standards for the program, provide both a therapeutic, 
yet professional setting for all parties involved in the study, ensure 
the safety of both the veterans and the dogs and provide industry 
expertise and job training skill sets to veterans chosen to 
participate. AMVETS also applauds Congressman Grimm for going the extra 
step by finding multiple choices for offset funding.
    AMVETS strongly supports H.R. 1154, the ``the Veterans Equal 
Treatment for Service Dogs Act.'' AMVETS believes this cost free piece 
of legislation will permanently eliminate an often overlooked and 
unwarranted hurdle to care disabled veterans are currently experiencing 
when seeking their necessary VA health care services. To date, 38 CFR, 
Part 1, Sec. 1.218(a)(11) states:

         ``Dogs and other animals. Dogs and other animals, except 
        seeing-eye dogs, shall not be brought upon property except as 
        authorized by the head of the facility or designee''.

    AMVETS finds the aforesaid language of 38 CFR, Part 1, 
Sec. 1.218(a)(11), to be inconsistent and outdated when compared to the 
sections of Title 38 it is to govern. While numerous parts of Title 38, 
specifically Section 1714, are constantly updated to reflect the health 
care needs of today's wounded warriors, 38 CFR, Part 1, 
Sec. 1.218(a)(11) has been overlooked and has thus failed to be updated 
since July of 1985. This outdated regulation is, to date, resulting in 
disabled veterans utilizing VA approved Service Dogs as a prosthetic 
device to be denied entrance into the VAMCs and CBOCs they depend on 
for life sustaining care. Given the current authorities outlined by 
this subsection, there continues to be wide spread inconsistencies in 
the policies governing access to VAMCs and CBOCs. These inconsistencies 
are resulting in disabled veterans who may have never experienced any 
sort of access problems at their previous VAMC are now met with the 
serious issue of not being allowed to enter a VA facility with their 
prosthetic device.
    For example, Army veteran, Sue Downes lost both of her legs when 
her convoy hit multiple IEDs in 2007 in Iraq. Today, after years of 
rehabilitation, Ms. Downes utilizes several VA-provided prosthetic 
devices and her Service Dog, which is considered a prosthetic device by 
VA, and thus is provided benefits for its upkeep. These include her two 
prosthetic legs and her Service Dog, Lila. Ms. Downes depends on her 
prosthetic legs for mobility and her Service Dog for balance and 
further mobility assistance. Lila, Ms. Downes' Service Dog, provides 
her with not only mobility and balance, but just as important, 
independence. Recently, while visiting with lawmakers in our Nation's 
capital, Ms. Downes stated:

         ``I do not understand why VA will provide for the upkeep of 
        both prosthetic devices, my legs and my Service Dog, yet I am 
        only allowed to bring one of the two into VA facilities? I 
        truly do not understand what the reasoning behind this rule is; 
        especially since my legs, on their own, are not enough for me 
        to safely get around. Lila was trained to and now provides me 
        assistance that no cane or walker could ever provide. Lila has 
        given me back my independence as a self sufficient mother of 
        two and active member of my community.''

    AMVETS believes disabled veterans, such as Ms. Downes, using 
Service Dogs must have the same access rights to VA care and facilities 
as currently afforded to blind veterans using Guide Dogs. AMVETS also 
believes VA should never refuse care to a veteran based on their 
disability or the prosthetic device they use to assist them. Moreover, 
AMVETS believes H.R. 1154 will permanently eliminate the aforesaid 
through updating the policies outlined by 38 CFR, Part 1, Section 
1.218, as well as more accurately reflecting the policies outlined in 
38 CFR, Section 1714.
    Recently, VA officials stated that H.R. 1154 was unnecessary due to 
the fact that under existing statutory authority in 38 U.S.C. 901, VA 
can implement national policy for all VA properties. While AMVETS 
somewhat agrees with this statement, the fact remains that VA has been 
unwilling to exercise this authority. In March of 2011, VA did somewhat 
exercise this authority through the publication of VHA Directive 2011-
013. However, AMVETS still believes the actual regulation must be 
changed, since directives expire and are much harder to track and to 
enforce compliance. As such, numerous VAMCs have incomplete, 
inconsistent or non-existent access policies for Service Dogs. This 
creates a frustrating and stressful experience for a veteran Service 
Dog user who must receive their routine care at one VAMC, yet must go 
to a different VAMC for surgery or specialty care. The individual VAMC 
access policies, if they exist, between the two facilities will most 
likely be different, thereby creating an unnecessary and avoidable 
hurdle to care these disabled veterans must now address.
    For example, take Army veteran Kevin Stone. Mr. Stone suffered a 
severe spinal cord injury while on active duty. Living in the foothills 
of the Smokey Mountains, Mr. Stone uses Mountain Home VAMC for his 
routine health care. Yet, the closest VA Spinal Cord Injury Care Center 
for Mr. Stone is Charlie Norwood VAMC in August, Georgia. 
Unfortunately, in mid 2009, Mr. stone was caught off guard when he was 
denied access to the facility for his annual SCI care. Mr. Stone was 
informed that only blind veterans were allowed to bring their dogs into 
VA hospitals and that he would have to make other arrangements if he 
wished to receive his SCI care. Finally after nearly 6 months of 
delayed care, a Member of Congress had to get involved, just so Mr. 
Stone could receive his life sustaining SCI care. Mr. Stone's situation 
was stressful for all of the parties involved and did not have to 
escalate to such levels. Mr. Stone's situation immediately brought 
forth concerns and questions for AMVETS on how many other disabled 
veterans utilizing the assistance of a Service Dog have been denied 
access to a VAMC or CBOC for care. As we are all aware, the simple fact 
remains that not every disabled veteran using a Service Dog has access 
to a Member of Congress for help in their case. This is only one of the 
many, many examples of the challenges today's disabled veterans 
utilizing Service Dogs, experience when seeking care with the VA 
system.
    While AMVETS applauds VA's recent efforts in addressing this issue 
through the publication of a temporary directive, we still strongly 
believe there are loopholes that still need to be addressed and 
corrected in order to guarantee veterans receive the care and services 
they need, regardless of their disability. As we are all aware, 
directives expire and this issue needs a permanent fix, right now. 
AMVETS has worked very closely with VA over the past few years to 
assist in the development and implementation of policies and procedures 
regarding Service Dogs. AMVETS strong support of H.R. 1154 is in no way 
intended to be a criticism of VA or their actions in addressing this 
issue. AMVETS strongly believes H.R. 1154 only stands to help, not 
hinder, VA in the efforts through the codification of the new policy 
outlined in their directive addressing Guide and Service Dogs on VA 
properties. With this in mind, H.R. 1154 will not only strengthen VA's 
new efforts, but will also provide a permanent correction through 
closing all possible loopholes and by implementing a stronger, non-
discriminatory, uniformed access policy.
    AMVETS supports H.R. 1855, the ``Veterans Traumatic Brain Injury 
Rehabilitative Services Act of 2011''. While AMVETS is aware that 
Traumatic Brain Injuries (TBI) are physical injuries, we are also aware 
of the psychological and cognitive impact TBI can have on a veteran. 
The irrefutable medical data showing the correlating symptoms of TBI 
and several psychological disorders clearly illustrates the need for a 
more ``holistic'' approach in the treatment and care of veterans who 
have sustained a Traumatic Brain Injury. This being said, AMVETS 
strongly supports the language set forth by H.R. 1855, as we believe it 
will set standards of care in which all aspects of a veterans TBI will 
be addressed. We too often see veterans being treated for one injury at 
a time. AMVETS believes VA needs to address and treat the veteran and 
their injuries as a whole, in order to achieve the best physical and 
psychological outcomes of care. AMVETS applauds Congressmen Walz and 
Bilirakis for their initiative, through the introduction of H.R. 1855, 
in changing the way VA cares for TBI and its' related symptoms. AMVETS 
again lends our support to H.R. 1855.
    AMVETS strongly supports H.R. 2074, the ``Veterans Sexual Assault 
Prevention Act.'' AMVETS was, and still is, outraged by the Government 
Accountability Office's (GAO) report of findings regarding sexual 
assault in VA facilities, released in early June 2011. AMVETS finds it 
even more disturbing that hundreds of sexual assaults were not reported 
to VA leadership officials or the VA Office of the Inspector General, 
which is in direct violation of VA policy and Federal regulations. 
AMVETS finds it to be reprehensible that any veteran receiving care in 
a VA facility would be subject and/or at risk of being sexually 
assaulted or harassed. Moreover, AMVETS finds it inexcusable that VA 
leadership, at all levels, has allowed such occurrences to continue to 
happen without taking strong actions to protect the same veterans they 
have vowed to protect and care for. While AMVETS also understands that 
top VA leadership was not made aware of nearly 300 cases of sexual 
assault by VISN level leadership, AMVETS still finds it inexcusable 
that stronger procedures and safeguards were not already in place to 
address these types of matters before they escalated to current levels. 
In 2011, VA has the ability to provide electronic limbs, state of the 
art surgical procedures and world-class care to the veterans they 
serve. With that being said, AMVETS must respectfully ask why VA cannot 
provide even the most basic of safety measures in these same 
facilities? AMVETS concurs with the Chairwomen's statement that ``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.'' Furthermore, AMVETS also 
concurs with Chairman Miller's statement that ``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.'' AMVETS 
applauds Congresswoman Buerkle and Chairman Miller for their swift 
actions in an effort to correct these gross and intolerable errors and 
urges all Members of Congress to follow their lead through the swift 
passage of H.R. 2074.
    AMVETS supports H.R. 2530, to amend Title 38 to provide increased 
flexibility in establishing rates for reimbursement of State homes by 
the Secretary of the Department of Veterans Affairs for nursing home 
care provided to veterans. At a time in our Nation's history when we 
simultaneously have a large influx in aging veterans requiring home 
care and disabled veterans returning with substantial injuries also 
requiring home care, it is time to revisit the policies and procedures 
associated with our State Veterans Homes (SVH). In December 2006, P.L. 
109-461, the ``Veterans Benefits, Health Care, and Information 
Technology Act of 2006'', authorized the VA to pay higher per-diem 
payments for care in SVHs to certain veterans with service-connected 
disabilities. This long-awaited regulation was issued in April 2009, 
with a retroactive effective date of March 2007. However, it took the 
VA 2 years to issue the rules and regulations to implement P.L. 109-461 
and yet the rates are still not up to par. Currently, per-diem payments 
do not cover the full cost of providing services to veterans residing 
in SVHs, which has resulted in many SVHs to lose millions of dollars 
and even worse, due to these losses the inability to admit and care for 
more severely disabled veterans in their facilities. This has become a 
huge problem for the Medicare/Medicaid certified SVHs operating in 31 
States, because current statutory language notes that the ``per-diem 
rates paid by VA constitute payment in full.'' Thus, SVHs are 
prohibited from billing Medicare and Medicaid for services they provide 
to disabled veterans, yet are not reimbursed for by VA. These services 
include, but are not limited to, X-Rays, labs, PET scans, dialysis and 
many other critical and medically necessary medical procedures and 
tests. In reality the current ``actual per-diem payments'' provided by 
VA to SVHs have increased, but the total reimbursement is much lower 
than what SVHs received prior to the enactment of P.L. 109-461, as a 
result of their inability to bill Medicare and Medicaid. This is an 
issue that has been overlooked for too long and has resulted in too 
many veterans not being able to receive the care they need. AMVETS 
strongly supports H.R. 2530 and urges its swift passage.
    AMVETS also supports draft legislation, the ``Veterans Health Care 
Facilities Capital Improvement Act of 2011''. AMVETS finds this piece 
of legislation to be of the utmost importance. While the bill addresses 
several different matters, AMVETS biggest concern is regarding VA's 
enhanced lease program. As we are all aware, Secretary Shinseki has 
laid out a plan who's ultimate goal is to end homelessness among 
veterans within 5 years. There has been no opposition to this goal from 
any Member of Congress or the VSO community. It is a fair assumption to 
believe we all want to end homelessness among our veteran population as 
soon as possible. However, AMVETS believes a critical piece of the 
Secretary's plan is in danger of being eliminated. More specifically, 
VA's enhanced lease program.
    VA's enhanced lease program is responsible for, and comprised of 
facilities used for, over 95 percent of VA's homeless and at risk 
veteran and family housing units. If this program were to be allowed to 
expire, thousands of veterans and their families will find themselves 
with nowhere to go, except back to the streets. AMVETS believes that if 
we are to realize the goal of ending homelessness among the population 
of men and women who have so selflessly served our great nation, we 
must pass this piece of legislation to ensure the continuance of the 
enhanced lease program. Again, AMVETS supports the ``Veterans Health 
Care Facilities Capital Improvement Act of 2011'' of legislation and 
urges its quick passage.
    Finally, AMVETS supports draft legislation, the ``Honey Sue Newby 
Spina Bifida Attendant Care Act'', to amend title 38, United States 
Code, to authorize the Secretary of Veterans Affairs to provide 
assisted living services to certain children of Vietnam veterans who 
are suffering from Spina bifida.
    Chairwoman Buerkle and distinguished Members of the Subcommittee, 
AMVETS would again like to thank you for inviting us to share with you 
our opinions and recommendations on these very important pieces of 
legislation. This concludes my testimony and I stand ready to answer 
any questions you may have for me.

                                 
          Prepared Statement of Robert L. Jesse, M.D., Ph.D.,
      Principal Deputy Under Secretary for Health, Veterans Health
          Administration, U.S. Department of Veterans Affairs

    Chairwoman Buerkle, Ranking Member Michaud, and distinguished 
Members of the Subcommittee:
    Thank you for inviting me here today to present the 
Administration's views on H.R. 198, the Veterans Dog Training Therapy 
Act; H.R. 1154, the Veterans Equal Treatment for Service Dogs Act (VETS 
Dogs Act); H.R. 1855, the Veterans' Traumatic Brain Injury 
Rehabilitative Services' Improvements Act of 2011; H.R. 2074, the 
Veterans Sexual Assault Prevention Act; and H.R. 2530, a bill to 
increase flexibility in establishing rates for reimbursement of State 
Homes. Joining me today are Jim Sullivan, Director of the Office of 
Asset Enterprise Management; Jane Clare Joyner, Deputy Assistant 
General Counsel; and Charlma Quarles, Deputy Assistant General Counsel. 
We have not had sufficient time to develop official views and estimates 
regarding the draft Honey Sue Newby Spina Bifida Attendant Care Act or 
section 9 of the draft Veterans Health Care Facilities Capital 
Improvement Act of 2011. We will forward the views and estimated costs 
on these items to you as soon as they are available.

H.R. 198 ``Veterans Dog Training Therapy Act''

    H.R. 198 would require the Secretary, within 120 days of enactment, 
to carry out a pilot program to assess the effectiveness of addressing 
post-deployment mental health and post-traumatic stress disorder (PTSD) 
symptoms of Veterans through a therapeutic medium of training service 
dogs for other Veterans with disabilities. The bill would require the 
Secretary to conduct the pilot program at a minimum of three but not 
more than five Department of Veterans Affairs (VA) medical centers for 
a 5 year period. Veterans diagnosed with PTSD or other post-deployment 
mental health conditions would be eligible to volunteer to participate. 
The bill requires that the VA medical centers selected as program sites 
have available the following resources: a dedicated space suitable for 
grooming and training dogs indoors, classroom and office space, storage 
capacity, other areas for periodic use of training dogs with 
wheelchairs and for other exercises, outdoor exercise and toileting 
space for dogs, and the provision of weekly field trips to train dogs 
in other environments. The pilot program must be administered under the 
direction of a certified recreational therapist, and the Secretary 
would be required to establish a Director of Service Dog Training with 
specific experience such as experience in teaching others to train 
service dogs in a vocational setting, to oversee the training of 
service dogs at selected VA medical facilities. Each pilot site would 
also be required to have certified service dog training instructors.
    The bill also includes provisions concerning the service dogs 
themselves. The bill requires VA to ensure that each service dog in 
training is purpose-bred for this work with an adequate temperament and 
health clearance. Dogs in animal shelters or foster homes are not to be 
overlooked as candidates, but only as determined appropriate by VA. The 
Secretary must also ensure that each service dog in training is taught 
all essential commands required of service dogs, that the service dog 
in training lives at the pilot program site or at a volunteer foster 
home while receiving training, that the pilot programs include both 
lecture of service dog training methodologies and practical hands-on 
training and grooming of service dogs, and that the programs are 
designed to maximize the therapeutic benefit of the Veterans 
participating in the program and to produce well-trained service dogs 
for Veterans with disabilities. The Secretary would be required to give 
hiring preference for service dog training instructor positions to 
Veterans who have successfully graduated from PTSD or other residential 
treatment programs and who have received adequate certification in 
service dog training.
    VA would be required to collect data on the pilot program and 
determine its effectiveness for the Veteran participants. Specifically, 
under this bill, VA must consider whether the pilot program effectively 
reduces the stigma associated with PTSD or other post-deployment mental 
health conditions, improves emotional regulation or patience, instills 
or re-establishes a sense of purpose among participants, provides an 
opportunity to help fellow Veterans, facilitates community 
reintegration, exposes service dogs to new environments in order to 
help Veterans reduce social isolation and withdrawal, builds 
relationship skills, relaxes the hyper-vigilant survival state, 
improves sleep patterns, and enables Veterans to decrease the use of 
pain medication. VA would be required to submit an annual report to 
Congress following the end of the first year of the pilot program and 
each year thereafter to inform Congress about the details of the 
program and its effectiveness in specific areas.
    VA recognizes the therapeutic value to Veterans diagnosed with PTSD 
of training service dogs for persons with disabilities; however, VA 
cannot support H.R. 198.
    VA has used Animal Assisted Therapy, or Animal Facilitated Therapy, 
for many years as part of VA's comprehensive approach to health care. 
VA is currently utilizing therapy dogs as a component of treatment in a 
number of facilities and settings, including VA's Community Living 
Centers, palliative care units, and most recently in recovery treatment 
programs. In July 2008, a Service Dog Training Program was established 
as a therapy component at the Palo Alto Veterans Healthcare System 
(Menlo Park Division), in collaboration with Bergin University. 
Patients who have been diagnosed with PTSD and assigned to the Men and 
Women's Trauma Recovery Program have the option to participate in the 
training of service dogs as one of their activities in their 
comprehensive recovery program. This training focuses on basic 
obedience (e.g., commands such as ``sit,'' ``stay,'' and ``heel'') and 
public access skills (sensitizing dogs to different environments) to 
prepare the dogs to become service dogs for persons with mobility 
impairments. Initial patient self-reports and informal observations by 
staff have been positive, and VA staff members have indicated that the 
training of dogs, in combination with established recovery therapies, 
is showing promise.
    H.R. 198 imposes specific requirements that focus on the training 
of service dogs. The bill is very prescriptive as to the requirements 
of the proposed pilot program (e.g., staffing guidelines), and it would 
require evaluation of a large and very detailed list of factors, many 
of which cannot be measured with any degree of specificity or 
reliability. We are available to work with the Committee to design a 
workable program and an appropriate mechanism to evaluate whether 
training service dogs is a clinically appropriate form of treatment.
    VA estimates the total cost for this bill would be $2 million in 
the first year of the program and $10 million over 5 years.

H.R. 1154 ``Veterans Equal Treatment for Service Dogs Act (VETS Dogs 
        Act)''

    H.R. 1154 would prohibit the Secretary from excluding service dogs 
from any VA facilities or property or any facilities or property that 
receive funding from VA.
    VA acknowledges that trained service dogs can have a significant 
role in maintaining functionality and promoting maximum independence of 
Veterans with disabilities. VA recognizes the need for persons with 
disabilities to be accompanied by their trained service dogs on VA 
properties consistent with the same terms and conditions, and subject 
to the same regulations as generally govern the admission of members of 
the public to the property. However, H.R. 1154 is unnecessary.
    Under existing statutory authority in 38 U.S.C. Sec. 901, VA can 
implement national policy for all VA properties, and in fact did so for 
VHA facilities and property on March 10, 2011 (VHA Directive 2011-013), 
directing that both Veterans and members of the public with 
disabilities who require the assistance of a trained guide dog or 
trained service dog be authorized to enter VHA facilities and property 
accompanied by their trained guide dog or trained service dog 
consistent with the same terms and conditions, and subject to the same 
regulations that govern the admission of members of the public to the 
property. We would be glad to provide a copy of the Directive for the 
record. This Directive requires each Veterans Integrated Service 
Network (VISN) Director to ensure all VHA facilities have a written 
policy on access for guide and service dogs meeting the requirements of 
the national policy by June 30, 2011, and VA is reviewing these 
policies to ensure their compliance with national standards. In 
addition, VA intends to initiate rulemaking that will establish 
criteria for service dog access to all VA facilities and property in a 
manner consistent with the same terms and conditions, and subject to 
the same regulations, as generally govern the admission of members of 
the public to the property while maintaining a safe environment for 
patients, employees, visitors, and service dogs.
    H.R. 1154 would prohibit the Secretary from excluding service dogs 
from any facility or on any property that receives funding from the 
Secretary. Such a prohibition is unnecessary because it duplicates 
other statutes discussed below.
    Any non-VA facilities and properties with which H.R. 1154 is 
concerned that are also owned or controlled by the Federal Government 
must under current law at 40 U.S.C. Sec. 3103, admit on the same terms 
and conditions, and subject to the same regulations, as generally 
govern the admission of the public to the property, specially trained 
and educated guide dogs or other service animals accompanying 
individuals with disabilities. Other non-VA properties not otherwise 
owned or controlled by the Federal Government, including but not 
limited to professional offices of health care providers, hospitals, 
and other service establishments, will almost certainly meet the 
definition of a place of public accommodation or public entity under 
the Americans with Disabilities Act of 1990 as prescribed in 
regulations at 28 CFR Sec. Sec. 35.104 and 36.104, and therefore be 
required to modify their policies, practices, or procedures to permit 
the use of a service animal by an individual with a disability in 
accordance with 28 CFR Sec. Sec. 35.136 and 36.302. We would note that 
VA facilities are not subject to the Americans with Disabilities Act of 
1990, but are subject to the Rehabilitation Act. The Rehabilitation Act 
does not specifically address the issue of service dogs in buildings or 
on property owned or controlled by the Federal Government, but does 
prohibit discrimination against individuals with disabilities, 
including those who use service animals, in Federally-funded or -
conducted programs and activities. In addition, as explained above, 
there are other existing authorities that address the issue of bringing 
guide dogs and other service animals onto VA property.
    VA estimates that there would be no costs associated with 
implementing this bill.

H.R. 1855 ``Veterans' Traumatic Brain Injury Rehabilitative Services' 
        Improvements Act of 2011''

    In 2008, Congress established several programs targeted at the 
comprehensive rehabilitation of Veterans and members of the Armed 
Services receiving VA care and services for Traumatic Brain Injuries 
(TBI). In general, H.R. 1855 seeks to improve those programs 
(established by 38 U.S.C. Sec. Sec. 1710C-E) by requiring 
rehabilitative services, as defined by the bill and discussed below, to 
be an integral component of those ongoing programs. With one exception, 
we have no objection to H.R. 1855.
    Currently, the provisions of 38 U.S.C. Sec. 1710C set forth the 
requirements for an individualized rehabilitation and reintegration 
plan that must be developed for each Veteran or member of the Armed 
Forces receiving VA inpatient or outpatient rehabilitative hospital 
care or medical services for a TBI. VA Handbook 1172.04, Physical 
Medicine and Rehabilitation Individualized Rehabilitation and Community 
Reintegration Care Plan, implements section 1710C.
    Section 2(a) of H.R. 1855 would amend some of the mandated 
requirements in section 1710C. Specifically, it would clarify that the 
goal of each individualized plan is to maximize the individual's 
independence and quality of life. It would also require, as part of a 
plan's stated rehabilitative objectives, the sustaining of improvements 
made in the areas of physical, cognitive, and vocational functioning. 
Section 2(a) of the bill would further require that each such plan 
include rehabilitation objectives for improving and sustaining 
improvements in the individual's behavioral functioning as well as 
mental health.
    These amendments would not alter VA's policy or operations in any 
significant way, as VA's primary aim for Veterans with serious or 
severe injuries has always been, and continues to be, maximizing their 
independence, health, and quality of life. It is out of these concerns 
that VA has developed robust rehabilitation therapy programs to help 
them learn or re-learn skills and develop resources for sustaining 
gains made in their rehabilitation.
    Section 2(a) of the bill would require the individual plans to 
include access, as warranted, to all appropriate rehabilitative 
services of the TBI continuum of care. The law now requires these plans 
to provide access, as warranted, to rehabilitative components of the 
TBI continuum of care (which includes, as appropriate, access to long-
term care services).
    Current law also requires that each individualized plan include a 
description of the specific ``rehabilitation treatments and other 
services'' needed to achieve the patient's rehabilitation and 
reintegration goals. Section 2(a) of the bill would replace all 
references to ``treatments'' in the affected provision with 
``services.'' This would ostensibly broaden the scope of rehabilitative 
benefits available to these patients beyond what is deemed to be 
treatment per se.
    It would also add to each plan the specific objective of improving 
(and sustaining improvements in) the patient's behavioral functioning. 
That addition, together with the existing rehabilitation objective to 
improve a patient's cognitive functioning, would effectively encompass 
all relevant mental health issues related to TBI. For that reason, we 
believe the bill's other amendment to separately include a 
rehabilitation objective for improving ``mental health'' would create 
confusion or redundancy. We thus recommend that language be deleted.
    Most notably, Section 2(a) of H.R. 1855 would establish a new 
definition of the term ``rehabilitative services,'' for purposes of all 
of VA's specially targeted, statutory programs for TBI patients (i.e., 
38 U.S.C. Sec. Sec. 1710C-E). Such services would include not only 
those that fall under the current statutory definition found in 38 
U.S.C. Sec. 1701 but also ``services (which may be of ongoing duration) 
to sustain, and prevent loss of, functional gains that have been 
achieved.'' In addition, they would include ``any other services or 
supports that may contribute to maximizing an individual's independence 
and quality of life.'' This last definition is overly broad and could 
be read to include services or items well beyond the field of health 
care. It is also unworkable. What maximizes an individual's ``quality 
of life'' is highly subjective and, as such, the term defies consistent 
interpretation and application. We believe enactment of that last 
provision of the proposed new definition would conflict with and exceed 
our primary statutory mission, which is to provide medical and hospital 
care. It should therefore be deleted, leaving only the first two prongs 
of the definition.
    Next, as briefly alluded to above, the individualized 
rehabilitation and reintegration plans required by section 1710C must 
include access, where appropriate, to long-term care services. The 
eligibility and other requirements of VA's mandated comprehensive 
program of long-term care for the rehabilitation of post-acute TBI are 
found in 38 U.S.C. Sec. 1710D. Section 2(b) of H.R. 1855 would require 
the Secretary to include rehabilitative services (as that term would be 
defined by Section 2(a) of the bill) in the comprehensive program. It 
would also eliminate the word ``treatment'' in the description of the 
interdisciplinary teams to be used in carrying out that program. We 
have no objection to this proposed revision.
    Lastly, Congress authorized VA, under specified circumstances, to 
furnish hospital care and medical services required by an 
individualized rehabilitation and reintegration plan through a 
cooperative agreement. (A cooperative agreement may be entered only 
with an appropriate public or private entity that has established long-
term neurobehavioral rehabilitation and recovery programs.) This 
authority is found at 38 U.S.C. Sec. 1710E. Section 2(c) of H.R. 1855 
would add ``rehabilitative services'' (again as defined by Section 2(a) 
of the bill) to the types of services that may be provided under those 
agreements. We have no objection to this proposed revision.
    Finally, we note as a technical matter that there is a 
typographical error in the spelling of ``ophthalmologist'' in Section 
1710C(c)(2)(S) of title 38, U.S.C. Additionally, current law permits 
inclusion of ``educational therapists'' among the TBI experts 
responsible for conducting comprehensive assessments of these patients. 
(These assessments are then used to design the individualized plans 
discussed above.) However, this categorization of professionals is no 
longer used in the field of medical rehabilitation.
    We do not otherwise object to H.R. 1855. No new costs would be 
associated with its enactment.

H.R. 2074 ``Veterans Sexual Assault Prevention Act''

    H.R. 2074 would amend title 38, United States Code, by adding a new 
section 1709 known as the ``Veterans Sexual Assault Prevention Act.'' 
Section 1709 would require VA to ``develop and implement a centralized 
and comprehensive policy on the reporting and tracking of sexual 
assault incidents and other safety incidents that occur'' at VA medical 
facilities including incidents of sexual assault, criminal and 
purposeful unsafe acts, alcohol or substance abuse related acts, and 
acts involving abuse of a patient. VA would need to develop and 
implement this policy by October 1, 2011. In addition, Section 1709(d) 
would require VA to submit an annual report to Congress discussing 
implementation and effectiveness of the policy.
    VA considers the safety and security of our Veterans, employees and 
visitors to be among our highest priorities. We take all allegations 
seriously and investigate them thoroughly.
    In response to a recent Government Accountability Office (GAO) 
report (GAO-11-530) entitled ``VA Health Care: Actions Needed to 
Prevent Sexual Assaults and Other Safety Incidents,'' VA has convened 
an interdisciplinary Safety/Security Workgroup including 
representatives from VHA and VA corporate offices, including the Office 
of Operations, Security and Preparedness (OSP) and the Office of 
General Counsel. VA has charged the Safety/Security Workgroup to define 
steps necessary to ensure VA is taking every action required to respond 
effectively to reports of sexual victimization of Veterans, employees, 
and visitors. The Workgroup is developing appropriate proactive 
interventions to reduce the risk of these events, testing a 
computerized reporting system for ongoing data tracking and trending, 
and is currently establishing guidance for training of staff and 
providers. Initial action plans from the Workgroup have been submitted, 
with a final written report to be completed by September 30, 2011. The 
Workgroup's Chairs provide weekly updates to VA's Under Secretary for 
Health, ensuring that leadership is aware of the progress being made 
and can intervene to continue our efforts to improve facility safety.
    We believe H.R. 2074 is unnecessary because our current efforts are 
fulfilling much of what it would require. In addition to the Workgroup, 
VA is already undertaking other efforts to enhance the safety and 
security of our facilities. For example, VA is evaluating its risk 
assessment tools and is developing enterprise-wide assessments that 
consider issues beyond the Veteran's legal history and medical record. 
VA is taking steps to consider universal risk for violence and design 
appropriate intervention actions. These are important steps to improve 
evaluations of patient risk. Mandatory training on security issues is 
also in development, and VA plans to provide educational materials for 
patients and visitors as well so they can help contribute to a safer VA 
environment for everyone. VA's Integrated Operations Center (IOC), 
established in 2009, provides oversight of VA facilities 24 hours a 
day, 7 days a week and is responsible for collecting any reports of 
serious incidents, including alleged criminal behavior at VA 
facilities. VHA is already developing an oversight system like that 
described in the bill. It will be in place later this summer, and will 
have clear and consistent guidance on the management and treatment of 
sexual assaults by the end of 2011.
    While we agree with many of the aims of H.R. 2074, and are 
proceeding with similar initiatives, we do have several concerns with 
the bill as written. First, the timeline for the implementation of this 
policy is not feasible. VA is committed to enacting this policy, but 
needs time to complete work on reporting tools and processes and to 
pilot these initiatives before the policy will be fully implemented so 
that we can achieve the shared goal of increased safety. Second, VA is 
concerned that the term ``other safety incidents'' is overly broad. 
While the bill requires VA to define the term ``safety incident'' and 
provides the Secretary the authority to prescribe regulations to 
implement the legislation, ``other safety incidents'' could be read 
broadly to include any safety incident, including workplace issues 
(such as a slip and fall situation) and occupational safety concerns. 
VA believes the intent of this provision is to focus on the security of 
patients, employees and visitors, and we will define this term 
accordingly. We are happy to work with the Committee to refine this 
language in the legislation.
    VA also has serious concerns with the requirement that VA report 
``alcohol or substance abuse related acts'' committed by Veterans. VA 
is an integrated health care system that treats all of the health care 
needs of Veterans, including substance use disorders and alcoholism. 
With our focus on universal precautions, we will assess all potential 
risks, not just those associated with substance use disorders. Alcohol 
and drug misuse are associated with a host of medical, social, mental 
health, and employment problems. Fortunately, these problems are 
treatable and with treatment, the lives of our patients and their loved 
ones can be enriched. VA does not want to create a disincentive for 
Veterans to seek treatment for these conditions and recommends that 
this provision be deleted from the bill.
    Since VA is already making significant improvements in our tracking 
and reporting system that meet or exceed the requirements of the 
legislation, we estimate that this bill would result in no additional 
costs. We appreciated the opportunity to discuss this issue and hear 
your recommendations on June 13. We are happy to meet with the 
Committee to discuss this issue in more detail.

H.R. 2530 Increased Flexibility in Rates of Reimbursement for State 
        Homes

    H.R. 2530 would require State homes and VA to contract, or enter 
into a provider agreement under 38 U.S.C. Sec. 1720(c)(1)(A), for the 
purpose of providing nursing home care in these homes to Veterans who 
need it for a service-connected condition or have a service-connected 
rating of 70 percent or greater. This payment methodology would replace 
the current per diem grant payments for these Veterans which were 
implemented in 2009. VA supports this provision in principle as 
subsection (a)(1) is consistent with section 104 of VA's draft bill 
``Veterans Health Care Act of 2011,'' which was transmitted to Congress 
on June 7, 2011.
    We do have technical concerns with how the bill would treat 
provider agreements, as distinguished from arrangements with State 
Veterans Homes on a contract basis. The requirement in subsection 
(a)(2) that payments under each provider agreement be based on a 
methodology developed by VA in consultation with the State home would 
prevent VA from using provider agreements with State homes. The 
authority for using provider agreements in 38 U.S.C. Sec. 1720(c)(1)(A) 
essentially authorizes VA to enter into agreements like the Centers for 
Medicare and Medicaid Services (CMS) does under the Medicare program 
without entering into contracts. There are no procedures for 
negotiating rates of payments under the Medicare program. This 
facilitates entering into these agreements. If H.R. 2530 were enacted 
and negotiations are required under this authority, VA would only be 
able to contract. We are happy to work with the Committee to refine 
this language in the legislation.
    VA estimates that there would be no additional costs associated 
with H.R. 2530.

H.R. _____ ``Veterans Health Care Facilities Capital Improvement Act of 
        2011''

    H.R. _____, the ``Veterans Health Care Facilities Capital 
Improvement Act of 2011'', would authorize certain Department of 
Veterans Affairs major medical facility projects and leases, extend 
certain expiring provisions of law, and modify certain other 
authorities. Specifically, this bill would provide authorization for 
major medical facility construction projects and major medical facility 
leases, all of which are consistent with projects and leases requested 
in Department of Veterans Affairs' draft construction authorization 
bill.
    Section 2 would authorize construction of a project for seismic 
corrections for Building 100 in Seattle, Washington, in an amount not 
to exceed $51,800,000. Also authorized is a project for construction of 
seismic corrections and renovation of various buildings, the initial 
phase of which is Building 209 for housing facilities for homeless 
Veterans in West Los Angeles, California, in an amount not to exceed 
$35,500,000.
    Section 3 would modify the authorization of five major medical 
facility construction projects. The authorization of the Veterans 
Affairs Medical Center in Fayetteville, Arkansas, would be modified to 
include a parking garage. The total amount for this project is 
$90,600,000. The previous extension of authorization for the project at 
the Veterans Affairs Medical Center in Orlando, Florida is modified to 
include a Simulation, Learning, Education and Research Network Center. 
The amount of the previously authorized project for the project at the 
Veterans Affairs Medical Center in Palo Alto, California, is increased 
to $716,600,000. The amount of the previously authorized project at the 
Veterans Affairs Medical Center in San Juan, Puerto Rico, is increased 
to $277,000,000. The amount of the previously authorized project at the 
Veterans Affairs Medical Center in St. Louis, Missouri, is increased to 
$346,300,000.
    Section 4 would authorize the Secretary to carry out eight major 
medical facility leases, all of which were included in VA's draft 
construction bill. Specifically, Section 4 would authorize the 
Secretary to carry out major medical facility leases for a community-
based outpatient clinic in Columbus, Georgia, in an amount not to 
exceed $5,335,000; an outpatient clinic in Fort Wayne, Indiana, in an 
amount not to exceed $2,845,000; an outpatient clinic in Mobile, 
Alabama, in an amount not to exceed $6,565,000; an outpatient clinic in 
Rochester, New York, in an amount not to exceed $9,232,000; a 
community-based Outpatient Clinic in Salem, Oregon, in an amount not to 
exceed $2,549,000; an outpatient clinic in San Jose, California, in an 
amount not to exceed $9,546,000; an outpatient clinic in South Bend, 
Indiana, in an amount not to exceed $6,731,000; and, a community-based 
outpatient clinic in Springfield, Missouri, in an amount not to exceed 
$6,489,000.
    Section 5 would authorize appropriations for the projects and 
leases listed in Sections 2, 3 and 4, subject to certain limitations. 
With the exception of Section 5(b), this section is consistent with the 
Department of Veterans Affairs draft construction authorization bill. 
Section 5(b) indicates that $850,070,000 is authorized to be 
appropriated for certain major medical facility projects that were 
previously authorized. However, we believe the correct amount to be 
authorized for Section 5(b) is $914,507,000.
    Section 6 would make certain amendments to VA's enhanced-use lease 
(EUL) authority, including granting a much-needed 10-year extension to 
the current legislation, before it expires at the end of this calendar 
year. Section 6 of the draft bill would also allow the Secretary to 
consider proposed EUL business plans by other organizations within the 
Department, as opposed to just VA's Veterans Health Administration. 
Third, the draft bill would incorporate certain business parameters to 
ensure EUL compliance with the latest capital scoring rules and 
guidelines. Fourth, it would allow the Department to deposit and use 
future EUL proceeds as part of the agency's major and minor 
construction accounts. And fifth, the draft bill would add clarifying 
language to emphasize that the Federal Government's underlying real 
property ownership, and leaseback of any lands through EULs are exempt 
from State and local taxes, fees, and assessments. I would like to 
thank the Subcommittee for addressing VA's EUL authority extension in 
the Veterans Health Care Facilities Capital Improvement Act of 2011.
    The EUL authority was enacted in August 1991, and is codified in 
sections 8161 through 8169 of title 38 of the U.S. Code. In 2001, the 
authority was renewed for an additional 10 years through the end of 
2011. The Department's authority to enter into additional EUL 
agreements will expire on December 31, 2011. Without a reinstatement of 
the EUL authority, VA will no longer have the mechanism in place to 
acquire third-party investment for new facilities, space, services or 
revenue to serve Veterans.
    The EUL authority allows VA to outlease land and improvements under 
the department's jurisdiction or control, to public or private sector 
entities for up to 75 years. In return, VA receives negotiated monetary 
and/or in-kind consideration. The outleased property is developed, 
used, and maintained for agreed-upon uses that directly or indirectly 
support VA's mission.
    EULs have provided a variety of benefits such as enhanced services 
to Veterans, operations and maintenance cost savings, private 
investment, new long-term revenue for VA, job creation, and additional 
tax revenues for local, State and Federal sectors. In some instances, 
EULs have helped VA meet its environmental goals by creating on-site 
renewable energy facilities enabling VA to reduce its greenhouse gas 
emissions.
    Since the original EUL legislation passed in August 1991, more than 
60 projects have been awarded--18 of these for housing providing 1,066 
housing units benefiting Veterans. From FY 2006 to 2010, EULs have 
generated approximately $266 in total consideration.
    In terms of Veterans housing, EUL provides multiple benefits: 
helping to reduce homelessness among our Veterans while leveraging 
underutilized assets, reducing the inventory of underutilized real 
estate, and transferring the operation and maintenance costs to the 
developers--while maintaining VA control of the underlying assets.
    Currently, VA has 19 EUL projects underway to provide nearly 2,200 
units of housing for homeless Veterans and their families; and 
approximately 600 units of assisted living and senior housing, which 
will be curtailed if VA's EUL authority is not extended.
    Additionally, if VA's EUL authority is not extended, it will halt 
another 34 housing projects under VA's Building Utilization Review and 
Reuse (BURR) Initiative, which involves approximately 1,700 units of 
housing for homeless Veterans, and 900 units of senior, non-senior 
independent living, and assisted living housing for Veterans.
    Congressional approval of VA's EUL authority extension is critical 
for VA to continue the successful efforts to facilitate the provision 
of homeless housing for Veterans and their families through public/
private ventures. EUL is a valuable tool used by the Secretary in VA's 
multi-faceted approach to eliminate Veteran homelessness. If the EUL 
authority is not extended, a total of 5,500 housing units for homeless 
Veterans and Veterans at-risk-for homelessness will be affected.
    Section 7 of the Act would modify the requirements relating to 
Congressional approval of certain medical facility acquisitions. 
Specifically, the Secretary would be required to submit additional 
information in the prospectus for each major construction facility. We 
do not object to these modifications.
    Section 8 would designate the Department of Veterans Affairs 
telehealth clinic in Craig, Colorado as the ``Major William Edward 
Adams Department of Veterans Affairs.'' The Department has no objection 
to this proposal and defers to Congress in the naming of Federal 
property.
    Section 9 would extend certain expiring authorities. Subsection (a) 
of section 9 would amend 38 U.S.C. Sec. 1703 to extend the recovery 
audit program for fee basis and other medical service contracts until 
September 30, 2020. This authority is currently set to expire on 
September 30, 2013.
    Subsection (b) would amend 38 U.S.C. Sec. 2031 to extend until 
December 31, 2018, VA's authority to provide certain services to 
seriously mentally ill Veterans. Title 38 U.S.C. Sec. 2031(a) 
authorizes VA to provide to seriously mentally ill Veterans, including 
homeless Veterans, (1) outreach services, (2) care, treatment, 
rehabilitation, and other services, and (3) therapeutic transitional 
housing assistance. This authority is currently set to expire on 
December 31, 2011.
    Subsection (c) would amend 38 U.S.C. Sec. 2033 to extend until 
December 31, 2018, VA's authority to expand and improve benefits to 
homeless Veterans. Title 38 U.S.C. Sec. 2033 authorizes VA, subject to 
appropriations, to operate a program to expand and improve the 
provision of benefits and services to homeless Veterans. The program 
includes establishing sites under VA jurisdiction to be centers for the 
provision of comprehensive services to homeless Veterans in at least 
each of the 20 largest metropolitan statistical areas. This authority 
is currently set to expire on December 31, 2011.
    Subsection (d) would amend 38 U.S.C. Sec. 2041(c) to extend, 
through December 31, 2018, the Secretary's authority to enter into 
agreements with homeless providers for the purpose of selling, leasing, 
or donating homes acquired through the guaranteed loan program. This 
authority is currently set to expire on December 31, 2011.
    Subsection (e) would amend 38 U.S.C. Sec. 2066 to extend 
Congressional authority to continue the Advisory Committee for Homeless 
Veterans until December 31, 2018. This authority is currently set to 
expire on December 30, 2011.
    Subsection (f) would amend 38 U.S.C. Sec. 8118(a)(5) to extend 
until December 31, 2018, the Secretary of VA's authority to transfer 
real properties under his jurisdiction and control, to other Federal 
agencies, State agencies, public or private entities, or Indian tribes. 
This authority is currently set to expire on December 31, 2011.
    While VA requested extensions of sections 2031, 2033, 2041 and 2066 
of title 38, U.S.C. in our draft bills the ``Veterans Health Care Act 
of 2011'' and ``Veterans Benefit Programs Improvement Act of 2011,'' 
which were transmitted to Congress on June 7 and May 19, 2011, the 
draft ``Veterans Health Care Facilities Capital Improvement Act of 
2011'' would extend these authorities for a considerably longer period 
of time. VA requires additional time to evaluate these provisions and 
we will provide views and costs on this section for the record.
    This concludes my prepared statement. Thank you for the opportunity 
to testify before the Subcommittee. I would be pleased to respond to 
any questions you or Members of the Subcommittee may have.

                                 
            Prepared Statement of Fred S. Sganga, President,
              National Association of State Veterans Homes
I. Overview

    The National Association of State Veterans Homes (``NASVH'') 
appreciates the opportunity to submit this statement on H.R. 2530, 
sponsored by Mr. Michaud and Chairman Miller. The bill will provide for 
increased flexibility in establishing rates of reimbursement for State 
Veterans Homes by the Secretary of Veterans Affairs for nursing home 
care provided to service-connected disabled veterans. The text of H.R. 
2530 is identical to legislative language approved by the Senate 
Committee on Veterans' Affairs on June 29, 2011, as section 109 of S. 
914.
    H.R. 2530 is intended to remedy the consequences of the 
implementation of section 211(a) of the Veterans Benefits, Health Care, 
and Information Technology Act of 2006 (Pub. L. No. 109-461) (the 
``2006 Act''). Section 211(a) of the 2006 Act established new payment 
mechanisms by the VA for the long-term care of service-connected 
disabled veterans at State Veterans Homes (the ``70 Percent Program''). 
NASVH believes that the 70 Percent Program must be remedied promptly by 
legislation. Continuation of the 70 Percent Program in its current form 
will not only inhibit the long-term care of service-connected disabled 
veterans, but will also threaten the financial viability of many of the 
Nation's State Veterans Homes.
    NASVH's membership consists of the administrators and staff of 
State-operated Veterans Homes throughout the United States and in the 
Commonwealth of Puerto Rico. NASVH members currently operate 142 
Veterans Homes in all 50 States and Puerto Rico. Our nursing homes 
provide over 29,000 nursing home and domiciliary beds for veterans and 
their spouses, and for the gold-star parents of veterans. Our nursing 
homes assist the VA by providing long-term care services for 
approximately 53 percent of the VA's long-term care workload at the 
very reasonable cost of only about 12 percent of the VA's long-term 
care budget. On average, the daily cost of care of a veteran at a State 
Veterans Home is less than 50 percent of the cost of care at a VA long-
term care facility.
    Particularly in these times of tight Federal budgets and deficit 
reduction imperatives, the national State Veterans Home system is an 
economical alternative to other VA long-term care programs. In fact, a 
report by the VA's Office of Inspector General stated:
    A growing portion of the aging and infirm veteran population 
requires domiciliary and nursing home care. The SVH [State Veterans 
Home] option has become increasingly necessary in the era of VAMC [VA 
Medical Center] downsizing and the increasing need to discharge long-
term care patients to community based facilities. VA's contribution to 
SVH per diem rates, which does not exceed 50 percent of the cost to 
treat patients, is significantly less than the cost of care in VA and 
community facilities.

II. Inadequacies of the Current 70 Percent Program

    Implementation of the 70 Percent Program has created very serious 
unintended consequences for State Veterans Homes throughout the 
country. The 70 Percent Program authorized payment of different per 
diem amounts by the VA to State Veterans Homes which provide nursing 
home care to veterans with service-connected disabilities. Although the 
2006 Act creating the 70 Percent Program became effective on March 31, 
2007, the VA did not issue regulations to implement the 70 Percent 
Program until April 29, 2009, and problems arose immediately with its 
implementation. Since that time, NASVH has met repeatedly with VA 
officials in an attempt to modify the 70 Percent Program 
administratively to solve these problems, but both NASVH and the VA now 
agree that some of the problems with the 70 Percent Program can only be 
solved fully by a modification of the law.
    The problems with the 70 Percent Program are as follows. Although 
VA regulations implementing the 70 Percent Program state that the 
Program provides a ``higher per diem rate'' for veterans with service-
connected disabilities, the regulations actually result in 
significantly lower total amounts being paid to many State Veterans 
Homes providing ``skilled nursing care'' to veterans with service-
connected disabilities. In fact, the 70 Percent Program, in its current 
form, substantially underpays State Veterans Homes for ``skilled 
nursing care,'' and pays State Veterans Homes only about 1/2 to 2/3 of 
what Medicare previously paid to State Veterans Homes for the same care 
of the same veterans, and only about 1/3 to 1/2 of what the VA 
currently pays itself for the same care of the same veterans with 
service-connected disabilities.
    ``Skilled nursing care'' is relatively common nursing care that 
involves significant amounts of rehabilitative services such as 
physical therapy, occupational therapy, speech therapy, expensive 
pharmaceuticals, and specialty medical services that often are not 
easily accessible at a nearby VA Medical Center by a State Veterans 
Home. As implemented, the 70 Percent Program does not provide to many 
State Veterans Homes their total cost of ``skilled nursing care'' for 
service-connected disabled veterans, despite Congressional intent. This 
is a problem largely for those 34 States that have Medicare-certified 
State Veterans Homes and that provide a substantial amount of skilled 
nursing care to veterans with service-connected disabilities. The 
number of States that have Medicare-certified State Veterans Homes that 
provide ``skilled nursing care'' is steadily increasing.
    The 70 Percent Program's inadequate reimbursement levels have 
caused many State Veterans Homes that provide a substantial amount of 
skilled nursing care to veterans simply not to admit veterans to their 
State Veterans Homes under the 70 Percent Program, to limit the numbers 
of such admissions, or to admit veterans under the 70 Percent Program 
without restriction and expose themselves to substantial financial 
losses. This is exactly the opposite result sought by Congress when it 
passed the 2006 Act. In short, although the current 70 Percent Program 
is workable for some State Veterans Homes which provide largely non-
skilled nursing care to veterans with service-connected disabilities, 
it causes substantial problems for an increasing majority of States in 
the Nation which provide substantial amounts of skilled nursing care to 
such veterans in State Veterans Homes. As such, the 70 Percent Program 
is not achieving its central intended purposes, and it must be 
corrected.
    In addition, because of a quirk in the existing 70 Percent Program 
law, almost no State Veterans Home in the Nation actually is paid the 
``higher'' prevailing per diem rate established by the VA for the 70 
Percent Program. This is so because a combination of 38 U.S.C. 
Sec. 1745 and the VA regulations implementing Sec. 1745 require that 
State Veterans Homes be paid only ``the lesser of'' the per diem rate 
established by the VA for the 70 Percent Program or a rate determined 
under OMB Form A-87. The OMB Form A-87 rate is almost always 
significantly less than the prevailing per diem rate published by the 
VA for the 70 Percent Program, and this has caused an additional 
financial hardship for State Veterans Homes.
    Lastly, the most regrettable unintended consequence of the 70 
Percent Program is that, for service-connected disabled veterans, it 
unnecessarily replaced a program (under 38 U.S.C. Sec. 1741) that had 
worked well for decades for the States that have Medicare-certified 
State Veterans Homes with a program (under 38 U.S.C. Sec. 1745) that 
has a multitude of regulatory and financial problems.

III. The Remedy Proposed by H.R. 2530

    NASVH has been working with the VA since the 70 Percent Program 
regulations were implemented in 2009 to resolve these difficulties. 
Although reluctant to overhaul the program initially, the VA now has 
recognized the need for substantial changes. The VA transferred 
administrative responsibility for the financial aspects of the 70 
Percent Program from the VA Office of Geriatrics and Extended Care to 
the VA Chief Business Office. NASVH has met several times with senior 
officials at the Chief Business Office and we are confident that they 
are sincerely trying to solve the problems of the 70 Percent program.
    Most recently, the VA and its Chief Business Office have proposed 
to amend the current 70 Percent Program statutory language under 38 
U.S.C. Sec. 1745 to authorize the VA to enter into direct contracts 
with State Veterans Homes under 38 U.S.C. Sec. 1720 that could 
adequately and accurately reimburse State Veterans Homes for providing 
long-term care to 70 Percent Program veterans. This is, in essence, the 
remedy proposed by H.R. 2530. However, this solution will work 
effectively only if it is implemented fairly by the VA, taking into 
account the following considerations.
    First, as stated above, NASVH is working with the VA Chief Business 
Office to develop adequate and accurate reimbursement measures for the 
long-term care of 70 Percent Program veterans. The most equitable 
approach appears to be to establish that payments by the VA for basic 
long-term care under section 1720 contracts be comparable to the 
existing ``higher'' prevailing per diem rate established by 38 U.S.C. 
Sec. 1745. This is a mechanism that will work effectively to reimburse 
State Veterans Homes for the basic nursing care of service-connected 
disabled veterans.
    Second, any payment program implemented by the VA should require 
that payments by the VA for ``outlier'' specialty medical services and 
drugs provided to veterans by State Veterans Homes under a section 1720 
contract be made at rates and under eligibility criteria comparable to 
those used by Medicare. Rather than leave the determination of the 
reimbursement levels for such services provided to service-connected 
disabled veterans to the whims or annual changes in VA policy or 
personnel, Medicare payment levels and eligibility criteria can serve 
as constant and fair guidance for any VA program to reimburse State 
Veterans Homes for ``outlier'' specialty medical services and drugs 
under section 1720 contracts for the long-term care of service-
connected disabled veterans.
    Third, we emphasize that a contract is a two-sided instrument. Both 
sides must agree for a contract to exist. The ability of a State 
Veterans Home to enter into a contract with the VA for the long-term 
care of a service-connected disabled veteran means necessarily that a 
State Veterans Home also has the option not to enter into such a 
contract, if the State Veterans Home believes that the reimbursement 
terms offered by the VA for the care of such a veteran are not 
adequate. In short, the VA will succeed in having State Veterans Homes 
provide significant amounts of nursing home care to service-connected 
disable veterans only if the VA pays State Veterans Homes adequately 
for such care.
    Lastly, it is important for the Subcommittee to realize that the 
enactment of the above provisions should not cost the Federal 
Government anything additional and should, in fact, save the Federal 
Government substantial amounts of money. This is so because of the 
simple fact that enactment of the Bill's proposals described above will 
encourage more service-connected disabled veterans to receive long-term 
care at State Veterans Homes rather than at VA long-term care 
facilities, and State Veterans Homes cost far less on a per veteran per 
day basis than VA long-term care facilities.
    The cost differences are dramatic. The average cost per veteran per 
day at a VA long-term care facility is $944.25 (VA, Volume II, Medical 
Programs and Information Technology Programs, Congressional Submission, 
FY 2012 Funding and FY 2013 Advance Appropriations Request, page 1H-
19). Assuming enactment of the proposals described above, the average 
cost per veteran per day at a State Veterans Home, including basic 
care, drugs, and outlier specialty costs is not likely to exceed 
$450.00 per day. Accordingly, every service-connected disabled veteran 
that receives long-term care at a State Veterans Home rather than at a 
VA long-term care facility will save the Federal Government over $494 
per day, or $180,310 per veteran per year.
    Nationally, there are 24,422 State Veterans Home nursing facility 
beds that could be occupied by 70 Percent Program veterans. On the 
average, 13 percent of these beds, or almost 3,175 beds, are 
unoccupied. Approximately 2,000 additional State Veterans Home nursing 
facility beds that could be occupied by 70 Percent Program veterans are 
under construction. Accordingly, if State Veterans Homes were to fill 
only their currently vacant beds with 70 Percent Program veterans, the 
Federal Government would save approximately $5.7 billion over 10 years. 
If only half of the vacant State Veterans Home long-term care beds were 
filled by 70 Percent Program veterans instead of such veterans 
receiving long-term care services at VA long-term care facilities, the 
Federal Government would save $2.8 billion over 10 years.
    Currently, however, many State Veterans Homes, especially those 
providing ``skilled nursing care,'' are discouraging the admission of 
service-connected disabled veterans to their facilities because the 
payment structure under the current 70 Percent Program is so 
inadequate. The solution to this is to pay State Veterans Homes 
adequately and accurately to care for service-connected disabled 
veterans. State Veterans Homes cost far less on a per veteran per day 
basis than VA long-term care facilities. The VA should fully utilize a 
less-costly resource (State Veterans Homes) before using a more-costly 
resource (VA long-term care facilities). It is simply good business, 
and good veterans health care policy, for the Chief Business Office of 
the VA to seek to reimburse State Veterans Homes adequately for the 
long-term care of service-connected disabled veterans.
    NASVH thanks the Subcommittee for its continuing efforts to solve 
this important problem, and we encourage the Members of the 
Subcommittee to favorably report H.R. 2530. We look forward to 
continuing to work with the VA and Congress to resolve these issues 
promptly so that we can better serve our Nation's veterans.

                                 
                  Prepared Statement of Rick A. Yount,
                    Director, Paws for Purple Hearts

    Madam Chairwoman and Members of the Subcommittee, as the Founder 
and Director of the Paws for Purple Hearts program, I would like to 
thank you for the opportunity to submit a statement for the record in 
support of H.R. 198, the Veterans Dog Training Therapy Act and H.R. 
1154, the Veterans Equal Treatment for Service Dogs Act. I am pleased 
that the Subcommittee is recognizing the important roles that dogs are 
playing in helping to heal the physical and psychological wounds of our 
Nation's Veterans.

H.R. 198

    Attached to this statement is an overview of the Paws for Purple 
Hearts (PPH) program that inspired the introduction of H.R. 198, the 
Veterans Dog Training Therapy Act. The program's pilot was originally 
implemented at the Palo Alto VA Trauma Recovery Program at Menlo Park 
commencing in July 2008. It has since expanded to DoD medical 
facilities, including Walter Reed Army Medical Center and the National 
Intrepid Center of Excellence for Psychological Health and Traumatic 
Brain Injury. The provisions of H.R. 198 are based on the PPH program 
developed at VA Menlo Park.
    I created the PPH program based on my experience as a licensed 
social worker and certified service dog instructor. The program was 
designed to provide meaningful therapeutic activities based on the 
continued mission of caring for the needs of a fellow Veteran. The 
training was developed to address all three symptom clusters associated 
with post-traumatic stress disorder (PTSD). Since beginning this 
therapeutic intervention model 3 years ago at VA Menlo Park, I have 
witnessed amazing responses to this program from both active duty 
Servicemembers involved in the current conflicts, as well as Vietnam 
Veterans who have participated in the training of service dogs for 
their fellow Veterans. Many accredited assistance dog organizations 
involve prisoners and at-risk teens in the training of dogs to serve 
people with disabilities. When it comes to training dogs for Veterans, 
no one takes that task more seriously than those who served by their 
sides in conflict. Veterans who have experienced psychological wounds 
never stray from the core value of caring for their fellow Veterans. 
This warrior ethos serves as a powerful motivational tool to inspire 
Veterans with psychological injuries, including PTSD, to voluntarily 
participate in the training of service dogs for their comrades. After 
teaching hundreds of college students and at-risk teens to train 
service dogs, I have found no one more dedicated to the cause than the 
Warriors and Veterans I have worked with in the PPH program.
    Training a service dog for a fellow Veteran provides a valuable 
opportunity for the Veteran trainer to reintegrate into civilian life. 
As part of the training, the Veterans have the responsibility to teach 
the dogs that the world is a safe place. Through that process, they 
must convince themselves of the same. The Veteran trainers are taught 
to praise and treat the dogs when they hear a car backfire or other 
startling events. Rather than turning inward to ruminate on their past 
trauma, they must get outside of their own heads to focus on the dogs 
and their mission to help another Veteran. Additionally, the dogs act 
as social lubricants and offer opportunities to Veterans, who often 
isolate themselves from society, to experience positive interactions 
with members of the community. The training requires the emotionally 
numb Veterans to use demonstrative positive emotion in order to 
successfully teach their dogs. Veterans participating in the program 
have reported that using positive emotions to praise the dogs has 
significantly improved their family dynamics as their children respond 
to this positive parenting strategy.
    PPH offers a symbiotic opportunity to address the needs of two 
cohorts of Veterans in one program. It is safe, available, cost-
effective, and has earned the respect of VA and DoD health care 
providers. In addition to the recognized mental health benefits of the 
training, the quality of the service dogs that result from that 
training was documented recently by the History Channel's ``Modern 
Marvels'' program dedicated to dogs. Venuto, the PPH dog that was 
featured in the program, enhanced the mental health of 20+ Veterans 
with PTSD as they participated in his training. Venuto was then 
successfully partnered with a Veteran who is paraplegic as a result of 
a Spinal Cord Injury (SCI).
    To substantially benefit over 20 Veterans with one dog allows the 
VA to provide outreach to a greater number of Veterans without the 
logistical challenges of providing a dog to each Veteran. Also, the 
Veteran trainers gain valuable dog handling and care skills should they 
receive a service dog in the future. As described in the attachment, 
the presence of the service dogs in training at VA and DoD medical 
facilities also benefits other patients and health care providers.
    The positive clinical observations of the VA Menlo Park service dog 
training program were formally presented during workshops at the VA 
National Mental Health Conference and the International Society for 
Traumatic Stress Studies Conference in 2009. I was joined by a Menlo 
Park VA Staff Psychologist and a Recreational Therapist in making those 
presentations. The workshops inspired significant interest from other 
VA Medical Centers in replicating the program at their sites.
    There is a great opportunity for collaboration between the VA and 
the DoD with regard to the training, provision, and research associated 
with service dogs. The Army Surgeon General held an Animal-Assisted 
Intervention Symposium in December of 2009. The Army Family Act Plan of 
2010 identified ``providing service dogs to Wounded Warriors'' as the 
#2 priority out of 82 issues. The leadership at the National Intrepid 
Center of Excellence (NICoE) for Psychological Health and Traumatic 
Brain Injury under the Defense Centers of Excellence has embraced 
service dog training as an intervention worthy of research. The VA 
could simplify the task of collecting specified outcomes by partnering 
with the NICoE to avoid duplication of effort and waste of resources.
    The VA has questioned whether there is a substantial need for 
service dogs by Veterans. This issue was addressed in a 2007 study 
published in the Psychosocial Process Journal that indicated 42 percent 
of randomly selected Veterans with SCI desired information concerning 
service dogs. The study determined that ``Among veterans with SCI there 
is a substantial interest in service dogs. Health care providers have a 
responsibility for educating individuals with SCI about the potential 
benefits and drawbacks of service dogs and for facilitating the process 
of obtaining information from service dog training organizations.'' The 
study concluded that, ``The VA could help support these organizations 
financially or establish training centers of its own to increase the 
availability of trained dogs in order to accomplish what Public Law 
107-135 intended.''
    The Department of Veterans Affairs is not currently providing any 
funding for the service dog training therapy pilot program at VA Menlo 
Park, even though VA officials have recognized the therapeutic value of 
the program. Private donors provided the seed funding to demonstrate 
the efficacy of this intervention for the symptoms of PTSD. Although 
the Secretary currently has the authority to establish a VA funded 
Veterans service dog training pilot program, the Department has 
resisted taking any financial responsibility for this promising 
intervention. Consequently, enactment of H.R. 198 is necessary to 
sustain the VA Menlo Park pilot program and to expand this model to 
other VA treatment facilities.

                               H.R. 1154

    I support the provisions of H.R. 1154, the Veterans Equal Treatment 
for Service Dogs Act, because Veterans should be afforded the same 
rights at VA facilities as other Americans are provided under the 
Americans with Disabilities Act. Language needs to be included in the 
bill to ensure that service dogs in training under the guidance of 
certified instructors associated with Veterans Dog Training Therapy 
programs receive the same status as fully trained service dogs for 
purposes of access to VA facilities.

                               __________

                      Paws for Purple Hearts (PPH)
                           PROGRAM LOCATIONS

Palo Alto VA Health Care System          Walter Reed Army Medical Center
Trauma Recovery Program                       Warrior Transition Brigade
Menlo Park, CA 94025                                Washington, DC 20307


                 National Intrepid Center of Excellence
                     National Naval Medical Center
                           Bethesda, MD 20889
INTRODUCTION

    Paws for Purple Hearts (PPH) is a dual-purpose program created to 
meet the needs of Servicemembers and Veterans with physical and/or 
psychological injuries. The approach uses the process of service-dog 
training to remediate Post-Traumatic Stress symptoms in Servicemembers 
and Veterans. The trained dogs are then placed with fellow Veterans who 
have mobility-limiting injuries.
    Founded on the time-honored tradition of Veterans-helping-Veterans, 
PPH enables Servicemembers and Veterans to actively provide support for 
their fellow injured Servicemembers and regain a tangible sense of 
purpose. PPH is currently being implemented at Department of Defense 
(DoD) and Veterans Administration (VA) sites. Two hundred active duty 
and Veterans with PTSD have participated in the program since it was 
first offered in 2008. Five service-dogs trained by PPH instructors 
have been placed with Veterans. Two Servicemembers have become 
accredited service dog-trainers and are pursuing careers in this field.
    The curriculum of the service-dog training program is specifically 
designed to remediate the core-symptoms of post-traumatic stress, such 
as re-experiencing, avoidance, and hyperarousal. Clinical experience to 
date has been encouraging with respect to traumatic stress symptom and 
harm reduction, a decrease in the need for pain and sleep medicine and 
improved communication skills and sense of well-being.

PROGRAM OVERVIEW AND HISTORY

    Paws for Purple Hearts (PPH) is an innovative therapeutic service-
dog-training program that teaches Veterans and active duty military 
personnel with post-traumatic stress disorder (PTSD) the skill of 
training service-dogs for Veterans with war-related injuries. The use 
of psychiatric service-dogs with patients who have psychiatric 
disorders is well described (Barker & Dawson, 1998; Mason & Hagan, 
1999). Studies have shown that under stressful conditions, the presence 
of a dog is effective at reducing stress responses in healthy adults, 
adults with hypertension, and in children with attachment disorders 
(Allen, 1991 and 1999; Kortschal, 2010). PPH is a voluntary program and 
is used as an adjunct to a wide range of PTSD treatments including 
Cognitive Behavioral Therapy (CBT), Prolonged Exposure (PE), Cognitive 
Processing Therapy (CPT) and/or medications.
    PPH was created by social worker and professional dog trainer Rick 
Yount, in 2006. It was inspired by the success of a therapeutic 
service-dog training program he started in Morgantown, West Virginia to 
help at-risk teens develop social skills while providing them with a 
rewarding career path. Yount's Golden Rule Assistance Dog Program 
(GRAD) was offered to public school drop-outs through Morgantown's 
Alternative Learning Center. Several GRAD-trained assistance dogs were 
placed with disabled veterans. In July 2008, Yount's Paws for Purple 
Hearts program was implemented at the Palo Alto VA's Men's Trauma 
Recovery Program in Menlo Park, California. One hundred and thirty 
Servicemembers have participated in that program. Based on the 
program's success, Yount was asked to establish PPH at Walter Reed's 
Army Warrior Transition Brigade (WTB). Forty-five Soldiers have 
participated in the formal Internship Program or the Patient Service-
dog Training Program since February, 2009. In October of 2010, PPH was 
invited to be part of the PTSD and Traumatic Brain Injury research and 
treatment mission at the new National Intrepid Center of Excellence 
(NICoE), in Bethesda, MD.

MILITARY NEED FOR SERVICE DOGS AND COST EFFECTIVENESS

    A 2009 study published in The American Journal of Public Health 
found that close to 40 percent of Iraq and Afghanistan Veterans treated 
at American health centers during the previous 6 years were diagnosed 
with PTSD, depression, or other mental health issues. The study also 
found that a lack of social support--being separated, divorced, 
widowed, etc., may pose a serious risk for new post-deployment mental 
health problems and underscores the need for social support services 
for returning Veterans who are unmarried and/or without social support. 
(Seal, et al., 2009). Sixty percent of PTSD patients still meet the 
criteria for PTSD after being treated with empirically supported 
interventions (Monson, 2006; Schnurr, 2007). Therefore, it is 
imperative to explore adjunctive treatments for PTSD that may improve 
outcomes.
    There is also substantial interest in service-dogs among Veterans 
with Spinal Cord Injury. A survey in 2007 showed that 30 percent of 
Veterans with Spinal Cord Injury reported at least some interest in 
obtaining a service-dog and 42 percent desired information concerning 
service-dogs (Brashear, 2007). This urgent need of Veterans for well-
trained service-dogs has been recognized by Congress with passage of 
several laws authorizing the Department of Veterans Affairs to provide 
service-dogs to disabled Veterans.
    The 2010 Army Family Action Plan named ``provide service-dogs for 
Wounded Warriors'' as the #2 priority out of 82 issues. Involving 
Veterans and Servicemembers in the training of service-dogs for fellow 
Veterans creates a symbiotic opportunity to serve two needs with one 
program.
    The PPH Program supplies high-quality purpose-bred service dogs. 
Certified PPH dog-trainers or selected ``puppy-parents'' take 
responsibility for the welfare and behavior of the dogs at all times 
when the dogs are on military or VA property. This allows active-duty 
Servicemembers and Veterans with PTSD who cannot or do not own dogs, to 
have the opportunity to experience the high quality connection with a 
dog that provides the powerful relief of PTSD symptoms. It also 
circumvents the logistical difficulties of owning and keeping dogs on 
base and in medical centers. The program is also highly cost-effective, 
providing dog-assisted therapeutic relief to a large number of PTSD 
patients with a limited number of service dogs. For instance, in the 
course of the 30-60 day PPH program offered at the Palo Alto VA 
Hospital, as many as 20 patients with PTSD may participate in the 
training of single service dog. All participants come away from the 
program with the valuable knowledge and skills that will allow them to 
connect with dogs they may own in the future in the most rewarding and 
therapeutic way.

WORKING DOGS/WORKING TRAINERS

    Paws for Purple Hearts engages Servicemembers in the active duty of 
creating valuable service dogs for other disabled Servicemembers. PPH's 
training philosophy is based on a strong bond and positive methods of 
shaping behaviors. Mastering the skills and patience required to train 
a service dog helps the PPH trainers to regain control of their 
emotions, focus their attention, and improve their social competence 
and overall sense of wellbeing. Two participants in the Palo Alto VA 
program have gone on to pursue accreditation as professional dog 
trainers and we anticipate that many more will be inspired to become 
professionally involved in creating the thousands of service dogs that 
will be needed by our wounded warriors.

DOGS HEALING THE WORKPLACE

    The impact of the PPH Program on Veterans and Servicemembers has 
been observed to reach well beyond its participants. Nearly 500 
Servicemembers have benefited indirectly from the presence of the PPH 
program in PTSD residential treatment. These are Vets who share rooms 
with the dogs and their trainers, those who interact with the dogs as 
``uncles,'' and those who encounter dogs that are present in their 
various treatment groups. A conservative estimate of 650 WTs have also 
been indirectly impacted by the presence of this program on the campus 
of Walter Reed. The presence of the program on VA and military 
installations brings these PPH participants and their dogs into 
friendly contact with dozens of other Servicemembers every day and 
provides not only a stress reducing interaction, but also the 
opportunity for the PPH participants to share their positive 
experiences with fellow Veterans and Servicemembers.

DOGS HEALING THE HOME

    The methodology used in training service dogs to assist individuals 
with mobility impairments has striking similarities to the best 
practices of effective parenting. The goal of creating a respectful and 
responsible service dog requires the employment of sound behavioral 
shaping techniques based on positive and humane methods. Using the 
service dog training to draw attention to these parallels provides a 
means to teach critical parenting tools in a non-threatening manner.

HOW THE PROGRAM WORKS

    PTSD symptoms fall into three broad categories: Re-experiencing, 
avoidance/numbing and increased arousal. The interventions in the PPH 
program are targeted to remediate each category of these symptoms as 
follows:

    1.  Re-experiencing: Procedures used in training PPH service-dogs 
require the trainer to focus on the dog's ``here and now'' point of 
view to recognize the ``teachable moments'' when instruction will be 
most effectively processed and retained. The presence of the dog during 
a stressful situation or encounter changes the context of the arousal 
event and anchors the trainer in the present, reminding the 
Servicemembers or Veterans that they are no longer in dangerous 
circumstances. If the patient/trainee does experience a trigger for 
symptoms, the presence of the dog can lower anxiety levels.
    2.  Avoidance and Numbing: Training a service-dog requires that it 
be carefully exposed to a wide range of experiences in the community. 
This creates a need for servicemembers with PTSD to challenge their 
impulses to isolate and avoid those same environments that the dogs 
must learn to tolerate. Dogs are natural social lubricants and so it is 
nearly impossible for the trainer to isolate from other people during 
this part of the training. Interactions with others in the company of 
the dogs, has been reported to be less threatening since the focus of 
the interaction is on the dog and the training.

        In order to shape the behavior of a service-dog, the trainer 
must also connect successfully with the dog. PTSD patient-trainers must 
overcome their emotional and affective numbness in order to heighten 
their tone of voice, bodily movements, and capacity for patience in 
order deliver their commands with positive, assertive clarity of 
intention and confidence. In doing this, trainers soon discover they 
can earn their dog's attention and best guide them to the correct 
response. The dog's success must then be rewarded with emotionally-
based praise. The PPH training technique allows the trainers to 
experience rewarding positive emotional stimulation and social 
feedback. The basic daily needs of a service-dog involve structured 
activities that also bring the trainer and dog into the kind of close 
nurturing contact that further creates a behavioral and psychological 
antidote to social avoidance.

    3.  Arousal: PPH service-dogs are bred to be responsive to human 
emotions and needs. Their sensitivity to and reflection of their 
trainer's emotional state provides immediate and accurate measures of 
the trainer's projected emotion. This also challenges the trainer to 
overcome his or her tendency for startle reactions in order to relay a 
sense of security and positive feedback when their young dogs are faced 
with environmental challenges such a loud sirens and approach by 
strangers.

        PPH service-dogs are also bred to be affectionate and have a 
low-arousal temperament that puts their trainers ``at ease.'' With 
these dogs at their sides, PPH trainers perceive greater safety and 
social competence and are able to shift out of their hyper-vigilant, 
defensive mode into a relaxed state that makes them ready and able to 
connect with others.

CLINICAL OBSERVATIONS AND PARTICIPANT TESTIMONIALS

    Over the last 3 years, anecdotal reports from the PPH program 
director and PTSD treatment team members indicate that PPH participants 
exhibit the following improvements.

      Increase in patience, impulse control, emotional 
regulation
      Improved ability to display affect, decrease in emotional 
numbness
      Improved sleep
      Decreased depression, increase in positive sense of 
purpose
      Decrease in startle responses
      Decrease in pain medications
      Increased sense of belongingness/acceptance
      Increase in assertiveness skills
      Improved parenting skills and family dynamics
      Less war stories and more in the moment thinking
      Lowered stress levels, increased sense of calm

    The following are observations made by Rick Yount after operating 
PPH for 2 years at the Palo Alto VA and at Walter Reed (Case 1), 
testimonies from Servicemembers who participated in the program (Case 
2-5), and testimony from a disabled Veteran who has received a PPH 
trained mobility-assistance dog (Case 6). All persons involved in these 
accounts gave consent for their story to be included here.
    Case 1: A Marine hit by multiple separate IED explosions during his 
multiple tours in Operation Iraqi Freedom (OIF) and Operation Enduring 
Freedom (OEF), the war in Afghanistan, had been in the PTSD treatment 
program for several weeks but was not participating in treatment 
despite a myriad of behavioral and pharmacological interventions. He 
sat in the corner with his sunglasses on, occasionally twitching his 
head from side to side in a tic-like manner. His peers were hesitant to 
interact with him due to his body language and lack of motivation to 
respond to their attempts to connect with him. His interest in the dogs 
prompted him to participate in the PPH program. Within two days of 
working in the PPH program, he began to smile and bond with the dog. 
His involvement led to his first positive interactions with staff and 
fellow Veterans. Instead of leaving the PTSD program without 
successfully completing it, he was able to finish the entire program 
and process his trauma through the support of his dog, peers and 
treatment team.
    Case 2: This testimony was given by a PPH participant with PTSD who 
served in Iraq as a National Guard Reservist was struggling with family 
issues:

    My family has noticed a difference in the way I interact with them 
as a result of working with my service-dog in training. I am patient 
with my children when they are around, I haven't yelled at them in 
several months and they aren't afraid of me when I'm around. I think 
that is a direct result of working with my dog. I have also benefited 
from the association with my service-dog in training as we spend time 
on bonding every day. I feel loved by him and I feel comforted when he 
is around. It's been nearly 4 years since I have felt comforted. When 
the dog is with me people that I pass come up and talk to me and I have 
social interaction that I wouldn't have had without the dog. I'm 
grateful the VA started this program and I got to be part of it. I wish 
more veterans got the opportunity I've been given to work with these 
amazing animals. Please consider this program on a larger scale so more 
veterans can benefit from training or receiving a service-dog.

    Case 3: A young soldier, recently returned from Iraq, arrived in 
the PTSD program. He had recently attempted to take his own life. His 
struggle with hopelessness continued to inhibit his affect and stifle 
his ability to engage in treatment. One of the dogs interacted with him 
while he was waiting for the next group to begin. He smiled as he pat 
the dog on his head. He began training the next day, taking the 
training tasks very seriously. His psychiatrist told the Director of 
the Service-dog Program that the dog had accomplished what the doctor 
had been unable to do in 6 months. After his discharge from the 
program, the soldier was partnered with a service-dog to continue 
helping with his PTSD symptoms.
    Case 4: A Marine who had served as a ``Devil Dog'' (term used to 
refer to a Marine) for 19 years was treated for PTSD in 2005. He 
returned for treatment in 2006 when he was unable to control his anger. 
He asked to join the newly instituted PPH program. He voluntarily 
provided this account of his experience with PPH:

    I would have never imagined by working with these dogs my life 
would change forever. After over a year with severe sleep, depression 
and anger issues I found myself able to sleep for longer periods of 
time during the night and found myself calm during times where I would 
have exploded in anger. After analyzing this major change in my 
behavior the doctors quickly discovered that the common denominator was 
a service-dog trainee named Verde.
    Please understand that my story is not a rare one. I have seen 
remarkable changes in not only myself but in the other residents that 
have participated in the training of these animals. For years doctors 
have thrown medication at my issues with minimal results but Verde has 
caused my life that would have been surely shortened by my issues to be 
full again. I know that I will always suffer with PTSD issues but 
having my new friend by my side like a fellow Marine will ensure that 
my quality of life will improve.

    Case 5: Army Veteran returned from Iraq showing many of the signs 
of PTSD. Over the next 4 years, his depression deepened, he lost his 
job and was divorced. He tried many different medications and finally 
was enrolled in the PTSD program. He volunteered this testimony about 
PPH:

    While in the program I learned a lot about PTSD and gained many 
tools to help me cope with the disorder, but there was one part of the 
program that stood apart; Paws for Purple Hearts. Soon after signing up 
to train the dogs I found myself sleeping better and was in a 
surprisingly good mood, before I knew it I was not hiding in my room 
anymore. I started laughing again and I began to feel good. I felt good 
about myself and what I was doing; helping to train this dog for a 
fellow veteran. Going out and not isolating was a huge leap forward for 
me. When you are with one of these dogs everyone wants to stop you and 
talk to you. This is not the most comfortable thing for someone with 
PTSD. After a while I was having conversation with complete strangers. 
They come with such a positive attitude that it reinforces that not all 
people in the world are bad and it begins to rebuild trust, which is 
one of the many things that one with PTSD struggles with. Another 
struggle is self restraint and patience and working with a dog will 
test your patience. If at any time I feel uneasy or start to have a 
little anxiety all I have to do is reach down and pet my dog or maybe 
even bend down and give him a hug, and it seems that everything is 
going to be just fine.
    As my time for being part of this program came near an end, I 
discovered I wanted and needed to continue being part of this program. 
So I enrolled in The Bergin University of Canine Studies, to further 
expand my education in the service-dog field. In May of 2010 I 
completed the AS program. The PPH program has not only helped me in 
learning to cope with PTSD, but it has also helped me find what it is 
that I want to do in life. I know without this I could easily slip back 
into a lot of the old patterns that I had. My hope is to share with 
other Veterans the wonder of working with these dogs and help them get 
the same help I got through this program.

    Case 6: The following is a personal account of how a PPH bred and 
Veteran-trained service dog has affected the life of the Veteran with 
PTSD who also uses a wheelchair as a result of his spinal cord injury. 
He suffered a spinal cord injury while serving in the Army during the 
Vietnam era. He received his service-dog in December 2009. His dog 
helps by pulling his wheelchair, retrieving dropped objects, bracing 
for transfers and opening doors. The impact that his dog has had on his 
PTSD symptoms are expressed in his reflections.

    Since being paired with my dog I have realized many benefits. Some 
nights I couldn't turn my brain off. I would be on hyper vigilance 
unable to sleep at all. I was given Trazadone (PRN). I hated the way I 
would feel the next day from Trazadone. Since receiving my dog, my 
sleep has improved 100 percent and I no longer use it. Over the years 
I've been prescribed many meds for pain (300 mg. TDI) Gabapentin for 
burning pain nerve, Morphine, and Oxycontin. I now take no pain meds 
and have learned to live with my constant pain which flairs with 
activity or weather. I have also taken several prescription drugs to 
treat depression including Prozac and Welbutron. I feel no need to take 
depression medication anymore either.

    The Veteran also reported significant improvement in his emotional 
control, positive social interaction and parenting skills and family 
dynamics.

THE NEED FOR EMPIRICAL STUDY OF THE PPH INTERVENTION

    The PPH research team, in collaboration with senior research 
officials at the NICoE, has designed the first research protocol to 
examine, systematically, PTSD symptom reduction as well as the 
physiologic and behavioral changes that occur during interactions 
between Veterans suffering from PTSD and dogs in the PPH service-dog-
training program that is ongoing at Walter Reed Army Medical Center's 
Warrior Transition Brigade and at the Palo Alto Veterans Administration 
Health care System Men's Trauma Recovery Program.
    Based on the scientific literature and clinical observations of the 
program to date, we hypothesize that we will be able to scientifically 
verify that PTSD symptoms will be reduced, psychosocial functioning 
will increase and markers of stress as well as inflammation will be 
reduced by the human-dog interaction in the PPH training program. This 
is exactly the sort of ``evidence-based research'' into the mind/body 
therapeutic effects of human-animal interaction that has been lacking 
and causing a resistance to the placement of service-dogs with 
Servicemembers and Veterans despite Congressional approval of 
legislation supporting this effort and the growing demand from Wounded 
Warriors. We hope that the PPH study will advance not only our 
scientific understanding of the healing powers of animals in our lives, 
but provide the science that the DoD and VA need to approve animal-
assisted therapy programs and the placement of service dogs with 
Servicemembers and Veterans with psychiatric and physical disabilities.
    * * * Footnote references are available upon request

                                 
       Prepared Statement of David E. Sharpe, Founder, Pets2Vets
INTRODUCTION

    Madame Chairwoman and Members of the Subcommittee, I would like to 
thank the Subcommittee for the opportunity to submit my written 
testimony. I applaud the ongoing efforts by Congress to address issues 
facing active duty servicemen and women, veterans and emergency first 
responders such as PTSD, TBI and other mental health issues.

MY STORY AND THE FOUNDING OF P2V

    My name is David E. Sharpe. I am 32 years old and served in the 
U.S. Air Force Security Forces for 6 years (1999--2005) where I endured 
several incidents that, I thought, didn't affect my personal 
relationships with my family, friends, and colleagues. A short time 
after my first deployment to Saudi Arabia during November 2001 in 
support of Operation Enduring Freedom, I encountered a one-one 
confrontation with a Taliban sympathizer pointing his weapon in my face 
during Entry Control Point Checks. A second incident occurred in 2004 
while I was on patrol in the country of Pakistan and noticed two 
suicide bombers directly outside the base perimeter (razor wire) with a 
ladder (used to cross the razor wire) and a belt of explosives strapped 
to one of the men's chest while pointing at the chow hall area. One 
could only believe that these two men were planning to fulfill a 
successful suicide bombing attack against U.S. military personnel.
    Upon my return from my first deployment in March 2002, I began to 
act violently towards my family, friends and myself--all symptoms of my 
being diagnosed 8 years later by the VA with having PTSD and 
depression. I found myself waking up in the middle of the night with 
cold sweats, random crying, having outbursts while blaming and 
questioning myself how I had handled the life-threatening situations I 
had found myself in. However, my life would get much worse before it 
would improve.
    I finally hit bottom on the bedroom floor of my apartment. I sat, 
legs folded, ready to finish the fight with the demons that had 
followed me back from the war zone: the sudden rages; the punched 
walls; the profanities tossed at anyone who tried to help me. There was 
nothing in my room other than dirty Air Force uniforms, some empty 
bottles of alcohol and a crushing despair. I took a deep breath. I shut 
my eyes and closed my lips a little tighter around the cool steel of my 
.45. And then something licked my ear. I looked around and locked gazes 
with a pair of brown eyes. Cheyenne, my sheltered dog, cocked her head 
to one side--it was just one of those looks that an animal gives you. 
It was a look like: What are you doing? Who's going to take care of me? 
Who else is going to let me sleep in your bed? For a long minute, I 
stared into the puzzled face of my 6-month-old pit bull mix. And then 
slowly, reluctantly, I backed the barrel of my .45 out of my mouth. 
There is no doubt about it; I owe Cheyenne my life.
    Immediately, I felt so relieved, like a 10,000-pound weight had 
been lifted off my chest. Soon after, my family and friends noticed a 
significant change in my behavior--a reduced number of outbursts, 
better attitude, no more suicide attempts--all because of this little 
pit bull mix puppy. Cheyenne's heroics were in her unconditional love 
and devotion to me--the devotion and love that most pet owners can 
attest to. It's interesting that a torn-eared puppy from a shabby 
animal rescue saved me. Not my father (a retired 32-year U.S. Army 
RANGER) or my grandfather (a PT Boat Commander in the South Pacific 
during World War II) or a friend. It was Cheyenne who was the force 
that pulled me back into society. I couldn't talk to anybody--not my 
father, not the counselors--but I can talk to my sheltered dog, and she 
never judges me. Eight years later, my father stated, ``He's [me] a 
different person now. All that stuff was taking over his life. That dog 
[Cheyenne] just listened to him for hours.'' \1\ But all that time I 
had suffered in silence.
---------------------------------------------------------------------------
    \1\ Dogs' devotion helps heal vets' inner wounds; The Washington 
Post; June 23, 2011; Steve Hendrix.
---------------------------------------------------------------------------
    For the first time in January 2010 (with the help of a friend), I 
walked into the Washington, D.C. VA Hospital to seek additional help in 
my life. The process to determine my having PTSD and depression was 
very frustrating; however, it was worth the time. I will admit that 
there was some fear of speaking to a human for the first time about my 
military service and I was somewhat apprehensive. But, Cheyenne helped 
me become an extrovert, and telling another person or persons proved to 
not be so difficult as I thought it would be.
    One year later, on January 11, 2011, I married Jenny Fritcher, an 
Air Force staff sergeant stationed at Ramstein Air Base in Germany. My 
wife will be discharged from active duty and join me in Arlington, 
Virginia in August 2011. More importantly, we're expecting our first 
child in January 2012--I credit all of this to my sheltered dog, 
Cheyenne. Through the unconditional love of my sheltered dog and my 
training her to perform basic manners (e.g. sit, stay, nudge my hand 
when I get hyper vigilant) I became resilient and am now a productive 
member of society, working as a Program Analyst in the Intelligence 
Community.
    Because of Cheyenne and my belief that other veterans could benefit 
from animals like her, I set out on a mission in October 2009 with only 
$2,500 in my savings account to create the nonprofit organization, Pets 
2 Vets, or P2V (www.P2V.org). P2V pairs active duty military, veterans 
and emergency first responders dealing with the stress of their service 
with shelter animals as part of their healing process. This innovative 
and enterprising organization proves that an outside-of-the-box concept 
can help others like me in a very short time and is somewhat grounded 
in science. A July 2011 study published in the Journal of Personality 
and Social Psychology revealed that pet owners had greater self-esteem, 
greater levels of exercise and physical fitness, and they tended to be 
less lonely than nonowners.\2\ These are exactly the qualities needed 
by veterans with mental health disorders, and my goal is for P2V to aid 
them in their recovery while at the same time saving our Nation's 
shelter animals.
---------------------------------------------------------------------------
    \2\ Journal of Personality and Social Psychology; Friends With 
Benefits: On the Positive Consequences of Pet Ownership; July 4, 2011; 
Allen R. McConnell, Christina M. Brown, Tonya M. Shoda, Laura E. 
Stayton, and Colleen E. Martin.
---------------------------------------------------------------------------
    Today, P2V has aided dozens of our Nation's heroes while finding 
loving homes for shelter animals in just under its first 2 years of 
operation. The organization currently serves veterans by using 
volunteers who are trained by a VA licensed clinical psychologist. The 
volunteers pick up the veterans from their homes (rural areas included) 
and transport them to P2V-partner shelters to adopt or visit animals of 
their choice--the VA doesn't have to provide the facility, and veterans 
are removed from the monotony of a hospital environment. P2V also 
provides transportation for veterans by its volunteers in rural areas 
to visit or adopt shelter animals. P2V pays for or its partner shelters 
waive adoption fees, supplies a gift card for necessary pet equipment 
(leash, collar, feeding-water bowls and crate), and pays for the 
veteran's first 2 years of pet insurance (Banfield Pet Hospital 
Wellness Plans; located at 770 locations nationwide), and basic manners 
training. Finally, veterans are provided multiple options in the 
selection of a companion animal (dog or cat). In conjunction with the 
appropriate health care services, the entire P2V process allows 
veterans to feel a sense of self worth and accomplishment that helps 
lead them on the road to becoming a productive member of society. For 
example, Marine sergeant Jimmy Childers, recipient of a shelter dog 
named Tidus stated, ``Tidus isn't going to be fetching my [prosthetic] 
leg for me or anything. He's here to bring joy into my life, and he 
does that every day.'' \3\
---------------------------------------------------------------------------
    \3\ Dogs' devotion helps heal vets' inner wounds; The Washington 
Post; June 23, 2011; Steve Hendrix.

---------------------------------------------------------------------------
PROPOSED LEGISLATION

    H.R. 198, Veterans Dog Therapy Training Act, introduced by Reps. 
Grimm (R-NY), Michaud (D-ME), King (R-NY) and Lance (R-NJ) provides the 
assessment of addressing post-deployment mental health and PTSD 
symptoms through a therapeutic medium of training service dogs for 
veterans with disabilities. P2V supports the concept of such 
legislation but is concerned that the bill is too narrowly drafted to 
benefit a large number of veterans.
    Currently, the legislation only allows for a pilot program to 
assess the effectiveness of the training of service animals on the 
mental health of veterans suffering from post-traumatic stress disorder 
or other post deployment mental health conditions. However, as we have 
learned over the years, the VA needs all available resources--a toolbox 
of sorts--to address the mental health crisis facing our Nation's 
veterans. Therefore, P2V recommends the Committee broaden the scope of 
the bill to encourage the VA to partner other community-based service/
companion animal programs already in existence and review their 
effectiveness on the well-being of veterans in need. P2V as well as 
many other organizations can provide successful and inexpensive models 
that can augment traditional services as well as serve as alternatives 
to conventional care.
    In conclusion, while many veterans do require the assistance of a 
highly trained service animal and could benefit from training such 
animals, most veterans with whom I have spoken simply are looking for 
the companionship of an animal to feel acknowledged and accepted.
    My sheltered dog is the sole reason why I am here today. 
Furthermore, my dog has allowed me to grow close relationships with my 
family and friends with the help of the Department of Veterans' 
Affairs, and I believe that other veterans can benefit from the same 
type of companionship. I appreciate your time and the opportunity to 
share my personal experiences with having PTSD, educating you about P2V 
and making recommendations on H.R. 198.
    [The attachments are being retained in the Committee files.]

                                 
           Prepared Statement of Greg Jacob, Policy Director,
                     Servicewomen's Action Network

    Madam Chairwoman and Distinguished Members:
    Servicewomen's Action Network (SWAN) is a national organization 
that supports, defends, and empowers today's servicewomen and women 
veterans of all eras. SWAN's vision is to transform military culture by 
securing equal opportunity and the freedom to serve in uniform without 
threat of harassment, discrimination, intimidation or assault. SWAN 
also seeks to reform veterans' services on a national scale to 
guarantee equal access to quality health care, benefits and resources 
for women veterans and their families.
    SWAN fully supports H.R. 2074, a bill to require a comprehensive 
policy on reporting and tracking sexual assault incidents and other 
safety incidents that occur at Department of Veterans Affairs (VA) 
medical facilities.
    SWAN has unique insight into the issue of sexual assault at the VA. 
Our National Peer Support Helpline receives numerous calls from 
veterans seeking help to remedy a negative experience at the VA. Some 
of these veterans, both men and women, tell us they were sexually 
harassed or sexually assaulted at VA facilities, reported it, and saw 
absolutely nothing done by the VA in response.

      One client told us that while receiving an EKG, a male 
technician inappropriately touched her breasts during the procedure and 
repeatedly commented on her appearance. Afterward she did not know how 
to report the incident, left the hospital and has not returned to the 
VA since.
      Another veteran was raped by her VA psychiatrist who was 
a retired Air Force officer. She reported this to the VA administration 
who told her they could do nothing based on her word alone. She then 
reported him to the authorities. Although he was not prosecuted, as a 
result of this veteran's courage the psychiatrist had his treatment 
license suspended for 5 years.
      Another caller who is employed by the VA as a police 
officer has apprehended a VA technician twice for sexually assaulting 
patients and turned him over to the VA administration both times. Yet 
this technician has not been charged with any crime, is still employed 
at the same VA and still regularly works with women patients. The 
officer is completely frustrated with a system that allows rapists to 
roam the hospitals free to prey on vulnerable patients.

    H.R. 2074 would help to reform this system by requiring the VA 
develop a comprehensive program for reporting and handling sexual 
assault complaints, a first step in what SWAN hopes will become a 
rigorous system that keeps everyone who uses the VA safe and secure. An 
institution that provides for the health care needs of veterans ought 
to have an effective reporting system in place, particularly given the 
rampant levels of sexual assault and sexual harassment within the 
active duty military. The Department of Defense estimates that in 2010 
alone, there were over 19,000 sexual assaults in the military,\1\ or 52 
sexual assaults per day. It is negligent and dangerous to think that 
somehow those tens of thousands of survivors and perpetrators simply go 
away after being discharged. The numbers of sexual trauma survivors, 
both male and female, utilizing the VA is substantial. VA reports that 
in FY 2010 68,379 patients had at least one outpatient visit to a VHA 
facility that was for the treatment of a condition(s) related to 
Military Sexual Trauma. 61 percent (or 41,475) of those patients were 
women; 39 percent (or 26,904) were men.\2\
---------------------------------------------------------------------------
    \1\ Department of Defense, DMDC. 2011. ``2010 Workplace and Gender 
Relations Survey of Active Duty Members.'' Available: http://
www.sapr.mil/media/pdf/research/
DMDC_2010_WGRA_Overview_Report_of_Sexual_Assault.pdf.
    \2\ Department of Veterans Affairs, Office of Mental Health 
Services, Military Sexual Trauma Support Team. (2011). Summary of 
Military Sexual Trauma-related Outpatient Care Report, FY 2010. 
Washington, DC: Department of Veterans Affairs, Office of Mental Health 
Services.
---------------------------------------------------------------------------
    VA serves tens of thousands of high-risk veterans every year, and 
as an institution it must accept responsibility for the care and safety 
of all its patients from the time they walk onto the grounds of a VA 
facility until they walk off. The VA must not only do so by providing 
top notch medical treatment, but also superior administrative support 
as well. That means every VA run facility must develop a well 
publicized process in place to handle sexual harassment and sexual 
assault complaints, must have policies that enforce rules and 
discipline offenders, must train every member of their staff annually 
on sexual harassment and sexual assault response, must maintain a 
security presence that is attentive and effective, and must invest in 
an infrastructure that allows for a completely safe visit. Safety and 
care for VA patients should not start or stop at the front door.
    The stakes are high. With the number of veterans eligible for care 
rising year after year and with the rape, sexual assault and sexual 
harassment crisis continuing unabated in the military, it is essential 
that the VA protect patients from sexual predators. If the VA fails to 
do this, veterans desperately in need of care will avoid seeking it out 
which will result in untold suffering, chronic mental illness, 
substance abuse, homelessness and in some cases suicide or death. Our 
Nation's veterans deserve better, and H.R. 2074 will help to ensure 
that.
    Respectfully Submitted.

                                 
          Tipton, Hon. Scott R., a Representative in Congress
                   from the State of Colorado, letter
                                      U.S. House of Representatives
                                                    Washington, DC.
                                                      July 22, 2011

Dear House Committee on Veterans' Affairs Subcommittee on Health:

    I am honored to submit this statement in support of Section 8 of 
the Veterans Health Care Facilities Capital Improvements Act of 2011. 
This section will now replace and mirrors legislation that I introduced 
in the form of H.R. 1658. Section 8 of this legislation seeks to rename 
the Department of Veterans Affairs telehealth clinic in Craig, 
Colorado, after Major William Edward Adams.
    It is only fitting and proper that we pay tribute to a heroic 
American who was awarded our Nation's highest honor for his conspicuous 
gallantry in the Kontum Province in the Central Highlands of Vietnam. 
Major William Edward Adams is an inspiration to every citizen of our 
great nation, and a reminder to all Americans that some will sacrifice 
everything to preserve our way of life.
    Maj. Adams was born in Casper, Wyoming, and raised in Craig, 
Colorado. He went to high school in Missouri at the Wentworth Military 
Academy. He graduated from Colorado State University, where he also met 
his future wife Sandra Adams. Upon graduation he joined the United 
States Army. Major Adams was deployed to Vietnam in 1970.
    On May 25th, 1971, Maj. Adams willingly volunteered for a 
helicopter rescue mission that would undoubtedly endanger his lightly 
armored aircraft and his life. The mission was to fly into a remote 
fire base that was under heavy attack to pick up three critically 
wounded soldiers. Maj. Adams was fully aware of the advantageous 
position of the enemy's formidable anti-aircraft guns; as well as the 
clear skies that would provide no cover from the imminent barrage. 
While directing and coordinating fire support from other attack 
helicopters, Major Adams landed his aircraft and picked up the three 
wounded soldiers. As he began his return flight, Maj. Adams' helicopter 
was bombarded with enemy rocket and gunfire. He calmly regained control 
of the aircraft, and prepared to make an emergency landing, but the 
helicopter exploded before Maj. Adams could touch down. For these 
actions, Major William Edward Adams posthumously received the Medal of 
Honor.
    It gives me great pride to know that I have fellow countrymen who 
are capable of such selfless feats of bravery. Thus, renaming the VA 
telehealth clinic in Craig, Colorado, after Major Adams honor is an 
appropriate honor and is also supported by the community.
            Sincerely,

                                                       Scott Tipton
                                                 Member of Congress

                                 
    Prepared Statement of Heather L. Ansley, Esq., MSW, Director of 
  Veterans Policy, VetsFirst, a Program of United Spinal Association.

    Chairwoman Buerkle, Ranking Member Michaud, and other distinguished 
Members of the Subcommittee, thank you for the opportunity to submit 
written testimony regarding VetsFirst's views on the Veterans Dog 
Training Therapy Act (H.R. 198) and the Veterans Equal Treatment for 
Service Dogs Act (H.R. 1154).
    VetsFirst represents the culmination of 60 years of service to 
veterans and their families. United Spinal Association, through its 
veterans service program, VetsFirst, maintains a nationwide network of 
veterans service officers who provide representation for veterans, 
their dependents and survivors in their pursuit of Department of 
Veterans Affairs (VA) benefits and health care before the VA and in the 
Federal courts. Today, United Spinal Association is not only a VA-
recognized national veterans service organization, but is also a leader 
in advocacy for all people with disabilities.
    Service animals provide multi-faceted assistance to people with 
disabilities. Specifically, service animals promote community 
integration. In addition to performing specific tasks such as pulling a 
wheel chair or opening a door, these same service animals can also help 
to break down barriers between people with disabilities and society. In 
addition to increased social interaction, many people with disabilities 
also report experiencing a greater sense of independence.
    For many years, Congress has recognized the benefits that service 
animals provide for veterans with disabilities. Specifically, Congress 
has authorized VA to provide guide dogs for veterans with visual 
impairments. In 2002, Congress expanded the authority to include 
service dogs for veterans with hearing and mobility impairments. Most 
recently, Congress further expanded VA's authority to include service 
dogs for veterans who have mental health concerns.
    VetsFirst is pleased to lend our support to legislation that we 
believe will further promote and facilitate the use of service animals 
by veterans with disabilities.

The Veterans Dog Training Therapy Act (H.R. 198)

    VetsFirst strongly supports the Veterans Dog Training Therapy Act 
(H.R. 198) and the substitute amendment that will be submitted at 
Committee markup. The proposed amendment to this legislation would 
ensure that accredited service dog agencies and trainers will provide 
appropriate training and consultation with VA to provide opportunities 
for veterans with mental health concerns to train service dogs for 
fellow veterans with disabilities.
    We support efforts to ensure that properly trained service animals 
are available to veterans who can benefit from their assistance. The 
Veterans Dog Training Therapy Act provides a unique opportunity to 
benefit not only veterans seeking the assistance of a service dog but 
also provides veterans with post-deployment mental health concerns or 
post-traumatic stress disorder the opportunity to benefit from training 
these dogs. The dual nature of this approach will assist a wide range 
of veterans.
    VetsFirst also believes that requiring VA to work in conjunction 
with accredited service dog agencies and trainers will benefit all 
participating veterans. Specifically, veterans assisting with training 
will be required to follow a structured process to ensure that the 
service dog is appropriately trained. As a result, veterans receiving 
these service dogs will be assured that the dogs are properly trained 
and able to assist them. Furthermore, the skills learned by the veteran 
trainers could be helpful in allowing them to successfully pursue a 
career in the service animal field.
    Consequently, VetsFirst urges passage of the Veterans Dog Training 
Therapy Act. We understand that Congressman Grimm has identified 
possible offset funding for this important legislation.

The Veterans Equal Treatment for Service Dogs Act (H.R. 1154)

    VetsFirst, strongly supports the Veterans Equal Treatment for 
Service (VETS) Dogs Act (H.R. 1154). This legislation would ensure that 
all veterans with disabilities who use service dogs are able to access 
VA facilities.
    VA regulation, 38 CFR Sec. 1.218(a)(11), which applies to ``all 
property under the charge and control of VA,'' states that, ``Dogs and 
other animals, except seeing-eye dogs, shall not be brought upon 
property except as authorized by the head of the facility or 
designee.'' Exempting guide dogs but not service dogs from VA property 
leads to unequal protection for veterans and people with disabilities. 
In addition, allowing the use of service dogs to vary by VA facility 
has resulted in veterans encountering different access policies based 
on the discretion of the individual facility directors.
    The VETS Dogs Act, which has wide bipartisan support, specifically 
states that the VA Secretary may not prohibit the use of service dogs 
in VA facilities or on VA property. .
    Immediately prior to the introduction of this legislation, the 
Veterans Health Administration (VHA) issued VHA Directive 2011-013 
titled, ``Guide Dogs and Service Dogs on VHA Property.'' If properly 
implemented and maintained, the directive could address past access 
difficulties. Although VetsFirst acknowledges the actions of VA in 
issuing the directive, we believe that the VETS Dogs Act must be passed 
to ensure that veterans with disabilities who use service dogs have the 
assurance of equal access to VA facilities.
    Thus, we urge swift passage of the VETS Dogs Act to specifically 
mandate access to VA services and facilities for all veterans with 
disabilities who use service dogs.
    Thank you for the opportunity to submit written testimony 
concerning VetsFirst's views on H.R. 198 and H.R. 1154. VetsFirst 
believes that the ability to use service animals is a critical option 
for many people with disabilities. Together, H.R. 198 and H.R. 1154 
provide the legislative authority to ensure that veterans are able to 
more fully benefit from service dogs.
    We appreciate your leadership on behalf of our Nation's veterans 
with disabilities. VetsFirst stands ready to work in partnership to 
ensure that all veterans are able to reintegrate in to their 
communities and remain valued, contributing members of society.

                                 
             Prepared Statement of Wounded Warrior Project
    Chairwoman Buerkle, Ranking Member Michaud and Members of the 

Subcommittee:
    Wounded Warrior Project (WWP) welcomes the Subcommittee's 
consideration of H.R. 1855 and is pleased to offer our views on this 
important bipartisan legislation.
    WWP works to help ensure that this generation of wounded warriors 
thrives--physically, psychologically and economically. Our policy 
objectives are targeted to filling gaps in programs or policies--and 
eliminating barriers--that impede warriors from thriving. Importantly, 
those objectives reflect the experiences and concerns of wounded 
warriors and family members whom we serve daily across the country.
    H.R. 1855 addresses some of the deepest concerns we have heard from 
warriors' families, and we are very pleased to be able to 
enthusiastically support this measure. Its enactment would realize a 
key goal of our policy agenda. Most important, it would materially 
change lives.

                 Traumatic Brain Injury Rehabilitation

    Impressive military logistics and advances in military medicine 
have saved the lives of many combatants injured in Iraq and Afghanistan 
who would likely not have survived in previous conflicts. As a result, 
servicemembers are returning home in unprecedented numbers with severe 
polytraumatic injuries. Among the most complex are severe traumatic 
brain injuries. Each case of traumatic brain injury is unique. 
Depending on the injury site and other factors, individuals may 
experience a wide range of problems--from profound neurological and 
cognitive deficits manifested in difficulty with speaking, vision, 
eating, or incontinence to marked behavioral symptoms. While 
individuals who have experienced a mild or moderate TBI may experience 
symptoms that are only temporary and eventually dissipate, others may 
experience symptoms such as headaches and difficulty concentrating for 
years to come.
    Those with severe TBI may face such profound cognitive and 
neurological impairment that they require a lifetime of caretaking. As 
clinicians themselves recognize, it is difficult to predict a person's 
ultimate level of recovery.\1\ But to be effective in helping an 
individual recover from a brain injury and return to a life as 
independent and productive as possible, rehabilitation must be targeted 
to the specific needs of the individual patient. In VA parlance, 
rehabilitation must be ``veteran-centered.''
---------------------------------------------------------------------------
    \1\ Sharon M. Benedict, PhD, ``Polytrauma Rehabilitation Family 
Education Manual,'' Department of Veterans Affairs Polytrauma 
Rehabilitation Center, McGuire VA Medical Center, Richmond, Virginia; 
http://saa.dva.state.wi.us/Docs/TBI/Family_Ed_Manual112007.pdf 
(accessed April 27, 2010).
---------------------------------------------------------------------------
    While many VA facilities have dedicated rehabilitation-medicine 
staff, the scope of services actually provided to veterans with a 
severe TBI can be limited, both in duration and in the range of 
services VA will provide or authorize. It is all too common for 
families--reliant on VA to help a loved one recover after sustaining a 
severe traumatic brain injury--to be told that VA can no longer provide 
a particular service because the veteran is no longer making 
significant progress. Yet ongoing rehabilitation is often needed to 
maintain function,\2\ and veterans with traumatic brain injury who are 
denied maintenance therapy can easily regress and lose cognitive, 
physical and other gains made during earlier rehabilitation.
---------------------------------------------------------------------------
    \2\ Ibid.
---------------------------------------------------------------------------
    Some do make a good recovery after suffering a severe TBI. But many 
have considerable difficulty with community integration even after 
undergoing rehabilitative care, and may need further services and 
supports.\3\ Medical literature has documented the need to use 
rehabilitative therapy long after acute care ends to maintain function 
and quality of life.4,5,6 While improvement may plateau at a 
certain point in the recovery process, it is essential that progress is 
maintained through continued therapy and support. The literature is 
clear in demonstrating the fluctuation that severe TBI patients may 
experience over the course of a lifetime. One study found that even 10 
to 20 years after injury individuals were still suffering from feelings 
of hostility, depression, anxiety, and further deficiencies in 
psychomotor reaction and processing speed.\7\ While some are able to 
maintain functional improvements gained during acute rehabilitative 
therapy, others continue to experience losses in independence, 
employability, and cognitive function with increasing intervals of 
time.\8\ Given such variation in individual progress, rehabilitation 
plans must be dynamic, innovative, and long term--involving patient-
centered planning and provision of a range of individualized 
services.\9\
---------------------------------------------------------------------------
    \3\ Nathan D. Cope, M.D., and William E. Reynolds, DDS, MPH; 
``Systems of Care,'' in Textbook of Traumatic Brain Injury (4th ed.), 
American Psychiatric Publishing (2005), 533-568.
    \4\ Hoofien D, Gilboa A, Vakils E, et al. ``Traumatic brain injury 
(TBI) 10-20 years later: a comprehensive outcome study of psychiatric 
symptomatology, cognitive abilities and psychosocial functioning.'' 
Brain Injury 15.3(2001):189-209.
    \5\ Sander A, Roebuck T, Struchen M, et al. ``Long-term maintenance 
of gains obtained in postacute rehabilitation by persons with traumatic 
brain injury.'' Journal of Head Trauma Rehabilitation 16.4(2001): 356-
373.
    \6\ Sloan S, Winkler D, Callaway L. ``Community Integration 
Following Severe Traumatic Brain Injury: Outcomes and Best Practice.'' 
Brain Impairment 5.1(May 2004): 12--29.
    \7\ Hoofien, et al. 201.
    \8\ Sander, et al. 370.
    \9\ Sloan, et al. 22.
---------------------------------------------------------------------------
    For this generation of young veterans, reintegration into their 
communities and pursuing life goals such as meaningful employment, 
marriage, and independent living may be as important as their medical 
recovery. Yet studies have found that as many as 45 percent of 
individuals with a severe traumatic brain injury are poorly 
reintegrated into their community, and social isolation is reported as 
one of the most persistent issues experienced by such patients.\10\ Yet 
research has demonstrated that individuals with severe TBI who have 
individualized plans and services to foster independent living skills 
and social interaction are able to participate meaningfully in 
community settings.\11\ While improving and maintaining physical and 
cognitive function is paramount to social functioning, many aspects of 
community reintegration cannot be achieved solely through medical 
services. Other non-medical models of rehabilitative care--including 
life-skills coaching, supported employment, and community-reintegration 
therapy--have provided critical support for community integration. But 
while such supports can afford TBI patients opportunities for gaining 
greater independence and improved quality of life, VA medical 
facilities too often deny requests to provide these ``non-medical'' 
supports for TBI patients. While such services could often be provided 
under existing law through other VA programs,\12\ it is troubling that 
institutional barriers stand in the way of meeting veterans' needs 
under a ``one-VA'' approach. Instead, rigid adherence to a medical 
model and foreclosing social supports is, unfortunately, a formula for 
denying veterans with severe traumatic brain injury the promise of full 
recovery. This barrier must be eliminated.
---------------------------------------------------------------------------
    \10\ Sloan, et al. 12.
    \11\ Nathan D. Cope, M.D., and William E. Reynolds, DDS, MPH; 
``Systems of Care,'' 533-568.
    \12\ See VA's program of independent living services (administered 
by the Veterans Benefits Administration) under 38 U.S.C. sec. 3120, and 
VA's authority under 38 U.S.C. sec. 1718(d)(2) to furnish supported 
employment services as part of the rehabilitative services provided 
under the compensated work therapy program (administered by the 
Veterans Health Administration).
---------------------------------------------------------------------------
                               H.R. 1855

    H.R. 1855 would amend current law to clarify the scope of VA's 
responsibilities in providing rehabilitative care to veterans with 
traumatic brain injury. While current law (codified in sections 1710C 
and 1710D of title 38, U.S. Code) directs VA to provide comprehensive 
care in accord with individualized rehabilitation plans to veterans 
with traumatic brain injury, in some instances warriors with severe 
traumatic brain injury are not receiving services they need, and in 
other instances, VA has cut off rehabilitative services prematurely.
    Ambiguities in current law appear to contribute to such problems. 
For example, while the above-cited provisions of law do not define the 
term ``rehabilitation,'' the phrase ``rehabilitative services'' is 
defined for VA health-care purposes (in section 1701(8) of title 38) to 
mean ``such professional, counseling, and guidance services and 
treatment programs as are necessary to restore, to the maximum extent 
possible, the physical, mental, and psychological functioning of an ill 
or disabled person.'' That provision could be read to limit services to 
restoring function, but not to maintaining gains that have been made. 
(Yet limiting TBI rehabilitative care in that manner risks setting back 
progress that has been made.) As defined, the term ``rehabilitative 
services'' is also limited to services to restore ``physical, mental 
and psychological functioning.'' In our view, rehabilitation from a 
traumatic brain injury should be broader, to include also cognitive and 
vocational functioning, and, given the research cited above, should not 
necessarily be limited to services furnished by health professionals.
    In essence, H.R. 1855 would provide that in planning for and 
providing rehabilitative services to veterans with traumatic brain 
injuries, VA must ensure that those services----

    1.  are directed not simply to ``improving functioning'' but to 
sustaining improvement and preventing loss of functional gains that 
have been achieved (and, as such, that rehabilitation may be continued 
indefinitely); and
    2.  are not to be limited to services provided by health 
professionals but include any other services or supports that 
contribute to maximizing the veteran's independence and quality of 
life.

    WWP strongly supports this legislation. It would eliminate barriers 
too many have experienced, and would offer the promise of making good 
on the profound obligation we owe those who struggle with complex life-
changing brain injuries.
    We urge the Committee to adopt this important legislation, and 
would welcome the opportunity to work with you to ensure its enactment.
                                 

                   MATERIAL SUBMITTED FOR THE RECORD
                                U.S. Department of Veterans Affairs
                                                    Washington, DC.
                                                     August 5, 2011
Mr. Randall Williamson
Director, Health Care
U.S. Government Accountability Office
441 G Street, NW
Washington, DC 20548

Dear Mr. Williamson:

    In accordance with the Office of Management and Budget Circular A-
50, the Department of Veterans Affairs (VA) is providing an update on 
the actions taken by VA in response to the eight recommendations 
contained in the June 7, 2011, U.S. Government Accountability Office 
(GAO) final report, VA Health Care: Action Needed to Prevent Sexual 
Assaults and other Safety Incidents (GAO-11-530).
    In commenting on GAO's draft report, VA concurred with GAO's 
recommendations to the Department. The enclosure provides details about 
progress VA has made in implementing GAO's recommendations since 
responding to the draft report.
            Sincerely,

                                                   John R. Gingrich
                                                     Chief of Staff
    Enclosure

                               __________

                                                          Enclosure
          Department of Veterans Affairs (VA) 60 Day Update to
          Government Accountability Office (GAO) Final Report

  VA HEALTH CARE: Actions Needed to Prevent Sexual Assaults and Other 
                            Safety Incidents
                              (GAO-11-530)

    To improve VA's monitoring of allegations of sexual assault, we 
recommend that the Secretary of the Department of Veterans Affairs 
direct the Under Secretary for Health to take the following four 
actions:

    Recommendation 1: Ensure that a consistent definition of sexual 
assault is used for reporting purposes by all medical facilities 
throughout the system to ensure that consistent information on these 
incidents is reported from medical facilities through VISNs to VHA 
Central Office Leadership.

    VA Update to Final Report: Concur. An interdisciplinary work group 
was formed and charged with developing a definition of sexual assault. 
The work group adopted the following definition of sexual assault:

         ``Any type of sexual contact or attempted sexual contact that 
        occurs without the explicit consent of the recipient of the 
        unwanted sexual activity. Assaults may involve psychological 
        coercion, physical force, or victims who cannot consent due to 
        mental illness or other factors. Falling under this definition 
        of sexual assault are sexual activities such as forced sexual 
        intercourse, sodomy, oral penetration, or penetration using an 
        object, molestation, fondling, and attempted rape. Victims of 
        sexual assault can be male or female. This does not include 
        cases involving only indecent exposure, exhibitionism, or 
        sexual harassment.''

    VA's Assistant Secretary for the Office of Operations, Security and 
Preparedness (OSP) communicated this definition, as well as other 
policy and processes, to Under Secretaries, Assistant Secretaries, and 
other key officials in a June 16, 2011, memorandum, ``Clarification of 
Policy of Sexual Assault Reporting'' (Attachment A). The Deputy Under 
Secretary for Health for Operations and Management (DUSHOM) 
subsequently issued a July 7, 2011, memorandum, ``Actions Needed to 
Improve Reporting of Allegations of Sexual Assaults'' (Attachment B), 
to VISN Directors regarding the definition, as well as the new policies 
and processes. This memorandum required VHA field facilities to take 
specific actions in regard to reporting sexual assaults including:

      Specifying a definition for what is to be reported as an 
allegation of or an actual sexual assault;
      Outlining requirements for reporting all allegations of 
sexual assault on VA property (or off-property in the execution of 
official VA duties) in accordance with VA Directive 0321, Serious 
Incident Reports;
      Requiring facilities to submit:

          an initial issue brief that includes specific 
        information to the Office of the DUSHOM within 24 hours of 
        reporting the incident, and a follow-up issue brief to provide 
        details about any investigation, results of the investigation, 
        actions taken by the facility, and any process or policy 
        improvements made to mitigate future events;

      Communicating with the Office of Inspector General (OIG).

    Recommendation 2: Clarify expectations about what information 
related to sexual incidents should be reported to and communicated 
within VISN and VHA Central Office leadership teams, such as officials 
responsible for residential programs and inpatient mental health units.

    VA Update to Final Report: Concur. The two memoranda mentioned in 
the status update for Recommendation 1 clarified and reinforced 
expectations on what information related to sexual incidents should be 
reported. The interdisciplinary work group is continuing its review and 
will identify any additional guidance and clarification that is needed 
in its report to the Under Secretary for Health (USH) no later than 
(NLT) September 30, 2011.

    Recommendation 3: Implement a centralized tracking mechanism that 
would allow sexual assault incidents to be consistently monitored by 
VHACO staff;

    VA Update to Final Report: Concur. The interdisciplinary work group 
is developing and will implement a computerized mechanism to monitor 
sexual assault and other safety incidents. Currently, the Office of the 
DUSHOM is conducting centralized tracking and monitoring through a 
manual process.

    An automated process is under fast track development. Nine VISNs 
are piloting key components, including the automation of issue briefs. 
It is expected that the new automated centralized tracking system will 
replace the manual centralized tracking system by October 31, 2011. An 
updated timeline and status will be provided in a report to the USH NLT 
September 30, 2011.

    Recommendation 4: Develop an automated mechanism within the 
centralized VA police reporting system that signals VA police officers 
to refer cases involving potential felonies, such as rape allegations, 
to the VA OIG to facilitate increased communication and partnership 
between these two entities.

    VA Update to Final Report: Concur. As of June 20, 2011, when VA 
police officers enter information into the Veterans Affairs Police 
System (VAPS), the VAPS automatically sends the VA OIG all incidents of 
sexual assaults and other major felonies. The VAPS system automatically 
sends a special alert to VA OIG Special Agents at VA OIG Headquarters 
and to all regional Special Agents in Charge of VA OIG Field Offices.

    To help identify risks and address vulnerabilities in physical 
security precautions at VA medical facilities, we recommend that the 
Secretary of the Department of Veterans Affairs direct the Under 
Secretary for Health to take the following four actions.

    Recommendation 5: Establish guidance specifying what should be 
included in legal history discussions with veterans and how this 
information should be documented in veterans' psychosocial assessments;

    VA Update to Final Report: Concur. The interdisciplinary work group 
is conducting a literature review and consulting with peers to explore 
what information should be obtained when assessing a Veteran's risk for 
misconduct, and how this information might be used within the required 
limits for maintaining confidentiality and rights of privacy.

    The work group's assessment, in consultation with the VA Office of 
General Counsel, and the VHA Office of Ethics in Health Care, will 
determine what specific guidance may need to be developed. An action 
plan for the development, implementation, and communication of the 
guidance will be established once the assessment is complete. This 
process will also address what appropriate action needs to be taken to 
standardize documentation in Veterans' psychosocial assessments.
    An updated timeline and status will be provided in a report to the 
USH NLT September 30, 2011, in regard to establishing guidance 
specifying what should be included in legal history discussions with 
Veterans and how this information should be documented in Veterans' 
psychosocial assessments.

    Recommendation 6: Ensure medical centers determine whether existing 
stationary, computer-based, and portable personal panic-alarm systems 
operate effectively through mandatory regular testing.

    VA Update to Final Report: Concur. The Office of the DUSHOM has 
worked with the interdisciplinary work group to re-emphasize the need 
for routine testing of panic alarms as well as to ensure the alarms are 
functioning correctly.

    The DUSHOM issued a memorandum, ``Actions Needed to Improve 
Physical Security Requirements'' on June 10, 2011, (Attachment C), that 
tasked each Network Director to ensure that each facility within each 
network has a physical security assessment plan that includes:
    Policies for use and testing of alarm systems, including panic 
alarms:

      Regular testing of these alarm systems, including panic 
alarms;
      Documentation of testing; and
      A plan and implementation strategy for 24/7 response 
capabilities and preventative maintenance.

    All VISN Directors have documented and attested, with supporting 
documentation, that each VAMC has been reviewed for compliance, each 
VISN is compliant with physical security policies, and action plans and 
timelines have been developed to implement physical assessment plans to 
ensure adequate security controls.
    The interdisciplinary work group will provide an update on the 
outcome of this action item in its September 30, 2011, report to the 
USH.

    Recommendation 7: Ensure that alarm systems effectively notify 
relevant staff in both medical facilities' VA police command and 
control centers and unit nursing stations.

    VA Update to Final Report: Concur. In order to ensure that each 
facility is addressing the issue, the DUSHOM, in the previously 
referenced June 10, 2011, memorandum, re-emphasized existing policy and 
procedures about the use of alarm systems and tasked VISN Directors to 
ensure that local facilities have established systems that meet the 
specific location and function needs as well as develop a process to 
include regular testing of these systems based on industry and 
manufacturers' standards.
    As noted in Recommendation 6, each VISN Director has documented and 
attested that each VAMC is in compliance with the new requirements.
    The interdisciplinary work group will provide an update on the 
outcome of this action item in its September 30, 2011, report to the 
USH.

    Recommendation 8: Require relevant medical center stakeholders to 
coordinate and consult on (1) plans for new and renovated units and (2) 
any changes to physical security features, such as closed-circuit 
television cameras.

    VA Update to Final Report: Concur. At the national level, the 
interdisciplinary work group is working with VA Office of Construction 
and Facilities Management (CFM) and OSP about how best to formalize 
consultation during the planning and design processes for all 
construction projects. CFM currently maintains a Technical Information 
Library including planning and design standards for all VA services/
departments, and these standards currently provide planning and design 
guidelines for VA construction projects. Incorporating planning design 
standards emphasizing privacy and safety concerns will need to be 
considered during the development of new standards and updates to 
current standards. The interdisciplinary work group will include a 
recommendation about this issue in its September 30, 2011, report to 
the USH.

                               __________

                                                         Memorandum

Department of Veterans Affairs


Date:                                                                                             June 16, 2011
From:                                         Assistant Secretary, Operations, Security, and Preparedness (007)
Subj:                                      Clarification of Policy for Sexual Assault Reporting (VAIQ#--7124911)
To:                                           Under Secretaries, Assistant Secretaries, and Other Key Officials



        1.  VA Directive 0321, Section 2.a., January 21,2010, 
        (attached) requires all Serious Incidents in the VA to be 
        reported to the VA Integrated Operations Center (VA IOC) as 
        soon as possible but no later than 2 hours after the awareness 
        of the incident.
        2.  Section 2.c.(9). of VA Directive 0321 includes a 
        requirement to report sexual assaults: ``Incidents on VA 
        property that result in serious illness or bodily injury to 
        include sexual assault, aggravated assault and child abuse.''
        3.  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 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.''
        4.  It is important that leadership know in a timely manner all 
        allegations of sexual assault that occur on VA property or at 
        any time while official VA duties are being performed. As such, 
        effective immediately, all Under Secretaries, Assistant 
        Secretaries, and other Key Officials will ensure that the IOC 
        is notified within 2 hours of any and all allegations of sexual 
        assault. Notification may be made via telephone by calling 
        (202) 461-5510 or via email to [email protected]. It is understood 
        that these initial notifications will be followed by more 
        comprehensive information as it becomes available.

Jose D. Riojas

Attachment (1)
cc: VA Integrated Operations Center

                               __________


Department of Veterans Affairs                         VA Directive 0321
Washington, DC 20420                                   Transmittal Sheet



    1.  REASON FOR ISSUE: This Directive establishes specific 
Department policy for Serious Incident Reports (SIRs).
    2.  SUMMARY OF CONTENTS/MAJOR CHANGES: The Directive provides VA 
policy and responsibilities for SIRs.
    3.  RESPONSIBLE OFFICE: The Office of Operations, Security and 
Preparedness, Office of Emergency Management Is responsible for the 
contents of this Directive.
    4.  RELATED HANDBOOK: VA Handbook 0321 Serious Incident Reports
    5.  RESCISSION: None


CERTIFIED BY:                           BY DIRECTION OF THE SECRETARY OF
                                                       VETERANS AFFAIRS:

Roger W. Baker                                            Jose D. Riojas
Assistant Secretary for                          Assistant Secretary for
Information and Technology        Operations, Security, and Preparedness



DISTRIBUTION: Electronic Distribution.

                               __________

                                                  VA DIRECTIVE 0321
                        SERIOUS INCIDENT REPORTS
    1. PURPOSE. To establish policy for Serious Incident Reports (SIR) 
In order to facilitate reporting of certain high-interest incidents, 
significant events, and critical emerging or sensitive matters 
occurring throughout VA that are likely to result in National media or 
Congressional attention.

    2. POLICY.

    a.  This directive requires that Serious Incidents in the VA 
infrastructure that are likely to result in National media or 
Congressional attention be reported to the VA Integrated Operations 
Center (VA IOC) as soon as possible but no later than 2 hours after 
awareness of the incident.
    b.  The SIR will inform the Secretary of any adverse event or 
incident likely to result In National media or Congressional attention. 
Discussed within the VA Handbook 0321 Serious Incident Reports, are the 
identified procedures and operational requirements implementing this 
policy.
    c.  The following are the reportable events and incidents:

        1.  Public information regarding the arrest of a VA Employee 
        (police report, public release, etc.);
        2.  Major disruption to the normal operations of a VA facility;
        3.  Deaths on VA property due to suspected homicide, suicide, 
        accidents, and/or suspicious deaths;
        4.  VA Police involved shootings;
        5.  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;
        9.  Incidents on VA property that result in serious illness or 
        bodily injury to include sexual assault, aggravated assault and 
        child abuse.

    d.  Nothing In this policy for reporting serious Incidents changes 
existing reporting requirements under 36 CFR 1.200'' 1.205 (Referrals 
of Information Regarding Criminal Violations).
    e.  In the event of an actual or alleged data breach, notify the 
information security officer, privacy officer, and supervisor, and 
follow other established procedures as provided by VA Handbooks 6500 
``Information Security Program,'' and 6500.2 ``Management of Security 
and Privacy Incidents.''

    3. RESPONSIBILITIES.

    a.  The Secretary of Veterans Affairs will ensure the development 
of policies and procedures for Serious Incident Reports.
    b.  Assistant Secretary for Operations, Security, and Preparedness

        1.  Ensures development of coordinated procedures, standardized 
        reports, forms and tools for Implementing polley In this 
        Directive In consultation with Under Secretaries, Assistant 
        Secretaries, and Other Key Officials;
        2.  Implements and maintains policies and procedures for SIRs;
        3.  Informs Administrations, Staff and Program Offices, of SIR 
        submissions;
        4.  Ensures the VA 10C receives, tracks, displays, distributes, 
        stores, and proactively collects additional data to produce 
        SIRs for VA senior leadership;
        5.  Ensures the VA roc gathers and analyzes data and develops 
        accurate reports.

    c.  Under Secretaries, Assistant Secretaries. and Other Key 
Officials

        1.  Supports the Office of Operations, Security, and 
        Preparedness in developing procedures for implementing policy 
        in this Directive;
        2.  Ensures that all relevant VA employees are aware of and 
        adhere to this policy;
        3.  Ensures standard operating procedures are developed In 
        support of VA SIR policies and procedures.
        4.  Ensures Field activities comply with SIR policies and 
        procedures.

                               __________

                                                         Memorandum

Department of Veterans Affairs


Date:                                                                                              July 7, 2011
From:                                      Deputy Under Secretary for Health for Operations and Management (10N)
Subj:                                      Actions Needed to Improve Reporting of Allegations of Sexual Assaults
To:                                                                                Network Directors (10N 1-23)



     1.  Background. On June 7, 2011, the Government Accountability 
Office (GAO) issued its report: VA HEALTH CARE: Actions Needed to 
Prevent Sexual Assaults and Other Safety Incidents, and provided 
recommendations to the Department of Veterans Affairs to improve both 
the reporting and monitoring of sexual assault incidents and the tools 
used to identify risks and address vulnerabilities at VA facilities.
     2.  The safety and security of all individuals on our campuses is 
paramount. A multidisciplinary team, the Safety and Security from 
Sexual Victimization Workgroup, has been established to address all of 
the recommendations in this report and will provide an action plan by 
July 15, 2011. To ensure we continue to provide a safe environment at 
our facilities, there are several actions we can undertake prior to the 
workgroup issuing its final recommendations--namely ensuring compliance 
with reporting allegations of sexual assaults.
     3.  To ensure accurate reporting, sexual assault is as defined by 
GAO and adopted by the VA's Safety and Assault Prevention Workgroup:

         ``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.''

     4.  You, and your subordinate managers, must ensure that all 
allegations of sexual assault on VA property (or off-property in the 
execution of official VA duties) involving a Veteran, VA employee, 
contractor, visitor, or volunteer are reported within 2 hours in 
accordance with the Serious Incident Reporting guidelines. If the 
incident occurs during an off-tour, the Administrative Officer of the 
Day will report the incident to the following email group [email protected] 
as a ``Heads Up'' (an alleged incident of sexual assault has occurred, 
more complete information to follow). Within 24 hours of reporting the 
incident, an Issue Brief (IB) will be sent to the Deputy Under 
Secretary for Health for Operations and Management through your 
Veterans Integrated Service Network Support Team.
     5.  The following elements should be included in the IB: date of 
incident; location of the incident; description of the incident; 
immediate actions taken; type of investigation the facility plans to 
conduct; any involvement or reporting to an outside law enforcement 
agency or health care organization.
     6.  Each VISN must submit a follow up issue brief to: provide 
details regarding additional actions taken by the facility to 
investigate the allegations; any actions taken by the facility, to 
include personnel actions; as a result of its investigation; legal 
disposition and whether the incident is substantiated; and any process 
improvements or policy changes being made to try to mitigate future 
events.
     7.  Information to be reported to the Office of the Inspector 
General 38 C. F. R. 1.203 (2010) [1.203 covers reporting to VA. Police] 
requires the following: Information about actual or possible violations 
of criminal laws related to VA programs, operations, facilities, or 
involving VA employees, where the violation of criminal law occurs on 
VA premises, will be reported by VA management officials to the VA 
police component with responsibility for the VA station or facility in 
question. If there is no VA police component with jurisdiction over the 
offense, the information will be reported to Federal, state or local 
law enforcement officials, as appropriate.
     8.  All criminal matters that involve felonies shall be reported 
to the Office of Inspector General (OIG) as required by regulation 38 
C. F. R. 1.204 (2010). The regulation requires all potential felonies 
including rape, aggravated assault and serious abuse of the patient to 
be reported to VA OIG for investigation. Hence all allegations of 
sexual assault will be reported to the OIG to enable them to determine 
which allegations rise to the level of a potential felony.
     9.  It is important for all sexual assaults to be reported up and 
through the VHA management chain starting with facility leadership to 
the VISN and to VACO in a timely manner. Parallel reporting to the OIG 
will occur where required.
    10.  Additional guidance regarding the reporting, tracking and 
monitoring of sexual assault activity will be provided as a result of 
the Workgroup's recommendations.

William Schoenhard, FACHE

                               __________

                                                         Memorandum

Department of Veterans Affairs


Date:                                                                                             June 10, 2011
From:                                      Deputy Under Secretary for Health for Operations and Management (10N)
Subj:                                                  Actions Needed to Improve Physical Security Requirements
To:                                                                                Network Directors (10N 1-23)



    1.  Background. On June 7, 2011, the Government Accountability 
Office (GAO) issued its report: VA HEALTH CARE: Actions Needed to 
Prevent Sexual Assaults and Other Safety Incidents, and provided 
recommendations to the Department of Veterans Affairs to improve both 
the reporting and monitoring of sexual assault incidents and the tools 
used to identify risks and address vulnerabilities at VA facilities. A 
multidisciplinary team, the Safety and Security from Sexual 
Victimization Workgroup, has been established to address all of the 
recommendations in this report and will provide an action plan by July 
15, 2011.
    2.  The safety and security of all individuals on our campuses is 
paramount. There are a few things that we can undertake immediately 
without waiting for the workgroup's recommendations, namely ensuring 
compliance with all existing safety and security policies and 
procedures.
    3.  A systematic environmental assessment must be undertaken now at 
all of our facilities to eliminate environmental factors that may 
contribute to physical security deficiencies. Per VA Handbook 0730/2, 
Security and Law Enforcement, Directors of VA field facilities are 
responsible for the physical security protection of persons on VA 
property and this memorandum provides additional information and 
standards to further enhance safety and security precautions.

        a.  Policy for Testing Alarm Systems. VHA recognizes and 
        acknowledges the importance of regularly testing physical 
        security systems. Therefore, it is expected that all VA 
        facilities should have established policies regarding the use 
        and testing of alarm systems to include panic alarms. These 
        policies should be specific to the unique circumstances at each 
        VAMC, but designed to comply with the stringent standards of 
        The Joint Commission (TJC). If a VAMC does not have a policy, 
        the VAMC must establish and implement a policy NLT 30 days 
        after date of this memo.
        b.  Testing and Preventative Maintenance. It is imperative that 
        testing and preventative maintenance of these systems be 
        conducted regularly in accordance with VAMC policies and 
        manufacturers' requirements for each system. VA Handbook 0730/2 
        sets forth detailed physical requirements for alarms for 
        specific functions at each VAMC based on the risks inherent in 
        a given area (e.g., pharmacy would be a higher risk area than 
        environmental services). The handbook further specifies that 
        the exact location of panic/duress alarm switches are to be 
        determined by physical security surveys of the protected area/
        s. Due to the variability in types of alarm systems based on 
        location and services offered, each Service in each VAMC must 
        have established and must enforce standard operating procedures 
        (SOP) for regular alarm testing based on industry and 
        manufacturer standards. At a minimum testing will be conducted 
        semi-annually with a systematic process for the documentation 
        of all alarm system testing.
        c.  Monitoring of Alarm Systems. Additionally, each VAMC must 
        have a 24/7 plan and implementation strategy for: VA Police 
        command and control centers to monitor alarms and surveillance 
        cameras; and Response capabilities for all alarm systems.
        d.  Summary of Requirements to Ensure Physical Security. To 
        summarize, every Network Director is responsible for ensuring 
        that each VAMC has a physical security assessment plan that 
        includes:

           Policies for use and testing of alarm systems, 
        including panic alarms;
           Regular testing of these alarms systems, including 
        panic alarms;
           Documentation of testing:

             A plan and implementation strategy for VA Police 
        command and control centers to monitor alarms and surveillance 
        cameras; and

           A plan and implementation strategy for 24f7 response 
        capabilities and preventative maintenance.

    4.  Every Network Directors must document and submit the attached 
attestation that each VAMC has been reviewed for compliance, the VISN 
is compliant with all physical security policies, and an action plan 
and timeline have been developed to implement a physical assessment 
plan to ensure adequate security controls. Network Directors will send 
the completed attestations with supporting documentation to Deesha 
Brown no later than 2pm (EST) on June 24, 2011. If you have any 
questions, please contact Deesha Brown, Executive Assistant to the 
DUSHOM, at [email protected] or (202) 461-6945 or Michael Moreland, 
Network Director VISN 4, in his capacity as the Chair of the 
Environment of Care subgroup of the Safety and Security from Sexual 
Victimization Workgroup, at [email protected] or (412) 822-3316.
    5.  Additional guidance may be forthcoming as a result of the 
analysis of the VISN's environmental assessments and will be provided 
as a result of the Workgroup's recommendations.

William Schoenhard, FACHE
Attachment: (2)

                                 
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