U.S. Government Accountability Office (GAO) on Veteran's Administration (VA) Health Care: Actions Needed to Prevent Sexual Assaults and Other Safety Incidents
The U.S. Government Accountability Office ("GAO") issued the June 7, 2011 report (GAO-11-530) on "Veterans' Administration Health Care: Actions Needed to Prevent Sexual Assaults and Other Safety Incidents." To read the full report, click on the hyperlinks below.
Highlights Page (PDF) Full Report (PDF, 78 pages) Accessible Text Recommendations (HTML)
Summary
Changes in patient demographics present unique challenges for the Veterans' Administration in providing safe environments for all veterans treated in Department of Veterans Affairs ("VA") facilities.
The GAO was asked to examine whether or not sexual assault incidents are fully reported and what factors may contribute to any observed underreporting, how facility staff determine sexual assault-related risks veterans may pose in residential and inpatient mental health settings and precautions facilities take to prevent sexual assaults and other safety incidents.
The GAO reviewed relevant laws, VA policies and sexual assault incident documentation from January 2007 through July 2010 provided by VA officials and the VA Office of the Inspector General ("OIG"). In addition, the GAO visited and reviewed portions of selected veterans' medical records at five judgmentally selected VA medical facilities chosen to ensure the residential and inpatient mental health units at the facilities varied in size and complexity. Finally, the GAO spoke with the four Veterans Integrated Service Networks ("VISN") that oversee these VA medical facilities.
The GAO found that many of the nearly 300 sexual assault incidents reported to the VA police were not reported to VA leadership officials and the VA OIG. Specifically, for the four VISNs the GAO spoke with, VISN and VA Central Office officials did not receive reports of most sexual assault incidents reported to the VA police. Also, nearly two-thirds of sexual assault incidents involving rape allegations originating in VA facilities were not reported to the VA OIG, as required by VA regulation.
In addition, the GAO identified several factors that may contribute to the underreporting of sexual assault incidents including unclear guidance and deficiencies in VA's oversight. The VA does not have risk assessment tools designed to examine sexual assaultrelated risks veterans may pose. Instead, VA staff at the residential programs and inpatient mental health units GAO visited said they examine information about veterans' legal histories along with other personal information as part of a multidisciplinary assessment process.
VA clinicians reported that they obtain legal history information directly from veterans, but these self-reported data are not always complete or accurate. In reviewing selected veterans' medical records, the GAO found that complete legal history information was not always documented.
In addition, VA has not provided clear guidance on how such legal history information should be collected or documented. VA facilities that the GAO visited used a variety of precautions intended to prevent sexual assaults and other safety incidents; however, the GAO found some of these measures were deficient, compromising facilities' efforts to prevent sexual assaults and other safety incidents. For example, facilities often used patientoriented precautions, such as placing electronic flags on high-risk veterans' medical records or increasing staff observation of veterans who posed risks to others.
These VA facilities also used physical security precautions--such as closed-circuit surveillance cameras to actively monitor units, locks and alarms to secure key areas, and police assistance when incidents occurred. These physical precautions were intended to prevent a broad range of safety incidents, including sexual assaults, through monitoring patients and activities, securing residential programs and inpatient mental health units, and educating staff about security issues and ways to deal with them.
However, the GAO found significant weaknesses in the implementation of these physical security precautions at these VA facilities, including poor monitoring of surveillance cameras, alarm system malfunctions, and the failure of alarms to alert both VA police and clinical staff when triggered.
Inadequate system installation and testing procedures contributed to these weaknesses. Further, facility officials at most of the locations the GAO visited said the VA police were understaffed. Such weaknesses could lead to delayed response times to incidents and seriously erode efforts to prevent or mitigate sexual assaults and other safety incidents.
The GAO recommends that VA improve both the reporting and monitoring of sexual assault incidents and the tools used to identify risks and address vulnerabilities at VA facilities. VA concurred with the GAO's recommendations and provided an action plan to address them.
For more information about a Miami-Dade, Broward and Palm Beach County home health care agency for seniors and other family members, contact Brian Gauthier at A Family Member HomeCare (954) 986-5090 or www.afamilymemberhomecare.com. Serving Coconut Creek Cooper City Coral Springs Dania Beach Davie Deerfield Beach Fort Lauderdale Hallandale Beach, Hillsboro Beach Hollywood Lauderdale Lakes Lauderdale-by-the-Sea Lauderhill Lazy Lake Lighthouse Point Margate Miramar North Lauderdale Oakland Park Parkland Pembroke Park Pembroke Pines Plantation Pompano Beach Sea Ranch Lakes Southwest Ranches Sunrise Tamarac Weston Wilton Manors Aventura Sunny Isles Beach Hialeah Miami Lakes Boca Raton Delray Beach
Highlights Page (PDF) Full Report (PDF, 78 pages) Accessible Text Recommendations (HTML)
Summary
Changes in patient demographics present unique challenges for the Veterans' Administration in providing safe environments for all veterans treated in Department of Veterans Affairs ("VA") facilities.
The GAO was asked to examine whether or not sexual assault incidents are fully reported and what factors may contribute to any observed underreporting, how facility staff determine sexual assault-related risks veterans may pose in residential and inpatient mental health settings and precautions facilities take to prevent sexual assaults and other safety incidents.
The GAO reviewed relevant laws, VA policies and sexual assault incident documentation from January 2007 through July 2010 provided by VA officials and the VA Office of the Inspector General ("OIG"). In addition, the GAO visited and reviewed portions of selected veterans' medical records at five judgmentally selected VA medical facilities chosen to ensure the residential and inpatient mental health units at the facilities varied in size and complexity. Finally, the GAO spoke with the four Veterans Integrated Service Networks ("VISN") that oversee these VA medical facilities.
The GAO found that many of the nearly 300 sexual assault incidents reported to the VA police were not reported to VA leadership officials and the VA OIG. Specifically, for the four VISNs the GAO spoke with, VISN and VA Central Office officials did not receive reports of most sexual assault incidents reported to the VA police. Also, nearly two-thirds of sexual assault incidents involving rape allegations originating in VA facilities were not reported to the VA OIG, as required by VA regulation.
In addition, the GAO identified several factors that may contribute to the underreporting of sexual assault incidents including unclear guidance and deficiencies in VA's oversight. The VA does not have risk assessment tools designed to examine sexual assaultrelated risks veterans may pose. Instead, VA staff at the residential programs and inpatient mental health units GAO visited said they examine information about veterans' legal histories along with other personal information as part of a multidisciplinary assessment process.
VA clinicians reported that they obtain legal history information directly from veterans, but these self-reported data are not always complete or accurate. In reviewing selected veterans' medical records, the GAO found that complete legal history information was not always documented.
In addition, VA has not provided clear guidance on how such legal history information should be collected or documented. VA facilities that the GAO visited used a variety of precautions intended to prevent sexual assaults and other safety incidents; however, the GAO found some of these measures were deficient, compromising facilities' efforts to prevent sexual assaults and other safety incidents. For example, facilities often used patientoriented precautions, such as placing electronic flags on high-risk veterans' medical records or increasing staff observation of veterans who posed risks to others.
These VA facilities also used physical security precautions--such as closed-circuit surveillance cameras to actively monitor units, locks and alarms to secure key areas, and police assistance when incidents occurred. These physical precautions were intended to prevent a broad range of safety incidents, including sexual assaults, through monitoring patients and activities, securing residential programs and inpatient mental health units, and educating staff about security issues and ways to deal with them.
However, the GAO found significant weaknesses in the implementation of these physical security precautions at these VA facilities, including poor monitoring of surveillance cameras, alarm system malfunctions, and the failure of alarms to alert both VA police and clinical staff when triggered.
Inadequate system installation and testing procedures contributed to these weaknesses. Further, facility officials at most of the locations the GAO visited said the VA police were understaffed. Such weaknesses could lead to delayed response times to incidents and seriously erode efforts to prevent or mitigate sexual assaults and other safety incidents.
The GAO recommends that VA improve both the reporting and monitoring of sexual assault incidents and the tools used to identify risks and address vulnerabilities at VA facilities. VA concurred with the GAO's recommendations and provided an action plan to address them.
For more information about a Miami-Dade, Broward and Palm Beach County home health care agency for seniors and other family members, contact Brian Gauthier at A Family Member HomeCare (954) 986-5090 or www.afamilymemberhomecare.com. Serving Coconut Creek Cooper City Coral Springs Dania Beach Davie Deerfield Beach Fort Lauderdale Hallandale Beach, Hillsboro Beach Hollywood Lauderdale Lakes Lauderdale-by-the-Sea Lauderhill Lazy Lake Lighthouse Point Margate Miramar North Lauderdale Oakland Park Parkland Pembroke Park Pembroke Pines Plantation Pompano Beach Sea Ranch Lakes Southwest Ranches Sunrise Tamarac Weston Wilton Manors Aventura Sunny Isles Beach Hialeah Miami Lakes Boca Raton Delray Beach
0 comments:
Post a Comment