[House Hearing, 116 Congress] [From the U.S. Government Publishing Office] EXAMINING VA'S POLICE FORCE ======================================================================= HEARING BEFORE THE SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS OF THE COMMITTEE ON VETERANS' AFFAIRS U.S. HOUSE OF REPRESENTATIVES ONE HUNDRED SIXTEENTH CONGRESS FIRST SESSION __________ TUESDAY, JUNE 11, 2019 __________ Serial No. 116-16 __________ Printed for the use of the Committee on Veterans' Affairs [GRAPHIC NOT AVAILABLE IN TIFF FORMAT] Available via the World Wide Web: http://www.govinfo.gov __________ U.S. GOVERNMENT PUBLISHING OFFICE 40-765 WASHINGTON : 2021 -------------------------------------------------------------------------------------- COMMITTEE ON VETERANS' AFFAIRS MARK TAKANO, California, Chairman JULIA BROWNLEY, California DAVID P. ROE, Tenessee, Ranking KATHLEEN M. RICE, New York Member CONOR LAMB, Pennsylvania, Vice- GUS M. BILIRAKIS, Florida Chairman AUMUA AMATA COLEMAN RADEWAGEN, MIKE LEVIN, California American Samoa MAX ROSE, New York MIKE BOST, Illinois CHRIS PAPPAS, New Hampshire NEAL P. DUNN, Florida ELAINE G. LURIA, Virginia JACK BERGMAN, Michigan SUSIE LEE, Nevada JIM BANKS, Indiana JOE CUNNINGHAM, South Carolina ANDY BARR, Kentucky GILBERT RAY CISNEROS, JR., DANIEL MEUSER, Pennsylvania California STEVE WATKINS, Kansas COLLIN C. PETERSON, Minnesota CHIP ROY, Texas GREGORIO KILILI CAMACHO SABLAN, W. GREGORY STEUBE, Florida Northern Mariana Islands COLIN Z. ALLRED, Texas LAUREN UNDERWOOD, Illinois ANTHONY BRINDISI, New York Ray Kelley, Democratic Staff Director Jon Towers, Republican Staff Director SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS CHRIS PAPPAS, New Hampshire, Chairman KATHLEEN M. RICE, New York JACK BERGMAN, Michigan, Ranking MAX ROSE, New York Member GILBERT RAY CISNEROS, JR., AUMUA AMATA COLEMAN RADEWAGEN, California American Samoa COLLIN C. PETERSON, Minnesota MIKE BOST, Illinois CHIP ROY, Texas 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 ---------- Tuesday, June 11, 2019 Page Examining VA's Police Force...................................... 1 OPENING STATEMENTS Honorable Chris Pappas, Chairman................................. 1 Honorable Jack Bergman, Ranking Member........................... 2 WITNESSES Mr. Michael Missal, Inspector General, U.S. Department of Veterans Affairs............................................... 4 Prepared Statement........................................... 27 Ms. Renee Oshinski, Acting Deputy Under Secretary for Health for Operations and Management, Veterans Health Administration, U.S. Department of Veterans Affairs................................. 5 Prepared Statement........................................... 31 Accompanied by: Mr. Kevin T. Hanretta, Principal Deputy Assistant Secretary for Operations, Security, and Preparedness, U.S. Department of Veterans Affairs Mr. Frederick Jackson, Director, Office of Security & Law Enforcement, U.S. Department of Veterans Affairs STATEMENTS FOR THE RECORD American Federation Of Government Employees, AFL-CIO (AFGE)...... 34 Letter from AFGE Law Enforcement Committee....................... 36 Jean Telfort..................................................... 37 EXAMINING VA'S POLICE FORCE ---------- Tuesday, June 11, 2019 Committee on Veterans' Affairs, U. S. House of Representatives, Washington, D.C. The Subcommittee met, pursuant to notice, at 10:04 a.m., in Room 210, House Visitors Center, Hon. Chris Pappas [Chairman of the Subcommittee] presiding. Present: Representatives Pappas, Rice, Rose, Cisneros, and Bergman. Also Present: Representative Moulton and Representative Mast. OPENING STATEMENT OF CHRIS PAPPAS, CHAIRMAN Mr. Pappas. Today's hearing will come to order. Today's hearing of the Oversight and Investigation Subcommittee is entitled, ``Examining VA's Police Force.'' The Subcommittee will examine the policies, operations, and management of the Department of Veterans Affairs Police Force. A major focus of the hearing is a recent Office of Inspector General report. The Department's Police Force has a vital mission. VA Police protect the veterans, staff, visitors, and property at VA facilities. More than 4,000 police not only respond to crime and keep the peace across more than 150 VA facilities, they do this in a health care setting, which adds to both the importance and complexity of the police mission. A police officer may be the first VA employee they see as they enter the facility, and officers are interacting continually with veterans who are awaiting medical treatments or arranging for follow-up care. And the VA Police often encounter veterans sitting alone on a bench on the grounds or in the parking lot. I think it is correct to say the VA Police are the part of the health care mission of the Department. The tragedy of veteran's suicide underscores the importance of our VA Police Officers and their work. Since the beginning of the year, seven veterans have committed suicide within the Department of Veterans Affairs facilities. VA Police are often the first to encounter veterans during an attempt and are part of the response team. The importance of VA Police duties and responsibilities means that we can and should find ways to improve their operations. In December, the Inspector General released a report examining VA Police. Central to the findings were serious problems with the governance structure. To put it more simply, the Inspector General asked the question, who is in charge? I was surprised to read in the IG report that the answer is actually pretty complicated. Each VA hospital administrator is in charge of its own small police force of a couple dozen officers. Each hospital administrator determines the number of police and level of resources, and is responsible for implementing policies about security, use of force, and hiring and firing for officers. Meanwhile, two separate offices at the VA headquarters establishes policies and handles oversight. That is why at today's hearing we have multiple people from VA headquarters. The Inspector General report was clear in finding that, quote, ``VA did not have adequate and coordinated governance over its police program to ensure effective management and oversight.'' It found, quote, ``confusion about police program roles and authority.'' The IG made several important recommendations to clarify leadership and address some critical problems; however, I understand the IG recommendations have not yet been implemented, nor have we seen new police policies from headquarters. In addition, there are workforce-related concerns, including questions as to whether VA Police have adequate staffing resources, including a very high vacancy rate. According to the IG, 40 percent of VA medical facilities have a vacancy rate among police of 20 percent or higher. The Subcommittee has also heard of other concerns, including how VA handles allegations involving inappropriate use of force and potential violations of veterans' civil rights. We are here today to find solutions and learn how the Department will address the challenges faced by VA Police. I look forward to the testimony of today's witnesses. And, with that, I would like to recognize Ranking Member Bergman for 5 minutes for any opening remarks he may wish to make. OPENING STATEMENT OF JACK BERGMAN, RANKING MEMBER Mr. Bergman. Thank you, Mr. Chairman. Comprised of nearly 4200 Federal law enforcement officers, the Department of Veterans Affairs Police maintain physical security at VA facilities, and ensure patient, visitor, and employee safety. According to the Office of Inspector General, VA's police force is one of the top ten largest law enforcement organizations in the Federal Government. Running such a large, decentralized entity requires clear lines of authority and vigilant oversight. In its December 2018 report, the Office of Inspector General found several areas of concern within the VA Police program, many of which stem from the fact that Veterans Health Administration and the Office of Security and Law Enforcement are jointly responsible for different aspects of the police program. OSLE is part of the VA's Central Office under the auspices of the Assistant Secretary for Human Resources and Administration. OSLE writes the police policies, trains the officers, investigates criminal incidents at VA facilities, and inspects local medical center police units for compliance. However, badged officers do not report to OSLE; rather, they report to the medical center's chief of police, who reports to the facility director, who in turn reports to the VISN director, who in turn reports to the Deputy Under Secretary for Health for Operations and Management. This is, this is Bureaucracy 101. A large government agency with two separate governing offices, which, as OIG found, creates confusion regarding program roles and office authorities. This makes it difficult for VA to effectively monitor its police force, identify trends, and quickly react to issues. For example, OIG found that OSLE did not timely inspect 103 of the 139 medical centers, or 74 percent, that have VA police units due to a shortage of inspectors. This means that facility police departments lost timely feedback, which is critical for process improvement. Moreover, on top of the delayed inspections, the policies for which the inspectors were evaluating police unit compliance are often outdated and in need of revision. I understand that VA is addressing OIG's recommendations, so I would like assurance that VA has a sense of urgency in addressing its shortcomings and to get a better sense of whether VA is taking appropriate action. To that end, I would like to hear Mr. Missal's assessment of whether VA is on track to close out OIG's recommendations by the end of 2019 and what, if any, barriers exist to doing so. From VA, I want to hear specifics. It is not enough to say that VA is looking into the matter, I would like to know specifically what VA is doing to address OIG's recommendations. Is VA considering a reorganization of the police service? If so, I want to know who is overseeing that review, what options VA is considering, and what is the timeline for the review. Also, at nearly every hearing we identify a deficiency that ties back to human resources; this hearing is no exception. The VA's police force has nearly 700 vacancies, that is approximately 17 percent of the force. In fact, according to OIG, one facility had a vacancy rate of nearly 45 percent. From VHA, I want to hear specifics concerning what it is doing to improve officer recruitment and retention. I understand that VA is working on addressing career opportunities and pay, but VA has had recruitment and retention authorities available to it under existing law, so how did the police service get to its current state? Can VA document that the current recruitment and retention authorities are insufficient? Was it a lack of oversight or was it simply not a priority for medical center directors? From OSLE, for example, I want to know who is accountable for developing the police officer staffing model, a project that has been ongoing since 2016, and when will the model be rolled out to all facilities. In the end, we all want VA to provide patients, visitors, and employees with safe environments. To the VA Police officer standing post, thank you for your vigilance. I hope that this hearing shines needed light on the program and spurs VA to address the identified deficiencies. With that, Mr. Chairman, I yield back. Mr. Pappas. Thank you, General Bergman. I will now recognize our first witness, Mr. Michael Missal, Inspector General of the Department of Veterans Affairs. Mr. Missal was confirmed by the Senate in his role in 2016. He has had previous experience in both the private sector and at other government agencies, including the Securities and Exchange Commission. The Office of Inspector General conducts investigations, audits, evaluations, and inspections of VA programs to eliminate waste and fraud, as well as to detect and prevent criminal activity. The Subcommittee thanks you for appearing today, Mr. Missal. You have 5 minutes. STATEMENT OF MICHAEL MISSAL Mr. Missal. Thank you. Chairman Pappas, Ranking Member Bergman, and Members of the Subcommittee, I appreciate the opportunity to discuss the Office of Inspector General's oversight of the Department of Veterans Affairs Police program. I would like to highlight the findings from our December 2018 report, ``Inadequate Governance of the VA Police Program at Medical Facilities.'' The focus of this audit was to determine whether the VA Police program has an effective governance structure in place, meets requirements for size and qualifications, and conducts adequate inspections to ensure compliance with policies and procedures. Having an effective governance structure is critically important to the functioning of any organization. We felt this audit was particularly significant as the governance and staffing of the VA Police impacts the safety of veterans and their families, VA personnel, and visitors to VA facilities. VA Police officers provide security and law enforcement services at VHA facilities, as well as Veterans Benefits Administration offices co-located with VHA facilities and some VA National Cemeteries. They are authorized to carry firearms in an official capacity, investigate criminal activity, and arrest individuals on Department property for offenses committed within VA's jurisdiction and consistent with other law enforcement agency agreements. VA's police force consists of approximately 4,000 officers at 139 of the 141 VA medical centers, which places it among the ten largest law enforcement workforces in the Federal Government. Responsibility for the police program is shared between VHA and the VA Office of Operations, Security, and Preparedness. On September 14th, 2018, VA Secretary Robert Wilkie reassigned OSP to the Assistant Secretary for Human Resources and Administration, and the position of Assistant Secretary for OSP was eliminated. Our audit found that VA did not have adequate and coordinated governance over its police program to ensure effective management and oversight for its police officer workforce nationwide. We determined that the governance problems occurred and persisted in part because of confusion about police program roles and authority between VHA and OSP. Governance issues also resulted from a lack of centralized management or clearly designated staff within VHA to manage and oversee the police program. Our audit made four general findings. First, VHA and the Office of Security and Law Enforcement, which is part of OSP, did not track and assess police program operations and performance in a systemic and effective manner. Second, VA lacked facility-appropriate police officer staffing models and had extensive shortages of VA Police officers. Third, there was not timely inspections of police operations at VA medical centers. As of September 30th, 2017, 103 of the 139 VA medical facilities with police units were not timely inspected. And, fourth, VA Police officers lacked guidance on investigating any misconduct of facility leaders who manage the police program or control its resources. We made five recommendations to the VA Deputy Secretary that focused on the areas of governance, staffing, the inspection program, and processes. VA concurred with all and the recommendations remain open today. Given the issues we identified in this audit, we started additional audit work on information management within the police program. This work is focused on whether the VA Police program's information management strategy and systems provide its leader and workforce with the information needed to manage and guide operational performance. Mr. Chairman, this concludes my statement. I am happy to answer any questions that you or other Members of the Subcommittee may have. [The prepared statement of Michael Missal appears in the Appendix] Mr. Pappas. Thank you, Mr. Missal. I will now recognize our second witness, Ms. Renee Oshinski, Acting Deputy Under Secretary for Health for Operations and Management of the Veterans Health Administration. Ms. Oshinski has been serving in this role on an acting basis for about 6 months, having previously served as the network director for VISN 12 since December of 2016. Ms. Oshinski will provide testimony for all three of our Department of Veterans Affairs witnesses, including Mr. Kevin Hanretta, Principal Deputy Assistant Secretary for Operations, Security, and Preparedness. We have as well Mr. Frederick Jackson, Director of the Office of Security and Law Enforcement. However, all of the VA witnesses appearing today will respond to questions. The Subcommittee thanks you all for appearing today. Ms. Oshinski, you have 5 minutes. STATEMENT OF RENEE OSHINSKI Ms. Oshinski. Thank you. Good morning, Chairman Pappas, Ranking Member Bergman, and Members of the Subcommittee. Thank you for the opportunity to discuss the Department of Veterans Affairs' current and future policing strategy. I am accompanied today by Kevin Hanretta, the Principal Deputy Assistant Secretary for Operations, Security, and Preparedness, and Frederick Jackson, the Executive Director for the Office of Security and Law Enforcement. VA Police Officers are Federal law enforcement officers who serve critical roles in securing facilities and protecting patients, visitors, employees, and VA property. They provide security and law enforcement services at VHA and VBA offices that are co-located with VHA facilities. The officers sometimes provide security for national cemeteries. VA Police are one of our most important ambassadors, because they work to resolve incidents across a variety of settings in a humane and respectful manner. Ensuring physical security for VA medical centers can be complicated, as VA must balance safety and security, while providing an open and welcoming health care environment. Collaboration between law enforcement and health care professionals is crucial when responding to violent incidents or police calls for service in the field. To address security issues, VA medical centers have implemented panic buttons, limited guest hours, increased police presence, installed security cameras, enhanced emergency preparedness, and more. Physical security and vulnerability assessments are done at each medical center to identify unique risks, because what works at a rural facility may not apply at an urban facility. The Office of Security and Law Enforcement, OSLE, is responsible for implementing an effective security program within VA by ensuring officers apply 21st century police techniques in the line of duty. Special agents and inspectors within OSLE have responsibility to provide direct technical support to VA police chiefs and facility management within their designated areas. These special agents and inspectors are in regular contact with their respective police chiefs. The VA Police officers' methods of law enforcement are unique because our work is conducted in a health care setting. We serve a population of trained military veterans suffering from a variety of medical and psychological traumas. Due to this environment, all VA Police officers receive specialized training at the VA Law Enforcement Training Center, the LETC. The LETC is located in Little Rock, Arkansas, and is accredited by the Federal Law Enforcement Training Accreditation Board. It is recognized as meeting the highest standards in Federal law enforcement training. It is the sole Federal Government provider of a training program that emphasizes the use of nonphysical techniques. All VA Police officers go through a 10-week basic course at the LETC. They receive 30 hours of training specific to de- escalation and conflict management, with a special focus on awareness of suicide and its prevention. Officers also complete nearly 24 hours of de-escalation training where they learn skills to effect positive outcomes in real-life scenarios. VA appreciates the reviews done by both the Office of the Inspector General and the Government Accountability Office, as they have led to strengthening of our current VA Police service. In response to these reviews, in November of 2018, VHA enhanced our governance structure by hiring a Senior Security Officer. In February of 2019, the VHA Executive in Charge directed each network to detail a full-time FTE to serve as the VISN police chief. Over the last 4 months, these VISN chiefs have worked to close gaps in inspection results, implement systemic process improvements, promote retention and hiring and growth strategies, and mitigate physical security vulnerabilities. They have been a welcomed asset to the field. VA is looking at ways to improve the governance structure at the department level to ensure better accountability, the proper application of policy, and allow for rapid deployment of assets. They have expanded oversight to include developing a new chief orientation guide; developing a training program for hospital leaders who oversee police services; developing a national mitigation strategy for inspections and physical security vulnerabilities; and enhancing communication and reporting of critical incidents through our leadership structure. We look forward to this opportunity to improve our security operations and keeping our Nation's veterans safe, while providing the top-quality care they have earned. Chairman Pappas, we appreciate the Subcommittee's continued support and encouragement in identifying and resolving challenges as we find new ways to care for veterans. This concludes my testimony. My colleagues and I are prepared to respond to any questions you might have. [The prepared statement of Renee Oshinski appears in the Appendix] Mr. Pappas. Well, thank you, Ms. Oshinski. Thank you to each of our witnesses for appearing here today. I would now like to open the questioning portion of this Subcommittee meeting, and I will begin by recognizing myself for 5 minutes. I would like to return to a question that was posed in the IG report and that is this: who is in charge? This is a critical concern that I think we need to unpack here this morning. So, Mr. Missal, I want to first go to you. I recognize that the Deputy Under Secretary described several improvements that the VA is making to help address the concerns that you have raised, I am wondering how close this gets to addressing the concerns and will the improvements that she described here this morning be enough to satisfy your office? Mr. Missal. We have not yet had an opportunity to formally assess them. One of our recommendations is for VA to do an assessment of their governance. We are not here, since we are not here to make management recommendations, we will not suggest which way they should go. We just found deficiencies in the current format, including how it was implemented. So what we are trying to do here is to get a sense from them of what they think works best for them. Mr. Pappas. Okay. And so to the VA witnesses here today, I am wondering if you have a specific timetable to address the governance concerns that were raised in the IG report. Ms. Oshinski. We are working on a number of areas that were identified as deficiencies in the OIG report and, as I said, we really appreciate this opportunity to discuss where we are moving. We are looking at a variety of improving our staffing models and that is scheduled to be completed by the end of September. So we would have a better idea of whether or not our current staffing model needs to be improved. We are also looking at a whole variety of issues, making sure that we have the correct position descriptions and we will have an appropriate career ladder. One of the issues that we have had is it is hard to retain individuals without having that. These are all pieces of what I think is the governance structure that we need to put in place. The Secretary is looking at all the actions that we are taking, and will be evaluating and making a determination as to where we move forward in the future. Mr. Pappas. Earlier this year at a Committee hearing I asked Dr. Stone, head of the Veterans Health Administration, about this specific issue, and he indicated that a new VA Police policy is in the works. I am wondering if you could comment on the scope of a new policy that might be coming forward, recognizing it may not yet be complete, but I am curious when we might see further details on that. Ms. Oshinski. My sense would be--again, I believe we are trying to put together all the pieces, trying to address all the things that the IG identified as deficiencies, putting those together and bringing it forward to the Secretary and the Deputy Secretary to look at where we need to move. So I am not certain exactly when that will be completed, but we do have a number of pieces that will be finalized by the end of the calendar year. Mr. Pappas. So the steps you indicated that the Department is taking in your testimony, those are just a few of the improvements you are looking to make and, if I am just building off of what you just said, we would expect to see a more comprehensive, formal package at some point in the near future? Ms. Oshinski. Yes, I certainly believe that that is true. We are working--and not believe, I know that is true--we are working on a whole host of issues on what can we do to improve both our police presence and the governance of those police. One of the last things that any one of us want is confusion at a medical center when there is an issue. I mean, we all want to know what the chain of command is, because that is the way to a successful resolution of any incident. So, if there is confusion, we need to correct that. Mr. Pappas. Well, thank you. One last question before my time is up. I want to address the issue of inspections and the IG report discovered that 74 percent of VA medical facilities with police units weren't inspected in a timely manner, and I understand that the VA's Office of Security and Law Enforcement recently hired additional inspectors. Ms. Oshinski, what progress has the VA made in the backlog of police unit inspections and what trends are you beginning to see in the overall assessments that have been performed? Ms. Oshinski. One of the things, a major impact is hiring additional staff to complete the inspections. I probably will hand this over to Mr. Jackson and Mr. Hanretta to give specifics, but right now we are looking at, we hired ten additional staff in OSLE, and they are moving forward and keeping up with the current schedule. So, Mr. Jackson, can I turn it to you? Mr. Jackson. Yes, sir. In the IG report, it mentioned the shortages of the agents that were going out to conduct inspections. Since as of March of 2019 now, the ten bodies that we had requested are now all on board. Right now we had scheduled 88 inspections for this year, we are on the glide path to get all of those complete. And so we were thankful for the number of people. As we continue to move forward, we will continue to look at those additional resources that may be needed to continue to keep that momentum in the right direction. Mr. Pappas. Well, thank you. I would like to follow up on this a little bit later maybe in round 2, my time is up right now, but I appreciate your response. In lieu of Ranking Member Bergman having his 5 minutes of questioning, he would like to defer to Mr. Mast of Florida, who is joining us here today. Welcome. Our colleague Mr. Mast of Florida has asked to participate in today's Subcommittee hearing, and I would like to request unanimous consent to allow him to join us on the dais. If there are no objections, I now recognize him for 5 minutes. Mr. Mast. Thank you. Thank you for deferring as well. I appreciate, you know, getting me up to the front, you didn't have to do that. Thank you. Listen, this is an important issue to me. In a span of about 10 days back in February, we had both a shooting in the ER of our West Palm Beach VA medical center and a suicide. This is something that I believe at the same hearing you were speaking about before, a budget hearing, you spoke to Secretary Wilkie about this issue, and he said, to quote him, ``As a result of what happened at Palm Beach, we have a new security protocol in place that will apply to the entire country. We have undergone''--have undergone, we have already done it, we have undergone--``a complete review of our security protocols''--not we are going to undertake this--``We have undergone a complete review of our security protocols. What happened at Palm Beach with the wounding of three medical professionals has led us to revamp the entire way we do security,'' because I will tell you that the method that was used there was entirely unexpected. I find it hard to believe that somebody pulling a firearm out of a scooter is an entirely creative attack, it is not that creative. I am worried that that is unexpected when we look at how we assess threat. But in that, I would like you to tell us, Ms. Oshinski, what has been revamped for the entire country in the way that we do security? Ms. Oshinski. Any time there is a serious event at any one of our medical centers, we look in depth at what occurred and try to make improvements, because the last thing any of us want is to repeat a mistake that leads to another serious incident. So in this case I think there are a number of things that occurred. One thing is we are asking at all sites that when people come[KKJ1] to the emergency department in a wheelchair or some other of their own vehicle they be put in a wheelchair that is owned by the medical center. So that is one way. It is very difficult, I think, when you have somebody who is handicapped, we need to make sure that they are in our owned equipment. So that is one thing that happened. I mean-- Mr. Mast. So, to pause, you are saying that now at West Palm Beach VA, if you showed up in a scooter or your own wheelchair, you are going to be transferred into a VA-owned wheelchair? Ms. Oshinski. Correct. Mr. Mast. Is that occurring as we speak? Ms. Oshinski. That is what the police are telling me, yes. Mr. Mast. Interesting. Please continue. Ms. Oshinski. Yes. Another thing that is again at West Palm Beach, sometimes we find that there are concerns that we missed in the vulnerability assessment. So, for example, we are undergoing a construction project at West Palm Beach, because we need to make sure that we have adequate coverage by cameras and that is happening, another thing. We are also doing more extensive rounding in our parking lots. West Palm Beach is not the only place where that needed to happen. We need to reiterate with everyone that part of our responsibility is making sure that the parking facilities where veterans are coming in are patrolled. So another part of what we are doing as a result of what happened at West Palm Beach. Mr. Mast. So let me pause on the patrol there. In the same week, I went to both the West Palm Beach VA and the Orlando VA. You drive to the Orlando VA, they are checking for IDs prior to driving on the campus, albeit I only had to hold any ID up in my window, I didn't have to actually roll down my window; nobody read it, nobody looked at it. I could have been anybody, but they did at least ask that I hold an ID up in my window. I think there is some hole in there. West Palm Beach VA, you drive directly onto the campus. Obviously, just between two VAs, there is a little bit of disconnect between what is going on with security. They say, if you have seen one VA, you have seen one VA, and there is a lot of truth in that. So, to ask a couple specific questions on my local VA, West Palm Beach. One, will there be checking of IDs as people enter the campus? And, two, are people's IDs supposed to be checked as they actually enter the hospital? And I ask this because I am constantly getting photos and reports from my veterans going in and out of the VA often saying, there is nobody at the front door, there is nobody checking IDs or sometimes there are. What is the standard of what is actually supposed to occur there and is it being enforced? And when you talk about needing more agents to go out there to conduct inspections, what about the VA director that is actually in charge of the facility being responsible for their facility? Ms. Oshinski. On a variety of fronts, yes, we should be checking an ID, and I am told that that is now happening at West Palm Beach. So I will verify that and get back to you to make sure that is happening, whether it is at that-- Mr. Mast. Your standard is, somebody enters the hospital, their ID should be checked? Ms. Oshinski. That is what I am going to verify-- Mr. Mast. Thank you. Ms. Oshinski [continued]. --yes, but that is my understanding of one of the things that was to occur as a result of the incident. And I completely agree with you, one of the reasons we want to do this review of what should be adequate staffing based on risks, one of the areas that we are continuing to look at and I think recognizing with what we had heard from GAO and the OIG, that our vulnerability assessments need to be improved at our sites. We will be in the process of doing that and, obviously, one of the things that we will consider as we--moving West Palm Beach high into that implementation period. Mr. Mast. Thank you for the time, Mr. Chairman. Mr. Pappas. Thank you. I now recognize Miss Rice for 5 minutes. Miss Rice. Thank you very much, Mr. Chairman. I would like to just tell the story of one of my constituents, because I think that it really illustrates a lot of the issues that we are talking about here today. His name is Jean Telfort and he served 10 years in active duty, during which time he was deployed to Afghanistan. At the time of his separation from active duty, he was determined to have a 100- percent service-connected disability, on top of being diagnosed with PTSD. In November of 2017, he required spine surgery because of an injury that was related to his service, and that surgery was meant to prevent him from becoming--losing--suffering paralysis, long-term paralysis. After the surgery, he was told he was going to need physical therapy and occupational therapy, and the VA told him that he could get that in a community-based facility outside of the VA in his community, near his community where he lived, and for a number of months that is where he went to get his physical therapy and his occupational therapy. At one point, and I have yet to be able to discover why this happened, the VA told him you are no longer eligible for Choice and care in the community, and you have got to come back to a VA facility that was in East Meadow--near him, but still it was a VA facility. He went to the VA facility to continue his PT and his OT and, when he got there, he was told that they don't have that kind of treatment that they could give him at that location. So he had to go to the VA hospital in Northport to address his issue. He spent 2 days going over there trying to continue his PT and his OT, and this was over a 5-week period, during which time the pain was increasing, because he was not doing the requisite therapy that he needed post- surgery. On June 6th, 2018, he returned to Northport for his second PT appointment and got into a verbal disagreement with the MSA, who was the medical specialist assistant who was behind the counter, who was not--according to other witnesses, was not being very responsive to his needs. She then at some point called the VA Police, who showed up; they tried to de-escalate the situation. He sat down. They talked to the MSA, who in his opinion was giving wrong information. He engaged the police officer again and at some point, he was literally body-slammed onto the ground with his arms twisted behind his back. This is someone who is post-spinal surgery. He informed them of that, I can't breathe, I just had spinal surgery. They kept him on the ground until a physical therapist who had treated him before came and said, he is of no danger, please take the handcuffs off, they refused to do that. They transported him to the hospital, where they handcuffed him to the bed. He was treated by a doctor. I mean, you can imagine not just the physical pain that he was going through, but the emotional and mental anguish that he suffered as a result of this. He asked for the police report, to get the police report, so he could--and he wanted to speak to--if they were going to speak to witnesses, he wanted them to get his side of the story as well. They never spoke to him the first two weeks. They told him they would send him the police incident report in the mail. Instead, what he got in the mail was two summonses to appear in Federal magistrate court for criminal charges of whatever they were, p.s. they shouldn't have been anything. He goes to court. There is no judge, he is told to come back. He goes back on another date, nothing happens again. This incident keeps going on and on and on. So it implicates not just the difficulty of ensuring that people get the proper health care they need, whether it is within the VA or outside of the VA, but also the treatment that people get, if and when it is determined that the VA Police need to get involved. So the questions that I have are many. First of all--and, by the way, I have asked to speak to the head of the VA Police in the district at the VA in Northport and I have yet, as a congressperson, been able to get any contact information for that individual, so that I can try to find out what is going on. We were able to determine that the two summonses that this veteran received in Federal court are now in the status of deferred prosecution, which, as a former prosecutor, says to me that this is what you do when you say, okay, if you stay out of trouble for 6 months, this case is going to go away. He never saw a judge, never had his day in court, and this is now in the status of deferred prosecution. On top of that, it was discovered during this review that the MSA and/or others improperly accessed Mr. Telfort's medical records and input information regarding this specific encounter that was factually incorrect, which--I mean, I can't even begin to go into the privacy issues that are implicated there. My understanding is that the people who put that information and improperly accessed his account were reprimanded and retrained. In my opinion, they should have been fired. So I don't even know to whom my question goes to here, but--and I respect the position that the VA Police are in. This is a very tense situation that most of them are coming into when they are summoned to a situation that is happening at a VA facility, I get that, I understand that. That is why it is incredibly important for them to get the proper training, especially dealing with individuals who have been diagnosed with PTSD and also have very serious physical manifestations of those injuries as well. So I hope we have a second round. I never do this, I never take up all of my time doing this, but I just felt so compelled to make this case for this veteran. And, Mr. Chairman, I would also ask unanimous consent if I could enter a statement, his statement for the record on behalf of my constituent Mr. Jean Telfort, so it can be part of this record as well. And I hope we have a second round, so we can dig a little deeper into the issues implicated by this one story. Thank you, Mr. Chairman. I apologize for going over. Mr. Pappas. Without objection, we will take that statement, and I do hope we can do a second round here as well. Mr. Pappas. With that, I would like to recognize Mr. Cisneros for 5 minutes. Mr. Cisneros. Thank you, Mr. Chairman. I just want to follow up on that question, because the same thing happened at the Loma Linda facility a few years ago in Riverside, California, where an individual got frustrated, was going to try to attempt to go to the Long Beach facility. They pretty much took him, slammed him to the ground, hit his head, and he ended up dying of a seizure. In the training that you said that they get, you talk about de-escalation training they receive when they are going through this. How effective is that training? I mean, really, what are they doing over there? And why is this--if they are getting this training, why are we having these situations where individuals are being injured or hurt or killed? Ms. Oshinski. It is really troubling. It is hard for me to sit here and answer questions after hearing, you know, the stories that you are talking about. And certainly any time anything like this occurs, we have to go back and question whether or not the things that we are doing are being effective. But I do believe we have looked at our training and continue not only to do the initial training, but retraining of people. We obviously need to do more. We need to take a look at what we can learn in each of these situations where we have something that did not occur as we would hope. I mean, we are trying to do de-escalation not only with the police officers, but in the case that Miss Rice brought up really de-escalation on the part of the MSA or the individual who was checking that person in to be seen, we need to make sure that we have that happening across all our medical centers, because we are continuing, as I said, to try and balance what is happening in a health care environment with people maybe feeling threatened. I know that we are trying to do even more. If I could recognize Mr. Hanretta, if you would like to talk about some of the things that we are trying to do for training individuals to ensure that we do not have inappropriate use of force. Mr. Hanretta. Thank you again. And I will also defer to Mr. Jackson, who leads the law enforcement training center, but I am very proud of the performance of our police officers having completed the Law Enforcement Training Center program. Ten weeks, much of it focused on de-escalation scenarios. And so, again, these two incidents are very unfortunate, and I do not believe characterize the VA Police in the field serving our Nation's veterans. But let me ask Mr. Jackson to specifically talk about the level and type of training that VA Police officers receive. Mr. Jackson. Yes, sir. Years ago, the VA Police Academy was only 5 weeks, and that was in 2009, and we saw the need to increase that to 8 weeks. And one of the reasons was because we wanted to get much, much more, many more scenario-based situations whereby an officer had to deal with a veteran that was in distress. Even after the 8 weeks, we looked again and we said, we need to increase this some more to 10 weeks. So in that 10-week period, although we do the traditional law enforcement, a lot of it more than any other police academy, deals with the de-escalating situations and actually putting them in scenarios whereby they have to pass that scenario in order to graduate. And this is done from the day that they walk into the academy until the day that they leave. Now, the second issue is that--was-- Mr. Cisneros. I don't want to--I don't mean to cut you off, and if you have more to answer, if you could submit that for the statement. But the other thing I want to address, too, and maybe it is the stress on the officers themselves. You know, you have a shortage, and your written statement says of 700 officers. Some of the facilities are undermanned by 20 percent and higher. I mean, how much overtime are these individuals working? How much stress is put on them? How much--if they are not working overtime, how undermanned are they where they are having to do so much more? What is the stress level of our officers over at the VA facilities? Ms. Oshinski. We are looking--one of the efforts that we made with the introduction of the VISN level police officers is that is one of the things that they are taking a closer look at. What is our use of overtime and how is that impacted by our vacancy rates? So we are--I do think it is something that we need to be concerned about. We are looking at it and hopefully we can resolve it with the efforts that we are making to increase our staffing. Mr. Cisneros. All right. I yield back my time. Mr. Pappas. Thank you. I would now like to recognize Mr. Rose for 5 minutes. Mr. Rose. Thank you, Mr. Chairman. I think as we analyze the threat landscape across the country, it is clear that our VA facilities are a top target for future terrorist attacks and instances of lone wolf shooters, if you really want to his America's psyche and where it hurts, it should attack our VA. And so I have--in my capacity as Subcommittee Chairman of Intelligence and Counter terrorism on Homeland Security really dug into what the NYPD is doing from a partnership basis, as well as other major law enforcement agencies. And I have not seen the VA participating in any of this. NYPD Shield program, monthly meetings, weekly meetings, so on and so forth. Can you speak to the partnerships that you all are engaging in, particularly from a counter terror standpoint and potentially where you could improve? Ms. Oshinski. I am not able to address that. I would have to submit that for the record. I apologize. Mr. Rose. Okay. Does anyone have anything to speak to in terms of partnerships from what you are doing on a counter terror standpoint? Mr. Hanretta. Sure, let me just address one of the responsibilities of the VA police chief at the facility level is to build the relationship with the local law enforcement. And so one of those challenges is the ongoing threat of an active shooter. And so between VA police who train very specifically at the facility level to respond to that type of incident, we partner with local law enforcement. We also partner with the FBI in the area. So-- Mr. Rose. Does every VA facility have a plan in place, written, to respond to an active shooter incident? Mr. Hanretta. I would defer. My response would be yes, it is a requirement. And so I know they practice that because it is a real threat and a concern by everyone: the VA police, our employees, as well as the veterans coming to our facilities. Mr. Rose. Okay. Moving on to the issue of suicide. We all are aware of these recent instances of suicides on VA campuses. From your experience from--I know you all are looking into this issue, what are we doing well and what can we do better? Ms. Oshinski. You are right. We are looking very intensively at that. One of the things that I do need to share with you is that we have gotten to be a lot more proactive in looking at social media, for example, because one of the things that we are finding out, because as you discussed, many of the people using the VA as a place where they would look to harm themselves often post or are talking to people on social media. So we have really upped our review of that. And actually just recent--just last week, stopped somebody who had posted on Facebook and said where they were going to do this, that our police found them at the front door of that facility and were able to talk with them and get them admitted. I am actually really glad you brought this up. Mr. Cisneros talked about Loma Linda and I feel compelled to just share a story about Loma Linda. Back in March, a police dispatcher got a call from somebody who said that they were going to commit suicide. The policeman kept them on the phone and found out his location, which was on the third floor of the parking garage at Loma Linda. This happened, I think, at 12:55. By 1:10, we had talked that individual down. We had brought other police there and a psychiatrist from the site. And so it was another save. So I think we are trying to do many of those things. What can we do to make sure that we are listening when veterans call and talk to us? Mr. Rose. Is there any formal document related to what you are doing on social media? Any policy, SOP? Ms. Oshinski. There is not an SOP that I am aware of. Mr. Rose. Okay. So I just want to put two requests on the record for you all. Ms. Oshinski. Yes, sir. Mr. Rose. If you could potentially try to put something on paper regarding social media, I think you are very correct to be focusing on that. And number two, if you could please make an effort to formally partner with what the NYPD is doing and the FBI in New York City, because we are not seeing it and I think there is more to do because you are a target. Ms. Oshinski. Okay. Thank you. Mr. Rose. Thanks. Mr. Pappas. Thank you, Mr. Rose. I would now like to recognize Ranking Member Bergman for 5 minutes. Mr. Bergman. Thank you, Mr. Chairman. We deal with a lot of words and phrases here, both in our testimony: verbal and written, and words and phrases count. Any time we say, ``No timelines,'' that means in my mind, what I hear is no sense of urgency. Because if you don't have a specific timeline, you can't do markers against it. So I would urge specific timelines. Sometimes timelines are not met, but without a timeline, you don't know where you are in the process and that is particularly confusing. And speaking of confusion, I have got three pages here of the wired diagram of--just starting with the secretary of the VA down. That is--if you can understand this diagram, I think we have one step to the next step in success, which is the future organization of the VA and how we can get these things done with a sense of urgency. So Mr. Missal, your testimony states, ``Responsibility for the police program is splintered between VHA and the VA Office of Operations, Security, and Preparedness.'' I am curious about your use of the word splintered in that statement. Would you please explain what you mean by splintered? Mr. Missal. What we found in the audit that there were two different groups that had responsibility over the police force, and by using the word splintered, what we were trying to drive home is there was real confusion about who had what responsibility, and even within senior people, whether or not they were properly implementing that responsibility. We found a general awareness with some people of what they should have been doing here and this is such an important area, for it to work properly, the governance structure has to be very solid. And in this situation, we found that there was confusion. And given how disparate the two groups were, having confusion just exasperates the problem. Mr. Bergman. So being splintered kind of added to the confusion? Mr. Missal. Correct. Mr. Bergman. Ms. Oshinski, in your written testimony, you state that officers are matrixed to OSLE and that OSLE has tacit oversight of all police units in the field. What do you mean by matrixed to OSLE and tacit oversight, and do you think that this contributes to the confusion identified by the IG? Ms. Oshinski. Thank you for the opportunity to clarify. So by matrixed, I believe we are talking about the idea that we do this as a partnership. Honestly, as we try to do law enforcement in a health care environment, we need to have both sides represented in a review of what it is that we are trying to accomplish. So while there may be the direct line authority at the medical center, there is also authority within OSLE to make sure that people are trained, to make sure that if there are any issues that they help to determine how we overcome those. Any time there is an issue with use of force, that automatically goes to OSLE[OSP3]. There is nothing that is further done by medical center leadership about anything like that. So there are specific areas that belong to OSLE and some areas that belong to the medical center. Mr. Bergman. Yes, I would suggest to you that a police force kind of resembles the military in that it has a specific chain of command. So when you are executing a plan or when things go bad, people know whose responsibility is what. And that specific chain of command goes a long way towards having a more effective police force. Ms. Oshinski, in your written testimony, you say that VA believes that there is a need for additional staff. I want to explore that for a minute here. We regularly hear that VA has between 35 to 40,000 vacancies. Correct me if I am mistaken, but Congress funds those vacant positions through the annual appropriation, which means that VA has the money to fill the approximately 700 vacant police officer positions. How did VA determine that it needs additional staff when it has 700 vacancies and has not completed its police staffing model? Ms. Oshinski. One of the areas, I think, that at least from the initial overview is we do not have a good career path where we can encourage people to stay at the VA, and to become leaders in-- Mr. Bergman. There is a career path, and let me see if I am over on my time. I hope we are going to get a second round, but my next--I will yield back, but my next question is do we need a career path to hire someone initially? And I yield back. Mr. Pappas. Thank you. We will get to that in round two. Our colleague Congressman Seth Moulton of Massachusetts has asked to participate in today's Subcommittee hearing, and I would like to request unanimous consent to allow him to join us on the dais. And if there are no objections, I would like to recognize Congressman Moulton for 5 minutes. Hearing no objection, you are recognized, Mr. Moulton. Mr. Moulton. Thank you, Mr. Chairman. Mr. Hanretta, I have entered into the record reporting from the Boston Globe about an incident at the Bedford VA in Massachusetts where an off- duty officer drove drunk to a car dealership, ran out of gas, demanded to be filled up by the car dealership, and when they refused, threatened the car dealership employees with a gun. After he was arrested, he cursed out the local cops, stuffed the holding cell with toilet paper, and beat his own head against a cell door. Now, he had previously been dismissed from the State Troopers, had his gun permit revoked by the town during a domestic incident complaint, and had two sexual harassment charges filed against him. This exemplary officer was selected to be an instructor at the VA's police academy. So can you just help me understand how that would happen? How this man, of all people, would be sent to the elite VA police academy? Mr. Hanretta. Sir, that current situation is currently under investigation. The way we work together with VHA is when a VA police officer is identified for either criminal conduct or performance, then the Office of Security and Law Enforcement sends a special agent down to take an independent look at the situation. In this particular case, at the time of his selection, we were not aware of all of the background circumstances. Immediately, that offer was rescinded and again it is currently, to the best of my knowledge and I will defer to Mr. Jackson, under investigation based on his behavior. Mr. Moulton. Well, sir, I am glad to hear it is under investigation. It is my understanding that perhaps part of the reason why you did not understand all of those allegations is that the chief of the Bedford VA police at the time, Shawn Kelley, was shielding the man from scrutiny. And that's until the Boston Globe spotlight team inquired about the incident. This gentleman, Shawn Kelley, I understand, is now under consideration to be the chief of VA police in Manchester, New Hampshire. Is that true? Mr. Hanretta. Sir, let me refer to Mr. Jackson, because I know he is intimately involved with this case. Mr. Moulton. Okay. Mr. Jackson? Mr. Jackson. Sir, I know nothing about him going to another area to be a chief of police. Nothing at all. That would be news to myself. But secondly, also while he did go down to the law enforcement training center, he was never an instructor because he had to shadow some of the experts first before being fully authorized -- Mr. Moulton. Well, Mr. Jackson, I am glad to hear that. I have no idea why this man would even wear the uniform, period. Now, I am also aware that--using Bedford as an example, that despite the fact that the VA in Bedford has a larger police force than the Town of Bedford, than the one that protects the entire community, every time the VA Bedford police force makes an arrest, they have to call the Bedford police to do it, because they don't actually have the authority to--I may perhaps messing up the precise terminology here, but they don't have the authority to actually have that arrest. So you have a VA police force in charge of a small fraction of the number of people in the town and they don't even have arrest authority. So I mean, I guess my fundamental question is why does this force even exist? I mean, shouldn't we just be paying a little bit of this money, a small portion of the $3 million budget of the VA Police Department every year just to the Bedford Police Department, which have to--it seems like they have to do all of their work anyway, including dealing with the discipline of VA officers. Ms. Oshinski, would you like to take that? Ms. Oshinski. Yes, thank you. One of the things, just to emphasize--you are right. We don't do arrest authority on the VA campuses. We have been talking about how--what our police do is really try to balance security and health care in the same environment, and the de-escalation techniques. I recognize that there seems to be some variance with what you do in the community. Any time we find anything criminal, it goes to the OIG. So we really are trying to keep a safe and secure environment, not community policing. Mr. Moulton. Well, I am over time, but I would just suggest that if the hallmark of the VA police is their de-escalation techniques, that doesn't seem to be what was employed by this officer when he couldn't get gas from a car dealership when he was driving drunk. Mr. Chairman, I yield back. Mr. Pappas. Thank you very much, Mr. Moulton, and I hope that the VA could confirm that information about a potential transfer for the Committee if that, in fact, has taken place. Ms. Oshinski. We will, thank you. Mr. Pappas. Well, thank you. We would like to have some additional questions. I recognize myself for 5 minutes. Mr. Missal, I wanted to address something that was brought up in the testimony from the VA. OSLE has ``tacit oversight over all of the VA police units in the field.'' And I am wondering if you could help me understand that term, how that fits into the current model of their governance structure and whether or not you feel that that is a sufficient model. Mr. Missal. In our report, we identified issues with the governance structure. I don't know the term tacit oversight. What I would say is they certainly have responsibility to inspect the police, to identify any issues that they find. One of the things we identified in our report was that they were late in their inspections, which obviously hinders their oversight. The actual oversight of the individual police force, though, goes through VHA and they have the direct authority. Mr. Pappas. Could you talk a little bit about other police units and Federal agencies, how they are structured? I know your report brought up a couple of examples, Federal Protective Service and the U.S. Park Police. How does that compare to what we are seeing in the VA? Mr. Missal. We were looking at those other services more for the number of officers and in terms of what they were covering, what their jurisdiction was, as opposed to their actual structure. VA is unique the way it is organized from other Federal agencies. So it is really hard to compare. Mr. Pappas. Okay. I am wondering if we could talk a little bit about the pay incentives that exist to help recruit and retain officers. First, I just want to acknowledge that the Subcommittee received a written statement from the American Federation of Government Employees, which represents many VA employees. And I ask unanimous consent that we include that statement for the record. Ms. Oshinski, as you consider steps to reduce vacancies, are you in discussion with labor representatives? Ms. Oshinski. those discussions would be at the local level, not at the national level. So there may be discussions ongoing at the various sites as we put out different advertisements. And also, just responding to some of the things you were saying, also the special salary rates and trying to look at what is happening in the community, if we are having trouble retaining. And I think there is a difference. You can often hire people in, but to retain them, once we have trained them down at the LETC, trying to keep them often requires that we go out and do special salary rates. Mr. Pappas. Are there any constraints, statutorily speaking, or any others that might exist that need to be addressed for the VA's pay scale to become more competitive? Ms. Oshinski. A couple of things that we are doing, as I was talking earlier, it may not have come across, but as we do position descriptions, making sure that we have people graded at the right level. One of the things that we have done is raise the entry level to a GS-6, so that you are looking at a higher level than at a 5. Just finding that the comparison to the private sector, which is where we get many of our police officers. You know, 85 percent of our police are veterans. So they often have experience in the military, or they may have worked in a local community policing agency. So we have to do more to make sure that our rates are competitive. So we are looking both at special salary rates and what are the entry level and then the steps up the chain. Mr. Pappas. And how has that trended over time? Where things stand today in terms of the vacancy rate if we look back 1 year, 5 years, you know, how have we gotten to this point today? Ms. Oshinski. I would have to submit that for the record. Mr. Pappas. Okay. Well, I thank you very much for your responses there, and I would like to recognize Mr. Mast for 5 minutes if he has additional questions. Mr. Mast. Thank you again, Mr. Chairman. You know, I want to step back on something that Mr. Moulton was speaking about. I wanted to get to it earlier, but I want to make sure I have the numbers correct in what you are saying. There are currently 4,000 filled VA police force positions and 700 vacancies; am I understanding that correctly? So the total full up would be 4,700 roughly? Ms. Oshinski. Roughly, yes. Mr. Mast. So at 4,000, by 139 facilities, we are talking about roughly 28 officers per facility. Would that be a rough average, or would you see these disbursed in a little bit different way? Mr. Oshinski. Well, the number of individuals at the site, obviously, is going to base on the size of the numbers of people who are there, the size of the campuses, and as we talked about, security vulnerabilities that may exist at some places or not exist at others. Mr. Mast. Could you give me an example of one of the larger facilities that has, say, the most officers versus one of the smaller facilities that has a more minimal number of officers of that 139? Ms. Oshinski. You would be looking at places that perhaps have multiple campuses, a Palo Alto, California. Mr. Mast. How many officers might they have at Palo? Ms. Oshinski. I would have to look at what that might be. Mr. Mast. Okay. So on average, so if we moved that up to 4,700, we would be looking at--well, we could place 33 per facility if we did that. Is it that there are not enough officers? Is that enough--Mr. Moulton, he did reference the fact that in some of his cities, that is more officers that are in law enforcement for an entire city on a VA campus, on a single VA campus, maybe multiple campuses, but that is quite a few officers. Where-- Ms. Oshinski. So one of the things that we are doing is trying to develop that staffing model to address these very items. There may be things with vulnerabilities where we need more. There may be places where we need less. So we are doing a staffing assessment. We are going to be using, I think we had talked about data that had been put together by Homeland Security in assessing those. That will be considered, and we hope to have those staffing models completed by September 30th. Mr. Mast. Thank you. And to go back to something that you referenced; I want to make sure that I understand this correctly. You said in response to the shooting in West Palm Beach VA, that individuals coming into the hospital in a wheelchair would be--or a scooter, some sort of mobility platform, would be removed from their mobility platform, moved into a hospital mobility platform, wheelchair, something to that effect, whatever it may be. Do you mean anybody and everybody coming into the facility or just those going into the ER? Ms. Oshinski. Just[KKJ4] those going into the emergency department. Mr. Mast. What do you see is the difference in terms of threat assessment between somebody going into the ER versus somebody coming in a mobility platform anywhere else? Not that I by any means think this is the most well thought through approach to doing this, but in the threat assessment, what is the difference? Ms. Oshinski. And I would have to look into that in more detail. So I would have to get back to you. I do think that some of the issue, honestly, you know, when we talk about staffing levels has been having people be able to transport folks. So I think we are looking at probably a staging as we do that. I know often when you go to a community hospital, you are put in their chairs when you go there. So I think that really is probably what is happening in the community as well. Mr. Mast. I have done threat assessment, very specifically as my work prior to a Member of Congress on a number of different fronts with different agencies, and I see absolutely no difference in terms of the threat of whether somebody is going into the ER for perhaps some sort of trauma. If we are talking about some instance of being institutionalized for mental health counseling, that might be different. But I see no difference in the threat of somebody coming into the ER versus another part of the facility in terms of what they could bring in that would pose a threat to people within the hospital or patients within the hospital, anybody else. So what I would like to ask of you is would you please be willing to give me a brief--come into my office, give ma brief on everything that has been put into place, since we are not going to be able to cover all of this? Ms. Oshinski. Certainly. Mr. Mast. Thank you. I appreciate that and I yield back, Mr. Chairman. Mr. Pappas. Thank you. I recognize Ms. Rice for 5 minutes. Ms. Rice. Thank you, Mr. Chairman. I think, Mr. Jackson, you would be the appropriate person for me to start with these questions. So there were findings by your agency that the officers reacted in Mr. Telfort's case in an appropriate way. And the writing--the way that they come to the conclusion, it just seemed very perfunctory and like there was not going to be any other outcome other than the police acted accordingly. I just want to know if you can explain to me why you think it was appropriate, first of all, to take the physical action that they did against Mr. Telfort and hold him down, knowing that he was--because he told them that he had just had spinal surgery, et cetera, and he was in pain, couldn't breathe. And then further, why they issued those summons to go to Federal court, which now have, for all intents and purposes been dismissed. Mr. Jackson. Yes, ma'am. When the incident happened on the 6th and I saw a letter that came in from your office, I think within 2 days later we were there because one incident of a use of force is one too many. One of our special agents talked to Mr. Telfort for at least a couple hours or so, and got with him immediately. The issue there was with the collection of the evidence and the other witnesses that said what Mr. Telfort did, that was the conclusion after gathering all of the evidence without--we didn't have any video, just the witnesses that came forward and said, well, based upon what the police said to him and what Mr. Telfort said, the witnesses that the officers acted properly. Now, I think to further that along, what we have done to improve working with VHA to improve healthcare professionals dealing with veterans is our verbal defense in a healthcare training that we have gone out to do to give so many employees that deal with veterans. So the first reaction is not to call the police but to diffuse the situation before calling the police. Ms. Rice. So I agree with you and I think I turn to Ms. Oshinski to talk about that. The medical support assistant is the first line of defense in terms of any de-escalation that may be necessary. And I think it is--forgetting about what the police did once they were called, it seems to me that it is uncontroverted that the MSA was in a unique position to de- escalate the situation by just addressing his frustration and understanding that this is a man in pain. And it doesn't seem like any de-escalation attempts were made at that level. Do people in those positions, medical support assistants, get de-escalation trainings too since they really are in the front lines and you don't get to a police situation unless you have an MSA or someone in that position to call them? Ms. Oshinski. Before I answer, I just have to say how difficult it was to listen to what you described during your discussion and I am so sorry about what happened, and I wish we could go back and do it over again. But going back to the MSA, yes, they do get some de-escalation training. I think one of the issues with those individuals is they are that front face to veterans, and we need to make sure that we are doing the right things related to customer service, related to-- Ms. Rice. They are all about--to me, if they don't do proper customer service, what is their job? Ms. Oshinski. Right. Ms. Rice. They are actually not the ones giving the healthcare treatment. They are not doctors. They are simply there to address the specific needs that are right in front of them. And you can understand someone in Mr. Telfort's situation being frustrated. I still haven't gotten an answer as to why it was okay for him to get PT and OT in a community setting and then have the rug pulled out from under him and said, ``No, you have to go back to a VA facility.'' And then go to that facility and be told, ``We can't give you that kind of care here. You have to go to the hospital, which is an hour and a half away.'' I mean, the level--I would--I have not been--well, some people think I probably should be diagnosed with--anyone who works here should be diagnosed with that, but here is a person who has been diagnosed with Post Traumatic Stress Disorder and he--just at every step of the way, from the time that he was getting the treatment that he needed to have the rug pulled out from under him is just--and I am not holding you responsible for that. I am still trying to get answers as to why that happened. But let me just, because my time is almost up. It is up. Just one quick question. I am so troubled by the fact that someone, and it is not even clear from the documentation that I have gotten, someone accessed his medical records and put defamatory information in them that was proven to be factually incorrect. To me, there is no amount of retraining that that person can undergo to understand that what--that was not a training issue. That was this person trying to cover their behind and put in information that was intentionally false to put them in a better light and the victim in a worse light. And so to me, I don't know if you are the right person to ask this to, but that person should be terminated. If you violate a sacrosanct rule that you are not allowed to access someone's medical records, unless it is for purposes of putting in what treatment you have just given them, that was not the case here. So I would ask--maybe we can follow up after this hearing on that because I haven't gotten sufficient--I don't think, you know, retraining someone like that is the answer. It is not a retraining. It is an ethics issue. So I would appreciate it if we could follow up after this hearing. Ms. Oshinski. Yes. Ms. Rice. Thank you. And I apologize again for going over. Thank you, Mr. Chairman. Mr. Pappas. Thank you. Ranking Member Bergman is recognized for 5 minutes. Mr. Bergman. Thanks again, Mr. Chairman. As Mr. Moulton pointed out in his example, the VA hired an officer who had been dismissed from the State Police and had had his gun privileges, his weapons privileges pulled for domestic violence. Have you or anyone in the VA reviewed the medical center's HR department to understand and correct problems in the screening process? I mean, how did this fall through the crack? Any thoughts? Ms. Oshinski. It is frustrating, obviously, for us as well. We have looked at screening processes-- Mr. Bergman. Did you look at this one in specific? Ms. Oshinski. Not this one in specific. Mr. Bergman. Okay. I would suggest, then, rather than--this is an example where we can go in the specifics and then go back to generalities, as opposed to generalities to work towards specifics. So please take that for action. Mr. Missal, recommendation four, number four of your December 2018 report concerned the hiring of additional OSLE investigation staff. OSLE has hired nine of the ten additional authorized employees, yet their recommendation remains open. Is this sufficient to close out the recommendation? In other words, is nine out of ten good enough, and if not, what remains for VA to do before you will close that recommendation? Mr. Missal. With respect to that recommendation, what we asked for was an assessment. So we don't know if nine, ten is the right number. When we make a recommendation, we typically ask for documentation about what the plan is to complete what needs to be done. And my understanding is as of now, we have not yet gotten that assessment. We asked about it. As soon as we see that assessment, if it is satisfactory, we may be able to close this recommendation. Mr. Bergman. Okay. Ms. Oshinski, your written testimony states that there were 375 officers who left the VA in fiscal year 2018. Later in that paragraph, you state that the number two reason for officers leaving was a lack of opportunity for advancement. Would you please elaborate on that lack of opportunity for advancement for the police? Ms. Oshinski. One of the issues has been that we talk about a career ladder. So detective, inspector, assistant chief, chief. One of the things that happens is that you can't give people enough opportunities to move up. And so what we are trying to look at is what is the appropriate level? How much supervision do we need? And I think we have pointed out here there are multiple opportunities where we can improve how we do business. Some of that by how we supervise those individuals, so that we give people an opportunity to move up. When it feels like people are not moving out of chief positions and there is nowhere for someone to go, they begin to look at jobs in the community. Because once they have some of these credentials, they certainly are able to qualify for jobs with other law enforcement agencies. Mr. Bergman. Okay. Ms. Oshinski, would you please provide the Committee an example or two of the evidence practices from other Federal agencies and private industries that you have incorporated into the police program? Ms. Oshinski. One of the things that we are now trying to do in regard to hiring, we were looking at how do private sector facilities, because I think as Mr. Missal so aptly talked about, it is difficult sometimes to look at other Federal agencies because VA is very different, to look at other healthcare agencies, how do they hire their armed guards because about half of the hospitals around the country do have them. What we are finding, and what we have now--are now beginning to implement is a two pronged approach to interview process. The first interview would be with individuals who are law enforcement oriented to make sure that people meet those basic law enforcement qualifications. The second interview panel, and the people who make it through that panel would go to a second panel, which would look at what is their fit in a healthcare environment? How do they fit in our mechanism of using de-escalation as the primary way of doing thing? How would they recognize someone who is suffering from mental illness who may be in danger of suicide? So that is a major one that I think we are implementing right now. Mr. Bergman. Okay. And I see my time is about up. I would just like to ask one question, if you would please, I am guessing you don't have this information at your fingertips, so please take it for the record. But with nearly 700 vacancies in the police services, I am quite curious as to whether VA police officer is eligible to join the union, and if so, how many police officers receive taxpayer funded union time? So if you would take that for the record, I would appreciate it. And Mr. Chairman, I yield back. Mr. Pappas. Thank you, Mr. Bergman. Just a couple closing points before we conclude the hearing. I would just first like to underscore the non-partisan nature of the issues and questions regarding the department's police force and I really look forward to working with Ranking Member Bergman and all of our Subcommittee Members on both sides of the aisle as we continue to monitor developments, review policies, receive additional reports, and press for improvements, which is really essential. I want to thank all of our witnesses for their testimony today. Inspector General Missal, I would like to express thanks to you and your staff for the ongoing oversight work in this critical area. Your report on the VA policing policies and today's testimony represent critical findings, and as we heard, has already made a positive impact. Our Subcommittee staff will keep in close touch with you with the ongoing audits of VA policing. And to Ms. Oshinski, Mr. Hanretta, and Mr. Jackson, I thank you for your testimony as well. Your appearance today clearly represents a willingness for the department to work with Congress to move forward to improving the policies and resources of the VA's police. Please also convey on behalf of the Subcommittee our thanks to the work of the many officers and staff throughout the VA police force. Members will have 5 legislative days to revise and extend the remarks and include extraneous material. And without objection, the Subcommittee stands adjourned. [Whereupon, at 11:27 a.m., the Subcommittee was adjourned.] A P P E N D I X ---------- Prepared Statement of Inspector General Michael J. Missal Chairman Pappas, Ranking Member Bergman, and Members of the Subcommittee, thank you for the opportunity to discuss the Office of Inspector General's (OIG's) oversight of the Department of Veterans Affairs (VA) security and law enforcement program (police program). The OIG is committed to serving veterans and the public by conducting oversight of VA programs and operations through independent audits, inspections, reviews, and investigations. That oversight is particularly compelling when the safety of VA personnel, veterans and their families, and visitors to VA facilities are at issue. How VA police providing those protective and law enforcement services are guided, managed, and supported certainly warrants close scrutiny. The Office of Security and Law Enforcement's (OS&LE) Police Service group has different divisions responsible for such functions as public safety, investigations, infrastructure protection, executive protection, and police unit inspections. My statement focuses on the policing duties carried out primarily in VA medical facilities, particularly the effectiveness of the police program governance structure and the challenges VA has faced in staffing and overseeing its police workforce. I would like to highlight the findings from a December 2018 OIG report, Inadequate Governance of the VA Police Program at Medical Facilities and our most recent staffing report. \1\ I would also like to note that the OIG subsequently published a report on Mismanagement of the VA Executive Protection Division in 2019, which falls within the Police Service group. \2\ That report found that VA failed to develop adequate threat assessments and written policies, which contributed to security vulnerabilities. Common challenges identified in these and other OIG reports such as staffing shortages, the splintering of oversight responsibilities, confusion about roles, and lack of clear guidance can undermine VA's well-intentioned goals and objectives. --------------------------------------------------------------------------- \1\ Inadequate Governance of the VA Police Program at Medical Facilities, December 13, 2018, and OIG Determination of Veterans Health Administration's Occupational Staffing Shortages FY 2018, June 14, 2018. \2\ Mismanagement of the VA Executive Protection Division, January 17, 2019. --------------------------------------------------------------------------- BACKGROUND VA's Veterans Health Administration (VHA) provides health care to over 6 million veterans in its medical facilities. Federal law provides the VA Secretary with the authority and responsibility to protect patients, visitors, employees, and VA property. \3\ VA police officers provide security and law enforcement services at VHA facilities, as well as Veterans Benefits Administration offices collocated with VHA facilities, and some VA national cemeteries. They are authorized to carry firearms in an official capacity, investigate criminal activity, and arrest individuals on department property for offenses committed within VA's jurisdiction and consistent with other law enforcement agency agreements. \4\ VA's police force consists of approximately 4,000 officers, at 139 of 141 VA medical facilities, which places it among the 10 largest law enforcement workforces in the Federal government. Other Federal agencies provide security at the remaining VA healthcare facilities, such as the Manilla Outpatient Clinic. --------------------------------------------------------------------------- \3\ Title 38, United States Code, Sec. 901, Authority to prescribe rules for conduct and penalties for violations. \4\ Title 38, United States Code, Sec. 902, Enforcement and arrest authority of Department police officers. --------------------------------------------------------------------------- Responsibility for the police program is splintered between VHA and the VA Office of Operations, Security, and Preparedness (OSP). In addition, on September 14, 2018, VA Secretary Wilkie reassigned OSP to the Assistant Secretary for Human Resources and Administration and the position of Assistant Secretary for OSP was eliminated. VHA has historically had primary responsibility for the police program, including ensuring VA police officers were qualified and maintained physical security on agency property. \5\ VA policy designated the Deputy Under Secretary for Health for Operations and Management (DUSHOM) as the senior VHA official (together with Veterans Integrated Service Network (VISN) directors) for ensuring police program requirements are achieved, such as maintaining enough officers on duty with proper equipment and supervision. \6\ Each of the 18 VISNs have designated a VISN police chief who provides technical guidance and assistance to their respective network medical facilities. Primary responsibility for operations, however, falls to the local VA police chiefs who report to their medical facility directors, who in turn are responsible for verifying police officers' qualifications, ensuring law enforcement activities are accomplished, and maintaining enough officers on duty at the facility to protect people and property. --------------------------------------------------------------------------- \5\ Department of Medicine and Surgery Supplement MP-1, Part 1, Change 42, Chapter 2, Investigation, Security and Law Enforcement Policy, paragraph 11a (2) and 13d (1), July 23, 1986. \6\ VA Directive 0730, Security and Law Enforcement, paragraph 3g, December 12, 2012. --------------------------------------------------------------------------- OSP is a VA staff office that provides limited department-level program oversight of VA's security and law enforcement activities. Aligned under OSP, the OS&LE is responsible for developing and issuing national police program policies, protecting the VA Secretary and Deputy Secretary, investigating potential criminal incidents at VA facilities, and conducting inspections of medical facility police units to determine if program requirements are being met. Police inspections provide a check on the adequate implementation of critical program operations such as physical security, rapid response activities, police staffing, and investigative activities. They are also meant to identify any corrective actions needed. The police inspections include assessments of risks to patients, visitors, and employees. VA GOVERNANCE OVER THE POLICE PROGRAM WAS INADEQUATE FOR CONDUCTING EFFECTIVE OVERSIGHT The OIG received complaints through the its Hotline related to the accountability and performance of some VA police officers at medical facilities. The OIG recognized the importance of examining how oversight of VA police performance is conducted at a system-wide level. The focus of the audit was to determine whether the VA police program has an effective governance structure in place, meets requirements for size and qualifications, and conducts adequate inspections to ensure compliance with policies and procedures. The OIG determined that VA did not have adequate and coordinated governance over its police program to ensure effective management and oversight for its police officer workforce at its medical facilities nationwide. The OIG found that the governance problems occurred and persisted, in part, because of confusion about police program roles and authority between VHA and OS&LE. The DUSHOM told the audit team that OS&LE was responsible for centrally managing police program activities at VHA facilities. However, OS&LE did not have that responsibility and did not have authority, for example, to manage funding and pay decisions for VA police, to hold medical facilities accountable for adhering to police program policies, or to require staff within VHA to help perform timely inspections of medical facilities. Governance issues also stemmed from a lack of a centralized management or clearly designated staff within VHA to manage and oversee the police program. Because the assignment of OSP to VA's Human Resources and Administration Assistant Secretary was made after the audit work was conducted, that office's oversight role in this mix was not evaluated. The OIG audit revealed four key areas of concern:Systemic tracking and assessment of police program operations and performance by VHA and OS&LE Facility-appropriate police officer staffing models and officer shortages at VA medical facilities Timeliness of inspections of police operations at VA medical facilities Guidance on how VA police officers investigate the alleged misconduct of facility leaders who manage the police program or control its resources VHA and OS&LE Did Not Track and Assess Police Program Operations and Performance in a Systemic and Effective Manner The OIG determined that the Office of the DUSHOM lacked mechanisms to systematically track and assess police program operations and performance at medical facilities, such as whether facilities maintained sufficient numbers of police officers to protect patients, visitors, and employees. The DUSHOM told the OIG that he had been unaware of trends or patterns occurring within the police program at VA medical facilities. His office also did not track and assess VA police workload indicators system-wide, including the number and type of arrests, traffic violations, and investigative activities. In February 2018, he said that he had not received the results of OS&LE's inspection activities for FY 2017. He also reported not having received any inspection results for FY 2018, except for facilities whose police programs were rated marginally satisfactory or unsatisfactory by OS&LE. Similarly, OS&LE did not prepare trend analyses or assessments of its inspection results and recommendations on police program performance at medical facilities. VA Lacked Facility-Appropriate Police Officer Staffing Models and Had Extensive Shortages of VA Police Officers The OIG found that VA could not have confidence that facilities maintained sufficient numbers of police officers to provide security and protection services given oversight system deficiencies. VHA lacked police officer staffing models that could be tailored to the needs of similar types of medical facilities to determine the appropriate number and composition of police officers. The OIG also found that many medical facilities were below their individual authorized levels of police officers. According to information provided from the Office of the DUSHOM for the OIG audit, VHA reported 4,881 police officer positions were authorized as of January 31, 2018, but 875 positions (18 percent) were vacant or in the process of being filled. Fifty-six of the 139 medical facilities with VA police operations (40 percent) reported officer vacancy rates of 20 percent or higher. Concerns about policing shortages in the audit are consistent with the OIG's staffing report released in June 2019, which examines medical facility directors' self-reported clinical and nonclinical staffing shortages. With regard to nonclinical shortages, police were the second highest reported nonclinical staffing need. \7\ --------------------------------------------------------------------------- \7\ OIG Determination of Veterans Health Administration's Occupational Staffing Shortages FY 2018, June 14, 2018. --------------------------------------------------------------------------- VA medical facility staff at five sites that the OIG visited noted several factors contributing to recruitment and retention challenges, including problems obtaining local facility approval to hire police officers due to changes in facility management. \8\ In addition, VA police salaries were not competitive with other local and Federal agencies and there were competing priorities in hiring healthcare staff. The OIG determined that four of the five medical facilities visited had over 20 percent vacancy rates. The medical facilities did not fully use staffing strategies such as recruitment planning or the use of special salary rates or incentives. --------------------------------------------------------------------------- \8\ The OIG selected five VA medical facilities for on-site review in North Little Rock, Arkansas; Denver, Colorado; Washington, DC; Albany, New York; and Columbia, South Carolina. --------------------------------------------------------------------------- The OIG found that the lack of facility-appropriate police staffing models and insufficient police coverage at VA medical facilities can affect security activities. VA medical facilities with insufficient numbers of police officers had to borrow officers from other facilities and use overtime pay to augment staffing levels to ensure adequate coverage. \9\ For example, the Hampton, Virginia, VA Medical Center (VAMC) borrowed 23 police officers from nine other medical facilities to work at the VAMC from December 2017 through April 2018, based on facility records. A shortage of police officers at the VAMC had been a concern since at least June 2017, when nine of 23 authorized police officer position were vacant. --------------------------------------------------------------------------- \9\ According to the VHA Chief Financial Officer, VHA facilities spent approximately $26.6 million in fiscal year (FY) 2017 on overtime pay for its police services. --------------------------------------------------------------------------- OS&LE Did Not Conduct Timely Inspections of VA Police Operations The OIG determined that as of September 30, 2017, OS&LE did not timely inspect 103 of the 139 VA medical facilities with police units (74 percent). OS&LE written procedures required its staff to inspect VA medical facility police units on a two-year cycle. On November 7, 2014, OS&LE changed that inspection process to require inspections of medical facility police units on a four-year cycle. OS&LE updated its own internal process on that same day to include an expectation that VISN police chiefs would perform midcycle (two-year) inspections. However, most VISN police chiefs did not start this process, and OS&LE did not receive any inspection reports in FY 2017 as expected. \10\ --------------------------------------------------------------------------- \10\ On April 14, 2018, OS&LE reverted to requiring its own staff to inspect VA medical facility police units on a two-year cycle. --------------------------------------------------------------------------- Based on the number and type of deficiencies identified in the inspection, OS&LE assigns police units an overall rating of outstanding, highly satisfactory, satisfactory, marginally satisfactory, or unsatisfactory. OS&LE written procedures require its staff to reinspect VA medical facility police units within one year for a marginally satisfactory rating and within 90 or 180 days for an unsatisfactory rating (depending on the governing policy in place at that time). The OIG found that of the 103 VA medical facility police units not inspected within prescribed time periods 95 VA medical facility police units had overdue cyclical inspections by an average of 286 days, or about 10 months, over the two-year inspection cycle; Four VA medical facility police units previously rated as marginally satisfactory were not reinspected within one year (with the average for these untimely reinspections at 345 days, or close to 12 months, beyond the one-year reinspection requirement); and Four VA medical facility police units previously rated as unsatisfactory were not reinspected within the applicable 90- or 180- day reinspection requirement (with the average for these reinspections at 162 days, or just over five months beyond the applicable timeline). The OIG determined that these delays were attributed to OS&LE having limited staff available for inspections. Since 2014, OS&LE had six employees in its inspection division to inspect medical facility police units along with other divisional duties. There were only three employees available for inspections by the end of FY 2017 (that is, September 2017) because the other three employees were reassigned within OS&LE to assist with the protection of the then VA Secretary and Deputy Secretary. Having overdue inspections of medical facility police units limits VA's ability to know whether programs or police officers are performing adequately, and whether previously identified deficiencies are corrected. VA has taken important steps in this area. OSP requested 10 additional employees for FY 2019 to support OS&LE operations including inspections of medical facility police units. As of April 2019, OSP reported that nine employees were hired with seven of them solely focused on performing police inspections. VA Officers Lacked Guidance on Investigating Facility Leaders Who Manage Their Program or Control Its Resources Under the supervision of the medical facility director, VA police officers investigate reported crimes and misconduct, and the police chiefs brief and consult with the facility director on the status of all investigative activities to determine further investigative or referral actions. The OIG identified two instances in which VA police officers performed investigations into alleged misconduct of facility leaders who managed the police program or had control over program resources at their own medical facilities. These types of investigations occurred because VA did not have written guidance specifically for VA police on how to appropriately investigate misconduct allegations involving their local facility leaders, including coordination with other offices and documenting decisions. RECOMMENDATIONS The OIG made five recommendations to the VA Deputy Secretary that focused on the areas of governance, staffing, the inspection program, and processes. 1. Clarify program responsibilities between the Veterans Health Administration and the Office of Operations, Security, and Preparedness, and evaluate the need for a centralized management entity for the security and law enforcement program across all medical facilities. 2.Ensure police staffing models are implemented for determining facility-appropriate levels for officers at medical facilities. 3.Make certain medical facilities use strategies to address police staffing challenges such as having documented recruitment plans for police officer positions that include a determination of the need for special salary rates and incentives. 4.Assess the staffing levels for the Office of Security and Law Enforcement police inspection program and authorize and provide sufficient resources to conduct timely inspections of police units at medical facilities to help identify program compliance issues. 5.Ensure procedures are developed for appropriately handling VA police investigations of medical facility leaders. At the time the OIG report was published, the acting VA Deputy Secretary concurred with all recommendations and requested that recommendation five be closed. However, the OIG considered this recommendation to be open until written procedures were developed for VA police officers concerning how they should appropriately handle their investigations of medical facility leaders. As of April 2019, VA responded that it plans to have the Office of General Counsel and Office of Accountability and Whistleblower Protection coordinate to assist with language to be crafted for inclusion into the latest VA Handbook 0730. This will provide procedures for VA police to refer allegations against medical facility leadership to the proper investigative authority. Until the OIG receives documentation, that recommendation, and all others, remain open. ONGOING WORK ON THE POLICE PROGRAM From information gleaned from the police governance audit, the OIG learned that the information systems VA police use to make resource- allocation and other key management decisions have created obstacles to their work. Effective program governance relies on information management to respond to risks and achieve program objectives. Recognizing the critical link between these systems and monitoring capabilities, the OIG is currently conducting additional audit work on information management within the police program. This work will focus on whether the VA police program's information management strategy and systems provide its leaders and workforce with the information needed to manage and guide operational performance. The audit team will identify the causes of VA's challenges in transitioning to a new police information system and the impact on the operation and governance of the program. CONCLUSION Having an effective governance structure is critically important to the functioning of any program. The confusion about program roles and authority makes it difficult for VA to have any degree of certainty that its police personnel and resources are being effectively deployed. The safety of veterans, VA staff, and visitors to VA medical facilities is of paramount importance to VA. To achieve its goals for protecting those individuals and VA property, the governance structure, staffing issues, and proper program oversight processes must be addressed. At the center of those decisions are whether the governance structure should be more centralized and, if so, how that should be accomplished. That includes determining whether medical facility directors are best positioned to provide oversight of police functions and how information flows both up and down the various levels of VA to ensure that staffing, policies, practices, and oversight are effective. Mr. Chairman, this concludes my statement. I would be happy to answer any questions you or other Members of the Subcommittee may have. Prepared Statement of Renee Oshinski Good morning Chairman Pappas, Ranking Member Bergman, and Members of the Subcommittee. Thank you for the opportunity to discuss VA's current and future policing strategy. I am accompanied today by Kevin Hanretta, the Principal Deputy Assistant Secretary for Operations, Security, and Preparedness (OSP), and Frederick Jackson, the Executive Director for the Office of Security and Law Enforcement. Introduction VA police officers are Federal law enforcement officers who serve a critical role in securing VA property and protecting patients, visitors, and employees. These officers provide security and law enforcement services at all VHA Medical Centers and at Veterans Benefits Administration (VBA) offices that are co-located with VHA facilities. These officers are also sometimes responsible for providing security and law enforcement services at VA national cemeteries. Ensuring physical security at VA Medical Centers (VAMC) can be complicated because VA police must balance safety and security concerns with providing an open and welcoming health care environment to our nation's Veterans. To address physical security issues, VAMCs have implemented: panic buttons, badge restricted access to certain areas, limited guest hours, security camera monitoring, emergency preparedness training, and more. In addition to physical security enhancements, VA facilities have also increased police presence on VA campuses. To accurately allocate resources, Physical Security and Vulnerability Assessments are performed at the local level every two years to identify risk at each VAMC as requirements may differ. For example, what works in a rural hospital may not make sense in an urban setting. The one crucial, consistent requirement at all VAMCs is collaboration between law enforcement and health professionals when responding to violent incidents or police calls for service in the field. It is VA's goal to ensure health care providers and police personnel work collaboratively while protecting the safety of our unique Veteran population. The Office of Security and Law Enforcement (OSLE) is responsible for ensuring that VA has an effective program in place for the protection of Veterans, staff, and visitors who use VA facilities. Through an active program of policy reviews and development, along with researching and applying the most modern of police techniques, OSLE works to ensure that VA facilities have highly effective VA Police programs. Further, Special Agents/Inspectors within OSLE have responsibility for certain regions of the country and provide direct technical and logistical support to VA Police Chiefs and VHA facility management within their assigned regions. These Special Agents/ Inspectors are in regular contact with their respective Police Chiefs and facilities and are available to respond as needed when situations arise. Structure and Accountability The primary responsibilities of the VA Police are to deter and prevent crime, maintain order, and investigate crime (ranging from misdemeanor to felony offenses), that may have occurred within the jurisdiction of the Department. VA Police are also our frontline staff with each Veteran. How VA Police handle law enforcement/safety issues is a critical component of the customer service culture instilled at each individual facility. As such, police/law enforcement staff are some of our most important customer service ambassadors. Currently, VA police forces fall under the organizational structure and management control of VHA with each local police unit being aligned under the Medical Center Director's office. VA Police are organizationally structured as an administrative service line within the Medical Center, but they are matrixed to OSLE for all matters related to criminal activity or specific to law enforcement. OSLE, organizationally located within OSP, has tacit oversight of all VA Police units in the field through issuance of VA policy, inspections of police programs, and the training of VA police officers. Oversight and accountability for law enforcement activities is the responsibility of the Chief of Police at each Medical Center. The Chief of Police is directly accountable to the Medical Center leadership and, for all matters related to criminal activity, use of force, or investigations, to OSLE. VA does not have a centralized budget line for VA Police. The budget for police services is allocated by facility leadership based on their unique needs and requirements. Annually, as with all services lines, the Chief is responsible for formulating a budget and presenting their budget requirements for the following fiscal year to the Chief Financial Officer at the VAMC. Federal Law Enforcement Best Practices Other Federal agencies with law enforcement responsibilities similar to VA have a centralized program office that oversees operations as well as some oversight functions. These agencies include, for example, the Department of Homeland Security's Federal Protective Service, the Department of Interior's National Park Service, and the Army Military Police Corps. As VA continues to modernize its police force, we will continue to incorporate the very best evidence-based practices from Federal and private industries. To incorporate those best practices, VA will need to look to private sector health care organizations and our university affiliates who use armed police services in addition to those best practices from Federal entities. VA has a unique responsibility to provide a healing environment while balancing the need to provide safety and security to Veterans, staff, and visitors. VA Police Officer Training VA police officers' encounters and methods of law enforcement are often unique because their work is conducted in and around a clinical or medical setting. Enhanced methodology and incident solutions (including advanced interpersonal communication, conflict resolution, and problem-solving skills) are required to be successful. VA Police also often encounter trained military Veterans suffering from medical and psychological traumas. Due to the unique policing environment, all VA police officers receive specialized training at the VA Law Enforcement Training Center (LETC). Located in North Little Rock, Arkansas, the VA LETC is accredited by the Federal Law Enforcement Training Accreditation Board and is recognized as meeting the highest standards in Federal law enforcement training. The VA LETC embraces a 21st century policing framework to teach new police officers how to respond in a Veteran-centered environment unique to VA. It is the sole Federal government provider of a training program that emphasizes the use of non-physical techniques to ensure the safety of patients, visitors, and staff while maintaining order at VA facilities. VA police officers are taught the necessary skills to resolve incidents in a humane, respectful manner. At the VA LETC, VA police officers go through a 10-week basic training course where they receive 30.5 hours of classroom training specific to de-escalation and conflict management techniques with a new special focus on suicide awareness and prevention. Officers also complete nearly 24 hours of practical based scenarios in which they are expected to successfully employ and utilize de-escalation skills to affect positive outcomes in real-life scenarios. VA leadership will continue to focus on providing security education that incorporates issues specific to health care. As our police officers play an active and vital role in the clinical arena, security training with an emphasis on health care will enable our police officers to use their independent judgement to assess situations and determine appropriate responses to our unique Veteran population. VA police officers also receive continuous in-service and specialized training beyond the basic training course. Moreover, other government agencies use the VA LETC as a training site due its reputation for excellence. These agencies include the Department of the Air Force Police, Navy Master of Arms, National Institute of Health, National Geospatial Institute, and the Federal Bureau of Prisons. VA Police Officer Staffing Statistics VA recognizes that the Department has a shortage of 700 police officers and needs to do a better job with the hiring process. VA has initiated changes to the hiring process for facility level chiefs. A recent best practice identified a large private sector organization in Missouri that includes two interview panels, one comprised of law enforcement personnel and the other of hospital leaders, to ensure the organization is hiring ``an individual that can operate in both worlds.'' The use of two interview panels will ensure VA hires police that are a good fit with our health care environment and the Veterans we serve. Policing in a health care environment is different from traditional policing. VA currently employs nearly 4,200 police officers. The average yearly growth rate from fiscal years (FY) 2014- 2018 was 3.1 percent. There were 402 net gains (increases above losses) for a total of 12.3 percent growth since 2014. Despite the 3.1 percent growth, VA believes there is a need for additional staff. The average age of VA police officers is 45 years and their average tenure is 12 years. Many of our VA police officers are currently retirement eligible or working with the Agency as a second career. The average salary for this occupation is approximately $53,000 for FY 2019. The median salary cited by the Bureau of Labor Statistics is slightly over $63,000 for police and detectives nationwide. Total loss rates from FY 2014 - FY 2018 range between 7.5 percent and 10.3 percent, and voluntary quit rates range between 4.9 percent and 6.7 percent. In 2018, 32.4 percent of VA police officer turnover was due to transfer to another Federal agency; 20.6 percent transferred to state and local government agencies; and 13.2 percent of police left VA employment for the private industry or self-employment. The remaining 33.8 percent of the turnover was due to retirements, resignations without explanations, and removals. VA recognizes the need to improve retention of these officers. The VA Exit Survey provides 15 possible responses as reasons for leaving VA. For analysis, these reasons are consolidated into six thematic categories: advancement, personal/family, workplace issues, compensation/benefits, retirement, and no response. Recognizing lack of opportunity and compensation are key reasons for loss, VA is currently working on a structured career ladder and assisting facilities in submitting special pay rates where VA police officers are compensated below the prevailing rate in the surrounding community. VA's police workforce response rate on the exit survey is low at 18 percent (68 responses out of 375 losses in FY 2018). Of those that responded, the most frequently cited reasons for leaving VA were: (1) workplace issues; (2) lack of opportunities for advancement; and, (3) compensation/benefits. In 2016, OSLE introduced a VA Police Officer Staffing Model initiative that has been piloted at select facilities. When completed, this model will establish Department-wide staffing requirements for VHA, VBA, and the National Cemetery Administration by determining the optimal number of police officers using demographic information from local facilities. Medical Center Director VA Handbook 0730, Security and Law Enforcement provides requirements for security and law enforcement at VAMCs. Medical Center Directors are required to provide for the protection of persons on Department property in accordance with the standards set forth in Handbook 0730; provide for the protection of government property; ensure law enforcement activities are accomplished in a legally and technically correct manner; maintain and equip a sufficient number of VA police officers to ensure the protection of persons and property; and ensure that law enforcement and security measures are sufficient to meet such requirements. Additionally, the Joint Commission, the organization that accredits over 21,000 U.S. health care organizations and programs, sets standards and expectations at a leadership level for the Medical Center Director. At a minimum, the Medical Center Director is responsible for assessing and addressing security risks associated with the environment of care that could affect patients, staff, and other people coming to the hospital's facilities and controlling access to and from areas identified as security sensitive. The Medical Center Director is also responsible for identifying and implementing procedures related to security incident responses at a medical facility, training staff on security procedures, and orienting all staff to both the procedures to be followed during a security incident and the respective responsibilities of staff, including orienting staff to how such security procedures will affect staff, patients, and visitors. Medical Center Directors, in conjunction with Chiefs of Police, OSLE, OSP, and the VA LETC collaborate and build community partnerships aimed at addressing specific medical and security issues relevant within the Veteran community. For instance, the VA LETC in conjunction with VHA clinical leaders, developed community training to bolster suicide prevention initiatives. The training provides guidance on identifying individuals who may be ``at risk'' for suicide and identifies prevention measures that can be implemented. The collaborative training emphasizes recognition of the warning signs of suicide and encourages individuals to assist in bringing ``at risk'' individuals to VA facilities for care before they reach a point of crisis. Office of the Inspector General (OIG) and Government Accountability Office (GAO) Reports VA appreciates the reviews done by both OIG and GAO as these reports, though critical, have strengthened VA's police service. In February of 2019, the VHA Executive In-Charge directed the Veteran Integrated Service Networks (VISN) to assign a full-time police chief to each VISN office. Each Network currently has a VISN Chief that oversees facility police operations on a full-time basis. The VISN Chiefs' function is to improve processes and address deficiencies, identify facilities that need assistance with requesting special pay rates for officers, implement mitigation plans for facility specific physical security vulnerabilities, examine trends in the police program's evaluations, develop systematic strategies to address challenges, and to work closely with OSLE and Human Resources to develop an appropriate and overdue career ladder for VA officers. In keeping with the advances made at the VISN level, VA is also looking at ways to improve the governance structure at the Department-level to ensure better accountability, proper application of policy, and to allow for rapid deployment of assets, as needed. VHA has also expanded oversight of the police service by hiring a VHA Senior Security Officer, developing a New Chief Orientation Guide, working with OSLE and VA LETC to train hospital leaders overseeing police services, developing national mitigation strategies based on findings from inspection reports and physical security vulnerabilities assessments, developing enhanced communication reporting to ensure VHA senior leadership are aware and responsive to critical incidents and security risks, and by instituting daily communications between VHA senior leadership and VISN Chiefs. Conclusion We look forward to this opportunity for our improvement efforts to further restore the trust of our Veterans and continue to improve access to care inside and outside VA. Our objective is to give our Nation's Veterans the top-quality care they have earned and deserve while keeping them safe within our walls. Chairman Pappas, we appreciate this Subcommittee's continued support and encouragement in identifying and resolving challenges as we find new ways to care for Veterans. This concludes my testimony. My colleagues and I are prepared to respond to any questions you may have. STATEMENTS FOR THE RECORD AMERICAN FEDERATION OF GOVERNMENT EMPLOYEES, AFL-CIO Chairman Pappas, Ranking Member Bergman, and Members of the Subcommittee, the American Federation of Government Employees, AFL-CIO and its National Veterans Affairs (VA) Council (AFGE) appreciate the opportunity to submit a statement for the record on oversight of the VA's police force. AFGE represents more than 700,000 Federal and District of Columbia government employees, 260,000 of whom are proud VA employees including the vast majority of rank and file members of the VA police force. AFGE appreciates the thorough oversight conducted by the VA Office of Inspector General (OIG) in its December 13, 2018 report, ``Inadequate Governance of the VA Police Program at Medical Facilities.'' As the largest labor representative of front-line medical professionals and support personnel at VA medical facilities across the nation, we regularly hear concerns about the safety of veterans, their families and the employees who care for them because of chronic short staffing of VA police and other deficiencies in the operation of the VA Police Program. The VA currently has over 50,000 unfilled positions, and the vast majority of those unfilled positions are at medical facilities. AFGE was dismayed by Secretary Wilkie's recent testimony that he is not planning to fill all the vacant positions. It is also problematic that the current vacancy data reported by the VA does not break down the data by position. Lawmakers, employee representatives and veterans' groups would be better able to hold the VA accountable for adequate police staffing if such data were available. The short staffing of VA police greatly affects facility safety, especially in emergency rooms and mental health units. Most facilities appear to have only two officers assigned to cover the entire medical facility campus, regardless of the number of patients treated, building size or distance between buildings on the same campus. Similarly, VA police coverage is absent in many Community-Based Outpatient Clinics and other VA outpatient clinics. Consequently, clinic employees feel especially vulnerable because they often must rely exclusively on overtaxed local police forces in the event of a dangerous incident. AFGE local presidents at medical facilities in Florida, Missouri and other locations where veteran suicides have occurred in the recent past have also pointed to short staffing of police officers as causing a critical gap in workplace and patient safety. VA provides invaluable training to its police officers to respond to veterans threatening to take their own lives. These specially trained first responders are spread too thin to do their part to help prevent such tragedies. Our Hampton, Virginia local president has reported that due to the 48 percent police vacancy rate at her facility identified by the OIG, the facility may have to resort to the costly contracting out of security officers with less specialized training. Prior efforts to use contract security officers at the Hampton facility were unsuccessful and diverted precious VA dollars away from other needs. We have also heard that other facilities are considering contracting out this vital function. Our Palo Alto, California local reported that management's response to chronic short staffing of police officers is to restrict the ability of officers to take leave and require frequent graveyard shifts, leading to fatigue and low morale. Human Resources has not been responsive to the union's concerns about police officer working conditions or the urgent need to hire more officers. Thus, it is no surprise that the VA police force experiences 100% turnover every four years. Many AFGE locals echo the view that VA has significant weaknesses in recruitment and retention of a strong VA police force. VA police pay is not competitive with other Federal agencies or the private sector. Even when special salary rates are approved in high cost areas, the approval process has been slow, and officers are frustrated by the agency's unwillingness to provide retroactive pay to the date of approval. Another contributing factor to recruitment and retention challenges is the longstanding inequity in pay and benefits within the Federal law enforcement workforce. VA police are not considered law enforcement officers, and do not have comparable pay and benefits with other Federal police forces with similar jobs and duties. Therefore, AFGE strongly supports H.R. 1195, the ``Law Enforcement Officer Equity Act'' that would amend the definition of the term ``law enforcement officer'' to include VA police officers and other Federal employees whose duties include the investigation or apprehension of suspected or convicted individuals and who are authorized to carry a firearm. AFGE is pleased that Fred Jackson, Director of the Office of Security and Law Enforcement (OS&LE), recently stated to our members that he recognizes that the current staffing model of two police per facility is inadequate. Mr. Jackson also indicated that he is looking at new staffing models that consider the size of the facility and the geographic area that needs to be covered. AFGE strongly urges the Subcommittee to ensure that front line police officers and their employee representatives have meaningful input into the process for addressing the deficiencies identified by the OIG. To that end, we have attached a recent letter sent by Andrew U. Peterson, Acting Vice Chair of the AFGE Law Enforcement Committee to Acting VA Deputy Secretary James M. Byrne stating that he and his colleagues welcome the OIG report and requesting that Deputy Secretary James act on the recommendation of AFGE National VA Council President Alma Lee to form a joint labor-management work group or exploratory committee to review proposed changes, conduct surveys and outline all areas of impact. Labor-management collaboration could be extremely valuable for addressing all the OIG recommendations including staffing models, retention and recruitment strategies, ensuring timely inspections, effective officer investigations and overall accountability for policy program operations and performance. Training is another area where the input of front-line employees and their union representatives are critical. We received a report that the Law Enforcement Training Center Training does not distinguish adequately between new officers and those who join the VA police force with substantial prior experience. Collaboration on the design of future training programs could avoid duplication and address unmet training needs. AFGE strongly supports H.R. 1309, the ``Workplace Violence Prevention for Health Care and Social Service Workers Act'' that would require the Occupational Health and Safety Administration (OSHA) to establish a new rule and require employers to develop workplace violence prevention plans. Each plan would ``be developed and implemented with the meaningful participation of direct care employees and, where applicable, employee representatives and collective bargaining.'' More effective governance of the VA Police Program and formal ongoing VA labor-management collaboration would be essential components to this new OSHA rule. Thank you for considering the views of AFGE. We look forward to working with the Subcommittee to achieve improvements in the VA Police Program and ensure that veterans, their families and the dedicated employees who care for them are safe. Letter from AFGE Law Enforcement Committee March 17, 2019 To: The Honorable James M. Byrne, Acting Deputy Secretary of Department of Veterans Affairs Subject: VA OIG Report #17-01007-01, Inadequate Governance of VA Police Mr. Byrne, In December 2018, you received the VA Office of Inspector General's Report, ``Inadequate Governance of the VA Police Program at Medical Facilities.'' The issues presented in the OIG report are not new to VA Police. In fact, rank and file Officers welcome this report, as it reflects concerns that we have been attempting to address for many years. I am aware that you have received and are taking action on the report. As the National VA Council (NVAC) Representative on the Executive Board of the American Federation of Government Employees (AFGE) Law Enforcement Steering Committee, I have presented some points of discussion to NVAC President Alma Lee regarding the OIG Report. President Lee recommended a joint work group or exploratory committee with agency and union representatives for reviewing potential improvements to the VA Police Service. The group would review the pros and cons of different ideas, conduct surveys, and outline all areas of impact. We would like the agency to consider such a cooperative effort to develop improvements to the VA Police Service. Together, we may come up with solutions that would lead to long term proactive developments for the Police Service, and ultimately improve the safety and security of our facilities for Veterans, visitors, and employees alike. We look forward to hearing back on the possibility of collaboration. Andrew U. Peterson Acting Vice Chair and NVAC Representative AFGE Law Enforcement Committee, American Federation of Government Employees, AFL-CIO JEAN TELFORT My name is Jean Telfort, and I am a 100% service-connected disabled veteran. I have been diagnosed with Post-Traumatic Stress Disorder (PTSD) and have suffered debilitating nerve damage to my left arm, a shattered upper hip and thigh, and spine injuries from my tour of duty in Afghanistan. I live in Nassau County, New York, and have been receiving care at the Northport VA Medical Center since 2012. In November 2017, I required spine surgery to prevent quadriplegia. After the surgery, physical therapy (PT) and occupational therapy (OT) were a vital part of the recovery process. I successfully received PT and OT at a community facility close to home where I had been treated in the past. However, Northport ended my community care about four months after my surgery, and my treatment did not resume until I had my first PT session at Northport on June 4, 2018. I had gone nearly five weeks without the therapy necessary for my rehabilitation, and my level of discomfort and pain had started to increase. On June 6, 2018, I woke up with major back pain. That morning, I returned to Northport for my second PT appointment and saw my primary care doctor to consult about the pain I was experiencing post-surgery. My doctor sent me to take x-rays and then to Northport's Physical Medicine and Rehabilitation (PM&R) Clinic to make an appointment with a shoulder specialist. I arrived at PM&R and greeted the two medical support assistants (MSAs) at the front desk. One of the individuals acknowledged me and I proceeded to explain that I had been instructed to schedule an appointment with a specialist. The other MSA, who had been on her cellphone up until this point, interjected and told me my story was unnecessary because the two specialists were not in. She said I could leave a note for them to follow-up. I tried to explain the urgency of the situation due to the pain I was in and asked whether someone else might be able to assist me. The MSA went from annoyed to angry and told me ``we are not going to do this today.'' I asked what she meant by that, and she continued to speak over me during the brief, and frustratingly rude, exchange that followed. After some back and forth, she threatened to call the police on me. I welcomed the call because I had done nothing except ask for assistance. She called the police. Almost immediately, a young police officer entered the waiting area. I stood calmly in front of the reception desk and leaned on the counter. I had stopped engaging in the exchange with the MSA, so the room was quiet when the officer arrived. He asked, ``Sir, is everything okay?'' I answered, ``Officer, I was sent down here by my primary care doctor to schedule an appointment for specialty care. Since I arrived here, this lady has done nothing to help me except telling me what's not going to happen; she kept interrupting me every time I tried to speak by talking over me. When I tried to remind her that I am the patient and needed to be heard, she followed no professional protocol and threatened to call you guys on me. I don't have a problem, maybe she does.'' The lone officer said, ``Okay Sir, would you like to take a walk while I get her version of the story?'' I replied, ``Officer I have been up since 5AM to get here on time for a 7:30 PT appointment. I am tired. I will take a seat and wait to see if anybody will help me. The Officer said ``Okay.'' I sat down and started to read the book I had with me. The MSA proceeded to tell the officer her version of the story. A bystander two seats to my left whispered ``that's not what happened at all.'' I stood up remaining in front of the chair and said, ``Officer when you're finished, there are people here who witnessed what happened and they are willing to speak to you.'' As the officer affirmed he would do so, two other officers walked in. One of them came directly up to me, got in my face and said, ``You need to calm down.'' I explained that I was simply trying to communicate with the original officer about what had transpired. The officer who got into my face then ordered me to ``sit down'' again. I replied, ``Officer, I am fine.'' He then grabbed my left arm in a forceful manner-this is the arm with nerve damage, muscle atrophy and finger paralysis-and said, ``LET'S GO FOR A WALK.'' I responded, ``Officer, you have no right to put your hand on me, you need to let me go.'' All I can remember after that moment is bracing myself for impact as I was lifted and body-slammed to the ground face down. There were multiple officers on me, one officer was pressing my neck on the ground while I screamed: ``I just had spine surgery, I can't breathe!'' My scream didn't seem to matter. They handcuffed my left arm and tried very awkwardly to force my right arm to my back-this resulted in three tears to my shoulder. I felt a knee in the center of my back and a foot pressed between my shoulder blades. I continued to cry out in pain and shame. I then heard the voice of one of my former therapists. She asked the officers what they were doing, explained that she knew me, and that I had problems with my hips and hands and had just received spinal surgery. One of the officers responded that I had resisted arrest, which led to my therapist's next question, ``arrest for what?'' She ran over, grabbed my face and told me to look at her. She said, ``It's okay, I am going to help.'' I was crying; ashamed, shocked, humiliated and in terrible pain. I asked my therapist what had just happened as I struggled to process how I had gotten to this point. I was surrounded by paramedics and a doctor. The doctor was asking me questions and trying to reassure me that everything would be okay. I told the doctor I was in severe pain and my shoulder felt like it was on fire. The doctor requested that the handcuffs be removed. One of the officers responded ``No'' and added that I ``would escalate'' if my hands were free. The doctor observed that I was in tears and appeared to be under control. The officers provided me some relief by putting the two handcuffs together. Being transported to ER in handcuffs only furthered my humiliation. When I arrived at the ER, the attending physician informed me that I would need to calm down before I received treatment because my blood pressure was too elevated. The officers were asked to remove the handcuffs. They handcuffed me to the bed like a criminal. About five officers stood on the other side on the curtain that separated us. I could hear them seemingly try to get their story straight. I overheard one of them say, ``You saw when he hit me,'' and my heart sank. I realized they were trying to blame me for their actions. To protect myself, I asked the nurse to contact the OEF/OIF Program Manager to be my advocate and witness. I spent hours in the ER and went to Radiology for several X-rays to ensure nothing was broken and the screws in my back were not displaced. After I was discharged, I requested to see the patient advocate to place a complaint. I was advised to get a copy of the incident report, so I went to the police annex to do so. I was told I needed to complete a request form and the incident report would be mailed to me. Over a week later, instead of an incident report, I received two tickets in the mail: one for disorderly conduct with a $130 fine attached, the other for assaulting/resisting an officer. I was shocked-I hadn't assaulted anyone, and now I was being summoned to Federal court. Two days after receiving these tickets, I returned to the Northport VA police annex to follow up on my request for a copy of the police report. I was told it wasn't ready, and that it would be mailed out in a couple days. I didn't know anything about the legal process for dealing with tickets from the VA in Federal court. I had to make several calls to local law offices and Federal defenders to understand the severity of the situation these tickets could cause. Everyone I spoke to about the incident requested either a video or police report. Growing frustrated by the lack of support, I returned to Northport a week later to follow up on the status of the police report. After an unsuccessful attempt to retrieve it from the police annex, I was directed to another office for assistance. Finally, after a forty-five- minute wait, two weeks and three trips to Northport, I was handed the police report. However, nobody could provide me with any information about the summons I had received. The tickets couldn't be located in any system, and the only advice I was given was to wait and see what unfolds. Another month passed before I received a formal notification in the mail to appear at the U.S. District Court for the Eastern District of New York in August. When I showed up for my first appearance in court, there was no judge present that day. A lawyer representing the Northport VA police was there, as well as an officer from the police annex who I recognized as the individual I had spoken to previously about obtaining the report. The lawyer spoke to me about negotiating a plea deal and read from some of the witness statements he had. The officer informed me that he had conducted an investigation of the incident and produced six witness statements. I didn't understand why an officer from the Northport VA police would be the one handling an investigation into an incident involving his other officers. He had never spoken to me to get my account of the incident but had concluded in the report that I was at fault and his officers acted accordingly. The report hadn't mentioned my interaction with the first officer on the scene, and there had only been two eye-witnesses present when the incident had occurred. I didn't accept the plea deal that day. I didn't have any legal representation at that point, and I was not confident that taking the word of the lawyer for the Northport VA police would be in my best interest. Northport's representation failed to appear for my next two scheduled court dates. The last time I appeared in court was in January, and a different lawyer was present this time on behalf of Northport. Again, the lawyer tried to intimidate me into taking a plea without seeing a judge. Last week marked one year since my unfortunate incident with the Northport VA police, and I am still in the dark about what is going on. Despite several court appearances, I have yet to see a judge and no one seems able to inform me about the status of these tickets. Following the incident, it was weeks before I could restart the PT I needed for my back. I am still receiving PT for my right shoulder. New problems surfaced with my left arm, leading my spinal surgeon to believe the incident created new nerve damage. These physical wounds are accompanied by the emotional and psychological struggles that I face every day. I have been through a lot in my 52 years of living, but this incident was the most humiliating and painfully devastating experience of my life. In the seven years that I have been receiving care at the Northport VA, I have never had an issue with anyone until that day when I was confronted by the VA police. I earned my healthcare through my service, and veterans deserve to access care at VA facilities without fear of being harmed when they are seeking help. I believe that the Northport VA and its police officers failed me on Wednesday, June 6, 2018, and they continue to harm me with each passing moment I am denied closure. The negative impact this whole ordeal has had on my health and overall well-being is not a representation of the VA living up to its mission statement to care for veterans. [all]