VA Office of Inspector General Office of Audits and Evaluations Logo Department of Veterans Affairs Office of Inspector General Seal Veterans Health Administration Audit of Guide and Service Dog Program OFFICE OF AUDITS & EVALUATIONS July 7, 2010 10-01714-188 ACRONYMS AND ABBREVIATIONS ADI Assistance Dogs International PSAS Prosthetics and Sensory Aids Service PTSD Post-Traumatic Stress Disorder To Report Suspected Wrongdoing in VA Programs and Operations: Telephone: 1-800-488-8244 E-Mail: vaoighotline@va.gov (Hotline Information: http://www.va.gov/oig/contacts/hotline.asp) Department of Veterans Affairs Office of Inspector General Seal Report Highlights: Audit of VHA’s Guide and Service Dog Program Why We Did This Audit The Conference Report to accompany Public Law 111-117, Consolidated Appropriations Act, 2010, directed the OIG to review the Guide and Service Dog Program. VHA is authorized to provide financial support for guide dogs to assist visually impaired veterans and service dogs to assist veterans with mobility, hearing, or mental impairments. The audit evaluated VHA’s progress in providing guide and service dogs to qualified veterans. What We Found VHA faces challenges implementing the Guide and Service Dog Program in the absence of implementing criteria. VHA assisted visually impaired veterans in obtaining guide dogs for several decades. VHA only started assisting mobility and hearing impaired veterans with service dogs in 2008—6 years after being authorized to do so. Since FY 2009, VHA provided financial support to over 230 veterans for guide dogs. However, VHA provided financial support to only eight veterans for service dogs. VHA personnel told us the actual demand for service dogs is unknown. This occurred because VHA had not provided sufficient guidance to VA medical center personnel to ensure consistent decisions on veterans’ requests for service dogs. Also, VHA had not made their personnel fully aware of these potential benefits and the application process involved. VHA Handbook 1173.05 only prescribes policies and procedures applicable to providing guide dogs to visually impaired veterans. VHA is in the process of determining the appropriateness of using service dogs to assist veterans with mental impairments. What We Recommended We recommended the Under Secretary for Health issue comprehensive interim guidance to ensure VA medical center personnel are aware of and better understand the qualifying criteria for service dog benefits and the process required to apply for them. Agency Comments The Under Secretary for Health agreed to develop clinical criteria to determine whether a veteran would benefit from a service dog. The Under Secretary also stated that immediately after the formal regulations exercising VHA’s authority are published, scheduled for July 2011, VHA will issue a directive defining VHA’s policy on issuing service dogs. We will monitor implementation of the planned actions. (original signed by:) BELINDA J. FINN Assistant Inspector General for Audits and Evaluations TABLE OF CONTENTS Introduction.....................................................................................................................................1 Results and Recommendations ........................................................................................................2 Finding VHA Faces Challenges Implementing the Guide and Service Dog Program.....2 Appendix A Scope and Methodology..................................................................................... 8 Appendix B Agency Comments........................................................................................... 10 Appendix C OIG Contact and Staff Acknowledgments....................................................... 12 Appendix D Report Distribution .......................................................................................... 13 Audit of VHA’s Guide and Service Dog Program Objective Legislative History VHA’s Guide and Service Dog Program INTRODUCTION The Conference Report to accompany Public Law 111-117, Consolidated Appropriations Act, 2010, directed the OIG to review the Guide and Service Dog Program. The audit evaluated VHA’s progress providing guide and service dogs to qualified veterans. Appendix A describes the scope and methodology used to answer the audit objective. Since 1961, VHA had been authorized to assist visually impaired veterans with guide dogs by paying for veterinary care, equipment necessary for the dog to maintain its assistive role, and travel expenses for training purposes. In January 2002, Public Law 107-135 expanded VA’s authority to include service dogs trained for the aid of hearing and mobility impaired veterans. Then in December 2009, Public Law 111-117 authorized VA to provide service dogs trained to aid individuals with mental illnesses, including posttraumatic stress disorder (PTSD). VHA received $1.8 billion in FY 2010 Prosthetic Specific Purpose Funds to cover their prosthetics costs—including costs associated with guide and service dogs. VHA Handbook 1173.05 prescribes policies and procedures applicable to providing guide dogs to visually impaired veterans. From October 1, 2008 through March 31, 2010, VHA paid for veterinary care and equipment for over 230 guide dogs for visually impaired veterans. Patient care providers prescribe prosthetic items such as guide and service dogs to help the needs of disabled veterans. A guide dog is one that has been specially trained to guide a blind or visually impaired person. A service dog is one that has been specifically trained to help people who have disabilities other than visual impairments. Service dogs can be trained to assist veterans with daily living activities, by pulling a wheelchair, by picking up or retrieving items, or by alerting the hearing impaired to intruders or sounds. Once prescribed by the provider, VHA’s Prosthetics and Sensory Aids Service (PSAS) staff at either VA Central Office or the VA medical center work with the provider and veteran to determine if the item is authorized and available. PSAS in Central Office authorizes service dogs for veterans. VA medical center PSAS staff authorizes guide dogs for the visually impaired veterans. If authorized, the veteran obtains the dog from an accredited, nonprofit organization with no charge to VA or the veteran for the dog. Eligible expenses are billed directly to the veteran’s VA medical center. From October 1, 2008 through March 31, 2010, VHA paid about $243,000 for eligible expenses or about $870 per dog in FY 2009. Audit of VHA’s Guide and Service Dog Program Finding Guide and Service Dog Authorizations RESULTS AND RECOMMENDATIONS VHA Faces Challenges Implementing the Guide and Service Dog Program VHA faces challenges implementing the Guide and Service Dog Program in the absence of implementing criteria. While VHA authorizes guide dogs to assist visually impaired veterans, VHA’s authorization of service dogs to veterans with other impairments such as hearing or mobility had been limited to only eight veterans. VHA had not authorized any service dogs to veterans with mental impairments. This occurred because VHA had not provided sufficient guidance to VA medical center personnel to ensure consistent decisions on veterans’ requests for service dogs. Specifically: . VHA Handbook 1173.05 only prescribes policies and procedures applicable to providing guide dogs to visually impaired veterans; the handbook does not address service dogs. In June 2009, VHA submitted a draft regulation addressing both guide and service dogs to the VA’s Office of General Counsel but are not expecting approval until July 2011. . VA medical center staffs were not fully aware of the financial support that VHA provides for veterans with service dogs. We found that knowledge and use of service dogs at VA medical centers was incomplete and inconsistent. . VHA is in the process of determining the appropriateness of using service dogs to assist veterans with mental impairments. In October 2009, Congress required VA to conduct a study of the value of providing service dogs to mentally disabled veterans. Then in December 2009, Congress directed VA to immediately begin the process of assisting veterans with mental illnesses who would benefit from having a service dog. As a result, VHA’s Guide and Service Dog Program could not ensure that all qualified veterans received the opportunity to benefit from service dogs. Since FY 2009, VHA provided financial support to over 230 visually impaired veterans for guide dogs but approved financial support to only 8 veterans with service dogs. PSAS’s national director told us he was not receiving many requests for service dog benefits, no wait list for authorization existed, and he was not sure what additional demand for service dogs existed. Also, medical center personnel could not provide us the number of veterans who were previously Audit of VHA’s Guide and Service Dog Program Regulations and Interim Guidance denied a service dog, or an estimate of veterans who may benefit from the assistance of a dog in the future. We contacted representatives from 4 of 33 accredited nonprofit organizations in the United States that provide service dogs and found that in May 2010, 72 veterans had service dogs provided by these organizations. Table 1. Veterans with Service Dogs Table 1. Veterans with Service Dogs According to the organizations’ representatives, these service dogs provided a myriad of services to the veterans. We did not determine whether these veterans qualify for VA benefits. However, the number of veterans who obtained service dogs outside VHA demonstrates a demand exists that VHA needs to address. VHA had not provided sufficient guidance necessary to ensure consistent decisions and the fullest consideration of service dogs. In June 2009, VHA submitted a draft regulation explaining qualifications and benefit details necessary to provide financial support to veterans with service dogs to the VA Office of General Counsel. According to the PSAS national director, the proposed regulation mirrors the current guide dog regulation on authorized expenditures and authorizes travel expenses. In addition, the regulation requires that service dogs are trained by and obtained from an accredited entity. A representative from the Office of General Counsel told us the draft directive was in their normal 2-year review process with an expected approval date of July 2011. The lack of sufficient guidance has resulted in inconsistent decisions on veterans’ requests for service dogs. For example: . Two veterans applying for benefits for a seizure alert dog to treat epilepsy received different results. A veteran at the Indianapolis VA Medical Center received approval for a seizure alert dog in January 2010. The approval record stated that a seizure alert dog is “a reasonable treatment option.” However, that same month, a veteran at the Washington DC VA Medical Center received a denial for a seizure alert VHA Outreach Audit of VHA’s Guide and Service Dog Program dog because epilepsy did not result in mobility limitation and seizure alert dogs “do not meet criteria for VA support.” . A mental health coordinator at the Columbia VA Medical Center suggested to mental health patients that getting a service dog would be beneficial and that VA could pay for some of the expenses. However, in March 2010, the PSAS coordinator at that facility told veterans not to apply for benefits because he had received guidance from VHA stating that VHA was not authorizing service dogs for mental health disabilities. From 2002 to 2006, VA conducted three research studies and a scientific literature review to identify any potential benefits of service dogs. Based on the results of the studies and literature review, VHA could not determine whether service dogs were an effective treatment option for veterans. However, in an effort to maximize veteran benefits, the Secretary of VA signed a memorandum in January 2008 stating VA would approve service dogs for physically or hearing impaired veterans on a case-by-case basis. The criteria established in the memorandum for approval was to determine if the dog effectively performs a task that cannot be achieved through assistive technology or daily living aids. VHA’s guidance may be contributing to the low number of authorized service dogs and VHA’s inability to identify the demand for service dogs. According to the PSAS national director, prior to 2008, VHA’s guidance to VA medical center personnel was to deny requests for service dog benefits. Since 2008, VHA’s guidance has been to use service dogs after considering other options. A memorandum signed by the Secretary of VA in January 2008, stated service dogs may be provided when the dog can: “… effectively perform a task that cannot be achieved through assistive technology or daily living aids.” Minutes from a Chief Medical Officer conference call held in February 2010 encouraged the Chief Medical Officers to inform clinicians that VHA supports service dogs. It further stated no definitive criteria existed that justified the provision of a service dog and reiterated the guidance contained in the Secretary of VA’s January 2008 memorandum. Without approved regulations explaining qualifications and benefit details, VA medical center staffs need interim guidance to help ensure consistent decisions and the fullest consideration of service dogs. VHA had not provided sufficient outreach to ensure VA medical center staffs were aware of the financial support that VHA provides for veterans with service dogs. In FY 2009 and FY 2010, VHA increased their outreach Audit of VHA’s Guide and Service Dog Program Service Dogs for Mentally Impaired Veterans efforts to veterans by informing them of the benefits from having a dog and VA’s available financial support by: . Signing a Memorandum of Understanding with Assistance Dogs International (ADI) to gain their assistance in preparing educational materials for providers and veterans . Providing information about service dogs on VA’s website . Providing information at ADI conferences about the financial support VA provides to veterans with service dogs . Presenting information about service dogs to Veterans Service Organizations In FY 2010, VHA increased their outreach efforts to VA medical center staff by providing information about service dogs in Network Directors and Chief Medical Officer conference calls. However, we found that knowledge and use of service dogs at VA medical centers was still incomplete and inconsistent. Interviews with VA medical center staff found that these recent efforts had not completely filtered down to all staff. We interviewed 34 providers and 15 PSAS employees at 15 VA medical centers. Of the 15 medical centers, personnel at 9 medical centers (60 percent) were generally aware of VHA’s policies and procedures related to guide and service dogs. Personnel at eight medical centers (53 percent) acknowledged that they were not fully aware of the benefits offered or the application process. For example, a spinal cord injury coordinator at the Dayton VA Medical Center was aware of treatment options using service dogs but was not aware that VHA provides financial support to veterans using this option. VHA needs to ensure VA medical center providers and PSAS employees completely understand the benefits offered and application process. VHA was not approving service dogs for veterans with mental health illnesses, including PTSD, because they had not yet determined the feasibility and advisability of using service dogs to assist veterans with these illnesses. In December 2009, Congress passed Public Law 111-117, Consolidated Appropriations Act, 2010 which authorized VA to approve service dogs to qualified veterans with mental impairments, including PTSD. The Conference Report to this Act directed VA immediately begin the process of assisting veterans with mental impairments who would benefit from having a service dog. In October 2009, the National Defense Authorization Act for FY 2010 required VA to start a study, no later than July 25, 2010, to Audit of VHA’s Guide and Service Dog Program Conclusion Recommendations Management Comments and OIG Response determine the effectiveness of using service dogs for veterans with mental impairments. The Office of Research and Development was preparing the research proposal for a 3-year study and has a deadline to submit the proposal to the first of four review panels by July 15, 2010. Since VA was still in the process of determining the appropriateness and benefit of service dogs as a treatment option, they were not approving service dogs for veterans with mental health impairments. However, VHA informed those veterans who were denied this treatment option that VHA plans to study the use of service dogs for veterans with mental health impairments and they may apply to become part of the study. In our opinion, VHA’s ongoing efforts in preparing a study adequately addressed the National Defense Authorization Act for FY 2010 requirement. Therefore, we are not making a recommendation regarding this issue. VHA faces challenges implementing the Guide and Service Dog Program in the absence of implementing criteria. VHA assisted visually impaired veterans in obtaining guide dogs for several decades but only started assisting veterans with service dogs in 2008—6 years after being authorized to do so. VHA had not authorized requests from veterans with mental health impairments seeking service dogs since the feasibility and advisability of this practice is currently unknown. We recommended the Under Secretary for Health: 1. Issue comprehensive interim guidance, until the draft regulation addressing service dogs is finalized, to ensure VA medical center providers and PSAS employees better understand the benefits offered and process to apply for service dogs. The Under Secretary for Health agreed with our finding and, in principle, with our recommendation. The Under Secretary stated that VHA is currently processing formal regulations to exercise VHA’s authority granted in 38 U. S. C. §1714(c). The purposes of the regulations are to provide notice to the public of the Secretary of Veterans Affairs decision to provide the benefit and set the criteria for the provision of service dogs when it is clinically indicated. Currently, such regulations have been drafted and are in the review process. A directive to define policy for the issuance of service dogs to eligible veterans with mobility or hearing impairments; outline the benefits covered by VHA related to obtaining and funding training, veterinary care, and hardware; and set specific criteria to exercise this authority is also being prepared. This directive will match the regulations and will be issued immediately after the regulations are published. In the interim, by Audit of VHA’s Guide and Service Dog Program October 2010 VHA will develop guidance on clinical criteria to determine whether a veteran will benefit from a service dog trained for the aid of the hearing impaired or trained for the aid of persons with spinal cord injury or dysfunction or other chronic impairment that substantially limits mobility to veterans with such injury, dysfunction, or impairment. We will monitor VHA’s implementation of planned actions. Developing clinical criteria should ensure that staff is aware of the aid that service dogs can provide, consider this option, and refer the veteran to an accredited dog agency if appropriate. Appendix B contains the full text of the Under Secretary’s comments. Appendix A Scope Methodology Table 2. Medical Centers in OIG Review Sample Reliability of Computer- Processed Data Scope and Methodology The audit focused on the Guide and Service Dog Program for the period FY 2009 through 2nd quarter FY 2010. Specific areas of review included regulation, policy, guidance, outreach, and veteran enrollment. To assess the status of the Guide and Service Dog Program, we interviewed PSAS staff in Central Office, clinical and PSAS staff at 15 medical centers, and representatives from 6 nonprofit organizations. We reviewed current regulations and policies as well as procedures. We selected a non-statistical sample of 15 medical centers—five with payments for guide dogs, five with requests for service dogs, and five with no payments for guide or service dogs from FY 2005 to FY 2009. Table 2. Medical Centers in OIG Review Sample To select VA medical center staff for interviews, we contacted facility directors and requested and interviewed prosthetic and provider contacts that would be familiar with the Guide and Service Dog Program. We non-statistically selected four nonprofit organizations that train service dogs to identify the level of outreach by VHA and attempted to assess the general demand for guide and service dogs. To address our audit objective, we assessed the reliability of VBA’s National Prosthetics Patient Database to provide a total number of unique veterans with a guide or service dog that received benefits and their related costs from FY 2009 to 2nd quarter FY 2010. We validated and reconciled information with selected VA medical centers. We concluded the data used to accomplish the audit objectives was sufficiently reliable in regards to the total number of unique veterans with a dog and the related costs. However, we relied on other sources for the number of unique veterans with a service dog because the database was not a reliable source to identify whether a unique veteran used a service or guide dog. Compliance with Government Audit Standards We conducted our audit work from March through May 2010. Our assessment of internal controls focused on those controls relating to our audit objective. We conducted this performance audit in accordance with generally accepted government auditing standards that requires that we plan and perform the audit to obtain sufficient and appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objective. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions. Appendix B Agency Comments Department of Memorandum Veterans Affairs Date: June 28, 2010 From: Under Secretary for Health (10) Subj: OIG Draft Report, Audit of Guide and Service Dog Program, (WebCIMS 453107) To: Assistant Inspector General for Audit (54A) 1. I have reviewed the Department of Veterans Affairs (VA) Office of Inspector General (OIG) draft report and recommendation to issue comprehensive interim guidance to ensure VA medical center personnel are aware of and better understand the qualifying criteria for service dog benefits and the process required to apply for them. I agree that issuing interim guidance would be beneficial. 2. The Veterans Health Administration (VHA) is currently processing formal regulations to exercise VHA’s authority granted in 38 U. S. C. §1714(c). Currently, such regulations have been drafted and are in the review process. A directive to define policy for the issuance of service dogs to eligible Veterans with mobility or hearing impairments; outline the benefits covered by VHA related to obtaining and funding training, veterinary care, and hardware; and set specific criteria to exercise this authority is also being prepared. This directive will match the regulations and will be issued immediately after the regulations are published. 3. In response to the OIG recommendation, VHA will develop guidance on clinical criteria to determine whether a Veteran will benefit from a service dog trained for the aid of the hearing impaired or trained for the aid of persons with spinal cord injury or dysfunction or other chronic impairment that substantially limits mobility to Veterans with such injury, dysfunction, or impairment. 4. Thank you for the opportunity to review the draft report. If you have any questions, please contact Linda H. Lutes, Director, Management Review Service (10B5) at (202) 461-7014. (original signed by:) Robert A. Petzel, M.D. Attachment VETERANS HEALTH ADMINISTRATION (VHA) Action Plan Office of Inspector General (OIG) Draft Report, Audit of Guide and Service Dog Program, (WebCIMS 453107) Date of Draft Report: June 2010 Recommendations/ Status Completion Actions Date Recommendation 1. Issue comprehensive interim guidance, until the draft regulation addressing service dogs is finalized, to ensure VA medical center providers and PSAS employees better understand the benefits offered and process to apply for service dogs. VHA Comments Concur in principle The Veterans Health Administration (VHA) is currently processing formal regulations to exercise VHA’s authority granted in 38 U. S. C. §1714(c). The purposes of the regulations are to provide notice to the public of the Secretary of Veterans Affairs decision to provide the benefit and set the criteria for the provision of service dogs when it is clinically indicated. Currently, such regulations have been drafted and are in the review process. A directive to define policy for the issuance of service dogs to eligible Veterans with mobility or hearing impairments; outline the benefits covered by VHA related to obtaining and funding training, veterinary care, and hardware; and set specific criteria to exercise this authority is also being prepared. This directive will match the regulations and will be issued immediately after the regulations are published. In the interim, VHA will develop guidance on clinical criteria to determine whether a Veteran will benefit from a service dog trained for the aid of the hearing impaired or trained for the aid of persons with spinal cord injury or dysfunction or other chronic impairment that substantially limits mobility to Veterans with such injury, dysfunction, or impairment In process October 1, 2010 Veterans Health Administration June 2010 Appendix C OIG Contact and Staff Acknowledgments OIG Contact Larry Reinkemeyer, 816-997-6940 Acknowledgments Joseph Janasz Brad Lewis Daniel Morris Lynn Scheffner Appendix D Report Distribution VA Distribution Office of the Secretary Veterans Health Administration Veterans Benefits Administration Assistant Secretaries Office of General Counsel Non-VA Distribution House Committee on Veterans’ Affairs House Appropriations Subcommittee on Military Construction, Veterans Affairs, and Related Agencies House Committee on Oversight and Government Reform Senate Committee on Veterans’ Affairs Senate Appropriations Subcommittee on Military Construction, Veterans Affairs, and Related Agencies Senate Committee on Homeland Security and Governmental Affairs National Veterans Service Organizations Government Accountability Office Office of Management and Budget This report will be available in the near future on the OIG’s Web site at http://www.va.gov/oig/publications/reports-list.asp. This report will remain on the OIG Web site for at least 2 fiscal years after it is issued.