RICHMOND, Va. (WRIC)-A newly released report from Virginia’s government watchdog agency found some state-run behavioral health facilities failed to properly investigate reports of sexual abuse. 

The latest review from the Office of the State Inspector General stems from unannounced inspections conducted throughout 2021 at all twelve facilities operated by the Department of Behavioral Health and Developmental Services.

OSIG’s Healthcare Compliance Manager Keith Davies said the probe into sexual abuse procedures focused on four facilities. They include the Commonwealth Center for Children & Adolescents in Staunton, Central State Hospital in Petersburg, Southeastern Virginia Training Center in Chesapeake and Southern Virginia Mental Health Institute in Danville. 

Sexual allegations were one of six areas that OSIG investigated for its broader annual report. Davies said these four facilities weren’t chosen for this topic for any particular reason. 

Overall, OSIG found internal policies at some facilities left out key details outlined in state law and gave flawed instructions for when allegations of sexual abuse should be reported. 

“I don’t think there was any overt attempt to hide any of these allegations, no,” Davies said. “Our goal is to bring forward recommendations for improvement.”

That said, OSIG said these omissions could result in the underreporting of serious incidents and the dismissal of allegations without a thorough investigation. The report said this could expose patients to harm and lead to the exploitation of vulnerable populations.

For example, one omission led a facility to misinterpret the criteria for reporting sexual allegations, leading staff to only report instances that they directly witnessed or discovered, according to OSIG. 

At Central State Hospital, the report said the staff didn’t complete incident forms as required for any of the six allegations OSIG reviewed that patients submitted reports for last year. 

“The limiting of incident reports to “only witnessed” incidents could place patients at risk and therefore deprive them of their right of protection from abuse, neglect and exploitation. It also diminishes the ability of the facility to track such incidents and ensure that staff has taken reasonable measures to mitigate the risk.,” the report continued. 

Another policy told staff that they didn’t have to continue an investigation if a clinical assessment determined an allegation is “more likely than not to be symptomatic of the patient’s illness or disability.”

OSIG said facilities should thoroughly investigate all allegations of abuse and neglect, regardless of a patient’s mental health status or report history. 

In two cases at Central State, OSIG said staff deemed complaints “improbable” and didn’t conduct a complete investigation.

OSIG reviewed four additional “serious incidents that were sexual in nature” that allegedly occurred at Southern Virginia Mental Health Institute last year. 

“In all of these incidents, staff did not provide the victims with the opportunity to speak with law enforcement or a magistrate in order to seek criminal remedy,” the report said.

In those cases, OSIG said staff also failed to accurately report the risk level of the incidents. The report said the label indicated there was no risk or liability identified when it should’ve indicated criminal activity. OSIG said this would’ve triggered additional reporting to patient advocacy and regulatory agencies for possible further review. 

In all four facilities inspected, OSIG said the staff did not have adequate guidance in terms of identifying the elements that constitute sexual abuse under state law.  

“Without adequate definitions and proper training, staff may not document and investigate reports of sexual abuse and potentially expose patients to harm,” the report said. 

Davies said he’s confident that the new administration is committed to making improvements.

Asked about the findings at an event on Friday, Governor Glenn Youngkin said he had yet to review the full report but he welcomed the feedback. 

“We’re engaged and so we’re thankful that in fact this report was published. We need a budget that includes funding for training so that we can in fact move forward against a lot of these issues,” Youngkin said. 

Meanwhile, DBHDS pushed back on some of OSIG’s findings. The agency didn’t make anyone available for an interview on Friday. 

In an email, DBHDS Communications Director Lauren Cunningham questioned why OSIG didn’t include the agency’s response in the inspection report, something she called common practice. 

“It is important to note that DBHDS reports all plausible allegations of sexual abuse or assault to the state police and/or local law enforcement,” Cunningham furthered. “OSIG would like every incident reported to state police; however, in our repeated engagements with state police, they have made it clear they only want allegations that are plausible and will not investigate further allegations. Based on diagnosis and history of patient complaints, some allegations require more validation — Of note, these situations are more harassment in nature and are not serious sexual crimes.”

Cunningham said other state and local law enforcement partners have not shared similar concerns with the handling of cases upon further review as requested by OSIG. She furthered that DBHDS’ departmental instructions outline facility directors’ discretion on handling reports from patients that make frequent complaints, which she said was approved by the Office of the Attorney General. 

“While OSIG has continued to express concern over sexual abuse allegations, DBHDS has not been provided any support to demonstrate that adequate guidance has not been provided to staff,” Cunningham said.