WASHINGTON, D.C. – U.S. Senator Jerry Moran (R-Kan.) – ranking member of the Senate Veterans’ Affairs Committee – initiated an investigation with the U.S. Government Accountability Office (GAO) regarding the Veterans Crisis Line (VCL) after being alerted by current and former VA employees of substantial evidence of mismanagement, creating a danger to the health and safety of veterans nationwide.

“VA’s history with secret waiting lists of veterans in desperate need for care is deplorable,” said Sen. Moran in a letter to GAO. “If the Veterans Crisis Line is letting veterans who reach out in moments of desperation slip through the cracks, as alleged, it needs to be known and it needs to be stopped. With nearly 900,000 contacts made to the VCL in 2022 alone, a 15% increase from 2020, any breakdowns in this lifesaving resource for veterans must be found and corrected immediately. Any program leaders who are aware of gaps in the service and preventing transparency should be held accountable and replaced.”

This week, Sen. Moran called on Department of Veterans Affairs (VA) Secretary Denis McDonough to make certain the VA fully cooperates with an independent investigation of the VA’s Veterans Crisis Line (VCL).

“The OIG report and subsequent whistleblower allegations raise grave concerns for the health and safety of our veterans,” said Sen. Moran in a letter to Secretary McDonough. “My expectation is you will take immediate action to guarantee VA’s full cooperation with the oversight by Congress and the investigation by GAO. Without hesitation, I expect you to address all critical deficiencies in the Veterans Crisis Line and take appropriate personnel actions without waiting for the full conclusion of this investigation.”

Sen. Moran’s full letter to GAO can be found HERE and below.

Sen. Moran’s full letter to Sec. McDonough can be found HERE and below:

November 6, 2023

Dear Mr. Dodaro,

On September 14, 2023, the Department of Veterans Affairs (VA) Office of Inspector General (OIG) published a report regarding insufficient Veterans Crisis Line (VCL) staff management of a patient who died by suicide. VCL staff failed to take appropriate action with a veteran who died by suicide the same night the veteran contacted the VCL. Beyond that tragedy, the OIG uncovered systemic issues at the VCL, a lack of standard operating procedures and policies, and overall inadequate oversight. Additionally, the OIG discovered that VCL leadership provided advice and incorrect information to VCL staff prior to interviews with the OIG, finding that it may “compromise the accuracy and integrity of information provided.”

At a Senate Veterans’ Affairs Committee hearing examining the OIG report on September 20, 2023, VA’s program leaders left us with more questions than answers. Following the hearing, my Committee staff met with current and former employees of the VCL and found substantial evidence of mismanagement creating a danger to the health and safety of veterans nationwide. Among the most concerning issues raised was a credible allegation that VCL staff are currently transferring veterans who present with complex needs to a special unit within VCL, a unit which is severely understaffed by an undertrained workforce. Further, a break in record retention is reportedly resulting in a complete loss of communication with veterans whose health and safety are at a heightened risk, unless they follow up again with the VCL after the transfer has been made.

VA’s history with secret waiting lists of veterans in desperate need for care is deplorable. If the Veterans Crisis Line is letting veterans who reach out in moments of desperation slip through the cracks, as alleged, it needs to be known and it needs to be stopped. With nearly 900,000 contacts made to the VCL in 2022 alone, a 15% increase from 2020, any breakdowns in this lifesaving resource for veterans must be found and corrected immediately. Any program leaders who are aware of gaps in the service and preventing transparency should be held accountable and replaced.

I request a thorough audit of the Veterans Crisis Line, to include the following non-exclusive elements:

1. VCL Operations, specifically of the Call Center, Silent Monitoring, and Complex Needs units.

a. How does VA determine and address workforce needs for the VCL?

b. Is the overall operational staffing plan appropriately organized in accordance with contact demand and administrative requirements?

c. What information does VCL management maintain regarding vacancies, turnover rates, training of new staff, and continuing education/training for all staff members, including those in specialized units of the VCL?

2. Information Technology and Record Retention.

a. How are prior communications with veterans stored and secured? For what purposes are the records used? Is the record retention policy sufficient?

b. Are management and information security controls adequate to preclude crisis contacts from being left on indefinite hold when transferred to the Complex Needs unit?

c. Are information security controls adequate to prevent unauthorized access to the systems?

3. Oversight and Quality Assurance.

a. What is VA’s management structure for the VCL, and what type of routine oversight is provided?

b. How does VA ensure that VCL staff follow-up with veterans who need additional contact?

c. Is the Quality Assurance program for VCL reliable? Please examine Complaints, Silent Monitoring, Critical Incidents, Sentinel Events, and Root Cause/Aggregated Analyses.

d. How does VA ensure that all Sentinel event and Disclosure decisions are made in accordance with VA policy?

e. Are the results of the quality assurance program used to develop and shape continuing education for VCL staff?

It is stated that ending veteran suicide is VA’s top clinical priority. A thorough Government Accountability Office review of the Veterans Crisis Line would help VA and Congress to address this program’s flaws and move us closer to that goal. The Veterans Crisis Line is on the front line to support veterans whose health and safety are at heightened risk. Any mismanagement of this critical program unduly increases that risk and is completely unacceptable.

Thank you for your attention to this request. If you have any questions, please contact my staff at the Senate Committee on Veterans’ Affairs.

November 14, 2023

Dear Secretary McDonough,

On November 6, 2023, I requested the Government Accountability Office (GAO) conduct a thorough audit of the Veterans Crisis Line (VCL) after an alarming report from VA’s Office of the Inspector General (OIG) and subsequent credible whistleblower disclosures of gross mismanagement creating a danger to the health and safety of veterans nationwide. GAO committed to quickly begin this work.

As described in the enclosed letter to GAO, according to multiple whistleblowers, VCL responders are currently transferring veterans determined to present complex needs to an indefinite waiting list for eventual contact from a special unit. Despite a statutory requirement for the VCL “to be staffed by appropriately trained mental health personnel and available at all times,” this special unit of responders for “Callers With Complex Needs” is allegedly severely understaffed and undertrained. Worse yet, a break in record retention is reportedly resulting in a complete loss of communication with veterans who are disconnected while waiting on hold in this queue.

The Budget and Accounting Act of 1921 requires that all departments “shall furnish to the Comptroller General such information regarding the powers, duties, activities, organization, financial transactions, and methods of business of their respective offices as he may… require.” I am reminding the Department of this statutory responsibility as the September 14, 2023 VA OIG report found VCL leadership provided advice and incorrect information to VCL staff prior to interviews with the OIG, which may have served to “compromise the accuracy and integrity of information provided.” Such interference is a flagrant violation of federal employees’ duty to cooperate with investigations under the Inspector General Act of 1978.

The OIG report and subsequent whistleblower allegations raise grave concerns for the health and safety of our veterans. My expectation is you will take immediate action to guarantee VA’s full cooperation with the oversight by Congress and the investigation by GAO. I also expect you and every leader within VA to make certain that whistleblowers raising these concerns are protected from any retaliation. Failure to do so could continue the endangerment our most vulnerable veterans and their families when they come to the VCL in need of urgent VA assistance.

Without hesitation, I expect you to address all critical deficiencies in the Veterans Crisis Line and take appropriate personnel actions without waiting for the full conclusion of this investigation. Please keep my Senate Veterans’ Affairs Committee staff, and the investigators assisting us, informed every step of the way.

Thank you for your prompt attention to this important issue.

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