Part 19 — Findings and Recommendations printable pdf

Part 19 — Findings and Recommendations



Overview

The Borden Report 2026 examines whether the Borden Avenue Veterans’ Residence (BAVR) provides an environment consistent with the purpose of the Department of Veterans Affairs Grant and Per Diem (GPD) Program and whether the federal, municipal, and nonprofit organizations responsible for the program provide sufficient oversight, accountability, safety, and transitional support.

The findings arise from federal regulations and VA guidance, government records, contracts and budgets, financial information, emergency-response and arrest data, government oversight reports, meeting records, correspondence, Veteran testimony, program materials, and comparative information concerning other Veteran transitional programs. The existing Findings and Recommendations appropriately recognize that not every reported concern constitutes an established violation and that incomplete records require verification rather than assumption.

The cumulative record nevertheless supports substantially stronger recommendations for independent investigation, particularly concerning federal GPD funding, the use of public resources, serious incidents, repeated arrests, emergency activity, and unresolved law-enforcement calls associated with the facility.

1. GPD Must Remain a Veteran Transitional Program

Finding. GPD is intended to assist Veterans experiencing homelessness in moving toward permanent housing and greater stability. Homelessness does not itself establish that a Veteran has a mental-health or substance-use disorder requiring a specialized therapeutic environment.

This distinction is particularly important because the records reviewed for this report identify Borden Avenue's authorized GPD beds as Service Intensive rather than Clinical Treatment beds. The Modified Therapeutic Community approach examined in Part 11 was developed for populations with behavioral-health and substance-use needs. Applying treatment-oriented structures broadly without individualized need could create a mismatch between the approved GPD model and actual program operations.

Recommendation. VA should conduct a formal program-compliance review to determine whether Borden Avenue's admission practices, case management, behavioral-health structure, resident requirements, and services remain consistent with its approved Service Intensive GPD model. The review should determine whether Veterans are receiving individualized transitional services based upon documented needs rather than being placed into a generalized treatment framework.

2. VA Should Conduct a Full Investigation and Audit of Borden Avenue GPD Funding

Finding. Borden Avenue receives federal support through VA's GPD Program while also operating within a substantial DHS-funded municipal contract. The report identifies significant expenditures involving staffing, security, food, transportation, behavioral-health services, administration, and other operational functions. These overlapping funding streams make it important to determine precisely what federal GPD funds purchase, whether funded services are actually delivered, and whether expenditures advance the purposes for which VA awarded the funding.

Financial records alone cannot establish misuse. Nor does the size of the DHS contract demonstrate that federal funds were improperly spent. The combination of federal funding, municipal expenditures, questions concerning available services, GPD capacity, housing outcomes, transportation, nutrition, recreational resources, and program operations nevertheless provides a substantial basis for comprehensive federal review.

Recommendation. The Department of Veterans Affairs should conduct, or refer for appropriate independent investigation, a full financial and programmatic audit of federal funding associated with Borden Avenue. The review should examine:

• GPD payments and reimbursements received by or attributable to Borden Avenue.
• Authorized beds compared with actual GPD enrollment and reimbursable occupancy.
• Services represented as supported by federal GPD funding.
• Payroll, staffing, administrative, transportation, food, security, and service expenditures where relevant to the federal award.
• Potential duplication or improper allocation between VA-funded and DHS-funded services.
• Compliance with the approved GPD grant, applicable regulations, and authorized program model.
• Whether reported expenditures correspond with documented services and Veteran outcomes.

Where the evidence warrants, VA should refer financial questions to the VA Office of Inspector General or other appropriate federal auditing or investigative authority. The purpose should be to determine independently whether federal funds were properly claimed, allocated, documented, and used for their authorized Veteran transitional-housing purposes.

3. Continued Illegal Activity and Public-Safety Conditions Require Independent Investigation

Finding. The public-safety record associated with 21-10 Borden Avenue is one of the most significant issues identified by this report. FOIL records examined in Part 9 document approximately 1,365 emergency-service calls between August 2024 and December 2025, averaging nearly three calls per day. The records include ambulance responses, emotionally disturbed persons, violent EDP incidents, assaults, disputes, suspected overdoses, injuries, and other emergencies.

Separate FOIL arrest records identify 82 arrest entries between September 2022 and December 2025, including assault-related and felony charges. Approximately 70 entries appear to concern alleged conduct occurring inside 21-10 Borden Avenue. These records document arrests and allegations, not convictions, and they should not be interpreted as establishing criminal responsibility for individuals whose cases have not been adjudicated.

The emergency records raise an additional oversight concern because approximately 60 percent reportedly contain no publicly available final disposition. The absence of a disposition does not establish that no action occurred, that records were concealed, or that illegal activity was ignored. It does, however, leave a substantial portion of the documented emergency activity unresolved within the records presently available for public review.

Recommendation. Appropriate City and federal authorities should conduct a coordinated investigation of recurring alleged illegal activity and serious safety incidents at Borden Avenue, including patterns of assaults, drug activity, overdoses, weapons-related incidents, violence, and other conduct reflected in NYPD and emergency-response records.

The investigation should reconcile NYPD calls, arrests, EMS responses, ICL incident reports, security records, DHS records, VA serious-incident records, resident complaints, and available dispositions. Its purpose should be to determine what occurred, whether recurring patterns exist, whether provider and agency responses were adequate, and whether additional prevention, enforcement, treatment, security, or corrective measures are necessary.

4. Emergency Calls Without Final Dispositions Require Reconciliation

Finding. A large number of emergency calls without publicly available final dispositions creates an evidentiary gap. Without disposition information, oversight authorities cannot readily determine how many calls resulted in arrests, hospital transportation, reports, referrals, unfounded complaints, resolved disputes, or other outcomes.

This gap becomes more significant when considered alongside the arrest record and frequency of ambulance, EDP, assault, overdose, and dispute calls.

Recommendation. NYPD, DHS, ICL, and VA should reconcile the approximately 1,365 emergency events with available internal and external records. The review should determine, where records permit:

• Nature and outcome of each serious event.
• Whether an arrest, summons, hospital transport, or other intervention occurred.
• Whether the event involved a GPD participant.
• Whether an internal incident report was generated.
• Whether VA notification was required and completed.
• Whether recurring individuals, locations, times, or types of incidents reveal preventable patterns.

Aggregate findings should be made available for oversight purposes while protecting personally identifiable, medical, and law-enforcement-sensitive information.

5. Major-Incident Reporting Must Be Independently Verified

Finding. Available records raise questions concerning whether qualifying deaths, overdoses, serious assaults, hospitalizations, injuries, and other major incidents were consistently reported through applicable VA GPD channels. The present evidence does not establish that every emergency call was reportable or that an unreported call constituted a violation.

The volume of documented emergency activity nevertheless makes reconciliation necessary.

Recommendation. VA should conduct a retrospective comparison of its Borden Avenue incident records against ICL, DHS, NYPD, EMS, and other available records. Any apparent discrepancy should be individually evaluated under the reporting requirements applicable when the incident occurred. Where failures are substantiated, VA should determine their cause, require corrective action, and consider appropriate grant-management or enforcement measures.

6. Housing Outcomes and GPD Capacity Require Independent Audit

Finding. Permanent housing remains the principal objective of GPD. VA FOIA information reviewed elsewhere in this report identified 154 authorized GPD beds, while reported enrollment declined from 124 Veterans in June 2024 to 107 in August 2024. Those figures do not establish that every unused authorized bed represented a physically vacant or immediately available placement.

The VA OIG's national findings concerning GPD outcome-data reliability further demonstrate why reported permanent-housing outcomes should be independently supported rather than accepted without verification.

Recommendation. VA should audit Borden Avenue's utilization and housing outcomes, including admissions, referrals, rejected or deferred placements, length of stay, permanent-housing exits, negative exits, transfers, unverified destinations, and returns to homelessness. The review should also determine why authorized GPD capacity was not fully enrolled during periods identified in the federal records.

7. Safety Must Be Treated as a Transitional Outcome

Finding. Veterans cannot be expected to stabilize effectively in an environment where repeated emergencies or serious disturbances interfere with sleep, medical care, employment, housing searches, treatment, or personal security. Emergency activity does not by itself establish provider wrongdoing, but its frequency is a legitimate program-performance indicator.

Recommendation. VA and DHS should establish measurable safety indicators for Borden Avenue and evaluate trends over time. The objective should not be fewer 911 calls because residents or staff are discouraged from seeking assistance. The objective should be fewer emergencies because preventable crises, violence, overdoses, and dangerous conditions actually decline.

8. Contractor Expenditures Should Be Connected to Veteran Outcomes

Finding. Borden Avenue operates through substantial public expenditures. Budget compliance alone does not establish whether those expenditures produce effective Veteran services.

Recommendation. DHS should conduct a comprehensive contract-performance review connecting major spending categories with actual service delivery and outcomes. VA's federal financial review and DHS's municipal contract review should be coordinated sufficiently to identify duplication, gaps, inconsistent cost allocation, or services funded but not demonstrably delivered.

9. Veterans Should Receive Individualized Services and Independent-Living Opportunities

Finding. Veterans entering GPD have different barriers to permanent housing. Some require behavioral-health treatment, while others principally require housing assistance, employment, benefits, transportation, healthcare coordination, documentation, or practical independent-living preparation.

Recommendation. Individual service plans should determine the services provided. Borden Avenue should expand practical opportunities involving computers, employment preparation, budgeting, cooking and nutrition, transportation, household management, peer mentoring, recreation, community participation, and other activities that prepare Veterans for independent housing.

10. Women Veterans Require Comparable Veteran-Specific Access

Finding. The report identifies a continuing gap in Veteran-specific transitional capacity for women Veterans in New York City. General municipal shelter placement does not necessarily provide an equivalent GPD transitional pathway.

Recommendation. VA and New York City should develop appropriate Veteran-specific transitional capacity for women, including accommodations for privacy, disability, safety, and family circumstances. Future planning should also examine appropriate pathways for Veterans with dependent children.

11. Oversight Must Include Independent and Unannounced Review

Finding. Scheduled inspections and provider-generated records cannot independently capture ordinary conditions throughout a residential program. Resident experience provides an additional source of quality-assurance information.

Recommendation. VA and appropriate City authorities should conduct periodic unannounced inspections examining sanitation, safety, staffing, meals, security, transportation, housing progress, computer and recreational access, grievances, independent-living resources, and ordinary program operations. Veterans should be provided confidential opportunities to speak with reviewers without provider personnel present.

12. Oversight Findings Must Produce Corrective Action

Finding. Borden Avenue is subject to multiple layers of governmental and organizational oversight. Multiple oversight bodies do not guarantee accountability when concerns are repeatedly referred without identifiable resolution.

Recommendation. Significant findings should move through a documented process:

Concern → Investigation → Finding → Responsible Entity → Corrective Action → Deadline → Independent Verification → Closure

VA, DHS, ICL, DVS, the Veterans Task Force, Veterans Advisory Board, City Council, and independent investigative bodies should remain within their respective authorities while ensuring that referrals do not become substitutes for resolution.

13. Borden Avenue's Continued Suitability Should Be Formally Evaluated

Finding. The cumulative record—including emergency activity, arrests, transportation issues, physical location, institutional structure, service questions, GPD utilization, community integration, and the needs of vulnerable Veterans—raises a legitimate question concerning whether Borden Avenue remains the most appropriate site and operational model for New York City's GPD population.

Recommendation. VA and New York City should conduct a formal feasibility analysis examining whether the existing facility should be substantially restructured or whether the GPD program would operate more effectively in a purpose-designed location closer to Manhattan VA healthcare and homeless-Veteran services.

The Bellevue area should remain among the alternatives evaluated, together with other feasible locations. Any analysis should consider safety, cost, capacity, transportation, healthcare access, privacy, accessibility, women Veterans, family circumstances, proximity to VA services, and the ability to provide genuine transitional rather than primarily institutional shelter services.

Conclusion

The cumulative evidence examined in the Borden Report 2026 supports a stronger level of governmental review than routine contract monitoring or periodic program inspection. The combination of substantial federal and municipal funding, approximately 1,365 emergency calls, 82 arrest entries, numerous emergency records without publicly available final dispositions, questions concerning serious-incident reporting, GPD utilization, housing outcomes, and the delivery of transitional services provides a reasonable basis for comprehensive independent financial, programmatic, and public-safety investigations.

These recommendations do not presume criminal conduct, financial fraud, regulatory violations, or wrongdoing by ICL, DHS, VA personnel, residents, or other individuals. Investigations are recommended precisely because the available records raise significant questions that cannot responsibly be answered through assumption. The appropriate governmental response is to reconcile the records, determine what occurred, identify deficiencies where evidence establishes them, and document corrective action.

The federal government has a particular responsibility because Borden Avenue participates in a program created specifically to assist homeless Veterans. VA should therefore examine not only whether federal GPD funds were administratively accounted for, but whether those funds purchased the services represented, supported the authorized program model, protected participating Veterans, and produced measurable progress toward permanent housing.

Public-safety review should be equally comprehensive. The number of emergency calls and arrests should not be used to stigmatize homeless Veterans or discourage requests for police or medical assistance. They should instead prompt investigation into why such activity has occurred with this frequency, whether identifiable patterns can be prevented, whether alleged illegal activity continues within the facility, and whether governmental and provider responses have been sufficient.

The objective remains the same throughout this report. A Veteran entering GPD should encounter a safe transitional environment, individualized assistance, access to earned VA resources, preparation for independent living, meaningful community participation, and a documented pathway into sustainable permanent housing.

Achieving that objective requires more than funding and program existence. It requires financial transparency, verified outcomes, independent investigation, public-safety accountability, effective corrective action, and continuous governmental oversight. Those standards provide the most meaningful measure of whether Borden Avenue is fulfilling the responsibility entrusted to it by the Department of Veterans Affairs, New York City, and the Veterans the program exists to serve.