Testimony 

Before the Subcommittee on Oversight 

and Investigations, Committee on 

Veterans’ Affairs, House of 

Representatives

United States General Accounting Office 

GAO

For Release on Delivery 

Expected at 10:00 a.m. EST 

Wednesday, March 31, 2004 VA HEALTH CARE 

Veterans at Risk from 

Inconsistent Screening of 

Practitioners 

Statement of Cynthia A. Bascetta 

Director, Health Care—Veterans’ 

 Health and Benefits Issues 

GAO-04-625T 
www.gao.gov/cgi-bin/getrpt?GAO-04-625T.

To view the full product, including the scope 

and methodology, click on the link above. 

For more information, contact Cynthia A. 

Bascetta at (202) 512-7101. 

Highlights of GAO-04-625T, a testimony 

before the Subcommittee on Oversight 

and Investigations, Committee on 

Veterans' Affairs, House of 

Representatives 

March 31, 2004

VA HEALTH CARE

Veterans at Risk from Inconsistent 

Screening of Practitioners 

GAO identified key VA screening requirements that include verifying state 

licenses and national certificates; completing background investigations, 

including fingerprinting to check for criminal histories; and checking 

national databases for reports of practitioners who have been professionally 

disciplined or excluded from federal health care programs. GAO reviewed 

100 practitioners’ personnel files at each of four facilities it visited and found 

mixed compliance with the existing key VA screening requirements. GAO 

also found that VA has not conducted oversight of its facilities’ compliance 

with the key screening requirements. 

Four Facilities’ Compliance with Existing Key VA Screening Requirements 

Compliance with key screening requirements 

Key screening requirements Facility A Facility B Facility C Facility D 

Credentials verified for practitioners VA 

intends to hire A W A A

Credentials verified for practitioners 

currently employed in VA W W W W

List of Excluded Individuals and Entities 

queried for practitioners VA intends to hire W A A A

Background investigation completed or 

requested for practitioners currently 

employed in VA 

W A A W

Declaration for Federal Employment form 

completed for practitioners currently 

employed in VA 

W W W W

Source: GAO analysis of VA facility files. 

W Indicates a compliance rate of 90 percent or greater. 

A Indicates a compliance rate of less than 90 percent. 

GAO found adequate screening requirements for certain practitioners, such 

as physicians and dentists, for whom all licenses are verified by contacting 

state licensing boards. However, existing screening requirements for others, 

such as nurses and respiratory therapists currently employed in VA, are less 

stringent because they do not require verifying all state licenses and national 

certificates. Moreover, they require only physical inspection of these 

credentials rather than contacting licensing boards or certifying 

organizations. Physical inspection alone can be misleading; not all 

credentials indicate whether they are restricted, and credentials can be 

forged. VA also does not require facility officials to query, for other than 

physicians and dentists, a national database that includes reports of 

disciplinary actions and criminal convictions involving all licensed 

practitioners. In addition, many practitioners with direct patient care 

access, such as medical residents, are not required to undergo background 

investigations, including fingerprinting to check for criminal histories. This 

pattern of gaps and mixed compliance with key VA key screening 

requirements create vulnerabilities to the extent that VA remains unaware of 

practitioners who could place patients at risk. 

VA employs about 190,000 

individuals including physicians, 

nurses, and therapists at its 

facilities. It supplements these 

practitioners with contract staff 

and medical residents. Cases of 

practitioners causing intentional 

harm to patients have raised 

concerns about VA’s screening of 

practitioners’ professional 

credentials and personal 

backgrounds. This testimony is 

based on GAO’s report VA Health 

Care: Improved Screening of 

Practitioners Would Reduce Risk 

to Veterans, GAO-04-566 (Mar. 31,

2004). GAO was asked to (1) 

identify and assess the extent to 

which selected VA facilities comply 

with existing key VA screening 

requirements and (2) determine the 

adequacy of these requirements for 

its practitioners. 

GAO recommended that VA expand

its existing verification process to 

require that all state licenses and 

national certificates be verified by 

contacting state licensing boards 

and national certifying 

organizations, expand the query of 

a national database to include all 

licensed practitioners, and 

fingerprint all practitioners who 

have direct patient care access. 

GAO also recommended that VA 

conduct oversight of its facilities to 

ensure their compliance with all 

screening requirements. VA 

generally agreed with the report’s 

findings and plans to develop a 

detailed action plan to implement 

GAO’s recommendations. 
Page 1 GAO-04-625T 

Mr. Chairman and Members of the Subcommittee: 

I am pleased to be here today to discuss the findings and 

recommendations in our report, which you are releasing today, on the 

Department of Veterans Affairs (VA) policies and practices for screening 

health care practitioners.1

 VA employs about 190,000 individuals, including 

physicians, nurses, pharmacists, and therapists, at its facilities, and it 

supplements these practitioners with contract staff, medical consultants, 

and medical residents. VA has screening requirements intended to help 

ensure that its health care practitioners’ professional credentials are 

verified and their personal backgrounds are checked for evidence of 

incompetence or criminal behavior. 

While such requirements cannot guarantee safety in health care settings, 

they are intended to minimize the chance of patients receiving care from 

someone who is incompetent or who may intentionally harm them. 

According to medical forensic experts, however, the deliberate harm of 

patients by health care practitioners is a problem in the health care sector 

in general. The well-publicized case of Dr. Michael Swango, who pleaded 

guilty to murdering three veterans while a medical resident training at the 

VA facility in Northport, New York, and was sentenced to three 

consecutive life terms without the possibility of parole, illustrates the 

potentially disastrous effect of inadequate screening of health care 

practitioners. 

You asked us to examine VA’s policies and practices intended to ensure 

that health care practitioners at its facilities have appropriate professional 

credentials and personal backgrounds to provide safe care to veterans. 

Specifically, we (1) identified key VA screening requirements and assessed 

the extent to which selected VA facilities complied with these screening 

requirements for its health care practitioners and (2) determined the 

adequacy of the key VA screening requirements for health care 

practitioners. 

To do our work, we selected 43 occupations in which practitioners have 

direct patient care access or have an impact on patient care and identified 

 1

U.S. General Accounting Office, VA Health Care: Improved Screening of Practitioners 

Would Reduce Risk to Veterans, GAO-04-566 (Washington, D.C.: Mar. 31, 2004). 
Page 2 GAO-04-625T 

the key screening requirements that applied to these occupations.2 To 

identify the key screening requirements, we reviewed VA employment 

screening policies and interviewed VA headquarters and facility officials 

and practitioners. To assess the extent to which VA facilities complied 

with the key screening requirements, we visited four VA facilities and 

reviewed a statistically random sample of about 100 practitioners’ 

personnel files at each site. We selected facilities to visit based on 

geographic variation, affiliations with medical schools to train residents, 

and types of health care services provided. Additionally, we obtained 

documentation on how quickly facilities took action after obtaining the 

results of background investigations. Our results cannot be generalized to 

other facilities. To determine the adequacy of the key screening 

requirements, we examined whether these screening requirements were 

complete, and whether VA applied them to all practitioners it intended to 

hire, practitioners currently employed in VA, contract health care staff, 

medical residents, and volunteers. We also interviewed representatives of 

state licensing boards and national certifying organizations and officials 

and representatives of organizations that operate national databases 

containing information on state licenses and national certificates. We did 

our work from August 2003 through March 2004 in accordance with 

generally accepted government auditing standards. 

In summary, we identified key VA screening requirements and found 

mixed compliance with these requirements in the four facilities we visited. 

The key screening requirements are those that are intended to ensure that 

VA facilities employ health care practitioners who have valid professional 

credentials and personal backgrounds to safely deliver health care to 

veterans. While we found that all facilities generally checked, on a periodic 

basis, the professional credentials of practitioners currently employed in 

VA, they did not verify all of the credentials of all of the practitioners they 

intended to hire. Furthermore, VA facilities varied in how quickly they 

took action after obtaining the results of background investigations. 

During the site visit at one facility, we discovered returned background 

investigation results that were over a year old but had not been reviewed. 

We brought them to the attention of facility officials, who reviewed the 

reports and then terminated a nursing assistant who had been fired by a 

previous non-VA employer for patient abuse. Although VA established an 

 2

Although VA has many employment screening requirements, such as whether the applicant 

is a United States citizen, we selected only those requirements that pertain to patient 

safety, such as verification of credentials and background investigations. 
Page 3 GAO-04-625T 

office more than a year ago to perform oversight of human resources 

functions, including whether its facilities comply with these key screening 

requirements, that office has not conducted any compliance reviews at 

facilities. Furthermore, VA has not implemented a policy for the human 

resources program evaluation to be performed by this office and has not 

provided funds to support this office. This pattern of mixed compliance 

creates vulnerabilities to the extent that VA remains unaware of 

practitioners it employs who could place patients at risk. 

We also found gaps in the key VA screening requirements that VA officials 

used to verify the professional credentials and personal backgrounds of 

health care practitioners. We found adequate screening requirements for 

certain practitioners, such as physicians and dentists, for whom facilities 

are required to verify all licenses by contacting state licensing boards. 

However, existing screening requirements for others, such as nurses 

currently employed in VA, are less stringent because they do not require 

that facilities verify all state licenses that a nurse may holdonly one must 

be checkedand they require only physical inspection of the license 

rather than contacting the state licensing board to verify the status of the 

license. VA also does not require verifying national certificatesthe 

credentials held by other health care practitioners, such as respiratory 

therapistsby contacting the national certifying organizations for 

practitioners VA intends to hire and periodically for those employed in VA. 

Physical inspection alone can be misleading; not all professional 

credentials indicate whether they have had disciplinary actions taken 

against them, and credentials can be forged. VA also does not require 

facility officials to query a national database, for other than physicians and 

dentists, that contains reports of professional disciplinary actions and 

criminal convictions, involving all licensed practitioners. In addition, many 

practitioners with direct patient care access, such as medical residents, 

are not required to undergo background investigations, including 

fingerprinting to check for criminal histories. 

To better ensure the safety of veterans receiving health care at VA 

facilities, in our report we recommend that VA conduct more thorough 

screening of practitioners VA intends to hire and practitioners currently 

employed in VA by expanding its verification requirement that facility 

officials contact state licensing boards and national certifying 

organizations for all state licenses and national certificates; expanding the 

query of a national database to include all licensed practitioners that VA 

intends to hire and periodically for practitioners currently employed in VA; 

and requiring fingerprint checks for all health care practitioners who were 

previously exempted from background investigations and who have direct 
Page 4 GAO-04-625T 

patient care access. Furthermore, we recommend that VA conduct 

oversight to help ensure that facilities comply with all screening 

requirements. In commenting on a draft of our report, VA generally agreed 

with our findings and conclusions and stated that it will develop a detailed 

action plan to implement our recommendations. 

VA operates the largest integrated health care system in the United States 

providing care to nearly 5 million veterans per year. The VA health care 

system consists of hospitals, ambulatory clinics, nursing homes, 

residential rehabilitation treatment programs, and readjustment 

counseling centers. In addition to providing medical care, VA is the largest 

educator of health care professionals, training more than 28,000 medical 

residents annually as well as other types of trainees. 

State licenses are issued by state licensing boards, which generally 

establish licensing requirements, and licensed practitioners may be 

licensed in more than one state.3

 “Current and unrestricted licenses” are 

licenses that are in good standing in the state where they are issued. To 

keep a license current, practitioners must renew their licenses before they 

expire and meet renewal requirements established by state licensing 

boards. Renewal requirements include criteria, such as continuing 

education, but renewal procedures and requirements vary by state and 

occupation. When a licensing board discovers a licensee is in violation of 

licensing requirements or established law, for example, abusing 

prescription drugs or intentionally or negligently providing poor quality 

care that results in adverse health effects, it may place restrictions on or 

revoke a license. Restrictions imposed by a state licensing board can limit 

or prohibit a practitioner from practicing in that particular state. Some, but 

not all, state licenses are marked to indicate that the licenses have had 

restrictions placed on them. Generally, state licensing boards maintain a 

database of information on restrictions, which employers can obtain at no 

cost either by accessing the information on a board’s Web site or by 

contacting the board directly. 

National certificates are issued by national certifying organizations, which 

are separate and independent from state licensing boards.4

 These 

 3

State licenses are issued by offices in states, territories, commonwealths, or the District of 

Columbia, collectively referred to as state licensing boards. 

4

Some practitioners may hold both national certificates and state licenses. 

Background 
Page 5 GAO-04-625T 

organizations establish professional standards that are national in scope 

for certain occupations, such as respiratory and occupational therapists. 

Practitioners who are required to have national certificates to work at VA 

must have current and unrestricted certificates. Practitioners may renew 

these credentials periodically by paying a fee and verifying that they 

obtained required educational credit hours. A national certifying 

organization can restrict or revoke a certificate for violations of the 

organization’s professional standards. Like state licensing boards, national 

certifying organizations maintain databases of information on disciplinary 

actions taken against practitioners with national certificates, and many 

can be accessed at no cost. 

We identified key VA screening requirements and found mixed compliance 

with these requirements in the four facilities we visited. The key screening 

requirements are those that are intended to ensure that VA facilities 

employ health care practitioners who have valid professional credentials 

and personal backgrounds to deliver safe health care to veterans. None of 

the four VA facilities complied with all of the screening requirements. In 

addition, VA does not currently conduct oversight of its facilities to 

determine if they comply with the key screening requirements. 

Key VA screening requirements include: 

• verifying the professional credentials of practitioners VA intends to hire; 

• verifying periodically the professional credentials of practitioners 

currently employed in VA facilities; 

• querying, prior to hiring, the Department of Health and Human Services’ 

Office of Inspector General’s List of Excluded Individuals and Entities 

(LEIE) to identify practitioners who have been excluded from 

participation in all federal health care programs;5

• ensuring that background investigations are requested or completed for 

practitioners currently employed in VA facilities; 

• ensuring that the Declaration for Federal Employment form (Form 306) is 

completed by practitioners currently employed in VA facilities; and 

 5

LEIE, a database maintained by the Department of Health and Human Services’ Office of 

Inspector General, provides information to the public, health care providers, patients, and 

others relating to parties excluded from participation in Medicare, Medicaid, and all federal 

health care programs. 

VA Facilities 

Demonstrated Mixed 

Compliance with Key 

VA Screening 

Requirements 
Page 6 GAO-04-625T 

• verifying that the educational institutions listed by a practitioner VA 

intends to hire are checked against lists of diploma mills that sell fictitious 

college degrees and other fraudulent professional credentials. 

To show the variability in the level of compliance among the four VA 

facilities we visited, we measured their performance in five of the six 

screening requirements, against a compliance rate of at least 90 percent 

for each requirement, even though VA policy allows no deviation from 

these requirements. Table 1 summarizes the compliance results we found 

for the five requirements among the four VA facilities we visited. For the 

sixth requirement to match the educational institutions listed by a 

practitioner against lists of diploma mills, we asked facility officials if they 

did this check and then asked them to produce the lists of diploma mills 

they use. 

Table 1: Facilities’ Rate of Compliance with Existing Key VA Screening 

Requirements 

 Compliance with key screening requirementsa

Key screening requirements Facility A Facility B Facility C Facility D 

Credentials verified for practitioners 

VA intends to hire 

A W A A

Credentials verified for practitioners 

currently employed in VA 

W W W W

LEIE queried for practitioners VA 

intends to hire 

W A A A

Background investigation requested 

or completed for practitioners 

currently employed in VA 

W A A W

Declaration for Federal Employment 

form completed for practitioners 

currently employed in VA 

W W W W

Source: GAO analysis of VA facility files. 

W Indicates a compliance rate of 90 percent or greater. 

A Indicates a compliance rate of less than 90 percent. 

Note: Some screening requirements do not require verifying all licenses a practitioner might hold or 

verifying professional credentials by contacting state licensing boards or national certifying 

organizations. 

a

Tested for significance at the 95 percent confidence level. 

All four facilities generally complied with VA’s existing policies for 

verifying the professional credentials of practitioners currently employed 

in VA facilities, either by contacting the state licensing boards for 
Page 7 GAO-04-625T 

practitioners such as physicians or physically inspecting the licenses or 

national certificates for practitioners such as nurses and respiratory 

therapists. They also generally ensured that practitioners VA intended to 

hire had completed the Declaration for Federal Employment form, which 

requires the practitioner to disclose, among others things, criminal 

convictions, employment terminations, and delinquencies on federal loans. 

However, three of the facilities did not follow VA’s policies for verifying 

the professional credentials of practitioners VA intends to hire, and three 

did not compare practitioners’ names to LEIE prior to hiring them. Two of 

the four facilities conducted background investigations on practitioners 

currently employed in their facilities at least 90 percent of the time, but the 

other two facilities did not. 

We also asked officials whether their facilities checked the educational 

institutions listed by a practitioner VA intended to hire against a list of 

diploma mills to verify that the practitioner’s degree was not obtained 

from a fraudulent institution. An official at one of the four facilities told us 

he consistently performed this check. Officials at the other three facilities 

stated that they did not perform the check because they did not have lists 

of diploma mills. 

In addition to assessing the rate of compliance with the key screening 

requirements, we found that VA facilities varied in how quickly they took 

action to deal with background investigations that returned questionable 

results, such as discrepancies in work or criminal histories. The Office of 

Personnel Management (OPM) gives a VA facility up to 90 days to take 

action after the facility receives investigation results with questionable 

findings. We reviewed the timeliness of actions taken by facility officials 

from August 1, 2002, through August 23, 2003, at the 4 facilities we visited 

and 6 additional facilities geographically spread across the VA health care 

system. We found that officials at 5 of the 10 facilities took action within 

the 90-day time frame, with the number of days ranging on average from 13 

to 68. Officials at 3 facilities exceeded the 90-day time frame on average by 

36 to 290 days. One facility took action on its cases prior to OPM closing 

the investigation, and another facility did not have the information 

available to report. 

One of the cases that exceeded the 90-day time frame involved a nursing 

assistant who was hired to work in a VA nursing home in June 2002. In 

August 2002, OPM sent the results of its background investigation to the 

VA facility, reporting that the nursing assistant had been fired from a nonVA nursing home for patient abuse. During our review, we found this case 

among stacks of OPM results of background investigations that were 
Page 8 GAO-04-625T 

stored in a clerk’s office on a cart and in piles on the desk and on other 

workspaces. After we brought this case to the attention of facility officials 

in December 2003, they reviewed the report and then terminated the 

nursing assistant, who had worked at the VA facility for more than 1 year, 

for not disclosing this information on the Declaration for Federal 

Employment form. 

VA has not conducted oversight of its facilities’ compliance with the key 

screening requirements. Instead, VA has relied on OPM to do limited 

reviews of whether facilities were meeting certain human resources 

requirements, such as completion of background investigations. These 

reviews did not include determining whether the facilities were verifying 

professional credentials. Although VA established the Office of Human 

Resources Oversight and Effectiveness in January 2003 to conduct such 

oversight, the office has not conducted any facility compliance 

evaluations. In addition, VA has not implemented a policy for the human 

resources program evaluation to be performed by this office and has not 

provided the resources necessary to support this office. 

Gaps in VA’s requirements for screening the professional credentials and 

personal backgrounds of practitioners create vulnerabilities in its 

screening processes that could place patients at risk by allowing health 

care practitioners who might harm patients to work in VA facilities. For 

certain VA practitioners, screening requirements include the verification of 

all state licenses by contacting the state licensing boards to verify that 

licenses are current and unrestricted. For example, all state licenses for 

physicians and dentists are verified by contacting state licensing boards to 

ensure the licenses are in good standing when VA intends to hire them and 

periodically during employment. Similarly, all licenses for nurses and 

pharmacists VA intends to hire are verified by contacting the state 

licensing boards. However, once hired, periodic screening for nurses and 

pharmacists simply involves a VA official’s physical inspection of one state 

license, even if the practitioner has multiple state licenses, creating a gap 

in the verification process. 

VA’s requirements allow a practitioner to select the license under which he 

or she will work in VA, and this license can be from any state, not 

necessarily the one in which the VA facility is located. A practitioner may 

have a restricted state license as a result of a disciplinary action, yet show 

a facility official a license from another state that is unrestricted. VA 

facility officials informed us that checking one state license was sufficient 

because state licensing boards share information on disciplinary actions 

Gaps in Key VA 

Screening 

Requirements Create 

Vulnerabilities 
Page 9 GAO-04-625T 

and licenses are marked when restricted. However, according to state 

licensing board officials, one cannot determine with certainty that a 

license is valid and unrestricted unless the licensing board is contacted 

directly. These officials explained that state licensing boards do not 

always exchange information about disciplinary actions taken against a 

practitioners and not all states mark licenses that are restricted. Moreover, 

licenses can be forged, even though state licensing boards have taken 

steps to minimize this problem. Therefore, physical inspection of a license 

alone can be misleading. 

To supplement the screening of the state licenses of physicians and 

dentists, VA requires facilities to query two national databasesthe 

National Practitioner Data Bank (NPDB) and the Federation of State 

Medical Boards (FSMB) databasewhich contain information about 

disciplinary actions taken against practitioners. Another available national 

database, the Healthcare Integrity and Protection Data Bank (HIPDB), 

contains information on professional disciplinary actions and criminal 

convictions involving all licensed health care practitioners, not just 

physicians and dentists. VA is currently accessing HIPDB automatically 

when it queries NPDB for physicians and dentists because the databases 

share information. However, VA does not require its facilities to do so for 

all licensed practitioners even though it is authorized to query HIPDB 

without a fee. 

VA also requires that practitioners it intends to hire and who must have 

national certificates to work in VA facilities, such as respiratory therapists, 

disclose the national certificates and any state licenses they have ever 

held. However, VA facility officials are not required to check state licenses 

disclosed by these practitioners and are only required to physically inspect 

the national certificates. As with physical inspection of state licenses, 

physical inspection of national certificates alone can be misleading; not all 

certificates are marked if restricted, and they can be forged. The only way 

to know with certainty if a national certificate is current and unrestricted 

is to contact the issuing national certifying organization. 

In addition to gaps in VA’s verification of professional credentials, VA has 

not implemented consistent background screening requirements, which 

would include fingerprint checks, for all practitioners. Although VA 

requires background investigations for some practitioners currently 

employed in VA, it does not require these investigations for all types of 

practitioners. VA requested and received OPM’s permission to exempt 

certain categories of health care practitioners from background 

investigations based on VA’s assessment that these types of practitioners 
Page 10 GAO-04-625T 

do not need to be investigated. Table 2 lists the practitioners that VA 

exempts from background investigations. 

Table 2: Types of Practitioners VA Exempts from Background Investigations 

Types of practitioners 

VA exempts Length of appointment 

Contract health care 

practitioners or practitioners 

who work without direct 

compensation from VA 

• 6 months or less in a single continuous appointment or 

series of appointments 

Medical consultants • 1 year or less and not reappointed 

• 1 year or more but less than 30 days in a calendar 

year and not reappointed 

Medical residents • 1 year or less of continuous service at a VA facility 

Source: Department of Veterans Affairs, VA Manual MP-1, Part I, Chapter 5, Change 1 (Washington, D.C.: 1979). 

OPM began to offer a fingerprint-only checka new screening optionfor 

use by federal agencies in 2001. Compared to background investigations, 

which typically take several months to complete, fingerprint-only check 

results can be obtained within 3 weeks at a cost of less than $25.6

 In 

commenting on a draft of our report, VA said that it planned to implement 

fingerprint-only checks for all contract health care practitioners, medical 

residents, medical consultants, and practitioners who work without direct 

compensation from VA, as well as certain volunteers. However, VA has not 

issued guidance to its facilities instructing them to implement fingerprintonly checks on all these practitioners. VA did issue guidance to its 

facilities to implement fingerprint-only checks for volunteers who have 

access to patients, patient information, or pharmaceuticals. 

Implementing fingerprint-only checks for practitioners who are currently 

exempt from background investigations would detect practitioners with 

criminal histories. According to the lead VA Office of Inspector General 

investigator in the Dr. Swango case, if Dr. Swango had undergone a 

fingerprint check at the VA facility where he trained, VA facility officials 

would have identified his criminal history and could have taken 

appropriate action. Additionally, one of the facilities we visited had 

implemented fingerprint-only checks of medical residents training in the 

 6

Departments and agencies may obtain fingerprints in two ways: either using paper or using 

computerized technology, which became available in 1999. Computerized technology 

typically produces fingerprint match results in 2 days. 
Page 11 GAO-04-625T 

facility and contract health care practitioners. An official at this facility 

stated that fingerprint-only checks of medical residents and contract 

practitioners were a necessary component of ensuring the safety of 

veterans in the facility. FSMB in 1996 recommended that states perform 

background investigations, including criminal history checks, on medical 

residents to better protect patients because residents have varying levels 

of unsupervised patient care. 

VA’s screening requirements are intended to ensure the safety of veterans 

by identifying practitioners with restricted or fraudulent credentials, 

criminal backgrounds, or questionable work histories. However, 

compliance with the existing key screening requirements was mixed at the 

four facilities we visited. None of the four facilities complied with all of the 

key VA screening requirements. However, all four facilities generally 

complied with VA’s requirement to periodically verify the credentials of 

practitioners for their continued employment. Although VA created the 

Office of Human Resources Oversight and Effectiveness in January 2003 

expressly to provide oversight of VA’s human resources practices at its 

facilities, it has not provided resources for this office to carry out its 

oversight function. Without such oversight, VA cannot provide reasonable 

assurance that its facilities comply with requirements intended to ensure 

the safety of veterans receiving health care in VA facilities. 

Even if VA facilities had complied with all key screening requirements, 

gaps in VA’s existing screening requirements allow some practitioners 

access to patients without a thorough screening of their professional 

credentials and personal backgrounds. For example, although the 

screening requirements for verifying professional credentials for some 

occupations, such as physicians, are adequate, VA does not apply the same 

screening requirements for all occupations with direct patient care access. 

Specifically, VA does not require that all licenses be verified, or that 

licenses and national certificates be verified by contacting state licensing 

boards or national certifying organizations. Similarly, while VA relies on 

two national databases to identify physicians and dentists who have 

disciplinary actions taken against them, VA does not require facility 

officials to query HIPDB. This national database provides information on 

reports of professional disciplinary actions and criminal convictions that 

may involve currently employed licensed practitioners and those VA 

intends to hire. As part of its query of another database, VA accesses 

HIPDB automatically for physicians and dentists, but practitioners such as 

nurses, pharmacists, and physical therapists do not have their state 

licenses checked against this national database. In addition, VA does not 

Concluding 

Observations 
Page 12 GAO-04-625T 

require all practitioners with direct patient care access, such as medical 

residents, to have their fingerprints checked against a criminal history 

database. These gaps create vulnerabilities that could allow incompetent 

practitioners or practitioners with the intent to harm patients into VA’s 

health care system. In light of the gaps we found and mixed compliance 

with the key screening requirements by VA facilities, we believe effective 

oversight could reduce the potential risks to the safety of veterans 

receiving health care in VA facilities. 

In our report, we recommend that VA take the following four actions: 

• expand the verification requirement that facility officials contact state 

licensing boards and national certifying organizations to include all state 

licenses and national certificates held by practitioners VA intends to hire 

and currently employed practitioners, 

• expand the query of the Healthcare Integrity and Protection Data Bank to 

include all licensed practitioners that VA intends to hire and periodically 

query this database for practitioners currently employed in VA, 

• require fingerprint checks for all health care practitioners who were 

previously exempted from background investigations and who have direct 

patient care access, and 

• conduct oversight to help ensure that facilities comply with all key 

screening requirements for practitioners VA intends to hire and 

practitioners currently employed by VA. 

Mr. Chairman, this concludes my prepared remarks. I will be pleased to 

answer any questions you or other Members of the Subcommittee may 

have. 

For further information regarding this testimony, please contact Cynthia 

A. Bascetta at (202) 512-7101. Mary Ann Curran and Marcia Mann also 

contributed to this statement. 

Contact and 

Acknowledgments 

(290366) 
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To order by Phone: Voice: (202) 512-6000 

TDD: (202) 512-2537 

Fax: (202) 512-6061 

Contact: 

Web site: www.gao.gov/fraudnet/fraudnet.htm 

E-mail: fraudnet@gao.gov

Automated answering system: (800) 424-5454 or (202) 512-7470 

Jeff Nelligan, Managing Director, NelliganJ@gao.gov (202) 512-4800 

U.S. General Accounting Office, 441 G Street NW, Room 7149 

Washington, D.C. 20548 

GAO’s Mission 

Obtaining Copies of 

GAO Reports and 

Testimony 

Order by Mail or Phone 

To Report Fraud, 

Waste, and Abuse in 

Federal Programs 

Public Affairs