Report to the Chairman, Subcommittee 

on Oversight and Investigations, 

Committee on Veterans’ Affairs, House 

of Representatives 

United States General Accounting Office 

GAO 

March 2004 VA HEALTH CARE

Improved Screening of 

Practitioners Would 

Reduce Risk to 

Veterans 

GAO-04-566 
www.gao.gov/cgi-bin/getrpt?GAO-04-566.

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-04-566, a report to the 

Chairman, Subcommittee on Oversight 

and Investigations, Committee on 

Veterans’ Affairs, House of 

Representatives 

March 2004

VA HEALTH CARE

Improved Screening of Practitioners 

Would Reduce Risk to Veterans 

GAO identified key screening requirements that VA uses to verify the 

professional credentials and personal backgrounds of its health care 

practitioners. These requirements include verifying professional credentials; 

completing background investigations for certain practitioners, including 

fingerprinting to check for criminal histories; and checking national 

databases that contain reports of practitioners who have been professionally 

disciplined or excluded from federal health care programs. 

GAO found adequate screening requirements for certain practitioners, such 

as physicians, for whom all licenses are verified by contacting state licensing 

boards. However, screening requirements for others, such as currently 

employed nurses and respiratory therapists, are less stringent because they 

do not require verification of all licenses and national certificates. Moreover, 

they require only physical inspection of the credential rather than contacting 

state licensing boards and national 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 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. 

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 of applicants verified A W A A

Credentials of employed practitioners 

verified W W W W

List of Excluded Individuals and Entities 

queried for applicants W A A A

Background investigation completed or 

requested for employed practitioners W A A W

Declaration for Federal Employment form 

completed for employed practitioners 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. 

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

screening requirements. This pattern of mixed compliance and the gaps in 

key VA screening requirements creates vulnerabilities to the extent that VA 

remains unaware of practitioners who could place patients at risk. 

Cases of practitioners causing 

intentional harm to patients have 

raised concerns about VA’s 

screening of practitioners’ 

professional credentials and 

personal backgrounds. GAO was 

asked to (1) identify key VA 

screening requirements, 

(2) evaluate their adequacy, and 

(3) assess compliance with these 

screening requirements. GAO 

reviewed VA’s policies and 

identified key VA screening 

requirements for 43 health care 

occupations; interviewed officials 

from VA, licensing boards, and 

certifying organizations; and 

randomly sampled about 100 

practitioners’ personnel files at 

each of four VA facilities we 

visited. 

GAO recommends that VA expand 

its existing verification process to 

require that all state licenses and 

national certificates held by all 

practitioners be verified by 

contacting the appropriate 

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 recommends 

that VA conduct oversight of its 

facilities to ensure their 

compliance with all key screening 

requirements. VA generally agreed 

with GAO’s findings and will 

develop a detailed action plan to 

implement the recommendations. 
Page i GAO-04-566 VA Screening of Practitioners 

Letter 1

Results in Brief 3

Background 5

VA Policy Requires Its Facilities to Check Many Practitioners’ 

Professional Credentials and Personal Backgrounds 6

Gaps in Key VA Screening Requirements Create Vulnerabilities 12

VA Facilities Did Not Comply with All of the Key VA Screening 

Requirements 17

Conclusions 20

Recommendations for Executive Action 21

Agency Comments 22

Appendix I Scope and Methodology 24 

Appendix II Results of Our Compliance Reviews at VA Facilities 29 

Appendix III Comments from the Department of Veterans Affairs 31 

Appendix IV GAO Contact and Staff Acknowledgments 33 

GAO Contact 33

Acknowledgments 33

Tables 

Table 1: Types of Practitioners VA Exempts from Background 

Investigations 16

Table 2: Facilities’ Rate of Compliance with Existing Key VA 

Screening Requirements 18

Table 3: State Licensure and National Certification Requirements 

for the 43 VA Occupations 25

Table 4: VA Facility Compliance with Key Screening 

RequirementsProfessional Credentials Verification 29

Table 5: Facility Compliance with Key Screening 

RequirementsPersonal Background Screening 29

Contents 
Page ii GAO-04-566 VA Screening of Practitioners 

Table 6: Average Number of Days from Obtaining Background 

Investigation Results to VA Facility Action (August 1, 2002, 

to August 23, 2003) 30

Figures 

Figure 1: VA’s Process for Credentials Verification with State 

Licensing Boards and National Certifying Organizations 8

Figure 2: Gaps in Group B Employed Practitioners’ Credentials 

Verification with State Licensing Boards 13

Figure 3: Gaps in Group C Applicants’ and Employed Practitioners’ 

Credentials Verification with State Licensing Boards and 

National Certifying Organizations 15

Abbreviations 

FSMB Federation of State Medical Boards 

HIPDB Healthcare Integrity and Protection Data Bank 

LEIE List of Excluded Individuals and Entities 

NPDB National Practitioner Data Bank 

OPM Office of Personnel Management 

SLB state licensing board 

VA Department of Veterans Affairs 

This is a work of the U.S. government and is not subject to copyright protection in the 

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reproduce this material separately. 
Page 1 GAO-04-566 VA Screening of Practitioners 

March 31, 2004 

The Honorable Steven Buyer 

Chairman 

Subcommittee on Oversight and Investigations 

Committee on Veterans’ Affairs 

House of Representatives 

Dear Mr. Chairman: 

The Department of Veterans Affairs (VA) is responsible for safeguarding 

veterans receiving health care in its facilities by ensuring that its health 

care practitioners are qualified to provide care to their patients. 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.1

 VA has screening requirements intended to help ensure that its 

health care practitioners’ professional credentials are verified and their 

personal backgrounds checked for evidence of incompetence or criminal 

behavior. According to medical forensic experts, the deliberate harm of 

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

and VA’s requirements are intended to minimize the chance of veterans 

receiving care from someone who is incompetent or may intentionally 

harm them. 

Events at VA facilities have raised concerns about VA’s screening of the 

professional credentials and personal backgrounds of health care 

practitioners at its facilities. In 1993, Dr. Michael Joseph Swango entered 

the VA health care system as a medical resident, although before entering 

the residency program he had been convicted and imprisoned for 2 years 

for aggravated battery against his fellow employees. Dr. Swango had 

admitted to medical school officials that he had a prior arrest and 

conviction, but lied about the nature of the crime. In 2000, he pleaded 

guilty to murdering three veterans at the VA facility located in Northport, 

New York, and received a sentence of three consecutive life terms without 

the possibility of parole. In another case, in 2000, events at the VA facility 

 1

Contract staff may include intensive care nurses, emergency room physicians, or 

respiratory therapists. These staff have access to and provide care to patients. 

United States General Accounting Office 

Washington, DC 20548 
Page 2 GAO-04-566 VA Screening of Practitioners 

in Albany, New York, raised concerns about VA’s process for checking the 

credentials of individuals employed at its facilities. VA hired a research 

assistant to help administer several cancer studies. The research assistant 

had lost his medical license because he had forged his medical credentials. 

Once at VA, the research assistant allegedly falsified data that were used 

to qualify veterans for cancer studies, and this may have resulted in the 

untimely deaths of several veterans. In 2003, the researcher was indicted 

in federal court on charges including manslaughter, criminally negligent 

homicide, and fraud. 

You asked that we 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 care to veterans. 

Specifically, we (1) identified key VA screening requirements for its health 

care practitioners, (2) determined the adequacy of these screening 

requirements, and (3) assessed the extent to which selected VA facilities 

complied with these screening requirements. 

We reviewed health care occupations in VA and selected 43 occupations in 

which practitioners have direct patient care access or have an impact on 

patient care. See appendix I for a list of the 43 health care occupations 

included in our study. We reviewed VA employment screening policies and 

practices to identify those requirements that applied to the selected 

occupations and were key requirements for safeguarding veterans 

receiving health care in VA facilities.2

 To determine the adequacy of the 

key screening requirements, we examined whether they were complete, 

and whether VA applied them to all applicants, current employees, 

contract staff, medical residents, and volunteers. We also interviewed VA 

human resource officials, VA headquarters and VA facility officials, and 

facility practitioners; 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 also reviewed VA’s policy on background 

investigations to determine its criteria for conducting background 

investigations. To assess the extent to which VA facilities complied with 

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

personnel files for practitioners at each site. From VA’s automated pay 

 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-04-566 VA Screening of Practitioners 

system, we selected a statistically random sample of 100 current 

practitioners in the 43 occupations for each facility we visited. We 

reviewed these practitioners’ files to determine whether the facilities had 

documentation that demonstrated compliance with key VA screening 

requirements. We visited facilities located in Big Spring, Texas; New 

Orleans, Louisiana; Seattle, Washington; and the District of Columbia, 

based on geographic variation, affiliations with medical schools to train 

residents, and types of health care services provided. Of the four facilities 

we visited, three are large facilities located in major metropolitan areas 

and are affiliated with at least one medical school. The remaining facility is 

small, providing mainly primary care and long-term care services to 

veterans and is located in a rural area. Additionally, from the four facilities 

we visited and from six other facilities we selected based on geographic 

variation, we obtained documentation on how quickly facilities took 

action after obtaining the results of background investigations. Our results 

cannot be generalized to other facilities. For a complete description of our 

scope and methodology, see appendix I. Our work was conducted from 

August 2003 through March 2004 in accordance with generally accepted 

government auditing standards. 

We identified key screening requirements in VA’s policies for checking the 

professional credentials and personal backgrounds of health care 

practitioners in its facilities. These requirements are in place to verify state 

licenses and national certificates for applicants VA intends to hire and for 

continued employment of practitioners; to check health care practitioners 

against national databases that contain reports of professional disciplinary 

actions and criminal convictions; and to investigate the personal 

backgrounds of health care practitioners, including checking fingerprints 

against a fingerprint-based criminal history database. 

We found adequate screening requirements for certain practitioners, such 

as physicians and dentists. These screening requirements include having 

facility officials verify all physicians’ and dentists’ licenses by contacting 

state licensing boards for applicants VA intends to hire and periodically for 

their continued employment. Screening requirements for other 

practitioners, such as currently employed nurses, are less stringent 

because they do not require that VA facility officials check all licenses. 

Moreover, they do not require contacting state licensing boards, but 

instead require physical inspection of the license only. VA 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 applicants VA intends to hire and periodically 

Results in Brief 
Page 4 GAO-04-566 VA Screening of Practitioners 

for their continued employment. Physical inspection of credentials alone 

can be misleading; not all state licenses and national certificates indicate 

whether they are restricted, and licenses and certificates can be forged. 

Also, other than for physicians and dentists, VA does not require facility 

officials to query a national database that contains 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 records. These gaps create 

vulnerabilities because VA may remain unaware of health care 

practitioners who could place patients at risk. 

In the four facilities we visited, we found mixed compliance with the 

existing key VA screening requirements. All facilities generally checked 

the professional credentials of practitioners periodically for continued 

employment. However, they were less compliant in checking the 

professional credentials of applicants that 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 employer 

for patient abuse. Although VA established an office more than a year ago 

to perform oversight of human resources functions, including whether its 

facilities comply with these key screening requirements, it has not started 

these reviews. There is no VA policy outlining the human resources 

program evaluations to be performed by this office, and the resources 

have not been provided to support the functions of this office. 

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

facilities, we recommend that VA conduct more thorough screening of 

both applicants it intends to hire and current employees by expanding 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; expanding the query of a 

national database to include all licensed practitioners that VA intends to 

hire and periodically for continued employment; and requiring fingerprint 

checks for all health care practitioners who were previously exempted 

from background investigations and who have direct patient care access. 

Furthermore, VA should conduct oversight to help ensure that facilities 

comply with all key screening requirements for applicants and current 

employees. In commenting on a draft of this report, VA generally agreed 
Page 5 GAO-04-566 VA Screening of Practitioners 

with our findings and conclusions and stated that it would provide details 

on how it plans to address our recommendations when the final report is 

issued. 

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 state licensing requirements governing their licensed 

practitioners.3

 Current and unrestricted licenses are licenses that are in 

good standing in the states that issued them, and licensed practitioners 

may hold licenses from more than one state. To keep a license current, 

practitioners must renew their licenses before they expire and meet 

renewal requirements established by state licensing boards, such as 

continuing education. Renewal procedures and requirements vary by state 

and occupation. When licensing boards discover violations of licensing 

practices, such as the abuse of prescription drugs or the provision of poor 

quality of care that results in adverse health effects, they may place 

restrictions on licenses or revoke them. Restrictions from a state licensing 

board can limit or prohibit a practitioner from practicing in that particular 

state. Some, but not all, issued state licenses are marked in such a way as 

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 often 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 

organizations establish professional standards that are national in scope 

for certain occupations, such as respiratory and occupational therapists. 

 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 a national certificate and a state license. 

Background 
Page 6 GAO-04-566 VA Screening of Practitioners 

Practitioners who are required to have a national certificate to practice in 

VA may renew these credentials periodically by paying a fee and verifying 

that they obtained required educational credit hours. National certifying 

organizations can place restrictions on a certification or revoke 

certification for violations of the organization’s professional standards. 

Like state licensing boards, national certifying organizations maintain a 

database 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 that are intended to ensure 

that VA facilities employ health care practitioners who have valid 

professional credentials and personal backgrounds appropriate to deliver 

safe health care to veterans. Officials at VA facilities are required to verify 

whether credentialsstate licenses and national certificatesheld by 

applicants and employees are current and unrestricted.5

 VA also requires 

its facilities to check the names of all applicants VA intends to hire against 

a federal list of individuals who have been excluded from participation in 

any federal health care programs and to compare applicants’ educational 

institutions against lists of fraudulent institutions.6

 Additionally, VA 

requires that individuals in certain positions undergo a background 

investigation, which includes checking their fingerprints against a 

fingerprint-based criminal history database. 

 5

Professional credentials held by practitioners may include licenses, registrations, and 

certifications. We refer to these credentials as state licenses or national certificates. 

6

The term applicants refers to those practitioners that VA facility officials plan to hire. 

VA Policy Requires Its 

Facilities to Check 

Many Practitioners’ 

Professional 

Credentials and 

Personal 

Backgrounds 
Page 7 GAO-04-566 VA Screening of Practitioners 

VA policy requires officials at its facilities to screen applicants to 

determine whether they possess at least one current and unrestricted state 

license or an appropriate national certificate, whichever is applicable for 

the position they seek. We classified VA’s practitioners into three groups, 

depending upon the credentials and the verification process VA requires 

for employment. Figure 1 illustrates VA’s process for credentials 

verification with state licensing boards and national certifying 

organizations for these groups for applicants VA intends to hire and for 

employed practitioners, whose credentials are checked periodically.7 8

Groups A and B represent practitioners who must be licensed to work in 

VA. However, the requirements and process VA uses to verify professional 

credentials is different for each of these groups. Group C represents 

practitioners who must have a national certificate to work in VA and may 

also have a state license. 

 7

The frequency of when practitioners’ credentials are checked depends on their occupation 

and the requirements of the state or national organization that issued the credential. 

8

We use the term employed practitioners to refer to practitioners who have been hired by 

VA and to distinguish them from practitioners who have applied for VA employment, but 

have not been hired. 

VA Policy Requires 

Verification of the Status 

of State Licenses and 

National Certificates 
Page 8 GAO-04-566 VA Screening of Practitioners 

Figure 1: VA’s Process for Credentials Verification with State Licensing Boards and 

National Certifying Organizations 

Note: Groups A and B represent practitioners who must be licensed to work in VA. Some group B 

psychologists and social workers may undergo the same credentials verification process as 

practitioners in group A. Group C represents practitioners who must have a national certificate to 

work in VA and may also have a state license. 

a

Physician assistants are not required to have a license to work in VA, but their credentials are 

verified using a process that is similar to other group A practitioners. 

The process used to screen applicants in all three groups has two stages. 

First, applicants are required to disclose, if applicable, their state licenses 

and national certificates. Second, VA facility officials are required to verify 

whether applicants’ state licenses or national certificates are current and 

unrestricted. To verify applicants’ credentials, VA officials are required to 
Page 9 GAO-04-566 VA Screening of Practitioners 

either contact state licensing boards or to physically inspect an applicant’s 

national certificate. Officials are also required to document that they 

verified the status of the professional credentials. 

VA also has requirements for verifying the credentials of its employed 

practitioners. Like the verification process for applicants, this process 

involves employed practitioners’ disclosures and VA verification of that 

information. VA employed practitioners in group A are required to disclose 

all of their current licenses, while those in group B must disclose only one 

license. For employed practitioners in group A, facility officials are also 

required to determine if any expired licenses disclosed as current and 

unrestricted at the beginning of employment had restrictions placed on 

them prior to their expiration. VA depends on its employed practitioners in 

group B to inform facility officials of any change in the status of their 

license, including any that have expired. Employed practitioners in group 

C must disclose a national certificate. VA officials must confirm that the 

disclosed licenses and certificates are current and unrestricted. For group 

A practitioners, VA facility officials contact the appropriate state licensing 

boards directly; for groups B and C they physically inspect the state 

license or national certificate. VA officials verify these credentials 

periodically depending on the occupation and the requirements of the 

state or national organization that issued the license or certificate. For 

example, a registered nurse with a state license from Virginia must renew 

the license every 3 years, while a respiratory therapist must renew the 

national certificate every 5 years.9

 VA officials are required to document 

these verifications. 

If VA’s verification process identifies that a state licensing board or 

national certifying organization took disciplinary action against a 

practitioner, facility officials are required to determine the circumstances 

of the disciplinary action. Licensing boards and certifying organizations 

have various options for disciplining practitioners. For example, a nurse 

who is abusing drugs and voluntarily enters a drug abuse program may 

retain a license to practice with supervision when administering drugs. In 

contrast, a physician whose treatment results in the death or the 

permanent disability of a patient may have a license revoked. On the basis 

of a review of the action taken by the state licensing board or national 

 9

The requirement for respiratory therapists to renew their national certificate every 5 years 

became effective in July 2002 and affects those national certificates obtained after June 30, 

2002. 
Page 10 GAO-04-566 VA Screening of Practitioners 

certifying organization, VA officials are to determine whether an applicant 

should be hired or an employed practitioner should be retained or 

terminated. 

To supplement its checks with state licensing boards, VA has requirements 

for searching for disciplinary actions taken against licensed practitioners 

that might not have been disclosed by physician and dentist applicants and 

employed practitioners. VA requires its facilities to check national 

databases for information on disciplinary actions taken against these 

practitioners. Specifically, VA requires that facility officials query the 

Federation of State Medical Boards (FSMB) database, which includes 

records of disciplinary actions taken against physicians by all state 

licensing boards.10 Similarly, VA requires facility officials to query the 

National Practitioner Data Bank (NPDB), which contains information 

including disciplinary actions taken against physicians and dentists.11

Facility officials must document the results of these queries. 

VA policy requires its facilities to check the names of all applicants VA 

intends to hire against a federal list of individuals who have been excluded 

from participation in any federal health care program.12 The list, referred to 

as the List of Excluded Individuals and Entities (LEIE), is maintained by 

the Department of Health and Human Services’ Office of Inspector 

General. Since March 1999, VA facilities are to electronically query the 

LEIE Web site on all applicants prior to employment. 

VA also requires its facilities to make sure that an applicant’s educational 

degrees are authentic. VA requires that applicants for some positions, such 

as social workers, have degrees from accredited institutions. To prevent 

 10FSMB represents state medical licensing boards and establishes standards for physician 

licensure and practice. FSMB operates a national database to collect, record, and distribute 

to state medical boards and other appropriate agencies data on disciplinary actions taken 

against physicians by the boards and other governmental authorities. 

11The Health Resources and Services Administration of the Department of Health and 

Human Services is responsible for the management of NPDB. 

12The Balanced Budget Act significantly expanded the authority of the Department of 

Health and Human Services to exclude certain individuals and entities from participation in 

federal health care programs. Exclusion is mandatory for those convicted of Medicarerelated crimes, patient abuse, and certain health care fraud and controlled substance 

crimes. Exclusion is permissive for other offenses, including professional health care 

license revocation. See Pub. L. No. 105-33 § 4331(c), 111 Stat. 251, 396; 42 U.S.C. § 1320a-7. 

VA Policy Requires Checks 

of Applicants and Their 

Credentials against Lists 

Designed to Prevent Fraud 

and Abuse 
Page 11 GAO-04-566 VA Screening of Practitioners 

the use of fraudulent degrees to obtain employment, VA requires that its 

facilities compare the educational institutions listed by an applicant 

against existing lists of “diploma mills” that sell fictitious college degrees 

and other professional credentials. 

VA’s employed practitioners are required to undergo a background 

investigation that verifies their personal histories.13 A background 

investigation verifies, for instance, an individual’s history of employment, 

education, and residence. It also includes a fingerprint check that searches 

for evidence of criminal activity by comparing fingerprints against a 

database of criminal records. The Office of Personnel Management (OPM) 

conducts the investigations for VA and reports its results back to the 

facility that requested the investigation. 

In conjunction with the background investigation, VA employed 

practitioners are required to disclose information about their professional 

and personal backgrounds by filling out the Declaration for Federal 

Employment form—also known as form 306. Employed practitioners are 

asked to disclose, among other things, information about criminal 

convictions, employment terminations, military court-martials, and 

delinquencies on federal loans. Failure to disclose information requested 

on form 306 is grounds for dismissal. Facility officials compare the 

information obtained from form 306 with the results obtained through the 

background investigation to determine whether employed practitioners 

have been forthcoming in their disclosures. If the background 

investigation results include questionable issues, such as discrepancies in 

work or criminal histories, the facility has 90 days to take action. 

 13Executive Order 10450, April 27, 1953, requires all persons employed by federal 

departments and agencies to undergo a background investigation to ensure that their 

employment is consistent with national security interests. It is administered by the Office 

of Personnel Management (OPM), which has issued implementing regulations in part 732 of 

Title 5 of the Code of Federal Regulations. OPM may grant exemptions to the executive 

order and, with regard to VA, background investigations are not required for employees 

appointed for 6 months or less. Related regulations regarding determinations of an 

individual’s suitability for federal employment, based on their character, conduct, 

knowledge, and ability, are contained in part 732 of the Code of Federal Regulations. 

VA Policy Requires 

Background Investigations 

and Disclosures for 

Certain Employed 

Practitioners 
Page 12 GAO-04-566 VA Screening of Practitioners 

Gaps in key VA screening requirements result in vulnerabilities when 

screening certain health care practitioners. Although the screening 

requirements for some occupations, such as physicians, are adequate 

because they require verifying all licenses by contacting state licensing 

boards, screening requirements for other occupations are less stringent. 

These less stringent requirements do not require checking all licenses, and 

they require physical inspection of one license only rather than contacting 

the state licensing board. Similarly, VA does not require contacting 

national certifying organizations to verify national certificatesthe 

credentials held by health care practitioners, such as respiratory 

therapists. Physical inspection of credentials alone can be misleading; not 

all state licenses and national certificates indicate whether they are 

restricted, and licenses and certificates can be forged. While VA requires 

checking a national database for physicians and dentists, it does not 

require that facility officials query a national database that contains 

reports of disciplinary actions and criminal convictions involving all 

licensed practitioners. In addition, VA does not require that all 

practitioners undergo background investigations, including fingerprinting, 

to check for criminal records. These gaps create vulnerabilities because 

VA may remain unaware of health care practitioners who could place 

patients at risk. 

VA’s requirements for verifying the professional credentials of applicants it 

intends to hire and employed practitioners in group A, such as physicians 

and dentists, are complete and thorough. This is also the case for 

applicants VA intends to hire in group B, such as nurses and pharmacists. 

VA requires facility officials to verify all state licenses by contacting the 

appropriate state licensing boards. To supplement these requirements for 

physicians and dentists, VA officials also must query FSMB and NPDB to 

identify reports of any disciplinary actions involving these practitioners. 

In contrast to all practitioners in group A, the process for verification of 

licenses for group B practitioners has gaps, as illustrated in figure 2. VA’s 

verification process for group B practitioners that it intends to hire is as 

stringent as the process used for group A practitioners. However, the 

process used to verify licenses for continued employment of group B 

practitioners is less stringent, because facility officials are required to 

check only one state license, which is selected by the practitioner. 

Furthermore, officials are not required to contact the state licensing board 

directly, but instead may simply physically inspect the one state license to 

check its status. 

Gaps in Key VA 

Screening 

Requirements Create 

Vulnerabilities 

VA Has Adequate 

Requirements for Verifying 

Professional Credentials of 

Certain Practitioners 

Gaps Exist in VA’s 

Requirements for Verifying 

Professional Credentials of 

Other Practitioners 
Page 13 GAO-04-566 VA Screening of Practitioners 

Figure 2: Gaps in Group B Employed Practitioners’ Credentials Verification with State Licensing Boards 

Employed practitioners in group B with multiple state licenses select the 

one state license under which they will continue to practice in VA. The 

license selected does not have to be from the state where the VA facility is 

located. VA officials check only that single license. As a result, these 

employed practitioners could have a restricted license in one state, or 

several restricted state licenses, but offer VA officials an unrestricted 

license from another state for verification. 

Moreover, the method required to periodically verify the status of licenses 

for continued employment of practitioners in group B is not thorough. VA 

facility officials are only required to physically inspect the license—

instead of contacting the state licensing board. VA facility officials we 

interviewed were unaware of the inherent vulnerabilities in relying on a 

physical inspection. According to licensing board officials, one cannot 

determine with certainty that a license is valid and unrestricted unless the 

state licensing board is contacted directly. These officials explained that 

state licensing boards do not always exchange information. Furthermore, 

physical inspection of licenses alone can be misleading because not all 

state licensing boards mark a license to indicate that it is restricted, and 

licenses can be forged, even though licensing boards have taken steps to 

minimize this problem. Licensing board officials also pointed out that 

many state boards do not charge a fee to verify licenses. 
Page 14 GAO-04-566 VA Screening of Practitioners 

Unlike the national database queries of FSMB for physicians and NPDB for 

physicians and dentists, VA does not require facility officials to query the 

Healthcare Integrity and Protection Data Bank (HIPDB), a national 

database that contains information on disciplinary actions and criminal 

convictions involving all licensed practitioners.14 All government agencies, 

including state licensing boards, are required to report to HIPDB. VA 

accesses HIPDB when it queries the NPDB for physicians and dentists 

because the databases share information. However, VA does not require its 

facilities to query HIPDB for all licensed practitioners even though VA is 

authorized by statute to query this database at no charge. 

VA’s requirements for verifying the professional credentials of both 

applicants and employed practitioners in group C also have gaps, as 

illustrated in figure 3. For both applicants and employed practitioners in 

group C, which include respiratory therapists and dietitians for example, 

facility officials are only required to physically inspect the national 

certificate to check its status. The physical inspection is required when 

these practitioners apply for employment and periodically for continued 

employment. Additionally, VA requires applicants in group C to disclose all 

of the state licenses they have ever held, but does not require facility 

officials to verify any of these state licenses. 

 14HIPDB was developed after the Health Insurance Portability and Accountability Act of 

1996 was enacted, which added new section 1128E to the Social Security Act, requiring 

development of the database. See Pub. L. No. 104-191, § 221(a), 110 Stat. 1936, 2009 

(codified at 42 U.S.C. § 1320a-7e(2000)). The applicable regulations are contained in Part 61 

of Title 45 of the Code of Federal Regulations. HIPDB is maintained and operated by the 

Health Resources and Services Administration in the Department of Health and Human 

Services. 
Page 15 GAO-04-566 VA Screening of Practitioners 

Figure 3: Gaps in Group C Applicants’ and Employed Practitioners’ Credentials Verification with State Licensing Boards and 

National Certifying Organizations 

However, according to officials from national certifying organizations, the 

authenticity and status of a national certificate can only be assured by 

contacting the national certifying organizations directly. For example, an 

official from the National Board for Respiratory Care told us that 

practitioners that were certified prior to July 2002 are not required to 

renew their certificates—they can voluntarily choose to recertify. Thus, 

physical inspection of a certificate will not ensure that there has been no 

disciplinary action taken by the board since the certificate was issued. 

VA has not implemented consistent background screening requirements, 

which include fingerprint checks, for all practitioners. Although VA 

requires background investigations for newly hired employed 

practitioners, it does not require background investigations for certain 

contract health care practitioners, practitioners who work without 

compensation from VA, medical consultants, and medical residents. VA, 

with prior approval from OPM, has the authority to determine which 

positions in VA require a background investigation. VA requested and 

received permission from OPM to exempt certain categories of health care 

practitioners from background investigations, based on VA’s assessment 

VA Has Not Implemented 

Consistent Background 

Screening Requirements 
Page 16 GAO-04-566 VA Screening of Practitioners 

that these types of practitioners do not need a background investigation. 

Table 1 lists the types of practitioners that VA exempts from background 

investigations. 

Table 1: Types of Practitioners VA Exempts from Background Investigations 

Types of practitioners VA 

exempts Length of appointment 

Contract health care 

practitioners or practitioners 

that 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). 

VA requested and received permission from OPM, in 2001 and 2003, to 

perform fingerprint-only checks for contract health care practitioners, 

who work in a facility for 6 months or less and are currently exempt from 

background investigations, and for all volunteers who have access to 

patients, patient information, or pharmaceuticals.15 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 checks can be obtained 

within 3 weeks or less and cost less than $25, about a quarter of the cost of 

a background investigation.16 In commenting on a draft of this report, VA 

said that it planned to implement fingerprint-only checks for all contract 

health care practitioners, medical residents, medical consultants, and 

practitioners that work without direct compensation from VA, as well as 

certain volunteers. However, VA has not issued guidance to its facilities 

instructing them to implement fingerprint-only 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. 

 15VA’s volunteer program is the largest in the federal government, providing volunteers to 

assist veterans by augmenting staff in such settings as hospitals and nursing homes. 

16Departments 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 17 GAO-04-566 VA Screening of Practitioners 

Implementing fingerprint-only checks for practitioners who are currently 

exempt from background investigations would detect practitioners with a 

criminal history. 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 

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

stated that at a minimum, fingerprint-only checks of medical residents and 

contract practitioners were necessary to help ensure the safety of veterans 

in the facility. FSMB in 1996 recommended that states perform 

background investigations, including criminal history checks, on medical 

residents in order to better protect patients because residents have varying 

levels of unsupervised patient care. This recommendation, in part, resulted 

from reports that over a 4-year period more than 500 residents had 

performance, behavioral, or criminal problems during their training. 

In the four facilities we visited, we found mixed compliance with the 

existing key VA screening requirements which are intended to ensure that 

applicants and employed practitioners at VA facilities 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 key 

requirements. Moreover, VA does not conduct oversight of its facilities to 

determine if they comply with these key screening requirements. 

In order to show the variability in the level of compliance among the four 

VA facilities we visited, we measured their performance against a 

compliance rate of at least 90 percent for each of five of the six screening 

requirements, even though VA allows no deviation from these 

requirements. Table 2 summarizes the rate of compliance among the four 

VA facilities we visited. For detailed information about our analysis and 

each facility’s compliance with a particular requirement, see appendixes I 

and II. For the sixth requirementmatching 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. 

VA Facilities Did Not 

Comply with All of 

the Key VA Screening 

Requirements 
Page 18 GAO-04-566 VA Screening of Practitioners 

Table 2: 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 of applicants verified A W A A

Credentials of employed 

practitioners verified W W W W

List of Excluded Individuals and 

Entities queried for applicants W A A A

Background investigation completed 

or requested for employed 

practitioners W A A W

Declaration for Federal Employment 

form completed for employed 

practitioners 

(form 306) W W W W

Source: GAO analysis of VA facility files. 

WIndicates 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 employed practitioners, either by 

contacting the state licensing board for practitioners, such as physicians, 

or physically inspecting the license or national certificate for practitioners, 

such as nurses and respiratory therapists. They also generally ensured that 

applicants VA intended to hire had completed the Declaration for Federal 

Employment form, which requires the applicants to disclose, among other 

things, information about criminal convictions, employment terminations, 

and delinquencies on federal loans. However, three of the four facilities 

did not follow VA’s policies for verifying all of the professional credentials 

of applicants and three facilities did not compare applicants’ names to 

LEIE prior to hiring them. Two of the four facilities conducted background 

investigations on their employed practitioners 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 an applicant against a list of diploma mills to verify 

that the applicant’s degree was not obtained from a fraudulent institution. 
Page 19 GAO-04-566 VA Screening of Practitioners 

An official at one of the four facilities told us his staff consistently 

performed this check. Officials at the other three facilities stated they did 

not perform the check because they did not have a list 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. 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, to 

August 23, 2003, at the four facilities we visited and six 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. For 

additional information on the average number of days it took each facility 

to report its actions, see appendix II. 

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 

stored on a cart and in piles on the desk and on other work surfaces of a 

clerk’s office. After we brought this case to the attention of facility 

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

the employee for not disclosing this information on the Declaration for 

Federal Employment form 306. The employee had worked at the VA 

facility for more than 1 year. 

Another case at the same facility that exceeded the 90-day time frame 

involved an employee who had been convicted for possession of illegal 

drugs prior to being hired by VA. He had been hired at the facility in 

August 2002 and was to complete a background investigation form at that 

time. In June 2003, almost 1 year after being hired, a facility official 

realized the employee had not completed and returned this form and gave 

the employee the form to complete. The employee returned the completed 

form in the same month and it was sent to OPM, which returned the 

results of its investigation to the facility in July 2003, before the 
Page 20 GAO-04-566 VA Screening of Practitioners 

employee’s probationary period of 1 year was completed. The OPM report 

revealed numerous arrests for possession of illegal drugs. During our 

December 2003 review and about 120 days after the investigation results 

were returned from OPM, we found this report and brought it to the 

attention of the facility director. Later, a facility official told us that VA’s 

regional counsel stated that since the employee’s 1-year probationary 

period had ended and the employee had disclosed this information on the 

Declaration for Federal Employment form 306, the facility could not take 

action to terminate the employee. 

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. There is no VA policy outlining the human resources program 

evaluations to be performed by this office, and the resources have not 

been provided to support the functions of this office. 

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

by identifying applicants and employed practitioners with restricted or 

fraudulent credentials, criminal backgrounds, or questionable work 

histories. However, 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. VA relies on two 

national databases to identify physicians and dentists who have had 

disciplinary actions taken against them. In addition, VA accesses a third 

national database, HIPDB, for physicians and dentists, because HIPDB is 

linked to one of the two national databases VA currently accesses. HIPDB 

is a national database that contains reports of disciplinary actions and 

criminal convictions involving all licensed practitioners, not just 

physicians and dentists. However VA does not require facility officials to 

query HIPDB for all licensed practitioners. As a result, practitioners such 

Conclusions 
Page 21 GAO-04-566 VA Screening of Practitioners 

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

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

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 addition to these gaps, 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 conduct oversight of VA facilities’ compliance 

with these requirements. 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. 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. 

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

facilities, we recommend that the Secretary of Veterans Affairs direct the 

Under Secretary for Health to 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 applicants and 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 continued employment, 

• 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 applicants and current employees. 

Recommendations for 

Executive Action 
Page 22 GAO-04-566 VA Screening of Practitioners 

In commenting on a draft of this report, VA generally agreed with our 

findings and conclusions. VA acknowledged that we identified gaps in its 

process for conducting background and credentialing checks and that we 

provided what appeared to be reasonable recommendations to close those 

gaps. VA stated that it would provide a detailed action plan to implement 

our recommendations when the final report was issued. 

VA said that our draft report inaccurately omitted VA’s querying HIPDB for 

practitioners who practice independently. We revised our report to clarify 

that NPDB queries performed by VA automatically check HIPDB for these 

practitioners because the databases are linked. However, VA does not 

perform queries of HIPDB for the majority of its licensed practitioners, 

which includes nurses, pharmacists, physical therapists, and dental 

hygienists. VA also incorrectly stated that the draft report did not include 

VA’s requirement to query FSMB for physicians. In addition, VA said that it 

planned to implement fingerprint-only checks for all contract health care 

practitioners, medical residents, medical consultants, and practitioners 

that work without direct compensation from VA, as well as certain 

volunteers. However, VA has not issued guidance to its facilities 

instructing them to implement fingerprint-only checks for all these 

practitioners. Further, VA stated that the title of the report implied that 

veterans are receiving inadequate care on a broad basis. We disagree. The 

title reflects vulnerabilities created by the gaps in the screening of 

practitioners that could place veterans at risk by allowing incompetent 

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

care system. VA provided technical comments which we incorporated, as 

appropriate. VA’s written comments are reprinted in appendix III. 

As agreed with your office, unless you publicly announce its contents 

earlier, we plan no further distribution of this report until 30 days after its 

date. We will then send copies of this report to the Secretary of Veterans 

Affairs and other interested parties. We also will make copies available to 

others upon request. In addition, the report will be available at no charge 

at the GAO Web site at http://www.gao.gov. 

Agency Comments 
Page 23 GAO-04-566 VA Screening of Practitioners 

If you or your staff have any questions about this report, please call me at 

(202) 512-7101. Another contact and key contributors are listed in 

appendix IV. 

Sincerely yours, 

Cynthia A. Bascetta 

Director, Health Care—Veterans’ 

 Health and Benefits Issues 
Appendix I: Scope and Methodology 

Page 24 GAO-04-566 VA Screening of Practitioners 

We examined VA’s policies and practices that are intended to ensure that 

health care practitioners at its facilities have appropriate credentials and 

backgrounds to provide care to veterans. Specifically, we (1) identified 

key VA screening requirements for its health care practitioners, (2) 

determined the adequacy of these screening requirements, and (3) 

assessed the extent to which selected VA facilities complied with these 

screening requirements. 

To identify key VA screening requirements for its health care practitioners, 

we reviewed VA’s policies and VA Handbook 5005, which explains how to 

implement the screening policies. We limited our review to 43 occupations 

in VA that have direct patient care access or have an impact on patient 

care. See table 3 for a list of the occupations included in our review. To 

identify the 43 occupations, we consulted with VA human resource 

officials. We interviewed human resource officials at VA headquarters and 

at each facility we visited. We classified the practitioners who are required 

to have professional credentialsa state license or a national 

certificateinto three groups according to VA’s requirements for verifying 

these credentials. Groups A and B represent practitioners who must be 

licensed to work in VA. However, the requirements and process VA uses to 

verify professional credentials is different for each of these groups. Group 

C represents practitioners who must have a national certificate to work in 

VA and may also have a state license. Practitioners not included in the 

three groups are not required to have either a license or a national 

certificate to work in VA facilities. 

Appendix I: Scope and Methodology 
Appendix I: Scope and Methodology 

Page 25 GAO-04-566 VA Screening of Practitioners 

Table 3: State Licensure and National Certification Requirements for the 43 VA Occupations 

Occupation 

code Occupation title 

Occupations that 

require a state license 

to work in VA 

Occupations that 

require a national 

certificate to work in 

VA 

Occupations that do 

not require a state 

license or a national 

certificate to work in 

VA 

101 Social Science X 

102 Social Science Aid and Technician X 

180 Psychology X 

181 Psychology Aid and Technician X 

185 Social Work X 

186 Social Services Aid and Assistant X 

187 Social Services X 

189 Recreation Aid and Assistant X 

413 Physiology X 

601 General Health Science X 

602 Medical Officer (Physician) X 

603 Physician’s Assistant X 

605 Nurse Anesthetist X X 

610 Registered Nursea X 

620 Practical Nurse X 

621 Nursing Assistant X 

622 Medical Supply Aide/Technician X 

630 Dietitian and Nutritionist X 

631 Occupational Therapist X 

633 Physical Therapist X 

635 Corrective Therapist X 

636 Rehabilitation Therapy Assistant X 

638 Recreation/Creative Arts Therapist X 

640 Health Aid and Technician X 

644 Medical Technologist X 

645 Medical Technician X 

646 Pathology Technician X 

647 Diagnostic Radiologic Technologist X 

648 Therapeutic Radiologic Technologist X 

649 Medical Instrument Technician X 

651 Respiratory Therapistb X 

660 Pharmacist X 
Appendix I: Scope and Methodology 

Page 26 GAO-04-566 VA Screening of Practitioners 

Occupation 

code Occupation title 

Occupations that 

require a state license 

to work in VA 

Occupations that 

require a national 

certificate to work in 

VA 

Occupations that do 

not require a state 

license or a national 

certificate to work in 

VA 

661 Pharmacy Technician X 

662 Optometrist X 

665 Speech Pathology and Audiology X 

667 Orthotist and Prosthetist X 

668 Podiatrist X 

672 Prosthetic Representative X 

680 Dental Officer (Dentist) X 

681 Dental Assistant X 

682 Dental Hygiene X 

1320 Chemistry X 

1715 Vocational Rehabilitation X 

Source: VA Handbook 5005, April 15, 2002. 

a

Registered Nurse—includes nurse practitioners and clinical nurse specialists. 

To determine the adequacy of the key VA screening requirements, we 

analyzed VA’s policies and procedures to identify whether there were 

inconsistencies in how the requirements were applied among various 

types of practitioners. We interviewed VA headquarters and facility 

officials and practitioners at the facilities we visited to determine how 

VA’s policies are implemented in facilities. In addition, we interviewed 

representatives from 13 state licensing boards and the District of Columbia 

Board of Nursing and 2 national certifying organizations to determine if 

VA’s requirements for verifying professional credentials are adequate for 

identifying practitioners without valid and unrestricted state licenses and 

national certificates.1

To assess the extent to which VA facilities we visited complied with the 

key screening requirements, we chose a judgmental sample of four VA 

facilities that varied in size, location, and medical school affiliations to 

assess the extent to which these selected facilities complied with these 

 1

The licensing boards contacted were Alabama, Arkansas, California, Delaware, District of 

Columbia, Florida, Indiana, Louisiana, Massachusetts, New Jersey, New Mexico, Oregon, 

Texas, and Washington. The national certifying organizations contacted were the National 

Board for Respiratory Care and the National Board for Certification in Occupational 

Therapy. 
Appendix I: Scope and Methodology 

Page 27 GAO-04-566 VA Screening of Practitioners 

requirements. The four facilities are located in Big Spring, Texas; New 

Orleans, Louisiana; Seattle, Washington; and the District of Columbia. We 

chose these facilities based on geographic variation, affiliations with 

medical schools to train residents, and types of health care services 

provided. Of the four facilities we visited, three are large facilities located 

in major metropolitan areas and each are affiliated with at least one 

medical school. The remaining facility is small, providing mainly primary 

care and long-term care services to veterans and is located in a rural area. 

For each facility, VA provided, from its automated pay system, a list of 

current practitioners in the 43 occupations. As a result of using VA’s 

automated pay system, our sample does not include those practitioners 

providing care through a contract or training agreement or without direct 

compensation from VA. For each of the four facilities, we selected a 

random sample of 100 practitioners either hired or assigned to their 

current position no earlier than January 1, 1993. We chose to limit our 

review to approximately the last 10 years because VA changed its process 

for credentials verification in the early 1990s. For each of these 

practitioners, we reviewed their personnel files to check that the facility 

had complied with the following key VA screening requirements: 

• verify state licenses and national certificates for applicants; 

• verify state licenses and national certificates for employed practitioners; 

• query the List of Excluded Individuals and Entities (LEIE) prior to hire; 

• ensure completion of background investigations, including fingerprints; 

• ensure completion of the Declaration for Federal Employment form, also 

known as form 306; and 

• verify that the educational institutions listed by a practitioner VA intends 

to hire are checked against lists of diploma mills. 

In order to show the variability in the level of compliance among the four 

VA facilities we visited, we distinguished between facilities that had a 

compliance rate of at least 90 percent for each of five of the six screening 

requirements and those that did not. For each facility and key screening 

requirement, we compared the percentage of personnel files found in 

compliance to an acceptance level of 90 percent. In order to confirm that a 

requirement had a compliance rate less than 90 percent, we performed a 

one-sided significance test at the 95 percent confidence level. See 

appendix II for detailed information on the four VA facilities’ compliance 

with each of the key VA screening requirements. Our results from these 

four facilities cannot be generalized to other facilities. In order to 

determine compliance with the key screening requirement to verify that 

the educational institutions listed by a practitioner are not fraudulent, we 
Appendix I: Scope and Methodology 

Page 28 GAO-04-566 VA Screening of Practitioners 

asked facility human resources staff if they performed this screening and 

asked them to produce their lists of diploma mills. 

Additionally, we reviewed VA facilities’ response times to 214 background 

investigation results returned from OPM with questionable issues, from 

August 1, 2002, to August 23, 2003, at the four locations we visited and six 

other VA facilities selected based on geographic location. The six 

additional facilities were located in Boston, Massachusetts; East Orange, 

New Jersey; Indianapolis, Indiana; Palo Alto, California; Portland, Oregon; 

and San Diego, California. For these 10 facilities, we asked officials to 

provide the date they took action on cases returned from OPM, and from 

VA headquarters we obtained the dates when OPM returned the cases to 

the facility. We determined the average number of days it took each 

facility to take action after these cases were returned from OPM with 

questionable issues. Our results cannot be generalized to other VA 

facilities. See appendix II for detailed information on the results of our 

analysis. 
Appendix II: Results of Our Compliance 

Reviews at VA Facilities 

Page 29 GAO-04-566 VA Screening of Practitioners 

Tables 4 and 5 show the sample counts used to measure compliance and 

the results of our review for five of the requirements. Table 6 shows the 

average number of days it took each facility to take action after cases with 

questionable issues were returned from OPM. 

Table 4: VA Facility Compliance with Key Screening RequirementsProfessional 

Credentials Verification 

Credentials of applicants 

verified 

 Credentials of employed 

practitioners verified 

Facility 

Number in 

sample

Number where 

verification 

followed VA policy

Number in 

sample 

Number where 

verification 

followed VA policy

Facility A 81 61 74 74

Facility B 77 71 59 59

Facility C 74 43 67 67

Facility D 62 47 56 55

Source: GAO analysis of facility files. 

Note: The number of practitioners in the sample may be less than the number of practitioner files 

reviewed at each facility because the requirement may not apply to all VA applicants or employed 

practitioners. 

Table 5: Facility Compliance with Key Screening RequirementsPersonal Background Screening 

List of Excluded Individuals and 

Entities (LEIE) queried for 

applicants prior to hiring 

Background investigation completed or 

requested for employed practitioners 

 Declaration for Federal 

Employment form (form 

306) completed for 

employed practitioners 

Facility 

Number in 

sample 

Number queried 

prior to hire 

Number in 

sample

Number with a completed 

or requested background 

investigation 

Number in 

sample

Number with 

completed 

form 306

Facility A 61 53 99a93 94 92

Facility B 72 26 99b27 93 80

Facility C 64 5 100 47 83 77

Facility D 66 39 100 98 92 86

Source: GAO analysis of facility files. 

Note: The number of practitioners in the sample may be less than the number of practitioner files 

reviewed at each facility because the requirement may not apply to all VA applicants or employed 

practitioners. 

a

One personnel file was not available because the practitioner resigned and the file was sent to 

storage. 

b

Facility B was unable to locate one personnel file; therefore, we sampled 99 files at that location. 

Appendix II: Results of Our Compliance 

Reviews at VA Facilities 
Appendix II: Results of Our Compliance 

Reviews at VA Facilities 

Page 30 GAO-04-566 VA Screening of Practitioners 

Table 6: Average Number of Days from Obtaining Background Investigation Results 

to VA Facility Action (August 1, 2002, to August 23, 2003) 

Facility 

Average number of days for 

facility action 

Number of background 

investigation results reviewed

Facility A 13 14

Facility B 282 41

Facility C 21 15

Facility D -14a 17

Facility E 26 11

Facility F 34 43

Facility G 68 39

Facility H 126 33

Facility I 380 1

Facility J No data available No data available

Source: GAO analysis of facility data. 

a

A negative number of days indicates that the facility took action on its cases before OPM returned 

the investigation results. 
Appendix III: Comments from the Department 

of Veterans Affairs 

Page 31 GAO-04-566 VA Screening of Practitioners 

Appendix III: Comments from the 

Department of Veterans Affairs 
Appendix III: Comments from the Department 

of Veterans Affairs 

Page 32 GAO-04-566 VA Screening of Practitioners 
Appendix IV: GAO Contact and Staff 

Acknowledgments 

Page 33 GAO-04-566 VA Screening of Practitioners 

Marcia A. Mann, (202) 512-9526 

In addition to the contact named above, Jacquelyn T. Clinton, Jessica 

Cobert, Mary Ann Curran, Martha A. Fisher, Krister Friday, Lesia Mandzia, 

and Marie Stetser made key contributions to this report. 

Appendix IV: GAO Contact and Staff 

Acknowledgments 

GAO Contact 

Acknowledgments 

(290306) 
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