VA Health Care: Improved Screening of Practitioners Would Reduce Risk to Veterans
Published: 2004-03-31T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Cases of practitioners causing intentional harm to patients have raised concerns about the Department of Veterans Affairs' (VA) 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.
section_title: What GAO Found
paragraphs: 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. 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.

section_title: Letter
paragraphs: 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. 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  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. 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  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.
subsections: section_title: Background
paragraphs: 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. 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. These  organizations establish professional standards that are national in scope  for certain occupations, such as respiratory and occupational therapists.
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.
section_title: VA Policy Requires Its Facilities to Check Many Practitioners’ Professional Credentials and Personal Backgrounds
paragraphs: 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. 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. Additionally, VA  requires that individuals in certain positions undergo a background  investigation, which includes checking their fingerprints against a  fingerprint-based criminal history database.
subsections: section_title: VA Policy Requires Verification of the Status of State Licenses and National Certificates
paragraphs: 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.   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.
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  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. 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  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. Similarly, VA requires facility officials to query the  National Practitioner Data Bank (NPDB), which contains information  including disciplinary actions taken against physicians and dentists.  Facility officials must document the results of these queries.
section_title: VA Policy Requires Checks of Applicants and Their Credentials against Lists Designed to Prevent Fraud and Abuse
paragraphs: 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. 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  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.
section_title: VA Policy Requires Background Investigations and Disclosures for Certain Employed Practitioners
paragraphs: VA’s employed practitioners are required to undergo a background  investigation that verifies their personal histories. 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.
section_title: Gaps in Key VA Screening Requirements Create Vulnerabilities
paragraphs: 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.
subsections: section_title: VA Has Adequate Requirements for Verifying Professional Credentials of Certain Practitioners
paragraphs: 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.
section_title: Gaps Exist in VA’s Requirements for Verifying Professional Credentials of Other Practitioners
paragraphs: 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.
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.
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. 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.
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.
section_title: VA Has Not Implemented Consistent Background Screening Requirements
paragraphs: 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  that these types of practitioners do not need a background investigation.  Table 1 lists the types of practitioners that VA exempts from background  investigations.
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. 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. 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.
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.
section_title: VA Facilities Did Not Comply with All of the Key VA Screening Requirements
paragraphs: 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.
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.
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 non- VA 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  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.
section_title: Conclusions
paragraphs: 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  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.
section_title: Recommendations for Executive Action
paragraphs: 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.
section_title: Agency Comments
paragraphs: 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.
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.
section_title: Appendix I: Scope and Methodology
paragraphs: 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.
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.
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  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  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.
section_title: Appendix II: Results of Our Compliance Reviews at VA Facilities
paragraphs: 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.
section_title: Appendix III: Comments from the Department of Veterans Affairs
section_title: Appendix IV: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Acknowledgments
paragraphs: 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.