VA Health Care: Steps Taken to Improve Practitioner Screening, but Facility Compliance with Screening Requirements Is Poor
Published: 2006-05-25T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: In March 2004, GAO reported on gaps in VA's requirements for screening the professional credentials and personal backgrounds of health care practitioners (GAO-04-566). GAO found that VA's requirements did not ensure thorough screening of VA practitioners. VA concurred with four recommendations GAO made to improve practitioner screening. GAO was asked to determine the extent to which (1) VA has taken steps to improve practitioner screening by implementing GAO's recommendations and (2) VA facilities are in compliance with VA's practitioner screening requirements. GAO reviewed VA's current practitioner screening policies to determine if gaps remain, interviewed VA officials, and sampled about 60 practitioner files at each of seven VA facilities selected based on size and geographic location.
section_title: What GAO Found
paragraphs: VA has taken steps to improve health care practitioner screening by partially implementing each of four recommendations made in GAO's March 2004 report; however, gaps still remain in VA's practitioner screening requirements. In response to two of GAO's recommendations, VA expanded its screening requirements for all VA applicants to include a verification of all state licenses and national certificates and requires facility officials to query the Healthcare Integrity and Protection Data Bank (HIPDB), which contains information on individuals involved in health care-related civil judgments and criminal convictions and licensing and certification actions. VA, however, has not yet expanded these screening requirements to apply to all health care practitioners currently employed at VA facilities, as GAO recommended. In response to the third GAO recommendation, VA issued a policy in August 2005 that requires individuals who previously were exempt from receiving any level of background investigation to have, at a minimum, their fingerprints screened against a criminal history database. As of October 19, 2005, 37 VA medical facilities had not fully implemented this new requirement because they had not obtained or installed the necessary electronic fingerprint equipment. Since then VA has made progress; as of February 1, 2006, 2 medical facilities had not installed the equipment. Finally, VA has partially implemented GAO's fourth recommendation to conduct oversight of its facilities' compliance with VA practitioner screening requirements; however, GAO found the oversight does not address all of the facility compliance issues GAO previously identified. GAO found poor compliance with four of the five selected VA practitioner screening requirements at the seven VA facilities visited in 2005. None of the seven facilities had a compliance rate of 90 percent or more for all five screening requirements GAO reviewed. Two facilities that had implemented VA's fingerprint-only background investigations--a relatively new form of background investigation--did not comply with VA's requirement to document that the results of the fingerprint check against a criminal history database had been reviewed and used to make a decision on the individual's suitability to work at a VA medical facility.

section_title: Letter
paragraphs: The Department of Veterans Affairs (VA) is responsible for ensuring that  its health care practitioners are qualified to provide care to their patients.  VA employs more than 193,000 individuals at its medical facilities,  including physicians, nurses, pharmacists, and therapists. In addition, VA  supplements these salaried health care practitioners with nonsalaried  health care practitioners obtained through contracts and fee-for-service  arrangements (fee basis), as well as nonsalaried practitioners working  without direct compensation from VA (without compensation or WOC).  To help ensure that VA’s salaried and nonsalaried health care practitioners  hold the necessary professional credentials to provide care, VA has  screening requirements that VA medical facility officials must follow in  verifying these credentials and checking practitioners’ personal  backgrounds for evidence of incompetence or criminal behavior.
In March 2004, we reported and testified on gaps in VA’s screening  requirements. We found that VA did not require that all of its health care  practitioners with access to patients be thoroughly screened. In addition,  we found mixed compliance with existing VA screening requirements at  each of the four VA medical facilities we visited. We concluded that the  gaps in and mixed compliance with VA’s screening requirements created  vulnerabilities that could allow VA to employ health care practitioners  who could either place patients at risk of receiving poor care or cause  them intentional harm. In our 2004 report, we made four  recommendations to address the gaps we identified in VA’s screening  requirements and the noncompliance we found at the four VA medical  facilities we visited.
VA concurred with our recommendations to    expand verification of all state licenses and national certificates by  contacting the appropriate licensing boards and national certifying  organizations for all VA health care practitioners,    expand query of the Healthcare Integrity and Protection Data Bank  (HIPDB) to include all licensed health care practitioners at VA facilities,    conduct fingerprint-only background investigations for all VA health care  practitioners with direct patient care access, and    conduct oversight of medical facilities to ensure compliance with all of  VA’s key screening requirements.
You asked us to determine the status of VA’s implementation of these  recommendations to strengthen its health care practitioner screening  requirements. In this report, we determined the extent to which (1) VA has  taken steps to improve health care practitioner screening by implementing  the four recommendations made in our March 2004 report and (2) VA  medical facilities are in compliance with VA’s health care practitioner  screening requirements.
To determine the extent to which VA has taken steps to improve health  care practitioner screening by implementing the four recommendations  made in our March 2004 report, we interviewed VA headquarters and  facility officials and reviewed VA’s policies and procedures that contain  current health care practitioner screening requirements to see if the gaps  we identified in 2004 were closed. We also reviewed the report of a task  force VA formed to improve its health care practitioner screening  procedures following the issuance of our 2004 report.
To determine the extent to which VA medical facilities complied with VA  health care practitioner screening requirements, we selected seven VA  medical facilities to visit. These facilities varied in terms of size and  geographic location. Two of the seven facilities we visited were sites from  our previous review. We visited facilities located in Fargo, North Dakota;  Kansas City, Missouri; Miami, Florida; New Orleans, Louisiana; Salt Lake  City, Utah; San Antonio, Texas; and the District of Columbia. For each  facility, VA provided from its automated pay system a list of salaried  health care practitioners in the 43 occupations we included in our previous  report. At each facility we reviewed a random sample of personnel files to  determine whether the files included documentation demonstrating that  the facility’s health care practitioners had their professional credentials  verified and backgrounds checked in compliance with VA’s screening  requirements. At each of the facilities, our sample of personnel files  consisted of about 50 personnel files for salaried health care practitioners  who were hired prior to October 1, 2004, and 10 to 12 personnel files for  salaried health practitioners who were hired on or after October 1, 2004.  In addition to the random sample of salaried health care practitioners, we  also reviewed at each facility 20 personnel files for nonsalaried health care  practitioners paid by VA on a fee basis and all of the files for the facility’s  WOC health care practitioners who work in a clinical area at the facility.  In collecting information on the screening requirements from personnel  files at each facility, we employed standard data collection techniques to  ensure the accuracy and reliability of the data used in this report. At each  facility we also reviewed about five contracts that the facility used to  supplement its health care practitioner staffing in order to determine how  facility officials screen the personal backgrounds and professional  credentials of these nonsalaried health care practitioners. Finally, at each  facility we also interviewed the officials responsible for coordinating  volunteer activities to determine how volunteers are screened prior to  beginning work at the facility.
To measure the seven facilities’ compliance with VA’s health care  practitioner screening requirements, we selected five requirements for our  review. Although VA has multiple employment screening requirements,  we selected five that pertain to safeguarding veterans receiving health care  in VA facilities. The screening requirements we selected for salaried health  care practitioners are (1) completing VA Form 2280, which medical facility  officials must do in order to determine the appropriate type of background  investigation needed for each health care practitioner job category;   (2) performing a background investigation; (3) querying HIPDB;   (4) completing an employment checklist, which VA officials are to use to  document the completion of VA screening requirements for those salaried  health care practitioners VA intends to hire; and (5) verifying the status of  state licenses and national certificates. In addition, we measured facility  compliance with one of these screening requirements, performing a  background investigation, for VA nonsalaried fee basis and WOC health  care practitioners. To show the variability in the level of compliance  among the seven VA facilities we visited, we distinguished between  facilities that had a compliance rate of at least 90 percent of the personnel  files we reviewed for each of the five screening requirements and facilities  that did not. VA requires a compliance rate of 100 percent. Our findings for  the screening requirements cannot be generalized to other VA facilities.
For a complete description of our scope and methodology, see appendix I.  Our work was conducted from April 2005 through April 2006 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 through hospitals,  ambulatory clinics, nursing homes, residential rehabilitation treatment  programs, and readjustment counseling centers. VA also utilizes national  and local medical professional services contracts to supplement its health  care practitioner staffing. 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 health care  professionals.
Depending on the employment requirements of their positions, health care  practitioners who work at VA facilities are required to hold either valid— meaning current and unrestricted—state medical licenses or national  certificates. State licenses are issued by state licensing boards, which  generally establish state licensing requirements governing their licensed  health care practitioners. Current and unrestricted licenses are those in  good standing in the states that issued them, and licensed health care  practitioners may hold licenses from more than one state. To keep a  license current, health care 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 substandard 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 health care  practitioner from practicing in that state. Some, but not all, issued state  licenses are marked to indicate that the licenses have had restrictions  placed on them. Generally, state licensing boards maintain a database of  information on restrictions, which employers can 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.  Health care practitioners who are required to have valid national  certificates 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 databases of information on disciplinary actions  taken against health care practitioners with national certificates, and many  can be accessed at no cost.
VA policy requires officials at its medical facilities to screen applicants for  positions at VA to determine whether each applicant possesses at least  one current and unrestricted state license or an appropriate national  certificate, whichever is applicable for the position sought by the  applicant. VA also requires officials at its medical facilities to periodically  verify licenses or national certificates held by health care practitioners  already employed at VA (employed health care practitioners). The  frequency of when health care practitioners’ credentials must be checked  depends on their occupations and the renewal requirements of the state or  national organizations that issued the credentials.
In general, for both applicants and employed health care practitioners,  VA’s screening process proceeds in two stages. First, applicants and  employed health care practitioners are required to disclose to VA, if  applicable, their state licenses and national certificates. Applicants  disclose their credentials to VA during the application process, and  employed health care practitioners disclose credentials to VA as they  expire and are renewed with the state licensing board or certifying  organization. Second, VA facility officials are required to verify whether  the disclosed credentials are valid.
In addition to holding valid professional credentials, upon hiring, health  care practitioners are required to undergo background investigations that  verify their personal and professional histories. Depending on the  position in question, the extent of the background investigations for health  care practitioners may vary. For example, background investigations in VA  may vary from a traditional background investigation covering a health  care practitioner’s personal and professional background for up to   10 years to the minimum of a fingerprint-only background investigation.  VA facility officials are required to complete VA Form 2280, which  documents the level of risk posed by a particular position and determines  the level of background investigation required for employment.
The traditional background investigation is the most common type of  background investigation conducted by VA on its health care practitioners.  A traditional 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 background  investigations for VA and reports its results to the facility that requested  the investigation. VA facilities are required to review background  investigation results, determine employment suitability, and report their  decisions to OPM within 90 days.
In 2001 OPM began to offer a new type of background investigation for use  by federal agencies, a fingerprint-only background investigation.  Compared to traditional background investigations, which verify personal,  professional, and criminal histories and typically take several months to  complete, fingerprint-only background investigations verify criminal  histories only and can be completed within 3 weeks or less and cost less  than $25, about a quarter of the cost of a traditional background  investigation.
In March 2004, we reported on VA’s screening policies and the gaps we  found in VA’s requirement for screening applicants that may result in VA  health care practitioners’ personal backgrounds and professional  credentials not being thoroughly screened. For example, for health care  practitioners who were required to have national certificates to work in  VA, facility officials were required to physically inspect each applicant’s  national certificate. However, we found a gap wherein officials were not  required to contact the organization issuing the certificate, even though  restrictions may have been placed on the certificate after it was issued. In  contrast, we found that for state licenses VA’s policy required officials at  its medical facilities to screen applicants to determine whether they  possessed at least one current and unrestricted state license. Applicants  were required to disclose to VA any state licenses they held. To verify a  state license, VA officials were required to contact the issuing state  licensing board to determine if the license was current and unrestricted.  Officials were also required to document that they verified the status of  the license.
As part of our 2004 report, we also found gaps in VA’s screening  requirements for health care practitioners currently employed at its  medical facilities. For example, not all VA currently employed health care  practitioners with licenses were required to disclose all of their current  licenses. Some currently employed health care practitioners, such as  nurses and pharmacists, were required to disclose only one license, even if  they possess multiple licenses, and facility officials were not required to  contact the issuing state board to determine if the license is current and  unrestricted. Instead, facility officials were required to physically inspect  the one state license, even though some licenses are not marked to  indicate restrictions. See figure 1 for the health care practitioner screening  gaps we identified for both VA’s applicants and currently employed health  care practitioners.
In our March 31, 2004, report, we also found that VA did not query HIPDB  for all health care practitioners. Additionally, VA required some health  care practitioners with direct access to patients to undergo background  investigations that verify their personal and professional histories, but did  not require this of others, such as medical residents.
In response to a draft of our report, VA’s Under Secretary for Health  commissioned a task force on March 30, 2004, to review the screening  requirements for all VA health care occupations, including applicants,  those currently employed, and health care trainees. The task force was to  identify the needed improvements to VA’s screening processes and to  make recommendations to VA’s National Leadership Board.
section_title: VA Has Taken Steps to Improve Health Care Practitioner Screening Requirements, but Gaps Remain
paragraphs: VA has taken steps to improve health care practitioner screening by  partially implementing each of the four recommendations made in our  March 2004 report; however, gaps still remain in VA’s health care  practitioner screening requirements. These gaps are found in the  requirements for verifying professional credentials and querying HIPDB  for currently employed practitioners. In addition, VA has not yet  implemented fingerprint-only background investigations at two medical  facilities. Finally, while VA has formalized an oversight program within its  Office of Human Resource Management (HRM), the program does not  address all of the compliance issues we identified in our earlier report.
subsections: section_title: VA Has Partially Implemented Our Recommendation to Expand Verification of Health Care Practitioners’ Professional Credentials
paragraphs: VA has partially implemented our recommendation that VA facility  officials contact state licensing boards and national certifying  organizations to verify all state licenses and national certificates held by  all VA health care practitioners. To address our recommendation, VA  expanded the verification requirement to include licenses and certificates  of all applicants VA intends to hire. In addition, VA issued a memorandum  on September 2, 2004, directing VA facility officials to establish a formal  procedure for conducting and then documenting the screening of  professional credentials for applicants. As part of the memorandum, VA  provided its medical facilities with an employment checklist that officials  are required to use to document the completion of VA’s screening  requirements for applicants for salaried and nonsalaried positions,  including fee basis and WOC health care practitioners. Facility officials  are permitted to modify the format of the employment checklist as long as  the modified checklist includes all the screening requirements contained  in the original checklist.
VA has proposed a policy change that will require the consistent screening  of credentials for both health care practitioners applying to work at VA  medical facilities and those currently employed. This screening would  apply to both salaried and nonsalaried health care practitioners. Once VA  issues its proposed policy for screening credentials, VA facility officials  will be required—in addition to using the employment checklist—to  document the verification of all health care practitioners’ state licenses  and national certificates in the computerized database of practitioners’  credentials that VA facility officials maintain, VetPro. VA currently  requires facility officials to use VetPro to document the verification of  some health care practitioners’ credentials, including physicians, dentists,  and nurse practitioners. VA is in the process of expanding the database so  it can store documentation of all of VA’s licensed and certified health care  practitioners. Once the proposed policy for screening credentials is  approved and the database is expanded, VA facility officials will have   2 years to enter all licensed and certified health care practitioners into this  database and will be able to electronically document the verification of all  health care practitioners’ licenses and certificates in one centralized  location.
While VA has expanded its requirements for verifying the professional  credentials of applicants, the department has not, as we recommended,  required its medical facilities to verify all state licenses or national  certificates held by all employed health care practitioners by contacting  the appropriate state licensing boards or national certifying organizations.  For example, for certain currently employed health care practitioners,  such as nurses and pharmacists, VA facility officials are still not required  to contact state licensing boards to verify whether the practitioner holds a  valid and unrestricted license. Instead, facility officials are only required to  physically inspect the original license. As we reported in 2004, one cannot  determine with certainty that a license is valid and unrestricted unless the  state licensing board is contacted directly. In addition, VA has not, as we  recommended, required facility officials to verify all of the licenses held by  these same health care practitioners instead of physically inspecting one  license of the practitioner’s choosing. As a result, a currently employed  health care practitioner could have a restricted license in one state but  offer VA officials an unrestricted license from another state. We reviewed  a draft of VA’s policy that when issued will fully address our  recommendation to require medical facility officials to verify all state  licenses and national certificates of currently employed health care  practitioners with the relevant issuing boards or organizations. According  to a VA official, this policy is expected to be issued in June 2006.
section_title: VA Partially Implemented Our Recommendation to Require Medical Facilities to Query HIPDB
paragraphs: VA has partially implemented our recommendation to expand the query of  HIPDB to include all licensed health care practitioners that VA intends to  hire and to periodically query HIPDB for those already employed at VA. To  respond to our recommendation, VA issued a memorandum on July 13,  2004, that requires officials at all of its medical facilities to query HIPDB  for all applicants for VA employment. In addition to VA applicants, VA’s  memorandum requires that facility officials query HIPDB for most  volunteers before offering them volunteer assignments. VA’s requirement  that its medical facilities query HIPDB for all applicants as well as new  volunteers goes beyond our recommendation to query applicants who hold  licenses; however, VA’s requirement does not, as we recommended,  require VA facilities to periodically query HIPDB for health care  practitioners who are currently employed by VA.
VA officials told us that VA is working with the Department of Health and  Human Services (HHS) to develop a process whereby VA can  electronically query HHS data banks, including HIPDB, for VA employees.  Once this process is in place and VA is using it to periodically query  HIPDB for those currently employed at VA, the department will have fully  implemented our recommendation. However, VA did not provide a time  frame for implementing this electronic query of HIPDB.
section_title: VA Policy on Fingerprint- Only Background Investigations Addressed Our Recommendation, but Was Not Fully Implemented
paragraphs: In August 2005, VA issued a policy that when implemented across VA will  address our recommendation to expand the use of fingerprint-only  background investigations for practitioners previously exempt from  background investigations who have direct access to patients. VA’s policy  requires, at a minimum, that all newly hired health care practitioners’  fingerprints be checked against a criminal history database. The  requirement applies to nonsalaried health care practitioners working  through a fee basis arrangement, WOC and contract health care  practitioners, and some volunteers. It also includes trainees, such as  medical residents, who previously were exempt from any type of  background investigation. For traditional and fingerprint-only background  investigations, VA’s policy requires facility officials to review the results of  the background investigation and within 5 days of receiving the results  determine the practitioner’s suitability to work at a VA medical facility.  Facility officials are required by VA to document the results of their  background investigation reviews in personnel files. VA’s policy requires  the use of electronic fingerprinting, in lieu of paper-based fingerprinting, at  all VA medical facilities.
While VA’s policy addresses our recommendation, not all of VA’s medical  facilities had implemented the policy as of February 1, 2006. The August  2005 policy requires that all VA medical facilities purchase and begin using  electronic fingerprint machines by September 1, 2005. During our review,  we found that VA did not know which facilities had purchased and begun  to use the electronic fingerprint equipment in the course of implementing  VA’s fingerprinting policy. In response to our inquiry, VA surveyed its  facilities and found that as of October 19, 2005, 37 facilities did not have  electronic fingerprint machines operational by September 1, 2005. Since  then VA has made progress; as of February 1, 2006, 2 VA medical facilities  had not implemented this new requirement.
section_title: VA Partially Implemented Our Recommendation to Conduct Oversight of Facilities’ Compliance with Screening Requirements
paragraphs: VA has partially implemented our recommendation to conduct oversight to  help ensure that facilities comply with select screening requirements for  applicants and employed health care practitioners. To address our  recommendation, in April 2004 VA formalized a program within HRM,  which oversees VA medical facility compliance with human resource  functions. The program is responsible for overseeing VA’s facility human  resource functions, which include conducting background investigations  and verifying the professional credentials of applicants and current  employees. Officials from HRM’s oversight program conduct site visits to  VA facilities, interview facility officials, and review a random sample of  personnel files to determine whether VA facilities are performing  background investigations in a timely manner and verifying the  professional credentials of health care practitioners.
While this oversight program helps ensure that facilities are conducting  background investigations and verifying professional credentials for some  categories of health care practitioners, it does not ensure that facilities are  complying with all of VA’s key screening requirements, as we  recommended in 2004. For example, officials from the oversight program  are not required to review personnel files for fee basis health care  practitioners, even though these practitioners also have direct access to  patients. Further, oversight officials’ guidelines do not include  requirements to check personnel files to ensure that facility officials query  HIPDB and verify all health care practitioners’ licenses and certifications  with the relevant issuing organizations.
In May 2005, we observed an oversight review conducted by HRM officials,  during which officials reviewed some of VA’s health care practitioner  screening requirements as applied to salaried health care practitioners and  some types of nonsalaried health care practitioners. Although HRM  officials discussed the results of their personnel file reviews with VA  officials at the facility they visited, HRM officials did not document the  number of files they reviewed and found in compliance.
section_title: VA Facilities Did Not Comply with Health Care Practitioner Screening Requirements
paragraphs: Across the seven VA facilities we visited, we found poor compliance with  four of the five selected screening requirements we reviewed for salaried  health care practitioners as well as the one screening requirement we  selected for nonsalaried health care practitioners. The five screening  requirements we selected include two implemented by VA in response to  our recommendations—querying HIPDB and completing an employment  checklist to document completion of VA’s screening requirements—and  three others that were in place at the time of our 2004 review. The latter  require VA facilities to verify health care practitioners’ state licenses and  national certificates; complete VA Form 2280, which is used to determine  the appropriate type of background investigation needed for each health  care practitioner job category; and conduct background investigations. We  measured facilities’ compliance with all these requirements as they pertain  to their salaried health care practitioners, and we also measured facilities’  compliance with the background investigation requirement as it pertains  to VA’s nonsalaried health care practitioners—that is, practitioners paid by  VA on a fee basis, WOC practitioners, and practitioners hired through  contracts.
At the seven facilities we visited, we found that none of these facilities  complied with all five screening requirements we reviewed for their  salaried health care practitioners. In order to show the variability in the  level of compliance among the seven VA facilities, we measured their  performance against a compliance rate of at least 90 percent for each of  the five VA screening requirements, even though VA policy requires   100 percent compliance with these requirements. None of the seven  facilities had a compliance rate of 90 percent or more for all five screening  requirements we reviewed. Figure 2 summarizes the rate of compliance  among the seven facilities we visited for salaried health care practitioners.  For the screening requirement to perform background investigations, at  six of seven VA facilities we were unable to find documentation—in at  least 90 percent of the health care practitioners’ personnel files we  reviewed—that background investigations were either scheduled or  completed for these salaried practitioners. (For detailed information about  our analysis and documentation requirements to demonstrate compliance,  see app. I, and for information regarding the extent of each facility’s  compliance with a particular requirement, see app. II.)
As shown in figure 2, facilities did not uniformly comply with the two  screening requirements VA implemented to address our recommendations.  We found that for health care practitioners hired since October 1, 2004,  only two facilities were querying HIPDB as required, and none of the seven  facilities consistently completed the required employment checklist to  document the completion of screening requirements for applicants VA  intends to hire. While two facilities performed HIPDB queries on  applicants, one of these facilities completed the queries immediately prior  to our visit. During our site visits, we also found that two facilities had  created their own employment checklists. While facilities are permitted to  modify the format of the checklist as long as the modification includes all  of the screening requirements contained in the original checklist issued in  September 2004, we found that the checklists used by these two facilities  did not include all of the screening requirements.
Two of the seven facilities we visited were also included in our March 2004  report. Since our last site visit, these two facilities improved their  performance in conducting background investigations for salaried health  care practitioners to compliance rates of 75 and 72 percent, as shown in  figure 3. However, both facilities were still well below our compliance rate  of 90 percent.
As part of our review, we also measured facilities’ compliance with VA’s  background investigation requirement for health care practitioners other  than those salaried by VA. We found that all seven of the facilities we  visited did not meet VA’s background investigation requirements for fee  basis and WOC health care practitioners. For example, although one  facility conducted background investigations on WOC health care  practitioners at a rate of 90 percent or better, no facility met the  requirement for both groups of health care practitioners. Furthermore, at  four of the seven facilities we visited, facility human resource management  staff could not produce a comprehensive list of all WOC health care  practitioners working at the facility because human resource management  staff were not screening all WOC health care practitioners prior to their  beginning work at the VA facility. Figure 4 summarizes the seven facilities’  rate of compliance with VA’s background investigation requirement as  applied to fee basis and WOC health care practitioners. (For detailed  information about each facility’s compliance with this requirement, see  app. II.)
Like their efforts conducting background investigations for fee basis and  WOC health care practitioners, the efforts of most VA facilities we visited  did not meet this requirement for health care practitioners obtained  through contracts. Specifically, we found that one of seven medical  facilities was conducting and documenting background investigations for  contract health care practitioners, as VA requires. The other six facilities  were not in compliance with this requirement.
In March 2005, a VA headquarters official announced that facility officials  should implement fingerprint-only background investigations for  volunteers, as soon as the facilities’ electronic fingerprint equipment was  operational or no later than September 1, 2005. Of the seven facilities we  visited prior to September 1, 2005, we found that four facilities had the  equipment needed to begin performing fingerprint-only background  investigations. Three of the four facilities were fingerprinting volunteers,  and the fourth facility had not begun to fingerprint volunteers, even  though the equipment was operational. However, for the three facilities  fingerprinting volunteers, we found documentation at only one facility to  indicate that officials were reviewing the fingerprint results from OPM and  determining whether volunteers were suitable to work in the VA medical  facility, as required by VA policy. We also found that VA does not have a  standardized method for facility officials to document their review of  fingerprint-only background investigation results, as it has for other types  of background investigations. For example, traditional background  investigation results are reported in a format that includes designated  space for facility officials to document that the results of the investigation  have been reviewed and a decision made regarding suitability to work in  the medical facility. At two facilities we found background investigation  results for volunteers that showed criminal histories, such as aggravated  assault and drug-related convictions. However, while officials at the two  facilities assured us that the results of fingerprint-only investigations were  being reviewed, we did not find documentation of this review.
section_title: Conclusions
paragraphs: Although VA concurred with all of our March 2004 recommendations to  close the gaps in its health care practitioner screening processes, none of  the four were fully implemented as of March 2006. VA’s screening  requirements are intended to ensure the safety of veterans receiving care  in VA facilities by identifying health care practitioners with restricted or  fraudulent credentials, criminal backgrounds, or questionable work  histories. As we found in our previous report, VA continues to apply  different screening requirements to its licensed and certified health care  practitioners. For example, we found that VA requires medical facilities to  verify with the appropriate state licensing boards or national certifying  organizations all state licenses or national certificates held by some health  care practitioners, such as physicians and applicants for VA employment,  but not for other health care practitioners, such as nurses currently  employed by VA. In the interim, while VA is developing a policy that would  apply screening requirements consistently across all licensed and certified  health care practitioners and satisfy one of our recommendations, it has  established two requirements that apply to new health care practitioners  entering VA’s health care system. As a result of the continuing gaps in VA’s  health care practitioner screening process, practitioners may continue to  have access to patients without thorough screening of their professional  credentials and personal backgrounds.
Furthermore, although VA agreed with our 2004 recommendation to  oversee its facilities to ensure their compliance with key screening  requirements, VA’s limited oversight has not ensured facility compliance.  As a result, VA may not know whether its facilities are in compliance with  its screening requirements. This raises concerns because we found that  none of the VA medical facilities we visited were in compliance with all of  the new or existing VA screening requirements we reviewed for salaried or  nonsalaried health care practitioners. We found that the extent to which  facilities complied with four of the five selected VA screening  requirements was poor at the VA facilities we visited. For example, while  there was improvement at the two facilities we revisited, these facilities  did not meet our 90 percent compliance rate for conducting background  investigations on salaried health care practitioners. Moreover, we found  that all seven medical facilities did poorly in conducting background  investigations on fee basis and WOC health care practitioners as required  by VA even though these practitioners have the same access to patients  and their information as other VA health care practitioners. Further, two  of the three facilities that were conducting VA’s new fingerprint-only  background investigation did not have documentation that the results  were being reviewed by officials as required. This lack of compliance with  current screening requirements continues to place veterans at risk.
section_title: Recommendations for Executive Action
paragraphs: To better ensure the safety of veterans receiving health care at VA medical  facilities, we recommend that the Secretary of Veterans Affairs take the  following two actions:    expand the HRM oversight program to include a review of VA facilities’  compliance with screening requirements for all types of salaried and  nonsalaried health care practitioners and    standardize a method for documenting facility officials’ review of  fingerprint-only background investigation results and decisions regarding  suitability to work in VA medical facilities.
section_title: Agency Comments
paragraphs: In commenting on a draft of this report, VA agreed with our findings and  conclusions and concurred with our recommendations. VA agreed that  expanded program oversight and standardizing a method for documenting  fingerprint-only background investigation results would be useful. VA  stated that while it believes that most facilities continue to improve their  practitioner screening effectiveness, VA also recognizes that there is  variability and lack of standardization across its health care system. VA  stated that it would provide an action plan for implementing our  recommendations after issuance of this report.
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If you or your staff members have any questions, please contact me at  (202) 512- 7101 or ekstrandl@gao.gov. Contact points for our Offices of  Congressional Relations and Public Affairs may be found on the last page  of this report. GAO staff members who made major contributions to this  report are listed in appendix IV.
section_title: Appendix I: Scope and Methodology
paragraphs: We examined the Department of Veterans Affairs (VA) policies and  practices to determine if VA had implemented the recommendations we  made in March 2004 to strengthen its screening of applicants’ and  employed health care practitioners’ professional credentials and personal  backgrounds. Specifically, we determined the extent to which (1) VA has  taken steps to improve health care practitioner screening by implementing  the four recommendations made in our March 2004 report and (2) VA  medical facilities are in compliance with VA’s health care practitioner  screening requirements.
To determine the extent to which VA has taken steps to improve health  care practitioner screening by implementing the four recommendations  made in our March 2004 report, we reviewed VA employment screening  policies and interviewed VA headquarters and facility officials. Based on  our review of VA documents and interviews with officials, we determined  what steps VA has taken to ensure that gaps we identified in its  verification of state licenses and national certificates and background  investigation requirements have been closed. We also reviewed the report  of a task force VA formed to respond to our recommendations to improve  VA’s screening of professional credentials and personal backgrounds. We  interviewed officials at VA’s Office of Security and Law Enforcement in  Little Rock, Arkansas, and VA’s National Acquisition Center in Hines,  Illinois, to review how VA screens the professional credentials and  personal backgrounds of health care practitioners working in VA medical  facilities through a contract.
To determine how VA conducts oversight of its facilities’ compliance with  screening of applicants and current employees, we interviewed officials  responsible for implementing VA’s Office of Human Resource Management  (HRM) evaluation and accountability program. We also observed an  oversight review site visit conducted by VA’s HRM at the VA medical  facility in Providence, Rhode Island, and attended a VA training class that  provided facility human resource managers with the knowledge necessary  to review the results of background investigations.
To determine the extent to which selected VA medical facilities we visited  are in compliance with VA’s health care practitioner screening  requirements, we chose a judgmental sample of seven VA medical facilities  that varied in geographic location to assess the extent to which these  selected facilities complied with the screening requirements included in  our review. The seven facilities were located in Fargo, North Dakota;  Kansas City, Missouri; Miami, Florida; New Orleans, Louisiana; Salt Lake  City, Utah; San Antonio, Texas; and the District of Columbia. Two of the  seven facilities we visited were sites from our previous review. Of the  seven facilities we visited, six were large facilities located in major  metropolitan areas and the remaining facility is of a smaller size.
For each facility, VA provided from its automated pay system a list of  salaried health care practitioners in the 43 occupations we included in our  previous review. See table 1 for a list of the 43 occupations included in our  review. Because we used VA’s automated pay system, our sample does not  include those health care practitioners providing care through a contract  or fee-for-service agreement or without compensation (WOC) from VA.
For each of the seven facilities we selected a random sample of about   50 salaried health care practitioners who were hired prior to October 1,  2004, from VA’s list of salaried employees. In addition, we selected 10 to 12  files of salaried health care practitioners who were hired on or after  October, 1, 2004, to determine if new VA requirements for health care  practitioner screening had been implemented by the facility. In addition to  the random sample of salaried employees we reviewed at each facility, we  also requested 20 personnel files for health care practitioners paid by VA  through a fee-for-service arrangement (fee basis) and all health care  practitioners who work in a clinical area at the VA facility but receive  compensation from a source other than VA (WOC).
We reviewed each selected health care practitioner’s personnel file to  determine whether the facility had documented evidence that it complied  with the following VA screening requirements:    determine the position risk level by completing VA Form 2280;    ensure completion of background investigations;    query the Healthcare Integrity and Protection Data Bank (HIPDB) for all  applicants after October 1, 2004;    complete an employment checklist for those hired after October 1, 2004;    verify state licenses and national certificates for applicants and employed  health care practitioners.
For each screening requirement, we reviewed practitioners’ personnel files  to determine whether the files contained documented evidence that the  screening requirement had been completed. See table 2 for the documents  required to demonstrate evidence of facility compliance. Compliance  could also be demonstrated if facilities were able to provide additional  documentation not available in the personnel files we reviewed. Using a  standard data collection instrument, we collected information on each  facility’s compliance with the five screening requirements from a sample  of personnel files. To ensure the reliability of the data collected, the  information collected at each facility was double-checked for a sample of  files. The data from all data collection instruments were entered into an  electronic database, and 100 percent of the electronic files were verified  against the completed data collection instrument.
In addition to the personnel files, we reviewed about five contracts at each  of the seven medical facilities that the facilities use to supplement health  care practitioner staffing to determine how these nonsalaried health care  practitioners’ professional credentials and personal backgrounds are  screened. We also interviewed VA officials about the process the facilities  use to screen trainees, including medical residents, and volunteers who  work in patient care areas.
In order to show the variability in the level of compliance among the seven  VA facilities we visited, we distinguished between facilities that had a  compliance rate of at least 90 percent for each of the five screening  requirements that we reviewed and those that did not. For each facility  and screening requirement included in our review, 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 seven VA facilities’ compliance with each VA screening requirement in  our review. Our findings from these seven facilities cannot be generalized  to other VA facilities.
Our work was conducted from April 2005 through April 2006 in  accordance with generally accepted government auditing standards.
section_title: Appendix II: Results of Our Compliance Reviews at Seven VA Facilities
paragraphs: Tables 3 and 4 show the sample counts used to measure compliance and  the results of our review for the background investigation screening  requirement. Tables 5 and 6 show the sample counts used to measure  compliance with the remaining health care practitioner screening  requirements that we included in our review.
section_title: Appendix III: Comments from the Department of Veterans Affairs
section_title: Appendix IV: GAO Contact and Staff Acknowledgments
subsections: section_title: Acknowledgments
paragraphs: In addition to the contact named above, Marcia A. Mann, Assistant  Director; Linda Diggs; Alison Farley; Martha A. Fisher; Krister Friday; and  Marion M. Slachta made key contributions to this report.