VA Health Care: Veterans at Risk from Inconsistent Screening of Practitioners
Published: 2004-03-31T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The Department of Veterans Affairs (VA) employs about 190,000 individuals including physicians, nurses, and therapists at its facilities. It supplements these practitioners with contract staff and medical residents. Cases of practitioners causing intentional harm to patients have raised concerns about VA's screening of practitioners' professional credentials and personal backgrounds. This testimony is based on GAO's report VA Health Care: Improved Screening of Practitioners Would Reduce Risk to Veterans, GAO-04-566 (Mar. 31, 2004). GAO was asked to (1) identify and assess the extent to which selected VA facilities comply with existing key VA screening requirements and (2) determine the adequacy of these requirements for its practitioners.
section_title: What GAO Found
paragraphs: GAO identified key VA screening requirements that include verifying state licenses and national certificates; completing background investigations, including fingerprinting to check for criminal histories; and checking national databases for reports of practitioners who have been professionally disciplined or excluded from federal health care programs. GAO reviewed 100 practitioners' personnel files at each of four facilities it visited and found mixed compliance with the existing key VA screening requirements. GAO also found that VA has not conducted oversight of its facilities' compliance with the key screening requirements. GAO found adequate screening requirements for certain practitioners, such as physicians and dentists, for whom all licenses are verified by contacting state licensing boards. However, existing screening requirements for others, such as nurses and respiratory therapists currently employed in VA, are less stringent because they do not require verifying all state licenses and national certificates. Moreover, they require only physical inspection of these credentials rather than contacting licensing boards or certifying organizations. Physical inspection alone can be misleading; not all credentials indicate whether they are restricted, and credentials can be forged. VA also does not require facility officials to query, for other than physicians and dentists, a national database that includes reports of disciplinary actions and criminal convictions involving all licensed practitioners. In addition, many practitioners with direct patient care access, such as medical residents, are not required to undergo background investigations, including fingerprinting to check for criminal histories. This pattern of gaps and mixed compliance with key VA key screening requirements create vulnerabilities to the extent that VA remains unaware of practitioners who could place patients at risk.

section_title: Letter
paragraphs: I am pleased to be here today to discuss the findings and  recommendations in our report, which you are releasing today, on the  Department of Veterans Affairs (VA) policies and practices for screening  health care practitioners. VA employs about 190,000 individuals, including  physicians, nurses, pharmacists, and therapists, at its facilities, and it  supplements these practitioners with contract staff, medical consultants,  and medical residents. VA has screening requirements intended to help  ensure that its health care practitioners’ professional credentials are  verified and their personal backgrounds are checked for evidence of  incompetence or criminal behavior.
While such requirements cannot guarantee safety in health care settings,  they are intended to minimize the chance of patients receiving care from  someone who is incompetent or who may intentionally harm them.  According to medical forensic experts, however, the deliberate harm of  patients by health care practitioners is a problem in the health care sector  in general. The well-publicized case of Dr. Michael Swango, who pleaded  guilty to murdering three veterans while a medical resident training at the  VA facility in Northport, New York, and was sentenced to three  consecutive life terms without the possibility of parole, illustrates the  potentially disastrous effect of inadequate screening of health care  practitioners.
You asked us to examine VA’s policies and practices intended to ensure  that health care practitioners at its facilities have appropriate professional  credentials and personal backgrounds to provide safe care to veterans.  Specifically, we (1) identified key VA screening requirements and assessed  the extent to which selected VA facilities complied with these screening  requirements for its health care practitioners and (2) determined the  adequacy of the key VA screening requirements for health care  practitioners.
To do our work, we selected 43 occupations in which practitioners have  direct patient care access or have an impact on patient care and identified  the key screening requirements that applied to these occupations. To  identify the key screening requirements, we reviewed VA employment  screening policies and interviewed VA headquarters and facility officials  and practitioners. To assess the extent to which VA facilities complied  with the key screening requirements, we visited four VA facilities and  reviewed a statistically random sample of about 100 practitioners’  personnel files at each site. We selected facilities to visit based on  geographic variation, affiliations with medical schools to train residents,  and types of health care services provided. Additionally, we obtained  documentation on how quickly facilities took action after obtaining the  results of background investigations. Our results cannot be generalized to  other facilities. To determine the adequacy of the key screening  requirements, we examined whether these screening requirements were  complete, and whether VA applied them to all practitioners it intended to  hire, practitioners currently employed in VA, contract health care staff,  medical residents, and volunteers. We also interviewed representatives of  state licensing boards and national certifying organizations and officials  and representatives of organizations that operate national databases  containing information on state licenses and national certificates. We did  our work from August 2003 through March 2004 in accordance with  generally accepted government auditing standards.
In summary, we identified key VA screening requirements and found  mixed compliance with these requirements in the four facilities we visited.  The key screening requirements are those that are intended to ensure that  VA facilities employ health care practitioners who have valid professional  credentials and personal backgrounds to safely deliver health care to  veterans. While we found that all facilities generally checked, on a periodic  basis, the professional credentials of practitioners currently employed in  VA, they did not verify all of the credentials of all of the practitioners they  intended to hire. Furthermore, VA facilities varied in how quickly they  took action after obtaining the results of background investigations.  During the site visit at one facility, we discovered returned background  investigation results that were over a year old but had not been reviewed.  We brought them to the attention of facility officials, who reviewed the  reports and then terminated a nursing assistant who had been fired by a  previous non-VA employer for patient abuse. Although VA established an  office more than a year ago to perform oversight of human resources  functions, including whether its facilities comply with these key screening  requirements, that office has not conducted any compliance reviews at  facilities. Furthermore, VA has not implemented a policy for the human  resources program evaluation to be performed by this office and has not  provided funds to support this office. This pattern of mixed compliance  creates vulnerabilities to the extent that VA remains unaware of  practitioners it employs who could place patients at risk.
We also found gaps in the key VA screening requirements that VA officials  used to verify the professional credentials and personal backgrounds of  health care practitioners. We found adequate screening requirements for  certain practitioners, such as physicians and dentists, for whom facilities  are required to verify all licenses by contacting state licensing boards.  However, existing screening requirements for others, such as nurses  currently employed in VA, are less stringent because they do not require  that facilities verify all state licenses that a nurse may holdonly one must  be checkedand they require only physical inspection of the license  rather than contacting the state licensing board to verify the status of the  license. VA also does not require verifying national certificatesthe  credentials held by other health care practitioners, such as respiratory  therapistsby contacting the national certifying organizations for  practitioners VA intends to hire and periodically for those employed in VA.  Physical inspection alone can be misleading; not all professional  credentials indicate whether they have had disciplinary actions taken  against them, and credentials can be forged. VA also does not require  facility officials to query a national database, for other than physicians and  dentists, that contains reports of professional disciplinary actions and  criminal convictions, involving all licensed practitioners. In addition, many  practitioners with direct patient care access, such as medical residents,  are not required to undergo background investigations, including  fingerprinting to check for criminal histories.
To better ensure the safety of veterans receiving health care at VA  facilities, in our report we recommend that VA conduct more thorough  screening of practitioners VA intends to hire and practitioners currently  employed in VA by expanding its verification requirement that facility  officials contact state licensing boards and national certifying  organizations for all state licenses and national certificates; expanding the  query of a national database to include all licensed practitioners that VA  intends to hire and periodically for practitioners currently employed in VA;  and requiring fingerprint checks for all health care practitioners who were  previously exempted from background investigations and who have direct  patient care access. Furthermore, we recommend that VA conduct  oversight to help ensure that facilities comply with all screening  requirements. In commenting on a draft of our report, VA generally agreed  with our findings and conclusions and stated that it will develop a detailed  action plan to implement our recommendations.
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 licensing requirements, and licensed practitioners may be  licensed in more than one state. “Current and unrestricted licenses” are  licenses that are in good standing in the state where they are issued. To  keep a license current, practitioners must renew their licenses before they  expire and meet renewal requirements established by state licensing  boards. Renewal requirements include criteria, such as continuing  education, but renewal procedures and requirements vary by state and  occupation. When a licensing board discovers a licensee is in violation of  licensing requirements or established law, for example, abusing  prescription drugs or intentionally or negligently providing poor quality  care that results in adverse health effects, it may place restrictions on or  revoke a license. Restrictions imposed by a state licensing board can limit  or prohibit a practitioner from practicing in that particular state. Some, but  not all, state licenses are marked to indicate that the licenses have had  restrictions placed on them. Generally, state licensing boards maintain a  database of information on restrictions, which employers can obtain at no  cost either by accessing the information on a board’s Web site or by  contacting the board directly.
National certificates are issued by national certifying organizations, which  are separate and independent from state licensing boards. 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 national certificates to work at VA  must have current and unrestricted certificates. Practitioners may renew  these credentials periodically by paying a fee and verifying that they  obtained required educational credit hours. A national certifying  organization can restrict or revoke a certificate for violations of the  organization’s professional standards. Like state licensing boards, national  certifying organizations maintain databases of information on disciplinary  actions taken against practitioners with national certificates, and many  can be accessed at no cost.
section_title: VA Facilities Demonstrated Mixed Compliance with Key VA Screening Requirements
paragraphs: We identified key VA screening requirements and found mixed compliance  with these requirements in the four facilities we visited. The key screening  requirements are those that are intended to ensure that VA facilities  employ health care practitioners who have valid professional credentials  and personal backgrounds to deliver safe health care to veterans. None of  the four VA facilities complied with all of the screening requirements. In  addition, VA does not currently conduct oversight of its facilities to  determine if they comply with the key screening requirements.
Key VA screening requirements include:    verifying the professional credentials of practitioners VA intends to hire;    verifying periodically the professional credentials of practitioners  currently employed in VA facilities;    querying, prior to hiring, the Department of Health and Human Services’  Office of Inspector General’s List of Excluded Individuals and Entities  (LEIE) to identify practitioners who have been excluded from  participation in all federal health care programs;    ensuring that background investigations are requested or completed for  practitioners currently employed in VA facilities;    ensuring that the Declaration for Federal Employment form (Form 306) is  completed by practitioners currently employed in VA facilities; and    verifying that the educational institutions listed by a practitioner VA  intends to hire are checked against lists of diploma mills that sell fictitious  college degrees and other fraudulent professional credentials.
To show the variability in the level of compliance among the four VA  facilities we visited, we measured their performance in five of the six  screening requirements, against a compliance rate of at least 90 percent  for each requirement, even though VA policy allows no deviation from  these requirements. Table 1 summarizes the compliance results we found  for the five requirements among the four VA facilities we visited. For the  sixth requirement to match the educational institutions listed by a  practitioner against lists of diploma mills, we asked facility officials if they  did this check and then asked them to produce the lists of diploma mills  they use.
All four facilities generally complied with VA’s existing policies for  verifying the professional credentials of practitioners currently employed  in VA facilities, either by contacting the state licensing boards for  practitioners such as physicians or physically inspecting the licenses or  national certificates for practitioners such as nurses and respiratory  therapists. They also generally ensured that practitioners VA intended to  hire had completed the Declaration for Federal Employment form, which  requires the practitioner to disclose, among others things, criminal  convictions, employment terminations, and delinquencies on federal loans.  However, three of the facilities did not follow VA’s policies for verifying  the professional credentials of practitioners VA intends to hire, and three  did not compare practitioners’ names to LEIE prior to hiring them. Two of  the four facilities conducted background investigations on practitioners  currently employed in their facilities at least 90 percent of the time, but the  other two facilities did not.
We also asked officials whether their facilities checked the educational  institutions listed by a practitioner VA intended to hire against a list of  diploma mills to verify that the practitioner’s degree was not obtained  from a fraudulent institution. An official at one of the four facilities told us  he consistently performed this check. Officials at the other three facilities  stated that they did not perform the check because they did not have lists  of diploma mills.
In addition to assessing the rate of compliance with the key screening  requirements, we found that VA facilities varied in how quickly they took  action to deal with background investigations that returned questionable  results, such as discrepancies in work or criminal histories. The Office of  Personnel Management (OPM) gives a VA facility up to 90 days to take  action after the facility receives investigation results with questionable  findings. We reviewed the timeliness of actions taken by facility officials  from August 1, 2002, through August 23, 2003, at the 4 facilities we visited  and 6 additional facilities geographically spread across the VA health care  system. We found that officials at 5 of the 10 facilities took action within  the 90-day time frame, with the number of days ranging on average from 13  to 68. Officials at 3 facilities exceeded the 90-day time frame on average by  36 to 290 days. One facility took action on its cases prior to OPM closing  the investigation, and another facility did not have the information  available to report.
One of the cases that exceeded the 90-day time frame involved a nursing  assistant who was hired to work in a VA nursing home in June 2002. In  August 2002, OPM sent the results of its background investigation to the  VA facility, reporting that the nursing assistant had been fired from a 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 in a clerk’s office on a cart and in piles on the desk and on other  workspaces. After we brought this case to the attention of facility officials  in December 2003, they reviewed the report and then terminated the  nursing assistant, who had worked at the VA facility for more than 1 year,  for not disclosing this information on the Declaration for Federal  Employment form.
VA has not conducted oversight of its facilities’ compliance with the key  screening requirements. Instead, VA has relied on OPM to do limited  reviews of whether facilities were meeting certain human resources  requirements, such as completion of background investigations. These  reviews did not include determining whether the facilities were verifying  professional credentials. Although VA established the Office of Human  Resources Oversight and Effectiveness in January 2003 to conduct such  oversight, the office has not conducted any facility compliance  evaluations. In addition, VA has not implemented a policy for the human  resources program evaluation to be performed by this office and has not  provided the resources necessary to support this office.
section_title: Gaps in Key VA Screening Requirements Create Vulnerabilities
paragraphs: Gaps in VA’s requirements for screening the professional credentials and  personal backgrounds of practitioners create vulnerabilities in its  screening processes that could place patients at risk by allowing health  care practitioners who might harm patients to work in VA facilities. For  certain VA practitioners, screening requirements include the verification of  all state licenses by contacting the state licensing boards to verify that  licenses are current and unrestricted. For example, all state licenses for  physicians and dentists are verified by contacting state licensing boards to  ensure the licenses are in good standing when VA intends to hire them and  periodically during employment. Similarly, all licenses for nurses and  pharmacists VA intends to hire are verified by contacting the state  licensing boards. However, once hired, periodic screening for nurses and  pharmacists simply involves a VA official’s physical inspection of one state  license, even if the practitioner has multiple state licenses, creating a gap  in the verification process.
VA’s requirements allow a practitioner to select the license under which he  or she will work in VA, and this license can be from any state, not  necessarily the one in which the VA facility is located. A practitioner may  have a restricted state license as a result of a disciplinary action, yet show  a facility official a license from another state that is unrestricted. VA  facility officials informed us that checking one state license was sufficient  because state licensing boards share information on disciplinary actions  and licenses are marked when restricted. However, according to state  licensing board officials, one cannot determine with certainty that a  license is valid and unrestricted unless the licensing board is contacted  directly. These officials explained that state licensing boards do not  always exchange information about disciplinary actions taken against a  practitioners and not all states mark licenses that are restricted. Moreover,  licenses can be forged, even though state licensing boards have taken  steps to minimize this problem. Therefore, physical inspection of a license  alone can be misleading.
To supplement the screening of the state licenses of physicians and  dentists, VA requires facilities to query two national databasesthe  National Practitioner Data Bank (NPDB) and the Federation of State  Medical Boards (FSMB) databasewhich contain information about  disciplinary actions taken against practitioners. Another available national  database, the Healthcare Integrity and Protection Data Bank (HIPDB),  contains information on professional disciplinary actions and criminal  convictions involving all licensed health care practitioners, not just  physicians and dentists. VA is currently accessing HIPDB automatically  when it queries NPDB for physicians and dentists because the databases  share information. However, VA does not require its facilities to do so for  all licensed practitioners even though it is authorized to query HIPDB  without a fee.
VA also requires that practitioners it intends to hire and who must have  national certificates to work in VA facilities, such as respiratory therapists,  disclose the national certificates and any state licenses they have ever  held. However, VA facility officials are not required to check state licenses  disclosed by these practitioners and are only required to physically inspect  the national certificates. As with physical inspection of state licenses,  physical inspection of national certificates alone can be misleading; not all  certificates are marked if restricted, and they can be forged. The only way  to know with certainty if a national certificate is current and unrestricted  is to contact the issuing national certifying organization.
In addition to gaps in VA’s verification of professional credentials, VA has  not implemented consistent background screening requirements, which  would include fingerprint checks, for all practitioners. Although VA  requires background investigations for some practitioners currently  employed in VA, it does not require these investigations for all types of  practitioners. VA requested and received OPM’s permission to exempt  certain categories of health care practitioners from background  investigations based on VA’s assessment that these types of practitioners  do not need to be investigated. Table 2 lists the practitioners that VA  exempts from background investigations.
OPM began to offer a fingerprint-only checka new screening optionfor  use by federal agencies in 2001. Compared to background investigations,  which typically take several months to complete, fingerprint-only check  results can be obtained within 3 weeks at a cost of less than $25. In  commenting on a draft of our report, VA said that it planned to implement  fingerprint-only checks for all contract health care practitioners, medical  residents, medical consultants, and practitioners who work without direct  compensation from VA, as well as certain volunteers. However, VA has not  issued guidance to its facilities instructing them to implement 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  criminal histories. According to the lead VA Office of Inspector General  investigator in the Dr. Swango case, if Dr. Swango had undergone a  fingerprint check at the VA facility where he trained, VA facility officials  would have identified his criminal history and could have taken  appropriate action. Additionally, one of the facilities we visited had  implemented fingerprint-only checks of medical residents training in the  facility and contract health care practitioners. An official at this facility  stated that fingerprint-only checks of medical residents and contract  practitioners were a necessary component of ensuring the safety of  veterans in the facility. FSMB in 1996 recommended that states perform  background investigations, including criminal history checks, on medical  residents to better protect patients because residents have varying levels  of unsupervised patient care.
section_title: Concluding Observations
paragraphs: VA’s screening requirements are intended to ensure the safety of veterans  by identifying practitioners with restricted or fraudulent credentials,  criminal backgrounds, or questionable work histories. However,  compliance with the existing key screening requirements was mixed at the  four facilities we visited. None of the four facilities complied with all of the  key VA screening requirements. However, all four facilities generally  complied with VA’s requirement to periodically verify the credentials of  practitioners for their continued employment. Although VA created the  Office of Human Resources Oversight and Effectiveness in January 2003  expressly to provide oversight of VA’s human resources practices at its  facilities, it has not provided resources for this office to carry out its  oversight function. Without such oversight, VA cannot provide reasonable  assurance that its facilities comply with requirements intended to ensure  the safety of veterans receiving health care in VA facilities.
Even if VA facilities had complied with all key screening requirements,  gaps in VA’s existing screening requirements allow some practitioners  access to patients without a thorough screening of their professional  credentials and personal backgrounds. For example, although the  screening requirements for verifying professional credentials for some  occupations, such as physicians, are adequate, VA does not apply the same  screening requirements for all occupations with direct patient care access.  Specifically, VA does not require that all licenses be verified, or that  licenses and national certificates be verified by contacting state licensing  boards or national certifying organizations. Similarly, while VA relies on  two national databases to identify physicians and dentists who have  disciplinary actions taken against them, VA does not require facility  officials to query HIPDB. This national database provides information on  reports of professional disciplinary actions and criminal convictions that  may involve currently employed licensed practitioners and those VA  intends to hire. As part of its query of another database, VA accesses  HIPDB automatically for physicians and dentists, but practitioners such as  nurses, pharmacists, and physical therapists do not have their state  licenses checked against this national database. In addition, VA does not  require all practitioners with direct patient care access, such as medical  residents, to have their fingerprints checked against a criminal history  database. These gaps create vulnerabilities that could allow incompetent  practitioners or practitioners with the intent to harm patients into VA’s  health care system. In light of the gaps we found and mixed compliance  with the key screening requirements by VA facilities, we believe effective  oversight could reduce the potential risks to the safety of veterans  receiving health care in VA facilities.
In our report, we recommend that VA take the following four actions:    expand the verification requirement that facility officials contact state  licensing boards and national certifying organizations to include all state  licenses and national certificates held by practitioners VA intends to hire  and currently employed practitioners,    expand the query of the Healthcare Integrity and Protection Data Bank to  include all licensed practitioners that VA intends to hire and periodically  query this database for practitioners currently employed in VA,  require fingerprint checks for all health care practitioners who were  previously exempted from background investigations and who have direct  patient care access, and    conduct oversight to help ensure that facilities comply with all key  screening requirements for practitioners VA intends to hire and  practitioners currently employed by VA.
Mr. Chairman, this concludes my prepared remarks. I will be pleased to  answer any questions you or other Members of the Subcommittee may  have.
section_title: Contact and Acknowledgments
paragraphs: For further information regarding this testimony, please contact Cynthia  A. Bascetta at (202) 512-7101. Mary Ann Curran and Marcia Mann also  contributed to this statement.