VA Health Care: Steps Taken to Improve Practitioner Screening, but Facility Compliance with Screening Requirements Is Poor
Released: 2006-06-15T00:00:00

Letter

Background

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.

VA Has Taken Steps to Improve Health Care Practitioner Screening Requirements, but Gaps Remain

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.

VA Has Partially Implemented Our Recommendation to Expand Verification of Health Care Practitioners’ Professional Credentials

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.

VA Partially Implemented Our Recommendation to Require Medical Facilities to Query HIPDB

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.

VA Policy on Fingerprint- Only Background Investigations Addressed Our Recommendation, but Was Not Fully Implemented

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.

VA Partially Implemented Our Recommendation to Conduct Oversight of Facilities’ Compliance with Screening Requirements

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.

VA Facilities Did Not Comply with Health Care Practitioner Screening Requirements

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.

Conclusions

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.

Recommendations for Executive Action

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.

Agency Comments

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.

Appendix I: Scope and Methodology

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.

Appendix II: Results of Our Compliance Reviews at Seven VA Facilities

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.

Appendix III: Comments from the Department of Veterans Affairs

Appendix IV: GAO Contact and Staff Acknowledgments

Acknowledgments

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.