VA operates the largest integrated health care system in the United States, providing care to nearly 5 million veterans per year. The VA health care system consists of hospitals, ambulatory clinics, nursing homes, residential rehabilitation treatment programs, and readjustment counseling centers. In addition to providing medical care, VA is the largest educator of health care professionals, training more than 28,000 medical residents annually, as well as other types of trainees. State licenses are issued by state licensing boards, which generally establish state licensing requirements governing their licensed practitioners. Current and unrestricted licenses are licenses that are in good standing in the states that issued them, and licensed practitioners may hold licenses from more than one state. To keep a license current, practitioners must renew their licenses before they expire and meet renewal requirements established by state licensing boards, such as continuing education. Renewal procedures and requirements vary by state and occupation. When licensing boards discover violations of licensing practices, such as the abuse of prescription drugs or the provision of poor quality of care that results in adverse health effects, they may place restrictions on licenses or revoke them. Restrictions from a state licensing board can limit or prohibit a practitioner from practicing in that particular state. Some, but not all, issued state licenses are marked in such a way as to indicate that the licenses have had restrictions placed on them. Generally, state licensing boards maintain a database of information on restrictions, which employers can often obtain at no cost either by accessing the information on a board’s Web site or by contacting the board directly. National certificates are issued by national certifying organizations, which are separate and independent from state licensing boards. These organizations establish professional standards that are national in scope for certain occupations, such as respiratory and occupational therapists. Practitioners who are required to have a national certificate to practice in VA may renew these credentials periodically by paying a fee and verifying that they obtained required educational credit hours. National certifying organizations can place restrictions on a certification or revoke certification for violations of the organization’s professional standards. Like state licensing boards, national certifying organizations maintain a database of information on disciplinary actions taken against practitioners with national certificates and many can be accessed at no cost. We identified key VA screening requirements that are intended to ensure that VA facilities employ health care practitioners who have valid professional credentials and personal backgrounds appropriate to deliver safe health care to veterans. Officials at VA facilities are required to verify whether credentialsstate licenses and national certificatesheld by applicants and employees are current and unrestricted. VA also requires its facilities to check the names of all applicants VA intends to hire against a federal list of individuals who have been excluded from participation in any federal health care programs and to compare applicants’ educational institutions against lists of fraudulent institutions. Additionally, VA requires that individuals in certain positions undergo a background investigation, which includes checking their fingerprints against a fingerprint-based criminal history database. VA policy requires officials at its facilities to screen applicants to determine whether they possess at least one current and unrestricted state license or an appropriate national certificate, whichever is applicable for the position they seek. We classified VA’s practitioners into three groups, depending upon the credentials and the verification process VA requires for employment. Figure 1 illustrates VA’s process for credentials verification with state licensing boards and national certifying organizations for these groups for applicants VA intends to hire and for employed practitioners, whose credentials are checked periodically. Groups A and B represent practitioners who must be licensed to work in VA. However, the requirements and process VA uses to verify professional credentials is different for each of these groups. Group C represents practitioners who must have a national certificate to work in VA and may also have a state license. The process used to screen applicants in all three groups has two stages. First, applicants are required to disclose, if applicable, their state licenses and national certificates. Second, VA facility officials are required to verify whether applicants’ state licenses or national certificates are current and unrestricted. To verify applicants’ credentials, VA officials are required to either contact state licensing boards or to physically inspect an applicant’s national certificate. Officials are also required to document that they verified the status of the professional credentials. VA also has requirements for verifying the credentials of its employed practitioners. Like the verification process for applicants, this process involves employed practitioners’ disclosures and VA verification of that information. VA employed practitioners in group A are required to disclose all of their current licenses, while those in group B must disclose only one license. For employed practitioners in group A, facility officials are also required to determine if any expired licenses disclosed as current and unrestricted at the beginning of employment had restrictions placed on them prior to their expiration. VA depends on its employed practitioners in group B to inform facility officials of any change in the status of their license, including any that have expired. Employed practitioners in group C must disclose a national certificate. VA officials must confirm that the disclosed licenses and certificates are current and unrestricted. For group A practitioners, VA facility officials contact the appropriate state licensing boards directly; for groups B and C they physically inspect the state license or national certificate. VA officials verify these credentials periodically depending on the occupation and the requirements of the state or national organization that issued the license or certificate. For example, a registered nurse with a state license from Virginia must renew the license every 3 years, while a respiratory therapist must renew the national certificate every 5 years. VA officials are required to document these verifications. If VA’s verification process identifies that a state licensing board or national certifying organization took disciplinary action against a practitioner, facility officials are required to determine the circumstances of the disciplinary action. Licensing boards and certifying organizations have various options for disciplining practitioners. For example, a nurse who is abusing drugs and voluntarily enters a drug abuse program may retain a license to practice with supervision when administering drugs. In contrast, a physician whose treatment results in the death or the permanent disability of a patient may have a license revoked. On the basis of a review of the action taken by the state licensing board or national certifying organization, VA officials are to determine whether an applicant should be hired or an employed practitioner should be retained or terminated. To supplement its checks with state licensing boards, VA has requirements for searching for disciplinary actions taken against licensed practitioners that might not have been disclosed by physician and dentist applicants and employed practitioners. VA requires its facilities to check national databases for information on disciplinary actions taken against these practitioners. Specifically, VA requires that facility officials query the Federation of State Medical Boards (FSMB) database, which includes records of disciplinary actions taken against physicians by all state licensing boards. Similarly, VA requires facility officials to query the National Practitioner Data Bank (NPDB), which contains information including disciplinary actions taken against physicians and dentists. Facility officials must document the results of these queries. VA policy requires its facilities to check the names of all applicants VA intends to hire against a federal list of individuals who have been excluded from participation in any federal health care program. The list, referred to as the List of Excluded Individuals and Entities (LEIE), is maintained by the Department of Health and Human Services’ Office of Inspector General. Since March 1999, VA facilities are to electronically query the LEIE Web site on all applicants prior to employment. VA also requires its facilities to make sure that an applicant’s educational degrees are authentic. VA requires that applicants for some positions, such as social workers, have degrees from accredited institutions. To prevent the use of fraudulent degrees to obtain employment, VA requires that its facilities compare the educational institutions listed by an applicant against existing lists of “diploma mills” that sell fictitious college degrees and other professional credentials. VA’s employed practitioners are required to undergo a background investigation that verifies their personal histories. A background investigation verifies, for instance, an individual’s history of employment, education, and residence. It also includes a fingerprint check that searches for evidence of criminal activity by comparing fingerprints against a database of criminal records. The Office of Personnel Management (OPM) conducts the investigations for VA and reports its results back to the facility that requested the investigation. In conjunction with the background investigation, VA employed practitioners are required to disclose information about their professional and personal backgrounds by filling out the Declaration for Federal Employment form—also known as form 306. Employed practitioners are asked to disclose, among other things, information about criminal convictions, employment terminations, military court-martials, and delinquencies on federal loans. Failure to disclose information requested on form 306 is grounds for dismissal. Facility officials compare the information obtained from form 306 with the results obtained through the background investigation to determine whether employed practitioners have been forthcoming in their disclosures. If the background investigation results include questionable issues, such as discrepancies in work or criminal histories, the facility has 90 days to take action. Gaps in key VA screening requirements result in vulnerabilities when screening certain health care practitioners. Although the screening requirements for some occupations, such as physicians, are adequate because they require verifying all licenses by contacting state licensing boards, screening requirements for other occupations are less stringent. These less stringent requirements do not require checking all licenses, and they require physical inspection of one license only rather than contacting the state licensing board. Similarly, VA does not require contacting national certifying organizations to verify national certificatesthe credentials held by health care practitioners, such as respiratory therapists. Physical inspection of credentials alone can be misleading; not all state licenses and national certificates indicate whether they are restricted, and licenses and certificates can be forged. While VA requires checking a national database for physicians and dentists, it does not require that facility officials query a national database that contains reports of disciplinary actions and criminal convictions involving all licensed practitioners. In addition, VA does not require that all practitioners undergo background investigations, including fingerprinting, to check for criminal records. These gaps create vulnerabilities because VA may remain unaware of health care practitioners who could place patients at risk.