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 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 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.