VA Health Care
Improved Screening of Practitioners Would Reduce Risk to Veterans Gao ID: GAO-04-566 March 31, 2004Cases of practitioners causing intentional harm to patients have raised concerns about the Department of Veterans Affairs' (VA) screening of practitioners' professional credentials and personal backgrounds. GAO was asked to (1) identify key VA screening requirements, (2) evaluate their adequacy, and (3) assess compliance with these screening requirements. GAO reviewed VA's policies and identified key VA screening requirements for 43 health care occupations; interviewed officials from VA, licensing boards, and certifying organizations; and randomly sampled about 100 practitioners' personnel files at each of four VA facilities we visited.
GAO identified key screening requirements that VA uses to verify the professional credentials and personal backgrounds of its health care practitioners. These requirements include verifying professional credentials; completing background investigations for certain practitioners, including fingerprinting to check for criminal histories; and checking national databases that contain reports of practitioners who have been professionally disciplined or excluded from federal health care programs. GAO found adequate screening requirements for certain practitioners, such as physicians, for whom all licenses are verified by contacting state licensing boards. However, screening requirements for others, such as currently employed nurses and respiratory therapists, are less stringent because they do not require verification of all licenses and national certificates. Moreover, they require only physical inspection of the credential rather than contacting state licensing boards and national 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 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. VA has not conducted oversight of its facilities' compliance with the key screening requirements. This pattern of mixed compliance and the gaps in key VA screening requirements creates vulnerabilities to the extent that VA remains unaware of practitioners who could place patients at risk.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: Team: Phone:GAO-04-566, VA Health Care: Improved Screening of Practitioners Would Reduce Risk to Veterans
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Report to the Chairman, Subcommittee on Oversight and Investigations,
Committee on Veterans' Affairs, House of Representatives:
United States General Accounting Office:
GAO:
March 2004:
VA Health Care:
Improved Screening of Practitioners Would Reduce Risk to Veterans:
GAO-04-566:
GAO Highlights:
Highlights of GAO-04-566, a report to the Chairman, Subcommittee on
Oversight and Investigations, Committee on Veterans‘ Affairs, House of
Representatives
Why GAO Did This Study:
Cases of practitioners causing intentional harm to patients have raised
concerns about VA‘s screening of practitioners‘ professional
credentials and personal backgrounds. GAO was asked to
(1) identify key VA screening requirements,
(2) evaluate their adequacy, and
(3) assess compliance with these screening requirements.
GAO reviewed VA‘s policies and identified key VA screening requirements
for 43 health care occupations; interviewed officials from VA,
licensing boards, and certifying organizations; and randomly sampled
about 100 practitioners‘ personnel files at each of four VA facilities
we visited.
VA has not conducted oversight of its facilities‘ compliance with the
key screening requirements. This pattern of mixed compliance and the
gaps in key VA screening requirements creates vulnerabilities to the
extent that VA remains unaware of practitioners who could place
patients at risk.
What GAO Found:
GAO identified key screening requirements that VA uses to verify the
professional credentials and personal backgrounds of its health care
practitioners. These requirements include verifying professional
credentials; completing background investigations for certain
practitioners, including fingerprinting to check for criminal
histories; and checking national databases that contain reports of
practitioners who have been professionally disciplined or excluded from
federal health care programs.
GAO found adequate screening requirements for certain practitioners,
such as physicians, for whom all licenses are verified by contacting
state licensing boards. However, screening requirements for others,
such as currently employed nurses and respiratory therapists, are less
stringent because they do not require verification of all licenses and
national certificates. Moreover, they require only physical inspection
of the credential rather than contacting state licensing boards and
national 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 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.
What GAO Recommends:
GAO recommends that VA expand its existing verification process to
require that all state licenses and national certificates held by all
practitioners be verified by contacting the appropriate licensing
boards and national certifying organizations, expand the query of a
national database to include all licensed practitioners, and
fingerprint all practitioners who have direct patient care access. GAO
also recommends that VA conduct oversight of its facilities to ensure
their compliance with all key screening requirements. VA generally
agreed with GAO‘s findings and will develop a detailed action plan to
implement the recommendations.
www.gao.gov/cgi-bin/getrpt?GAO-04-566.
To view the full product, including the scope and methodology, click on
the link above. For more information, contact Cynthia A. Bascetta at
(202) 512-7101.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
VA Policy Requires Its Facilities to Check Many Practitioners'
Professional Credentials and Personal Backgrounds:
Gaps in Key VA Screening Requirements Create Vulnerabilities:
VA Facilities Did Not Comply with All of the Key VA Screening
Requirements:
Conclusions:
Recommendations for Executive Action:
Agency Comments:
Appendix I: Scope and Methodology:
Appendix II: Results of Our Compliance Reviews at VA Facilities:
Appendix III: Comments from the Department of Veterans Affairs:
Appendix IV: GAO Contact and Staff Acknowledgments:
GAO Contact:
Acknowledgments:
Tables:
Table 1: Types of Practitioners VA Exempts from Background
Investigations:
Table 2: Facilities' Rate of Compliance with Existing Key VA Screening
Requirements:
Table 3: State Licensure and National Certification Requirements for
the 43 VA Occupations:
Table 4: VA Facility Compliance with Key Screening
RequirementsæProfessional Credentials Verification:
Table 5: Facility Compliance with Key Screening RequirementsæPersonal
Background Screening:
Table 6: Average Number of Days from Obtaining Background Investigation
Results to VA Facility Action (August 1, 2002, to August 23, 2003):
Figures:
Figure 1: VA's Process for Credentials Verification with State
Licensing Boards and National Certifying Organizations:
Figure 2: Gaps in Group B Employed Practitioners' Credentials
Verification with State Licensing Boards:
Figure 3: Gaps in Group C Applicants' and Employed Practitioners'
Credentials Verification with State Licensing Boards and National
Certifying Organizations:
Abbreviations:
FSMB: Federation of State Medical Boards:
HIPDB: Healthcare Integrity and Protection Data Bank:
LEIE: List of Excluded Individuals and Entities:
NPDB: National Practitioner Data Bank:
OPM: Office of Personnel Management:
SLB: state licensing board:
VA: Department of Veterans Affairs:
United States General Accounting Office:
Washington, DC 20548:
March 31, 2004:
The Honorable Steven Buyer:
Chairman:
Subcommittee on Oversight and Investigations:
Committee on Veterans' Affairs:
House of Representatives:
Dear Mr. Chairman:
The Department of Veterans Affairs (VA) is responsible for safeguarding
veterans receiving health care in its facilities by ensuring that its
health care practitioners are qualified to provide care to their
patients. 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.[Footnote 1] VA has screening
requirements intended to help ensure that its health care
practitioners' professional credentials are verified and their personal
backgrounds checked for evidence of incompetence or criminal behavior.
According to medical forensic experts, the deliberate harm of patients
by health care practitioners is a problem in the health care sector,
and VA's requirements are intended to minimize the chance of veterans
receiving care from someone who is incompetent or may intentionally
harm them.
Events at VA facilities have raised concerns about VA's screening of
the professional credentials and personal backgrounds of health care
practitioners at its facilities. In 1993, Dr. Michael Joseph Swango
entered the VA health care system as a medical resident, although
before entering the residency program he had been convicted and
imprisoned for 2 years for aggravated battery against his fellow
employees. Dr. Swango had admitted to medical school officials that he
had a prior arrest and conviction, but lied about the nature of the
crime. In 2000, he pleaded guilty to murdering three veterans at the VA
facility located in Northport, New York, and received a sentence of
three consecutive life terms without the possibility of parole. In
another case, in 2000, events at the VA facility in Albany, New York,
raised concerns about VA's process for checking the credentials of
individuals employed at its facilities. VA hired a research assistant
to help administer several cancer studies. The research assistant had
lost his medical license because he had forged his medical credentials.
Once at VA, the research assistant allegedly falsified data that were
used to qualify veterans for cancer studies, and this may have resulted
in the untimely deaths of several veterans. In 2003, the researcher was
indicted in federal court on charges including manslaughter, criminally
negligent homicide, and fraud.
You asked that we 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 care to veterans. Specifically, we (1) identified key VA
screening requirements for its health care practitioners, (2)
determined the adequacy of these screening requirements, and (3)
assessed the extent to which selected VA facilities complied with these
screening requirements.
We reviewed health care occupations in VA and selected 43 occupations
in which practitioners have direct patient care access or have an
impact on patient care. See appendix I for a list of the 43 health care
occupations included in our study. We reviewed VA employment screening
policies and practices to identify those requirements that applied to
the selected occupations and were key requirements for safeguarding
veterans receiving health care in VA facilities.[Footnote 2] To
determine the adequacy of the key screening requirements, we examined
whether they were complete, and whether VA applied them to all
applicants, current employees, contract staff, medical residents, and
volunteers. We also interviewed VA human resource officials, VA
headquarters and VA facility officials, and facility practitioners;
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 also reviewed VA's policy on background
investigations to determine its criteria for conducting background
investigations. To assess the extent to which VA facilities complied
with the key screening requirements, we visited four VA facilities and
reviewed personnel files for practitioners at each site. From VA's
automated pay system, we selected a statistically random sample of 100
current practitioners in the 43 occupations for each facility we
visited. We reviewed these practitioners' files to determine whether
the facilities had documentation that demonstrated compliance with key
VA screening requirements. We visited facilities located in Big Spring,
Texas; New Orleans, Louisiana; Seattle, Washington; and the District of
Columbia, based on geographic variation, affiliations with medical
schools to train residents, and types of health care services provided.
Of the four facilities we visited, three are large facilities located
in major metropolitan areas and are affiliated with at least one
medical school. The remaining facility is small, providing mainly
primary care and long-term care services to veterans and is located in
a rural area. Additionally, from the four facilities we visited and
from six other facilities we selected based on geographic variation, we
obtained documentation on how quickly facilities took action after
obtaining the results of background investigations. Our results cannot
be generalized to other facilities. For a complete description of our
scope and methodology, see appendix I. Our work was conducted from
August 2003 through March 2004 in accordance with generally accepted
government auditing standards.
Results in Brief:
We identified key screening requirements in VA's policies for checking
the professional credentials and personal backgrounds of health care
practitioners in its facilities. These requirements are in place to
verify state licenses and national certificates for applicants VA
intends to hire and for continued employment of practitioners; to check
health care practitioners against national databases that contain
reports of professional disciplinary actions and criminal convictions;
and to investigate the personal backgrounds of health care
practitioners, including checking fingerprints against a fingerprint-
based criminal history database.
We found adequate screening requirements for certain practitioners,
such as physicians and dentists. These screening requirements include
having facility officials verify all physicians' and dentists' licenses
by contacting state licensing boards for applicants VA intends to hire
and periodically for their continued employment. Screening requirements
for other practitioners, such as currently employed nurses, are less
stringent because they do not require that VA facility officials check
all licenses. Moreover, they do not require contacting state licensing
boards, but instead require physical inspection of the license only. VA
does not require verifying national certificatesæthe credentials held
by other health care practitioners, such as respiratory therapistsæby
contacting the national certifying organizations for applicants VA
intends to hire and periodically for their continued employment.
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. Also, other
than for physicians and dentists, VA does not require facility
officials to query a national database that contains 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 records. These gaps create vulnerabilities because VA may
remain unaware of health care practitioners who could place patients at
risk.
In the four facilities we visited, we found mixed compliance with the
existing key VA screening requirements. All facilities generally
checked the professional credentials of practitioners periodically for
continued employment. However, they were less compliant in checking the
professional credentials of applicants that 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 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, it has not started these reviews. There is no VA policy
outlining the human resources program evaluations to be performed by
this office, and the resources have not been provided to support the
functions of this office.
To better ensure the safety of veterans receiving health care at VA
facilities, we recommend that VA conduct more thorough screening of
both applicants it intends to hire and current employees by expanding
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;
expanding the query of a national database to include all licensed
practitioners that VA intends to hire and periodically for continued
employment; and requiring fingerprint checks for all health care
practitioners who were previously exempted from background
investigations and who have direct patient care access. Furthermore, VA
should conduct oversight to help ensure that facilities comply with all
key screening requirements for applicants and current employees. In
commenting on a draft of this report, VA generally agreed with our
findings and conclusions and stated that it would provide details on
how it plans to address our recommendations when the final report is
issued.
Background:
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.[Footnote 3] 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.[Footnote 4] 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.
VA Policy Requires Its Facilities to Check Many Practitioners'
Professional Credentials and Personal Backgrounds:
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 credentialsæstate licenses and national
certificatesæheld by applicants and employees are current and
unrestricted.[Footnote 5] 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.[Footnote 6]
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 Verification of the Status of State Licenses and
National Certificates:
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.[Footnote 7] [Footnote 8] 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.
Figure 1: VA's Process for Credentials Verification with State
Licensing Boards and National Certifying Organizations:
[See PDF for image]
Note: Groups A and B represent practitioners who must be licensed to
work in VA. Some group B psychologists and social workers may undergo
the same credentials verification process as practitioners in group A.
Group C represents practitioners who must have a national certificate
to work in VA and may also have a state license.
[A] Physician assistants are not required to have a license to work in
VA, but their credentials are verified using a process that is similar
to other group A practitioners.
[End of figure]
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.[Footnote 9] 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.[Footnote 10]
Similarly, VA requires facility officials to query the National
Practitioner Data Bank (NPDB), which contains information including
disciplinary actions taken against physicians and dentists.[Footnote
11] Facility officials must document the results of these queries.
VA Policy Requires Checks of Applicants and Their Credentials against
Lists Designed to Prevent Fraud and Abuse:
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.[Footnote 12] 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 Policy Requires Background Investigations and Disclosures for
Certain Employed Practitioners:
VA's employed practitioners are required to undergo a background
investigation that verifies their personal histories.[Footnote 13] 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 Create Vulnerabilities:
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 certificatesæthe 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.
VA Has Adequate Requirements for Verifying Professional Credentials of
Certain Practitioners:
VA's requirements for verifying the professional credentials of
applicants it intends to hire and employed practitioners in group A,
such as physicians and dentists, are complete and thorough. This is
also the case for applicants VA intends to hire in group B, such as
nurses and pharmacists. VA requires facility officials to verify all
state licenses by contacting the appropriate state licensing boards. To
supplement these requirements for physicians and dentists, VA officials
also must query FSMB and NPDB to identify reports of any disciplinary
actions involving these practitioners.
Gaps Exist in VA's Requirements for Verifying Professional Credentials
of Other Practitioners:
In contrast to all practitioners in group A, the process for
verification of licenses for group B practitioners has gaps, as
illustrated in figure 2. VA's verification process for group B
practitioners that it intends to hire is as stringent as the process
used for group A practitioners. However, the process used to verify
licenses for continued employment of group B practitioners is less
stringent, because facility officials are required to check only one
state license, which is selected by the practitioner. Furthermore,
officials are not required to contact the state licensing board
directly, but instead may simply physically inspect the one state
license to check its status.
Figure 2: Gaps in Group B Employed Practitioners' Credentials
Verification with State Licensing Boards:
[See PDF for image]
[End of figure]
Employed practitioners in group B with multiple state licenses select
the one state license under which they will continue to practice in VA.
The license selected does not have to be from the state where the VA
facility is located. VA officials check only that single license. As a
result, these employed practitioners could have a restricted license in
one state, or several restricted state licenses, but offer VA officials
an unrestricted license from another state for verification.
Moreover, the method required to periodically verify the status of
licenses for continued employment of practitioners in group B is not
thorough. VA facility officials are only required to physically inspect
the license--instead of contacting the state licensing board. VA
facility officials we interviewed were unaware of the inherent
vulnerabilities in relying on a physical inspection. According to
licensing board officials, one cannot determine with certainty that a
license is valid and unrestricted unless the state licensing board is
contacted directly. These officials explained that state licensing
boards do not always exchange information. Furthermore, physical
inspection of licenses alone can be misleading because not all state
licensing boards mark a license to indicate that it is restricted, and
licenses can be forged, even though licensing boards have taken steps
to minimize this problem. Licensing board officials also pointed out
that many state boards do not charge a fee to verify licenses.
Unlike the national database queries of FSMB for physicians and NPDB
for physicians and dentists, VA does not require facility officials to
query the Healthcare Integrity and Protection Data Bank (HIPDB), a
national database that contains information on disciplinary actions and
criminal convictions involving all licensed practitioners.[Footnote
14] All government agencies, including state licensing boards, are
required to report to HIPDB. VA accesses HIPDB when it queries the NPDB
for physicians and dentists because the databases share information.
However, VA does not require its facilities to query HIPDB for all
licensed practitioners even though VA is authorized by statute to query
this database at no charge.
VA's requirements for verifying the professional credentials of both
applicants and employed practitioners in group C also have gaps, as
illustrated in figure 3. For both applicants and employed practitioners
in group C, which include respiratory therapists and dietitians for
example, facility officials are only required to physically inspect the
national certificate to check its status. The physical inspection is
required when these practitioners apply for employment and periodically
for continued employment. Additionally, VA requires applicants in group
C to disclose all of the state licenses they have ever held, but does
not require facility officials to verify any of these state licenses.
Figure 3: Gaps in Group C Applicants' and Employed Practitioners'
Credentials Verification with State Licensing Boards and National
Certifying Organizations:
[See PDF for image]
[End of figure]
However, according to officials from national certifying organizations,
the authenticity and status of a national certificate can only be
assured by contacting the national certifying organizations directly.
For example, an official from the National Board for Respiratory Care
told us that practitioners that were certified prior to July 2002 are
not required to renew their certificates--they can voluntarily choose
to recertify. Thus, physical inspection of a certificate will not
ensure that there has been no disciplinary action taken by the board
since the certificate was issued.
VA Has Not Implemented Consistent Background Screening Requirements:
VA has not implemented consistent background screening requirements,
which include fingerprint checks, for all practitioners. Although VA
requires background investigations for newly hired employed
practitioners, it does not require background investigations for
certain contract health care practitioners, practitioners who work
without compensation from VA, medical consultants, and medical
residents. VA, with prior approval from OPM, has the authority to
determine which positions in VA require a background investigation. VA
requested and received permission from OPM to exempt certain categories
of health care practitioners from background investigations, based on
VA's assessment that these types of practitioners do not need a
background investigation. Table 1 lists the types of practitioners that
VA exempts from background investigations.
Table 1: Types of Practitioners VA Exempts from Background
Investigations:
Types of practitioners VA exempts: Contract health care practitioners
or practitioners that work without direct compensation from VA;
Length of appointment:
* 6 months or less in a single continuous appointment or series of
appointments.
Types of practitioners VA exempts: Medical consultants;
Length of appointment:
* 1 year or less and not reappointed;
* 1 year or more but less than 30 days in a calendar year and not
reappointed.
Types of practitioners VA exempts: Medical residents;
Length of appointment:
* 1 year or less of continuous service at a VA facility.
Source: Department of Veterans Affairs, VA Manual MP-1, Part I, Chapter
5, Change 1 (Washington, D.C.: 1979).
[End of table]
VA requested and received permission from OPM, in 2001 and 2003, to
perform fingerprint-only checks for contract health care practitioners,
who work in a facility for 6 months or less and are currently exempt
from background investigations, and for all volunteers who have access
to patients, patient information, or pharmaceuticals.[Footnote 15] OPM
began to offer a fingerprint-only checkæa new screening optionæfor use
by federal agencies in 2001. Compared to background investigations,
which typically take several months to complete, fingerprint-only
checks can be obtained within 3 weeks or less and cost less than $25,
about a quarter of the cost of a background investigation.[Footnote 16]
In commenting on a draft of this report, VA said that it planned to
implement fingerprint-only checks for all contract health care
practitioners, medical residents, medical consultants, and
practitioners that 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 a criminal history. 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 at a minimum,
fingerprint-only checks of medical residents and contract practitioners
were necessary to help ensure the safety of veterans in the facility.
FSMB in 1996 recommended that states perform background investigations,
including criminal history checks, on medical residents in order to
better protect patients because residents have varying levels of
unsupervised patient care. This recommendation, in part, resulted from
reports that over a 4-year period more than 500 residents had
performance, behavioral, or criminal problems during their training.
VA Facilities Did Not Comply with All of the Key VA Screening
Requirements:
In the four facilities we visited, we found mixed compliance with the
existing key VA screening requirements which are intended to ensure
that applicants and employed practitioners at VA facilities 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 key requirements. Moreover, VA does not conduct oversight of
its facilities to determine if they comply with these key screening
requirements.
In order to show the variability in the level of compliance among the
four VA facilities we visited, we measured their performance against a
compliance rate of at least 90 percent for each of five of the six
screening requirements, even though VA allows no deviation from these
requirements. Table 2 summarizes the rate of compliance among the four
VA facilities we visited. For detailed information about our analysis
and each facility's compliance with a particular requirement, see
appendixes I and II. For the sixth requirementæmatching the educational
institutions listed by a practitioner against lists of diploma millsæwe
asked facility officials if they did this check and then asked them to
produce the lists of diploma mills they use.
Table 2: Facilities' Rate of Compliance with Existing Key VA Screening
Requirements:
Key screening requirements: Credentials of applicants verified;
Compliance with key screening requirements[A]: Facility A: Less than 90
percent compliance rate;
Compliance with key screening requirements[A]: Facility B;
Compliance rate of 90 percent or greater;
Compliance with key screening requirements[A]: Facility C;
Less than 90 percent compliance rate;
Compliance with key screening requirements[A]: Facility D;
Less than 90 percent compliance rate.
Key screening requirements: Credentials of employed practitioners
verified;
Compliance with key screening requirements[A]: Facility A;
Compliance rate of 90 percent or greater;
Compliance with key screening requirements[A]: Facility B;
Compliance rate of 90 percent or greater;
Compliance with key screening requirements[A]: Facility C;
Compliance rate of 90 percent or greater;
Compliance with key screening requirements[A]: Facility D;
Compliance rate of 90 percent or greater.
Key screening requirements: List of Excluded Individuals and Entities
queried for applicants;
Compliance with key screening requirements[A]: Facility A;
Compliance rate of 90 percent or greater;
Compliance with key screening requirements[A]: Facility B;
Less than 90 percent compliance rate;
Compliance with key screening requirements[A]: Facility C;
Less than 90 percent compliance rate;
Compliance with key screening requirements[A]: Facility D;
Less than 90 percent compliance rate.
Key screening requirements: Background investigation completed or
requested for employed practitioners;
Compliance with key screening requirements[A]: Facility A;
Compliance rate of 90 percent or greater;
Compliance with key screening requirements[A]: Facility B;
Less than 90 percent compliance rate;
Compliance with key screening requirements[A]: Facility C;
Less than 90 percent compliance rate;
Compliance with key screening requirements[A]: Facility D;
Compliance rate of 90 percent or greater.
Key screening requirements: Declaration for Federal Employment form
completed for employed practitioners (form 306);
Compliance with key screening requirements[A]: Facility A;
Compliance rate of 90 percent or greater;
Compliance with key screening requirements[A]: Facility B;
Compliance rate of 90 percent or greater;
Compliance with key screening requirements[A]: Facility C;
Compliance rate of 90 percent or greater;
Compliance with key screening requirements[A]: Facility D;
Compliance rate of 90 percent or greater.
Source: GAO analysis of VA facility files.
Note: Some screening requirements do not require verifying all licenses
a practitioner might hold or verifying professional credentials by
contacting state licensing boards or national certifying organizations.
[A] Tested for significance at the 95 percent confidence level.
[End of table]
All four facilities generally complied with VA's existing policies for
verifying the professional credentials of employed practitioners,
either by contacting the state licensing board for practitioners, such
as physicians, or physically inspecting the license or national
certificate for practitioners, such as nurses and respiratory
therapists. They also generally ensured that applicants VA intended to
hire had completed the Declaration for Federal Employment form, which
requires the applicants to disclose, among other things, information
about criminal convictions, employment terminations, and delinquencies
on federal loans. However, three of the four facilities did not follow
VA's policies for verifying all of the professional credentials of
applicants and three facilities did not compare applicants' names to
LEIE prior to hiring them. Two of the four facilities conducted
background investigations on their employed practitioners 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 an applicant against a list of
diploma mills to verify that the applicant's degree was not obtained
from a fraudulent institution. An official at one of the four
facilities told us his staff consistently performed this check.
Officials at the other three facilities stated they did not perform the
check because they did not have a list 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. 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, to August 23, 2003, at the four facilities we visited
and six 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. For
additional information on the average number of days it took each
facility to report its actions, see appendix II.
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 on a cart and in piles on the desk and
on other work surfaces of a clerk's office. After we brought this case
to the attention of facility officials in December 2003, they reviewed
the report and then terminated the employee for not disclosing this
information on the Declaration for Federal Employment form 306. The
employee had worked at the VA facility for more than 1 year.
Another case at the same facility that exceeded the 90-day time frame
involved an employee who had been convicted for possession of illegal
drugs prior to being hired by VA. He had been hired at the facility in
August 2002 and was to complete a background investigation form at that
time. In June 2003, almost 1 year after being hired, a facility
official realized the employee had not completed and returned this form
and gave the employee the form to complete. The employee returned the
completed form in the same month and it was sent to OPM, which returned
the results of its investigation to the facility in July 2003, before
the employee's probationary period of 1 year was completed. The OPM
report revealed numerous arrests for possession of illegal drugs.
During our December 2003 review and about 120 days after the
investigation results were returned from OPM, we found this report and
brought it to the attention of the facility director. Later, a facility
official told us that VA's regional counsel stated that since the
employee's 1-year probationary period had ended and the employee had
disclosed this information on the Declaration for Federal Employment
form 306, the facility could not take action to terminate the employee.
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. There is no VA policy outlining the human
resources program evaluations to be performed by this office, and the
resources have not been provided to support the functions of this
office.
Conclusions:
VA's screening requirements are intended to ensure the safety of
veterans by identifying applicants and employed practitioners with
restricted or fraudulent credentials, criminal backgrounds, or
questionable work histories. However, 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. VA relies on two
national databases to identify physicians and dentists who have had
disciplinary actions taken against them. In addition, VA accesses a
third national database, HIPDB, for physicians and dentists, because
HIPDB is linked to one of the two national databases VA currently
accesses. HIPDB is a national database that contains reports of
disciplinary actions and criminal convictions involving all licensed
practitioners, not just physicians and dentists. However VA does not
require facility officials to query HIPDB for all licensed
practitioners. As a result, practitioners such as nurses, pharmacists,
and physical therapists do not have their state licenses checked
against a 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 addition to these gaps, 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 conduct oversight of VA
facilities' compliance with these requirements. 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. 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.
Recommendations for Executive Action:
To better ensure the safety of veterans receiving health care at VA
facilities, we recommend that the Secretary of Veterans Affairs direct
the Under Secretary for Health to 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 applicants and
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 continued employment,
* 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 applicants and current employees.
Agency Comments:
In commenting on a draft of this report, VA generally agreed with our
findings and conclusions. VA acknowledged that we identified gaps in
its process for conducting background and credentialing checks and that
we provided what appeared to be reasonable recommendations to close
those gaps. VA stated that it would provide a detailed action plan to
implement our recommendations when the final report was issued.
VA said that our draft report inaccurately omitted VA's querying HIPDB
for practitioners who practice independently. We revised our report to
clarify that NPDB queries performed by VA automatically check HIPDB for
these practitioners because the databases are linked. However, VA does
not perform queries of HIPDB for the majority of its licensed
practitioners, which includes nurses, pharmacists, physical
therapists, and dental hygienists. VA also incorrectly stated that the
draft report did not include VA's requirement to query FSMB for
physicians. In addition, VA said that it planned to implement
fingerprint-only checks for all contract health care practitioners,
medical residents, medical consultants, and practitioners that 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 for all these practitioners.
Further, VA stated that the title of the report implied that veterans
are receiving inadequate care on a broad basis. We disagree. The title
reflects vulnerabilities created by the gaps in the screening of
practitioners that could place veterans at risk by allowing incompetent
practitioners or those with the intent to harm patients into VA's
health care system. VA provided technical comments which we
incorporated, as appropriate. VA's written comments are reprinted in
appendix III.
As agreed with your office, unless you publicly announce its contents
earlier, we plan no further distribution of this report until 30 days
after its date. We will then send copies of this report to the
Secretary of Veterans Affairs and other interested parties. We also
will make copies available to others upon request. In addition, the
report will be available at no charge at the GAO Web site at http://
www.gao.gov.
If you or your staff have any questions about this report, please call
me at (202) 512-7101. Another contact and key contributors are listed
in appendix IV.
Sincerely yours,
Signed by:
Cynthia A. Bascetta
Director, Health Care--Veterans' Health and Benefits Issues:
[End of section]
Appendix I: Scope and Methodology:
We examined VA's policies and practices that are intended to ensure
that health care practitioners at its facilities have appropriate
credentials and backgrounds to provide care to veterans. Specifically,
we (1) identified key VA screening requirements for its health care
practitioners, (2) determined the adequacy of these screening
requirements, and (3) assessed the extent to which selected VA
facilities complied with these screening requirements.
To identify key VA screening requirements for its health care
practitioners, we reviewed VA's policies and VA Handbook 5005, which
explains how to implement the screening policies. We limited our review
to 43 occupations in VA that have direct patient care access or have an
impact on patient care. See table 3 for a list of the occupations
included in our review. To identify the 43 occupations, we consulted
with VA human resource officials. We interviewed human resource
officials at VA headquarters and at each facility we visited. We
classified the practitioners who are required to have professional
credentialsæa state license or a national certificateæinto three groups
according to VA's requirements for verifying these credentials. 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. Practitioners not included in the three
groups are not required to have either a license or a national
certificate to work in VA facilities.
Table 3: State Licensure and National Certification Requirements for
the 43 VA Occupations:
Occupation code: 101;
Occupation title: Social Science;
Occupations that require a state license to work in VA: No;
Occupations that require a national certificate to work in VA: No;
Occupations that do not require a state license or a national
certificate to work in VA: Yes.
Occupation code: 102;
Occupation title: Social Science Aid and Technician;
Occupations that require a state license to work in VA: No;
Occupations that require a national certificate to work in VA: No;
Occupations that do not require a state license or a national
certificate to work in VA: Yes.
Occupation code: 180;
Occupation title: Psychology;
Occupations that require a state license to work in VA: Yes;
Occupations that require a national certificate to work in VA: No;
Occupations that do not require a state license or a national
certificate to work in VA: No.
Occupation code: 181;
Occupation title: Psychology Aid and Technician;
Occupations that require a state license to work in VA: No;
Occupations that require a national certificate to work in VA: No;
Occupations that do not require a state license or a national
certificate to work in VA: Yes.
Occupation code: 185;
Occupation title: Social Work;
Occupations that require a state license to work in VA: Yes;
Occupations that require a national certificate to work in VA: No;
Occupations that do not require a state license or a national
certificate to work in VA: No.
Occupation code: 186;
Occupation title: Social Services Aid and Assistant;
Occupations that require a state license to work in VA: No;
Occupations that require a national certificate to work in VA: No;
Occupations that do not require a state license or a national
certificate to work in VA: Yes.
Occupation code: 187;
Occupation title: Social Services;
Occupations that require a state license to work in VA: No;
Occupations that require a national certificate to work in VA: No;
Occupations that do not require a state license or a national
certificate to work in VA: Yes.
Occupation code: 189;
Occupation title: Recreation Aid and Assistant;
Occupations that require a state license to work in VA: No;
Occupations that require a national certificate to work in VA: No;
Occupations that do not require a state license or a national
certificate to work in VA: Yes.
Occupation code: 413;
Occupation title: Physiology;
Occupations that require a state license to work in VA: No;
Occupations that require a national certificate to work in VA: No;
Occupations that do not require a state license or a national
certificate to work in VA: Yes.
Occupation code: 601;
Occupation title: General Health Science;
Occupations that require a state license to work in VA: No;
Occupations that require a national certificate to work in VA: No;
Occupations that do not require a state license or a national
certificate to work in VA: Yes.
Occupation code: 602;
Occupation title: Medical Officer (Physician);
Occupations that require a state license to work in VA: Yes;
Occupations that require a national certificate to work in VA: No;
Occupations that do not require a state license or a national
certificate to work in VA: No.
Occupation code: 603;
Occupation title: Physician's Assistant;
Occupations that require a state license to work in VA: No;
Occupations that require a national certificate to work in VA: Yes;
Occupations that do not require a state license or a national
certificate to work in VA: No.
Occupation code: 605;
Occupation title: Nurse Anesthetist;
Occupations that require a state license to work in VA: Yes;
Occupations that require a national certificate to work in VA: Yes;
Occupations that do not require a state license or a national
certificate to work in VA: No.
Occupation code: 610;
Occupation title: Registered Nurse[A];
Occupations that require a state license to work in VA: Yes;
Occupations that require a national certificate to work in VA: No;
Occupations that do not require a state license or a national
certificate to work in VA: No.
Occupation code: 620;
Occupation title: Practical Nurse;
Occupations that require a state license to work in VA: Yes;
Occupations that require a national certificate to work in VA: No;
Occupations that do not require a state license or a national
certificate to work in VA: No.
Occupation code: 621;
Occupation title: Nursing Assistant;
Occupations that require a state license to work in VA: No;
Occupations that require a national certificate to work in VA: No;
Occupations that do not require a state license or a national
certificate to work in VA: Yes.
Occupation code: 622;
Occupation title: Medical Supply Aide/Technician;
Occupations that require a state license to work in VA: No;
Occupations that require a national certificate to work in VA: No;
Occupations that do not require a state license or a national
certificate to work in VA: Yes.
Occupation code: 630;
Occupation title: Dietitian and Nutritionist;
Occupations that require a state license to work in VA: No;
Occupations that require a national certificate to work in VA: Yes;
Occupations that do not require a state license or a national
certificate to work in VA: No.
Occupation code: 631;
Occupation title: Occupational Therapist;
Occupations that require a state license to work in VA: No;
Occupations that require a national certificate to work in VA: Yes;
Occupations that do not require a state license or a national
certificate to work in VA: No.
Occupation code: 633;
Occupation title: Physical Therapist;
Occupations that require a state license to work in VA: Yes;
Occupations that require a national certificate to work in VA: No;
Occupations that do not require a state license or a national
certificate to work in VA: No.
Occupation code: 635;
Occupation title: Corrective Therapist;
Occupations that require a state license to work in VA: No;
Occupations that require a national certificate to work in VA: No;
Occupations that do not require a state license or a national
certificate to work in VA: Yes.
Occupation code: 636;
Occupation title: Rehabilitation Therapy Assistant;
Occupations that require a state license to work in VA: No;
Occupations that require a national certificate to work in VA: No;
Occupations that do not require a state license or a national
certificate to work in VA: Yes.
Occupation code: 638;
Occupation title: Recreation/Creative Arts Therapist;
Occupations that require a state license to work in VA: No;
Occupations that require a national certificate to work in VA: No;
Occupations that do not require a state license or a national
certificate to work in VA: Yes.
Occupation code: 640;
Occupation title: Health Aid and Technician;
Occupations that require a state license to work in VA: No;
Occupations that require a national certificate to work in VA: No;
Occupations that do not require a state license or a national
certificate to work in VA: Yes.
Occupation code: 644;
Occupation title: Medical Technologist;
Occupations that require a state license to work in VA: No;
Occupations that require a national certificate to work in VA: No;
Occupations that do not require a state license or a national
certificate to work in VA: Yes.
Occupation code: 645;
Occupation title: Medical Technician;
Occupations that require a state license to work in VA: No;
Occupations that require a national certificate to work in VA: No;
Occupations that do not require a state license or a national
certificate to work in VA: Yes.
Occupation code: 646;
Occupation title: Pathology Technician;
Occupations that require a state license to work in VA: No;
Occupations that require a national certificate to work in VA: No;
Occupations that do not require a state license or a national
certificate to work in VA: Yes.
Occupation code: 647;
Occupation title: Diagnostic Radiologic Technologist;
Occupations that require a state license to work in VA: No;
Occupations that require a national certificate to work in VA: Yes;
Occupations that do not require a state license or a national
certificate to work in VA: No.
Occupation code: 648;
Occupation title: Therapeutic Radiologic Technologist;
Occupations that require a state license to work in VA: No;
Occupations that require a national certificate to work in VA: Yes;
Occupations that do not require a state license or a national
certificate to work in VA: No.
Occupation code: 649;
Occupation title: Medical Instrument Technician;
Occupations that require a state license to work in VA: No;
Occupations that require a national certificate to work in VA: No;
Occupations that do not require a state license or a national
certificate to work in VA: Yes.
Occupation code: 651;
Occupation title: Respiratory Therapist[B];
Occupations that require a state license to work in VA: No;
Occupations that require a national certificate to work in VA: Yes;
Occupations that do not require a state license or a national
certificate to work in VA: No.
Occupation code: 660;
Occupation title: Pharmacist;
Occupations that require a state license to work in VA: Yes;
Occupations that require a national certificate to work in VA: No;
Occupations that do not require a state license or a national
certificate to work in VA: No.
Occupation code: 661;
Occupation title: Pharmacy Technician;
Occupations that require a state license to work in VA: No;
Occupations that require a national certificate to work in VA: No;
Occupations that do not require a state license or a national
certificate to work in VA: Yes.
Occupation code: 662;
Occupation title: Optometrist;
Occupations that require a state license to work in VA: Yes;
Occupations that require a national certificate to work in VA: No;
Occupations that do not require a state license or a national
certificate to work in VA: No.
Occupation code: 665;
Occupation title: Speech Pathology and Audiology;
Occupations that require a state license to work in VA: No;
Occupations that require a national certificate to work in VA: No;
Occupations that do not require a state license or a national
certificate to work in VA: Yes.
Occupation code: 667;
Occupation title: Orthotist and Prosthetist;
Occupations that require a state license to work in VA: No;
Occupations that require a national certificate to work in VA: No;
Occupations that do not require a state license or a national
certificate to work in VA: Yes.
Occupation code: 668;
Occupation title: Podiatrist;
Occupations that require a state license to work in VA: Yes;
Occupations that require a national certificate to work in VA: No;
Occupations that do not require a state license or a national
certificate to work in VA: No.
Occupation code: 672;
Occupation title: Prosthetic Representative;
Occupations that require a state license to work in VA: No;
Occupations that require a national certificate to work in VA: No;
Occupations that do not require a state license or a national
certificate to work in VA: Yes.
Occupation code: 680;
Occupation title: Dental Officer (Dentist);
Occupations that require a state license to work in VA: Yes;
Occupations that require a national certificate to work in VA: No;
Occupations that do not require a state license or a national
certificate to work in VA: No.
Occupation code: 681;
Occupation title: Dental Assistant;
Occupations that require a state license to work in VA: No;
Occupations that require a national certificate to work in VA: Yes;
Occupations that do not require a state license or a national
certificate to work in VA: No.
Occupation code: 682;
Occupation title: Dental Hygiene;
Occupations that require a state license to work in VA: Yes;
Occupations that require a national certificate to work in VA: No;
Occupations that do not require a state license or a national
certificate to work in VA: No.
Occupation code: 1320;
Occupation title: Chemistry;
Occupations that require a state license to work in VA: No;
Occupations that require a national certificate to work in VA: No;
Occupations that do not require a state license or a national
certificate to work in VA: Yes.
Occupation code: 1715;
Occupation title: Vocational Rehabilitation;
Occupations that require a state license to work in VA: No;
Occupations that require a national certificate to work in VA: No;
Occupations that do not require a state license or a national
certificate to work in VA: Yes.
Source: VA Handbook 5005, April 15, 2002.
[A] Registered Nurse--includes nurse practitioners and clinical nurse
specialists.
[End of table]
To determine the adequacy of the key VA screening requirements, we
analyzed VA's policies and procedures to identify whether there were
inconsistencies in how the requirements were applied among various
types of practitioners. We interviewed VA headquarters and facility
officials and practitioners at the facilities we visited to determine
how VA's policies are implemented in facilities. In addition, we
interviewed representatives from 13 state licensing boards and the
District of Columbia Board of Nursing and 2 national certifying
organizations to determine if VA's requirements for verifying
professional credentials are adequate for identifying practitioners
without valid and unrestricted state licenses and national
certificates.[Footnote 17]
To assess the extent to which VA facilities we visited complied with
the key screening requirements, we chose a judgmental sample of four VA
facilities that varied in size, location, and medical school
affiliations to assess the extent to which these selected facilities
complied with these requirements. The four facilities are located in
Big Spring, Texas; New Orleans, Louisiana; Seattle, Washington; and the
District of Columbia. We chose these facilities based on geographic
variation, affiliations with medical schools to train residents, and
types of health care services provided. Of the four facilities we
visited, three are large facilities located in major metropolitan areas
and each are affiliated with at least one medical school. The remaining
facility is small, providing mainly primary care and long-term care
services to veterans and is located in a rural area. For each facility,
VA provided, from its automated pay system, a list of current
practitioners in the 43 occupations. As a result of using VA's
automated pay system, our sample does not include those practitioners
providing care through a contract or training agreement or without
direct compensation from VA. For each of the four facilities, we
selected a random sample of 100 practitioners either hired or assigned
to their current position no earlier than January 1, 1993. We chose to
limit our review to approximately the last 10 years because VA changed
its process for credentials verification in the early 1990s. For each
of these practitioners, we reviewed their personnel files to check that
the facility had complied with the following key VA screening
requirements:
* verify state licenses and national certificates for applicants;
* verify state licenses and national certificates for employed
practitioners;
* query the List of Excluded Individuals and Entities (LEIE) prior to
hire;
* ensure completion of background investigations, including
fingerprints;
* ensure completion of the Declaration for Federal Employment form,
also known as form 306; and:
* verify that the educational institutions listed by a practitioner VA
intends to hire are checked against lists of diploma mills.
In order to show the variability in the level of compliance among the
four VA facilities we visited, we distinguished between facilities that
had a compliance rate of at least 90 percent for each of five of the
six screening requirements and those that did not. For each facility
and key screening requirement, 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 four
VA facilities' compliance with each of the key VA screening
requirements. Our results from these four facilities cannot be
generalized to other facilities. In order to determine compliance with
the key screening requirement to verify that the educational
institutions listed by a practitioner are not fraudulent, we asked
facility human resources staff if they performed this screening and
asked them to produce their lists of diploma mills.
Additionally, we reviewed VA facilities' response times to 214
background investigation results returned from OPM with questionable
issues, from August 1, 2002, to August 23, 2003, at the four locations
we visited and six other VA facilities selected based on geographic
location. The six additional facilities were located in Boston,
Massachusetts; East Orange, New Jersey; Indianapolis, Indiana; Palo
Alto, California; Portland, Oregon; and San Diego, California. For
these 10 facilities, we asked officials to provide the date they took
action on cases returned from OPM, and from VA headquarters we obtained
the dates when OPM returned the cases to the facility. We determined
the average number of days it took each facility to take action after
these cases were returned from OPM with questionable issues. Our
results cannot be generalized to other VA facilities. See appendix II
for detailed information on the results of our analysis.
[End of section]
Appendix II: Results of Our Compliance Reviews at VA Facilities:
Tables 4 and 5 show the sample counts used to measure compliance and
the results of our review for five of the requirements. Table 6 shows
the average number of days it took each facility to take action after
cases with questionable issues were returned from OPM.
Table 4: VA Facility Compliance with Key Screening
RequirementsæProfessional Credentials Verification:
Facility: Facility A;
Credentials of applicants verified: Number in sample: 81;
Credentials of applicants verified: Number where verification followed
VA policy: 61;
Credentials of employed practitioners verified: Number in sample: 74;
Credentials of employed practitioners verified: Number where
verification followed VA policy: 74.
Facility: Facility B;
Credentials of applicants verified: Number in sample: 77;
Credentials of applicants verified: Number where verification followed
VA policy: 71;
Credentials of employed practitioners verified: Number in sample: 59;
Credentials of employed practitioners verified: Number where
verification followed VA policy: 59.
Facility: Facility C;
Credentials of applicants verified: Number in sample: 74;
Credentials of applicants verified: Number where verification followed
VA policy: 43;
Credentials of employed practitioners verified: Number in sample: 67;
Credentials of employed practitioners verified: Number where
verification followed VA policy: 67.
Facility: Facility D;
Credentials of applicants verified: Number in sample: 62;
Credentials of applicants verified: Number where verification followed
VA policy: 47;
Credentials of employed practitioners verified: Number in sample: 56;
Credentials of employed practitioners verified: Number where
verification followed VA policy: 55.
Source: GAO analysis of facility files.
Note: The number of practitioners in the sample may be less than the
number of practitioner files reviewed at each facility because the
requirement may not apply to all VA applicants or employed
practitioners.
[End of table]
Table 5: Facility Compliance with Key Screening Requirements--Personal
Background Screening:
Facility: Facility A;
List of Excluded Individuals and Entities (LEIE) queried
for applicants prior to hiring: Number in sample: 61;
List of Excluded Individuals and Entities (LEIE) queried
for applicants prior to hiring: Number queried prior to hire: 53;
Background investigation completed or requested for
employed practitioners: Number in sample: 99[A];
Background investigation completed or requested for
employed practitioners: Number with a completed or requested background
investigation: 93;
Declaration for Federal Employment form (form 306) completed for
employed practitioners: Number in sample: 94;
Declaration for Federal Employment form (form 306) completed for
employed practitioners: Number with completed form 306: 92.
Facility: Facility B;
List of Excluded Individuals and Entities (LEIE) queried
for applicants prior to hiring: Number in sample: 72;
List of Excluded Individuals and Entities (LEIE) queried
for applicants prior to hiring: Number queried prior to hire: 26;
Background investigation completed or requested for
employed practitioners: Number in sample: 99[B];
Background investigation completed or requested for
employed practitioners: Number with a completed or requested background
investigation: 27;
Declaration for Federal Employment form (form 306) completed for
employed practitioners: Number in sample: 93;
Declaration for Federal Employment form (form 306) completed for
employed practitioners: Number with completed form 306: 80.
Facility: Facility C;
List of Excluded Individuals and Entities (LEIE) queried
for applicants prior to hiring: Number in sample: 64;
List of Excluded Individuals and Entities (LEIE) queried
for applicants prior to hiring: Number queried prior to hire: 5;
Background investigation completed or requested for
employed practitioners: Number in sample: 100;
Background investigation completed or requested for
employed practitioners: Number with a completed or requested background
investigation: 47;
Declaration for Federal Employment form (form 306) completed for
employed practitioners: Number in sample: 83;
Declaration for Federal Employment form (form 306) completed for
employed practitioners: Number with completed form 306: 77.
Facility: Facility D;
List of Excluded Individuals and Entities (LEIE) queried
for applicants prior to hiring: Number in sample: 66;
List of Excluded Individuals and Entities (LEIE) queried
for applicants prior to hiring: Number queried prior to hire: 39;
Background investigation completed or requested for
employed practitioners: Number in sample: 100;
Background investigation completed or requested for
employed practitioners: Number with a completed or requested background
investigation: 98;
Declaration for Federal Employment form (form 306) completed for
employed practitioners: Number in sample: 92;
Declaration for Federal Employment form (form 306) completed for
employed practitioners: Number with completed form 306: 86.
Source: GAO analysis of facility files.
Note: The number of practitioners in the sample may be less than the
number of practitioner files reviewed at each facility because the
requirement may not apply to all VA applicants or employed
practitioners.
[A] One personnel file was not available because the practitioner
resigned and the file was sent to storage.
[B] Facility B was unable to locate one personnel file; therefore, we
sampled 99 files at that location.
[End of table]
Table 6: Average Number of Days from Obtaining Background Investigation
Results to VA Facility Action (August 1, 2002, to August 23, 2003):
Facility: Facility A; Average number of days for facility action: 13;
Number of background investigation results reviewed: 14.
Facility: Facility B; Average number of days for facility action: 282;
Number of background investigation results reviewed: 41.
Facility: Facility C; Average number of days for facility action: 21;
Number of background investigation results reviewed: 15.
Facility: Facility D; Average number of days for facility action: -
14[A]; Number of background investigation results reviewed: 17.
Facility: Facility E; Average number of days for facility action: 26;
Number of background investigation results reviewed: 11.
Facility: Facility F; Average number of days for facility action: 34;
Number of background investigation results reviewed: 43.
Facility: Facility G; Average number of days for facility action: 68;
Number of background investigation results reviewed: 39.
Facility: Facility H; Average number of days for facility action: 126;
Number of background investigation results reviewed: 33.
Facility: Facility I; Average number of days for facility action: 380;
Number of background investigation results reviewed: 1.
Facility: Facility J; Average number of days for facility action: No
data available; Number of background investigation results reviewed: No
data available.
Source: GAO analysis of facility data.
[A] A negative number of days indicates that the facility took action
on its cases before OPM returned the investigation results.
[End of table]
[End of section]
Appendix III: Comments from the Department of Veterans Affairs:
THE SECRETARY OF VETERANS AFFAIRS
WASHINGTON:
March 26, 2004:
Ms. Cynthia A. Bascetta Director:
Heath Care Team:
U. S. General Accounting Office
441 G Street, NW:
Washington, DC 20548:
Dear Ms. Bascetta:
The Department of Veterans Affairs (VA) has reviewed your draft report,
VA HEALTH CARE: Improved Screening of Practitioners Would Reduce Risk
to Veterans (GAO-04-566) and generally agrees with your findings and
conclusions. As the Department was provided a limited time to review
the draft report, VA will provide the General Accounting Office (GAO)
with a detailed action plan to implement the recommendations in its
comments to the final report.
VA is committed to ensuring that the practitioners who are responsible
for delivering quality health care to our Nations veterans and their
beneficiaries are qualified to do so both in professional
qualifications and personal ethical integrity. To this end, VA has
developed a set of policies and procedures to ensure that its
practitioners are of the caliber needed for such a high calling. VA
recognizes the accuracy in the report's description of VA's policies
and requirements for conducting background and credentialing checks.
GAO identifies gaps in VA's process and provides what appear to be
reasonable recommendations to close those gaps.
However, VA offers some suggestions for the overall accuracy of GAO's
message. GAO acknowledges that VA's requirements for verifying
professional credentials of practitioners in Group A, such as
physicians and dentists, are complete and thorough.
Broad statements throughout the report, including the recommendations,
do not differentiate between the fully credentialed licensed
independent practitioners (i.e., all physicians, dentists, most
optometrists and podiatrists and other credentialed professionals such
as psychologists, pharmacists, advanced practice registered nurses and
social workers who practice independently by law and facility approval)
and the remaining licensed practitioners. For all individuals
privileged to provide care without supervision, VA does query the
National Practitioner Data Bank and the Health Integrity and Protection
Data Bank. In addition, VA queries the Federation of State Medical
Boards' Data Center on all
physicians. VA believes that a clearer view of VA's credentialing
process would be presented if GAO acknowledged these data queries.
In addition, the draft report title strongly implies that veterans are
receiving inadequate care on a broad basis. VA suggests the title be
revised to "Improved Screening of Practitioners Would Enhance Safety of
Veterans.":
The enclosure discusses technical corrections VA believes would improve
the overall accuracy and clarity of GAO's report. The Department
appreciates the opportunity to review and comment on your draft report.
Sincerely yours,
Signed by:
Anthony J. Principi:
Enclosure:
[End of section]
Appendix IV: GAO Contact and Staff Acknowledgments:
GAO Contact:
Marcia A. Mann, (202) 512-9526:
Acknowledgments:
In addition to the contact named above, Jacquelyn T. Clinton, Jessica
Cobert, Mary Ann Curran, Martha A. Fisher, Krister Friday, Lesia
Mandzia, and Marie Stetser made key contributions to this report.
FOOTNOTES
[1] Contract staff may include intensive care nurses, emergency room
physicians, or respiratory therapists. These staff have access to and
provide care to patients.
[2] Although VA has many employment screening requirements, such as
whether the applicant is a United States citizen, we selected only
those requirements that pertain to patient safety, such as verification
of credentials and background investigations.
[3] State licenses are issued by offices in states, territories,
commonwealths, or the District of Columbia, collectively referred to as
state licensing boards.
[4] Some practitioners may hold both a national certificate and a state
license.
[5] Professional credentials held by practitioners may include
licenses, registrations, and certifications. We refer to these
credentials as state licenses or national certificates.
[6] The term applicants refers to those practitioners that VA facility
officials plan to hire.
[7] The frequency of when practitioners' credentials are checked
depends on their occupation and the requirements of the state or
national organization that issued the credential.
[8] We use the term employed practitioners to refer to practitioners
who have been hired by VA and to distinguish them from practitioners
who have applied for VA employment, but have not been hired.
[9] The requirement for respiratory therapists to renew their national
certificate every 5 years became effective in July 2002 and affects
those national certificates obtained after June 30, 2002.
[10] FSMB represents state medical licensing boards and establishes
standards for physician licensure and practice. FSMB operates a
national database to collect, record, and distribute to state medical
boards and other appropriate agencies data on disciplinary actions
taken against physicians by the boards and other governmental
authorities.
[11] The Health Resources and Services Administration of the Department
of Health and Human Services is responsible for the management of NPDB.
[12] The Balanced Budget Act significantly expanded the authority of
the Department of Health and Human Services to exclude certain
individuals and entities from participation in federal health care
programs. Exclusion is mandatory for those convicted of Medicare-
related crimes, patient abuse, and certain health care fraud and
controlled substance crimes. Exclusion is permissive for other
offenses, including professional health care license revocation. See
Pub. L. No. 105-33 § 4331(c), 111 Stat. 251, 396; 42 U.S.C. § 1320a-7.
[13] Executive Order 10450, April 27, 1953, requires all persons
employed by federal departments and agencies to undergo a background
investigation to ensure that their employment is consistent with
national security interests. It is administered by the Office of
Personnel Management (OPM), which has issued implementing regulations
in part 732 of Title 5 of the Code of Federal Regulations. OPM may
grant exemptions to the executive order and, with regard to VA,
background investigations are not required for employees appointed for
6 months or less. Related regulations regarding determinations of an
individual's suitability for federal employment, based on their
character, conduct, knowledge, and ability, are contained in part 732
of the Code of Federal Regulations.
[14] HIPDB was developed after the Health Insurance Portability and
Accountability Act of 1996 was enacted, which added new section 1128E
to the Social Security Act, requiring development of the database. See
Pub. L. No. 104-191, § 221(a), 110 Stat. 1936, 2009 (codified at 42
U.S.C. § 1320a-7e(2000)). The applicable regulations are contained in
Part 61 of Title 45 of the Code of Federal Regulations. HIPDB is
maintained and operated by the Health Resources and Services
Administration in the Department of Health and Human Services.
[15] VA's volunteer program is the largest in the federal government,
providing volunteers to assist veterans by augmenting staff in such
settings as hospitals and nursing homes.
[16] Departments and agencies may obtain fingerprints in two ways:
either using paper or using computerized technology, which became
available in 1999. Computerized technology typically produces
fingerprint match results in 2 days.
[17] The licensing boards contacted were Alabama, Arkansas, California,
Delaware, District of Columbia, Florida, Indiana, Louisiana,
Massachusetts, New Jersey, New Mexico, Oregon, Texas, and Washington.
The national certifying organizations contacted were the National Board
for Respiratory Care and the National Board for Certification in
Occupational Therapy.
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