VA Health Care
Steps Taken to Improve Practitioner Screening, but Facility Compliance with Screening Requirements Is Poor Gao ID: GAO-06-544 May 25, 2006In March 2004, GAO reported on gaps in VA's requirements for screening the professional credentials and personal backgrounds of health care practitioners (GAO-04-566). GAO found that VA's requirements did not ensure thorough screening of VA practitioners. VA concurred with four recommendations GAO made to improve practitioner screening. GAO was asked to determine the extent to which (1) VA has taken steps to improve practitioner screening by implementing GAO's recommendations and (2) VA facilities are in compliance with VA's practitioner screening requirements. GAO reviewed VA's current practitioner screening policies to determine if gaps remain, interviewed VA officials, and sampled about 60 practitioner files at each of seven VA facilities selected based on size and geographic location.
VA has taken steps to improve health care practitioner screening by partially implementing each of four recommendations made in GAO's March 2004 report; however, gaps still remain in VA's practitioner screening requirements. In response to two of GAO's recommendations, VA expanded its screening requirements for all VA applicants to include a verification of all state licenses and national certificates and requires facility officials to query the Healthcare Integrity and Protection Data Bank (HIPDB), which contains information on individuals involved in health care-related civil judgments and criminal convictions and licensing and certification actions. VA, however, has not yet expanded these screening requirements to apply to all health care practitioners currently employed at VA facilities, as GAO recommended. In response to the third GAO recommendation, VA issued a policy in August 2005 that requires individuals who previously were exempt from receiving any level of background investigation to have, at a minimum, their fingerprints screened against a criminal history database. As of October 19, 2005, 37 VA medical facilities had not fully implemented this new requirement because they had not obtained or installed the necessary electronic fingerprint equipment. Since then VA has made progress; as of February 1, 2006, 2 medical facilities had not installed the equipment. Finally, VA has partially implemented GAO's fourth recommendation to conduct oversight of its facilities' compliance with VA practitioner screening requirements; however, GAO found the oversight does not address all of the facility compliance issues GAO previously identified. GAO found poor compliance with four of the five selected VA practitioner screening requirements at the seven VA facilities visited in 2005. None of the seven facilities had a compliance rate of 90 percent or more for all five screening requirements GAO reviewed. Two facilities that had implemented VA's fingerprint-only background investigations--a relatively new form of background investigation--did not comply with VA's requirement to document that the results of the fingerprint check against a criminal history database had been reviewed and used to make a decision on the individual's suitability to work at a VA medical facility.
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-06-544, VA Health Care: Steps Taken to Improve Practitioner Screening, but Facility Compliance with Screening Requirements Is Poor
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Report to the Chairman, Committee on Veterans' Affairs, House of
Representatives:
United States Government Accountability Office:
GAO:
May 2006:
VA Health Care:
Steps Taken to Improve Practitioner Screening, but Facility Compliance
with Screening Requirements Is Poor:
VA Screening of Practitioners:
GAO-06-544:
GAO Highlights:
Highlights of GAO-06-544, a report to the Chairman, Committee on
Veterans‘ Affairs, House of Representatives.
Why GAO Did This Study:
In March 2004, GAO reported on gaps in VA‘s requirements for screening
the professional credentials and personal backgrounds of health care
practitioners (GAO-04-566). GAO found that VA‘s requirements did not
ensure thorough screening of VA practitioners. VA concurred with four
recommendations GAO made to improve practitioner screening.
GAO was asked to determine the extent to which (1) VA has taken steps
to improve practitioner screening by implementing GAO‘s recommendations
and (2) VA facilities are in compliance with VA‘s practitioner
screening requirements. GAO reviewed VA‘s current practitioner
screening policies to determine if gaps remain, interviewed VA
officials, and sampled about 60 practitioner files at each of seven VA
facilities selected based on size and geographic location.
What GAO Found:
VA has taken steps to improve health care practitioner screening by
partially implementing each of four recommendations made in GAO‘s March
2004 report;
however, gaps still remain in VA‘s practitioner screening requirements.
In response to two of GAO‘s recommendations, VA expanded its screening
requirements for all VA applicants to include a verification of all
state licenses and national certificates and requires facility
officials to query the Healthcare Integrity and Protection Data Bank
(HIPDB), which contains information on individuals involved in health
care-related civil judgments and criminal convictions and licensing and
certification actions. VA, however, has not yet expanded these
screening requirements to apply to all health care practitioners
currently employed at VA facilities, as GAO recommended. In response to
the third GAO recommendation, VA issued a policy in August 2005 that
requires individuals who previously were exempt from receiving any
level of background investigation to have, at a minimum, their
fingerprints screened against a criminal history database. As of
October 19, 2005, 37 VA medical facilities had not fully implemented
this new requirement because they had not obtained or installed the
necessary electronic fingerprint equipment. Since then VA has made
progress;
as of February 1, 2006, 2 medical facilities had not installed the
equipment. Finally, VA has partially implemented GAO‘s fourth
recommendation to conduct oversight of its facilities‘ compliance with
VA practitioner screening requirements;
however, GAO found the oversight does not address all of the facility
compliance issues GAO previously identified.
GAO found poor compliance with four of the five selected VA
practitioner screening requirements at the seven VA facilities visited
in 2005. None of the seven facilities had a compliance rate of 90
percent or more for all five screening requirements GAO reviewed. Two
facilities that had implemented VA‘s fingerprint-only background
investigations”a relatively new form of background investigation”did
not comply with VA‘s requirement to document that the results of the
fingerprint check against a criminal history database had been reviewed
and used to make a decision on the individual‘s suitability to work at
a VA medical facility.
Figure: Facilities‘ Rates of Compliance with Select VA Screening
Requirements for Health Care Practitioners (2005):
[See PDF for Image]
[End of Figure]
What GAO Recommends:
GAO recommends that VA expand its oversight program to include a review
of VA screening requirements for all types of health care practitioners
and that VA standardize a method for documenting the review of
fingerprint-only investigation results. VA agreed with GAO‘s findings
and concurred with the recommendations. VA further stated that it will
provide an action plan on how it will implement the recommendations at
a later date.
[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-06-544].
To view the full product, including the scope and methodology, click on
the link above. For more information, contact Laurie E. Ekstrand at
(202) 512-7101 or ekstrandl@gao.gov.
[End of Section]
Contents:
Letter:
Results in Brief:
Background:
VA Has Taken Steps to Improve Health Care Practitioner Screening
Requirements, but Gaps Remain:
VA Facilities Did Not Comply with Health Care Practitioner Screening
Requirements:
Conclusions:
Recommendations for Executive Action:
Agency Comments:
Appendix I: Scope and Methodology:
Appendix II: Results of Our Compliance Reviews at Seven VA Facilities:
Appendix III: Comments from the Department of Veterans Affairs:
Appendix IV: GAO Contact and Staff Acknowledgments:
Tables:
Table 1: State Licensure and National Certification Requirements for
the 43 VA Occupations:
Table 2: Health Care Practitioners Included in Our Review of Select VA
Screening Requirements and the Documentation Required to Demonstrate
Compliance:
Table 3: VA Facility Compliance with Screening Requirements for
Salaried Health Care Practitioners--Background Investigations (2005):
Table 4: VA Facility Compliance with Screening Requirements for Fee
Basis and WOC Health Care Practitioners--Background Investigations
(2005):
Table 5: VA Facility Compliance with Screening Requirements for
Salaried Health Care Practitioners--HIPDB Query and State License and
National Certificate Verification (2005):
Table 6: VA Facility Compliance with Screening Requirements for
Salaried Health Care Practitioners--Employment Checklist Completed and
Position Risk Level Determined (2005):
Figures:
Figure 1: Gaps Identified in VA's Process for Verifying Health Care
Practitioner Credentials with State Licensing Boards and National
Certifying Organizations, March 2004:
Figure 2: Facilities' Rates of Compliance with Select VA Screening
Requirements for Salaried Health Care Practitioners (2005):
Figure 3: Background Investigation Compliance Rates for Salaried Health
Care Practitioners at Revisited VA Medical Facilities (2005):
Figure 4: VA Facility Compliance with Background Investigation
Screening Requirements for Fee Basis and WOC Health Care Practitioners
(2005):
Abbreviations:
HHS: Department of Health and Human Services:
HIPDB: Healthcare Integrity and Protection Data Bank:
HRM: Office of Human Resource Management:
OPM: Office of Personnel Management:
SLB: state licensing board :
VA: Department of Veterans Affairs:
WOC: without compensation:
United States Government Accountability Office:
Washington, DC 20548:
May 25, 2006:
The Honorable Steve Buyer:
Chairman:
Committee on Veterans' Affairs:
House of Representatives:
Dear Mr. Chairman:
The Department of Veterans Affairs (VA) is responsible for ensuring
that its health care practitioners are qualified to provide care to
their patients. VA employs more than 193,000 individuals at its medical
facilities, including physicians, nurses, pharmacists, and therapists.
In addition, VA supplements these salaried health care practitioners
with nonsalaried health care practitioners obtained through contracts
and fee-for-service arrangements (fee basis),[Footnote 1] as well as
nonsalaried practitioners working without direct compensation from VA
(without compensation or WOC). To help ensure that VA's salaried and
nonsalaried health care practitioners hold the necessary professional
credentials to provide care,[Footnote 2] VA has screening requirements
that VA medical facility officials must follow in verifying these
credentials and checking practitioners' personal backgrounds for
evidence of incompetence or criminal behavior.
In March 2004, we reported and testified on gaps in VA's screening
requirements.[Footnote 3] We found that VA did not require that all of
its health care practitioners with access to patients be thoroughly
screened. In addition, we found mixed compliance with existing VA
screening requirements at each of the four VA medical facilities we
visited. We concluded that the gaps in and mixed compliance with VA's
screening requirements created vulnerabilities that could allow VA to
employ health care practitioners who could either place patients at
risk of receiving poor care or cause them intentional harm. In our 2004
report, we made four recommendations to address the gaps we identified
in VA's screening requirements and the noncompliance we found at the
four VA medical facilities we visited.
VA concurred with our recommendations to:
² expand verification of all state licenses and national certificates
by contacting the appropriate licensing boards and national certifying
organizations for all VA health care practitioners,
² expand query of the Healthcare Integrity and Protection Data Bank
(HIPDB)[Footnote 4] to include all licensed health care practitioners
at VA facilities,
² conduct fingerprint-only background investigations for all VA health
care practitioners with direct patient care access,[Footnote 5] and:
² conduct oversight of medical facilities to ensure compliance with all
of VA's key screening requirements.
You asked us to determine the status of VA's implementation of these
recommendations to strengthen its health care practitioner screening
requirements. In this report, we determined the extent to which (1) VA
has taken steps to improve health care practitioner screening by
implementing the four recommendations made in our March 2004 report and
(2) VA medical facilities are in compliance with VA's health care
practitioner screening requirements.
To determine the extent to which VA has taken steps to improve health
care practitioner screening by implementing the four recommendations
made in our March 2004 report, we interviewed VA headquarters and
facility officials and reviewed VA's policies and procedures that
contain current health care practitioner screening requirements to see
if the gaps we identified in 2004 were closed. We also reviewed the
report of a task force VA formed to improve its health care
practitioner screening procedures following the issuance of our 2004
report.
To determine the extent to which VA medical facilities complied with VA
health care practitioner screening requirements, we selected seven VA
medical facilities to visit. These facilities varied in terms of size
and geographic location. Two of the seven facilities we visited were
sites from our previous review. We visited facilities located in Fargo,
North Dakota; Kansas City, Missouri; Miami, Florida; New Orleans,
Louisiana; Salt Lake City, Utah; San Antonio, Texas; and the District
of Columbia.[Footnote 6] For each facility, VA provided from its
automated pay system a list of salaried health care practitioners in
the 43 occupations we included in our previous report. At each facility
we reviewed a random sample of personnel files to determine whether the
files included documentation demonstrating that the facility's health
care practitioners had their professional credentials verified and
backgrounds checked in compliance with VA's screening requirements. At
each of the facilities, our sample of personnel files consisted of
about 50 personnel files for salaried health care practitioners who
were hired prior to October 1, 2004, and 10 to 12 personnel files for
salaried health practitioners who were hired on or after October 1,
2004.[Footnote 7] In addition to the random sample of salaried health
care practitioners, we also reviewed at each facility 20 personnel
files for nonsalaried health care practitioners paid by VA on a fee
basis and all of the files for the facility's WOC health care
practitioners who work in a clinical area at the facility.[Footnote 8]
In collecting information on the screening requirements from personnel
files at each facility, we employed standard data collection techniques
to ensure the accuracy and reliability of the data used in this report.
At each facility we also reviewed about five contracts that the
facility used to supplement its health care practitioner staffing in
order to determine how facility officials screen the personal
backgrounds and professional credentials of these nonsalaried health
care practitioners. Finally, at each facility we also interviewed the
officials responsible for coordinating volunteer activities to
determine how volunteers are screened prior to beginning work at the
facility.[Footnote 9]
To measure the seven facilities' compliance with VA's health care
practitioner screening requirements, we selected five requirements for
our review. Although VA has multiple employment screening
requirements,[Footnote 10] we selected five that pertain to
safeguarding veterans receiving health care in VA facilities. The
screening requirements we selected for salaried health care
practitioners are (1) completing VA Form 2280, which medical facility
officials must do in order to determine the appropriate type of
background investigation needed for each health care practitioner job
category; (2) performing a background investigation; (3) querying
HIPDB; (4) completing an employment checklist, which VA officials are
to use to document the completion of VA screening requirements for
those salaried health care practitioners VA intends to hire; and (5)
verifying the status of state licenses and national certificates. In
addition, we measured facility compliance with one of these screening
requirements, performing a background investigation, for VA nonsalaried
fee basis and WOC health care practitioners. To show the variability in
the level of compliance among the seven VA facilities we visited, we
distinguished between facilities that had a compliance rate of at least
90 percent of the personnel files we reviewed for each of the five
screening requirements and facilities that did not. VA requires a
compliance rate of 100 percent. Our findings for the screening
requirements cannot be generalized to other VA facilities.
For a complete description of our scope and methodology, see appendix
I. Our work was conducted from April 2005 through April 2006 in
accordance with generally accepted government auditing standards.
Results in Brief:
Although VA has taken steps to improve health care practitioner
screening by partially implementing each of the four recommendations
made in our March 2004 report, gaps still remain in VA's health care
practitioner screening requirements. For all health care practitioners
applying for VA employment, VA expanded its screening requirements to
require verification of all the state licenses and national
certificates these practitioners hold and require facility officials to
query HIPDB before the practitioners are hired. However, VA has not
expanded these screening requirements so that they apply to all health
care practitioners currently employed at VA medical
facilities.[Footnote 11] We reviewed a draft VA policy that when issued
will fully address our recommendation to require medical facility
officials to verify all state licenses and national certificates of
currently employed health care practitioners with the relevant issuing
boards or organizations. In response to our recommendation to expand
the use of fingerprint-only background investigations for those
previously exempt from receiving any kind of background investigation,
VA issued a policy in August 2005 requiring these individuals to have,
at a minimum, a fingerprint-only background investigation, in which
fingerprints are screened against a criminal history database. However,
as of October 19, 2005, 37 VA medical facilities had not begun to
implement this new requirement because they had not obtained or
installed the necessary electronic fingerprint equipment. Since then,
VA has made progress;
as of February 1, 2006, 2 VA medical facilities had not implemented
VA's new requirement. Finally, VA has partially implemented our
recommendation to conduct oversight of its facilities' compliance with
VA health care practitioner screening requirements. We found that VA's
oversight does not address all of the medical facility compliance
issues we identified in our 2004 report.
At the seven VA facilities we visited, we found poor compliance with
four of the five selected VA health care practitioner screening
requirements. None of the seven facilities had a compliance rate of 90
percent or more for all five screening requirements we reviewed, and VA
policy requires 100 percent compliance with these requirements. For the
screening requirement to perform background investigations, at six of
seven VA facilities we were unable to find documentation--in at least
90 percent of the health care practitioners' personnel files we
reviewed--that a background investigation was either scheduled or
completed for these salaried practitioners. We also found that
facilities' rates of compliance were lower in performing background
investigations on fee basis, contract, and WOC health care
practitioners than in performing background investigations for salaried
health care practitioners. Further, while reviewing three facilities'
implementation of VA's fingerprint-only background investigations--a
relatively new form of background investigation--we found that two of
the facilities did not document that the results of the fingerprint-
only background investigation had been reviewed and a decision made on
the individual's suitability to work at the VA facility.
To better ensure the safety of veterans receiving health care at VA
medical facilities, we recommend that VA expand its human resource
management oversight program to include a review of VA facilities'
compliance with screening requirements for all types of salaried and
nonsalaried health care practitioners. In addition, we recommend that
VA standardize a method for documenting facility officials' review of
fingerprint-only background investigation results and decisions
regarding suitability to work in the VA medical facility. In commenting
on a draft of this report, VA agreed with our findings and conclusions
and concurred with our recommendations. VA also stated that it will
provide an action plan for implementing these recommendations after
issuance of this report.
Background:
VA operates the largest integrated health care system in the United
States, providing care to nearly 5 million veterans per year through
hospitals, ambulatory clinics, nursing homes, residential
rehabilitation treatment programs, and readjustment counseling centers.
VA also utilizes national and local medical professional services
contracts to supplement its health care practitioner staffing. In
addition to providing medical care, VA is the largest educator of
health care professionals, training more than 28,000 medical residents
annually, as well as other types of health care professionals.
Depending on the employment requirements of their positions, health
care practitioners who work at VA facilities are required to hold
either valid--meaning current and unrestricted--state medical licenses
or national certificates. State licenses are issued by state licensing
boards, which generally establish state licensing requirements
governing their licensed health care practitioners.[Footnote 12]
Current and unrestricted licenses are those in good standing in the
states that issued them, and licensed health care practitioners may
hold licenses from more than one state. To keep a license current,
health care practitioners must renew their licenses before they expire
and meet renewal requirements established by state licensing boards,
such as continuing education. Renewal procedures and requirements vary
by state and occupation. When licensing boards discover violations of
licensing practices, such as the abuse of prescription drugs or the
provision of substandard care that results in adverse health effects,
they may place restrictions on licenses or revoke them. Restrictions
from a state licensing board can limit or prohibit a health care
practitioner from practicing in that state.[Footnote 13] Some, but not
all, issued state licenses are marked to indicate that the licenses
have had restrictions placed on them. Generally, state licensing boards
maintain a database of information on restrictions, which employers can
often obtain at no cost either by accessing the information on a
board's Web site or by contacting the board directly.
National certificates are issued by national certifying organizations,
which are separate and independent from state licensing
boards.[Footnote 14] These organizations establish professional
standards that are national in scope for certain occupations, such as
respiratory and occupational therapists. Health care practitioners who
are required to have valid national certificates to practice in VA may
renew these credentials periodically by paying a fee and verifying that
they obtained required educational credit hours. National certifying
organizations can place restrictions on a certification or revoke
certification for violations of the organization's professional
standards. Like state licensing boards, national certifying
organizations maintain databases of information on disciplinary actions
taken against health care practitioners with national certificates, and
many can be accessed at no cost.
VA policy requires officials at its medical facilities to screen
applicants for positions at VA to determine whether each applicant
possesses at least one current and unrestricted state license or an
appropriate national certificate, whichever is applicable for the
position sought by the applicant. VA also requires officials at its
medical facilities to periodically verify licenses or national
certificates held by health care practitioners already employed at VA
(employed health care practitioners). The frequency of when health care
practitioners' credentials must be checked depends on their occupations
and the renewal requirements of the state or national organizations
that issued the credentials.
In general, for both applicants and employed health care practitioners,
VA's screening process proceeds in two stages. First, applicants and
employed health care practitioners are required to disclose to VA, if
applicable, their state licenses and national certificates. Applicants
disclose their credentials to VA during the application process, and
employed health care practitioners disclose credentials to VA as they
expire and are renewed with the state licensing board or certifying
organization. Second, VA facility officials are required to verify
whether the disclosed credentials are valid.
In addition to holding valid professional credentials, upon hiring,
health care practitioners are required to undergo background
investigations that verify their personal and professional
histories.[Footnote 15] Depending on the position in question, the
extent of the background investigations for health care practitioners
may vary. For example, background investigations in VA may vary from a
traditional background investigation covering a health care
practitioner's personal and professional background for up to 10 years
to the minimum of a fingerprint-only background investigation. VA
facility officials are required to complete VA Form 2280, which
documents the level of risk posed by a particular position and
determines the level of background investigation required for
employment.
The traditional background investigation is the most common type of
background investigation conducted by VA on its health care
practitioners. A traditional background investigation verifies, for
instance, an individual's history of employment, education, and
residence. It also includes a fingerprint check that searches for
evidence of criminal activity by comparing fingerprints against a
database of criminal records. The Office of Personnel Management (OPM)
conducts background investigations for VA and reports its results to
the facility that requested the investigation.[Footnote 16] VA
facilities are required to review background investigation results,
determine employment suitability, and report their decisions to OPM
within 90 days.
In 2001 OPM began to offer a new type of background investigation for
use by federal agencies, a fingerprint-only background investigation.
Compared to traditional background investigations, which verify
personal, professional, and criminal histories and typically take
several months to complete, fingerprint-only background investigations
verify criminal histories only and can be completed within 3 weeks or
less and cost less than $25, about a quarter of the cost of a
traditional background investigation.
In March 2004, we reported on VA's screening policies and the gaps we
found in VA's requirement for screening applicants that may result in
VA health care practitioners' personal backgrounds and professional
credentials not being thoroughly screened. For example, for health care
practitioners who were required to have national certificates to work
in VA, facility officials were required to physically inspect each
applicant's national certificate. However, we found a gap wherein
officials were not required to contact the organization issuing the
certificate, even though restrictions may have been placed on the
certificate after it was issued. In contrast, we found that for state
licenses VA's policy required officials at its medical facilities to
screen applicants to determine whether they possessed at least one
current and unrestricted state license. Applicants were required to
disclose to VA any state licenses they held. To verify a state license,
VA officials were required to contact the issuing state licensing board
to determine if the license was current and unrestricted. Officials
were also required to document that they verified the status of the
license.
As part of our 2004 report, we also found gaps in VA's screening
requirements for health care practitioners currently employed at its
medical facilities. For example, not all VA currently employed health
care practitioners with licenses were required to disclose all of their
current licenses. Some currently employed health care practitioners,
such as nurses and pharmacists, were required to disclose only one
license, even if they possess multiple licenses, and facility officials
were not required to contact the issuing state board to determine if
the license is current and unrestricted. Instead, facility officials
were required to physically inspect the one state license, even though
some licenses are not marked to indicate restrictions. See figure 1 for
the health care practitioner screening gaps we identified for both VA's
applicants and currently employed health care practitioners.
Figure 1: Gaps Identified in VA's Process for Verifying Health Care
Practitioner Credentials with State Licensing Boards and National
Certifying Organizations, March 2004:
[See PDF for image]
[A] Physician assistants are not required to have licenses to work in
VA, but their credentials are verified using a process that is similar
to that for other health care practitioners in this category.
[End of figure]
In our March 31, 2004, report, we also found that VA did not query
HIPDB for all health care practitioners. Additionally, VA required some
health care practitioners with direct access to patients to undergo
background investigations that verify their personal and professional
histories, but did not require this of others, such as medical
residents.
In response to a draft of our report, VA's Under Secretary for Health
commissioned a task force on March 30, 2004, to review the screening
requirements for all VA health care occupations, including applicants,
those currently employed, and health care trainees. The task force was
to identify the needed improvements to VA's screening processes and to
make recommendations to VA's National Leadership Board.[Footnote 17]
VA Has Taken Steps to Improve Health Care Practitioner Screening
Requirements, but Gaps Remain:
VA has taken steps to improve health care practitioner screening by
partially implementing each of the four recommendations made in our
March 2004 report; however, gaps still remain in VA's health care
practitioner screening requirements. These gaps are found in the
requirements for verifying professional credentials and querying HIPDB
for currently employed practitioners. In addition, VA has not yet
implemented fingerprint-only background investigations at two medical
facilities. Finally, while VA has formalized an oversight program
within its Office of Human Resource Management (HRM), the program does
not address all of the compliance issues we identified in our earlier
report.
VA Has Partially Implemented Our Recommendation to Expand Verification
of Health Care Practitioners' Professional Credentials:
VA has partially implemented our recommendation that VA facility
officials contact state licensing boards and national certifying
organizations to verify all state licenses and national certificates
held by all VA health care practitioners. To address our
recommendation, VA expanded the verification requirement to include
licenses and certificates of all applicants VA intends to hire. In
addition, VA issued a memorandum on September 2, 2004, directing VA
facility officials to establish a formal procedure for conducting and
then documenting the screening of professional credentials for
applicants. As part of the memorandum, VA provided its medical
facilities with an employment checklist that officials are required to
use to document the completion of VA's screening requirements for
applicants for salaried and nonsalaried positions, including fee basis
and WOC health care practitioners.[Footnote 18] Facility officials are
permitted to modify the format of the employment checklist as long as
the modified checklist includes all the screening requirements
contained in the original checklist.
VA has proposed a policy change that will require the consistent
screening of credentials for both health care practitioners applying to
work at VA medical facilities and those currently employed. This
screening would apply to both salaried and nonsalaried health care
practitioners. Once VA issues its proposed policy for screening
credentials, VA facility officials will be required--in addition to
using the employment checklist--to document the verification of all
health care practitioners' state licenses and national certificates in
the computerized database of practitioners' credentials that VA
facility officials maintain, VetPro. VA currently requires facility
officials to use VetPro to document the verification of some health
care practitioners' credentials, including physicians, dentists, and
nurse practitioners. VA is in the process of expanding the database so
it can store documentation of all of VA's licensed and certified health
care practitioners. Once the proposed policy for screening credentials
is approved and the database is expanded, VA facility officials will
have 2 years to enter all licensed and certified health care
practitioners into this database and will be able to electronically
document the verification of all health care practitioners' licenses
and certificates in one centralized location.
While VA has expanded its requirements for verifying the professional
credentials of applicants, the department has not, as we recommended,
required its medical facilities to verify all state licenses or
national certificates held by all employed health care practitioners by
contacting the appropriate state licensing boards or national
certifying organizations. For example, for certain currently employed
health care practitioners, such as nurses and pharmacists, VA facility
officials are still not required to contact state licensing boards to
verify whether the practitioner holds a valid and unrestricted license.
Instead, facility officials are only required to physically inspect the
original license. As we reported in 2004, one cannot determine with
certainty that a license is valid and unrestricted unless the state
licensing board is contacted directly. In addition, VA has not, as we
recommended, required facility officials to verify all of the licenses
held by these same health care practitioners instead of physically
inspecting one license of the practitioner's choosing.[Footnote 19] As
a result, a currently employed health care practitioner could have a
restricted license in one state but offer VA officials an unrestricted
license from another state. We reviewed a draft of VA's policy that
when issued will fully address our recommendation to require medical
facility officials to verify all state licenses and national
certificates of currently employed health care practitioners with the
relevant issuing boards or organizations. According to a VA official,
this policy is expected to be issued in June 2006.
VA Partially Implemented Our Recommendation to Require Medical
Facilities to Query HIPDB:
VA has partially implemented our recommendation to expand the query of
HIPDB to include all licensed health care practitioners that VA intends
to hire and to periodically query HIPDB for those already employed at
VA. To respond to our recommendation, VA issued a memorandum on July
13, 2004, that requires officials at all of its medical facilities to
query HIPDB for all applicants for VA employment. In addition to VA
applicants, VA's memorandum requires that facility officials query
HIPDB for most volunteers before offering them volunteer
assignments.[Footnote 20] VA's requirement that its medical facilities
query HIPDB for all applicants as well as new volunteers goes beyond
our recommendation to query applicants who hold licenses;
however, VA's requirement does not, as we recommended, require VA
facilities to periodically query HIPDB for health care practitioners
who are currently employed by VA.
VA officials told us that VA is working with the Department of Health
and Human Services (HHS) to develop a process whereby VA can
electronically query HHS data banks, including HIPDB, for VA employees.
Once this process is in place and VA is using it to periodically query
HIPDB for those currently employed at VA, the department will have
fully implemented our recommendation. However, VA did not provide a
time frame for implementing this electronic query of HIPDB.
VA Policy on Fingerprint-Only Background Investigations Addressed Our
Recommendation, but Was Not Fully Implemented:
In August 2005, VA issued a policy that when implemented across VA will
address our recommendation to expand the use of fingerprint-only
background investigations for practitioners previously exempt from
background investigations who have direct access to patients. VA's
policy requires, at a minimum, that all newly hired health care
practitioners' fingerprints be checked against a criminal history
database.[Footnote 21] The requirement applies to nonsalaried health
care practitioners working through a fee basis arrangement, WOC and
contract health care practitioners, and some volunteers. It also
includes trainees, such as medical residents, who previously were
exempt from any type of background investigation. For traditional and
fingerprint-only background investigations, VA's policy requires
facility officials to review the results of the background
investigation and within 5 days of receiving the results determine the
practitioner's suitability to work at a VA medical facility.[Footnote
22] Facility officials are required by VA to document the results of
their background investigation reviews in personnel files. VA's policy
requires the use of electronic fingerprinting, in lieu of paper-based
fingerprinting, at all VA medical facilities.
While VA's policy addresses our recommendation, not all of VA's medical
facilities had implemented the policy as of February 1, 2006. The
August 2005 policy requires that all VA medical facilities purchase and
begin using electronic fingerprint machines by September 1, 2005.
During our review, we found that VA did not know which facilities had
purchased and begun to use the electronic fingerprint equipment in the
course of implementing VA's fingerprinting policy. In response to our
inquiry, VA surveyed its facilities and found that as of October 19,
2005, 37 facilities did not have electronic fingerprint machines
operational by September 1, 2005. Since then VA has made progress;
as of February 1, 2006, 2 VA medical facilities had not implemented
this new requirement.
VA Partially Implemented Our Recommendation to Conduct Oversight of
Facilities' Compliance with Screening Requirements:
VA has partially implemented our recommendation to conduct oversight to
help ensure that facilities comply with select screening requirements
for applicants and employed health care practitioners. To address our
recommendation, in April 2004 VA formalized a program within HRM, which
oversees VA medical facility compliance with human resource functions.
The program is responsible for overseeing VA's facility human resource
functions, which include conducting background investigations and
verifying the professional credentials of applicants and current
employees. Officials from HRM's oversight program conduct site visits
to VA facilities, interview facility officials, and review a random
sample of personnel files to determine whether VA facilities are
performing background investigations in a timely manner and verifying
the professional credentials of health care practitioners.
While this oversight program helps ensure that facilities are
conducting background investigations and verifying professional
credentials for some categories of health care practitioners, it does
not ensure that facilities are complying with all of VA's key screening
requirements, as we recommended in 2004. For example, officials from
the oversight program are not required to review personnel files for
fee basis health care practitioners, even though these practitioners
also have direct access to patients. Further, oversight officials'
guidelines do not include requirements to check personnel files to
ensure that facility officials query HIPDB and verify all health care
practitioners' licenses and certifications with the relevant issuing
organizations.
In May 2005, we observed an oversight review conducted by HRM
officials, during which officials reviewed some of VA's health care
practitioner screening requirements as applied to salaried health care
practitioners and some types of nonsalaried health care practitioners.
Although HRM officials discussed the results of their personnel file
reviews with VA officials at the facility they visited, HRM officials
did not document the number of files they reviewed and found in
compliance.
VA Facilities Did Not Comply with Health Care Practitioner Screening
Requirements:
Across the seven VA facilities we visited, we found poor compliance
with four of the five selected screening requirements we reviewed for
salaried health care practitioners as well as the one screening
requirement we selected for nonsalaried health care practitioners. The
five screening requirements we selected include two implemented by VA
in response to our recommendations--querying HIPDB and completing an
employment checklist to document completion of VA's screening
requirements--and three others that were in place at the time of our
2004 review. The latter require VA facilities to verify health care
practitioners' state licenses and national certificates;
complete VA Form 2280, which is used to determine the appropriate type
of background investigation needed for each health care practitioner
job category; and conduct background investigations. We measured
facilities' compliance with all these requirements as they pertain to
their salaried health care practitioners, and we also measured
facilities' compliance with the background investigation requirement as
it pertains to VA's nonsalaried health care practitioners--that is,
practitioners paid by VA on a fee basis, WOC practitioners, and
practitioners hired through contracts.
At the seven facilities we visited, we found that none of these
facilities complied with all five screening requirements we reviewed
for their salaried health care practitioners. In order to show the
variability in the level of compliance among the seven VA facilities,
we measured their performance against a compliance rate of at least 90
percent for each of the five VA screening requirements,[Footnote 23]
even though VA policy requires 100 percent compliance with these
requirements. None of the seven facilities had a compliance rate of 90
percent or more for all five screening requirements we reviewed. Figure
2 summarizes the rate of compliance among the seven facilities we
visited for salaried health care practitioners. For the screening
requirement to perform background investigations, at six of seven VA
facilities we were unable to find documentation--in at least 90 percent
of the health care practitioners' personnel files we reviewed--that
background investigations were either scheduled or completed for these
salaried practitioners. (For detailed information about our analysis
and documentation requirements to demonstrate compliance, see app. I,
and for information regarding the extent of each facility's compliance
with a particular requirement, see app. II.)
As shown in figure 2, facilities did not uniformly comply with the two
screening requirements VA implemented to address our recommendations.
We found that for health care practitioners hired since October 1,
2004, only two facilities were querying HIPDB as required, and none of
the seven facilities consistently completed the required employment
checklist to document the completion of screening requirements for
applicants VA intends to hire. While two facilities performed HIPDB
queries on applicants, one of these facilities completed the queries
immediately prior to our visit. During our site visits, we also found
that two facilities had created their own employment checklists. While
facilities are permitted to modify the format of the checklist as long
as the modification includes all of the screening requirements
contained in the original checklist issued in September 2004, we found
that the checklists used by these two facilities did not include all of
the screening requirements.
Figure 2: Facilities' Rates of Compliance with Select VA Screening
Requirements for Salaried Health Care Practitioners (2005):
[See PDF for image]
Notes: It is important to note that our review of the different
practitioner screening requirements includes different subsets of
salaried health care practitioners. That is, all health care
practitioners are required to have a background investigation
regardless of when they were hired, while only those health care
practitioners hired after October 1, 2004, are also required to have a
completed employment checklist in their personnel files. Facilities
were found to be in compliance if they were able to provide
documentation not available in the personnel file. Site visits to these
seven VA facilities were conducted from April 2005 through August 2005.
[A] Tested for significance at the 95 percent confidence level.
[B] Applies to all health care practitioners hired on or after October
1, 2004, and certain health care practitioners hired prior to this
date, such as physicians and dentists. Findings for this screening
requirement cannot be generalized to the facility being reviewed
because of the sample size.
[C] Applies to all health care practitioners hired on or after October
1, 2004. Findings for this screening requirement cannot be generalized
to the facility being reviewed because of the sample size.
[End of figure]
Two of the seven facilities we visited were also included in our March
2004 report. Since our last site visit, these two facilities improved
their performance in conducting background investigations for salaried
health care practitioners to compliance rates of 75 and 72 percent, as
shown in figure 3. However, both facilities were still well below our
compliance rate of 90 percent.
Figure 3: Background Investigation Compliance Rates for Salaried Health
Care Practitioners at Revisited VA Medical Facilities (2005):
[See PDF for image]
Note: Site visits to these two VA facilities were conducted from April
2005 through August 2005.
[End of figure]
As part of our review, we also measured facilities' compliance with
VA's background investigation requirement for health care practitioners
other than those salaried by VA. We found that all seven of the
facilities we visited did not meet VA's background investigation
requirements for fee basis and WOC health care practitioners. For
example, although one facility conducted background investigations on
WOC health care practitioners at a rate of 90 percent or better, no
facility met the requirement for both groups of health care
practitioners. Furthermore, at four of the seven facilities we visited,
facility human resource management staff could not produce a
comprehensive list of all WOC health care practitioners working at the
facility because human resource management staff were not screening all
WOC health care practitioners prior to their beginning work at the VA
facility. Figure 4 summarizes the seven facilities' rate of compliance
with VA's background investigation requirement as applied to fee basis
and WOC health care practitioners. (For detailed information about each
facility's compliance with this requirement, see app. II.)
Figure 4: VA Facility Compliance with Background Investigation
Screening Requirements for Fee Basis and WOC Health Care Practitioners
(2005):
[See PDF for image]
Notes: Three facilities did not perform background investigations on
fee basis health care practitioners, and four facilities did not
perform background investigations on WOC health care practitioners.
Contract health care practitioners were excluded from this figure
because facilities did not maintain personnel files. Site visits to
these seven VA facilities were conducted from April 2005 through August
2005.
[End of figure]
Like their efforts conducting background investigations for fee basis
and WOC health care practitioners, the efforts of most VA facilities we
visited did not meet this requirement for health care practitioners
obtained through contracts. Specifically, we found that one of seven
medical facilities was conducting and documenting background
investigations for contract health care practitioners, as VA requires.
The other six facilities were not in compliance with this requirement.
In March 2005, a VA headquarters official announced that facility
officials should implement fingerprint-only background investigations
for volunteers, as soon as the facilities' electronic fingerprint
equipment was operational or no later than September 1, 2005. Of the
seven facilities we visited prior to September 1, 2005, we found that
four facilities had the equipment needed to begin performing
fingerprint-only background investigations. Three of the four
facilities were fingerprinting volunteers, and the fourth facility had
not begun to fingerprint volunteers, even though the equipment was
operational. However, for the three facilities fingerprinting
volunteers, we found documentation at only one facility to indicate
that officials were reviewing the fingerprint results from OPM and
determining whether volunteers were suitable to work in the VA medical
facility, as required by VA policy. We also found that VA does not have
a standardized method for facility officials to document their review
of fingerprint-only background investigation results, as it has for
other types of background investigations. For example, traditional
background investigation results are reported in a format that includes
designated space for facility officials to document that the results of
the investigation have been reviewed and a decision made regarding
suitability to work in the medical facility. At two facilities we found
background investigation results for volunteers that showed criminal
histories, such as aggravated assault and drug-related convictions.
However, while officials at the two facilities assured us that the
results of fingerprint-only investigations were being reviewed, we did
not find documentation of this review.
Conclusions:
Although VA concurred with all of our March 2004 recommendations to
close the gaps in its health care practitioner screening processes,
none of the four were fully implemented as of March 2006. VA's
screening requirements are intended to ensure the safety of veterans
receiving care in VA facilities by identifying health care
practitioners with restricted or fraudulent credentials, criminal
backgrounds, or questionable work histories. As we found in our
previous report, VA continues to apply different screening requirements
to its licensed and certified health care practitioners. For example,
we found that VA requires medical facilities to verify with the
appropriate state licensing boards or national certifying organizations
all state licenses or national certificates held by some health care
practitioners, such as physicians and applicants for VA employment, but
not for other health care practitioners, such as nurses currently
employed by VA. In the interim, while VA is developing a policy that
would apply screening requirements consistently across all licensed and
certified health care practitioners and satisfy one of our
recommendations, it has established two requirements that apply to new
health care practitioners entering VA's health care system. As a result
of the continuing gaps in VA's health care practitioner screening
process, practitioners may continue to have access to patients without
thorough screening of their professional credentials and personal
backgrounds.
Furthermore, although VA agreed with our 2004 recommendation to oversee
its facilities to ensure their compliance with key screening
requirements, VA's limited oversight has not ensured facility
compliance. As a result, VA may not know whether its facilities are in
compliance with its screening requirements. This raises concerns
because we found that none of the VA medical facilities we visited were
in compliance with all of the new or existing VA screening requirements
we reviewed for salaried or nonsalaried health care practitioners. We
found that the extent to which facilities complied with four of the
five selected VA screening requirements was poor at the VA facilities
we visited. For example, while there was improvement at the two
facilities we revisited, these facilities did not meet our 90 percent
compliance rate for conducting background investigations on salaried
health care practitioners. Moreover, we found that all seven medical
facilities did poorly in conducting background investigations on fee
basis and WOC health care practitioners as required by VA even though
these practitioners have the same access to patients and their
information as other VA health care practitioners. Further, two of the
three facilities that were conducting VA's new fingerprint-only
background investigation did not have documentation that the results
were being reviewed by officials as required. This lack of compliance
with current screening requirements continues to place veterans at
risk.
Recommendations for Executive Action:
To better ensure the safety of veterans receiving health care at VA
medical facilities, we recommend that the Secretary of Veterans Affairs
take the following two actions:
² expand the HRM oversight program to include a review of VA
facilities' compliance with screening requirements for all types of
salaried and nonsalaried health care practitioners and:
² standardize a method for documenting facility officials' review of
fingerprint-only background investigation results and decisions
regarding suitability to work in VA medical facilities.
Agency Comments:
In commenting on a draft of this report, VA agreed with our findings
and conclusions and concurred with our recommendations. VA agreed that
expanded program oversight and standardizing a method for documenting
fingerprint-only background investigation results would be useful. VA
stated that while it believes that most facilities continue to improve
their practitioner screening effectiveness, VA also recognizes that
there is variability and lack of standardization across its health care
system. VA stated that it would provide an action plan for implementing
our recommendations after issuance of this report.
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
[Hyperlink, http://www.gao.gov].
If you or your staff members have any questions, please contact me at
(202) 512-7101 or ekstrandl@gao.gov. Contact points for our Offices of
Congressional Relations and Public Affairs may be found on the last
page of this report. GAO staff members who made major contributions to
this report are listed in appendix IV.
Sincerely yours,
Signed by:
Laurie E. Ekstrand:
Director, Health Care:
[End of section]
Appendix I: Scope and Methodology:
We examined the Department of Veterans Affairs (VA) policies and
practices to determine if VA had implemented the recommendations we
made in March 2004 to strengthen its screening of applicants' and
employed health care practitioners' professional credentials and
personal backgrounds. Specifically, we determined the extent to which
(1) VA has taken steps to improve health care practitioner screening by
implementing the four recommendations made in our March 2004 report and
(2) VA medical facilities are in compliance with VA's health care
practitioner screening requirements.
To determine the extent to which VA has taken steps to improve health
care practitioner screening by implementing the four recommendations
made in our March 2004 report, we reviewed VA employment screening
policies and interviewed VA headquarters and facility officials. Based
on our review of VA documents and interviews with officials, we
determined what steps VA has taken to ensure that gaps we identified in
its verification of state licenses and national certificates and
background investigation requirements have been closed. We also
reviewed the report of a task force VA formed to respond to our
recommendations to improve VA's screening of professional credentials
and personal backgrounds. We interviewed officials at VA's Office of
Security and Law Enforcement in Little Rock, Arkansas, and VA's
National Acquisition Center in Hines, Illinois, to review how VA
screens the professional credentials and personal backgrounds of health
care practitioners working in VA medical facilities through a contract.
To determine how VA conducts oversight of its facilities' compliance
with screening of applicants and current employees, we interviewed
officials responsible for implementing VA's Office of Human Resource
Management (HRM) evaluation and accountability program. We also
observed an oversight review site visit conducted by VA's HRM at the VA
medical facility in Providence, Rhode Island, and attended a VA
training class that provided facility human resource managers with the
knowledge necessary to review the results of background investigations.
To determine the extent to which selected VA medical facilities we
visited are in compliance with VA's health care practitioner screening
requirements, we chose a judgmental sample of seven VA medical
facilities that varied in geographic location to assess the extent to
which these selected facilities complied with the screening
requirements included in our review. The seven facilities were located
in Fargo, North Dakota; Kansas City, Missouri; Miami, Florida; New
Orleans, Louisiana; Salt Lake City, Utah; San Antonio, Texas; and the
District of Columbia. Two of the seven facilities we visited were sites
from our previous review. Of the seven facilities we visited, six were
large facilities located in major metropolitan areas and the remaining
facility is of a smaller size.
For each facility, VA provided from its automated pay system a list of
salaried health care practitioners in the 43 occupations we included in
our previous review. See table 1 for a list of the 43 occupations
included in our review. Because we used VA's automated pay system, our
sample does not include those health care practitioners providing care
through a contract or fee-for-service agreement or without compensation
(WOC) from VA.
Table 1: 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: [Empty];
Occupations that require a national certificate to work in VA: [Empty];
Occupations that do not require a state license or a national
certificate to work in VA: X.
Occupation code: 102;
Occupation title: Social science aide and technician;
Occupations that require a state license to work in VA: [Empty];
Occupations that require a national certificate to work in VA: [Empty];
Occupations that do not require a state license or a national
certificate to work in VA: X.
Occupation code: 180;
Occupation title: Psychology;
Occupations that require a state license to work in VA: X;
Occupations that require a national certificate to work in VA: [Empty];
Occupations that do not require a state license or a national
certificate to work in VA: [Empty].
Occupation code: 181;
Occupation title: Psychology aide and technician;
Occupations that require a state license to work in VA: [Empty];
Occupations that require a national certificate to work in VA: [Empty];
Occupations that do not require a state license or a national
certificate to work in VA: X.
Occupation code: 185;
Occupation title: Social work;
Occupations that require a state license to work in VA: X;
Occupations that require a national certificate to work in VA: [Empty];
Occupations that do not require a state license or a national
certificate to work in VA: [Empty].
Occupation code: 186;
Occupation title: Social services aide and assistant;
Occupations that require a state license to work in VA: [Empty];
Occupations that require a national certificate to work in VA: [Empty];
Occupations that do not require a state license or a national
certificate to work in VA: X.
Occupation code: 187;
Occupation title: Social services;
Occupations that require a state license to work in VA: [Empty];
Occupations that require a national certificate to work in VA: [Empty];
Occupations that do not require a state license or a national
certificate to work in VA: X.
Occupation code: 189;
Occupation title: Recreation aide and assistant;
Occupations that require a state license to work in VA: [Empty];
Occupations that require a national certificate to work in VA: [Empty];
Occupations that do not require a state license or a national
certificate to work in VA: X.
Occupation code: 413;
Occupation title: Physiology;
Occupations that require a state license to work in VA: [Empty];
Occupations that require a national certificate to work in VA: [Empty];
Occupations that do not require a state license or a national
certificate to work in VA: X.
Occupation code: 601;
Occupation title: General health science;
Occupations that require a state license to work in VA: [Empty];
Occupations that require a national certificate to work in VA: [Empty];
Occupations that do not require a state license or a national
certificate to work in VA: X.
Occupation code: 602;
Occupation title: Medical officer (physician);
Occupations that require a state license to work in VA: X;
Occupations that require a national certificate to work in VA: [Empty];
Occupations that do not require a state license or a national
certificate to work in VA: [Empty].
Occupation code: 603;
Occupation title: Physician's assistant;
Occupations that require a state license to work in VA: [Empty];
Occupations that require a national certificate to work in VA: X;
Occupations that do not require a state license or a national
certificate to work in VA: [Empty].
Occupation code: 605;
Occupation title: Nurse anesthetist;
Occupations that require a state license to work in VA: X;
Occupations that require a national certificate to work in VA: X;
Occupations that do not require a state license or a national
certificate to work in VA: [Empty].
Occupation code: 610;
Occupation title: Registered nurse[A];
Occupations that require a state license to work in VA: X;
Occupations that require a national certificate to work in VA: [Empty];
Occupations that do not require a state license or a national
certificate to work in VA: [Empty].
Occupation code: 620;
Occupation title: Practical nurse;
Occupations that require a state license to work in VA: X;
Occupations that require a national certificate to work in VA: [Empty];
Occupations that do not require a state license or a national
certificate to work in VA: [Empty].
Occupation code: 621;
Occupation title: Nursing assistant;
Occupations that require a state license to work in VA: [Empty];
Occupations that require a national certificate to work in VA: [Empty];
Occupations that do not require a state license or a national
certificate to work in VA: X.
Occupation code: 622;
Occupation title: Medical supply aide/technician;
Occupations that require a state license to work in VA: [Empty];
Occupations that require a national certificate to work in VA: [Empty];
Occupations that do not require a state license or a national
certificate to work in VA: X.
Occupation code: 630;
Occupation title: Dietitian and nutritionist;
Occupations that require a state license to work in VA: [Empty];
Occupations that require a national certificate to work in VA: X;
Occupations that do not require a state license or a national
certificate to work in VA: [Empty].
Occupation code: 631;
Occupation title: Occupational therapist;
Occupations that require a state license to work in VA: [Empty];
Occupations that require a national certificate to work in VA: X;
Occupations that do not require a state license or a national
certificate to work in VA: [Empty].
Occupation code: 633;
Occupation title: Physical therapist;
Occupations that require a state license to work in VA: X;
Occupations that require a national certificate to work in VA: [Empty];
Occupations that do not require a state license or a national
certificate to work in VA: [Empty].
Occupation code: 635;
Occupation title: Corrective therapist;
Occupations that require a state license to work in VA: [Empty];
Occupations that require a national certificate to work in VA: [Empty];
Occupations that do not require a state license or a national
certificate to work in VA: X.
Occupation code: 636;
Occupation title: Rehabilitation therapy assistant;
Occupations that require a state license to work in VA: [Empty];
Occupations that require a national certificate to work in VA: [Empty];
Occupations that do not require a state license or a national
certificate to work in VA: X.
Occupation code: 638;
Occupation title: Recreation/creative arts therapist;
Occupations that require a state license to work in VA: [Empty];
Occupations that require a national certificate to work in VA: [Empty];
Occupations that do not require a state license or a national
certificate to work in VA: X.
Occupation code: 640;
Occupation title: Health aide and technician;
Occupations that require a state license to work in VA: [Empty];
Occupations that require a national certificate to work in VA: [Empty];
Occupations that do not require a state license or a national
certificate to work in VA: X.
Occupation code: 644;
Occupation title: Medical technologist;
Occupations that require a state license to work in VA: [Empty];
Occupations that require a national certificate to work in VA: [Empty];
Occupations that do not require a state license or a national
certificate to work in VA: X.
Occupation code: 645;
Occupation title: Medical technician;
Occupations that require a state license to work in VA: [Empty];
Occupations that require a national certificate to work in VA: [Empty];
Occupations that do not require a state license or a national
certificate to work in VA: X.
Occupation code: 646;
Occupation title: Pathology technician;
Occupations that require a state license to work in VA: [Empty];
Occupations that require a national certificate to work in VA: [Empty];
Occupations that do not require a state license or a national
certificate to work in VA: X.
Occupation code: 647;
Occupation title: Diagnostic radiologic technologist;
Occupations that require a state license to work in VA: [Empty];
Occupations that require a national certificate to work in VA: X;
Occupations that do not require a state license or a national
certificate to work in VA: [Empty].
Occupation code: 648;
Occupation title: Therapeutic radiologic technologist;
Occupations that require a state license to work in VA: [Empty];
Occupations that require a national certificate to work in VA: X;
Occupations that do not require a state license or a national
certificate to work in VA: [Empty].
Occupation code: 649;
Occupation title: Medical instrument technician;
Occupations that require a state license to work in VA: [Empty];
Occupations that require a national certificate to work in VA: [Empty];
Occupations that do not require a state license or a national
certificate to work in VA: X.
Occupation code: 651;
Occupation title: Respiratory therapist;
Occupations that require a state license to work in VA: [Empty];
Occupations that require a national certificate to work in VA: X;
Occupations that do not require a state license or a national
certificate to work in VA: [Empty].
Occupation code: 660;
Occupation title: Pharmacist;
Occupations that require a state license to work in VA: X;
Occupations that require a national certificate to work in VA: [Empty];
Occupations that do not require a state license or a national
certificate to work in VA: [Empty].
Occupation code: 661;
Occupation title: Pharmacy technician;
Occupations that require a state license to work in VA: [Empty];
Occupations that require a national certificate to work in VA: [Empty];
Occupations that do not require a state license or a national
certificate to work in VA: X.
Occupation code: 662;
Occupation title: Optometrist;
Occupations that require a state license to work in VA: X;
Occupations that require a national certificate to work in VA: [Empty];
Occupations that do not require a state license or a national
certificate to work in VA: [Empty].
Occupation code: 665;
Occupation title: Speech pathology and audiology;
Occupations that require a state license to work in VA: [Empty];
Occupations that require a national certificate to work in VA: [Empty];
Occupations that do not require a state license or a national
certificate to work in VA: X.
Occupation code: 667;
Occupation title: Orthotist and prosthetist;
Occupations that require a state license to work in VA: [Empty];
Occupations that require a national certificate to work in VA: [Empty];
Occupations that do not require a state license or a national
certificate to work in VA: X.
Occupation code: 668;
Occupation title: Podiatrist;
Occupations that require a state license to work in VA: X;
Occupations that require a national certificate to work in VA: [Empty];
Occupations that do not require a state license or a national
certificate to work in VA: [Empty].
Occupation code: 672;
Occupation title: Prosthetic representative;
Occupations that require a state license to work in VA: [Empty];
Occupations that require a national certificate to work in VA: [Empty];
Occupations that do not require a state license or a national
certificate to work in VA: X.
Occupation code: 680;
Occupation title: Dental officer (dentist);
Occupations that require a state license to work in VA: X;
Occupations that require a national certificate to work in VA: [Empty];
Occupations that do not require a state license or a national
certificate to work in VA: [Empty].
Occupation code: 681;
Occupation title: Dental assistant;
Occupations that require a state license to work in VA: [Empty];
Occupations that require a national certificate to work in VA: X;
Occupations that do not require a state license or a national
certificate to work in VA: [Empty].
Occupation code: 682;
Occupation title: Dental hygiene;
Occupations that require a state license to work in VA: X;
Occupations that require a national certificate to work in VA: [Empty];
Occupations that do not require a state license or a national
certificate to work in VA: [Empty].
Occupation code: 1320;
Occupation title: Chemistry;
Occupations that require a state license to work in VA: [Empty];
Occupations that require a national certificate to work in VA: [Empty];
Occupations that do not require a state license or a national
certificate to work in VA: X.
Occupation code: 1715;
Occupation title: Vocational rehabilitation;
Occupations that require a state license to work in VA: [Empty];
Occupations that require a national certificate to work in VA: [Empty];
Occupations that do not require a state license or a national
certificate to work in VA: X.
Source: VA Handbook 5005, April 15, 2002.
[A] "Registered nurse" includes nurse practitioners and clinical nurse
specialists.
[End of table]
For each of the seven facilities we selected a random sample of about
50 salaried health care practitioners who were hired prior to October
1, 2004, from VA's list of salaried employees. In addition, we selected
10 to 12 files of salaried health care practitioners who were hired on
or after October, 1, 2004, to determine if new VA requirements for
health care practitioner screening had been implemented by the
facility. In addition to the random sample of salaried employees we
reviewed at each facility, we also requested 20 personnel files for
health care practitioners paid by VA through a fee-for-service
arrangement (fee basis) and all health care practitioners who work in a
clinical area at the VA facility but receive compensation from a source
other than VA (WOC).
We reviewed each selected health care practitioner's personnel file to
determine whether the facility had documented evidence that it complied
with the following VA screening requirements:
² determine the position risk level by completing VA Form 2280;
² ensure completion of background investigations;
² query the Healthcare Integrity and Protection Data Bank (HIPDB) for
all applicants after October 1, 2004;
² complete an employment checklist for those hired after October 1,
2004;
and:
² verify state licenses and national certificates for applicants and
employed health care practitioners.
For each screening requirement, we reviewed practitioners' personnel
files to determine whether the files contained documented evidence that
the screening requirement had been completed. See table 2 for the
documents required to demonstrate evidence of facility compliance.
Compliance could also be demonstrated if facilities were able to
provide additional documentation not available in the personnel files
we reviewed. Using a standard data collection instrument, we collected
information on each facility's compliance with the five screening
requirements from a sample of personnel files. To ensure the
reliability of the data collected, the information collected at each
facility was double-checked for a sample of files. The data from all
data collection instruments were entered into an electronic database,
and 100 percent of the electronic files were verified against the
completed data collection instrument.
Table 2: Health Care Practitioners Included in Our Review of Select VA
Screening Requirements and the Documentation Required to Demonstrate
Compliance:
Screening requirements: Conducting background investigations;
Health care practitioners included in our review: * VA salaried; * Fee
basis; * WOC;
Documentation required to demonstrate compliance: * Notice of scheduled
or completed background investigation from the Office of Personnel
Management (OPM).
Screening requirements: Completing VA Form 2280 for each job category;
Health care practitioners included in our review: * VA salaried;
Documentation required to demonstrate compliance: * Completed VA Form
2280.
Screening requirements: Querying HIPDB;
Health care practitioners included in our review: * VA salaried health
care practitioners hired on or after October 1, 2004;
* Certain health care practitioners hired prior to this date, such as
physicians and dentists;
Documentation required to demonstrate compliance: * HIPDB query
printout;
* National Practitioner Data Bank query printout, which includes a
query of HIPDB.
Screening requirements: Completing employment checklist;
Health care practitioners included in our review: * VA salaried health
care practitioners hired on or after October 1, 2004;
Documentation required to demonstrate compliance: * Completed
employment checklist which met VA requirements.
Screening requirements: Verifying license, certification, or both;
Health care practitioners included in our review: * VA salaried health
care practitioners required to have a state license or national
certificate to work in VA;
Documentation required to demonstrate compliance: * Printouts, letters,
and telephone contact reports from state licensing boards and national
certification organizations;
* VA Form 4862, indicating that the original license or certificate had
been visually inspected by a VA facility official.
Source: GAO.
[End of table]
In addition to the personnel files, we reviewed about five contracts at
each of the seven medical facilities that the facilities use to
supplement health care practitioner staffing to determine how these
nonsalaried health care practitioners' professional credentials and
personal backgrounds are screened. We also interviewed VA officials
about the process the facilities use to screen trainees, including
medical residents, and volunteers who work in patient care areas.
In order to show the variability in the level of compliance among the
seven VA facilities we visited, we distinguished between facilities
that had a compliance rate of at least 90 percent for each of the five
screening requirements that we reviewed and those that did not. For
each facility and screening requirement included in our review, we
compared the percentage of personnel files found in compliance to an
acceptance level of 90 percent. In order to confirm that a requirement
had a compliance rate less than 90 percent, we performed a one-sided
significance test at the 95 percent confidence level. See appendix II
for detailed information on the seven VA facilities' compliance with
each VA screening requirement in our review. Our findings from these
seven facilities cannot be generalized to other VA facilities.
Our work was conducted from April 2005 through April 2006 in accordance
with generally accepted government auditing standards.
[End of section]
Appendix II: Results of Our Compliance Reviews at Seven VA Facilities:
Tables 3 and 4 show the sample counts used to measure compliance and
the results of our review for the background investigation screening
requirement. Tables 5 and 6 show the sample counts used to measure
compliance with the remaining health care practitioner screening
requirements that we included in our review.
Table 3: VA Facility Compliance with Screening Requirements for
Salaried Health Care Practitioners--Background Investigations (2005):
Facility: Facility A;
Number in sample: 61;
Number with completed or requested background investigations: 52.
Facility: Facility B;
Number in sample: 59;
Number with completed or requested background investigations: 50.
Facility: Facility C;
Number in sample: 62;
Number with completed or requested background investigations: 54.
Facility: Facility D;
Number in sample: 60;
Number with completed or requested background investigations: 45.
Facility: Facility E;
Number in sample: 60;
Number with completed or requested background investigations: 57.
Facility: Facility F;
Number in sample: 63;
Number with completed or requested background investigations: 55.
Facility: Facility G;
Number in sample: 60;
Number with completed or requested background investigations: 43.
Source: GAO analysis of VA facility files.
Note: Site visits to these seven VA facilities were conducted from
April 2005 through August 2005.
[End of table]
Table 4: VA Facility Compliance with Screening Requirements for Fee
Basis and WOC Health Care Practitioners--Background Investigations
(2005):
Facility: Facility A;
Fee basis health care practitioners: Number in sample: 20;
Fee basis health care practitioners: Number with completed or requested
background investigations: 7;
WOC health care practitioners: Number in sample: [A];
WOC health care practitioners: Number with completed or requested
background investigations: [A].
Facility: Facility B;
Fee basis health care practitioners: Number in sample: 21;
Fee basis health care practitioners: Number with completed or requested
background investigations: 0;
WOC health care practitioners: Number in sample: 26;
WOC health care practitioners: Number with completed or requested
background investigations: 0.
Facility: Facility C;
Fee basis health care practitioners: Number in sample: 20;
Fee basis health care practitioners: Number with completed or requested
background investigations: 17;
WOC health care practitioners: Number in sample: 52;
WOC health care practitioners: Number with completed or requested
background investigations: 21.
Facility: Facility D;
Fee basis health care practitioners: Number in sample: 20;
Fee basis health care practitioners: Number with completed or requested
background investigations: 7;
WOC health care practitioners: Number in sample: [A];
WOC health care practitioners: Number with completed or requested
background investigations: [A].
Facility: Facility E;
Fee basis health care practitioners: Number in sample: 20;
Fee basis health care practitioners: Number with completed or requested
background investigations: 16;
WOC health care practitioners: Number in sample: 40;
WOC health care practitioners: Number with completed or requested
background investigations: 26.
Facility: Facility F;
Fee basis health care practitioners: Number in sample: [A];
Fee basis health care practitioners: Number with completed or requested
background investigations: [A];
WOC health care practitioners: Number in sample: 21;
WOC health care practitioners: Number with completed or requested
background investigations: 20.
Facility: Facility G;
Fee basis health care practitioners: Number in sample: 20;
Fee basis health care practitioners: Number with completed or requested
background investigations: 0;
WOC health care practitioners: Number in sample: 54;
WOC health care practitioners: Number with completed or requested
background investigations: 0.
Source: GAO analysis of VA facility files.
Note: Site visits to these seven VA facilities were conducted from
April 2005 through August 2005.
[A] Facility officials stated that they do not conduct background
investigations as required for these categories of nonsalaried health
care practitioners.
[End of table]
Table 5: VA Facility Compliance with Screening Requirements for
Salaried Health Care Practitioners--HIPDB Query and State License and
National Certificate Verification (2005):
Facility: Facility A;
HIPDB query: Number in sample: 17;
HIPDB query: Number queried prior to hire: 13;
State license and national certificate verification: Number in sample:
46;
State license and national certificate verification: Number where
verification followed VA policy: 44.
Facility: Facility B;
HIPDB query: Number in sample: 21;
HIPDB query: Number queried prior to hire: 14;
State license and national certificate verification: Number in sample:
45;
State license and national certificate verification: Number where
verification followed VA policy: 44.
Facility: Facility C;
HIPDB query: Number in sample: 18;
HIPDB query: Number queried prior to hire: 0;
State license and national certificate verification: Number in sample:
44;
State license and national certificate verification: Number where
verification followed VA policy: 41.
Facility: Facility D;
HIPDB query: Number in sample: 19;
HIPDB query: Number queried prior to hire: 19;
State license and national certificate verification: Number in sample:
45;
State license and national certificate verification: Number where
verification followed VA policy: 42.
Facility: Facility E;
HIPDB query: Number in sample: 22;
HIPDB query: Number queried prior to hire: 20;
State license and national certificate verification: Number in sample:
48;
State license and national certificate verification: Number where
verification followed VA policy: 37.
Facility: Facility F;
HIPDB query: Number in sample: 24;
HIPDB query: Number queried prior to hire: 13;
State license and national certificate verification: Number in sample:
45;
State license and national certificate verification: Number where
verification followed VA policy: 44.
Facility: Facility G;
HIPDB query: Number in sample: 17;
HIPDB query: Number queried prior to hire: 10;
State license and national certificate verification: Number in sample:
38;
State license and national certificate verification: Number where
verification followed VA policy: 24.
Source: GAO analysis of VA facility files.
Notes: The number of health care 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
health care practitioners. Site visits to these seven VA facilities
were conducted from April 2005 through August 2005.
[End of table]
Table 6: VA Facility Compliance with Screening Requirements for
Salaried Health Care Practitioners--Employment Checklist Completed and
Position Risk Level Determined (2005):
Facility: Facility A;
Employment checklist completed: Number in sample: 10;
Employment checklist completed: Number with completed employment
checklists: 8;
Position risk level determined (VA Form 2280): Number in sample: 61;
Position risk level determined (VA Form 2280): Number with position
risk level determined and documented on VA Form 2280: 34.
Facility: Facility B;
Employment checklist completed: Number in sample: 10;
Employment checklist completed: Number with completed employment
checklists: 0;
Position risk level determined (VA Form 2280): Number in sample: 59;
Position risk level determined (VA Form 2280): Number with position
risk level determined and documented on VA Form 2280: 0.
Facility: Facility C;
Employment checklist completed: Number in sample: 10;
Employment checklist completed: Number with completed employment
checklists: 5;
Position risk level determined (VA Form 2280): Number in sample: 62;
Position risk level determined (VA Form 2280): Number with position
risk level determined and documented on VA Form 2280: 0.
Facility: Facility D;
Employment checklist completed: Number in sample: 10;
Employment checklist completed: Number with completed employment
checklists: 0;
Position risk level determined (VA Form 2280): Number in sample: 60;
Position risk level determined (VA Form 2280): Number with position
risk level determined and documented on VA Form 2280: 58.
Facility: Facility E;
Employment checklist completed: Number in sample: 10;
Employment checklist completed: Number with completed employment
checklists: 4;
Position risk level determined (VA Form 2280): Number in sample: 60;
Position risk level determined (VA Form 2280): Number with position
risk level determined and documented on VA Form 2280: 59.
Facility: Facility F;
Employment checklist completed: Number in sample: 12;
Employment checklist completed: Number with completed employment
checklists: 1;
Position risk level determined (VA Form 2280): Number in sample: 63;
Position risk level determined (VA Form 2280): Number with position
risk level determined and documented on VA Form 2280: 8.
Facility: Facility G;
Employment checklist completed: Number in sample: 10;
Employment checklist completed: Number with completed employment
checklists: 0;
Position risk level determined (VA Form 2280): Number in sample: 60;
Position risk level determined (VA Form 2280): Number with position
risk level determined and documented on VA Form 2280: 0.
Source: GAO analysis of VA facility files.
Notes: The number of health care 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
health care practitioners. Site visits to these seven VA facilities
were conducted from April 2005 through August 2005.
[End of table]
[End of section]
Appendix III: Comments from the Department of Veterans Affairs:
The Deputy Secretary Of Veterans Affairs:
Washington:
May 17, 2006:
Ms. Laurie Ekstrand:
Director:
Health Care Team:
U. S. Government Accountability Office:
441 G Street, NW:
Washington, DC 20548:
Dear Ms. Ekstrand:
The Department of Veterans Affairs (VA) has reviewed your draft report,
VA HEALTH CARE: Steps Taken to Improve Practitioner Screening, but
Facility Compliance with Screening Requirements is Poor (GAO-06-544)
and agrees with your findings and conclusions and concurs with your
recommendations. VA agrees that expanded program oversight as well as a
standardized method for documenting fingerprinting-only background
investigation results, would be very useful.
While I believe that most facilities continue to improve their
practitioner screening effectiveness, I also recognize that there is
variability and lack of standardization throughout the system. At
times, roles and responsibilities for policy implementation among
various program elements are unclear. The Veterans Health
Administration (VHA) will consider two key challenges: developing
standardized operating procedures that all facilities must apply in
various stages of their screening processes, and creating systematic
oversight and reporting mechanisms at each organizational level to
assure that facilities are, in fact, appropriately complying with
screening requirements.
VHA is exploring options to achieve these goals. VA will provide an
action plan to implement the Government Accountability Office's
recommendations when responding to your final report.
Thank you for the opportunity to comment on your draft report.
Sincerely yours,
Signed by:
Gordon H. Mansfield:
[End of section]
Appendix IV: GAO Contact and Staff Acknowledgments:
GAO Contact:
Laurie E. Ekstrand (202) 512-7101 or ekstrandl@gao.gov:
Acknowledgments:
In addition to the contact named above, Marcia A. Mann, Assistant
Director; Linda Diggs; Alison Farley; Martha A. Fisher; Krister Friday;
and Marion M. Slachta made key contributions to this report.
[End of section]
(290421):
FOOTNOTES
[1] VA medical facilities may contract with local or national companies
in order to obtain certain types of health care practitioners, such as
nurses, physicians, or respiratory therapists, who may have access to
and provide care to patients.
[2] Professional credentials held by health care practitioners may
include medical licenses, registrations, and certifications. We refer
to these credentials as state licenses and national certificates.
[3] GAO, VA Health Care: Improved Screening of Practitioners Would
Reduce Risk to Veterans, GAO-04-566 (Washington, D.C.: Mar. 31, 2004),
and VA Health Care: Veterans at Risk from Inconsistent Screening of
Practitioners, GAO-04-625T (Washington, D.C.: Mar. 31, 2004).
[4] HIPDB is a national data bank that contains information on health
care practitioners involved in health care-related civil judgments and
criminal convictions as well as practitioners who have had disciplinary
actions taken against their licenses or national certificates.
[5] Fingerprint-only background investigations verify an individual's
criminal history, based on a fingerprint check, against criminal
history databases. In contrast, traditional background investigations
verify an individual's criminal history based on a fingerprint check
and also include a more extensive investigation of an individual's
professional and personal history.
[6] We visited the New Orleans VA medical facility in July 2005, prior
to the facility being closed as a result of Hurricane Katrina.
[7] We selected these additional salaried health care practitioners in
order to determine if new screening requirements VA established on July
13, 2004, and September 2, 2004, had been implemented by facility
officials.
[8] WOC health care practitioners include individuals working in
patient care or research areas that are paid by a source other than VA.
For example, researchers and research assistants assigned to work at
the VA medical facility but paid by the affiliated university would be
considered WOC health care practitioners.
[9] 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.
[10] Employment refers to all health care practitioners, salaried and
nonsalaried, working in VA facilities.
[11] In this report, we use "applicant" to describe health care
practitioners who VA facility officials plan to hire, and we use
"currently employed" to describe health care practitioners who already
work at VA facilities.
[12] State licenses are issued by offices in states, territories,
commonwealths, or the District of Columbia, collectively referred to as
state licensing boards.
[13] A state licensing board may limit a health care practitioner's
ability to perform certain activities, for example, a health care
practitioner may not be allowed to prescribe or administer certain
types of medications.
[14] Some health care practitioners may hold both national certificates
and state licenses.
[15] Executive Order 10450, April 27, 1953, requires all persons
employed by federal departments and agencies to undergo background
investigations to ensure that their employment is consistent with
national security interests.
[16] OPM was created and given the authority to administer background
investigations by Executive Order 12107 (Dec. 28, 1978). OPM has issued
regulations addressing the determination of an individual's suitability
for federal employment, based on character, conduct, knowledge, and
ability, as part 732 of title 5 of the Code of Federal Regulations.
[17] The National Leadership Board serves in an advisory capacity to
VA's Under Secretary for Health on matters pertaining to policy,
planning, and performance.
[18] VA requires the completed employment checklist to be filed in the
personnel folder.
[19] VA Handbook 5005, pt. II, ch. 3, para. 17a (1).
[20] Volunteers who are high school students, those who will work at a
facility for a short time, or those who will not provide services
directly to patients are exempt from the HIPDB query requirement.
[21] VHA Directive 0710, Personnel Suitability and Security Program,
August 19, 2005.
[22] VHA Directive 0710.
[23] A 90 percent compliance rate means that 90 percent of the health
care practitioner files we examined provided documentation that the
screening requirement had been met in accordance with VA policy.
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