VA Health Care: Steps Taken to Improve Practitioner Screening,
but Facility Compliance with Screening Requirements Is Poor
(25-MAY-06, GAO-06-544).
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.
-------------------------Indexing Terms-------------------------
REPORTNUM: GAO-06-544
ACCNO: A54726
TITLE: VA Health Care: Steps Taken to Improve Practitioner
Screening, but Facility Compliance with Screening Requirements Is
Poor
DATE: 05/25/2006
SUBJECT: Background investigations
Fingerprints
Health care personnel
Hiring policies
Internal controls
Noncompliance
Physicians
Professional licenses
Personnel qualifications
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GAO-06-544
* Results in Brief
* Background
* VA Has Taken Steps to Improve Health Care Practitioner Scree
* VA Has Partially Implemented Our Recommendation to Expand Ve
* VA Partially Implemented Our Recommendation to Require Medic
* VA Policy on Fingerprint-Only Background Investigations Addr
* VA Partially Implemented Our Recommendation to Conduct Overs
* VA Facilities Did Not Comply with Health Care Practitioner S
* Conclusions
* Recommendations for Executive Action
* Agency Comments
* GAO Contact
* Acknowledgments
* GAO's Mission
* Obtaining Copies of GAO Reports and Testimony
* Order by Mail or Phone
* To Report Fraud, Waste, and Abuse in Federal Programs
* Congressional Relations
* Public Affairs
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
GAO-06-544
Contents
Letter 1
Results in Brief 4
Background 6
VA Has Taken Steps to Improve Health Care Practitioner Screening
Requirements, but Gaps Remain 12
VA Facilities Did Not Comply with Health Care Practitioner Screening
Requirements 16
Conclusions 21
Recommendations for Executive Action 22
Agency Comments 22
Appendix I Scope and Methodology 24
Appendix II Results of Our Compliance Reviews at Seven VA Facilities 30
Appendix III Comments from the Department of Veterans Affairs 34
Appendix IV GAO Contact and Staff Acknowledgments 35
Tables
Table 1: State Licensure and National Certification Requirements for the
43 VA Occupations 26
Table 2: Health Care Practitioners Included in Our Review of Select VA
Screening Requirements and the Documentation Required to Demonstrate
Compliance 28
Table 3: VA Facility Compliance with Screening Requirements for Salaried
Health Care Practitioners-Background Investigations (2005) 30
Table 4: VA Facility Compliance with Screening Requirements for Fee Basis
and WOC Health Care Practitioners-Background Investigations (2005) 31
Table 5: VA Facility Compliance with Screening Requirements for Salaried
Health Care Practitioners-HIPDB Query and State License and National
Certificate Verification (2005) 32
Table 6: VA Facility Compliance with Screening Requirements for Salaried
Health Care Practitioners-Employment Checklist Completed and Position Risk
Level Determined (2005) 33
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 11
Figure 2: Facilities' Rates of Compliance with Select VA Screening
Requirements for Salaried Health Care Practitioners (2005) 18
Figure 3: Background Investigation Compliance Rates for Salaried Health
Care Practitioners at Revisited VA Medical Facilities (2005) 19
Figure 4: VA Facility Compliance with Background Investigation Screening
Requirements for Fee Basis and WOC Health Care Practitioners (2005) 20
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
This is a work of the U.S. government and is not subject to copyright
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separately.
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),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,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.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.
1VA 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.
2Professional credentials held by health care practitioners may include
medical licenses, registrations, and certifications. We refer to these
credentials as state licenses and national certificates.
3GAO, 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).
VA concurred with our recommendations to
o 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,
o expand query of the Healthcare Integrity and Protection Data
Bank (HIPDB)4 to include all licensed health care practitioners at
VA facilities,
o conduct fingerprint-only background investigations for all VA
health care practitioners with direct patient care access,5 and
o 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.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, 2004.7 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.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.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,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.
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.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.
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.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.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.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.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.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
aPhysician 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.
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.17
VA has taken steps to improve health care practitioner screening
by partially implementing each of the four recommendations made in
our March 2004 report; however, gaps still remain in VA's health
care practitioner screening requirements. These gaps are found in
the requirements for verifying professional credentials and
querying HIPDB for currently employed practitioners. In addition,
VA has not yet implemented fingerprint-only background
investigations at two medical facilities. Finally, while VA has
formalized an oversight program within its Office of Human
Resource Management (HRM), the program does not address all of the
compliance issues we identified in our earlier report.
VA has partially implemented our recommendation that VA facility
officials contact state licensing boards and national certifying
organizations to verify all state licenses and national
certificates held by all VA health care practitioners. To address
our recommendation, VA expanded the verification requirement to
include licenses and certificates of all applicants VA intends to
hire. In addition, VA issued a memorandum on September 2, 2004,
directing VA facility officials to establish a formal procedure
for conducting and then documenting the screening of professional
credentials for applicants. As part of the memorandum, VA provided
its medical facilities with an employment checklist that officials
are required to use to document the completion of VA's screening
requirements for applicants for salaried and nonsalaried
positions, including fee basis and WOC health care
practitioners.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.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 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.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.
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.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.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 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.
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,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.)
Figure 2: Facilities' Rates of Compliance with Select VA Screening
Requirements for Salaried Health Care Practitioners (2005)
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.
aTested for significance at the 95 percent confidence level.
bApplies 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.
cApplies 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.
As shown in figure 2, facilities did not uniformly comply with the
two screening requirements VA implemented to address our
recommendations. We found that for health care practitioners hired
since October 1, 2004, only two facilities were querying HIPDB as
required, and none of the seven facilities consistently completed
the required employment checklist to document the completion of
screening requirements for applicants VA intends to hire. While
two facilities performed HIPDB queries on applicants, one of these
facilities completed the queries immediately prior to our visit.
During our site visits, we also found that two facilities had
created their own employment checklists. While facilities are
permitted to modify the format of the checklist as long as the
modification includes all of the screening requirements contained
in the original checklist issued in September 2004, we found that
the checklists used by these two facilities did not include all of
the screening requirements.
Two of the seven facilities we visited were also included in our
March 2004 report. Since our last site visit, these two facilities
improved their performance in conducting background investigations
for salaried health care practitioners to compliance rates of 75
and 72 percent, as shown in figure 3. However, both facilities
were still well below our compliance rate of 90 percent.
Figure 3: Background Investigation Compliance Rates for Salaried
Health Care Practitioners at Revisited VA Medical Facilities
(2005)
Note: Site visits to these two VA facilities were conducted from
April 2005 through August 2005.
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)
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.
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:
o 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
o 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 http://www.gao.gov .
If you or your staff members have any questions, please contact me
at (202) 512- 7101 or [email protected] . 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,
Laurie E. Ekstrand Director, Health Care
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
Occupations
Occupations that do not
Occupations that require require a state
that require a national license or a
a state certificate national
Occupation license to to work in certificate to
code Occupation title work in VA VA work in VA
101 Social science X
102 Social science aide X
and technician
180 Psychology X
181 Psychology aide and X
technician
185 Social work X
186 Social services aide X
and assistant
187 Social services X
189 Recreation aide and X
assistant
413 Physiology X
601 General health X
science
602 Medical officer X
(physician)
603 Physician's assistant X
605 Nurse anesthetist X X
610 Registered nursea X
620 Practical nurse X
621 Nursing assistant X
622 Medical supply X
aide/technician
630 Dietitian and X
nutritionist
631 Occupational X
therapist
633 Physical therapist X
635 Corrective therapist X
636 Rehabilitation X
therapy assistant
638 Recreation/creative X
arts therapist
640 Health aide and X
technician
644 Medical technologist X
645 Medical technician X
646 Pathology technician X
647 Diagnostic radiologic X
technologist
648 Therapeutic X
radiologic
technologist
649 Medical instrument X
technician
651 Respiratory therapist X
660 Pharmacist X
661 Pharmacy technician X
662 Optometrist X
665 Speech pathology and X
audiology
667 Orthotist and X
prosthetist
668 Podiatrist X
672 Prosthetic X
representative
680 Dental officer X
(dentist)
681 Dental assistant X
682 Dental hygiene X
1320 Chemistry X
1715 Vocational X
rehabilitation
Source: VA Handbook 5005, April 15, 2002.
a"Registered nurse" includes nurse practitioners and clinical nurse
specialists.
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:
o determine the position risk level by completing VA Form 2280;
o ensure completion of background investigations;
o query the Healthcare Integrity and Protection Data Bank (HIPDB)
for all applicants after October 1, 2004;
o complete an employment checklist for those hired after October
1, 2004; and
o 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
Source: GAO.
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.
4HIPDB 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.
5Fingerprint-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.
6We visited the New Orleans VA medical facility in July 2005, prior to the
facility being closed as a result of Hurricane Katrina.
7We 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.
8WOC 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.
Results in Brief
9VA'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.
10Employment refers to all health care practitioners, salaried and
nonsalaried, working in VA facilities.
11In 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.
Background
12State licenses are issued by offices in states, territories,
commonwealths, or the District of Columbia, collectively referred to as
state licensing boards.
13A 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.
14Some health care practitioners may hold both national certificates and
state licenses.
15Executive 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.
16OPM 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.
VA Has Taken Steps to Improve Health Care Practitioner Screening Requirements,
but Gaps Remain
VA Has Partially Implemented Our Recommendation to Expand Verification of Health
Care Practitioners' Professional Credentials
17The National Leadership Board serves in an advisory capacity to VA's
Under Secretary for Health on matters pertaining to policy, planning, and
performance.
18VA requires the completed employment checklist to be filed in the
personnel folder.
VA Partially Implemented Our Recommendation to Require Medical Facilities to
Query HIPDB
19VA Handbook 5005, pt. II, ch. 3, para. 17a (1).
20Volunteers 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.
VA Policy on Fingerprint-Only Background Investigations Addressed Our
Recommendation, but Was Not Fully Implemented
VA Partially Implemented Our Recommendation to Conduct Oversight of Facilities'
Compliance with Screening Requirements
21VHA Directive 0710, Personnel Suitability and Security Program, August
19, 2005.
22VHA Directive 0710.
VA Facilities Did Not Comply with Health Care Practitioner Screening
Requirements
23A 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.
Appendix I: Scope and Methodology Appendix I: Scope and Methodology
Table 1: State Licensure and National Certification Requirements for the
43 VA Occupations
Occupations
Occupations that do not
Occupations that require require a state
that require a national license or a
a state certificate national
Occupation license to to work in certificate to
code Occupation title work in VA VA work in VA
101 Social science X
102 Social science aide X
and technician
180 Psychology X
181 Psychology aide and X
technician
185 Social work X
186 Social services aide X
and assistant
187 Social services X
189 Recreation aide and X
assistant
413 Physiology X
601 General health X
science
602 Medical officer X
(physician)
603 Physician's assistant X
605 Nurse anesthetist X X
610 Registered nursea X
620 Practical nurse X
621 Nursing assistant X
622 Medical supply X
aide/technician
630 Dietitian and X
nutritionist
631 Occupational X
therapist
633 Physical therapist X
635 Corrective therapist X
636 Rehabilitation X
therapy assistant
638 Recreation/creative X
arts therapist
640 Health aide and X
technician
644 Medical technologist X
645 Medical technician X
646 Pathology technician X
647 Diagnostic radiologic X
technologist
648 Therapeutic X
radiologic
technologist
649 Medical instrument X
technician
651 Respiratory therapist X
660 Pharmacist X
661 Pharmacy technician X
662 Optometrist X
665 Speech pathology and X
audiology
667 Orthotist and X
prosthetist
668 Podiatrist X
672 Prosthetic X
representative
680 Dental officer X
(dentist)
681 Dental assistant X
682 Dental hygiene X
1320 Chemistry X
1715 Vocational X
rehabilitation
Source: VA Handbook 5005, April 15, 2002.
a"Registered nurse" includes nurse practitioners and clinical nurse
specialists.
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:
o determine the position risk level by completing VA Form 2280;
o ensure completion of background investigations;
o query the Healthcare Integrity and Protection Data Bank (HIPDB)
for all applicants after October 1, 2004;
o complete an employment checklist for those hired after October
1, 2004; and
o 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
Source: GAO.
In addition to the personnel files, we reviewed about five
contracts at each of the seven medical facilities that the
facilities use to supplement health care practitioner staffing to
determine how these nonsalaried health care practitioners'
professional credentials and personal backgrounds are screened. We
also interviewed VA officials about the process the facilities use
to screen trainees, including medical residents, and volunteers
who work in patient care areas.
In order to show the variability in the level of compliance among
the seven VA facilities we visited, we distinguished between
facilities that had a compliance rate of at least 90 percent for
each of the five screening requirements that we reviewed and those
that did not. For each facility and screening requirement included
in our review, we compared the percentage of personnel files found
in compliance to an acceptance level of 90 percent. In order to
confirm that a requirement had a compliance rate less than 90
percent, we performed a one-sided significance test at the 95
percent confidence level. See appendix II for detailed information
on the seven VA facilities' compliance with each VA screening
requirement in our review. Our findings from these seven
facilities cannot be generalized to other VA facilities.
Our work was conducted from April 2005 through April 2006 in
accordance with generally accepted government auditing standards.
Appendix II: Results of Our Compliance Reviews at Seven VA Facilities
Tables 3 and 4 show the sample counts used to measure compliance
and the results of our review for the background investigation
screening requirement. Tables 5 and 6 show the sample counts used
to measure compliance with the remaining health care practitioner
screening requirements that we included in our review.
Table 3: VA Facility Compliance with Screening Requirements for
Salaried Health Care Practitioners-Background Investigations
(2005)
Number with completed or requested background
Facility Number in sample investigations
Facility A 61 52
Facility B 59 50
Facility C 62 54
Facility D 60 45
Facility E 60 57
Facility F 63 55
Facility G 60 43
Source: GAO analysis of VA facility files.
Note: Site visits to these seven VA facilities were conducted from
April 2005 through August 2005.
Table 4: VA Facility Compliance with Screening Requirements for
Fee Basis and WOC Health Care Practitioners-Background
Investigations (2005)
Fee basis health care
practitioners WOC health care practitioners
Number with completed Number with
or requested completed or
Number in background Number in requested background
Facility sample investigations sample investigations
Facility A 20 7 a a
Facility B 21 0 26 0
Facility C 20 17 52 21
Facility D 20 7 a a
Facility E 20 16 40 26
Facility F a a 21 20
Facility G 20 0 54 0
Source: GAO analysis of VA facility files.
Note: Site visits to these seven VA facilities were conducted from
April 2005 through August 2005.
aFacility officials stated that they do not conduct background
investigations as required for these categories of nonsalaried
health care practitioners.
Table 5: VA Facility Compliance with Screening Requirements for
Salaried Health Care Practitioners-HIPDB Query and State License
and National Certificate Verification (2005)
State license and national
HIPDB query certificate verification
Number in Number queried Number in Number where verification
Facility sample prior to hire sample followed VA policy
Facility A 17 13 46 44
Facility B 21 14 45 44
Facility C 18 0 44 41
Facility D 19 19 45 42
Facility E 22 20 48 37
Facility F 24 13 45 44
Facility G 17 10 38 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.
Table 6: VA Facility Compliance with Screening Requirements for
Salaried Health Care Practitioners-Employment Checklist Completed
and Position Risk Level Determined (2005)
Position risk level
determined (VA Form
Employment checklist completed 2280)
Number with position
risk level determined
Number in Number with completed Number in and documented on VA
Facility sample employment checklists sample Form 2280
Facility A 10 8 61 34
Facility B 10 0 59 0
Facility C 10 5 62 0
Facility D 10 0 60 58
Facility E 10 4 60 59
Facility F 12 1 63 8
Facility G 10 0 60 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.
Appendix III: Comments from the Department of Veterans Affairs
Appendix IV: GAO Contact and Staff Acknowledgments
Contact
Laurie E. Ekstrand (202) 512-7101 or [email protected]
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.
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Screening Health care practitioners Documentation required to
requirements included in our review demonstrate compliance
Conducting o VA salaried o Notice of scheduled
background o Fee basis or completed background
investigations o WOC investigation from the
Office of Personnel
Management (OPM)
Completing VA Form o VA salaried o Completed VA Form
2280 for each job 2280
category
Querying HIPDB o VA salaried health o HIPDB query printout
care practitioners o National
hired on or after Practitioner Data Bank
October 1, 2004 query printout, which
o Certain health care includes a query of
practitioners hired HIPDB
prior to this date,
such as physicians and
dentists
Completing o VA salaried health o Completed employment
employment checklist care practitioners checklist which met VA
hired on or after requirements
October 1, 2004
Verifying license, o VA salaried health o Printouts, letters,
certification, or care practitioners and telephone contact
both required to have a reports from state
state license or licensing boards and
national certificate to national certification
work in VA organizations
o VA Form 4862,
indicating that the
original license or
certificate had been
visually inspected by a
VA facility official
(290421)
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
[email protected].
Highlights of GAO-06-544 , a report to the Chairman, Committee on
Veterans' Affairs, House of Representatives
May 2006
VA HEALTH CARE
Steps Taken to Improve Practitioner Screening, but Facility Compliance
with Screening Requirements Is Poor
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 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.
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.
Facilities' Rates of Compliance with Select VA Screening Requirements for
Health Care Practitioners (2005)
*** End of document. ***