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entitled 'VA Health Care: Improved Screening of Practitioners Would 
Reduce Risk to Veterans' which was released on March 31, 2004.

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Report to the Chairman, Subcommittee on Oversight and Investigations, 
Committee on Veterans' Affairs, House of Representatives:

United States General Accounting Office:

GAO:

March 2004:

VA Health Care:

Improved Screening of Practitioners Would Reduce Risk to Veterans:

GAO-04-566:

GAO Highlights:

Highlights of GAO-04-566, a report to the Chairman, Subcommittee on 
Oversight and Investigations, Committee on Veterans’ Affairs, House of 
Representatives 

Why GAO Did This Study:

Cases of practitioners causing intentional harm to patients have raised 
concerns about VA’s screening of practitioners’ professional 
credentials and personal backgrounds. GAO was asked to 
(1) identify key VA screening requirements, 
(2) evaluate their adequacy, and 
(3) assess compliance with these screening requirements. 
GAO reviewed VA’s policies and identified key VA screening requirements 
for 43 health care occupations; interviewed officials from VA, 
licensing boards, and certifying organizations; and randomly sampled 
about 100 practitioners’ personnel files at each of four VA facilities 
we visited. 

VA has not conducted oversight of its facilities’ compliance with the 
key screening requirements. This pattern of mixed compliance and the 
gaps in key VA screening requirements creates vulnerabilities to the 
extent that VA remains unaware of practitioners who could place 
patients at risk.

What GAO Found:

GAO identified key screening requirements that VA uses to verify the 
professional credentials and personal backgrounds of its health care 
practitioners. These requirements include verifying professional 
credentials; completing background investigations for certain 
practitioners, including fingerprinting to check for criminal 
histories; and checking national databases that contain reports of 
practitioners who have been professionally disciplined or excluded from 
federal health care programs.

GAO found adequate screening requirements for certain practitioners, 
such as physicians, for whom all licenses are verified by contacting 
state licensing boards. However, screening requirements for others, 
such as currently employed nurses and respiratory therapists, are less 
stringent because they do not require verification of all licenses and 
national certificates. Moreover, they require only physical inspection 
of the credential rather than contacting state licensing boards and 
national certifying organizations. Physical inspection alone can be 
misleading; not all credentials indicate whether they are restricted, 
and credentials can be forged. VA also does not require facility 
officials to query, for other than physicians and dentists, a national 
database that includes reports of disciplinary actions involving all 
licensed practitioners. In addition, many practitioners with direct 
patient care access, such as medical residents, are not required to 
undergo background investigations, including fingerprinting to check 
for criminal histories. 

What GAO Recommends:

GAO recommends that VA expand its existing verification process to 
require that all state licenses and national certificates held by all 
practitioners be verified by contacting the appropriate licensing 
boards and national certifying organizations, expand the query of a 
national database to include all licensed practitioners, and 
fingerprint all practitioners who have direct patient care access. GAO 
also recommends that VA conduct oversight of its facilities to ensure 
their compliance with all key screening requirements. VA generally 
agreed with GAO’s findings and will develop a detailed action plan to 
implement the recommendations.

www.gao.gov/cgi-bin/getrpt?GAO-04-566.

To view the full product, including the scope and methodology, click on 
the link above. For more information, contact Cynthia A. Bascetta at 
(202) 512-7101.

[End of section]

Contents:

Letter:

Results in Brief:

Background:

VA Policy Requires Its Facilities to Check Many Practitioners' 
Professional Credentials and Personal Backgrounds:

Gaps in Key VA Screening Requirements Create Vulnerabilities:

VA Facilities Did Not Comply with All of the Key VA Screening 
Requirements:

Conclusions:

Recommendations for Executive Action:

Agency Comments:

Appendix I: Scope and Methodology:

Appendix II: Results of Our Compliance Reviews at VA Facilities:

Appendix III: Comments from the Department of Veterans Affairs:

Appendix IV: GAO Contact and Staff Acknowledgments:

GAO Contact:

Acknowledgments:

Tables:

Table 1: Types of Practitioners VA Exempts from Background 
Investigations:

Table 2: Facilities' Rate of Compliance with Existing Key VA Screening 
Requirements:

Table 3: State Licensure and National Certification Requirements for 
the 43 VA Occupations:

Table 4: VA Facility Compliance with Key Screening 
RequirementsæProfessional Credentials Verification:

Table 5: Facility Compliance with Key Screening RequirementsæPersonal 
Background Screening:

Table 6: Average Number of Days from Obtaining Background Investigation 
Results to VA Facility Action (August 1, 2002, to August 23, 2003):

Figures:

Figure 1: VA's Process for Credentials Verification with State 
Licensing Boards and National Certifying Organizations:

Figure 2: Gaps in Group B Employed Practitioners' Credentials 
Verification with State Licensing Boards:

Figure 3: Gaps in Group C Applicants' and Employed Practitioners' 
Credentials Verification with State Licensing Boards and National 
Certifying Organizations:

Abbreviations:

FSMB: Federation of State Medical Boards: 
HIPDB: Healthcare Integrity and Protection Data Bank: 
LEIE: List of Excluded Individuals and Entities:  
NPDB: National Practitioner Data Bank: 
OPM: Office of Personnel Management:  
SLB: state licensing board: 
VA: Department of Veterans Affairs:

United States General Accounting Office:

Washington, DC 20548:

March 31, 2004:

The Honorable Steven Buyer: 
Chairman: 
Subcommittee on Oversight and Investigations: 
Committee on Veterans' Affairs: 
House of Representatives:

Dear Mr. Chairman:

The Department of Veterans Affairs (VA) is responsible for safeguarding 
veterans receiving health care in its facilities by ensuring that its 
health care practitioners are qualified to provide care to their 
patients. VA employs about 190,000 individuals including physicians, 
nurses, pharmacists, and therapists at its facilities, and it 
supplements these practitioners with contract staff, medical 
consultants, and medical residents.[Footnote 1] VA has screening 
requirements intended to help ensure that its health care 
practitioners' professional credentials are verified and their personal 
backgrounds checked for evidence of incompetence or criminal behavior. 
According to medical forensic experts, the deliberate harm of patients 
by health care practitioners is a problem in the health care sector, 
and VA's requirements are intended to minimize the chance of veterans 
receiving care from someone who is incompetent or may intentionally 
harm them.

Events at VA facilities have raised concerns about VA's screening of 
the professional credentials and personal backgrounds of health care 
practitioners at its facilities. In 1993, Dr. Michael Joseph Swango 
entered the VA health care system as a medical resident, although 
before entering the residency program he had been convicted and 
imprisoned for 2 years for aggravated battery against his fellow 
employees. Dr. Swango had admitted to medical school officials that he 
had a prior arrest and conviction, but lied about the nature of the 
crime. In 2000, he pleaded guilty to murdering three veterans at the VA 
facility located in Northport, New York, and received a sentence of 
three consecutive life terms without the possibility of parole. In 
another case, in 2000, events at the VA facility in Albany, New York, 
raised concerns about VA's process for checking the credentials of 
individuals employed at its facilities. VA hired a research assistant 
to help administer several cancer studies. The research assistant had 
lost his medical license because he had forged his medical credentials. 
Once at VA, the research assistant allegedly falsified data that were 
used to qualify veterans for cancer studies, and this may have resulted 
in the untimely deaths of several veterans. In 2003, the researcher was 
indicted in federal court on charges including manslaughter, criminally 
negligent homicide, and fraud.

You asked that we examine VA's policies and practices intended to 
ensure that health care practitioners at its facilities have 
appropriate professional credentials and personal backgrounds to 
provide care to veterans. Specifically, we (1) identified key VA 
screening requirements for its health care practitioners, (2) 
determined the adequacy of these screening requirements, and (3) 
assessed the extent to which selected VA facilities complied with these 
screening requirements.

We reviewed health care occupations in VA and selected 43 occupations 
in which practitioners have direct patient care access or have an 
impact on patient care. See appendix I for a list of the 43 health care 
occupations included in our study. We reviewed VA employment screening 
policies and practices to identify those requirements that applied to 
the selected occupations and were key requirements for safeguarding 
veterans receiving health care in VA facilities.[Footnote 2] To 
determine the adequacy of the key screening requirements, we examined 
whether they were complete, and whether VA applied them to all 
applicants, current employees, contract staff, medical residents, and 
volunteers. We also interviewed VA human resource officials, VA 
headquarters and VA facility officials, and facility practitioners; 
representatives of state licensing boards and national certifying 
organizations; and officials and representatives of organizations that 
operate national databases containing information on state licenses and 
national certificates. We also reviewed VA's policy on background 
investigations to determine its criteria for conducting background 
investigations. To assess the extent to which VA facilities complied 
with the key screening requirements, we visited four VA facilities and 
reviewed personnel files for practitioners at each site. From VA's 
automated pay system, we selected a statistically random sample of 100 
current practitioners in the 43 occupations for each facility we 
visited. We reviewed these practitioners' files to determine whether 
the facilities had documentation that demonstrated compliance with key 
VA screening requirements. We visited facilities located in Big Spring, 
Texas; New Orleans, Louisiana; Seattle, Washington; and the District of 
Columbia, based on geographic variation, affiliations with medical 
schools to train residents, and types of health care services provided. 
Of the four facilities we visited, three are large facilities located 
in major metropolitan areas and are affiliated with at least one 
medical school. The remaining facility is small, providing mainly 
primary care and long-term care services to veterans and is located in 
a rural area. Additionally, from the four facilities we visited and 
from six other facilities we selected based on geographic variation, we 
obtained documentation on how quickly facilities took action after 
obtaining the results of background investigations. Our results cannot 
be generalized to other facilities. For a complete description of our 
scope and methodology, see appendix I. Our work was conducted from 
August 2003 through March 2004 in accordance with generally accepted 
government auditing standards.

Results in Brief:

We identified key screening requirements in VA's policies for checking 
the professional credentials and personal backgrounds of health care 
practitioners in its facilities. These requirements are in place to 
verify state licenses and national certificates for applicants VA 
intends to hire and for continued employment of practitioners; to check 
health care practitioners against national databases that contain 
reports of professional disciplinary actions and criminal convictions; 
and to investigate the personal backgrounds of health care 
practitioners, including checking fingerprints against a fingerprint-
based criminal history database.

We found adequate screening requirements for certain practitioners, 
such as physicians and dentists. These screening requirements include 
having facility officials verify all physicians' and dentists' licenses 
by contacting state licensing boards for applicants VA intends to hire 
and periodically for their continued employment. Screening requirements 
for other practitioners, such as currently employed nurses, are less 
stringent because they do not require that VA facility officials check 
all licenses. Moreover, they do not require contacting state licensing 
boards, but instead require physical inspection of the license only. VA 
does not require verifying national certificatesæthe credentials held 
by other health care practitioners, such as respiratory therapistsæby 
contacting the national certifying organizations for applicants VA 
intends to hire and periodically for their continued employment. 
Physical inspection of credentials alone can be misleading; not all 
state licenses and national certificates indicate whether they are 
restricted, and licenses and certificates can be forged. Also, other 
than for physicians and dentists, VA does not require facility 
officials to query a national database that contains reports of 
disciplinary actions and criminal convictions involving all licensed 
practitioners. In addition, many practitioners with direct patient care 
access, such as medical residents, are not required to undergo 
background investigations, including fingerprinting to check for 
criminal records. These gaps create vulnerabilities because VA may 
remain unaware of health care practitioners who could place patients at 
risk.

In the four facilities we visited, we found mixed compliance with the 
existing key VA screening requirements. All facilities generally 
checked the professional credentials of practitioners periodically for 
continued employment. However, they were less compliant in checking the 
professional credentials of applicants that they intended to hire. 
Furthermore, VA facilities varied in how quickly they took action after 
obtaining the results of background investigations. During the site 
visit at one facility, we discovered returned background investigation 
results that were over a year old but had not been reviewed. We brought 
them to the attention of facility officials, who reviewed the reports 
and then terminated a nursing assistant who had been fired by a 
previous employer for patient abuse. Although VA established an office 
more than a year ago to perform oversight of human resources functions, 
including whether its facilities comply with these key screening 
requirements, it has not started these reviews. There is no VA policy 
outlining the human resources program evaluations to be performed by 
this office, and the resources have not been provided to support the 
functions of this office.

To better ensure the safety of veterans receiving health care at VA 
facilities, we recommend that VA conduct more thorough screening of 
both applicants it intends to hire and current employees by expanding 
the verification requirement that facility officials contact state 
licensing boards and national certifying organizations to include all 
state licenses and national certificates held by practitioners; 
expanding the query of a national database to include all licensed 
practitioners that VA intends to hire and periodically for continued 
employment; and requiring fingerprint checks for all health care 
practitioners who were previously exempted from background 
investigations and who have direct patient care access. Furthermore, VA 
should conduct oversight to help ensure that facilities comply with all 
key screening requirements for applicants and current employees. In 
commenting on a draft of this report, VA generally agreed with our 
findings and conclusions and stated that it would provide details on 
how it plans to address our recommendations when the final report is 
issued.

Background:

VA operates the largest integrated health care system in the United 
States, providing care to nearly 5 million veterans per year. The VA 
health care system consists of hospitals, ambulatory clinics, nursing 
homes, residential rehabilitation treatment programs, and readjustment 
counseling centers. In addition to providing medical care, VA is the 
largest educator of health care professionals, training more than 
28,000 medical residents annually, as well as other types of trainees.

State licenses are issued by state licensing boards, which generally 
establish state licensing requirements governing their licensed 
practitioners.[Footnote 3] Current and unrestricted licenses are 
licenses that are in good standing in the states that issued them, and 
licensed practitioners may hold licenses from more than one state. To 
keep a license current, practitioners must renew their licenses before 
they expire and meet renewal requirements established by state 
licensing boards, such as continuing education. Renewal procedures and 
requirements vary by state and occupation. When licensing boards 
discover violations of licensing practices, such as the abuse of 
prescription drugs or the provision of poor quality of care that 
results in adverse health effects, they may place restrictions on 
licenses or revoke them. Restrictions from a state licensing board can 
limit or prohibit a practitioner from practicing in that particular 
state. Some, but not all, issued state licenses are marked in such a 
way as to indicate that the licenses have had restrictions placed on 
them. Generally, state licensing boards maintain a database of 
information on restrictions, which employers can often obtain at no 
cost either by accessing the information on a board's Web site or by 
contacting the board directly.

National certificates are issued by national certifying organizations, 
which are separate and independent from state licensing 
boards.[Footnote 4] These organizations establish professional 
standards that are national in scope for certain occupations, such as 
respiratory and occupational therapists. Practitioners who are required 
to have a national certificate to practice in VA may renew these 
credentials periodically by paying a fee and verifying that they 
obtained required educational credit hours. National certifying 
organizations can place restrictions on a certification or revoke 
certification for violations of the organization's professional 
standards. Like state licensing boards, national certifying 
organizations maintain a database of information on disciplinary 
actions taken against practitioners with national certificates and many 
can be accessed at no cost.

VA Policy Requires Its Facilities to Check Many Practitioners' 
Professional Credentials and Personal Backgrounds:

We identified key VA screening requirements that are intended to ensure 
that VA facilities employ health care practitioners who have valid 
professional credentials and personal backgrounds appropriate to 
deliver safe health care to veterans. Officials at VA facilities are 
required to verify whether credentialsæstate licenses and national 
certificatesæheld by applicants and employees are current and 
unrestricted.[Footnote 5] VA also requires its facilities to check the 
names of all applicants VA intends to hire against a federal list of 
individuals who have been excluded from participation in any federal 
health care programs and to compare applicants' educational 
institutions against lists of fraudulent institutions.[Footnote 6] 
Additionally, VA requires that individuals in certain positions undergo 
a background investigation, which includes checking their fingerprints 
against a fingerprint-based criminal history database.

VA Policy Requires Verification of the Status of State Licenses and 
National Certificates:

VA policy requires officials at its facilities to screen applicants to 
determine whether they possess at least one current and unrestricted 
state license or an appropriate national certificate, whichever is 
applicable for the position they seek. We classified VA's practitioners 
into three groups, depending upon the credentials and the verification 
process VA requires for employment. Figure 1 illustrates VA's process 
for credentials verification with state licensing boards and national 
certifying organizations for these groups for applicants VA intends to 
hire and for employed practitioners, whose credentials are checked 
periodically.[Footnote 7] [Footnote 8] Groups A and B represent 
practitioners who must be licensed to work in VA. However, the 
requirements and process VA uses to verify professional credentials is 
different for each of these groups. Group C represents practitioners 
who must have a national certificate to work in VA and may also have a 
state license.

Figure 1: VA's Process for Credentials Verification with State 
Licensing Boards and National Certifying Organizations:

[See PDF for image]

Note: Groups A and B represent practitioners who must be licensed to 
work in VA. Some group B psychologists and social workers may undergo 
the same credentials verification process as practitioners in group A. 
Group C represents practitioners who must have a national certificate 
to work in VA and may also have a state license.

[A] Physician assistants are not required to have a license to work in 
VA, but their credentials are verified using a process that is similar 
to other group A practitioners.

[End of figure]

The process used to screen applicants in all three groups has two 
stages. First, applicants are required to disclose, if applicable, 
their state licenses and national certificates. Second, VA facility 
officials are required to verify whether applicants' state licenses or 
national certificates are current and unrestricted. To verify 
applicants' credentials, VA officials are required to either contact 
state licensing boards or to physically inspect an applicant's national 
certificate. Officials are also required to document that they verified 
the status of the professional credentials.

VA also has requirements for verifying the credentials of its employed 
practitioners. Like the verification process for applicants, this 
process involves employed practitioners' disclosures and VA 
verification of that information. VA employed practitioners in group A 
are required to disclose all of their current licenses, while those in 
group B must disclose only one license. For employed practitioners in 
group A, facility officials are also required to determine if any 
expired licenses disclosed as current and unrestricted at the beginning 
of employment had restrictions placed on them prior to their 
expiration. VA depends on its employed practitioners in group B to 
inform facility officials of any change in the status of their license, 
including any that have expired. Employed practitioners in group C must 
disclose a national certificate. VA officials must confirm that the 
disclosed licenses and certificates are current and unrestricted. For 
group A practitioners, VA facility officials contact the appropriate 
state licensing boards directly; for groups B and C they physically 
inspect the state license or national certificate. VA officials verify 
these credentials periodically depending on the occupation and the 
requirements of the state or national organization that issued the 
license or certificate. For example, a registered nurse with a state 
license from Virginia must renew the license every 3 years, while a 
respiratory therapist must renew the national certificate every 5 
years.[Footnote 9] VA officials are required to document these 
verifications.

If VA's verification process identifies that a state licensing board or 
national certifying organization took disciplinary action against a 
practitioner, facility officials are required to determine the 
circumstances of the disciplinary action. Licensing boards and 
certifying organizations have various options for disciplining 
practitioners. For example, a nurse who is abusing drugs and 
voluntarily enters a drug abuse program may retain a license to 
practice with supervision when administering drugs. In contrast, a 
physician whose treatment results in the death or the permanent 
disability of a patient may have a license revoked. On the basis of a 
review of the action taken by the state licensing board or national 
certifying organization, VA officials are to determine whether an 
applicant should be hired or an employed practitioner should be 
retained or terminated.

To supplement its checks with state licensing boards, VA has 
requirements for searching for disciplinary actions taken against 
licensed practitioners that might not have been disclosed by physician 
and dentist applicants and employed practitioners. VA requires its 
facilities to check national databases for information on disciplinary 
actions taken against these practitioners. Specifically, VA requires 
that facility officials query the Federation of State Medical Boards 
(FSMB) database, which includes records of disciplinary actions taken 
against physicians by all state licensing boards.[Footnote 10] 
Similarly, VA requires facility officials to query the National 
Practitioner Data Bank (NPDB), which contains information including 
disciplinary actions taken against physicians and dentists.[Footnote 
11] Facility officials must document the results of these queries.

VA Policy Requires Checks of Applicants and Their Credentials against 
Lists Designed to Prevent Fraud and Abuse:

VA policy requires its facilities to check the names of all applicants 
VA intends to hire against a federal list of individuals who have been 
excluded from participation in any federal health care 
program.[Footnote 12] The list, referred to as the List of Excluded 
Individuals and Entities (LEIE), is maintained by the Department of 
Health and Human Services' Office of Inspector General. Since March 
1999, VA facilities are to electronically query the LEIE Web site on 
all applicants prior to employment.

VA also requires its facilities to make sure that an applicant's 
educational degrees are authentic. VA requires that applicants for some 
positions, such as social workers, have degrees from accredited 
institutions. To prevent the use of fraudulent degrees to obtain 
employment, VA requires that its facilities compare the educational 
institutions listed by an applicant against existing lists of "diploma 
mills" that sell fictitious college degrees and other professional 
credentials.

VA Policy Requires Background Investigations and Disclosures for 
Certain Employed Practitioners:

VA's employed practitioners are required to undergo a background 
investigation that verifies their personal histories.[Footnote 13] A 
background investigation verifies, for instance, an individual's 
history of employment, education, and residence. It also includes a 
fingerprint check that searches for evidence of criminal activity by 
comparing fingerprints against a database of criminal records. The 
Office of Personnel Management (OPM) conducts the investigations for VA 
and reports its results back to the facility that requested the 
investigation.

In conjunction with the background investigation, VA employed 
practitioners are required to disclose information about their 
professional and personal backgrounds by filling out the Declaration 
for Federal Employment form--also known as form 306. Employed 
practitioners are asked to disclose, among other things, information 
about criminal convictions, employment terminations, military court-
martials, and delinquencies on federal loans. Failure to disclose 
information requested on form 306 is grounds for dismissal. Facility 
officials compare the information obtained from form 306 with the 
results obtained through the background investigation to determine 
whether employed practitioners have been forthcoming in their 
disclosures. If the background investigation results include 
questionable issues, such as discrepancies in work or criminal 
histories, the facility has 90 days to take action.

Gaps in Key VA Screening Requirements Create Vulnerabilities:

Gaps in key VA screening requirements result in vulnerabilities when 
screening certain health care practitioners. Although the screening 
requirements for some occupations, such as physicians, are adequate 
because they require verifying all licenses by contacting state 
licensing boards, screening requirements for other occupations are less 
stringent. These less stringent requirements do not require checking 
all licenses, and they require physical inspection of one license only 
rather than contacting the state licensing board. Similarly, VA does 
not require contacting national certifying organizations to verify 
national certificatesæthe credentials held by health care 
practitioners, such as respiratory therapists. Physical inspection of 
credentials alone can be misleading; not all state licenses and 
national certificates indicate whether they are restricted, and 
licenses and certificates can be forged. While VA requires checking a 
national database for physicians and dentists, it does not require that 
facility officials query a national database that contains reports of 
disciplinary actions and criminal convictions involving all licensed 
practitioners. In addition, VA does not require that all practitioners 
undergo background investigations, including fingerprinting, to check 
for criminal records. These gaps create vulnerabilities because VA may 
remain unaware of health care practitioners who could place patients at 
risk.

VA Has Adequate Requirements for Verifying Professional Credentials of 
Certain Practitioners:

VA's requirements for verifying the professional credentials of 
applicants it intends to hire and employed practitioners in group A, 
such as physicians and dentists, are complete and thorough. This is 
also the case for applicants VA intends to hire in group B, such as 
nurses and pharmacists. VA requires facility officials to verify all 
state licenses by contacting the appropriate state licensing boards. To 
supplement these requirements for physicians and dentists, VA officials 
also must query FSMB and NPDB to identify reports of any disciplinary 
actions involving these practitioners.

Gaps Exist in VA's Requirements for Verifying Professional Credentials 
of Other Practitioners:

In contrast to all practitioners in group A, the process for 
verification of licenses for group B practitioners has gaps, as 
illustrated in figure 2. VA's verification process for group B 
practitioners that it intends to hire is as stringent as the process 
used for group A practitioners. However, the process used to verify 
licenses for continued employment of group B practitioners is less 
stringent, because facility officials are required to check only one 
state license, which is selected by the practitioner. Furthermore, 
officials are not required to contact the state licensing board 
directly, but instead may simply physically inspect the one state 
license to check its status.

Figure 2: Gaps in Group B Employed Practitioners' Credentials 
Verification with State Licensing Boards:

[See PDF for image]

[End of figure]

Employed practitioners in group B with multiple state licenses select 
the one state license under which they will continue to practice in VA. 
The license selected does not have to be from the state where the VA 
facility is located. VA officials check only that single license. As a 
result, these employed practitioners could have a restricted license in 
one state, or several restricted state licenses, but offer VA officials 
an unrestricted license from another state for verification.

Moreover, the method required to periodically verify the status of 
licenses for continued employment of practitioners in group B is not 
thorough. VA facility officials are only required to physically inspect 
the license--instead of contacting the state licensing board. VA 
facility officials we interviewed were unaware of the inherent 
vulnerabilities in relying on a physical inspection. According to 
licensing board officials, one cannot determine with certainty that a 
license is valid and unrestricted unless the state licensing board is 
contacted directly. These officials explained that state licensing 
boards do not always exchange information. Furthermore, physical 
inspection of licenses alone can be misleading because not all state 
licensing boards mark a license to indicate that it is restricted, and 
licenses can be forged, even though licensing boards have taken steps 
to minimize this problem. Licensing board officials also pointed out 
that many state boards do not charge a fee to verify licenses.

Unlike the national database queries of FSMB for physicians and NPDB 
for physicians and dentists, VA does not require facility officials to 
query the Healthcare Integrity and Protection Data Bank (HIPDB), a 
national database that contains information on disciplinary actions and 
criminal convictions involving all licensed practitioners.[Footnote 
14] All government agencies, including state licensing boards, are 
required to report to HIPDB. VA accesses HIPDB when it queries the NPDB 
for physicians and dentists because the databases share information. 
However, VA does not require its facilities to query HIPDB for all 
licensed practitioners even though VA is authorized by statute to query 
this database at no charge.

VA's requirements for verifying the professional credentials of both 
applicants and employed practitioners in group C also have gaps, as 
illustrated in figure 3. For both applicants and employed practitioners 
in group C, which include respiratory therapists and dietitians for 
example, facility officials are only required to physically inspect the 
national certificate to check its status. The physical inspection is 
required when these practitioners apply for employment and periodically 
for continued employment. Additionally, VA requires applicants in group 
C to disclose all of the state licenses they have ever held, but does 
not require facility officials to verify any of these state licenses.

Figure 3: Gaps in Group C Applicants' and Employed Practitioners' 
Credentials Verification with State Licensing Boards and National 
Certifying Organizations:

[See PDF for image]

[End of figure]

However, according to officials from national certifying organizations, 
the authenticity and status of a national certificate can only be 
assured by contacting the national certifying organizations directly. 
For example, an official from the National Board for Respiratory Care 
told us that practitioners that were certified prior to July 2002 are 
not required to renew their certificates--they can voluntarily choose 
to recertify. Thus, physical inspection of a certificate will not 
ensure that there has been no disciplinary action taken by the board 
since the certificate was issued.

VA Has Not Implemented Consistent Background Screening Requirements:

VA has not implemented consistent background screening requirements, 
which include fingerprint checks, for all practitioners. Although VA 
requires background investigations for newly hired employed 
practitioners, it does not require background investigations for 
certain contract health care practitioners, practitioners who work 
without compensation from VA, medical consultants, and medical 
residents. VA, with prior approval from OPM, has the authority to 
determine which positions in VA require a background investigation. VA 
requested and received permission from OPM to exempt certain categories 
of health care practitioners from background investigations, based on 
VA's assessment that these types of practitioners do not need a 
background investigation. Table 1 lists the types of practitioners that 
VA exempts from background investigations.

Table 1: Types of Practitioners VA Exempts from Background 
Investigations:

Types of practitioners VA exempts: Contract health care practitioners 
or practitioners that work without direct compensation from VA; 
Length of appointment: 
* 6 months or less in a single continuous appointment or series of 
appointments.

Types of practitioners VA exempts: Medical consultants; 
Length of appointment: 
* 1 year or less and not reappointed; 
* 1 year or more but less than 30 days in a calendar year and not 
reappointed.

Types of practitioners VA exempts: Medical residents; 
Length of appointment: 
* 1 year or less of continuous service at a VA facility.

Source: Department of Veterans Affairs, VA Manual MP-1, Part I, Chapter 
5, Change 1 (Washington, D.C.: 1979).

[End of table]

VA requested and received permission from OPM, in 2001 and 2003, to 
perform fingerprint-only checks for contract health care practitioners, 
who work in a facility for 6 months or less and are currently exempt 
from background investigations, and for all volunteers who have access 
to patients, patient information, or pharmaceuticals.[Footnote 15] OPM 
began to offer a fingerprint-only checkæa new screening optionæfor use 
by federal agencies in 2001. Compared to background investigations, 
which typically take several months to complete, fingerprint-only 
checks can be obtained within 3 weeks or less and cost less than $25, 
about a quarter of the cost of a background investigation.[Footnote 16] 
In commenting on a draft of this report, VA said that it planned to 
implement fingerprint-only checks for all contract health care 
practitioners, medical residents, medical consultants, and 
practitioners that work without direct compensation from VA, as well as 
certain volunteers. However, VA has not issued guidance to its 
facilities instructing them to implement fingerprint-only checks on all 
these practitioners. VA did issue guidance to its facilities to 
implement fingerprint-only checks for volunteers who have access to 
patients, patient information, or pharmaceuticals.

Implementing fingerprint-only checks for practitioners who are 
currently exempt from background investigations would detect 
practitioners with a criminal history. According to the lead VA Office 
of Inspector General investigator in the Dr. Swango case, if Dr. Swango 
had undergone a fingerprint check at the VA facility where he trained, 
VA facility officials would have identified his criminal history and 
could have taken appropriate action. Additionally, one of the 
facilities we visited had implemented fingerprint-only checks of 
medical residents training in the facility and contract health care 
practitioners. An official at this facility stated that at a minimum, 
fingerprint-only checks of medical residents and contract practitioners 
were necessary to help ensure the safety of veterans in the facility. 
FSMB in 1996 recommended that states perform background investigations, 
including criminal history checks, on medical residents in order to 
better protect patients because residents have varying levels of 
unsupervised patient care. This recommendation, in part, resulted from 
reports that over a 4-year period more than 500 residents had 
performance, behavioral, or criminal problems during their training.

VA Facilities Did Not Comply with All of the Key VA Screening 
Requirements:

In the four facilities we visited, we found mixed compliance with the 
existing key VA screening requirements which are intended to ensure 
that applicants and employed practitioners at VA facilities have valid 
professional credentials and personal backgrounds to deliver safe 
health care to veterans. None of the four VA facilities complied with 
all of the key requirements. Moreover, VA does not conduct oversight of 
its facilities to determine if they comply with these key screening 
requirements.

In order to show the variability in the level of compliance among the 
four VA facilities we visited, we measured their performance against a 
compliance rate of at least 90 percent for each of five of the six 
screening requirements, even though VA allows no deviation from these 
requirements. Table 2 summarizes the rate of compliance among the four 
VA facilities we visited. For detailed information about our analysis 
and each facility's compliance with a particular requirement, see 
appendixes I and II. For the sixth requirementæmatching the educational 
institutions listed by a practitioner against lists of diploma millsæwe 
asked facility officials if they did this check and then asked them to 
produce the lists of diploma mills they use.

Table 2: Facilities' Rate of Compliance with Existing Key VA Screening 
Requirements:

Key screening requirements: Credentials of applicants verified; 
Compliance with key screening requirements[A]: Facility A: Less than 90 
percent compliance rate; 
Compliance with key screening requirements[A]: Facility B; 
Compliance rate of 90 percent or greater; 
Compliance with key screening requirements[A]: Facility C; 
Less than 90 percent compliance rate; 
Compliance with key screening requirements[A]: Facility D; 
Less than 90 percent compliance rate.

Key screening requirements: Credentials of employed practitioners 
verified; 
Compliance with key screening requirements[A]: Facility A; 
Compliance rate of 90 percent or greater; 
Compliance with key screening requirements[A]: Facility B; 
Compliance rate of 90 percent or greater; 
Compliance with key screening requirements[A]: Facility C; 
Compliance rate of 90 percent or greater; 
Compliance with key screening requirements[A]: Facility D; 
Compliance rate of 90 percent or greater.

Key screening requirements: List of Excluded Individuals and Entities 
queried for applicants; 
Compliance with key screening requirements[A]: Facility A; 
Compliance rate of 90 percent or greater; 
Compliance with key screening requirements[A]: Facility B; 
Less than 90 percent compliance rate; 
Compliance with key screening requirements[A]: Facility C; 
Less than 90 percent compliance rate; 
Compliance with key screening requirements[A]: Facility D; 
Less than 90 percent compliance rate.

Key screening requirements: Background investigation completed or 
requested for employed practitioners; 
Compliance with key screening requirements[A]: Facility A; 
Compliance rate of 90 percent or greater; 
Compliance with key screening requirements[A]: Facility B; 
Less than 90 percent compliance rate; 
Compliance with key screening requirements[A]: Facility C; 
Less than 90 percent compliance rate; 
Compliance with key screening requirements[A]: Facility D; 
Compliance rate of 90 percent or greater.

Key screening requirements: Declaration for Federal Employment form 
completed for employed practitioners (form 306); 
Compliance with key screening requirements[A]: Facility A; 
Compliance rate of 90 percent or greater; 
Compliance with key screening requirements[A]: Facility B; 
Compliance rate of 90 percent or greater; 
Compliance with key screening requirements[A]: Facility C; 
Compliance rate of 90 percent or greater; 
Compliance with key screening requirements[A]: Facility D; 
Compliance rate of 90 percent or greater. 

Source: GAO analysis of VA facility files.

Note: Some screening requirements do not require verifying all licenses 
a practitioner might hold or verifying professional credentials by 
contacting state licensing boards or national certifying organizations.

[A] Tested for significance at the 95 percent confidence level.

[End of table]

All four facilities generally complied with VA's existing policies for 
verifying the professional credentials of employed practitioners, 
either by contacting the state licensing board for practitioners, such 
as physicians, or physically inspecting the license or national 
certificate for practitioners, such as nurses and respiratory 
therapists. They also generally ensured that applicants VA intended to 
hire had completed the Declaration for Federal Employment form, which 
requires the applicants to disclose, among other things, information 
about criminal convictions, employment terminations, and delinquencies 
on federal loans. However, three of the four facilities did not follow 
VA's policies for verifying all of the professional credentials of 
applicants and three facilities did not compare applicants' names to 
LEIE prior to hiring them. Two of the four facilities conducted 
background investigations on their employed practitioners at least 90 
percent of the time, but the other two facilities did not.

We also asked officials whether their facilities checked the 
educational institutions listed by an applicant against a list of 
diploma mills to verify that the applicant's degree was not obtained 
from a fraudulent institution. An official at one of the four 
facilities told us his staff consistently performed this check. 
Officials at the other three facilities stated they did not perform the 
check because they did not have a list of diploma mills.

In addition to assessing the rate of compliance with the key screening 
requirements, we found that VA facilities varied in how quickly they 
took action to deal with background investigations that returned 
questionable results, such as discrepancies in work or criminal 
histories. OPM gives a VA facility up to 90 days to take action after 
the facility receives investigation results with questionable findings. 
We reviewed the timeliness of actions taken by facility officials from 
August 1, 2002, to August 23, 2003, at the four facilities we visited 
and six additional facilities geographically spread across the VA 
health care system. We found that officials at 5 of the 10 facilities 
took action within the 90-day time frame, with the number of days 
ranging on average from 13 to 68. Officials at 3 facilities exceeded 
the 90-day time frame on average by 36 to 290 days. One facility took 
action on its cases prior to OPM closing the investigation, and another 
facility did not have the information available to report. For 
additional information on the average number of days it took each 
facility to report its actions, see appendix II.

One of the cases that exceeded the 90-day time frame involved a nursing 
assistant who was hired to work in a VA nursing home in June 2002. In 
August 2002, OPM sent the results of its background investigation to 
the VA facility, reporting that the nursing assistant had been fired 
from a non-VA nursing home for patient abuse. During our review, we 
found this case among stacks of OPM results of background 
investigations that were stored on a cart and in piles on the desk and 
on other work surfaces of a clerk's office. After we brought this case 
to the attention of facility officials in December 2003, they reviewed 
the report and then terminated the employee for not disclosing this 
information on the Declaration for Federal Employment form 306. The 
employee had worked at the VA facility for more than 1 year.

Another case at the same facility that exceeded the 90-day time frame 
involved an employee who had been convicted for possession of illegal 
drugs prior to being hired by VA. He had been hired at the facility in 
August 2002 and was to complete a background investigation form at that 
time. In June 2003, almost 1 year after being hired, a facility 
official realized the employee had not completed and returned this form 
and gave the employee the form to complete. The employee returned the 
completed form in the same month and it was sent to OPM, which returned 
the results of its investigation to the facility in July 2003, before 
the employee's probationary period of 1 year was completed. The OPM 
report revealed numerous arrests for possession of illegal drugs. 
During our December 2003 review and about 120 days after the 
investigation results were returned from OPM, we found this report and 
brought it to the attention of the facility director. Later, a facility 
official told us that VA's regional counsel stated that since the 
employee's 1-year probationary period had ended and the employee had 
disclosed this information on the Declaration for Federal Employment 
form 306, the facility could not take action to terminate the employee.

VA has not conducted oversight of its facilities' compliance with the 
key screening requirements. Instead, VA has relied on OPM to do limited 
reviews of whether facilities were meeting certain human resources 
requirements, such as completion of background investigations. These 
reviews did not include determining whether the facilities were 
verifying professional credentials. Although VA established the Office 
of Human Resources Oversight and Effectiveness in January 2003 to 
conduct such oversight, the office has not conducted any facility 
compliance evaluations. There is no VA policy outlining the human 
resources program evaluations to be performed by this office, and the 
resources have not been provided to support the functions of this 
office.

Conclusions:

VA's screening requirements are intended to ensure the safety of 
veterans by identifying applicants and employed practitioners with 
restricted or fraudulent credentials, criminal backgrounds, or 
questionable work histories. However, gaps in VA's existing screening 
requirements allow some practitioners access to patients without a 
thorough screening of their professional credentials and personal 
backgrounds. For example, although the screening requirements for 
verifying professional credentials for some occupations, such as 
physicians, are adequate, VA does not apply the same screening 
requirements for all occupations with direct patient care access. 
Specifically, VA does not require that all licenses be verified, or 
that licenses and national certificates be verified by contacting state 
licensing boards or national certifying organizations. VA relies on two 
national databases to identify physicians and dentists who have had 
disciplinary actions taken against them. In addition, VA accesses a 
third national database, HIPDB, for physicians and dentists, because 
HIPDB is linked to one of the two national databases VA currently 
accesses. HIPDB is a national database that contains reports of 
disciplinary actions and criminal convictions involving all licensed 
practitioners, not just physicians and dentists. However VA does not 
require facility officials to query HIPDB for all licensed 
practitioners. As a result, practitioners such as nurses, pharmacists, 
and physical therapists do not have their state licenses checked 
against a national database. In addition, VA does not require all 
practitioners with direct patient care access, such as medical 
residents, to have their fingerprints checked against a criminal 
history database. These gaps create vulnerabilities that could allow 
incompetent practitioners or practitioners with the intent to harm 
patients into VA's health care system.

In addition to these gaps, compliance with the existing key screening 
requirements was mixed at the four facilities we visited. None of the 
four facilities complied with all of the key VA screening requirements. 
However, all four facilities generally complied with VA's requirement 
to periodically verify the credentials of practitioners for their 
continued employment. Although VA created the Office of Human Resources 
Oversight and Effectiveness in January 2003 expressly to provide 
oversight of VA's human resources practices at its facilities, it has 
not provided resources for this office to conduct oversight of VA 
facilities' compliance with these requirements. Without such oversight, 
VA cannot provide reasonable assurance that its facilities comply with 
requirements intended to ensure the safety of veterans receiving health 
care in VA facilities. In light of the gaps we found and mixed 
compliance with the key screening requirements by VA facilities, we 
believe effective oversight could reduce the potential risks to the 
safety of veterans receiving health care in VA facilities.

Recommendations for Executive Action:

To better ensure the safety of veterans receiving health care at VA 
facilities, we recommend that the Secretary of Veterans Affairs direct 
the Under Secretary for Health to take the following four actions:

* expand the verification requirement that facility officials contact 
state licensing boards and national certifying organizations to include 
all state licenses and national certificates held by applicants and 
employed practitioners,

* expand the query of the Healthcare Integrity and Protection Data Bank 
to include all licensed practitioners that VA intends to hire and 
periodically query this database for continued employment,

* require fingerprint checks for all health care practitioners who were 
previously exempted from background investigations and who have direct 
patient care access, and:

* conduct oversight to help ensure that facilities comply with all key 
screening requirements for applicants and current employees.

Agency Comments:

In commenting on a draft of this report, VA generally agreed with our 
findings and conclusions. VA acknowledged that we identified gaps in 
its process for conducting background and credentialing checks and that 
we provided what appeared to be reasonable recommendations to close 
those gaps. VA stated that it would provide a detailed action plan to 
implement our recommendations when the final report was issued.

VA said that our draft report inaccurately omitted VA's querying HIPDB 
for practitioners who practice independently. We revised our report to 
clarify that NPDB queries performed by VA automatically check HIPDB for 
these practitioners because the databases are linked. However, VA does 
not perform queries of HIPDB for the majority of its licensed 
practitioners, which includes nurses, pharmacists, physical 
therapists, and dental hygienists. VA also incorrectly stated that the 
draft report did not include VA's requirement to query FSMB for 
physicians. In addition, VA said that it planned to implement 
fingerprint-only checks for all contract health care practitioners, 
medical residents, medical consultants, and practitioners that work 
without direct compensation from VA, as well as certain volunteers. 
However, VA has not issued guidance to its facilities instructing them 
to implement fingerprint-only checks for all these practitioners. 
Further, VA stated that the title of the report implied that veterans 
are receiving inadequate care on a broad basis. We disagree. The title 
reflects vulnerabilities created by the gaps in the screening of 
practitioners that could place veterans at risk by allowing incompetent 
practitioners or those with the intent to harm patients into VA's 
health care system. VA provided technical comments which we 
incorporated, as appropriate. VA's written comments are reprinted in 
appendix III.

As agreed with your office, unless you publicly announce its contents 
earlier, we plan no further distribution of this report until 30 days 
after its date. We will then send copies of this report to the 
Secretary of Veterans Affairs and other interested parties. We also 
will make copies available to others upon request. In addition, the 
report will be available at no charge at the GAO Web site at http://
www.gao.gov.

If you or your staff have any questions about this report, please call 
me at (202) 512-7101. Another contact and key contributors are listed 
in appendix IV.

Sincerely yours,

Signed by: 

Cynthia A. Bascetta 
Director, Health Care--Veterans' Health and Benefits Issues:

[End of section]

Appendix I: Scope and Methodology:

We examined VA's policies and practices that are intended to ensure 
that health care practitioners at its facilities have appropriate 
credentials and backgrounds to provide care to veterans. Specifically, 
we (1) identified key VA screening requirements for its health care 
practitioners, (2) determined the adequacy of these screening 
requirements, and (3) assessed the extent to which selected VA 
facilities complied with these screening requirements.

To identify key VA screening requirements for its health care 
practitioners, we reviewed VA's policies and VA Handbook 5005, which 
explains how to implement the screening policies. We limited our review 
to 43 occupations in VA that have direct patient care access or have an 
impact on patient care. See table 3 for a list of the occupations 
included in our review. To identify the 43 occupations, we consulted 
with VA human resource officials. We interviewed human resource 
officials at VA headquarters and at each facility we visited. We 
classified the practitioners who are required to have professional 
credentialsæa state license or a national certificateæinto three groups 
according to VA's requirements for verifying these credentials. Groups 
A and B represent practitioners who must be licensed to work in VA. 
However, the requirements and process VA uses to verify professional 
credentials is different for each of these groups. Group C represents 
practitioners who must have a national certificate to work in VA and 
may also have a state license. Practitioners not included in the three 
groups are not required to have either a license or a national 
certificate to work in VA facilities.

Table 3: State Licensure and National Certification Requirements for 
the 43 VA Occupations:

Occupation code: 101; 
Occupation title: Social Science; 
Occupations that require a state license to work in VA: No; 
Occupations that require a national certificate to work in VA: No; 
Occupations that do not require a state license or a national 
certificate to work in VA: Yes.

Occupation code: 102; 
Occupation title: Social Science Aid and Technician; 
Occupations that require a state license to work in VA: No; 
Occupations that require a national certificate to work in VA: No; 
Occupations that do not require a state license or a national 
certificate to work in VA: Yes.

Occupation code: 180; 
Occupation title: Psychology; 
Occupations that require a state license to work in VA: Yes; 
Occupations that require a national certificate to work in VA: No; 
Occupations that do not require a state license or a national 
certificate to work in VA: No.

Occupation code: 181; 
Occupation title: Psychology Aid and Technician; 
Occupations that require a state license to work in VA: No; 
Occupations that require a national certificate to work in VA: No; 
Occupations that do not require a state license or a national 
certificate to work in VA: Yes.

Occupation code: 185; 
Occupation title: Social Work; 
Occupations that require a state license to work in VA: Yes; 
Occupations that require a national certificate to work in VA: No; 
Occupations that do not require a state license or a national 
certificate to work in VA: No.

Occupation code: 186; 
Occupation title: Social Services Aid and Assistant; 
Occupations that require a state license to work in VA: No; 
Occupations that require a national certificate to work in VA: No; 
Occupations that do not require a state license or a national 
certificate to work in VA: Yes.

Occupation code: 187; 
Occupation title: Social Services; 
Occupations that require a state license to work in VA: No; 
Occupations that require a national certificate to work in VA: No; 
Occupations that do not require a state license or a national 
certificate to work in VA: Yes.

Occupation code: 189; 
Occupation title: Recreation Aid and Assistant; 
Occupations that require a state license to work in VA: No; 
Occupations that require a national certificate to work in VA: No; 
Occupations that do not require a state license or a national 
certificate to work in VA: Yes.

Occupation code: 413; 
Occupation title: Physiology; 
Occupations that require a state license to work in VA: No; 
Occupations that require a national certificate to work in VA: No; 
Occupations that do not require a state license or a national 
certificate to work in VA: Yes.

Occupation code: 601; 
Occupation title: General Health Science; 
Occupations that require a state license to work in VA: No; 
Occupations that require a national certificate to work in VA: No; 
Occupations that do not require a state license or a national 
certificate to work in VA: Yes.

Occupation code: 602; 
Occupation title: Medical Officer (Physician); 
Occupations that require a state license to work in VA: Yes; 
Occupations that require a national certificate to work in VA: No; 
Occupations that do not require a state license or a national 
certificate to work in VA: No.

Occupation code: 603; 
Occupation title: Physician's Assistant; 
Occupations that require a state license to work in VA: No; 
Occupations that require a national certificate to work in VA: Yes; 
Occupations that do not require a state license or a national 
certificate to work in VA: No.

Occupation code: 605; 
Occupation title: Nurse Anesthetist; 
Occupations that require a state license to work in VA: Yes; 
Occupations that require a national certificate to work in VA: Yes; 
Occupations that do not require a state license or a national 
certificate to work in VA: No.

Occupation code: 610; 
Occupation title: Registered Nurse[A]; 
Occupations that require a state license to work in VA: Yes; 
Occupations that require a national certificate to work in VA: No; 
Occupations that do not require a state license or a national 
certificate to work in VA: No.

Occupation code: 620; 
Occupation title: Practical Nurse; 
Occupations that require a state license to work in VA: Yes; 
Occupations that require a national certificate to work in VA: No; 
Occupations that do not require a state license or a national 
certificate to work in VA: No.

Occupation code: 621; 
Occupation title: Nursing Assistant; 
Occupations that require a state license to work in VA: No; 
Occupations that require a national certificate to work in VA: No; 
Occupations that do not require a state license or a national 
certificate to work in VA: Yes.

Occupation code: 622; 
Occupation title: Medical Supply Aide/Technician; 
Occupations that require a state license to work in VA: No; 
Occupations that require a national certificate to work in VA: No; 
Occupations that do not require a state license or a national 
certificate to work in VA: Yes.

Occupation code: 630; 
Occupation title: Dietitian and Nutritionist; 
Occupations that require a state license to work in VA: No; 
Occupations that require a national certificate to work in VA: Yes; 
Occupations that do not require a state license or a national 
certificate to work in VA: No.

Occupation code: 631; 
Occupation title: Occupational Therapist; 
Occupations that require a state license to work in VA: No; 
Occupations that require a national certificate to work in VA: Yes; 
Occupations that do not require a state license or a national 
certificate to work in VA: No.

Occupation code: 633; 
Occupation title: Physical Therapist; 
Occupations that require a state license to work in VA: Yes; 
Occupations that require a national certificate to work in VA: No; 
Occupations that do not require a state license or a national 
certificate to work in VA: No.

Occupation code: 635; 
Occupation title: Corrective Therapist; 
Occupations that require a state license to work in VA: No; 
Occupations that require a national certificate to work in VA: No; 
Occupations that do not require a state license or a national 
certificate to work in VA: Yes.

Occupation code: 636; 
Occupation title: Rehabilitation Therapy Assistant; 
Occupations that require a state license to work in VA: No; 
Occupations that require a national certificate to work in VA: No; 
Occupations that do not require a state license or a national 
certificate to work in VA: Yes.

Occupation code: 638; 
Occupation title: Recreation/Creative Arts Therapist; 
Occupations that require a state license to work in VA: No; 
Occupations that require a national certificate to work in VA: No; 
Occupations that do not require a state license or a national 
certificate to work in VA: Yes.

Occupation code: 640; 
Occupation title: Health Aid and Technician; 
Occupations that require a state license to work in VA: No; 
Occupations that require a national certificate to work in VA: No; 
Occupations that do not require a state license or a national 
certificate to work in VA: Yes.

Occupation code: 644; 
Occupation title: Medical Technologist; 
Occupations that require a state license to work in VA: No; 
Occupations that require a national certificate to work in VA: No; 
Occupations that do not require a state license or a national 
certificate to work in VA: Yes.

Occupation code: 645; 
Occupation title: Medical Technician; 
Occupations that require a state license to work in VA: No; 
Occupations that require a national certificate to work in VA: No; 
Occupations that do not require a state license or a national 
certificate to work in VA: Yes.

Occupation code: 646; 
Occupation title: Pathology Technician; 
Occupations that require a state license to work in VA: No; 
Occupations that require a national certificate to work in VA: No; 
Occupations that do not require a state license or a national 
certificate to work in VA: Yes.

Occupation code: 647; 
Occupation title: Diagnostic Radiologic Technologist; 
Occupations that require a state license to work in VA: No; 
Occupations that require a national certificate to work in VA: Yes; 
Occupations that do not require a state license or a national 
certificate to work in VA: No.

Occupation code: 648; 
Occupation title: Therapeutic Radiologic Technologist; 
Occupations that require a state license to work in VA: No; 
Occupations that require a national certificate to work in VA: Yes; 
Occupations that do not require a state license or a national 
certificate to work in VA: No.

Occupation code: 649; 
Occupation title: Medical Instrument Technician; 
Occupations that require a state license to work in VA: No; 
Occupations that require a national certificate to work in VA: No; 
Occupations that do not require a state license or a national 
certificate to work in VA: Yes.

Occupation code: 651; 
Occupation title: Respiratory Therapist[B]; 
Occupations that require a state license to work in VA: No; 
Occupations that require a national certificate to work in VA: Yes; 
Occupations that do not require a state license or a national 
certificate to work in VA: No.

Occupation code: 660; 
Occupation title: Pharmacist; 
Occupations that require a state license to work in VA: Yes; 
Occupations that require a national certificate to work in VA: No; 
Occupations that do not require a state license or a national 
certificate to work in VA: No.

Occupation code: 661; 
Occupation title: Pharmacy Technician; 
Occupations that require a state license to work in VA: No; 
Occupations that require a national certificate to work in VA: No; 
Occupations that do not require a state license or a national 
certificate to work in VA: Yes.

Occupation code: 662; 
Occupation title: Optometrist; 
Occupations that require a state license to work in VA: Yes; 
Occupations that require a national certificate to work in VA: No; 
Occupations that do not require a state license or a national 
certificate to work in VA: No.

Occupation code: 665; 
Occupation title: Speech Pathology and Audiology; 
Occupations that require a state license to work in VA: No; 
Occupations that require a national certificate to work in VA: No; 
Occupations that do not require a state license or a national 
certificate to work in VA: Yes.

Occupation code: 667; 
Occupation title: Orthotist and Prosthetist; 
Occupations that require a state license to work in VA: No; 
Occupations that require a national certificate to work in VA: No; 
Occupations that do not require a state license or a national 
certificate to work in VA: Yes.

Occupation code: 668; 
Occupation title: Podiatrist; 
Occupations that require a state license to work in VA: Yes; 
Occupations that require a national certificate to work in VA: No; 
Occupations that do not require a state license or a national 
certificate to work in VA: No.

Occupation code: 672; 
Occupation title: Prosthetic Representative; 
Occupations that require a state license to work in VA: No; 
Occupations that require a national certificate to work in VA: No; 
Occupations that do not require a state license or a national 
certificate to work in VA: Yes.

Occupation code: 680; 
Occupation title: Dental Officer (Dentist); 
Occupations that require a state license to work in VA: Yes; 
Occupations that require a national certificate to work in VA: No; 
Occupations that do not require a state license or a national 
certificate to work in VA: No.

Occupation code: 681; 
Occupation title: Dental Assistant; 
Occupations that require a state license to work in VA: No; 
Occupations that require a national certificate to work in VA: Yes; 
Occupations that do not require a state license or a national 
certificate to work in VA: No.

Occupation code: 682; 
Occupation title: Dental Hygiene; 
Occupations that require a state license to work in VA: Yes; 
Occupations that require a national certificate to work in VA: No; 
Occupations that do not require a state license or a national 
certificate to work in VA: No.

Occupation code: 1320; 
Occupation title: Chemistry; 
Occupations that require a state license to work in VA: No; 
Occupations that require a national certificate to work in VA: No; 
Occupations that do not require a state license or a national 
certificate to work in VA: Yes.

Occupation code: 1715; 
Occupation title: Vocational Rehabilitation; 
Occupations that require a state license to work in VA: No; 
Occupations that require a national certificate to work in VA: No; 
Occupations that do not require a state license or a national 
certificate to work in VA: Yes. 

Source: VA Handbook 5005, April 15, 2002.

[A] Registered Nurse--includes nurse practitioners and clinical nurse 
specialists.

[End of table]

To determine the adequacy of the key VA screening requirements, we 
analyzed VA's policies and procedures to identify whether there were 
inconsistencies in how the requirements were applied among various 
types of practitioners. We interviewed VA headquarters and facility 
officials and practitioners at the facilities we visited to determine 
how VA's policies are implemented in facilities. In addition, we 
interviewed representatives from 13 state licensing boards and the 
District of Columbia Board of Nursing and 2 national certifying 
organizations to determine if VA's requirements for verifying 
professional credentials are adequate for identifying practitioners 
without valid and unrestricted state licenses and national 
certificates.[Footnote 17]

To assess the extent to which VA facilities we visited complied with 
the key screening requirements, we chose a judgmental sample of four VA 
facilities that varied in size, location, and medical school 
affiliations to assess the extent to which these selected facilities 
complied with these requirements. The four facilities are located in 
Big Spring, Texas; New Orleans, Louisiana; Seattle, Washington; and the 
District of Columbia. We chose these facilities based on geographic 
variation, affiliations with medical schools to train residents, and 
types of health care services provided. Of the four facilities we 
visited, three are large facilities located in major metropolitan areas 
and each are affiliated with at least one medical school. The remaining 
facility is small, providing mainly primary care and long-term care 
services to veterans and is located in a rural area. For each facility, 
VA provided, from its automated pay system, a list of current 
practitioners in the 43 occupations. As a result of using VA's 
automated pay system, our sample does not include those practitioners 
providing care through a contract or training agreement or without 
direct compensation from VA. For each of the four facilities, we 
selected a random sample of 100 practitioners either hired or assigned 
to their current position no earlier than January 1, 1993. We chose to 
limit our review to approximately the last 10 years because VA changed 
its process for credentials verification in the early 1990s. For each 
of these practitioners, we reviewed their personnel files to check that 
the facility had complied with the following key VA screening 
requirements:

* verify state licenses and national certificates for applicants;

* verify state licenses and national certificates for employed 
practitioners;

* query the List of Excluded Individuals and Entities (LEIE) prior to 
hire;

* ensure completion of background investigations, including 
fingerprints;

* ensure completion of the Declaration for Federal Employment form, 
also known as form 306; and:

* verify that the educational institutions listed by a practitioner VA 
intends to hire are checked against lists of diploma mills.

In order to show the variability in the level of compliance among the 
four VA facilities we visited, we distinguished between facilities that 
had a compliance rate of at least 90 percent for each of five of the 
six screening requirements and those that did not. For each facility 
and key screening requirement, we compared the percentage of personnel 
files found in compliance to an acceptance level of 90 percent. In 
order to confirm that a requirement had a compliance rate less than 90 
percent, we performed a one-sided significance test at the 95 percent 
confidence level. See appendix II for detailed information on the four 
VA facilities' compliance with each of the key VA screening 
requirements. Our results from these four facilities cannot be 
generalized to other facilities. In order to determine compliance with 
the key screening requirement to verify that the educational 
institutions listed by a practitioner are not fraudulent, we asked 
facility human resources staff if they performed this screening and 
asked them to produce their lists of diploma mills.

Additionally, we reviewed VA facilities' response times to 214 
background investigation results returned from OPM with questionable 
issues, from August 1, 2002, to August 23, 2003, at the four locations 
we visited and six other VA facilities selected based on geographic 
location. The six additional facilities were located in Boston, 
Massachusetts; East Orange, New Jersey; Indianapolis, Indiana; Palo 
Alto, California; Portland, Oregon; and San Diego, California. For 
these 10 facilities, we asked officials to provide the date they took 
action on cases returned from OPM, and from VA headquarters we obtained 
the dates when OPM returned the cases to the facility. We determined 
the average number of days it took each facility to take action after 
these cases were returned from OPM with questionable issues. Our 
results cannot be generalized to other VA facilities. See appendix II 
for detailed information on the results of our analysis.

[End of section]

Appendix II: Results of Our Compliance Reviews at VA Facilities:

Tables 4 and 5 show the sample counts used to measure compliance and 
the results of our review for five of the requirements. Table 6 shows 
the average number of days it took each facility to take action after 
cases with questionable issues were returned from OPM.

Table 4: VA Facility Compliance with Key Screening 
RequirementsæProfessional Credentials Verification:

Facility: Facility A; 
Credentials of applicants verified: Number in sample: 81; 
Credentials of applicants verified: Number where verification followed 
VA policy: 61; 
Credentials of employed practitioners verified: Number in sample: 74; 
Credentials of employed practitioners verified: Number where 
verification followed VA policy: 74.

Facility: Facility B; 
Credentials of applicants verified: Number in sample: 77; 
Credentials of applicants verified: Number where verification followed 
VA policy: 71; 
Credentials of employed practitioners verified: Number in sample: 59; 
Credentials of employed practitioners verified: Number where 
verification followed VA policy: 59.

Facility: Facility C; 
Credentials of applicants verified: Number in sample: 74; 
Credentials of applicants verified: Number where verification followed 
VA policy: 43; 
Credentials of employed practitioners verified: Number in sample: 67; 
Credentials of employed practitioners verified: Number where 
verification followed VA policy: 67.

Facility: Facility D; 
Credentials of applicants verified: Number in sample: 62; 
Credentials of applicants verified: Number where verification followed 
VA policy: 47; 
Credentials of employed practitioners verified: Number in sample: 56; 
Credentials of employed practitioners verified: Number where 
verification followed VA policy: 55. 

Source: GAO analysis of facility files.

Note: The number of practitioners in the sample may be less than the 
number of practitioner files reviewed at each facility because the 
requirement may not apply to all VA applicants or employed 
practitioners.

[End of table]

Table 5: Facility Compliance with Key Screening Requirements--Personal 
Background Screening:

Facility: Facility A; 
List of Excluded Individuals and Entities (LEIE) queried 
for applicants prior to hiring: Number in sample: 61; 
List of Excluded Individuals and Entities (LEIE) queried 
for applicants prior to hiring: Number queried prior to hire: 53; 
Background investigation completed or requested for 
employed practitioners: Number in sample: 99[A]; 
Background investigation completed or requested for 
employed practitioners: Number with a completed or requested background 
investigation: 93; 
Declaration for Federal Employment form (form 306) completed for 
employed practitioners: Number in sample: 94; 
Declaration for Federal Employment form (form 306) completed for 
employed practitioners: Number with completed form 306: 92.

Facility: Facility B; 
List of Excluded Individuals and Entities (LEIE) queried 
for applicants prior to hiring: Number in sample: 72; 
List of Excluded Individuals and Entities (LEIE) queried 
for applicants prior to hiring: Number queried prior to hire: 26; 
Background investigation completed or requested for 
employed practitioners: Number in sample: 99[B]; 
Background investigation completed or requested for 
employed practitioners: Number with a completed or requested background 
investigation: 27; 
Declaration for Federal Employment form (form 306) completed for 
employed practitioners: Number in sample: 93; 
Declaration for Federal Employment form (form 306) completed for 
employed practitioners: Number with completed form 306: 80.

Facility: Facility C; 
List of Excluded Individuals and Entities (LEIE) queried 
for applicants prior to hiring: Number in sample: 64; 
List of Excluded Individuals and Entities (LEIE) queried 
for applicants prior to hiring: Number queried prior to hire: 5; 
Background investigation completed or requested for 
employed practitioners: Number in sample: 100; 
Background investigation completed or requested for 
employed practitioners: Number with a completed or requested background 
investigation: 47; 
Declaration for Federal Employment form (form 306) completed for 
employed practitioners: Number in sample: 83; 
Declaration for Federal Employment form (form 306) completed for 
employed practitioners: Number with completed form 306: 77.

Facility: Facility D; 
List of Excluded Individuals and Entities (LEIE) queried 
for applicants prior to hiring: Number in sample: 66; 
List of Excluded Individuals and Entities (LEIE) queried 
for applicants prior to hiring: Number queried prior to hire: 39; 
Background investigation completed or requested for 
employed practitioners: Number in sample: 100; 
Background investigation completed or requested for 
employed practitioners: Number with a completed or requested background 
investigation: 98; 
Declaration for Federal Employment form (form 306) completed for 
employed practitioners: Number in sample: 92; 
Declaration for Federal Employment form (form 306) completed for 
employed practitioners: Number with completed form 306: 86. 

Source: GAO analysis of facility files.

Note: The number of practitioners in the sample may be less than the 
number of practitioner files reviewed at each facility because the 
requirement may not apply to all VA applicants or employed 
practitioners.

[A] One personnel file was not available because the practitioner 
resigned and the file was sent to storage.

[B] Facility B was unable to locate one personnel file; therefore, we 
sampled 99 files at that location.

[End of table]

Table 6: Average Number of Days from Obtaining Background Investigation 
Results to VA Facility Action (August 1, 2002, to August 23, 2003):

Facility: Facility A; Average number of days for facility action: 13; 
Number of background investigation results reviewed: 14.

Facility: Facility B; Average number of days for facility action: 282; 
Number of background investigation results reviewed: 41.

Facility: Facility C; Average number of days for facility action: 21; 
Number of background investigation results reviewed: 15.

Facility: Facility D; Average number of days for facility action: -
14[A]; Number of background investigation results reviewed: 17.

Facility: Facility E; Average number of days for facility action: 26; 
Number of background investigation results reviewed: 11.

Facility: Facility F; Average number of days for facility action: 34; 
Number of background investigation results reviewed: 43.

Facility: Facility G; Average number of days for facility action: 68; 
Number of background investigation results reviewed: 39.

Facility: Facility H; Average number of days for facility action: 126; 
Number of background investigation results reviewed: 33.

Facility: Facility I; Average number of days for facility action: 380; 
Number of background investigation results reviewed: 1.

Facility: Facility J; Average number of days for facility action: No 
data available; Number of background investigation results reviewed: No 
data available.

Source: GAO analysis of facility data.

[A] A negative number of days indicates that the facility took action 
on its cases before OPM returned the investigation results.

[End of table]

[End of section]

Appendix III: Comments from the Department of Veterans Affairs:

THE SECRETARY OF VETERANS AFFAIRS 
WASHINGTON:

March 26, 2004:

Ms. Cynthia A. Bascetta Director:

Heath Care Team:

U. S. General Accounting Office 
441 G Street, NW:
Washington, DC 20548:

Dear Ms. Bascetta:

The Department of Veterans Affairs (VA) has reviewed your draft report, 
VA HEALTH CARE: Improved Screening of Practitioners Would Reduce Risk 
to Veterans (GAO-04-566) and generally agrees with your findings and 
conclusions. As the Department was provided a limited time to review 
the draft report, VA will provide the General Accounting Office (GAO) 
with a detailed action plan to implement the recommendations in its 
comments to the final report.

VA is committed to ensuring that the practitioners who are responsible 
for delivering quality health care to our Nations veterans and their 
beneficiaries are qualified to do so both in professional 
qualifications and personal ethical integrity. To this end, VA has 
developed a set of policies and procedures to ensure that its 
practitioners are of the caliber needed for such a high calling. VA 
recognizes the accuracy in the report's description of VA's policies 
and requirements for conducting background and credentialing checks. 
GAO identifies gaps in VA's process and provides what appear to be 
reasonable recommendations to close those gaps.

However, VA offers some suggestions for the overall accuracy of GAO's 
message. GAO acknowledges that VA's requirements for verifying 
professional credentials of practitioners in Group A, such as 
physicians and dentists, are complete and thorough.

Broad statements throughout the report, including the recommendations, 
do not differentiate between the fully credentialed licensed 
independent practitioners (i.e., all physicians, dentists, most 
optometrists and podiatrists and other credentialed professionals such 
as psychologists, pharmacists, advanced practice registered nurses and 
social workers who practice independently by law and facility approval) 
and the remaining licensed practitioners. For all individuals 
privileged to provide care without supervision, VA does query the 
National Practitioner Data Bank and the Health Integrity and Protection 
Data Bank. In addition, VA queries the Federation of State Medical 
Boards' Data Center on all 
physicians. VA believes that a clearer view of VA's credentialing 
process would be presented if GAO acknowledged these data queries.

In addition, the draft report title strongly implies that veterans are 
receiving inadequate care on a broad basis. VA suggests the title be 
revised to "Improved Screening of Practitioners Would Enhance Safety of 
Veterans.":

The enclosure discusses technical corrections VA believes would improve 
the overall accuracy and clarity of GAO's report. The Department 
appreciates the opportunity to review and comment on your draft report.

Sincerely yours,

Signed by: 

Anthony J. Principi:

Enclosure:

[End of section]

Appendix IV: GAO Contact and Staff Acknowledgments:

GAO Contact:

Marcia A. Mann, (202) 512-9526:

Acknowledgments:

In addition to the contact named above, Jacquelyn T. Clinton, Jessica 
Cobert, Mary Ann Curran, Martha A. Fisher, Krister Friday, Lesia 
Mandzia, and Marie Stetser made key contributions to this report.

FOOTNOTES

[1] Contract staff may include intensive care nurses, emergency room 
physicians, or respiratory therapists. These staff have access to and 
provide care to patients.

[2] Although VA has many employment screening requirements, such as 
whether the applicant is a United States citizen, we selected only 
those requirements that pertain to patient safety, such as verification 
of credentials and background investigations. 

[3] State licenses are issued by offices in states, territories, 
commonwealths, or the District of Columbia, collectively referred to as 
state licensing boards.

[4] Some practitioners may hold both a national certificate and a state 
license.

[5] Professional credentials held by practitioners may include 
licenses, registrations, and certifications. We refer to these 
credentials as state licenses or national certificates.

[6] The term applicants refers to those practitioners that VA facility 
officials plan to hire.

[7] The frequency of when practitioners' credentials are checked 
depends on their occupation and the requirements of the state or 
national organization that issued the credential.

[8] We use the term employed practitioners to refer to practitioners 
who have been hired by VA and to distinguish them from practitioners 
who have applied for VA employment, but have not been hired. 

[9] The requirement for respiratory therapists to renew their national 
certificate every 5 years became effective in July 2002 and affects 
those national certificates obtained after June 30, 2002.

[10] FSMB represents state medical licensing boards and establishes 
standards for physician licensure and practice. FSMB operates a 
national database to collect, record, and distribute to state medical 
boards and other appropriate agencies data on disciplinary actions 
taken against physicians by the boards and other governmental 
authorities. 

[11] The Health Resources and Services Administration of the Department 
of Health and Human Services is responsible for the management of NPDB.

[12] The Balanced Budget Act significantly expanded the authority of 
the Department of Health and Human Services to exclude certain 
individuals and entities from participation in federal health care 
programs. Exclusion is mandatory for those convicted of Medicare-
related crimes, patient abuse, and certain health care fraud and 
controlled substance crimes. Exclusion is permissive for other 
offenses, including professional health care license revocation. See 
Pub. L. No. 105-33 § 4331(c), 111 Stat. 251, 396; 42 U.S.C. § 1320a-7.

[13] Executive Order 10450, April 27, 1953, requires all persons 
employed by federal departments and agencies to undergo a background 
investigation to ensure that their employment is consistent with 
national security interests. It is administered by the Office of 
Personnel Management (OPM), which has issued implementing regulations 
in part 732 of Title 5 of the Code of Federal Regulations. OPM may 
grant exemptions to the executive order and, with regard to VA, 
background investigations are not required for employees appointed for 
6 months or less. Related regulations regarding determinations of an 
individual's suitability for federal employment, based on their 
character, conduct, knowledge, and ability, are contained in part 732 
of the Code of Federal Regulations.

[14] HIPDB was developed after the Health Insurance Portability and 
Accountability Act of 1996 was enacted, which added new section 1128E 
to the Social Security Act, requiring development of the database. See 
Pub. L. No. 104-191, § 221(a), 110 Stat. 1936, 2009 (codified at 42 
U.S.C. § 1320a-7e(2000)). The applicable regulations are contained in 
Part 61 of Title 45 of the Code of Federal Regulations. HIPDB is 
maintained and operated by the Health Resources and Services 
Administration in the Department of Health and Human Services.

[15] VA's volunteer program is the largest in the federal government, 
providing volunteers to assist veterans by augmenting staff in such 
settings as hospitals and nursing homes. 

[16] Departments and agencies may obtain fingerprints in two ways: 
either using paper or using computerized technology, which became 
available in 1999. Computerized technology typically produces 
fingerprint match results in 2 days.

[17] The licensing boards contacted were Alabama, Arkansas, California, 
Delaware, District of Columbia, Florida, Indiana, Louisiana, 
Massachusetts, New Jersey, New Mexico, Oregon, Texas, and Washington. 
The national certifying organizations contacted were the National Board 
for Respiratory Care and the National Board for Certification in 
Occupational Therapy. 

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