This is the accessible text file for GAO report number GAO-06-544 
entitled 'VA Health Care: Steps Taken to Improve Practitioner 
Screening, but Facility Compliance with Screening Requirements Is Poor' 
which was released on June 15, 2006. 

This text file was formatted by the U.S. Government Accountability 
Office (GAO) to be accessible to users with visual impairments, as part 
of a longer term project to improve GAO products' accessibility. Every 
attempt has been made to maintain the structural and data integrity of 
the original printed product. Accessibility features, such as text 
descriptions of tables, consecutively numbered footnotes placed at the 
end of the file, and the text of agency comment letters, are provided 
but may not exactly duplicate the presentation or format of the printed 
version. The portable document format (PDF) file is an exact electronic 
replica of the printed version. We welcome your feedback. Please E-mail 
your comments regarding the contents or accessibility features of this 
document to Webmaster@gao.gov. 

This is a work of the U.S. government and is not subject to copyright 
protection in the United States. It may be reproduced and distributed 
in its entirety without further permission from GAO. Because this work 
may contain copyrighted images or other material, permission from the 
copyright holder may be necessary if you wish to reproduce this 
material separately. 

Report to the Chairman, Committee on Veterans' Affairs, House of 
Representatives: 

United States Government Accountability Office: 

GAO: 

May 2006: 

VA Health Care: 

Steps Taken to Improve Practitioner Screening, but Facility Compliance 
with Screening Requirements Is Poor: 

VA Screening of Practitioners: 

GAO-06-544: 

GAO Highlights: 

Highlights of GAO-06-544, a report to the Chairman, Committee on 
Veterans’ Affairs, House of Representatives. 

Why GAO Did This Study: 

In March 2004, GAO reported on gaps in VA’s requirements for screening 
the professional credentials and personal backgrounds of health care 
practitioners (GAO-04-566). GAO found that VA’s requirements did not 
ensure thorough screening of VA practitioners. VA concurred with four 
recommendations GAO made to improve practitioner screening. 

GAO was asked to determine the extent to which (1) VA has taken steps 
to improve practitioner screening by implementing GAO’s recommendations 
and (2) VA facilities are in compliance with VA’s practitioner 
screening requirements. GAO reviewed VA’s current practitioner 
screening policies to determine if gaps remain, interviewed VA 
officials, and sampled about 60 practitioner files at each of seven VA 
facilities selected based on size and geographic location. 

What GAO Found: 

VA has taken steps to improve health care practitioner screening by 
partially implementing each of four recommendations made in GAO’s March 
2004 report; 
however, gaps still remain in VA’s practitioner screening requirements. 
In response to two of GAO’s recommendations, VA expanded its screening 
requirements for all VA applicants to include a verification of all 
state licenses and national certificates and requires facility 
officials to query the Healthcare Integrity and Protection Data Bank 
(HIPDB), which contains information on individuals involved in health 
care-related civil judgments and criminal convictions and licensing and 
certification actions. VA, however, has not yet expanded these 
screening requirements to apply to all health care practitioners 
currently employed at VA facilities, as GAO recommended. In response to 
the third GAO recommendation, VA issued a policy in August 2005 that 
requires individuals who previously were exempt from receiving any 
level of background investigation to have, at a minimum, their 
fingerprints screened against a criminal history database. As of 
October 19, 2005, 37 VA medical facilities had not fully implemented 
this new requirement because they had not obtained or installed the 
necessary electronic fingerprint equipment. Since then VA has made 
progress; 
as of February 1, 2006, 2 medical facilities had not installed the 
equipment. Finally, VA has partially implemented GAO’s fourth 
recommendation to conduct oversight of its facilities’ compliance with 
VA practitioner screening requirements; 
however, GAO found the oversight does not address all of the facility 
compliance issues GAO previously identified. 

GAO found poor compliance with four of the five selected VA 
practitioner screening requirements at the seven VA facilities visited 
in 2005. None of the seven facilities had a compliance rate of 90 
percent or more for all five screening requirements GAO reviewed. Two 
facilities that had implemented VA’s fingerprint-only background 
investigations—a relatively new form of background investigation—did 
not comply with VA’s requirement to document that the results of the 
fingerprint check against a criminal history database had been reviewed 
and used to make a decision on the individual’s suitability to work at 
a VA medical facility. 

Figure: Facilities’ Rates of Compliance with Select VA Screening 
Requirements for Health Care Practitioners (2005): 

[See PDF for Image] 

[End of Figure] 

What GAO Recommends: 

GAO recommends that VA expand its oversight program to include a review 
of VA screening requirements for all types of health care practitioners 
and that VA standardize a method for documenting the review of 
fingerprint-only investigation results. VA agreed with GAO’s findings 
and concurred with the recommendations. VA further stated that it will 
provide an action plan on how it will implement the recommendations at 
a later date. 

[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-06-544]. 

To view the full product, including the scope and methodology, click on 
the link above. For more information, contact Laurie E. Ekstrand at 
(202) 512-7101 or ekstrandl@gao.gov. 

[End of Section] 

Contents: 

Letter: 

Results in Brief: 

Background: 

VA Has Taken Steps to Improve Health Care Practitioner Screening 
Requirements, but Gaps Remain: 

VA Facilities Did Not Comply with Health Care Practitioner Screening 
Requirements: 

Conclusions: 

Recommendations for Executive Action: 

Agency Comments: 

Appendix I: Scope and Methodology: 

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

Appendix III: Comments from the Department of Veterans Affairs: 

Appendix IV: GAO Contact and Staff Acknowledgments: 

Tables: 

Table 1: State Licensure and National Certification Requirements for 
the 43 VA Occupations: 

Table 2: Health Care Practitioners Included in Our Review of Select VA 
Screening Requirements and the Documentation Required to Demonstrate 
Compliance: 

Table 3: VA Facility Compliance with Screening Requirements for 
Salaried Health Care Practitioners--Background Investigations (2005): 

Table 4: VA Facility Compliance with Screening Requirements for Fee 
Basis and WOC Health Care Practitioners--Background Investigations 
(2005): 

Table 5: VA Facility Compliance with Screening Requirements for 
Salaried Health Care Practitioners--HIPDB Query and State License and 
National Certificate Verification (2005): 

Table 6: VA Facility Compliance with Screening Requirements for 
Salaried Health Care Practitioners--Employment Checklist Completed and 
Position Risk Level Determined (2005): 

Figures: 

Figure 1: Gaps Identified in VA's Process for Verifying Health Care 
Practitioner Credentials with State Licensing Boards and National 
Certifying Organizations, March 2004: 

Figure 2: Facilities' Rates of Compliance with Select VA Screening 
Requirements for Salaried Health Care Practitioners (2005): 

Figure 3: Background Investigation Compliance Rates for Salaried Health 
Care Practitioners at Revisited VA Medical Facilities (2005): 

Figure 4: VA Facility Compliance with Background Investigation 
Screening Requirements for Fee Basis and WOC Health Care Practitioners 
(2005): 

Abbreviations: 

HHS: Department of Health and Human Services: 
HIPDB: Healthcare Integrity and Protection Data Bank: 
HRM: Office of Human Resource Management: 
OPM: Office of Personnel Management: 
SLB: state licensing board :
VA: Department of Veterans Affairs: 
WOC: without compensation: 

United States Government Accountability Office: 

Washington, DC 20548: 

May 25, 2006: 

The Honorable Steve Buyer: 
Chairman: 
Committee on Veterans' Affairs: 
House of Representatives: 

Dear Mr. Chairman: 

The Department of Veterans Affairs (VA) is responsible for ensuring 
that its health care practitioners are qualified to provide care to 
their patients. VA employs more than 193,000 individuals at its medical 
facilities, including physicians, nurses, pharmacists, and therapists. 
In addition, VA supplements these salaried health care practitioners 
with nonsalaried health care practitioners obtained through contracts 
and fee-for-service arrangements (fee basis),[Footnote 1] as well as 
nonsalaried practitioners working without direct compensation from VA 
(without compensation or WOC). To help ensure that VA's salaried and 
nonsalaried health care practitioners hold the necessary professional 
credentials to provide care,[Footnote 2] VA has screening requirements 
that VA medical facility officials must follow in verifying these 
credentials and checking practitioners' personal backgrounds for 
evidence of incompetence or criminal behavior. 

In March 2004, we reported and testified on gaps in VA's screening 
requirements.[Footnote 3] We found that VA did not require that all of 
its health care practitioners with access to patients be thoroughly 
screened. In addition, we found mixed compliance with existing VA 
screening requirements at each of the four VA medical facilities we 
visited. We concluded that the gaps in and mixed compliance with VA's 
screening requirements created vulnerabilities that could allow VA to 
employ health care practitioners who could either place patients at 
risk of receiving poor care or cause them intentional harm. In our 2004 
report, we made four recommendations to address the gaps we identified 
in VA's screening requirements and the noncompliance we found at the 
four VA medical facilities we visited. 

VA concurred with our recommendations to: 

² expand verification of all state licenses and national certificates 
by contacting the appropriate licensing boards and national certifying 
organizations for all VA health care practitioners, 

² expand query of the Healthcare Integrity and Protection Data Bank 
(HIPDB)[Footnote 4] to include all licensed health care practitioners 
at VA facilities, 

² conduct fingerprint-only background investigations for all VA health 
care practitioners with direct patient care access,[Footnote 5] and: 

² conduct oversight of medical facilities to ensure compliance with all 
of VA's key screening requirements. 

You asked us to determine the status of VA's implementation of these 
recommendations to strengthen its health care practitioner screening 
requirements. In this report, we determined the extent to which (1) VA 
has taken steps to improve health care practitioner screening by 
implementing the four recommendations made in our March 2004 report and 
(2) VA medical facilities are in compliance with VA's health care 
practitioner screening requirements. 

To determine the extent to which VA has taken steps to improve health 
care practitioner screening by implementing the four recommendations 
made in our March 2004 report, we interviewed VA headquarters and 
facility officials and reviewed VA's policies and procedures that 
contain current health care practitioner screening requirements to see 
if the gaps we identified in 2004 were closed. We also reviewed the 
report of a task force VA formed to improve its health care 
practitioner screening procedures following the issuance of our 2004 
report. 

To determine the extent to which VA medical facilities complied with VA 
health care practitioner screening requirements, we selected seven VA 
medical facilities to visit. These facilities varied in terms of size 
and geographic location. Two of the seven facilities we visited were 
sites from our previous review. We visited facilities located in Fargo, 
North Dakota; Kansas City, Missouri; Miami, Florida; New Orleans, 
Louisiana; Salt Lake City, Utah; San Antonio, Texas; and the District 
of Columbia.[Footnote 6] For each facility, VA provided from its 
automated pay system a list of salaried health care practitioners in 
the 43 occupations we included in our previous report. At each facility 
we reviewed a random sample of personnel files to determine whether the 
files included documentation demonstrating that the facility's health 
care practitioners had their professional credentials verified and 
backgrounds checked in compliance with VA's screening requirements. At 
each of the facilities, our sample of personnel files consisted of 
about 50 personnel files for salaried health care practitioners who 
were hired prior to October 1, 2004, and 10 to 12 personnel files for 
salaried health practitioners who were hired on or after October 1, 
2004.[Footnote 7] In addition to the random sample of salaried health 
care practitioners, we also reviewed at each facility 20 personnel 
files for nonsalaried health care practitioners paid by VA on a fee 
basis and all of the files for the facility's WOC health care 
practitioners who work in a clinical area at the facility.[Footnote 8] 
In collecting information on the screening requirements from personnel 
files at each facility, we employed standard data collection techniques 
to ensure the accuracy and reliability of the data used in this report. 
At each facility we also reviewed about five contracts that the 
facility used to supplement its health care practitioner staffing in 
order to determine how facility officials screen the personal 
backgrounds and professional credentials of these nonsalaried health 
care practitioners. Finally, at each facility we also interviewed the 
officials responsible for coordinating volunteer activities to 
determine how volunteers are screened prior to beginning work at the 
facility.[Footnote 9] 

To measure the seven facilities' compliance with VA's health care 
practitioner screening requirements, we selected five requirements for 
our review. Although VA has multiple employment screening 
requirements,[Footnote 10] we selected five that pertain to 
safeguarding veterans receiving health care in VA facilities. The 
screening requirements we selected for salaried health care 
practitioners are (1) completing VA Form 2280, which medical facility 
officials must do in order to determine the appropriate type of 
background investigation needed for each health care practitioner job 
category; (2) performing a background investigation; (3) querying 
HIPDB; (4) completing an employment checklist, which VA officials are 
to use to document the completion of VA screening requirements for 
those salaried health care practitioners VA intends to hire; and (5) 
verifying the status of state licenses and national certificates. In 
addition, we measured facility compliance with one of these screening 
requirements, performing a background investigation, for VA nonsalaried 
fee basis and WOC health care practitioners. To show the variability in 
the level of compliance among the seven VA facilities we visited, we 
distinguished between facilities that had a compliance rate of at least 
90 percent of the personnel files we reviewed for each of the five 
screening requirements and facilities that did not. VA requires a 
compliance rate of 100 percent. Our findings for the screening 
requirements cannot be generalized to other VA facilities. 

For a complete description of our scope and methodology, see appendix 
I. Our work was conducted from April 2005 through April 2006 in 
accordance with generally accepted government auditing standards. 

Results in Brief: 

Although VA has taken steps to improve health care practitioner 
screening by partially implementing each of the four recommendations 
made in our March 2004 report, gaps still remain in VA's health care 
practitioner screening requirements. For all health care practitioners 
applying for VA employment, VA expanded its screening requirements to 
require verification of all the state licenses and national 
certificates these practitioners hold and require facility officials to 
query HIPDB before the practitioners are hired. However, VA has not 
expanded these screening requirements so that they apply to all health 
care practitioners currently employed at VA medical 
facilities.[Footnote 11] We reviewed a draft VA policy that when issued 
will fully address our recommendation to require medical facility 
officials to verify all state licenses and national certificates of 
currently employed health care practitioners with the relevant issuing 
boards or organizations. In response to our recommendation to expand 
the use of fingerprint-only background investigations for those 
previously exempt from receiving any kind of background investigation, 
VA issued a policy in August 2005 requiring these individuals to have, 
at a minimum, a fingerprint-only background investigation, in which 
fingerprints are screened against a criminal history database. However, 
as of October 19, 2005, 37 VA medical facilities had not begun to 
implement this new requirement because they had not obtained or 
installed the necessary electronic fingerprint equipment. Since then, 
VA has made progress; 
as of February 1, 2006, 2 VA medical facilities had not implemented 
VA's new requirement. Finally, VA has partially implemented our 
recommendation to conduct oversight of its facilities' compliance with 
VA health care practitioner screening requirements. We found that VA's 
oversight does not address all of the medical facility compliance 
issues we identified in our 2004 report. 

At the seven VA facilities we visited, we found poor compliance with 
four of the five selected VA health care practitioner screening 
requirements. None of the seven facilities had a compliance rate of 90 
percent or more for all five screening requirements we reviewed, and VA 
policy requires 100 percent compliance with these requirements. For the 
screening requirement to perform background investigations, at six of 
seven VA facilities we were unable to find documentation--in at least 
90 percent of the health care practitioners' personnel files we 
reviewed--that a background investigation was either scheduled or 
completed for these salaried practitioners. We also found that 
facilities' rates of compliance were lower in performing background 
investigations on fee basis, contract, and WOC health care 
practitioners than in performing background investigations for salaried 
health care practitioners. Further, while reviewing three facilities' 
implementation of VA's fingerprint-only background investigations--a 
relatively new form of background investigation--we found that two of 
the facilities did not document that the results of the fingerprint- 
only background investigation had been reviewed and a decision made on 
the individual's suitability to work at the VA facility. 

To better ensure the safety of veterans receiving health care at VA 
medical facilities, we recommend that VA expand its human resource 
management oversight program to include a review of VA facilities' 
compliance with screening requirements for all types of salaried and 
nonsalaried health care practitioners. In addition, we recommend that 
VA standardize a method for documenting facility officials' review of 
fingerprint-only background investigation results and decisions 
regarding suitability to work in the VA medical facility. In commenting 
on a draft of this report, VA agreed with our findings and conclusions 
and concurred with our recommendations. VA also stated that it will 
provide an action plan for implementing these recommendations after 
issuance of this report. 

Background: 

VA operates the largest integrated health care system in the United 
States, providing care to nearly 5 million veterans per year through 
hospitals, ambulatory clinics, nursing homes, residential 
rehabilitation treatment programs, and readjustment counseling centers. 
VA also utilizes national and local medical professional services 
contracts to supplement its health care practitioner staffing. In 
addition to providing medical care, VA is the largest educator of 
health care professionals, training more than 28,000 medical residents 
annually, as well as other types of health care professionals. 

Depending on the employment requirements of their positions, health 
care practitioners who work at VA facilities are required to hold 
either valid--meaning current and unrestricted--state medical licenses 
or national certificates. State licenses are issued by state licensing 
boards, which generally establish state licensing requirements 
governing their licensed health care practitioners.[Footnote 12] 
Current and unrestricted licenses are those in good standing in the 
states that issued them, and licensed health care practitioners may 
hold licenses from more than one state. To keep a license current, 
health care practitioners must renew their licenses before they expire 
and meet renewal requirements established by state licensing boards, 
such as continuing education. Renewal procedures and requirements vary 
by state and occupation. When licensing boards discover violations of 
licensing practices, such as the abuse of prescription drugs or the 
provision of substandard care that results in adverse health effects, 
they may place restrictions on licenses or revoke them. Restrictions 
from a state licensing board can limit or prohibit a health care 
practitioner from practicing in that state.[Footnote 13] Some, but not 
all, issued state licenses are marked to indicate that the licenses 
have had restrictions placed on them. Generally, state licensing boards 
maintain a database of information on restrictions, which employers can 
often obtain at no cost either by accessing the information on a 
board's Web site or by contacting the board directly. 

National certificates are issued by national certifying organizations, 
which are separate and independent from state licensing 
boards.[Footnote 14] These organizations establish professional 
standards that are national in scope for certain occupations, such as 
respiratory and occupational therapists. Health care practitioners who 
are required to have valid national certificates to practice in VA may 
renew these credentials periodically by paying a fee and verifying that 
they obtained required educational credit hours. National certifying 
organizations can place restrictions on a certification or revoke 
certification for violations of the organization's professional 
standards. Like state licensing boards, national certifying 
organizations maintain databases of information on disciplinary actions 
taken against health care practitioners with national certificates, and 
many can be accessed at no cost. 

VA policy requires officials at its medical facilities to screen 
applicants for positions at VA to determine whether each applicant 
possesses at least one current and unrestricted state license or an 
appropriate national certificate, whichever is applicable for the 
position sought by the applicant. VA also requires officials at its 
medical facilities to periodically verify licenses or national 
certificates held by health care practitioners already employed at VA 
(employed health care practitioners). The frequency of when health care 
practitioners' credentials must be checked depends on their occupations 
and the renewal requirements of the state or national organizations 
that issued the credentials. 

In general, for both applicants and employed health care practitioners, 
VA's screening process proceeds in two stages. First, applicants and 
employed health care practitioners are required to disclose to VA, if 
applicable, their state licenses and national certificates. Applicants 
disclose their credentials to VA during the application process, and 
employed health care practitioners disclose credentials to VA as they 
expire and are renewed with the state licensing board or certifying 
organization. Second, VA facility officials are required to verify 
whether the disclosed credentials are valid. 

In addition to holding valid professional credentials, upon hiring, 
health care practitioners are required to undergo background 
investigations that verify their personal and professional 
histories.[Footnote 15] Depending on the position in question, the 
extent of the background investigations for health care practitioners 
may vary. For example, background investigations in VA may vary from a 
traditional background investigation covering a health care 
practitioner's personal and professional background for up to 10 years 
to the minimum of a fingerprint-only background investigation. VA 
facility officials are required to complete VA Form 2280, which 
documents the level of risk posed by a particular position and 
determines the level of background investigation required for 
employment. 

The traditional background investigation is the most common type of 
background investigation conducted by VA on its health care 
practitioners. A traditional background investigation verifies, for 
instance, an individual's history of employment, education, and 
residence. It also includes a fingerprint check that searches for 
evidence of criminal activity by comparing fingerprints against a 
database of criminal records. The Office of Personnel Management (OPM) 
conducts background investigations for VA and reports its results to 
the facility that requested the investigation.[Footnote 16] VA 
facilities are required to review background investigation results, 
determine employment suitability, and report their decisions to OPM 
within 90 days. 

In 2001 OPM began to offer a new type of background investigation for 
use by federal agencies, a fingerprint-only background investigation. 
Compared to traditional background investigations, which verify 
personal, professional, and criminal histories and typically take 
several months to complete, fingerprint-only background investigations 
verify criminal histories only and can be completed within 3 weeks or 
less and cost less than $25, about a quarter of the cost of a 
traditional background investigation. 

In March 2004, we reported on VA's screening policies and the gaps we 
found in VA's requirement for screening applicants that may result in 
VA health care practitioners' personal backgrounds and professional 
credentials not being thoroughly screened. For example, for health care 
practitioners who were required to have national certificates to work 
in VA, facility officials were required to physically inspect each 
applicant's national certificate. However, we found a gap wherein 
officials were not required to contact the organization issuing the 
certificate, even though restrictions may have been placed on the 
certificate after it was issued. In contrast, we found that for state 
licenses VA's policy required officials at its medical facilities to 
screen applicants to determine whether they possessed at least one 
current and unrestricted state license. Applicants were required to 
disclose to VA any state licenses they held. To verify a state license, 
VA officials were required to contact the issuing state licensing board 
to determine if the license was current and unrestricted. Officials 
were also required to document that they verified the status of the 
license. 

As part of our 2004 report, we also found gaps in VA's screening 
requirements for health care practitioners currently employed at its 
medical facilities. For example, not all VA currently employed health 
care practitioners with licenses were required to disclose all of their 
current licenses. Some currently employed health care practitioners, 
such as nurses and pharmacists, were required to disclose only one 
license, even if they possess multiple licenses, and facility officials 
were not required to contact the issuing state board to determine if 
the license is current and unrestricted. Instead, facility officials 
were required to physically inspect the one state license, even though 
some licenses are not marked to indicate restrictions. See figure 1 for 
the health care practitioner screening gaps we identified for both VA's 
applicants and currently employed health care practitioners. 

Figure 1: Gaps Identified in VA's Process for Verifying Health Care 
Practitioner Credentials with State Licensing Boards and National 
Certifying Organizations, March 2004: 

[See PDF for image] 

[A] Physician assistants are not required to have licenses to work in 
VA, but their credentials are verified using a process that is similar 
to that for other health care practitioners in this category. 

[End of figure] 

In our March 31, 2004, report, we also found that VA did not query 
HIPDB for all health care practitioners. Additionally, VA required some 
health care practitioners with direct access to patients to undergo 
background investigations that verify their personal and professional 
histories, but did not require this of others, such as medical 
residents. 

In response to a draft of our report, VA's Under Secretary for Health 
commissioned a task force on March 30, 2004, to review the screening 
requirements for all VA health care occupations, including applicants, 
those currently employed, and health care trainees. The task force was 
to identify the needed improvements to VA's screening processes and to 
make recommendations to VA's National Leadership Board.[Footnote 17] 

VA Has Taken Steps to Improve Health Care Practitioner Screening 
Requirements, but Gaps Remain: 

VA has taken steps to improve health care practitioner screening by 
partially implementing each of the four recommendations made in our 
March 2004 report; however, gaps still remain in VA's health care 
practitioner screening requirements. These gaps are found in the 
requirements for verifying professional credentials and querying HIPDB 
for currently employed practitioners. In addition, VA has not yet 
implemented fingerprint-only background investigations at two medical 
facilities. Finally, while VA has formalized an oversight program 
within its Office of Human Resource Management (HRM), the program does 
not address all of the compliance issues we identified in our earlier 
report. 

VA Has Partially Implemented Our Recommendation to Expand Verification 
of Health Care Practitioners' Professional Credentials: 

VA has partially implemented our recommendation that VA facility 
officials contact state licensing boards and national certifying 
organizations to verify all state licenses and national certificates 
held by all VA health care practitioners. To address our 
recommendation, VA expanded the verification requirement to include 
licenses and certificates of all applicants VA intends to hire. In 
addition, VA issued a memorandum on September 2, 2004, directing VA 
facility officials to establish a formal procedure for conducting and 
then documenting the screening of professional credentials for 
applicants. As part of the memorandum, VA provided its medical 
facilities with an employment checklist that officials are required to 
use to document the completion of VA's screening requirements for 
applicants for salaried and nonsalaried positions, including fee basis 
and WOC health care practitioners.[Footnote 18] Facility officials are 
permitted to modify the format of the employment checklist as long as 
the modified checklist includes all the screening requirements 
contained in the original checklist. 

VA has proposed a policy change that will require the consistent 
screening of credentials for both health care practitioners applying to 
work at VA medical facilities and those currently employed. This 
screening would apply to both salaried and nonsalaried health care 
practitioners. Once VA issues its proposed policy for screening 
credentials, VA facility officials will be required--in addition to 
using the employment checklist--to document the verification of all 
health care practitioners' state licenses and national certificates in 
the computerized database of practitioners' credentials that VA 
facility officials maintain, VetPro. VA currently requires facility 
officials to use VetPro to document the verification of some health 
care practitioners' credentials, including physicians, dentists, and 
nurse practitioners. VA is in the process of expanding the database so 
it can store documentation of all of VA's licensed and certified health 
care practitioners. Once the proposed policy for screening credentials 
is approved and the database is expanded, VA facility officials will 
have 2 years to enter all licensed and certified health care 
practitioners into this database and will be able to electronically 
document the verification of all health care practitioners' licenses 
and certificates in one centralized location. 

While VA has expanded its requirements for verifying the professional 
credentials of applicants, the department has not, as we recommended, 
required its medical facilities to verify all state licenses or 
national certificates held by all employed health care practitioners by 
contacting the appropriate state licensing boards or national 
certifying organizations. For example, for certain currently employed 
health care practitioners, such as nurses and pharmacists, VA facility 
officials are still not required to contact state licensing boards to 
verify whether the practitioner holds a valid and unrestricted license. 
Instead, facility officials are only required to physically inspect the 
original license. As we reported in 2004, one cannot determine with 
certainty that a license is valid and unrestricted unless the state 
licensing board is contacted directly. In addition, VA has not, as we 
recommended, required facility officials to verify all of the licenses 
held by these same health care practitioners instead of physically 
inspecting one license of the practitioner's choosing.[Footnote 19] As 
a result, a currently employed health care practitioner could have a 
restricted license in one state but offer VA officials an unrestricted 
license from another state. We reviewed a draft of VA's policy that 
when issued will fully address our recommendation to require medical 
facility officials to verify all state licenses and national 
certificates of currently employed health care practitioners with the 
relevant issuing boards or organizations. According to a VA official, 
this policy is expected to be issued in June 2006. 

VA Partially Implemented Our Recommendation to Require Medical 
Facilities to Query HIPDB: 

VA has partially implemented our recommendation to expand the query of 
HIPDB to include all licensed health care practitioners that VA intends 
to hire and to periodically query HIPDB for those already employed at 
VA. To respond to our recommendation, VA issued a memorandum on July 
13, 2004, that requires officials at all of its medical facilities to 
query HIPDB for all applicants for VA employment. In addition to VA 
applicants, VA's memorandum requires that facility officials query 
HIPDB for most volunteers before offering them volunteer 
assignments.[Footnote 20] VA's requirement that its medical facilities 
query HIPDB for all applicants as well as new volunteers goes beyond 
our recommendation to query applicants who hold licenses; 
however, VA's requirement does not, as we recommended, require VA 
facilities to periodically query HIPDB for health care practitioners 
who are currently employed by VA. 

VA officials told us that VA is working with the Department of Health 
and Human Services (HHS) to develop a process whereby VA can 
electronically query HHS data banks, including HIPDB, for VA employees. 
Once this process is in place and VA is using it to periodically query 
HIPDB for those currently employed at VA, the department will have 
fully implemented our recommendation. However, VA did not provide a 
time frame for implementing this electronic query of HIPDB. 

VA Policy on Fingerprint-Only Background Investigations Addressed Our 
Recommendation, but Was Not Fully Implemented: 

In August 2005, VA issued a policy that when implemented across VA will 
address our recommendation to expand the use of fingerprint-only 
background investigations for practitioners previously exempt from 
background investigations who have direct access to patients. VA's 
policy requires, at a minimum, that all newly hired health care 
practitioners' fingerprints be checked against a criminal history 
database.[Footnote 21] The requirement applies to nonsalaried health 
care practitioners working through a fee basis arrangement, WOC and 
contract health care practitioners, and some volunteers. It also 
includes trainees, such as medical residents, who previously were 
exempt from any type of background investigation. For traditional and 
fingerprint-only background investigations, VA's policy requires 
facility officials to review the results of the background 
investigation and within 5 days of receiving the results determine the 
practitioner's suitability to work at a VA medical facility.[Footnote 
22] Facility officials are required by VA to document the results of 
their background investigation reviews in personnel files. VA's policy 
requires the use of electronic fingerprinting, in lieu of paper-based 
fingerprinting, at all VA medical facilities. 

While VA's policy addresses our recommendation, not all of VA's medical 
facilities had implemented the policy as of February 1, 2006. The 
August 2005 policy requires that all VA medical facilities purchase and 
begin using electronic fingerprint machines by September 1, 2005. 
During our review, we found that VA did not know which facilities had 
purchased and begun to use the electronic fingerprint equipment in the 
course of implementing VA's fingerprinting policy. In response to our 
inquiry, VA surveyed its facilities and found that as of October 19, 
2005, 37 facilities did not have electronic fingerprint machines 
operational by September 1, 2005. Since then VA has made progress; 
as of February 1, 2006, 2 VA medical facilities had not implemented 
this new requirement. 

VA Partially Implemented Our Recommendation to Conduct Oversight of 
Facilities' Compliance with Screening Requirements: 

VA has partially implemented our recommendation to conduct oversight to 
help ensure that facilities comply with select screening requirements 
for applicants and employed health care practitioners. To address our 
recommendation, in April 2004 VA formalized a program within HRM, which 
oversees VA medical facility compliance with human resource functions. 
The program is responsible for overseeing VA's facility human resource 
functions, which include conducting background investigations and 
verifying the professional credentials of applicants and current 
employees. Officials from HRM's oversight program conduct site visits 
to VA facilities, interview facility officials, and review a random 
sample of personnel files to determine whether VA facilities are 
performing background investigations in a timely manner and verifying 
the professional credentials of health care practitioners. 

While this oversight program helps ensure that facilities are 
conducting background investigations and verifying professional 
credentials for some categories of health care practitioners, it does 
not ensure that facilities are complying with all of VA's key screening 
requirements, as we recommended in 2004. For example, officials from 
the oversight program are not required to review personnel files for 
fee basis health care practitioners, even though these practitioners 
also have direct access to patients. Further, oversight officials' 
guidelines do not include requirements to check personnel files to 
ensure that facility officials query HIPDB and verify all health care 
practitioners' licenses and certifications with the relevant issuing 
organizations. 

In May 2005, we observed an oversight review conducted by HRM 
officials, during which officials reviewed some of VA's health care 
practitioner screening requirements as applied to salaried health care 
practitioners and some types of nonsalaried health care practitioners. 
Although HRM officials discussed the results of their personnel file 
reviews with VA officials at the facility they visited, HRM officials 
did not document the number of files they reviewed and found in 
compliance. 

VA Facilities Did Not Comply with Health Care Practitioner Screening 
Requirements: 

Across the seven VA facilities we visited, we found poor compliance 
with four of the five selected screening requirements we reviewed for 
salaried health care practitioners as well as the one screening 
requirement we selected for nonsalaried health care practitioners. The 
five screening requirements we selected include two implemented by VA 
in response to our recommendations--querying HIPDB and completing an 
employment checklist to document completion of VA's screening 
requirements--and three others that were in place at the time of our 
2004 review. The latter require VA facilities to verify health care 
practitioners' state licenses and national certificates; 
complete VA Form 2280, which is used to determine the appropriate type 
of background investigation needed for each health care practitioner 
job category; and conduct background investigations. We measured 
facilities' compliance with all these requirements as they pertain to 
their salaried health care practitioners, and we also measured 
facilities' compliance with the background investigation requirement as 
it pertains to VA's nonsalaried health care practitioners--that is, 
practitioners paid by VA on a fee basis, WOC practitioners, and 
practitioners hired through contracts. 

At the seven facilities we visited, we found that none of these 
facilities complied with all five screening requirements we reviewed 
for their salaried health care practitioners. In order to show the 
variability in the level of compliance among the seven VA facilities, 
we measured their performance against a compliance rate of at least 90 
percent for each of the five VA screening requirements,[Footnote 23] 
even though VA policy requires 100 percent compliance with these 
requirements. None of the seven facilities had a compliance rate of 90 
percent or more for all five screening requirements we reviewed. Figure 
2 summarizes the rate of compliance among the seven facilities we 
visited for salaried health care practitioners. For the screening 
requirement to perform background investigations, at six of seven VA 
facilities we were unable to find documentation--in at least 90 percent 
of the health care practitioners' personnel files we reviewed--that 
background investigations were either scheduled or completed for these 
salaried practitioners. (For detailed information about our analysis 
and documentation requirements to demonstrate compliance, see app. I, 
and for information regarding the extent of each facility's compliance 
with a particular requirement, see app. II.) 

As shown in figure 2, facilities did not uniformly comply with the two 
screening requirements VA implemented to address our recommendations. 
We found that for health care practitioners hired since October 1, 
2004, only two facilities were querying HIPDB as required, and none of 
the seven facilities consistently completed the required employment 
checklist to document the completion of screening requirements for 
applicants VA intends to hire. While two facilities performed HIPDB 
queries on applicants, one of these facilities completed the queries 
immediately prior to our visit. During our site visits, we also found 
that two facilities had created their own employment checklists. While 
facilities are permitted to modify the format of the checklist as long 
as the modification includes all of the screening requirements 
contained in the original checklist issued in September 2004, we found 
that the checklists used by these two facilities did not include all of 
the screening requirements. 

Figure 2: Facilities' Rates of Compliance with Select VA Screening 
Requirements for Salaried Health Care Practitioners (2005): 

[See PDF for image] 

Notes: It is important to note that our review of the different 
practitioner screening requirements includes different subsets of 
salaried health care practitioners. That is, all health care 
practitioners are required to have a background investigation 
regardless of when they were hired, while only those health care 
practitioners hired after October 1, 2004, are also required to have a 
completed employment checklist in their personnel files. Facilities 
were found to be in compliance if they were able to provide 
documentation not available in the personnel file. Site visits to these 
seven VA facilities were conducted from April 2005 through August 2005. 

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

[B] Applies to all health care practitioners hired on or after October 
1, 2004, and certain health care practitioners hired prior to this 
date, such as physicians and dentists. Findings for this screening 
requirement cannot be generalized to the facility being reviewed 
because of the sample size. 

[C] Applies to all health care practitioners hired on or after October 
1, 2004. Findings for this screening requirement cannot be generalized 
to the facility being reviewed because of the sample size. 

[End of figure] 

Two of the seven facilities we visited were also included in our March 
2004 report. Since our last site visit, these two facilities improved 
their performance in conducting background investigations for salaried 
health care practitioners to compliance rates of 75 and 72 percent, as 
shown in figure 3. However, both facilities were still well below our 
compliance rate of 90 percent. 

Figure 3: Background Investigation Compliance Rates for Salaried Health 
Care Practitioners at Revisited VA Medical Facilities (2005): 

[See PDF for image] 

Note: Site visits to these two VA facilities were conducted from April 
2005 through August 2005. 

[End of figure] 

As part of our review, we also measured facilities' compliance with 
VA's background investigation requirement for health care practitioners 
other than those salaried by VA. We found that all seven of the 
facilities we visited did not meet VA's background investigation 
requirements for fee basis and WOC health care practitioners. For 
example, although one facility conducted background investigations on 
WOC health care practitioners at a rate of 90 percent or better, no 
facility met the requirement for both groups of health care 
practitioners. Furthermore, at four of the seven facilities we visited, 
facility human resource management staff could not produce a 
comprehensive list of all WOC health care practitioners working at the 
facility because human resource management staff were not screening all 
WOC health care practitioners prior to their beginning work at the VA 
facility. Figure 4 summarizes the seven facilities' rate of compliance 
with VA's background investigation requirement as applied to fee basis 
and WOC health care practitioners. (For detailed information about each 
facility's compliance with this requirement, see app. II.) 

Figure 4: VA Facility Compliance with Background Investigation 
Screening Requirements for Fee Basis and WOC Health Care Practitioners 
(2005): 

[See PDF for image] 

Notes: Three facilities did not perform background investigations on 
fee basis health care practitioners, and four facilities did not 
perform background investigations on WOC health care practitioners. 
Contract health care practitioners were excluded from this figure 
because facilities did not maintain personnel files. Site visits to 
these seven VA facilities were conducted from April 2005 through August 
2005. 

[End of figure] 

Like their efforts conducting background investigations for fee basis 
and WOC health care practitioners, the efforts of most VA facilities we 
visited did not meet this requirement for health care practitioners 
obtained through contracts. Specifically, we found that one of seven 
medical facilities was conducting and documenting background 
investigations for contract health care practitioners, as VA requires. 
The other six facilities were not in compliance with this requirement. 

In March 2005, a VA headquarters official announced that facility 
officials should implement fingerprint-only background investigations 
for volunteers, as soon as the facilities' electronic fingerprint 
equipment was operational or no later than September 1, 2005. Of the 
seven facilities we visited prior to September 1, 2005, we found that 
four facilities had the equipment needed to begin performing 
fingerprint-only background investigations. Three of the four 
facilities were fingerprinting volunteers, and the fourth facility had 
not begun to fingerprint volunteers, even though the equipment was 
operational. However, for the three facilities fingerprinting 
volunteers, we found documentation at only one facility to indicate 
that officials were reviewing the fingerprint results from OPM and 
determining whether volunteers were suitable to work in the VA medical 
facility, as required by VA policy. We also found that VA does not have 
a standardized method for facility officials to document their review 
of fingerprint-only background investigation results, as it has for 
other types of background investigations. For example, traditional 
background investigation results are reported in a format that includes 
designated space for facility officials to document that the results of 
the investigation have been reviewed and a decision made regarding 
suitability to work in the medical facility. At two facilities we found 
background investigation results for volunteers that showed criminal 
histories, such as aggravated assault and drug-related convictions. 
However, while officials at the two facilities assured us that the 
results of fingerprint-only investigations were being reviewed, we did 
not find documentation of this review. 

Conclusions: 

Although VA concurred with all of our March 2004 recommendations to 
close the gaps in its health care practitioner screening processes, 
none of the four were fully implemented as of March 2006. VA's 
screening requirements are intended to ensure the safety of veterans 
receiving care in VA facilities by identifying health care 
practitioners with restricted or fraudulent credentials, criminal 
backgrounds, or questionable work histories. As we found in our 
previous report, VA continues to apply different screening requirements 
to its licensed and certified health care practitioners. For example, 
we found that VA requires medical facilities to verify with the 
appropriate state licensing boards or national certifying organizations 
all state licenses or national certificates held by some health care 
practitioners, such as physicians and applicants for VA employment, but 
not for other health care practitioners, such as nurses currently 
employed by VA. In the interim, while VA is developing a policy that 
would apply screening requirements consistently across all licensed and 
certified health care practitioners and satisfy one of our 
recommendations, it has established two requirements that apply to new 
health care practitioners entering VA's health care system. As a result 
of the continuing gaps in VA's health care practitioner screening 
process, practitioners may continue to have access to patients without 
thorough screening of their professional credentials and personal 
backgrounds. 

Furthermore, although VA agreed with our 2004 recommendation to oversee 
its facilities to ensure their compliance with key screening 
requirements, VA's limited oversight has not ensured facility 
compliance. As a result, VA may not know whether its facilities are in 
compliance with its screening requirements. This raises concerns 
because we found that none of the VA medical facilities we visited were 
in compliance with all of the new or existing VA screening requirements 
we reviewed for salaried or nonsalaried health care practitioners. We 
found that the extent to which facilities complied with four of the 
five selected VA screening requirements was poor at the VA facilities 
we visited. For example, while there was improvement at the two 
facilities we revisited, these facilities did not meet our 90 percent 
compliance rate for conducting background investigations on salaried 
health care practitioners. Moreover, we found that all seven medical 
facilities did poorly in conducting background investigations on fee 
basis and WOC health care practitioners as required by VA even though 
these practitioners have the same access to patients and their 
information as other VA health care practitioners. Further, two of the 
three facilities that were conducting VA's new fingerprint-only 
background investigation did not have documentation that the results 
were being reviewed by officials as required. This lack of compliance 
with current screening requirements continues to place veterans at 
risk. 

Recommendations for Executive Action: 

To better ensure the safety of veterans receiving health care at VA 
medical facilities, we recommend that the Secretary of Veterans Affairs 
take the following two actions: 

² expand the HRM oversight program to include a review of VA 
facilities' compliance with screening requirements for all types of 
salaried and nonsalaried health care practitioners and: 

² standardize a method for documenting facility officials' review of 
fingerprint-only background investigation results and decisions 
regarding suitability to work in VA medical facilities. 

Agency Comments: 

In commenting on a draft of this report, VA agreed with our findings 
and conclusions and concurred with our recommendations. VA agreed that 
expanded program oversight and standardizing a method for documenting 
fingerprint-only background investigation results would be useful. VA 
stated that while it believes that most facilities continue to improve 
their practitioner screening effectiveness, VA also recognizes that 
there is variability and lack of standardization across its health care 
system. VA stated that it would provide an action plan for implementing 
our recommendations after issuance of this report. 

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

If you or your staff members have any questions, please contact me at 
(202) 512-7101 or ekstrandl@gao.gov. Contact points for our Offices of 
Congressional Relations and Public Affairs may be found on the last 
page of this report. GAO staff members who made major contributions to 
this report are listed in appendix IV. 

Sincerely yours, 

Signed by: 

Laurie E. Ekstrand: 
Director, Health Care: 

[End of section] 

Appendix I: Scope and Methodology: 

We examined the Department of Veterans Affairs (VA) policies and 
practices to determine if VA had implemented the recommendations we 
made in March 2004 to strengthen its screening of applicants' and 
employed health care practitioners' professional credentials and 
personal backgrounds. Specifically, we determined the extent to which 
(1) VA has taken steps to improve health care practitioner screening by 
implementing the four recommendations made in our March 2004 report and 
(2) VA medical facilities are in compliance with VA's health care 
practitioner screening requirements. 

To determine the extent to which VA has taken steps to improve health 
care practitioner screening by implementing the four recommendations 
made in our March 2004 report, we reviewed VA employment screening 
policies and interviewed VA headquarters and facility officials. Based 
on our review of VA documents and interviews with officials, we 
determined what steps VA has taken to ensure that gaps we identified in 
its verification of state licenses and national certificates and 
background investigation requirements have been closed. We also 
reviewed the report of a task force VA formed to respond to our 
recommendations to improve VA's screening of professional credentials 
and personal backgrounds. We interviewed officials at VA's Office of 
Security and Law Enforcement in Little Rock, Arkansas, and VA's 
National Acquisition Center in Hines, Illinois, to review how VA 
screens the professional credentials and personal backgrounds of health 
care practitioners working in VA medical facilities through a contract. 

To determine how VA conducts oversight of its facilities' compliance 
with screening of applicants and current employees, we interviewed 
officials responsible for implementing VA's Office of Human Resource 
Management (HRM) evaluation and accountability program. We also 
observed an oversight review site visit conducted by VA's HRM at the VA 
medical facility in Providence, Rhode Island, and attended a VA 
training class that provided facility human resource managers with the 
knowledge necessary to review the results of background investigations. 

To determine the extent to which selected VA medical facilities we 
visited are in compliance with VA's health care practitioner screening 
requirements, we chose a judgmental sample of seven VA medical 
facilities that varied in geographic location to assess the extent to 
which these selected facilities complied with the screening 
requirements included in our review. The seven facilities were located 
in Fargo, North Dakota; Kansas City, Missouri; Miami, Florida; New 
Orleans, Louisiana; Salt Lake City, Utah; San Antonio, Texas; and the 
District of Columbia. Two of the seven facilities we visited were sites 
from our previous review. Of the seven facilities we visited, six were 
large facilities located in major metropolitan areas and the remaining 
facility is of a smaller size. 

For each facility, VA provided from its automated pay system a list of 
salaried health care practitioners in the 43 occupations we included in 
our previous review. See table 1 for a list of the 43 occupations 
included in our review. Because we used VA's automated pay system, our 
sample does not include those health care practitioners providing care 
through a contract or fee-for-service agreement or without compensation 
(WOC) from VA. 

Table 1: State Licensure and National Certification Requirements for 
the 43 VA Occupations: 

Occupation code: 101; 
Occupation title: Social science; 
Occupations that require a state license to work in VA: [Empty]; 
Occupations that require a national certificate to work in VA: [Empty]; 
Occupations that do not require a state license or a national 
certificate to work in VA: X. 

Occupation code: 102; 
Occupation title: Social science aide and technician; 
Occupations that require a state license to work in VA: [Empty]; 
Occupations that require a national certificate to work in VA: [Empty]; 
Occupations that do not require a state license or a national 
certificate to work in VA: X. 

Occupation code: 180; 
Occupation title: Psychology; 
Occupations that require a state license to work in VA: X; 
Occupations that require a national certificate to work in VA: [Empty]; 
Occupations that do not require a state license or a national 
certificate to work in VA: [Empty]. 

Occupation code: 181; 
Occupation title: Psychology aide and technician; 
Occupations that require a state license to work in VA: [Empty]; 
Occupations that require a national certificate to work in VA: [Empty]; 
Occupations that do not require a state license or a national 
certificate to work in VA: X. 

Occupation code: 185; 
Occupation title: Social work; 
Occupations that require a state license to work in VA: X; 
Occupations that require a national certificate to work in VA: [Empty]; 
Occupations that do not require a state license or a national 
certificate to work in VA: [Empty]. 

Occupation code: 186; 
Occupation title: Social services aide and assistant; 
Occupations that require a state license to work in VA: [Empty]; 
Occupations that require a national certificate to work in VA: [Empty]; 
Occupations that do not require a state license or a national 
certificate to work in VA: X. 

Occupation code: 187; 
Occupation title: Social services; 
Occupations that require a state license to work in VA: [Empty]; 
Occupations that require a national certificate to work in VA: [Empty]; 
Occupations that do not require a state license or a national 
certificate to work in VA: X. 

Occupation code: 189; 
Occupation title: Recreation aide and assistant; 
Occupations that require a state license to work in VA: [Empty]; 
Occupations that require a national certificate to work in VA: [Empty]; 
Occupations that do not require a state license or a national 
certificate to work in VA: X. 

Occupation code: 413; 
Occupation title: Physiology; 
Occupations that require a state license to work in VA: [Empty]; 
Occupations that require a national certificate to work in VA: [Empty]; 
Occupations that do not require a state license or a national 
certificate to work in VA: X. 

Occupation code: 601; 
Occupation title: General health science; 
Occupations that require a state license to work in VA: [Empty]; 
Occupations that require a national certificate to work in VA: [Empty]; 
Occupations that do not require a state license or a national 
certificate to work in VA: X. 

Occupation code: 602; 
Occupation title: Medical officer (physician); 
Occupations that require a state license to work in VA: X; 
Occupations that require a national certificate to work in VA: [Empty]; 
Occupations that do not require a state license or a national 
certificate to work in VA: [Empty]. 

Occupation code: 603; 
Occupation title: Physician's assistant; 
Occupations that require a state license to work in VA: [Empty]; 
Occupations that require a national certificate to work in VA: X; 
Occupations that do not require a state license or a national 
certificate to work in VA: [Empty]. 

Occupation code: 605; 
Occupation title: Nurse anesthetist; 
Occupations that require a state license to work in VA: X; 
Occupations that require a national certificate to work in VA: X; 
Occupations that do not require a state license or a national 
certificate to work in VA: [Empty]. 

Occupation code: 610; 
Occupation title: Registered nurse[A]; 
Occupations that require a state license to work in VA: X; 
Occupations that require a national certificate to work in VA: [Empty]; 
Occupations that do not require a state license or a national 
certificate to work in VA: [Empty]. 

Occupation code: 620; 
Occupation title: Practical nurse; 
Occupations that require a state license to work in VA: X; 
Occupations that require a national certificate to work in VA: [Empty]; 
Occupations that do not require a state license or a national 
certificate to work in VA: [Empty]. 

Occupation code: 621; 
Occupation title: Nursing assistant; 
Occupations that require a state license to work in VA: [Empty]; 
Occupations that require a national certificate to work in VA: [Empty]; 
Occupations that do not require a state license or a national 
certificate to work in VA: X. 

Occupation code: 622; 
Occupation title: Medical supply aide/technician; 
Occupations that require a state license to work in VA: [Empty]; 
Occupations that require a national certificate to work in VA: [Empty]; 
Occupations that do not require a state license or a national 
certificate to work in VA: X. 

Occupation code: 630; 
Occupation title: Dietitian and nutritionist; 
Occupations that require a state license to work in VA: [Empty]; 
Occupations that require a national certificate to work in VA: X; 
Occupations that do not require a state license or a national 
certificate to work in VA: [Empty]. 

Occupation code: 631; 
Occupation title: Occupational therapist; 
Occupations that require a state license to work in VA: [Empty]; 
Occupations that require a national certificate to work in VA: X; 
Occupations that do not require a state license or a national 
certificate to work in VA: [Empty]. 

Occupation code: 633; 
Occupation title: Physical therapist; 
Occupations that require a state license to work in VA: X; 
Occupations that require a national certificate to work in VA: [Empty]; 
Occupations that do not require a state license or a national 
certificate to work in VA: [Empty]. 

Occupation code: 635; 
Occupation title: Corrective therapist; 
Occupations that require a state license to work in VA: [Empty]; 
Occupations that require a national certificate to work in VA: [Empty]; 
Occupations that do not require a state license or a national 
certificate to work in VA: X. 

Occupation code: 636; 
Occupation title: Rehabilitation therapy assistant; 
Occupations that require a state license to work in VA: [Empty]; 
Occupations that require a national certificate to work in VA: [Empty]; 
Occupations that do not require a state license or a national 
certificate to work in VA: X. 

Occupation code: 638; 
Occupation title: Recreation/creative arts therapist; 
Occupations that require a state license to work in VA: [Empty]; 
Occupations that require a national certificate to work in VA: [Empty]; 
Occupations that do not require a state license or a national 
certificate to work in VA: X. 

Occupation code: 640; 
Occupation title: Health aide and technician; 
Occupations that require a state license to work in VA: [Empty]; 
Occupations that require a national certificate to work in VA: [Empty]; 
Occupations that do not require a state license or a national 
certificate to work in VA: X. 

Occupation code: 644; 
Occupation title: Medical technologist; 
Occupations that require a state license to work in VA: [Empty]; 
Occupations that require a national certificate to work in VA: [Empty]; 
Occupations that do not require a state license or a national 
certificate to work in VA: X. 

Occupation code: 645; 
Occupation title: Medical technician; 
Occupations that require a state license to work in VA: [Empty]; 
Occupations that require a national certificate to work in VA: [Empty]; 
Occupations that do not require a state license or a national 
certificate to work in VA: X. 

Occupation code: 646; 
Occupation title: Pathology technician; 
Occupations that require a state license to work in VA: [Empty]; 
Occupations that require a national certificate to work in VA: [Empty]; 
Occupations that do not require a state license or a national 
certificate to work in VA: X. 

Occupation code: 647; 
Occupation title: Diagnostic radiologic technologist; 
Occupations that require a state license to work in VA: [Empty]; 
Occupations that require a national certificate to work in VA: X; 
Occupations that do not require a state license or a national 
certificate to work in VA: [Empty]. 

Occupation code: 648; 
Occupation title: Therapeutic radiologic technologist; 
Occupations that require a state license to work in VA: [Empty]; 
Occupations that require a national certificate to work in VA: X; 
Occupations that do not require a state license or a national 
certificate to work in VA: [Empty]. 

Occupation code: 649; 
Occupation title: Medical instrument technician; 
Occupations that require a state license to work in VA: [Empty]; 
Occupations that require a national certificate to work in VA: [Empty]; 
Occupations that do not require a state license or a national 
certificate to work in VA: X. 

Occupation code: 651; 
Occupation title: Respiratory therapist; 
Occupations that require a state license to work in VA: [Empty]; 
Occupations that require a national certificate to work in VA: X; 
Occupations that do not require a state license or a national 
certificate to work in VA: [Empty]. 

Occupation code: 660; 
Occupation title: Pharmacist; 
Occupations that require a state license to work in VA: X; 
Occupations that require a national certificate to work in VA: [Empty]; 
Occupations that do not require a state license or a national 
certificate to work in VA: [Empty]. 

Occupation code: 661; 
Occupation title: Pharmacy technician; 
Occupations that require a state license to work in VA: [Empty]; 
Occupations that require a national certificate to work in VA: [Empty]; 
Occupations that do not require a state license or a national 
certificate to work in VA: X. 

Occupation code: 662; 
Occupation title: Optometrist; 
Occupations that require a state license to work in VA: X; 
Occupations that require a national certificate to work in VA: [Empty]; 
Occupations that do not require a state license or a national 
certificate to work in VA: [Empty]. 

Occupation code: 665; 
Occupation title: Speech pathology and audiology; 
Occupations that require a state license to work in VA: [Empty]; 
Occupations that require a national certificate to work in VA: [Empty]; 
Occupations that do not require a state license or a national 
certificate to work in VA: X. 

Occupation code: 667; 
Occupation title: Orthotist and prosthetist; 
Occupations that require a state license to work in VA: [Empty]; 
Occupations that require a national certificate to work in VA: [Empty]; 
Occupations that do not require a state license or a national 
certificate to work in VA: X. 

Occupation code: 668; 
Occupation title: Podiatrist; 
Occupations that require a state license to work in VA: X; 
Occupations that require a national certificate to work in VA: [Empty]; 
Occupations that do not require a state license or a national 
certificate to work in VA: [Empty]. 

Occupation code: 672; 
Occupation title: Prosthetic representative; 
Occupations that require a state license to work in VA: [Empty]; 
Occupations that require a national certificate to work in VA: [Empty]; 
Occupations that do not require a state license or a national 
certificate to work in VA: X. 

Occupation code: 680; 
Occupation title: Dental officer (dentist); 
Occupations that require a state license to work in VA: X; 
Occupations that require a national certificate to work in VA: [Empty]; 
Occupations that do not require a state license or a national 
certificate to work in VA: [Empty]. 

Occupation code: 681; 
Occupation title: Dental assistant; 
Occupations that require a state license to work in VA: [Empty]; 
Occupations that require a national certificate to work in VA: X; 
Occupations that do not require a state license or a national 
certificate to work in VA: [Empty]. 

Occupation code: 682; 
Occupation title: Dental hygiene; 
Occupations that require a state license to work in VA: X; 
Occupations that require a national certificate to work in VA: [Empty]; 
Occupations that do not require a state license or a national 
certificate to work in VA: [Empty]. 

Occupation code: 1320; 
Occupation title: Chemistry; 
Occupations that require a state license to work in VA: [Empty]; 
Occupations that require a national certificate to work in VA: [Empty]; 
Occupations that do not require a state license or a national 
certificate to work in VA: X. 

Occupation code: 1715; 
Occupation title: Vocational rehabilitation; 
Occupations that require a state license to work in VA: [Empty]; 
Occupations that require a national certificate to work in VA: [Empty]; 
Occupations that do not require a state license or a national 
certificate to work in VA: X. 

Source: VA Handbook 5005, April 15, 2002. 

[A] "Registered nurse" includes nurse practitioners and clinical nurse 
specialists. 

[End of table] 

For each of the seven facilities we selected a random sample of about 
50 salaried health care practitioners who were hired prior to October 
1, 2004, from VA's list of salaried employees. In addition, we selected 
10 to 12 files of salaried health care practitioners who were hired on 
or after October, 1, 2004, to determine if new VA requirements for 
health care practitioner screening had been implemented by the 
facility. In addition to the random sample of salaried employees we 
reviewed at each facility, we also requested 20 personnel files for 
health care practitioners paid by VA through a fee-for-service 
arrangement (fee basis) and all health care practitioners who work in a 
clinical area at the VA facility but receive compensation from a source 
other than VA (WOC). 

We reviewed each selected health care practitioner's personnel file to 
determine whether the facility had documented evidence that it complied 
with the following VA screening requirements: 

² determine the position risk level by completing VA Form 2280; 

² ensure completion of background investigations; 

² query the Healthcare Integrity and Protection Data Bank (HIPDB) for 
all applicants after October 1, 2004; 

² complete an employment checklist for those hired after October 1, 
2004; 
and: 

² verify state licenses and national certificates for applicants and 
employed health care practitioners. 

For each screening requirement, we reviewed practitioners' personnel 
files to determine whether the files contained documented evidence that 
the screening requirement had been completed. See table 2 for the 
documents required to demonstrate evidence of facility compliance. 
Compliance could also be demonstrated if facilities were able to 
provide additional documentation not available in the personnel files 
we reviewed. Using a standard data collection instrument, we collected 
information on each facility's compliance with the five screening 
requirements from a sample of personnel files. To ensure the 
reliability of the data collected, the information collected at each 
facility was double-checked for a sample of files. The data from all 
data collection instruments were entered into an electronic database, 
and 100 percent of the electronic files were verified against the 
completed data collection instrument. 

Table 2: Health Care Practitioners Included in Our Review of Select VA 
Screening Requirements and the Documentation Required to Demonstrate 
Compliance: 

Screening requirements: Conducting background investigations; 
Health care practitioners included in our review: * VA salaried; * Fee 
basis; * WOC; 
Documentation required to demonstrate compliance: * Notice of scheduled 
or completed background investigation from the Office of Personnel 
Management (OPM). 

Screening requirements: Completing VA Form 2280 for each job category; 
Health care practitioners included in our review: * VA salaried; 
Documentation required to demonstrate compliance: * Completed VA Form 
2280. 

Screening requirements: Querying HIPDB; 
Health care practitioners included in our review: * VA salaried health 
care practitioners hired on or after October 1, 2004; 
* Certain health care practitioners hired prior to this date, such as 
physicians and dentists; 
Documentation required to demonstrate compliance: * HIPDB query 
printout; 
* National Practitioner Data Bank query printout, which includes a 
query of HIPDB. 

Screening requirements: Completing employment checklist; 
Health care practitioners included in our review: * VA salaried health 
care practitioners hired on or after October 1, 2004; 
Documentation required to demonstrate compliance: * Completed 
employment checklist which met VA requirements. 

Screening requirements: Verifying license, certification, or both; 
Health care practitioners included in our review: * VA salaried health 
care practitioners required to have a state license or national 
certificate to work in VA; 
Documentation required to demonstrate compliance: * Printouts, letters, 
and telephone contact reports from state licensing boards and national 
certification organizations; 
* VA Form 4862, indicating that the original license or certificate had 
been visually inspected by a VA facility official. 

Source: GAO. 

[End of table] 

In addition to the personnel files, we reviewed about five contracts at 
each of the seven medical facilities that the facilities use to 
supplement health care practitioner staffing to determine how these 
nonsalaried health care practitioners' professional credentials and 
personal backgrounds are screened. We also interviewed VA officials 
about the process the facilities use to screen trainees, including 
medical residents, and volunteers who work in patient care areas. 

In order to show the variability in the level of compliance among the 
seven VA facilities we visited, we distinguished between facilities 
that had a compliance rate of at least 90 percent for each of the five 
screening requirements that we reviewed and those that did not. For 
each facility and screening requirement included in our review, we 
compared the percentage of personnel files found in compliance to an 
acceptance level of 90 percent. In order to confirm that a requirement 
had a compliance rate less than 90 percent, we performed a one-sided 
significance test at the 95 percent confidence level. See appendix II 
for detailed information on the seven VA facilities' compliance with 
each VA screening requirement in our review. Our findings from these 
seven facilities cannot be generalized to other VA facilities. 

Our work was conducted from April 2005 through April 2006 in accordance 
with generally accepted government auditing standards. 

[End of section] 

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

Tables 3 and 4 show the sample counts used to measure compliance and 
the results of our review for the background investigation screening 
requirement. Tables 5 and 6 show the sample counts used to measure 
compliance with the remaining health care practitioner screening 
requirements that we included in our review. 

Table 3: VA Facility Compliance with Screening Requirements for 
Salaried Health Care Practitioners--Background Investigations (2005): 

Facility: Facility A; 
Number in sample: 61; 
Number with completed or requested background investigations: 52. 

Facility: Facility B; 
Number in sample: 59; 
Number with completed or requested background investigations: 50. 

Facility: Facility C; 
Number in sample: 62; 
Number with completed or requested background investigations: 54. 

Facility: Facility D; 
Number in sample: 60; 
Number with completed or requested background investigations: 45. 

Facility: Facility E; 
Number in sample: 60; 
Number with completed or requested background investigations: 57. 

Facility: Facility F; 
Number in sample: 63; 
Number with completed or requested background investigations: 55. 

Facility: Facility G; 
Number in sample: 60; 
Number with completed or requested background investigations: 43. 

Source: GAO analysis of VA facility files. 

Note: Site visits to these seven VA facilities were conducted from 
April 2005 through August 2005. 

[End of table] 

Table 4: VA Facility Compliance with Screening Requirements for Fee 
Basis and WOC Health Care Practitioners--Background Investigations 
(2005): 

Facility: Facility A; 
Fee basis health care practitioners: Number in sample: 20; 
Fee basis health care practitioners: Number with completed or requested 
background investigations: 7; 
WOC health care practitioners: Number in sample: [A]; 
WOC health care practitioners: Number with completed or requested 
background investigations: [A]. 

Facility: Facility B; 
Fee basis health care practitioners: Number in sample: 21; 
Fee basis health care practitioners: Number with completed or requested 
background investigations: 0; 
WOC health care practitioners: Number in sample: 26; 
WOC health care practitioners: Number with completed or requested 
background investigations: 0. 

Facility: Facility C; 
Fee basis health care practitioners: Number in sample: 20; 
Fee basis health care practitioners: Number with completed or requested 
background investigations: 17; 
WOC health care practitioners: Number in sample: 52; 
WOC health care practitioners: Number with completed or requested 
background investigations: 21. 

Facility: Facility D; 
Fee basis health care practitioners: Number in sample: 20; 
Fee basis health care practitioners: Number with completed or requested 
background investigations: 7; 
WOC health care practitioners: Number in sample: [A]; 
WOC health care practitioners: Number with completed or requested 
background investigations: [A]. 

Facility: Facility E; 
Fee basis health care practitioners: Number in sample: 20; 
Fee basis health care practitioners: Number with completed or requested 
background investigations: 16; 
WOC health care practitioners: Number in sample: 40; 
WOC health care practitioners: Number with completed or requested 
background investigations: 26. 

Facility: Facility F; 
Fee basis health care practitioners: Number in sample: [A]; 
Fee basis health care practitioners: Number with completed or requested 
background investigations: [A]; 
WOC health care practitioners: Number in sample: 21; 
WOC health care practitioners: Number with completed or requested 
background investigations: 20. 

Facility: Facility G; 
Fee basis health care practitioners: Number in sample: 20; 
Fee basis health care practitioners: Number with completed or requested 
background investigations: 0; 
WOC health care practitioners: Number in sample: 54; 
WOC health care practitioners: Number with completed or requested 
background investigations: 0. 

Source: GAO analysis of VA facility files. 

Note: Site visits to these seven VA facilities were conducted from 
April 2005 through August 2005. 

[A] Facility officials stated that they do not conduct background 
investigations as required for these categories of nonsalaried health 
care practitioners. 

[End of table] 

Table 5: VA Facility Compliance with Screening Requirements for 
Salaried Health Care Practitioners--HIPDB Query and State License and 
National Certificate Verification (2005): 

Facility: Facility A; 
HIPDB query: Number in sample: 17; 
HIPDB query: Number queried prior to hire: 13; 
State license and national certificate verification: Number in sample: 
46; 
State license and national certificate verification: Number where 
verification followed VA policy: 44. 

Facility: Facility B; 
HIPDB query: Number in sample: 21; 
HIPDB query: Number queried prior to hire: 14; 
State license and national certificate verification: Number in sample: 
45; 
State license and national certificate verification: Number where 
verification followed VA policy: 44. 

Facility: Facility C; 
HIPDB query: Number in sample: 18; 
HIPDB query: Number queried prior to hire: 0; 
State license and national certificate verification: Number in sample: 
44; 
State license and national certificate verification: Number where 
verification followed VA policy: 41. 

Facility: Facility D; 
HIPDB query: Number in sample: 19; 
HIPDB query: Number queried prior to hire: 19; 
State license and national certificate verification: Number in sample: 
45; 
State license and national certificate verification: Number where 
verification followed VA policy: 42. 

Facility: Facility E; 
HIPDB query: Number in sample: 22; 
HIPDB query: Number queried prior to hire: 20; 
State license and national certificate verification: Number in sample: 
48; 
State license and national certificate verification: Number where 
verification followed VA policy: 37. 

Facility: Facility F; 
HIPDB query: Number in sample: 24; 
HIPDB query: Number queried prior to hire: 13; 
State license and national certificate verification: Number in sample: 
45; 
State license and national certificate verification: Number where 
verification followed VA policy: 44. 

Facility: Facility G; 
HIPDB query: Number in sample: 17; 
HIPDB query: Number queried prior to hire: 10; 
State license and national certificate verification: Number in sample: 
38; 
State license and national certificate verification: Number where 
verification followed VA policy: 24. 

Source: GAO analysis of VA facility files. 

Notes: The number of health care practitioners in the sample may be 
less than the number of practitioner files reviewed at each facility 
because the requirement may not apply to all VA applicants or employed 
health care practitioners. Site visits to these seven VA facilities 
were conducted from April 2005 through August 2005. 

[End of table] 

Table 6: VA Facility Compliance with Screening Requirements for 
Salaried Health Care Practitioners--Employment Checklist Completed and 
Position Risk Level Determined (2005): 

Facility: Facility A; 
Employment checklist completed: Number in sample: 10; 
Employment checklist completed: Number with completed employment 
checklists: 8; 
Position risk level determined (VA Form 2280): Number in sample: 61; 
Position risk level determined (VA Form 2280): Number with position 
risk level determined and documented on VA Form 2280: 34. 

Facility: Facility B; 
Employment checklist completed: Number in sample: 10; 
Employment checklist completed: Number with completed employment 
checklists: 0; 
Position risk level determined (VA Form 2280): Number in sample: 59; 
Position risk level determined (VA Form 2280): Number with position 
risk level determined and documented on VA Form 2280: 0. 

Facility: Facility C; 
Employment checklist completed: Number in sample: 10; 
Employment checklist completed: Number with completed employment 
checklists: 5; 
Position risk level determined (VA Form 2280): Number in sample: 62; 
Position risk level determined (VA Form 2280): Number with position 
risk level determined and documented on VA Form 2280: 0. 

Facility: Facility D; 
Employment checklist completed: Number in sample: 10; 
Employment checklist completed: Number with completed employment 
checklists: 0; 
Position risk level determined (VA Form 2280): Number in sample: 60; 
Position risk level determined (VA Form 2280): Number with position 
risk level determined and documented on VA Form 2280: 58. 

Facility: Facility E; 
Employment checklist completed: Number in sample: 10; 
Employment checklist completed: Number with completed employment 
checklists: 4; 
Position risk level determined (VA Form 2280): Number in sample: 60; 
Position risk level determined (VA Form 2280): Number with position 
risk level determined and documented on VA Form 2280: 59. 

Facility: Facility F; 
Employment checklist completed: Number in sample: 12; 
Employment checklist completed: Number with completed employment 
checklists: 1; 
Position risk level determined (VA Form 2280): Number in sample: 63; 
Position risk level determined (VA Form 2280): Number with position 
risk level determined and documented on VA Form 2280: 8. 

Facility: Facility G; 
Employment checklist completed: Number in sample: 10; 
Employment checklist completed: Number with completed employment 
checklists: 0; 
Position risk level determined (VA Form 2280): Number in sample: 60; 
Position risk level determined (VA Form 2280): Number with position 
risk level determined and documented on VA Form 2280: 0. 

Source: GAO analysis of VA facility files. 

Notes: The number of health care practitioners in the sample may be 
less than the number of practitioner files reviewed at each facility 
because the requirement may not apply to all VA applicants or employed 
health care practitioners. Site visits to these seven VA facilities 
were conducted from April 2005 through August 2005. 

[End of table] 

[End of section] 

Appendix III: Comments from the Department of Veterans Affairs: 

The Deputy Secretary Of Veterans Affairs: 
Washington: 

May 17, 2006: 

Ms. Laurie Ekstrand: 
Director: 
Health Care Team: 
U. S. Government Accountability Office: 
441 G Street, NW: 
Washington, DC 20548: 

Dear Ms. Ekstrand: 

The Department of Veterans Affairs (VA) has reviewed your draft report, 
VA HEALTH CARE: Steps Taken to Improve Practitioner Screening, but 
Facility Compliance with Screening Requirements is Poor (GAO-06-544) 
and agrees with your findings and conclusions and concurs with your 
recommendations. VA agrees that expanded program oversight as well as a 
standardized method for documenting fingerprinting-only background 
investigation results, would be very useful. 

While I believe that most facilities continue to improve their 
practitioner screening effectiveness, I also recognize that there is 
variability and lack of standardization throughout the system. At 
times, roles and responsibilities for policy implementation among 
various program elements are unclear. The Veterans Health 
Administration (VHA) will consider two key challenges: developing 
standardized operating procedures that all facilities must apply in 
various stages of their screening processes, and creating systematic 
oversight and reporting mechanisms at each organizational level to 
assure that facilities are, in fact, appropriately complying with 
screening requirements. 

VHA is exploring options to achieve these goals. VA will provide an 
action plan to implement the Government Accountability Office's 
recommendations when responding to your final report. 

Thank you for the opportunity to comment on your draft report. 

Sincerely yours, 

Signed by: 

Gordon H. Mansfield: 

[End of section] 

Appendix IV: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Laurie E. Ekstrand (202) 512-7101 or ekstrandl@gao.gov: 

Acknowledgments: 

In addition to the contact named above, Marcia A. Mann, Assistant 
Director; Linda Diggs; Alison Farley; Martha A. Fisher; Krister Friday; 
and Marion M. Slachta made key contributions to this report. 

[End of section] 

(290421): 

FOOTNOTES 

[1] VA medical facilities may contract with local or national companies 
in order to obtain certain types of health care practitioners, such as 
nurses, physicians, or respiratory therapists, who may have access to 
and provide care to patients. 

[2] Professional credentials held by health care practitioners may 
include medical licenses, registrations, and certifications. We refer 
to these credentials as state licenses and national certificates. 

[3] GAO, VA Health Care: Improved Screening of Practitioners Would 
Reduce Risk to Veterans, GAO-04-566 (Washington, D.C.: Mar. 31, 2004), 
and VA Health Care: Veterans at Risk from Inconsistent Screening of 
Practitioners, GAO-04-625T (Washington, D.C.: Mar. 31, 2004). 

[4] HIPDB is a national data bank that contains information on health 
care practitioners involved in health care-related civil judgments and 
criminal convictions as well as practitioners who have had disciplinary 
actions taken against their licenses or national certificates. 

[5] Fingerprint-only background investigations verify an individual's 
criminal history, based on a fingerprint check, against criminal 
history databases. In contrast, traditional background investigations 
verify an individual's criminal history based on a fingerprint check 
and also include a more extensive investigation of an individual's 
professional and personal history. 

[6] We visited the New Orleans VA medical facility in July 2005, prior 
to the facility being closed as a result of Hurricane Katrina. 

[7] We selected these additional salaried health care practitioners in 
order to determine if new screening requirements VA established on July 
13, 2004, and September 2, 2004, had been implemented by facility 
officials. 

[8] WOC health care practitioners include individuals working in 
patient care or research areas that are paid by a source other than VA. 
For example, researchers and research assistants assigned to work at 
the VA medical facility but paid by the affiliated university would be 
considered WOC health care practitioners. 

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

[10] Employment refers to all health care practitioners, salaried and 
nonsalaried, working in VA facilities. 

[11] In this report, we use "applicant" to describe health care 
practitioners who VA facility officials plan to hire, and we use 
"currently employed" to describe health care practitioners who already 
work at VA facilities. 

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

[13] A state licensing board may limit a health care practitioner's 
ability to perform certain activities, for example, a health care 
practitioner may not be allowed to prescribe or administer certain 
types of medications. 

[14] Some health care practitioners may hold both national certificates 
and state licenses. 

[15] Executive Order 10450, April 27, 1953, requires all persons 
employed by federal departments and agencies to undergo background 
investigations to ensure that their employment is consistent with 
national security interests. 

[16] OPM was created and given the authority to administer background 
investigations by Executive Order 12107 (Dec. 28, 1978). OPM has issued 
regulations addressing the determination of an individual's suitability 
for federal employment, based on character, conduct, knowledge, and 
ability, as part 732 of title 5 of the Code of Federal Regulations. 

[17] The National Leadership Board serves in an advisory capacity to 
VA's Under Secretary for Health on matters pertaining to policy, 
planning, and performance. 

[18] VA requires the completed employment checklist to be filed in the 
personnel folder. 

[19] VA Handbook 5005, pt. II, ch. 3, para. 17a (1). 

[20] Volunteers who are high school students, those who will work at a 
facility for a short time, or those who will not provide services 
directly to patients are exempt from the HIPDB query requirement. 

[21] VHA Directive 0710, Personnel Suitability and Security Program, 
August 19, 2005. 

[22] VHA Directive 0710. 

[23] A 90 percent compliance rate means that 90 percent of the health 
care practitioner files we examined provided documentation that the 
screening requirement had been met in accordance with VA policy. 

GAO's Mission: 

The Government Accountability Office, the investigative arm of 
Congress, exists to support Congress in meeting its constitutional 
responsibilities and to help improve the performance and accountability 
of the federal government for the American people. GAO examines the use 
of public funds; evaluates federal programs and policies; and provides 
analyses, recommendations, and other assistance to help Congress make 
informed oversight, policy, and funding decisions. GAO's commitment to 
good government is reflected in its core values of accountability, 
integrity, and reliability. 

Obtaining Copies of GAO Reports and Testimony: 

The fastest and easiest way to obtain copies of GAO documents at no 
cost is through the Internet. GAO's Web site ( www.gao.gov ) contains 
abstracts and full-text files of current reports and testimony and an 
expanding archive of older products. The Web site features a search 
engine to help you locate documents using key words and phrases. You 
can print these documents in their entirety, including charts and other 
graphics. 

Each day, GAO issues a list of newly released reports, testimony, and 
correspondence. GAO posts this list, known as "Today's Reports," on its 
Web site daily. The list contains links to the full-text document 
files. To have GAO e-mail this list to you every afternoon, go to 
www.gao.gov and select "Subscribe to e-mail alerts" under the "Order 
GAO Products" heading. 

Order by Mail or Phone: 

The first copy of each printed report is free. Additional copies are $2 
each. A check or money order should be made out to the Superintendent 
of Documents. GAO also accepts VISA and Mastercard. Orders for 100 or 
more copies mailed to a single address are discounted 25 percent. 
Orders should be sent to: 

U.S. Government Accountability Office 

441 G Street NW, Room LM 

Washington, D.C. 20548: 

To order by Phone: 

Voice: (202) 512-6000: 

TDD: (202) 512-2537: 

Fax: (202) 512-6061: 

To Report Fraud, Waste, and Abuse in Federal Programs: 

Contact: 

Web site: www.gao.gov/fraudnet/fraudnet.htm 

E-mail: fraudnet@gao.gov 

Automated answering system: (800) 424-5454 or (202) 512-7470: 

Public Affairs: 

Jeff Nelligan, managing director, 

NelliganJ@gao.gov 

(202) 512-4800 

U.S. Government Accountability Office, 

441 G Street NW, Room 7149 

Washington, D.C. 20548: