VA Health Care: Steps Taken to Improve Practitioner Screening,	 
but Facility Compliance with Screening Requirements Is Poor	 
(25-MAY-06, GAO-06-544).					 
                                                                 
In March 2004, GAO reported on gaps in VA's requirements for	 
screening the professional credentials and personal backgrounds  
of health care practitioners (GAO-04-566). GAO found that VA's	 
requirements did not ensure thorough screening of VA		 
practitioners. VA concurred with four recommendations GAO made to
improve practitioner screening. GAO was asked to determine the	 
extent to which (1) VA has taken steps to improve practitioner	 
screening by implementing GAO's recommendations and (2) VA	 
facilities are in compliance with VA's practitioner screening	 
requirements. GAO reviewed VA's current practitioner screening	 
policies to determine if gaps remain, interviewed VA officials,  
and sampled about 60 practitioner files at each of seven VA	 
facilities selected based on size and geographic location.	 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-06-544 					        
    ACCNO:   A54726						        
  TITLE:     VA Health Care: Steps Taken to Improve Practitioner      
Screening, but Facility Compliance with Screening Requirements Is
Poor								 
     DATE:   05/25/2006 
  SUBJECT:   Background investigations				 
	     Fingerprints					 
	     Health care personnel				 
	     Hiring policies					 
	     Internal controls					 
	     Noncompliance					 
	     Physicians 					 
	     Professional licenses				 
	     Personnel qualifications				 

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GAO-06-544

     

     * Results in Brief
     * Background
     * VA Has Taken Steps to Improve Health Care Practitioner Scree
          * VA Has Partially Implemented Our Recommendation to Expand Ve
          * VA Partially Implemented Our Recommendation to Require Medic
          * VA Policy on Fingerprint-Only Background Investigations Addr
          * VA Partially Implemented Our Recommendation to Conduct Overs
     * VA Facilities Did Not Comply with Health Care Practitioner S
     * Conclusions
     * Recommendations for Executive Action
     * Agency Comments
     * GAO Contact
     * Acknowledgments
     * GAO's Mission
     * Obtaining Copies of GAO Reports and Testimony
          * Order by Mail or Phone
     * To Report Fraud, Waste, and Abuse in Federal Programs
     * Congressional Relations
     * Public Affairs

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

United States Government Accountability Office

GAO

May 2006

VA HEALTH CARE

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

GAO-06-544

Contents

Letter 1

Results in Brief 4
Background 6
VA Has Taken Steps to Improve Health Care Practitioner Screening
Requirements, but Gaps Remain 12
VA Facilities Did Not Comply with Health Care Practitioner Screening
Requirements 16
Conclusions 21
Recommendations for Executive Action 22
Agency Comments 22
Appendix I Scope and Methodology 24
Appendix II Results of Our Compliance Reviews at Seven VA Facilities 30
Appendix III Comments from the Department of Veterans Affairs 34
Appendix IV GAO Contact and Staff Acknowledgments 35

Tables

Table 1: State Licensure and National Certification Requirements for the
43 VA Occupations 26
Table 2: Health Care Practitioners Included in Our Review of Select VA
Screening Requirements and the Documentation Required to Demonstrate
Compliance 28
Table 3: VA Facility Compliance with Screening Requirements for Salaried
Health Care Practitioners-Background Investigations (2005) 30
Table 4: VA Facility Compliance with Screening Requirements for Fee Basis
and WOC Health Care Practitioners-Background Investigations (2005) 31
Table 5: VA Facility Compliance with Screening Requirements for Salaried
Health Care Practitioners-HIPDB Query and State License and National
Certificate Verification (2005) 32
Table 6: VA Facility Compliance with Screening Requirements for Salaried
Health Care Practitioners-Employment Checklist Completed and Position Risk
Level Determined (2005) 33

Figures

Figure 1: Gaps Identified in VA's Process for Verifying Health Care
Practitioner Credentials with State Licensing Boards and National
Certifying Organizations, March 2004 11
Figure 2: Facilities' Rates of Compliance with Select VA Screening
Requirements for Salaried Health Care Practitioners (2005) 18
Figure 3: Background Investigation Compliance Rates for Salaried Health
Care Practitioners at Revisited VA Medical Facilities (2005) 19
Figure 4: VA Facility Compliance with Background Investigation Screening
Requirements for Fee Basis and WOC Health Care Practitioners (2005) 20

Abbreviations

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

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separately.

United States Government Accountability Office

Washington, DC 20548

May 25, 2006

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

Dear Mr. Chairman:

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

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

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

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

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

VA concurred with our recommendations to

           o  expand verification of all state licenses and national
           certificates by contacting the appropriate licensing boards and
           national certifying organizations for all VA health care
           practitioners,
           o  expand query of the Healthcare Integrity and Protection Data
           Bank (HIPDB)4 to include all licensed health care practitioners at
           VA facilities,
           o  conduct fingerprint-only background investigations for all VA
           health care practitioners with direct patient care access,5 and
           o  conduct oversight of medical facilities to ensure compliance
           with all of VA's key screening requirements.

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

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

           To determine the extent to which VA medical facilities complied
           with VA health care practitioner screening requirements, we
           selected seven VA medical facilities to visit. These facilities
           varied in terms of size and geographic location. Two of the seven
           facilities we visited were sites from our previous review. We
           visited facilities located in Fargo, North Dakota; Kansas City,
           Missouri; Miami, Florida; New Orleans, Louisiana; Salt Lake City,
           Utah; San Antonio, Texas; and the District of Columbia.6 For each
           facility, VA provided from its automated pay system a list of
           salaried health care practitioners in the 43 occupations we
           included in our previous report. At each facility we reviewed a
           random sample of personnel files to determine whether the files
           included documentation demonstrating that the facility's health
           care practitioners had their professional credentials verified and
           backgrounds checked in compliance with VA's screening
           requirements. At each of the facilities, our sample of personnel
           files consisted of about 50 personnel files for salaried health
           care practitioners who were hired prior to October 1, 2004, and 10
           to 12 personnel files for salaried health practitioners who were
           hired on or after October 1, 2004.7 In addition to the random
           sample of salaried health care practitioners, we also reviewed at
           each facility 20 personnel files for nonsalaried health care
           practitioners paid by VA on a fee basis and all of the files for
           the facility's WOC health care practitioners who work in a
           clinical area at the facility.8 In collecting information on the
           screening requirements from personnel files at each facility, we
           employed standard data collection techniques to ensure the
           accuracy and reliability of the data used in this report. At each
           facility we also reviewed about five contracts that the facility
           used to supplement its health care practitioner staffing in order
           to determine how facility officials screen the personal
           backgrounds and professional credentials of these nonsalaried
           health care practitioners. Finally, at each facility we also
           interviewed the officials responsible for coordinating volunteer
           activities to determine how volunteers are screened prior to
           beginning work at the facility.9

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

           aTested for significance at the 95 percent confidence level.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

           o  expand the HRM oversight program to include a review of VA
           facilities' compliance with screening requirements for all types
           of salaried and nonsalaried health care practitioners and
           o  standardize a method for documenting facility officials' review
           of fingerprint-only background investigation results and decisions
           regarding suitability to work in VA medical facilities.

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

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

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

           Sincerely yours,

           Laurie E. Ekstrand Director, Health Care

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

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

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

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

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

                                                                Occupations   
                                                 Occupations    that do not   
                                    Occupations  that require require a state 
                                    that require  a national   license or a   
                                      a state    certificate     national     
Occupation                        license to   to work in  certificate to  
code       Occupation title       work in VA       VA        work in VA    
101        Social science                                         X        
102        Social science aide                                    X        
              and technician                                  
180        Psychology                 X                    
181        Psychology aide and                                    X        
              technician                                      
185        Social work                X                    
186        Social services aide                                   X        
              and assistant                                   
187        Social services                                        X        
189        Recreation aide and                                    X        
              assistant                                       
413        Physiology                                             X        
601        General health                                         X        
              science                                         
602        Medical officer            X                    
              (physician)                                     
603        Physician's assistant                   X       
605        Nurse anesthetist          X            X       
610        Registered nursea          X                    
620        Practical nurse            X                    
621        Nursing assistant                                      X        
622        Medical supply                                         X        
              aide/technician                                 
630        Dietitian and                           X       
              nutritionist                                    
631        Occupational                            X       
              therapist                                       
633        Physical therapist         X                    
635        Corrective therapist                                   X        
636        Rehabilitation                                         X        
              therapy assistant                               
638        Recreation/creative                                    X        
              arts therapist                                  
640        Health aide and                                        X        
              technician                                      
644        Medical technologist                                   X        
645        Medical technician                                     X        
646        Pathology technician                                   X        
647        Diagnostic radiologic                   X       
              technologist                                    
648        Therapeutic                             X       
              radiologic                                      
              technologist                                    
649        Medical instrument                                     X        
              technician                                      
651        Respiratory therapist                   X       
660        Pharmacist                 X                    
661        Pharmacy technician                                    X        
662        Optometrist                X                    
665        Speech pathology and                                   X        
              audiology                                       
667        Orthotist and                                          X        
              prosthetist                                     
668        Podiatrist                 X                    
672        Prosthetic                                             X        
              representative                                  
680        Dental officer             X                    
              (dentist)                                       
681        Dental assistant                        X       
682        Dental hygiene             X                    
1320       Chemistry                                              X        
1715       Vocational                                             X        
              rehabilitation                                  

Source: VA Handbook 5005, April 15, 2002.

a"Registered nurse" includes nurse practitioners and clinical nurse
specialists.

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

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

           o  determine the position risk level by completing VA Form 2280;
           o  ensure completion of background investigations;
           o  query the Healthcare Integrity and Protection Data Bank (HIPDB)
           for all applicants after October 1, 2004;
           o  complete an employment checklist for those hired after October
           1, 2004; and
           o  verify state licenses and national certificates for applicants
           and employed health care practitioners.

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

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

           Source: GAO.

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

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

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



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

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

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

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

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

                                Results in Brief

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

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

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

                                   Background

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

22VHA Directive 0710.

      VA Facilities Did Not Comply with Health Care Practitioner Screening
                                  Requirements

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

                                  

Appendix I: Scope and Methodology Appendix I: Scope and Methodology

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

                                                                Occupations   
                                                 Occupations    that do not   
                                    Occupations  that require require a state 
                                    that require  a national   license or a   
                                      a state    certificate     national     
Occupation                        license to   to work in  certificate to  
code       Occupation title       work in VA       VA        work in VA    
101        Social science                                         X        
102        Social science aide                                    X        
              and technician                                  
180        Psychology                 X                    
181        Psychology aide and                                    X        
              technician                                      
185        Social work                X                    
186        Social services aide                                   X        
              and assistant                                   
187        Social services                                        X        
189        Recreation aide and                                    X        
              assistant                                       
413        Physiology                                             X        
601        General health                                         X        
              science                                         
602        Medical officer            X                    
              (physician)                                     
603        Physician's assistant                   X       
605        Nurse anesthetist          X            X       
610        Registered nursea          X                    
620        Practical nurse            X                    
621        Nursing assistant                                      X        
622        Medical supply                                         X        
              aide/technician                                 
630        Dietitian and                           X       
              nutritionist                                    
631        Occupational                            X       
              therapist                                       
633        Physical therapist         X                    
635        Corrective therapist                                   X        
636        Rehabilitation                                         X        
              therapy assistant                               
638        Recreation/creative                                    X        
              arts therapist                                  
640        Health aide and                                        X        
              technician                                      
644        Medical technologist                                   X        
645        Medical technician                                     X        
646        Pathology technician                                   X        
647        Diagnostic radiologic                   X       
              technologist                                    
648        Therapeutic                             X       
              radiologic                                      
              technologist                                    
649        Medical instrument                                     X        
              technician                                      
651        Respiratory therapist                   X       
660        Pharmacist                 X                    
661        Pharmacy technician                                    X        
662        Optometrist                X                    
665        Speech pathology and                                   X        
              audiology                                       
667        Orthotist and                                          X        
              prosthetist                                     
668        Podiatrist                 X                    
672        Prosthetic                                             X        
              representative                                  
680        Dental officer             X                    
              (dentist)                                       
681        Dental assistant                        X       
682        Dental hygiene             X                    
1320       Chemistry                                              X        
1715       Vocational                                             X        
              rehabilitation                                  

Source: VA Handbook 5005, April 15, 2002.

a"Registered nurse" includes nurse practitioners and clinical nurse
specialists.

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

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

           o  determine the position risk level by completing VA Form 2280;
           o  ensure completion of background investigations;
           o  query the Healthcare Integrity and Protection Data Bank (HIPDB)
           for all applicants after October 1, 2004;
           o  complete an employment checklist for those hired after October
           1, 2004; and
           o  verify state licenses and national certificates for applicants
           and employed health care practitioners.

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

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

           Source: GAO.

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

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

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

           Appendix II: Results of Our Compliance Reviews at Seven VA Facilities
		   
		   Tables 3 and 4 show the sample counts used to measure compliance
           and the results of our review for the background investigation
           screening requirement. Tables 5 and 6 show the sample counts used
           to measure compliance with the remaining health care practitioner
           screening requirements that we included in our review.

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

                                Number with completed or requested background 
Facility   Number in sample                                 investigations 
Facility A               61                                             52 
Facility B               59                                             50 
Facility C               62                                             54 
Facility D               60                                             45 
Facility E               60                                             57 
Facility F               63                                             55 
Facility G               60                                             43 

           Source: GAO analysis of VA facility files.

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

           Table 4: VA Facility Compliance with Screening Requirements for
           Fee Basis and WOC Health Care Practitioners-Background
           Investigations (2005)
		   
		   
                   Fee basis health care                 
                       practitioners           WOC health care practitioners
                         Number with completed                    Number with
                                  or requested                   completed or
              Number in             background Number in requested background
Facility      sample         investigations    sample       investigations
Facility A        20                      7                   a          a 
Facility B        21                      0                  26          0 
Facility C        20                     17                  52         21 
Facility D        20                      7                   a          a 
Facility E        20                     16                  40         26 
Facility F         a                      a                  21         20 
Facility G        20                      0                  54          0 


           Source: GAO analysis of VA facility files.

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

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

           Table 5: VA Facility Compliance with Screening Requirements for
           Salaried Health Care Practitioners-HIPDB Query and State License
           and National Certificate Verification (2005)
		   
		   
                                    State license and national     
                 HIPDB query         certificate verification      
              Number in Number queried Number in    Number where verification
Facility      sample  prior to hire    sample           followed VA policy
Facility A        17       13    46                          44 
Facility B        21       14    45                          44 
Facility C        18        0    44                          41 
Facility D        19       19    45                          42 
Facility E        22       20    48                          37 
Facility F        24       13    45                          44 
Facility G        17       10    38                          24 

           Source: GAO analysis of VA facility files.

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

           Table 6: VA Facility Compliance with Screening Requirements for
           Salaried Health Care Practitioners-Employment Checklist Completed
           and Position Risk Level Determined (2005)
		   
		   
                                                         Position risk level
                                                         determined (VA Form
                   Employment checklist completed               2280)
                                                         Number with position
                                                        risk level determined
              Number in Number with completed Number in  and documented on VA
Facility      sample employment checklists    sample             Form 2280
Facility A        10                               8       61           34
Facility B        10                               0       59            0
Facility C        10                               5       62            0
Facility D        10                               0       60           58
Facility E        10                               4       60           59
Facility F        12                               1       63            8
Facility G        10                               0       60            0


           Source: GAO analysis of VA facility files.

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

           Appendix III: Comments from the Department of Veterans Affairs
		   
		   Appendix IV: GAO Contact and Staff Acknowledgments
		   
		   Contact
		   
		   Laurie E. Ekstrand (202) 512-7101 or [email protected]

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

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Screening            Health care practitioners  Documentation required to  
requirements         included in our review     demonstrate compliance     
Conducting              o  VA salaried             o  Notice of scheduled  
background              o  Fee basis               or completed background 
investigations          o  WOC                     investigation from the  
                                                      Office of Personnel     
                                                      Management (OPM)        
Completing VA Form      o  VA salaried             o  Completed VA Form    
2280 for each job                                  2280                    
category                                        
Querying HIPDB          o  VA salaried health      o  HIPDB query printout 
                           care practitioners         o  National             
                           hired on or after          Practitioner Data Bank  
                           October 1, 2004            query printout, which   
                           o  Certain health care     includes a query of     
                           practitioners hired        HIPDB                   
                           prior to this date,     
                           such as physicians and  
                           dentists                
Completing              o  VA salaried health      o  Completed employment 
employment checklist    care practitioners         checklist which met VA  
                           hired on or after          requirements            
                           October 1, 2004         
Verifying license,      o  VA salaried health      o  Printouts, letters,  
certification, or       care practitioners         and telephone contact   
both                    required to have a         reports from state      
                           state license or           licensing boards and    
                           national certificate to    national certification  
                           work in VA                 organizations           
                                                      o  VA Form 4862,        
                                                      indicating that the     
                                                      original license or     
                                                      certificate had been    
                                                      visually inspected by a 
                                                      VA facility official    

(290421)

www.gao.gov/cgi-bin/getrpt? GAO-06-544 .

To view the full product, including the scope

and methodology, click on the link above.

For more information, contact Laurie E. Ekstrand at (202) 512-7101 or
[email protected].

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

May 2006

VA HEALTH CARE

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

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

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

What GAO Recommends

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

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

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

Facilities' Rates of Compliance with Select VA Screening Requirements for
Health Care Practitioners (2005)
*** End of document. ***