One Issue Is Access to Controlled Substances
Click to Enlarge: a) DEA registrations are required for certain health care practitioners licensed to dispense, administer, or prescribe controlled substances. Source: Government Accountability Office Report February 2023
WASHINGTON, DC — VA apparently lacks the personnel needed to complete timely background checks on all new staff, resulting in employees going to work at VA hospitals without ever being fully vetted, according to a legislator.
This has raised concerns about veteran safety among lawmakers, who use the case of Reta Mays as the most egregious example of what could happen if background checks are not performed in a timely manner.
In 2021, Mays, a nursing assistant at the Clarksburg VAMC was convicted of murdering at least seven veterans under her care. A VA Office of the Inspector General (OIG) report later found that she had not received a timely background check. Had such a check occurred, it might have prevented her from remaining in her position.
While Mays’s case is a gruesome outlier, legislators said they also worry about the more common occurrence of VA failing to ensure that staff with access to controlled substances do not have a criminal history involving illicit drugs.
“Evidence suggests VA is failing to follow the law and common-sense policy resulting in background check deficiencies,” declared Rep. Jen Kiggans (R-VA), chair of the VA House Oversight Subcommittee. “Some employees were never given a background check in the first place. This includes hundreds of employees with indications of a controlled substance criminal history that the GAO [the Government Accountability Office] estimates have not completed background investigations.”
According to VA’s regulations, individuals with a drug-related felony on their record require the department to obtain a waiver from the Drug Enforcement Agency to allow them to work in a position that gives them access to controlled substances.
The GAO looked at 12,569 employees with indications of a history with controlled substances. Of those, 1,800 had felony convictions, some of whom had no background check performed at all. Looking at a sample of 50 employees with felonies on their record, GAO found that VA did not request waivers for 48 and could not confirm it had requested waivers for the remaining two.
According to GAO investigators, VHA has no guidance for determining whether an employee has access to controlled substances, and so has no formal way of knowing when a waiver is needed.
The VA Office of the Inspector General (OIG) has issued several reports on VHA’s background check deficiencies, placing the blame on a significant lack of staff to conduct these checks, as well as inefficient data systems to track the progress of employee vetting.
“A high-performing screening program is critical for VHA to ensure the integrity of its workforce,” Shawn Steele, OIG’s director of Healthcare Infrastructure Division, told the subcommittee. “VA faces high vacancy rates and significant staffing shortages across many of its programs and operations, including critical positions within VHA. These shortages extend to human resources and personnel suitability staff essential to the hiring and vetting process.”
Insufficient Staff
In the wake of a 2018 OIG report on the topic, VHA implemented a number of new policies and program controls designed to provide better governance over its personnel suitability program. However, when OIG conducted a follow-up audit in 2023, it found that many of those policies and programs had been abandoned. Because VHA’s Workforce Management and Consulting Office did not have sufficient staff to conduct reviews of how its program was faring nationwide, it abdicated responsibility to the VISNS, who also did not have the staff for the job, Steele said.
In its recent audit, OIG investigators spoke with five VISN personnel security chiefs. Four reported routinely processing background investigations to help facilities when that facility’s adjudicator—the employee whose job it is to process background investigations—was on leave. Some facilities have only one adjudicator in charge of vetting several thousand employees, while other facilities have none at all and rely on support from the VISN.
The OIG report also detailed how VA relies on two data systems to complete background checks. While one system captures data about what type of investigation is needed for each position, the other tracks data from that investigation. Auditors found that the systems regularly contain missing or inaccurate information, and that VA lacked one authoritative source for its personnel suitability program.
According to VA leaders, the department is working on its staffing problems and expects to do better in 2024.
“We’re increasing our staffing to try and tackle those issues to try and make sure we don’t end up in situations … where we just have one person on site to adjudicate background investigations,” said Jessica Bonjorni, VA’s chief of Human Capital Management.
Bonjorni admitted that this effort is hindered by the slow speed of VA’s hiring process, which is currently averaging 169 days.
Asked whether VA can contract out adjudicator positions, Bonjorni noted that it’s against the law to contract out that role.
“We are asking them to make a decision about whether someone is suitable for federal employment, and that’s not something we want to outsource,” she said.
