Report Summary

Title: Noncompliant and Deficient Processes and Oversight of State Licensing Board and National Practitioner Data Bank Reporting Policies by VA Medical Facilities
Report Number: 20-00827-126 Download
Issue Date: 4/7/2022
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Hotline Healthcare Inspection
Release Type: Unrestricted

The VA Office of Inspector General (OIG) conducted an inspection to assess VA medical facilities’ compliance and processes regarding Veterans Health Administration (VHA) policies for reporting healthcare professionals to state licensing boards (SLBs) and the National Practitioner Data Bank (NPDB).

The OIG found widespread noncompliance with SLB and NPDB reporting processes applied by facilities to healthcare professionals whose conduct or competence led to separation from employment. Failure to comply with reporting policies leaves SLBs and recipients of NPDB information unaware of a healthcare professional’s practice deficiencies and ultimately violates an important VA commitment to protect the health of veterans and the public. Moreover, the OIG found a lack of programmatic oversight of compliance with SLB and NPDB reporting processes.

For a majority of cases involving separated healthcare professionals, facility directors failed to follow mandatory processes for reporting healthcare professionals to SLBs. The OIG identified SLB reporting noncompliance was related to staff misunderstanding policy and poor facility processes.

In 15 of 35 physician or dentist cases appealing a separation from employment, facility directors failed to submit NPDB reports as required by federal regulation and VHA policy. Conflicting language in VHA policies, misunderstanding of policies, and poor facility processes contributed to the failures.

VHA SLB and NPDB reporting policies did not assign programmatic oversight to ensure facility leaders’ compliance with SLB and NPDB reporting processes. The lack of programmatic oversight contributed to the failure of VHA leaders to detect and intervene upon facility noncompliance.

The OIG made four recommendations to the Under Secretary for Health regarding ensuring SLB and NPDB reporting compliance and programmatic oversight as well as aligning NPDB policy with federal regulation.

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