The U.S. Department of Veterans Affairs (VA) Office of Inspector General (OIG) released a scathing audit report on the “Personnel Suitability Program” for the Veterans Health Administration (VHA). Mincing no words, the OIG noted that “the VA did not provide effective governance of the personnel suitability program to ensure that background investigation requirements were met at medical facilities nationwide.”

Appalling situation at the VHA

Digging into the audit a bit deeper we sadly find a total lack of process and procedure, creating the vulnerability of inappropriate personnel being placed into positions of responsibility and direct patient contact (or both).

VHA requires background investigations for “most” medical staff. These are identified as, “physicians, nurses, pharmacists, and laboratory technicians” The OIG estimates that 6.2% of medical staff (6,200 staff members) never had a background check initiated. Approximately 65.9% of all medical employees whose backgrounds were checked required administrative adjudication.

The requirement to marry the completed background check with an employee’s personnel file seems both logical and of great importance. That said, the OIG estimates that 35,215 VHA employees did not have their Certificate of Investigation placed in their electronic personnel file.

Overwhelmed at the VHA and VA

To put it gently, the VHA was and is systemically overwhelmed.

The OIG estimates that of those background investigations processed, about 13 percent (10,400) were not adjudicated in a timely manner across multiple VA Medical Centers.

The VHA did not detect and correct these irregularities because they had no one to do it. Thus, lack of focus on what is important effectively “exposed veterans and employees to individuals who have not been properly vetted.”

Finding 1 –  VA’s management of the Personnel Suitability Program for VHA employees needs improvement.

An understatement if there ever was one. As pointed out by the OIG, “the lack of background investigations and adjudications is in direct violation of E.O. 13764 and OPM regulations.”

The OIG provided examples of individuals who had direct access to patients in VA Medical Centers.

  • Dayton VA Medical Center – a registered nurse worked 1,452 days before a background check was initiated. The OIG’s visit to the facility was responsible for the error being discovered.
  • Charlie Norwood VA Medical Center (Augusta, Ga.) – as was the case in Dayton, the OIG’s visit revealed that a registered nurse had been employed at the center for 774 days without a background check being initiated.

The PSS (Personnel Security and Suitability) Program Management Office acknowledge they lacked sufficient staff to perform any regular oversight of the suitability program. In 2017, this office, PSS, conducted a nationwide review and found that the Long Beach Healthcare System to be the most egregious. This facility had a backlog of over “2,900 delinquent suitability adjudications”

Recommendations – Of the eight recommendations, seven pertain to getting the VHA and VA on the same page as far as adjudication, division of labor and process flow. In addition, named entities, all designed to provide clarity of process, and get the background investigation and adjudication process operating within the scope of E.O. 13764. The eighth recommendation directs the VA and VHA to “evaluate human capital needs and coordinate appropriate resources to manage personnel suitability workload at VA medical facilities.

Finding 2 – The VA needs to improve the reliability of human resources data

The OIG found that uniformity of process was lacking throughout the VHA. Specifically, the fact that electronic personnel files and physical hard copy personnel files were both being used. Furthermore, the general lack of an effective case management system precluded the VHA and VA from making informed decisions.

Recommendations – As was the case with the prior finding, the recommendations were largely administrative reorganization. With an admonishment to “ensure that personnel suitability investigation data are fully evaluated and reliable for program tracking and oversight.”

The OIG report signals how the security clearance and suitability process is broken across the federal government. At the VA, as with other organizations, it’s not simply the background investigation process that’s in trouble. The records keeping and overall management system that determines who is granted a security clearance, and who should be eligible for a security clearance, is in need of reform.

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Christopher Burgess (@burgessct) is an author and speaker on the topic of security strategy. Christopher, served 30+ years within the Central Intelligence Agency. He lived and worked in South Asia, Southeast Asia, the Middle East, Central Europe, and Latin America. Upon his retirement, the CIA awarded him the Career Distinguished Intelligence Medal, the highest level of career recognition. Christopher co-authored the book, “Secrets Stolen, Fortunes Lost, Preventing Intellectual Property Theft and Economic Espionage in the 21st Century” (Syngress, March 2008). He is the founder of