Personnel Suitability Process Concerns at the Beckley VA Medical Center in West Virginia

The personnel suitability program for the Veterans Health Administration (VHA) is intended to ensure that employees hired to care for patients or handle veterans’ sensitive information undergo background investigations and are suited to hold their positions. After a former nursing assistant pled guilty in 2020 to second-degree murder of seven patients at the Louis A. Johnson VA Medical Center in Clarksburg, West Virginia, the OIG undertook an inspection that found the Clarksburg facility did not adjudicate her background investigation within the required 90 days. This prompted a follow-up audit (still ongoing) of VHA’s personnel suitability program, during which the VA Office of Inspector General (OIG) identified issues with the background checks for the Beckley VA Medical Center in West Virginia. This report details the breakdowns in Beckley’s suitability process. Some employees did not have suitability checks initiated or were not fingerprinted as required, while other employees’ background investigations were delayed, discontinued in error, or not completed and evaluated within the required time. These issues occurred, in part, because only one employee was responsible for initiating and evaluating investigations at Beckley. Further, the VHA program office did not conduct required inspections of the Veterans Integrated Service Network (VISN) 5 human resource office to ensure suitability checks were adequately supported. Moreover, VISN 5 did not complete required oversight at Beckley (and other facilities) because it had lacked permanent staff to perform those functions. Consequently, some employees were caring for patients even though they had not yet passed suitability checks—although no evidence of patient harm was identified. VHA concurred with OIG’s three recommendations for VISN 5 to conduct an audit of background investigations for Beckley personnel, establish a plan to conduct compliance checks at other VISN 5 facilities, and evaluate staffing levels and allocate staff as needed for the personnel suitability program.