Department of Health and Human Services
OFFICE OF 
   
INSPECTOR GENERAL 
 
 
 
 
 
 
 
 
NU  RSING FACILITIES  
 
E I
MPLOYMENT OF  NDIVIDUALS 
 
 
W C C  
ITH  RIMINAL  ONVICTIONS
 
 
 
 
 
 
Daniel R. Levinson  
Inspector General 
 
March 2011 
OEI-07-09-00110   
   
 E X E C U T I V E   S U M M A R Y  
OBJECTIVE
 
To determine whether and to what extent nursing facilities employed 
individuals with criminal convictions. 
BACKGROUND 
A member of Congress requested that the Office of Inspector General 
(OIG) undertake this evaluation.  Federal regulation prohibits Medicare 
and Medicaid nursing facilities from employing individuals found guilty 
of abusing, neglecting, or mistreating residents by a court of law, or who 
have had a finding entered into the State nurse aide registry concerning 
abuse, neglect, or mistreatment of residents or misappropriation of their 
property.  Interpretive guidelines from the Centers for Medicare & 
Medicaid Services (CMS) for this regulation state that [nursing] 
facilities must be thorough in their investigations of the past histories of 
individuals they are considering hiring.  However, Federal law does not 
require that nursing facilities conduct State or Federal Bureau of 
Investigation (FBI) criminal background checks.  State background 
check requirements vary in terms of what must be checked 
(e.g., statewide criminal history databases, publically available sex 
offender registries) and who must be checked (e.g., direct-care workers 
only, all staff). 
We selected a stratified random sample of 260 nursing facilities from 
the universe of 15,728 Medicare-certified nursing facilities and 
requested data on all individuals who were employed by the sampled 
nursing facilities on June 1, 2009.  To gain access to criminal history 
record information, we entered into an Information Transfer Agreement 
with FBI.  We compared employee data with the criminal history 
records FBI provided to identify individuals with criminal convictions 
employed by the sampled nursing facilities.   
  OEI-07-09-00110  NURSING FACILITIES EMPLOYMENT OF INDIVIDUALS WITH CRIMINAL CONVICTIONS  i   
   
E X E C U T I V E   S U M M A R Y  
 
  Consistent with the congressional request and objective of this 
evaluation, we used FBI data to determine whether 
 
individuals employed by nursing facilities had criminal 
  convictions.  Federal regulation prohibits Medicare and 
Medicaid nursing facilities from employing individuals found 
  guilty of abusing, neglecting, or mistreating residents by a 
court of law, or who have had a finding entered into the State 
 
nurse aide registry concerning abuse, neglect, or mistreatment 
  of residents or misappropriation of their property.  
FBI-maintained criminal history records do not contain 
  detailed information (i.e., they do not indicate whether the 
victim of a crime was a nursing facility resident) to determine 
 
whether a conviction disqualifies an individual from nursing 
  facility employment under Federal regulation.  Therefore, we 
did not determine whether these individuals were employed in 
  violation of Federal regulation as that question is outside the 
scope of this evaluation.
 
FINDINGS 
Almost all nursing facilities employed one or more individuals with 
at least one criminal conviction.  Our analysis of FBI-maintained 
criminal history records revealed that 92 percent of nursing facilities 
employed at least one individual with at least one criminal conviction.  
Nearly half of nursing facilities employed five or more individuals with 
at least one conviction.  Forty-four percent of employees with 
convictions were convicted of crimes against property (e.g., burglary, 
shoplifting, writing bad checks), making it the most common type of 
crime committed.  Overall, 5 percent of nursing facility employees had 
at least one conviction in FBI-maintained criminal history records.  
Most convictions occurred prior to employment.  Eighty-four percent of 
employees with convictions had their most recent conviction prior to 
their beginning date of employment.   
Despite the lack of a Federal requirement for nursing facilities to 
conduct criminal background checks, most States required, and/or 
nursing facilities reported conducting, some type of background 
check.  Forty-three States required nursing facilities to conduct either 
an FBI or a statewide criminal background check for prospective 
employees.  Some nursing facilities located in the remaining eight 
States reported conducting criminal background checks even though 
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they were not required to do so.  All but 2 percent of nursing facilities 
reported conducting some type of background check. 
RECOMMENDATION 
After completion of our data collection, the Patient Protection and 
Affordable Care Act (P.L. 111-148) became Federal law.  It requires the 
Secretary of Health & Human Services (HHS) to carry out a nationwide 
program for States to conduct national and statewide criminal 
background checks for direct patient access employees of nursing 
facilities and other providers.  States may participate in this National 
Background Check Program by entering into agreements with the 
Secretary.     
In light of our findings and in carrying out the mandate for HHS to 
implement the nationwide criminal background check program, we 
recommend that CMS: 
Develop background check procedures.  To ensure that States conduct 
background checks consistently, CMS should (1) clearly define the 
employee classifications that are direct patient access employees and 
(2) work with participating States to develop a list of State and local 
convictions that disqualify an individual from nursing facility employment 
under the Federal regulation and periods for which each conviction bars 
the individual from employment.   
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 
RESPONSE 
In its written comments on the draft report, CMS agreed with our 
recommendation.  CMS stated that in its solicitation to States for the 
National Background Check Program, the definition of direct patient 
access employee is anyone who routinely comes into contact or has the 
potential to come into contact with residents or clients, which for 
nursing facilities should include all staff.  CMS also stated that it will 
work with the States through the National Background Check Program 
to assist them in developing lists of convictions that disqualify 
individuals from employment, as well as defining whether any of those 
conviction types can be assumed to be mitigated because of the passage 
of time and which convictions should never be considered mitigated or 
rehabilitated. 
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 T A B L E   O F   C O N T E N T S  
EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i
 
 
I N T RO DUC T IO N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 
 
 
F I N D IN G S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 
Almost all nursing facilities employed one or more individuals 
with at least one criminal conviction . . . . . . . . . . . . . . . . . . . . . . . 11 
Despite the lack of a Federal requirement for nursing facilities  
to conduct criminal background checks, most States required, 
and/or nursing facilities reported conducting, some type of 
background check . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 
   
R E C O MMEN D A T ION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 
Agency Comments and Office of Inspector General Response . . . 17 
 
 
APPENDIXES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 
A:  Profile of Sampled Nursing Facility Employee          
Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 
B:  Profile of Sampled Nursing Facilities Background Check 
Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 
C:  Different Types of Resources Reveal Different Information . . 20 
  D:  Point Estimates and Confidence Intervals. . . . . . . . . . . . . . . . 21 
  E:  Agency Comments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 
 
 
A C K NO WL E D G M E N T S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 
   
 
 
 I N T R O D U C T I O N  
OBJECTIVE
 
To determine whether and to what extent nursing facilities employed 
individuals with criminal convictions.
BACKGROUND 
A member of Congress requested that the Office of Inspector General 
(OIG) undertake this evaluation.  This information has never been 
collected nationally prior to this evaluation.   
Federal Requirement 
Nursing facilities participating in Medicare and Medicaid are required 
to provide services that maintain the dignity and well-being of all 
residents.1, 2  Federal regulation prohibits Medicare and Medicaid 
nursing facilities from employing individuals found guilty of abusing, 
neglecting, or mistreating residents by a court of law.  Employment of 
individuals who have had a finding entered into the State nurse aide 
registry3 concerning abuse, neglect, or mistreatment of residents or 
misappropriation of their property is also prohibited.4  Interpretive 
guidelines from the Centers for Medicare & Medicaid Services (CMS) for 
this regulation state that [nursing] facilities must be thorough in their 
investigations of the past histories of individuals they are considering 
hiring.5   
Neither Federal law nor regulation specifically requires that nursing 
facilities check State or Federal Bureau of Investigation (FBI) criminal 
history records for prospective employees.  Despite this, nursing 
facilities have access to FBI criminal history records to conduct criminal 
background checks on individuals applying for positions involving direct 
 
1 In this report, we refer to Medicare-certified skilled nursing facilities and 
Medicaid-certified nursing facilities as nursing facilities. 
2 Social Security Act,  1819(b)(2) and 1919(b)(2). 
3 A nurse aide is any individual providing nursing or nursing-related services to 
residents in a nursing facility who is not a licensed health professional, a registered 
dietitian, or someone who volunteers to provide such services without pay.  Nurse aides 
assist residents in their activities of daily living, such as bathing, dressing, eating, and 
toileting.  Sections 1819(e)(2) and 1919(e)(2) of the Social Security Act and 
42 CFR  483.156 require each State to establish and maintain a registry of individuals who 
have completed training and who the State finds to be competent to function as nurse aides.   
4 42 CFR  483.13(c)(1)(ii). 
5 CMS, State Operations Manual, Appendix PP, F225. 
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I N T R O D U C T I O N  
patient care.6  Some States require such checks under their own 
authority.  Sources of background check information and specific State 
requirements are discussed below. 
Sources of Background Check Information 
FBI criminal background checks.  For FBI criminal background checks, an 
individual provides identifying information (usually full name, Social 
Security number (SSN), date of birth, race, and gender) and a set of 
fingerprints (electronic or rolled manually) to a State law enforcement 
agency.  The State law enforcement agency provides the individuals 
information and fingerprints to FBI to match against criminal background 
information maintained in its databases (e.g., the Interstate Identification 
Index, which is an electronic repository of criminal history record 
information that FBI maintains).  FBI then provides the requesting law 
enforcement agency with a criminal history report, if one is found, 
containing the dates of any arrests, arresting agencies, and offenses for 
which the individual was charged and/or convicted.  The FBI database 
includes information on both Federal crimes and crimes reported by 
States.   
Statewide criminal background checks.  For statewide criminal 
background checks, an individual must provide identifying information 
similar to that required to conduct an FBI criminal background check, 
but usually is not required to submit fingerprints.  This type of 
background check is conducted by a State law enforcement agency 
(e.g., State Police, Highway Patrol) and provides information similar to 
that in the Interstate Identification Index, but only for crimes 
committed within that State.   
Additional databases.  In addition to conducting an FBI and/or statewide 
criminal background check, some nursing facilities search other 
available databases (e.g., State abuse registries, National Sex Offender 
Registry).  Additionally, Federal regulations require all States to 
maintain a nurse aide registry, which nursing facilities are required to 
check for nurse aides.7  The information contained in these databases 
may also disqualify an individual from employment in a nursing facility, 
but checking these databases is not a component of FBI or statewide 
criminal background checks. 
 
6 P.L. 105-277  124 (Oct. 21, 1998).  Section 124 does not further define direct patient 
care. 
7 42 CFR  483.75(e)(6). 
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State Requirements for Background Checks on Nursing Facility Employees 
State background check requirements vary in terms of what must be 
checked (e.g., statewide criminal history databases, publically available 
sex offender registries) and who must be checked (e.g., direct-care 
workers only, all staff).  Ten States require an FBI criminal background 
check as well as a statewide check.  Thirty-three States require a 
criminal background check in the State where the nursing facility is 
located.  The remaining eight States do not have a background check 
requirement.8  The State requirements or the lack thereof do not 
prohibit nursing facilities from conducting more extensive checks on 
their own initiative.  Table 1 provides an overview of the types of 
criminal background checks States require. 
Table 1:  Nursing Facility Criminal Background Check Requirements by 
State 
Type of Check  Number of 
States 
Required  States
FBI and Statewide  AK, AZ, DE, ID, MI, MS, NM, NV, NY, TN  10 
AR, CA, DC, FL, GA, IL, IN, IA, KS, KY, 
LA, ME, MD, MA, MN, MO, NE, NH, NJ, 
Statewide*  33 
NC, OH, OK, OR, PA, RI, SC, TX, UT, VA, 
VT, WA, WV, WI 
None  AL, CO, CT, HI**, MT, ND, SD, WY  8 
     Total    51 
Source:  OIG Internet research and phone calls to States, 2009. 
*Note:  Some States that require statewide checks also require nursing facilities to conduct an 
FBI check if the individual has not lived in the State for a minimum period of time 
(e.g., 5 years). 
**Note:  A statute requiring FBI checks exists in Hawaii; however, no implementing rules have 
been published.  A Hawaii State official confirmed that nursing facilities are not yet required to 
conduct such checks.  
 
State-Identified Disqualifying Conditions 
As discussed above, Federal regulation prohibits employing individuals 
who have certain types of convictions or who have certain findings 
entered against them in State nurse aide registries.  In addition, some 
States have more specifically identified types of convictions that bar 
individuals from obtaining employment in nursing facilities.  States 
differ in regard to what types of convictions disqualify individuals and 
 
8 This report refers to the 50 States and the District of Columbia as States. 
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I N T R O D U C T I O N  
how recently a conviction must have occurred to disqualify them.  For 
example, one State lists nine types of convictions (including murder, 
voluntary manslaughter, and felony battery within the previous 5 years) 
that bar individuals from employment at nursing facilities. 
Internet research and structured interviews with State staff indicate 
that some States allow individual nursing facilities to make decisions 
regarding the employability of individuals with criminal convictions, 
while others rely on a State agency (e.g., Department of Public Health) 
to make such determinations.  Some States allow employees to work at 
nursing facilities provisionally until the results of their background 
checks are obtained. 
Legislative History Regarding Background Check Requirements 
The Medicare Prescription Drug, Improvement, and Modernization Act 
of 2003 (MMA) established a Background Check Pilot Program.9  The 
purpose of the pilot program was to identify efficient, effective, and 
economical procedures for conducting State and national criminal 
background checks on prospective direct patient access employees, as 
defined in the statute.10  Participating States required a 
fingerprint-based FBI and statewide criminal background check, as well 
as a search of other databases (e.g., State nurse aide registries, State 
sex offender registries) likely to contain disqualifying information.  CMS 
selected seven States (Alaska, Idaho, Illinois, Michigan, Nevada, New 
Mexico, and Wisconsin) to participate in the pilot program, which 
concluded in September 2007.11  Across the participating States, 
204,339 criminal background checks were initiated, of which 
7,463 resulted in individuals not being hired by a nursing facility; an 
additional 38,400 individuals withdrew their applications prior to 
completion of their criminal background checks.12 
On March 23, 2010, the Patient Protection and Affordable Care Act 
(P.L. 111-148) became Federal law.  Section 6201 requires the Secretary 
 
9 P.L. 108-173,  307. 
10 Section 307 of P.L. 108-173 defines a direct patient access employee as any 
individual (other than a volunteer) who has access to a patient or resident of a long-term 
care facility or provider through employment or through a contract with such facility or 
provider, as determined by a participating State for purposes of conducting the pilot 
program in such State.  This term applies to employees checked through the pilot program. 
11 States participation in the pilot program began between 2005 and 2006. 
12 Abt Associates, Inc., Evaluation of the Background Check Pilot Program, August 2008, 
p. 207. 
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I N T R O D U C T I O N  
of Health & Human Services (Secretary) to carry out a nationwide 
program for States to conduct national and statewide criminal 
background checks for direct patient access employees of nursing 
facilities and other providers similar to the pilot program the MMA 
established.  This National Background Check Program is to be 
conducted through means that utilize a fingerprint-based search of 
State and Federal criminal history records.  States may participate in 
the nationwide program by entering into agreements with the 
Secretary.  Grant funding will be disbursed to States in fiscal years 
2010 through 2012.  
Related Testimony and Reports 
In 2002, the Government Accountability Office (GAO) testified before 
the U.S. Senate Special Committee on Aging that sources (e.g., State 
nurse aide registries) used to screen prospective employees do not 
contain complete or up-to-date information.13  GAO noted that some 
States require nursing facilities to conduct only statewide criminal 
background checks.  Consequently, individuals who have been convicted 
of crimes in one State can cross State lines to obtain employment in 
another State.   
In 2005, OIG issued two reports related to the employment of nurse 
aides in nursing facilities nationwide.  In the first report, OIG found 
that more than 1,500 nurse aides with substantiated findings of abuse, 
neglect, or misappropriation of property in 1 State had active 
certifications in other States.14  In addition, 36 employees who were not 
nurse aides (e.g., janitors) with histories of abuse in 1 State had active 
certifications as nurse aides in other States.  The second report found 
that while 85 percent of nursing facilities conducted background checks 
of nurse aides, half of these were limited in scope (e.g., they covered a 
single State).15 
 
13 GAO, Many Shortcomings Exist in Efforts to Protect Residents from Abuse 
(GAO-02-448T), March 2002. 
14 OIG, Nurse Aide Registries:  State Compliance and Practices (OEI-07-03-00380), 
February 2005. 
15 OIG, Nurse Aide Registries:  Long Term Care Facility Compliance and Practices  
(OEI-07-04-00140), July 2005. 
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METHODOLOGY 
Scope and Limitations 
We reviewed FBI criminal histories of individuals employed by sampled 
nursing facilities on June 1, 2009.  We did not determine the criminal 
histories of individuals employed in other types of long-term care 
settings (e.g., hospice) or nursing facility residents.  Additionally, we did 
not seek to determine the effectiveness of conducting criminal 
background checks as an employment screening tool for nursing facility 
employees.   
Our estimate of the number of nursing facility employees with criminal 
convictions relies entirely upon the accuracy of the information 
contained in FBIs Interstate Identification Index.  Because the 
Interstate Identification Index relies on local, State, and Federal law 
enforcement agencies to report criminal records, it is possible that not 
all criminal history record information was accurate and up-to-date. 
The criminal history record information we received from FBI suggested 
that the records did not contain all of the convictions for particular 
employees.  For example, criminal history record information contained 
notations of probation violations (suggesting that a conviction occurred), 
but the record did not contain the convictions leading to the imposition 
of probation periods.  In addition, many charges had no corresponding 
disposition information (e.g., conviction, dismissal), so we could not 
determine whether a conviction occurred.  Finally, it is possible that 
some individuals records did not contain convictions because they were 
removed following a judicial diversion program (e.g., completion of an 
alcohol and substance abuse education course). 
Our estimates are conservative because we did not include criminal 
convictions if we could not conclusively identify the individual (e.g., if 
identifiers were similar but did not exactly match).  Also, we could not 
confirm that the information that nursing facilities provided us was 
accurate or that the information the employees provided to the nursing 
facilities was accurate.   
FBI-maintained criminal history records do not contain detailed 
information (i.e., whether the victim of a crime was a nursing facility 
resident) to determine whether a conviction disqualifies an individual 
from nursing facility employment under Federal regulation.  Therefore, 
we limited our use of the FBI data, consistent with the congressional 
request, to determining whether individuals employed by nursing 
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facilities had criminal convictions, but we did not determine whether 
these individuals were employed in violation of Federal regulation. 
Finally, the Information Transfer Agreement16 entered into by FBI and 
OIG stipulates that identifying information contained in FBI records 
shall be used only for research and statistical purposes.  Therefore, we 
were prohibited from recontacting nursing facilities to further inquire 
about the background checks they conducted on specific individuals.  In 
addition, the Information Transfer Agreement prohibits OIG from 
releasing information that may be used to identify individuals or 
nursing facilities associated with this evaluation. 
Sample and Data Sources 
We selected a stratified random sample from the universe of 
15,728 nursing facilities contained in the Online Survey, Certification, 
and Reporting (OSCAR) database as of February 10, 2009.  To produce 
nationwide estimates of the number and percentage of nursing facilities 
employing individuals with criminal convictions, we selected a sample of 
260 nursing facilities from 3 strata as shown in Table 2.   
Table 2:  Nursing Facility Population and Sample Size 
Stratum Definition  Population Size  Sample Size
Nursing facilities from States that require FBI 
1,987  110 
and statewide checks 
Nursing facilities from States that require 
12,687  110 
statewide checks 
Nursing facilities from States that have no 
1,054  40 
background check requirement 
     Total  15,728  260 
Source:  OSCAR database, February 10, 2009. 
 
We chose to stratify based on State background check requirements in 
an effort to determine whether differing requirements played a role in 
nursing facility employment of individuals with criminal convictions.  
We did not identify an effect that might be explained by a number of 
factors (e.g., checks conducted by nursing facilities in addition to those 
that their States require, differences among States regarding the 
 
16 An Information Transfer Agreement governs the terms of OIGs access to FBI criminal 
history records for research purposes. 
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I N T R O D U C T I O N  
circumstances that prohibit individuals from working in nursing 
facilities). 
Data Collection 
Employee data.  From each of the 260 sampled nursing facilities, we 
requested information for all noncontract individuals who were 
employed on June 1, 2009.17  We requested each employees full name, 
SSN, date of birth, race, gender, beginning date of employment, and job 
classification.  We also requested whether each individual was 
considered a direct-care employee.18  Four nursing facilities did not 
respond to our request because they were no longer operating; therefore, 
we received data for 35,286 employees from 256 nursing facilities.19  See 
Appendix A for a profile of sampled nursing facility employee 
characteristics. 
To assess whether a nursing facility provided us with information for all 
of its employees, we compared the number of employees submitted to us 
with the total number of employees listed in the OSCAR database for 
that facility.  We contacted four nursing facilities that provided 
information for +/- 25 percent of the number of employees as listed in 
OSCAR to determine whether the information provided correctly 
answered our request.  We requested and received revised employee 
data from these four facilities; however, given routine staffing 
fluctuations, we did not question the accuracy of employee data that 
closely approximated the number of employees listed in OSCAR. 
Mail survey.  We sent the administrator of each of the sampled nursing 
facilities a survey about background check procedures.  The survey 
included questions about the types of background checks they 
conducted, when the nursing facilities began conducting background 
checks, what the costs of conducting background checks were, and what 
job classifications they considered direct care.  We received completed 
 
17 We did not request identifying information for individuals who provide services for a 
nursing facility through a staffing agency (e.g., contract employees).  Generally, for States 
that require criminal background checks, staffing agencies, not the nursing facilities, are 
responsible for conducting checks and making decisions about employment for contract 
employees. 
18 Sampled nursing facilities differed on what job classifications constituted direct-care 
staff. 
19 Nursing facilities provided information on 46 individuals who were employed in 
2 different sampled nursing facilities as of June 1, 2009.  Therefore, we collected data on 
35,240 unique individuals. 
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surveys from all 256 nursing facilities.  See Appendix B for a profile of 
sampled nursing facilities reported background check characteristics.  
Criminal history records.  To gain access to criminal history record 
information, we entered into an Information Transfer Agreement with 
FBI.  We provided the employee data obtained from nursing facilities to 
FBI.  FBI performed a name-based match with the Interstate 
Identification Index.  Of the 35,286 names we provided, we received the 
criminal history record information for approximately 
11,200 individuals who closely matched the names we provided.20  
Because FBI uses an algorithm to conduct name-based searches, we 
received multiple matches for some of the searches, especially for 
individuals with common names. 
Analysis 
Employee data and criminal history records.  Using the SSN, date of birth, 
race, and gender identifiers, we further examined the matches FBI 
provided to identify the individuals employed by the nursing facilities.  
We determined that approximately 4,400 individuals matched the 
identifiers of the individuals employed by sampled nursing facilities.21 
We analyzed the information to identify individuals with criminal 
convictions employed by the sampled nursing facilities.  Using six broad 
categories of offenses, we recorded convictions for each positively 
matched individuals criminal history.22  Following are examples of 
specific offenses included in each broad category; these lists do not 
include every specific offense we found in each of the six categories:  
  crimes against persons:  assault, battery, murder, rape, robbery; 
  crimes against property:  burglary, larceny, possession of stolen 
property, shoplifting, theft, vandalism, writing bad checks; 
  driving under the influence of drugs or alcohol (DUI):  driving under 
the influence, driving while intoxicated; 
 
20 FBI did not provide any matches for approximately 24,000 individuals; therefore, we 
did not perform further analysis on these individuals. 
21 The identifiers of the other approximately 6,800 individuals did not match the 
identifiers of the sampled nursing facility employees (e.g., different date of birth, different 
SSN). 
22 We consulted FBI definitions of crime to assist us in categorizing offenses.  Accessed 
at http://www.fbi.gov/ucr/ on August 14, 2009. 
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  driving-related crimes (other than DUI):  leaving the scene of an 
accident, transporting an open container of alcohol in a vehicle; 
  drug-related crimes:  possession of drugs or paraphernalia, sale of 
controlled substances; and 
  other:  disorderly conduct, prostitution, resisting arrest, weapons 
violations. 
Sex offender registries.  The criminal history record information 
provided by FBI indicated that a few nursing facility employees were 
registered as sexual offenders.  Because additional information is 
readily available on sexual offenses, we examined Federal and State sex 
offender registries for these employees.23  The examination of these 
registries demonstrated how such checks can provide additional 
information to complement a criminal background check.  See 
Appendix C for the results of our review. 
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspection and Evaluation approved by the Council of the Inspectors 
General on Integrity and Efficiency. 
 
23 Most other types of offenses (e.g., drug-related crimes) do not have similar registries. 
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 F I N D I N G S  
Consistent with a congressional request, the objective of this 
evaluation is to determine whether and to what extent 
 
nursing facilities employed individuals with criminal 
  convictions.  Federal regulation prohibits Medicare and 
Medicaid nursing facilities from employing individuals found 
 
guilty of abusing, neglecting, or mistreating residents by a 
court of law, or who have had a finding entered into the 
 
State nurse aide registry concerning abuse, neglect, or 
  mistreatment of residents or misappropriation of their 
property.  FBI-maintained criminal history records do not 
 
contain detailed information (i.e., they do not indicate 
whether the victim of a crime was a nursing facility resident) 
 
to determine whether a conviction disqualifies an individual 
  from nursing facility employment under Federal regulation.  
Therefore, we used the FBI data to determine whether 
 
individuals employed by nursing facilities had criminal 
convictions.  We did not determine whether these individuals 
 
were employed in violation of Federal regulation as that 
  question is outside the scope of this evaluation. 
 
Almost all nursing facilities employed one or more  Our analysis of FBI-maintained 
individuals with at least one criminal conviction  criminal history records revealed 
that 92 percent of nursing facilities 
employed at least one individual with at least one criminal conviction.24  
The number of individuals with at least 1 conviction employed by these 
nursing facilities ranged from 1 to 66.   
Nearly half of nursing facilities employed five or more individuals with 
at least one conviction.  For example, a nursing facility with a total of 
164 employees had 34 employees with at least 1 conviction each.  These 
34 individuals had 102 total convictions categorized as follows:  
29 convictions for crimes categorized as other, 25 convictions for crimes 
against property, 18 drug-related convictions, 16 convictions for crimes 
against persons, 8 convictions for DUI, and 6 driving-related 
convictions.  Table 3 shows the percentages of nursing facilities that 
employed various percentages of employees with convictions. 
 
24 Appendix D presents the point estimates and confidence intervals for all population 
estimates. 
  OEI-07-09-00110  NURSING FACILITIES EMPLOYMENT OF INDIVIDUALS WITH CRIMINAL CONVICTIONS  11   
   
F I N D I N G S  
Table 3:  Percentage of Nursing Facilities That Employed Various 
Percentages of Employees With Criminal Convictions 
Percentage of Employees With Criminal  Percentage of 
Convictions  Nursing Facilities
None  7.7% 
Up to 5.0%  51.8% 
Greater than 5.0% to 10.0%  26.0% 
Greater than 10.0% to 15.0%  6.3% 
Greater than 15.0% to 20.0%  5.7% 
Greater than 20.0% to 25.0%  2.5% 
     Total  100.0% 
Source:  OIG analysis of FBI criminal history records and nursing facility employee data, 2009. 
 
The most common criminal conviction was for crimes against property 
Among employees with criminal convictions, the most common criminal 
conviction was for crimes against property, such as burglary, 
shoplifting, and writing bad checks (44 percent).  Table 4 shows the 
categories of crimes for which nursing facility employees were convicted. 
Table 4:  Categories of Crimes for Which Nursing Facility Employees 
Were Convicted 
Percentage of Employees 
Category of Crime 
With Criminal Convictions
Crimes against property  43.6%* 
Other  26.4% 
DUI  20.3% 
Drug-related crimes  16.2% 
Crimes against persons  13.1% 
Driving-related crimes other than DUI  11.9% 
Source:  OIG analysis of FBI criminal history records and nursing facility employee 
data, 2009. 
Percentages do not sum to 100 percent because some employees had criminal 
convictions of more than one category. 
*The percentage of employees with property convictions was statistically higher than all 
the other categories at the 95-percent confidence level. 
 
  OEI-07-09-00110  NURSING FACILITIES EMPLOYMENT OF INDIVIDUALS WITH CRIMINAL CONVICTIONS  12   
   
F I N D I N G S  
Five percent of nursing facility employees had at least one criminal 
conviction 
Overall, 5 percent of nursing facility employees had at least one 
conviction in FBI-maintained criminal history records.  Employees with 
at least one conviction in their criminal history records averaged 
two convictions per employee.  The number of criminal convictions per 
employee in our sample ranged from 1 to 110.   
Five percent of staff identified by the nursing facilities as direct-care 
employees had criminal convictions, which mirrors the conviction rate 
for nursing facility staff in general.  The term direct-care staff 
encompasses many job classifications (e.g., nurses, nurse aides).  
Sampled nursing facilities differed on what job classifications 
constituted direct-care staff.  In addition to reporting which of their 
employees they consider direct-care staff, nursing facilities reported the 
job classifications of all of their employees.  Table 5 shows the 
percentage of employees with certain job classifications who had 
convictions. 
Table 5:  Nursing Facility Employees With Certain Job Classifications 
Who Had Convictions 
Percentage of 
 
Employees With 
Job Classification 
Convictions
Housekeeping/laundry/maintenance/security  6.5% 
Certified nursing and medication aides  6.4% 
Dietary  5.7% 
Nursing (e.g., registered and licensed practical nurses)  3.6% 
All other  2.7% 
Administration  2.6% 
Source:  OIG analysis of FBI criminal history records and nursing facility employee data, 2009. 
 
Most criminal convictions occurred prior to employment 
Eighty-four percent of employees with criminal convictions had their 
most recent conviction prior to their beginning date of employment.  Of 
the employees with criminal convictions prior to the beginning date of 
employment, 38 percent had their most recent conviction 10 or more 
years prior to employment.  For example, 1 individual employed since 
2005 had 13 convictions for crimes against property, the last of which 
was in 1988.  No further convictions appeared in this employees 
  OEI-07-09-00110  NURSING FACILITIES EMPLOYMENT OF INDIVIDUALS WITH CRIMINAL CONVICTIONS  13   
   
F I N D I N G S  
criminal history record.  Table 6 shows the elapsed time between an 
employees most recent conviction before his or her beginning date of 
employment. 
Table 6:  Elapsed Time Between Employees Most Recent Conviction 
Before Beginning Date of Employment 
Percentage of Employees 
Elapsed Time Before Beginning 
With Convictions Prior to 
Date of Employment 
Employment
Less than 1 year  7.5% 
1 year to less than 5 years  28.6% 
5 years to less than 10 years  26.1% 
10 years or more  37.8% 
     Total  100.0% 
Source:  OIG analysis of FBI criminal history records and nursing facility employee 
data, 2009. 
 
Sixteen percent of employees with convictions had their most recent 
conviction after their beginning date of employment.  For example, one 
individual employed since January 2009 in a nursing facility 
housekeeping department was convicted of assault in July 2009.  The 
individual pleaded guilty to the charge and was sentenced to 2 years 
probation and 60 hours of community service.  Another individual 
employed in a nursing facility maintenance department since 1978 had 
no convictions listed in the criminal history record until 1991.  The 
individuals criminal history record listed a total of five convictions (two 
for drug-related crimes and three for DUI), all of which occurred after 
the beginning date of employment.  A nursing facility would need to 
conduct periodic criminal background checks to identify these 
convictions.  Table 7 shows the elapsed time between an employees 
beginning date of employment and his or her most recent conviction. 
  OEI-07-09-00110  NURSING FACILITIES EMPLOYMENT OF INDIVIDUALS WITH CRIMINAL CONVICTIONS  14   
   
FF II NN DD II NN GG SS   
Table 7:  Elapsed Time Between Employees Beginning Date of 
Employment and Most Recent Conviction 
Percentage of Employees With 
Elapsed Time After Beginning Date 
Convictions After Beginning 
of Employment 
Date of Employment
Less than 6 months  15.8% 
6 months to less than 1 year  10.7% 
1 year to less than 2 years  22.4% 
2 years to less than 5 years  23.3% 
5 years to less than 10 years  14.9% 
10 years or more  12.8% 
     Total  100.0%* 
Source:  OIG analysis of FBI criminal history records and nursing facility employee data, 2009.
*Percentages do not sum to 100 percent because of rounding. 
 
Forty-three States required 
Despite the lack of a Federal requirement for 
nursing facilities to conduct 
nursing facilities to conduct criminal 
either an FBI or a statewide 
background checks, most States required, 
criminal background check for 
and/or nursing facilities reported conducting, 
prospective employees.  Ten 
some type of background check  States required FBI criminal 
background checks and 
33 States required statewide criminal background checks. 
Some nursing facilities located in the remaining eight States reported 
conducting criminal background checks even though they were not 
required to do so.  All but 2 percent of nursing facilities reported 
conducting some type of background check.25  The most common type of 
background check nursing facilities reported conducting was a 
statewide criminal background check, followed by other types of checks 
(e.g., State abuse registries, State nurse aide registries) and then FBI 
criminal background checks.26  Half of nursing facilities reported using 
 
25 These nursing facilities were located in two States; one State required nursing 
facilities to conduct statewide criminal background checks and the other State had no 
requirements for conducting criminal background checks. 
26 Difference was statistically significant at the 95-percent confidence level.  The 
percentage of nursing facilities that reported conducting each type of check and the results 
of the difference tests are available in Appendix D. 
  OEI-07-09-00110  NURSING FACILITIES EMPLOYMENT OF INDIVIDUALS WITH CRIMINAL CONVICTIONS  15   
   
F I N D I N G S  
other sources for background checks, such as State-specific abuse or sex 
offender registries and private agencies.   
Administrators for 94 percent of nursing facilities that conduct 
background checks reported conducting them on all classifications of 
employees.  Another 4 percent reported conducting background checks 
only on direct-care staff.27  However, sampled nursing facilities differed 
on what job classifications constituted direct-care staff.  For example, 
14 nursing facilities considered all employees in the nursing facilities to 
be direct care (i.e., having the potential of direct access to residents), 
while other nursing facilities limited the definition to discrete job 
classifications (e.g., nurses, therapists, and activity workers).     
 
 
27 The remaining facilities did not answer this question. 
  OEI-07-09-00110  NURSING FACILITIES EMPLOYMENT OF INDIVIDUALS WITH CRIMINAL CONVICTIONS  16   
   
 R E C O M M E N D A T I O N  
 
After completion of our data collection, the Patient Protection and 
Affordable Care Act (P.L. 111-148) became Federal law.  It requires the 
Secretary to carry out a nationwide program for States to conduct 
national and statewide criminal background checks for direct patient 
access employees of nursing facilities and other providers similar to the 
pilot program MMA established.  The program is being carried out in 
fiscal years 2010 through 2012.  Public Law 111-148 also requires OIG 
to review the nationwide program and submit a report to Congress no 
later than 180 days after the completion of the nationwide program. 
In light of our findings and in carrying out the mandate for the 
Department of Health & Human Services to implement the nationwide 
criminal background check program, we recommend that CMS: 
Develop background check procedures 
To ensure that States conduct background checks consistently, CMS 
should (1) clearly define the employee classifications that are direct 
patient access employees and (2) work with participating States to 
develop a list of State and local convictions that disqualify an individual 
from nursing facility employment under the Federal regulation and 
periods for which each conviction bars the individual from employment.   
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 
RESPONSE 
In its written comments on the draft report, CMS agreed with our 
recommendation to develop background check procedures.  CMS stated 
that in its solicitation to States for the National Background Check 
Program, the definition of direct patient access employee is anyone 
who routinely comes into contact or has the potential to come into 
contact with residents or clients.  For nursing facilities, this definition 
should include all staff.   
CMS also stated that it will work with the States through the National 
Background Check Program to assist them in developing lists of 
convictions that disqualify individuals from employment, as well as 
defining whether any of those conviction types can be assumed to be 
mitigated because of the passage of time and which convictions should 
never be considered mitigated or rehabilitated.  We did not make any 
changes to the report based on CMSs comments.  The full text of CMSs 
comments on the draft report can be found in Appendix E. 
  OEI-07-09-00110  NURSING FACILITIES EMPLOYMENT OF INDIVIDUALS WITH CRIMINAL CONVICTIONS  17   
   
 A P P E N D I X   ~   A  
Table A-1:  Profile of Sampled Nursing Facility Employee Characteristics 
Number of 
Percentage of 
Characteristic  Subgroup  Employees 
Employees
(n=35,286) 
Certified nursing and medication aides  12,456  35.3% 
Nursing (e.g., registered and licensed practical nurses)  6,986  19.8% 
Dietary  3,866  11.0% 
Housekeeping/laundry/maintenance/security  3,814  10.8% 
Administration  3,584  10.2% 
Supervisory nursing  1,090  3.1% 
Hospitality/activities/chaplains  1,018  2.9% 
Job Classification 
Therapists  866  2.5% 
Aides not otherwise specified  677  1.9% 
Social workers  466  1.3% 
Other clinical personnel  258  0.7% 
Other  79  0.2% 
Transportation  81  0.2% 
Beauticians  45  0.1% 
Male  5,171  14.7% 
Gender  Female  29,893  84.7% 
Not specified  222  0.6% 
Under 21  1,926  5.5% 
2130  7,065  20.0% 
3140  7,274  20.6% 
Age on June 1, 2009  4150  8,520  24.1% 
5160  7,434  21.1% 
Over 60  3,066  8.7% 
Not specified  1  Less than 0.1% 
White  19,412  55.0% 
Black or African American  8,791  24.9% 
Race  Hispanic  2,777  7.9% 
Asian  1,383  3.9% 
Other or not specified  2,923  8.3% 
Yes  24,605  69.7% 
Direct-Care Employee  No  10,677  30.3% 
Not specified  4  Less than 0.1% 
0 to 2 years  15,047  42.6% 
Greater than 2 to 5 years  7,818  22.2% 
Greater than 5 to 8 years  3,816  10.8% 
Length of Employment  Greater than 8 to 10 years  1,780  5.0% 
on June 1, 2009  Greater than 10 to 15 years  2,761  7.8% 
Greater than 15 to 20 years  1,841  5.2% 
Greater than 20 years  2,220  6.3% 
Not specified  3  Less than 0.1% 
Source:  Office of Inspector General analysis of nursing facility employee data, 2009. 
Subgroups for some characteristics may not sum to 100 percent because of rounding. 
  OEI-07-09-00110  NURSING FACILITIES EMPLOYMENT OF INDIVIDUALS WITH CRIMINAL CONVICTIONS  18   
   
 A P P E N D I X   ~   B  
Table B-1:  Profile of Sampled Nursing Facilities Reported Background Check Characteristics  
Number of 
Percentage 
Sampled 
of Sampled 
Characteristic  Subgroup  Nursing 
Nursing 
Facilities 
Facilities
(n=252) 
19881999  93  36.9% 
20002004  59  23.4% 
Year Nursing Facility 
Began Conducting  20052008  49  19.4% 
Background Checks 
Since establishment of the nursing facility  24  9.5% 
Unknown/not specified  27  10.7% 
$0   33  13.1% 
2008 Total Costs for  Less than $1,000  50  19.8% 
Background Checks  $1,000 to less than $5,000  112  44.4% 
$5,000 to less than $10,000  22  8.7% 
$10,000 to less than $15,000  6  2.4% 
Range:  $0$29,565  
$15,000 or more  5  2.0% 
Average:  $2,781 
Unknown/not specified  24  9.5% 
$0   33  13.1% 
2008 Cost Per  Less than $25  89  35.3% 
Background Check  $25 to less than $50  44  17.5% 
$50 to less than $75  33  13.1% 
Range:  $0$190.08   More than $75  41  16.3% 
Average:  $37.15  Unknown/not specified  12  4.8% 
Source:  Office of Inspector General analysis of nursing facility survey responses, 2009. 
Percentages do not sum to 100 percent because of rounding. 
  OEI-07-09-00110  NURSING FACILITIES EMPLOYMENT OF INDIVIDUALS WITH CRIMINAL CONVICTIONS  19   
   
F I N D I N G S  
 A P P E N D I X   ~   C  
Different Types of Resources Reveal Different Information 
In our analysis of the Federal Bureau of Investigation (FBI) criminal 
history records, we identified seven individuals employed in five 
sampled nursing facilities whose criminal history records indicated that 
they are currently registered as sex offenders.  We chose to examine 
Federal and State sex offender registries to see what additional 
information these registries might contain about these employees and 
how additional checks might complement a criminal background check.  
Conducting name searches on the National Sex Offender Registry (a 
public Web site) positively identified only four of the seven individuals 
as sex offenders.28  Conducting name searches on Web sites for 
individual State sex offender registries yielded six of the seven 
individuals names. 
There was one name that FBI criminal history records identified as a 
sex offender that we could not identify on the national or relevant State 
sex offender registries.  The criminal history record showed a  
February 2009 registration as a sex offender with the sheriffs 
department located in the county in which the employing nursing 
facility was located.  We were unable to verify this information with 
another source because the Web site for the sheriffs department did not 
offer the ability to search its sex offender registry.  
Upon closer examination of two individuals whose FBI criminal history 
records indicated Subject of record is a registered sexual offender, the 
individuals names were included on a list found on a Web site 
maintained by their State Office of Attorney General.  The title of the 
list was Convicted Sex Offenders and Offenders Against Children.    
For both individuals, the information indicated that they were 
registered offenders against children and not registered sexual 
offenders.  The description key of the list indicated that the two 
individuals were offenders against children, who have not yet 
committed a sexually-related offense.  
The results of this analysis demonstrate that searches of different 
sources of background check information may produce different criminal 
history information.   
 
28 The Dru Sjodin National Sex Offender Public Web site can be accessed at  
http://www.nsopw.gov.  
  OEI-07-09-00110  NURSING FACILITIES EMPLOYMENT OF INDIVIDUALS WITH CRIMINAL CONVICTIONS  20   
   
   A P P E N D I X   ~   D  
Table D-1:  Point Estimates and Confidence Intervals 
95-Percent 
Sample 
Estimate Characteristic  Point Estimate  Confidence 
Size
Interval  
Estimates of nursing facilities that employ individuals with convictions 
Percentage of nursing facilities that employ one or more 
256  92.3  87.095.6 
individuals with at least one conviction 
Percentage of nursing facilities that employ five or more 
256  47.8  40.155.5 
individuals with at least one conviction 
Estimates of nursing facilities whose employees include certain percentages of individuals with convictions 
Percentage of nursing facilities with 0 percent of employees with 
256  7.7  4.513.0 
convictions 
Percentage of nursing facilities with up to 5 percent of employees 
256  51.8  44.059.5 
with convictions 
Percentage of nursing facilities with more than 5 and up to 
256  26.0  19.833.4 
10 percent of employees with convictions 
Percentage of nursing facilities with more than 10 and up to 
256  6.3  3.511.0 
15 percent of employees with convictions 
Percentage of nursing facilities with more than 15 and up to 
256  5.7  2.910.9 
20 percent of employees with convictions 
Percentage of nursing facilities with more than 20 and up to 
256  2.5  0.96.8 
25 percent of employees with convictions 
Estimates of nursing facility employees with one or more convictions 
Percentage of nursing facility employees with crimes against 
1,772  43.6  39.547.7 
property 
Percentage of nursing facility employees with other crimes  1,772  26.4  23.729.4 
Percentage of nursing facility employees with driving under the 
1,772  20.3  17.623.2 
influence of drugs or alcohol (DUI) crimes 
Percentage of nursing facility employees with drug-related crimes  1,772  16.2  13.719.0 
Percentage of nursing facility employees with crimes against 
1,772  13.1  11.215.4 
persons 
Percentage of nursing facility employees with driving-related 
1,772  11.9  9.914.3 
crimes other than DUI 
continued on next page 
  OEI-07-09-00110  NURSING FACILITIES EMPLOYMENT OF INDIVIDUALS WITH CRIMINAL CONVICTIONS  21   
   
A P P E N D I X   ~   D  
Table D-1:  Point Estimates and Confidence Intervals (Continued) 
95-Percent 
Sample  Point 
Estimate Characteristic  Confidence 
Size Estimate 
Interval  
Estimates of nursing facility employees with convictions in certain job classifications 
Nursing facility employees that have at least one conviction  35,286  4.9  4.25.9 
Percentage of direct-care staff with convictions  24,605  5.1  4.26.3 
Percentage of housekeeping/laundry/maintenance/security staff 
3,814  6.5  5.387.81 
with convictions 
Percentage of certified nursing and medication aides with 
12,456  6.4  5.18.0 
convictions 
Percentage of dietary staff with convictions  3,866  5.7  4.77.0 
Percentage of nursing staff (e.g., registered and licensed practical 
6,986  3.6  2.84.7 
nurses) with convictions 
Percentage of all other types of staff with convictions  4,581  2.7  2.13.5 
Percentage of administrative staff with convictions  3,584  2.6  1.93.6 
Estimates of nursing facility employees whose most recent conviction was prior to employment 
Percentage of nursing facility employees with convictions who 
have their most recent conviction prior to the beginning date of  1,772  84.0  80.487.0 
employment 
Percentage whose most recent conviction was less than 1 year 
1,498  7.5  5.89.8 
prior to beginning employment 
Percentage whose most recent conviction was more than 1 year 
1,498  28.6  25.032.5 
but less than 5 years prior to beginning employment 
Percentage whose most recent conviction was more than 5 years 
1,498  26.1  21.731.0 
but less than 10 years prior to beginning employment 
Percentage whose most recent conviction was more than 10 years 
1,498  37.8  33.842.0 
prior to beginning employment 
continued on next page 
  OEI-07-09-00110  NURSING FACILITIES EMPLOYMENT OF INDIVIDUALS WITH CRIMINAL CONVICTIONS  22   
   
A P P E N D I X   ~   D  
Table D-1:  Point Estimates and Confidence Intervals (Continued) 
95-Percent 
Sample  Point 
Estimate Characteristic  Confidence 
Size Estimate 
Interval  
Estimates of nursing facility employees whose most recent conviction was after beginning employment 
Percentage of nursing facility employees with convictions 
whose most recent conviction was after beginning  1,772  16.0  13.019.6 
employment 
Percentage whose most recent conviction was less than 
274  15.8  10.922.4 
6 months after beginning employment 
Percentage whose most recent conviction was more than 
274  10.7  7.016.0 
6 months but less than 1 year after beginning employment 
Percentage whose most recent conviction was more than 
274  22.4  16.130.1 
1 year but less than 2 years after beginning employment 
Percentage whose most recent conviction was more than 
274  23.3  19.028.2 
2 years but less than 5 years after beginning employment 
Percentage whose most recent conviction was more than 
274  14.9  10.620.7 
5 years but less than 10 years after beginning employment 
Percentage whose most recent conviction was more than 
274  12.8  8.020.0 
10 years after beginning employment 
Estimates of nursing facilities that conduct different types of background checks 
Percentage of nursing facilities that do not conduct any 
256  2.4  0.86.8 
type of background check 
Percentage of nursing facilities that reported conducting 
256  87.4  81.691.6 
Statewide criminal history checks 
Percentage of nursing facilities that reported using other 
256  50.8  43.158.6 
sources for background checks 
Percentage of nursing facilities that reported conducting 
256  23.5  18.030.0 
FBI criminal history checks 
Percentage of nursing facilities that conduct background 
256  93.7  88.996.5 
checks on all employees 
Percentage of nursing facilities that conduct background 
256  3.9  2.07.6 
checks only on direct-care employees 
Source:  Office of Inspector General (OIG) analysis of Federal Bureau of Investigation (FBI) criminal history records and 
nursing facility employee data, 2009. 
  OEI-07-09-00110  NURSING FACILITIES EMPLOYMENT OF INDIVIDUALS WITH CRIMINAL CONVICTIONS  23   
   
A P P E N D I X   ~   D  
Table D-2:  Point Estimates and Confidence Intervals for Differences in Categories of Convictions 
Percentage of  95-Percent 
Category of  Percentage 
Employees With  Confidence Interval  p-value
Conviction  Difference
Convictions on Difference 
Property  43.6 
17.1  10.623.7  <0.0001 
Other  26.4 
Property  43.6 
23.3  15.431.2  <0.0001 
DUI  20.3 
Property  43.6 
27.4  21.033.8  <0.0001 
Drugs  16.2 
Property  43.6 
30.4  23.837.0  <0.0001 
Persons  13.1 
Property  43.6 
31.6  25.537.8  <0.0001 
Other driving (not DUI)  11.9 
Confidence intervals and p-values are reported for each single comparison.  Applying a Bonferroni threshold of 0.05/5, 
differences for all five simultaneous comparisons are statistically significant at the 95-percent confidence level.  
Source:  OIG analysis of FBI criminal history records and nursing facility employee data, 2009. 
 
Table D-3:  Point Estimates and Confidence Intervals for Differences in Type of Check Conducted  
Percentage of  95-Percent 
Type of  Percentage 
Nursing Facilities  Confidence Interval  p-value
Background Check  Difference
Conducting Check on Difference 
Statewide*  87.4 
36.6  27.146.1  <0.0001 
Using other source  50.8 
Statewide  87.4 
64.0  56.571.4  <0.0001 
FBI  23.5 
Using other source  50.8 
27.4  17.037.7  <0.0001 
FBI  23.5 
*Confidence intervals and p-values are reported for each single comparison.  Applying a Bonferroni threshold of 0.05/3, 
differences for all three simultaneous comparisons are statistically significant at the 95-percent confidence level. 
Source:  OIG analysis of nursing facility survey responses, 2009. 
  
  OEI-07-09-00110  NURSING FACILITIES EMPLOYMENT OF INDIVIDUALS WITH CRIMINAL CONVICTIONS  24  x 
A  P  PEN  D  E 

AGENCY COMMENTS 
.,..,.'''''''4;'  . 
~
(,"5'r  DEPARTMENT OF HEALTH & HUMAN SERVICES  Centers lor Medicare & Medicaid ServIces 
200 Independence Avenue SW 
Wasl1lnglon, DC 20201 
JAN  1 2 1.011 
DATE: 
TO: 	 Daniel R. Levinson 
Inspector General 
FROM: 	 Donald M. Berwick, M.D. 
Administrator 
SUBJECT: 	 Office ofInspector General (OlG) Draft Report: ''Nursing Facilities' Employment of 
Individuals With Criminal Convictions" (OEI-07-09-00110) 
Thank you for the opportunity 10 review and comment on the subject OIG draft report.  The OIG's 
study focused on determining whether and to what extent nursing facilities employed individuals 
with criminal convictions. During this study, the OIG: 
 	 Found almost all nursing facilities employed one or more individuals with at least one 
criminal conviction. 
 	 Discovered that despite the lack ofa Federal requirement for nursing facilities to conduct 
criminal background checks, most States required and/or nursing facilities reported 
conducting some type of background check. 
In its report, OIG made recommendations to the Secretary of Health and Human Services (HHS) and 
the Administrator of the Centers for Medicare & Medicaid Services (eMS).  In making these 
recommendations, OIG took into consideration the Patient Protection and Affordable Care Act 
(P.L.111-148) provision that the HHS Secretary must implement a nationwide grant program for 
States to conduct national and statewide criminal background checks for direct patient access 
employees of nursing facilities and other providers.  Our response to these recommendations is stated 
below. 
OIG Recommendation 
To develop background check procedures and ensure that States conduct background checks 
consistently, eMS should clearly define the employee classifications that are direct patient access 
employees. 
OEI070900110  NURSING FACILITIES' EMPLOYMENT OF INDIVIDUALS WITH CRIMINAL CONVICTIONS  25   
   
A P P E N D I X   ~   E  
  OEI-07-09-00110  NURSING FACILITIES EMPLOYMENT OF INDIVIDUALS WITH CRIMINAL CONVICTIONS  26   
   
 A C K N O W L E D G M E N T S  
This report was prepared under the direction of Brian T. Pattison, 
Regional Inspector General for Evaluation and Inspections in the 
Kansas City regional office, and Deborah Walden, Deputy Regional 
Inspector General. 
Tricia Fields served as the team leader for this study.  Other principal 
Office of Evaluation and Inspections staff from the Kansas City regional 
office who contributed to the report include LCDR Mike Garner, Rae 
Hutchison, and Michala Walker; central office staff who contributed 
include Kevin Farber, Jennifer Jones, and Sandy Khoury.  
 
  OEI-07-09-00110  NURSING FACILITIES EMPLOYMENT OF INDIVIDUALS WITH CRIMINAL CONVICTIONS  27   
 
 
Office of Inspector General 
http://oig.hhs.gov 
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 
amended, is to protect the integrity of the Department of Health and Human Services 
(HHS) programs, as well as the health and welfare of beneficiaries served by those 
programs.  This statutory mission is carried out through a nationwide network of audits, 
investigations, and inspections conducted by the following operating components: 
Office of Audit Services 
The Office of Audit Services (OAS) provides auditing services for HHS, either by conducting 
audits with its own audit resources or by overseeing audit work done by others.  Audits 
examine the performance of HHS programs and/or its grantees and contractors in carrying 
out their respective responsibilities and are intended to provide independent assessments of 
HHS programs and operations.  These assessments help reduce waste, abuse, and 
mismanagement and promote economy and efficiency throughout HHS. 
Office of Evaluation and Inspections 
The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide 
HHS, Congress, and the public with timely, useful, and reliable information on significant 
issues.  These evaluations focus on preventing fraud, waste, or abuse and promoting 
economy, efficiency, and effectiveness of departmental programs.  To promote impact, OEI 
reports also present practical recommendations for improving program operations.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations 
of fraud and misconduct related to HHS programs, operations, and beneficiaries.  With 
investigators working in all 50 States and the District of Columbia, OI utilizes its resources 
by actively coordinating with the Department of Justice and other Federal, State, and local 
law enforcement authorities.  The investigative efforts of OI often lead to criminal 
convictions, administrative sanctions, and/or civil monetary penalties. 
Office of Counsel to the Inspector General 
The Office of Counsel to the Inspector General (OCIG) provides general legal services to 
OIG, rendering advice and opinions on HHS programs and operations and providing all 
legal support for OIGs internal operations.  OCIG represents OIG in all civil and 
administrative fraud and abuse cases involving HHS programs, including False Claims Act, 
program exclusion, and civil monetary penalty cases.  In connection with these cases, OCIG 
also negotiates and monitors corporate integrity agreements.  OCIG renders advisory 
opinions, issues compliance program guidance, publishes fraud alerts, and provides other 
guidance to the health care industry concerning the anti-kickback statute and other OIG 
enforcement authorities.