DEPARTMENT OF HEALTH &. HUMAN SERVICES 	 Office of Inspector General 
Washington, D.C. 20201 
19 2012 
~JAN 
TO: 	 Marilyn Tavellller 
Acting Administrator 
Centers for Medicare & Medicaid Services 
FROM:  Stuart WrigHt 
Deputy Inspector General 
for Evaluation and Inspections 
SUBJECT: 	 Memorandum Report:  Nationwide Program for National and State 
Background Checks for Long-Term-Care Employees -Results of 
Long-Term-Care Provider Administrator Survey, OEI-07-10-00421 
The Patient Protection and Affordable Care Act (ACA) mandates that the Office of 
Inspector General (OIG) submit a report to Congress evaluating the Nationwide Program 
for National and State Background Checks on Direct Patient Access Employees of 
Long-Term-Care Facilities and Providers not later than 180 days after the program's 
completion.  This memorandum report provides the results of a survey oflong-term-care 
provider administrators.  The purpose ofthe survey was to collect baseline data on 
current practices regarding conducting background checks on potential employees and 
the effects on the long-term-care workforce.  We plan to use this information in the 
mandated report to assess the effects of background checks on the availability of 
long-term-care workers. 
SUMMARY 
Section 6201 of the ACA established the Nationwide Program for National and State 
Background Checks on Direct Patient Access Employees of Long-Term-Care Facilities 
and Providers. 1  This voluntary program provides grants to States, the District of 
Columbia, and U.S. territories (States) to implement programs to conduct background 
checks on prospective long-term-care employees, and mandates an OIG evaluation of the 
State programs.  ACA requires OIG to evaluate certain aspects of participating States' 
programs.  For example, OIG must determine the extent to which conducting background 
checks leads to any unintended consequences, including a reduction in the available 
workforce for long-term-care providers. 
I P.L. 111-148, enacted March 23, 2010. 
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In May 2011, we surveyed long-term-care provider administrators in participating States 
about their current procedures for conducting background checks, the effects of 
background checks on the pool of prospective employees, and the availability and quality 
of prospective employees.  Survey results indicate that 94 percent of administrators 
conducted background checks on prospective employees.  Only 4 percent of those 
administrators encountered individuals who were unwilling to undergo a background 
check.  Twenty-three percent of administrators believed that their organizations current 
background check procedures reduced the pool of prospective employees.  Overall, 
81 percent of administrators believed that there is a sufficient pool of qualified applicants 
for job vacancies.  However, survey results indicate that 9 percent of administrators did 
not receive applications from qualified individuals for at least some job vacancies.  
 
BACKGROUND 
 
Nationwide Program for National and State Background Checks on Direct Patient 
Access Employees of Long-Term-Care Facilities and Providers 
Section 6201 of ACA requires the Secretary of Health and Human Services to carry out a 
nationwide program in which States conduct national and State background checks of 
prospective direct patient access employees of nursing facilities and other long-term-care 
providers.2  The program is administered by the Centers for Medicare & Medicaid 
Services (CMS) in cooperation with the Federal Bureau of Investigation (FBI).  ACA 
provides up to $160 million in Federal funds for the program. 
 
To implement the nationwide program, CMS began soliciting applications for grant 
awards in June 2010.  Program start dates for each participating State vary based on when 
the State received a grant award.  Once grants are awarded, it is expected that States may 
need some preparation time before they require long-term-care providers to begin 
conducting background checks.  For example, States may need to set up information 
systems to accommodate the background check process or enact legislation that amends 
the requirements for long-term-care providers.  Therefore, there may be some lag time 
between the program start date and the date that long-term-care providers begin 
conducting background checks.  Some States had background check programs in place 
before they received their grants.  The grants require these States to expand or improve 
their programs in some way.3  For example, a State that had a program requiring 
background checks only on employees of nursing facilities would have to expand the 
program to include employees of other provider types (e.g., hospices, home health 
agencies).  CMS plans to make all grant awards by September 30, 2012; however, the 
completion date of the program (i.e., the date that participating States deplete their grant 
funds) is unknown at this time.  As of October 2011, 17 States had received grants. 
   
                                                 
2 Section 6201(a)(6)(D) defines direct patient access employee as any individual 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 and has duties that involve 
(or may involve) one-on-one contact with a patient or resident of the facility or provider, as determined by the State for purposes of 
the nationwide program. 
3 CMS, Funding Opportunity Announcement for Nationwide Program for National and State Background Checks, p. 14. 
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Mandated OIG Evaluation 
The ACA mandate requires OIG to submit a report to Congress evaluating the program 
not later than 180 days after its completion.  In July 2010, we began an evaluation 
entitled Nationwide Program for National and State Background Checks for 
Long-Term-Care Employees (OEI-07-10-00420).  To comply with the required 
timeframe, the evaluation follows the progress of the nationwide program in each State as 
it is carried out, rather than conducting a retrospective review at the end of the program.    
 
According to ACA, OIG must include the following in its evaluation: 
 
1.  A review of the various procedures implemented by participating States for 
long-term-care facilities or providers, including staffing agencies, to conduct 
background checks of prospective direct patient access employees under the 
nationwide program and identification of the most appropriate, efficient, and effective 
procedures for conducting such background checks; 
 
2.  An assessment of the costs of conducting such background checks (including startup 
and administrative costs); 
 
3.  A determination of the extent to which conducting such background checks leads to 
any unintended consequences, including a reduction in the available workforce for 
long-term-care facilities or providers;  
 
4.  An assessment of the impact of the nationwide program on reducing the number of 
incidents of neglect, abuse, and misappropriation of resident property to the extent 
practicable; and 
 
5.  An evaluation of other aspects of the nationwide program, as determined appropriate 
by the Secretary.4 
 
The information in this memorandum report pertains to the third issue above and will 
serve as a baseline in determining the effects of background checks on long-term-care 
workforce availability in the mandated report.  The mandated report will also cover all 
other issues listed above. 
 
METHODOLOGY 
 
Sample Selection 
In February 2011, we obtained data for the following provider types from the Online 
Survey, Certification, and Reporting (OSCAR) system:  nursing facilities, skilled nursing 
facilities, home health agencies, hospices, and Intermediate Care Facilities for the 
Mentally Retarded (ICF/MR).  As of March 2011, 10 States had been awarded funding 
under the nationwide program:  Alaska, California, Connecticut, Delaware, District of 
Columbia, Florida, Illinois, Missouri, New Mexico, and Rhode Island.  We stratified the 
population of long-term-care providers by the number in each participating State to 
                                                 
4 P.L. 111 148  6201(a)(7)(A)(ii). 
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ensure that States with smaller numbers of providers were represented.  One stratum 
consisted of providers in States with 500 or fewer providers (Alaska, Delaware, District 
of Columbia, New Mexico, and Rhode Island), and the other stratum consisted of 
providers in States with more than 500 providers (California, Connecticut, Florida, 
Illinois, and Missouri).  We selected a stratified random sample of 100 providers from 
each stratum.  If we had not stratified the population, the sample would likely not have 
included providers from each of the 10 States.  Table 1 shows the number of providers in 
the population and sample by stratum and State. 
 
Table 1:  Number of Providers in Population and Sample by 
Stratum and State 
Providers in  Providers in 
Stratum  State 
Population  Sample 
Alaska  89  4 
Delaware  157  8 
1  District of Columbia  330  21 
New Mexico  489  33 
Rhode Island  450  34 
Stratum 1 Total  1,515  100 
California  6,200  40 
Connecticut  932  4 
2  Florida  3,399  23 
Illinois  3,534  22 
Missouri  2,065  11 
Stratum 2 Total  16,130  100 
Overall Total  17,645  200 
Source:  OSCAR database, 2011. 
 
Our population of long-term-care providers included only those that were in operation at 
the time of our data collection.  In May 2011, we mailed a survey to the administrators of 
the sampled providers.  We asked about their current procedures for conducting 
background checks on prospective employees and whether they believe that their 
background check procedures reduce the pool of prospective employees.  We requested 
workforce data on the number of applicants and the number of persons hired for recently 
filled positions, if available.  Finally, we solicited administrators opinions regarding the 
availability and quality of long-term-care applicants.  We did not independently validate 
the survey responses. 
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Response Rate 
We received responses from 153 sampled providers.  We determined that the remaining 
47 sampled providers were no longer in operation through telephone contact attempts and 
Internet searches.  Therefore, we received responses from 100 percent of providers that 
were eligible to respond to the survey.  Table 2 shows the number of responses for each 
provider type in each State by stratum.   
 
Table 2:  Number of Eligible Sample Responses by Stratum, State, and Provider Type 
Nursing 
Facilities/
Home Health 
Stratum  State  Skilled  Hospices  ICF/MRs  Total 
Agencies 
Nursing 
Facilities 
Alaska  0  1  3  0  4 
Delaware  4  3  0  0  7 
1  District of Columbia  5  2  0  9  16 
New Mexico  7  9  4  3  23 
Rhode Island  13  4  1  7  25 
California  12  10  2  6  30 
Connecticut  1  2  0  0  3 
2  Florida  7  12  0  0  19 
Illinois  7  4  0  4  15 
Missouri  9  1  1  0  11 
Total  65  48  11  29  153 
Source:  Administrator responses to OIG survey, 2011. 
 
Standards 
This study was conducted in accordance with the Quality Standards for Inspection and 
Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency. 
 
 
RESULTS 
 
Current Background Check Procedures 
Ninety-four percent of administrators in the 10 participating States conducted background 
checks on prospective employees.5  Of the administrators who conducted background 
checks, 82 percent conducted a State criminal history check, 41 percent conducted an FBI 
criminal history check, and 63 percent used other sources, such as sex offender registries 
                                                 
5 Appendix A presents point estimates and 95-percent confidence intervals for all population estimates.  We projected our results to 
the population of long-term-care providers in operation at the time of our data collection. 
OEI-07-10-00421    Results of Long-Term-Care Provider Administrator Survey  Page 6  Marilyn Tavenner 
 
and the OIG List of Excluded Individuals/Entities.  Of the administrators who conducted 
background checks, 95 percent conducted them for all prospective employees, while 
5 percent conducted them only for certain positions.   
 
The information reported by administrators for this survey is consistent with information 
reported by nursing facility administrators for a survey we conducted in June 2009 for the 
report entitled Nursing Facilities Employment of Individuals With Criminal Convictions 
(OEI-07-09-00110).  That report found that 98 percent of nursing facilities conducted 
some type of background check on prospective employees.  We note that the statistics 
from both surveys suggest that because most long-term-care providers were already 
conducting background checks prior to the implementation of the State background check 
programs, implementation of the new programs may not actually require much change, if 
any, in the providers current procedures. 
 
Administrators Experiences With Conducting Background Checks 
We asked administrators who conducted background checks whether they encountered 
any prospective employees who were unwilling to undergo one.  Four percent of 
administrators had this experience.  According to these administrators, prospective 
employees may have been unwilling to undergo a background check because their 
criminal history included convictions that might disqualify them from employment.  The 
six administrators who responded affirmatively estimated that between 1 and 5 percent of 
prospective employees were unwilling to undergo a background check.  In addition, they 
estimated that between 1 and 6 percent of prospective employees withdrew their 
applications after learning of the background check.  While only 4 percent of 
administrators encountered prospective employees who were unwilling to undergo a 
background check, a much higher percentage held beliefs about the link between 
background check requirements and a reduction in the pool of prospective employees.  
Twenty-three percent of administrators believed that their organizations current 
background check procedures reduced the pool of prospective employees.  A similar 
percentage of administrators, 27 percent, believed some prospective employees did not 
apply because of their organizations background check procedures.   
 
Thirty-two percent of administrators commented on the link between background check 
requirements and a reduction in the pool of prospective employees.  Eleven 
administrators expressed their belief that the reduction in the pool occurs because the 
background check requirement is commonly known to prospective employees before 
applying, which results in individuals with disqualifying convictions not submitting 
applications.  In support of the background checks, 11 administrators commented that the 
elimination of individuals with disqualifying convictions from the workforce pool is 
appropriate to protect the safety of their organizations clients and staff.  Nine 
administrators commented that they believe background check requirements have not 
reduced their number of prospective employees.  These administrators said that few 
prospective employees have disqualifying convictions and that they consistently receive a 
sufficient number of applications for job vacancies.  However, one administrator 
commented that the amount of time needed to process background checks reduces the 
OEI-07-10-00421    Results of Long-Term-Care Provider Administrator Survey  Page 7  Marilyn Tavenner 
 
pool of prospective employees.  Another stated that a time limit on disqualifying offenses 
should be established. 
  
Workforce Data 
We asked administrators for the number of (1) job vacancies, (2) applications received 
for job vacancies, and (3) filled job vacancies for the period January 1 to May 1, 2011.  
Of the 153 respondents to our survey, 122 were able to provide definitive numbers for 
each of these three elements.  Nine percent of administrators had no job vacancies for the 
period; accordingly, they received no applications and did not fill any vacancies.  
Demonstrating the variety of sizes of providers in our sample, the number of job 
vacancies ranged from 0 to 180, the number of applications received from 0 to 2,422, and 
the number of job vacancies filled from 0 to 164.  On average, administrators received 
approximately six applications for every job vacancy and filled nearly all of their 
vacancies.  The results of the administrators responses are shown in Table 3. 
Table 3:  Workforce Data 
Element  Average  Median 
Job Vacancies  11  6 
Applications Received  61  24 
Job Vacancies Filled  10  4 
Source:  OIG analysis of administrator responses, 2011. 
 
Availability and Quality of Long-Term-Care Employees 
Overall, survey results indicate that 81 percent of administrators had a sufficient pool of 
applicants for job vacancies.  Administrators who did not have a sufficient pool of 
applicants cited prospective employees preferences for working in health care settings 
other than long-term care, low pay, and lack of desire to work in a rural area.  We asked 
administrators whether they received applications for job vacancies from qualified 
individuals.  Nine percent of administrators did not.  None of these administrators 
believed that their organizations background check requirement was a reason that 
applications from qualified individuals were not received.  Instead, they said that 
individuals who applied did not have the requisite education, skills, or certification for 
the position.   
 
We also asked administrators if there were particular job positions that they had difficulty 
filling with qualified individuals.  Unrelated to background checks, nearly half of 
administrators (45 percent) had difficulty filling certain positions, such as registered 
nurse; physical, occupational, and speech therapist; social worker; and certified nurse 
aide. 
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CONCLUSION 
 
The survey results provide a baseline of information regarding the effects that conducting 
background checks have on the long-term-care workforce in the first 10 States to receive 
background check program grants.  Nearly all administrators conduct background checks 
on prospective employees and current background check procedures do not appear to 
greatly reduce the available workforce.  When State programs are complete or nearing 
completion, we will conduct a second survey to determine whether changes in 
background check procedures decrease the workforce pool.  We will request the same 
workforce data and opinions as in the first survey.  We will present the results in the 
mandated report entitled Nationwide Program for National and State Background Checks 
for Long-Term-Care Employees (OEI-07-10-00420). 
 
CMS may wish to provide the information in this memorandum report to States that 
participate in the background check program as well as those States that are considering 
participation.  This report is being issued directly in final form because it contains no 
recommendations.  If you have comments or questions about this report, please provide 
them within 60 days.  Please refer to report number OEI-07-10-00421 in all 
correspondence. 
 
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APPENDIX A 
Table A-1:  Point Estimates and Confidence Intervals 
Sample  Point  95-Percent 
Estimate 
Size  Estimate  Confidence Interval 
Current Background Check Procedures 
Administrators who conducted background checks  153  94.0  86.597.5 
Administrators who conducted State criminal history checks  147  81.9  72.188.8 
Administrators who conducted FBI criminal history checks  147  40.9  30.551.2 
Administrators who conducted other checks (e.g., sex 
offender registries, Office of Inspector General (OIG) List of  147  62.5  52.272.8 
Excluded Individuals/Entities) 
Administrators who conducted background checks on all 
147  94.6  87.297.9 
prospective employees 
Administrators who conducted background checks only for 
147  5.4  2.112.8 
certain positions 
Administrators who encountered prospective employees 
153  4.2  1.511.1 
who were unwilling to undergo a background check 
Administrators who believed that their organizations current 
background check procedures reduce the pool of  153  23.4  15.633.5 
prospective employees 
Administrators who believed that prospective employees do 
not apply because of their organizations background check  153  27.0  17.636.5 
procedures 
Administrators who offered comments about the link 
between background check requirements and a reduction in  147  32.1  22.241.9 
the pool of prospective employees 
Workforce Data 
Average number of job vacancies  122  10.9  8.213.6 
Average number of applications received  122  61.0  42.379.6 
Average number of job vacancies filled  122  9.7  7.212.2 
Median number of job vacancies  122  6.1  3.59.8 
Median number of applications received  122  24.1  14.938.9 
Median number of job vacancies filled  122  3.8  2.59.4 
Availability and Quality of Long-Term-Care Employees 
Administrators who had a sufficient pool of qualified 
153  80.8  71.687.5 
applicants for job vacancies 
Administrators who did not receive applications for job 
153  8.9  4.516.8 
vacancies from qualified individuals 
Administrators who had difficulty filling particular job 
153  45.2  35.055.4 
positions with qualified individuals 
Source:  OIG analysis of administrator responses, 2011. 
 
OEI-07-10-00421    Results of Long-Term-Care Provider Administrator Survey