Department of Health and Human Services

OFFICE OF 

INSPECTOR GENERAL 

N A R : 

URSE  IDE  EGISTRIES
L T C F
ONG  ERM  ARE  ACILITY 

C P
OMPLIANCE AND  RACTICES

Daniel R. Levinson 

Inspector General 

July 2005

OEI-07-04-00140
 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 OIG's Office of Audit Services (OAS) provides all 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 in order to reduce waste, abuse, and 
mismanagement and to promote economy and efficiency throughout the department. 
Office of Evaluation and Inspections 
The OIG's Office of Evaluation and Inspections (OEI) conducts management and 
program evaluations (called inspections) that focus on issues of concern to the 
department, the Congress, and the public. The findings and recommendations contained 
in the inspections reports generate rapid, accurate, and up-to-date information on the 
efficiency, vulnerability, and effectiveness of departmental programs. The OEI also 
oversees State Medicaid fraud control units, which investigate and prosecute fraud and 
patient abuse in the Medicaid program. 
Office of Investigations 
The OIG's Office of Investigations (OI) conducts criminal, civil, and administrative 
investigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries 
and of unjust enrichment by providers. The investigative efforts of OI lead to criminal 
convictions, administrative sanctions, 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 in OIG's internal operations. The OCIG imposes program exclusions and 
civil monetary penalties on health care providers and litigates those actions within the 
department. The OCIG also represents OIG in the global settlement of cases arising 
under the Civil False Claims Act, develops and monitors corporate integrity agreements, 
develops compliance program guidances, renders advisory opinions on OIG sanctions to 
the health care community, and issues fraud alerts and other industry guidance.    E X E C U T I V E   S U M M A R Y  

OBJECTIVE 
To determine (1) the extent to which long term care (LTC) facilities 
report that they are in compliance with Federal regulations as related 
to the use of State nurse aide registries, and (2) what additional 
procedures LTC facilities have established to screen nurse aides. 
BACKGROUND 
Federal regulations (42 CFR  483.156) require each State and the 
District of Columbia to maintain a nurse aide registry of all individuals 
who are registered to work as nurse aides in that State, as well as all 
individuals who have been prohibited from employment as nurse aides 
in LTC facilities due to substantiated adverse findings of abuse, neglect, 
or misappropriation of property. 
Federal regulations (42 CFR  483.13(c)(1)) prohibit LTC facilities from 
employing individuals who have a substantiated adverse finding 
entered into the State nurse aide registry or who have been found guilty 
in a court of law of abusing, neglecting, or mistreating LTC facility 
residents. Federal regulations (42 CFR  483.75 (e)(5)) require LTC 
facilities to check their State nurse aide registry to ensure that potential 
nurse aides are registered.  The LTC facilities must also check every 
other State nurse aide registry they believe will include any information 
on that individual (42 CFR  483.75(e)(6)).  In addition, Federal 
regulations (42 CFR  483.75(e)(2)) prohibit LTC facilities from using 
[employing] any individual as a nurse aide for more than 4 months 
unless that individual is registered as a nurse aide.   
This study was based on questionnaire responses from a simple random 
sample of 200 LTC facility administrators, as well as nurse aide 
employment information from each of these facilities.  We evaluated all 
nurse aides records to determine if they were registered or had 
substantiated adverse findings on nurse aide registries.  
FINDINGS 
Long term care facility administrators reported checking their State 
nurse aide registries before hiring, as Federal regulations require; 
the registry results affected some hiring decisions. All LTC facility 
administrators reported checking their State nurse aide registries prior 
to hiring nurse aides.  Furthermore, we did not identify any nurse aides 
  OEI-07-04-00140  NURSE AIDE REGISTRIES:  LONG TERM CARE FACILITY COMPLIANCE AND PRACTICES  i  E X E C U T I V E   S U M M A R Y  
with substantiated adverse findings of abuse, neglect, or 
misappropriation of property entered on the nurse aide registry of the 
State in which they were employed.  Forty-four percent of 
administrators reported periodically rechecking employed nurse aides 
against their State nurse aide registry to ensure that substantiated 
adverse findings had not been posted to the registry. 
Fifty-five percent of administrators reported checking only their own 
State registry and thus are most likely not in compliance with 
Federal regulations.  In a 2005 OIG study Nurse Aide Registries: 
State Compliance and Practices (OEI-07-03-00380), we found that 
approximately 99,000 nurse aides had active registrations in multiple 
States, that 1,552 nurse aides had substantiated adverse findings, that 
450 nurse aides had pending findings in one State and an active 
registration in another State, and that 314 nurse aides had 
substantiated adverse findings in multiple States.  These findings 
support the importance of LTC facilities checking other States 
registries that they believe will include information on a nurse aide to 
ensure that employed nurse aides do not have substantiated adverse 
findings. 
Seventeen percent of LTC facilities employed individuals as nurse 
aides without required registrations.  Fifteen percent of LTC facilities 
employed individuals without registrations as nurse aides for longer 
than 4 months.  Five percent of LTC facilities employed individuals with 
expired registrations due to State regulations; of these, half also 
employed nurse aides for longer than 4 months without registration.  
The LTC facilities that employ nurse aides without registrations are not 
in compliance with Federal regulations.   
Eighty-five percent of administrators reported establishing 
additional screening procedures; some of these methods may not 
be fully effective.  The LTC facility administrators reported 
establishing various procedures in attempts to ensure that they do not 
hire or employ individuals with court convictions or criminal 
backgrounds.  The most common screening procedures were criminal 
background checks and/or personal and employment reference checks. 
However, of the 159 LTC facilities that conducted criminal background 
checks, 50 percent conducted checks that were limited in scope.  Those 
LTC facilities that conduct criminal background checks of limited scope 
(e.g., covering only the State in which the LTC is located) may fail to 
identify nurse aides who have criminal histories in other States. 
  OEI-07-04-00140  NURSE AIDE REGISTRIES:  LONG TERM CARE FACILITY COMPLIANCE AND PRACTICES  ii  EEE XXX EEE CCC UUU TTT III VVV EEE     SSS UUU MMM MMM AAA RRR YYY

RECOMMENDATIONS 
Ensuring that only registered nurse aides without substantiated 
adverse findings of abuse, neglect, or misappropriation are employed in 
LTC facilities necessitates a partnership among States, the Centers for 
Medicare & Medicaid Services (CMS), and LTC facilities. States and 
LTC facilities must diligently comply with Federal regulations 
regarding nurse aide registries. The LTC facilities that do not comply 
with Federal regulations or do not use available information about 
potential nurse aides could expose facility residents to greater risk of 
harm. We recommend that CMS: 
o 	 Utilize existing communication channels (e.g., survey and 
certification processes) to ensure that LTC facilities comply with 
Federal regulations that require them to check the nurse aide 
registries of other States that they believe will contain 
information about an individual prior to hiring and to not employ 
individuals as nurse aides for more than 4 months without 
registration. 
o 	 Encourage LTC facilities to use available resources (e.g., State nurse 
aide registries, background check services) to ensure that nurse 
aides with substantiated adverse findings or criminal backgrounds 
are not employed. Possible methods that CMS could use to achieve 
this include: (1) requiring all LTC facilities to perform periodic 
(e.g., annual or biennial) inquiries of State nurse aide registries on 
employed nurse aides and (2) requiring comprehensive criminal 
background checks by all LTC facilities prior to hiring nurse aides. 
CMS concurred with a 1998 OIG recommendation that CMS 
consider developing a Federal requirement for criminal background 
checks. While no such requirement has yet been developed, the 
Medicare Prescription Drug, Improvement, and Modernization Act 
of 2003 (Public Law 108-173, section 307) established a Background 
Check Pilot Program for long term care facilities or providers to 
conduct background checks on prospective direct patient access 
employees in up to 10 States. The results of this pilot will be 
informative as to the viability of this second option. 
AGENCY COMMENTS 
In its comments to the draft report, CMS recognized the effort and 
expressed appreciation for OIGs work related to nurse aide registry 
requirements. CMS concurred with our recommendations. CMS will 
OEI-07-04-00140  NURSE AIDE REGISTRIES:  LONG TERM CARE FACILITY COMPLIANCE AND PRACTICES  iii  E X E C U T I V E   S U M M A R Y  
issue a survey and certification letter to all State survey agencies asking 
them to share the communication with all long term care facility 
providers to reinforce the importance of checking nurse aide registries 
and not allowing nurse aides to work for more than 4 months without 
successfully passing a competency evaluation examination.  In addition, 
CMS will utilize the existing Background Check Pilot Program to 
provide insight on further efforts to ensure that only nurse aides in good 
standing are employed in long term care facilities. 
OIG RESPONSE 
We appreciate CMSs comments to this report and note that CMS is 
taking action to address issues raised in this report.  We look forward to 
learning the results of the Criminal Background Check Pilot Program.  
Changes were made to the report to reflect technical comments received 
from CMS. 
  OEI-07-04-00140  NURSE AIDE REGISTRIES:  LONG TERM CARE FACILITY COMPLIANCE AND PRACTICES  iv    T A B L E   O F   C O N T E N T S  

EXECUTIVE SUMMARY ........................................  i

INTRODUCTION ................................................ 1 

FINDINGS ....................................................... 6 

Checking State registries before hiring......................... 6 

Checking other State registries before hiring ................... 7 

Employing nurse aides without registrations ................... 8 

Additional screening procedures. .............................. 9 

RECOMMENDATIONS ......................................... 11 

AGENCY COMMENTS ......................................... 13 

APPENDIXES .................................................. 16 

A:  Required Components of State Nurse Aide Registries ....... 16 

B: Confidence Intervals for Key Estimates .................... 17 

ACKNOWLEDGMENTS ......................................... 18 
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  I N T R O D U C T I O N  

OBJECTIVE 
To determine (1) the extent to which long term care (LTC) facilities 
report that they are in compliance with Federal regulations as related 
to the use of State nurse aide registries, and (2) what additional 
procedures LTC facilities have established to screen nurse aides. 
BACKGROUND 
Federal Requirements. 
The Omnibus Budget Reconciliation Act of 1987 contained provisions 
designed to ensure delivery of quality care to LTC facility residents.1 
Federal statute (42 U.S.C.  1395i-3) and regulations require each State 
and the District of Columbia (hereinafter referred to as a State) to 
maintain nurse aide registries of all individuals who are registered to 
work as nurse aides in that State (i.e., all individuals who have 
completed nurse aide training and/or whom the State deems competent 
to function as a nurse aide2), as well as all individuals who have been 
prohibited from employment as nurse aides in LTC facilities because of 
substantiated adverse findings of abuse, neglect, or misappropriation of 
property.3  Nurse aide registries are intended to ensure that LTC 
facilities employ only registered nurse aides who do not have 
substantiated adverse findings.  (For a description of the components of 
nurse aide registries as required by Federal regulation, see 
Appendix A.) 
Federal regulations prohibit LTC facilities from employing individuals 
who have had a finding of abuse, neglect, mistreatment of residents, or 
misappropriation of residents property entered into the State nurse 
1 We refer to nursing homes and skilled nursing facilities as long term care (LTC) facilities 
in this report. 
2 42 CFR  483.75(e) defines a nurse aide as any individual providing nursing or 
nursing-related services to residents in a facility who is not a licensed health professional, 
a registered dietitian, or someone who volunteers to provide such services without pay.  
3 42 CFR  488.301 defines abuse as the willful infliction of injury, unreasonable 
confinement, intimidation, or punishment with resulting physical harm, pain or mental 
anguish.  Neglect is defined as failure to provide goods and services necessary to avoid 
physical harm, mental anguish, or mental illness.  Misappropriation of resident property 
is defined as the deliberate misplacement, exploitation, or wrongful, temporary or 
permanent use of a residents belongings or money without the residents consent. 
  OEI-07-04-00140  NURSE AIDE REGISTRIES:  LONG TERM CARE FACILITY COMPLIANCE AND PRACTICES  1  II NN TT RR OO DD UU CC TT II OO NN

aide registry or who have been found guilty in a court of law of abusing, 
neglecting, or mistreating LTC facility residents.4 Information 
regarding court convictions may or may not be included on State nurse 
aide registries. Federal regulations require LTC facilities to check the 
State nurse aide registry for all hired nurse aides and to check every 
State nurse aide registry that they believe will include information on 
an individual.5 
Federal regulations allow nurse aides to work for up to 4 months before 
becoming registered in the State in which they are working to provide 
sufficient time for their training. However, individuals must become 
registered within 4 months to continue working as nurse aides. 6 
Other Studies Found Weaknesses With Nurse Aide Registries. 
Previous studies of nurse aide registries identified a number of 
weaknesses with nurse aide registry practices in some States and 
indicated that State compliance with Federal nurse aide registry 
regulations was inconsistent. A 2005 Office of Inspector General (OIG) 
study addressed State compliance with nurse aide registry 
requirements and examined the accuracy of nurse aide registry 
information.7 That study found that some States failed to update their 
nurse aide registries timely with substantiated adverse findings and 
that inactive nurse aides were not removed from some nurse aide 
registries, as Federal regulations require. Further, OIG found that 
some States charged an access fee or limited the number of nurse aide 
records that could be requested per access. States had concerns 
regarding the usefulness of nurse aide registries to LTC facilities and 
whether facilities checked the nurse aide registry for all hired nurse 
aides. 
Although criminal background checks are not required by Federal 
statute or regulation,8 such checks can enable LTC facilities to comply 
with the Federal requirement that such facilities not hire nurse aides 
4 42 CFR  483.13(c)(1). 

5 42 CFR  483.75(e)(5) and (6).

6 42 CFR  483.75(e).

7 Nurse Aide Registries: State Compliance and Practices. Office of Inspector General, 

OEI-07-03-00380. 
8 Public Law 108-173, Section 307 established a Background Check Pilot Program for LTC 
facilities or providers to conduct background checks on prospective direct patient access 
employees in 10 States. 
OEI-07-04-00140  NURSE AIDE REGISTRIES:  LONG TERM CARE FACILITY COMPLIANCE AND PRACTICES  2  III NNN TTT RRR OOO DDD UUU CCC TTT III OOO NNN
who have been found guilty in a court of law of abusing, neglecting, or 
mistreating residents. A 1998 OIG audit reported that, in most States, 
criminal background checks for nurse aides were limited to State 
records, and some individuals with criminal histories were not recorded 
on nurse aide registries.9 OIG recommended that the Centers for 
Medicare & Medicaid Services (CMS) work with the Administration on 
Aging and the States to improve the safety of LTC facility residents and 
to strengthen safeguards against employment of abusive workers. 
METHODOLOGY 
This study was based on information from multiple sources: 
(1) a review of Federal statutes and regulations regarding nurse aide 
registries, (2) a review of the existing literature and previous studies on 
nurse aide registries, (3) questionnaire responses from a simple random 
sample of 200 LTC facility administrators, and (4) nurse aide 
employment information from each of the 200 sampled LTC facilities. 
Sample Selection. 
We selected a simple random sample of LTC facilities from the 
population of such facilities contained in the Online Survey, 
Certification and Reporting (OSCAR) database as of March 26, 2004. 
Our sample consisted of 200 of the 16,261 LTC facilities in the 
51 States. 
LTC Facility Administrator Questionnaire. 
The administrators of each of the 200 LTC facilities completed a mail 
questionnaire regarding the practices, policies, and procedures they 
followed in checking potential and employed nurse aides on nurse aide 
registries. We analyzed the questionnaire data to determine LTC 
facilities reported compliance with Federal regulations and the types of 
additional procedures LTC facilities had instituted to screen potential 
nurse aides. 
Nurse Aide Employment Information. 
From each of the 200 LTC facilities, we requested information on all of 
the nurse aides employed by the facility on September 1, 2003. The 
information requested included the full name, Social Security number, 
date of birth, registration number, and the beginning and ending dates 
of employment for each nurse aide. We received employment 
9 Safeguarding LTC Residents. Office of Inspector General, A-12-97-00003, 09/98. 
OEI-07-04-00140  NURSE AIDE REGISTRIES:  LONG TERM CARE FACILITY COMPLIANCE AND PRACTICES  3  I N T R O D U C T I O N  
information from all 200 LTC facilities, for a total of 8,123 nurse aides.  
We also requested documentation of the LTC facilities verification(s) of 
each nurse aides registration.  
As part of the 2005 OIG study reviewing State compliance with nurse 
aide registry requirements, we received complete nurse aide registries 
from all States as of September 1, 2003.  We matched the 8,123 nurse 
aides hired prior to September 1, 2003, with the 51 State nurse aide 
registries to determine if any nurse aides had a substantiated adverse 
finding of abuse, neglect, or misappropriation of property. 
Because Federal regulations allow individuals to work for up to 
4 months before becoming registered as nurse aides, our analysis 
regarding registration included only those individuals who were hired 
before May 1, 2003.  By removing the 1,529 nurse aides hired by the 
200 LTC facilities between May 1 and September 1, 2003, the number of 
nurse aides included in our analysis was reduced from 8,123 to 6,594.  
We matched the 6,594 nurse aides with the 51 State nurse aide 
registries to ensure they were registered as of September 1, 2003.  For 
any nurse aide we could not match in the 51 State nurse aide registries 
due to incorrect Social Security numbers and/or incorrect names, we 
recontacted the LTC facilities to either verify or obtain correct 
identifying information.  We queried the nurse aide registries a second 
time in August 2004 using the corrected identifying information. 
We determined that an LTC facility was not in compliance with Federal 
regulations if it employed one or more nurse aides without registration.  
Limitations of Identifying Nurse Aides Without Registrations or With 
Substantiated Adverse Findings. 
It is possible that some LTC facilities may not have provided 
employment information on all of their nurse aides. In an attempt to 
identify LTC facilities that may have provided incomplete information, 
we compared the number of nurse aides each facility provided with the 
number of nurse aides listed in the OSCAR database.  To ensure that a 
complete list of nurse aides had been provided, we identified extreme 
outliers and contacted the nine LTC facilities that provided employment 
information for less than half the number of nurse aides listed in the 
OSCAR database.  To ensure that the information provided by the LTC 
facilities included only nurse aides and not other LTC facility staff, we 
also contacted the 14 LTC facilities that provided employment 
information for more than twice the number of nurse aides listed in the 
OSCAR database.  The LTC facility administrators either provided 
  OEI-07-04-00140  NURSE AIDE REGISTRIES:  LONG TERM CARE FACILITY COMPLIANCE AND PRACTICES  4  II NN TT RR OO DD UU CC TT II OO NN
updated lists of nurse aides or stated that the information they 
originally provided was correct. We then repeated the matching process 
with any new information provided. 
Standards. 
This inspection was conducted in accordance with the Quality 
Standards for Inspections issued by the Presidents Council on 
Integrity and Efficiency. 
OEI-07-04-00140  NURSE AIDE REGISTRIES:  LONG TERM CARE FACILITY COMPLIANCE AND PRACTICES  5    F I N D I N G S

Long term care facility administrators reported  Federal regulations require 
checking their State nurse aide registries LTC facilities to check their 
 before hiring; the registry results affected  State nurse aide registry to 
ensure that all hired nurse 
some hiring decisions 
aides are registered.10  Federal 
regulations also require that LTC facilities must not employ individuals 
whose records contain substantiated adverse findings.11 
All LTC facility administrators reported that they checked their own 
State nurse aide registry to ensure that potential nurse aides are 
registered. In fact, 42 administrators reported not hiring a potential 
nurse aide because of the results of a registry inquiry.  Furthermore, 
when we matched the employment information for the 8,123 nurse aides 
that the 200 LTC facility administrators supplied with the appropriate 
State nurse aide registry, we did not identify any nurse aides with 
substantiated adverse findings of abuse, neglect, or misappropriation of 
property entered on the nurse aide registry for the State in which they 
were employed. Given this evidence, it seems likely that LTC facility 
administrators are in compliance with Federal requirements prohibiting 
the employment of nurse aides with substantiated adverse findings. 
Although not required to do so, 44 percent of administrators reported 
rechecking employed nurse aides against their State nurse aide registry 
to ensure that substantiated adverse findings had not been posted to the 
registry.  (See Appendix B for confidence intervals for all point 
estimates.) The most commonly reported reason for this practice was 
concern that nurse aides may be employed by more than one LTC 
facility and could have substantiated adverse findings resulting from 
actions at another facility. Of the 87 administrators who reported 
rechecking the nurse aide registry for substantiated adverse findings 
subsequent to hiring, 15 identified at least one nurse aide who had a 
change of status (e.g., conviction of abuse at a previous job, failure to 
attain registration, or failure to renew registration due to a change of 
address), and 14 of these administrators terminated those nurse aides.12 
10 42 CFR  483.75(e)(5). 
11 42 CFR  483.13(c)(1). 
12 The remaining LTC facility administrator reported that she may terminate nurse aides 
based on the nature of the change identified. 
  OEI-07-04-00140  NURSE AIDE REGISTRIES:  LONG TERM CARE FACILITY COMPLIANCE AND PRACTICES  6  F I N D I N G S  

Fifty-five percent of administrators reported  In addition to requiring that they 
checking only their own State registry and  check their own State nurse aide 
thus are most likely not in compliance  registry, Federal regulations 
require LTC facilities to check every 
with Federal requirements 
other State nurse aide registry they 
believe will include any information on a potential nurse aide.13 
Although believe is not specifically defined in regulation, employment 
applications, reference checks, or background checks would provide LTC 
facilities with clear evidence of the other State nurse aide registries that 
might contain information about a potential nurse aide.  In the 
2005 OIG study, we identified approximately 99,000 nurse aides who 
had registrations in multiple States, suggesting that interstate 
movement of nurse aides is not uncommon. This finding supports the 
importance of LTC facilities checking the registries of other States 
before hiring a nurse aide. 
When surveyed about checking other State registries, administrators 
had the choice of choosing one of the following:  (1) Yes, we check other 
States registries; (2) No, we only check our own State registry; or 
(3) No, we do not check any State registries.  Fifty-five percent of 
administrators selected option 2, reporting that they only check their 
own States nurse aide registry prior to hiring a nurse aide.14  Given 
that our prior studies clearly demonstrated that some nurse aides have 
moved from one State to another, it is possible that LTC facilities have 
at least some nurse aides who worked as nurse aides in other States 
prior to seeking employment at their facility.  Thus, LTC facilities that 
reported checking only their own registry are likely not in compliance 
with Federal regulations. 
From our prior study,15 when we examined the universe of nurse aides, 
we found that 1,552 nurse aides had substantiated adverse findings and 
450 nurse aides had pending findings of abuse, neglect, or  
13 42 CFR  483.75(e)(6). 

14 The remaining administrators selected other responses. 

15  Nurse Aide Registries:  State Compliance and Practices.  Office of Inspector General, 

OEI-07-03-00380. 
  OEI-07-04-00140  NURSE AIDE REGISTRIES:  LONG TERM CARE FACILITY COMPLIANCE AND PRACTICES  7  FFF III NNN DDD III NNN GGG SSS  
misappropriation of property in one State and an active registration in 
another State;16 and 314 nurse aides had records with substantiated 
adverse findings in multiple States. 
Through our process of matching identifying information that the LTC 
facilities provided for the 8,123 nurse aides against the 51 State nurse 
aide registries, we identified a nurse aide who had a record with a 
substantiated adverse finding from 1999 on the New Mexico nurse aide 
registry and was employed in Texas on September 1, 2003. The 
administrator of the Texas LTC facility reported that the facility does 
not check other States nurse aide registries prior to hiring potential 
nurse aides. 
Seventeen percent of LTC facilities employed  Fifteen percent of LTC facilities 
employed at least one individual as a 
individuals as nurse aides without 
nurse aide for longer than 4 months 
required registrations 
without registration. 
Federal regulations prohibit LTC facilities from using [employing] any 
individual as a nurse aide for more than 4 months unless that 
individual is registered as a nurse aide.17 However, LTC facilities can 
hire nurse aides for up to 4 months before they are registered, allowing 
the individual to participate in a training program to become registered. 
At the end of the 4 months, if an individual is not listed in the 
appropriate State nurse aide registry, the LTC facility must follow up to 
ensure that the individual actually becomes registered. Evidence of 
registration is maintained in the appropriate State nurse aide 
registry.18 
On September 1, 2003, 15 percent of LTC facilities employed at least 
one individual as a nurse aide for longer than 4 months without 
registration, accounting for a total of 40 nurse aides. We queried the 
nurse aide registries in August 2004 to verify whether these nurse aides 
were listed as registered. We found that 29 nurse aides were still not 
listed as registered and 11 nurse aides were listed as registered, but 
16 Although Federal regulations do not require that nurse aides with pending findings of 
abuse, neglect, or misappropriation of property be listed as such on their respective 
registries, we include information about these 450 nurse aides because it suggests 
information that LTC facilities could learn about nurse aides if registries in other States 
were checked. 
17 42 CFR  483.75(e)(2). 
18 42 CFR  483.75(e)(5). 
OEI-07-04-00140  NURSE AIDE REGISTRIES:  LONG TERM CARE FACILITY COMPLIANCE AND PRACTICES  8  F I N D I N G S  
their registration dates were after September 1, 2003.  Thus these nurse 
aides were employed without registration for more than 4 months, a 
violation of Federal regulations.  Despite the administrators of these 
LTC facilities reporting that they had practices in place to ensure that 
individuals without registrations are not employed for longer than 
4 months (e.g., confirming registration by checking the nurse aide 
registry after 4 months of employment, requiring nurse aides to provide 
proof of registration, and completing the paperwork required to obtain 
registrations for nurse aides), none of these LTC facilities could produce 
documentation of registration for any of the nurse aides in question. 
Five percent of LTC facilities (three percent of which are included above) 
employed nurse aides with expired registrations. 
Federal regulations require State nurse aide registries to remove 
registrations for individuals who have performed no nursing or 
nursing-related services for a period of 24 consecutive months (unless 
the individual's registry record includes documented findings of abuse, 
neglect, or misappropriation of property).  However, some States have 
established more stringent requirements that call for nurse aide 
registrations to expire at regular intervals unless the nurse aide takes 
action to renew his or her registration.  We identified 5 percent of LTC 
facilities that employed nurse aides with expired registrations that had 
expired due to State requirements, accounting for 16 nurse aides.  In 
effect, these 10 LTC facilities employed nurse aides without valid 
registrations, per State requirements.  We could not confirm whether 
these individuals met the Federal requirement for performing nursing 
or nursing-related services in accordance with 42 CFR  483.75(e).  
Three percent of LTC facilities exhibited both conditions (employing 
individuals as nurse aides without registrations and nurse aides with 
expired registrations). 
Eighty-five percent of administrators reported  Federal regulations prohibit 
establishing additional screening procedures; some  LTC facilities from employing 
of these methods may not be fully effective  any individual who has been 
found guilty of abusing, 
neglecting, or mistreating residents by a court of law; 19 however, these 
convictions are not necessarily recorded on a States nurse aide registry. 
Although not required to do so by Federal regulation, some LTC facility 
19 42 CFR  483.13(c)(1)(ii)(A). 
  OEI-07-04-00140  NURSE AIDE REGISTRIES:  LONG TERM CARE FACILITY COMPLIANCE AND PRACTICES  9  FFFF IIII NNNN DDDD IIII NNNN GGGG SSSS
  
administrators reported establishing various procedures in attempts to 
ensure that they do not hire or employ individuals with such 
convictions. 
In addition to checking the  Table 1: Screening Procedures of the 
State nurse aide registry,  200 LTC Facilities 
the most common  Number of LTC 
Check Conducted 
Facilities 
screening procedures, as 
Criminal Background 
reported by 85 percent of  91 
Only 
administrators, were 
conducting criminal  Reference Only  10 
background checks and/or 
Criminal Background 
68 
checking personal and  Check and Reference 
employment references. 
Neither  31 
Table 1 illustrates the 
Source: Office of Inspector General, 2004 
number of administrators 
who reported conducting criminal background and/or reference checks. 
However, of the 159 LTC facilities that conducted criminal background 
checks, 50 percent conducted checks that were limited in scope (covering 
only their State or the individuals reported previous addresses). Those 
LTC facilities that conduct criminal background checks of limited scope 
may fail to identify nurse aides who have criminal histories in other 
States. This finding is consistent with a 1998 OIG audit, which 
reported that in most States criminal background checks for nurse aides 
were limited to State records. In that report, OIG recommended that 
CMS consider developing a Federal requirement for criminal 
background checks and CMS concurred. 
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  R E C O M M E N D A T I O N S  

RECOMMENDATIONS 
Ensuring that only registered nurse aides without substantiated 
adverse findings of abuse, neglect, or misappropriation are employed in 
LTC facilities necessitates a partnership among States, CMS, and LTC 
facilities. States and LTC facilities must diligently comply with Federal 
regulations regarding nurse aide registries.  The LTC facilities that do 
not comply with Federal regulations or do not use available information 
about potential nurse aides could expose facility residents to greater 
risk of harm.  We recommend that CMS: 
o 	 Utilize existing communication channels (e.g., survey and 
certification processes) to ensure that LTC facilities comply with 
Federal regulations that require them to check the nurse aide 
registries of other States that they believe will contain 
information about an individual prior to hiring and to not employ 
individuals as nurse aides for more than 4 months without 
registration. 
o 	 Encourage LTC facilities to use available resources (e.g., State 
nurse aide registries, background check services) to ensure that 
nurse aides with substantiated adverse findings or criminal 
backgrounds are not employed.  Possible methods that CMS could 
use to achieve this include: (1) requiring all LTC facilities to 
perform periodic (e.g., annual or biennial) inquiries of State nurse 
aide registries on employed nurse aides and (2) requiring 
comprehensive criminal background checks by all LTC facilities 
prior to hiring nurse aides. CMS concurred with a 1998 OIG 
recommendation that CMS consider developing a Federal 
requirement for criminal background checks.  While no such 
requirement has yet been developed, the Medicare Prescription 
Drug, Improvement, and Modernization Act of 2003 (Public 
Law 108-173 section 307) established a Background Check Pilot 
Program for LTC facilities or providers to conduct background 
checks on prospective direct patient access employees in up to 
10 States. The results of this pilot will be informative as to the 
viability of this second option. 
AGENCY COMMENTS 
In its comments to the draft report, CMS recognized the effort and 
expressed appreciation for OIGs work related to nurse aide registry 
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requirements.  CMS concurred with our recommendations.  CMS will 
issue a survey and certification letter to all State survey agencies asking 
them to share the communication with all LTC facility providers to 
reinforce the importance of checking nurse aide registries and not 
allowing nurse aides to work for more than 4 months without 
successfully passing a competency evaluation examination.  In addition, 
CMS will utilize the existing Background Check Pilot Program to 
provide insight on further efforts to ensure that only nurse aides in good 
standing are employed in LTC facilities. 
OIG RESPONSE 
We appreciate CMSs comments to this report and note that CMS is 
taking action to address issues raised in this report.  We look forward to 
learning the results of the Criminal Background Check Pilot Program.  
Changes were made to the report to reflect technical comments received 
from CMS. 
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Required Components of State Nurse Aide Registries 
Pursuant to 42 CFR  483.156(c), nurse aide registries must include: 
(1) The full name of the individual,  
(2) Identifying information, 
(3) The date the individual became eligible for placement in the nurse 
aide registry, and 
(4) Information regarding substantiated adverse findings (as 
appropriate). 
Each States nurse aide registry must include information on 
individuals who have active registrations and are thus employable and 
on individuals whose records include substantiated adverse findings.  
States are required to remove nurse aide registry records of individuals 
who have not performed nursing or nursing-related services for a period 
of 24 consecutive months, thus becoming inactive and no longer 
employable.  Individuals with records of substantiated adverse findings 
must remain on the nurse aide registry permanently except in certain 
cases of neglect.  
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Confidence Intervals for Key Estimates 
Confidence Interval  
Finding  Point Estimate  Ratio 
95 Percent 
Administrators Who Reported Rechecking Nurse Aide 
43.5%  36.5% - 50.7%  87/200 
Registries 
Administrators Who Reported Not Checking Other States' 
55.0%  47.8% - 62.0%  110/200 
Nurse Aide Registries 
LTC Facilities That Employed Nurse Aides Without 
14.5%  9.9% - 20.2%  29/200 
Registrations For Longer Than 4 Months 
LTC Facilities That Employed Nurse Aides With Expired 
5.0%  2.4% - 9.0%  10/200 
Registrations 
LTC Facilities That Established Additional Screening 
84.5%  78.7% - 89.2%  169/200 
Procedures 
LTC Facilities That Conducted Background 
50.3%  42.3% - 58.3%  80/159 
Checks of Limited Scope 
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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 Gina C. Maree, Assistant Regional 
Inspector General.  Other principal Office of Evaluation and Inspections 
staff who contributed include: 
Tricia Fields, Team Leader 
Brian T. Whitley, Project Leader 
Dennis Tharp, Program Analyst 
Michala Walker, Program Analyst 
Sandy Khoury, Program Specialist 
Tricia Davis, Director, Medicare & Medicaid Branch 
Barbara Tedesco, Mathematical Statistician 
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