U.S. Department of Health and Human Services 
Office of Inspector General 
 
National Background 
NOTICE  THIS DRAFT 
RESTRICTED TO OFFICIAL  Check Program for 
USE 
 
Long-Term-Care 
This document is a draft report of 
the Office of Inspector General 
and is subject to revision;  Providers: Assessment 
therefore, recipients of this draft 
should not disclose its contents for 
purposes other than for official  of State Programs 
review and comment under any 
circumstances.  This draft and all 
Concluded Between  
copies thereof remain the property 
of, and must be returned on 
demand to, the Office of Inspector   
2013 and 2016
General. 
 
 
 
 
 
 
 
 
OEI-07-16-00160  Suzanne Murrin 
April 2019  Deputy Inspector General 
  for Evaluation and 
oig.hhs.gov  Inspections  Report in Brief  U.S. Department of Health and Human Services 
April 2019 
Office o  f Inspector General 
OEI-07-16-00160 
 
 
Why OIG Did This Review 
National Background Check Program for 
Background checks are an important 
Long-Term-Care  Providers: Assessment of 
safety measure that can help protect 
the 9 million beneficiaries who rely 
State Programs Concluded Between  
on long-term-care services each year 
2013 and 2016  for safe, dependable care.  These 
checks can prevent individuals with 
The National Background Check Program  disqualifying histories (e.g., 
(Program) provides grants to States to develop  Key Takeaway  convictions for patient abuse, patient 
systems to conduct background checks of State  Seven out of 10 States  neglect, and theft from patients) 
and Federal criminal history records for  implemented all or most of  from being hired to care for 
prospective long-term-care employees.  the background  check  beneficiaries.    
  requirements fundamental to   
What OIG Found  protecting beneficiaries from   Congress mandates that OIG 
The 10 States that had concluded their  long-term-care providers with  evaluate various aspects of Program 
participation in the Program by 2016 varied as to  disqualifying histories.  Three  implementation.  This report 
States did not have legislative 
the degree to which they achieved  provides an assessment of States that 
implementation of Program requirements.  Seven  authority to meet Program  concluded Program participation 
of these 10 States implemented all or most of the  requirements.  CMS should  prior to 2017, and it also provides 
selected requirements.  Three States did not have  expand its assistance to  information for CMS to assist States 
States that struggle to fully 
the necessary authority through State legislation  that continue to participate in the 
and could not fully implement background check  implement the National  Program. 
Background Check Program. 
programs.   
  How OIG Did This Review 
Of the background checks that 8 of the 10 States 
We reviewed grant-monitoring 
conducted, nearly 80,000 resulted in determinations of ineligibility for 
documents and financial reports to 
prospective employees.  The number of determinations of ineligibility and rates 
determine the extent to which the  
of ineligibility varied among the States (i.e., from less than 1 percent to 
10 States that concluded participation 
8 percent).  None of the States reported a reduction in available workforce for 
between 2013 and 2016 had 
long-term-care facilities or providers  as a result of the Program. 
implemented selected Program 
What OIG Recommends   requirements.  Additionally, we 
To better protect beneficiaries from potential harm, CMS should take  surveyed the 10 States to collect 
appropriate action to encourage participating States to obtain necessary  information on their experiences with 
authorities to fully implement Program requirements.  CMS concurred with our  their respective background check 
recommendation. programs.   
TABLE OF CONTENTS  
BACKGROUND  1 
Objective  1 
Methodology  4 
   
FINDINGS  7 
Seven States implemented all or most selected Program requirements; three States did not  7 
have legislative authority to meet Program requirements 
States varied in the number and rate of background checks that resulted in determinations  9 
of ineligibility 
   
CONCLUSION AND RECOMMENDATION  12 
CMS should take appropriate action to encourage participating States to obtain necessary  12 
authorities to fully implement Program requirements 
Agency Comments and Office of Inspector General Response  13 
APPENDICES   14 
A: Mandate for National Background Check Program Evaluation and   14 
ReportP.L. No. 111-148,  6201(a)(7)  
B: Beginning and Ending Dates of States National Background Check Program   15 
C: Expenditures for the National Background Check Program  16 
D: Related Reports  17 
E: Detailed Methodology    19 
F: States Implementation of 13 Selected Program Requirements  20 
G: State-by-State Implementation of Selected Program Requirements  21 
H: Agency Comments  32 
ACKNOWLEDGMENTS  34 
   
ENDNOTES  36 
   
BACKGROUND 
 
Objective 
To assess the implementation and impact of States National 
Background Check Programs for Long-Term-Care Providers 
concluded between 2013 and 2016. 
Over 9 million beneficiaries in the United States rely on long-term-care 
services in nursing homes and through other providers such as home 
health, hospice, and personal care services agencies.1, 2  Beneficiaries and 
their family members trust in these providers for dependable, safe care.   
The Office of Inspector General (OIG) and the Centers for Medicare & 
Medicaid Services (CMS) have identified patient abuse, patient neglect, and 
misappropriation of property (i.e., theft) as widespread problems that cause 
harm to beneficiaries receiving long-term-care services.3, 4  Studies have 
shown that some nurse aides who were convicted of abuse, neglect, or theft 
had previous criminal convictions that could have been detected through 
background checks.5, 6  This suggests that background checks are a safety 
measure that can provide protections for beneficiaries who rely on  
long-term-care services.   
Enacted by legislation in 2010, the National Background Check Program 
(Program) provides grants to States to develop systems to conduct 
background checks of State and Federal criminal history records.7   
Congress mandated that OIG produce an evaluation of the Program within 
180 days of Program completion, which could occur as late as 2024.  (See 
Appendix A for the evaluation mandate.)  The beginning and end dates of 
the grants are staggered, with 10 States concluding participation between 
2013 and 2016, and 19 States continuing participation past 2016.  (See 
Appendix B for grant beginning and end dates.)  In 2016, OIG published 
a report on State implementation of the Program.8  This 2019 report is the 
second in a series of reports designed to assist CMSand States continuing 
in the Programin promoting Program improvements and increasing 
protections for the vulnerable population of beneficiaries receiving 
long-term-care services.  
Background 
Congress established the Program to identify efficient, effective, and 
economical procedures for conducting State and national background 
checks on prospective employees who would have direct access to 
patients.9, 10  (We refer to employees who have such access as direct patient 
access employees, and to applicants for such positions as prospective 
employees.)  Participating States received grants to develop systems 
National Background Check Program for Long-Term-Care Providers: Assessment of State Programs Concluded Between 2013 and 2016  1 
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to conduct fingerprint-based Federal and State criminal records checks and 
to search registries that contain disqualifying information.11, 12  The Program 
expands on a pilot version, the 20052007 Background Check Pilot 
Program.13  
The Program provides Federal grant funds to participating States.  
Specifically, it requires States to contribute $1 for every $3 of Federal funds 
received.  To ensure that States meet Program objectives, Federal funds that 
States receive are subject to withdrawal restrictions.14  The Program awarded 
grants of up to $3 million to each of 29 States that applied for Program 
participation in fiscal years (FYs) 2010 through 2018.15  See Appendix C for 
information related to Federal grant awards and State matching funds for 
States that concluded grant participation in 2016.  
Requirements for Participating States 
States must meet broad statutory and grant requirements (which this report 
describes as Program requirements), but they have some flexibility in how 
they meet each requirement.  For example, States must define direct patient 
access employees, but they have flexibility in determining which types of 
prospective employees they include in their respective Programs.  
Additionally, States must require all prospective long-term-care employees 
to undergo background checks; however, the statute does not designate 
which entitya State government agency or the prospective employer
should be responsible for making the final determination of ineligibility.  
Some States already had laws that facilitated implementation of these 
requirements; other States pursued legislation to implement some Program 
requirements.    
Types of background checks required.  In their processes, States must 
include several types of background checks and other monitoring 
activities.16  The required checks include the following: (1) a search of any 
databases and the abuse registries of all known States in which the 
prospective employee lived;17 (2) a check of State criminal history records; 
(3) a fingerprint-based check of Federal Bureau of Investigation (FBI) 
criminal history records;18, 19 and (4) a search of the records of any 
proceedings in the State that may contain disqualifying information about 
the prospective employee.20, 21  Additionally, States must describe and test 
methods to reduce duplication of fingerprinting, including the development 
of rap back capabilitya process whereby a State receives automatic 
notification of any criminal convictions that prospective employees receive 
after their initial background checks have been conducted. 22, 23  In this 
report, we refer to this process as continuous monitoring.  States are 
required to report to CMS their quarterly data on Program outcomes, such 
as the numbers of background checks they conducted and the numbers of 
checks that resulted in determinations of ineligibility. 
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Participating States must implement all required background checks for 
prospective employees among the following nine types of long-term-care 
facilities or providers: 
  skilled nursing facilities; 
  nursing facilities; 
  home health agencies; 
  providers of hospice care; 
  long-term-care hospitals; 
  providers of personal care services; 
  providers of adult day care; 
  residential care providers that arrange for long-term-care services or 
provide long-term-care services; and 
  intermediate-care facilities for individuals with intellectual 
disabilities.24 
Types of offenses that constitute disqualifying offenses.  As part of the 
Program, States must ensure that background checks examine any 
databases that may contain information on an applicants history that could 
disqualify the applicant from employment.  The Program defines 
disqualifying information as certain Federal and State convictions or 
findings related to patient abuse or neglect; health care fraud; theft; 
offenses involving controlled substances; obstruction of an investigation and 
other related offenses.25  Additionally, States may specify other types of 
offenses that constitute disqualifying information.26  For example, some 
States have specified child abuse, forgery, sexual abuse, terrorist threats, 
kidnapping, and drug trafficking as disqualifying offenses.  States also have 
flexibility to determine which State databases and abuse registries they will 
search for disqualifying information. 
CMS Program Oversight   
CMS is required to perform essential grant oversight activities in its 
administration of the Program.  These activities include monitoring of 
required State matching funds and instructing States to submit Federal 
financial reports (FFRs), progress reports, and related documentation during 
Program participation.  States are required to submit these reports no later 
than 90 calendar days after the end of the grant period.27  CMS must 
complete all grant closeout actions no later than 1 year after receipt of all 
required reports.28  At the time of our review, OIG notified CMS that grants 
for two States that had ended their Program participation in September 
2016 were still open for withdrawal of Federal funds.29  Once we notified 
CMS, it reviewed the open grants and worked with States to complete the 
required closeout procedures. 
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CMS also requires States to report data on key elements of their grant 
activities.  These elements include the following: (1) detailed information on 
the number of background checks that various providers requested; 
(2) information gathered during background checks and employment 
decisions that are made on the basis of this information; (3) whether 
prospective employees challenged the results of adverse decisions; and 
(4) the outcomes of any challenges.30   
Technical Assistance.  CMS awarded a technical assistance contract to 
support participating States.  The technical assistance contractor 
(Contractor) assists States in all aspects of Program implementation, such as 
writing proposals for necessary changes in State law or administrative rules; 
defining specifications for information systems; implementing fingerprinting 
technology; and integrating existing State databases.  The Contractor also 
reviews States quarterly reports and works with States to improve their data 
reporting.  Finally, the Contractor facilitates conference calls, Web seminars, 
and in-person conferences with participating States and CMS officials.   
CMS Authorities.  Instructions for the Program inform States that Federal 
funds could be subject to withdrawal restrictions if States do not implement 
Program requirements.31 
Related Report 
In 2016, OIG conducted an evaluation that described the overall State 
implementation status during the first 4 years of the Program.32  The 
25 States participating in the Program reported having achieved varying 
levels of implementation.  We found that some States had not obtained 
legislation that would enable them to conduct background checks and 
others had not implemented processes to collect fingerprints and conduct 
continuous monitoring of criminal convictions.  We recommended that CMS 
work with States to improve the quality of States required data reporting 
and that CMS continue working with participating States to fully implement 
their background check programs.  CMS concurred with both 
recommendations and implemented the first recommendation.  CMS 
continues working to implement the second recommendation.  
See Appendix D for previous OIG work related to the Program. 
Methodology  Scope 
We evaluated each of the Programs for the 10 States that concluded 
participation between 2013 and 2016: Alaska, Connecticut, the District of 
Columbia, Delaware, Florida, Illinois, Maryland, Missouri, New Mexico, and 
Rhode Island.  See Appendix B for a listing of all participating States, 
including those States that continued to participate in the Program.   
Congress directs OIG to analyze the most appropriate, efficient, and 
effective procedures for conducting background checks, as well as an 
assessment of the Program cost.  We will reserve these analyses for the final 
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rollup report once all States have completed the Program, which could 
occur as late as 2024.  See Appendix A for the reporting mandate. 
Data Sources and Analysis 
We analyzed 13 Program requirements that are directly related to States 
identifying prospective long-term-care employees with histories that may 
result in a determination of ineligibility for employment: 
  Determine which individuals are direct patient access employees. 
  Require all prospective direct patient access employees to undergo 
background checks. 
  Include the nine facility and provider types defined by the Program. 
  Identify disqualifying offenses. 
  Establish a Statewide program. 
  Collect applicants fingerprints for Federal/State checks. 
  Conduct checks of Federal criminal history.  
  Conduct checks of State criminal history.  
  Conduct checks of State abuse/neglect registry for applicants current 
States of residence. 
  Conduct checks of State abuse/neglect registry for applicants prior 
States of residence. 
  Conduct records search of any proceedings in the State that may 
contain disqualifying information. 
  Notify facilities and providers of convictions identified through 
continuous monitoring.  
  Report convictions to required databases.33  
We obtained data from several sources to conduct our analysis.  From CMS, 
we collected monitoring documents (e.g., financial and progress reports) 
submitted by States related to their implementation of Program 
requirements and compared their progress in meeting the requirements.  
We surveyed officials from the 10 States regarding Program outcomes and 
effectiveness.  We then confirmed with State officials that the data we 
obtained from these sources were consistent with State records. 
Data Limitations 
Congress requires an evaluation of the Programs impact on reducing the 
number of incidents of abuse, neglect, and theft.34  However, the data 
available do not permit this analysis.35 
See Appendix E for a detailed methodology. 
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Standards  We conducted this study in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General on 
Integrity and Efficiency.   
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FINDINGS 
Seven States  Background checks can provide protections from abuse, neglect, and theft 
for beneficiaries who rely on long-term-care services.  The 10 States that 
implemented all or 
concluded Program participation varied in their implementation of 
most selected 
13 selected Program requirements that identify prospective employees who 
Program  are potentially determined to be ineligible for employment.     
requirements; three  Appendix F includes information on each States implementation status for 
States did not have  all 13 Program requirements and Appendix G provides additional details in 
State scorecards. 
legislative authority 
to meet Program  Five States implemented all selected Program requirements 
requirements   Alaska, the District of Columbia, Florida, New Mexico, and Rhode Island 
implemented all 13 selected Program requirements.  In addition, these 
States conducted background checks for more than the required nine types 
of facilities and providers.  Specifically, these States established statutes 
requiring background checks for as many as 39 types of facilities and 
providers (e.g., ambulatory surgery centers, rural health clinics, respite care 
providers).   
Two States implemented most of the selected Program 
requirements 
Delaware and Connecticut implemented most of the selected Program 
requirements.  The one program requirement that neither State fully 
implemented was to conduct background checks for all nine required types 
of facilities and providers in their respective State programs during the grant 
period.  (See Exhibit 1 on the next page.) 
Delaware conducted background checks for all provider types in its 
program except adult day care providers.  At the conclusion of the grant in 
2016, Connecticut had not implemented background checks for three of the 
nine provider types in its programlong-term-care hospitals (LTCHs); 
residential care providers that arrange for long-term-care services; and 
intermediate-care facilities for individuals with intellectual disabilities 
(ICF/IIDs).  We note that in February 2018, Connecticut expanded its 
Program and implemented background checks for these provider types. 
Additionally, Connecticut did not conduct continuous monitoring, and 
therefore did not notify facilities and providers of convictions identified 
through continuous monitoring.  In States that fail to conduct continuous 
monitoring and fail to notify providers of new convictions, providers could 
continue to employ staff who had received a disqualifying conviction after 
being hired.  These failures may put beneficiaries at risk of harm.  
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Three States did not have legislative authority to meet Program 
requirements 
Illinois, Maryland, and Missouri did not have legislative authority to meet 
Program requirements.  Illinois implemented a State-only program that did 
not include fingerprint-based checks of FBI criminal history records.  
Maryland State officials reported that the State was unable to pass enabling 
legislation and, as a result, discontinued Program implementation after 
June 2014.  The State discontinued withdrawing funds after receiving 
$55,154 of the Federal share of its grant.  Missouri State officials reported 
that they used $2,639,164 of Federal grant funds to develop 
a comprehensive background check system but were unable to implement 
the program in the absence of legislative authority.  Though these States 
made some progress, they lacked legislative authority to fully implement 
Program requirements that may reduce beneficiaries risk for theft, abuse, 
and neglect. 
Exhibit 1: Two States implemented most Program requirements; 
three States did not have legislative authority to meet Program 
requirements  
Source: OIG analysis of States implementation of selected Program requirements, 2018 
*Illinois and Missouri conducted State-only checks; however, many program requirements are contingent 
on States conducting fingerprint-based checks of FBI criminal history records.  Maryland did not pass 
enabling legislation, ended Program participation, and discontinued drawing down Federal grant funds. 
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States varied in the  State identification of prospective employees who are ineligible for 
employment in long-term-care providers and facilities is imperative to 
number and rate 
protecting beneficiaries receiving services in these settings.  Collectively,  
of background 
8 of 10 States conducted nearly 80,000 background checks that disqualified 
checks that  prospective employees.36   
resulted in 
The number and rate of determinations of ineligibility varied among the 
determinations of  States.  Alaska had the highest rate of determinations of ineligibility
8 percent.  Florida conducted the greatest number of background checks, 
ineligibility 
resulting in the greatest number of determinations of ineligibility64,374.  
See Exhibit 2 on the next page for the numbers of background checks 
completed and rates of determinations of ineligibility for each State. 
The individual characteristics of each States program may have contributed 
to the differences among States in their rates of determination of 
ineligibility.  However, none of the States reported a reduction in available 
workforce for long-term-care facilities or providers as a result of the 
Program. 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
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Exhibit 2:  Background checks and determinations of ineligibility 
Checks with 
State   Completed  Determinations  Percentage 
Checks  Ineligible 
of Ineligibility 
Alaska  49,115  3,965  8.07% 
Florida  1,174,264  64,374  5.48% 
Illinois*  210,656  7,533  3.58% 
New Mexico  102,539  3,057  2.98% 
District of 
30,053  162  0.54% 
Columbia 
Rhode Island  6,382  32  0.50% 
Connecticut  14,453  53  0.37% 
Delaware  4,521  2  0.04% 
Maryland**  NA  NA  NA 
Missouri***  NA  NA  NA 
Total  1,591,983  79,178  NA 
Source: OIG analysis of State background check data, 2018. 
 
* Illinois conducts State-only checks and does not report determinations of ineligibility stemming from 
registry checks.   
 ** Maryland discontinued implementation of the Program after June 2014 and did not report data. 
*** Missouri conducts name-based checks of State criminal history records, but it does not report final 
determinations of eligibility for employment. 
Four States had the greatest percentages of determinations of 
ineligibility  
Florida, Illinois, Alaska, and New Mexico had the greatest percentages of 
determinations of ineligibility.  Florida requires disqualification for arrests or 
charges for disqualifying offenses, rather than only for convictions for 
disqualifying offenses.  We could not definitively determine why Illinois, 
Alaska, and New Mexico had some of the highest rates of determinations of 
ineligibility.  Interestingly, Illinois was among the States with high rates of 
determinations of ineligibility, despite the fact that it checked only its own 
State records.  If Illinois had conducted the required Federal background 
checks, it may have identified additional prospective employees as 
ineligible.  It is also important to note that Illinois rate may underrepresent 
its actual rate of determination of ineligibility.  Illinois did not report checks 
with determinations of ineligibility that stemmed from review of State abuse 
registries.    
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Four States had less than 1 percent of background checks resulting 
in determinations of ineligibility 
The background check programs in the District of Columbia, Connecticut, 
Rhode Island, and Delaware resulted in the lowest rates of determinations of 
ineligibility of prospective employees.  Certain characteristics of their 
programs may have influenced these results.  In the District of Columbia, a 
prospective employee who has committed a disqualifying offense may still 
be eligible for employment if there was only one offense, the offense does 
not involve abuse, and there are no pending charges at the time of hire.  In 
Rhode Island, the State conducts criminal history checks, but employers are 
responsible for making the final disqualification determination rather than 
the State disqualifying applicants directly. 
The State of Delaware offered an explanation for its rates of determinations 
of ineligibility.  Delaware instituted mandatory background checks in 1998 
and, for the first several years, these checks disqualified approximately 4 to 
5 percent of the applicant pool.  However, over the years, that rate declined 
to less than 1 percent.  The State suggested that prospective employees 
with disqualifying backgrounds are now familiar with the background check 
program and no longer apply for these positions.     
Two States did not report any determinations of ineligibility of 
prospective employees  
Missouri and Maryland did not report determinations of ineligibility during 
the grant period.  Although Missouri conducted name-based State checks, it 
did not report final determinations of eligibility for employment as required 
by the Program.  Maryland discontinued its efforts to develop a background 
check program when it became apparent the needed legislation would not 
pass.  As a result, Maryland did not make determinations of eligibility and 
had no data to report.   
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CONCLUSION AND RECOMMENDATION  
Background checks can provide beneficiaries who rely on long-term-care 
services with protections from abuse, neglect, and theft by preventing 
prospective employees with disqualifying offenses from being employed by 
these care providers and facilities.  However, three States did not have 
legislative authority to fully implement background check programs.   
In 2016, CMS concurred with OIGs recommendation to work with 
participating States to fully implement their background check programs.  
We encourage CMS to continue its technical assistance to participating 
States that have challenges implementing aspects of the Program.  
To better protect beneficiaries from harm, OIG recommends that: 
CMS should take appropriate action to encourage participating 
States to obtain necessary authorities to fully implement 
Program requirements 
CMS should take appropriate actionssuch as scheduling future grant 
payments based on implementation of requirements, or issuing deficiency 
noticesto encourage participating States to obtain the necessary 
legislative authority to fully implement Program requirements. 
   
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AGENCY COMMENTS AND OFFICE OF 
INSPECTOR GENERAL RESPONSE 
The Centers for Medicare & Medicaid services (CMS) concurred with our 
recommendation for it to take appropriate action to encourage 
participating States to obtain the necessary authorities to fully implement 
Program requirements.  CMS agreed to look at ways to encourage grantee 
States to fully implement program requirements. 
CMS reinforced its commitment to working with grantee States to 
successfully implement their national background check programs.  CMS 
plans to monitor grant funds, require States to report data on key elements 
of their grant activities, and provide technical assistance to States in all 
aspects of implementation.  Additionally, CMS is working to establish the 
National Forum for Background Checks to serve as a resource to support 
States with the sustainability of their programs.   
The full text of CMS comments can be found in Appendix H.   
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APPENDIX A: Mandate for National 
Background Check Program Evaluation and 
ReportP.L. No. 111-148,  6201(a)(7)  
(A) EVALUATION. 
(i) IN GENERAL.The Inspector General of the Department of Health and Human Services shall 
conduct an evaluation of the nationwide Program. 
(ii) INCLUSION OF SPECIFIC TOPICS.The evaluation conducted under clause (i) shall include the 
following: 
(I) 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 direct patient 
access employees under the nationwide Program and identification of the most appropriate, 
efficient, and effective procedures for conducting such background checks. 
(II) An assessment of the costs of conducting such background checks (including startup and 
administrative costs). 
(III) 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. 
(IV) 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. 
(V) An evaluation of other aspects of the nationwide Program, as determined appropriate by the 
Secretary. 
(B) REPORT.Not later than 180 days after the completion of the nationwide Program, the 
Inspector General of the Department of Health and Human Services shall submit a report to 
Congress containing the results of the evaluation conducted under subparagraph (A). 
   
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APPENDIX B: Beginning and Ending Dates of 
States National Background Check Programs 
State  Grant Award Date  Scheduled Grant End Date*  Actual Grant End Date 
Delaware  9/30/2010     9/29/2013 
Illinois  12/31/2010     12/30/2014 
Maryland  1/31/2013     1/30/2016 
Alaska  9/30/2010     9/29/2016 
Connecticut  9/30/2010     9/29/2016 
Florida  9/30/2010     9/29/2016 
Missouri  9/30/2010     9/29/2016 
Rhode Island  9/30/2010     9/29/2016 
District of Columbia  12/31/2010     12/30/2016 
New Mexico  12/31/2010     12/30/2016 
California  2/1/2011     1/31/2017 
Oklahoma  4/5/2011     4/4/2017 
Kentucky  5/20/2011     5/19/2017 
Michigan  5/20/2013     5/19/2017 
Utah  7/11/2011     7/10/2017 
North Carolina  7/13/2011     7/12/2017 
Maine  10/1/2011     9/30/2017 
Nevada  10/1/2011     9/30/2017 
West Virginia  10/1/2011     9/30/2017 
 
Georgia  7/25/2012   7/24/2018 
 
Minnesota  8/30/2012   7/31/2018 
 
Hawaii  12/17/2012   12/16/2018 
Ohio  4/22/2013    4/21/2019 
Kansas**  7/1/2015  6/30/2019    
Oregon  7/29/2013  7/28/2019   
Puerto Rico  12/17/2012  12/16/2019   
Idaho**  6/1/2018  5/31/2021   
Mississippi**  6/1/2018  5/31/2021   
Wisconsin**  6/1/2018  5/31/2021    
Source: CMS Notice of Award and Contractor website.  Dates reflect schedule as of January 1, 2019. 
 
* Initially, the Centers for Medicare & Medicaid Services (CMS) awarded grants for 2 years with a maximum of four 1-year extensions.  Later, CMS 
allowed States 3-year initial grants with a maximum of three 1-year extensions.  Puerto Rico was awarded an additional 1-year extension. 
** Kansas. Idaho, Mississippi, and Wisconsin have not fully extended their grant periods.  According to information we obtained from the CMS 
Contractor, Kansas may extend to 2021; Idaho, Mississippi, and Wisconsin may extend to 2024.  CMS may issue extensions closer to States 
respective grant end dates. 
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APPENDIX C: Expenditures for the National 
Background Check Program 
 
State  Federal Funds  State Funds  Total 
Alaska*  $1,501,844   $499,731   $ 2,001,575  
Connecticut  $2,664,344   $1,242,812   $3,907,156  
Delaware  $2,629,399   $1,000,000   $3,629,399  
District of Columbia  $2,931,308   $981,508   $3,912,816  
Florida  $2,990,438   $4,104,765   $7,095,203  
Illinois*  $1,152,415   $673,032   $1,825,447  
Maryland  $55,154   $23,483   $78,637  
Missouri  $2,639,164   $1,000,000   $3,639,164  
New Mexico*  $1,418,998   $472,999   $1,891,997  
Rhode Island**  $982,648   $743,145   $1,725,793  
Total  $ 18,965,712   $10,741,475   $29,707,187  
Source: Final Federal Financial Reports (FFRs).   
 
* Alaska, Illinois, and New Mexico participated in the 20052007 Background Check Pilot Program and were limited to $1.5 million in Federal 
assistance for this grant.   
** The Federal funding amount for Rhode Island is taken from the States final FFR, dated July 11, 2018.  The State funding amount for Rhode Island 
is taken from the States quarterly FFR, dated September 30, 2016.  We used this quarterly FFR because the State did not report State funding on 
the final FFR. 
 
 
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APPENDIX D: Related Reports 
Ensuring a Qualified Long-Term Care Workforce: From Pre-Employment 
Screens to On-the-Job Monitoring 
In 2006, the U.S. Department of Health and Human Services Office of the 
Assistant Secretary for Planning and Evaluation contracted for a study of the 
efficacy of various approaches to pre-employment screening and  
on-the-job monitoring of nurse aides to prevent resident abuse in nursing 
homes.37  An examination of four States concluded that criminal background 
checks are a valuable tool for employers during the hiring process and that 
their use does not limit the pool of potential job applicants.  Data from 
1 State revealed that of the 710 individuals entered into the abuse registry 
with a substantiated finding of abuse, neglect, or exploitation, 21 percent 
also had a criminal conviction prior to employment. 
Nursing Facilities Employment of Individuals with Criminal Convictions, 
OEI-07-09-00110 
In 2011, OIG conducted an evaluation of individuals with criminal convictions 
employed in nursing home facilities that found 92 percent of nursing 
facilities employed at least one individual with at least one criminal 
conviction.38  Overall, 5 percent of nursing facility employees had at least 
one criminal conviction.  In this evaluation, a national survey of nursing 
home facility administrators found that almost all facilities conducted some 
form of background check.  
Nationwide Program for National and State Background Checks for 
Long-Term-Care EmployeesResults of Long-Term-Care Provider 
Administrator Survey, OEI-07-10-00421 
In 2012, OIG conducted an evaluation of the nationwide Program for 
national and State background checks that surveyed long-term-care 
provider administrators.39  We found that 94 percent of administrators 
conducted background checks on prospective employees.  Twenty-three 
percent of surveyed administrators believed that their organizations 
background check procedures reduced the pool of prospective employees. 
Criminal Convictions for Nurse Aides with Substantiated Findings of Abuse, 
Neglect, and Misappropriation, OEI-07-10-00422 
Also in 2012, OIG conducted an evaluation that found nurse aides with 
substantiated findings of abuse, neglect, and/or misappropriation of 
property also had previous criminal convictions that could have been 
detected through background checks.40  Nineteen percent of nurse aides 
with substantiated findings had at least one conviction in their criminal 
history records prior to their substantiated finding.  Among these nurse 
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OEI-07-16-00160   
aides, the most common conviction (53 percent) was for crimes against 
property (e.g., burglary, shoplifting, and writing bad checks).  
State Requirements for Conducting Background Checks on Home Health 
Agency Employees, OEI-07-14-00131 
In 2014, OIG conducted an evaluation of State requirements for conducting 
background checks on home health agency (HHA) employees and surveyed 
State officials about their respective background check programs.41  The 
evaluation found that 41 States required HHAs to conduct background 
checks on prospective employees.  Of the 10 States that had no 
requirements for background checks, 4 States reported that they planned to 
implement such requirements in the future.  Thirty-five States specified 
convictions that disqualified individuals from employment, and 16 States 
allowed an individual who had been disqualified from employment to apply 
to have his/her conviction(s) waived. 
Home Health Agencies Conducted Background Checks of Varying Types, 
OEI-07-14-00130 
In 2015, OIG conducted an evaluation of the varying types of background 
checks conducted by HHAs; we reviewed selected employees whose 
convictions were likely to disqualify them from HHA employment.42  We 
found that 4 percent of HHA employees had at least one criminal 
conviction.  FBI criminal history records were not detailed enough to enable 
us to definitively determine whether employees with criminal convictions 
should have been disqualified from HHA employment. 
National Background Check Program for Long-Term-Care Employees: Interim 
Report, OEI-07-10-00420 
In 2016, OIG conducted an evaluation of the National Background Check 
Program for Long-Term-Care Employees describing the overall State 
implementation status during the first 4 years of the Program.43  The 
25 States participating in the grant Program reported having achieved 
varying levels of implementation.  Fifteen States did not conduct continuous 
monitoring of criminal convictions.  Thirteen States did not obtain legislation 
that would enable them to conduct background checks.  Ten States had not 
implemented processes to collect fingerprints.  The study provided CMS 
with information to assist in its ongoing administration of the Program. 
In this evaluation, OIG recommended that CMS continue working with 
States to fully implement their background check programs.  Additionally, 
OIG recommended that CMS continue working with participating States to 
improve the quality of their required data reporting to ensure that CMS can 
conduct effective oversight of the program.  CMS concurred with both 
recommendations and implemented the first recommendation.  CMS 
continues working to implement the second recommendation.  
   
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APPENDIX E: Detailed Methodology 
CMS Reports and Grant Documents 
We obtained from CMS the reports and documents submitted by States 
related to their implementation of the National Background Check Program 
(Program).  We collected from CMS and the Contractor the financial and 
progress reports that they received from each State that concluded its 
Program participation.  We obtained Program funding source amounts from 
the Federal Financial Reports (FFRs), and we obtained Program costs from 
the Contractor.   
We reviewed these reports and documents and compared them to the 
Program requirements.  We reviewed the reports for implemented 
requirements and Program activities including the number of background 
checks that States conducted and the rates of determinations of ineligibility 
for prospective employees.  As part of this analysis, we selected 
13 requirements that most directly related to identifying prospective 
long-term-care employees with histories that make them ineligible for 
employment.  We also reviewed the reports to identify the overall Program 
costs, including startup cost, administrative cost, and total costs.   
Survey of State Officials 
As each of the 10 State Programs concluded, we conducted a survey with 
State Program officials to gather information about the overall operation of 
their respective State Programs; the sustainability of the Program after grant 
funding ends; and whether any unintended consequences resulted from the 
States participation in the Program.  We reviewed the surveys to identify 
the costs of conducting individual background checks.  We also asked State 
officials to provide recommendations with regard to improving technical 
assistance and Program oversight that CMS provides.  Finally, we provided 
each State with a checklist regarding its implementation of Program 
requirements for verification.   
 
   
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APPENDIX F: States Implementation of 
13 Selected Program Requirements   
This appendix summarizes States implementation of the 13 selected Program requirements.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Source: OIG analysis of States implementation of selected Program requirements, 2018. 
*Illinois and Missouri conducted State-only checks.  Maryland did not pass enabling legislation, ended Program participation, and 
discontinued drawing down Federal grant funds.   
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APPENDIX G: State-by-State Implementation of 
Selected Program Requirements  
This appendix summarizes State-by-State implementation of selected 
Program requirements, as drawn from CMS documents (e.g., financial and 
progress reports) submitted by States.  We also highlight information 
specific to individual State Programs, such as provider and facility types 
included in the background check programs; State and Federal funding for 
the Program; numbers of checks, and rates of determinations of ineligibility.  
Additionally, we note the cost of individual checks in each State, which 
varies in many cases as a result of States flexibility in Program setup (e.g., 
screening vendors can set their fees, and States can set administrative fees). 
 
This appendix also lists State-reported Program costs as defined by CMS.  
Startup (developmental) costs are expenses associated with developing  
a program or systemgenerally, one-time or setup costs.  Administrative 
(operational and incremental) costs are ongoing expenses necessary to 
operate a program (e.g., staff and maintenance) and recurring expenses to 
process background checks (e.g., fees for State police, vendor fees, etc.). 
 
   
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National Background Check Program for Long-Term-Care Providers: Assessment of State Programs Concluded Between 2013 and 2016  28 
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National Background Check Program for Long-Term-Care Providers: Assessment of State Programs Concluded Between 2013 and 2016  29 
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National Background Check Program for Long-Term-Care Providers: Assessment of State Programs Concluded Between 2013 and 2016  30 
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APPENDIX H: Agency Comments 
DEPARTMENT OF HEALTH & HUMAN SERVICES  Centers for Medicare & Medicaid Services 
Administrator 
Washington, DC 20201 
MAR  2 9 2019 
DATE: 
TO:  Daniel R. Levinson 
Inspector General 
FROM:  Seema Verma 
Administrator 
SUBJECT:  Office of Inspector General (OIG) Draft Report: National Background Check 
Program (NBCP) for Long-Term-Care Providers: Assessment of State Programs 
Concluded Between 2013 and 2016 (OEI-07-16-00160) 
The Centers for Medicare & Medicaid Services (CMS) appreciates the opportunity to review and 
comment on the Office of Inspector General's (OIG) draft report. CMS is committed to 
providing Medicare and Medicaid beneficiaries in long-term care facilities with high-quality 
care. 
Since its implementation in 2010, the NBCP has awarded grants to 29 states and U.S. territories 
to identify efficient, effective, and economical procedures for long-term care facilities and 
providers to conduct background checks on prospective direct patient access employees on a 
statewide basis. The goal of the program is to prohibit the hiring o'f employees who have 
histories of abuse or relevant criminal violations from serving the vulnerable long-term care 
population. To date, CMS has awarded more than $64 million so that states may design their 
comprehensive national background check programs. CMS is committed to working with grantee 
states to successfully implement their national background check programs, including 
monitoring of grant funds as well as requiring states to report data on key elements of their grant 
activities. The data collected helps CMS ensure that each state's program is meeting the 
background check requirements. As OIG notes, CMS also provides technical assistance to states 
in all aspects of implementation of their NBCP, such as writing proposals for necessary state law 
or administrative rule changes and working with states to improve their data reporting. 
In addition, CMS has worked with states to establish the National Forum for Background 
Checks, represented by both current and graduated NBCP states, to serve as a resource to support 
states with sustainability of their background check programs. CMS' focus has been on 
providing a growing library of resources for both prospective and active grantee NBCP states to 
draw from as prospective states determine their readiness to become a grantee state and active 
grantee states work to meet the grant requirements for eventual graduation from the NBCP. 
OIG's recommendation and CMS' response are below. 
OIG Recommendation 
CMS should take appropriate action to encourage participating States to obtain necessary 
authorities to fully implement Program requirements. 
National Background Check Program for Long-Term-Care Providers: Assessment of State Programs Concluded Between 2013 and 2016  32 
OEI-07-16-00160   
CMS Response 
CMS concurs with the OIG's recommendation. CMS will look at ways to encourage grantee states 
to fully implement program requirements. 
   
National Background Check Program for Long-Term-Care Providers: Assessment of State Programs Concluded Between 2013 and 2016  33 
OEI-07-16-00160   
 
ACKNOWLEDGMENTS 
Jamila Murga served as the team leader for this study, and Dana Squires 
served as lead analyst.  Others in the Office of Evaluation and Inspections 
who conducted the study include Cody Johnson, Katharine Fry, and  
Andrea Staples.  Office of Evaluation and Inspections central office staff who 
provided support include Kevin Farber, Seta Hovagimian, Christine Moritz, 
and Michael Novello.  Office of Audit Services staff who provided support 
include Keith Peters and Maria Tse. 
This report was prepared under the direction of Brian T. Whitley, Regional 
Inspector General for Evaluation and Inspections in the Kansas City regional 
office, and Jennifer E. King, Deputy Regional Inspector General.  
To obtain additional information concerning this report or to obtain copies, 
contact the Office of Public Affairs at Public.Affairs@oig.hhs.gov.   
   
National Background Check Program for Long-Term-Care Providers: Assessment of State Programs Concluded Between 2013 and 2016  34 
OEI-07-16-00160   
ABOUT THE OFFICE OF INSPECTOR GENERAL 
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  The Office of Audit Services (OAS) provides auditing services for HHS, either 
by conducting audits with its own audit resources or by overseeing audit 
Services 
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  The Office of Evaluation and Inspections (OEI) conducts national evaluations 
to provide HHS, Congress, and the public with timely, useful, and reliable 
and Inspections 
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  The Office of Investigations (OI) conducts criminal, civil, and administrative 
investigations of fraud and misconduct related to HHS Programs, 
Investigations 
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 Office of Counsel to the Inspector General (OCIG) provides general 
legal services to OIG, rendering advice and opinions on HHS Programs and 
the Inspector 
operations and providing all legal support for OIGs internal operations.  
General 
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. 
National Background Check Program for Long-Term-Care Providers: Assessment of State Programs Concluded Between 2013 and 2016  35 
OEI-07-16-00160   
ENDNOTES 
 
1 A CMS statistical report notes that in 2014, approximately 6.76 million Medicare beneficiaries were served by skilled nursing 
facilities, home health agencies, and hospice providers.  CMS, 2015 CMS Statistics, December 2015.  Accessed at 
https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/CMS-Statistics-Reference-
Booklet/Downloads/2015CMSStatistics.pdf on December 4, 2018. 
2 A CMS statistical report notes that in 2014, approximately 2.5 million Medicaid beneficiaries were served by nursing facilities, 
Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IIDs), and personal care services.  CMS, CMS Fast Facts, 
August 2018.  Accessed at https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/CMS-Fast-
Facts/index.html on December 4, 2018. 
3 CMS, Third Announcement CFDA #93.506 (CMS-1A1-11-001), April 2011, p. 5. 
4 OIG, Criminal Convictions for Nurse Aides with Substantiated Findings of Abuse, Neglect, and Misappropriation, OEI-07-10-00422, 
October 2012. 
5 Ibid. 
6 Office of Disability, Aging and Long-Term Care Policy, Ensuring A Qualified Long-Term Care Workforce:  From Pre-Employment 
Screens to On-the-Job Monitoring, May 2006.  Accessed at https://aspe.hhs.gov/system/files/pdf/74676/LTCWqual.pdf on 
September 14, 2006. 
7 P.L. No. 111-148  6201. The legislation formally describes the Nationwide Program for National and State Background Checks for 
Direct Patient Access Employees of Long Term Care Facilities and Providers.  In this report, we refer to this program as the 
National Background Check Program, or Program. 
8 OIG, National Background Check Program for Long-Term-Care Employees: Interim Report, OEI-07-10-00420, January 2016. 
9 P.L. No. 111-148  6201 (a). 
10 The term direct patient access employee means 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 the purposes of 
the nationwide Program.  This term does not include volunteers, unless the volunteer has duties that are equivalent to those of  
a direct patient access employee.  P.L. No. 111-148,  6201(a)(6)(D). 
11 P.L. No. 111-148,  6201 (a). 
12 In this report, we also use the term Programs to refer to individual States respective background check programs. 
13 Seven States participated in the 20052007 Background Check Pilot Program: Alaska, Idaho, Illinois, Michigan, Nevada, 
New Mexico, and Wisconsin.  Not all States participated in the pilot for the full 3 years.  The States in this pilot program conducted 
204,339 background checks, of which 7,463 resulted in the disqualification of prospective employees from long-term-care 
facilities.  Abt Associates Inc. and University of Colorado at Denver and Health Sciences Center, Evaluation of the Background Check 
Pilot Program, August 2008.  Accessed at https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-
Reports/Reports/Downloads/White8-2008.pdf on October 2, 2008. 
14 CMS, Third Announcement CFDA #93.506 (CMS-1A1-11-001), April 2011, p. 6.  
15 States in the 20052007 Background Check Pilot Program were limited to $1.5 million in Federal assistance for participation in 
the National Background Check Program. 
16 P.L. No. 111-148,  6201(a)(3)(A). 
17 The grant solicitation document published by CMS defines registries as State-based databases, in addition to the nurse aide 
registry, which may include lists of physicians, nurses, psychologists, and other professionals who are considered direct patient 
access employees.  Other registries may include the Medicare Exclusion Database, the Fraud Investigation Database, the 
Healthcare Integrity and Protection Data Bank, or the National Practitioner Data Bank.  
18 CMS established regulations that prohibit long-term-care facilities and providers from employing individuals found guilty of 
abuse, neglect, or misappropriation of patient funds.  In 1998, Congress enacted [P.L. No.] 105-277, which allows long term care 
facilities to request the [FBI] search its fingerprint database for criminal history matches.  CMS, Third Announcement CFDA #93.506 
(CMS-1A1-11-001), April 2011, p. 5. 
19 42 U.S.C.  1320a-7.  This statute prevents facilities that receive Federal health care dollars from hiring individuals who have been 
excluded by the Secretary.  Some of these convictions lead to mandatory exclusion, while others are permissiveallowing the 
 
36 
   
 
Secretary discretion as to whether to exclude the person even if he or she has a conviction.  These apply to both Federal and State 
law convictions. 
20 Participating States must ensure that background checks include checks of State criminal history records for relevant States and 
the records of any proceedings that may contain disqualifying information, such as the proceedings of licensing and disciplinary 
boards and State Medicaid Fraud Control Units.  P.L. No. 111-148,  6201(a)(3)(A). 
21 Criteria for disqualification are based on Federal and State laws.  Federal regulation prohibits Medicare and Medicaid nursing 
facilities from employing individuals who have been found guilty by a court of law of abusing, neglecting, or mistreating residents, 
or individuals who have had a finding entered into the State nurse aide registry concerning abuse, neglect, or mistreatment of 
residents or misappropriation of residents property (42 CFR  483.13(c)(1)(ii)).  State laws vary with regard to the types of 
convictions that disqualify prospective employees from employment in long-term-care. 
22 P.L. No. 111-148,  6201(a)(4)(B)(viii). 
23 State law-enforcement inform State agencies of any criminal conviction that an employee receives subsequent to the 
pre-employment background check.  The State agency in turn informs the facility or provider that has hired the employee with the 
conviction.  Once a State has implemented this process of continuous monitoring of criminal convictions, there is no further need 
for employers to conduct future periodic criminal background checks on employees. 
24 P.L. No. 111-148,  6201(a)(6)(E). 
25 Additional offenses are described in 42 U.S.C.  1320a-7.   
26 P.L. No. 111-148,  6201(a)(4)(B)(vii) and 6201(a)(6)(A)(ii). 
27 2 CFR 200.343(a).  
28 2 CFR 200.343(g).  
29 Grants for Alaska and Rhode Island remained open after the required time frame for closure, but neither State withdrew funds 
after the grant period.  
30 CMS, Third Announcement CFDA #93.506 (CMS-1A1-11-001), April 2011, p. 20.  
31 CMS, Third Announcement CFDA #93.506 (CMS-1A1-11-001), April 2011, p. 7. 
32 OIG, National Background Check Program for Long-Term-Care Employees: Interim Report, OEI-07-10-00420, January 2016. 
33 P.L. No. 111-148,  6201(a). 
34 P.L. No. 111-148,  6201(a)(7)(ii)(IV).   
35 States are not required to collect data on any reduction in incidents of neglect, abuse, and theft as a result of the Program.  
Additionally, no single data source tracks these incidents across the nine provider types, for these States (i.e., there are three data 
sources that each partially aggregate this information for some provider types.  These are CMSs Automated Survey Processing 
Environment (ASPEN) Complaint Tracking System (ACTS), Administration for Community Livings (ACL) National Ombudsmen 
Reporting System (NORS), and OIGs Medicaid Fraud Control Unit (MFCU) Annual Statistical Reports.  These sources represent 
several of the nine provider types served by the Program but are not exhaustive.  ACTS, NORS, and MFCU function in unique 
populations and collect data based on different parameters.  Therefore, analysis of each data source produces disparate results 
which are not comparable to one another).  Further, factors outside the Program may affect the number of these incidents (e.g., 
changes in State laws, enhanced or reduced enforcement actions, CMS and State education and outreach campaigns, differences 
in reporting practices, etc.).  Finally, we are unable to measure the number of prospective employees with criminal histories or 
records of abuse that may be deterred from applying for employment because of background check requirements. 
36 Two States did not report sufficient data to be included in this calculation.  Maryland discontinued implementation of the 
Program after June 2014 and did not report data.  Missouri conducted name-based State checks, however, the State did not report 
final determinations of eligibility for employment. 
37 The Lewin Group, Ensuring A Qualified Long-Term Care Workforce:  From Pre-Employment Screens to 
On-the-Job Monitoring, May 2006.  Accessed at https://aspe.hhs.gov/system/files/pdf/74676/LTCWqual.pdf on September 14, 
2006. 
38 OIG, Nursing Facilities Employment of Individuals with Criminal Convictions, OEI-07-09-00110, February 2011. 
39 OIG, Nationwide Program for National and State Background Checks for Long-Term-Care EmployeesResults of Long-Term-Care 
Provider Administrator Survey, OEI-07-10-00421, January 2012. 
40 OIG, Criminal Convictions for Nurse Aides with Substantiated Findings of Abuse, Neglect, and Misappropriation,  
OEI-07-10-00422, October 2012. 
41 OIG, State Requirements for Conducting Background Checks on Home Health Agency Employees, OEI-07-14-00131, May 2014. 
42 OIG, Home Health Agencies Conducted Background Checks of Varying Types, OEI-07-14-00130, May 2015. 
43 OIG, National Background Check Program for Long-Term-Care Employees: Interim Report, OEI-07-10-00420, January 2016. 
37