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Department of Health and Human Services

OFFICE OF 

INSPECTOR GENERAL 

S F N A
TATE  EES FOR  URSE  IDE 

R
EGISTRATION

Daniel R. Levinson

Inspector General 

December 2005

OEI-07-05-00070
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Office of Inspector General 

http://oig.hhs.gov 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, 
as amended, is to protect the integrity of the Department of Health and Human Services 
(HHS) programs, as well as the health and welfare of beneficiaries served by those 
programs.  This statutory mission is carried out through a nationwide network of audits, 
investigations, and inspections conducted by the following operating components: 
Office of Audit Services 
The Office of Audit Services (OAS) provides 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 HHS. 
Office of Evaluation and Inspections 
The Office of Evaluation and Inspections (OEI) conducts management and program 
evaluations (called inspections) that focus on issues of concern to HHS, 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.  OEI also oversees State Medicaid fraud control 
units which investigate and prosecute fraud and patient abuse in the Medicaid program. 
Office of Investigations 
The 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 
HHS.  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.  Report Template Version  = 01-26-05 
  E X E C U T I V E   S U M M A R Y  

OBJECTIVE 
To determine whether, and to what extent, States impose fees related to 
registration on individuals listed in their nurse aide registries. 
BACKGROUND 
The Omnibus Budget Reconciliation Act of 1987 (OBRA 1987) included 
numerous provisions intended to lead to improvements in the quality of 
care in long term care facilities.  For instance, OBRA 1987 requires that 
each State establish and maintain a nurse aide registry.  This registry 
consists of individuals who have successfully completed nurse aide 
training and competency evaluation programs or have otherwise been 
deemed competent to function as nurse aides, as well as individuals who 
have been barred from serving as nurse aides due to substantiated 
adverse findings of abuse, neglect, and misappropriation.  
Sections 1819(e)(2) and 1919(e)(2) of the Social Security Act prohibit 
States from imposing any charges related to registration on individuals 
listed in the registry.   
This study was based on two methods of data collection:  (1) Web site 
searches and telephone inquiries to determine whether each State 
imposed fees related to registration of individuals on nurse aide 
registries; and (2) surveys mailed to those States that, based on Office of 
Inspector General (OIG) Web site searches and telephone inquiries, 
indicated they might be charging fees that statute, regulation, and 
manual provisions prohibit. 
FINDINGS 
Twenty-four States imposed fees that nurse aides may be required to pay 
for placement on nurse aide registries. Some States charged nurse aides 
more than one type of fee (e.g., a fee for initial placement and a fee for 
continued placement), while other States charged nurse aides only one 
fee.  Twenty States listed nurse aides as a source of payment for initial 
placement fees, and 14 States listed nurse aides as a source of payment 
for continued placement fees on their registries. Seven States charged 
fees for criminal background checks and/or fingerprinting required for 
initial placement on their registries that nurse aides may be required to 
pay. 
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Four States imposed fees on nurse aides as a requirement to work in long 
term care facilities. These four States did not explicitly charge for initial or 
continued placement on the registry, but required fees for a nurse aide to 
work in a long term care facility. Failure to pay these fees could lead to 
nurse aides being removed from the registry. 
Guidance was provided only to States that requested it and oversight 
conducted of all States regarding registry fees was limited. Based on 
survey responses from the subset of States that charged fees, five States 
reported that they sought additional guidance from the Centers for 
Medicare & Medicaid Services (CMS). The nature of the guidance these 
States received varied, such as advice provided over the telephone, or a 
mailed copy of the governing regulation. It does not appear that CMS 
shared the guidance with other States or regions. Ten States reported 
that they sought guidance from their own State legal entities, rather than 
CMS. 
RECOMMENDATIONS 
OIG recommends that CMS: 
Ensure States cease imposing fees on nurse aides that violate 
Federal requirements. The statute, regulation, and State Medicaid 
Manual offer broad prohibitions against charging fees on nurse aides for 
placement on nurse aide registries. However, OIG found that a number 
of States are charging such fees. CMS should take action to ensure that 
this practice is discontinued. 
Clarify prohibitions on the charging of fees related to nurse aide 
registries. The actions of States identified in this study suggest that the 
statute, regulation, and/or State Medicaid Manual may not provide 
sufficient guidance and that additional guidance is necessary. For 
example, CMS could issue program guidance to all States to help clarify 
the prohibitions on fees. 
Conduct appropriate oversight to prevent States from charging 
inappropriate fees. This study provides specific information on which 
States require immediate oversight. Additionally, CMS may want to 
develop a process for ongoing oversight to prevent States from charging 
prohibited fees in the future. 
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AGENCY COMMENTS 
CMS concurred with all three OIG recommendations. CMS indicated 
that it will work through the regional offices to notify States found to be 
imposing fees in violation of Federal requirements that such practices 
must cease and will ensure proper revenue offsets were made to any 
claims for Federal financial participation. CMS indicated that it will 
also ensure that all State Medicaid agencies receive written reminders 
of statutory and regulatory provisions that prohibit charges on nurse 
aides related to the nurse aide registry, that regional offices will receive 
a copy of the report, and that regional offices conduct periodic reviews of 
States compliance with nurse aide registry requirements. 
OFFICE OF INSPECTOR GENERAL RESPONSE 
OIG appreciates CMSs comments to this report and is encouraged with 
the active participation CMS plans to take in ensuring that nurse aides 
are not charged fees related to their placement on their respective 
States nurse aide registry. 
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  T A B L E   O F   C O N T E N T S  

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

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

FINDINGS ....................................................... 4 

States imposed fees forplacementon registries  . . . . . . . . . . . . . . .  4

States imposed fees foremployment  . . . . . . . . . . . . . . . . . . . . . . . .  5

Guidance in response toStates and limited oversight. . . . . . . . . . .  6

RECOMMENDATIONS .......................................... 8

APPENDIXES .................................................. 10 

A:	  State Fees for Initial Placementon Registries. . . . . . . . . . . . .  10

B:	  State Fees for Continued Placementon Registries  . . . . . . . . .  11

C: 	State Fees for Criminal Background Check and/or

Fingerprintingfor Placement onRegistries. . . . . . . . . . . . . . .  12

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

ACKNOWLEDGMENTS ......................................... 15
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  I N T R O D U C T I O N  

OBJECTIVE 
To determine whether, and to what extent, States impose fees related to 
registration on individuals listed in their nurse aide registries. 
BACKGROUND 
The Omnibus Budget Reconciliation Act of 1987 included numerous 
provisions intended to lead to improvements in the quality of care in 
long term care facilities, such as the requirement that each State 
establish and maintain a nurse aide registry.  This registry lists 
individuals who have successfully completed nurse aide training and 
competency evaluation programs or have otherwise been deemed 
competent to function as nurse aides, as well as individuals who are 
barred from serving as nurse aides due to substantiated adverse 
findings of abuse, neglect, and misappropriation. 
Prohibition Against Nurse Aide Registry Fees 
Sections 1819(e)(2) and 1919(e)(2) of the Social Security Act (the Act) 
and Federal regulation 42 CFR  483.156(b)(4) prohibit States from 
imposing any charges related to registration on individuals listed in the 
registry. State Medicaid Manual section 2514(H) directs that the States 
 . . . may not impose any charges on a nurse aide relating to the 
registry, and section 4460 directs that the State must  . . . ensure that 
the nurse aide registry . . . does not impose any charges related to 
registration on individuals listed in the registry. 
Other Nurse Aide Registry Studies 
This report is one of several Office of Inspector General (OIG) studies 
regarding nurse aide registries.  The first report, Nurse Aide 
Registries: State Compliance and Practices (OEI-07-03-00380) found, 
in part, that States failed to update registries with substantiated 
adverse findings and remove records of inactive nurse aides, as 
required.  The second report, Nurse Aide Registries:  Long Term Care 
Facility Compliance and Practices (OEI-07-04-00140) found that 
17 percent of long term care facilities employed individuals as nurse 
aides without required registrations.  While conducting these studies, 
OIG was informed that States might be charging fees for placing 
individuals on their respective registries. 
After initiating this study, OIG learned that the Centers for 
Medicare & Medicaid Services (CMS) requested all States to complete a 
self-assessment related to nurse aide registry requirements.  This 
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activity occurred in response to prior OIG reports.  Part of the 
self-assessment asked States to report compliance regarding fees 
charged for placement of individuals on nurse aide registries.  At the 
time of this review, the results of this self-assessment were not 
available.   
METHODOLOGY 
OIG utilized two methods of data collection in this study:  (1) Web site 
searches and telephone inquiries to determine whether each State 
imposed fees related to registration of individuals on nurse aide 
registries; and (2) surveys mailed to those States that, based on OIG 
Web site searches and telephone inquiries, indicated the State might be 
charging fees that statute, regulation, and manual provisions prohibit. 
Web Site Searches and Telephone Inquiries 
For each of the 50 States and the District of Columbia (hereinafter 
referred to as a State), OIG accessed the nurse aide registry Web site, if 
available, to determine whether or not the State imposed fees associated 
with placement of individuals on the nurse aide registry (excluding 
training and competency evaluation fees).  OIG then contacted all 
States via telephone. For those States that had information on their 
Web sites about whether fees were charged, OIG confirmed this 
information. For all other States, OIG obtained information about 
whether or not fees were charged. 
Survey Responses 
Based on information collected through Web site searches and 
telephone inquiries, OIG identified States that imposed fees for such 
things as initial placement on the registry, renewal of registrations, and 
criminal background checks and/or fingerprinting.  OIG mailed a brief 
survey to these States asking about the fees charged, sources of 
payment, and the guidance the States had sought, if any, when deciding 
to charge these fees.  OIG received a 100 percent response rate to the 
survey. 
OIG followed up with CMS central office regarding guidance provided to 
individual States and oversight conducted.  OIG requested, and 
subsequently received from CMS, all guidance it reported providing to 
States on fees related to nurse aide registration. 
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Standards 
This study was conducted in accordance with the Quality Standards for 
Inspections issued by the Presidents Council on Integrity and 
Efficiency and the Executive Council on Integrity and Efficiency. 
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  F I N D I N G S  
Based on information obtained 
Twenty-four States imposed fees that nurse 
from State nurse aide registry Web 
aides may be required to pay for placement on 
sites and telephone inquiries, and 
nurse aide registries 
confirmed through State responses 
to a mail survey, OIG determined that 24 States imposed fees that 
nurse aides may be required to pay for initial and/or continued 
placement on nurse aide registries.1  This number might be higher as 
other States may have bundled the registry fees into competency 
evaluation or other fees; therefore, for some States OIG was unable to 
identify the fees specific to registration.  Some States charged nurse 
aides more than one type of fee (e.g., a fee for initial placement and a fee 
for continued placement), while other States charged nurse aides only 
one fee.  Registry fees included application, registration, initial 
certification, reciprocity,2 renewal of registrations, criminal background 
checks, and/or fingerprinting.  In all 24 States, either the nurse aide is 
solely responsible for payment of the fees, or the nurse aide pays in 
specified circumstances, such as if the nurse aide was unemployed at 
the time of renewal. 
Twenty States charged a fee that nurse aides may be required to pay for 
initial placement on the registry 
OIG identified the following types and ranges of fees for initial 
placement on the registry:  application ($15-$50), registration ($15), 
initial certification ($12-$120), and reciprocity ($10-$58).  A listing of 
State fees for initial placement can be found in Appendix A.  The States 
various uses of application, registration, and initial certification 
are synonymous and are not related to completion of a training 
program, for which fees may sometimes be charged pursuant to sections 
1819(f)(2)(A)(iv) and 1919(f)(2)(A)(iv) of the Act.  Rather, these charges 
are merely for inclusion in the registry.  Alaska charged the highest 
total fees ($170) for initial placement on the registry.  In response to the 
mail survey, 10 of the 20 States that charged fees for initial placement 
on the registry reported that nurse aides are the sole source of payment.  
1 All 24 States charged at least 1 fee that nurse aides may be required to pay even if other 
fees were paid only by the long term care facility. 
2 Reciprocity is a process by which a registered nurse aide from another State may qualify 
for registration in a new State by virtue of his or her status in the previous State.  An 
individual is only eligible for reciprocity if he or she has been entered on a nurse aide 
registry in another State in accordance with the training and competency evaluation 
requirements of section 1919(f)(2) of the Act, and if the individual is currently listed on 
that States nurse aide registry as active and without substantiated adverse findings. 
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The remaining 10 States reported that fees were received from either 
nurse aides or long term care facilities. 
Fourteen States charged a fee that nurse aides may be required to pay for 
continued placement on the registry 
Fees ranged from $5 to $120 for (typically biennial) renewals, or more if 
the renewal was processed after the expiration date. A listing of State 
fees for continued placement can be found in Appendix B. Eight States 
reported that fees were received from either nurse aides or long term 
care facilities, and six States reported that fees were received from 
nurse aides only. In addition to the 14 States, 4 States reported that 
fees were received from long term care facilities only, which does not 
violate the prohibition on charging nurse aides, so long as the costs are 
not passed on to nurse aides. One additional State did not charge if the 
renewal was accomplished timely, but charged $10 for each year past 
the expiration date, not to exceed $100. 
Seven States charged fees that nurse aides may be required to pay for 
criminal background checks and/or fingerprinting for placement on the 
registry 
The criminal background checks and/or fingerprinting were required as 
a condition for initial placement on the registry, and fees ranged from 
$5 to $600. A listing of State fees for criminal background checks and/or 
fingerprinting can be found in Appendix C. Of the seven States, 
four reported that fees were received from nurse aides only, and 
three States reported that fees were received from either nurse aides, 
long term care facilities, or State entities. Other States may have 
conducted criminal background checks and/or fingerprinting of their 
nurse aides, but did not charge a fee. 
In the mail survey, four States
Four States imposed fees on nurse aides as a 
reported not charging for initial
requirement to work in long term care facilities 
or continued placement on the 
registry, but charged fees for nurse aides to work in long term care 
facilities. Two of these States required an initial certification, 
application, or renewal fee in order for a nurse aide to work in a long 
term care facility. For example, in its response to the mail survey, 
Nevada staff stated, Nevada does not charge any amount for a person 
to be placed on the registry . . . however, [Nevada] charge[s] a fee for an 
application for a certificate to practice as a nursing assistant. 
Similarly, New Hampshire responded, No fees are applied to the 
registry placement process. However, OIG learned during the 
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F I N D I N G
 S  
telephone inquiry that New Hampshire nurse aides working in long 
term care facilities must become licensed nursing assistants and pay a 
$20 license application fee.  Both Nevada and New Hampshire charged 
renewal fees for this certificate or license, respectively.  Arkansas and 
Delaware charged fees for criminal background checks and/or 
fingerprinting required for employment in a long term care facility.  
These States reported that fees were received from long term care 
facilities, State entities, or nurse aides. 
Payment or nonpayment of fees in these States does not affect 
a nurse aides initial placement on the registry.  However, 
42 CFR  483.156(c)(2) requires that individuals who have performed no 
nursing or nursing-related services for a period of 24 consecutive 
months be removed from the registry, unless the individuals registry 
record includes documented substantiated findings of abuse, neglect, or 
misappropriation of property.  OIG alerted CMS that these fees may 
relate to the registry given that failure to pay the fees will ultimately 
result in the nurse aides removal from the registry.  In these States, it 
is therefore difficult to conclude whether the fees charged to nurse aides 
are, in effect, fees for placement on the States registries.  
OIG asked States that charged 
Guidance was provided only to States that 
fees what guidance they sought 
requested it and oversight conducted of
from CMS concerning charges to 
 all States regarding registry fees
nurse aides. Based on survey 
 was limited 
responses from this subset of 
States, five reported that they 
sought additional guidance from CMS.  The nature of the guidance 
these States received from CMS varied, such as advice provided over the 
telephone or a mailed copy of the governing regulation. It does not 
appear that CMS shared the guidance with other States or regions. 
Ten States reported that they sought guidance from their own State 
legal entities on charging registry fees, rather than from CMS.  This 
may demonstrate that these States were unclear about the legality of 
fees for nurse aide registration. 
OIG requested from CMS examples of guidance it provided to States 
(see examples in the text box on the next page), which came from both 
central and regional offices.  This guidance does not appear to have 
clarified the uncertainty regarding the breadth of the prohibition on 
charging fees to nurse aides, as illustrated by the results of this study. 
  OEI-07-05-00070  STATE FEES FOR NURSE AIDE REGISTRATION  6  Exampl s of CMS guidance to States:
Oregon-In 1992, CMS region X conducted a program
review of the nurse aide registry and stated in the report
that employed nurse aides cannot be charged training,
, or renewal fees and that these fees
testing, certification
must be paid by the employer. However, unemployed nurse
aides may be charged fees.
Virginia-In 1995, CMS region III issued a letter stating
that if Virginias statutory due process requirements go
beyond Federal requirements, then the State is permitted to
charge fees for these activities.
Arizona-In 1999, CMS region IX responded to an inquiry
saying that the State may not impose a charge for
fingerprinting of individuals listed in the registry.
Kentucky-In 1999, CMS central offce provided a response
to an inquiry via electronic mail stating that Kentucky
cannot impose charges on nurse aides to remain on the
registry (i. , charge renewal fees).
OIG found little evidence of CMS oversight as it relates to fees States
charge for nurse aide registration. Only one State reported in the mail
survey that the CMS regional offce had conducted a program review
which was in 1992, and recommended that the State cease charging
employed nurse aides for certification fees. While the State 
has ceased
charging fees to employed nurse aides, as per CMS guidance, the State
continues to charge fees to unemployed nurse aides.
OIG followed up with CMS central offce staff about the extent of
program reviews conducted. OIG was told that the CMS component
that previously performed the program reviews was disbanded in the
mid-1990s. OIG was also told that the CMS regional offce Medicaid
Financial Management work plan for fiscal year 2005 includes one
planned review of compliance with nurse aide training and competency
evaluation program requirements in one region. This review would
include an examination of nurse aide registry fees. Finally, in late
2004, CMS did ask all States to complete a self-assessment related to
nurse aide registry requirements in response to prior OIG reports.
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Twenty-four States imposed fees on nurse aides for initial or continued 
placement on nurse aide registries, a violation of Federal requirements. 
In addition, four States imposed fees on nurse aides for the ability to 
work in long term care facilities, which could have a direct effect on 
nurse aides placement on the registry.  Finally, CMS provided guidance 
only in response to specific State requests and conducted limited 
oversight of all States regarding registry fees.  Therefore, OIG 
recommends that CMS: 
Ensure States cease imposing fees on nurse aides that violate Federal 
requirements 
The statute, regulation, and State Medicaid Manual offer broad 
prohibitions against charging fees on nurse aides for placement on 
nurse aide registries.  However, OIG found that a number of States are 
charging such fees.  CMS should take action to ensure that this practice 
is discontinued. 
Clarify prohibitions on the charging of fees related to nurse aide registries 
The actions of States identified in this study suggest that the statute, 
regulation, and/or State Medicaid Manual may not provide sufficient 
guidance and that additional guidance is necessary.  For example, CMS 
could issue program guidance to all States to help clarify the 
prohibitions on fees. 
Conduct appropriate oversight to prevent States from charging 
inappropriate fees 
This study provides specific information on which States require 
immediate oversight.  Additionally, CMS may want to develop a process 
for ongoing oversight to prevent States from charging prohibited fees in 
the future. 
AGENCY COMMENTS 
CMS concurred with all three OIG recommendations.  CMS indicated 
that it will work through the regional offices to notify States found to be 
imposing fees in violation of Federal requirements that such practices 
must cease and will ensure proper revenue offsets were made to any 
claims for Federal financial participation.  CMS indicated that it will 
also ensure that all State Medicaid agencies receive written reminders 
of statutory and regulatory provisions that prohibit charges on nurse 
aides related to the nurse aide registry, that regional offices will receive 
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R E C O M M E N D A T I O N S  
a copy of the report, and that regional offices conduct periodic reviews of 
States compliance with nurse aide registry requirements. 
OFFICE OF INSPECTOR GENERAL RESPONSE 
OIG appreciates CMSs comments to this report and is encouraged with 
the active participation CMS plans to take in ensuring that nurse aides 
are not charged fees related to their placement on their respective 
States nurse aide registry. 
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  A P P E N D I X   ~   A  

State Fees for Initial Placement on Registries 
Initial 
State  Application  Registration  Reciprocity* 
Certification 
Alaska  $50  $0  $120  $0 
Arizona  $0  $0  $0  $45 
California  $15  $0  $0  $0 
Colorado  $20  $0  $0  $10 
Connecticut  $0  $0  $0  $58 
District of Columbia  $0  $0  $12**  $15 
Kansas  $0  $0  $20  $0 
Maryland  $0  $0  $20  $0 
Massachusetts  $0  $0  $0  $20 
Michigan  $0  $0  $12  $0 
Mississippi  $0  $0  $0  $25 
New Jersey  $0  $0  $0  $30 
New Mexico  $0  $0  $0  $35 
New York  $0  $0  $0  $50 
Oklahoma  $0  $0  $0  $15 
Oregon  $0  $0  $40  $0 
Rhode Island  $25  $0  $0  $0 
Vermont  $20  $0  $0  $0 
Washington  $0  $15  $15  $0 
Wyoming  $0  $0  $60  $0
Source:  Office of Inspector General survey of State fees, 2005. 
* - The reciprocity fee is in addition to application, registration, and initial certification 
     fees.  For a discussion of reciprocity, see footnote 2 on page 4. 
** - Fee paid by long term care facilities only. 
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State Fees for Continued Placement on 
Registries 
State  Fee 
Alaska  $120 
Arizona  fee for late renewal only 
California  $20* 
Colorado  $20* 
Maryland  $30 
Michigan  $20 
Mississippi  $25 
Oklahoma  $5 
Oregon  $40* 
Rhode Island  $24 
South Carolina  $25 
Vermont  $25* 
Virginia  $45 
Washington  $25* 
Wyoming  $50
Source:  Office of Inspector General survey of State fees, 2005. 
* - Renewal fee if renewal completed timely; 
     additional late fees apply. 
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  A P P E N D I X   ~   C  

State Fees for Criminal Background Check 
and/or Fingerprinting for Placement on 
Registries 
State  Fee 
Alaska  $59-$89 
California  $42-$62 
Colorado  $30-$600 
Florida  $33-$57 
Pennsylvania  $24 
Rhode Island  $5 
Wyoming  $60 
Source:  Office of Inspector General survey of State fees, 2005. 
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  A G E N C Y   C O M M E N T S  
Centers for Medicare & Medicaid Services Comments 
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A G E N C Y   C O M M E N T S

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  A C K N O W L E D G M E N T S  

This report was prepared under the direction of Brian T. Pattison, 
Regional Inspector General for Evaluation and Inspections in the 
Kansas City regional office, and 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, Program Analyst 
Dennis Tharp, Program Analyst 
Sandy Khoury, Program Specialist 
Tricia Davis, Director, Medicare & Medicaid Branch 
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