U.S. Department of Health and Human Services 
Office of Inspector General 
 
National Background 
Check Program for 
Long-Term-Care 
Providers: Assessment 
of State Programs 
Concluded in  
2017 and 2018 
OEI-07-18-00290 
Suzanne Murrin 
August 2019 
Deputy Inspector General  
 
for Evaluation and Inspections 
oig.hhs.gov  Report in Brief  U.S. Department of Health and Human Services 
August 2019 
Office  of Inspector General 
OEI-07-18-00290 
 
 
Why OIG Did This Review 
National Background Check Program for 
Background checks are an 
Long-Term-Care Providers: Assessment of 
important safety measure that can 
help protect the 9 million 
State Programs Concluded in 
beneficiaries who rely on 
2017 and 2018  long-term-care services each year 
for safe, dependable care.  These 
The National Background Check Program  checks can prevent individuals with 
(Program) provides grants to States to develop  Key Takeaway  disqualifying histories (e.g., 
systems to conduct background checks of State  Nine of the 11 States that  convictions for patient abuse, 
and Federal criminal history records for  concluded their participation  patient neglect, and theft from 
prospective long-term-care employees.  in the National Background  patients) from being hired to care 
  Check Program in 2017 and  for beneficiaries.    
What OIG Found  2018 did not implement all   
The 11 States that concluded their participation in  of the selected Program  Congress mandates that OIG 
the Program in 2017 and 2018 varied as to the  requirements, primarily  evaluate various aspects of Program 
degree to which they were able to implement  because of a lack of  implementation.  This report 
Program requirements.  Two States implemented  legislative authority for  provides an assessment of 11 of the 
all selected Program requirements.  Nine States  certain Program  12 States that concluded Program 
did not implement all the selected Program  requirements.   participation in 2017 and 2018.  (The 
requirements, primarily because of a lack of  12th State did not submit closeout 
legislative authority for certain Program  documents in time to be included in 
requirements.  Five of these nine States implemented most of the selected  this study.)  This report also provides 
Program requirements; four of the nine States implemented only some of the  information for CMS to assist other 
selected Program requirements.      States that continue to participate in 
  the Program.  Seven States had 
Of the background checks that States conducted, over 25,000 resulted in  ongoing grants after the reviewed 
determinations of ineligibility for prospective employees.  The number of  closeout period.  In future work, we 
determinations of ineligibility varied among the States, as did the rates of  will assess these States and the 
determinations of ineligibility (from 0 percent to 3 percent).  None of the States  overall Program.  
provided evidence of unintended consequences associated with conducting 
background checks, such as a reduction in the available workforce for long- How OIG Did This Review 
term-care facilities or providers.  We reviewed grant-monitoring 
  documents and financial reports to 
What OIG Concludes   determine the extent to which  
11 States that concluded participation 
The findings of this report are consistent with our previous assessments of the 
between 2017 and 2018 had 
Program and provide further support for one open OIG recommendation.  We 
implemented 13 selected Program 
strongly encourage the Centers for Medicare & Medicaid Services (CMS) to 
requirements.  Additionally, we 
implement this open recommendation:  take appropriate actions to encourage 
surveyed the 11 States to collect 
States to obtain the necessary legislative authority to fully implement Program 
information on their experiences with 
requirements.  We are not offering any new recommendations at this time.
their respective background check 
programs. 
   
TABLE OF CONTENTS  
BACKGROUND  1 
Objective  1 
Methodology  4 
   
FINDINGS  7 
Two States implemented all selected Program requirements; nine States did not meet all  7 
requirements, primarily because of a lack of legislative authority 
States varied in the number and rate of background checks that resulted in determinations  10 
of ineligibility 
   
CONCLUSION   12 
   
APPENDICES   13 
A: Mandate for National Background Check Program Evaluation and Report           13 
B: Beginning and Ending Dates of States Respective Programs   14 
C: Expenditures for the National Background Check Program  15 
D: Related Reports  16 
E: Detailed Methodology    19 
F: Summary of States Implementation of 13 Selected Program Requirements    20 
G: State-by-State Implementation of Selected Program Requirements      21 
   
ACKNOWLEDGMENTS  33 
   
ENDNOTES  35 
   
BACKGROUND 
 
Objective 
To assess the implementation and impact of States National 
Background Check Programs for Long-Term-Care Providers 
concluded in 2017 and 2018. 
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 rely on long-term-care services each year for safe, 
dependable 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 for 
Long-Term-Care Providers provides grants to States to develop systems to 
conduct background checks of State and Federal criminal history records.7 
(The full formal name of the program is Nationwide Program for National 
and State Background Checks for Direct Patient Access Employees of Long 
Term Care Facilities and Providers.  In this report, we generally refer to it as 
the Program, with a few references to it as the National Background 
Check Program.)   
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 12 States concluding participation between 
2017 and 2018, and 7 States continuing participation past 2018.8  (See 
Appendix B for grant beginning and end dates.)  In January 2016 and 
April 2019, OIG published reports on State implementation of the  
Program.9, 10  This report is the third in a series designed to assist CMSand 
States that are continuing in the Programin promoting Program 
improvements and increasing protections for the vulnerable population of 
beneficiaries who receive long-term-care services.  OIG will release 
subsequent reports as additional States complete the Program.   
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OEI-07-18-00290   
Background 
Congress established the Program to identify efficient, effective, and 
economical procedures for conducting national and State background 
checks on prospective employees who would have direct access to 
patients.11, 12  (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 to conduct fingerprint-based Federal and State criminal records 
checks and to search registries that contain disqualifying information.13  
The Program expands on a pilot version, the 20052007 Background Check 
Pilot Program.14  
The Program provides Federal grant funds to participating States.  
It requires States to contribute $1 for every $3 of Federal funds they 
receive.15  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 2018.16  See Appendix C for information related to Federal grant 
awards and State matching funds for the 11 States in this evaluation, all of 
which concluded grant participation in 2017 or 2018.  
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.  
States may need to enact legislation to be able to implement Program 
requirements if they do not have the necessary legislative authority prior to 
Program participation.  
Types of background checks required.  In their processes, States must 
include several types of background checks and other monitoring 
activities.17  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;18 (2) a check of State criminal history records; 
(3) a fingerprint-based check of Federal Bureau of Investigation (FBI) 
criminal history records;19, 20 and (4) a search of the records of any 
proceedings in the State that may contain disqualifying information about 
the prospective employee.21, 22  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. 23, 24  In this 
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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. 
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.25 
Types of offenses that constitute disqualifying offenses.  As part of the 
Program, States must ensure that background checks use databases that 
contain information that could disqualify an 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.26  Additionally, States may 
specify other types of offenses that constitute disqualifying information.27  
For example, some States have specified child abuse, forgery, sexual abuse, 
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.28  CMS must 
complete all grant closeout actions no later than 1 year after receipt of all 
required reports.29   
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CMS also requires States to report data on key elements of their grant 
activities.  These elements include (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 Reports 
In April 2019, OIG published an evaluation of the 10 States that concluded 
Program participation by 2016.32  These 10 States varied as to the degree to 
which they achieved implementation of Program requirements.  Most States 
implemented all or most of the selected requirements.  Several States did 
not have the necessary legislative authority to fully implement background 
check programs.  We recommended that CMS take appropriate action to 
encourage participating States to obtain the necessary authorities to fully 
implement Program requirements.  CMS concurred with this 
recommendation andper OIGs standard response schedule for 
recommendationswill provide a plan in October 2019 to implement the 
recommendation. 
In 2016, OIG published an evaluation that described the overall State 
implementation status during the first 4 years of the Program.33  In this 
evaluation, we recommended that CMS work with States to improve the 
quality of States required reporting of data and that CMS continue working 
with participating States to fully implement their background check 
programs.  CMS concurred with and implemented the first recommendation 
by providing States with individual technical assistance, data review, and 
data validation.  CMS concurred with and implemented the second 
recommendation by developing the National Background Check Program 
Interim Progress Report to track States progress towards implementing 
program requirements. 
See Appendix D for previous OIG work related to the Program. 
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OEI-07-18-00290   
Methodology  Scope 
We evaluated each of the programs for 11 of the 12 States that concluded 
Program participation between 2017 and 2018: California, Georgia, Kentucky, 
Maine, Michigan, Minnesota, Nevada, North Carolina, Oklahoma, Utah, and 
West Virginia.  Hawaii also concluded participation in December 2018; 
however, it had not submitted closeout documents at the time of this 
evaluation and therefore is not included in this report.  An assessment of 
Hawaiis program will be included in a subsequent report.  See Appendix B 
for a listing of all States that have participated in the Program or are 
currently participating in the Program.  
Congress directed OIG to analyze the most appropriate, efficient, and 
effective procedures for conducting background checks, as well as to assess 
the Program cost.  We will reserve these analyses for the final 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 search of records 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.34  
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We evaluated each State on its implementation of the 13 Program 
requirements during its grant period.  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.  We compared their 
progress in meeting the requirements.  We surveyed officials from the 
11 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 required an evaluation of the Programs impact on reducing the 
number of incidents of abuse, neglect, and theft.35  However, the data 
available do not permit this analysis.36 
See Appendix E for a detailed methodology. 
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 
Two States  Background checks can provide protections from abuse, neglect, and theft 
for beneficiaries who rely on long-term-care services.  The 11 States in this 
implemented all 
evaluation varied in their implementation of selected Program requirements.  
selected Program 
As we had found in our previous report on States respective Programs, we 
requirements; nine  found in this evaluation that some States were unable to implement all 
selected Program requirements, primarily because of a lack of legislative 
States did not meet 
authority.   
all requirements, 
Appendix F includes information on each States implementation status for 
primarily because of 
each of the 13 selected Program requirements.  Appendix G provides 
a lack of legislative 
additional details in State scorecards. 
authority 
Two States implemented all selected Program requirements 
 
Minnesota and West Virginia implemented all 13 selected Program 
requirements.  Minnesota established a background check program prior to 
participation in the Program.  During its Program participation, Minnesota 
spent over $30 million in combined Federal and State funds, with a Federal 
share of $3 million, on enhancing its established program.  West Virginia 
received legislative authority to participate in the Program with the 
enactment of the West Virginia Clearance for Access: Registry and 
Employment Screening Act (WV CARES).  WV CARES is West Virginias 
comprehensive approach to screening direct patient access employees as 
outlined in the States updated public health and public safety codes.  
Nine States did not implement all the selected Program 
requirements, primarily because of a lack of legislative authority to 
implement certain Program requirements   
Five States implemented most of the selected Program requirements and 
four States implemented only some of the selected Program requirements.  
Though these States made some progress, most lacked legislative authority 
to fully implement Program requirements that may reduce beneficiaries risk 
for abuse, neglect, and misappropriation of property.  See Exhibit 1 on the 
next page. 
 
 
 
 
 
 
 
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Exhibit 1: Nine States did not fully implement Program requirements  
Source: OIG analysis of States implementation of selected Program requirements, 2019. 
 
Five States implemented most requirements.  Four StatesGeorgia, 
Oklahoma, Michigan, and Utahimplemented most of the selected 
Program requirements butduring our review periodlacked the 
necessary legislative authority to implement a few of the 13 requirements.  
One StateNevadaimplemented most of the selected Program 
requirements but was unable to implement all requirements due to 
technical difficulties.  
  Three StatesGeorgia, Michigan, and Oklahomalacked legislative 
authority to conduct background checks of all nine types of facilities 
and providers.  Georgia lacked the legislative authority to conduct 
checks on five of the nine types, and Michigan and Oklahoma lacked 
the legislative authority to conduct checks on one of the nine types.  
Additionally, Georgia lacked the legislative authority to require all 
direct patient access employees to undergo background checks.  
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We note that after its grant ended, Georgia obtained legislation to 
expand its program to include all types of facilities and providers 
except for long-term-care hospitals.  Georgias expansion also 
required all direct patient access employees to undergo background 
checks.   
  One StateUtahis a closed record State that does not distribute 
the results of background checks to the public and was therefore 
unable to implement the reporting of convictions to required 
databases.37   
Nevada was not able to complete 1 of the 13 selected Program 
requirements; the State encountered technical difficulties and was unable to 
implement continuous monitoring for new disqualifications after individuals 
begin employment.  However, Nevada continued working on this 
requirement after the grant ended and plans to begin continuous 
monitoring by the end of calendar year 2019. 
Four States implemented only some requirements.  Four States
California, Kentucky, Maine, and North Carolinaimplemented only some 
Program requirements because of a lack of legislative authority.   
  Two StatesMaine and Californiaimplemented State-only 
programs that did not include fingerprint-based checks of Federal 
criminal history records for all types of facilities and providers.  
Maine lacked legislative authority to conduct checks of Federal 
criminal history records for all nine types.  California lacked 
legislative authority to include checks of Federal criminal histories for 
six of the nine types.  Additionally, California did not have legislative 
authority to conduct checks of abuse and neglect registries for three 
of the nine types.   
  One StateKentuckylacked legislative authority to require direct 
patient access employees to undergo background checks, making its 
program voluntary for providers.  Because Kentuckys program is 
voluntary, the State could not fully implement other Program 
requirements.   
  One StateNorth Carolinadeveloped a voluntary pilot program 
that was implemented after the grant period closed; however, the 
State continues to lack legislation to make the program mandatory 
for providers.  During its Program participation, North Carolina was 
able to complete one Program requirementdetermining which 
individuals are direct patient access employees.  
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States varied in the  To protect beneficiaries who receive services from long-term-care providers 
and facilities, States must identify prospective employees who are ineligible 
number and rate 
for employment in these settings.  Collectively, 10 of 11 States conducted 
of background 
over 25,000 background checks that disqualified prospective employees.38   
checks that 
The number and rate of determinations of ineligibility varied among the 
resulted in  States.  Michigan had the highest rate of determinations of ineligibility 
determinations of  (3.4 percent, or 13,520 checks) and conducted the greatest number of 
background checks (399,665 checks).  Maine had the lowest rate of 
ineligibility 
determinations of ineligibility (0 percent).  Georgia conducted the lowest 
number of background checks (3,201 checks).  See Exhibit 2 below for the 
numbers of background checks completed and rates of determinations of 
ineligibility.  
The individual characteristics of each States program may have contributed 
to the differences in their respective rates of determination of ineligibility.  
However, none of the States provided evidence of unintended 
consequences associated with conducting background checks, such as 
a reduction in the available workforce for long-term-care facilities or 
providers. 
Exhibit 2:  Background checks and determinations of ineligibility 
Checks With  Percentage 
Completed 
State   Determinations  Determined 
Checks 
of Ineligibility  Ineligible 
Michigan  399,665  13,520  3.38% 
Minnesota  281,652  7,748  2.75% 
Utah  41,008  1,088  2.65% 
Kentucky  23,468  546  2.33% 
Nevada  57,289  969  1.69% 
Georgia  3,201  52  1.62% 
West Virginia  57,317  900  1.57% 
Oklahoma  86,780  928  1.07% 
California*  14,617  113  0.77% 
Maine*  6,042  0  0.00% 
North Carolina**  N/A  N/A  N/A 
Total  971,039  25,864  N/A*** 
Source: OIG analysis of State background check data, 2019.39 
* California and Maine conduct State-only checks.   
** North Carolina was unable to implement most Program requirements during the grant period and did not 
report data. 
*** The total percentage ineligible is represented as N/A since the data that the States report are not 
comparable. 
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Four States had the greatest percentages of determinations of 
ineligibility  
Michigan, Minnesota, Utah, and Kentucky had the greatest percentages of 
determinations of ineligibility.  Michigan and Minnesota conduct checks of 
criminal history records, in some cases going back 15 years following the 
completion of a sentence for a disqualifying offense.  Utah is part of 
an automated regional system for fingerprint identification that shares 
criminal history records among nine Western States.40  Kentucky has 
an extensive list of offenses that disqualify prospective employees, including 
conviction for a misdemeanor relating to abuse, neglect, or exploitation.  
Two States had the lowest percentages of determinations of 
ineligibility 
The background check programs in California and Maine resulted in the 
lowest rates of determinations of ineligibility of prospective employees.  
Certain characteristics of their programs may have influenced these results.  
California and Maine conducted only name-based State checks, which may 
have contributed to their having lower determinations of ineligibility.  
Additionally, California did not conduct checks of abuse and neglect 
registries for all types of facilities and providers.   
One State did not complete any checks and did not report any 
determinations of ineligibility of prospective employees  
North Carolina did not report determinations of ineligibility during the grant 
period.  North Carolina developed a voluntary pilot program during its 
Program participation that was implemented after the conclusion of the 
States grant.  As a result, North Carolina did not make determinations of 
eligibility and had no data to report.  
   
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CONCLUSION  
Background checks are an important safety measure that can help protect 
the 9 million beneficiaries who rely on long-term-care services each year for 
safe, dependable care.  These checks can prevent individuals with 
disqualifying histories (e.g., convictions for patient abuse, patient neglect, 
and theft from patients) from being hired to care for beneficiaries.  This 
report found that 8 of the 11 States we reviewed lacked legislative authority 
to implement certain requirements of the program.  The findings of this 
report are consistent with our previous assessments of the Program and 
provide further support for one open OIG recommendation.  We strongly 
encourage CMS to implement this open recommendation:  take appropriate 
actions to encourage States to obtain the necessary legislative authority to 
fully implement Program requirements.  We are not offering any new 
recommendations at this time. 
   
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APPENDIX A: Mandate for National 
Background Check Program Evaluation and 
Report 
P.L. No. 111-148,  6201(a)(7) 
 6201(a)(7) EVALUATION AND REPORT. 
(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 start up 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 Respective Programs 
White cells indicate States in this report.  Gray cells indicate States in previous or future reports.  
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 
Oregon  7/29/2013    7/28/2019 
Puerto Rico  12/17/2012  12/16/2019   
Kansas***  7/1/2015  6/30/2020    
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 the website for the CMS technical assistance contractor (Contractor). 
* Initially, 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. 
** As of May 24, 2019, Hawaii had not submitted closeout documentation for the National Background Check Program and is therefore not 
included in this report.  
*** Kansas, Idaho, Mississippi, and Wisconsin have the option of extending their grant periods.  According to information we obtained from the 
Contractor, Kansas has the option to extend to 2021, and Idaho, Mississippi, and Wisconsin have the option to 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 
California  $2,353,530  $784,510  $3,138,040 
Georgia  $1,863,718  $662,956  $2,526,674 
Kentucky  $2,697,202  $899,065  $3,596,266 
Maine  $2,821,875  $981,629  $3,803,504 
Michigan*  $1,281,031  $500,000  $1,781,031 
Minnesota  $3,000,000  $28,582,117  $31,582,117 
Nevada*  $1,054,775  $374,042  $1,428,817 
North Carolina  $1,836,154  $992,397  $2,828,551 
Oklahoma  $3,000,000  $1,000,000  $4,000,000 
Utah  $2,767,931  $1,000,000  $3,767,931 
West Virginia  $2,706,547  $2,019,353  $4,725,899 
Total**  $25,382,763  $37,796,069  $63,178,830 
Source: Final Federal Financial Reports (FFRs) as of July 24, 2019.   
* Michigan and Nevada participated in the 20052007 Background Check Pilot Program and were limited to $1.5 million in Federal assistance for 
this grant.   
** Results are rounded. 
 
 
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APPENDIX D: Related OIG Reports 
NOTE: This current report, our April 2019 report, our 2016 report 
(OEI-07-10-00420), and our 2012 report (OEI-07-10-00421) all examine the 
same grant program.  (The 2016 and 2012 reports refer to it by slightly 
different names.)  
National Background Check Program for Long-Term-Care Providers: 
Assessment of State Programs Concluded Between 2013 and 2016,  
OEI-07-16-00160 
In April 2019, OIG published an evaluation of the National Background 
Check Program for Long-Term-Care Providers for the 10 States that 
concluded their participation by 2016.41  These 10 States varied as to the 
degree to which they achieved implementation of the 13 selected Program 
requirements.  Seven of the States implemented all or most of the selected 
Program requirements.  Three States did not have the necessary authority 
through State legislation and could not fully implement background check 
programs. 
In this evaluation, OIG recommended that CMS take appropriate action to 
encourage participating States to obtain necessary authorities to fully 
implement Program requirements.  CMS concurred with this 
recommendation andper OIGs standard response schedule for 
recommendationswill provide a plan in October 2019 to implement the 
recommendation. 
National Background Check Program for Long-Term-Care Employees: Interim 
Report, OEI-07-10-00420 
In 2016, OIG published an evaluation of the National Background Check 
Program for Long-Term-Care Employees, describing the overall status of 
State implementation during the first 4 years of the Program.42  The 
25 States participating in the 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 reporting of data to ensure that CMS 
can conduct effective oversight of the program.  CMS concurred with and 
implemented the first recommendation by providing States with individual 
technical assistance, data review, and data validation.  CMS concurred with 
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and implemented the second recommendation by developing the National 
Background Check Program Interim Progress Report to track States 
progress towards implementing program requirements. 
Home Health Agencies Conducted Background Checks of Varying Types, 
OEI-07-14-00130 
In 2015, OIG published an evaluation of the varying types of background 
checks conducted by home health agencies (HHAs) and reviewed selected 
employees whose convictions were likely to disqualify them from HHA 
employment.43  OIG found that 4 percent of HHA employees had at least 
one criminal conviction.  FBI criminal history records were not detailed 
enough to enable OIG to definitively determine whether employees with 
criminal convictions should have been disqualified from HHA employment. 
State Requirements for Conducting Background Checks on Home Health 
Agency Employees, OEI-07-14-00131 
In 2014, OIG published an evaluation of State requirements for conducting 
background checks on HHA employees and surveyed State officials about 
their respective background check programs.44  OIG 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. 
Criminal Convictions for Nurse Aides with Substantiated Findings of Abuse, 
Neglect, and Misappropriation, OEI-07-10-00422 
In 2012, OIG published 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.45  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 
aides, the most common conviction (53 percent) was for crimes against 
property (e.g., burglary, shoplifting, and writing bad checks).  
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 published an evaluation of the nationwide Program for national 
and State background checks that surveyed long-term-care provider 
administrators.46  OIG 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. 
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Nursing Facilities Employment of Individuals with Criminal Convictions, 
OEI-07-09-00110 
In 2011, OIG published 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.47  Overall, 5 percent of nursing facility employees had at least 
one criminal conviction.  All but 2 percent of nursing facilities reported 
conducting some type of background check.  
The full reports can be found at www.oig.hhs.gov.  
 
 
   
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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 technical assistance contractor 
(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 Program 
requirements that most directly related to identifying prospective 
long-term-care employees with histories that make them ineligible for 
employment.  We evaluated States on their implementation of the  
13 selected Program requirements during their respective grant periods.  
We also reviewed the financial reports to identify the overall Program costs, 
including startup cost, administrative cost, and total costs.   
Survey of State Officials 
As each of the 11 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: Summary of 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, 2019. 
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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 facility and provider 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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ACKNOWLEDGMENTS 
Andrea Staples and Dana Squires served as the team leaders for this study.  
Others in the Office of Evaluation and Inspections who conducted the study 
included William Ash, Katharine Fry, and Haley Lubeck.  Office of Evaluation 
and Inspections central office staff who provided support included 
Kevin Farber, Christine Moritz, and Michael Novello.   
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.   
   
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OEI-07-18-00290   
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. 
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OEI-07-18-00290   
 
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, and providers of 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.   
8 Hawaii had not submitted closeout documents at the time of this evaluation and is therefore not included in this report.  
An evaluation of Hawaiis Program will be included in a subsequent report. 
9 OIG, National Background Check Program for Long-Term-Care Employees: Interim Report, OEI-07-10-00420, January 2016.   
10 OIG, National Background Check Program for Long-Term-Care Providers: Assessment of State Programs Concluded Between 2013 
and 2016, OEI-07-16-00160, April 2019.  
11 P.L. No. 111-148  6201 (a). 
12 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). 
13 P.L. No. 111-148,  6201 (a). 
14 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 program for the full 3 years.  The States in the 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. 
15 CMS, Third Announcement CFDA #93.506 (CMS-1A1-11-001), April 2011, p. 6.  
16  States that had participated in the 20052007 Background Check Pilot Program were each limited to $1.5 million in Federal 
assistance for participation in the National Background Check Program. 
17 P.L. No. 111-148,  6201(a)(3)(A). 
18 The grant solicitation document that CMS published defines registries as any State-based databases and nurse aide registries 
that identify those who have been approved by state requirements to provide care to residents of patients in long-term-care 
facilities or by providers of long-term-care services.  These registries may includebut are not limited toregistries that list 
physicians, nurses, psychologists, and other professionals who are considered direct patient access employees.  In addition, other 
registries or databases may include the Medicare Exclusion Database, the Fraud Investigation Database, the Healthcare Integrity 
and Protection Data Bank, and/or the National Practitioner Data Bank.   
19 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. 
 
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OEI-07-18-00290    
 
20 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.  Others are permissiveallowing the 
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.  
21 P.L. No. 111-148,  6201(a)(3)(A).  Participating States must ensure that background checks include checks of (1) State criminal 
history records for relevant States and (2) 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.    
22 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 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. 
23 P.L. No. 111-148,  6201(a)(4)(B)(viii). 
24 Continuous monitoring means that if an employee receives a criminal conviction subsequent  to the pre-employment 
background check, the States law enforcement informs the State agency.  In turn, the State agency informs the facility or provider 
that has hired the employee with the conviction.  Once a State has implemented continuous monitoring of criminal convictions, 
there is no further need for employers to conduct future periodic criminal background checks on employees. 
25 P.L. No. 111-148,  6201(a)(6)(E). 
26 Additional offenses are described in 42 U.S.C.  1320a-7.   
27  P.L. No.  111-148,  6201(a)(4)(B)(vii) and 6201(a)(6)(A)(ii).  
28 2 CFR 200.343(a).  
29 2 CFR 200.343(g).  
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 Providers: Assessment of State Programs Concluded Between 2013 
and 2016, OEI-07-16-00160, April 2019.  
33 OIG, National Background Check Program for Long-Term-Care Employees: Interim Report, OEI-07-10-00420, January 2016.   
34 P.L. No. 111-148,  6201(a). 
35 P.L. No. 111-148,  6201(a)(7)(ii)(IV).   
36 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 types of facilities and providers for these States.  Three 
data sources aggregate this information for some types of facilities and providers:  (1) CMSs Automated Survey Processing 
Environment (ASPEN) Complaint Tracking System (ACTS); (2) the Administration for Community Livings (ACL) National  
Ombudsman Reporting System (NORS); and (3) the Annual Statistical Reports of OIGs Medicaid Fraud Control Unit (MFCU).  
These sources represent several of the nine types of facilities and providers served by the Program, but they are not exhaustive.  
ACTS, NORS, and each States MFCU function in unique populations and collect data based on different parameters.  Therefore, 
analysis of each source of data produces disparate results that 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 who may be deterred from applying for employment 
because of background check requirements. 
37 Some form of criminal history information is open to the public in open records States.  In closed records States, access to 
criminal history information is not generally available to the public but is available to authorized entities.  Accessed at 
https://www.nationalservice.gov/sites/default/files/documents/Utah_508.pdf on May 20, 2019.  
38 North Carolina did not report data to be included in this calculation.   
39 Data for Exhibit 2 is taken from the Grantee Data Files that States reported to the Contractor following States respective final 
quarters of Program participation.  Numbers and rates of ineligibility determinations represent the reported Final Fitness 
Determination for each completed background check, which can be based on different criteria for each State.  The amount of 
time that each  State reported these figures vary (e.g., Michigan reported data for the full duration of their program, while Maine 
reported only for the final few quarters).      
40  The Western Identification Network (WIN) automated fingerprint identification system includes criminal history records from 
nine Western States.  
 
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OEI-07-18-00290    
 
41 OIG, National Background Check Program for Long-Term-Care Providers: Assessment of State Programs Concluded Between 2013 
and 2016, OEI-07-16-00160, April 2019.   
42 OIG, National Background Check Program for Long-Term-Care Employees: Interim Report, OEI-07-10-00420, January 2016.   
43 OIG, Home Health Agencies Conducted Background Checks of Varying Types, OEI-07-14-00130, May 2015.   
44 OIG, State Requirements for Conducting Background Checks on Home Health Agency Employees, OEI-07-14-00131, May 2014.   
45 OIG, Criminal Convictions for Nurse Aides with Substantiated Findings of Abuse, Neglect, and Misappropriation,  
OEI-07-10-00422, October 2012.    
46 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.   
47 OIG, Nursing Facilities Employment of Individuals with Criminal Convictions, OEI-07-09-00110, February 2011.   
 
 
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