Department of Health and Human Services 
OFFICE OF 
 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
 
N B
ATIONAL  ACKGROUND 
C  P
HECK  ROGRAM FOR 
 
  L -T -C
ONG ERM ARE 
 
E  :  I
MPLOYEES    NTERIM 
 
R  
  EPORT 
 
 
Suzanne Murrin  
Deputy Inspector General 
for Evaluation and Inspections  
 
January 2016 
OEI-07-10-00420   
   
EXECUTIVE SUMMARY:  NATIONAL BACKGROUND CHECK PROGRAM FOR 
LONG-TERM-CARE EMPLOYEES:  INTERIM REPORT  
OEI-07-10-00420 
 
WHY WE DID THIS STUDY    
 
Long-term-care employees provide essential care to patients in settings such as nursing facilities, 
home health agencies, and hospices.  Ensuring that these employees have undergone a minimum 
level of screening helps protect the safety of beneficiaries in these settings.  The Patient 
Protection and Affordable Care Act (ACA) provides grants to States to implement background 
check programs for prospective long-term-care employees.  The ACA also requires the Office of 
Inspector General (OIG) to conduct an evaluation of this grant programknown as the National 
Background Check Programafter its completion.  This interim report describes the overall 
implementation status and States results from the first 4 years of the program, and provides the 
Centers for Medicare & Medicaid Services (CMS) with information that may assist its ongoing 
administration of this program.  OIG also plans to issue a final evaluation of the grant program  
after its completion. 
 
HOW WE DID THIS STUDY  
 
We reviewed reports that each of the 25 States participating in the grant program submitted to 
CMS. These reports contained data on implementation milestones and expenditures and 
reflected each States progress from program inception through September 30, 2014.  The 
earliest program inception date was September 30, 2010.  We also reviewed the data that 
14 States provided regarding the number of background checks completed.  CMS permits States 
to determine when their programs are sufficiently implemented to begin submitting 
background-check data. 
 
WHAT WE FOUND 
 
Four years into the grant program, the 25 States that are receiving grants reported having 
achieved varying levels of program implementation.  Specifically, some States have not obtained 
legislation that would enable them to conduct background checks.  Other States have not yet 
implemented processes to collect fingerprints and monitor criminal history information after 
individuals begin employment.  Only 6 of the 25 States have submitted to CMS data sufficient to 
calculate the percentage of prospective employees who were disqualified because of their 
background checks. In these six States, 3 percent of prospective employees were disqualified 
from employment.  Of the remaining 19 States, 11 States were not yet submitting data reports 
and 8 States had data gaps that prevented the calculation of disqualification rates.  
 
WHAT WE RECOMMEND   
 
We recommend that CMS continue to work with participating States to fully implement their 
background check programs and to improve required reporting to ensure that CMS can conduct 
effective oversight of the grant program.  CMS concurred with both of our recommendations. 
   
TABLE OF CONTENTS 
 
Objective......................................................................................................1 

Background..................................................................................................1 

Methodology................................................................................................5 

Findings........................................................................................................7 

The 25 States receiving grants reported having achieved 
varying levels of program implementation ......................................7 

In the six States with sufficiently complete data to calculate 
 
disqualification rates, 3 percent of prospective employees were 

disqualified from employment .........................................................9 

Most of the States receiving grants were not yet reporting data  

or reported data that could not be used to calculate  

disqualification rates ......................................................................12 

Conclusion and Recommendations ............................................................14 

Agency Comments and Office of Inspector General Response .................15 

Appendixes ................................................................................................16 

A: Participating States and Dates of Grant Awards ......................16 

B: Spending for the National Background Check Program..........17 

C: Elements of Quarterly Data Files .............................................18 

D: Related Reports........................................................................19 

E: Agency Comments  ...................................................................21 

Acknowledgments......................................................................................23 

 
   
   
OBJECTIVE 
To provide an interim report on the implementation status and early results 
of the National Background Check Program for long-term-care 
employees. 
BACKGROUND 
National Background Check Program 
The Patient Protection and Affordable Care Act (ACA) established the 
Nationwide Program for National and State Background Checks on Direct 
Patient Access Employees of Long-Term-Care Facilities and Providers 
(National Background Check Program or program).1 This voluntary 
program provides grants to States, the District of Columbia, and U.S. 
territories (States) to implement programs to conduct background checks 
on prospective long-term-care employees in settings such as nursing 
facilities, home health agencies, and hospices.  The Centers for Medicare 
& Medicaid Services (CMS) administers and oversees the program. 
The ACA mandates that the Office of Inspector General (OIG) conduct an 
evaluation of the program and that it submit a report to Congress within 
180 days of completion of the program.2  On the basis of the expected end 
dates of the grants, the program will not be complete until 2018 at the 
earliest.3    
This interim report describes the current overall implementation status and 
States early results from the first 4 years of the program, fiscal years 
(FYs) 20102014. The goal of this report is to provide CMS with 
information to assist in its ongoing administration of this program. 
Grant Solicitations. CMS began soliciting applications for grant awards 
on a national basis in June 2010. At the end of FY 2014, 25 States had 
received grants to participate in the program.  As of December 2015, CMS 
was still accepting new grant applications.  Grants for this program are not 
competitive; rather, any application that meets a minimum score receives 
an award. 
____________________________________________________________ 
1 P.L. No.  111-148,  6201. 
 
2 The ACA does not specify a completion date for the program.   We  will define a State 

program as complete when the States grant expires, regardless of whether the State has a 

fully implemented program or has depleted all grant funds.   When all  participating States 

grants have expired,  we will consider the program complete with  regard to the due date 

for the mandated evaluation. 
 
3 Kansas was awarded a grant on July 1,  2015.  This report  only includes States that had 

been awarded  grants as of September 30, 2014;  therefore, Kansas is not included in this 

report.  Because of Kansas recent grant award, the program will not  be complete until 

2018 at the earliest. 

National Background Check Program for Long-Term-Care Employees:  Interim Report (OEI-07-10-00420)   1 
   
   
The dates that States received their grant awards and the length of the 
States grant periods vary.  States began receiving grant awards in 
September 2010.  The first six States to receive grants had 2-year grant 
periods, with opportunities to request up to four 1-year extensions.4   The 
remaining States had 3-year grant periods, with opportunities to request 
three 1-year extensions.  Appendix A  lists each participating State, grant 
award date, and expected grant end date. 
Funding. The ACA provides up to $160 million in Federal funds to 
implement the program.5   To receive funding, a State must guarantee 
a particular amount of non-Federal contributions as a condition of 
receiving the Federal match.6   The ACA provides that [t]he payment 
amount to each State . . . shall be three times the amount that the State 
guarantees to make available. . . .7  See Appendix B for each States grant 
award amount and percentage of funds spent as of September 30, 2014. 
Participating State Requirements. Some States may need to obtain 
legislative authority to meet grant requirements (e.g., to conduct 
background checks on prospective employees).  Other States may have 
already had such authority prior to receiving their grants.   
Participating States are required to include three types of background 
checks in their processes:  (1) a search of State-based abuse and neglect 
registries and databases (e.g., nurse aide registries), (2) a check of State 
criminal history records, and (3) a fingerprint-based check of FBI criminal 
history records.8   To obtain FBI criminal history records, States must 
establish methods for collecting and processing fingerprints. 
Participating States must also require background checks for all 
prospective direct-patient-access employees of 10 types of long-term-care 
____________________________________________________________ 
4 These extensions give the States an extra year to spend their existing  grant funds. 

5 P.L. No.  111-148,  6201(b)(1). 
 
6  Ibid.,  6201(a)(5). 
 
7  Ibid.,  6201(a)(5)(A). 
 
8 P.L. No.  111-148,  6201(a)(3)(A); CMS,  Nationwide Program for National  and State 

Background Checks for Direct Patient Access Employees of Long Term Care Facilities 

and Providers, Ninth Announcement CFDA  # 93.506, May 2013, p.  6.  Accessed online 

at http://www.cms.hhs.gov/Medicare/Provider-Enrollment-and-Certification/ 
 
SurveyCertificationGenInfo/Downloads/nbgcpgmsoli.pdf on  July 20, 2015.  Statewide 

background checks are typically conducted by a State law enforcement agency and 

include information  for crimes committed within that State.  For an FBI background 
 
check, a State law enforcement agency provides the FBI with an individuals identifying 
 
information and fingerprints.  The FBI checks them against its criminal background 

database and sends the results back to the State law enforcement agency.  The FBIs 

database includes information both on Federal crimes and State-reported crimes from all 

States.  
  
National Background Check Program for Long-Term-Care Employees:  Interim Report (OEI-07-10-00420)   2 
   
   
providers that receive Medicare or Medicaid payments.9   The 10 provider 
types are: 
1.	   skilled nursing facilities,  
2.	   nursing facilities, 
3.	   home health agencies,  
4.	   providers of hospice care, 
5.	   long-term-care hospitals, 
6.	   providers of personal care services, 
7.	   providers of adult day care, 
8.	   residential care providers that arrange for, or directly provide 
long-term-care services, 
9. 	  intermediate care facilities for the mentally retarded,10 and 
10.  any other facility or provider of long-term-care services that a State 
determines to be appropriate.11  
Finally, participating States are required to describe and test methods to 
reduce duplication of fingerprinting.12  Such methods continuously 
monitor individuals who have undergone a fingerprint-based background 
check and whose fingerprints are retained after the check for subsequent 
arrests. If the individual is subsequently arrested, he or she will be 
fingerprinted. The post-arrest fingerprints are then matched against a 
database that contains the fingerprints that were initially submitted, and 
the State notifies the employer of the individuals arrest.  Once such 
processes are implemented in a State, there is no further need for 
employers to conduct periodic criminal background checks or to collect 
additional sets of fingerprints on continuously employed individuals in 
that State for as long as the State retains the initial set of fingerprints. 
State laws and Federal regulations govern long-term-care providers  
employment of individuals with criminal convictions.  State laws 
concerning what types of convictions disqualify individuals from 
 ____________________________________________________________ 
9 Section 6201(a)(6)(D)  of the ACA  defines direct patient access employee as any 

individual who has access to a patient or resident of a long-term-care facility or provider 
 
through employment or through a contract with such  facility or provider and has duties 

that involve (or may involve) one-on-one contact with a patient or resident of the facility 

or provider, as determined  by the State for purposes of the nationwide program. 
 
10 P.L. No.  111-256, enacted  October 5, 2010, required the Federal  Government to
  
replace the term mental retardation with intellectual disability in Federal health, 

education,  and labor policy. 
 
11 P.L. No.  111-148,  6201(a)(6)(E). 
 
12  Ibid.,  6201(a)(4)(B)(viii).  This section  refers to these methods as rap  back 

capabilities. 

National Background Check Program for Long-Term-Care Employees:  Interim Report (OEI-07-10-00420)   3 
   
   
long-term-care employment vary among States.  Federal law does not 
address this issue, although Federal regulation does prohibit Medicare and 
Medicaid nursing facilities from  employing individuals found guilty of 
abusing, neglecting, or mistreating residents by a court of law, or who 
have had a finding entered into the State nurse aide registry concerning 
abuse, neglect, or mistreatment of residents or misappropriation of their 
property.13  States participating in the program must establish an 
independent appeal process for individuals who believe that they should 
not have been disqualified based on the background check information.14  
Quarterly Reports. Participating States are required to submit quarterly 
reports to CMS.   The purpose of the quarterly reports is to allow CMS to 
highlight project accomplishments, and identify best practices, strengths, 
obstacles, and technical assistance needs.  Furthermore, the quarterly 
reports provide a basis to evaluate . . . overall progress toward obtaining 
your States goals and objectives.15   The quarterly reports have four parts: 
1. 	  a project narrative, which describes progress toward 

implementation milestones; 

2. 	  a Federal Financial Report (i.e., SF-425); 
3. 	  expenditure data for the current quarter and since program 
 
inception; and 

4. 	  a file containing cumulative data (e.g., provider type, fingerprint 
collection date, employment eligibility determination date, appeal 
decision) on each background check conducted since program 
inception. These data files should contain 30 data elements; see 
Appendix C for a list of the 30 elements.   
CMS provided additional guidance to States with respect to the fourth part 
on data reporting. It instructs States how to report the records representing 
continuous monitoring of criminal history information.16 This guidance 
was effective beginning with the report for the quarter ending  
March 31, 2014. The guidance states that a new record identifier should 
be created for every notification resulting from continuous monitoring that 
matches an existing employee in the background check system.  The 
notification should not be connected to any previous background check 
conducted on that employee.  Fewer data elements are required for records 
____________________________________________________________ 
13 42 CFR   483.13(c)(1)(ii). 

14 P.L. No.  111-148,  6201(a)(4)(B). 
 
15 CMS, memo to  participating  States, CMS National Background Check Program 

Quarterly Report, June 7, 2011. 
  
16 CMS, Upcoming Changes to CMS Program Data Report for NBCP, February  1, 2014. 

National Background Check Program for Long-Term-Care Employees:  Interim Report (OEI-07-10-00420)   4 
   
   
representing continuous monitoring of criminal history information than 
are required for records representing pre-employment background checks. 
Technical Assistance. CMS awarded a technical assistance contract to 
support participating States. The technical assistance contractor can assist 
States with all aspects of participating in the program, such as writing 
proposals for necessary State law or administrative rule changes, defining  
information system specifications, implementing fingerprinting 
technology, and integrating existing State databases.  The technical 
assistance contractor also reviews States quarterly reports and works with 
States to improve their data reporting.  Finally, the technical assistance 
contractor facilitates conference calls, Web seminars, and in-person 
conferences with participating States and CMS officials.   
Mandated OIG Evaluation 
To fulfill the  ACA mandate, OIG must submit an evaluation report to 
Congress not later than 180 days after the completion of the program.  The 
final evaluation must identify appropriate, efficient, and effective 
procedures for conducting background checks, assess program costs, and 
determine the extent to which conducting background checks led to any 
unintended consequences. It will also attempt to address the impact of the 
program on reducing the number of incidents of neglect, abuse, and 
misappropriation of resident property to the extent practicable.  
Related Reports 
Since 2010, OIG has issued five reports that address criminal background 
checks for and employment of individuals with criminal convictions in 
long-term care.  See Appendix D for information on selected OIG reports 
related to this subject.  
METHODOLOGY 
This interim report includes the 25 States that had received grants as of 
September 30, 2014.  We relied on two data sources for this report:  
(1) quarterly reports from participating States and (2) discussions with 
CMS and technical assistance contractor staff.    
Data Collection and Analysis 
Quarterly Reports.  We obtained and analyzed quarterly reports for the 
period ending September 30, 2014, for all 25 participating States.17  We  
analyzed the project narratives from the quarterly reports to obtain 
information on each States reported progress toward completing 
____________________________________________________________ 
17 The State of Maryland  put its program on  hold in summer 2014; the program was still 
on hold as of September 2015.  The last  quarterly report submitted by the State of 
Maryland was for the  quarter ending  June  30,  2014.  Therefore, we used Marylands 
June  2014  quarterly report in this evaluation.  
National Background Check Program for Long-Term-Care Employees:  Interim Report (OEI-07-10-00420)   5 
   
   
implementation milestones.   We used the expenditure data from the 
quarterly reports to calculate each States grant award amount and 
percentage of funds expended as of September 30, 2014.18    
Fourteen of the twenty-five States included data files in their quarterly 
reports representing the background checks they had conducted.19  We  
reviewed the background check data files for completeness.  However,  
only 6 of the 14 States data reports were sufficiently complete to calculate 
the percentage of checks that resulted in disqualification.  We performed 
those calculations and confirmed our results with State officials.   
Both CMS and its technical assistance contractor maintain ongoing 
contact with States regarding implementation of their programs and 
required reporting. We conferred with staff from CMS and from the 
technical assistance contractor to ensure that we had a complete 
understanding of the quarterly reports and differences in the ways that 
States reported information.   
Scope 
This interim report includes the 25 States that had received grants as of 
September 30, 2014.  The ACA mandate requires OIG to submit a report 
within 180 days of completion of the program.  On the basis of expected 
end dates of grants, the program will not be complete until 2018 at the 
earliest. We will continue to follow the progress of the national program in 
each State as it is implemented, and we will issue a final report as 
required. 
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General 
on Integrity and Efficiency. 
   
____________________________________________________________ 
18 The information from the Federal  Financial Reports was not necessary to address the  
objective of this evaluation. 
19 The remaining 11 States included project narratives and expenditure data in their 
quarterly reports, but not data files.  It  is unknown whether these 11  States were  
conducting background checks and  not reporting them, or if they were  not yet conducting  
checks. 
National Background Check Program for Long-Term-Care Employees:  Interim Report (OEI-07-10-00420)   6 
   
   
FINDINGS 
The 25 States receiving grants reported having 
achieved varying levels of program implementation 
The 25 States vary in their progress in reaching three key milestones:  
obtaining legislative authority, collecting fingerprints, and implementing 
continuous monitoring of criminal history information.  This variation 
arises from unique factors affecting each State.  One of these factors is the 
date that each State received its grant award.  Six of the 
twenty-five participating States were awarded grants after 
September 30, 2012; therefore, these States have had less time to 
implement their programs than States that received grant awards earlier.20   
Further, the key milestones need not be reached in the same order in every  
State. One State might begin building program infrastructure 
(e.g., information systems) while working with its legislature to obtain the 
authority to conduct background checks.  Another State might decide to 
obtain legislative authority before building any program infrastructure.  A  
third State may have had some program infrastructure in place for 
conducting background checks before it received its grant.   
Chart 1 shows the number of participating States that had not yet reached  
three key milestones.  
Chart 1:  Number of Participating States That Had Not Yet Reached 
Three Key  Milestones 
25   
  es 20   
at
St15 
f 
o 15 States 
er 10  13 States 
b
m 10 States 
u 5 
N
0 
Not yet having  Not yet collecting  Not yet monitoring 
enabling  fingerprints  criminal history 
legislation  information 
continuously 
Key  Milestones Not Yet Reached 
Source:  OIG analysis of September 2014 program narratives, 2015. 
____________________________________________________________ 
20 Participating States received grant awards between September 2010 and July 2013. 
National Background Check Program for Long-Term-Care Employees:  Interim Report (OEI-07-10-00420)  7 
   
   
Thirteen of twenty-five States reported that they were in the 
process of obtaining enabling legislation  
Thirteen of the twenty-five participating States reported that they were in 
the process of obtaining legislative authority to fully implement the 
requirements of the program.   The remaining 12 participating States 
reported having obtained such authority.21  In Missouri, attempts to pass 
legislation in four sessions were not successful.  However, Missouri has 
moved ahead with building an information system that meets the 
requirements of the program (e.g., execution of registry checks and State 
and FBI background checks). Missouri is using its system to conduct 
registry checks while awaiting legislative authority to conduct 
fingerprint-based State and FBI background checks.  Similarly, legislation 
has been submitted three times in Kentucky, but has not passed.  The 
Kentucky State agency made another attempt to obtain legislative 
authority in the 2015 session, and implemented a voluntary background 
check program for providers through administrative regulation. 
Ten of twenty-five States reported that they did not yet have 
the ability to collect fingerprints  
Ten of the twenty-five participating States reported that they did not yet 
have the ability to collect fingerprints.  Of these 10 States, 7 States 
reported that they were beginning to develop the ability to collect 
fingerprints and 3 States reported that they had not yet begun to develop 
the ability to collect fingerprints.  The remaining 15 States reported that 
they were able to collect fingerprints.   
Among the States collecting fingerprints, New Mexico reported that 
implementing electronic fingerprinting resulted in efficiencies and savings 
for both the State agency and long-term-care providers.  The State agency 
reduced its program staff by one employee and cut average timeframes for 
processing background checks from over 7 weeks to less than 1 week.  
Costs for long-term-care providers to conduct background checks were 
reduced through a combination of decreased postage expenses and staff 
hours. 
Fifteen of twenty-five States reported that they did not yet have 
the capability to monitor criminal history information  
subsequent to initial background checks 
Of the 25 participating States, 11 States reported that they were in the 
process of developing continuous monitoring capabilities and 4 States 
reported that they had not yet started developing such capabilities.  The 
____________________________________________________________ 
21 Two of the twelve States that reported that they had  obtained legislative authority 
appearon the basis of the comments in their September 2014 program narrativesto 
have only partial authority to  conduct background checks as required by the program.      
National Background Check Program for Long-Term-Care Employees:  Interim Report (OEI-07-10-00420)   8 
   
   
remaining 10 States reported that they had implemented continuous 
monitoring capabilities. For some  States, legislation is needed to 
implement continuous monitoring of criminal history information.  Even if 
States have legislation that requires fingerprint-based background checks, 
the legislation may not include the authority to retain fingerprints over 
time. 
In States that have implemented continuous monitoring of criminal history 
information, employers are alerted when current employees are arrested.  
Continuous monitoring reuses the original set of fingerprints collected 
from each employee during the initial background check, rather than 
requiring additional subsequent sets of fingerprints.  
Florida began continuously monitoring criminal history information on 
January 1, 2013.  Florida reported that from that date to May 31, 2014, 
approximately 4,300 individuals were flagged through the continuous 
monitoring system.  Approximately 30 percent of the flagged individuals 
became ineligible for employment as a result of offenses that occurred 
after their initial background checks.   
 
In the six States with sufficiently complete data to 
calculate disqualification rates, 3 percent of 
prospective employees were disqualified from 
employment  
Six States conducted a total of 1,046,121 background checks between the 
inception of their programs and September 30, 2014.  Three percent of 
prospective employees were disqualified from long-term-care employment 
on the basis of those checks. These six States conducted all three types of  
required background checks and reported their outcomes, conducted 
checks on at least 9 of the 10 required types of providers, and submitted 
cumulative data in their data reports.22  Table 1 shows the number and 
outcomes of background checks conducted in six States.
 ____________________________________________________________ 
22 As  of September 2014, Michigan  was not yet conducting checks on employees of adult 
day health providers, and Oklahoma was not yet conducting checks on employees of 
long-term-care hospitals. 
National Background Check Program for Long-Term-Care Employees:  Interim Report (OEI-07-10-00420)   9 
   
Table 1: Number of Background Checks Conducted by Six States Between Program Inception and September 30, 2014  
Checks With a Determination of:  
Percentage of  
Total Checks  Checks Resulting 
State  
Conducted   Eligible for  Ineligible for  Pending   Closed Prior to  Unknown1   in Determinations 
Employment   Employment   Determination  of Ineligible  
Alaska  46,969   21,875   1,872   20,6252  2,597   0  4.0%3  
District of Columbia  15,091   12,412   148  149  2,382   0  1.0%  
Florida4  787,683   733,081   26,007   28,227   152  216  3.3%  
Michigan  138,134   116,897   1,479   1,237   18,448   73  1.1%  
New Mexico  39,110   33,914   441  69  4,686   0  1.1%  
Oklahoma  19,134   14,139   78  435  4,482   0  0.4% 
   Total   1,046,121   932,318   30,025   50,742   32,747   289  2.9%  
1 Two States included some records in their data  reports that had contradictory  information in the fields for determinations  and for appeal results.  Other records from these two States had different determinations 
for multiple records with the same record identification number.  For both types of records, we  counted one instance of each unique record identification number among  the total checks conducted.  Because these 
records had contradictory information regarding the determination made, we categorized them as determination unknown.  
 
2 Alaska program staff explained that when they prepared their September 2014 quarterly report, approximately 3,000 determinations were pending.  Staff theorized that these pending determinations resulted from 
terminations of  individuals who had been previously determined to be qualified for employment.  Alaskas data system may have deleted the original determination result of qualified when an individuals 
employment was terminated, causing the status of  the determination to appear to be pending. 
 
3 The data system that Alaska  used when it prepared its September 2014 report would change  the original determination when a record resulting from continuous monitoring of criminal history information was 
received.  If the original result was qualified and the new information  caused the person to become disqualified, the result on the original record was changed to disqualified.  This resulted in a higher  
percentage of disqualified applicants than if Alaskas data system had not changed the original  determinations. 
 
4 In Floridas September 2014 quarterly data report, the State reported a number of records that resulted from continuous monitoring of criminal history information.  However, the State was unable to distinguish 
these records from those resulting from initial background checks.  Records resulting from continuous monitoring of  criminal history information did not indicate a  status of qualified or disqualified, making them 
appear to be pending.  Therefore, Florida appears to have lower numbers of qualified and disqualified applicants and a higher number of pending applicants compared to States that do not report records resulting 
from continuous monitoring, or to States that  report records resulting  from continuous monitoring that can be distinguished from initial background checks. 
 
Source: OIG analysis of State quarterly data reports for  the period ending September 30, 2014, and confirmations by State officials.  Quarterly data reports accessed at http://bgcheckinfo.cna.org/ on 
December 5, 2014.  
 
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Only three of these States provided data in which records 
resulting from continuous monitoring of criminal history 
information could be distinguished from records resulting 
from initial background checks 
Six States submitted data sufficient to calculate the percentage of checks 
resulting in disqualification. However, only three States data reports 
included records resulting from continuous monitoring of criminal history 
information that could be distinguished from records for initial 
background checks. According to CMS guidance, 13 of the 30 data 
elements (e.g., facility/provider type, employee type) should be left blank 
for records resulting from continuous monitoring.23  Two States did not 
report records resulting from continuous monitoring that could be 
distinguished from records for initial background checks, and one State 
did not report any records resulting from continuous monitoring. 
 	  Records resulting from continuous monitoring for Michigan, 
New Mexico, and Oklahoma can be distinguished from records 
representing initial background checks because they have blank 
values for employee type and facility type, and for the majority of 
the other 11 data elements that should be blank for records 
resulting from continuous monitoring.  Staff from CMSs technical 
assistance contractor confirmed that these records resulted from  
continuous monitoring. 
 	  None of Alaskas records had blank values for all 13 data elements 
that should be blank to indicate records resulting from continuous 
monitoring. Instead of creating a new record to represent the 
results of continuous monitoring, Alaskas data system changed the 
determination of the original background check record from  
eligible to ineligible when continuous monitoring disqualified 
a previously qualified employee.  Alaska program officials 
confirmed that the States data system changed determinations in 
this manner.  
 	  Staff from CMSs technical assistance contractor confirmed that 
Florida included records resulting from continuous monitoring in 
the States data report; however, none of Floridas records had 
blank values for all 13 data elements that should be blank to 
indicate records resulting from  continuous monitoring.  It is not 
possible to distinguish the records that have blank values for some  
of the 13 data elements because they are the results of continuous 
____________________________________________________________ 
23 CMS, Upcoming Changes to CMS Program Data Report for NBCP, February  1, 2014. 
National Background Check Program for Long-term-care Employees:  Interim Report (OEI-07-10-00420)   11 
   
   
monitoring from the records that have blank values because the 
information is simply missing. 
 	  The District of Columbias data report did not include records 
resulting from continuous monitoring of criminal history 
information.  The District of Columbia reported that it had not yet 
started to develop continuous monitoring capabilities. 
 
Most of the States receiving grants were not yet 
reporting data or reported data that could not be used 
to calculate disqualification rates  
Nineteen States were unable to report data that could be used to calculate 
disqualification rates.  Eleven States were not yet submitting data reports 
during the period of our review.  Eight States conducted background 
checks and submitted data reports on those checks; however, gaps in the 
data submitted prevented the calculation of disqualification rates.  Some of 
the gaps in the data were due to varying levels of progress in program  
implementation.  Specifically, Georgia, Illinois, and Oregon were not yet 
conducting all three required types of checks. 
Other gaps resulted from States lack of reporting of required information: 
 	  Delaware, Georgia, Kentucky, Nevada, and Oregon did not report 
the results of checks on employees of three or more of the required 
provider types. 
 	  Georgia and Illinois did not report the results of abuse registry 
checks as required. Georgia did not report the results of any abuse 
registry checks. Illinois reported only the results of abuse registry 
checks that did not disqualify the applicant; applicants that were 
disqualified by the abuse registry check were not reported.   
 	  Georgia did not report applications that were closed prior to the 
completion of the determination.  Georgia program staff explained 
that their data system cannot yet identify applicants who 
voluntarily withdraw from the hiring process. 
 	  California and Utah were not submitting cumulative data.  Rather, 
their quarterly reports included only background checks that 
started and were completed in the same quarter.  If a final 
determination was not issued in the same quarter that the 
background check started, it was not reflected in any quarterly 
report. 
National Background Check Program for Long-Term-Care Employees:  Interim Report (OEI-07-10-00420)   12 
   
   
Without complete and comparable data reports from all participating 
States, program outcomes cannot be calculated, nor can the effectiveness 
of the background check program be assessed.   
 
   
National Background Check Program for Long-Term-Care Employees:  Interim Report (OEI-07-10-00420)   13 
   
   
CONCLUSION AND RECOMMENDATIONS 
CMS needs accurate data to determine program outcomes and conduct 
effective oversight of the National Background Check Program.  OIG also 
requires accurate program data to identify the most efficient and effective 
methods of conducting background checks in the report mandated by 
Section 6201 of the ACA.  Of the 25 States receiving grant awards, 
6 States had sufficiently complete data to calculate disqualification rates.  
In those six States, 3 percent of prospective employees were disqualified 
from employment.  Most of the States receiving grants were not yet 
reporting data or reported data that could not be used to calculate 
disqualification rates. 
To ensure that effective oversight of the National Background Check 
Program can be conducted, we recommend that CMS: 
Continue working with participating States to fully implement 
their background check programs 
CMS, through its technical assistance contractor, should continue assisting 
participating States to fully implement their background check programs. 
CMS should assist States with activities such as: 
 	  submitting legislative proposals to obtain authority for States to 
conduct all 3 required types of background checks on all 
10 required provider types, 
	   developing the capacity to collect fingerprints, and 
	   implementing continuous monitoring of criminal history 

information. 

Continue working with participating States to improve required 
reporting to ensure that CMS can conduct effective oversight 
of the program 
CMS could accomplish this through:   
	   Working with States, as necessary, to submit records resulting from  
continuous monitoring of criminal history information in 
accordance with CMS guidance.  
	   Use lessons learned from States that are already reporting data to 
assist States that are not yet reporting data to do so as specified by 
CMS. 
	   Ensuring that States report required data elements in their quarterly 
reports (e.g., results of registry checks).  States should report all 
data elements pertaining to the program milestones they have 
reached.  
	   Working with States, as necessary, to submit cumulative data. 
National Background Check Program for Long-Term-Care Employees:  Interim Report (OEI-07-10-00420)   14 
   
   
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL  
RESPONSE 
CMS concurred with both of our recommendations. 
In response to our first recommendation, CMS stated that it has 
extendedfor an unspecified periodthe deadline for responding to the 
ninth solicitation for grant proposals. We ask that in its final management  
decision, CMS provide information on how it intends to address our first 
recommendation, i.e., that it continue to work with participating States to 
fully implement their programs.   
In response to our second recommendation, CMS stated that it works with 
States on the required quarterly reports and provides technical assistance 
to States as needed. We ask that in its final management decision, CMS 
provide information on how it intends to address the second 
recommendation in full, including (1) using lessons learned from the 
States that are reporting data to assist States that are not reporting data and 
(2) providing increased oversight of the data it is receiving from States to  
ensure that States report all data elements pertaining to the program  
milestones they have reached. 
For the full text of CMSs comments, see Appendix E. 
   
National Background Check Program for Long-Term-Care Employees:  Interim Report (OEI-07-10-00420)   15 
   
   
APPENDIX A 
Participating States and Dates of Grant Awards 
State   Grant Award Date   Grant End Date*  
Alaska   October 1, 2010   September 29, 2016 
California  February 1, 2011   January  31, 2016 
Connecticut  September 30, 2010  September 29, 2016 
Delaware   September 30, 2010  January  31, 2014 
District of Columbia  January 1, 2011   December 30, 2016 
Florida   September 30, 2010  September 29, 2016 
Georgia  July 25, 2012   July 24, 2016  
Hawaii  December 17, 2012  December 16, 2016 
Illinois   December 31, 2010  December 30, 2014 
Kentucky  May 20, 2011   May 19, 2016  
Maine  October 3, 2011   September 30, 2016 
Maryland   January 31, 2013  January 30, 2016 
Michigan  May 20, 2013   May 19, 2016  
Minnesota  August 30, 2012   July 31, 2016  
Missouri  September 30, 2010  September 29, 2016 
Nevada   September 1, 2011  September 30, 2016 
New Mexico  December 31, 2010  December 30, 2016 
North Carolina   July 13, 2011   July 12, 2016  
Ohio   April 22, 2013   April 21, 2016  
Oklahoma   April 6, 2011   April 4, 2016  
Oregon   July 29, 2013   July 28, 2016  
Puerto Rico   December 17, 2012  December 16, 2016 
Rhode Island   September 30, 2010  September 29, 2016 
Utah   July 11, 2011   July 10, 2016  
West Virginia   October 1, 2011   September 30, 2016 
*Dates  shown include extensions approved as of December 2015.  Additional extensions may be subsequently  
approved.  
Source:  CNA Analysis & Solutions, BGCheckInfo.  Accessed at  http://bgcheckinfo.cna.org/  on December 2, 2014, 
and confirmed with a CMS official. 
 
 
   
National Background Check Program for Long-Term-Care Employees:  Interim Report (OEI-07-10-00420)   16 
   
   
APPENDIX B 
Spending for the National Background Check Program 
P.L. No. 108-173,  307 established a Background Check Pilot Program, 
under which Alaska, Idaho, Illinois, Michigan, Nevada, New Mexico, and 
Wisconsin received grants.  Federal funds per State for the National 
Background Check Program are limited to $1.5 million for States that 
participated in the pilot program and $3 million for States that did not.   
Federal funds are provided at a rate of three times the amount of funds that 
a State guarantees.  However, States can meet their financial contributions 
early in the grant period, such that actual spending is not at a consistent 
rate of $3 of Federal funds for every $1 of State funds. 
Total Federal  Percentage of  
Federal  State 
State   Award and State  Background Check 
Spending   Spending  
Matching Funds   Program Funds Spent  
Alaska   $1,476,766   $492,255   $2,000,000   98%  
California  $1,594,899   $243,860   $4,000,000   46%  
Connecticut  $1,776,661   $945,461   $3,462,758   79%  
Delaware  $2,639,761   $1,000,000   $4,000,000   91%  
District of Columbia  $1,670,441   $518,198   $3,565,463   61%  
Florida  $2,827,287   $2,518,566   $4,097,292   130%*  
Georgia  $698,376   $263,836   $3,628,709   27%  
Hawaii  $0  $0  $1,063,300   0%  
Illinois   $1,081,145   $673,032   $2,173,032   81%  
Kentucky  $1,253,905   $704,325   $4,000,000   49%  
Maine  $428,541   $449,465   $3,926,516   22%  
Maryland  $70,449   $34,583   $1,814,028   6%  
Michigan  $341,152   $252,064   $2,000,000   30%  
Minnesota  $223,528   $1,489,235   $4,489,238   38%  
Missouri  $2,388,061   $976,271   $4,002,628   84%  
Nevada  $369,001   $195,603   $1,459,289   39%  
New Mexico  $1,253,956   $363,466   $2,000,000   81%  
North Carolina   $176,987   $662,024   $3,062,765   27%  
Ohio   $992,732   $282,523   $2,854,006   45%  
Oklahoma  $661,578   $220,526   $3,431,455   26%  
Oregon   $16,548   $5,516   $4,000,000   1%  
Puerto Rico   $501,006   $501,980   $3,967,291   27%  
Rhode Island   $374,602   $374,918   $1,805,816   42%  
Utah  $1,339,597   $885,523   $4,000,000   56%  
West Virginia   $70,647   $583,992   $1,627,899   40% 
     Total   $24,227,626   $14,717,222   $76,431,485   51%  
*Florida has provided State  funds in excess of its minimum matching amount. 

Source:  CNA Analysis & Solutions, BGCheckInfo.  Accessed at  http://bgcheckinfo.cna.org/  on December 5, 2014. 

National Background Check Program for Long-Term-Care Employees:  Interim Report (OEI-07-10-00420)   17 
   
   
APPENDIX C 
Elements of Quarterly Data Files  
Required for  
Data  Required for Records 
Pre-Employment 
Element  Element Name   Representing 
Background Check 
Number   Continuous Monitoring  
Records  
1  Record ID   Yes   Yes  
2  Facility/Provider  Type  Yes   No 
3  Employee Categories  Yes   No 
4  Record Creation Date   Yes   Yes  
5  Registry/Database Search Date   Yes   No 
6  Registry/Database Search Determination Results  Yes   No 
7  Fingerprint Collection Date  Yes   No 
8  Fingerprint Type   Yes   No 
9  Fingerprint Rejection Date   Yes   No 
10  State Background Check Request Date   Yes   No 
11  State Background Check Response Date  Yes   Yes  
12  Missing Disposition  Yes   Yes  
13  State Fitness Determination Results  Yes   Yes  
14  State Fitness Determination Date   Yes   Yes  
15  Closed Prior to Determination   Yes   No 
16  Date Application Closed  Yes   No 
17  FBI Fingerprint-Based Background Check Request Date   Yes   No 
18  FBI Fingerprint-Based Background Check Return Date   Yes   Yes  
19  Fitness Determination Based on Federal Results  Yes   Yes  
20  Fitness Determination Based on Federal Results Date  Yes   Yes  
21  Fitness Determination Responsibility  Yes   No 
22  Final Overall Fitness Determination  Yes   Yes  
23  Final Fitness Determination Notification Date  Yes   Yes  
24*  Applicant Appeal  Yes   Yes  
25  Appeal Date   Yes   Yes  
26  Appeal Type   Yes   Yes  
27  Appeal Decision  Yes   Yes  
28  Appeal Decision Date   Yes   Yes  
29  Fitness Determination Renotification Date for Appeal  Yes   Yes  
30  Permanent (Nonprovisional) Hire Date   Yes   No 
* Fields 2429 are required only if the applicant appeals the determination. 
Source:  CNA Analysis & Solutions, BGCheckInfo.  Accessed at  http://bgcheckinfo.cna.org/ on July 29, 2014.  
 
National Background Check Program for Long-Term-Care Employees:  Interim Report (OEI-07-10-00420)   18 
   
   
APPENDIX D 
Related Reports 
This appendix provides information on selected OIG reports published 
since 2010 that address criminal background checks for and employment  
of individuals with criminal convictions in long-term care. 
Nursing Facilities Employment  of Individuals With Criminal 
Convictions, OEI-07-09-00110, March 2011 
This evaluation determined whether and to what extent nursing facilities 
employed individuals with criminal convictions.  It found that 92 percent 
of nursing facilities employed at least one individual with at least one 
criminal conviction.  Overall, 5 percent of nursing facility employees had 
at least one criminal conviction.  The evaluation also found that almost all 
nursing 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, January 2012 
This report provided the results of a survey of long-term-care provider 
administrators about their procedures for conducting background checks, 
the effects of background checks on the pool of prospective employees, 
and the availability and quality of prospective employees. It found that 
94 percent of administrators conducted background checks on prospective 
employees.  Twenty-three percent of 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, October 2012 
This evaluation determined the extent to which nurse aides with 
substantiated findings of abuse, neglect, and/or misappropriation recorded 
on nurse aide registries had previous criminal convictions that could have 
been detected through background checks.  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).  
Finally, nurse aides with substantiated findings in 2010 had a higher rate 
of convictions than nurse aides employed in nursing facilities overall. 
State Requirements for Conducting Background Checks on Home 
Health Agency Employees, OEI-07-14-00131, May 2014 
This report provided the results of a survey of State officials regarding 
State requirements for conducting background checks for prospective 
home health agency (HHA) employees, including the job positions for 
National Background Check Program for Long-Term-Care Employees:  Interim Report (OEI-07-10-00420)   19 
   
   
which States require HHAs to conduct background checks and the types of 
convictions that States consider to be disqualifying for HHA employment.  
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 specify 
convictions that disqualify individuals from employment, and 16 States 
allow an individual who has been disqualified from employment to submit 
an application to have his/her conviction(s) waived.  
Home Health Agencies Conducted Background Checks of Varying 
Types, OEI-07-14-00130, May 2015 
This evaluation identified the criminal convictions of employees of 
a sample of Medicare-certified HHAs, and included an indepth review of 
six purposively selected employees whose convictions were likely to 
disqualify them from HHA employment.  It found that 4 percent of HHA  
employees had at least one criminal conviction; those convictions may or 
may not have disqualified them from employment.  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.  Our review of the six selected HHA  
employees found that three had convictions for crimes against persons that 
appearedon the basis of available datato disqualify them from  
employment in HHAs; however, circumstances may have allowed their 
employment.  The remaining three individuals convictions did not 
disqualify them from employment in their respective States.  
   
National Background Check Program for Long-Term-Care Employees:  Interim Report (OEI-07-10-00420)   20 
  APPENDIX E 
Agency Comments 
(. ' f-
,~y;s.VICt<r.,~
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DEPARTMENT OF HEALTH &_F_I_DM_AN_sE_R_v_rc_E_s_  _____ Services
~5~ 
200 Independence Avenue SW 
Washington, DC 20201 
NOV  "6 2015 
To: 	 Daniel R. Levinson 

Inspector General 

Office of the Inspector General 

From: 	 Andrew M. Slavitt 

Acting Administrator 

Centers for Medicare & Medicaid Services 

Subject: 	 National Background Check Program for Long-term-care Employees: Interim 
Report, OEI-07-10-00420 
The Centers for Medicare & Medicaid Services (CMS) appreciates the opportunity to review and 
comment on the Office ofthe Inspector General's (OIG) draft report.  CMS is committed to 
ensuring Medicare and Medicaid beneficiaries receive high quality health care. 
Currently, CMS is sponsoring the National Background Check Program (NBCP), a national 
program to identify efficient, effective, and economical procedures for long tenn care facilities 
and providers to conduct background checks on a statewide basis for all potential direct patient 
access employees. To date, CMS has awarded nearly $63 million to 26 States and U.S. 
Territories so that they may design comprehensive national background check programs. Two 
States, Delaware and Illinois, have graduated from the program. Delaware graduated from the 
program inBeptember 2013 and with the use of grant funds expanded the breadth of provider 
types and transformed a paper~based, labor-intensive background check system into a fully 
automated system. Illinois graduated from the program in December 2014 and also used grant 
funds to modernize their background check computer system. This updated system interfaces 
with other agencies, including the Illinois State Police. Additionally, an intemet-based training 
program was developed to educate providers on the use of the background check system. 
OIG Recommendation 
The OIG recommends that CMS continue working with participating States to fully implement 
their background check programs. 
CMS Response 
CMS concurs with this recommendation. CMS encourages States and U.S. Tenitol'ies to 
participate in the National Background Check Program (NBCP). The deadline for responding to 
the ninth solicitation for grant proposals from States and U.S. Territories for inclusion in this 
National Background Check Program deadline has been extended and applications will be 
accepted on a flow basis and acted on every 30 days. 
National Background Check Program for Long-Term-Care Employees:  Interim Report (OEl-07-10-00420)  21   
   
   
National Background Check Program for Long-Term-Care Employees:  Interim Report (OEI-07-10-00420)  22 
   
   
 
ACKNOWLEDGMENTS 
This report was prepared under the direction of Brian T.  Whitley, Regional 
Inspector General for Evaluation and Inspections in the Kansas City 
regional office.  
Tricia Fields served as the team leader for this study.  Other Office of 
Evaluation and Inspections staff from the Kansas City regional office who 
conducted the study include Michala Walker.  Central office staff who 
provided support include Kevin Farber, Berivan Demir Neubert, 
Christine Moritz, and Sherri Weinstein.  
National Background Check Program for Long-Term-Care Employees:  Interim Report (OEI-07-10-00420)   23 
   
Office of Inspector General
http://oig.hhs.gov  
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95452, 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 individuals 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 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.  These assessments help reduce waste, abuse, and  
mismanagement and promote economy and efficiency  throughout  HHS. 
Office of Evaluation and Inspections 
The Office  of  Evaluation and Inspections (OEI)  conducts national evaluations to  provide 
HHS, Congress, and the public with timely, useful, and reliable 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 Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations  
of fraud and misconduct  related to HHS programs, operations, and individuals.  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 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 for OIGs  internal operations.  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.