Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

NATIONAL BACKGROUND 

CHECK PROGRAM FOR 

LONG-TERM-CARE 

EMPLOYEES: INTERIM 

REPORT 

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 program—known as the National 

Background Check Program—after 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 State’s 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) 2010–2014. 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 State’s 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 State’s 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 individual’s 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 FBI’s 

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 individual’s 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. 

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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 State’s 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. 

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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 State’s 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 Maryland’s 

June 2014 quarterly report in this evaluation. 

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implementation milestones. We used the expenditure data from the 

quarterly reports to calculate each State’s 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

13 States 

10 States 

15 States 

0 

5 

10 

15 

20 

25 

Not yet having 

enabling 

legislation 

Not yet collecting 

fingerprints 

Not yet monitoring 

criminal history 

information 

continuously 

Number of States 

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. 

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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 

appear—on the basis of the comments in their September 2014 program narratives—to 

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. 

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National Background Check Program for Long-term-care Employees: Interim Report (OEI-07-10-00420) 

Table 1: Number of Background Checks Conducted by Six States Between Program Inception and September 30, 2014 

State Total Checks Conducted 

Checks With a Determination of: 

Eligible for 

Employment 

Ineligible for 

Employment Pending Closed Prior to Determination Unknown1 

Alaska 46,969 21,875 1,872 20,6252 2,597 0 District of Columbia 15,091 12,412 148 149 2,382 0 

Florida4 787,683 733,081 26,007 28,227 152 216 

Michigan 138,134 116,897 1,479 1,237 18,448 73 

New Mexico 39,110 33,914 441 69 4,686 0 

Oklahoma 19,134 14,139 78 435 4,482 0 

 Total 1,046,121 932,318 30,025 50,742 32,747 289 

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 

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 c

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 de

terminations of individuals who had been previously determined to be qualified for employment. Alaska’s data system may have deleted the original determination result of “qualified” whemployment 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 h

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 resu

percentage of disqualified applicants than if Alaska’s data system had not changed the original determinations. 

4 In Florida’s September 2014 quarterly data report, the State reported a number of records that resulted from continuous monitoring of criminal history information. However, the State w

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 “d

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 nfrom 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

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 CMS’s technical 

assistance contractor confirmed that these records resulted from 

continuous monitoring. 

	 None of Alaska’s 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, Alaska’s 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 State’s data system changed determinations in 

this manner. 

	 Staff from CMS’s technical assistance contractor confirmed that 

Florida included records resulting from continuous monitoring in 

the State’s data report; however, none of Florida’s 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. 
 

monitoring from the records that have blank values because the 

information is simply missing. 

	 The District of Columbia’s 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. 

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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 

extended—for an unspecified period—the 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 CMS’s 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 
 

National Background Check Program for Long-Term-Care Employees: Interim Report (OEI-07-10-00420) 17 

 

 

 

 

 

 

 

 

 

 

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. 

State Federal 

Spending 

State 

Spending 

Total Federal 

Award and State 

Matching Funds 

Percentage of 

Background Check 

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) 18 

APPENDIX C 

Elements of Quarterly Data Files 

Data 

Element 

Number 

Element Name 

Required for 

Pre-Employment 

Background Check 

Records 

Required for Records 

Representing 

Continuous Monitoring 

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 24–29 are required only if the applicant appeals the determination. 

Source: CNA Analysis & Solutions, BGCheckInfo. Accessed at http://bgcheckinfo.cna.org/ on July 29, 2014. 
 

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 Employees—Results 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 

appeared—on the basis of available data—to 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 

,~y;s.VICt<r.,~ ( . 'f- DEPARTMENT OF HEALTH &_F_IDMAN ___sE_R_v_rc_E_s ______~ce_n_te_rs_1o_r_M_ed_1c_ar_e_&_M_ed_1c_a1_d 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 OIG’s 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.