Department of Health and Human Services


OFFICE OF 

INSPECTOR GENERAL 

NURSE AIDE REGISTRIES: 


LONG TERM CARE FACILITY 


COMPLIANCE AND PRACTICES


Daniel R. Levinson 


Inspector General 


July 2005


OEI-07-04-00140

Office of Inspector General 
 http://oig.hhs.gov 

The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, 

as amended, is to protect the integrity of the Department of Health and Human Services 

(HHS) programs, as well as the health and welfare of beneficiaries served by those 

programs. This statutory mission is carried out through a Nationwide network of audits, 

investigations, and inspections conducted by the following operating components: 

Office of Audit Services 

The OIG's Office of Audit Services (OAS) provides all auditing services for HHS, either by 

conducting audits with its own audit resources or by overseeing audit work done by others. 

Audits examine the performance of HHS programs and/or its grantees and contractors 

in carrying out their respective responsibilities and are intended to provide independent 

assessments of HHS programs and operations in order to reduce waste, abuse, and 

mismanagement and to promote economy and efficiency throughout the department. 

Office of Evaluation and Inspections 

The OIG's Office of Evaluation and Inspections (OEI) conducts management and 

program evaluations (called inspections) that focus on issues of concern to the 

department, the Congress, and the public. The findings and recommendations contained 

in the inspections reports generate rapid, accurate, and up-to-date information on the 

efficiency, vulnerability, and effectiveness of departmental programs. The OEI also 

oversees State Medicaid fraud control units, which investigate and prosecute fraud and 

patient abuse in the Medicaid program. 

Office of Investigations 

The OIG's Office of Investigations (OI) conducts criminal, civil, and administrative 

investigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries 

and of unjust enrichment by providers. The investigative efforts of OI lead to criminal 

convictions, administrative sanctions, or civil monetary penalties. 

Office of Counsel to the Inspector General 

The Office of Counsel to the Inspector General (OCIG) provides general legal services to 

OIG, rendering advice and opinions on HHS programs and operations and providing all 

legal support in OIG's internal operations. The OCIG imposes program exclusions and 

civil monetary penalties on health care providers and litigates those actions within the 

department. The OCIG also represents OIG in the global settlement of cases arising 

under the Civil False Claims Act, develops and monitors corporate integrity agreements, 

develops compliance program guidances, renders advisory opinions on OIG sanctions to 

the health care community, and issues fraud alerts and other industry guidance. 
Δ EXECUTIVE SUMMAR Y 

OBJECTIVE 

To determine (1) the extent to which long term care (LTC) facilities 

report that they are in compliance with Federal regulations as related 

to the use of State nurse aide registries, and (2) what additional 

procedures LTC facilities have established to screen nurse aides. 

BACKGROUND 

Federal regulations (42 CFR § 483.156) require each State and the 

District of Columbia to maintain a nurse aide registry of all individuals 

who are registered to work as nurse aides in that State, as well as all 

individuals who have been prohibited from employment as nurse aides 

in LTC facilities due to substantiated adverse findings of abuse, neglect, 

or misappropriation of property. 

Federal regulations (42 CFR § 483.13(c)(1)) prohibit LTC facilities from 

employing individuals who have a substantiated adverse finding 

entered into the State nurse aide registry or who have been found guilty 

in a court of law of abusing, neglecting, or mistreating LTC facility 

residents. Federal regulations (42 CFR § 483.75 (e)(5)) require LTC 

facilities to check their State nurse aide registry to ensure that potential 

nurse aides are registered. The LTC facilities must also check every 

other State nurse aide registry they believe will include any information 

on that individual (42 CFR § 483.75(e)(6)). In addition, Federal 

regulations (42 CFR § 483.75(e)(2)) prohibit LTC facilities from using 

[employing] any individual as a nurse aide for more than 4 months 

unless that individual is registered as a nurse aide. 

This study was based on questionnaire responses from a simple random 

sample of 200 LTC facility administrators, as well as nurse aide 

employment information from each of these facilities. We evaluated all 

nurse aides’ records to determine if they were registered or had 

substantiated adverse findings on nurse aide registries. 

 OE I-07-04-00 140 

FINDINGS 

Long term care facility administrators reported checking their State 

nurse aide registries before hiring, as Federal regulations require; 

the registry results affected some hiring decisions. All LTC facility 

administrators reported checking their State nurse aide registries prior 

to hiring nurse aides. Furthermore, we did not identify any nurse aides 

NURSE AI D E RE G I S T R I E S : L O N G T E R M CARE FA C I L I TY C O M P L I A NCE AND P RACT I C ES i 
EXE CUTIVE S U MMAR Y 

with substantiated adverse findings of abuse, neglect, or 

misappropriation of property entered on the nurse aide registry of the 

State in which they were employed. Forty-four percent of 

administrators reported periodically rechecking employed nurse aides 

against their State nurse aide registry to ensure that substantiated 

adverse findings had not been posted to the registry. 

Fifty-five percent of administrators reported checking only their own 

State registry and thus are most likely not in compliance with 

Federal regulations. In a 2005 OIG study “Nurse Aide Registries: 

State Compliance and Practices” (OEI-07-03-00380), we found that 

approximately 99,000 nurse aides had active registrations in multiple 

States, that 1,552 nurse aides had substantiated adverse findings, that 

450 nurse aides had pending findings in one State and an active 

registration in another State, and that 314 nurse aides had 

substantiated adverse findings in multiple States. These findings 

support the importance of LTC facilities’ checking other States’ 

registries that they believe will include information on a nurse aide to 

ensure that employed nurse aides do not have substantiated adverse 

findings. 

Seventeen percent of LTC facilities employed individuals as nurse 

aides without required registrations. Fifteen percent of LTC facilities 

employed individuals without registrations as nurse aides for longer 

than 4 months. Five percent of LTC facilities employed individuals with 

expired registrations due to State regulations; of these, half also 

employed nurse aides for longer than 4 months without registration. 

The LTC facilities that employ nurse aides without registrations are not 

in compliance with Federal regulations. 

Eighty-five percent of administrators reported establishing 

additional screening procedures; some of these methods may not 

be fully effective. The LTC facility administrators reported 

establishing various procedures in attempts to ensure that they do not 

hire or employ individuals with court convictions or criminal 

backgrounds. The most common screening procedures were criminal 

background checks and/or personal and employment reference checks. 

However, of the 159 LTC facilities that conducted criminal background 

checks, 50 percent conducted checks that were limited in scope. Those 

LTC facilities that conduct criminal background checks of limited scope 

(e.g., covering only the State in which the LTC is located) may fail to 

identify nurse aides who have criminal histories in other States. 

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EXE CUTIVE S CUTIVE S U MMAR Y

RECOMMENDATIONS 

Ensuring that only registered nurse aides without substantiated 

adverse findings of abuse, neglect, or misappropriation are employed in 

LTC facilities necessitates a partnership among States, the Centers for 

Medicare & Medicaid Services (CMS), and LTC facilities. States and 

LTC facilities must diligently comply with Federal regulations 

regarding nurse aide registries. The LTC facilities that do not comply 

with Federal regulations or do not use available information about 

potential nurse aides could expose facility residents to greater risk of 

harm. We recommend that CMS: 

o Utilize existing communication channels (e.g., survey and 

certification processes) to ensure that LTC facilities comply with 

Federal regulations that require them to check the nurse aide 

registries of other States that they believe will contain 

information about an individual prior to hiring and to not employ 

individuals as nurse aides for more than 4 months without 

registration. 

o Encourage LTC facilities to use available resources (e.g., State nurse 

aide registries, background check services) to ensure that nurse 

aides with substantiated adverse findings or criminal backgrounds 

are not employed. Possible methods that CMS could use to achieve 

this include: (1) requiring all LTC facilities to perform periodic 

(e.g., annual or biennial) inquiries of State nurse aide registries on 

employed nurse aides and (2) requiring comprehensive criminal 

background checks by all LTC facilities prior to hiring nurse aides. 

CMS concurred with a 1998 OIG recommendation that CMS 

consider developing a Federal requirement for criminal background 

checks. While no such requirement has yet been developed, the 

Medicare Prescription Drug, Improvement, and Modernization Act 

of 2003 (Public Law 108-173, section 307) established a Background 

Check Pilot Program for long term care facilities or providers to 

conduct background checks on prospective direct patient access 

employees in up to 10 States. The results of this pilot will be 

informative as to the viability of this second option. 

AGENCY COMMENTS 

In its comments to the draft report, CMS recognized the effort and 

expressed appreciation for OIG’s work related to nurse aide registry 

requirements. CMS concurred with our recommendations. CMS will 

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EXE CUTIVE S U MMAR Y 

issue a survey and certification letter to all State survey agencies asking 

them to share the communication with all long term care facility 

providers to reinforce the importance of checking nurse aide registries 

and not allowing nurse aides to work for more than 4 months without 

successfully passing a competency evaluation examination. In addition, 

CMS will utilize the existing Background Check Pilot Program to 

provide insight on further efforts to ensure that only nurse aides in good 

standing are employed in long term care facilities. 

OIG RESPONSE 

We appreciate CMS’s comments to this report and note that CMS is 

taking action to address issues raised in this report. We look forward to 

learning the results of the Criminal Background Check Pilot Program. 

Changes were made to the report to reflect technical comments received 

from CMS. 

 OE I-07-04-00 140 NURSE AI D E RE G I S T R I E S : L O N G T E R M CARE FA C I L I TY C O M P L I A NCE AND P RACT I C ES iv 
Δ T ABLE OF CONTENTS 

EXECUTI VE SUMMARY ........................................ i

INTRODUCTI ON ................................................ 1 

FINDI NGS ....................................................... 6 

Checking State registries before hiring......................... 6 

Checking other State registries before hiring ................... 7 

Employing nurse aides without registrations ................... 8 

Additional screening procedures. .............................. 9 

RECOM M E NDATI O NS ......................................... 11 

AGENCY COMME NTS ......................................... 13 

APPENDI XES .................................................. 16 

A: Required Components of State Nurse Aide Registries ....... 16 

B: Confidence Intervals for Key Estimates .................... 17 

ACKN O W LEDGMENTS ......................................... 18 
ΔINTROD UCT ION

 INTRODU C TION 

OBJECTIVE 

To determine (1) the extent to which long term care (LTC) facilities 

report that they are in compliance with Federal regulations as related 

to the use of State nurse aide registries, and (2) what additional 

procedures LTC facilities have established to screen nurse aides. 

BACKGROUND 

Federal Requirements. 

The Omnibus Budget Reconciliation Act of 1987 contained provisions 

designed to ensure delivery of quality care to LTC facility residents.1 

Federal statute (42 U.S.C. § 1395i-3) and regulations require each State 

and the District of Columbia (hereinafter referred to as a State) to 

maintain nurse aide registries of all individuals who are registered to 

work as nurse aides in that State (i.e., all individuals who have 

completed nurse aide training and/or whom the State deems competent 

to function as a nurse aide2), as well as all individuals who have been 

prohibited from employment as nurse aides in LTC facilities because of 

substantiated adverse findings of abuse, neglect, or misappropriation of 

property.3 Nurse aide registries are intended to ensure that LTC 

facilities employ only registered nurse aides who do not have 

substantiated adverse findings. (For a description of the components of 

nurse aide registries as required by Federal regulation, see 

Appendix A.) 

Federal regulations prohibit LTC facilities from employing individuals 

who have had a finding of abuse, neglect, mistreatment of residents, or 

misappropriation of residents’ property entered into the State nurse 

1 We refer to nursing homes and skilled nursing facilities as long term care (LTC) facilities 

in this report. 

2 42 CFR § 483.75(e) defines a nurse aide as “any individual providing nursing or 

nursing-related services to residents in a facility who is not a licensed health professional, 

a registered dietitian, or someone who volunteers to provide such services without pay.” 

3 42 CFR § 488.301 defines abuse as “the willful infliction of injury, unreasonable 

confinement, intimidation, or punishment with resulting physical harm, pain or mental 

anguish.” Neglect is defined as “failure to provide goods and services necessary to avoid 

physical harm, mental anguish, or mental illness.” Misappropriation of resident property 

is defined as “the deliberate misplacement, exploitation, or wrongful, temporary or 

permanent use of a resident’s belongings or money without the resident’s consent.” 

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INTROD UCT ION

aide registry or who have been found guilty in a court of law of abusing, 

neglecting, or mistreating LTC facility residents.4 Information 

regarding court convictions may or may not be included on State nurse 

aide registries. Federal regulations require LTC facilities to check the 

State nurse aide registry for all hired nurse aides and to check every 

State nurse aide registry that they believe will include information on 

an individual.5 

Federal regulations allow nurse aides to work for up to 4 months before 

becoming registered in the State in which they are working to provide 

sufficient time for their training. However, individuals must become 

registered within 4 months to continue working as nurse aides. 6 

Other Studies Found Weaknesses With Nurse Aide Registries. 

Previous studies of nurse aide registries identified a number of 

weaknesses with nurse aide registry practices in some States and 

indicated that State compliance with Federal nurse aide registry 

regulations was inconsistent. A 2005 Office of Inspector General (OIG) 

study addressed State compliance with nurse aide registry 

requirements and examined the accuracy of nurse aide registry 

information.7 That study found that some States failed to update their 

nurse aide registries timely with substantiated adverse findings and 

that inactive nurse aides were not removed from some nurse aide 

registries, as Federal regulations require. Further, OIG found that 

some States charged an access fee or limited the number of nurse aide 

records that could be requested per access. States had concerns 

regarding the usefulness of nurse aide registries to LTC facilities and 

whether facilities checked the nurse aide registry for all hired nurse 

aides. 

Although criminal background checks are not required by Federal 

statute or regulation,8 such checks can enable LTC facilities to comply 

with the Federal requirement that such facilities not hire nurse aides 

4 42 CFR § 483.13(c)(1). 

5 42 CFR §§ 483.75(e)(5) and (6).

6 42 CFR § 483.75(e).

7 “Nurse Aide Registries: State Compliance and Practices.” Office of Inspector General, 

OEI-07-03-00380. 

8 Public Law 108-173, Section 307 established a Background Check Pilot Program for LTC 

facilities or providers to conduct background checks on prospective direct patient access 

employees in 10 States. 

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INTROD UCT ION

who have been found guilty in a court of law of abusing, neglecting, or 

mistreating residents. A 1998 OIG audit reported that, in most States, 

criminal background checks for nurse aides were limited to State 

records, and some individuals with criminal histories were not recorded 

on nurse aide registries.

9 OIG recommended that the Centers for 

Medicare & Medicaid Services (CMS) work with the Administration on 

Aging and the States to improve the safety of LTC facility residents and 

to strengthen safeguards against employment of abusive workers. 

METHODOLOGY 

This study was based on information from multiple sources: 

(1) a review of Federal statutes and regulations regarding nurse aide 

registries, (2) a review of the existing literature and previous studies on 

nurse aide registries, (3) questionnaire responses from a simple random 

sample of 200 LTC facility administrators, and (4) nurse aide 

employment information from each of the 200 sampled LTC facilities. 

Sample Selection. 

We selected a simple random sample of LTC facilities from the 

population of such facilities contained in the Online Survey, 

Certification and Reporting (OSCAR) database as of March 26, 2004. 

Our sample consisted of 200 of the 16,261 LTC facilities in the 

51 States. 

LTC Facility Administrator Questionnaire. 

The administrators of each of the 200 LTC facilities completed a mail 

questionnaire regarding the practices, policies, and procedures they 

followed in checking potential and employed nurse aides on nurse aide 

registries. We analyzed the questionnaire data to determine LTC 

facilities’ reported compliance with Federal regulations and the types of 

additional procedures LTC facilities had instituted to screen potential 

nurse aides. 

Nurse Aide Employment Information. 

From each of the 200 LTC facilities, we requested information on all of 

the nurse aides employed by the facility on September 1, 2003. The 

information requested included the full name, Social Security number, 

date of birth, registration number, and the beginning and ending dates 

of employment for each nurse aide. We received employment 

9 “Safeguarding LTC Residents.” Office of Inspector General, A-12-97-00003, 09/98. 

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INTROD UCT ION 

information from all 200 LTC facilities, for a total of 8,123 nurse aides. 

We also requested documentation of the LTC facilities’ verification(s) of 

each nurse aide’s registration. 

As part of the 2005 OIG study reviewing State compliance with nurse 

aide registry requirements, we received complete nurse aide registries 

from all States as of September 1, 2003. We matched the 8,123 nurse 

aides hired prior to September 1, 2003, with the 51 State nurse aide 

registries to determine if any nurse aides had a substantiated adverse 

finding of abuse, neglect, or misappropriation of property. 

Because Federal regulations allow individuals to work for up to 

4 months before becoming registered as nurse aides, our analysis 

regarding registration included only those individuals who were hired 

before May 1, 2003. By removing the 1,529 nurse aides hired by the 

200 LTC facilities between May 1 and September 1, 2003, the number of 

nurse aides included in our analysis was reduced from 8,123 to 6,594. 

We matched the 6,594 nurse aides with the 51 State nurse aide 

registries to ensure they were registered as of September 1, 2003. For 

any nurse aide we could not match in the 51 State nurse aide registries 

due to incorrect Social Security numbers and/or incorrect names, we 

recontacted the LTC facilities to either verify or obtain correct 

identifying information. We queried the nurse aide registries a second 

time in August 2004 using the corrected identifying information. 

We determined that an LTC facility was not in compliance with Federal 

regulations if it employed one or more nurse aides without registration. 

Limitations of Identifying Nurse Aides Without Registrations or With 

Substantiated Adverse Findings. 

It is possible that some LTC facilities may not have provided 

employment information on all of their nurse aides. In an attempt to 

identify LTC facilities that may have provided incomplete information, 

we compared the number of nurse aides each facility provided with the 

number of nurse aides listed in the OSCAR database. To ensure that a 

complete list of nurse aides had been provided, we identified extreme 

outliers and contacted the nine LTC facilities that provided employment 

information for less than half the number of nurse aides listed in the 

OSCAR database. To ensure that the information provided by the LTC 

facilities included only nurse aides and not other LTC facility staff, we 

also contacted the 14 LTC facilities that provided employment 

information for more than twice the number of nurse aides listed in the 

OSCAR database. The LTC facility administrators either provided 

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INTROD UCT ION

updated lists of nurse aides or stated that the information they 

originally provided was correct. We then repeated the matching process 

with any new information provided. 

Standards. 

This inspection was conducted in accordance with the “Quality 

Standards for Inspections” issued by the President’s Council on 

Integrity and Efficiency. 

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Δ FINDINGS

Long term care facility administrators reported 

checking their State nurse aide registries

 before hiring; the registry results affected 

some hiring decisions 

Federal regulations require 

LTC facilities to check their 

State nurse aide registry to 

ensure that all hired nurse 

aides are registered.10 Federal 

regulations also require that LTC facilities must not employ individuals 

whose records contain substantiated adverse findings.11 

All LTC facility administrators reported that they checked their own 

State nurse aide registry to ensure that potential nurse aides are 

registered. In fact, 42 administrators reported not hiring a potential 

nurse aide because of the results of a registry inquiry. Furthermore, 

when we matched the employment information for the 8,123 nurse aides 

that the 200 LTC facility administrators supplied with the appropriate 

State nurse aide registry, we did not identify any nurse aides with 

substantiated adverse findings of abuse, neglect, or misappropriation of 

property entered on the nurse aide registry for the State in which they 

were employed. Given this evidence, it seems likely that LTC facility 

administrators are in compliance with Federal requirements prohibiting 

the employment of nurse aides with substantiated adverse findings. 

Although not required to do so, 44 percent of administrators reported 

rechecking employed nurse aides against their State nurse aide registry 

to ensure that substantiated adverse findings had not been posted to the 

registry. (See Appendix B for confidence intervals for all point 

estimates.) The most commonly reported reason for this practice was 

concern that nurse aides may be employed by more than one LTC 

facility and could have substantiated adverse findings resulting from 

actions at another facility. Of the 87 administrators who reported 

rechecking the nurse aide registry for substantiated adverse findings 

subsequent to hiring, 15 identified at least one nurse aide who had a 

change of status (e.g., conviction of abuse at a previous job, failure to 

attain registration, or failure to renew registration due to a change of 

address), and 14 of these administrators terminated those nurse aides.12 

10 42 CFR § 483.75(e)(5). 

11 42 CFR § 483.13(c)(1). 

12 The remaining LTC facility administrator reported that she may terminate nurse aides 

based on the nature of the change identified. 

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F I NDING S 

Fifty-five percent of administrators reported 

checking only their own State registry and 

thus are most likely not in compliance 

with Federal requirements 

In addition to requiring that they 

check their own State nurse aide 

registry, Federal regulations 

require LTC facilities to check every 

other State nurse aide registry they 

believe will include any information on a potential nurse aide.13 

Although “believe” is not specifically defined in regulation, employment 

applications, reference checks, or background checks would provide LTC 

facilities with clear evidence of the other State nurse aide registries that 

might contain information about a potential nurse aide. In the 

2005 OIG study, we identified approximately 99,000 nurse aides who 

had registrations in multiple States, suggesting that interstate 

movement of nurse aides is not uncommon. This finding supports the 

importance of LTC facilities’ checking the registries of other States 

before hiring a nurse aide. 

When surveyed about checking other State registries, administrators 

had the choice of choosing one of the following: (1) Yes, we check other 

States’ registries; (2) No, we only check our own State registry; or 

(3) No, we do not check any State registries. Fifty-five percent of 

administrators selected option 2, reporting that they only check their 

own State’s nurse aide registry prior to hiring a nurse aide.14 Given 

that our prior studies clearly demonstrated that some nurse aides have 

moved from one State to another, it is possible that LTC facilities have 

at least some nurse aides who worked as nurse aides in other States 

prior to seeking employment at their facility. Thus, LTC facilities that 

reported checking only their own registry are likely not in compliance 

with Federal regulations. 

From our prior study,15 when we examined the universe of nurse aides, 

we found that 1,552 nurse aides had substantiated adverse findings and 

450 nurse aides had pending findings of abuse, neglect, or 

13 42 CFR § 483.75(e)(6). 

14 The remaining administrators selected other responses. 

15 “Nurse Aide Registries: State Compliance and Practices.” Office of Inspector General, 

OEI-07-03-00380. 

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F I NDING S 

misappropriation of property in one State and an active registration in 

another State;16 and 314 nurse aides had records with substantiated 

adverse findings in multiple States. 

Through our process of matching identifying information that the LTC 

facilities provided for the 8,123 nurse aides against the 51 State nurse 

aide registries, we identified a nurse aide who had a record with a 

substantiated adverse finding from 1999 on the New Mexico nurse aide 

registry and was employed in Texas on September 1, 2003. The 

administrator of the Texas LTC facility reported that the facility does 

not check other States’ nurse aide registries prior to hiring potential 

nurse aides. 

Seventeen percent of LTC facilities employed 

individuals as nurse aides without 

required registrations 

Fifteen percent of LTC facilities 

employed at least one individual as a 

nurse aide for longer than 4 months 

without registration. 

OE I-07-04-00 140 

Federal regulations prohibit LTC facilities from using [employing] any 

individual as a nurse aide for more than 4 months unless that 

individual is registered as a nurse aide.17 However, LTC facilities can 

hire nurse aides for up to 4 months before they are registered, allowing 

the individual to participate in a training program to become registered. 

At the end of the 4 months, if an individual is not listed in the 

appropriate State nurse aide registry, the LTC facility must follow up to 

ensure that the individual actually becomes registered. Evidence of 

registration is maintained in the appropriate State nurse aide 

registry.18 

On September 1, 2003, 15 percent of LTC facilities employed at least 

one individual as a nurse aide for longer than 4 months without 

registration, accounting for a total of 40 nurse aides. We queried the 

nurse aide registries in August 2004 to verify whether these nurse aides 

were listed as registered. We found that 29 nurse aides were still not 

listed as registered and 11 nurse aides were listed as registered, but 

16 Although Federal regulations do not require that nurse aides with pending findings of 

abuse, neglect, or misappropriation of property be listed as such on their respective 

registries, we include information about these 450 nurse aides because it suggests 

information that LTC facilities could learn about nurse aides if registries in other States 

were checked. 

17 42 CFR § 483.75(e)(2). 

18 42 CFR § 483.75(e)(5). 

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F I NDING S 

their registration dates were after September 1, 2003. Thus these nurse 

aides were employed without registration for more than 4 months, a 

violation of Federal regulations. Despite the administrators of these 

LTC facilities’ reporting that they had practices in place to ensure that 

individuals without registrations are not employed for longer than 

4 months (e.g., confirming registration by checking the nurse aide 

registry after 4 months of employment, requiring nurse aides to provide 

proof of registration, and completing the paperwork required to obtain 

registrations for nurse aides), none of these LTC facilities could produce 

documentation of registration for any of the nurse aides in question. 

Five percent of LTC facilities (three percent of which are included above) 

employed nurse aides with expired registrations. 

Federal regulations require State nurse aide registries to remove 

registrations for individuals who have performed no nursing or 

nursing-related services for a period of 24 consecutive months (unless 

the individual's registry record includes documented findings of abuse, 

neglect, or misappropriation of property). However, some States have 

established more stringent requirements that call for nurse aide 

registrations to expire at regular intervals unless the nurse aide takes 

action to renew his or her registration. We identified 5 percent of LTC 

facilities that employed nurse aides with expired registrations that had 

expired due to State requirements, accounting for 16 nurse aides. In 

effect, these 10 LTC facilities employed nurse aides without valid 

registrations, per State requirements. We could not confirm whether 

these individuals met the Federal requirement for performing nursing 

or nursing-related services in accordance with 42 CFR § 483.75(e). 

Three percent of LTC facilities exhibited both conditions (employing 

individuals as nurse aides without registrations and nurse aides with 

expired registrations). 

Eighty-five percent of administrators reported Federal regulations prohibit 

LTC facilities from employing 

any individual who has been 

establishing additional screening procedures; some 

of these methods may not be fully effective 

found guilty of abusing, 

neglecting, or mistreating residents by a court of law; 19 however, these 

convictions are not necessarily recorded on a State’s nurse aide registry. 

Although not required to do so by Federal regulation, some LTC facility 

19 42 CFR § 483.13(c)(1)(ii)(A). 

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F I NDING S 

administrators reported establishing various procedures in attempts to 

ensure that they do not hire or employ individuals with such 

convictions. 

In addition to checking the 

State nurse aide registry, 

the most common 

screening procedures, as 

reported by 85 percent of 

administrators, were 

conducting criminal 

background checks and/or 

checking personal and 

employment references. 

Table 1 illustrates the 

Table 1: Screening Procedures of the 

200 LTC Facilities 

Check Conducted Number of LTC 

Facilities 

Criminal Background 

Only 

91 

Reference Only 10 

Criminal Background 

Check and Reference 

68 

Neither 31 

number of administrators Source: Office of Inspector General, 2004 

who reported conducting criminal background and/or reference checks. 

However, of the 159 LTC facilities that conducted criminal background 

checks, 50 percent conducted checks that were limited in scope (covering 

only their State or the individual’s reported previous addresses). Those 

LTC facilities that conduct criminal background checks of limited scope 

may fail to identify nurse aides who have criminal histories in other 

States. This finding is consistent with a 1998 OIG audit, which 

reported that in most States criminal background checks for nurse aides 

were limited to State records. In that report, OIG recommended that 

CMS consider developing a Federal requirement for criminal 

background checks and CMS concurred. 

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ΔFEXE R IE NDING C OCUTIVE S CUTIVE S MMENDA S TU I MMAR O N S Y

 RECOMME NDA TIONS 

RECOMMENDATIONS 

Ensuring that only registered nurse aides without substantiated 

adverse findings of abuse, neglect, or misappropriation are employed in 

LTC facilities necessitates a partnership among States, CMS, and LTC 

facilities. States and LTC facilities must diligently comply with Federal 

regulations regarding nurse aide registries. The LTC facilities that do 

not comply with Federal regulations or do not use available information 

about potential nurse aides could expose facility residents to greater 

risk of harm. We recommend that CMS: 

o Utilize existing communication channels (e.g., survey and 

certification processes) to ensure that LTC facilities comply with 

Federal regulations that require them to check the nurse aide 

registries of other States that they believe will contain 

information about an individual prior to hiring and to not employ 

individuals as nurse aides for more than 4 months without 

registration. 

o Encourage LTC facilities to use available resources (e.g., State 

nurse aide registries, background check services) to ensure that 

nurse aides with substantiated adverse findings or criminal 

backgrounds are not employed. Possible methods that CMS could 

use to achieve this include: (1) requiring all LTC facilities to 

perform periodic (e.g., annual or biennial) inquiries of State nurse 

aide registries on employed nurse aides and (2) requiring 

comprehensive criminal background checks by all LTC facilities 

prior to hiring nurse aides. CMS concurred with a 1998 OIG 

recommendation that CMS consider developing a Federal 

requirement for criminal background checks. While no such 

requirement has yet been developed, the Medicare Prescription 

Drug, Improvement, and Modernization Act of 2003 (Public 

Law 108-173 section 307) established a Background Check Pilot 

Program for LTC facilities or providers to conduct background 

checks on prospective direct patient access employees in up to 

10 States. The results of this pilot will be informative as to the 

viability of this second option. 

AGENCY COMMENTS 

In its comments to the draft report, CMS recognized the effort and 

expressed appreciation for OIG’s work related to nurse aide registry 

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R E C O MMENDA T I O N S 

requirements. CMS concurred with our recommendations. CMS will 

issue a survey and certification letter to all State survey agencies asking 

them to share the communication with all LTC facility providers to 

reinforce the importance of checking nurse aide registries and not 

allowing nurse aides to work for more than 4 months without 

successfully passing a competency evaluation examination. In addition, 

CMS will utilize the existing Background Check Pilot Program to 

provide insight on further efforts to ensure that only nurse aides in good 

standing are employed in LTC facilities. 

OIG RESPONSE 

We appreciate CMS’s comments to this report and note that CMS is 

taking action to address issues raised in this report. We look forward to 

learning the results of the Criminal Background Check Pilot Program. 

Changes were made to the report to reflect technical comments received 

from CMS. 

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Δ AGENCY COMMENTS 

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A G E N C Y CO MMENT S

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A G E N C Y CO MMENT S

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Δ APPENDIX ~ A 

Required Components of State Nurse Aide Registries 

Pursuant to 42 CFR § 483.156(c), nurse aide registries must include: 

(1) The full name of the individual, 

(2) Identifying information, 

(3) The date the individual became eligible for placement in the nurse 

aide registry, and 

(4) Information regarding substantiated adverse findings (as 

appropriate). 

Each State’s nurse aide registry must include information on 

individuals who have active registrations and are thus employable and 

on individuals whose records include substantiated adverse findings. 

States are required to remove nurse aide registry records of individuals 

who have not performed nursing or nursing-related services for a period 

of 24 consecutive months, thus becoming inactive and no longer 

employable. Individuals with records of substantiated adverse findings 

must remain on the nurse aide registry permanently except in certain 

cases of neglect. 

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Δ APPENDIX ~ B 

Confidence Intervals for Key Estimates 

Finding Point Estimate Confidence Interval 

95 Percent Ratio 

Administrators Who Reported Rechecking Nurse Aide 

Registries 

43.5% 36.5% - 50.7% 87/200 

Administrators Who Reported Not Checking Other States' 

Nurse Aide Registries 

55.0% 47.8% - 62.0% 110/200 

LTC Facilities That Employed Nurse Aides Without 

Registrations For Longer Than 4 Months 14.5% 9.9% - 20.2% 29/200 

LTC Facilities That Employed Nurse Aides With Expired 

Registrations 5.0% 2.4% - 9.0% 10/200 

LTC Facilities That Established Additional Screening 

Procedures 

84.5% 78.7% - 89.2% 169/200 

LTC Facilities That Conducted Background 

Checks of Limited Scope 

50.3% 42.3% - 58.3% 80/159 

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Δ ACKNOWLEDGMENTS 

This report was prepared under the direction of Brian T. Pattison, 

Regional Inspector General for Evaluation and Inspections in the 

Kansas City regional office, and Gina C. Maree, Assistant Regional 

Inspector General. Other principal Office of Evaluation and Inspections 

staff who contributed include: 

Tricia Fields, Team Leader 

Brian T. Whitley, Project Leader 

Dennis Tharp, Program Analyst 

Michala Walker, Program Analyst 

Sandy Khoury, Program Specialist 

Tricia Davis, Director, Medicare & Medicaid Branch 

Barbara Tedesco, Mathematical Statistician 

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