United States General Accounting Office

GAO Report to the Honorable

Ron Wyden, U.S. Senate

September 1996 LONG-TERM CARE

Some States Apply

Criminal Background

Checks to Home Care

Workers

G O A

years

1921 - 1996

GAO/PEMD-96-5

GAO United States

General Accounting Office

Washington, D.C. 20548

Program Evaluation and

Methodology Division

B-271516 

September 27, 1996

The Honorable Ron Wyden

United States Senate

Dear Senator Wyden:

By 1989, an estimated 5.3 million of the noninstitutionalized persons age

65 and older, or about 17 percent of the 31 million elderly Americans,

needed some regular assistance with a basic or instrumental activity of

daily living. Just over 1 million of these persons were severely disabled

and required assistance in several areas. Moreover, the need for such

assistance is projected to accelerate as the elderly population surges to

80 million by the middle of the 21st century.

Elderly persons generally prefer home and community-based services to

nursing homes, and a variety of economic and demographic trends make it

likely that increasing numbers of elderly and disabled persons will

eventually turn to paid home care workers for these services. Such home

care workers have frequent, unsupervised access to potentially vulnerable

adults and their property. Accordingly, you asked that we examine the

federal and state provisions that protect vulnerable elderly and disabled

persons from home care workers with histories of crime and patient

abuse. In this report, we describe

• The federal or state requirements for licensure, registration, or

certification that apply to home care workers and organizations;

• The extent to which states have used the federally mandated registry for

nursing home aides or a similar mechanism to identify home care workers

with past involvement in abuse, neglect, or misappropriation of property;

and

• The extent to which states have required criminal background checks of

home care workers.

Results in Brief Assessing the extent of problems with abuse, neglect, or misappropriation

in the home care industry is a difficult task. Formal safeguards for home

care consumers vary widely across political jurisdictions, public programs,

and types of providers; and in some instances, few safeguards exist.

We have three key results of our evaluation to report. Few states have

licensure requirements for types of workers that are among the most

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common providers of home care services. However, the vast majority of

states license or otherwise regulate some types of home care organizations

or professionals, and some states indicate that all types of home care

organizations are subject to a state licensure requirement.

While all states must maintain a registry for nursing home aides in

accordance with federal law, only about a quarter have incorporated home

care workers into it or have developed a separate registry for home care

workers.

Finally, we found that slightly over a quarter of the states require criminal

background checks on some types of home care workers, though these

checks are generally limited to a state’s own criminal records. States with

a statute requiring such checks may access Federal Bureau of

Investigation (FBI) data for this purpose, but few states have made use of

this capacity with respect to home care workers. Although there is no

charge for checking these data for criminal justice purposes, fees are

charged for checks for employment screening, and some state officials

have cited these fees as a factor in reluctance to make greater use of the

FBI data.

Background

Home Care By “home care,” we mean not only health care services delivered in the

home, but also assistance with basic and instrumental activities of daily

living, such as eating, dressing, bathing, toileting, transferring from bed to

chair, shopping, cooking, and laundry. These services are provided by a

variety of organizations, including temporary employment firms, nurse

registries, and home health agencies. The types of individual workers

providing home care services are equally varied, including home health

aides, homemakers, and choreworkers, as well as professional social

workers, occupational therapists, and physical therapists. However, it is

believed that 70 to 80 percent of all paid long-term home care is provided

by workers variously known as home health aides, personal care aides,

personal care attendants, or homemakers.

The Federal Role The federal government finances home care services through several

means, including Medicare, Medicaid, Veterans’ Administration programs,

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Older Americans Act funds, Social Services Block Grants, and various

demonstration and waiver programs. However, the broadest federal

programs for supporting these services are generally recognized to be

Medicare and Medicaid. The federal government indirectly regulates some

home care workers through the requirement that agencies or individual

providers that participate in the Medicare and Medicaid programs meet

various conditions of participation.1

In addition to these conditions of participation, the Medicare and Medicaid

Patient and Program Protection Act of 1987 requires that the Secretary of

Health and Human Services (HHS) exclude from participation in title XVIII

(Medicare), and direct states to exclude from participation in programs

authorized by title XIX (Medicaid) and title XX (Social Services Block

Grants), any individual or entity convicted of program-related crimes or

who has been convicted under federal or state law of a criminal offense

related to neglect or abuse of patients in connection with delivery of a

health care item or service.2

 Also, the Secretary may direct a state to

disqualify those convicted of other crimes, such as fraud in the delivery of

health care services, obstruction of justice, or crimes related to the

manufacture, distribution, prescription, or dispensing of a controlled

substance. HHS has issued related regulations (see 42 C.F.R sections

1001.101 to 1001.102 and 1002.203), but these regulations do not require

home care worker background investigations and apply only to offenses

occurring in connection with the delivery of health care services.

Other Sources of Home

Care Requirements

State or local governments or professional boards also impose

requirements on home care organizations and independent workers in

connection with agency or individual licensure or registration processes.

The coverage of these nonfederal requirements varies from large segments

of the home care industry to particular types of workers. Some states also

assist consumers in distinguishing licensed or registered workers from

others by limiting the advertisement of particular services to those who

are licensed or registered. (See appendixes I and II.)

Reasons for Interest in

Worker Screening

Several factors contribute to recent interest in background screening

requirements for home care workers. These include the increasing size

1

See our earlier reports, entitled Long-Term Care: Status of Quality Assurance and Measurement in

Home and Community-Based Services (GAO/PEMD-94-19; March 1994) and Medicare: Assuring the

Quality of Home Health Services (GAO/HRD-90-7; October 1989).

2

42 U.S.C. 1320a-7.

Page 3 GAO/PEMD-96-5 Criminal Background Checks for Home Care Workers
B-271516 

and obvious vulnerability of the population in need of home care services,

the challenges the home care setting poses for worker supervision, rapid

expansion of the home care industry, unrelenting demand for home care

services in the face of worker shortages, the low wages typically available

to paraprofessional workers serving a largely low- or fixed-income

population, diffuse responsibility for worker selection, and anecdotal

reports of abuses by home care workers with criminal history.

Home care is provided to persons living at home who, because of a

chronic condition or illness, often cannot care for themselves. Studies of

home health care utilization have found that the typical recipient is a

woman with functional limitations who is very elderly, has a low income,

and lives alone.

The number of persons needing home care is expected to increase as the

very elderly population grows from the 3 million persons over age 85 in

1990 to more than 15 million in 2050. Among those in need of home care,

reliance on paid home care workers is also expected to rise, partly

because adults in the baby boom generation have had smaller numbers of

children and will therefore have fewer available to provide or supervise

their care in old age. In addition, projections indicate that labor force

participation will continue to increase among women, who have

traditionally provided much of the informal care for the elderly. Although

future cohorts of elderly persons may be better off financially, long-term

care costs are expected to increase faster than personal income.

Although the home care work force is entrusted with significant

responsibilities and sometimes demanding work with little supervision or

assistance, home care work is often characterized by part-time

employment, lower wages, and an absence of fringe benefits. Moreover,

workers are in high demand, and managers of proprietary home care

agencies indicate that the speed with which they can provide workers to

fill newly identified needs is often critical to their firms’ success. In this

context, the expanding demand for home care services and the rapid

growth of the home care industry combined with an absence of

appropriate safeguards could create pressures to hire potentially

unqualified job applicants.

In addition, in an effort to stretch home care funding and empower

consumers, some states are adopting policies that encourage or require

aged and disabled beneficiaries to take direct responsibility for hiring and

supervising their home care workers who are paid with state or federal

Page 4 GAO/PEMD-96-5 Criminal Background Checks for Home Care Workers
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funds. Thus, vulnerable home care consumers increasingly need access

either to the tools for evaluating potential workers or to a list of

prequalified candidates. In the absence of the ability to offer attractive

salaries, however, individual consumers may feel hard-pressed to impose

extensive requirements on workers, for fear they will lose potentially good

workers to less demanding employers.

Finally, anecdotal reports of abuses by a small number of home care

workers with criminal history have raised the issue of whether and how

such workers should be screened for criminal background.3

 Limited

experience in screening for criminal background among home care

workers suggests that a segment of workers have criminal history, but that

such history does not always portend criminal behavior.4

 However,

advocates of criminal background screening argue that the use of this

process may deter any individuals with criminal intent from entering the

field.

Types of Screening While some localities have experimented with other methods for screening

applicants for home care work, this report is concerned primarily with two

potential forms of background screening: use of worker registries and use

of mandatory criminal background checks.5

 Under the Omnibus Budget

Reconciliation Act of 1987, states must keep registries of individuals

3

See, for example, Little Hoover Commission, “Unsafe in Their Own Homes: State Programs Fail to

Protect Elderly from Indignity, Abuse and Neglect” (Sacramento: Commission on California State

Government and Economy, November 1991), p. 2. See also, Lea Thompson, Consumer Alert: “Take

Care,” Dateline NBC Investigation of Home Care, November 10, 1995. The latter report cites five cases

in which workers with prior criminal history were later implicated in serious crimes against home care

recipients.

4

A March 1987 report by the Auditor General of California estimated 6.4 percent of the home care

providers in the state’s In-Home Supportive Services (IHSS) program had criminal convictions.

Following this report, a special project arranged for fingerprint-based criminal background checks of

providers new to Santa Clara County’s IHSS contractor or newly added to the county’s registry of

potential providers. In addition, recipients of IHSS services were permitted to refer for criminal

background clearance any providers they were newly considering for employment. A 1990 draft report

on the results of this project noted that over 2 years, 76.6 percent of the 462 prospective providers who

were referred for criminal history checks completed the process, and 10.7 percent of those completing

the process had criminal records. In the second year of the project, 211 prospective providers were

referred, 162 (77 percent) completed the process, and 15.4 percent of them had prior criminal records.

Providers who submitted to the fingerprinting were allowed to work during the 35-100 days required

for criminal background clearance, and no adverse consequences were observed.

5

Erie County, New York, for example, has established a variation of a worker registry in which a

quasi-governmental agency centralizes employment data for persons working for member companies,

allowing potential employers to more easily verify an applicant’s industry-related employment history.

The effectiveness of this process depends on the cooperation of a full complement of industry

members. The process is handled by a nongovernmental agency in order to allay some industry

members’ concerns that competitors would otherwise use the registry as a tool for recruiting their

skilled employees.

Page 5 GAO/PEMD-96-5 Criminal Background Checks for Home Care Workers
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qualified to work as nurses’ aides in nursing homes that participate in

Medicaid and Medicare, and these registers must note any instances in

which states find that such aides have been involved in resident abuse,

neglect, or misappropriation of property from a nursing home patient.

Before employing someone as an aide, a nursing home that participates in

Medicare or Medicaid must check the registry for prior incidents involving

the prospective worker and verify that the worker meets appropriate

training standards. This registry is important for two reasons: (1) there is

some overlap between the nursing home and home care work force; and

(2) it is a model for worker screening that has already been incorporated

in the Medicare and Medicaid programs that some states have extended to

cover other types of workers, including home care workers.

With respect to criminal background checks, several variations are

possible. Federal, state, or local law enforcement data may be used by

states for criminal background checks, and each has advantages and

limitations. Although checks using state and local data are more readily

implemented, they are not as comprehensive as those employing national

records because they miss convictions that have occurred even in

neighboring states or communities. Also, if they are based primarily on the

name, birthdate, and social security number provided by the job applicant,

they can result in false positives or false negatives.

The FBI may share interstate criminal history data with state officials if

authorized by a state statute approved by the U.S. Attorney General for the

purpose of determining the fitness of persons to work with children, the

elderly, or individuals with disabilities.6

 Under the law, an entity qualified

under such a state law (for example, a licensed home care agency), may

request that an FBI-authorized state agency conduct a national background

check of an applicant provider. Such checks employ the national criminal

history background check system, which contains state and federal

criminal history records, and may be requested only when the person to be

checked provides fingerprints and a signed statement regarding the

presence and nature of any previous criminal convictions. The FBI

routinely charges states at least $22 for processing each fingerprint check

for a nonvolunteer care provider.7

 The law requires that the FBI-authorized

state agency make “reasonable efforts” to respond to such inquiries within

6

42 U.S.C. 5119a.

7

The law permits the FBI and authorized state agencies to collect $18, or the actual cost, whichever is

less, to process the fingerprint card of a “volunteer” care provider. The FBI charges $18 for this service

($16 for billing states).

Page 6 GAO/PEMD-96-5 Criminal Background Checks for Home Care Workers
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15 business days.8 We report results on the extent to which states have

taken advantage of this law in connection with home care workers, who

primarily serve the elderly.

Scope and

Methodology

To describe federal and state requirements applying to home care

organizations and workers, we reviewed federal conditions for

participation in Medicare and Medicaid and surveyed state governments

regarding their methods for regulating organizations and individuals who

provide home care. The terminology used to refer to various types of home

care workers is highly variable, and thus, our survey adopted the standard

definitions we present in the glossary.

Although licensure or registration does not necessarily ensure a better

standard of care, we asked about these practices because they indicate

that a state has identified certain organizations or individuals and thus has

the capacity to apply additional requirements, such as criminal

background checks or special training. We also asked about states’

experience in operating the federally mandated registry for nursing home

aides that records documented findings of abuse, neglect, or

misappropriation of a resident’s property and the states’ use of this or

similar registries for home care workers. Finally, we inquired about the

presence of state requirements for criminal background checks of workers

and the records covered by these checks.

We completed our survey between August 1994 and April 1996. We

received responses from 49 states and the District of Columbia. We did not

independently verify the accuracy of state officials’ responses to our

survey questions regarding state laws and policies.

In addition to surveying state officials, we interviewed home care

providers and state and local officials in California, New York, and Oregon

regarding their approaches to screening home care workers. We also

spoke with home care consumers in Oregon and with officials from the FBI

and the Health Care Financing Administration (HCFA) and reviewed

relevant literature on the utilization, regulation, and characteristics of

home care. Our work was conducted in accordance with generally

accepted government auditing standards.

We did not assess the extent of the problems linked to home care

providers, nor did we determine to what extent the use of a criminal

8

42 U.S.C. 5119a(a)(2).

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background check is linked to a lower incidence of abuse, theft, or

misappropriation of property. Although in our interviews with consumers

we received some anecdotal reports of rough handling, verbal abuse, and

theft, we were unable to assess the extent of such problems. Doing so is

generally complicated because investigating and documenting such

incidents is difficult; they tend to be underreported, and the reports that

do exist are scattered among various administrative and law enforcement

record systems. We also did not assess the extent to which the operators

of home care organizations voluntarily purchase fidelity bonds, which

protect covered employers against losses due to employee dishonesty and

may be conditioned on certain employee screening practices.

Principal Findings Of those persons who received paid home care in 1989, half paid for their

care without any assistance from public sources or insurance.9

 Some of

this privately financed home care is provided by agencies that participate

in Medicare and Medicaid and are therefore subject to limited federal

requirements; however, the existence of such a large private market

suggests that a substantial portion of assistance may be provided by

organizations and individuals that function outside these programs.10 Care

provided outside federal programs is governed by state and local

requirements, which may also apply to federally financed care in the state

in which it is delivered.

How Do States Regulate

Home Care Providers?

States take a wide variety of approaches to categorizing and licensing

home care organizations. Among the 50 jurisdictions responding to our

survey, 41 required that at least certain organizations obtain a specific

license before providing home care services, with 35 licensing at least

some of the home care organizations that do not participate in the

Medicare program. In fact, 11 states indicated that all home care

9

See K. Liu and K. Manton, “Changes in Home Care Use by Disabled Elderly Persons: 1982-1989,” Pub.

No. 94-398 EPW (Washington, D.C.: Congressional Research Service, May 6, 1994). Also see Agency for

Health Care Policy and Research, “National Medical Expenditure Survey—Home Health Care: Use,

Expenditures, and Sources of Payment,” AHCPR Pub. No. 93-0040 (Washington, D.C.: U.S. Government

Printing Office, April 1993).

10See A.L. Jones, “Hospices and Home Health Agencies: Data from the 1991 National Health Provider

Inventory,” Advance Data, No. 257 (CDC, National Center for Health Statistics, November 3, 1994).

Using a sampling frame limited to “health care providers,” this survey found that 81.8 percent of home

health agencies were Medicare-certified, and a similar percentage (82.5 percent) were

Medicaid-certified, with these certified agencies accounting for 89.1 percent of the patients cared for

by organizations included in the survey. While this survey found that most home health agencies are

Medicare- or Medicaid-certified, it did not cover independent workers who provide home care services

and would have omitted most agencies that provide largely nonmedical supportive services.

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B-271516 

organizations were publicly regulated through state licensure. (See 

table 1.)

Table 1: States That Require Home

Care Organizations to Obtain a

License Organizations that

must be licensed Statea Number

Percentage of

U.S. population

over age 65

Allb Alaska, Florida, Indiana,

Louisiana, Maine, Nebraska,

New Hampshire, New Mexico,

Oklahoma, Texas, Washington

11 22.5

Certainc Arkansas, Arizona, California,

Colorado, Connecticut, District

of Columbia, Delaware,

Georgia, Hawaii, Idaho, Illinois,

Kansas, Kentucky, Maryland,

Minnesota, Missouri,

Mississippi, North Carolina,

North Dakota, New Jersey,

Nevada, New York, Oregon,

Pennsylvania, Rhode Island,

South Carolina, Tennessee,

Utah, Virginia, Wisconsin

30 62.0

None Alabama, Iowa,

Massachusetts, Michigan,

Ohio, South Dakota, Vermont,

West Virginia, Wyoming

9 15.2

No response Montana 1 0.3

aIncludes the 50 states and the District of Columbia.

bSome states that indicated that all home care organizations must obtain a state license

nevertheless indicated that their states had no restrictions against the advertisement of certain

home care services by unlicensed organizations.

cAmong the states indicating that certain providers are licensed, Colorado, Mississippi, Missouri,

and Wisconsin licensed only Medicare-certified organizations.

However, even states that regulate some home care services may not

prohibit advertisement of similar-sounding services by organizations that

are not licensed, registered, or certified. In 45 states, companion,

housekeeping and homemaker, or shopping services may be legally

advertised by organizations that are not licensed, registered, or certified.

(See appendix I.) More states regulated the advertisement of personal

care, home health, and home nursing. However, 30 states told us that

unlicensed and uncertified organizations might legally advertise personal

care; 14 did not specifically prohibit such organizations from advertising

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home health care, and 22 did not prohibit their advertisement of home

nursing or related home care services.

Although most states require that at least certain professionals who

provide paid home care obtain a state license, they are not likely to require

licensure or registration of some common types of home care workers.

While individual licensure is a common practice for the regulation of

practical nurses, physical therapists, occupational therapists, social

workers, and registered nurses, it is not common for home health aides,

homemakers, or choreworkers. As shown in appendix II, we found that

individuals who were neither licensed nor state-registered could advertise

personal care, companion, housekeeping and homemaker, or shopping

services in most states. Even home health and home nursing services

could legally be advertised by unlicensed and unregistered individuals in

about a third of the states. Some state officials also identified related

categories of service, such as adult day care and case management, that

unlicensed and unregistered providers could legally advertise.

Consumers seeking to file complaints against home care workers are faced

with a somewhat complex regulatory structure in some states, while in

other cases, no administrative complaint is possible, and they must file a

criminal complaint with the local police or a civil suit.11 In most states, the

responsibility for licensure of nursing home and home care workers was

spread across multiple agencies, units, or professional boards. Similarly,

although 20 states issued only one type of license to home care

organizations, nearly as many recognized two or more types of home care

organizations in their licensing processes.

Do States Compile a

Registry of Home Care

Workers?

A minority of states (14) reported routinely including at least some types

of home care workers in their state’s mandatory registry for nurses’ aides.12

 When we interviewed officials of home care organizations, some

11Difficulties inherent in litigation against home care providers are described in Sandra H. Johnson,

“Quality Control Regulation of Home Health Care,” Houston Law Review, 26 (1989), pp. 901-53.

12Although HCFA had not issued guidelines for the operation of nurses’ aide registries at the time our

survey began, most states reported they had developed their own guidelines. State agencies

responsible for surveys and certification of nursing facilities must have a process for receipt of

complaints and timely review and investigation of allegations of neglect, abuse, and misappropriation.

The agencies must notify the nurse’s aide, provide a reasonable opportunity for a hearing, and make a

finding. Some states require conviction by a court of law or a separate administrative process involving

the district attorney. In most states, once a finding is entered in the registry, it remains indefinitely.

States generally reported that persons with findings of involvement in abuse, neglect, or

misappropriation constituted less than 1 percent of registrants. Roughly two-thirds of states reported

only minor concerns with the registry’s effectiveness or operation. Generally, states allow anyone to

request a check of the nurses’ aide registry, and most do not currently charge a fee for registry checks,

although a few (Connecticut, Florida, and Iowa) reported charges of less than $6 per report.

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expressed concerns about entering qualified employees on any public

register that their competitors might use for recruitment. In addition, while

administrative expenses for the initiation of the nurse’s aide registry have

already been incurred, adding home care workers to the established

registry process would require additional resources, such as increased

time for data entry. More importantly, there may be greater difficulty in

substantiating complaints about home care workers since they are

generally subject to less oversight than nursing home workers.

Do States Conduct

Criminal Background

Checks?

Fifteen states reported requiring criminal background checks of at least

some of the individuals who may be employed as home care workers. In

these states, checks were usually a condition of agency licensure or

certification, although in a few states, they were also a condition of

individual licensure or registration. States reporting criminal background

check requirements for home care workers included Alaska, California,

Florida, Idaho, Indiana, Louisiana, Nevada, Ohio, Oklahoma, Oregon,

Rhode Island, Texas, Utah, Virginia, and Washington.13 Twelve of these

states indicated that state statutes or regulations specified the

jurisdictions that these checks must cover, but the breadth of the check

was generally limited to a state’s own criminal records, which may be

problematic where many workers come from neighboring states.

At least three states—Idaho, Nevada, and Ohio—reported using national

FBI data, but officials of other states we interviewed cited the expense of

FBI data as a reason for not using it. Almost all states that reported

requiring such checks indicated that a criminal background could be

grounds for denying employment or refusing licensure or for some other

type of adverse action, such as probationary certification.

Conclusions While it is difficult to assess the extent of problems with abuse, neglect, or

misappropriation of property in the home care industry, we found that

federal regulations do not require criminal background checks of home

care workers. While some states and localities have instituted criminal

background checks or other safeguards, states’ approaches to regulating

home care are quite varied, and in some instances, there may be few

13In Utah, applicants for registration as a Health Care Assistant are asked to provide a sworn statement

regarding their criminal background. In Minnesota, a statute allows but does not require a criminal

background check. Although state officials in California told us that the state has a law requiring a type

of criminal background check that is not based on fingerprints, a state official told us that the law has

not been enforced.

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formal safeguards to protect potentially vulnerable elderly persons from

unscrupulous operators.

Every state must maintain a registry of nursing home workers noting those

who have been involved in incidents of abuse, neglect, or

misappropriation from patients. Although some states incorporate home

care workers in a registry, and such registries may be valuable for

identifying individuals who have met particular training standards, the

effectiveness of such registries in identifying workers with histories of

poor performance may depend heavily on the capacity to document

incidents occurring in a largely unsupervised environment. While some

states have instituted criminal background checks for some home care

providers, few have used the FBI’s national data, citing cost concerns.

Agency Comments Officials of the Health Care Financing Administration and the Federal

Bureau of Investigation reviewed a draft of this report, and provided

primarily technical comments, which have been incorporated as

appropriate. HCFA officials also noted that,

“While we agree with and support efforts designed to eliminate fraud and abuse and

increase quality of care, we are unconvinced that there is enough consensus on the

mechanisms which should be employed to address these concerns. Consequently, we

believe States should be given the flexibility to determine how best to address these

issues.”

With respect to criminal background checks, FBI officials note that,

“The FBI’s user-fee program is the sole basis by which it funds processing of noncriminal

justice applicant fingerprints card submissions for licensing and employment purposes.

The FBI’s budget does not contain any Congressional authorization or appropriation for

funding of this part of its fingerprints operation.”

As we arranged with your office, unless you publicly announce its

contents earlier, we plan no further distribution of this report until 30 days

after the date of this letter. At that time, we will send copies of the report

to interested congressional committees, the Secretary of HHS, the

Administrator of HCFA, the Assistant Secretary for Aging, the Director of

the FBI, and other federal and state officials. We will also make copies

available to others upon request.

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If you have any questions or would like additional information, please

contact me at (202) 512-3092 or Sushil K. Sharma, Assistant Director, at

(202) 512-3460. Other major contributors to this report are listed in

appendix III.

Sincerely yours,

Kwai-Cheung Chan

Director of Program Evaluation

 in Physical Systems Areas

Page 13 GAO/PEMD-96-5 Criminal Background Checks for Home Care Workers
Contents

Letter 1

Appendix I 

Services That

Organizations That

Are Neither

Medicare-Certified

Nor State-Licensed

May Legally Advertise

16

Appendix II 

Services That

Individuals Who Are

Neither

State-Licensed Nor

State-Registered May

Legally Advertise

18

Appendix III 

Major Contributors to

This Report

20

Glossary 21

Table Table 1: States That Require Home Care Organizations to Obtain

a License

9

Abbreviations

FBI Federal Bureau of Investigation

HCFA Health Care Financing Administration

HHS Department of Health and Human Services

Page 14 GAO/PEMD-96-5 Criminal Background Checks for Home Care Workers
Page 15 GAO/PEMD-96-5 Criminal Background Checks for Home Care Workers
Appendix I 

Services That Organizations That Are

Neither Medicare-Certified Nor

State-Licensed May Legally Advertise

State Personal care Companion

Housekeeping

and homemaker Shopping Home health Home nursing

Alabama No Yes Yes Yes Yes Yes

Alaska No No Yes Yes No No

Arizona Yes Yes Yes Yes No Yes

Arkansas No Yes Yes Yes No No

California Yes Yes Yes Yes No No

Colorado Yes Yes Yes Yes Yes Yes

Connecticut Yes Yes Yes Yes No Yes

Delaware Yes Yes Yes Yes No No

District of Columbia No Yes Yes Yes Yes Yes

Florida No Yes Yes Yes No No

Georgia a a a a a a

Hawaii Yes Yes Yes Yes No No

Idaho Yes Yes Yes Yes No Yes

Illinois Yes Yes Yes Yes Yes Yes

Indiana Yes Yes Yes Yes a a

Iowa Yes Yes Yes Yes No No

Kansas Yes Yes Yes Yes No No

Kentucky Yes Yes Yes Yes No No

Louisiana No No No No No No

Maine No Yes Yes Yes No No

Maryland Yes Yes Yes Yes No No

Massachusetts Yes Yes Yes Yes Yes Yes

Michigan Yes Yes Yes Yes Yes Yes

Minnesota No a Yes Yes No No

Mississippi No Yes Yes Yes No Yes

Missouri Yes Yes Yes Yes Yes Yes

Nebraska a a Yes Yes a a

New Jersey No No No No No No

Nevada Yes Yes Yes Yes No No

New Hampshire No Yes Yes Yes No No

New Mexico Yes Yes Yes Yes No a

New York No Yes Yes Yes No No

North Carolina No Yes Yes Yes No No

North Dakota Yes Yes Yes Yes No Yes

Ohio Yes Yes Yes Yes Yes Yes

Oklahoma No Yes Yes Yes No No

Oregon Yes Yes Yes Yes No Yes

(continued)

Page 16 GAO/PEMD-96-5 Criminal Background Checks for Home Care Workers
Appendix I 

Services That Organizations That Are

Neither Medicare-Certified Nor

State-Licensed May Legally Advertise

State Personal care Companion

Housekeeping

and homemaker Shopping Home health Home nursing

Pennsylvania Yes Yes Yes Yes Yes Yes

Rhode Island No Yes No Yes No No

South Carolina Yes Yes Yes Yes No Yes

South Dakota Yes Yes Yes Yes Yes Yes

Tennessee Yes Yes Yes Yes No No

Texas No No Yes Yes No No

Utah Yes Yes Yes Yes No Yes

Vermont Yes Yes Yes Yes Yes Yes

Virginia No Yes Yes Yes No No

Washington No No No No No No

West Virginia Yes Yes Yes Yes Yes Yes

Wisconsin Yes Yes Yes Yes Yes Yes

Wyoming Yes Yes Yes Yes Yes Yes

aNo response provided for this item.

Page 17 GAO/PEMD-96-5 Criminal Background Checks for Home Care Workers
Appendix II 

Services That Individuals Who Are Neither

State-Licensed Nor State-Registered May

Legally Advertise

State Personal care Companion

Housekeeping

and homemaker Shopping Home health Home nursing

Alabama Yes Yes Yes Yes No No

Alaska No No Yes Yes No No

Arizona Yes Yes Yes Yes No Yes

Arkansas Yes Yes Yes Yes Yes Yes

California Yes Yes Yes Yes No No

Colorado Yes Yes Yes Yes Yes Yes

Connecticut Yes Yes Yes Yes No Yes

Delaware Yes Yes Yes Yes Yes No

District of Columbia Yes Yes Yes Yes Yes Yes

Florida No No No Yes No No

Georgia Yes Yes Yes Yes Yes Yes

Hawaii Yes Yes Yes Yes No No

Idaho Yes Yes Yes Yes No Yes

Illinois Yes Yes Yes Yes Yes Yes

Indiana Yes Yes Yes Yes No No

Iowa Yes Yes Yes Yes No No

Kansas Yes Yes Yes Yes Yes Yes

Kentucky Yes Yes Yes Yes No No

Louisiana No No No No No No

Maine No No Yes Yes No No

Maryland Yes Yes Yes Yes No No

Massachusetts Yes Yes Yes Yes Yes Yes

Michigan Yes Yes Yes Yes Yes Yes

Minnesota No a Yes Yes No No

Mississippi No Yes Yes Yes No Yes

Missouri Yes Yes Yes Yes Yes Yes

Nebraska Yes Yes Yes Yes No No

Nevada Yes Yes Yes Yes No No

New Hampshire No Yes Yes Yes No No

New Jersey a a a a a a

New Mexico Yes Yes Yes a No a

New York Yes Yes Yes Yes Yes Yes

North Carolina No Yes Yes Yes No No

North Dakota Yes Yes Yes Yes No Yes

Ohio Yes Yes Yes Yes Yes Yes

Oklahoma No Yes Yes Yes No No

Oregon Yes Yes Yes Yes No No

(continued)

Page 18 GAO/PEMD-96-5 Criminal Background Checks for Home Care Workers
Appendix II 

Services That Individuals Who Are Neither

State-Licensed Nor State-Registered May

Legally Advertise

State Personal care Companion

Housekeeping

and homemaker Shopping Home health Home nursing

Pennsylvania Yes Yes Yes Yes Yes Yes

Rhode Island Yes Yes Yes Yes Yes Yes

South Carolina Yes Yes Yes Yes No No

South Dakota Yes Yes Yes Yes Yes No

Tennessee Yes Yes Yes Yes No No

Texas No Yes Yes Yes No No

Utah No Yes Yes Yes No No

Vermont Yes Yes Yes Yes Yes Yes

Virginia a a a a a a

Washington Yes Yes Yes Yes No No

West Virginia Yes Yes Yes Yes Yes Yes

Wisconsin Yes Yes Yes Yes No No

Wyoming Yes Yes Yes Yes No No

aNo response provided for this item.

Page 19 GAO/PEMD-96-5 Criminal Background Checks for Home Care Workers
Appendix III 

Major Contributors to This Report

Program Evaluation

and Methodology

Division

Betty Ward-Zukerman, Project Manager

R.E. Canjar, Project Staff

Ed Logsdon, Project Staff

Venkareddy Chennareddy, Referencer

Office of General

Counsel

Susan Poling, Assistant General Counsel

Page 20 GAO/PEMD-96-5 Criminal Background Checks for Home Care Workers
Glossary

Chore Services Performance of tasks such as shopping, yard work, and housecleaning that

generally do not require hands-on contact with the consumer.

Chore Worker A title sometimes given to home care workers who perform chore

services.

Companion A title sometimes given to home care workers who perform companion

services.

Companion Services “Friendly visitor” services that may include assisting home care clients as

they perform basic or instrumental activities of daily living. This term may

connote services to clients who are less dependent than those receiving

services labeled “home health” or “personal care.”

Criminal Background

Check

A review of police or other law enforcement records designed to

determine whether a particular person has been convicted of unlawful

acts.

Home Care Organization A for-profit or nonprofit entity that provides any of or all the home care

services described below under “home care services.” This term excludes

home care providers who are self-employed or personal employees of

home care consumers.

Home Care Services Services provided to ill or disabled persons in private residences to assist

them either in recovering from illness or in continuing to live in their own

homes. Such services may be of any duration (short term, long term). They

include assistance with basic activities of daily living (for example,

bathing, eating, toileting), instrumental activities (for example, shopping,

meal preparation, laundry), or chronic medical conditions (for example,

catheter care, parenteral nutrition, wound care). Home care services are

provided under the rubric of home health care, personal care,

companionship, homemaker services, chore services, occupational

therapy, and physical therapy. The services are provided by a range of

personnel, from nurses and therapists to workers with little formal

training or education.

Page 21 GAO/PEMD-96-5 Criminal Background Checks for Home Care Workers
Glossary

Home Care Worker Anyone who performs home care services. This designation includes

professional nurses and therapists as well as paraprofessional workers

with little formal training.

Home Health Aide A title sometimes applied to a paraprofessional home care worker who

generally provides basic home health care and incidental personal care

services. Agencies that are Medicare-certified must ensure that home

health aides in their employ meet specific Medicare training requirements.

Home Health Care Assistance with health care provided in private residences to persons with

disabilities. This designation may include services of professional nurses

and therapists as well as those of paraprofessionals, such as home health

aides and personal care aides. Specific services may include

administration of medication, catheter care, wound care, and occupational

or physical therapy.

Homemaker Services Housekeeping assistance that may include cooking, cleaning, and laundry

and generally does not involve hands-on contact with the consumer.

License Permission to practice or operate in a certain capacity (for example, as a

home health aide) that is extended only to license holders. Licenses may

be extended to either businesses or individual workers. They are generally

subject to renewal at designated intervals and may presume satisfaction of

certain standards or submission to certain oversight processes.

Medicare-Certified A designation given to an entity that is approved for participation in the

Medicare program and is therefore eligible for Medicare reimbursement

(for example, a “certified” home health agency). Nurse’s aides who are

qualified to work in nursing homes that participate in Medicare or

Medicaid are also sometimes called “certified” nurse’s aides.

Occupational Therapist A title used by professionals who help persons with disabilities to develop,

recover, or maintain daily living and work skills or to compensate for loss

of function. An occupational therapist may also design or make special

equipment needed at home or at work. Persons who use this title generally

hold a bachelor’s degree in occupational therapy.

Page 22 GAO/PEMD-96-5 Criminal Background Checks for Home Care Workers
Glossary

Personal Care Aide A title sometimes given to paraprofessional home care workers who

perform personal care services. People who perform these functions are

also sometimes known as personal attendants or personal care workers.

Personal Care Services Functional assistance, including help with basic activities of daily living

(such as eating, bathing, toileting, and transferring from bed to chair), that

generally involves hands-on contact with the consumer.

Physical Therapist A title used by professionals who perform tasks designed to improve

mobility, relieve muscle pain, and prevent or limit the permanent physical

disabilities of patients suffering from injuries or disease. Unlike an

occupational therapist, a physical therapist focuses exclusively on

physical disabilities. Physical therapists are usually licensed and graduates

of an accredited physical therapy program.

Practical Nurse A home care worker who cares for the sick, injured, convalescing, and

handicapped under the direction of a physician or registered nurse. Such

workers perform tasks such as taking vital signs, treating bedsores,

administering injections and enemas, providing assistance with personal

care, giving alcohol rubs and massages, and inserting catheters. In some

states, practical nurses are referred to as vocational nurses. Many of the

functions performed by workers in this category are also performed by

persons called home health aides, but practical nurses are more likely to

have passed through a state licensing process and are consequently

referred to as licensed practical nurses or licensed vocational nurses.

Registered Nurse A graduate of any accredited nursing school who has passed the national

licensing examination. A registered nurse may include a person with an

associate’s degree in nursing (A.D.N.), a bachelor’s degree in nursing

(B.S.N.), or a hospital nursing diplomate.

Registry A list of individuals who work in a designated capacity or meet specific

qualifications. Depending on state rules, participation in a registry may

either be voluntary or mandatory. The content of registry entries may

range from worker name and address to detailed information about

worker qualifications, background, and past performance. Registration,

Page 23 GAO/PEMD-96-5 Criminal Background Checks for Home Care Workers
Glossary

unlike licensure, may not imply possession of a document, evidence of

fulfillment of particular requirements, or periodic submission to oversight.

Social Worker A person who helps individuals and families cope with problems such as

inadequate housing, serious illness, financial mismanagement, handicaps,

or substance abuse, generally through direct counseling or referral. Social

workers generally hold a bachelor’s degree in social work or a related

field.

Temporary Staffing Agency A type of temporary employment service that provides health care

workers on a contract basis. Such workers are generally considered

employees of the temporary staffing agency rather than of the

organizations or individuals for whom they perform services.

(973434) Page 24 GAO/PEMD-96-5 Criminal Background Checks for Home Care Workers
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