DEPARTMENT OF HEALTH &. HUMAN SERVICES 	 Office of Inspector General 

Washington, D.C. 20201 

JAN 19 2012 

TO: 	 Marilyn Tavellller 

Acting Administrator 

Centers for Medicare & Medicaid Services 

FROM: Stuart WrigHt 

Deputy Inspector General 

for Evaluation and Inspections 

SUBJECT: 	 Memorandum Report: 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 

The Patient Protection and Affordable Care Act (ACA) mandates that the Office of 

Inspector General (OIG) submit a report to Congress evaluating the Nationwide Program 

for National and State Background Checks on Direct Patient Access Employees of 

Long-Term-Care Facilities and Providers not later than 180 days after the program's 

completion. This memorandum report provides the results of a survey oflong-term-care 

provider administrators. The purpose ofthe survey was to collect baseline data on 

current practices regarding conducting background checks on potential employees and 

the effects on the long-term-care workforce. We plan to use this information in the 

mandated report to assess the effects of background checks on the availability of 

long-term-care workers. 

SUMMARY 

Section 6201 of the ACA established the Nationwide Program for National and State 

Background Checks on Direct Patient Access Employees of Long-Term-Care Facilities 

and Providers. 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, and mandates an OIG evaluation of the 

State programs. ACA requires OIG to evaluate certain aspects of participating States' 

programs. For example, OIG must determine the extent to which conducting background 

checks leads to any unintended consequences, including a reduction in the available 

workforce for long-term-care providers. 

I P.L. 111-148, enacted March 23, 2010. 

OEI-07-10-00421 Results of Long-Term-Care Provider Administrator Survey 
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OEI-07-10-00421 Results of Long-Term-Care Provider Administrator Survey

In May 2011, we surveyed long-term-care provider administrators in participating States 

about their current procedures for conducting background checks, the effects of 

background checks on the pool of prospective employees, and the availability and quality 

of prospective employees. Survey results indicate that 94 percent of administrators 

conducted background checks on prospective employees. Only 4 percent of those 

administrators encountered individuals who were unwilling to undergo a background 

check. Twenty-three percent of administrators believed that their organizations’ current 

background check procedures reduced the pool of prospective employees. Overall, 

81 percent of administrators believed that there is a sufficient pool of qualified applicants 

for job vacancies. However, survey results indicate that 9 percent of administrators did 

not receive applications from qualified individuals for at least some job vacancies. 

BACKGROUND

Nationwide Program for National and State Background Checks on Direct Patient 

Access Employees of Long-Term-Care Facilities and Providers

Section 6201 of ACA requires the Secretary of Health and Human Services to carry out a 

nationwide program in which States conduct national and State background checks of

prospective direct patient access employees of nursing facilities and other long-term-care 

providers.2 The program is administered by the Centers for Medicare & Medicaid 

Services (CMS) in cooperation with the Federal Bureau of Investigation (FBI). ACA 

provides up to $160 million in Federal funds for the program.

To implement the nationwide program, CMS began soliciting applications for grant 

awards in June 2010. Program start dates for each participating State vary based on when 

the State received a grant award. Once grants are awarded, it is expected that States may 

need some preparation time before they require long-term-care providers to begin 

conducting background checks. For example, States may need to set up information 

systems to accommodate the background check process or enact legislation that amends 

the requirements for long-term-care providers. Therefore, there may be some lag time 

between the program start date and the date that long-term-care providers begin 

conducting background checks. Some States had background check programs in place 

before they received their grants. The grants require these States to expand or improve

their programs in some way.3 For example, a State that had a program requiring 

background checks only on employees of nursing facilities would have to expand the 

program to include employees of other provider types (e.g., hospices, home health 

agencies). CMS plans to make all grant awards by September 30, 2012; however, the 

completion date of the program (i.e., the date that participating States deplete their grant 

funds) is unknown at this time. As of October 2011, 17 States had received grants.

 2 Section 6201(a)(6)(D) 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.

3 CMS, Funding Opportunity Announcement for Nationwide Program for National and State Background Checks, p. 14.
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OEI-07-10-00421 Results of Long-Term-Care Provider Administrator Survey

Mandated OIG Evaluation

The ACA mandate requires OIG to submit a report to Congress evaluating the program 

not later than 180 days after its completion. In July 2010, we began an evaluation 

entitled Nationwide Program for National and State Background Checks for 

Long-Term-Care Employees (OEI-07-10-00420). To comply with the required

timeframe, the evaluation follows the progress of the nationwide program in each State as 

it is carried out, rather than conducting a retrospective review at the end of the program. 

According to ACA, OIG must include the following in its evaluation:

1. A review of the various procedures implemented by participating States for 

long-term-care facilities or providers, including staffing agencies, to conduct 

background checks of prospective direct patient access employees under the 

nationwide program and identification of the most appropriate, efficient, and effective 

procedures for conducting such background checks;

2. An assessment of the costs of conducting such background checks (including startup 

and administrative costs);

3. A determination of the extent to which conducting such background checks leads to 

any unintended consequences, including a reduction in the available workforce for 

long-term-care facilities or providers; 

4. An assessment of the impact of the nationwide program on reducing the number of 

incidents of neglect, abuse, and misappropriation of resident property to the extent 

practicable; and

5. An evaluation of other aspects of the nationwide program, as determined appropriate 

by the Secretary.4

The information in this memorandum report pertains to the third issue above and will 

serve as a baseline in determining the effects of background checks on long-term-care 

workforce availability in the mandated report. The mandated report will also cover all 

other issues listed above.

METHODOLOGY

Sample Selection

In February 2011, we obtained data for the following provider types from the Online 

Survey, Certification, and Reporting (OSCAR) system: nursing facilities, skilled nursing 

facilities, home health agencies, hospices, and Intermediate Care Facilities for the 

Mentally Retarded (ICF/MR). As of March 2011, 10 States had been awarded funding

under the nationwide program: Alaska, California, Connecticut, Delaware, District of 

Columbia, Florida, Illinois, Missouri, New Mexico, and Rhode Island. We stratified the 

population of long-term-care providers by the number in each participating State to 

 4 P.L. 111 148 § 6201(a)(7)(A)(ii).
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OEI-07-10-00421 Results of Long-Term-Care Provider Administrator Survey

ensure that States with smaller numbers of providers were represented. One stratum 

consisted of providers in States with 500 or fewer providers (Alaska, Delaware, District 

of Columbia, New Mexico, and Rhode Island), and the other stratum consisted of 

providers in States with more than 500 providers (California, Connecticut, Florida, 

Illinois, and Missouri). We selected a stratified random sample of 100 providers from 

each stratum. If we had not stratified the population, the sample would likely not have 

included providers from each of the 10 States. Table 1 shows the number of providers in 

the population and sample by stratum and State.

Table 1: Number of Providers in Population and Sample by

Stratum and State

Stratum State Providers in 

Population

Providers in 

Sample

1

Alaska 89 4

Delaware 157 8

District of Columbia 330 21

New Mexico 489 33

Rhode Island 450 34

Stratum 1 Total 1,515 100

2

California 6,200 40

Connecticut 932 4

Florida 3,399 23

Illinois 3,534 22

Missouri 2,065 11

Stratum 2 Total 16,130 100

Overall Total 17,645 200

Source: OSCAR database, 2011.

Our population of long-term-care providers included only those that were in operation at 

the time of our data collection. In May 2011, we mailed a survey to the administrators of 

the sampled providers. We asked about their current procedures for conducting 

background checks on prospective employees and whether they believe that their 

background check procedures reduce the pool of prospective employees. We requested 

workforce data on the number of applicants and the number of persons hired for recently 

filled positions, if available. Finally, we solicited administrators’ opinions regarding the 

availability and quality of long-term-care applicants. We did not independently validate 

the survey responses.
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OEI-07-10-00421 Results of Long-Term-Care Provider Administrator Survey 

Response Rate

We received responses from 153 sampled providers. We determined that the remaining 

47 sampled providers were no longer in operation through telephone contact attempts and 

Internet searches. Therefore, we received responses from 100 percent of providers that 

were eligible to respond to the survey. Table 2 shows the number of responses for each 

provider type in each State by stratum. 

Table 2: Number of Eligible Sample Responses by Stratum, State, and Provider Type

Stratum State

Nursing 

Facilities/

Skilled 

Nursing 

Facilities

Home Health 

Agencies Hospices ICF/MRs Total

1 

Alaska 0 1 3 0 4 

Delaware 4 3 0 0 7 

District of Columbia 5 2 0 9 16

New Mexico 7 9 4 3 23

Rhode Island 13 4 1 7 25

2 

California 12 10 2 6 30

Connecticut 1 2 0 0 3 

Florida 7 12 0 0 19

Illinois 7 4 0 4 15

Missouri 9 1 1 0 11

Total 65 48 11 29 153

Source: Administrator responses to OIG survey, 2011.

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. 

RESULTS

Current Background Check Procedures

Ninety-four percent of administrators in the 10 participating States conducted background 

checks on prospective employees.5

 

 Of the administrators who conducted background 

checks, 82 percent conducted a State criminal history check, 41 percent conducted an FBI 

criminal history check, and 63 percent used other sources, such as sex offender registries 

5 Appendix A presents point estimates and 95-percent confidence intervals for all population estimates. We projected our results to 

the population of long-term-care providers in operation at the time of our data collection.
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OEI-07-10-00421 Results of Long-Term-Care Provider Administrator Survey

and the OIG List of Excluded Individuals/Entities. Of the administrators who conducted

background checks, 95 percent conducted them for all prospective employees, while 

5 percent conducted them only for certain positions. 

The information reported by administrators for this survey is consistent with information 

reported by nursing facility administrators for a survey we conducted in June 2009 for the 

report entitled Nursing Facilities’ Employment of Individuals With Criminal Convictions

(OEI-07-09-00110). That report found that 98 percent of nursing facilities conducted 

some type of background check on prospective employees. We note that the statistics 

from both surveys suggest that because most long-term-care providers were already 

conducting background checks prior to the implementation of the State background check 

programs, implementation of the new programs may not actually require much change, if 

any, in the providers’ current procedures.

Administrators’ Experiences With Conducting Background Checks

We asked administrators who conducted background checks whether they encountered 

any prospective employees who were unwilling to undergo one. Four percent of 

administrators had this experience. According to these administrators, prospective 

employees may have been unwilling to undergo a background check because their 

criminal history included convictions that might disqualify them from employment. The 

six administrators who responded affirmatively estimated that between 1 and 5 percent of 

prospective employees were unwilling to undergo a background check. In addition, they 

estimated that between 1 and 6 percent of prospective employees withdrew their 

applications after learning of the background check. While only 4 percent of 

administrators encountered prospective employees who were unwilling to undergo a 

background check, a much higher percentage held beliefs about the link between 

background check requirements and a reduction in the pool of prospective employees. 

Twenty-three percent of administrators believed that their organization’s current 

background check procedures reduced the pool of prospective employees. A similar 

percentage of administrators, 27 percent, believed some prospective employees did not 

apply because of their organization’s background check procedures. 

Thirty-two percent of administrators commented on the link between background check 

requirements and a reduction in the pool of prospective employees. Eleven

administrators expressed their belief that the reduction in the pool occurs because the 

background check requirement is commonly known to prospective employees before 

applying, which results in individuals with disqualifying convictions not submitting 

applications. In support of the background checks, 11 administrators commented that the 

elimination of individuals with disqualifying convictions from the workforce pool is 

appropriate to protect the safety of their organizations’ clients and staff. Nine 

administrators commented that they believe background check requirements have not 

reduced their number of prospective employees. These administrators said that few

prospective employees have disqualifying convictions and that they consistently receive a 

sufficient number of applications for job vacancies. However, one administrator

commented that the amount of time needed to process background checks reduces the 
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OEI-07-10-00421 Results of Long-Term-Care Provider Administrator Survey

pool of prospective employees. Another stated that a time limit on disqualifying offenses 

should be established.

Workforce Data

We asked administrators for the number of (1) job vacancies, (2) applications received 

for job vacancies, and (3) filled job vacancies for the period January 1 to May 1, 2011. 

Of the 153 respondents to our survey, 122 were able to provide definitive numbers for

each of these three elements. Nine percent of administrators had no job vacancies for the 

period; accordingly, they received no applications and did not fill any vacancies. 

Demonstrating the variety of sizes of providers in our sample, the number of job 

vacancies ranged from 0 to 180, the number of applications received from 0 to 2,422, and 

the number of job vacancies filled from 0 to 164. On average, administrators received

approximately six applications for every job vacancy and filled nearly all of their 

vacancies. The results of the administrators’ responses are shown in Table 3.

Table 3: Workforce Data

Element Average Median

Job Vacancies 11 6

Applications Received 61 24

Job Vacancies Filled 10 4

Source: OIG analysis of administrator responses, 2011.

Availability and Quality of Long-Term-Care Employees

Overall, survey results indicate that 81 percent of administrators had a sufficient pool of 

applicants for job vacancies. Administrators who did not have a sufficient pool of 

applicants cited prospective employees’ preferences for working in health care settings 

other than long-term care, low pay, and lack of desire to work in a rural area. We asked 

administrators whether they received applications for job vacancies from qualified 

individuals. Nine percent of administrators did not. None of these administrators 

believed that their organization’s background check requirement was a reason that 

applications from qualified individuals were not received. Instead, they said that

individuals who applied did not have the requisite education, skills, or certification for 

the position. 

We also asked administrators if there were particular job positions that they had difficulty 

filling with qualified individuals. Unrelated to background checks, nearly half of 

administrators (45 percent) had difficulty filling certain positions, such as registered 

nurse; physical, occupational, and speech therapist; social worker; and certified nurse 

aide.
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CONCLUSION

The survey results provide a baseline of information regarding the effects that conducting 

background checks have on the long-term-care workforce in the first 10 States to receive 

background check program grants. Nearly all administrators conduct background checks 

on prospective employees and current background check procedures do not appear to 

greatly reduce the available workforce. When State programs are complete or nearing 

completion, we will conduct a second survey to determine whether changes in 

background check procedures decrease the workforce pool. We will request the same 

workforce data and opinions as in the first survey. We will present the results in the 

mandated report entitled Nationwide Program for National and State Background Checks 

for Long-Term-Care Employees (OEI-07-10-00420).

CMS may wish to provide the information in this memorandum report to States that 

participate in the background check program as well as those States that are considering 

participation. This report is being issued directly in final form because it contains no 

recommendations. If you have comments or questions about this report, please provide 

them within 60 days. Please refer to report number OEI-07-10-00421 in all 

correspondence.
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OEI-07-10-00421 Results of Long-Term-Care Provider Administrator Survey 

APPENDIX A 

Table A-1: Point Estimates and Confidence Intervals

Estimate Sample 

Size

Point 

Estimate

95-Percent 

Confidence Interval

Current Background Check Procedures

Administrators who conducted background checks 153 94.0 86.5–97.5

Administrators who conducted State criminal history checks 147 81.9 72.1–88.8

Administrators who conducted FBI criminal history checks 147 40.9 30.5–51.2

Administrators who conducted other checks (e.g., sex 

offender registries, Office of Inspector General (OIG) List of 

Excluded Individuals/Entities)

147 62.5 52.2–72.8

Administrators who conducted background checks on all 

prospective employees 147 94.6 87.2–97.9

Administrators who conducted background checks only for 

certain positions 147 5.4 2.1–12.8

Administrators who encountered prospective employees 

who were unwilling to undergo a background check 153 4.2 1.5–11.1

Administrators who believed that their organization’s current 

background check procedures reduce the pool of 

prospective employees

153 23.4 15.6–33.5

Administrators who believed that prospective employees do 

not apply because of their organizations’ background check 

procedures

153 27.0 17.6–36.5

Administrators who offered comments about the link 

between background check requirements and a reduction in 

the pool of prospective employees

147 32.1 22.2–41.9

Workforce Data

Average number of job vacancies 122 10.9 8.2–13.6

Average number of applications received 122 61.0 42.3–79.6

Average number of job vacancies filled 122 9.7 7.2–12.2

Median number of job vacancies 122 6.1 3.5–9.8

Median number of applications received 122 24.1 14.9–38.9

Median number of job vacancies filled 122 3.8 2.5–9.4

Availability and Quality of Long-Term-Care Employees

Administrators who had a sufficient pool of qualified 

applicants for job vacancies 153 80.8 71.6–87.5

Administrators who did not receive applications for job 

vacancies from qualified individuals 153 8.9 4.5–16.8

Administrators who had difficulty filling particular job 

positions with qualified individuals 153 45.2 35.0–55.4

Source: OIG analysis of administrator responses, 2011.