Department of Health and Human Services

OFFICE OF 

INSPECTOR GENERAL 

 

NURSING FACILITIES’ 

EMPLOYMENT OF INDIVIDUALS 

WITH CRIMINAL CONVICTIONS 

 

Daniel R. Levinson 

Inspector General 

March 2011 

OEI-07-09-00110 
 

 EXECUTIVE SUMMARY 

OBJECTIVE

To determine whether and to what extent nursing facilities employed 

individuals with criminal convictions. 

BACKGROUND 

A member of Congress requested that the Office of Inspector General 

(OIG) undertake this evaluation. Federal regulation prohibits Medicare 

and Medicaid nursing facilities from employing individuals found guilty 

of abusing, neglecting, or mistreating residents by a court of law, or who 

have had a finding entered into the State nurse aide registry concerning 

abuse, neglect, or mistreatment of residents or misappropriation of their 

property. Interpretive guidelines from the Centers for Medicare & 

Medicaid Services (CMS) for this regulation state that “[nursing] 

facilities must be thorough in their investigations of the past histories of 

individuals they are considering hiring.” However, Federal law does not 

require that nursing facilities conduct State or Federal Bureau of 

Investigation (FBI) criminal background checks. State background 

check requirements vary in terms of what must be checked 

(e.g., statewide criminal history databases, publically available sex 

offender registries) and who must be checked (e.g., direct-care workers 

only, all staff). 

We selected a stratified random sample of 260 nursing facilities from 

the universe of 15,728 Medicare-certified nursing facilities and 

requested data on all individuals who were employed by the sampled 

nursing facilities on June 1, 2009. To gain access to criminal history 

record information, we entered into an Information Transfer Agreement 

with FBI. We compared employee data with the criminal history 

records FBI provided to identify individuals with criminal convictions 

employed by the sampled nursing facilities. 

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EXECUTIVE SUMMARY 

Consistent with the congressional request and objective of this 

evaluation, we used FBI data to determine whether 

individuals employed by nursing facilities had criminal 

convictions. Federal regulation prohibits Medicare and 

Medicaid nursing facilities from employing individuals found 

guilty of abusing, neglecting, or mistreating residents by a 

court of law, or who have had a finding entered into the State 

nurse aide registry concerning abuse, neglect, or mistreatment 

of residents or misappropriation of their property. 

FBI-maintained criminal history records do not contain 

detailed information (i.e., they do not indicate whether the 

victim of a crime was a nursing facility resident) to determine 

whether a conviction disqualifies an individual from nursing 

facility employment under Federal regulation. Therefore, we 

did not determine whether these individuals were employed in 

violation of Federal regulation as that question is outside the 

scope of this evaluation.

FINDINGS 

Almost all nursing facilities employed one or more individuals with 

at least one criminal conviction. Our analysis of FBI-maintained 

criminal history records revealed that 92 percent of nursing facilities 

employed at least one individual with at least one criminal conviction. 

Nearly half of nursing facilities employed five or more individuals with 

at least one conviction. Forty-four percent of employees with 

convictions were convicted of crimes against property (e.g., burglary, 

shoplifting, writing bad checks), making it the most common type of 

crime committed. Overall, 5 percent of nursing facility employees had 

at least one conviction in FBI-maintained criminal history records. 

Most convictions occurred prior to employment. Eighty-four percent of 

employees with convictions had their most recent conviction prior to 

their beginning date of employment. 

Despite the lack of a Federal requirement for nursing facilities to 

conduct criminal background checks, most States required, and/or 

nursing facilities reported conducting, some type of background 

check. Forty-three States required nursing facilities to conduct either 

an FBI or a statewide criminal background check for prospective 

employees. Some nursing facilities located in the remaining eight 

States reported conducting criminal background checks even though 

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EXECUTIVE SUMMARY 

they were not required to do so. All but 2 percent of nursing facilities 

reported conducting some type of background check. 

RECOMMENDATION 

After completion of our data collection, the Patient Protection and 

Affordable Care Act (P.L. 111-148) became Federal law. It requires the 

Secretary of Health & Human Services (HHS) to carry out a nationwide 

program for States to conduct national and statewide criminal 

background checks for direct patient access employees of nursing 

facilities and other providers. States may participate in this National 

Background Check Program by entering into agreements with the 

Secretary. 

In light of our findings and in carrying out the mandate for HHS to 

implement the nationwide criminal background check program, we 

recommend that CMS: 

Develop background check procedures. To ensure that States conduct 

background checks consistently, CMS should (1) clearly define the 

employee classifications that are direct patient access employees and 

(2) work with participating States to develop a list of State and local 

convictions that disqualify an individual from nursing facility employment 

under the Federal regulation and periods for which each conviction bars 

the individual from employment. 

AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 

RESPONSE 

In its written comments on the draft report, CMS agreed with our 

recommendation. CMS stated that in its solicitation to States for the 

National Background Check Program, the definition of “direct patient 

access employee” is anyone who routinely comes into contact or has the 

potential to come into contact with residents or clients, which for 

nursing facilities should include all staff. CMS also stated that it will 

work with the States through the National Background Check Program 

to assist them in developing lists of convictions that disqualify 

individuals from employment, as well as defining whether any of those 

conviction types can be assumed to be mitigated because of the passage 

of time and which convictions should never be considered mitigated or 

rehabilitated.
 TABLE OF CONTENTS 

EXECUTIVE SUMMARY .....................................i

INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 

FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 

Almost all nursing facilities employed one or more individuals 

with at least one criminal conviction . . . . . . . . . . . . . . . . . . . . . . . 11 

Despite the lack of a Federal requirement for nursing facilities 

to conduct criminal background checks, most States required, 

and/or nursing facilities reported conducting, some type of 

background check . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 

 

RECOMMENDATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 

Agency Comments and Office of Inspector General Response . . . 17 

APPENDIXES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 

A: Profile of Sampled Nursing Facility Employee 

Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 

B: Profile of Sampled Nursing Facilities’ Background Check 

Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 

C: Different Types of Resources Reveal Different Information . . 20 

 D: Point Estimates and Confidence Intervals. . . . . . . . . . . . . . . . 21 

 E: Agency Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 

ACKNOWLEDGMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
 INTRODUCTION 

OBJECTIVE

To determine whether and to what extent nursing facilities employed 

individuals with criminal convictions.

BACKGROUND 

A member of Congress requested that the Office of Inspector General 

(OIG) undertake this evaluation. This information has never been 

collected nationally prior to this evaluation. 

Federal Requirement 

Nursing facilities participating in Medicare and Medicaid are required 

to provide services that maintain the dignity and well-being of all 

residents.1, 2 Federal regulation prohibits Medicare and Medicaid 

nursing facilities from employing individuals found guilty of abusing, 

neglecting, or mistreating residents by a court of law. Employment of 

individuals who have had a finding entered into the State nurse aide 

registry3 concerning abuse, neglect, or mistreatment of residents or 

misappropriation of their property is also prohibited.4 Interpretive 

guidelines from the Centers for Medicare & Medicaid Services (CMS) for 

this regulation state that “[nursing] facilities must be thorough in their 

investigations of the past histories of individuals they are considering 

hiring.”5 

Neither Federal law nor regulation specifically requires that nursing 

facilities check State or Federal Bureau of Investigation (FBI) criminal 

history records for prospective employees. Despite this, nursing 

facilities have access to FBI criminal history records to conduct criminal 

background checks on individuals applying for positions involving direct 

1 In this report, we refer to Medicare-certified skilled nursing facilities and 

Medicaid-certified nursing facilities as “nursing facilities.” 

2 Social Security Act, §§ 1819(b)(2) and 1919(b)(2). 

3 A nurse aide is any individual providing nursing or nursing-related services to 

residents in a nursing facility who is not a licensed health professional, a registered 

dietitian, or someone who volunteers to provide such services without pay. Nurse aides 

assist residents in their activities of daily living, such as bathing, dressing, eating, and 

toileting. Sections 1819(e)(2) and 1919(e)(2) of the Social Security Act and 

42 CFR § 483.156 require each State to establish and maintain a registry of individuals who 

have completed training and who the State finds to be competent to function as nurse aides. 

4 42 CFR § 483.13(c)(1)(ii). 

5 CMS, State Operations Manual, Appendix PP, F225. 

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INTRODUCTION 

patient care.6 Some States require such checks under their own 

authority. Sources of background check information and specific State 

requirements are discussed below. 

Sources of Background Check Information 

FBI criminal background checks. For FBI criminal background checks, an 

individual provides identifying information (usually full name, Social 

Security number (SSN), date of birth, race, and gender) and a set of 

fingerprints (electronic or rolled manually) to a State law enforcement 

agency. The State law enforcement agency provides the individual’s 

information and fingerprints to FBI to match against criminal background 

information maintained in its databases (e.g., the Interstate Identification 

Index, which is an electronic repository of criminal history record 

information that FBI maintains). FBI then provides the requesting law 

enforcement agency with a criminal history report, if one is found, 

containing the dates of any arrests, arresting agencies, and offenses for 

which the individual was charged and/or convicted. The FBI database 

includes information on both Federal crimes and crimes reported by 

States. 

Statewide criminal background checks. For statewide criminal 

background checks, an individual must provide identifying information 

similar to that required to conduct an FBI criminal background check, 

but usually is not required to submit fingerprints. This type of 

background check is conducted by a State law enforcement agency 

(e.g., State Police, Highway Patrol) and provides information similar to 

that in the Interstate Identification Index, but only for crimes 

committed within that State. 

Additional databases. In addition to conducting an FBI and/or statewide 

criminal background check, some nursing facilities search other 

available databases (e.g., State abuse registries, National Sex Offender 

Registry). Additionally, Federal regulations require all States to 

maintain a nurse aide registry, which nursing facilities are required to 

check for nurse aides.7 The information contained in these databases 

may also disqualify an individual from employment in a nursing facility, 

but checking these databases is not a component of FBI or statewide 

criminal background checks. 

6 P.L. 105-277 § 124 (Oct. 21, 1998). Section 124 does not further define “direct patient 

care.”

7 42 CFR § 483.75(e)(6).

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INTRODUCTION 

State Requirements for Background Checks on Nursing Facility Employees 

State background check requirements vary in terms of what must be 

checked (e.g., statewide criminal history databases, publically available 

sex offender registries) and who must be checked (e.g., direct-care 

workers only, all staff). Ten States require an FBI criminal background 

check as well as a statewide check. Thirty-three States require a 

criminal background check in the State where the nursing facility is 

located. The remaining eight States do not have a background check 

requirement.8 The State requirements or the lack thereof do not 

prohibit nursing facilities from conducting more extensive checks on 

their own initiative. Table 1 provides an overview of the types of 

criminal background checks States require. 

Table 1: Nursing Facility Criminal Background Check Requirements by 

State 

Type of Check 

Required States Number of States

FBI and Statewide AK, AZ, DE, ID, MI, MS, NM, NV, NY, TN 10 

Statewide* 

AR, CA, DC, FL, GA, IL, IN, IA, KS, KY, 

LA, ME, MD, MA, MN, MO, NE, NH, NJ, 

NC, OH, OK, OR, PA, RI, SC, TX, UT, VA, 

VT, WA, WV, WI 

33 

None AL, CO, CT, HI**, MT, ND, SD, WY 8 

 Total 51 

Source: OIG Internet research and phone calls to States, 2009.

*Note: Some States that require statewide checks also require nursing facilities to conduct an 

FBI check if the individual has not lived in the State for a minimum period of time 

(e.g., 5 years).

**Note: A statute requiring FBI checks exists in Hawaii; however, no implementing rules have 

been published. A Hawaii State official confirmed that nursing facilities are not yet required to 

conduct such checks. 

State-Identified Disqualifying Conditions 

As discussed above, Federal regulation prohibits employing individuals 

who have certain types of convictions or who have certain findings 

entered against them in State nurse aide registries. In addition, some 

States have more specifically identified types of convictions that bar 

individuals from obtaining employment in nursing facilities. States 

differ in regard to what types of convictions disqualify individuals and 

8 This report refers to the 50 States and the District of Columbia as “States.” 

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INTRODUCTION 

how recently a conviction must have occurred to disqualify them. For 

example, one State lists nine types of convictions (including murder, 

voluntary manslaughter, and felony battery within the previous 5 years) 

that bar individuals from employment at nursing facilities. 

Internet research and structured interviews with State staff indicate 

that some States allow individual nursing facilities to make decisions 

regarding the employability of individuals with criminal convictions, 

while others rely on a State agency (e.g., Department of Public Health) 

to make such determinations. Some States allow employees to work at 

nursing facilities provisionally until the results of their background 

checks are obtained. 

Legislative History Regarding Background Check Requirements 

The Medicare Prescription Drug, Improvement, and Modernization Act 

of 2003 (MMA) established a Background Check Pilot Program.9 The 

purpose of the pilot program was to “identify efficient, effective, and 

economical procedures” for conducting State and national criminal 

background checks on prospective “direct patient access employees,” as 

defined in the statute.10 Participating States required a 

fingerprint-based FBI and statewide criminal background check, as well 

as a search of other databases (e.g., State nurse aide registries, State 

sex offender registries) likely to contain disqualifying information. CMS 

selected seven States (Alaska, Idaho, Illinois, Michigan, Nevada, New 

Mexico, and Wisconsin) to participate in the pilot program, which 

concluded in September 2007.11 Across the participating States, 

204,339 criminal background checks were initiated, of which 

7,463 resulted in individuals’ not being hired by a nursing facility; an 

additional 38,400 individuals withdrew their applications prior to 

completion of their criminal background checks.12

On March 23, 2010, the Patient Protection and Affordable Care Act 

(P.L. 111-148) became Federal law. Section 6201 requires the Secretary 

4 

9 P.L. 108-173, § 307. 

10 Section 307 of P.L. 108-173 defines a “direct patient access employee” as any 

individual (other than a volunteer) 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, as determined by a participating State for purposes of conducting the pilot 

program in such State. This term applies to employees checked through the pilot program. 

11 States’ participation in the pilot program began between 2005 and 2006. 

12 Abt Associates, Inc., Evaluation of the Background Check Pilot Program, August 2008, 

p. 207. 

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INTRODUCTION 

of Health & Human Services (Secretary) to carry out a nationwide 

program for States to conduct national and statewide criminal 

background checks for direct patient access employees of nursing 

facilities and other providers similar to the pilot program the MMA 

established. This National Background Check Program is to be 

conducted through means that utilize a fingerprint-based search of 

State and Federal criminal history records. States may participate in 

the nationwide program by entering into agreements with the 

Secretary. Grant funding will be disbursed to States in fiscal years 

2010 through 2012. 

Related Testimony and Reports 

In 2002, the Government Accountability Office (GAO) testified before 

the U.S. Senate Special Committee on Aging that sources (e.g., State 

nurse aide registries) used to screen prospective employees do not 

contain complete or up-to-date information.13 GAO noted that some 

States require nursing facilities to conduct only statewide criminal 

background checks. Consequently, individuals who have been convicted 

of crimes in one State can cross State lines to obtain employment in 

another State. 

In 2005, OIG issued two reports related to the employment of nurse 

aides in nursing facilities nationwide. In the first report, OIG found 

that more than 1,500 nurse aides with substantiated findings of abuse, 

neglect, or misappropriation of property in 1 State had active 

certifications in other States.14 In addition, 36 employees who were not 

nurse aides (e.g., janitors) with histories of abuse in 1 State had active 

certifications as nurse aides in other States. The second report found 

that while 85 percent of nursing facilities conducted background checks 

of nurse aides, half of these were limited in scope (e.g., they covered a 

single State).15

5 

13 GAO, Many Shortcomings Exist in Efforts to Protect Residents from Abuse

(GAO-02-448T), March 2002. 

14 OIG, Nurse Aide Registries: State Compliance and Practices (OEI-07-03-00380), 

February 2005. 

15 OIG, Nurse Aide Registries: Long Term Care Facility Compliance and Practices 

(OEI-07-04-00140), July 2005. 

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INTRODUCTION 

METHODOLOGY 

Scope and Limitations 

We reviewed FBI criminal histories of individuals employed by sampled 

nursing facilities on June 1, 2009. We did not determine the criminal 

histories of individuals employed in other types of long-term care 

settings (e.g., hospice) or nursing facility residents. Additionally, we did 

not seek to determine the effectiveness of conducting criminal 

background checks as an employment screening tool for nursing facility 

employees. 

Our estimate of the number of nursing facility employees with criminal 

convictions relies entirely upon the accuracy of the information 

contained in FBI’s Interstate Identification Index. Because the 

Interstate Identification Index relies on local, State, and Federal law 

enforcement agencies to report criminal records, it is possible that not 

all criminal history record information was accurate and up-to-date. 

The criminal history record information we received from FBI suggested 

that the records did not contain all of the convictions for particular 

employees. For example, criminal history record information contained 

notations of probation violations (suggesting that a conviction occurred), 

but the record did not contain the convictions leading to the imposition 

of probation periods. In addition, many charges had no corresponding 

disposition information (e.g., conviction, dismissal), so we could not 

determine whether a conviction occurred. Finally, it is possible that 

some individuals’ records did not contain convictions because they were 

removed following a judicial diversion program (e.g., completion of an 

alcohol and substance abuse education course). 

Our estimates are conservative because we did not include criminal 

convictions if we could not conclusively identify the individual (e.g., if 

identifiers were similar but did not exactly match). Also, we could not 

confirm that the information that nursing facilities provided us was 

accurate or that the information the employees provided to the nursing 

facilities was accurate. 

FBI-maintained criminal history records do not contain detailed 

information (i.e., whether the victim of a crime was a nursing facility 

resident) to determine whether a conviction disqualifies an individual 

from nursing facility employment under Federal regulation. Therefore, 

we limited our use of the FBI data, consistent with the congressional 

request, to determining whether individuals employed by nursing 

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INTRODUCTION 

facilities had criminal convictions, but we did not determine whether 

these individuals were employed in violation of Federal regulation. 

Finally, the Information Transfer Agreement16 entered into by FBI and 

OIG stipulates that identifying information contained in FBI records 

shall be used only for research and statistical purposes. Therefore, we 

were prohibited from recontacting nursing facilities to further inquire 

about the background checks they conducted on specific individuals. In 

addition, the Information Transfer Agreement prohibits OIG from 

releasing information that may be used to identify individuals or 

nursing facilities associated with this evaluation. 

Sample and Data Sources 

We selected a stratified random sample from the universe of 

15,728 nursing facilities contained in the Online Survey, Certification, 

and Reporting (OSCAR) database as of February 10, 2009. To produce 

nationwide estimates of the number and percentage of nursing facilities 

employing individuals with criminal convictions, we selected a sample of 

260 nursing facilities from 3 strata as shown in Table 2. 

Table 2: Nursing Facility Population and Sample Size 

Stratum Definition Population Size Sample Size

Nursing facilities from States that require FBI 

and statewide checks 1,987 110 

Nursing facilities from States that require 

statewide checks 12,687 110 

Nursing facilities from States that have no 

background check requirement 1,054 40 

 Total 15,728 260 

Source: OSCAR database, February 10, 2009. 

We chose to stratify based on State background check requirements in 

an effort to determine whether differing requirements played a role in 

nursing facility employment of individuals with criminal convictions. 

We did not identify an effect that might be explained by a number of 

factors (e.g., checks conducted by nursing facilities in addition to those 

that their States require, differences among States regarding the 

16 An Information Transfer Agreement governs the terms of OIG’s access to FBI criminal 

history records for research purposes. 

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INTRODUCTION 

circumstances that prohibit individuals from working in nursing 

facilities). 

Data Collection 

Employee data. From each of the 260 sampled nursing facilities, we 

requested information for all noncontract individuals who were 

employed on June 1, 2009.17 We requested each employee’s full name, 

SSN, date of birth, race, gender, beginning date of employment, and job 

classification. We also requested whether each individual was 

considered a direct-care employee.18 Four nursing facilities did not 

respond to our request because they were no longer operating; therefore, 

we received data for 35,286 employees from 256 nursing facilities.19 See 

Appendix A for a profile of sampled nursing facility employee 

characteristics. 

To assess whether a nursing facility provided us with information for all 

of its employees, we compared the number of employees submitted to us 

with the total number of employees listed in the OSCAR database for 

that facility. We contacted four nursing facilities that provided 

information for +/- 25 percent of the number of employees as listed in 

OSCAR to determine whether the information provided correctly 

answered our request. We requested and received revised employee 

data from these four facilities; however, given routine staffing 

fluctuations, we did not question the accuracy of employee data that 

closely approximated the number of employees listed in OSCAR. 

Mail survey. We sent the administrator of each of the sampled nursing 

facilities a survey about background check procedures. The survey 

included questions about the types of background checks they 

conducted, when the nursing facilities began conducting background 

checks, what the costs of conducting background checks were, and what 

job classifications they considered direct care. We received completed 

17 We did not request identifying information for individuals who provide services for a 

nursing facility through a staffing agency (e.g., contract employees). Generally, for States 

that require criminal background checks, staffing agencies, not the nursing facilities, are 

responsible for conducting checks and making decisions about employment for contract 

employees. 

18 Sampled nursing facilities differed on what job classifications constituted direct-care 

staff. 

19 Nursing facilities provided information on 46 individuals who were employed in 

2 different sampled nursing facilities as of June 1, 2009. Therefore, we collected data on 

35,240 unique individuals. 

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INTRODUCTION 

surveys from all 256 nursing facilities. See Appendix B for a profile of 

sampled nursing facilities’ reported background check characteristics. 

Criminal history records. To gain access to criminal history record 

information, we entered into an Information Transfer Agreement with 

FBI. We provided the employee data obtained from nursing facilities to 

FBI. FBI performed a name-based match with the Interstate 

Identification Index. Of the 35,286 names we provided, we received the 

criminal history record information for approximately 

11,200 individuals who closely matched the names we provided.20 

Because FBI uses an algorithm to conduct name-based searches, we 

received multiple matches for some of the searches, especially for 

individuals with common names. 

Analysis 

Employee data and criminal history records. Using the SSN, date of birth, 

race, and gender identifiers, we further examined the matches FBI 

provided to identify the individuals employed by the nursing facilities. 

We determined that approximately 4,400 individuals matched the 

identifiers of the individuals employed by sampled nursing facilities.21

We analyzed the information to identify individuals with criminal 

convictions employed by the sampled nursing facilities. Using six broad 

categories of offenses, we recorded convictions for each positively 

matched individual’s criminal history.22 Following are examples of 

specific offenses included in each broad category; these lists do not 

include every specific offense we found in each of the six categories: 

 crimes against persons: assault, battery, murder, rape, robbery; 

 crimes against property: burglary, larceny, possession of stolen 

property, shoplifting, theft, vandalism, writing bad checks; 

 driving under the influence of drugs or alcohol (DUI): driving under 

the influence, driving while intoxicated; 

20 FBI did not provide any matches for approximately 24,000 individuals; therefore, we 

did not perform further analysis on these individuals. 

21 The identifiers of the other approximately 6,800 individuals did not match the 

identifiers of the sampled nursing facility employees (e.g., different date of birth, different 

SSN). 

22 We consulted FBI definitions of “crime” to assist us in categorizing offenses. Accessed 

at http://www.fbi.gov/ucr/ on August 14, 2009. 

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INTRODUCTION 

 driving-related crimes (other than DUI): leaving the scene of an 

accident, transporting an open container of alcohol in a vehicle; 

 drug-related crimes: possession of drugs or paraphernalia, sale of 

controlled substances; and 

 other: disorderly conduct, prostitution, resisting arrest, weapons 

violations. 

Sex offender registries. The criminal history record information 

provided by FBI indicated that a few nursing facility employees were 

registered as sexual offenders. Because additional information is 

readily available on sexual offenses, we examined Federal and State sex 

offender registries for these employees.23 The examination of these 

registries demonstrated how such checks can provide additional 

information to complement a criminal background check. See 

Appendix C for the results of our review. 

Standards 

This study was conducted in accordance with the Quality Standards for 

Inspection and Evaluation approved by the Council of the Inspectors 

General on Integrity and Efficiency. 

23 Most other types of offenses (e.g., drug-related crimes) do not have similar registries. 

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 FINDINGS 

Consistent with a congressional request, the objective of this 

evaluation is to determine whether and to what extent 

nursing facilities employed individuals with criminal 

convictions. Federal regulation prohibits Medicare and 

Medicaid nursing facilities from employing individuals found 

guilty of abusing, neglecting, or mistreating residents by a 

court of law, or who have had a finding entered into the 

State nurse aide registry concerning abuse, neglect, or 

mistreatment of residents or misappropriation of their 

property. FBI-maintained criminal history records do not 

contain detailed information (i.e., they do not indicate 

whether the victim of a crime was a nursing facility resident) 

to determine whether a conviction disqualifies an individual 

from nursing facility employment under Federal regulation. 

Therefore, we used the FBI data to determine whether 

individuals employed by nursing facilities had criminal 

convictions. We did not determine whether these individuals 

were employed in violation of Federal regulation as that 

question is outside the scope of this evaluation. 

Almost all nursing facilities employed one or more 

individuals with at least one criminal conviction 

Our analysis of FBI-maintained 

criminal history records revealed 

that 92 percent of nursing facilities 

employed at least one individual with at least one criminal conviction.24 

The number of individuals with at least 1 conviction employed by these 

nursing facilities ranged from 1 to 66. 

Nearly half of nursing facilities employed five or more individuals with 

at least one conviction. For example, a nursing facility with a total of 

164 employees had 34 employees with at least 1 conviction each. These 

34 individuals had 102 total convictions categorized as follows: 

29 convictions for crimes categorized as other, 25 convictions for crimes 

against property, 18 drug-related convictions, 16 convictions for crimes 

against persons, 8 convictions for DUI, and 6 driving-related 

convictions. Table 3 shows the percentages of nursing facilities that 

employed various percentages of employees with convictions. 

11 

24 Appendix D presents the point estimates and confidence intervals for all population 

estimates. 

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FINDINGS 

Table 3: Percentage of Nursing Facilities That Employed Various 

Percentages of Employees With Criminal Convictions 

Percentage of Employees With Criminal 

Convictions 

Percentage of 

Nursing Facilities

None 7.7% 

Up to 5.0% 51.8% 

Greater than 5.0% to 10.0% 26.0% 

Greater than 10.0% to 15.0% 6.3% 

Greater than 15.0% to 20.0% 5.7% 

Greater than 20.0% to 25.0% 2.5% 

 Total 100.0% 

Source: OIG analysis of FBI criminal history records and nursing facility employee data, 2009. 

The most common criminal conviction was for crimes against property 

Among employees with criminal convictions, the most common criminal 

conviction was for crimes against property, such as burglary, 

shoplifting, and writing bad checks (44 percent). Table 4 shows the 

categories of crimes for which nursing facility employees were convicted. 

Table 4: Categories of Crimes for Which Nursing Facility Employees 

Were Convicted 

Category of Crime Percentage of Employees 

With Criminal Convictions

Crimes against property 43.6%* 

Other 26.4% 

DUI 20.3% 

Drug-related crimes 16.2% 

Crimes against persons 13.1% 

Driving-related crimes other than DUI 11.9% 

Source: OIG analysis of FBI criminal history records and nursing facility employee 

data, 2009. 

Percentages do not sum to 100 percent because some employees had criminal 

convictions of more than one category. 

*The percentage of employees with property convictions was statistically higher than all 

the other categories at the 95-percent confidence level. 

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FINDINGS 

Five percent of nursing facility employees had at least one criminal 

conviction 

Overall, 5 percent of nursing facility employees had at least one 

conviction in FBI-maintained criminal history records. Employees with 

at least one conviction in their criminal history records averaged 

two convictions per employee. The number of criminal convictions per 

employee in our sample ranged from 1 to 110. 

Five percent of staff identified by the nursing facilities as direct-care 

employees had criminal convictions, which mirrors the conviction rate 

for nursing facility staff in general. The term “direct-care staff” 

encompasses many job classifications (e.g., nurses, nurse aides). 

Sampled nursing facilities differed on what job classifications 

constituted direct-care staff. In addition to reporting which of their 

employees they consider direct-care staff, nursing facilities reported the 

job classifications of all of their employees. Table 5 shows the 

percentage of employees with certain job classifications who had 

convictions. 

Table 5: Nursing Facility Employees With Certain Job Classifications 

Who Had Convictions

Job Classification 

Percentage of 

Employees With 

Convictions

Housekeeping/laundry/maintenance/security 6.5% 

Certified nursing and medication aides 6.4% 

Dietary 5.7% 

Nursing (e.g., registered and licensed practical nurses) 3.6% 

All other 2.7% 

Administration 2.6% 

Source: OIG analysis of FBI criminal history records and nursing facility employee data, 2009. 

Most criminal convictions occurred prior to employment 

Eighty-four percent of employees with criminal convictions had their 

most recent conviction prior to their beginning date of employment. Of 

the employees with criminal convictions prior to the beginning date of 

employment, 38 percent had their most recent conviction 10 or more 

years prior to employment. For example, 1 individual employed since 

2005 had 13 convictions for crimes against property, the last of which 

was in 1988. No further convictions appeared in this employee’s 

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FINDINGS 

criminal history record. Table 6 shows the elapsed time between an 

employee’s most recent conviction before his or her beginning date of 

employment. 

Table 6: Elapsed Time Between Employee’s Most Recent Conviction 

Before Beginning Date of Employment 

Elapsed Time Before Beginning 

Date of Employment 

Percentage of Employees 

With Convictions Prior to 

Employment

Less than 1 year 7.5% 

1 year to less than 5 years 28.6% 

5 years to less than 10 years 26.1% 

10 years or more 37.8% 

 Total 100.0% 

Source: OIG analysis of FBI criminal history records and nursing facility employee 

data, 2009. 

Sixteen percent of employees with convictions had their most recent 

conviction after their beginning date of employment. For example, one 

individual employed since January 2009 in a nursing facility 

housekeeping department was convicted of assault in July 2009. The 

individual pleaded guilty to the charge and was sentenced to 2 years’ 

probation and 60 hours of community service. Another individual 

employed in a nursing facility maintenance department since 1978 had 

no convictions listed in the criminal history record until 1991. The 

individual’s criminal history record listed a total of five convictions (two 

for drug-related crimes and three for DUI), all of which occurred after 

the beginning date of employment. A nursing facility would need to 

conduct periodic criminal background checks to identify these 

convictions. Table 7 shows the elapsed time between an employee’s 

beginning date of employment and his or her most recent conviction. 

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FINDINGS 

Table 7: Elapsed Time Between Employee’s Beginning Date of 

Employment and Most Recent Conviction 

Elapsed Time After Beginning Date 

of Employment 

Percentage of Employees With 

Convictions After Beginning 

Date of Employment

Less than 6 months 15.8% 

6 months to less than 1 year 10.7% 

1 year to less than 2 years 22.4% 

2 years to less than 5 years 23.3% 

5 years to less than 10 years 14.9% 

10 years or more 12.8% 

 Total 100.0%* 

Source: OIG analysis of FBI criminal history records and nursing facility employee data, 2009.

*Percentages do not sum to 100 percent because of rounding. 

Forty-three States required 

nursing facilities to conduct 

either an FBI or a statewide 

criminal background check for 

prospective employees. Ten 

States required FBI criminal 

background checks and 

33 States required statewide criminal background checks. 

Despite the lack of a Federal requirement for 

nursing facilities to conduct criminal 

background checks, most States required, 

and/or nursing facilities reported conducting, 

some type of background check 

Some nursing facilities located in the remaining eight States reported 

conducting criminal background checks even though they were not 

required to do so. All but 2 percent of nursing facilities reported 

conducting some type of background check.25 The most common type of 

background check nursing facilities reported conducting was a 

statewide criminal background check, followed by other types of checks 

(e.g., State abuse registries, State nurse aide registries) and then FBI 

criminal background checks.26 Half of nursing facilities reported using 

25 These nursing facilities were located in two States; one State required nursing 

facilities to conduct statewide criminal background checks and the other State had no 

requirements for conducting criminal background checks. 

26 Difference was statistically significant at the 95-percent confidence level. The 

percentage of nursing facilities that reported conducting each type of check and the results 

of the difference tests are available in Appendix D. 

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FINDINGS 

other sources for background checks, such as State-specific abuse or sex 

offender registries and private agencies. 

Administrators for 94 percent of nursing facilities that conduct 

background checks reported conducting them on all classifications of 

employees. Another 4 percent reported conducting background checks 

only on direct-care staff.27 However, sampled nursing facilities differed 

on what job classifications constituted direct-care staff. For example, 

14 nursing facilities considered all employees in the nursing facilities to 

be direct care (i.e., having the potential of direct access to residents), 

while other nursing facilities limited the definition to discrete job 

classifications (e.g., nurses, therapists, and activity workers). 

27 The remaining facilities did not answer this question. 
 

 RECOMMENDATION 

After completion of our data collection, the Patient Protection and 

Affordable Care Act (P.L. 111-148) became Federal law. It requires the 

Secretary to carry out a nationwide program for States to conduct 

national and statewide criminal background checks for direct patient 

access employees of nursing facilities and other providers similar to the 

pilot program MMA established. The program is being carried out in 

fiscal years 2010 through 2012. Public Law 111-148 also requires OIG 

to review the nationwide program and submit a report to Congress no 

later than 180 days after the completion of the nationwide program. 

In light of our findings and in carrying out the mandate for the 

Department of Health & Human Services to implement the nationwide 

criminal background check program, we recommend that CMS: 

Develop background check procedures 

To ensure that States conduct background checks consistently, CMS 

should (1) clearly define the employee classifications that are direct 

patient access employees and (2) work with participating States to 

develop a list of State and local convictions that disqualify an individual 

from nursing facility employment under the Federal regulation and 

periods for which each conviction bars the individual from employment. 

AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 

RESPONSE 

In its written comments on the draft report, CMS agreed with our 

recommendation to develop background check procedures. CMS stated 

that in its solicitation to States for the National Background Check 

Program, the definition of “direct patient access employee” is anyone 

who routinely comes into contact or has the potential to come into 

contact with residents or clients. For nursing facilities, this definition 

should include all staff. 

CMS also stated that it will work with the States through the National 

Background Check Program to assist them in developing lists of 

convictions that disqualify individuals from employment, as well as 

defining whether any of those conviction types can be assumed to be 

mitigated because of the passage of time and which convictions should 

never be considered mitigated or rehabilitated. We did not make any 

changes to the report based on CMS’s comments. The full text of CMS’s 

comments on the draft report can be found in Appendix E. 

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 APPENDIX ~ A 

Table A-1: Profile of Sampled Nursing Facility Employee Characteristics 

Characteristic Subgroup 

Number of 

Employees 

(n=35,286) 

Percentage of 

Employees

Certified nursing and medication aides 12,456 35.3% 

Nursing (e.g., registered and licensed practical nurses) 6,986 19.8% 

Dietary 3,866 11.0% 

Housekeeping/laundry/maintenance/security 3,814 10.8% 

Administration 3,584 10.2% 

Supervisory nursing 1,090 3.1% 

Hospitality/activities/chaplains 1,018 2.9% 

Therapists 866 2.5% 

Aides not otherwise specified 677 1.9% 

Social workers 466 1.3% 

Other clinical personnel 258 0.7% 

Other 79 0.2% 

Transportation 81 0.2% 

Job Classification 

Beauticians 45 0.1% 

Male 5,171 14.7% 

Gender Female 29,893 84.7% 

Not specified 222 0.6% 

Under 21 1,926 5.5% 

21–30 7,065 20.0% 

31–40 7,274 20.6% 

41–50 8,520 24.1% 

51–60 7,434 21.1% 

Over 60 3,066 8.7% 

Age on June 1, 2009 

Not specified 1 Less than 0.1% 

White 19,412 55.0% 

Black or African American 8,791 24.9% 

Hispanic 2,777 7.9% 

Asian 1,383 3.9% 

Race 

Other or not specified 2,923 8.3% 

Yes 24,605 69.7% 

Direct-Care Employee No 10,677 30.3% 

Not specified 4 Less than 0.1% 

0 to 2 years 15,047 42.6% 

Greater than 2 to 5 years 7,818 22.2% 

Greater than 5 to 8 years 3,816 10.8% 

Greater than 8 to 10 years 1,780 5.0% 

Greater than 10 to 15 years 2,761 7.8% 

Greater than 15 to 20 years 1,841 5.2% 

Greater than 20 years 2,220 6.3% 

Length of Employment 

on June 1, 2009 

Not specified 3 Less than 0.1% 

Source: Office of Inspector General analysis of nursing facility employee data, 2009. 

Subgroups for some characteristics may not sum to 100 percent because of rounding. 

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 APPENDIX ~ B 

Table B-1: Profile of Sampled Nursing Facilities’ Reported Background Check Characteristics 

Characteristic Subgroup 

Number of 

Sampled 

Nursing 

Facilities 

(n=252) 

Percentage 

of Sampled 

Nursing 

Facilities

1988–1999 93 36.9% 

2000–2004 59 23.4% 

2005–2008 49 19.4% 

Since establishment of the nursing facility 24 9.5% 

Year Nursing Facility 

Began Conducting 

Background Checks 

Unknown/not specified 27 10.7% 

$0 33 13.1% 

Less than $1,000 50 19.8% 

$1,000 to less than $5,000 112 44.4% 

2008 Total Costs for 

Background Checks 

$5,000 to less than $10,000 22 8.7% 

$10,000 to less than $15,000 6 2.4% 

$15,000 or more 5 2.0% Range: $0–$29,565 

Average: $2,781 

Unknown/not specified 24 9.5% 

$0 33 13.1% 

Less than $25 89 35.3% 

$25 to less than $50 44 17.5% 

2008 Cost Per 

Background Check 

$50 to less than $75 33 13.1% 

Range: $0–$190.08 More than $75 41 16.3% 

Average: $37.15 Unknown/not specified 12 4.8% 

Source: Office of Inspector General analysis of nursing facility survey responses, 2009. 

Percentages do not sum to 100 percent because of rounding. 

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FINDINGS APPENDIX ~ C 

Different Types of Resources Reveal Different Information 

In our analysis of the Federal Bureau of Investigation (FBI) criminal 

history records, we identified seven individuals employed in five 

sampled nursing facilities whose criminal history records indicated that 

they are currently registered as sex offenders. We chose to examine 

Federal and State sex offender registries to see what additional 

information these registries might contain about these employees and 

how additional checks might complement a criminal background check. 

Conducting name searches on the National Sex Offender Registry (a 

public Web site) positively identified only four of the seven individuals 

as sex offenders.28 Conducting name searches on Web sites for 

individual State sex offender registries yielded six of the seven 

individuals’ names. 

There was one name that FBI criminal history records identified as a 

sex offender that we could not identify on the national or relevant State 

sex offender registries. The criminal history record showed a 

February 2009 registration as a sex offender with the sheriff’s 

department located in the county in which the employing nursing 

facility was located. We were unable to verify this information with 

another source because the Web site for the sheriff’s department did not 

offer the ability to search its sex offender registry. 

Upon closer examination of two individuals whose FBI criminal history 

records indicated “Subject of record is a registered sexual offender,” the 

individuals’ names were included on a list found on a Web site 

maintained by their State Office of Attorney General. The title of the 

list was “Convicted Sex Offenders and Offenders Against Children.” 

For both individuals, the information indicated that they were 

“registered offenders against children” and not “registered sexual 

offenders.” The description key of the list indicated that the two 

individuals were “offenders against children, who have not yet 

committed a sexually-related offense.” 

The results of this analysis demonstrate that searches of different 

sources of background check information may produce different criminal 

history information. 

20 

28 The Dru Sjodin National Sex Offender Public Web site can be accessed at 

http://www.nsopw.gov. 

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 APPENDIX ~ D 

Table D-1: Point Estimates and Confidence Intervals 

Estimate Characteristic Sample 

Size Point Estimate 

95-Percent 

Confidence 

Interval 

Estimates of nursing facilities that employ individuals with convictions 

Percentage of nursing facilities that employ one or more 

individuals with at least one conviction 

256 92.3 87.0–95.6 

Percentage of nursing facilities that employ five or more 

individuals with at least one conviction 

256 47.8 40.1–55.5 

Estimates of nursing facilities whose employees include certain percentages of individuals with convictions 

Percentage of nursing facilities with 0 percent of employees with 

convictions 

256 7.7 4.5–13.0 

Percentage of nursing facilities with up to 5 percent of employees 

with convictions 

256 51.8 44.0–59.5 

Percentage of nursing facilities with more than 5 and up to 

10 percent of employees with convictions 

256 26.0 19.8–33.4 

Percentage of nursing facilities with more than 10 and up to 

15 percent of employees with convictions 

256 6.3 3.5–11.0 

Percentage of nursing facilities with more than 15 and up to 

20 percent of employees with convictions 

256 5.7 2.9–10.9 

Percentage of nursing facilities with more than 20 and up to 

25 percent of employees with convictions 

256 2.5 0.9–6.8 

Estimates of nursing facility employees with one or more convictions 

Percentage of nursing facility employees with crimes against 

property 

1,772 43.6 39.5–47.7 

Percentage of nursing facility employees with other crimes 1,772 26.4 23.7–29.4 

Percentage of nursing facility employees with driving under the 

influence of drugs or alcohol (DUI) crimes 1,772 20.3 17.6–23.2 

Percentage of nursing facility employees with drug-related crimes 1,772 16.2 13.7–19.0 

Percentage of nursing facility employees with crimes against 

persons 

1,772 13.1 11.2–15.4 

Percentage of nursing facility employees with driving-related 

crimes other than DUI 1,772 11.9 9.9–14.3 

continued on next page 
 

APPENDIX ~ D 

Table D-1: Point Estimates and Confidence Intervals (Continued) 

Estimate Characteristic Sample 

Size

Point 

Estimate 

95-Percent 

Confidence 

Interval 

Estimates of nursing facility employees with convictions in certain job classifications

Nursing facility employees that have at least one conviction 35,286 4.9 4.2–5.9 

Percentage of direct-care staff with convictions 24,605 5.1 4.2–6.3 

Percentage of housekeeping/laundry/maintenance/security staff 

with convictions 3,814 6.5 5.38–7.81 

Percentage of certified nursing and medication aides with 

convictions 12,456 6.4 5.1–8.0 

Percentage of dietary staff with convictions 3,866 5.7 4.7–7.0 

Percentage of nursing staff (e.g., registered and licensed practical 

nurses) with convictions 6,986 3.6 2.8–4.7 

Percentage of all other types of staff with convictions 4,581 2.7 2.1–3.5 

Percentage of administrative staff with convictions 3,584 2.6 1.9–3.6 

Estimates of nursing facility employees whose most recent conviction was prior to employment 

Percentage of nursing facility employees with convictions who 

have their most recent conviction prior to the beginning date of 

employment 

1,772 84.0 80.4–87.0 

Percentage whose most recent conviction was less than 1 year 

prior to beginning employment 1,498 7.5 5.8–9.8 

Percentage whose most recent conviction was more than 1 year 

but less than 5 years prior to beginning employment 1,498 28.6 25.0–32.5 

Percentage whose most recent conviction was more than 5 years 

but less than 10 years prior to beginning employment 1,498 26.1 21.7–31.0 

Percentage whose most recent conviction was more than 10 years 

prior to beginning employment 1,498 37.8 33.8–42.0 

continued on next page 

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APPENDIX ~ D 

Table D-1: Point Estimates and Confidence Intervals (Continued)

Estimate Characteristic Sample 

Size

Point 

Estimate 

95-Percent 

Confidence 

Interval 

Estimates of nursing facility employees whose most recent conviction was after beginning employment

Percentage of nursing facility employees with convictions 

whose most recent conviction was after beginning 

employment 

1,772 16.0 13.0–19.6 

Percentage whose most recent conviction was less than 

6 months after beginning employment 

274 15.8 10.9–22.4 

Percentage whose most recent conviction was more than 

6 months but less than 1 year after beginning employment 

274 10.7 7.0–16.0 

Percentage whose most recent conviction was more than 

1 year but less than 2 years after beginning employment 

274 22.4 16.1–30.1 

Percentage whose most recent conviction was more than 

2 years but less than 5 years after beginning employment 

274 23.3 19.0–28.2 

Percentage whose most recent conviction was more than 

5 years but less than 10 years after beginning employment 

274 14.9 10.6–20.7 

Percentage whose most recent conviction was more than 

10 years after beginning employment 

274 12.8 8.0–20.0 

Estimates of nursing facilities that conduct different types of background checks

Percentage of nursing facilities that do not conduct any 

type of background check 

256 2.4 0.8–6.8 

Percentage of nursing facilities that reported conducting 

Statewide criminal history checks 

256 87.4 81.6–91.6 

Percentage of nursing facilities that reported using other 

sources for background checks 

256 50.8 43.1–58.6 

Percentage of nursing facilities that reported conducting 

FBI criminal history checks 

256 23.5 18.0–30.0 

Percentage of nursing facilities that conduct background 

checks on all employees 

256 93.7 88.9–96.5 

Percentage of nursing facilities that conduct background 

checks only on direct-care employees 

256 3.9 2.0–7.6 

Source: Office of Inspector General (OIG) analysis of Federal Bureau of Investigation (FBI) criminal history records and 

nursing facility employee data, 2009. 

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APPENDIX ~ D 

Table D-2: Point Estimates and Confidence Intervals for Differences in Categories of Convictions 

Category of 

Conviction 

Percentage of 

Employees With 

Convictions

Percentage 

Difference

95-Percent 

Confidence Interval 

on Difference 

p-value

Property 43.6 

Other 26.4 

17.1 10.6–23.7 <0.0001 

Property 43.6 

DUI 20.3 

23.3 15.4–31.2 <0.0001 

Property 43.6 

Drugs 16.2 

27.4 21.0–33.8 <0.0001 

Property 43.6 

Persons 13.1 

30.4 23.8–37.0 <0.0001 

Property 43.6 

Other driving (not DUI) 11.9 

31.6 25.5–37.8 <0.0001 

Confidence intervals and p-values are reported for each single comparison. Applying a Bonferroni threshold of 0.05/5, 

differences for all five simultaneous comparisons are statistically significant at the 95-percent confidence level. 

Source: OIG analysis of FBI criminal history records and nursing facility employee data, 2009. 

Table D-3: Point Estimates and Confidence Intervals for Differences in Type of Check Conducted 

Type of 

Background Check 

Percentage of 

Nursing Facilities 

Conducting Check

Percentage 

Difference

95-Percent 

Confidence Interval 

on Difference 

p-value

Statewide* 87.4 

Using other source 50.8 

36.6 27.1–46.1 <0.0001 

Statewide 87.4 

FBI 23.5 

64.0 56.5–71.4 <0.0001 

Using other source 50.8 

FBI 23.5 

27.4 17.0–37.7 <0.0001 

*Confidence intervals and p-values are reported for each single comparison. Applying a Bonferroni threshold of 0.05/3, 

differences for all three simultaneous comparisons are statistically significant at the 95-percent confidence level. 

Source: OIG analysis of nursing facility survey responses, 2009. 

 

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A P PEN D x E 


AGENCY COMMENTS 

.,..,.'·''''«''4;' . 

(

,"5'r DEPARTMENT OF HEALTH & HUMAN SERVICES Centers lor Medicare & Medicaid ServIces 

200 Independence Avenue SW 

Wasl1lnglon, DC 20201 

DATE: JAN 1 2 1.011 

TO: 	 Daniel R. Levinson 

Inspector General 

FROM: 	 Donald M. Berwick, M.D. 

Administrator 

SUBJECT: 	 Office ofInspector General (OlG) Draft Report: ''Nursing Facilities' Employment of 

Individuals With Criminal Convictions" (OEI-07-09-00110) 

Thank you for the opportunity 10 review and comment on the subject OIG draft report. The OIG's 

study focused on determining whether and to what extent nursing facilities employed individuals 

with criminal convictions. During this study, the OIG: 

• 	 Found almost all nursing facilities employed one or more individuals with at least one 

criminal conviction. 

• 	 Discovered that despite the lack of a Federal requirement for nursing facilities to conduct 

criminal background checks, most States required and/or nursing facilities reported 

conducting some type of background check. 

In its report, OIG made recommendations to the Secretary of Health and Human Services (HHS) and 

the Administrator of the Centers for Medicare & Medicaid Services (eMS). In making these 

recommendations, OIG took into consideration the Patient Protection and Affordable Care Act 

(P.L.111-148) provision that the HHS Secretary must implement a nationwide grant program for 

States to conduct national and statewide criminal background checks for direct patient access 

employees of nursing facilities and other providers. Our response to these recommendations is stated 

below. 

OIG Recommendation 

To develop background check procedures and ensure that States conduct background checks 

consistently, eMS should clearly define the employee classifications that are direct patient access 

employees. 

OEI·07·09·00110 NURSING FACILITIES' EMPLOYMENT OF INDIVIDUALS WITH CRIMINAL CONVICTIONS 25 
 

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APPENDIX ~ E 
 

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 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 Deborah Walden, Deputy Regional 

Inspector General. 

Tricia Fields served as the team leader for this study. Other principal 

Office of Evaluation and Inspections staff from the Kansas City regional 

office who contributed to the report include LCDR Mike Garner, Rae 

Hutchison, and Michala Walker; central office staff who contributed 

include Kevin Farber, Jennifer Jones, and Sandy Khoury. 
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 Office of Audit Services (OAS) provides auditing services for HHS, either by conducting 

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

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

out their respective responsibilities and are intended to provide independent assessments of 

HHS programs and operations. These assessments help reduce waste, abuse, and 

mismanagement and promote economy and efficiency throughout HHS. 

Office of Evaluation and Inspections 

The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide 

HHS, Congress, and the public with timely, useful, and reliable information on significant 

issues. These evaluations focus on preventing fraud, waste, or abuse and promoting 

economy, efficiency, and effectiveness of departmental programs. To promote impact, OEI 

reports also present practical recommendations for improving program operations. 

Office of Investigations 

The Office of Investigations (OI) conducts criminal, civil, and administrative investigations 

of fraud and misconduct related to HHS programs, operations, and beneficiaries. With 

investigators working in all 50 States and the District of Columbia, OI utilizes its resources 

by actively coordinating with the Department of Justice and other Federal, State, and local 

law enforcement authorities. The investigative efforts of OI often lead to criminal 

convictions, administrative sanctions, and/or civil monetary penalties. 

Office of Counsel to the Inspector General 

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

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

legal support for OIG’s internal operations. OCIG represents OIG in all civil and 

administrative fraud and abuse cases involving HHS programs, including False Claims Act, 

program exclusion, and civil monetary penalty cases. In connection with these cases, OCIG 

also negotiates and monitors corporate integrity agreements. OCIG renders advisory 

opinions, issues compliance program guidance, publishes fraud alerts, and provides other 

guidance to the health care industry concerning the anti-kickback statute and other OIG 

enforcement authorities.