Long-Term Care Facilities: Information on Residents Who Are Registered Sex Offenders or Are Paroled for Other Crimes
Published: 2006-03-31T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Approximately 23,000 nursing homes and intermediate care facilities for people with mental retardation (ICF-MR) receive federal Medicare and Medicaid funding. Media reports have cited examples of convicted sex offenders residing in long-term care facilities and, in some cases, allegedly abusing other residents. Given concerns about resident safety, GAO was asked to assess (1) the prevalence of sex offenders and others on parole for non-sex offenses living in long-term care facilities and the extent of any abuse they may have caused, (2) the legal requirements for notifying facilities and others when offenders are residents, and (3) the extent to which facilities have different supervision and separation requirements for offenders. GAO analyzed a national database for sex offenders and analyzed state databases in a sample of eight states for sex offenders and parolees.
section_title: What GAO Found
paragraphs: By analyzing the FBI's National Sex Offender Registry (NSOR), which is a compilation of sex offender registries submitted by all states, GAO identified about 700 registered sex offenders living in nursing homes or ICFs-MR during 2005. Most identified sex offenders were male, under age 65, and living in nursing homes, and represented 0.05 percent of the 1.5 million residents of nursing homes and ICFs-MR. About 3 percent of nursing homes and 0.7 percent of ICFs-MR housed at least 1 identified sex offender during 2005. However, these estimates are understated due to data limitations. For example, because of a lack of resources or an inability to comply with certain FBI reporting requirements, states have had varying degrees of difficulty submitting their full state registries to the NSOR. While the FBI does not track NSOR submission rates, GAO compared sex offender registry data from seven of the eight states reviewed to NSOR data and found that the NSOR data included about 57 percent of sex offenders registered in these states, with submission rates ranging from 1 percent to 83 percent. Because a national data source on parolees that included address information was not available, GAO also obtained parolee databases from the eight reviewed states and identified 204 offenders on parole for non-sex offenses living in long-term care facilities. GAO could not determine the overall risk that registered sex offenders and parolees pose to other residents in long-term care facilities because offender status is not tracked with abuse reporting. Facility administrators expressed greater concern over the risk posed by cognitively impaired or mentally ill residents. Federal law requires state law enforcement agencies to release relevant information about registered sex offenders when necessary to protect the public, but GAO did not identify a similar federal law for the parolee population. States have broad discretion in how to implement the requirement for registered sex offender notification. Therefore, the extent to which states' community notification laws apply to all registered sex offenders or explicitly include long-term care facilities varies. For example, four of the eight states GAO reviewed--California, Illinois, Minnesota, and Oklahoma--had laws that specified long-term care facilities as entities to be notified for at least some registered sex offenders who entered them. However, some facility administrators GAO contacted were uncertain as to whether they could share information with staff and others about residents who were known offenders in light of the Privacy Rule issued under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Long-term care facilities GAO contacted do not routinely impose different supervision or separation requirements on residents who are offenders based solely on their prior convictions. Instead, these facilities base such decisions on the demonstrated behaviors of residents. Even if long-term care facilities wanted to impose different supervision and separation requirements on offenders, their ability to do so is limited because they are not always aware of residents' prior convictions.

section_title: Letter
paragraphs: Approximately 16,000 nursing homes and 6,600 intermediate care facilities  for people with mental retardation (ICF-MR) participate in Medicare,  Medicaid, or both, and receive federal funding to care for their residents.  Federal Medicare and Medicaid funds accounted for a significant portion  of total funding to these nursing homes and ICFs-MR—approximately   $43 billion of a total of over $110 billion in 2003, with about $37 billion  spent in nursing homes and $6 billion in ICFs-MR. Because of the large  amount of federal funding these long-term care facilities receive, there is a  strong interest in ensuring the safety and well-being of their vulnerable  residents.
Concerns about the quality of care provided to residents of long-term care  facilities are long-standing. Since 1998, a number of congressional hearings  have focused on ensuring the quality of care and protecting the safety and  rights of nursing home residents. Recently, news outlets and others have  reported accounts of convicted sex offenders residing in nursing homes  and, in some cases, allegedly abusing other residents. Often, nursing home  staff and residents’ families were not informed when convicted sex  offenders were residents. The admission to long-term care facilities of  individuals on parole for non-sex offenses raises similar concerns about  the potential for abuse. Because of your concerns about resident safety,  we are providing information on (1) the prevalence of offenders living in  nursing homes and ICFs-MR and the extent of abuse caused by such  offenders in these long-term care facilities; (2) whether federal and state  laws provide for notification of staff, residents’ families, and residents  when such offenders live in these long-term care facilities; and (3) the  extent to which these offenders are subject to supervision or separation  requirements that differ from those for other residents.
To determine the prevalence of registered sex offenders residing in these  long-term care facilities nationwide, we obtained the Federal Bureau of  Investigation’s (FBI) National Sex Offender Registry (NSOR), a national  database utilized by law enforcement that compiles information about  registered sex offenders submitted by all 50 states and the District of  Columbia, as of January 3, 2005. We used the NSOR to identify the home  addresses of registered sex offenders and matched them with the  addresses of nursing homes and ICFs-MR included in the Centers for  Medicare & Medicaid Services’ (CMS) Online Survey, Certification and  Reporting system (OSCAR) database, which compiles the results of state  nursing home surveys. To assess the completeness of the NSOR data, we  requested complete sex offender registries from eight states—California,  Florida, Illinois, Minnesota, Ohio, Oklahoma, New Jersey, and Utah— which we selected on the basis of a number of criteria, including variation  in geographic location and in the number of registered sex offenders  identified as living in these states’ long-term care facilities based on our  preliminary analyses. Seven of the eight states provided their sex offender  registries, and we compared the total number of sex offenders on each of  the state registries with the total number for each state identified through  the NSOR. In the course of comparing the results of the NSOR and state  sex offender registries analyses, we became aware that the NSOR did not  include the full sex offender registries of these states. Since no national  database exists for parolees that includes address information, we also  obtained parolee databases from each of these eight states. We matched  parolee addresses with addresses for nursing homes and ICFs-MR from  OSCAR for the eight states; however, because of the limited number of  states reviewed, we could not generalize these results as representative of  all states. We obtained state registries and parolee databases from January  through September 2005.
To gather information about the administration and content of state sex  offender registries, including their submission of records to the NSOR, we  interviewed state registry administrators from all eight states and  submitted a questionnaire via e-mail to all other states, receiving  responses from an additional 20 states. To assess the reliability of FBI and  state data, we discussed data quality control procedures, reviewed  relevant documentation with officials, and conducted electronic data  testing. We determined that while the NSOR does not include all registered  or convicted sex offenders, its records are regularly audited and are  sufficiently reliable for the purposes of this report. The lack of  comprehensiveness of the data was evaluated and taken into account in  our discussion of the results. We determined that the OSCAR database and  state parolee databases were sufficiently reliable for our purposes.
To obtain information about resident abuse perpetrated by sex offenders  and parolees residing in long-term care facilities, we reviewed existing  research and GAO reports and interviewed officials of industry  associations and long-term care ombudsmen. Within the eight states we  reviewed, we also interviewed state officials responsible for nursing home  and ICF-MR licensing, as well as administrators at 29 of 32 judgmentally  selected long-term care facilities—-4 from each state. We also relied on  these interviews, interviews with federal officials, and a review of federal  and state laws to determine whether federal and state laws provide for  notification of facility staff, residents, and residents’ families when  offenders live in these long-term care facilities and the extent to which  offenders are supervised and separated from other residents. In the eight  states we reviewed, we also examined states’ public sex offender Web site  registries to determine what information on registered sex offenders is  available to the public. We conducted our work from September 2004  through February 2006 in accordance with generally accepted government  auditing standards. (For additional information on our scope and  methodology, see app. I.)
subsections: section_title: Background
paragraphs: Nursing homes provide a residential setting and a range of health care  services for individuals who can no longer care for themselves because of  physical or mental limitations. According to the most recent National  Nursing Homes Survey (NNHS), approximately 90 percent of nursing  home residents were age 65 and older and more than two-thirds were  female. ICFs-MR are intended to provide a residential setting for  treatment, rehabilitation, and supervision of people who have mental  retardation or other disabilities, such as seizure disorders or behavior  problems. In 2005, approximately 85 percent of ICF-MR residents were  from 22 to 65; only 7 percent of the total resident population was over   65 years of age. In addition, unlike the nursing home population, the  majority of ICF-MR residents were male.
Approximately 1.5 million individuals lived in Medicaid- and Medicare- certified nursing homes and ICFs-MR in 2005. Federal Medicaid and  Medicare funds accounted for approximately 33 percent of total spending  on nursing homes, and the remaining funds were from a combination of  state, local, and private sources in 2003. In the same year, ICFs-MR, which  are funded almost exclusively by Medicaid, received about 58 percent of  their total funding from federal Medicaid funds and the remainder from  state Medicaid dollars. Medicaid, a joint federal-state program that  finances health care coverage for certain categories of low-income  individuals, is the primary payment source for long-term care services for  older people with low incomes and limited assets. Medicaid pays for an  array of long-term care services, including services to assist people with  activities of daily living like eating, dressing, bathing, and using the  bathroom. In contrast, Medicare, which covers a variety of health care  services and items for individuals who are 65 or older, have end-stage  renal disease, or are disabled, does not pay for most long-term care  services. Medicare covers short-term skilled nursing care following a  hospital stay.
To qualify for Medicare or Medicaid funding, these long-term care facilities  must meet certain federal requirements. For example, they are required to  conduct resident assessments that examine areas such as demographic  information, cognition, mood and behavior, psychosocial well-being,  health conditions, and physical functioning. For example, the  Preadmission Screening and Resident Review, which is required by federal  law to determine whether the potential resident needs nursing home care,  includes an assessment of mental capacity. Although federal regulations  require that a resident assessment be conducted prior to admission to  ICFs-MR, there is no standardized assessment tool and admission can be  based on a prior assessment by an outside source. Individuals being  admitted to an ICF-MR generally meet certain criteria, including having an  intellectual functioning level below 70 to 75 and significant limitations in  two or more adaptive skill areas. In addition, at a minimum, resident  assessments are conducted annually by nursing home and ICF-MR facility  staff after admission in order to continually address a resident’s needs. For  each resident for whom they receive Medicare or Medicaid funding, these  long-term care facilities are also required to develop a plan of care that  addresses the resident’s medical, social, and other needs, as determined by  the resident assessment. Long-term care facilities are also required to  protect residents’ rights and privacy. In addition, the Privacy Rule issued  under HIPAA provides individuals with protections regarding the  confidentiality of their health information and restricts the use and  disclosure of individuals’ health information by health care providers,  including nursing homes and ICFs-MR.
As a condition of Medicare or Medicaid participation, long-term care  facilities must report incidents of abuse according to state requirements.  CMS defines abuse as the willful infliction of injury, unreasonable  confinement, intimidation, or punishment with resulting physical harm,  pain, or mental anguish. Physical abuse generally includes hitting,  slapping, pushing, and sexual abuse, which is nonconsensual sexual  contact or nonconsensual sexual involvement of any kind. Although the  commission of a sexual offense may result in an incident of abuse, a  uniform definition of sexual offense does not exist, and states define  sexual offenses in their respective criminal codes. Some examples of  sexual offenses include rape, sexual assault, and incest. In some states,  related sexual offenses include child pornography and willful indecent  exposure in public.
Federal statute established the Jacob Wetterling Crimes Against Children  and Sex Offender Registration Program in 1994. The statute required  every state to have a program to register sex offenders by September 1997,  and required the Attorney General to provide states with guidelines for  developing their programs. At a minimum, an individual convicted of a  criminal offense against a minor or of a sexually violent offense must  register a current address for 10 years following his/her release from  prison or placement on parole, supervised release, or probation. In  addition, an individual who has one or more prior sexual offense  convictions, has been convicted of an aggravated offense, or is determined  to be a sexually violent predator must register a current address for life.  States may impose more stringent registration requirements on a broader  class of offenders than required by federal law. The law also mandates that  registered sex offenders verify their addresses at least annually and that  registered offenders classified as sexually violent predators verify their  addresses quarterly. Registered sex offenders must notify local law  enforcement officials within their state of address changes, and those who  move to a different state must comply with registration requirements in  the new state. States that do not comply with the Wetterling Program  requirements are subject to a 10 percent reduction in their Byrne Formula  Grant law enforcement funding.
The statute establishing the Wetterling Program was amended twice in  1996. The first amendment, Megan’s Law, required states to release  information about registered sex offenders when necessary to protect the  public, but this law did not specify how states must give notification. The  second amendment, the Pam Lychner Sexual Offender Tracking and  Identification Act of 1996, mandated the FBI’s creation of a national  database now known as the NSOR. According to the FBI, this national  database combines sex offender registries from all of the states to help law  enforcement officials track sex offenders on a national level.
Research on sex offender recidivism suggests that the majority of  individuals previously convicted of sex offenses do not commit additional  sex offenses, with one such study estimating that about 14 percent had a  new sex offense charge or conviction within 5 years of their release from  prison, increasing to 27 percent after 20 years. At the same time, however,  research also indicates that sex offenses are underreported. While it is  difficult to predict re-offense for any individual, certain factors such as  sexual deviancy, antisocial orientation, and an adverse family environment  may contribute to a higher likelihood of a re-offense. Those who have  strong social supports, such as a supportive family and a stable job, may  be less likely to re-offend. In addition, the likelihood of re-offending may  diminish as the sex offender ages.
Federal law requires that registered sex offenders be tracked on a national  and state level; however, parolees are generally monitored and supervised  by each state. Individuals released from prison prior to the completion of  their sentences may be subject to certain conditions and supervised as  parolees for a specified period. Typically the length of time states set for  parole is 1 to 3 years, although certain crimes and sentencing situations  may require more or less time. An individual can be convicted of a range of  crimes from fraud or forgery to murder and be eligible for parole. As of  December 2003, about 775,000 adults were on parole from federal and  state prisons nationwide.
section_title: Identification of Offenders Living in Long-Term Care Facilities and Assessment of the Risk They Pose Limited by Data Shortcomings
paragraphs: Using the NSOR, we identified 683 registered sex offenders living in long- term care facilities during 2005. However, this understates the national  prevalence of convicted sex offenders residing in long-term care facilities  for a number of reasons. While the NSOR is a national database that  compiles information about registered sex offenders submitted by all   50 states and the District of Columbia, it does not include convicted sex  offenders who are not on state registries, including those sex offenders  who are required by law to register but choose not to comply. It also does  not include all registered sex offenders, as states have had varying degrees  of difficulty submitting their records to the NSOR because of technical  problems, lack of resources, or inability to provide the required FBI  number for certain offenders. Because there is no national data source on  parolees that includes address information, we also obtained parolee  databases from the eight states we reviewed and identified 204 offenders  on parole for non-sex offenses living in long-term care facilities. The risk  of abuse within nursing homes or ICFs-MR by residents with prior  convictions is unclear because states we reviewed do not report the prior  convictions of residents who commit abuse; however, facility  administrators we interviewed more frequently expressed concern about  the potential for abuse by residents with cognitive impairments or mental  illness than by residents with prior convictions.
subsections: section_title: Most Sex Offenders Identified Were Male, Were under Age 65, and Resided in a Small Number of Nursing Homes and ICFs- MR
paragraphs: Using the NSOR, we identified 683 registered sex offenders living in long- term care facilities during 2005, representing about 0.05 percent of the  total 1.5 million residents of nursing homes and ICFs-MR. (See app. II.) Of  the approximately 16,000 nursing homes and 6,600 ICFs-MR that  participate in Medicare or Medicaid, we identified 3 percent of nursing  homes (470) and 0.7 percent of ICFs-MR (46) as housing at least 1  registered sex offender during 2005.
About 88 percent of the registered sex offenders we identified resided in  nursing homes, while the remaining 12 percent resided in ICFs-MR. Sex  offenders living in nursing homes were younger than the general nursing  home population, while those in ICFs-MR had a similar age distribution as  the general ICF-MR population. About 57 percent of registered sex  offenders we identified as living in nursing homes were under age 65,  compared to about 10 percent of the general nursing home population, and  30 percent were under age 50. Most sex offenders—95 percent—identified  as living in ICFs-MR were under age 65, which is similar to the age  distribution in the general population of these facilities. Similarly, nearly  all—99 percent—registered sex offenders we identified as residing in long- term care facilities were male, which is consistent with the gender of  registered sex offenders overall. Among registered sex offenders for whom  we had information on the nature of their crimes, the majority of  convictions were for rape and sexual assault of adults and minors.
section_title: Number of Offenders Identified as Living in Long-term Care Facilities Is Understated
paragraphs: The number of offenders that we identified as living in long-term care  facilities is understated because of shortcomings in the data. Specifically,  although national in scope, the NSOR does not include certain convicted  sex offenders who are not on state registries because the registries did not  exist at the time they were convicted or released from prison or because  their registration period has expired. The NSOR also does not include all  of the records of sex offenders who are registered in the states’ registries  because some states have had difficulty submitting their records to the  NSOR. NSOR records for convicted sex offenders who chose not to  comply with registration requirements may be incomplete or missing. In  addition, since no national data source for parolees exists that includes  parolee residence information, our data only include numbers of parolees  from the eight states we reviewed.
subsections: section_title: State Registries Do Not Include All Convicted Sex Offenders
paragraphs: While some states already had sex offender registries in place, the  Wetterling Program statute mandated that all states implement a registry  by September 1997. Most state registries only include those sex offenders  convicted or released from prison after a specified date, generally after  1990. Consequently, those convicted or released before the specified date  were not required to register and therefore are not included in our  analysis. This limitation may help explain the age distribution of registered  sex offenders we identified as living in nursing homes. While the majority  of offenders identified in nursing homes were under the age of 65, this  could be a consequence of the limited period that sex offender registries  have existed rather than an accurate reflection of the age distribution of  convicted sex offenders living in nursing homes, since many elderly sex  offenders would not be registered if their convictions predated the  implementation of their state’s registry.
The nearly 700 registered sex offenders we identified through the NSOR  database as living in long-term care facilities also do not include convicted  sex offenders whose registration period expired or whose information was  missing because they did not comply with registration requirements. While  noncompliance is difficult to track, four of the reviewed states provided us  with estimated noncompliance rates ranging from 4.5 percent to   25 percent. Similarly, the advocacy organization, Parents for Megan’s Law,  released estimates in 2003 that 24 percent of sex offenders nationally fail  to comply with registration requirements. Sex offenders may fail to  comply for several reasons, including a lack of understanding about  registration requirements or to avoid the possible negative consequences  experienced by some registered sex offenders, such as the loss of a job,  harassment, social stigmatization, or physical assault.
section_title: State Submissions to the NSOR Do Not Include All Registered Sex Offenders
paragraphs: We found a range of submission rates by state registries to the NSOR,  which suggests that the NSOR may be missing a portion of sex offenders  who are registered in states. Registry administrators from the 20 states  that responded to our e-mail questionnaire estimated their submission  rates to be from 46 percent to 100 percent of the total number of records  in their state registries. Most reported that at least 80 percent of their  records were submitted, while 2 states reported that they were only able  to submit about half of their records. We also compared the total number  of sex offenders included in the state registries to the number included in  the NSOR for 7 of the 8 states we reviewed. (See table 1.) The NSOR  included about 57 percent of sex offenders registered in these states, with  submission rates ranging from 1 to 83 percent. For example, Utah had  submitted about 1 percent of its registry to the NSOR. While the state  intends to fully submit its registry to the NSOR in the future, it currently  lacks the resources to do so, according to a state official. However, the  FBI considers state participation in the national database to be in  compliance with federal requirements if a state has submitted at least one  record to the NSOR. A DOJ official confirmed that all states have been  determined to be in compliance with NSOR submission requirements,  based on FBI notifications regarding each state’s participation in the  NSOR, and was not aware of any state that had been penalized with the  loss of Byrne Formula Grant law enforcement funding solely on the basis  of the extent of state NSOR participation.
Registry administrators from among the 8 states we reviewed and the 20  additional states that responded to our e-mail questionnaire reported that  several factors complicate their efforts to submit complete sex offender  registries to NSOR. For example, registry administrators frequently  responded that they were not able to submit records of registered sex  offenders who did not have FBI numbers. FBI numbers are required by the  FBI for all records submitted to the NSOR to ensure positive identification  of individuals for the purposes of employment background checks. States  may lack FBI numbers for several types of offenders, such as juvenile sex  offenders who do not receive FBI numbers or sex offenders from other  states. If a sex offender comes from out of state, his/her FBI number can  be obtained from the state where the conviction occurred, but it can be  labor-intensive if the other state does not cooperate or never submitted  fingerprint information to establish the offender’s FBI number. Registry  administrators in two of the states we reviewed estimated that in recent  years about 30 percent of the records they submitted to the NSOR were  rejected as incomplete. In addition, states are required to verify  information, including home address, for each registered offender at least  annually and quarterly for registered offenders classified as sexually  violent predators, a process that can also be labor-intensive. If states are  unable to verify an offender’s address information, the offender should be  considered noncompliant, and the NSOR record will not be up-to-date nor  reflect current address information. Some states have also experienced  technical difficulties submitting their registry records to the NSOR. An FBI  official told us that states that had registries prior to the creation of the  NSOR had difficulty reprogramming their registry databases to conform to  the NSOR formats. One of the states we reviewed did not realize until 2005  that only a fraction of its records were being submitted to the NSOR  because of a technical problem, and it is currently submitting records on  computer disks while making plans to implement a system for automatic  electronic submission of its full sex offender registry to the NSOR.
Although the FBI does not track states’ submission rates to the NSOR, it  does periodically assess state participation in the NSOR and provides  assistance to help states improve the comprehensiveness and accuracy of  their registries. In addition to the requirement that states annually validate  registry records, we were informed that the FBI conducts triennial audits  of states’ participation in the NSOR. During fiscal year 2005, the FBI also  conducted a fiscal audit, assessed states’ level of participation in the NSOR  and requested information from states about what assistance they need to  improve their participation. DOJ provides grants to help states improve  their law enforcement information systems, which states have utilized for  enhancements to their sex offender registries such as enabling the  automatic transmission of records to the NSOR and for monitoring data  accuracy. DOJ informed us that it also provides training and technical  assistance to states, and that the FBI has an advisory group that is  reviewing issues such as state submission of data to the NSOR and the  process for the verification and validation of NSOR records.
section_title: Approximately 200 Parolees Identified as Living in Long- term Care Facilities in Eight States
paragraphs: Using data provided by each of the eight states we reviewed, we identified  204 parolees as residents of long-term care facilities. (See table 2.)  Because there is no national source of data on parolees that includes their  home address information, our numbers are limited to the eight states and  cannot be generalized as representative of all states. Among parolees for  whom we had information on the nature of their crimes, the convictions  were most commonly for burglary, assault, murder, or drug-related  offenses.
section_title: Abuse by Offenders Who Live in Long-term Care Facilities Not Tracked, but Risk May Not Be Widespread
paragraphs: Long-term care facilities participating in Medicare or Medicaid are  required to report all allegations of abuse and neglect to officials in  accordance with applicable state law and, in the case of nursing homes,  this includes reporting to the state. This requirement would encompass  the reporting of abuse committed by staff or residents. In the eight states  we reviewed, long-term care facilities do stratify reported abuse into  categories, such as physical, sexual, financial, or resident-to-resident  abuse; however, they do not report information on whether residents  alleged to have caused abuse have prior convictions. The National  Ombudsman Reporting System (NORS) also collects nursing home abuse  data on a national level and includes various categories of abuse, such as  incidents that occur between residents and incidents perpetrated by  nursing home staff. Similar to the states we reviewed, NORS does not  track whether residents alleged to have abused other residents have prior  convictions.
Because data are not available nationally or in our reviewed states on  abuse perpetrated specifically by residents who have prior convictions,  the potential risk for abuse by offenders residing in long-term care  facilities cannot be accurately estimated. However, based on a number of  factors, including the small percentage of facilities identified as housing  offenders, the risk may not be widespread. For example, offenders  residing in nursing homes or ICFs-MR who have significant physical  limitations may be unable to commit abuse against other residents. In  addition, research on recidivism by sex offenders also suggests that most  do not re-offend and that the risk of re-offending may decline with age.
In our interviews with officials of long-term care facilities, state nursing  home associations, and state ombudsmen for long-term care, concern was  more frequently expressed about the behavior and potential for abuse by  cognitively impaired and mentally ill residents than about abuse by  residents with prior convictions. Several of those interviewed mentioned  they were concerned about the potential for abuse by residents with  Alzheimer’s disease or dementia, a disease for which their behavior may  change significantly after their admission and original assessment. The  administrator of a facility in Ohio that specializes in residents with  behavioral issues and that has housed multiple offenders said that he has  had fewer problems with his residents who are identified sex offenders  than with other residents who have behavioral problems. Several sources,  including ombudsmen, a researcher, and a nursing home advocate,  suggested that a resident’s behavioral issues are sometimes not fully  disclosed to a nursing home upon admission or that some nursing homes  with low occupancy may be more likely than others to accept mentally ill  patients in order to increase their occupancy levels.
Long-term care facility officials we interviewed, some of whom knew they  have had offenders as residents and some of whom spoke hypothetically,  said they would use their judgment to determine whether a registered sex  offender or parolee could appropriately be cared for in their facilities.  Several long-term care facility administrators told us that if they  discovered a resident was an offender, they would evaluate the potential  risk posed by that individual on a case-by-case basis. For example, the  facility administrator may determine the degree of safety risk on the basis  of whether the offender’s health status is such that the individual cannot  move independently. If the administrator determines that the risk is  greater than the long-term care facility can manage, the facility may  choose not to admit the offender.
section_title: States Required to Notify Community about Registered Sex Offenders, but Extent of Notification Varies
paragraphs: Federal law requires state law enforcement agencies to release relevant  information about registered sex offenders when necessary to protect the  public, but we did not identify a similar federal requirement pertaining to  the parolee population. The federal requirement for registered sex  offender notification allows states to implement this requirement at their  discretion, within broad federal guidelines. Consequently, the extent to  which states’ community notification laws apply to all registered sex  offenders or explicitly include nursing homes and ICFs-MR varies. Absent  direct notification, these facilities may not know they house offenders or  may only become aware of offenders through other means. For example,  in the case of registered sex offenders, facilities may identify some  offenders by reviewing publicly available Web sites, while for parolees,  they may become aware of the person’s criminal background from a  parole officer. When facility residents are known offenders, differing  interpretations exist among states, industry, and long-term care facility  officials as to whether sharing information about their prior convictions  may violate the Privacy Rule issued by HHS under HIPAA.
subsections: section_title: Federal Law Requires States to Provide Community Notification for Registered Sex Offenders, but Direct Notification to Long-term Care Facilities Varied
paragraphs: Megan’s Law, a 1996 amendment to the Wetterling Program statute,  required each state to release information about registered sex offenders  when necessary to protect the public. The law applied specifically to  registered sex offenders and not to convicted sex offenders who were not  obligated to register. Although Megan’s Law stipulated that information  about the victims of registered sex offenders was not to be released, it  otherwise did not specify the information to be disseminated about  registered sex offenders, did not mandate that community notification be  uniform for all registered sex offenders, and did not specify how states  were to release information.
Consequently, states’ community notification laws vary, particularly in  terms of the extent to which notification by law enforcement entities  applies to all registered sex offenders. Such variation was evident in the  notification laws of the eight states we reviewed. While two states we  reviewed—Illinois and Utah—apply community notification requirements  to all registered sex offenders uniformly in each state, the community  notification requirements in the remaining six states—California, Florida,  Minnesota, New Jersey, Ohio, and Oklahoma—vary depending on the  crime committed by the registered sex offender. For example, New  Jersey classifies its registered sex offenders into three categories based on  their assessed risk of re-offending. For sex offenders determined to be  lowest risk, state law requires notification of law enforcement agencies. In  contrast, for the highest risk sex offenders, the law requires notification of  additional entities, including schools, religious and youth organizations,  and those likely to encounter the offender. Similarly, Florida’s law  explicitly requires broad community notification when individuals  designated to be sexual predators reside in the community, but it does not  require broad notification for other sex offenders.
Variation also exists in the extent to which state community notification  laws explicitly require the notification of long-term care facilities. Four  states we reviewed—California, Illinois, Minnesota, and Oklahoma— passed laws in summer and fall 2005 that specified long-term care facilities  as entities to be notified for at least some registered sex offenders who  entered them.28, 29 Notification in these states is conducted by individual  facility officials, state or law enforcement officials, or registered sex  offenders themselves. For example, Illinois’ law requires long-term care  facilities to determine whether each resident or potential resident is a  registered sex offender and to notify staff, residents or their legal  guardians, and facility visitors when offenders are residents. Similarly,  Oklahoma’s law requires notification of these facilities by several methods.  For example, the Department of Corrections must notify the Department  of Health when any person in its custody seeks placement in these  facilities, and the Department of Health must then notify the facility of the  potential for the placement of a registered sex offender. When residents  are determined to be registered sex offenders, information about them  must be displayed in the facility in an area that is accessible to staff,  visitors, and residents. The law in California also requires state officials to  notify long-term care facilities when registered sex offenders are released  to them from the Department of Corrections and Rehabilitation, the State  Department of Mental Health, or other state-operated places of  confinement. The law does not provide for such notification when sex  offenders enter long-term care facilities from the community. Unlike other  states we reviewed, Minnesota’s law requires registered sex offenders to  disclose their status if seeking admission to long-term care facilities. Upon  receiving such notification from certain registered sex offenders, long- term care facilities are responsible for sharing this information with other  residents or their legal guardians. Minnesota also requires law  enforcement officials to notify health care facilities if they become aware  that a registered sex offender has been admitted for care.
2005 Cal. Adv. Legis. Serv. c. 466 (Dearing); 2005 Ill. Legis. Serv. 94-163 (West); 2005 Minn.  Laws c. 243.166; 2005 Okla. Sess. Laws Serv. c. 465 (West).
Requirements in state community notification laws specifying that nursing homes and  ICFs-MR be notified about registered sex offenders who were residents appear to be a  recent trend. For example, a 2001 review of state community notification laws by the  Bureau of Justice Statistics found that states generally did not notify nursing homes or  ICFs-MR when offenders entered the facilities.
The other four states we reviewed—Florida, New Jersey, Ohio, and Utah— do not specifically require the notification of long-term care facilities when  registered sex offenders enter them. Long-term care facilities in these  states, or in states where community notification of such facilities is not  required for all registered sex offenders, may not be aware of residents  who are offenders or must rely on other methods to identify such  individuals. For instance, administrators we interviewed at 8 of the   29 long-term care facilities indicated that one or more registered sex  offenders had lived in their facilities for some period. Each of these 8 long- term care facilities was notified about the registered sex offenders,  although the method of notification varied. For example, while 4 facilities  were notified before the offenders entered them, either by offenders’  family members or the state department of corrections, the 4 remaining  facilities were notified after the registered sex offenders were admitted,  either by local law enforcement officials who were verifying sex offenders’  residential addresses or by an advocacy group conducting research on  registered sex offenders living in certain long-term care facilities.
Long-term care facilities may access states’ publicly available sex offender  registry Web sites to determine where registered sex offenders reside. A  2003 amendment to the Wetterling Program statute required states to  maintain a publicly available Web site with information about registered  sex offenders. The law did not provide instruction on how these Web  sites should be designed or what specific information should be included.  Depending on the state, these Web sites provide varying amounts of  information to the public about registered sex offenders. For example, the  Web site registry in each of the eight states we reviewed included some  address information for all or a portion of the state’s adult registered sex  offenders. Five states we reviewed—Florida, Illinois, Ohio, Oklahoma, and  Utah—provided the full residential address of all the state’s adult  registered sex offenders, while three others—California, Minnesota, and  New Jersey—included certain registered sex offenders on their Web sites  and in some cases did not always list their full addresses. For example,  Minnesota separates offenders into three levels and includes Level 3  offenders—those deemed predatory or most likely to re-offend—on its  Web site. Approximately 6 percent of the registered sex offenders in this  state who are living in the community are assigned the highest risk level.  Similarly, New Jersey includes certain moderate and all high-risk  registered sex offenders on its Web site, which, according to a state  official, represents about 16 percent of all registered sex offenders in the  state. In California, a state official told us that its Web site registry  includes at least some address information for approximately 74 percent  of the state’s registered sex offenders, including full address information  for about 57 percent who committed crimes considered to be the most  serious. The remaining approximately 26 percent of the state’s registered  sex offenders are not posted on the Web site because they committed less  severe offenses or are excluded from the Web site for various reasons,  such as not being designated sexually violent predators. In addition, for  the registered sex offenders listed on the Web sites of the eight states we  reviewed, information is included about the crimes registered sex  offenders committed; their names, nicknames, or aliases, when applicable;  date of birth or age; and race or ethnicity.
While the NSOR database is not directly accessible by the general public,  long-term care facilities can access the recently developed National Sex  Offender Public Registry maintained by the DOJ. This Web site, which  was first launched in May 2005, seeks to compile public sex offender  registry information available through state Web sites, and as of January  2006, it included public registry data from all but two states. Although this  Web site provides the public with one-stop access to states’ online sex  offender registries, it may be of limited usefulness because states’ sex  offender registry Web sites, as described above, do not always include a  comprehensive list of registered sex offenders.
section_title: Although Community Notification of Parolees Not Uniformly Required, Parolees in Long-term Care Facilities Often Identified by Law Enforcement
paragraphs: We did not identify a federal law specifying community notification  requirements for law enforcement when parolees enter the community  that was similar to the federal law for registered sex offenders. However,  three of the eight states we reviewed—Illinois, Minnesota, and  Oklahoma—passed laws in summer 2005 that require community  notification for offenders who have committed crimes other than sex  offenses, including some offenders who are parolees. Illinois’ law  requires the state Department of Corrections to give some information to  certain long-term care facilities when parolees or certain other offenders  become residents. In addition, these long-term care facilities are required  to notify the other residents when parolees reside in their facilities. In  Minnesota and Oklahoma, long-term care facilities receive community  notification for some individuals convicted of non-sex offenses, including  some parolees, under the same requirements as those for registered sex  offenders. Minnesota’s law applies to individuals convicted of some  crimes, including murder or kidnapping. Oklahoma’s law requires  notification for individuals who are required to register under the Mary  Rippy Violent Crime Offenders Registration Act, which includes  individuals convicted of crimes such as murder or manslaughter in the  first degree.
Department of Corrections’ officials or other authorities in each of the  eight states we reviewed stated that as a matter of practice, they generally  notified long-term care facilities when individuals released from prison,  including parolees, are placed in such facilities. For example, according to  officials in Ohio’s Department of Rehabilitation and Corrections, when an  inmate who needs long-term care is paroled, a parole officer works with  the facility to ensure that medical records are transferred and that a plan  of care is established to meet the needs of the parolee.
section_title: Officials Uncertain about Ability of Long-term Care Facilities to Disclose Offender Information under the HIPAA Privacy Rule
paragraphs: While the HIPAA Privacy Rule applies to individually identifiable health  information, differing interpretations exist among state, industry, and long- term care facility officials we interviewed in the eight states regarding the  applicability of the rule to facilities’ efforts to notify others about residents  who have prior convictions, such as those who are registered sex  offenders or parolees. These difficulties existed regardless of whether this  information was obtained from a medical record or in another way, such  as from a law enforcement official. For instance, long-term care agency  officials from three states we reviewed indicated that protection of health  information under the HIPAA Privacy Rule did not extend to information  on prior convictions. In addition, long-term care facility and other agency  officials from these and three other states we reviewed maintained that it  was permissible to disclose information about a resident’s prior  convictions to employees in a long-term care facility who needed to know  in order to provide care for the resident. Yet other officials in six of the  eight states we reviewed told us they were either unsure whether the  HIPAA Privacy Rule would be violated by sharing information about the  prior convictions of any offender living in a facility or that they believed  the HIPAA Privacy Rule did not apply to disclosing such information about  residents who are offenders. Officials at 11 of the 29 long-term care  facilities we interviewed in eight states said that they were concerned they  would violate the HIPAA Privacy Rule if they disclosed information about  the prior convictions of offenders living in their respective facilities, but  indicated that they would notify staff if they became aware of such  residents.
We brought the issue of long-term care facilities’ uncertainty regarding the  applicability of the HIPAA Privacy Rule to the attention of an official of the  Department of Health and Human Services Office for Civil Rights (HHS- OCR), the federal entity responsible for implementing and enforcing the  HIPAA Privacy Rule. The official indicated that HHS-OCR has not  published regulations or other guidance specifically regarding the  applicability of the HIPAA Privacy Rule to the disclosure of information  related to prior convictions of long-term care facility residents. However,  the official stated that to the extent that such information is maintained by  long-term care facilities as protected health information under the HIPAA  Privacy Rule, such information could be used or disclosed for specifically  permitted purposes, such as when necessary to run the health care  operations of a facility or required by another federal or state law. In  addition, the HHS-OCR official indicated that affected entities, such as  long-term care facilities, would need to make the determination on a case- by-case basis as to whether the information is protected health  information, and if so, whether its intended use or disclosure is permitted  by the HIPAA Privacy Rule. The official added that long-term care facilities  should consult their legal counsel if they have questions in making this  determination. Although HHS-OCR does maintain a list of answers to  frequently asked questions about the HIPAA Privacy Rule on its Web site,  it does not cover this specific issue. In commenting on a draft of this  report, Department of Corrections officials from one state we reviewed  stated that it would be helpful for HHS-OCR to describe some situations in  which it believes HIPAA would not be applicable with regard to the  disclosure of information about offenders admitted to health care  facilities. They stated that HHS-OCR’s direction to approach each case  individually is not very helpful and that additional guidance would be very  useful.
section_title: Supervision and Separation of Long- Term Care Facility Residents Largely Based on Behavior, Not Prior Convictions
paragraphs: Residents’ prior convictions alone would not be sufficient in most cases to  subject them to supervision or separation requirements that differed from  other residents, according to facility officials we interviewed.  Administrators at only 2 of the 29 long-term care facilities we contacted  indicated that they have a specific policy to separate offenders from other  residents based solely on their prior convictions. Instead, long-term care  facilities in the eight states we reviewed typically base supervision and  separation decisions on behavioral issues that arise. For example, in the  states we reviewed, several long-term care ombudsmen, industry  association officials, and facility officials we interviewed indicated that the  residents they have particular concerns about, in terms of behavioral  problems, are those with mental illness, such as dementia, for which  behaviors are apt to change as the disease progresses.
Although most officials we spoke with at long-term care facilities in the  eight states we reviewed do not supervise or separate offenders based  solely on their prior convictions, some officials indicated the potential for  a future need for residential facilities separate from long-term care  facilities exclusively for certain offenders. For instance, Minnesota state  officials said that some long-term care facilities may be hesitant to accept  sex offenders as residents in the future, believing that certain sex  offenders pose a risk to the safety of other residents. Therefore, a state  commission has recommended the development of secure health care  settings that would serve people who have committed certain sex offenses  and who may not otherwise have access to services. In order to establish  this facility, state officials are working with federal officials to resolve  issues related to balancing resident rights with the safety interests of the  larger community.
Even if long-term care facility officials wanted to impose different  supervision and separation requirements on offenders, numerous factors  could affect their ability to do so. For example, as previously noted, long- term care facilities were not always notified when individuals with prior  convictions entered them. Federal laws we reviewed do not require long- term care facilities to obtain information about prior convictions, and  among the eight states we reviewed, only Illinois had such a requirement.  In addition, assessment tools long-term care facilities in these eight states  use to determine the health care needs of residents usually are not  designed to gather information about prior convictions. Even if facilities  obtained such information, federal and state laws that we reviewed  generally do not provide for specific supervision or separation practices  for facility residents with prior convictions.
section_title: Conclusions
paragraphs: Each incident of resident abuse committed by offenders living in nursing  homes—even if isolated or infrequent—is of concern. However, while  long-term care facilities may learn that certain of their residents are sex  offenders or parolees through required community notification or through  other means, our findings did not indicate that residents with prior  convictions are more likely than other residents to commit abuse within  these facilities. Absent such evidence, it may be more appropriate to focus  on residents’ behaviors versus their prior convictions when assessing the  potential for committing abuse. Facility officials we interviewed more  frequently expressed concerns about the behavior and potential for abuse  by cognitively impaired and mentally ill residents than by offenders who  may have no behavioral issues. Facilities already document problematic  behaviors and assess the risk of individuals through resident assessments  and care planning procedures, and when they accept residents with  behavioral issues or such issues arise after admission, they must  appropriately address those behaviors through the care planning for these  individuals or transfer them to facilities better equipped to handle such  residents. In addition, focusing on prior convictions alone can be  problematic in that some offenders, such as those with certain physical  impairments, likely do not pose a risk to other residents. Nonetheless, in  the interest of identifying potential risks and taking precautionary  measures, four states we reviewed—California, Illinois, Oklahoma, and  Minnesota—enacted measures in 2005 to require notification to long-term  care facilities when offenders are residents. Assessing their experiences as  they implement these measures over time, including any negative impact  on offenders’ access to long-term care, may be instructive for other states  with similar concerns.
While it was not part of our original objectives to fully evaluate the NSOR,  it was our primary data source for identifying registered sex offenders  residing in long-term care facilities. In the course of our analysis, we  became aware that the FBI’s NSOR, which links states’ sex offender  registration programs so that law enforcement agencies can identify sex  offenders regardless of which state maintains their registration, was  incomplete for the seven states we reviewed for this purpose. States face  various barriers to fully submitting their registry records to the NSOR,  including difficulties such as obtaining the required FBI number for each  offender and a lack of staff resources. While the FBI has been reviewing  issues related to states’ submission of records to the NSOR, it currently  does not track submission rates, so the proportion of state records missing  from the NSOR is not precisely known. Continued improvements in the  comprehensiveness of the NSOR can enhance the ability of local law  enforcement agencies to identify offenders and notify the community,  including long-term care facilities, where appropriate.
section_title: Recommendations for Executive Action
paragraphs: We recommend that the Attorney General direct the FBI to take the  following two actions:    assess the completeness of the NSOR, including state submission rates,    evaluate options for making it a more a comprehensive national database  of registered sex offenders.
section_title: Agency and State Comments and Our Evaluation
paragraphs: We provided copies of a draft of this report for comment to DOJ; HHS; and  the eight states we reviewed: California, Florida, Illinois, Minnesota, New  Jersey, Ohio, Oklahoma, and Utah. We received written responses from  DOJ and HHS, which are included in this report as appendixes III and IV,  respectively. We also received comments from California, Florida, Illinois,  Minnesota, New Jersey, and Oklahoma. These agency and state comments  and our evaluation follow.
DOJ commented that the recommendations are unnecessary because the  FBI already performs assessments of the NSOR and explores options for  improvement. For example, DOJ said that the FBI conducts triennial  audits of states’ NSOR participation, provides training and technical  assistance to states, and seeks input from states about what assistance  they need to improve their level of participation in the NSOR. DOJ  characterized our evaluation as incomplete because we did not ask for  information about the entire NSOR program or include a more extensive  discussion in the draft report of their efforts to improve the NSOR. We  obtained information about these efforts over the course of our work  through interviews with FBI staff, documents available on their Web site,  and through state officials. Because a comprehensive evaluation of the  NSOR was not one of our reporting objectives, we did not include a  complete listing of the FBI’s assistance to states in our draft report. To  respond to DOJ’s comments, we revised the report to include additional  information about the FBI’s initiatives to assist states in data submission  and to assess the accuracy of NSOR records. Including this additional  information, however, does not alter our overall finding concerning the  discrepancy between state sex offender registries and states’ NSOR  submissions.
We acknowledge, as DOJ pointed out in its comments, that there may be  valid reasons for a certain amount of discrepancy between state registries  and their NSOR submissions, such as if a state chooses not to submit the  records of sex offenders still incarcerated since their whereabouts do not  need to be tracked by the NSOR until their release. We also acknowledge  the challenge states face in maintaining current and accurate information  about registered sex offenders. However, we continue to believe that the  intent of the recommendations remains valid because of the evidence we  analyzed for a sample of states that a significant percentage of registered  sex offender records are not being successfully submitted by some states  to the NSOR, despite the states’ and FBI’s efforts to date. We believe the  FBI needs to track state submission rates to the NSOR as a measure of  comprehensiveness that can quantify the remaining gap as well as  improvements over time. We therefore revised the first recommendation  to specify that we are recommending that the FBI assess state submission  rates as a means of assessing the completeness of NSOR.
DOJ commented on three additional issues:    The risk posed by offenders residing in long-term care facilities.
DOJ suggested that GAO discounted the risk posed by sex offenders  residing in long-term care facilities based on insufficient evidence. We  agree that the placement of a sex offender into a long-term care facility  requires careful evaluation, particularly as the often-frail condition of long- term care residents makes them vulnerable to victimization. Based on our  research and interviews with administrators of long-term care facilities, it  is our view that the risk posed by offenders should be considered on a  case-by-case basis. The presumption that offenders pose a threat to other  residents could lead facilities to unnecessarily deny admission to low-risk  offenders or unnecessarily seclude them from other residents. DOJ did not  provide any new evidence to support its assertion that sex offenders pose  a greater threat than the analysis we presented in the report.
The likelihood that convicted sex offenders will commit additional  sex offenses after their release from prison. DOJ objected to our  citation of sex offender recidivism rates of 14 percent because they were  based on only a 5-year post-incarceration period, saying the period was  too short to be the basis of inferences about the likelihood that a sex  offender will commit additional sex offenses, and because of evidence that  sex offenses are underreported. We revised the report to clarify that the  same research also cites 20-year sex offender recidivism rates of   27 percent.
The usefulness of the NSOR in assisting law enforcement to  identify sex offenders residing in long-term care facilities. DOJ  questioned GAO’s assertion that improvements in the comprehensiveness  of the NSOR would improve the ability of local law enforcement to  identify sex offenders residing in nursing homes, commenting that  offenders would either already be on the state registry and thus  identifiable or they would not be registered and therefore not included in  the NSOR. We believe that a more comprehensive NSOR would improve  the tracking of sex offenders who enter long-term care facilities in the  same way it improves the tracking of sex offenders generally. If offenders  are registered in one state but move to another state and fail to register,  their records could be in the NSOR from the original state but not on the  registry of the second state. A more comprehensive NSOR thus better  ensures the national tracking of sex offenders who may choose to cross  state lines.
HHS commented that this report brought to its attention the uncertainty  that some long-term care facility officials have about the application of the  HIPAA Privacy Rule to the disclosure of conviction information, as well as  the issue that future guidance may be needed. HHS commented that the  report will help to resolve the uncertainty about the HIPAA Privacy Rule,  including clarifying that disclosures could be allowed for activities  necessary for the safe operation of the facility or as required by state laws.
DOJ, HHS, and the states also provided technical comments, which we  incorporated as appropriate.
As arranged with your offices, unless you publicly announce the contents  of this report earlier, we plan no further distribution of it until 30 days  after its issue date. At that time, we will send copies to the Attorney  General, the Secretary of Health and Human Services, and other interested  parties. We will also make copies available to others upon request. This  report is also available at no charge on GAO’s Web site at  http://www.gao.gov.
If you or your staffs have any questions about this report, please contact  me at (202) 512-7118 or allenk@gao.gov. Contact points for our Offices of  Congressional Relations and Public Affairs may be found on the last page  of this report. GAO staff who made major contributions to this report are  listed in appendix V.
section_title: Appendix I: Scope and Methodology
paragraphs: To determine the prevalence of registered sex offenders residing in long- term care facilities nationwide, we matched the addresses of registered  sex offenders listed in the Federal Bureau of Investigation’s (FBI) National  Sex Offender Registry (NSOR) as of January 3, 2005, with the addresses of  nursing homes and intermediate care facilities for people with mental  retardation (ICF-MR) listed in the Centers for Medicare & Medicaid  Services’ (CMS) Online Survey, Certification and Reporting system  (OSCAR) database. After standardizing address spellings and  abbreviations, we used SAS, a statistical analysis program, to compare  registered sex offender and long-term care facility addresses. Using a SAS  function that quantifies the magnitude of difference between two text  variables, we identified exact matches as well as near matches where the  addresses differed slightly. We manually reviewed the addresses that  differed slightly to determine if they were the same address.
To evaluate the comprehensiveness of the NSOR, we requested the full  state sex offender registries from 8 states—California, Florida, Illinois,  Minnesota, Ohio, Oklahoma, New Jersey, and Utah—in order to compare  the number of records in each registry to the number of records in the  NSOR for that state. We chose these 8 states on the basis of a number of  criteria, including variation in geographic location and in the number of  registered sex offenders identified as living in long-term care facilities  based on our preliminary analyses. California state officials did not  provide us with the state’s sex offender registry in view of their concerns  with state privacy laws. We also interviewed FBI staff about the  management of the NSOR database. To obtain information about the  administration and content of state registries, including their submission  of records to the NSOR, we interviewed state registry administrators from  the 8 states we reviewed and submitted a questionnaire via e-mail to the  remaining 42 states, receiving responses from 20 of them.
Since no national data source on parolees that includes address  information exists, we obtained parolee databases from each of the eight  states we reviewed. We matched parolee addresses to nursing homes and  ICFs-MR in OSCAR using the same methods we used for our analysis of  NSOR and state sex offender registries.
We excluded some records from our analysis because there was no valid  domestic address for the offender. Table 3 shows the number of records  we analyzed from all data sources for both registered sex offenders and  parolees, and the number of records excluded from each source because  of missing, invalid, or otherwise unusable address information.
To obtain information about resident abuse perpetrated by registered sex  offenders and parolees, we reviewed existing research and prior GAO  reports. We also interviewed long-term care facility administrators in the  eight states we reviewed, including administrators at facilities with  registered sex offenders as residents, as well as state department of health  and industry association officials and ombudsmen. To identify facilities for  administrator interviews, we initially chose four long-term care facilities in  each of the eight states we reviewed. These facilities were chosen from  two groups of facilities based on our initial analysis of NSOR and OSCAR  data. One group comprised facilities with registered sex offender matches  and the other group did not have any such matches, and when possible, we  selected two facilities from each grouping. If a selected facility refused our  request for an interview, we selected another facility as a replacement  from the same group. If a state did not have enough facilities with or  without sex offenders to complete two interviews from each group of  facilities, we used facilities from the other group. In all, we interviewed  administrators at 29 long-term care facilities, 11 with registered sex  offender matches and 18 without matches. We achieved a 91 percent  response rate for the facility interviews.
To determine whether federal laws provide for notification of facility staff,  residents, and residents’ families when sex offenders or parolees live in  long-term care facilities or for the supervision and separation of sex  offenders and parolees living in these facilities, we reviewed federal laws  and interviewed Department of Justice and CMS officials. We also  interviewed Department of Health and Human Services Office for Civil  Rights officials about the applicability of the Health Insurance Portability  and Accountability Act of 1996 Privacy Rule to the notification of facilities  about residents who are sex offenders or parolees.
To determine whether states we reviewed have laws or long-term care  facilities have practices that provide for notification of these individuals  and to determine the extent to which these individuals are subject to  supervision and separation requirements that differ from those for other  residents, we reviewed laws and interviewed state officials responsible for  long-term care facility licensing, industry officials, long-term care  ombudsmen, and the administrators at 29 long-term care facilities, which  were chosen based on the criteria discussed above. We also interviewed  Department of Corrections’ officials regarding their efforts to inform  facilities about their placement of parolees in them. To determine what  information on sex offenders is available to the public, we also reviewed  state sex offender Web site registries available in the states we reviewed.
The key sources used to identify registered sex offenders and parolees  living in long-term care facilities included CMS’s OSCAR database, the  NSOR, and parolee databases from selected states. To assess the reliability  of these data, we conducted electronic data testing, reviewed relevant  documentation, and interviewed knowledgeable agency officials about the  data quality control procedures. We determined that while the NSOR does  not include all registered or convicted sex offenders, its records are  regularly audited and are sufficiently reliable for the purposes of this  report. The lack of comprehensiveness of the data was evaluated and  taken into account in our discussion of the results. The OSCAR database  and state parolee databases were also found to be sufficiently reliable for  our purposes.
We conducted our work from September 2004 through February 2006 in  accordance with generally accepted government auditing standards.
section_title: Appendix II: Registered Sex Offenders Living in Nursing Homes and ICFs-MR
paragraphs: To determine the prevalence of registered sex offenders residing in long- term care facilities nationwide, we matched the addresses of registered  sex offenders listed in the NSOR as of January 3, 2005, with the addresses  of nursing homes and ICFs-MR listed in CMS’s OSCAR database. Using this  methodology we identified 683 registered sex offenders living in long-term  care facilities. The number of registered sex offenders identified as  residing in long-term care facilities in each state varied considerably,  ranging from 0 to 144, as demonstrated in table 4.
section_title: Appendix III: Comments from the Department of Justice
section_title: Appendix IV: Comments from the Department of Health and Human Services
section_title: Appendix V: GAO Contact and Staff Acknowledgments
subsections: section_title: Acknowledgments
paragraphs: In addition to the contact named above, Susan T. Anthony, Assistant  Director; George Bogart; Katherine Crumley; Michaela M. Monaghan;  Elizabeth T. Morrison; Sari B. Shuman; and Kara Sokol made key  contributions to this report.