By “home care,” we mean not only health care services delivered in the home, but also assistance with basic and instrumental activities of daily living, such as eating, dressing, bathing, toileting, transferring from bed to chair, shopping, cooking, and laundry. These services are provided by a variety of organizations, including temporary employment firms, nurse registries, and home health agencies. The types of individual workers providing home care services are equally varied, including home health aides, homemakers, and choreworkers, as well as professional social workers, occupational therapists, and physical therapists. However, it is believed that 70 to 80 percent of all paid long-term home care is provided by workers variously known as home health aides, personal care aides, personal care attendants, or homemakers. The federal government finances home care services through several means, including Medicare, Medicaid, Veterans’ Administration programs, Older Americans Act funds, Social Services Block Grants, and various demonstration and waiver programs. However, the broadest federal programs for supporting these services are generally recognized to be Medicare and Medicaid. The federal government indirectly regulates some home care workers through the requirement that agencies or individual providers that participate in the Medicare and Medicaid programs meet various conditions of participation. In addition to these conditions of participation, the Medicare and Medicaid Patient and Program Protection Act of 1987 requires that the Secretary of Health and Human Services (HHS) exclude from participation in title XVIII (Medicare), and direct states to exclude from participation in programs authorized by title XIX (Medicaid) and title XX (Social Services Block Grants), any individual or entity convicted of program-related crimes or who has been convicted under federal or state law of a criminal offense related to neglect or abuse of patients in connection with delivery of a health care item or service. Also, the Secretary may direct a state to disqualify those convicted of other crimes, such as fraud in the delivery of health care services, obstruction of justice, or crimes related to the manufacture, distribution, prescription, or dispensing of a controlled substance. HHS has issued related regulations (see 42 C.F.R sections 1001.101 to 1001.102 and 1002.203), but these regulations do not require home care worker background investigations and apply only to offenses occurring in connection with the delivery of health care services. State or local governments or professional boards also impose requirements on home care organizations and independent workers in connection with agency or individual licensure or registration processes. The coverage of these nonfederal requirements varies from large segments of the home care industry to particular types of workers. Some states also assist consumers in distinguishing licensed or registered workers from others by limiting the advertisement of particular services to those who are licensed or registered. (See appendixes I and II.) Several factors contribute to recent interest in background screening requirements for home care workers. These include the increasing size and obvious vulnerability of the population in need of home care services, the challenges the home care setting poses for worker supervision, rapid expansion of the home care industry, unrelenting demand for home care services in the face of worker shortages, the low wages typically available to paraprofessional workers serving a largely low- or fixed-income population, diffuse responsibility for worker selection, and anecdotal reports of abuses by home care workers with criminal history. Home care is provided to persons living at home who, because of a chronic condition or illness, often cannot care for themselves. Studies of home health care utilization have found that the typical recipient is a woman with functional limitations who is very elderly, has a low income, and lives alone. The number of persons needing home care is expected to increase as the very elderly population grows from the 3 million persons over age 85 in 1990 to more than 15 million in 2050. Among those in need of home care, reliance on paid home care workers is also expected to rise, partly because adults in the baby boom generation have had smaller numbers of children and will therefore have fewer available to provide or supervise their care in old age. In addition, projections indicate that labor force participation will continue to increase among women, who have traditionally provided much of the informal care for the elderly. Although future cohorts of elderly persons may be better off financially, long-term care costs are expected to increase faster than personal income. Although the home care work force is entrusted with significant responsibilities and sometimes demanding work with little supervision or assistance, home care work is often characterized by part-time employment, lower wages, and an absence of fringe benefits. Moreover, workers are in high demand, and managers of proprietary home care agencies indicate that the speed with which they can provide workers to fill newly identified needs is often critical to their firms’ success. In this context, the expanding demand for home care services and the rapid growth of the home care industry combined with an absence of appropriate safeguards could create pressures to hire potentially unqualified job applicants. In addition, in an effort to stretch home care funding and empower consumers, some states are adopting policies that encourage or require aged and disabled beneficiaries to take direct responsibility for hiring and supervising their home care workers who are paid with state or federal funds. Thus, vulnerable home care consumers increasingly need access either to the tools for evaluating potential workers or to a list of prequalified candidates. In the absence of the ability to offer attractive salaries, however, individual consumers may feel hard-pressed to impose extensive requirements on workers, for fear they will lose potentially good workers to less demanding employers. Finally, anecdotal reports of abuses by a small number of home care workers with criminal history have raised the issue of whether and how such workers should be screened for criminal background. Limited experience in screening for criminal background among home care workers suggests that a segment of workers have criminal history, but that such history does not always portend criminal behavior. However, advocates of criminal background screening argue that the use of this process may deter any individuals with criminal intent from entering the field. While some localities have experimented with other methods for screening applicants for home care work, this report is concerned primarily with two potential forms of background screening: use of worker registries and use of mandatory criminal background checks. Under the Omnibus Budget Reconciliation Act of 1987, states must keep registries of individuals qualified to work as nurses’ aides in nursing homes that participate in Medicaid and Medicare, and these registers must note any instances in which states find that such aides have been involved in resident abuse, neglect, or misappropriation of property from a nursing home patient. Before employing someone as an aide, a nursing home that participates in Medicare or Medicaid must check the registry for prior incidents involving the prospective worker and verify that the worker meets appropriate training standards. This registry is important for two reasons: (1) there is some overlap between the nursing home and home care work force; and (2) it is a model for worker screening that has already been incorporated in the Medicare and Medicaid programs that some states have extended to cover other types of workers, including home care workers. With respect to criminal background checks, several variations are possible. Federal, state, or local law enforcement data may be used by states for criminal background checks, and each has advantages and limitations. Although checks using state and local data are more readily implemented, they are not as comprehensive as those employing national records because they miss convictions that have occurred even in neighboring states or communities. Also, if they are based primarily on the name, birthdate, and social security number provided by the job applicant, they can result in false positives or false negatives. The FBI may share interstate criminal history data with state officials if authorized by a state statute approved by the U.S. Attorney General for the purpose of determining the fitness of persons to work with children, the elderly, or individuals with disabilities. Under the law, an entity qualified under such a state law (for example, a licensed home care agency), may request that an FBI-authorized state agency conduct a national background check of an applicant provider. Such checks employ the national criminal history background check system, which contains state and federal criminal history records, and may be requested only when the person to be checked provides fingerprints and a signed statement regarding the presence and nature of any previous criminal convictions. The FBI routinely charges states at least $22 for processing each fingerprint check for a nonvolunteer care provider. The law requires that the FBI-authorized state agency make “reasonable efforts” to respond to such inquiries within 15 business days. We report results on the extent to which states have taken advantage of this law in connection with home care workers, who primarily serve the elderly. To describe federal and state requirements applying to home care organizations and workers, we reviewed federal conditions for participation in Medicare and Medicaid and surveyed state governments regarding their methods for regulating organizations and individuals who provide home care. The terminology used to refer to various types of home care workers is highly variable, and thus, our survey adopted the standard definitions we present in the glossary. Although licensure or registration does not necessarily ensure a better standard of care, we asked about these practices because they indicate that a state has identified certain organizations or individuals and thus has the capacity to apply additional requirements, such as criminal background checks or special training. We also asked about states’ experience in operating the federally mandated registry for nursing home aides that records documented findings of abuse, neglect, or misappropriation of a resident’s property and the states’ use of this or similar registries for home care workers. Finally, we inquired about the presence of state requirements for criminal background checks of workers and the records covered by these checks. We completed our survey between August 1994 and April 1996. We received responses from 49 states and the District of Columbia. We did not independently verify the accuracy of state officials’ responses to our survey questions regarding state laws and policies. In addition to surveying state officials, we interviewed home care providers and state and local officials in California, New York, and Oregon regarding their approaches to screening home care workers.