Long-Term Care Facilities: Information on Residents Who Are	 
Registered Sex Offenders or Are Paroled for Other Crimes	 
(31-MAR-06, GAO-06-326).					 
                                                                 
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.		 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-06-326 					        
    ACCNO:   A50559						        
  TITLE:     Long-Term Care Facilities: Information on Residents Who  
Are Registered Sex Offenders or Are Paroled for Other Crimes	 
     DATE:   03/31/2006 
  SUBJECT:   Convictions					 
	     Criminals						 
	     Federal law					 
	     Government information dissemination		 
	     Long-term care					 
	     Nursing homes					 
	     Parolees						 
	     Records						 
	     Registries 					 
	     Reporting requirements				 
	     Sex crimes 					 
	     DOJ National Sex Offender Registry 		 

******************************************************************
** This file contains an ASCII representation of the text of a  **
** GAO Product.                                                 **
**                                                              **
** No attempt has been made to display graphic images, although **
** figure captions are reproduced.  Tables are included, but    **
** may not resemble those in the printed version.               **
**                                                              **
** Please see the PDF (Portable Document Format) file, when     **
** available, for a complete electronic file of the printed     **
** document's contents.                                         **
**                                                              **
******************************************************************
GAO-06-326

     

     * Results in Brief
     * Background
     * Identification of Offenders Living in Long-Term Care Facilit
          * Most Sex Offenders Identified Were Male, Were under Age 65,
          * Number of Offenders Identified as Living in Long-term Care F
               * State Registries Do Not Include All Convicted Sex Offenders
               * State Submissions to the NSOR Do Not Include All Registered
               * Approximately 200 Parolees Identified as Living in Long-term
          * Abuse by Offenders Who Live in Long-term Care Facilities Not
     * States Required to Notify Community about Registered Sex Off
          * Federal Law Requires States to Provide Community Notificatio
          * Although Community Notification of Parolees Not Uniformly Re
          * Officials Uncertain about Ability of Long-term Care Faciliti
     * Supervision and Separation of Long-Term Care Facility Reside
     * Conclusions
     * Recommendations for Executive Action
     * Agency and State Comments and Our Evaluation
     * GAO Contact
     * Acknowledgments
     * GAO's Mission
     * Obtaining Copies of GAO Reports and Testimony
          * Order by Mail or Phone
     * To Report Fraud, Waste, and Abuse in Federal Programs
     * Congressional Relations
     * Public Affairs

Report to Congressional Requesters

United States Government Accountability Office

GAO

March 2006

LONG-TERM CARE FACILITIES

Information on Residents Who Are Registered Sex Offenders or Are Paroled
for Other Crimes

GAO-06-326

Contents

Letter 1

Results in Brief 3
Background 6
Identification of Offenders Living in Long-Term Care Facilities and
Assessment of the Risk They Pose Limited by Data Shortcomings 11
States Required to Notify Community about Registered Sex Offenders, but
Extent of Notification Varies 18
Supervision and Separation of Long-Term Care Facility Residents Largely
Based on Behavior, Not Prior Convictions 25
Conclusions 26
Recommendations for Executive Action 27
Agency and State Comments and Our Evaluation 27
Appendix I Scope and Methodology 31
Appendix II Registered Sex Offenders Living in Nursing Homes and ICFs-MR
34
Appendix III Comments from the Department of Justice 36
Appendix IV Comments from the Department of Health and Human Services 41
Appendix V GAO Contact and Staff Acknowledgments 43

Tables

Table 1: Estimated Submission Rates to NSOR, by States Reviewed, 2005 14
Table 2: Parolees Identified as Living in Long-term Care Facilities in
States Reviewed, 2005 16
Table 3: Validity of Offender Address Data by Data Source 32
Table 4: Registered Sex Offenders Identified as Living in Nursing Homes
and ICFs-MR, by State, 2005 34

Abbreviations

CMS Centers for Medicare & Medicaid Services FBI Federal Bureau of
Investigation HHS Department of Health and Human Services HHS-OCR
Department of Health and Human Services Office for Civil Rights HIPAA
Health Insurance Portability and Accountability Act of 1996 ICF-MR
intermediate care facility for people with mental retardation NNHS
National Nursing Homes Survey NORS National Ombudsman Reporting System
NSOR National Sex Offender Registry OSCAR Online Survey, Certification and
Reporting system

This is a work of the U.S. government and is not subject to copyright
protection in the United States. It may be reproduced and distributed in
its entirety without further permission from GAO. However, because this
work may contain copyrighted images or other material, permission from the
copyright holder may be necessary if you wish to reproduce this material
separately.

United States Government Accountability Office

Washington, DC 20548

March 31, 2006

The Honorable Charles E. Grassley Chairman Committee on Finance United
States Senate

The Honorable Henry A. Waxman Ranking Minority Member Committee on
Government Reform House of Representatives

The Honorable Betty McCollum House of Representatives

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.1 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 offenses2 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.

1For this report, we refer to nursing homes and ICFs-MR together as
long-term care facilities.

2For this report, we refer to registered sex offenders and other offenders
on parole for non-sex offenses as offenders.

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.3 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.

3California state officials did not provide us with the state's sex
offender registry in view of their concerns with state privacy laws.

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.)

                                Results in Brief

Using the FBI's NSOR, we identified about 700 registered sex offenders
living in long-term care facilities during 2005, representing 0.05 percent
of the 1.5 million residents of these facilities. About 3 percent of
nursing homes and 0.7 percent of ICFs-MR housed a registered sex offender
during 2005. Almost 90 percent of registered sex offenders we identified
lived in nursing homes and were considerably younger than the general
nursing home population, with 57 percent under age 65 compared to about 10
percent of all nursing home residents. However, our count is understated
because of limitations in data availability. For example, 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 who were convicted or released from prison before
registration requirements went into effect and those who are required by
law to register but do not comply. While noncompliance is difficult to
track, four of the eight states we reviewed estimated noncompliance rates
that ranged from 4.5 percent to 25 percent of all sex offenders required
to register. In addition, 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, our analyses of the
registries obtained from seven of the eight states we reviewed indicated
NSOR submission rates averaging about 57 percent, ranging from 1 percent
to 83 percent, while the 20 other states that responded to our e-mail
questionnaire reported NSOR submission rates ranging from 46 percent to
100 percent. Because there is no national data source on parolees that
includes address information, we obtained parolee databases from all eight
states we reviewed and identified 204 offenders on parole for non-sex
offenses living in long-term care facilities. We could not estimate the
overall risk these registered sex offenders and parolees pose to other
residents in long-term care facilities because data are not available in
the reviewed states on abuse perpetrated specifically by residents who
have prior convictions. Facility administrators we interviewed more
frequently expressed concern over the potential for abuse by residents
with cognitive impairments or mental illness than those with prior
convictions.

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 law for the parolee
population. States have broad discretion on how to implement this
requirement for registered sex offenders and often do so through a process
known as community notification. Consequently, the extent to which states'
community notification laws apply to all registered sex offenders or
explicitly include long-term care facilities varies, and this variation
was evident in the eight states we reviewed. For example, while two states
we reviewed apply uniform community notification requirements to all
registered sex offenders, the six remaining states vary these notification
requirements depending on the crime committed by the registered sex
offender or risk to re-offend. Similarly, only half of the states we
reviewed specify that long-term care facilities be notified when at least
some registered sex offenders are residents. Long-term care facilities in
the remaining four states, or in states where community notification of
these facilities is not required for all registered sex offenders, may not
be aware of residents who are offenders or must rely on other methods,
such as publicly available state Web site registries, to identify such
individuals. While we identified no federal law that requires community
notification for parolees when they enter long-term care facilities, three
of the eight states we reviewed require community notification for all or
a subset of parolees. When long-term care facility residents are known
offenders, opinions differ among state and long-term care officials we
interviewed as to whether sharing information with other residents and
staff about such offenders' prior convictions violates the Privacy Rule
issued under the Health Insurance Portability and Accountability Act of
1996 (HIPAA). For example, while some state agency officials indicated
that the HIPAA Privacy Rule only applied to individuals' health
information and not their prior convictions, some long-term care facility
officials thought the HIPAA Privacy Rule prohibited the sharing of any
such information in most cases. Despite concerns that they may violate the
HIPAA Privacy Rule by disclosing information about the prior convictions
of certain residents, some long-term care facility officials said that
they would still 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 the Department
of Health and Human Services (HHS) in the event that this issue gains more
prominence in the future.

Having a prior conviction typically is not sufficient to subject offenders
to supervision or separation requirements that differ from those for other
residents, according to long-term care facility officials we interviewed.
Instead, these facilities generally base supervision and separation
requirements for residents on behavioral issues as they arise. Several
long-term care ombudsmen, industry association officials, and facility
officials in the states we reviewed indicated that the residents they are
most concerned about in terms of behavioral problems are those with mental
illness, particularly dementia, for which behaviors are apt to change as
the disease progresses. Officials at only 2 of the 29 long-term care
facilities we contacted said they have a specific policy to separate
offenders from other residents based solely on their prior convictions.
Even if long-term care facility officials wanted to impose different
separation and supervision requirements on offenders, their ability to do
so may be limited. Not only are long-term care facilities not always
notified when individuals with prior convictions enter them, the
assessment tools they use to determine the health care needs of residents
typically do not gather information about prior convictions. In addition,
in the event that a facility obtained such information, federal and state
laws that we reviewed generally do not provide for specific supervision or
separation requirements for facility residents with prior convictions.

While it was not part of our original objectives to fully evaluate the
NSOR, in the course of our work using the NSOR to identify registered sex
offenders residing in long-term care facilities, we became aware that the
database was incomplete for the seven states we reviewed for this purpose.
Therefore, to ensure that NSOR fulfills its potential as a national
database on registered sex offenders, we recommend that the Attorney
General direct the FBI to assess the completeness of the NSOR, including
state submission rates, and to evaluate options for making it a more
comprehensive national database of registered sex offenders.

In commenting on a draft of this report, the Department of Justice (DOJ)
said it believes the recommendations are unnecessary because the FBI
already performs assessments of the NSOR and explores options for
improvement. While we acknowledge the states' and FBI's efforts and
progress to date, we maintain that the intent of the recommendations
remains valid based on our analysis of a sample of states that indicates
some states are not submitting a significant percentage of registered sex
offender records to the NSOR. However, to be more specific regarding the
need to assess the completeness of NSOR, we revised the recommendations to
clarify that the FBI should assess state submission rates. HHS commented
that the report will help to resolve much of the uncertainty about the
application of the HIPAA Privacy Rule to the disclosure of conviction
information by a facility, including clarifying that information could be
used for activities necessary for the safe operation of the facility or
disclosures that are required by state laws.

                                   Background

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.4
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.

4The NNHS is conducted by the Centers for Disease Control and Prevention's
National Center for Health Statistics.

Approximately 1.5 million individuals lived in Medicaid- and
Medicare-certified nursing homes and ICFs-MR in 2005.5 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.6 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.7 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.8

5Of the 1.5 million individuals living in these long-term care facilities
in 2005, about 100,000 lived in 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.9 In some states,
related sexual offenses include child pornography and willful indecent
exposure in public.

6Adaptive skills include communication, self-care, home living, and social
skills. The criteria specify that these conditions need to have been
identified at or before the age of 18.

7CMS sets conditions of participation for facilities that receive federal
funding. Part of the conditions of participation requires that residents
have certain rights to personal privacy and the confidentiality of
personal records.

845 C.F.R. pts. 160 and 164 (2005).

9Rape is defined as forced sexual intercourse with a male or female
victim. Sexual assault is defined as a variety of victimizations that
involve unwanted sexual contact. Incest is defined as nonforcible sexual
intercourse between persons who are related to each other to a degree
where marriage is prohibited by law. Department of Justice, Bureau of
Justice Statistics, An Analysis of Data on Rape and Sexual Assault: Sex
Offenses and Offenders (Washington, D.C.: February 1997).

Federal statute established the Jacob Wetterling Crimes Against Children
and Sex Offender Registration Program in 1994.10 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.11 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.12 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.13

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.14 The second
amendment, the Pam Lychner Sexual Offender Tracking and Identification Act
of 1996,15 mandated the FBI's creation of a national database now known as
the NSOR.16 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.

10For this report, we refer to the Jacob Wetterling Crimes Against
Children and Sex Offender Registration Program as the Wetterling Program.

11Violent Crime and Law Enforcement Act of 1994, Pub. L. No. 103-322, S:
170101, 108 Stat. 1796, 2038 (1994) (codified at 42 U.S.C. S: 14071).

12Criminal offenses against minors include criminal sexual conduct toward
a minor and solicitation of a minor to engage in sexual conduct. "Sexually
violent offenses" include offenses that consist of aggravated sexual abuse
or sexual abuse. A "sexually violent predator" is defined as a person who
has been convicted of a sexually violent offense and who suffers from a
mental abnormality or personality disorder that makes the person likely to
engage in predatory sexually violent offenses. 42 U.S.C. S: 14071(a)(3).

13Under the Byrne Formula Grants Program, the DOJ's Bureau of Justice
Assistance provides federal financial assistance to grantees for the
purpose of enforcing state and local laws that establish offenses similar
to offenses established under the Controlled Substances Act and to improve
the functioning of the criminal justice system with emphasis on violent
crime and serious offenders. In fiscal year 2004, all 50 states, the
District of Columbia, and the U.S. territories received financial
assistance through Byrne Grants.

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.

14Pub. L. No. 104-145, S: 2, 110 stat. 1345 (1996) (codified at 42 U.S.C.
S: 14071).

15For this report, we refer to the Pam Lychner Sexual Offender Tracking
and Identification Act of 1996 as the Lychner Act.

16Pub. L. No. 104-236, S: 2, 110 Stat. 3093 (1996) (codified at 42 U.S.C.
S: 14072). The NSOR is a nationwide system that links the states' sex
offender registration and notification programs. The system uses a
person's FBI number to connect the registration information in the
National Criminal Information Center with the registrant's criminal
history information that includes his/her fingerprints. According to the
DOJ the NSOR should be used to enhance a state's ability to locate
offenders in its jurisdiction who may be violating the law by not
registering.

 Identification of Offenders Living in Long-Term Care Facilities and Assessment
               of the Risk They Pose Limited by Data Shortcomings

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.

Most Sex Offenders Identified Were Male, Were under Age 65, and Resided in a
Small Number of Nursing Homes and ICFs-MR

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.

Number of Offenders Identified as Living in Long-term Care Facilities Is
Understated

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.

  State Registries Do Not Include All Convicted Sex Offenders

While some states already had sex offender registries in place, the
Wetterling Program statute mandated that all states implement a registry
by September 1997.17 Most state registries only include those sex
offenders convicted or released from prison after a specified date,
generally after 1990.18 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.

17States could apply for a 2-year extension of the statutory deadline from
the DOJ if they had made good faith efforts to comply but were unable to
meet the original deadline for implementing a state sex offender registry.

18Scott Matson and Roxanne Lieb, Sex Offender Registration: A Review of
State Laws (Olympia, Wash.: Washington State Institute for Public Policy,
1996). Department of Justice, Bureau of Justice Statistics, Summary of
State Sex Offender Registries, 2001 (Washington, D.C.: 2002).

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.

  State Submissions to the NSOR Do Not Include All Registered Sex Offenders

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.19 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.

19An FBI official explained that the submission of one record demonstrates
that the state has completed the reprogramming of its database to conform
to NSOR standards.

Table 1: Estimated Submission Rates to NSOR, by States Reviewed, 2005

                    Number of sex  Number of sex offenders State's submission 
              offenders listed on  listed on NSOR, January       rate to NSOR 
State           state registry                  3, 2005       (percentage) 
Florida                 34,810                   25,494                 73 
Illinois                20,690                   13,349                 65 
Minnesota                    a                    9,769                  a 
New Jersey              11,382                    9,454                 83 
Ohiob                   16,864                    2,409                 14 
Oklahoma                 5,235                    4,234                 81 
Utah                     7,409                       49                  1 
Average                                                                 57 

Sources: GAO analysis of the FBI's NSOR as of January 3, 2005; state sex
offender registries as submitted by states to GAO from January through
August 2005.

aMinnesota initially submitted to GAO only those offenders residing in
Minnesota who could potentially be identified as nursing home residents,
which was the purpose of our request for the data, and therefore excluded
offenders who were listed as out of state, deported, homeless, civilly
committed, in the witness protection program, or address unknown.
Consequently, we could not determine an overall submission rate. As of
February 2006, Minnesota reported that 73 percent of its active
registrants had been accepted by the NSOR.

bAs of January 3, 2005, Ohio had not submitted the majority of its sex
offender registry because of technical problems, but a state official
reported that the state submitted registry data on computer disk in August
2005.

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.20 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.21 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.22 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.23 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.

20Under the Lychner Act, NSOR information must also be disclosed for
employment background checks. To ensure that information released in
background checks is accurate, a person's identification is verified using
fingerprints. The FBI number provides the necessary link between the sex
offender registry record and an offender's fingerprint records to
technically achieve the inclusion of an offender's NSOR records in
employment background checks.

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.

21States also have the option of searching for an offender's FBI number by
conducting inquiries of the FBI's Fingerprint Identification Record System
using name and date of birth or fingerprints.

22According to NSOR data documentation provided by the FBI certain pieces
of information are mandatory for state registry records to be accepted
into the NSOR, including: offender's name; physical characteristics,
including gender, height, weight, eye, and hair color; race; date of
birth; registration beginning and ending dates; FBI number; and conviction
information. The NSOR also includes other information, such as vehicle
license plate numbers and home address, but will accept records even if
this information is not provided.

23In addition to annual address verification, states are required to
validate information in the NSOR on an annual basis to ensure the accuracy
and completeness of the information.

  Approximately 200 Parolees Identified as Living in Long-term Care Facilities
  in Eight States

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.

Table 2: Parolees Identified as Living in Long-term Care Facilities in
States Reviewed, 2005

State      Nursing homes ICFs-MR Totala 
California            63       4     67 
Florida                7       0      7 
Illinois              70       4     74 
Minnesota              2       0      2 
New Jersey             2       1      3 
Ohio                  42       1     43 
Oklahoma               6       0      6 
Utah                   2       0      2 
Total                194      10    204 

Sources: GAO analysis of parolee databases for eight reviewed states,
January through September 2005; CMS's OSCAR database, 2004.

aResults do not include parolees who were also listed on state sex
offender registries or the NSOR.

Abuse by Offenders Who Live in Long-term Care Facilities Not Tracked, but Risk
May Not Be Widespread

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.24 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.

2442 C.F.R. S:S: 483.13(c)(2), 483.420(d)(2).

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.

 States Required to Notify Community about Registered Sex Offenders, but Extent
                             of Notification Varies

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.

Federal Law Requires States to Provide Community Notification for Registered Sex
Offenders, but Direct Notification to Long-term Care Facilities Varied

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.25 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,26 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.27 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.30 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.

25The federal law requires the registration of sex offenders convicted of
criminal offenses against minors or of sexually violent offenses or those
designated as sexually violent predators.

26730 ILCS Stat. Ann. S: 152/120 (West 2005); Utah Code Ann. S: 77-27-21.5
(2003).

27Cal. Penal Code S: 290.45 (Dearing 2005); Fla. Stat. Ann. S: 944.606
(West 2005); Minn. Stat. Ann. S: 244.052 (West 2003); N.J. Stat. Ann. S:
2C: 7-8 (West 2005); Ohio Rev. Code Ann. S:S: 2950.081, 2950.11 (Anderson
2005); Okla. Stat. Ann. Tit. 57, S: 584 (West 2005-2006).

282005 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).

29Requirements 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.

30Emergency rules implementing this law require licensed long-term care
facilities, such as nursing homes and ICFs-MR, to check the background of
potential residents through the state sex offender database. 77 Ill. Reg.
S: 300.625 (as added for emergency rules published on Sept. 2, 2005).
These rules expired on December 7, 2005, and have not yet been replaced by
permanent rules.

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.31 The law did not provide instruction on how
these Web sites should be designed or what specific information should be
included.32 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.

31The Prosecutorial Remedies and Other Tools to End the Exploitation of
Children Today Act of 2003, Pub. L. No. 108-21 S: 604, 117 Stat. 650, 688.

32DOJ has published proposed guidelines in the Federal Register with
respect to state Internet sites for sex offender information at 70 Fed.
Reg. 12721 (2005).

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.33 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.

Although Community Notification of Parolees Not Uniformly Required, Parolees in
Long-term Care Facilities Often Identified by Law Enforcement

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.34 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.

33See http://www.nsopr.gov/.

342005 Ill. Legis. Serv. 94-163 (West); 2005 Minn. Laws c. 243.166; 2005
Okla. Sess. Laws Serv. c. 465 (West).

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.

Officials Uncertain about Ability of Long-term Care Facilities to Disclose
Offender Information under the HIPAA Privacy Rule

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.

Supervision and Separation of Long-Term Care Facility Residents Largely Based on
                        Behavior, Not Prior Convictions

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.35 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.

3577 Ill. Reg. S:S: 300.615, 300.625 (as added by emergency rules
published Sept. 2, 2005). These rules expired on December 7, 2005, and
have not yet been replaced by permanent rules.

                                  Conclusions

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.

                      Recommendations for Executive Action

We recommend that the Attorney General direct the FBI to take the
following two actions:

           o  assess the completeness of the NSOR, including state submission
           rates, and
           o  evaluate options for making it a more a comprehensive national
           database of registered sex offenders.

           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:

           o  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.
           o  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.
           o  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 [email protected] . 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.

           Kathryn G. Allen Director, Health Care

           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.

           Table 3: Validity of Offender Address Data by Data Source

           Sources: GAO analysis of the NSOR, 2005; GAO analysis of parolee
           databases for eight reviewed states obtained March through
           September 2005.

           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.

           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.

           Table 4: Registered Sex Offenders Identified as Living in Nursing
           Homes and ICFs-MR, by State, 2005

           Sources: GAO analysis of the FBI's NSOR as of January 3, 2005;
           CMS's OSCAR database, 2004.

           Kathryn G. Allen, (202) 512-7118 or [email protected]

           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.

           The Government Accountability Office, the audit, evaluation and
           investigative arm of Congress, exists to support Congress in
           meeting its constitutional responsibilities and to help improve
           the performance and accountability of the federal government for
           the American people. GAO examines the use of public funds;
           evaluates federal programs and policies; and provides analyses,
           recommendations, and other assistance to help Congress make
           informed oversight, policy, and funding decisions. GAO's
           commitment to good government is reflected in its core values of
           accountability, integrity, and reliability.

           The fastest and easiest way to obtain copies of GAO documents at
           no cost is through GAO's Web site ( www.gao.gov ). Each weekday,
           GAO posts newly released reports, testimony, and correspondence on
           its Web site. To have GAO e-mail you a list of newly posted
           products every afternoon, go to www.gao.gov and select "Subscribe
           to Updates."

           The first copy of each printed report is free. Additional copies
           are $2 each. A check or money order should be made out to the
           Superintendent of Documents. GAO also accepts VISA and Mastercard.
           Orders for 100 or more copies mailed to a single address are
           discounted 25 percent. Orders should be sent to:

           U.S. Government Accountability Office 441 G Street NW, Room LM
           Washington, D.C. 20548

           To order by Phone: Voice: (202) 512-6000 TDD: (202) 512-2537 Fax:
           (202) 512-6061

           Contact:

           Web site: www.gao.gov/fraudnet/fraudnet.htm E-mail:
           [email protected] Automated answering system: (800) 424-5454 or
           (202) 512-7470

           Gloria Jarmon, Managing Director, [email protected] (202) 512-4400
           U.S. Government Accountability Office, 441 G Street NW, Room 7125
           Washington, D.C. 20548

           Paul Anderson, Managing Director, [email protected] (202)
           512-4800 U.S. Government Accountability Office, 441 G Street NW,
           Room 7149 Washington, D.C. 20548

                  Agency and State Comments and Our Evaluation

Appendix I: Scope and Methodology Appendix I: Scope and Methodology

                                                            Parolee data from
                                                             eight reviewed
                                             NSOR                states
Validity of offender address     Number of Share of    Number of  Share of
data                               records    total      records     total
State abbreviation does not                                                
match one of 50 states or                                            
Washington, D.C.                         27,141       7%           -     -
Offender incarcerated or                                                   
deported                                 23,863       6%         529    0%
Offender transient, homeless, or                                           
address unknown                           5,936       2%       1,653    1%
Address listed is invalid                 8,775       2%      11,879    5% 
City/state does not match zip                                              
code                                        327       0%          12    0%
Valid address                           304,489      82%     248,290   95% 
All                                     370,531     100%     262,363  100% 

Appendix II: Registered Sex Offenders Living in Nursing Homes and ICFs-MR
Appendix II: Registered Sex Offenders Living in Nursing Homes and ICFs-MR

State                Nursing homes ICFs-MR Total 
Alabama                          1       0     1 
Alaska                           3       0     3 
Arizona                         15       0    15 
Arkansas                        10       1    11 
California                     141       3   144 
Colorado                         9       6    15 
Connecticut                      9       2    11 
Delaware                         6       0     6 
District of Columbia             0       0     0 
Florida                         31       4    35 
Georgia                         14       0    14 
Hawaii                           0       0     0 
Idaho                            5       7    12 
Illinois                        78       2    80 
Indiana                          3       1     4 
Iowa                             9       5    14 
Kansas                           9       1    10 
Kentucky                         5       0     5 
Louisiana                       11       2    13 
Maine                            3       0     3 
Maryland                         2       0     2 
Massachusetts                    0       0     0 
Michigan                        18       1    19 
Minnesota                       22       3    25 
Mississippi                      0       0     0 
Missouri                        19       2    21 
Montana                          1       0     1 
Nebraska                         0       0     0 
Nevada                           0       0     0 
New Hampshire                    4       0     4 
New Jersey                      12       0    12 
New Mexico                      13       2    15 
New York                        10      23    33 
North Carolina                  10       0    10 
North Dakota                     0       0     0 
Ohio                             3       0     3 
Oklahoma                        10       1    11 
Oregon                           6       0     6 
Pennsylvania                     0       0     0 
Rhode Island                     1       0     1 
South Carolina                   1       3     4 
South Dakota                    11       0    11 
Tennessee                        1       0     1 
Texas                           61       8    69 
Utah                             0       0     0 
Vermont                          0       0     0 
Virginia                         7       2     9 
Washington                       8       0     8 
West Virginia                    1       0     1 
Wisconsin                       20       1    21 
Wyoming                          0       0     0 
Total                          603      80   683 

Appendix III: Comments from the Department of Justice Appendix III:
Comments from the Department of Justice

Appendix IV: Comments from the Department of Health and Human Services
Appendix IV: Comments from the Department of Health and Human Services

Appendix V: St Appendix V: GAO Contact and Staff Acknowledgments

                                  GAO Contact

                                Acknowledgments

(290416)

GAO's Mission

Obtaining Copies of GAO Reports and Testimony

Order by Mail or Phone

To Report Fraud, Waste, and Abuse in Federal Programs

Congressional Relations

Public Affairs

www.gao.gov/cgi-bin/getrpt? GAO-06-326 .

To view the full product, including the scope

and methodology, click on the link above.

For more information, contact Kathryn G. Allen at (202) 512-7118 or
[email protected].

Highlights of GAO-06-326 , a report to congressional requesters

March 2006

LONG-TERM CARE FACILITIES

Information on Residents Who Are Registered Sex Offenders or Are Paroled
for Other Crimes

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.

What GAO Recommends

GAO recommends that the Federal Bureau of Investigation (FBI) assess the
completeness of the National Sex Offender Registry (NSOR), including state
submission rates, and evaluate options to increase its comprehensiveness.
The Department of Justice (DOJ) commented that these recommendations are
unnecessary because of efforts already in place. GAO recognizes these
efforts but maintains that the recommendations remain valid.

By analyzing the FBI's 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.
*** End of document. ***