Long-Term Care: Some States Apply Criminal Background Checks to Home Care
Workers (Letter Report, 09/27/96, GAO/PEMD-96-5).

Persons needing assistance with daily activities generally prefer home-
and community-based services to nursing homes, and increasing numbers of
elderly and disabled persons are turning to paid home care workers for
such services. Home care workers have frequent, unsupervised access to
potentially vulnerable people and their property. This report examines
the federal and state provisions that protect vulnerable elderly and
disabled persons from home care workers with histories of crime and
patient abuse. GAO describes (1) federal or state requirements for
licensure, registration, or certification that apply to home care
workers and organizations; (2) the extent to which states have used the
federally mandated registry for nursing home aides or a similar
mechanism to identify home care workers with past involvement in abuse,
neglect, or misappropriation of property; and (3) the extent to which
states have required criminal background checks of home care workers.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  PEMD-96-5
     TITLE:  Long-Term Care: Some States Apply Criminal Background 
             Checks to Home Care Workers
      DATE:  09/27/96
   SUBJECT:  Home health care services
             State-administered programs
             Federal/state relations
             Licenses
             Elder care
             Elderly persons
             Long-term care
             Health care personnel
             Crimes or offenses
             Investigations by federal agencies
IDENTIFIER:  Medicare Program
             Medicaid Program
             California In-Home Supportive Services Program
             
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Cover
================================================================ COVER


Report to the Honorable
Ron Wyden, U.S.  Senate

September 1996

LONG-TERM CARE - SOME STATES APPLY
CRIMINAL BACKGROUND CHECKS TO HOME
CARE WORKERS

GAO/PEMD-96-5

Criminal Background Checks for Home Care Workers

(973434)


Abbreviations
=============================================================== ABBREV

  FBI - Federal Bureau of Investigation
  HCFA - Health Care Financing Administration
  HHS - Department of Health and Human Services

Letter
=============================================================== LETTER


B-271516

September 27, 1996

The Honorable Ron Wyden
United States Senate

Dear Senator Wyden: 

By 1989, an estimated 5.3 million of the noninstitutionalized persons
age 65 and older, or about 17 percent of the 31 million elderly
Americans, needed some regular assistance with a basic or
instrumental activity of daily living.  Just over 1 million of these
persons were severely disabled and required assistance in several
areas.  Moreover, the need for such assistance is projected to
accelerate as the elderly population surges to 80 million by the
middle of the 21st century. 

Elderly persons generally prefer home and community-based services to
nursing homes, and a variety of economic and demographic trends make
it likely that increasing numbers of elderly and disabled persons
will eventually turn to paid home care workers for these services. 
Such home care workers have frequent, unsupervised access to
potentially vulnerable adults and their property.  Accordingly, you
asked that we examine the federal and state provisions that protect
vulnerable elderly and disabled persons from home care workers with
histories of crime and patient abuse.  In this report, we describe

  -- The federal or state requirements for licensure, registration,
     or certification that apply to home care workers and
     organizations;

  -- The extent to which states have used the federally mandated
     registry for nursing home aides or a similar mechanism to
     identify home care workers with past involvement in abuse,
     neglect, or misappropriation of property; and

  -- The extent to which states have required criminal background
     checks of home care workers. 


   RESULTS IN BRIEF
------------------------------------------------------------ Letter :1

Assessing the extent of problems with abuse, neglect, or
misappropriation in the home care industry is a difficult task. 
Formal safeguards for home care consumers vary widely across
political jurisdictions, public programs, and types of providers; and
in some instances, few safeguards exist. 

We have three key results of our evaluation to report.  Few states
have licensure requirements for types of workers that are among the
most common providers of home care services.  However, the vast
majority of states license or otherwise regulate some types of home
care organizations or professionals, and some states indicate that
all types of home care organizations are subject to a state licensure
requirement. 

While all states must maintain a registry for nursing home aides in
accordance with federal law, only about a quarter have incorporated
home care workers into it or have developed a separate registry for
home care workers. 

Finally, we found that slightly over a quarter of the states require
criminal background checks on some types of home care workers, though
these checks are generally limited to a state's own criminal records. 
States with a statute requiring such checks may access Federal Bureau
of Investigation (FBI) data for this purpose, but few states have
made use of this capacity with respect to home care workers. 
Although there is no charge for checking these data for criminal
justice purposes, fees are charged for checks for employment
screening, and some state officials have cited these fees as a factor
in reluctance to make greater use of the FBI data. 


   BACKGROUND
------------------------------------------------------------ Letter :2


      HOME CARE
---------------------------------------------------------- Letter :2.1

By "home care," we mean not only health care services delivered in
the home, but also assistance with basic and instrumental activities
of daily living, such as eating, dressing, bathing, toileting,
transferring from bed to chair, shopping, cooking, and laundry. 
These services are provided by a variety of organizations, including
temporary employment firms, nurse registries, and home health
agencies.  The types of individual workers providing home care
services are equally varied, including home health aides, homemakers,
and choreworkers, as well as professional social workers,
occupational therapists, and physical therapists.  However, it is
believed that 70 to 80 percent of all paid long-term home care is
provided by workers variously known as home health aides, personal
care aides, personal care attendants, or homemakers. 


      THE FEDERAL ROLE
---------------------------------------------------------- Letter :2.2

The federal government finances home care services through several
means, including Medicare, Medicaid, Veterans' Administration
programs, Older Americans Act funds, Social Services Block Grants,
and various demonstration and waiver programs.  However, the broadest
federal programs for supporting these services are generally
recognized to be Medicare and Medicaid.  The federal government
indirectly regulates some home care workers through the requirement
that agencies or individual providers that participate in the
Medicare and Medicaid programs meet various conditions of
participation.\1

In addition to these conditions of participation, the Medicare and
Medicaid Patient and Program Protection Act of 1987 requires that the
Secretary of Health and Human Services (HHS) exclude from
participation in title XVIII (Medicare), and direct states to exclude
from participation in programs authorized by title XIX (Medicaid) and
title XX (Social Services Block Grants), any individual or entity
convicted of program-related crimes or who has been convicted under
federal or state law of a criminal offense related to neglect or
abuse of patients in connection with delivery of a health care item
or service.\2 Also, the Secretary may direct a state to disqualify
those convicted of other crimes, such as fraud in the delivery of
health care services, obstruction of justice, or crimes related to
the manufacture, distribution, prescription, or dispensing of a
controlled substance.  HHS has issued related regulations (see 42
C.F.R sections 1001.101 to 1001.102 and 1002.203), but these
regulations do not require home care worker background investigations
and apply only to offenses occurring in connection with the delivery
of health care services. 


--------------------
\1 See our earlier reports, entitled Long-Term Care:  Status of
Quality Assurance and Measurement in Home and Community-Based
Services (GAO/PEMD-94-19; March 1994) and Medicare:  Assuring the
Quality of Home Health Services (GAO/HRD-90-7; October 1989). 

\2 42 U.S.C.  1320a-7. 


      OTHER SOURCES OF HOME CARE
      REQUIREMENTS
---------------------------------------------------------- Letter :2.3

State or local governments or professional boards also impose
requirements on home care organizations and independent workers in
connection with agency or individual licensure or registration
processes.  The coverage of these nonfederal requirements varies from
large segments of the home care industry to particular types of
workers.  Some states also assist consumers in distinguishing
licensed or registered workers from others by limiting the
advertisement of particular services to those who are licensed or
registered.  (See appendixes I and II.)


      REASONS FOR INTEREST IN
      WORKER SCREENING
---------------------------------------------------------- Letter :2.4

Several factors contribute to recent interest in background screening
requirements for home care workers.  These include the increasing
size and obvious vulnerability of the population in need of home care
services, the challenges the home care setting poses for worker
supervision, rapid expansion of the home care industry, unrelenting
demand for home care services in the face of worker shortages, the
low wages typically available to paraprofessional workers serving a
largely low- or fixed-income population, diffuse responsibility for
worker selection, and anecdotal reports of abuses by home care
workers with criminal history. 

Home care is provided to persons living at home who, because of a
chronic condition or illness, often cannot care for themselves. 
Studies of home health care utilization have found that the typical
recipient is a woman with functional limitations who is very elderly,
has a low income, and lives alone. 

The number of persons needing home care is expected to increase as
the very elderly population grows from the 3 million persons over age
85 in 1990 to more than 15 million in 2050.  Among those in need of
home care, reliance on paid home care workers is also expected to
rise, partly because adults in the baby boom generation have had
smaller numbers of children and will therefore have fewer available
to provide or supervise their care in old age.  In addition,
projections indicate that labor force participation will continue to
increase among women, who have traditionally provided much of the
informal care for the elderly.  Although future cohorts of elderly
persons may be better off financially, long-term care costs are
expected to increase faster than personal income. 

Although the home care work force is entrusted with significant
responsibilities and sometimes demanding work with little supervision
or assistance, home care work is often characterized by part-time
employment, lower wages, and an absence of fringe benefits. 
Moreover, workers are in high demand, and managers of proprietary
home care agencies indicate that the speed with which they can
provide workers to fill newly identified needs is often critical to
their firms' success.  In this context, the expanding demand for home
care services and the rapid growth of the home care industry combined
with an absence of appropriate safeguards could create pressures to
hire potentially unqualified job applicants. 

In addition, in an effort to stretch home care funding and empower
consumers, some states are adopting policies that encourage or
require aged and disabled beneficiaries to take direct responsibility
for hiring and supervising their home care workers who are paid with
state or federal funds.  Thus, vulnerable home care consumers
increasingly need access either to the tools for evaluating potential
workers or to a list of prequalified candidates.  In the absence of
the ability to offer attractive salaries, however, individual
consumers may feel hard-pressed to impose extensive requirements on
workers, for fear they will lose potentially good workers to less
demanding employers. 

Finally, anecdotal reports of abuses by a small number of home care
workers with criminal history have raised the issue of whether and
how such workers should be screened for criminal background.\3

Limited experience in screening for criminal background among home
care workers suggests that a segment of workers have criminal
history, but that such history does not always portend criminal
behavior.\4 However, advocates of criminal background screening argue
that the use of this process may deter any individuals with criminal
intent from entering the field. 


--------------------
\3 See, for example, Little Hoover Commission, "Unsafe in Their Own
Homes:  State Programs Fail to Protect Elderly from Indignity, Abuse
and Neglect" (Sacramento:  Commission on California State Government
and Economy, November 1991), p.  2.  See also, Lea Thompson, Consumer
Alert:  "Take Care," Dateline NBC Investigation of Home Care,
November 10, 1995.  The latter report cites five cases in which
workers with prior criminal history were later implicated in serious
crimes against home care recipients. 

\4 A March 1987 report by the Auditor General of California estimated
6.4 percent of the home care providers in the state's In-Home
Supportive Services (IHSS) program had criminal convictions. 
Following this report, a special project arranged for
fingerprint-based criminal background checks of providers new to
Santa Clara County's IHSS contractor or newly added to the county's
registry of potential providers.  In addition, recipients of IHSS
services were permitted to refer for criminal background clearance
any providers they were newly considering for employment.  A 1990
draft report on the results of this project noted that over 2 years,
76.6 percent of the 462 prospective providers who were referred for
criminal history checks completed the process, and 10.7 percent of
those completing the process had criminal records.  In the second
year of the project, 211 prospective providers were referred, 162 (77
percent) completed the process, and 15.4 percent of them had prior
criminal records.  Providers who submitted to the fingerprinting were
allowed to work during the 35-100 days required for criminal
background clearance, and no adverse consequences were observed. 


      TYPES OF SCREENING
---------------------------------------------------------- Letter :2.5

While some localities have experimented with other methods for
screening applicants for home care work, this report is concerned
primarily with two potential forms of background screening:  use of
worker registries and use of mandatory criminal background checks.\5

Under the Omnibus Budget Reconciliation Act of 1987, states must keep
registries of individuals qualified to work as nurses' aides in
nursing homes that participate in Medicaid and Medicare, and these
registers must note any instances in which states find that such
aides have been involved in resident abuse, neglect, or
misappropriation of property from a nursing home patient.  Before
employing someone as an aide, a nursing home that participates in
Medicare or Medicaid must check the registry for prior incidents
involving the prospective worker and verify that the worker meets
appropriate training standards.  This registry is important for two
reasons:  (1) there is some overlap between the nursing home and home
care work force; and (2) it is a model for worker screening that has
already been incorporated in the Medicare and Medicaid programs that
some states have extended to cover other types of workers, including
home care workers. 

With respect to criminal background checks, several variations are
possible.  Federal, state, or local law enforcement data may be used
by states for criminal background checks, and each has advantages and
limitations.  Although checks using state and local data are more
readily implemented, they are not as comprehensive as those employing
national records because they miss convictions that have occurred
even in neighboring states or communities.  Also, if they are based
primarily on the name, birthdate, and social security number provided
by the job applicant, they can result in false positives or false
negatives. 

The FBI may share interstate criminal history data with state
officials if authorized by a state statute approved by the U.S. 
Attorney General for the purpose of determining the fitness of
persons to work with children, the elderly, or individuals with
disabilities.\6 Under the law, an entity qualified under such a state
law (for example, a licensed home care agency), may request that an
FBI-authorized state agency conduct a national background check of an
applicant provider.  Such checks employ the national criminal history
background check system, which contains state and federal criminal
history records, and may be requested only when the person to be
checked provides fingerprints and a signed statement regarding the
presence and nature of any previous criminal convictions.  The FBI
routinely charges states at least $22 for processing each fingerprint
check for a nonvolunteer care provider.\7 The law requires that the
FBI-authorized state agency make "reasonable efforts" to respond to
such inquiries within 15 business days.\8 We report results on the
extent to which states have taken advantage of this law in connection
with home care workers, who primarily serve the elderly. 


--------------------
\5 Erie County, New York, for example, has established a variation of
a worker registry in which a quasi-governmental agency centralizes
employment data for persons working for member companies, allowing
potential employers to more easily verify an applicant's
industry-related employment history.  The effectiveness of this
process depends on the cooperation of a full complement of industry
members.  The process is handled by a nongovernmental agency in order
to allay some industry members' concerns that competitors would
otherwise use the registry as a tool for recruiting their skilled
employees. 

\6 42 U.S.C.  5119a. 

\7 The law permits the FBI and authorized state agencies to collect
$18, or the actual cost, whichever is less, to process the
fingerprint card of a "volunteer" care provider.  The FBI charges $18
for this service ($16 for billing states). 

\8 42 U.S.C.  5119a(a)(2). 


   SCOPE AND METHODOLOGY
------------------------------------------------------------ Letter :3

To describe federal and state requirements applying to home care
organizations and workers, we reviewed federal conditions for
participation in Medicare and Medicaid and surveyed state governments
regarding their methods for regulating organizations and individuals
who provide home care.  The terminology used to refer to various
types of home care workers is highly variable, and thus, our survey
adopted the standard definitions we present in the glossary. 

Although licensure or registration does not necessarily ensure a
better standard of care, we asked about these practices because they
indicate that a state has identified certain organizations or
individuals and thus has the capacity to apply additional
requirements, such as criminal background checks or special training. 
We also asked about states' experience in operating the federally
mandated registry for nursing home aides that records documented
findings of abuse, neglect, or misappropriation of a resident's
property and the states' use of this or similar registries for home
care workers.  Finally, we inquired about the presence of state
requirements for criminal background checks of workers and the
records covered by these checks. 

We completed our survey between August 1994 and April 1996.  We
received responses from 49 states and the District of Columbia.  We
did not independently verify the accuracy of state officials'
responses to our survey questions regarding state laws and policies. 

In addition to surveying state officials, we interviewed home care
providers and state and local officials in California, New York, and
Oregon regarding their approaches to screening home care workers.  We
also spoke with home care consumers in Oregon and with officials from
the FBI and the Health Care Financing Administration (HCFA) and
reviewed relevant literature on the utilization, regulation, and
characteristics of home care.  Our work was conducted in accordance
with generally accepted government auditing standards. 

We did not assess the extent of the problems linked to home care
providers, nor did we determine to what extent the use of a criminal
background check is linked to a lower incidence of abuse, theft, or
misappropriation of property.  Although in our interviews with
consumers we received some anecdotal reports of rough handling,
verbal abuse, and theft, we were unable to assess the extent of such
problems.  Doing so is generally complicated because investigating
and documenting such incidents is difficult; they tend to be
underreported, and the reports that do exist are scattered among
various administrative and law enforcement record systems.  We also
did not assess the extent to which the operators of home care
organizations voluntarily purchase fidelity bonds, which protect
covered employers against losses due to employee dishonesty and may
be conditioned on certain employee screening practices. 


   PRINCIPAL FINDINGS
------------------------------------------------------------ Letter :4

Of those persons who received paid home care in 1989, half paid for
their care without any assistance from public sources or insurance.\9
Some of this privately financed home care is provided by agencies
that participate in Medicare and Medicaid and are therefore subject
to limited federal requirements; however, the existence of such a
large private market suggests that a substantial portion of
assistance may be provided by organizations and individuals that
function outside these programs.\10 Care provided outside federal
programs is governed by state and local requirements, which may also
apply to federally financed care in the state in which it is
delivered. 


--------------------
\9 See K.  Liu and K.  Manton, "Changes in Home Care Use by Disabled
Elderly Persons:  1982-1989," Pub.  No.  94-398 EPW (Washington,
D.C.:  Congressional Research Service, May 6, 1994).  Also see Agency
for Health Care Policy and Research, "National Medical Expenditure
Survey--Home Health Care:  Use, Expenditures, and Sources of
Payment," AHCPR Pub.  No.  93-0040 (Washington, D.C.:  U.S. 
Government Printing Office, April 1993). 

\10 See A.L.  Jones, "Hospices and Home Health Agencies:  Data from
the 1991 National Health Provider Inventory," Advance Data, No.  257
(CDC, National Center for Health Statistics, November 3, 1994). 
Using a sampling frame limited to "health care providers," this
survey found that 81.8 percent of home health agencies were
Medicare-certified, and a similar percentage (82.5 percent) were
Medicaid-certified, with these certified agencies accounting for 89.1
percent of the patients cared for by organizations included in the
survey.  While this survey found that most home health agencies are
Medicare- or Medicaid-certified, it did not cover independent workers
who provide home care services and would have omitted most agencies
that provide largely nonmedical supportive services. 


      HOW DO STATES REGULATE HOME
      CARE PROVIDERS? 
---------------------------------------------------------- Letter :4.1

States take a wide variety of approaches to categorizing and
licensing home care organizations.  Among the 50 jurisdictions
responding to our survey, 41 required that at least certain
organizations obtain a specific license before providing home care
services, with 35 licensing at least some of the home care
organizations that do not participate in the Medicare program.  In
fact, 11 states indicated that all home care organizations were
publicly regulated through state licensure.  (See
table 1.)



                                Table 1
                
                     States That Require Home Care
                   Organizations to Obtain a License

                                                            Percentage
Organization                                                   of U.S.
s that must                                                 population
be licensed   State\a                             Number   over age 65
------------  ------------------------------  --  ------  ------------
All\b         Alaska, Florida, Indiana,               11          22.5
               Louisiana, Maine, Nebraska,
               New Hampshire, New Mexico,
               Oklahoma, Texas, Washington
Certain\c     Arkansas, Arizona, California,          30          62.0
               Colorado, Connecticut,
               District of Columbia,
               Delaware, Georgia, Hawaii,
               Idaho, Illinois, Kansas,
               Kentucky, Maryland,
               Minnesota, Missouri,
               Mississippi, North Carolina,
               North Dakota, New Jersey,
               Nevada, New York, Oregon,
               Pennsylvania, Rhode Island,
               South Carolina, Tennessee,
               Utah, Virginia, Wisconsin
None          Alabama, Iowa, Massachusetts,            9          15.2
               Michigan, Ohio, South Dakota,
               Vermont, West Virginia,
               Wyoming
No response   Montana                                  1           0.3
----------------------------------------------------------------------
\a Includes the 50 states and the District of Columbia. 

\b Some states that indicated that all home care organizations must
obtain a state license nevertheless indicated that their states had
no restrictions against the advertisement of certain home care
services by unlicensed organizations. 

\c Among the states indicating that certain providers are licensed,
Colorado, Mississippi, Missouri, and Wisconsin licensed only
Medicare-certified organizations. 

However, even states that regulate some home care services may not
prohibit advertisement of similar-sounding services by organizations
that are not licensed, registered, or certified.  In 45 states,
companion, housekeeping and homemaker, or shopping services may be
legally advertised by organizations that are not licensed,
registered, or certified.  (See appendix I.) More states regulated
the advertisement of personal care, home health, and home nursing. 
However, 30 states told us that unlicensed and uncertified
organizations might legally advertise personal care; 14 did not
specifically prohibit such organizations from advertising home health
care, and 22 did not prohibit their advertisement of home nursing or
related home care services. 

Although most states require that at least certain professionals who
provide paid home care obtain a state license, they are not likely to
require licensure or registration of some common types of home care
workers.  While individual licensure is a common practice for the
regulation of practical nurses, physical therapists, occupational
therapists, social workers, and registered nurses, it is not common
for home health aides, homemakers, or choreworkers.  As shown in
appendix II, we found that individuals who were neither licensed nor
state-registered could advertise personal care, companion,
housekeeping and homemaker, or shopping services in most states. 
Even home health and home nursing services could legally be
advertised by unlicensed and unregistered individuals in about a
third of the states.  Some state officials also identified related
categories of service, such as adult day care and case management,
that unlicensed and unregistered providers could legally advertise. 

Consumers seeking to file complaints against home care workers are
faced with a somewhat complex regulatory structure in some states,
while in other cases, no administrative complaint is possible, and
they must file a criminal complaint with the local police or a civil
suit.\11 In most states, the responsibility for licensure of nursing
home and home care workers was spread across multiple agencies,
units, or professional boards.  Similarly, although 20 states issued
only one type of license to home care organizations, nearly as many
recognized two or more types of home care organizations in their
licensing processes. 


--------------------
\11 Difficulties inherent in litigation against home care providers
are described in Sandra H.  Johnson, "Quality Control Regulation of
Home Health Care," Houston Law Review, 26 (1989), pp.  901-53. 


      DO STATES COMPILE A REGISTRY
      OF HOME CARE WORKERS? 
---------------------------------------------------------- Letter :4.2

A minority of states (14) reported routinely including at least some
types of home care workers in their state's mandatory registry for
nurses' aides.\12 When we interviewed officials of home care
organizations, some expressed concerns about entering qualified
employees on any public register that their competitors might use for
recruitment.  In addition, while administrative expenses for the
initiation of the nurse's aide registry have already been incurred,
adding home care workers to the established registry process would
require additional resources, such as increased time for data entry. 
More importantly, there may be greater difficulty in substantiating
complaints about home care workers since they are generally subject
to less oversight than nursing home workers. 


--------------------
\12 Although HCFA had not issued guidelines for the operation of
nurses' aide registries at the time our survey began, most states
reported they had developed their own guidelines.  State agencies
responsible for surveys and certification of nursing facilities must
have a process for receipt of complaints and timely review and
investigation of allegations of neglect, abuse, and misappropriation. 
The agencies must notify the nurse's aide, provide a reasonable
opportunity for a hearing, and make a finding.  Some states require
conviction by a court of law or a separate administrative process
involving the district attorney.  In most states, once a finding is
entered in the registry, it remains indefinitely.  States generally
reported that persons with findings of involvement in abuse, neglect,
or misappropriation constituted less than 1 percent of registrants. 
Roughly two-thirds of states reported only minor concerns with the
registry's effectiveness or operation.  Generally, states allow
anyone to request a check of the nurses' aide registry, and most do
not currently charge a fee for registry checks, although a few
(Connecticut, Florida, and Iowa) reported charges of less than $6 per
report. 


      DO STATES CONDUCT CRIMINAL
      BACKGROUND CHECKS? 
---------------------------------------------------------- Letter :4.3

Fifteen states reported requiring criminal background checks of at
least some of the individuals who may be employed as home care
workers.  In these states, checks were usually a condition of agency
licensure or certification, although in a few states, they were also
a condition of individual licensure or registration.  States
reporting criminal background check requirements for home care
workers included Alaska, California, Florida, Idaho, Indiana,
Louisiana, Nevada, Ohio, Oklahoma, Oregon, Rhode Island, Texas, Utah,
Virginia, and Washington.\13 Twelve of these states indicated that
state statutes or regulations specified the jurisdictions that these
checks must cover, but the breadth of the check was generally limited
to a state's own criminal records, which may be problematic where
many workers come from neighboring states. 

At least three states--Idaho, Nevada, and Ohio--reported using
national FBI data, but officials of other states we interviewed cited
the expense of FBI data as a reason for not using it.  Almost all
states that reported requiring such checks indicated that a criminal
background could be grounds for denying employment or refusing
licensure or for some other type of adverse action, such as
probationary certification. 


--------------------
\13 In Utah, applicants for registration as a Health Care Assistant
are asked to provide a sworn statement regarding their criminal
background.  In Minnesota, a statute allows but does not require a
criminal background check.  Although state officials in California
told us that the state has a law requiring a type of criminal
background check that is not based on fingerprints, a state official
told us that the law has not been enforced. 


   CONCLUSIONS
------------------------------------------------------------ Letter :5

While it is difficult to assess the extent of problems with abuse,
neglect, or misappropriation of property in the home care industry,
we found that federal regulations do not require criminal background
checks of home care workers.  While some states and localities have
instituted criminal background checks or other safeguards, states'
approaches to regulating home care are quite varied, and in some
instances, there may be few formal safeguards to protect potentially
vulnerable elderly persons from unscrupulous operators. 

Every state must maintain a registry of nursing home workers noting
those who have been involved in incidents of abuse, neglect, or
misappropriation from patients.  Although some states incorporate
home care workers in a registry, and such registries may be valuable
for identifying individuals who have met particular training
standards, the effectiveness of such registries in identifying
workers with histories of poor performance may depend heavily on the
capacity to document incidents occurring in a largely unsupervised
environment.  While some states have instituted criminal background
checks for some home care providers, few have used the FBI's national
data, citing cost concerns. 


   AGENCY COMMENTS
------------------------------------------------------------ Letter :6

Officials of the Health Care Financing Administration and the Federal
Bureau of Investigation reviewed a draft of this report, and provided
primarily technical comments, which have been incorporated as
appropriate.  HCFA officials also noted that,

     "While we agree with and support efforts designed to eliminate
     fraud and abuse and increase quality of care, we are unconvinced
     that there is enough consensus on the mechanisms which should be
     employed to address these concerns.  Consequently, we believe
     States should be given the flexibility to determine how best to
     address these issues."

With respect to criminal background checks, FBI officials note that,

     "The FBI's user-fee program is the sole basis by which it funds
     processing of noncriminal justice applicant fingerprints card
     submissions for licensing and employment purposes.  The FBI's
     budget does not contain any Congressional authorization or
     appropriation for funding of this part of its fingerprints
     operation."

As we arranged with your office, unless you publicly announce its
contents earlier, we plan no further distribution of this report
until 30 days after the date of this letter.  At that time, we will
send copies of the report to interested congressional committees, the
Secretary of HHS, the Administrator of HCFA, the Assistant Secretary
for Aging, the Director of the FBI, and other federal and state
officials.  We will also make copies available to others upon
request. 

If you have any questions or would like additional information,
please contact me at (202) 512-3092 or Sushil K.  Sharma, Assistant
Director, at (202) 512-3460.  Other major contributors to this report
are listed in appendix III. 

Sincerely yours,

Kwai-Cheung Chan
Director of Program Evaluation
 in Physical Systems Areas


SERVICES THAT ORGANIZATIONS THAT
ARE NEITHER MEDICARE- CERTIFIED
NOR STATE-LICENSED MAY LEGALLY
ADVERTISE
=========================================================== Appendix I

                                         Housekeeping
                   Personal    Companio  and                     Home            Home
State\             care        n         homemaker     Shopping  health          nursing
-----------------  ----------  --------  ------------  --------  ----------  --  ----------
Alabama            No          Yes       Yes           Yes       Yes             Yes

Alaska             No          No        Yes           Yes       No              No

Arizona            Yes         Yes       Yes           Yes       No              Yes

Arkansas           No          Yes       Yes           Yes       No              No

California         Yes         Yes       Yes           Yes       No              No

Colorado           Yes         Yes       Yes           Yes       Yes             Yes

Connecticut        Yes         Yes       Yes           Yes       No              Yes

Delaware           Yes         Yes       Yes           Yes       No              No

District of        No          Yes       Yes           Yes       Yes             Yes
Columbia

Florida            No          Yes       Yes           Yes       No              No

Georgia            \a          \a        \a            \a        \a              \a

Hawaii             Yes         Yes       Yes           Yes       No              No

Idaho              Yes         Yes       Yes           Yes       No              Yes

Illinois           Yes         Yes       Yes           Yes       Yes             Yes

Indiana            Yes         Yes       Yes           Yes       \a              \a

Iowa               Yes         Yes       Yes           Yes       No              No

Kansas             Yes         Yes       Yes           Yes       No              No

Kentucky           Yes         Yes       Yes           Yes       No              No

Louisiana          No          No        No            No        No              No

Maine              No          Yes       Yes           Yes       No              No

Maryland           Yes         Yes       Yes           Yes       No              No

Massachusetts      Yes         Yes       Yes           Yes       Yes             Yes

Michigan           Yes         Yes       Yes           Yes       Yes             Yes

Minnesota          No          \a        Yes           Yes       No              No

Mississippi        No          Yes       Yes           Yes       No              Yes

Missouri           Yes         Yes       Yes           Yes       Yes             Yes

Nebraska           \a          \a        Yes           Yes       \a              \a

New Jersey         No          No        No            No        No              No

Nevada             Yes         Yes       Yes           Yes       No              No

New Hampshire      No          Yes       Yes           Yes       No              No

New Mexico         Yes         Yes       Yes           Yes       No              \a

New York           No          Yes       Yes           Yes       No              No

North Carolina     No          Yes       Yes           Yes       No              No

North Dakota       Yes         Yes       Yes           Yes       No              Yes

Ohio               Yes         Yes       Yes           Yes       Yes             Yes

Oklahoma           No          Yes       Yes           Yes       No              No

Oregon             Yes         Yes       Yes           Yes       No              Yes

Pennsylvania       Yes         Yes       Yes           Yes       Yes             Yes

Rhode Island       No          Yes       No            Yes       No              No

South Carolina     Yes         Yes       Yes           Yes       No              Yes

South Dakota       Yes         Yes       Yes           Yes       Yes             Yes

Tennessee          Yes         Yes       Yes           Yes       No              No

Texas              No          No        Yes           Yes       No              No

Utah               Yes         Yes       Yes           Yes       No              Yes

Vermont            Yes         Yes       Yes           Yes       Yes             Yes

Virginia           No          Yes       Yes           Yes       No              No

Washington         No          No        No            No        No              No

West Virginia      Yes         Yes       Yes           Yes       Yes             Yes

Wisconsin          Yes         Yes       Yes           Yes       Yes             Yes

Wyoming            Yes         Yes       Yes           Yes       Yes             Yes
-------------------------------------------------------------------------------------------
\a No response provided for this item. 


SERVICES THAT INDIVIDUALS WHO ARE
NEITHER STATE-LICENSED NOR
STATE-REGISTERED MAY LEGALLY
ADVERTISE
========================================================== Appendix II

                                         Housekeeping
                   Personal    Companio  and                     Home            Home
State\             care        n         homemaker     Shopping  health          nursing
-----------------  ----------  --------  ------------  --------  ----------  --  ----------
Alabama            Yes         Yes       Yes           Yes       No              No

Alaska             No          No        Yes           Yes       No              No

Arizona            Yes         Yes       Yes           Yes       No              Yes

Arkansas           Yes         Yes       Yes           Yes       Yes             Yes

California         Yes         Yes       Yes           Yes       No              No

Colorado           Yes         Yes       Yes           Yes       Yes             Yes

Connecticut        Yes         Yes       Yes           Yes       No              Yes

Delaware           Yes         Yes       Yes           Yes       Yes             No

District of        Yes         Yes       Yes           Yes       Yes             Yes
Columbia

Florida            No          No        No            Yes       No              No

Georgia            Yes         Yes       Yes           Yes       Yes             Yes

Hawaii             Yes         Yes       Yes           Yes       No              No

Idaho              Yes         Yes       Yes           Yes       No              Yes

Illinois           Yes         Yes       Yes           Yes       Yes             Yes

Indiana            Yes         Yes       Yes           Yes       No              No

Iowa               Yes         Yes       Yes           Yes       No              No

Kansas             Yes         Yes       Yes           Yes       Yes             Yes

Kentucky           Yes         Yes       Yes           Yes       No              No

Louisiana          No          No        No            No        No              No

Maine              No          No        Yes           Yes       No              No

Maryland           Yes         Yes       Yes           Yes       No              No

Massachusetts      Yes         Yes       Yes           Yes       Yes             Yes

Michigan           Yes         Yes       Yes           Yes       Yes             Yes

Minnesota          No          \a        Yes           Yes       No              No

Mississippi        No          Yes       Yes           Yes       No              Yes

Missouri           Yes         Yes       Yes           Yes       Yes             Yes

Nebraska           Yes         Yes       Yes           Yes       No              No

Nevada             Yes         Yes       Yes           Yes       No              No

New Hampshire      No          Yes       Yes           Yes       No              No

New Jersey         \a          \a        \a            \a        \a              \a

New Mexico         Yes         Yes       Yes           \a        No              \a

New York           Yes         Yes       Yes           Yes       Yes             Yes

North Carolina     No          Yes       Yes           Yes       No              No

North Dakota       Yes         Yes       Yes           Yes       No              Yes

Ohio               Yes         Yes       Yes           Yes       Yes             Yes

Oklahoma           No          Yes       Yes           Yes       No              No

Oregon             Yes         Yes       Yes           Yes       No              No

Pennsylvania       Yes         Yes       Yes           Yes       Yes             Yes

Rhode Island       Yes         Yes       Yes           Yes       Yes             Yes

South Carolina     Yes         Yes       Yes           Yes       No              No

South Dakota       Yes         Yes       Yes           Yes       Yes             No

Tennessee          Yes         Yes       Yes           Yes       No              No

Texas              No          Yes       Yes           Yes       No              No

Utah               No          Yes       Yes           Yes       No              No

Vermont            Yes         Yes       Yes           Yes       Yes             Yes

Virginia           \a          \a        \a            \a        \a              \a

Washington         Yes         Yes       Yes           Yes       No              No

West Virginia      Yes         Yes       Yes           Yes       Yes             Yes

Wisconsin          Yes         Yes       Yes           Yes       No              No

Wyoming            Yes         Yes       Yes           Yes       No              No
-------------------------------------------------------------------------------------------
\a No response provided for this item. 


MAJOR CONTRIBUTORS TO THIS REPORT
========================================================= Appendix III

PROGRAM EVALUATION AND METHODOLOGY
DIVISION

Betty Ward-Zukerman, Project Manager
R.E.  Canjar, Project Staff
Ed Logsdon, Project Staff
Venkareddy Chennareddy, Referencer

OFFICE OF GENERAL COUNSEL

Susan Poling, Assistant General Counsel


GLOSSARY
============================================================ Chapter 0


      CHORE SERVICES
-------------------------------------------------------- Chapter 0:0.1

Performance of tasks such as shopping, yard work, and housecleaning
that generally do not require hands-on contact with the consumer. 


      CHORE WORKER
-------------------------------------------------------- Chapter 0:0.2

A title sometimes given to home care workers who perform chore
services. 


      COMPANION
-------------------------------------------------------- Chapter 0:0.3

A title sometimes given to home care workers who perform companion
services. 


      COMPANION SERVICES
-------------------------------------------------------- Chapter 0:0.4

"Friendly visitor" services that may include assisting home care
clients as they perform basic or instrumental activities of daily
living.  This term may connote services to clients who are less
dependent than those receiving services labeled "home health" or
"personal care."


      CRIMINAL BACKGROUND CHECK
-------------------------------------------------------- Chapter 0:0.5

A review of police or other law enforcement records designed to
determine whether a particular person has been convicted of unlawful
acts. 


      HOME CARE ORGANIZATION
-------------------------------------------------------- Chapter 0:0.6

A for-profit or nonprofit entity that provides any of or all the home
care services described below under "home care services." This term
excludes home care providers who are self-employed or personal
employees of home care consumers. 


      HOME CARE SERVICES
-------------------------------------------------------- Chapter 0:0.7

Services provided to ill or disabled persons in private residences to
assist them either in recovering from illness or in continuing to
live in their own homes.  Such services may be of any duration (short
term, long term).  They include assistance with basic activities of
daily living (for example, bathing, eating, toileting), instrumental
activities (for example, shopping, meal preparation, laundry), or
chronic medical conditions (for example, catheter care, parenteral
nutrition, wound care).  Home care services are provided under the
rubric of home health care, personal care, companionship, homemaker
services, chore services, occupational therapy, and physical therapy. 
The services are provided by a range of personnel, from nurses and
therapists to workers with little formal training or education. 


      HOME CARE WORKER
-------------------------------------------------------- Chapter 0:0.8

Anyone who performs home care services.  This designation includes
professional nurses and therapists as well as paraprofessional
workers with little formal training. 


      HOME HEALTH AIDE
-------------------------------------------------------- Chapter 0:0.9

A title sometimes applied to a paraprofessional home care worker who
generally provides basic home health care and incidental personal
care services.  Agencies that are Medicare-certified must ensure that
home health aides in their employ meet specific Medicare training
requirements. 


      HOME HEALTH CARE
------------------------------------------------------- Chapter 0:0.10

Assistance with health care provided in private residences to persons
with disabilities.  This designation may include services of
professional nurses and therapists as well as those of
paraprofessionals, such as home health aides and personal care aides. 
Specific services may include administration of medication, catheter
care, wound care, and occupational or physical therapy. 


      HOMEMAKER SERVICES
------------------------------------------------------- Chapter 0:0.11

Housekeeping assistance that may include cooking, cleaning, and
laundry and generally does not involve hands-on contact with the
consumer. 


      LICENSE
------------------------------------------------------- Chapter 0:0.12

Permission to practice or operate in a certain capacity (for example,
as a home health aide) that is extended only to license holders. 
Licenses may be extended to either businesses or individual workers. 
They are generally subject to renewal at designated intervals and may
presume satisfaction of certain standards or submission to certain
oversight processes. 


      MEDICARE-CERTIFIED
------------------------------------------------------- Chapter 0:0.13

A designation given to an entity that is approved for participation
in the Medicare program and is therefore eligible for Medicare
reimbursement (for example, a "certified" home health agency). 
Nurse's aides who are qualified to work in nursing homes that
participate in Medicare or Medicaid are also sometimes called
"certified" nurse's aides. 


      OCCUPATIONAL THERAPIST
------------------------------------------------------- Chapter 0:0.14

A title used by professionals who help persons with disabilities to
develop, recover, or maintain daily living and work skills or to
compensate for loss of function.  An occupational therapist may also
design or make special equipment needed at home or at work.  Persons
who use this title generally hold a bachelor's degree in occupational
therapy. 


      PERSONAL CARE AIDE
------------------------------------------------------- Chapter 0:0.15

A title sometimes given to paraprofessional home care workers who
perform personal care services.  People who perform these functions
are also sometimes known as personal attendants or personal care
workers. 


      PERSONAL CARE SERVICES
------------------------------------------------------- Chapter 0:0.16

Functional assistance, including help with basic activities of daily
living (such as eating, bathing, toileting, and transferring from bed
to chair), that generally involves hands-on contact with the
consumer. 


      PHYSICAL THERAPIST
------------------------------------------------------- Chapter 0:0.17

A title used by professionals who perform tasks designed to improve
mobility, relieve muscle pain, and prevent or limit the permanent
physical disabilities of patients suffering from injuries or disease. 
Unlike an occupational therapist, a physical therapist focuses
exclusively on physical disabilities.  Physical therapists are
usually licensed and graduates of an accredited physical therapy
program. 


      PRACTICAL NURSE
------------------------------------------------------- Chapter 0:0.18

A home care worker who cares for the sick, injured, convalescing, and
handicapped under the direction of a physician or registered nurse. 
Such workers perform tasks such as taking vital signs, treating
bedsores, administering injections and enemas, providing assistance
with personal care, giving alcohol rubs and massages, and inserting
catheters.  In some states, practical nurses are referred to as
vocational nurses.  Many of the functions performed by workers in
this category are also performed by persons called home health aides,
but practical nurses are more likely to have passed through a state
licensing process and are consequently referred to as licensed
practical nurses or licensed vocational nurses. 


      REGISTERED NURSE
------------------------------------------------------- Chapter 0:0.19

A graduate of any accredited nursing school who has passed the
national licensing examination.  A registered nurse may include a
person with an associate's degree in nursing (A.D.N.), a bachelor's
degree in nursing (B.S.N.), or a hospital nursing diplomate. 


      REGISTRY
------------------------------------------------------- Chapter 0:0.20

A list of individuals who work in a designated capacity or meet
specific qualifications.  Depending on state rules, participation in
a registry may either be voluntary or mandatory.  The content of
registry entries may range from worker name and address to detailed
information about worker qualifications, background, and past
performance.  Registration, unlike licensure, may not imply
possession of a document, evidence of fulfillment of particular
requirements, or periodic submission to oversight. 


      SOCIAL WORKER
------------------------------------------------------- Chapter 0:0.21

A person who helps individuals and families cope with problems such
as inadequate housing, serious illness, financial mismanagement,
handicaps, or substance abuse, generally through direct counseling or
referral.  Social workers generally hold a bachelor's degree in
social work or a related field. 


      TEMPORARY STAFFING AGENCY
------------------------------------------------------- Chapter 0:0.22

A type of temporary employment service that provides health care
workers on a contract basis.  Such workers are generally considered
employees of the temporary staffing agency rather than of the
organizations or individuals for whom they perform services. 

*** End of document. ***