U.S. Department of Health and Human ServicesU.S. Department of Health and Human Services
This report was prepared under contract #HHS-100-03-0027 between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and the Lewin Group. For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/_/office_specific/daltcp.cfm or contact the ASPE Project Officer, Emily Rosenoff, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201. Her e-mail address is: Emily.Rosenoff@hhs.gov.
The opinions and views expressed in this report are those of the authors. They do not necessarily reflect the views of the Department of Health and Human Services, the contractor or any other funding organization.
This report was prepared by The Lewin Group for the Office of the Assistant Secretary for Planning and Evaluation (ASPE), U.S. Department of Health and Human Services (HHS). Charlene Liggins and Emily Rosenoff served as the Government Project Officers at ASPE, providing leadership, guidance and substantive input over the course of the project. We also acknowledge the important guidance and contributions of the Technical Advisory Group (Appendix D). We would like to extend our deepest appreciation to the staff members of the Arizona Board of Nursing and the Kansas Department of Health and Environment, Health Occupations Credentialing Unit for their willingness to share and analyze data from their nurse aide registries. Finally, we sincerely thank all of the individuals who participated in the study, including the national level key informants (Appendix D), stakeholders from the four case study states (Appendix D) and representatives from twelve nursing facilities.
In an effort to improve the quality of care provided in long-term care settings, as well as ensure a committed and qualified long-term care workforce, the Office of the Assistant Secretary for Planning and Evaluation, within the U.S. Department of Health and Human Services, contracted with The Lewin Group (Lewin) to study the efficacy of various approaches to pre-employment screening and on-the-job monitoring of nurse assistants to prevent resident abuse in nursing homes. This study is intended to inform policymakers, providers, consumers and other interested parties about the relative contributions and perceived effectiveness of existing federal mandates and state and provider based strategies for preventing or reducing the abuse of vulnerable adults.
Federal and state governments, education and training centers, and employers have created a variety of formal mechanisms aimed at preventing incidences of abuse, neglect and exploitation in nursing homes and other long-term care settings. These mechanisms span a wide spectrum and include certification and licensure of paraprofessional long-term care workers, various pre-employment screening, (e.g., nurse aide registries, criminal background checks and drug tests), and on-the-job training and monitoring.
The two primary methods used for pre-employment screening include checking nurse aide registries and conducting criminal background checks. Federal guidelines require each state to establish and maintain a registry of nurse aides that includes certification information and substantiated findings of abuse, neglect, or financial exploitation in nursing homes. At minimum, these registries must include: (1) the full name of the individual; (2) identifying information, (3) the date of certification; and (4) information regarding substantiated findings of abuse, neglect or misappropriation.1 Federal guidelines require nursing facilities to check their State nurse aide registry to ensure that hired nurse aides are certified to work and meet all state requirements, and that they do not have any substantiated findings of abuse, neglect or misappropriation associated with their license. In addition, long-term care facilities must check other relevant databases they believe will include any information on the potential employee (e.g., criminal background database).2
Some states, either through state law or by choice, collect data beyond the scope mandated through federal requirements for maintaining nurse aide registries. For example, states registries may include data on certified and non-certified health care workers in addition to nurse aides along with additional demographic information such as race/ethnicity, education level or current employer.
Examining the efficacy of screening mechanisms such as state nurse aide registries and criminal background checks comes at a particularly relevant time. Two recent federal studies highlight the urgency for the study from both a long-term care staffing perspective and from a quality perspective. The first study, conducted by the U.S. Health Resources and Services Administration, detailed a widespread shortage of nurse aides and home health aides with a high likelihood of increasingly severe shortages in the future.3 The second study conducted by the Office of the Inspector General (OIG) revealed that nurse aide registries often fail to provide accurate information because of failure to update data or purge outdated data.4
Previous studies have examined rates of abuse in nursing facilities, direct service worker capacity issues, and compliance of states to maintain nurse aide registries. This study looks across all of these issues, by examining the process states go through to collect and maintain information in their registries, state and employer mandated background check procedures, reporting and investigating policies/practices when abuse allegations are made, and the impact of such processes on the direct service workforce, employers and state agencies.
The goal of this study was to examine current practices at the state and facility levels regarding pre-employment screening and on-the-job monitoring, and how these influence the quality of the long term care workforce. In addition, this study sought to:
The efficacy of nurse aide registries and criminal background checks in preventing resident abuse in nursing facilities is difficult to ascertain. Making an accurate assessment regarding the effectiveness of these practices is difficult because every state has a different process for screening and disqualifying potential workers, documenting information in their registries, tracking subsequent employment or complaint data, investigating abuse allegations, reporting relevant findings, and coordinating efforts across state entities. Extensive variation across states affects the ability to make a definitive statement about the efficacy of these strategies to ensure a qualified workforce. The in-depth examination of four states revealed that some aspects of these systems work well, but limitations exist in each state that affects the overall utility of these practices. There is, however, consensus across stakeholders in all four states that criminal background checks are a necessary element of the hiring process. The technology, coordination capabilities and infrastructure exist through on-line registries, fingerprint databases and abuse registries to help employers make the best hiring decisions possible to protect the elderly in their care. States are building on their knowledge, experience, and capabilities to streamline these processes, but there is still room for improvement while balancing the resource intensiveness of making these changes. It is clear that relying on criminal background checks and nurse aide registries are not enough to prevent or reduce abuse in nursing facilities. Ongoing training, education and supervision for workers providing direct care are also key components to maintaining a quality workforce. A summary of our overall project conclusions are provided below.
Criminal background checks are a valuable tool for employers during the hiring process and their use does not limit the pool of potential job applicants. Stakeholders agree that conducting criminal background checks on potential employees is an important aspect of the hiring process to reduce the likelihood of hiring someone who has potential to harm residents in long-term care. There is widespread acceptance throughout the long-term care industry (similar to that of the child care industry), that this practice serves to protect vulnerable adults and ultimately prevent abuse. None of the nursing facilities experienced any negative impact on their applicant pool as a result of this requirement. From the perspective of employers, reducing the amount of time it takes to receive background check results would improve the current system.
A correlation exists between criminal history and incidences of abuse. Based on data we received from Arizona and Kansas, it does appear that nurse aides who had a previous criminal conviction (non-disqualifying offense) had higher rates of substantiated abuse than nurse aides without a criminal history. While this only represents the experience of two states, this analysis does provide evidence to support the rationale for checking the criminal history of potential direct care workers as a screening mechanism for quality.
Criminal background checks are only one component of preventing abuse. Despite a connection between past criminal history and subsequent allegations of abuse, stakeholders consistently reported the following as effective strategies for preventing abuse (many of which are not formal state or industry policy): adequate supervision/monitoring, presence of managers on the floor, decreasing staff burnout, adequate staffing levels, rotating nurse aides on the floor to alleviate pressure of difficult residents, increased education and training, obtaining meaningful employment references (beyond verification of employment dates), valuing and respecting staff, creative recruitment incentives to retain committed staff, instituting a drug-free workplace policy, minimizing temporary hires, and pointing out negative behaviors in the moment and using them as a staff development opportunity.
There are fewer policies in place that support or reinforce post-employment strategies to ensure a qualified workforce. Through this study we have discovered that there is significantly more effort and resources allocated to the pre-employment phase of ensuring a qualified long-term care workforce than the post-employment phase. The policy focus at the state and facility level is on pre-screening applicants before employment and there are structures and regulations in place that support this effort. However, once a worker is hired and working in the field, there is less guidance regarding how best to train, continuously educate and monitor existing employees. As stated before, most states have no process in place to notify employers if an active employee commits a crime that would have prohibited them from working during their background check prior to employment. In the event of employee complaints or allegations of abuse, the effectiveness of state systems often breaks down due to a lack of coordination between multiple state entities involved in the investigation and reporting process. Duplicative efforts waste state resources, prolong investigations and often keep employees out of the workforce unnecessarily.
National Level Considerations
The challenge of individual state registries. Individual state registries and the barriers associated with data sharing across states, limit employer access to useful information about substantiated abuse findings against workers found in other states. Since workers may have been employed in more than one state, a national nurse aide registry has been frequently mentioned as one way to address the issue of long-term care workers with substantiated findings of abuse, neglect, and/or financial exploitation crossing state lines to work in another state. Several issues may pose barriers for the creation of a national nurse aide registry. First, transfer of information across various state and national agencies may be difficult due to state laws and agency “ownership” of data. Second, the cost of creating and maintaining a national database would require commitment of both staff time and funds from both states and national agencies. Third, certification procedures and requirements vary across states, which further challenge any effort to standardize the process nationwide.
Use of disqualifying offenses and waivers. It is important to strike a balance between the need to protect vulnerable citizens from harm and creating unnecessary barriers to employment for qualified individuals, further reducing the potential pool of long-term care workers. There is a paucity of literature examining nurse aides and criminal recidivism and propensity to commit abuse. Criminal recidivism research shows that a history of past criminal convictions may be a possible predictor of future behavior.6 Other research by Cohen (1996) reports that the probability of future dangerous behavior of criminal offenders increases when circumstances are similar to past situations in which criminal behaviors occurred, which has implications for workers who have substantiated findings of resident abuse.7
A review of the Illinois Department of Public Health waiver process for individuals certified to work in hospitals and nursing facilities indicates that many individuals with criminal records can work in the health care field with minimal impact on patient safety. In Illinois, individuals with specific criminal convictions are banned from working in certain health care professions but can apply for waivers. In an examination of waiver applications from 1996 to 2003, 5,706 individuals with convictions applied for waivers. 4,130 (72%) of these individuals were granted waivers. Ninety-seven individuals (or 2.3% of the 4,130 individuals) had their waivers revoked; 38 of these individuals had revoked waivers because of substantiated finding of abuse, neglect, or theft and 59 individuals due to a second disqualifying conviction.8
Additional research in the area of criminal recidivism, specifically in relation to elder abuse, neglect, and financial exploitation is necessary to develop evidence based lists of disqualifying offenses. Justification for the inclusion or exclusion of various crimes that constitute states’ lists of disqualifying offenses is unclear, and the lack of consensus across states on this issue illustrates the complexity of making a solid connection between past criminal activity and the proclivity to commit abuse in long-term care settings. In the absence of such evidence, policymakers and employers must still balance the need to protect vulnerable populations with the need to maintain an adequate direct care workforce to accommodate a growing older adult population.
The screening process requires a significant amount of resources. As states make efforts to improve their screening processes (e.g., expanding the criminal background check to other states or incorporating federal level checks, expediting the turnaround time for results, expanding the screening process to other types of workers), the costs will inevitably increase. States will need additional capacity (staff and financial resources) to meet the demand for quality screens on increased numbers of workers in a timely manner. It is important to balance the financial burden across state agencies, employers and direct service workers in an equitable manner so that screening processes can continue to improve.
State Level Considerations
Keeping registry data current to maximize their utility. A recent OIG study revealed that nurse aide registries may not always contain the most up-to-date, or accurate information. In a survey of 200 randomly selected long-term care facility administrators, 44% (87 individuals) surveyed stated that they periodically rechecked nurse aide registries to ensure that substantiated findings had been posted to the registry. Fifteen administrators found that a nurse aide previously listed as registered and free of a substantiated finding of abuse was later listed to be unqualified for work due to a substantiated finding, failure to attain active registration status, or failure to be certified as a nurse aide. The nurse aide registry is only helpful to employers if the information is current.
Increasing the utility of the nurse aide registry with public awareness and education. In most states, employers are the only ones who benefit from the information contained in the nurse aide registry. By increasing consumer knowledge and use of the registry, the state can further protect the public by offering additional resources and information on individual long-term care workers.
Incorporating alternative screening mechanisms. Nursing home administrators use several practices (not required by federal regulations) to screen potential employees and to monitor current nurse aides. Eighty-five percent of administrators surveyed for a recent OIG report used additional screening procedures such as criminal background checks, and/or personal and employment reference checks.9 Implementing random drug tests and criminal background checks on existing employees may be another way to monitor employees after they have cleared original pre-employment screens. Conducting drug testing may be a more effective method for screening out individuals with a criminal history in drug abuse rather than a comprehensive ban.10 Findings demonstrate the need to use creative and multi-pronged strategies for screening and monitoring direct care paraprofessionals.
Examining states’ practices related to investigating and reporting abuse. Current state practices for investigating and reporting abuse cases appear duplicative and lack adequate coordination across entities. This creates overlap for agencies conducting the investigation, burden for the employers, and a protracted suspension period for the direct service worker involved.
In 2000, there were 35 million people 65 years of age and over in the U.S., an increase of 12% from 1990. When baby boomers (born from 1946 through 1964) reach the age of 65, starting in 2011, the number of individuals 65 years of age and over is expected to rise.11 The rapidly aging long-term care workforce and high turnover rate pose barriers for meeting the long-term care needs of the growing older adult population.
In an effort to improve the quality of care provided in long-term care settings, as well as ensure a committed and qualified long-term care workforce, the Office of the Assistant Secretary for Planning and Evaluation (ASPE), within the U.S. Department of Health and Human Services, contracted with The Lewin Group (Lewin) to study the efficacy of various approaches to pre-employment screening and on-the-job monitoring of nurse assistants to prevent resident abuse in nursing homes. This study is intended to inform policymakers, providers, consumers and other interested parties about the relative contributions and perceived effectiveness of existing federal mandates and state and provider based strategies for preventing or reducing the abuse of vulnerable adults.
Vulnerability of older adults in long-term care settings. Examining the value of federal, state and provider strategies for preventing or reducing the incidence of abuse is vital for the protection of residents in long-term care service settings. Long-term care consumers often have physical, cognitive and functional impairments that make defense from and reporting of abuse, neglect, or exploitation difficult. Consumers with long-term care needs may lack strong advocates provided through a spouse or family support network.
While abuse, neglect, and financial exploitation occur in a variety of formal and informal long-term care settings by both paid and unpaid caregivers, the quality of long-term care in nursing facilities is of particular concern because past reports have demonstrated higher incidences of abuse in comparison with other settings. The House Committee on Government Reform, for example, issued a report in 2001 that demonstrated a high rate of abuse in nursing homes. Over a two-year period, nearly one-third of all certified nursing facilities had been cited for some type of abuse violation that had the potential to cause harm or had actually caused harm to a nursing home resident. Ten percent of nursing homes were cited for abuse violations that caused actual harm to residents.12 A 2002 General Accounting Office (GAO) study estimated that almost 30% of the nations 17,000 nursing homes were cited for deficiencies involving actual harm to residents or placing them at risk of death or serious injury.13
Definitions of abuse, neglect and exploitation. According to the National Center on Elder Abuse, abuse, neglect, and exploitation in the context of long-term care are defined as any knowing, intentional, or negligent act by a caregiver or any other person that causes harm or a serious risk of harm to a vulnerable adult. Abuse in nursing homes is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish for all residents, even those in a coma (42 CFR § 488.301). This includes physical abuse (inflicting, or threatening to inflict, physical pain or injury on a vulnerable elder, or depriving them of a basic need), emotional abuse (inflicting mental pain, anguish, or distress on an elder person through verbal or nonverbal acts), and sexual abuse (non-consensual sexual contact of any kind). Neglect is generally defined as the intentional or unintentional withholding of food, medication, or other necessities that result in the older person’s failure to thrive.14 Federal statute (42 CFR § 488.301) states that neglect in nursing homes is the “failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.” Exploitation in the context of long-term care is defined as the illegal taking, misuse, or concealment of funds, property, or assets of a vulnerable elder.15 Individual states vary in their definitions of abuse, neglect, and exploitation.
Strategies to improve workforce quality and reduce risk of abuse. Federal and state governments, education and training centers, and employers have created a variety of formal mechanisms aimed at preventing incidences of abuse in nursing homes and other long-term care settings. These mechanisms span a wide spectrum and include certification and licensure of direct paraprofessional long-term care workers, various pre-employment screening, (e.g., nurse aide registries, criminal background checks and drug tests), and on-the-job training and monitoring.
Federal Guidelines for Certified Nurse Aide (CNA) Registries. The two primary methods used for pre-employment screening include checking nurse aide registries and conducting criminal background checks. Federal guidelines require each state to establish and maintain a registry of nurse aides that includes certification information and substantiated findings of abuse, neglect, or financial exploitation in nursing homes. At minimum, these registries must include: (1) the full name of the individual; (2) identifying information; (3) the date of certification; and (4) information regarding substantiated findings of abuse, neglect or misappropriation.16 Federal guidelines require nursing facilities to check their state nurse aide registry to ensure that hired nurse aides are certified to work and meet all state requirements, and that they do not have any substantiated findings of abuse, neglect or misappropriation associated with their license. In addition, long-term care facilities must check other relevant databases they believe will include any information on the potential employee (e.g., criminal background database).17
Requirements beyond Federal Guidelines. Some states, either through state law or by choice, collect data beyond the scope mandated through federal requirements for maintaining nurse aide registries. For example, states registries may include data on certified and non-certified health care workers in addition to nurse aides along with additional demographic information such as race/ethnicity, education level or current employer. See Appendix C for a comprehensive list of state requirements for certification and employment.
Statutes Authorizing Criminal Background Checks. Criminal background checks provide another avenue for screening potential long-term care employees. Two federal statutes enable health care providers to perform criminal background checks on prospective employees. Public law 105-277, Section 124 enables nursing facilities and home health care agencies to request fingerprint based national criminal history checks by the FBI for employees or job applicants seeking positions involving direct patient care. In addition, Public law 103-322 § 320928 enables federal criminal background checks to be performed on individuals employed in long-term care settings other than nursing facilities and home health agencies. This law allows for checks to be conducted on individuals who work for, own, or operate a business that provides care to the elderly or individuals with disabilities.
Despite these two laws, an earlier law passed by Congress in 1972, Public law 92-544, created a barrier for states attempting to conduct background checks. This law stipulated that in order for background checks to occur, states had to first pass a law authorizing health care employers to request such background checks from state and local government officials, and then seek approval of the law from the U.S. Attorney General. However, Public law 105-251 § 222, passed in 1998, remedied some of these barriers by enabling state designated businesses or organizations involved in the licensure or certification of individuals providing care to children, the elderly, or individuals with disabilities to request federal criminal background checks of potential employees even in the absence of a state statute authorizing criminal background checks.18
On-the-Job Monitoring. Long-term care facilities also play a role in maintaining the quality of the long-term care workforce through their employment and monitoring practices. These monitoring practices might include supervision of direct care paraprofessional workers by other personnel, training, and education. Gaining a better understanding of the effectiveness and use by employers of screening mechanisms as well as on-the-job monitoring enables policymakers and relevant stakeholders to understand the balance between the need to protect vulnerable individuals with long-term care needs with the need to ensure that potentially qualified long -term caretakers are not being inappropriately screened out by highly sensitive screening tools.
Examining the efficacy of screening mechanisms such as state nurse aide registries and criminal background checks comes at a particularly relevant time. Two recent federal studies highlight the urgency for the study from both a long-term care staffing perspective and from a quality perspective. The first study, conducted by the U.S. Health Resources and Services Administration, detailed a widespread shortage of nurse aides and home health aides with a high likelihood of increasingly severe shortages in the future.19 The second study conducted by the Office of the Inspector General (OIG) revealed that nurse aide registries often fail to provide accurate information because of failure to update data or purge outdated data.20
Previous studies have examined rates of abuse in nursing facilities, direct service worker capacity issues, and compliance of states to maintain nurse aide registries. This study looks across all of these issues, by examining state processes for collecting and maintaining information in their registries, state and employer mandated background check procedures, reporting and investigating policies/practices when abuse allegations are made, and the impact of such processes on the direct service workforce, employers and state agencies.
The remainder of this report includes the following sections:
Study methodology, including research goals and objectives, data collection methodology, data analysis, study assumptions and limitations.
Major findings, including the impact of pre-employment screening mechanisms, training and on-the-job monitoring in reducing the risk of resident abuse. In addition, findings include similarities and differences in pre-employment screening processes across state systems, gaps or limitations of current processes, emerging innovations within the states and recommendations shared by key informants for improving the screening process, improving communication and coordination of information across stakeholders and streamlining the system for employers and direct service workers.
Implications and conclusions, including key issues and themes related to major findings, as well as the policy, regulatory and practice implications of the study, and directions for future research.
The goal of the study was to examine current practices at the state and facility levels regarding pre-employment screening and on-the-job monitoring, and how these influence the quality of the long term care workforce. In addition, this study sought to:
For this study, Lewin relied on both primary and secondary data sources. The sources used include key informants at the federal, state, and facility levels, CNA registry data, abuse registry data and relevant literature and reports.
Federal and National Key Informant Interviews. Guided by ASPE and a technical advisory group (TAG), Lewin gathered data from a numerous primary sources to capture a variety of stakeholder perspectives. In the initial stages of the project, Lewin conducted fourteen key informant interviews targeting experts in several key areas related to the project, including: experts in long-term care, elder abuse, law enforcement, federal representatives working on related projects (Centers for Medicare and Medicaid Services (CMS)), and nursing home industry and direct care workforce representatives. Preliminary interviews focused on soliciting input related to project topics, strategies, and contacts for experts in the field. After speaking with key informants, Lewin formed a TAG representing a broad spectrum of stakeholders. TAG members assisted the research team with: (1) developing a work plan focused on eliciting a better understanding of how screening mechanisms are used and interpreted and the practice variation that exists across and within states, (2) clarifying relevant policies and identifying relevant research, and (3) ensuring that the project added to the existing body of research.
State Key Informant Interviews. Arizona, Illinois, Florida, and Washington were selected as case study states based on several relevant characteristics developed in collaboration with ASPE and the TAG. Criteria included:
For each state, Lewin conducted stakeholder discussions via telephone with selected state representatives. Lewin conducted interviews from September 2005 to January 2006 with the following stakeholders:
Interviews with state stakeholders focused on policies and practices related to the prevention of resident abuse in nursing homes--specifically, the approach to criminal background checks and use of nurse aide and abuse registries. Discussions with state staff provided a better understanding of the different practices imposed by the states and rationale pertaining to the employment of individuals with criminal histories or previous offenses of abuse, neglect or financial exploitation. In addition, stakeholders provided information about current state processes, capacity issues, system structures, and suggested improvements. Information gathered was used to contextualize discussions with employers at the facility level about their practices and perspectives on the value of different strategies for reducing the incidence of resident abuse.
Nursing Facility Site Visits, Interviews, and Surveys. In addition to telephone interviews with state level stakeholders, Lewin conducted in-person site visits or phone interviews with informants in three or four nursing facilities in each state.22 Nursing facilities were selected for the following reasons:
At each facility, Lewin conducted interviews from November 2005 to March 2006 with the following stakeholders:
Interviews with facility level stakeholders focused on the policies and practices employed by the facility regarding the screening, hiring, training and monitoring of nurse aides. Discussions with facility level stakeholders solicited, from a variety of perspectives, an understanding of the utility and relative contribution of registries and background checks in reducing the incidence of resident abuse and ensuring a qualified long-term care workforce. Discussions also revealed aspects of the process that are most and least useful, strategies employers use to enhance the screening process as part of corporate requirements, suggestions to improve the current system, and insight into effective training and monitoring practices.
Detailed discussion guides for all interviews with TAG members, key informants, and state and facility level stakeholders are included in Appendix E.
Analysis of Registry Data
Originally, ASPE intended to gain access to states’ registry data and criminal background databases and use this data to ascertain:
Lewin worked closely with the Arizona Board of Nursing (AZBN) and the Kansas Department of Health Occupations Credentialing to conduct a secondary data analysis of state nurse aide registries and criminal history databases to explore the relationship, if any, between past criminal convictions or previous incidences of abuse and proclivity towards abuse, neglect and financial exploitation. These two states were selected because they use both nurse aide registries and criminal background checks as screening mechanisms.
Lewin originally requested raw data files of the nurse aide and abuse registries, as well as information on criminal background status, from both Arizona and Kansas. Due to regulations that prohibit the release or sharing of information on individuals’ criminal history, Lewin then requested Arizona and Kansas to conduct the analyses of state databases and then share aggregated results with the research team. Lewin provided an analysis plan (see Appendix E) for both states to follow that would examine the differences in abuse rates between nurse aides who had a criminal conviction or previous substantiated abuse finding, and nurse aides without such history. The data analysis plan also included demographic characteristics of nurse aides with substantiated findings of abuse, neglect or exploitation.
Each state submitted information on the following:
Document Review
To augment interview and site visit data, relevant documents were reviewed, including federal reports, state statutes, research literature, and literature provided by nursing facilities. Appendix A contains the bibliography of literature reviewed.
Numerous barriers, outlined below, prevented Lewin from analyzing the relationship between criminal background and proclivity for abuse using registry data from multiple states.
Barriers to Accessing Data on Criminal History. Accessing the repository of criminal record data collected by state agencies is prohibited by federal laws and state statutes established to protect individual privacy. Sharing this information is prohibited, even in aggregated form. Similarly, in a limited number of states that follow an “open record” policy for releasing criminal background information, access to information remains highly restricted. For example, “open record” states may restrict information sharing on criminal background records to other state offices. Further, if “open record” states allow a non-state entity to access information, many allow these entities to conduct criminal background checks on a single individual only--using name, date of birth, or social security number.23
Barriers to Accessing Data on Substantiated Abuse. Similar barriers arise when attempting to access nurse aide registry information on substantiated findings of abuse, neglect, and financial exploitation. Due to privacy laws, states contacted could not release the full extent of their databases to entities outside the state agency. For example, despite having a rich database that contains abuse, neglect, misappropriation, and criminal background data, Wyoming could only provide information on whether a person has been disqualified and could only release information for individuals who consented to the release of their information. Approximately 56% of Wyoming nurse aide applicants consent to releasing information to third parties.
Relevant Data Housed in Multiple Registries, Maintained by Multiple Agencies. Access to criminal background data and state nurse aide registry data are not the only obstacles encountered in conducting the quantitative component of this study. For example, few states maintain information on licensure, abuse, neglect, financial exploitation, and criminal history in one registry.24 The majority of states maintain two or more registries containing information on licensure of various health professionals, findings of abuse, neglect, and misappropriation of property, and criminal background.25 Access to needed data would require the approval by multiple entities and these entities would need to release identifying information for each individual in order to match records from each state database. As noted previously, access to comprehensive identifying information is difficult. In addition to the difficulties of correlating data across multiple registries in one state, nurse aide registry data may be of poor quality.
Inconsistent Data Quality. The quality of nurse aide registry and criminal history data impacted our ability to conduct a meaningful analysis. A study by the OIG revealed that nurse aide registries often fail to provide accurate information. Federal law requires that substantiated findings of abuse, neglect, or financial exploitation be recorded within ten days of the substantiated finding. In the national survey, OIG conservatively estimated that one in four records of nurse aides with substantiated findings was not updated within the required ten day period. Of even greater concern was the finding that one in eight nurse aide records were not updated three months later, long after the federally mandated ten day period. Further, many states failed to meet the federal requirement of removing records of inactive nurse aides (defined as failure to practice in 24 consecutive months) therefore enabling uncertified individuals to continue working.26 Several states that were approached to participate in this study expressed resistance because databases were not consistently “purged.” Interestingly, some states indicated that they have never purged their database. Some states reported that they have several hundred-thousand records in their database, including many inactive workers which would compromise the quality of the data. For these states, conducting the secondary analysis would have required significant resources and data cleaning to produce meaningful results. Due to access barriers, Lewin needed to rely on the willingness of state workers to conduct this analysis. State contacts generally indicated a high level of interest in the study but simply did not have the staffing capacity to conduct the analyses.
To answer the questions posed by this study, it is essential to examine the various components that constitute the systems for pre-employment screening (i.e., use of nurse aide registries and criminal background checks) and post-employment processes (i.e., training, on-the-job monitoring, and complaint investigation and reporting practices). While there are federal requirements to maintain a nurse aide registry and conduct pre-employment background checks, there are no requirements standardizing the implementation practices employed by states and nursing facilities. As such, implementation of these requirements varies considerably across states. The following section presents findings from four states regarding pre- and post-employment practices and innovations. Illustrating the variation in practices across the four states are process flow charts contained in Appendix B depicting: (1) the process for CNAs seeking certification; (2) process for CNAs seeking employment; and (3) process for handling complaints or allegations against CNAs of abuse, neglect, or exploitation.
1. Maintenance of the Nurse Aide Registry
To understand the utility and overall effectiveness of the nurse aide registry, it is important to have a clear sense of the structure, content, maintenance and capabilities within the state for sharing relevant information. The department or association responsible for the nurse aide registry varies greatly in each state. There is also significant variety in the content recorded in states’ registries, as well as the means and timing of updates to the registry. Many states encounter difficulty in keeping the state nurse aide registry up-to-date since there are different entities within each state that keep track of the different aspects of information recorded. Through state level informant interviews in the four study states (Arizona, Florida, Illinois, Washington), the level of variation among responsible entities who maintain the nurse aide registry, the contents, and the ease with which updated information is accessed became evident.
The nurse aide registry is maintained by the AZBN, the Department of Health in Florida, the Department of Public Health in Illinois, and the Department of Social and Health Services in Washington. Though each state entity fulfills the same role, they are different sectors within each state government’s structure. Arizona, Florida, Illinois and Washington contain information on CNAs, registered nurses (RNs) and licensed practical nurses in their nurse aide registries. Illinois also includes home health aides, personal care aides, and developmental disability aides in its registry. All four states record most demographic information including social security number, name, address, etc. However, each state varies in keeping record of other relevant information, such as date of competency completion, employment status, criminal background check status and date, substantiated findings, disqualifying offenses, waiver status, and current employer.
The complexity of maintaining the nurse aide registry stems from the need to receive updated information from other state departments handling different types of information that must be recorded in the registry. Criminal background check status, for example, must be gathered from the background check unit in the state, which in many cases is different from the entity that maintains the nurse aide registry. Information about employment (i.e., employer and status) requires updated information from employers or by certified workers themselves. If this is not done regularly, it impedes the ability of the entity maintaining the nurse aide registry to keep current and accurate records. Also, limited staffing capacity to maintain the registry and high nurse aide turnover are additional challenges that states face in updating the nurse aide registries consistently and accurately.
2. Criminal Background Check Processes
a. Disqualifying criminal offenses
Federal guidelines require criminal background checks to be conducted prior to the employment of CNAs. The goal of conducting criminal background checks is to ascertain whether or not applicants have a “disqualifying” criminal conviction that would prohibit them from working in a long-term care setting. Most states have developed a list of criminal offenses that prohibit an individual from obtaining either state certification/licensure or employment (“blanket disqualification”). However, there is no consensus across states regarding which crimes should be considered disqualifying offenses. Some states’ disqualifying offense lists include felonies only, while other states include felonies and select misdemeanor offenses such as driving under the influence and domestic violence convictions. The length of time (number of years) since conviction that would prohibit a person from working in a long-term care setting also varies by state. In some states, any felony conviction, regardless of when it occurred, automatically disqualifies someone from being employed. In other states, only specific felonies committed in the last five years result in blanket disqualification. In some cases, states consider convictions on juvenile records when making a determination of suitability.
To examine the level of variation that exists across states in terms of the types of crimes resulting in “blanket disqualification,” Lewin compiled a cross-state summary including data from 50 states and the District of Columbia regarding the use of criminal background checks in screening CNAs (see Appendix C). These matrices provide a concise summary regarding the state entities that conduct criminal background checks on nurse aides, laws or regulations that authorize criminal background checks and types of crimes27 that result in disqualification from employment as a CNA.
Matrix 1 (in Appendix C) provides an overview of the criminal background check process by state and shows variability across states at the certification and employment levels. In addition to states cross-checking against lists of different disqualifying offenses, states also vary in their requirements for conducting either a state or federal (Federal Bureau of Investigations (FBI)) level background check. The timing of the background check also varies, with nearly 40% of states (n=20) requiring the criminal background check prior to certification of nurse aides, and 80% (n=4128) requiring the check before employment. One implication of states requiring the background check prior to employment but not prior to certification is that individuals with criminal backgrounds can become certified and listed in the registries, possibly leading to an overstatement of the CNA supply in these states. In addition, this policy can be an issue for nurse aides who can complete their training and education, receive state certification to work, yet are not able to secure a job if they cannot clear the background check.
Matrix 2 (in Appendix C) provides details regarding regulations by state, again illustrating enormous variation in policies and regulations, in terms of types of crime (felonies and misdemeanors) and allowable time period since conviction (five years, ten years, no limit, and inclusion of juvenile record), that constitute the basis for disqualifying a potential worker from employment in the long-term care industry. For example, the allowable time since conviction in Colorado is ten years for certain disqualifying offenses, while for other offenses there is no limit (i.e., any history of violent crime, regardless of when the crime was committed prohibits an individual from employment). The allowable time since conviction in Delaware ranges from 5-10 years depending on the type of offense, and Virginia grants exemptions for offenses committed more than five years prior to application if the individual has only one conviction.
b. Similarities in the criminal background check process across states
Stakeholder discussions and facility site visits and interviews revealed some common criminal background check practices among Arizona, Florida, Illinois, and Washington. These commonalities include the following:
State statutes mandate that nursing facilities perform checks on CNA certification/licensure status and criminal history. In each of the four states we examined, nursing facilities are required by law to verify that nurse aides seeking employment have active certification and that criminal background checks are completed before hiring. In addition, state certification entities perform criminal background checks and verify that the nurse aide has no disqualifying offenses on their record.
Waivers or exemptions are permitted in all four states. While a waiver or exemption process exists in these states, the procedure for granting waivers or exemptions varies widely. For example, Arizona does not permit exemptions to any individual with a history of a felony in the past five years. Illinois permits waivers for a select number of crimes and with the permission of the Director of Public Health. In Illinois, a waiver application of an individual who has been convicted of an offense and who is typically ineligible for a waiver is still accepted, though far fewer exceptions are granted. Florida permits waivers and Washington permits exemptions if applicants follow certain appeal procedures. In Florida, potential CNAs bear the burden of showing sufficient evidence that they should not be disqualified and can be granted waivers under certain conditions set forth by law. (See Appendix C for Disqualifying Offenses.)
Registries contain detailed information that exceeds requirements detailed in federal guidelines. Federal guidelines dictate that registries contain the following information: full name of the individual, identifying information (social security number, address, etc.), the date of certification, and information regarding any substantiated findings of abuse. However, all four states maintain additional information in their registry databases. For example, databases in all four states include some demographic information (e.g., gender, race, education). Databases in Arizona, Florida, and Washington can capture employment status. Illinois collects training information and waiver information. Two states, Illinois and Florida provide information about inactive CNAs. While states reported what their databases have the capacity to collect on all individuals, this level of data is not necessarily collected for each individual in the registry.
c. Background checks variation across states
Despite some commonalities in the process for checking criminal background and disqualifying offenses, there is significant variation in how states approach screening the long-term care workforce. Differences include the following:
In contrast to Florida and Washington, Illinois and Arizona perform criminal background checks on a diverse range of workers. Illinois maintains information on home health aides, personal care aides, and developmental disability aides. Arizona performs criminal background checks on all direct care, human services, and supportive services employees working in residential and long-term care facilities.
States use a variety of identifying information to perform checks on criminal history and disqualifying offenses. States use a variety of identifying information to perform background checks ranging from more reliable data such as fingerprints to less reliable data such as name and date of birth. For example, Arizona and Florida use fingerprint data for all checks. Illinois uses a combination of name and date of birth to perform an initial check and if this information results in a positive result for criminal history, Illinois runs an additional check using fingerprint data to confirm results. With additional funding received as part of the CMS demonstration, Illinois will move to a fingerprint system in January 2006. Similar to Illinois, Washington uses a combination of name, date of birth, and fingerprint data. In this case, name and date of birth are used to run an initial check and fingerprint data are only used when name and date of birth do not appropriately identify the individual or if a positive result occurs.
States use a variety of databases to run background checks. In Arizona, fingerprints are run through both state and national (FBI) databases. At the state level, Arizona relies on the Automated Fingerprint Identification System (AFIS) that houses all criminal prints collected in the state. At the national level, Arizona uses the FBI database. Florida uses fingerprints to check for criminal records in the Florida Department of Law Enforcement database. If this state level check results in a positive identification, fingerprint checks are run a second time against the FBI database. Illinois uses name and date of birth to check the state police database. If state level checks result in a positive identification, Illinois utilizes fingerprint data to check the FBI database. Washington uses identifying information such as name and date of birth to run a criminal background check through the Washington State Patrol database. If name and date of birth do not appropriately identify a person (such is the case when two people have the same name and date of birth), Washington utilizes fingerprint data. In addition, Washington will perform fingerprint checks using the FBI database in particular situations (e.g., when a person has recently moved to the state).
In contrast to Florida and Illinois, Arizona and Washington provide information on pending cases of abuse, neglect, or exploitation. In Arizona, entities or individuals submitting background check requests must provide the name, license number, and social security number in order to access whether or not applicants are currently under investigation for abuse, neglect, or exploitation. Washington also includes pending abuse cases filed against workers in their registry. Employers have the discretion to hire, ask the applicant for information regarding the circumstances, or deny employment based on pending charges noted in the registry.
d. System gaps--limitations of existing screening practices
An analysis of background check processes in these four states highlighted gaps in the criminal background check system that may lead to limitations in the effectiveness of these screening mechanisms. Identifying potential limitations to current background check processes may provide ideas for states trying to improve their systems and inform stakeholders about the complexities of this process.
Criminal background checks only capture activity prior to employment. One of the biggest gaps in the current system is the single point in time nature of the criminal background check. The underlying assumption for checking an individual’s criminal history is that individuals who commit certain types of crimes are not appropriate for working in close proximity with vulnerable populations in long-term care settings. There are additional assumptions about the character of individuals with a criminal history that make them less desirable employees. The current system has no method for tracking criminal activity that occurs after the worker is employed. Unless states require periodic review of criminal history on a regular basis, employers have no knowledge of any criminal behavior their employees may engage in once they are working.
Current systems do not effectively capture crimes committed in other states. One of the most common discussions we had with stakeholders centered on states’ inability to access information about criminal history outside their own state. Privacy protections often prohibit information sharing between states, and information collected in the FBI database relies on states’ submission--which is often incomplete. Costs of FBI fingerprint checks also prevent some states from checking the national database for every applicant seeking certification or employment.
Disqualifying criminal offenses that preclude an individual from obtaining either state certification or employment differ widely across all states. Appendix C details how all 50 states and the District of Columbia approach the criminal background check process and define “disqualifying criminal offenses” through their state statutes. States are not consistent in their criteria for blanket disqualifications that prohibit potential nurse aides from working in long-term care settings. Drug charges are a particular issue, as many interview respondents indicated that individuals with a history of drug related crimes are less reliable in terms of work attendance and job commitment, yet few states include drug convictions in their list of disqualifying offenses. In reference to their statutes regarding drug offenses, a representative from one state reported “You can use drugs and still work with the elderly; you just can’t sell them and work.” The rationale for which criminal offenses make the list in each state is inconsistent, and the time delimitation of certain offenses varies across states and lacks evidence to support any preference.
Information delay of criminal background check can put facilities and residents at risk. Facilities can hire employees while their criminal background check is pending. In some states, the criminal background check process can take several months. This may put both the residents and facility at risk as well as waste labor resources if in fact the background check shows criminal activity. Facilities rely on information they receive from the criminal background check and would like this process expedited so they can avoid hiring, training and investing in employees they may need to terminate based on results of the screen.
Inadequate communication and coordination between relevant stakeholders can impede the process. In all four states, multiple entities participate in the background check process. Consequently, communication and coordination of information across state agencies is critical to the criminal background check process. State and federal legislation can pose barriers to communication across agencies. States have tried to address communication issues. For example, Arizona offers a free quarterly newsletter to the public that contains information on verified cases of abuse, neglect, and misappropriation. This regular communication is one way to increase communication across relevant stakeholders.
Once allegations have been made and an investigation takes place, additional communication is necessary to close the loop and ensure substantiated findings make it to the appropriate registry. Multiple entities can investigate abuse allegations in skilled nursing facilities (state surveyor, APS, ombudsman, etc.), with no systematic coordination or communication of findings across investigative entities.
Inadequate resources result in gaps in the background check process. Additional financial resources and/or staff would improve the criminal background check process in several ways. Budget limitations and attendant staff allocation issues affect quality, completeness, and timeliness of registry data. For example, understaffing in Washington poses barriers to a comprehensive background check system because state patrol statutes mandate that pending cases must be dropped after 12 months. Inadequate staffing levels lead to unprocessed cases, which result in missed opportunities to review individuals. In addition, states frequently cited the high cost of procuring and processing fingerprint background checks as a barrier within the current system. Many states would rather use fingerprint checks at the state and national level, but simply cannot afford to implement this practice. Due to cost issues, some states are considering shifting the costs of background checks to applicants. However, this may prevent qualified applicants from applying for jobs.
Entities performing background checks use data that cannot be easily verified. Applicants can potentially falsify information if entities do not rely on fingerprint data. For example, some states rely on name and date of birth to perform state level background checks, defaulting to more reliable fingerprint data only when name and date of birth result in more than one match or when applicants have recently moved to the state (within three years). Individuals who do not want to submit fingerprint data can easily claim that they have lived in the state for more than three years and thus bypass the more rigorous fingerprint based background check.
Inaccurate “hits” or errors on the criminal background check may falsely exclude qualified workers. Individuals with common names may experience “positive hits” on their criminal background check when they in fact have not committed a crime. In this situation, some states are able to conduct a fingerprint background check to ensure they are checking the background of the correct individual, but this is not always the case. Individuals often bear the burden for clarifying errors associated with their background check results which is takes time and unnecessarily delays their entry into the workforce.
The background check process often fails to account for unlicensed workers in licensed facilities or individuals working outside licensed facilities. Current processes do not account for the criminal history of workers without licenses (e.g., housekeeping and kitchen staff) in licensed care facilities, yet these individuals often have frequent contact with residents. In addition, states do not have statutes requiring background checks on individuals working outside licensed facilities such as individuals providing home health care.
Interpretation of “pending” cases in the abuse registry is difficult for employers during the hiring process. Solid arguments exist on both sides of the issue of whether or not to include pending cases in abuse registries. One the one hand, including abuse cases that are pending in the registry allows employers to learn if there are issues of misconduct associated with someone they may be trying to hire into their organization. From a conservative standpoint, some employers welcome the information to be “safe” rather than sorry, and they appreciate the option to pursue details of the pending case with potential applicants they have particular interest in hiring. However, pending cases can be detrimental to a worker seeking a new job position before the case has reached resolution. States are required to investigate all allegations that are brought against an employee--whether frivolous in nature or not. While a case is pending, which can be up to several months, workers under investigation due to a false accusation have difficulty finding employment and are placed into a “guilty until proven innocent” framework until the case is dismissed.
Some states have adopted a waiver system for direct service workers to appeal a decision to prohibit employment while other states have no appeal system in place. Some state systems are “ironclad” and there are few opportunities for workers to appeal the decision made by the state. Issues highlighted previously factor into this scenario. Criminal background checks conducted with name and date of birth can often generate “false positives” for individuals with common names, for which there is little recourse in some states. Similarly, in states where there is no time delimitation associated with offenses, a potentially qualified and capable person may be prohibited to work because of an assault charge they had 20 years ago--regardless of maturation, rehabilitation or contextual factors associated with the crime.
3. Post-Employment Processes
Compared to pre-employment requirements at the federal, state, and employer levels, monitoring during the post-employment phase is less formal. There are fewer regulations and policies in place to track the criminal activity of nurse aides once they are actively employed. State resources are allocated primarily to pre-screening activities, with fewer resources and requirements focused on training (e.g., in-services, management training), monitoring practices or subsequent follow-up criminal background checks.
a. Training
Discussions with stakeholders at the state and nursing facility levels in the four study states revealed that the requirement states place on nursing facilities for on-the-job training primarily concern health and safety issues under licensure. Many of the facilities interviewed do provide on-going training to nurse aides regarding what constitutes abuse, neglect, and financial exploitation (committed by peers or residents’ relatives and friends), resident rights, clinical topics, and other related issues. However, the frequency and regularity of trainings specifically focused on preventing abuse and neglect varies by facility. Several nursing supervisors mentioned using potentially problematic behaviors (e.g., raised voices, negative comments about residents, delayed responses to call lights, etc.) as “teachable moments” to work with staff to better understand the connection between these behaviors and incidents of abuse and neglect.
Directors of nursing and staff development nurses at the facilities interviewed rarely, if ever, receive specialized management training that would assist them in recognizing incidences of abuse and neglect. They rely primarily on their experience in managing potentially difficult scenarios between residents and staff.
b. On-the-job monitoring
On-the-job monitoring is not well-defined, nor are there any state requirements to standardize facility practices. In the absence of any state requirements, independent and chain facilities reported implementing policies such as random drug testing and random criminal background checks to routinely monitor existing employees. In addition, facilities interviewed reported a variety of strategies to facilitate on-the-job monitoring, including locating work spaces for nursing supervisors on the floor, pairing new hires with experienced nurse aides, assigning pairs or teams of staff to residents, and offering ways for staff to report concerns about the behavior of their peers anonymously.
c. Complaint investigation and reporting
All facilities interviewed follow a similar set of procedures for responding to complaints and allegations. Following a complaint, nurse aides are suspended without pay while the facility conducts an internal investigation and notifies the state about the pending complaint. If the complaint is substantiated, the nurse aide is terminated, a report is filed with the state, and the nurse aide registry is notified. If the complaint is not substantiated, the nurse aide is reinstated with back pay and the state and registry are notified.
What complicates this process for employers is the fact that multiple entities (e.g., state licensing agency, ombudsman, attorney general, APS, law enforcement, etc.) can receive and investigate complaints and allegations simultaneously. Process flow charts in Appendix B show the state-specific processes for handling complaints or allegations against CNAs. The quality and level of coordination and communication across agencies varies by state, which further complicates and compromises the timeliness of the investigation process. Nursing facilities reported that the process for complaint investigation and resolution can be time-consuming given the possibility of multiple entities investigating the same complaint. In addition, state entities involved in reporting and investigation indicated that they are under-resourced and lack the staff to respond to cases efficiently and effectively. During the course of a protracted investigative process, a nurse aide under suspension without pay typically seeks other employment. If the allegations are not substantiated, employers can lose qualified workers.
The involvement of multiple entities and lack of role clarity among them also can be confusing for residents and their advocates in terms of which entity or agency to notify regarding a complaint or allegation.
Analyses of nurse aide and abuse registries in Arizona and Kansas suggest that there is a correlation between prior history of criminal conviction and subsequent incidences of abuse, neglect, and exploitation. We were not able to determine which crimes had the strongest association with subsequent findings of abuse, neglect or misconduct due to the privacy issues associated with sharing criminal background data on individuals. We did not have access to the type of crime or date of criminal conviction to further elucidate the relationship between prior criminal history and substantiated findings of abuse post-employment. States can perform this type of analysis on the data in their own administrative files, but the states we partnered with for this study did not have the resources to devote specifically to this effort. Findings from the two states are presented below.
Kansas
The Kansas Department of Health and Environment, Health Occupations Credentialing Unit analyzed their abuse registry from December 1990 to March 2005. Over this period, 710 individuals were entered with a substantiated finding of abuse, neglect or exploitation. Table 1 shows the distribution of individuals by type of substantiated allegation. Kansas calculated the percentage of nurse aides with a substantiated finding of abuse that also had a non-disqualifying criminal conviction prior to employment. Twenty-one percent of the 710 individuals in the abuse registry also had a “hit” when their criminal background check was conducted prior to employment, compared to 14% in the overall population of nurse aides in the state.
| TABLE 1 | ||||
|---|---|---|---|---|
| Abuse* N (%) |
Neglect N (%) |
Exploitation N (%) |
Total N (%) |
|
| Individuals by Abuse Type | 472 (66) | 190 (27) | 48 (7) | 710 (100) |
| * Abuse = physical, sexual, and verbal | ||||
Arizona
The Arizona Board of Nursing (AZBN) Abuse Registry contains information on RN aides under investigation by the AZBN. The AZBN investigates nurse aides for the following reasons: (1) a complaint is filed against an active nurse aide on-the-job, (2) the criminal background check results in a “positive hit,” or (3) the nurse aide answers “yes” to previous criminal conviction on the state application for certification. The registry contains information on pending cases and tracks potential violations, actual violations, substantiated findings and outcomes of all investigative actions (suspension, fines, additional hearing, case dismissal, etc.). As of April 2006, the AZBN Abuse Registry contains data on 4,154 individuals. Of the 4,154 individuals in the Abuse Registry, 1071 (26%) have a prior criminal conviction and 829 (20%) have an incidence of previous misconduct.
As of April 2006, there were a total of 20,764 active CNAs in the AZBN registry database. According to the AZBN, the number of CNA's that have submitted to fingerprints for certification are 13,799 (some nurse aides were certified by the state prior to implementation of the state requirement to conduct fingerprint background checks). From the population of active nurse aides who have submitted fingerprints, 9,426 have had both a state (Department of Public Safety (DPS)) and federal (FBI) fingerprint background check documented in the state database. Of the 9,426 individuals with documented state and federal checks, 6.2% had a positive “felon” or “offender” hit on the state background check through the DPS and 10.1% had a positive “felon” or “offender” hit on the federal background check conducted by the FBI.
Several aspects of the screening and monitoring process were cited by state informants and facilities as innovative practices that contribute to ensuring the employment of a high quality long-term care workforce.
Arizona Fingerprint Clearance Card System. The nursing facilities interviewed in Arizona cited the Fingerprint Clearance Card System, implemented in 1999, as an innovative practice for facilitating criminal background checks of employees and monitoring subsequent criminal behavior after they are employed. Arizona’s comprehensive Fingerprint Clearance Card System is administered by the DPS to perform background checks on and to track arrest activity of individuals working in positions of direct care and service of potentially vulnerable populations (e.g., nursing facilities, home health agencies, child care agencies, schools etc.). Development of the Fingerprint Clearance Card system occurred through collaborative efforts of five state agencies (Department of Health Services (DHS), Department of Education, Department of Economic Security, Department of Juvenile Corrections, and Administrative Office of the Court) in an effort to improve the quality of the workforce across professional fields. For example, to work in long-term care settings, individuals must obtain a Fingerprint Clearance Card by going through a background check.
It is important to note that technically CNAs are not required by the state to obtain Clearance Cards to work in long-term care settings because they already undergo a criminal background check during the certification process required by law and governed by the AZBN. However, the practice of most nursing facilities is currently to require potential hires to have a Clearance Card and it is common for facilities to require students training to be CNAs to have Clearance Cards before working directly with residents. Because the Fingerprint Clearance Card process was developed collaboratively across five state agencies, the resulting list of disqualifying offenses used is far more expansive than the list specified in the state statute for certifying nurses’ aides administered by the AZBN.
This Fingerprint Clearance Card system allows law enforcement to identify individuals who are direct care workers serving vulnerable populations when any arrest is made and fingerprints are taken. Upon arrest and booking, fingerprints are entered into a database (AFIS), which sends a “flag” to the (DPS) for individuals with Fingerprint Clearance Cards. DPS then notifies the appropriate agency representing the field in which the individual is currently employed (in the case of a long-term care employee, DHS would be notified) that the employee has been recently arrested for a crime. Ideally, in the case of a CNA arrest who has a Clearance Card, DHS would contact the AZBN so that employers could be notified of the employee’s recent conduct. This process gives employers updated information on employee conduct, and addresses the limitation of criminal background checks being performed at a single point in time prior to employment. However, the effectiveness of this notification chain is dependent on the accuracy and currency of the nurse aide registry and breaks down if the registry does not routinely receive updated information regarding changes in employment/employer status.
The Fingerprint Clearance Card is valid for six years and costs $52.00 ($24.00 for the FBI check, $3.00 for the Arizona Bureau, and $25.00 to DPS to support personnel costs and fingerprint technicians).
When individuals or entities request background check records, offer detailed information. In Arizona, individuals or entities requesting background check records do not simply receive a yes or no regarding the eligibility of an applicant. Instead, background check requests include detailed information such as the types of crimes the applicant has committed. This information may play a role in hiring decisions. If the applicant has a criminal conviction that does not automatically disqualify them from working, the employer can use their own discretion to assess the context of the crime and make an appropriate hiring decision based on their needs.
Illinois “Nursing Home Sweep” identifies workers with existing and relevant arrest warrants after they have cleared the criminal background check prior to employment. In Illinois, state police within the Medicaid Fraud Unit conduct monthly checks of all staff and residents within long-term care facilities that receive Medicaid financing to ascertain if any of these individuals have outstanding warrants for their arrest. The Medicaid Fraud Unit uses discretion to determine which arrest warrants are relevant to pursue based on contextual factors (e.g., warrants for unpaid parking tickets are bypassed, warrants for assault or theft are pursued). Officers arrive at facilities “unannounced” to make the appropriate arrest. According to the fraud unit in Illinois, arrests are made each month during these sweeps. When this process was first implemented, facilities were not fully supportive and viewed the process as intrusive. However, over time facilities have become accustomed to the process and recognize its benefit. Now many facilities proactively contact the fraud unit requesting the “sweep” as a means of quality checking current employees without paying for follow up criminal background checks.
Perform background checks a wide variety of individuals that serve people with long-term care needs. Florida performs background checks on any employee that has contact with residents in long-term care facilities. These checks include housekeeping, maintenance and kitchen staff.
Facility Level
Facilities with adequate resources contract with private companies to conduct their own pre-employment background checks. For the purposes of expediting the hiring process and minimizing potential liability, some facilities (many of which are part of national chains) contract directly with private firms to conduct background checks of potential employees. They report that the costs incurred are warranted because the background checks are conducted more quickly and cover databases from all 50 states. In addition, the list of disqualifying offenses required by corporate human resources policy typically is more stringent than that specified by the state.
Facilities require drug tests on all job applicants. Many facilities cited drug testing as a critical component of the hiring process because of the correlation between drug use and absenteeism, inferior caregiver skills, diminished therapeutic relationships with residents and overall unreliability on the job. Drug testing is considered an asset because of the negative impact drug use can have on the safety of the workplace environment for both staff and residents. The drug testing requirement is also seen as a deterrent for potentially unreliable and problematic staff. Many facilities we interviewed stated that far more applicants are denied employment due to positive drug tests than having a positive “hit” on their criminal background check.
Facilities conduct “random criminal background checks” and “random drug tests” annually on existing employees to maintain quality. Some larger chain facilities have corporate requirements to continually check the criminal status and/or drug use of existing employees. In addition to random drug tests for a sample of employees, one corporate chain has implemented random criminal background checks on an employee sample to determine whether existing employees have had relevant criminal convictions after passing the initial screen before hire.
Facilities offer financial incentives to employees for referring successful hires. To address the challenge of recruiting, hiring, and retaining qualified staff, several facilities interviewed offer financial incentive programs, such as bonuses and salary increases, to encourage current employees to refer qualified colleagues for open staff positions. These facilities believe that that peer referrals enhance the likelihood of identifying qualified candidates who will meet the hiring requirements, as well as fit successfully into the organizational culture and community.
Informants offered several suggestions for improving the background check process.
Create online registries. Representatives from Washington noted that online registries would enable interested parties to check the registry in real time instead of waiting for registry staff to sort through paper for relevant information.
Create a national registry. While cost and administrative issues present barriers to the creation of a national registry, representatives across states noted that a national registry would result in a much improved background check system since individuals would not be able to cross state lines to gain employment if disqualified for employment in another state.
Approach allegations of abuse, neglect, and exploitation of elderly as seriously as allegations of abuse, neglect, and exploitation of children. Several respondents noted that similar strategies could be used to prevent abuse, neglect, and exploitation in these two populations. Part of prevention includes the knowledge of substantial consequences when prosecuted for various crimes. Several informants noted that investigation and prosecution of elder abuse cases lacks the level of visibility and urgency that child abuse cases have historically received.
Perform background checks prior to training programs. Some interview respondents suggested that training programs clearly detail background check procedures so that individuals who may be potentially ineligible for work do not proceed through training programs without fully understanding what will be required of them to gain employment. In addition to notifying them of the background check requirement, nurse aide training programs should also inform students that waiver processes exist that, under certain circumstances, can enable a person with a disqualifying offense to gain certification.
Increase training and monitoring of long-term care staff. Increased training of long-term care staff was often cited as a way to prevent abuse, neglect, and exploitation. Recommendations included increasing the number of on-site trainings offered by state APS. In addition, increasing the presence of full-time paid ombudsmen in facilities may deter criminal activity as well as abuse, neglect, and exploitation.
The efficacy of nurse aide registries and criminal background checks in preventing resident abuse in nursing facilities is difficult to ascertain. Making an accurate assessment regarding the effectiveness of these practices is difficult because every state has a different process for screening and disqualifying potential workers, documenting information in their registries, tracking subsequent employment or complaint data, investigating abuse allegations, reporting relevant findings, and coordinating efforts across state entities. Extensive variation across states affects the ability to make a definitive statement about the efficacy of these strategies to ensure a qualified workforce. The in-depth examination of four states revealed that some aspects of these systems work well, but limitations exist in each state that affect the overall utility of these practices. There is, however, consensus across stakeholders in all four states that criminal background checks are a necessary element of the hiring process. The technology, coordination capabilities and infrastructure exist through on-line registries, fingerprint databases and abuse registries to help employers make the best hiring decisions possible to protect the elderly in their care. States are building on their knowledge, experience, and capabilities to streamline these processes, but there is still room for improvement while balancing the resource intensiveness of making these changes.
It is clear that relying on criminal background checks and nurse aide registries are not enough to prevent or reduce abuse in nursing facilities. Ongoing training, education and supervision for workers providing direct care are also key components to maintaining a quality workforce. A summary of our overall project conclusions are provided below.
Criminal background checks are a valuable tool for employers during the hiring process and their use does not limit the pool of potential job applicants. Stakeholders agree that conducting criminal background checks on potential employees is an important aspect of the hiring process to reduce the likelihood of hiring someone who has potential to harm residents in long-term care. There is widespread acceptance throughout the long-term care industry (similar to that of the child care industry), that this practice serves to protect vulnerable adults and ultimately prevent abuse. By virtue of prohibiting potential workers from certification or employment who have a “disqualifying criminal conviction”, the pool of individuals entering the long-term care field would theoretically be smaller. However, none of the nursing facilities interviewed experienced any negative impact on their applicant pool as a result of this requirement. According to sources from two state nurse aide registries, the number of CNAs continues to rise each year, further indicating that the criminal background check requirement is not significantly restricting the pool of potential workers entering this field. From the perspective of employers, reducing the amount of time it takes to receive background check results would improve the current system.
A correlation exists between criminal history and incidences of abuse. Based on data we received from Arizona and Kansas, it does appear that nurse aides who had a previous criminal conviction (non-disqualifying offense) had higher rates of substantiated abuse than nurse aides without a criminal history. Due to limitations with access to criminal history data, it is not clear which criminal offenses (if any) have the strongest correlation with subsequent findings of abuse, nor can we determine if the recency of a criminal conviction is a contributable factor in the correlation between criminal history and abuse. However, the analysis of these two states does provide evidence to support the rationale for checking the criminal history of potential direct care workers as a screening mechanism for quality.
Criminal background checks are only one element of preventing abuse. Despite a connection between past criminal history and subsequent allegations of abuse, stakeholders consistently reported the following as effective strategies for preventing abuse, (many of which are not formal state or industry policy): adequate supervision/monitoring, presence of managers on the floor, decreasing staff burnout, adequate staffing levels, rotating nurse aides on the floor to alleviate pressure of difficult residents, increased education and training, obtaining meaningful employment references (beyond verification of employment dates), valuing and respecting staff, creative recruitment incentives to retain committed staff, instituting a drug-free workplace policy, minimizing temporary hires, and pointing out negative behaviors in the moment and using them as a staff development opportunity.
There are fewer policies in place that support or reinforce post-employment strategies than pre-employment to ensure a qualified workforce. This study revealed that there are significantly more resources allocated to the pre-employment phase of ensuring a qualified long-term care workforce than the post-employment phase. The policy focus at the state and facility level is on pre-screening applicants before employment and there are structures and regulations in place that support this effort. However, once a worker is hired and working in the field, there is less guidance regarding how best to train, continuously educate and monitor existing employees. As stated before, most states have no process in place to notify employers if an active employee commits a crime that would have prohibited them from working during their background check prior to employment. In the event of employee complaints or allegations of abuse, the effectiveness of state systems often breaks down due to a lack of coordination between multiple state entities involved in the investigation and reporting process. Duplicative efforts waste state resources, prolong investigations and often keep employees out of the workforce unnecessarily.
National Level Considerations
The challenge of individual state registries. Individual state registries and the barriers associated with data sharing across states, limit employer access to useful information about substantiated abuse findings against workers found in other states. Since workers may have been employed in more than one state, a national nurse aide registry has been frequently mentioned as one way to address the issue of long-term care workers with substantiated findings of abuse, neglect, and/or financial exploitation crossing state lines to work in another state. Several issues may pose barriers for the creation of a national nurse aide registry. First, transfer of information across various state and national agencies may be difficult due to state laws and agency “ownership” of data. Second, the cost of creating and maintaining a national database would require commitment of both staff time and funds from both states and national agencies. Third, certification procedures and requirements vary across states, which further challenge any effort to standardize the process nationwide.
Use of disqualifying offenses and waivers. It is important to strike a balance between the need to protect vulnerable citizens from harm and creating unnecessary barriers to employment for qualified individuals, further reducing the potential pool of long-term care workers. There is a paucity of literature examining nurse aides and criminal recidivism and propensity to commit abuse. Criminal recidivism research shows that a history of past criminal convictions may be a possible predictor of future behavior.29 Other research by Cohen (1996) reports that the probability of future dangerous behavior of criminal offenders increases when circumstances are similar to past situations in which criminal behaviors occurred, which has implications for workers who have substantiated findings of resident abuse.30
A review of Illinois’s Department of Public Health waiver process for individuals certified for work in hospitals and nursing facilities shows that individuals with criminal records can work in the health care field with minimal impact on patient safety. In Illinois, individuals with specific criminal convictions are banned from working in certain health care professions but can apply for waivers. In an examination of waiver applications from 1996 to 2003, 5,706 individuals with convictions applied for waivers. 4,130 (72%) of these individuals were granted waivers. Ninety-seven individuals (or 2.3% of the 4,130 individuals) had their waivers revoked; 38 individuals had revoked waivers because of substantiated finding of abuse, neglect, or theft and 59 individuals due to a second disqualifying conviction.31
Additional research in the area of criminal recidivism, specifically in relation to elder abuse, neglect, and financial exploitation is necessary to develop evidence based lists of disqualifying offenses. Justification for the inclusion or exclusion of various crimes that constitute states’ lists of disqualifying offenses is unclear, and the lack of consensus across states on this issue illustrates the complexity of making a solid connection between past criminal activity and the proclivity to commit abuse in long-term care settings. In the absence of such evidence, policymakers and employers must still balance the need to protect vulnerable populations with the need to maintain an adequate direct care workforce to accommodate a growing older adult population.
The screening process requires a significant amount of resources. As states make efforts to improve their screening processes (e.g., expanding the criminal background check to other states or incorporating federal level checks, expediting the turnaround time for results, expanding the screening process to other types of workers), the costs will inevitably increase. States will need additional capacity (staff and financial resources) to meet the demand for quality screens on increased numbers of workers in a timely manner. It is important to balance the financial burden across state agencies, employers and direct service workers in an equitable manner so that screening processes can continue to improve.
State Level Considerations
Keeping registry data current to maximize their utility. A recent OIG study revealed that nurse aide registries may not always contain the most up-to-date, or accurate information. In a survey of 200 randomly selected long-term care facility administrators, 44% (87 individuals) surveyed stated that they periodically rechecked nurse aide registries to ensure that substantiated findings had been posted to the registry. Fifteen administrators found that a nurse aide previously listed as registered and free of a substantiated finding of abuse was later listed to be unqualified for work due to a substantiated finding, failure to attain active registration status, or failure to be certified as a nurse aide. The nurse aide registry is only helpful to employers if the information is current.
Increasing the utility of the nurse aide registry with public awareness and education. In most states, employers are the only ones who benefit from the information contained in the nurse aide registry. By increasing consumer knowledge and use of the registry, the state can further protect the public by offering additional resources and information on individual long-term care workers.
Incorporating alternative screening mechanisms. Nursing home administrators use several practices (not required by federal regulations) to screen potential employees and to monitor current nurse aides. Eighty-five percent of administrators surveyed for a recent OIG report used additional screening procedures such as criminal background checks, and/or personal and employment reference checks.32 Implementing random drug tests and criminal background checks on existing employees may be another way to monitor employees after they have cleared original pre-employment screens. Conducting drug testing may be a more effective method for screening out individuals with a criminal history in drug abuse rather than a comprehensive ban.33 Findings demonstrate the need to use creative and multi-pronged strategies for screening and monitoring direct care paraprofessionals.
Examining states’ practices related to investigating and reporting abuse. Current state practices for investigating and reporting abuse cases appear duplicative and may lack adequate coordination across entities. This creates overlap for agencies conducting the investigation, burden for the employers, and a protracted suspension period for the direct service worker involved.
There are several areas for future research that may further inform this issue but were beyond the scope of this study.
42 CFR 483.75 (e)(5); 42 CFR 483.13 (c)(1); 42 CFR 483.13 (C)(1)(ii)(A); 42 CFR 483.75 (e)(6).
National Center for Health Workforce Analysis, Bureau of Health Professions, Health Resources and Services Administration. (2004). Nursing Aides, Home Health Aides, and Related Health Care Occupations--National and Local Workforce Shortages and Associated Data Needs. vi-v.
Department of Health and Human Services, Office of the Inspector General. (2005). Nurse Aide Registries: State Compliance and Practices (OEI-07-03-00380). 8-13.
Lewin experienced multiple barriers to acquiring and linking nurse aide registry and abuse registry data from the states to analyze quantitatively the relationship between criminal history or past findings of abuse and subsequent abuse allegations. These limitations are detailed in the Study Limitations section of this report.
Cooper G., and Sheets, V. Criminal Conviction and Nursing Regulation: A Supporting Paper. Paper presented at the 1998 National Council of State Boards of Nursing Annual Meeting, Albuquerque, New Mexico. Cited in Massachusetts Board of Registration in Nursing. (1999). Good Moral Character: Qualification for Initial Nurse Licensure. Boston, MA.
Cohen, D. (1996). Notes on the Clinical Assessment of Dangerousness of Offender Populations. Retrieved September 16, 1999, from the World Wide Web: http://www.priory.com/psych/assessin.htm. Cited in Massachusetts Board of Registration in Nursing. (1999). Good Moral Character: Qualification for Initial Nurse Licensure. Boston, MA.
Personal communications with Linda Mills, April 27, 2005.
Department of Health and Human Services, Office of the Inspector General. (2005). Long Term Care Facility Compliance and Practices (OEI-07-04-00140).
Interview with Miriam Aukerman, Western Michigan Legal Services, February 2, 2005.
U.S. Census Bureau. (2001). U.S. Census 2000 Brief: The 65 Year and Older Population.
Special Investigations Division, Committee on Government Reform. (2001). Abuse of Residents is a Major Problem in U.S. Nursing Homes. 3-4.
U.S. General Accounting Office. (2002). Nursing Homes: More can be done to protect residents from abuse. (GAO-02-312); U.S. General Accounting Office. (2002). Nursing Homes: Many shortcomings exist in efforts to protect residents from abuse. (GAO 02-448T)
Levine, J. (October 2003). Elder neglect and abuse: A primer for primary care physicians. Geriatrics. Volume 58, Number 10.
National Center on Elder Abuse. (2005) Frequently Asked Questions. Retrieved January 8, 2006 from http://www.elderabusecenter.org/default.cfm?p=faqs.cfm#one.
42 CFR 483.75 (e)(5); 42 CFR 483.13 (c)(1); 42 CFR 483.13 (C)(1)(ii)(A); 42 CFR 483.75 (e)(6).
Federal Statutes Authorizing Criminal Background Checks for Nursing Facility Job Applicants and Employees. (Online), July 19, 2005. http://www.cms.hhs.gov/medicaid/reports/backchks.pdf.
National Center for Health Workforce Analysis, Bureau of Health Professions, Health Resources and Services Administration. (2004). Nursing Aides, Home Health Aides, and Related Health Care Occupations--National and Local Workforce Shortages and Associated Data Needs. vi-v.
Department of Health and Human Services, Office of the Inspector General. (2005). Nurse Aide Registries: State Compliance and Practices (OEI-07-03-00380). 8-13.
Lewin experienced multiple barriers to acquiring and linking nurse aide registry and abuse registry data from the states to analyze quantitatively the relationship between criminal history or past findings of abuse and subsequent abuse allegations. These limitations are detailed in the Study Limitations section of this report.
It is important to note that only for profit and non-profit facilities agreed to be interviewed. No public facilities participated in this project.
Interview with Hal Sklar, Federal Bureau of Investigations, December 13, 2004.
Arizona, Arkansas, California, Kansas, Michigan, and Wyoming maintain one registry for licensure, abuse, neglect, financial exploitation, and criminal history information.
Iowa, Washington, and Wisconsin confirmed that they maintain more than one registry for licensure, abuse, neglect, financial exploitation, and criminal history information.
Department of Health and Human Services, Office of the Inspector General. (2005). Nurse Aide Registries: State Compliance and Practices (OEI-07-03-00380). 8-13.
Because the list of disqualifying offenses in most states is so expansive, we have cited the statute for reference rather than providing a detailed listing of the specific offenses developed by each state.
Some states require both pre-certification and pre-employment checks.
Cooper, G., and Sheets, V. Criminal Conviction and Nursing Regulation: A Supporting Paper. Paper presented at the 1998 National Council of State Boards of Nursing Annual Meeting, Albuquerque, New Mexico. Cited in Massachusetts Board of Registration in Nursing. (1999). Good Moral Character: Qualification for Initial Nurse Licensure. Boston, MA.
Cohen, D. (1996). Notes on the Clinical Assessment of Dangerousness of Offender Populations. Retrieved September 16, 1999, from the World Wide Web: http://www.priory.com/psych/assessin.htm. Cited in Massachusetts Board of Registration in Nursing. (1999). Good Moral Character: Qualification for Initial Nurse Licensure. Boston, MA.
Personal communications with Linda Mills, April 27, 2005.
Department of Health and Human Services, Office of the Inspector General. (2005). Long Term Care Facility Compliance and Practices (OEI-07-04-00140).
Interview with Miriam Aukerman, Western Michigan Legal Services, February 2, 2005.
Alaska HHS Statute, Licensure of Child Care Facilities. (2003). Title 14, Chapter 35. Retrieved from http://nrc.uchsc.edu/STATES/AK/al_47.htm#pgfId-486626.
Alaska Regulations. (2002). Child Care Facilities Licensing. Chapter 62. Retrieved from http://nrc.uchsc.edu/STATES/AK/ak_62.htm#pgfId-709944.
Arizona Department of Economic Security. Certification and Supervision of Family Child Care Home Providers, Section 6 A.A.C.5, Article 52. Retrieved from http://nrc.uchsc.edu/STATES/AZ/az_3TOC.htm.
Arizona Department of Health and Human Services Regulations. Child Care Facilities. Section 9 A.A.C.5. Retrieved from http://nrc.uchsc.edu/STATES/AZ/Az_9TOC.htm.
Braun, K.L., Suzuki, K.M., Cusick, C.E., & Howard-Carhart, K. (1997). Developing and testing training materials on elder abuse and neglect for nurse aides. Journal of Elder Abuse & Neglect 9(1), 1-15.
California Regulations. (2004). Title 22, Division12, Chapter 1--General Licensing Requirements. Retrieved from http://nrc.uchsc.edu/STATES/CA/ca_22_12_1.htm#pgfId-845906.
Cohen, D. (1996). Notes on the Clinical Assessment of Dangerousness of Offender Populations. Retrieved September 16, 1999, from http://www.priory.com/psych/assessin.htm. Cited in Massachusetts Board of Registration in Nursing. (1999). Good Moral Character: Qualification for Initial Nurse Licensure. Boston, MA.
Cooper, G., and Sheets, V. Criminal Conviction and Nursing Regulation: A Supporting Paper. Paper presented at the 1998 National Council of State Boards of Nursing Annual Meeting, Albuquerque, NM. Cited in Massachusetts Board of Registration in Nursing. (1999). Good Moral Character: Qualification for Initial Nurse Licensure. Boston, MA.
Department of Health and Human Services, Office of the Inspector General. (2005). Long Term Care Facility Compliance and Practices (OEI-07-04-00140).
Department of Health and Human Services, Office of the Inspector General. (2005). Nurse Aide Registries: State Compliance and Practices (OEI-07-03-00380). 8-13.
Federal Nursing Homes Laws and Regulations. 42 CFR 483.156.
Federal Nursing Homes Laws and Regulations. 42 CFR 483.75 (e)(5); 42 CFR 483.13 (c)(1); 42 CFR 483.13 (C)(1)(ii)(A); 42 CFR 483.75 (e)(6).
Federal Statutes Authorizing Criminal Background Checks for Nursing Facility Job Applicants and Employees. (2005). Retrieved July 19, 2005 from http://www.cms.hhs.gov/medicaid/reports/backchks.pdf.
Kansas Child Care Licensing And Registration Laws. (2001). Retrieved from http://nrc.uchsc.edu/STATES/KS/ks_newTOC.htm.
Kieffer-Andrews, M. (1998). High Risk Behavior vs. Public Protection. Paper presented at the 1998 National Council of State Boards of Nursing Annual Meeting, Albuquerque, NM. Cited in Massachusetts Board of Registration in Nursing. (1999). Good Moral Character: Qualification for Initial Nurse Licensure. Boston, MA.
Levine, J. (October 2003). Elder neglect and abuse: A primer for primary care physicians. Geriatrics. Volume 58, Number 10.
Long Term Care Community Coalition. Certified Nurse Aide Screening and Continuing Education: A National Survey of State Requirements with Recommendations for Improvement. (2004). Retrieved July 20, 2005 from http://www.ltccc.org/publications/documents/CNAReqmtsApril2004.pdf.
Michigan Regulations. Child Care Licensing-Child Care Centers, Department of Consumer and Industry Services Director’s Office. (2003). Part I. General Provisions, R 400.5101 Definitions. Retrieved from http://nrc.uchsc.edu/STATES/MI/mi_400.htm#pgfId-629703.
National Center on Elder Abuse. (2005) Frequently Asked Questions. Retrieved January 8, 2006 from http://www.elderabusecenter.org/default.cfm?p=faqs.cfm#one.
National Center for Health Workforce Analysis, Bureau of Health Professions, Health Resources and Services Administration. (2004). Nursing Aides, Home Health Aides, and Related Health Care Occupations--National and Local Workforce Shortages and Associated Data Needs. vi-v.
National Child Care Information Center, Child Care Workforce Qualifications. Retrieved from http://www.nccic.org/poptopics/qualifications.html.