Ensuring a Qualified Long-Term Care Workforce: From Pre-Employment Screens to On-the-Job Monitoring


U.S. Department of Health and Human Services

Ensuring a Qualified Long-Term Care Workforce: From Pre-Employment Screens to On-the-Job Monitoring

Executive Summary

The Lewin Group

May 2006

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.


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:

  • Examine the utility and efficacy of nurse aide registries and criminal background checks as strategies for reducing the incidence of nursing facility resident abuse.
  • Determine the relationship (if any) between past criminal background or previous incidences of abuse and the proclivity toward subsequent abuse, neglect or exploitation.5
  • Identify, from the perspective of states and nursing facilities, limitations, innovative strategies, and recommendations for improving the current screening and monitoring process for ensuring a qualified long-term care workforce.


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.


  1. 42 CFR 483.156.

  2. 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).

  3. 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.

  4. 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.

  5. 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.

  6. 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.

  7. 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.

  8. Personal communications with Linda Mills, April 27, 2005.

  9. Department of Health and Human Services, Office of the Inspector General. (2005). Long Term Care Facility Compliance and Practices (OEI-07-04-00140).

  10. Interview with Miriam Aukerman, Western Michigan Legal Services, February 2, 2005.

The Full Report is also available from the DALTCP website (http://aspe.hhs.gov/_/office_specific/daltcp.cfm) or directly at http://aspe.hhs.gov/daltcp/reports/2006/LTCWqual.htm.