1.   Measuring the Success of the National Background Check Program and Planning for Future Evaluation
Brian T. Whitley, MPH, Regional Inspector General
Office of Evaluation and Inspections
Office of Inspector General
US Department of Health and Human Services
Region VII, Kansas City
Presented to Association of Health Facility State Agencies, August 6, 2019

2. Learning Objectives Understand: Discuss: Plan:
Understand OIG background check work to date and the congressional mandate.
Discuss:
Discuss recently published OIG background check work and its implications for continuing States.
Plan:
Plan for future OIG published work and fill data voids for the congressional mandate.

3. Understand: OIG’s body of work related to background checks.
Congressional mandate.

4. Previous Work
Nursing Facilities’ Employment of Individuals with Criminal Convictions, OEI
Long-Term-Care Provider Administrator Survey, OEI
Criminal Convictions for Nurse Aides with Substantiated Findings of Abuse, Neglect, and Misappropriation, OEI
State Requirements for Conducting Background Checks on Home Health Agency Employees, OEI
Home Health Agencies Conducted Background Checks of Varying Types, OEI
NOT NBCP reports

5. Findings Recommendations
92% of nursing facilities employed at least one individual with at least one criminal conviction.
5% of nursing facility employees had at least one criminal conviction.
Recommendations
CMS should clearly define direct access employees.
CMS should develop a list of disqualifying convictions.
Nursing Facilities’ Employment of Individuals with Criminal Convictions, OEI

6. Findings
94% of administrators conducted checks on prospective employees.
23% of administrators stated that background check procedures reduced the pool of prospective employees.
Long-Term-Care Provider Administrator Survey, OEI
19% of nurse aides with substantiated findings had previous criminal convictions that could have been detected through background checks.
Criminal Convictions for Nurse Aids with Substantiated Findings of Abuse, Neglect, and Misappropriation, OEI

7. Findings Recommendations
4% of HHA employees had at least one criminal conviction.
36% crimes against property.
12% crimes against persons.
58% of HHAs conducted periodic checks after hire.
Recommendations
CMS should promote minimum standards in background check procedures.
Lack of Federal laws, State requirements varied.
Encourage States to participate in the Program.
Home Health Agencies Conducted Background Checks of Varying Types, OEI

8. Congressionally Mandated Evaluation
Mandate for National Background Check Program Evaluation and Report.
P.L. No , § 6201(a)(7)
Submit a report to Congress covering 4 criteria on implementation, costs, unintended consequences, and impact within 180 days of Program completion.
Sometime between 2021–2025, depending on Program extensions.
10 provider types:
1. skilled nursing facilities,
2. nursing facilities,
3. home health agencies,
4. providers of hospice care,
5. long-term-care hospitals,
6. providers of personal care services,
7. providers of adult day care,
8. residential care providers that arrange for, or directly provide long-term-care services,
9. intermediate care facilities for the mentally retarded,10 and 10. any other facility or provider of long-term-care services that a State determines to be appropriate

9. Criteria 1: Implementation
Review procedures States implemented for long-term- care facilities or providers, including staffing agencies, to conduct background checks of direct patient access employees under the Program and identify the most appropriate, efficient, and effective procedures.
Criteria 2: Costs
Assess costs of conducting background checks (including startup and administrative costs).

10. Criteria 3: Unintended Consequences
Determine the extent to which conducting background checks leads to any unintended consequences.
Criteria 4: Impact
Assess the impact of the Program on reducing incidents of abuse, neglect, and misappropriation of resident property.

11. Discuss:
Recently conducted work.
Implications for continuing States.

12. Previous, Ongoing, and Future Work
Early Implementation Review (2014)
National Background Check Program for Long-Term-Care Employees: Interim Report, OEI
Preliminary Post-Grant Reviews (2019)
National Background Check Program for Long-Term-Care Providers: Assessment of State Programs Concluded Between and 2016, OEI
Second review to be published in the summer of 2019
Final Program Evaluation (2021–2025)

13. States in the early implementation review, 2014
Early Implementation Review: Findings
Of the 25 participating States in 2014:
15 did not conduct rap back monitoring,
13 did not obtain enabling legislation, and
10 did not collect fingerprints.
States in the early implementation review, 2014
National Background Check Program for Long-Term-Care Employees: Interim Report, OEI

14. States in the early implementation review, 2014
Early Implementation Review: Findings
Of the 25 participating States in 2014:
6 had sufficiently complete data for OIG to calculate disqualification rates, and;
3 could differentiate continuous monitoring results from initial results.
States in the early implementation review, 2014
The 6 States are Alaska, DC, Florida, Michigan, New Mexico, and Oklahoma.
The 3 states are Michigan, New Mexico, and Oklahoma.
National Background Check Program for Long-Term-Care Employees: Interim Report, OEI

15. States in the early implementation review, 2014
Early Implementation: Recommendations
Fully implement States’ background check programs (help with legislative proposals, develop capacity to collect fingerprints, rap- back).
Improve required reporting to ensure CMS can conduct effective oversight.
States in the early implementation review, 2014
National Background Check Program for Long-Term-Care Employees: Interim Report, OEI

16. 29 States are Program grantees.
Post-Grant Reporting
29 States are Program grantees.

17. Selected Requirements OIG Reviewed
Determine direct access employees
Require direct access employees to undergo background checks
Include 9 provider types
Identify disqualifying offenses
Establish a Statewide program
Collect fingerprints
Conduct State criminal history checks
Conduct Federal criminal history checks
Search records of proceedings that may contain disqualifying information
Notify providers of convictions identified through continuous monitoring
Report convictions to required databases.
Check State abuse/neglect registry in current State
Check State abuse/neglect registry in prior States

18. States in the post-grant review
Post-Grant Review: Findings
Of the 10 States in review:
5 implemented all background check requirements.
3 did not have legislative authority to meet Program requirements.
States in the post-grant review
The five States are Alaska, DC, Florida, New Mexico, and Rhode Island.
The three States are Illinois, Maryland, and Missouri.
National Background Check Program for Long-Term-Care Providers: Assessment of State Programs Concluded Between 2013 and 2016, OEI

19. States in the post-grant review
Post-Grant Review: Findings
Results from the States in review:
80,000 determinations of ineligibility with million checks.
State ineligibility rates ranged from 0.04% to %; ineligibility rates are not comparable across States.
States in the post-grant review
National Background Check Program for Long-Term-Care Providers: Assessment of State Programs Concluded Between 2013 and 2016, OEI

20. States in the post-grant review
Post-Grant Review: Recommendations
CMS should take appropriate action to encourage participating States to obtain necessary authorities to fully implement Program requirements.
States in the post-grant review
National Background Check Program for Long-Term-Care Providers: Assessment of State Programs Concluded Between 2013 and 2016, OEI

21. About Interim Reports
Interim reports are designed to assist CMS—and States continuing in the Program—by promoting Program improvements and increasing protections for the vulnerable population of beneficiaries receiving long-term-care services.

22. Plan:
Filling data voids to answer the congressional mandate.

23. Final Program Evaluation and our Congressional Mandate
Data for mandate criteria 1–3—implementation, cost, and unintended consequences—will come from States.
Data for mandate criteria 4—impact—will come from CMS and the ASPEN Complaints and Incidents Tracking System (ACTS).
Continued congressional interest
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