Abuse of vulnerable populations by those hired to care for them is a significant social problem in the United States. News reports of incidents of abuse are disturbing — and far too common. For example, a home health aide with an extensive criminal history who was using an alias was charged with writing unauthorized checks for thousands of dollars on the account of the person in her care. In another facility, a certified nursing assistant who had a previous assault conviction — and therefore should have been barred from direct contact with residents — molested a nursing home resident during a back massage. Perhaps most shockingly, a home health care aide on probation for burglary was convicted of murdering his 74-year-old former employer while burglarizing her home. The crime inspired a new state law that now requires criminal background checks for anyone seeking a home health care aide position.

Better background screening could have prevented those cases and countless others like them. More robust and consistent background screening of all long-term care and childcare workers is a proactive, preventative measure that can improve the safety and security of our youngest and oldest citizens. But nationwide consistency is needed to make existing background check programs more effective. Given that states often respond only to federal requirements with funding implications, better screenings will result if the following recommendations are implemented through federal legislation and rule-making:

  • Require fingerprint-based state and national criminal history checks to prevent identity fraud and uncover activity in other states.
  • Require searches of additional databases for administrative findings of unsuitability, including in other states.
  • Require statewide eligibility determinations with consistent criteria and an independent review process that applies to all types of care providers.
  • Require the same screening for all workers, owners/operators and contract staff who have access to care recipients or their assets.
  • Require those screenings for care workers in all settings, including home care, residential care (assisted living), and managed care environments.

Two comprehensive national background check programs have already proven such screenings can be implemented effectively, efficiently and equitably — and in all states.

The National Background Check Program (NBCP), authorized in 2010, is a voluntary program that has provided grants to 29 states to implement robust, statewide screening programs meeting the requirements described above to vet persons who work in long-term care facilities.

And in 2014, the Child Care Development Block Grant Reauthorization Act (CCDBGA) added a requirement across all states and territories that standardizes many of the same requirements for those who work in childcare settings. More than 40 states have passed legislation to implement checks that include fingerprint-based criminal history and additional information from other states.

Instead of adding to the patchwork, I recommend fine-tuning those two existing programs. For NBCP, broader implementation will solidify and publicize the significant successes experienced by states that did pass legislation leading to full implementation of the program. The Centers for Medicare and Medicaid Services can readily re-open the NBCP grant program and engage in outreach to encourage the remaining states. In addition, provisions should be added to the grant to tie grant resources to the passage of authorizing legislation. The Centers for Medicare and Medicaid Services can also support the expansion of the National Nurse Aide Registry to encompass all states, regardless of whether the state participates in NBCP. As an added incentive, Congress could set a timeline to incorporate NBCP into the regulatory legislation, much as it did for the CCDBGA.

CCDBGA background checks show that federal mandates do prompt state legislation. But fine tuning of the requirements is needed to improve data sharing among states, eliminate unnecessary overlap among the required searches, and provide more complete data from states about the metrics of their background checks. The Administration for Children and Families could proceed with its study of the relative value of interstate criminal history checks, such as the child abuse and sex offender registries. Congress could require every state and territory to establish and maintain a publicly available registry of child abuse perpetrators that would be accessible to childcare worker screening agencies in other states, similar to the nurse aide registries used for long-term care worker screening. Finally, the Administration for Children and Families could require states to submit a standard set of administrative data on all background checks conducted under the CCDBGA to monitor effectiveness and efficiency.


Ernest Baumann is a Sr. Principal Technical Advisor in CNA’s Center for Vulnerable Population Protection.

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