As the population ages, “home health-care worker” has become one of the fastest-growing occupations in the U.S. Some 3.5 million Americans received home health care through Medicare in 2012 (cost: $18.5 billion); many more get similar services through Medicaid or pay home-care agencies directly.
Most states have some rules to keep violent criminals from caring for vulnerable people in their homes, but 10 states—Alabama, Connecticut, Georgia, Hawaii, Montana, New Jersey, North Dakota, South Dakota, West Virginia, and Wyoming—require no background checks at all, according to a memo (PDF) published last week by Medicare’s chief watchdog. In the rest, home health agencies are governed by a patchwork of safeguards that vary from state to state.
“There are also no federal laws or regulations that prohibit [home health agencies] from hiring individuals who have been convicted of crimes (e.g., assault, rape, and theft) or who have had a finding concerning abuse, neglect,” or mistreatment, according to the analysis by the Department of Health and Human Services Office of Inspector General.
State laws vary widely. California and Texas require only statewide background checks, which don’t pick up convictions from other jurisdictions. New York, Florida, and Illinois mandate FBI fingerprint background checks, which include federal crimes and out-of-state offenses, according to the OIG report. Of the 10 states with no background-check laws, Connecticut, Georgia, Hawaii, and West Virginia are developing plans to require them.
The landscape is a big improvement from 10 years ago, says Suzanne Crisp of the Boston College School of Social Work, who co-authored a report (PDF) on screening home-care workers for AARP in 2010. “States have gone from being a bit lax in applying criminal background checks to being more and more stringent,” she says.
A program in seven states screened 220,000 applicants for long-term care jobs from 2005 to 2007, both in home care and facilities such as nursing homes, according to a 2008 Senate report. One in every two dozen—4.3 percent—was disqualified because of serious crimes.
Home health-care agencies in states with no rules mandating background checks are still required by Medicare, the federal health insurance program for the elderly and disabled, to vet prospective workers, Crisp says. But agencies that deal only with families paying for care directly may not be subject to the same rules. And state Medicaid programs, which cover poor patients, may have a different set of standards. Not every conviction bars someone from work as a home health aid; states rules vary for that too, and six of them haven’t specified what kind of criminal record should disqualify a worker, the OIG’s report says.
The inconsistencies contrast with the laws governing child care. All 50 states require criminal record checks for workers at licensed childcare centers, according to a 2011 report (PDF) by the Government Accountability Office. Still, the penalties for companies that don’t vet workers are all over the map, from $5 in North Dakota to $10,000 in Mississippi.
Background checks are only one of the safeguards needed in the long-term care system, Crisp says. To be effective, providers need oversight so that nurses check on home aides, state regulators audit agencies’ work, and patients have channels to report complaints, for example. Ensuring quality care, Crisp says, is “a never-ending process.”