Nursing Aides, Home Health Aides, and Related Health Care Occupations -- National and Local Workforce Shortages and Associated Data Needs

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Chapter 1. Project Overview | Chapter 2. Paraprofessional Workforce Supply and Demand | Chapter 3. Important Data Issues | Chapter 4. Existing National Data Sources | Chapter 5. State-Level Data Issues | Chapter 6. Occupation and Industry Classification Systems | Chapter 7. Current Data Collection Practice: CNA Registries | Chapter 8. Conclusions | Appendix A. Project Advisory Committee | Appendix B. Proposed State Data Collection Instrument | Appendix C. Occupational and Industry Definitions | Appendix D. Sample Data | Appendix E. Issues from Four States | Appendix F. CNA Registry Details | Appendix G. Annotated Bibliography | Appendix H. References

Appendix F. CNA Registry Details

This chapter describes the CNA registries and includes the following sections:

• Introduction
• Registry Background
• Legislative Mandate
• CNA Registries in the Fifty States
• Best Practices
• Discussion

Introduction
One of this report’s original hypotheses was that CNA registries would be logical platforms on which to build more effective systems for collecting and organizing data relating to long-term care paraprofessional workers. The intent was to consider expanding CNA registries so that they would include data on paraprofessional workers other than nurse aides and additional data elements that would support workforce planning. This thought was reinforced by the Federal government’s mandate to states to maintain registries of certified nurse aides working in nursing homes [OBRA 1987]. Additional impetus for expanding the scope of CNA registries is the increasing interest in mandating criminal background checks for direct care paraprofessional workers. Requirements relating to HIPAA may also support expanding the CNA registries.

To help understand the implications of extending existing CNA registries, this study included an inquiry of agencies responsible for the existing registries in each of the 50 states. Questions related to the contents of registry files, uses of the data, access to the files, and possibilities for using the registries for other purposes.

This chapter summarizes that inquiry. It has five sections. The first presents general background on the registries. The second briefly describes the current legislative mandate for CNA registries. The third presents tabulations of the specific inquiry questions. The fourth describes best practices among the states, and the fifth briefly describes the inquiry’s findings and general conclusions.

Registry Background
The main purpose of CNA registries is to track the background, training, and certification of workers who provide direct care to residents in nursing homes. In most states the registries include only CNAs working in skilled nursing facilities, although in some states there are additional classes of workers and provider organizations.

The registries are largely a creation of Federal legislation that directly addressed nursing home reform in the Federal Nursing Home Reform Act, Subtitle C of OBRA 1987. Subsequent Federal refinements of this law appear in OBRA 1989 and OBRA 1990. State nurse aide registries are funded through the Federal mandate with a 50% Federal match of state money.

Registries operate in a variety of ways. State agencies manage and maintain some. Seven are under contract to a national consultant who works directly with the state supervisory agencies to maintain and update registry files. This company also conducts required testing for CNAs in about a third of the states.

Registries have various configurations depending on the controlling state’s legislation and the purposes for which they exist. Some registries maintain only certification and demographic data about nurse aides, while others also contain criminal background information. Some registries list and track a more expansive group of paraprofessional workers including home health aides, medication aides, and, in some states, all direct care workers.

The desire to protect vulnerable people from criminal acts on the part of some states has sparked an interest in gathering background information on direct care workers, with the intent of identifying those with criminal histories. Using registries either to maintain background information or to manage the dissemination of information about criminal histories has caused some registries to evolve beyond their initial purposes of simply registering and tracking nurse aides in nursing homes.

As our inquiry discovered, states use registries for a variety of functions.

Some registries track only certified nurse aides, while others list a variety of additional categories of direct care workers. Registries may be a single, self-contained entity or they may have a separate registration mechanism and a separate abuse registry. For example, South Carolina’s health regulations state that “the nurse aide abuse registry program is responsible for placing Certified Nurse Aides with substantiated allegations of abuse, neglect or misappropriation of resident property, and or findings in a court of law on the Abuse Registry of the South Carolina Nurse Aide Registry.” ⁴² In South Carolina, the entity responsible for certifying nurse aides also maintains a patient abuse registry. However, this varies considerably by state. In Kansas, a separate agency, the Kansas Bureau of Investigation, manages the abuse registry and supplies background information about listed paraprofessionals to the Department of Health Occupations Credentialing, the agency responsible for registering nurse aides.

Criminal background checks for direct care paraprofessional workers other than nurse aides are becoming the norm in many states. As previously noted, these checks are motivated by an interest in public safety and the need to protect the consumer. This trend toward universal background examination of all direct care workers may provide some additional momentum for creating central registries that track the demographic characteristics of the entire direct care workforce. Such characteristics could include places of employment, criminal histories, and any substantiated findings of abuse and neglect.

Nomenclature Problems
Formal registration of direct care workers requires precise definitions and accurate. Standard nomenclature and definitions are critical prerequisites for effective registries. In some states, such as Indiana, Oklahoma, ⁴³ and Rhode Island, for example, the term “nurse aide” or “nurse assistant” is encompassing and includes any worker, certified or not, who performs nursing-related tasks delegated by a registered or licensed nurse, regardless of the setting in which the delegation occurs. In other states, such as New York, for example, “nurse aide” or “nurse assistant” is more specific and connotes only those workers certified to provide direct care in residential health care facilities. ⁴⁴

“Personal care attendant,” a term used in Federal classifications, has acquired many meanings across the country. Depending on the State or depending on the setting in which services are provided, a personal care attendant may be called a mental health aide, a behavioral assistant, a developmental disability aide, a respite worker, or a service aide. These differences in terminology impede comparison between states and, if not reconciled, could defeat any national initiative to use registry data to support national health workforce planning and policymaking.

Despite these difficulties, registries appear to have significant potential to support a number of planning and policymaking functions, in addition to their primary purpose of certifying the qualifications of the workers. This study includes a discussion of fieldwork that suggests individual provider organizations are anxious to have access to statistics that will allow them to benchmark their performance against that of other facilities. Their motivation is to gain a better understanding of workforce shortages in their areas and to formulate effective strategies in response to problems. Respondents see statewide data as imperative to developing legislative initiatives and aggregate national data as essential to understanding, defining, and implementing regulatory and reimbursement policy.

Registries hold the promise of providing data to users at these various levels, if the data are consistent across broad categories of direct care workers. Presently, limited funding and lack of organizational uniformity make such efforts impossible. However, with cooperation between the states and the Federal government, a consistent national data system based on registries could serve the needs of a variety of stakeholders.

Such an effort requires a major investment in technology, additional Federal funding of administration, and a definitive national consensus on what data to collect. It is important to recognize that presently there is no data collection effort focusing primarily on collecting paraprofessional worker data on the local, state, or Federal level [Chapter 3]. Instruments that collect data for other purposes such as patient outcome assessments (OSCAR, OASIS), cost reporting (Medicare and Medicaid), State and Federal licensing, comprehensive national workforce data (BLS, CPS), or quality assurance initiatives (ORYX) contain only limited information about direct care workers.

The supply of paraprofessional workers appears to be critically deficient in several states, although no definitive data exists to support that observation. Registries are a potentially important mechanism for assessing the supply, background, and training of direct care workers. However, this potential can only be realized through the coordinated efforts of various constituents.

Legislative Mandate
OBRA 1987 created new conditions for regulating nursing homes including the reform of facility standards, establishment of health and safety requirements, and new stipulations related to training and monitoring of nurse aides within facilities. ⁴⁵ This legislation required each State to establish a nurse aide registry.

The Code of Federal Regulations lists the requirement that each State must establish and maintain a registry of nurse aides that must contain the following information on each individual who has successfully completed a nurse aide training and competency evaluation program (in accordance with Federal regulations):

• Individual’s full name
• Information necessary to identify each individual
• Date the individual became eligible for placement in the registry through successfully completing a nurse aide training and competency evaluation program
• Information on any finding by the State survey agency of abuse, neglect, or misappropriation of property by the individual (including documentation of the allegation, any hearing, the finding, and a statement by the individual so accused) ⁴⁶

These regulations detail the requisite training, the competency assessments, the approval of programs, and a variety of other requirements surrounding the administration and use of nurse aides in nursing facilities.

CNA Registries in the Fifty States
This study included an inquiry of all 50 State registries and the District of Columbia. The inquiry solicited information regarding the respective registries and the types of data elements they maintained. Inquiries were mailed to non-informants at least three times and attempted telephone contact to increase the response rate.

Inquiry Responses
There were 45 responses to the inquiry. This section describes the responses and includes supplemental information gleaned from a variety of sources, most notably State web sites related to the registries. Although our work encompassed many aspects of the registries, a comprehensive study of their operation and contents was beyond the scope of this project. The examples below are illustrative and not all inclusive.

The Agencies Responsible for the Registries
Responsibility for the registries in all of the 45 states that responded rests with state government agencies including Departments of Public Health, Departments of Health and Environment, State Boards of Nursing, Divisions of Commerce and Economic Development, State Divisions of Aging, and Departments of Human or Social Services. For most states, the Department of Health (51%, 23 of 45) or Board of Nursing (31%, 14 of 45) manages the registry. Eight states (Alaska, Hawaii, Iowa, Maryland, Massachusetts, Missouri, Utah, and Washington) use one of the other departments of state government to supervise the registry.

In several states, occupational regulation in the form of Nurse Practice Acts and the consequent rules and regulations contain the state requirements for training and registration of nurse aides or nursing assistants. The definitions of these workers in statute vary widely. In other states, legislation and regulation governing the licensing and operation of facilities, e.g., nursing homes, home health agencies, adult residential care facilities, etc., contain the rules governing the required training and registration of these workers.

In seven states and the District of Columbia (Connecticut, Delaware, Mississippi, New Jersey, New York, Maryland, the District of Columbia, and as of October 2001, Pennsylvania), a private corporation, Assessment Systems Inc (ASI) ⁴⁷, manages the nurse aide registry and data base. This company also supplies approximately 30 states with competency testing through the National Nurse Aide Assessment Program. In states that use ASI, there is an active interface between ASI and the state administrative agencies responsible for supervising nurse aide testing or registration.

As previously indicated, many registries have evolved beyond their original mandates. Nurse aide registries may, as happens in Massachusetts, also manage or coordinate the reimbursement of costs for nurse aide training programs and testing expenses to qualified programs under Medicaid or Federal regulations. ⁴⁸

Workers Listed in the Registries
Table F-1 the variety of workers states list in their registries:

Table F-1. Types of Workers Listed in State Registries

*Lists home health aides when there has been a finding of abuse

Ninety-six percent of respondent states (43 of 45) list certified nurse aides in their registries. The two states that indicated exceptions use different terminology to describe these workers. Idaho lists certificated aides, and Pennsylvania lists registered aides.

Only 18% (8 of 45) list home health aides in their registries. Those states are California, Kansas, Maine, Oklahoma, Rhode Island, Utah, Wisconsin, and Wyoming. However, in some states, the term “nursing assistant” includes unlicensed direct care workers in a multitude of health care settings; therefore, lists of nursing assistants or aides may include those working in home care or other settings. Maryland and New Hampshire, for instance, have enacted such all-encompassing legislation.

In California, training is structured in such a way that CNAs can add an additional 40 hours of training and become dually certified as HHAs⁴⁹ . CNAs, HHAs, dually certified CNAs/HHAs, and hemodialysis technicians are all listed in the California registry. A worker who is currently certified and who has passed a criminal background check is given an active status. A worker who has failed the background assessment is placed on inactive status, making him/her unemployable by healthcare providers in any direct care capacity.

Indiana passed a law in 1999 that required the Indiana State Department of Health to register home health aides who have completed competency evaluation programs. ⁵⁰ In 2000, the State revised the definition of nurse aide to include any individual providing care delegated by a licensed professional in a range of settings including hospital, outpatient surgery centers, home health agencies, and hospices.⁵¹ Home health aides are now included in this definition.

Illinois is the only State that lists personal care aides in its registry.

Kansas registers nurse aides, home health aides, and medication aides but also requires criminal background checks on all health care workers in any health setting regardless of direct access to patients. ⁵²

Kansas, Missouri, Nebraska, North Dakota, and Oklahoma register certified medication aides, and Nebraska and Missouri maintain separate registries for them. In Nebraska, the Department of Health and Human Services Regulation and Licensure maintains the registries. ⁵³

Kentucky tracks home health aides only when there has been a finding of abuse.

In 2000, Maryland passed a law requiring certification of “an individual regardless of title, who routinely performs tasks delegated by an RN or an LPN for compensation.”⁵⁴ The law requires certification from the Board of Nursing for all nursing assistants including geriatric and home health nursing assistants and registration of all medication assistants. An aide who has a record of abuse, neglect, or misappropriation of property is excluded from certification or renewal of certification. The registry provides monthly updates to employers that detail any change in their aides’ status. ⁵⁵

Massachusetts lists nurse aides on its registry, but also lists any unlicensed direct care worker who has a substantiated finding of abuse on record.

The Minnesota Nursing Assistant Registry lists nursing assistants working in nursing homes or certified boarding care homes, including aides and orderlies and those employed by nursing pool agencies. ⁵⁶ Effective in 1999, the Minnesota legislature allowed individuals to take a competency evaluation without first enrolling in a nursing assistant education program. Although Federal legislation allows a nurse aide in training to be employed for up to four months before being certified, Minnesota now requires that any aide without the required training must pass the competency evaluation before beginning employment. However, those in standard nurse aide training programs in the State may still be employed prior to certification. ⁵⁷ This is an unusual model and is an interim legislative measure that requires evaluation by the Commissioner of Health before the legislature extends the rule.

Oklahoma has an extremely comprehensive aide registry. A nurse aide in Oklahoma is “any person who provides, for compensation, nursing care or health-related services to residents in a nursing facility, a specialized facility, a residential care home, or an adult day care center and who is not a licensed health professional…(including) any person who provides such services to individuals in their own homes as an employee or contract provider.”⁵⁸ This legislation addresses all direct care workers and requires that they be listed on a registry. Oklahoma has created a “uniform employment application for nurse aide staff” to register each worker.

Rhode Island registers all aides in health care facilities or home settings. According to the definition of nursing assistants in Rhode Island law, any nurse aide, orderly, or home health aide who is a paraprofessional in the State and who is providing care to an elderly, infirm, or disabled person within his/her training in a variety of settings including hospitals, patient homes, nursing facilities, and rehabilitation facilities must be registered. ⁵⁹

Effective January 2001, Utah no longer offers separate certification for home health aides. The State requires testing all existing home health aides by July 2001 to “grandfather” them as CNAs.

West Virginia lists only CNAs in its registry but is adding identifiers that would indicate the type of provider agency where the nurse aide is employed, i.e., home health long-term care, or in provision of personal care settings.

Several states list other categories of workers:

• California’s registry includes hemodialysis technicians.
• Illinois’ registry lists developmental disability aides.
• North Carolina lists all aides who have successfully completed nurse aide competency assessment regardless of the setting in which services are performed.
• Washington tracks all persons “ineligible” to work in nursing homes.
• Arkansas’ registry includes the names of CNAs who have completed training and competency assessment and also lists any employment restrictions due to criminal history. Since 1997, the registry also includes the names of non-CNAs, i.e., dietary, laundry, and maintenance workers, with criminal histories that would restrict or prevent employment by long-term care providers. This repository is called the Long-Term Care Facility Employment Clearance Registry. ⁶⁰

Configuration of the Registries
Although some states track unlicensed assistive personnel certifications as well as documentation of abuse and neglect in the same registry, other states maintain separate criminal abuse tracking systems. This may require an interface between two state systems when a provider of care is investigating the employability of a worker. However, in some cases where a dual configuration exists, one system automatically feeds to another so that providers or consumers can obtain the information requested from a single source.

North Carolina Division of Facility Services, which is a part of the Department of Health and Human Services, uses two separate registries. “An individual must successfully complete a state-approved nurse aide training and competency evaluation program to be listed on the Nurse Aide I Registry.” ⁶¹ This registry contains the aide’s name, certain demographic data, and the competency completion date. The department also maintains a separate registry called the Health Care Personnel Registry that contains "a listing of unlicensed assistive personnel (nurse aides) or unlicensed health care personnel (nurse aides, in-home aides, in-home personal care aides, adult care home personal care aides or their supervisors) who are being investigated for or have been found to have caused harm.” ⁶² Tracking of investigations occurs across all health care settings including nursing homes, hospitals, home care agencies, hospices, nursing pools, adult care homes, family care homes, state-operated hospitals, and residential facilities and hospitals for the mentally ill, developmentally disabled and substance abusers. ⁶³

Other states maintain separate registries by occupation. Missouri has a registry of Level I Medication Aides and Certified Medication Technicians. Nebraska has both a Nurse Aide Registry and a Medication Aide Registry. The certifying course for medication aide in Nebraska is either a 20- or 40-hour course that includes a competency evaluation. The length of the course is determined by the setting in which medication is to be administered. ⁶⁴ In most cases, a medication aide must have either nurse aide training or home health training before receiving certification to administer medication.

North Dakota has a unique arrangement in that nurse aides are listed on two registries in the state. The North Dakota Department of Health, Emergency Health Services Division maintains a Registry of Certified Nurse Aides, as does the North Dakota Board of Nursing. This registry is called the Nurse Assistant Registry, which is a “listing of all persons who are authorized by the board or included on another state registry and who have been recognized by the board to perform nursing interventions delegated and supervised by a licensed nurse.” ⁶⁵ The North Dakota Board of Nursing also registers medication assistants.

Texas has two registries. The first is the Nurse Aide Registry, which is located in the Texas Department of Human Services, and the second is the Misconduct Registry, which is maintained by the Texas Department of Public Safety. Legislation passed in 2001 requires that a facility or agency “shall search the Employee Misconduct Registry and the Nurse Aide Registry maintained under the OBRA of 1987.” ⁶⁶

Kentucky’s Board of Nursing maintains a nurse aide registry that contains the name, social security number, address, date of registration, and an “abuse registry indicator”. This indicator alerts a consumer to the aide’s disqualification from employment. The Cabinet for Health Services maintains an abuse registry that is a “listing of those individual nurse aides who have had an allegation of resident neglect, abuse, or misappropriation of resident property substantiated.” ⁶⁷

Not all registries update their listings by deleting workers who have not renewed registration. Federal regulations require that a nurse aide not have a 24-month consecutive lapse in work, and registries must ascertain that a nurse aide has worked in the previous 24 months to maintain active registration. ⁶⁸ This necessitates at least some sort of biennial renewal mechanism either by individual nurse aide registration or by employer survey. Although registries must track registration status, active or inactive, they are not required to remove records of those who are no longer in current standing. Indiana, for instance, listed 95,800 certified nurse aides in the State in 1999 even though only 31,000 were known to be working there in that year. Florida’s registry has accumulated 250,000 names since it began operation in 1985 with only a portion of those workers currently employed as aides. ⁶⁹ Florida updates aide status annually but retains the listing of all nurse aides registered since inception of the registry. Eight hours of work within the previous two years qualifies an aide as active in the state.

Registry Uses
All inquiry respondents indicate that registries exist to comply with Federal and State rules and regulations. In general, the registries confirm the certification status of nurse aides and their employability as determined by passing or failing a criminal background check conducted in the state.

Only 11% of the states (5 of 45) use the registries for monitoring and planning. Those states are Missouri, Nebraska, New Hampshire, North Carolina, and Wyoming.

Since 1989, New Hampshire has regulated nursing assistants under the Nurse Practice Act. Nursing assistants are now licensed by the State and registered with the State Board of Nursing. Nurse aides qualify in the State after completing 100 hours of training (40 in the classroom and 60 in a clinical practice setting) and passing competency testing by an independent evaluator. ⁷⁰ A nursing assistant must renew her license every two years by demonstrating 450 hours of nursing related activity during that period. A nursing assistant may be “given a number of job titles, from home health aide to patient care technician. Regardless of the title or setting, if a person is providing nursing-related activities that person must be licensed.” ⁷¹ The evolution to nursing assistant licensure in New Hampshire occurred as a result of a Certified Nursing Assistant Task Force, which was formed in New Hampshire in 1991. ⁷² New Hampshire is now considering a change in name for these workers to Licensed Nurse Aide.

North Carolina has conducted substantial national research on the subject of the paraprofessional workforce through its North Carolina Division of Facility Services, the Cecil B. Sheps Center for Health Services Research, and the Institute on Aging. The latter two are located at the University of North Carolina. ⁷³ Studies include “Comparing State Efforts to Address the Recruitment and Retention of Nurse Aides and Other Paraprofessional Aide Workers,” “A Follow-Up Survey to States on Wage Supplements for Medicaid and Other Public Funding to Address Aide Recruitment and Retention in Lon-Term Care Settings,” and “Results of a Follow-Up Survey to States on Career Ladder and Other Initiatives to Address Aide Recruitment and Retention in Long-Term Care Settings.” ⁷⁴

In Wyoming, hospitals, nursing homes, the University of Wyoming, and the medical and nursing associations have formed a coalition called the Wyoming Health Resources Network that is working with the University of Wyoming’s Center for Rural Health Research and Education to create a State registry of health workers. The registry is expected to contain information relating to both licensed and other allied health workers and facilities. ⁷⁵

Maine has created a Governor’s Task Force to investigate nurse aide issues. Maine is one of sixteen states that have introduced a wage pass-through targeting nurse aides to encourage workforce retention. ⁷⁶

Virginia has mandated the State Board of Nursing “to certify and maintain a registry of all certified nurse aides…(and) to collect, store, and make available nursing workforce information regarding the various categories of nurses certified, licensed or registered.” ⁷⁷ Subsequently, some data is collected to meet this requirement.

Funding
Funding for each registry is achieved through a memorandum of agreement between CMS and the appropriate state agency. Although there are limitations in Federal regulations on fees that may be charged to registrants, registries do collect some fees from registrants or from the provider agencies that make inquiries of the registry. More than a third (16 of 45 states) of those responding indicated receiving some fees from registrants, while only 4.4% (2 of 45) indicated that fees from provider organizations helped support the registry. Some variation would naturally occur in registries that track more than certified nurse aides. The Federal regulation that restricts fees charged to applicants doesn’t apply to unlicensed assistive personnel other than nurse, and, therefore, registries that track other paraprofessionals would be able to generate income from registering those workers. In some states, the cost of initial registration may not be charged to nurse aides, but renewal of registrations, on an annual or biennial basis depending on state mandate, may generate income for the registry.

In Arkansas, the State pays for the initial registration but individuals pay for renewals. In New Hampshire, CNAs registering under the Federal mandate do not pay the $20 biennial fee, but CNAs working in non-mandated environments do pay a fee.

Demographic Information in the Registries
Table F-2 shows the type of demographic information some of the registries contain. Registry information about nurse aides varies across states. All registries track by name, and 95.6% list an address that was current at the time of registration. More than two-thirds (31 of 45) of respondent states include other demographic information such as age, sex, or race. Eighty percent track the date of approved training. Nearly three-quarters (73%, 34 of 45) list the place of training and, with the exception of Kentucky, Minnesota, New York, New Mexico, Nevada, South Dakota, and Wisconsin, 84% (38 of 45) list the last date of registration.

Only 40% track the name and address of an aide’s employer. Those states are Arizona, Arkansas, Hawaii, Iowa, Kansas, Maine, Massachusetts, Minnesota, Mississippi, Nebraska, New Hampshire, North Carolina, North Dakota, Ohio, South Dakota, Texas, Wisconsin, and West Virginia. A change in employment triggers an update to the aide file in these registries. In some of these states, however, change in employment may be noted only at re-registration.

Seven states track the termination of employment. This is an important data item that would help to make a registry an effective mechanism for accurate tracking of direct care workers. If maintenance of CNA registration were employer-linked, the listing by current job status would yield counts of workers who were actually employed at any point in time. Florida and Kansas track nurse aides’ employment yearly by requiring that employers register, on October 1 and January 1, respectively, all workers on payrolls in health facilities on those dates.

Many types of identifiers distinguish nurse aides within the registries. Alabama, Arizona, California, Georgia, Kentucky, Illinois, Maine, Missouri, New Mexico, and Wisconsin list social security numbers of registrants. Other identifiers, including license or certification number of the nurse aide, may be used as a link to the registry system. In Iowa, search of the Nurse Aide Registry requires either the name of the nurse aide or the nurse aide id number the state issues. ⁷⁸ In Illinois, a search may be conducted by entering either the social security number or the name of the aide. ⁷⁹ Similarly, Georgia permits searching by name or social security number.

Table F-2. Type of Worker and Information in State Registries

Criminal or Misconduct Status in the Registries
Alaska, Arkansas, California, Hawaii, Illinois, Kansas, Maine, Mississippi, Nevada, Oklahoma, Washington, and Wyoming list criminal status in their nurse aide registries.

Alabama, Illinois, Kansas, Massachusetts, Nebraska, New Hampshire, New York, North Dakota, Ohio, Oklahoma, Rhode Island, South Dakota, Tennessee, Texas, Utah, and Washington list either substantiated findings or allegations of abuse and neglect. Illinois, Kansas, Oklahoma, and Washington track both criminal status and findings of abuse, neglect, or other violations.

States vary in their listing of allegations of abuse and neglect. This appears to be a controversial subject, with some advocates feeling that only substantiated findings should be listed on any public record. Supporters of this view suggest that accusations may not always be well founded since the populations served are sometimes confused or demented, and that the caregiver, on balance, deserves consideration in terms legal protection. The legislation requiring background checks on nurse aides does provide for the aide to have the opportunity to make a statement on the official record attached to the investigation or finding of abuse or neglect.

States handle criminal status or documented incidence of abuse, neglect or misappropriation of property differently. In 24 of the 45 respondent states, the CNA registry maintains some indication of complaint, adverse action, or documentation of discipline or findings of abuse. In Arizona, Colorado, Connecticut, Delaware, Georgia, Iowa, Idaho, Kentucky, New Mexico, North Carolina, Oregon, South Carolina, Virginia, and West Virginia this information may not be on the nurse aide file, but notification to the registry of a finding of abuse or misconduct does trigger a change in the registered status. Depending on state policy, misconduct information the registry receives from another investigative state agency causes removal of the aide’s name or a change of the aide’s status to inactive or ineligible for health care employment. Notification by the nurse aide registry to a separate abuse registry regarding a change in nurse aide status may also occur. In Florida, Maryland, Minnesota, Missouri, Pennsylvania, Vermont and Wisconsin, the nurse aide registry does not offer information about findings of abuse, neglect, or misappropriation of property. These records may be contained in a separate registry or may be accessed only by special request from approved providers making inquiries.

In Florida, the CNA registry is a part of the Department of Health. The board issues a certificate to practice as either a Level I or Level II CNA and maintains a registry of those with current certification. A CNA may work in a variety of health care settings including home health agencies. Each year in October, CNA employers are required to provide the registry with a list of all aides whom they have employed for at least eight hours in the previous 24 months. The registry is updated accordingly.⁸⁰ A CNA must work a minimum of 8 hours within two years to maintain a state certification. Depending on the place of employment, a background screening is required for nursing assistants. The CNA registry is authorized by statute to access the background-screening database of the Agency for Health Care Administration, which performs the required investigation. ⁸¹ The two databases maintain separate information.

In Kentucky, the Board of Nursing maintains the nurse aide registry, which contains an abuse registry indicator, but two separate state agencies investigate the actual allegations of abuse and neglect, while a third manages education and training.

Massachusetts’ General Laws a mandate that all long-term care facilities process a criminal offender record check for all employees providing direct care to patients. The Criminal History Systems Board maintains these “records of criminal offender status.” The Nurse Aide Registry is a separate entity that is part of the Division of Health Quality in the Massachusetts Department of Public Health. Thus, two distinct registries provide required information. Facilities must register their staff with the Criminal History Systems Board for employees to be allowed to request information. These selected individuals are approved to check employment applicants’ criminal histories. ⁸² Therefore, the process is not available to the public.

The Central Registry Unit of the Missouri Division of Aging receives all complaints of abuse, neglect, or other violations by a caregiver and refers the allegations to the appropriate investigative agency. The Division of Aging maintains a separate registry called the Employee Disqualification List (EDL) which all care providers in skilled nursing facilities and intermediate and residential care facilities, in-home care providers, and employers of temporary nursing assistants consult for information about potential employees. ⁸³ The Department of Social Services places a name on the list after an appropriate investigation and a final determination that prohibits employment in one of these settings. ⁸⁴ This list is available to authorized users only. However, a written request for information from an individual consumer will be honored.

In Pennsylvania, when an allegation against a nurse aide has merit, “a notation is made on the individual’s file on the Nurse Aide Registry. This prohibits future employment by that person in a nursing home.” ⁸⁵ Only the names of nurse aides in good standing are available for the public online through a web site link. Information about nurse aides disqualified from employment is available exclusively by individual telephone inquiry directly to the registry. ⁸⁶

A nursing assistant in Vermont is licensed and listed on a registry maintained by the Board of Nursing. A nurse aide must have completed appropriate training and competency evaluation and must not have been convicted of a crime that makes him or her unfit to provide services. The Board of Nursing also has the power to revoke the license of anyone who does not meet these conditions. Listing on the registry, therefore, assumes a current license in good standing, i.e., appropriate training, assessed competency, and no criminal finding on the record.

Wisconsin maintains a Nurse Aide Directory in the Wisconsin Department of Health and Family Services that lists nurse aides and medication aides who have completed training and competency testing. Listing of certified nurse aides on the Nurse Aide Directory is required regardless of setting in which the aide is providing care. The registry does not maintain any detailed records about the criminal background of a nurse or medication aide but does disqualify an aide when appropriate. ⁸⁷ Caregiver background checks are provided by another entity, the Wisconsin Caregiver Misconduct Registry, which is maintained in the same state department. The latter registry contains the names of any disqualified nurse aide or other “noncredentialed caregiver” with a confirmed finding of abuse, neglect, or other applicable offense on his or her record. A 1998 law in Wisconsin requires all health care providers including hospitals, nursing homes, home health agencies, hospices, personal care worker agencies, and supportive home care service agencies to conduct criminal background checks on all health care workers who will have access to clients. ⁸⁸ However, those seeking information solely about nurse aides can obtain it directly through the Nurse Aide Registry. ⁸⁹ An interactive voice response system indicates that the nurse aide has been disqualified for a finding of abuse or neglect, but the system offers no information about the finding. Only written requests to the registry yield that background information.

States handle notifying employers of new findings of criminal abuse in a variety of ways. In some states, employers must make repeated periodic inquiries of the system after initial verification of the nurse aide’s eligibility for employment to be certain that no change in eligibility has occurred. In other states, a monthly list of new findings alerts employers to new determinations of ineligibility. In any case, under Federal law, an employer may not knowingly employ under any circumstances any person who is disqualified from care giving by findings of abuse, neglect, or misappropriation of property. In some states, the list of offenses which lead to ineligibility are more extensive than the Federal criteria and may even include juvenile judgments.

Access to Nurse Aid Registry
Thirty-six percent of states offer access to the registries via the Internet, 91% offer access via telephone, 60% offer access by fax request, and 76% offer access by written request or by e-mail. Many states provide multiple options, with some states limiting the information available via some mediums.

Iowa, Idaho, New Hampshire, New Jersey, New York, North Carolina, and Wisconsin have telephone interactive voice response systems.

Fifty-eight percent of respondents have open public access to the registries. Some registries provide only limited public data such as active or inactive status. States may require a written inquiry or access by a special identifier when detailed information is needed. Such limited access assures confidentiality for the worker who is disqualified and protects the information from use by anyone not accessing the listings for employment purposes. Nevada and California allow limited public access. Missouri requires a social security number to obtain information. Ohio provides only the name and address of the certified employee when a public inquiry is made.

Delaware and Texas allow public access with special approval. Iowa, Kentucky, North Dakota, and Oregon require a special password.

Connecticut, Hawaii, South Dakota, and Vermont allow access to provider organizations only. Indiana limits access to those who purchase a subscription to the registry. ⁹⁰

New Mexico makes a nurse aides’ status available on an automated system. However, detailed information about aides with other than active status can only be obtained by speaking directly with a registry representative. ⁹¹

There was no assessment of access to criminal background registries, which are maintained separately from nurse aide registries. The research suggests that states often protect background information in any registry from full public dissemination or from public access. This comes from the view that a need to know about particular offenses is theoretically limited to potential employers, institutional providers, or private consumers. Special safeguards often identify qualified inquiries to the registry; therefore, access to detailed contents is limited.

Some states allow detailed inquiries by written request. This permits individuals who do not possess provider identifiers but who are considering private employment of a nurse aide to uncover any undesirable background that would affect patient care. Missouri initiated a Caregiver Background Screening Service through an executive order of the Governor that allows families to request background information on a potential caregiver through a written request form. ⁹² States sometimes require that the information provided remain confidential and prohibit use by people other than an employer or potential employer. Some states readily provide limited information to the public. New York, for instance, maintains an enumerated list of persons (by name and nurse aide certification number) of persons disqualified for employment as nurse aides. It is available to the public via the Internet. ⁹³

Anticipated Changes
Fifty-eight percent of states (26 of 45) plan no changes.

California, Kansas, and West Virginia indicated that they would add more occupations to their databases. Kansas is considering including non-certified employees of health care providers. California will add certified developmental disability attendants. West Virginia expects to include home health aides and personal care aides.
Maine has considered legislation to register all unlicensed assistive personnel, but the cost of registration has delayed passage of the proposed law.

Arizona, New Hampshire, and Rhode Island hope to use their registries for future workforce planning.

Utah and West Virginia indicate that they expect the registries will support more state agencies.

Maryland and Mississippi expect the registries will support criminal background checks.

West Virginia intends to track multiple employers. Oklahoma will include training and employment on their registries.

Connecticut, Florida, Mississippi, Oklahoma, Rhode Island, Utah, Washington, and West Virginia anticipate adding new data elements to enhance their registries.

Other plans for registry systems include expansion or creation of Internet access in Minnesota, Wisconsin, and Washington; more automation in Kansas; and the installation of an interactive voice response system in Utah.

Future Uses of Registries
Seventy-four percent of the states are willing to permit use of their registries for workforce planning, and 45% are willing to supply estimated counts of workers. Forty-nine percent are willing to provide data for workforce planning, and 49% are willing to allow using data for workforce reports. Some of the informants indicated that there were limitations on the availability of data, since it could only be used as authorized by the regulating agencies or as allowed in statute.

Thirty-eight percent indicated that additional funding would be necessary to support other uses of the registry. Twenty-seven percent responded that statutory or regulatory change would be required for such usage. Thirty-six percent of the registries would require new systems or new equipment to provide expanded services. Concerns were also expressed about the confidential nature of the information maintained and the need to preserve privacy.

Best Practices
Inquiry responses and an interview conducted with the Director of the Registry identified Kansas as a State that was progressive in both the structure and use of its CNA registry.

Kansas is unique in that, at the time the Federal mandated that states create registries, it had already legislated a requirement for registering some direct care workers. Subsequently, Kansas passed a legislative initiative that encouraged compilation of a uniform set of data to provide information about utilization, trends, and cost of health care, including information about health care occupations. ⁹⁴ This provided a strong impetus for systematic collection of data about the paraprofessional health workforce.

There are eleven agencies in the State that license, register, or certify health professionals. The Kansas Department of Health and Environment (KDHE) houses the Health Occupations Credentialing (HOC) section, which licenses such professionals as dietitians, nursing home administrators, and speech pathologists. HOC also certifies nurse aides, home health aides, and medication aides ⁹⁵ and houses the Nurse Aide Registry.

Kansas has a more extensive database than most states. A nurse aide, home health aide, or medication aide is certified as eligible for employment under state administrative rules promulgated in accord with Federal regulations. As a condition of continuing certification, Federal regulation requires documentation that a nurse aide has been actively employed during the previous twenty-four months. Kansas obtains verification of employment on an annual basis. This is achieved by a survey of health employers including hospitals, adult care homes, home health agencies, and some staffing agencies on January 1 of each year. The individual aide record is updated annually when employment information is submitted on the survey. The registry first certifies the aide as meeting the qualifications for employment and then verifies employment on an annual basis. Any prohibition from employment discovered in an aide’s background is also documented in the registry.

Notification to the registry of substantiated findings of abuse, neglect, or misappropriation of property by the Kansas Bureau of Investigation triggers an entry on the individual aide’s record, as does any Federal disqualification for fraud or abuse, or any other mandated prohibition on employment. The registry at HOC serves as a single source for certification confirmation and criminal background checks for employer inquiries on nurse aides, home health aides, or medication aides who are registered under Kansas law as qualified to be employed as direct care workers.

Findings of Abuse, Neglect, Misappropriation, or Other Disqualifying Criminal Behavior
HOC also provides a single source for inquiries regarding the criminal background of other uncertified adult care home and home health workers. In 1997, the State passed laws mandating all “operators of adult care homes, home health agencies, and staffing agencies to assure that no one worked in those settings who had a criminal history of a prescribed list of crimes.” ⁹⁶ The legislation required criminal record checks of any worker who was employed in a covered health care setting. The statutes that require providers to perform these checks are found in the licensing laws for nursing homes and other facilities and home health agencies. ⁹⁷ These laws require that all staff members, including office and dietary personnel but excluding licensed medical professionals, be subject to a background record check.

An update to their technical systems has given HOC the ability to have multiple interfaces with a variety of sources including the Kansas Bureau of Investigation (KBI), which is responsible for maintaining criminal records of individuals in the state. When HOC receives a request for a background record check for a potential employee, it forwards that inquiry to KBI. KBI conducts the record review and provides the search results to HOC. HOC then passes the results to the requesting employer.

This process suggests a possible resource for data on uncertified health workers. Since a core element of the criminal record check system is a job classification code, a statistical analysis by category of worker would be possible. The collection of names obtained through the various inquiries generated by this state mandate is not presently available on a public registry. However, this state directive does provide data on uncertified health workers in mandated facilities.

Also in Kansas, juvenile convictions affect the possibility of employment. Since this is protected information, it allows the KBI to funnel the information from a juvenile record to a defined and authorized user, HOC, that can then disseminate appropriate information to inquiring parties to the extent it is legally disclosable.

Employer Survey
Health care providers in mandated facilities complete the obligatory annual report that lists all health employees as of January 1 of the reporting year and submit it to HOC. Although data input requires about four months, the registry effectively captures an accurate count of workers as of January 1 each year. Updating current employment counts is endogenous to the process. Although these updates do not occur during the year, the database is sufficiently accurate at any point in time to allow for some reporting and tracking of trends. If an employee leaves or moves to another job, the change is not recorded until the subsequent filing.

Since implementing its new system in 2000, Kansas’ registry has over 130,000 individual records listed by job code. This has allowed Kansas to plan and create educational initiatives to address workforce requirements.

Planning for the Paraprofessional Workforce
In Kansas, an industry advisory group that consists of a variety of providers, including adult homes and hospitals, was formed to give government agencies feedback and to provide educational planning for appropriate employment programs. This has been particularly helpful from an educational perspective since required core competencies in particular settings are discussed, and core curricula addressing those needs can be created.

Kansas is a rural state with a need for flexibility in its workforce. Communities are often geographically isolated and dependent on local resources for care across settings. The HOC director suggested that Kansas viewed career options for paraprofessionals as part of a wheel rather than as a ladder. Each spoke in the wheel represented particular competencies needed for particular settings while the hub represented core competencies. The State has devised some innovative training to allow a certified nurse aide to work in home health by adding 20 hours of curriculum to the nurse aide training. A medication aide requires an additional 60 hours of training. The closing of mental health hospitals in the State also created a need for more flexibility in certification. Mental health workers were displaced, and the adult care provider community felt that many of those workers were qualified to work in other settings without having to begin with basic training. A 20-hour bridge course was designed to allow a mental health aide to become a certified nurse aide. Other modifications in training have since been instituted.

This flexibility in credentialing allows workers in small towns to provide care in multiple settings and also permits workers to have full-time employment. Providers in rural areas are not always able to offer sufficient caseloads to keep a worker employed for an eight-hour day. Cross certification meets the needs of the consumers, employers, and workers, allowing an aide to move across settings as required.

Kansas has been imaginative with its resources. Physical therapy assistants and occupational therapy assistants can take a bridge course focused on geriatric long-term care to test and certify as a CNA. Kansas is considering such other initiatives as training EMTs to become CNAs in a similar crossover curriculum.

Other Best Practices
Several other states have registries with features relevant to this study and/or to policymakers interested in standardizing registries across the U.S. For example, many states have comprehensive registries. Oklahoma has a very comprehensive registry with a standard application system. Rhode Island registers all aides working in health care facilities or patient homes. Illinois registers personal care aides and developmental disability aides in addition to CNAs. Vermont and New Hampshire license nurse assistants, which creates a number of interesting possibilities for tracking these workers. Such practices suggest that some states are interested in more expanded information and monitoring of paraprofessional workers.

Discussion
Worker registries appear to offer a useful model for improving data collection about direct care paraprofessional workers. Expanding the registries involves additional costs, especially if new categories of workers are added to the systems, new data elements are included, and additional background checks are required. However, there are few other options that provide access to consistent data at the local, state, and national levels.

Some observers suggest that making registries mandatory for all unlicensed direct care personnel would further impede the hiring process and create more delays in the route from training to provision of care. Creating more bureaucracy and enforcing more rules would further complicate an already difficult employment environment. However, Federal legislation allows for the employment of a nurse aide in a nursing facility on a provisional basis for up to four months without certification. The same option might be extended to other direct care workers who could begin employment while awaiting completion of the registration process.

The cost of such an undertaking seems to be the strongest objection of those whose opinions were sought. Although informants suggest that registries may be good starting points for data collection, they indicate that providers are taxed for resources under the new payment systems and there are no extra funds for registering or tracking direct care staff. There is agreement that continuity across states would help create a national database to inform policy and planning but that without Federal support, states would be unable to accomplish such an initiative. Funding is, therefore, a major impediment. States express motivation to know more about these workers and willingness to improve data collection, if it is supported.

Any new initiative to collect data on paraprofessionals will require technical, human, and financial resources. The consensus obtained from literature review, survey documents, and informant observation is that some initiative must be forthcoming and that the initiative must focus on the problems surrounding this workforce—data collection and analysis, workforce and workplace initiatives, education and career opportunities, and recruitment and retention strategies. Demographic trends suggest that the crisis in the workforce will intensify over the coming decades due to an aging population and more opportunity in other industries for people who currently provide this care. Although difficulties may be felt more acutely in some states or experienced differently by particular types of providers in the continuum of care, at some point the crisis will affect every component of the system—consumer, provider, and payer.

The first step in addressing the issue should be a careful assessment of the workforce. This can only be achieved through gathering and analyzing accurate data. Registries appear to provide an appropriate locus for such effort. Augmentation of the registries needs to include technical staffing that is able to extract appropriate data from the information collected. Presently, registries supply limited services for a defined audience. Any planning or policy initiatives require trained analysts with distinct objectives to produce standardized products that could be aggregated across states for national use or disseminated as regional information to providers in a locality.