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Outreach to Stakeholders: Benefits of a State Rap Back System

Outreach to Stakeholders: Benefits of a State Rap Back System

National Background Check Program (NBCP) grantee States may want to reach out to long term care (LTC) facilities and providers and other stakeholders to share information about the benefits of rap back systems. This resource document discusses the importance of State rap back systems, as well as the benefits of the systems, which States can share with their stakeholders. Also included is the text from a memorandum Illinois uses to provide its facilities and providers with information on the State’s rap back process. (See Attachment 1, Why a FEE_APP?)


What is a State rap back system?
Why are State rap back systems necessary?
What are the benefits of a State rap back system?
Where can I find an example of a document for sharing State rap back information with facilities and providers?
Additional Resources
Attachment 1 – Illinois uses this text to provide information regarding the benefits of State rap back to providers and facilities.

What is a State rap back system?

A State rap back system is a prospective and ongoing system of monitoring incidents of criminal activity. It is a mechanism that allows a State Criminal Justice Information Services department to immediately inform the grantee State agency of any new criminal history information that is obtained subsequent to an applicant’s background check. Once the grantee State agency verifies the new criminal history information, the agency may notify the employer, as appropriate. A State rap back system provides facilities and providers information that can be used to help protect LTC residents and beneficiaries from employees with disqualifying criminal convictions that occur after the employees begin work.

Why are State rap back systems necessary?

LTC facilities and providers continue to employ individuals with criminal records, despite having background check policies and procedures in place. To illustrate the problem, on September 27, 2009, the South Florida Sun Sentinel reported that more than 3,500 people with criminal records were working for Florida’s LTC facilities and providers. (See Additional Resource 1.) Demonstrating the nationwide prevalence of the problem, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) released a report in March 2011, “Nursing Facilities’ Employment of Individuals with Criminal Convictions,” saying, with some caveats, “that 92% of nursing facilities employed at least one individual with one criminal conviction.” (See Additional Resource 2; the caveats are discussed on pages 6, 7, and 11 of the report.) The HHS OIG released another report in October 2012, “Criminal Convictions for Nurse Aides With Substantiated Findings of Abuse, Neglect, and Misappropriation,” which found that “[19] percent of nurse aides with substantiated findings had at least one conviction in their criminal history records prior to their substantiated finding.” (See Additional Resource 3.)

While there are several reasons for this continuing problem, two issues are:

  1. Background checks are retrospective only. If an offense is committed the day after the background check is conducted, that information is not included in the background check results. The HHS OIG found that “16% of employees with convictions had their most recent conviction after their beginning date of employment.” (See Additional Resource 2.)
  2. Without a State rap back system in place, there is no system to notify providers and facilities when new disqualifying criminal offenses occur, as noted by the National Focus Group on the Retention of Civil Fingerprints. (See Additional Resource 4.)

What are the benefits of a State rap back system?

State rap back systems are beneficial in a number of important ways. First, a State rap back system helps prevent the continued employment of individuals with disqualifying convictions, enhancing the protection of LTC residents and beneficiaries. Further, such a system helps protect facilities and providers from incurring Federal fines, helps reduce costs and resource expenditures, and can speed up the hiring process, which helps facilities and providers as well as job applicants. More detail on these benefits is provided below.

Preventing continued employment of individuals with disqualifying convictions
A State rap back system offers ongoing monitoring of employees, eliminating the need for facilities and providers to take additional steps to conduct periodic background checks on existing employees. Facilities and providers can be assured that any new criminal history information will be verified by the grantee State agency and that they will be notified in a timely manner of any disqualifying offenses. This also applies during periods of provisional employment, as some employees may be hired provisionally while fingerprints are being processed or criminal history information is being evaluated. State rap back starts as soon as fingerprints are originally submitted, so new hits may come in during provisional employment while a fitness determination is being processed.

Further, facilities and providers will know that they are in compliance with State background check requirements. State rap back systems also allow facilities and providers to reassure residents and beneficiaries, prospective residents and beneficiaries, and their families that they have established ongoing procedures to help enhance safety.

Protecting facilities and providers from Federal fines
Facilities and providers employing individuals with disqualifying criminal convictions, even unknowingly, are subject to Federal fines. For each health care item or service provided directly or indirectly by excluded individuals or entities (excluded because of a disqualifying criminal conviction), there can be civil monetary penalties of up to $10,000 (section 1128A (a) (1)(D) of the Social Security Act). (See Additional Resources 5 and 6.) Rap back systems can assist employers in more quickly removing employees with disqualifying criminal convictions, protecting employers from Federal fines.

Reducing costs and resource expenditures
Illinois and Alaska have established State rap back systems for their NBCP programs and have already noticed financial benefits. For example, facilities and providers save on background check fees for newly hired individuals who are already registered in a State rap back system. Illinois found that in the first year of using its rap back system, facilities and providers reported that 7.6 percent of their new employees were already enrolled in the rap back system and did not require new background checks.

Another potential area of savings is insurance premiums, as noted in Attachment 1. Some insurance companies require that facilities and providers perform yearly background checks. The American Association for Long-Term Care Insurance website says “it is vital to check a private caregiver's criminal and sexual abuse records at least annually.” (See Additional Resource 7.) With a State rap back system in place, facilities and providers can automatically meet this guideline. Illinois found that facility and provider insurance premiums decreased when the insurance company required employers to perform background checks every year and there was a State rap back system in place. Lastly, processing rap back information electronically will be timely and economical, as also noted in Attachment 1.

Speeding up the hiring process
Applicants already in the State database who have no disqualifying information can be hired faster when applying for new jobs if a State rap back system is in place. This is because the State agency does not need to conduct new background checks on these individuals.

Where can I find an example of a document for sharing State rap back information with facilities and providers?

See Attachment 1 for the text of a memorandum that Illinois sends to its facilities and providers regarding rap back. (Note that FEE_APP for Illinois refers to a background check with a rap back submission.)

Additional Resources

  1. South Florida Sun Sentinel, “Convicted felons could be working in your mother or father's nursing home,” September 2009. Accessed at: http://ombudsman.myflorida.com/press_09282009.php.
  2. Department of Health and Human Services Office of Inspector General, “Nursing Facilities’ Employment of Individuals with Criminal Convictions,” March 2011. Accessed at: https://oig.hhs.gov/oei/reports/oei-07-09-00110.asp.
  3. U.S. Department of Health and Human Services Office of Inspector General, “Criminal Convictions for Nurse Aides With Substantiated Findings of Abuse, Neglect, and Misappropriation.” Accessed at: https://oig.hhs.gov/oei/reports/oei-07-10-00422.asp.
  4. Report of the National Focus Group on the Retention of Civil Fingerprints by Criminal History Record Repositories; SEARCH; 2007. Accessed at: https://www.ncjrs.gov/pdffiles1/bjs/225204.pdf.
  5. Office of Inspector General (OIG), “The Effect of Exclusion from Participation in Federal Health Care Programs,” September 1999. Accessed at: http://oig.hhs.gov/fraud/docs/alertsandbulletins/effected.htm.
  6. Section 1128 of the Social Security Act: Exclusion of Certain Individuals and Entities From Participation in Medicare and State Health Care Programs. Accessed at: http://www.ssa.gov/OP_Home/ssact/title11/1128.htm.
  7. American Association for Long-Term Care Insurance, “Who Provides Home Care.” Accessed at: http://www.aaltci.org/long-term-care-insurance/learning-center/home-health-care.php.

Attachment 1 – Illinois uses this text to provide information regarding the benefits of State rap back to providers and facilities.

Why a FEE_APP?

Under the provisions of the Health Care Worker Background Check Act you are required to do the fingerprint background check initiated through the Registry's web application. Any other background check is conducted under the Uniform Conviction Information Act (UCIA) law and is just for that specific point in time where our FEE_APP background check is ongoing. The Illinois State Police retain the fingerprints submitted under this Registry's system and will send a notification to Illinois Department of Public Health (IDPH) if there are any convictions in the future that are associated to these fingerprints. By entering in the employment information our computer system knows what facility the individual is working for and will send an email notification to that facility. If the convictions are disqualifying, the facility will be required to terminate the individual. This is why you do not need to initiate a fingerprint background check through the registry if the individual already has a FEE_APP background check, as it is ongoing. This is also why a UCIA name or UCIA fingerprint background check is no longer allowed.

There have been several instances where a person is working for a facility and a revised report comes in that now states the person has a disqualifying offense. Those people are walked out the door.

The cost to the facilities is being reduced and will continue to be reduced as time goes by because once a worker has a FEE_APP state police background check they do not need to get another yet the protection continues.

It reduces the cost for IDPH because many more background checks can be processed with only a minimal staff, due to the electronic nature of the process developed.

It reduces the cost to the IL State Police because all of the background checks are processed electronically without the State Police's intervention.

It reduces the cost for a facility's insurance because in the past some insurance companies would require yearly background checks on all the facility's employees.

By consolidating several State Agency waiver processes into one with IDPH, all of the background checks and waivers processing is more consistent. IDPH will not allow a waiver to be processed without a FEE_APP background check. If a revised response comes in with a new disqualifying conviction the waivers are immediately revoked and the employing facility is notified.

With IDPH making the determinations on the rap sheets, it provides consistency and better accuracy. Previously, the facilities had to make the determinations to the background check responses. Many facilities would not hire people that could have been hired because they were unsure of how to determine a conviction. This results in more qualified people getting jobs.

It allows workers to be employed faster. If the worker had a FEE-APP background check at a previous facility and is now seeking a new job, the new facility does not have to worry about putting the applicant into conditional hire. Some facilities would require the results of a background check to come back before hiring the person. With the up-to-date results on the Registry the new employer merely has to check the web links and the Registry and can proceed to hire without delay.

[END MEMO]