Direct care workers are, in many ways, the collective face of home-based care organizations. They are who clients and patients interact with. Therefore, regulators and providers are increasingly taking a closer look at who they’re hiring in the first place.
While it is shocking to see caregivers commit crimes against clients, it does happen. About one in six people aged 60 and older experienced some form of abuse during 2023, according to the World Health Organization. Rates of abuse against older people have increased since the COVID-19 pandemic and are predicted to continue rising as many countries experience rapidly aging populations. To combat this trend, increased vetting is essential when hiring individuals to care for seniors in their homes.
Background checks help home care agencies screen prospective caregivers before hiring them. In most states, employers must meet state-specific requirements for caregiver background checks, including criminal record checks and searches of abuse and neglect registries.
“Several states have regulatory requirements for screening caregivers who provide in-home services,” Angelo Spinola, home health, home care and hospice chair at the law firm Polsinelli, told Home Health Care News. “Florida, for example, requires a level-two background screening at hire and every five years.”
Level-two background screenings assess the criminal history record obtained via a fingerprint search through the Federal Bureau of Investigation (FBI) to determine whether the screened individuals have any disqualifying offenses.
“Even when not required by the state regulatory body, many home care agencies conduct criminal background checks on caregivers,” Spinola said. “It is also a good practice to conduct a driving record check for any caregiver who may drive the agency’s clients.”
Some employers choose to run additional screenings on candidates beyond what is required. These extra checks on home care workers – such as driving records, education and employment verification, professional license verification, and pre-employment drug screening – provide a more comprehensive view of the candidate, enhancing the employer’s confidence in their hiring decisions.
“We run a thorough background check including state, federal, municipal and county records,” Betsey Morthland, owner of a Visiting Angels franchise in Bettendorf, Iowa, told HHCN. “We run a complete motor vehicle history. We also check the abuse registries in our state and call references.”
Bryn Mawr, Pennsylvania-based Visiting Angels is a nationwide provider of home care services.
“In addition to running background checks annually and checking arrest records daily, we watch for caregivers who seem to grow overly attached to their clients,” Morthland said. “This can often lead to the sharing of personal information that might result in the client giving the caregiver money.”
While no federal law requires caregiver background checks, home care agencies wanting to receive Medicaid reimbursement must comply with state laws regarding these checks.
The Centers for Medicare & Medicaid Services (CMS) has awarded over $65 million to 28 states to develop comprehensive national background check programs for direct patient access employees. States participating in the National Background Check Program (NBCP) require agencies to conduct three essential background checks: a fingerprint-based FBI criminal history search, a search of the federal office of the Inspector General List of Excluded Individuals and Entities (LEIE), and a search of state abuse and neglect registries. Agencies in states that do not participate in NBCP must also comply to receive federal funding.
Running checks before hiring is an important step, but according to Spinola, conducting periodic background checks for current employees is also recommended.
“The scope and frequency of the background check is up to the agency, but the standard chosen by the agency should be consistently applied and communicated to the client,” he said. “Some agencies provide private clients with the option of running broader background checks on prospective caregivers at their own expense.”
Keep an eye out for red flags
There has been an unprecedented number of workplace violence incidents in client homes, initiated by both client and caregiver. It is crucial for agencies to conduct initial home safety inspections to ensure that the client’s home is not only safe for them but also for the caregivers, according to Spinola.
“For example, a potential client with dementia may own firearms that are not properly secured,” Spinola said. “Likewise, regular client check-ups where another agency representative can assess the client in the home and confirm their safety is a good practice. Implementing protocols for the client to report potential issues and technology in the home to detect abusive situations are good practices.”
If there is a cause for action against a caregiver, Morthland said reporting that person to the state has become a best practice for her agency.
“Depending on the issue, we report the caregiver to the state’s abuse hotline,” she said. “We also suspend the caregiver until an investigation can be conducted. In some cases, local law enforcement may also become involved.”
Spinola said that agencies that suspect abuse or potential abuse should respond quickly to address the situation by proactively conducting an investigation and addressing the problem.
“Ultimately, agency liability for the improper actions of a caregiver is unlikely if the agency has implemented the proper policies and procedures and consistently enforces the same,” he said.
Several jurisdictions have drafted legislation requiring companies to implement safety plans that may apply to home care agencies, according to Spinola. These states include California, Illinois, Kentucky, Montana, Rhode Island and Washington.
These programs generally require awareness training, review of de-escalation techniques and incident response protocols. Even agencies located in states that do not specifically require workplace safety plans should strongly consider implementing the same, given the increasing occurrences of violence in client homes.