Nursing homes that participate in Medicare or Medicaid operate under one of the most layered screening regimes in the employment world. A single hire can touch a federal conduct rule, a state nurse aide registry, a state criminal history or fingerprint law, and a federal exclusion database, all before the facility ever pulls a standard consumer report. Getting the order and the documentation right matters, because a gap in any one layer can put a facility’s certification, and its residents, at risk.
This guide walks through what federal rule actually requires, where state programs fill in the details, how the exclusion list works, and how the Fair Credit Reporting Act (FCRA) governs the process when a facility uses a third party consumer reporting agency to run the check.
The federal floor: 42 CFR 483.12
Medicare and Medicaid certified nursing facilities are bound by the federal requirements for long term care facilities codified at 42 CFR 483.12. The regulation prohibits a facility from employing an individual who has a disciplinary action in effect against their professional license from a state licensing board because of a finding of patient or resident abuse, neglect, mistreatment of residents, or misappropriation of resident property. It also bars employing anyone with a criminal conviction for abuse, neglect, exploitation, or misappropriation of property, as defined under state law, and it requires facilities to report reasonable suspicion of a crime against a resident. This is the baseline conduct standard every certified facility must apply, regardless of which state it operates in.
The nurse aide registry check
Facilities that employ nurse aides have an additional, specific duty under 42 CFR 483.156, which governs the state nurse aide registry. Each state maintains a registry of individuals who have completed a nurse aide training and competency evaluation program, and the registry also records any substantiated finding that a nurse aide neglected or abused a resident or misappropriated resident property. A nursing facility may not use an individual as a nurse aide, even on a temporary basis, unless that person is listed on the state registry as having met training and testing requirements and has no disqualifying finding recorded against their name. Checking the registry before an aide starts work, not after, is what the regulation contemplates, since the point of the rule is to keep a disqualified individual out of direct resident contact.
State fingerprint and criminal history programs
Federal health reform legislation authorized a federal-state National Background Check Program for long term care providers, encouraging states to build fingerprint based, multi-state and FBI criminal history check systems for direct patient access employees, funded in part through the Department of Health and Human Services. The authorizing text sits within the broader federal health reform law published at Public Law 111-148. States that adopted a program under this framework generally require long term care employers to submit fingerprints for a state and FBI criminal history check as a condition of hiring someone into a direct access role, but participation, scope, and the list of covered disqualifying offenses differ by state. Because the details vary, a nursing home should confirm the current fingerprinting and criminal history rule with its own state health department or state survey agency rather than assume a single national standard applies. The Centers for Medicare and Medicaid Services maintains general certification and compliance guidance for nursing homes on its nursing home certification and compliance page.
The HHS OIG List of Excluded Individuals and Entities
Separate from state licensing and criminal history checks, the Department of Health and Human Services Office of Inspector General (OIG) maintains the List of Excluded Individuals and Entities (LEIE). Federal law requires OIG to exclude individuals and entities convicted of certain offenses, such as Medicare or Medicaid fraud, patient abuse or neglect, and felony convictions related to controlled substances, from participation in any federally funded health care program. OIG also has discretion to exclude for a broader set of reasons, described on its exclusion authorities page. Employing or contracting with an excluded individual, even in a role that does not bill Medicare or Medicaid directly, can expose a facility to civil monetary penalties, because the exclusion reaches anyone whose salary or duties are paid for in whole or in part with federal health care program funds. OIG’s own guidance, published on its exclusions FAQ page, recommends that health care providers check the LEIE before hiring and screen their current workforce against the updated list on a regular basis, since names are added and removed as OIG actions take effect. A nursing home’s compliance program should document when each exclusion check was run and against which name variations, since the database is searched by name and can return false matches that need manual review.
How the layers compare
| Screening layer | Primary authority | What it covers | Who is checked |
|---|---|---|---|
| Federal conduct rule | 42 CFR 483.12 | Findings of abuse, neglect, mistreatment, or misappropriation tied to a license action or conviction | All facility staff with resident contact |
| State nurse aide registry | 42 CFR 483.156 | Training and competency status, substantiated abuse or neglect or misappropriation findings | Nurse aides, including temporary and agency aides |
| State fingerprint or criminal history program | State law, informed by federal grant programs | State and FBI criminal history record, disqualifying offenses defined by state | Direct patient access employees, scope varies by state |
| OIG exclusion list (LEIE) | Federal exclusion statute, OIG authority | Exclusion from federally funded health programs for fraud, abuse, neglect, or other cause | All employees and contractors paid in whole or part with federal health funds |
| FCRA consumer report | Fair Credit Reporting Act | Criminal records, employment history, and other background information compiled by a third party | Applicants and employees screened through a consumer reporting agency |
FCRA duties when a third party runs the check
When a nursing home uses a consumer reporting agency, such as a background screening company, to compile a criminal history or employment background report, the process is governed by the Fair Credit Reporting Act regulations that the Consumer Financial Protection Bureau administers, alongside guidance the Federal Trade Commission publishes for employers at Using Consumer Reports: What Employers Need to Know. In broad terms, an employer must provide the applicant a clear, standalone disclosure that a background report will be obtained, get written authorization before ordering the report, and, if the facility intends to take an adverse action such as declining to hire based on the report, send a pre-adverse action notice with a copy of the report and a summary of the applicant’s rights before the decision is final, followed by an adverse action notice once the decision is made. A background check does not automatically show every record that may exist for an applicant, since reporting is affected by state law, the type of search performed, and how far back records are reported, and employers should not assume that silence in a report means no record exists anywhere.
Building a workable screening sequence
Facilities that manage all of these obligations well tend to treat them as a sequence rather than a single event. A practical order looks like this:
- Confirm the role requires resident contact or is otherwise covered, since not every position triggers every layer of screening.
- Check the applicable state nurse aide registry for any role that involves aide duties, before the individual has any resident contact.
- Follow the state’s fingerprint or criminal history procedure where one applies, understanding that timing and covered offenses differ by state.
- Search the LEIE for the applicant’s name and document the search, then repeat the exclusion check on a recurring basis for current staff.
- If a third party consumer report is part of the process, provide the standalone disclosure, obtain written authorization, and follow the pre-adverse and adverse action sequence before any final decision tied to the report.
Facilities that also operate assisted living communities alongside skilled nursing often need a parallel process for that setting, since licensing and screening rules for assisted living can differ from the nursing facility rules discussed here. A related walkthrough is available in Reveal Background’s guide to assisted living facility background check requirements. For a closer look at how the exclusion database itself works, including the difference between the LEIE and the federal System for Award Management exclusion records, see healthcare exclusion screening: OIG LEIE and SAM checks.
Frequently asked questions
Does 42 CFR 483.12 apply to every nursing home employee?
The regulation focuses on individuals with resident contact and on findings of abuse, neglect, mistreatment, or misappropriation tied to a license action or conviction. Facilities generally apply the underlying screening standard broadly to direct care staff, but the exact scope of state implementation can vary, so a facility’s compliance team should confirm how its state survey agency interprets coverage.
How often should a facility check the OIG exclusion list?
OIG guidance recommends checking the LEIE before hiring and then rechecking regularly, since the list is updated as new exclusions and reinstatements occur. Facilities generally build a recurring check into their compliance calendar rather than relying on a single pre-hire search.
Do all states require fingerprint based background checks for nursing home employees?
Many states built fingerprint based criminal history programs for long term care employees using federal grant support, but participation and the scope of covered roles vary by state. A facility should confirm the current requirement with its own state health department or survey agency rather than assume a uniform national rule.
What is the difference between the nurse aide registry check and a criminal background check?
The nurse aide registry confirms training, competency testing status, and whether a substantiated finding of abuse, neglect, or misappropriation has been recorded against that aide. A criminal background check, run through a state program or a consumer reporting agency, looks at criminal court and arrest records more broadly. Both are typically required, and they serve different purposes.
Can a nursing home hire someone while a background check is pending?
Rules on conditional or provisional hiring during a pending background check vary by state and by facility policy, and some states restrict unsupervised resident contact until required checks clear. Facilities should confirm the applicable state rule before allowing an applicant to begin resident facing duties.
Who is responsible for sending FCRA adverse action notices, the facility or the screening company?
The FCRA places the disclosure, authorization, and adverse action notice duties on the employer that is using the report, not on the consumer reporting agency that compiled it, although many facilities use their screening provider’s tools to help generate the required notices.
Reveal Background helps long term care employers build compliant, layered screening programs that combine registry checks, exclusion screening, and FCRA compliant consumer reports. Learn more at Reveal Background.
This article is general information, not legal or medical advice. Nursing homes should consult qualified counsel and their state survey agency to confirm current requirements before adopting a screening policy.
