In prospect: a national hotline to screen nursing home job applicants.

Nursing home administrators may have a first-hand look at the criminal conviction records of millions of Americans, if Congress takes action on a national job applicant screening hotline now under consideration. It would take current certified nurse assistant (CNA) registries maintained by states several steps further toward a more controlled -- some would say intrusive -- hiring process. Statistically, nursing homes offer greater safety for the elderly than any other type of residence. According to the Bureau of Justice Statistics, Americans over 65 were victims of approximately 2.1 million crimes in 1992; of these crimes, approximately 78 percent were burglaries of private homes. The actual incidence of theft and burglaries in nursing homes was difficult to determine, but was described by a spokesperson for the Bureau as "much lower."

Statistics tell a similar story regarding violent crime. Older Americans are much less likely than average to be victims of violence: only 4 percent of crimes committed against the elderly involved violence, compared with 64.7 percent of crimes committed against 12-to-24 year-old youth. Even those "low" numbers, however, translate into roughly 84,000 violent crimes against the elderly in 1992.

Half of the violent crimes committed against older Americans took place either in the victim's private residence or near it; an additional 31 percent of violent crimes were committed on the street. Fewer than 10 percent of violent crimes against the elderly were committed in the broad category of health care facilities and other institutions, including nursing homes.

Despite the low incidence of crime in nursing homes, however, legislation now being developed would attempt to further lower the risks of victimization of the elderly by changing personnel screening procedures.

Current OBRA regulations require that each state maintain a registry of CNAs who provide most of the hands-on care for nursing home residents. In addition to basic information on qualifications, the registries note whether the CNAs have any documented allegations of abuse or theft committed against residents. The specific information in the file varies with each state, and employers from other states do not always have the right to access the registry. As a result, it is possible for an unemployed CNA to evade effective review of a history of crimes against patients by moving to a new state.

Officials of the state of Kentucky recently proposed to eliminate this problem of interstate "flight" of CNAs with histories of abuse against patients by changing the OBRA regulations to require sharing of information among states. The idea was to link the state registries through a national automated hotline. The hotline would allow employers to learn about any resident abuse or neglect problems recorded in any state where a nurse assistant has been certified.

Congressman Ron Wyden (D-Oregon), a member of the House Subcommittee on Health and Environment, convened a meeting in March with representatives of labor unions, consumer groups, and the nursing home industry to discuss the issue raised by Kentucky. Although Wyden's staff states that significant problems have to be resolved, including how the system would be financed, some type of national hotline providing access to the states' CNA registries could be enacted by Congress this year.

Some groups, however, want a more comprehensive solution that would include far more information on a larger number of people than is currently included in the state registries. The American Health Care Association (AHCA), representing approximately 11,000 for-profit nursing home and residential care facilities, has endorsed a national database that would include records of convictions unrelated to actions against nursing home residents or staff. In addition, AHCA would like the database to provide access to information on individuals entering the nurse assistant field for the first time, before they are certified. In theory, the proposal endorsed by AHCA would grant nursing home administrators the ability to review the arrest or conviction records of millions of Americans.

According to Paul Willging, Executive Vice President of AHCA, the issue of screening applicants who have never previously worked in nursing homes represents the greatest challenge to administrators attempting to reduce the risk of victimization of residents by staff. Attempts to obtain accurate references from former employers fail to consistently identify problem behaviors. Some employers have policies that limit responses to an acknowledgement that an applicant was an employee, often due to reluctance to discuss questionable incidents for fear of lawsuits by former employees. The national database would presumably reduce this exposure by creating an electronic intermediary between former employers and nursing home personnel departments. It also could include information on such relevant crimes as spouse abuse and domestic violence.

"We feel strongly that by establishing a national nurse assistant hotline containing information about abusive, neglectful, or criminal behavior, the federal government will be taking a major step toward assuring the safety of residents," said Willging.

Although specifics of the legislative proposal were not available at this writing, advocates for the national registry acknowledge that limiting its information to convictions could reduce the value of the service for screening personnel other than CNAs with records. Many employers prefer to avoid bad publicity and use personnel actions rather than criminal charges against workers who commit crimes on the job. Other professionals involved in nursing home care are more often disciplined by loss of state licensure rather than by criminal convictions when they violate patients' rights.

The AHCA-endorsed expansion of the proposal to establish a national electronic linkage for the state nurse assistant registries would complicate the passage of the legislation by bringing more players into the discussion. As a simple reform of existing OBRA regulations, the original proposal easily fell within the jurisdiction of the House Subcommittee on Health and Environment, where Congressman Wyden's position as the third-most senior Democrat ensures a fair hearing for the bill. The more comprehensive concept of a national hotline that includes conviction information on job applicants would, in contrast, likely involve the House Committee on the Judiciary, where Democratic civil libertarians and Republican opponents of Federal databases offer a much less welcoming environment.