Standard RD4-F.01: Written policies and procedures are established and implemented in regard to background checks being completed on personnel that have direct patient care and/or access to medical records. Background checks include: Office of Inspector General exclusion list, and criminal background record.

Documentation that background checks were conducted must be evident in the files for the following personnel:

• Employees who have direct patient care and/or access to patient records
• Contracted staff who have direct patient care and/or access to patient records.
  • If the facility uses outside personnel/organization, the contractual agreement requires that all contracted entities obtain the appropriate background checks.

Where to Search

Background checks must include searches of the following registries:

• Office of Inspector General (OIG) exclusion list: The OIG’s List of Excluded Individuals/Entities (LEIE) provides information to the healthcare industry, patients, and the public about individuals and entities currently excluded from participation in Medicare, Medicaid, and all other federal healthcare programs.
• Criminal background records: These records can be used to find out about the criminal histories of individuals. They are required to be checked in accordance with state regulations, which may define the level of background checks to be performed for each individual, obtainment method, time frame, subsequent checks, and offense stipulations. In the absence of state requirements, criminal background checks must be conducted within three months of the date of employment for all states in which the individual has lived or worked during the past three years.
• • Renal dialysis organizations must also have policies and procedures that detail special circumstances, if any, for hiring a person convicted of a crime. The P&P should include but are not limited to:
    • Documentation of any special considerations.
    • Restrictions.
    • Additional supervision requirements.

• National sex offender registry: This registry provides public access to sex offender data nationwide. The National Sex Offender Public Website (NSOPW) is operated by the U.S. Department of Justice in partnership with state, territorial, and tribal governments as a public safety resource.
  • For renal dialysis providers, this requirement only applies to any employee or contracted individual who enters a patient’s home on behalf of the organization.