Criminal History Screening Resource Guide An exclusive member product for Florida s long term care providers

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1 Criminal History Screening Resource Guide 2006 An exclusive member product for Florida s long term care providers

2 2006, Florida Health Care Association Criminal History Screening Resource Guide, Page 2

3 Contents Introduction 5 Skilled Nursing Facilities:An Overview of Criminal History Screening 7 The Law that Passed...7 Contract Employees...7 What you need...7 Agency s Criminal History Screening Databank...8 Liability...8 Facility Owner/Administrator/Financial Officer...8 The Exemption Process...9 Sexual Predator/Offender...9 Criminal History Screening Requirements Chart for Nursing Homes 11 Level 1 Criminal History State Search...11 Level 2 Criminal History Search Federal & State...11 Skilled Nursing Facilities: Frequently Asked Questions 13 Assisted Living Facilities:An Overview of Criminal History Screening 21 The Law that Passed...21 Personal Services...21 What you need...21 Agency s Criminal History Screening Databank...21 Facility Owner/Administrator/Financial Officer...22 The Exemption Process...22 Sexual Predator/Offender...23 Criminal History Screening Requirements Chart for ALFs 25 Level 1 Criminal History State Search...25 Level 2 Criminal History Search Federal & State...25 Attestations & Affidavits 47 Affidavits - Assisted Living Facilities...47 Attestations - Nursing Homes...47 Attestation of Residency - Nursing Homes...47 Appendix A 49 Agency for Health Care Administration Forms , Florida Health Care Association Criminal History Screening Resource Guide, Page

4 2006, Florida Health Care Association Criminal History Screening Resource Guide, Page 4

5 Introduction Florida s licensed skilled nursing and assisted living facilities, industry leaders, and state regulators take very seriously the charge to provide quality services to long term care residents living in our communities and an important aspect of this is in providing for their safety. One component of this is to safeguard residents by screening out persons with troubling criminal histories who might seek employment working with our vulnerable residents. The Florida Health Care Association s Quality Credentialing Foundation endorsed the development of this Criminal History Screening Resource Guide to pull together in one publication the statutory requirements and resources for both skilled nursing and assisted living facities in conducting effective criminal history screenings. The first section provides an overview for licensed skilled nursing facilities, followed by Florida statutes, codes, and forms. The second section offers the same material and resources for licensed assisted living facilities. In talking with hundreds of skilled nursing and assisted living facility providers, it is clear that many go over and beyond the statutory mandates in conducting and evaluating criminal history screenings. That being said, it has also become evident that in spite of the best screening efforts of facilities, sometimes the state s criminal reporting system has failed us and our residents with extremely rare, but disturbing outcomes. Still, it is the responsibility of the facility to take appropriate measures and closely follow state guidelines in screening employees and, with this guide, the Foundation seeks to provide a solid resource for facilties to do so. 2006, Florida Health Care Association Criminal History Screening Resource Guide, Page 5

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7 SNFs: An Overview Skilled Nursing Facilities: An Overview of Criminal History Screening The Law that Passed In 1998, section of Chapter 400, Part II, Florida Statutes, was created, requiring criminal history screening for three different types of skilled nursing facility personnel: Employees whose responsibilities require them to: (a) provide personal care or services to residents; (b) have access to resident living areas; or (c) have access to resident funds or other personal property. Because it is difficult to segregate these employees, FHCA recommends that all facility employees be screened according to the requirements of this law. Contract Employees In regard to contract employees, the Agency for Health Care Administration stated in a letter to FHCA dated 9/24/98: Contract staff will continue to be screened in accordance to their respective employer requirements. For purposes of implementing the background screening requirements of , F.S., employee is being defined as an actual employee of the facility, not contracted individuals, i.e. they are employed with and receive compensation from the nursing home, not the contract entity. Facilities are advised to have a contract with any employment agency they use which stipulates that the agency workers sent to the facility have met the background screening requirements of F.S. Volunteers are not required to be screened. What you need The law requires that a Level 1 screening must be completed and the facility must have in its possession evidence that the Level 1 screening has been completed before allowing an employee, regardless of the date of hire, to begin providing personal care or services to residents or to have access to resident living areas or resident funds or other personal property. Employees must complete an Attestation of Residency (see Attestations & Affidavits, p. 35) in order to document whether they have maintained continuous residence within the State of Florida for the five (5) years immediately preceding the date of request for background screening. Employees hired after October 1, 1998, who have not maintained continuous residency within the state of Florida for the five (5) years immediately preceding the date of request for background screening, must complete a Level 2 screening. Employees hired before October 1, 1998, who had not maintained continuous residency within the state of Florida for the five (5) years immediately preceding the date of request for their Level , Florida Health Care Association Criminal History Screening Resource Guide, Page 7

8 SNFs: An Overview background screening, would not have to complete a Level 2 screening. However, such employees would also need to attest that they have not been convicted of a disqualifying offense in another state or jurisdiction (see Attestations & Affidavits, p. 35). Employees who have a disqualifying offense cannot provide personal care or services to residents, have access to resident living areas or have access to funds or other personal property, (see The Exemption Process, next page). Employees requiring a Level 2 screening may work in a conditional status in the three areas addressed in the law for 180 days pending the results of the Level 2 screening if the facility possesses a clear Level 1 screening. Remember, a new employee who has already been qualified under a Level 2 screening and has maintained such continous residency within Florida shall not be required to complete a subsequent Level 2 screening as a condition of employment, s (1) (b), F.S. Agency s Criminal History Screening Databank Employees who have already been screened, and not disqualified, do not have to be screened again to comply with this law, provided the facility has evidence of the screening. The Agency for Health Care Administration posts the results of all of the screenings they conduct on their website in a databank ( then select Logon). This website is an all-round good first stop for facilities who are considering a new hire. The facility representative, using their pass code, can gain instant access to the Agency s site, and do a search on the person they are considering for employment. The site will indicate whether or not the potential new hire has already been screened in Florida by the Agency and will list whether, at that time, the person was OK to Hire or Not Okay to Hire. Facilities may also accept written verification of qualified screening results directly from the previous employer or other entity that conducted the screening. Employees do not have to be screened again when they change jobs as long as they have not been unemployed for more than 180 days and attest, under penalty of perjury, to not having been convicted of a disqualifying offense since the completion of the screening (see Attestations & Affidavits, p. 35). Liability Employers are protected from monetary and unemployment liability, and no cause of action for damages can arise against an employer who terminates an employee when he is notified that the employee has a disqualifying offense. Facility Owner/Administrator/Financial Officer Section , F.S. (see p. 11) of Chapter 400 specifies that, for nursing homes, the facility administrator who is responsible for the day-to-day operation of the licensed facility, and the facility financial officer who is responsible for the financial operation of the licensed facility, must complete a level 2 background screening. This requirement is also found in s , F.S. If the NHA has already had a level 2 screening conducted as part of their requirement for becoming a licensed NHA, that person does not have to be rescreened as long as they provide such proof to the Agency at time of application for facility licensure in the form of an affidavit of compliance with the provisions of chapter 435 using Agency forms, s (2), F.S. 2006, Florida Health Care Association Criminal History Screening Resource Guide, Page 8

9 SNFs: An Overview Similarly, if the facility owner is a firm, corporation, partnership, or association, then officers or board members must have a Level 2 screening completed. Further, the facility owner, if an individual, must have a level 2 screening completed. According to s , the Agency may also require that a Level 2 screening be conducted for a member of the board of directors of the licensee or an officer or an individual owning 5% or more of the licensee, if the Agency has probable cause to belive that such individual has been convicted of an offense prohibited under the level 2 screening standards listed in s. 435, F.S. Also, s , F.S. sets forth that any person who is a controlling interest who has been convicted of an offense in s. 435, F.S. must submit to the Agency a description and explanation of the conviction at the time application for licensure is made. Remember, once a person qualifies under a Level 2 screening, he/she does not have to be rescreened as long as they continue to live in Florida, s (1)(b), F.S. The Exemption Process Individuals who have been found guilty of, regardless of adjudication, or entered a plea of nolo contendere or guilty to, any offense prohibited in s , F.S., for Level 1 screening, and s , F.S. for Level 2 screening, are disqualified for employment as a nursing home employee in one of the three areas specified in F.S. or serving as owner, administrator, or financial officer. The employee or owner, administrator, or financial officer has the option to apply for an exemption from disqualification (see Appendix A) which, if granted, would allow him or her to provide personal services to residents or to serve as owner, administrator, or financial officer. Sexual Predator/Offender The Florida Department of Law Enforcement maintains a Sexual Offender database, located at Facilities should incorporate a search on this database of potential new hires. The database is not perfect and it will not reflect charges that are pending or have not been reported. As of this writing, it is not currently a regulatory mandate to check the Sexual Offender database, but it is good community policy, free, and easy to search. 2006, Florida Health Care Association Criminal History Screening Resource Guide, Page 9

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11 Criminal History Screening Requirements Chart for Nursing Homes Background Screening Requirements for Employees* Whose Responsibilities Include: (a) the provision of personal care or services to residents, or (b) having access to resident living areas, or (c) having access to resident funds or other personal property Level 1 Criminal History State Search 3 Choices for Requesting a Screening 1. Agency for Health Care Administration s Background Screening Unit ($23 per screening) Facilities can either download AHCA Form , July 05 from the Internet or they may request it from the Agency s Background Screening Unit at 850/ The results of this screening will usually be posted on the same day the Agency receives a completed screening request (see select Health Facilities; then Background Screening, then Logon). You will need a pass code to gain entry to this site; use the phone number above to request. The Agency will post an interpretation of their findings in the form of OK to Hire, Not Okay to Hire, No Record Found, or Pending (more information needed). 2. Florida Department of Law Enforcement ($23 for 1st person; $8 after) Employers may go directly to FDLE to conduct their Level 1 criminal history screenings (see Select Criminal History Records). The difference between this direct access and going through the Agency is that with the FDLE site, the results of a successful screening are instantaneous, and the employer must have the expertise to interpret the results from an official RAP sheet. 3. Third Party Vendor (as an intermediary) (i.e. Edge Information Management, Inc., FHCA Service Corporation Recommended Company) Any valid 3rd Party Vendor conducting background screening investigations on your behalf should have an ORI number assigned by FDLE. Level 2 Criminal History Search Federal & State This search consists of a search of the Florida Department of Law Enforcement (FDLE) and the Federal Bureau of Investigations (FBI) databases for any criminal arrest information both state and nationally. To request a Level 2 search, the applicant must first obtain an Applicant fingerprint card as provided by the Background Screening Unit (850/ ). It s a good idead for a facility to keep a batch of fingerprint cards on hand. It is imperative that the individual write legibly their complete name, address, social security number, date of birth, sex, race, height, weight, eye color and hair color in order for the FBI to process the card. The name and address of the facility requesting the search should also be listed under the Employer. If the FBI rejects a card because of illegible prints, the individual will have to be fingerprinted again and the card resubmitted. There is no charge for a resubmission. Make all checks/money orders payable to AHCA. Send completed forms and appropriate fees to: Background Screening Unit Agency for Health Care Administration 2727 Mahan Dr. Building 3, M.S. #40 Tallahassee, FL Has resided in state for more than 5 years x Has resided out of state within the last 5 years x * FHCA-FCAL suggests that all employees follow the requirements of this law. 2006, Florida Health Care Association Criminal History Screening Resource Guide, Page 11

12 2006, Florida Health Care Association Criminal History Screening Resource Guide, Page 12

13 SNFs: Frequently Asked Questions Skilled Nursing Facilities: Frequently Asked Questions How are Level 2 background screening requirements met for owners, administrators, and CFOs? These requirements are handled as part of the license application and renewal cycle. You will receive the necessary information and forms when you receive a license application package. How long does a facility have to submit for a background screening on a new employee? Up to ten calendar days, or five calendar days after receiving the necessary information from the new employee, F.S (1) (a-c). Remember, however, that an employee must have the qualifying results of a clear Level 1 screening completed and in the personnel files before working with access to residents, their property, or their personal space, (F.S (2) (a). Can an employee who is waiting to get their results from a Level 2 screening work with residents? A state-wide Level 1 screening must be completed prior to an employee providing personal care or services to residents or to have access to resident living areas or resident funds or other personal property. However, when a Level 2 screening is required, an employee may start working with residents in a conditional status for up to 180 days without the results of Level 2 screening as long as a complete, clear Level 1 screening is in the individual s personnel file, and documentation can be provided as to the date the Level 2 screening was initiated. Also, remember that a facility has up to ten calendar days, or five calendar days after receiving the necessary information from the new employee, to submit it for screening. What is an exemption? Sometimes a background screening is returned with a disqualifying offense which may have occurred early in a person s life or which may have been an isolated occurrence with extenuating circumstances. Florida government has tried to make allowances for those persons who may have made a mistake followed by years of good conduct and citizenship. There is a process by which a person may seek an exemption which will allow work with the elderly or with children. Appendix A (p. 37) offers some clarification on the Request for Exemption. You may also call the Background Screening Unit at 850/ to ask for the Exemption Hearing Request Packet which includes an application and a checklist. If a person is able to obtain an exemption, they will be able to work in long term care. Can facilities share background screening information on an individual? Yes; F.S. provides that every employer of employees covered by this chapter shall furnish copies of personnel records for employees or former employees to any other employer requesting this information. 2006, Florida Health Care Association Criminal History Screening Resource Guide, Page 13

14 SNFs: Frequently Asked Questions 6. What if the new hire has already been screened somewhere else? The Agency for Health Care Administration posts all of the screenings they conduct on their website (see site location from choice #1 from the preceding chart). This is an all-round good first stop for facilities who are considering a new hire. The facility representative, using their pass code, can gain instant access to the Agency s site, and do a search on the person they are considering for employment. The site will indicate whether or not the potential new hire has already been screened in Florida by the Agency and will list whether, at that time, the person was OK to Hire or Not Okay to Hire. If the new hire has not already been screened through the Agency, the site will return something like No Record Found. Facilities may also accept written verification of qualified screening results directly from the previous employer or other entity that conducted the screening. Remember that s (5), F.S. provides that if a person has already been screened and qualified as required and who have not been unemployed for more than 180 days thereafter shall not be required to be rescreened. However, the person must also attest to not having been convicted of a disqualifying offense since the completion of their last screening (see Attestations & Affidavits, p. 35). 2006, Florida Health Care Association Criminal History Screening Resource Guide, Page 14

15 Application for license.-- SNFs: F.S. (1) An application for a license as required by s shall be made to the agency on forms furnished by it and shall be accompanied by the appropriate license fee. (2) The application shall be under oath and shall contain the following: (a) The name, address, and social security number of the applicant if an individual; if the applicant is a firm, partnership, or association, its name, address, and employer identification number (EIN), and the name and address of any controlling interest; and the name by which the facility is to be known. (b) The name of any person whose name is required on the application under the provisions of paragraph (a) and who owns at least a 10-percent interest in any professional service, firm, association, partnership, or corporation providing goods, leases, or services to the facility for which the application is made, and the name and address of the professional service, firm, association, partnership, or corporation in which such interest is held. (c) The location of the facility for which a license is sought and an indication, as in the original application, that such location conforms to the local zoning ordinances. (d) The name of the person or persons under whose management or supervision the facility will be conducted and the name of the administrator. (e) A signed affidavit disclosing any financial or ownership interest that a person or entity described in paragraph (a) or paragraph (d) has held in the last 5 years in any entity licensed by this state or any other state to provide health or residential care which has closed voluntarily or involuntarily; has filed for bankruptcy; has had a receiver appointed; has had a license denied, suspended, or revoked; or has had an injunction issued against it which was initiated by a regulatory agency. The affidavit must disclose the reason any such entity was closed, whether voluntarily or involuntarily. (f) The total number of beds and the total number of Medicare and Medicaid certified beds. (g) Information relating to the number, experience, and training of the employees of the facility and of the moral character of the applicant and employees which the agency requires by rule, including the name and address of any nursing home with which the applicant or employees have been affiliated through ownership or employment within 5 years of the date of the application for a license and the record of any criminal convictions involving the applicant and any criminal convictions involving an employee if known by the applicant after inquiring of the employee. The applicant must demonstrate that sufficient numbers of qualified staff, by training or experience, will be employed to properly care for the type and number of residents who will reside in the facility. (h) Copies of any civil verdict or judgment involving the applicant rendered within the 10 years preceding the application, relating to medical negligence, violation of residents' rights, or wrongful death. As a condition of licensure, the licensee agrees to provide to the agency copies of any new verdict or judgment involving the applicant, relating to such matters, within 30 days after filing with the clerk of the court. The information required in this paragraph shall be maintained in the facility's licensure file and in an agency database which is available as a public record. (3) The applicant shall submit evidence which establishes the good moral character of the applicant, manager, supervisor, and administrator. No applicant, if the applicant is an Compiled & Formatted by Florida Health Care Association, 2006 Criminal History Screening Resource Guide, Page 15

16 SNFs: F.S. individual; no member of a board of directors or officer of an applicant, if the applicant is a firm, partnership, association, or corporation; and no licensed nursing home administrator shall have been convicted, or found guilty, regardless of adjudication, of a crime in any jurisdiction which affects or may potentially affect residents in the facility. (4) Each applicant for licensure must comply with the following requirements: (a) Upon receipt of a completed, signed, and dated application, the agency shall require background screening of the applicant, in accordance with the level 2 standards for screening set forth in chapter 435. As used in this subsection, the term "applicant" means the facility administrator, or similarly titled individual who is responsible for the day-to-day operation of the licensed facility, and the facility financial officer, or similarly titled individual who is responsible for the financial operation of the licensed facility. (b) The agency may require background screening for a member of the board of directors of the licensee or an officer or an individual owning 5 percent or more of the licensee if the agency has probable cause to believe that such individual has been convicted of an offense prohibited under the level 2 standards for screening set forth in chapter 435. (c) Proof of compliance with the level 2 background screening requirements of chapter 435 which has been submitted within the previous 5 years in compliance with any other health care or assisted living licensure requirements of this state is acceptable in fulfillment of paragraph (a). Proof of compliance with background screening which has been submitted within the previous 5 years to fulfill the requirements of the Financial Services Commission and the Office of Insurance Regulation pursuant to chapter 651 as part of an application for a certificate of authority to operate a continuing care retirement community is acceptable in fulfillment of the Department of Law Enforcement and Federal Bureau of Investigation background check. (d) A provisional license may be granted to an applicant when each individual required by this section to undergo background screening has met the standards for the Department of Law Enforcement background check, but the agency has not yet received background screening results from the Federal Bureau of Investigation, or a request for a disqualification exemption has been submitted to the agency as set forth in chapter 435, but a response has not yet been issued. A license may be granted to the applicant upon the agency's receipt of a report of the results of the Federal Bureau of Investigation background screening for each individual required by this section to undergo background screening which confirms that all standards have been met, or upon the granting of a disqualification exemption by the agency as set forth in chapter 435. Any other person who is required to undergo level 2 background screening may serve in his or her capacity pending the agency's receipt of the report from the Federal Bureau of Investigation; however, the person may not continue to serve if the report indicates any violation of background screening standards and a disqualification exemption has not been requested of and granted by the agency as set forth in chapter 435. (e) Each applicant must submit to the agency, with its application, a description and explanation of any exclusions, permanent suspensions, or terminations of the applicant from the Medicare or Medicaid programs. Proof of compliance with disclosure of ownership and control interest requirements of the Medicaid or Medicare programs shall be accepted in lieu of this submission. (f) Each applicant must submit to the agency a description and explanation of any conviction of an offense prohibited under the level 2 standards of chapter 435 by a member Compiled & Formatted by Florida Health Care Association, 2006 Criminal History Screening Resource Guide, Page 16

17 SNFs: F.S. corporation or organization if the director serves solely in a voluntary capacity for the corporation or organization, does not regularly take part in the day-to-day operational decisions of the corporation or organization, receives no remuneration for his or her services on the corporation or organization's board of directors, and has no financial interest and has no family members with a financial interest in the corporation or organization, provided that the director and the not-for-profit corporation or organization include in the application a statement affirming that the director's relationship to the corporation satisfies the requirements of this paragraph. (g) An application for license renewal must contain the information required under paragraphs (e) and (f). (5) The applicant shall furnish satisfactory proof of financial ability to operate and conduct the nursing home in accordance with the requirements of this part and all rules adopted under this part, and the agency shall establish standards for this purpose, including information reported under paragraph (2)(e). The agency also shall establish documentation requirements, to be completed by each applicant, that show anticipated facility revenues and expenditures, the basis for financing the anticipated cash-flow requirements of the facility, and an applicant's access to contingency financing. (6) If the applicant offers continuing care agreements as defined in chapter 651, proof shall be furnished that such applicant has obtained a certificate of authority as required for operation under that chapter. (7) As a condition of licensure, each licensee, except one offering continuing care agreements as defined in chapter 651, must agree to accept recipients of Title XIX of the Social Security Act on a temporary, emergency basis. The persons whom the agency may require such licensees to accept are those recipients of Title XIX of the Social Security Act who are residing in a facility in which existing conditions constitute an immediate danger to the health, safety, or security of the residents of the facility. (8) The agency may not issue a license to a nursing home that fails to receive a certificate of need under the provisions of ss It is the intent of the Legislature that, in reviewing a certificate-of-need application to add beds to an existing nursing home facility, preference be given to the application of a licensee who has been awarded a Gold Seal as provided for in s , if the applicant otherwise meets the review criteria specified in s (9) The agency may develop an abbreviated survey for licensure renewal applicable to a licensee that has continuously operated as a nursing facility since 1991 or earlier, has operated under the same management for at least the preceding 30 months, and has had during the preceding 30 months no class I or class II deficiencies. (10) As a condition of licensure, each facility must establish and submit with its application a plan for quality assurance and for conducting risk management. (11) The applicant must provide the agency with proof of a legal right to occupy the property before a license may be issued. Proof may include, but is not limited to, copies of warranty deeds, lease or rental agreements, contracts for deeds, or quitclaim deeds. Compiled & Formatted by Florida Health Care Association, 2006 Criminal History Screening Resource Guide, Page 17

18 Compiled & Formatted by Florida Health Care Association, 2006 Criminal History Screening Resource Guide, Page 18

19 SNFs: F.S Personnel screening requirement.-- (1) The agency shall require background screening as provided in chapter 435 for all employees or prospective employees of facilities licensed under this part who are expected to, or whose responsibilities may require them to: (a) Provide personal care or services to residents; (b) Have access to resident living areas; or (c) Have access to resident funds or other personal property. (2) Employers and employees shall comply with the requirements of s (a) Notwithstanding the provisions of s (1), facilities must have in their possession evidence that level 1 screening has been completed before allowing an employee to begin working with patients as provided in subsection (1). All information necessary for conducting background screening using level 1 standards as specified in s shall be submitted by the nursing facility to the agency. Results of the background screening shall be provided by the agency to the requesting nursing facility. (b) Employees qualified under the provisions of paragraph (a) who have not maintained continuous residency within the state for the 5 years immediately preceding the date of request for background screening must complete level 2 screening, as provided in chapter 435. Such employees may work in a conditional status up to 180 days pending the receipt of written findings evidencing the completion of level 2 screening. Level 2 screening shall not be required of employees or prospective employees who attest in writing under penalty of perjury that they meet the residency requirement. Completion of level 2 screening shall require the employee or prospective employee to furnish to the nursing facility a full set of fingerprints to enable a criminal background investigation to be conducted. The nursing facility shall submit the completed fingerprint card to the agency. The agency shall establish a record of the request in the database provided for in paragraph (c) and forward the request to the Department of Law Enforcement, which is authorized to submit the fingerprints to the Federal Bureau of Investigation for a national criminal history records check. The results of the national criminal history records check shall be returned to the agency, which shall maintain the results in the database provided for in paragraph (c). The agency shall notify the administrator of the requesting nursing facility or the administrator of any other facility licensed under chapter 393, chapter 394, chapter 395, chapter 397, chapter 429, or this chapter, as requested by such facility, as to whether or not the employee has qualified under level 1 or level 2 screening. An employee or prospective employee who has qualified under level 2 screening and has maintained such continuous residency within the state shall not be required to complete a subsequent level 2 screening as a condition of employment at another facility. (c) The agency shall establish and maintain a database of background screening information which shall include the results of both level 1 and level 2 screening. The Department of Law Enforcement shall timely provide to the agency, electronically, the results of each statewide screening for incorporation into the database. The agency shall, upon request from any facility, agency, or program required by or authorized by law to screen its employees or applicants, notify the administrator of the facility, agency, or program of the qualifying or disqualifying status of the employee or applicant named in the request. Compiled & Formatted by Florida Health Care Association, 2006 Criminal History Screening Resource Guide, Page 19

20 SNFs: F.S. (d) Applicants and employees shall be excluded from employment pursuant to s (3) The applicant is responsible for paying the fees associated with obtaining the required screening. Payment for the screening shall be submitted to the agency. The agency shall establish a schedule of fees to cover the costs of level 1 and level 2 screening. Facilities may reimburse employees for these costs. The Department of Law Enforcement shall charge the agency for a level 1 or level 2 screening a rate sufficient to cover the costs of such screening pursuant to s (3). The agency shall, as allowable, reimburse nursing facilities for the cost of conducting background screening as required by this section. This reimbursement will not be subject to any rate ceilings or payment targets in the Medicaid Reimbursement plan. (4)(a) As provided in s , the agency may grant an exemption from disqualification to an employee or prospective employee who is subject to this section and who has not received a professional license or certification from the Department of Health. (b) As provided in s , the appropriate regulatory board within the Department of Health, or that department itself when there is no board, may grant an exemption from disqualification to an employee or prospective employee who is subject to this section and who has received a professional license or certification from the Department of Health or a regulatory board within that department. (5) Any provision of law to the contrary notwithstanding, persons who have been screened and qualified as required by this section and who have not been unemployed for more than 180 days thereafter, and who under penalty of perjury attest to not having been convicted of a disqualifying offense since the completion of such screening, shall not be required to be rescreened. An employer may obtain, pursuant to s , written verification of qualifying screening results from the previous employer or other entity which caused such screening to be performed. (6) The agency and the Department of Health shall have authority to adopt rules pursuant to the Administrative Procedure Act to implement this section. (7) All employees shall comply with the requirements of this section by October 1, No current employee of a nursing facility as of the effective date of this act shall be required to submit to rescreening if the nursing facility has in its possession written evidence that the person has been screened and qualified according to level 1 standards as specified in s (1). Any current employee who meets the level 1 requirement but does not meet the 5-year residency requirement as specified in this section must provide to the employing nursing facility written attestation under penalty of perjury that the employee has not been convicted of a disqualifying offense in another state or jurisdiction. All applicants hired on or after October 1, 1998, shall comply with the requirements of this section. (8) There is no monetary or unemployment liability on the part of, and no cause of action for damages arising against an employer that, upon notice of a disqualifying offense listed under chapter 435 or an act of domestic violence, terminates the employee against whom the report was issued, whether or not the employee has filed for an exemption with the Department of Health or the Agency for Health Care Administration. Compiled & Formatted by Florida Health Care Association, 2006 Criminal History Screening Resource Guide, Page 20

21 ALFs: An Overview Assisted Living Facilities: An Overview of Criminal History Screening The Law that Passed The 1998 Legislature passed SB 714 amending Section of Chapter 400, Part III, Florida Statutes (see p. 15), which regulates the licensing of assisted living facilities. This section of the law requires background screening for three different types of assisted living personnel - (a) the facility owner if an individual, the administrator, and the financial officer, (b) an officer or board member if the facility owner is a firm, corporation, partnership, or association, or any person owning 5 percent or more of the facility if the agency has probable cause to believe that such person has been convicted of any offense prohibited by s , and (c) persons who provide personal services as defined in s (17). Personal Services (17) F.S. provides this definition: Personal services means direct physical assistance with or supervision of the activities of daily living and the self-administration of medication and other similar services which the department may define by rule. Personal services shall not be construed to mean the provision of medical, nursing, dental, or mental health services. What you need For employees providing personal services hired on or after October 1, 1998, the law requires that a Level 1 screening must be submitted to the Agency for Health Care Administration s Background Screening Unit within 10 days of an employee starting work, 58A (3)(a), FAC. The employee may provide personal services on a probationary status, (2) F.S. Employees who have a disqualifying offense, (2) (a)-(cc) F.S., cannot provide personal services to residents (see The Exemption Process, next page). Agency s Criminal History Screening Databank Assisted Living Facility employees who have already been screened, and not disqualified, through the Florida Department of Law Enforcement (FDLE), do not have to be screened again to comply with this law, provided the facility has evidence of a screening which is no more than 2 years old. Remember, the Agency for Health Care Administration posts the results of all of the screenings they conduct on their website. This is an all-round good first stop for facilities who are considering a new hire. The facility representative, using their pass code, can gain instant access to the Agency s site, and do a search on the person they are considering for employment. The site will indicate whether or not the potential new hire has already been screened in Florida by the Agency and will list whether, at that time, the person was OK to Hire or Not Okay to Hire. Facilities may also accept written verification of qualified screening results directly from the previous employer or other entity that conducted the screening. Employees do not have to be screened again when they change jobs as long as the screening is no more than 2 years old, the new employee has not been unemployed for more than 180 days, and prior employment was in the same type of occupation, s (2)(b), F.S. Also, those employees who provide proof of compliance with level 1 screening requirements obtained to meet any professional license requirements in this state (along with a copy of current professional license) would not have to be rescreened. This might be, for example, a registered nurse or other licensed professional, unless he/ she performs personal services for the residents of the facility. This person will need to complete an affidavit 2006, Florida Health Care Association Criminal History Screening Resource Guide, Page 21

22 ALFs: An Overview of current compliance with the background screening requirements, s (2)(a), F.S., (see Attestations & Affidavits, p. 35). Facility administrators will want to make sure that the personnel file contains a copy of the current professional license and the affidavit if they do not rescreen this new hire. Finally, those persons who are employed by a corporation or business entity that owns, operates, or manages more than one licensed facility, and have had a level 1 screening conducted by the corporation as a condition of initial or continued employment. Facility Owner/Administrator/Financial Officer Section (1) of the Florida Statutes requires that an ALF owner (if an individual), the administrator and the financial officer must complete a level 2 background screening. This requirement is also found in s , F.S. If the individual has already had a level 2 screening conducted as part of their requirement for becoming a licensed health care practitioner or nursing home administrator, that person does not have to be rescreened as long as they provide such proof to the Agency at time of application for facility licensure in the form of an affidavit of compliance with the provisions of chapter 435 using Agency forms, s (2), F.S. Similarly, if the facility owner is a firm, corporation, partnership, or association, then officers or board members must have a Level 2 screening completed if the Agency has probable cause to believe that such person has been convicted of any of the disqualifying offenses outlined in , F.S. Also, if the Agency has probable cause to believe that a person owning 5% or more of the facility has been convicted of one of these offenses, the Agency can require that a level 2 screening be conducted for that person, s (1)(a)(2); s (1). Also, s , F.S. sets forth that any person who is a controlling interest who has been convicted of an offense in s. 435, F.S. must submit to the Agency a description and explanation of the conviction at the time application for licensure is made. Volunteer board members are not required to undergo background screening, but do have to affirm their relationship to the licensed facility as detailed in s (1) (a)(2), F.S. Individuals requiring a Level 2 screening may work in a probationary status pending the results of the Level 2 screening (2) F.S., provided a facility has submitted the documentation within the time frame set forth in (1) (a) & (c). The Exemption Process Employees who have been found guilty of, regardless of adjudication, or entered a plea of nolo contendere or guilty to, any offense prohibited in s , F.S., for Level 1 screening, and s , F.S. for Level 2 screening, are disqualified for employment in an assisted living facility providing personal services or serving as owner, administrator, or financial officer as addressed in the law. The employee or owner, administrator, or financial officer has the option to apply for an exemption from disqualification (see Appendix A. p.37) which, if granted, would allow him or her to provide personal services to residents or to serve as owner, administrator, or financial officer. 2006, Florida Health Care Association Criminal History Screening Resource Guide, Page 22

23 ALFs: An Overview Sexual Predator/Offender The Florida Department of Law Enforcement maintains a Sexual Offender database, located at Facilities should incorporate a search on this database of potential new hires. The database is not perfect and it will not reflect charges that are pending or have not been reported. As of this writing, it is not currently a regulatory mandate to check the Sexual Offender database, but it is good community policy, free, and easy to search. 2006, Florida Health Care Association Criminal History Screening Resource Guide, Page 23

24 ALFs: An Overview 2006, Florida Health Care Association Criminal History Screening Resource Guide, Page 24

25 Criminal History Screening Requirements Chart for ALFs All employees hired on or after October 1, 1998, who perform personal services as defined in s (17). Personal services are defined as direct physical assistance with or supervision of the activities of daily living and the self-administration of medication and other similar services which the department may define by rule.* Level 1 Criminal History State Search 3 Choices for Requesting a Screening 1. Agency for Health Care Administration s Background Screening Unit ($23 per screening) Provides Personal Services x Owner, Administrator, CFO Facilities can either download AHCA Form , July 05 from the Internet or they may request it from the Agency s Background Screening Unit at 850/ The results of this screening will usually be posted on the same day the Agency receives a completed screening request (see select Health Facilities; then Background Screening, then Logon). You will need a pass code to gain entry to this site; use the phone number above to request. The Agency will post an interpretation of their findings in the form of OK to Hire, Not Okay to Hire, No Record Found, or Pending (more information needed). 2. Florida Department of Law Enforcement ($23 for 1st person; $8 after) Employers may go directly to FDLE to conduct their Level 1 criminal history screenings (see Select Criminal History Records). The difference between this direct access and going through the Agency is that with the FDLE site, the results of a successful screening are instantaneous, and the employer must have the expertise to interpret the results from an official RAP sheet. 3. Third Party Vendor (as an intermediary) (i.e. Edge Information Management, Inc., FHCA Service Corporation Recommended Company) Any valid 3rd Party Vendor conducting background screening investigations on your behalf should have an ORI number assigned by FDLE. Level 2 Criminal History Search Federal & State This search consists of a search of the Florida Department of Law Enforcement (FDLE) and the Federal Bureau of Investigations (FBI) databases for any criminal arrest information both state and nationally. To request a Level 2 search, the applicant must first obtain an Applicant fingerprint card as provided by the Background Screening Unit (850/ ). It s a good idead for a facility to keep a batch of fingerprint cards on hand. It is imperative that the individual write legibly their complete name, address, social security number, date of birth, sex, race, height, weight, eye color and hair color in order for the FBI to process the card. The name and address of the facility requesting the search should also be listed under the Employer. If the FBI rejects a card because of illegible prints, the individual will have to be fingerprinted again and the card resubmitted. There is no charge for a resubmission. Make all checks/money orders payable to AHCA. Send completed forms and appropriate fees to: x Background Screening Unit Agency for Health Care Administration 2727 Mahan Dr. Building 3, M.S. #40 Tallahassee, FL * FCAL suggests that facilities screen all employees who come in contact w/ residents or have access to their living areas. 2006, Florida Health Care Association Criminal History Screening Resource Guide, Page 25

26 ALFs: An Overview 2006, Florida Health Care Association Criminal History Screening Resource Guide, Page 26

27 ALFs: Frequently Asked Questions Frequently Asked Questions - Assisted Living Facilities How are Level 2 background screening requirements met for owners, administrators, and CFOs? These requirements are handled as part of the license application and renewal cycle. You will receive the necessary information and forms when you receive a license application package. How long does a facility have to submit for a background screening on a new employee? Up to ten calendar days, or five calendar days after receiving the necessary information from the new employee, F.S (1) (a-c). Which ALF employees are exempt from having a Level 1 background screening conducted? Employees working exclusively in food preparation, activities, and maintenance, for example, would not be required to have a background screening in order to work in an ALF as they do not provide personal services as defined in s However, it is a good idea to screen any employees who come in contact with residents or have access to their living areas. Which ALF employees have already met the Level 1 background screening requirement? There are three categories of employees who are considered to have already met the Level 1 background screening requirements: a) Those employees who provide proof of compliance with level 1 screening requirements obtained to meet any professional license requirements in this state (along with a copy of current professional license). This might be, for example, a registered nurse or other licensed professional. This person will need to complete an affidavit of current compliance with the background screening requirements, s (2)(a), F.S., (see Attestations & Affidavits, p. 35). b) Those employees who have been continuously employed in the same type of occupation without a breach in service which exceeds 180 days, and proof of compliance with the level 1 screening requirement which is no more than 2 years old is provided. Proof of compliance shall be provided directly from one employer to another, or you may also visit the A You may also visit the Agency s site, and do a search on the person being considered for employment (also see choice #1 from the preceding chart). c) Those persons who are employed by a corporation or business entity that owns, operates, or manages more than one licensed facility, and have had a level 1 screening conducted by the corporation as a condition of initial or continued employment. 5. What are considered to be personal services? (17) provides this definition: Personal services means direct physical assistance with or supervision of the activities of daily living and the self-administration of medication and other similar services which the department may define by rule. Personal services shall not be construed to mean the provision of medical, nursing, dental, or mental health services. 6. Can a personal services caregiver work while they are waiting to get the results of their screening? Yes, s (2) says they can work on a probationary status pending a determination of compliance. 2006, Florida Health Care Association Criminal History Screening Resource Guide, Page 27

28 ALFs: Frequently Asked Questions 2006, Florida Health Care Association Criminal History Screening Resource Guide, Page 28

29 ALFs: F.S Denial, revocation, or suspension of license; imposition of administrative fine; grounds.-- (1) The agency may deny, revoke, or suspend any license issued under this part, or impose an administrative fine in the manner provided in chapter 120, for any of the following actions by an assisted living facility, for the actions of any person subject to level 2 background screening under s , or for the actions of any facility employee: (a) An intentional or negligent act seriously affecting the health, safety, or welfare of a resident of the facility. (b) The determination by the agency that the owner lacks the financial ability to provide continuing adequate care to residents. (c) Misappropriation or conversion of the property of a resident of the facility. (d) Failure to follow the criteria and procedures provided under part I of chapter 394 relating to the transportation, voluntary admission, and involuntary examination of a facility resident. (e) A citation of any of the following deficiencies as defined in s : 1. One or more cited class I deficiencies. 2. Three or more cited class II deficiencies. 3. Five or more cited class III deficiencies that have been cited on a single survey and have not been corrected within the times specified. (f) A determination that a person subject to level 2 background screening under s (1) does not meet the screening standards of s or that the facility is retaining an employee subject to level 1 background screening standards under s (2) who does not meet the screening standards of s and for whom exemptions from disqualification have not been provided by the agency. (g) A determination that an employee, volunteer, administrator, or owner, or person who otherwise has access to the residents of a facility does not meet the criteria specified in s (2), and the owner or administrator has not taken action to remove the person. Exemptions from disqualification may be granted as set forth in s No administrative action may be taken against the facility if the person is granted an exemption. (h) Violation of a moratorium. (i) Failure of the license applicant, the licensee during relicensure, or a licensee that holds a provisional license to meet the minimum license requirements of this part, or related rules, at the time of license application or renewal. (j) A fraudulent statement or omission of any material fact on an application for a license or any other document required by the agency, including the submission of a license application that conceals the fact that any board member, officer, or person owning 5 percent or more of the facility may not meet the background screening requirements of s. 2006, Florida Health Care Association Criminal History Screening Resource Guide, Page 29

30 ALFs: F.S , or that the applicant has been excluded, permanently suspended, or terminated from the Medicaid or Medicare programs. (k) An intentional or negligent life-threatening act in violation of the uniform firesafety standards for assisted living facilities or other firesafety standards that threatens the health, safety, or welfare of a resident of a facility, as communicated to the agency by the local authority having jurisdiction or the State Fire Marshal. (l) Exclusion, permanent suspension, or termination from the Medicare or Medicaid programs. (m) Knowingly operating any unlicensed facility or providing without a license any service that must be licensed under this chapter or chapter 400. (n) Any act constituting a ground upon which application for a license may be denied. Administrative proceedings challenging agency action under this subsection shall be reviewed on the basis of the facts and conditions that resulted in the agency action. (2) Upon notification by the local authority having jurisdiction or by the State Fire Marshal, the agency may deny or revoke the license of an assisted living facility that fails to correct cited fire code violations that affect or threaten the health, safety, or welfare of a resident of a facility. (3) The agency may deny a license to any applicant or to any officer or board member of an applicant who is a firm, corporation, partnership, or association or who owns 5 percent or more of the facility, if the applicant, officer, or board member has or had a 25-percent or greater financial or ownership interest in any other facility licensed under this part, or in any entity licensed by this state or another state to provide health or residential care, which facility or entity during the 5 years prior to the application for a license closed due to financial inability to operate; had a receiver appointed or a license denied, suspended, or revoked; was subject to a moratorium on admissions; had an injunctive proceeding initiated against it; or has an outstanding fine assessed under this chapter or chapter 400. (4) The agency shall deny or revoke the license of an assisted living facility that has two or more class I violations that are similar or identical to violations identified by the agency during a survey, inspection, monitoring visit, or complaint investigation occurring within the previous 2 years. (5) An action taken by the agency to suspend, deny, or revoke a facility's license under this part, in which the agency claims that the facility owner or an employee of the facility has threatened the health, safety, or welfare of a resident of the 1 facility be heard by the Division of Administrative Hearings of the Department of Management Services within 120 days after receipt of the facility's request for a hearing, unless that time limitation is waived by both parties. The administrative law judge must render a decision within 30 days after receipt of a proposed recommended order. (6) The agency shall provide to the Division of Hotels and Restaurants of the Department of Business and Professional Regulation, on a monthly basis, a list of those assisted living facilities that have had their licenses denied, suspended, or revoked or that are involved in 2006, Florida Health Care Association Criminal History Screening Resource Guide, Page 30

31 ALFs: F.S. an appellate proceeding pursuant to s related to the denial, suspension, or revocation of a license. (7) Agency notification of a license suspension or revocation, or denial of a license renewal, shall be posted and visible to the public at the facility. (8) The agency may issue a temporary license pending final disposition of a proceeding involving the suspension or revocation of an assisted living facility license. 2006, Florida Health Care Association Criminal History Screening Resource Guide, Page 31

32 2006, Florida Health Care Association Criminal History Screening Resource Guide, Page 32

33 ALFs: F.S Background screening; exemptions.-- (1)(a) Level 2 background screening must be conducted on each of the following persons, who shall be considered employees for the purposes of conducting screening under chapter 435: 1. The facility owner if an individual, the administrator, and the financial officer. 2. An officer or board member if the facility owner is a firm, corporation, partnership, or association, or any person owning 5 percent or more of the facility if the agency has probable cause to believe that such person has been convicted of any offense prohibited by s For each officer, board member, or person owning 5 percent or more who has been convicted of any such offense, the facility shall submit to the agency a description and explanation of the conviction at the time of license application. This subparagraph does not apply to a board member of a not-for-profit corporation or organization if the board member serves solely in a voluntary capacity, does not regularly take part in the day-to-day operational decisions of the corporation or organization, receives no remuneration for his or her services, and has no financial interest and has no family members with a financial interest in the corporation or organization, provided that the board member and facility submit a statement affirming that the board member's relationship to the facility satisfies the requirements of this subparagraph. (b) Proof of compliance with level 2 screening standards which has been submitted within the previous 5 years to meet any facility or professional licensure requirements of the agency or the Department of Health satisfies the requirements of this subsection, provided that such proof is accompanied, under penalty of perjury, by an affidavit of compliance with the provisions of chapter 435. Proof of compliance with the background screening requirements of the Financial Services Commission and the Office of Insurance Regulation for applicants for a certificate of authority to operate a continuing care retirement community under chapter 651, submitted within the last 5 years, satisfies the Department of Law Enforcement and Federal Bureau of Investigation portions of a level 2 background check. (c) The agency may grant a provisional license to a facility applying for an initial license when each individual required by this subsection to undergo screening has completed the Department of Law Enforcement background checks, but has not yet received results from the Federal Bureau of Investigation, or when a request for an exemption from disqualification has been submitted to the agency pursuant to s , but a response has not been issued. (2) The owner or administrator of an assisted living facility must conduct level 1 background screening, as set forth in chapter 435, on all employees hired on or after October 1, 1998, who perform personal services as defined in s (17). The agency may exempt an individual from employment disqualification as set forth in chapter 435. Such persons shall be considered as having met this requirement if: (a) Proof of compliance with level 1 screening requirements obtained to meet any professional license requirements in this state is provided and accompanied, under penalty of perjury, by a copy of the person's current professional license and an affidavit of current compliance with the background screening requirements. 2006, Florida Health Care Association Criminal History Screening Resource Guide, Page 33

34 ALFs: F.S. (b) The person required to be screened has been continuously employed in the same type of occupation for which the person is seeking employment without a breach in service which exceeds 180 days, and proof of compliance with the level 1 screening requirement which is no more than 2 years old is provided. Proof of compliance shall be provided directly from one employer or contractor to another, and not from the person screened. Upon request, a copy of screening results shall be provided by the employer retaining documentation of the screening to the person screened. (c) The person required to be screened is employed by a corporation or business entity or related corporation or business entity that owns, operates, or manages more than one facility or agency licensed under this chapter, and for whom a level 1 screening was conducted by the corporation or business entity as a condition of initial or continued employment. 2006, Florida Health Care Association Criminal History Screening Resource Guide, Page 34

35 ALFs: 58A-5.019, FAC Assisted Living Facilities: 58A Florida Administrative Code Staffing Standards (3) BACKGROUND SCREENING. (a) All staff, hired on or after October 1, 1998, to provide personal services to residents must be screened in accordance with Section , F.S., and meet the screening standards of Section , F.S. A packet containing background screening forms and instructions may be obtained from the AHCA Background Screening Unit, 2727 Mahan Drive, Tallahassee, FL 32308; telephone (850) Within 10 days of the employee s starting work, the facility shall submit to the AHCA central office: 1. A completed Criminal History Check, AHCA Form , June 1998; 2 A signed Florida Abuse Hotline Information System Background Check, AHCA Form , July 1998; and 3. A check to cover the cost of screening. (b) The results of employee screening conducted by the agency shall be maintained in the employee s personnel file. (c) Staff with the following documentation in their personnel records shall be considered to have met the required screening requirement: 1. A copy of their current professional license which required Level 1 background screening as a condition of licensing, proof that a criminal history and abuse registry check have been conducted, and an affidavit of current compliance with Section , F.S.; 2. Proof of continuous employment in an occupation which requires Level 1 screening without a break in employment that exceeds 180 days, and proof that a criminal history and abuse registry check has been conducted within the previous 2 years; or 3. Proof of employment with a corporation or business entity or related entity that owns, operates, or manages more than one facility or agency licensed under Chapter 400, F.S., that conducted Level 1 screening as a condition of initial or continued employment. Compiled & Formatted by Florida Health Care Association, 2006 Criminal History Screening Resource Guide, Page 35

36 Compiled & Formatted by Florida Health Care Association, 2006 Criminal History Screening Resource Guide, Page 36

37 SNFs & ALFs: 435, F.S Applicability of this chapter Definitions Level 1 screening standards Level 2 screening standards Requirements for covered employees Exclusion from employment Exemptions from disqualification. TITLE XXXI LABOR CHAPTER 435 EMPLOYMENT SCREENING Payment for processing of fingerprints and state criminal records checks Confidentiality of personnel background check information Sharing of personnel information among employers Penalties Applicability of this chapter.--whenever a background screening for employment or a background security check is required by law for employment, unless otherwise provided by law, the provisions of this chapter shall apply. History.--s. 47, ch Definitions.--For the purposes of this chapter: (1) "Employee" means any person required by law to be screened pursuant to the provisions of this chapter. (2) "Employer" means any person or entity required by law to conduct screening of employees pursuant to this chapter. (3) "Licensing agency" means any state or county agency which grants licenses or registration permitting the operation of an employer or is itself an employer. When there is no state licensing Compiled & Formatted by Florida Health Care Association, 2006 Criminal History Screening Resource Guide, Page 37

38 SNFs & ALFs: 435, F.S. agency or the county licensing agency chooses not to conduct employment screening, "licensing agency" means the Department of Children and Family Services. History.--s. 47, ch ; s. 207, ch Level 1 screening standards.-- (1) All employees required by law to be screened shall be required to undergo background screening as a condition of employment and continued employment. For the purposes of this subsection, level 1 screenings shall include, but not be limited to, employment history checks and statewide criminal correspondence checks through the Florida Department of Law Enforcement, and may include local criminal records checks through local law enforcement agencies. (2) Any person for whom employment screening is required by statute must not have been found guilty of, regardless of adjudication, or entered a plea of nolo contendere or guilty to, any offense prohibited under any of the following provisions of the Florida Statutes or under any similar statute of another jurisdiction: (a) Section , relating to sexual misconduct with certain developmentally disabled clients and reporting of such sexual misconduct. (b) Section , relating to sexual misconduct with certain mental health patients and reporting of such sexual misconduct. (c) Section , relating to abuse, neglect, or exploitation of a vulnerable adult. (d) Section , relating to murder. (e) Section , relating to manslaughter, aggravated manslaughter of an elderly person or disabled adult, or aggravated manslaughter of a child. (f) Section , relating to vehicular homicide. (g) Section , relating to killing of an unborn quick child by injury to the mother. (h) Section , relating to assault, if the victim of the offense was a minor. (i) Section , relating to aggravated assault. (j) Section , relating to battery, if the victim of the offense was a minor. (k) Section , relating to aggravated battery. (l) Section , relating to kidnapping. Compiled & Formatted by Florida Health Care Association, 2006 Criminal History Screening Resource Guide, Page 38

39 SNFs & ALFs: 435, F.S. (m) Section , relating to false imprisonment. (n) Section , relating to sexual battery. (o) Former s , relating to prohibited acts of persons in familial or custodial authority. (p) Chapter 796, relating to prostitution. (q) Section , relating to lewd and lascivious behavior. (r) Chapter 800, relating to lewdness and indecent exposure. (s) Section , relating to arson. (t) Chapter 812, relating to theft, robbery, and related crimes, if the offense was a felony. (u) Section , relating to fraudulent sale of controlled substances, only if the offense was a felony. (v) Section , relating to abuse, aggravated abuse, or neglect of an elderly person or disabled adult. (w) Section , relating to lewd or lascivious offenses committed upon or in the presence of an elderly person or disabled adult. (x) Section , relating to exploitation of an elderly person or disabled adult, if the offense was a felony. (y) Section , relating to incest. (z) Section , relating to child abuse, aggravated child abuse, or neglect of a child. (aa) Section , relating to contributing to the delinquency or dependency of a child. (bb) Former s , relating to negligent treatment of children. (cc) Section , relating to sexual performance by a child. (dd) Chapter 847, relating to obscene literature. (ee) Chapter 893, relating to drug abuse prevention and control, only if the offense was a felony or if any other person involved in the offense was a minor. (ff) 1 Section , relating to sexual misconduct with certain forensic clients and reporting of such sexual misconduct. Compiled & Formatted by Florida Health Care Association, 2006 Criminal History Screening Resource Guide, Page 39

40 SNFs & ALFs: 435, F.S. (3) Standards must also ensure that the person: (a) For employees and employers licensed or registered pursuant to chapter 400 or chapter 429, and for employees and employers of developmental disabilities institutions as defined in s , intermediate care facilities for the developmentally disabled as defined in s , and mental health treatment facilities as defined in s , meets the requirements of this chapter. (b) Has not committed an act that constitutes domestic violence as defined in s History.--s. 47, ch ; s. 15, ch ; s. 21, ch ; s. 3, ch ; s. 87, ch ; s. 45, ch ; s. 62, ch ; s. 50, ch ; s. 4, ch ; s. 3, ch ; s. 89, ch ; s. 61, ch Note.--The cited section does not exist; s relates to prohibition of sexual misconduct with forensic clients Level 2 screening standards.-- (1) All employees in positions designated by law as positions of trust or responsibility shall be required to undergo security background investigations as a condition of employment and continued employment. For the purposes of this subsection, security background investigations shall include, but not be limited to, fingerprinting for all purposes and checks in this subsection, statewide criminal and juvenile records checks through the Florida Department of Law Enforcement, and federal criminal records checks through the Federal Bureau of Investigation, and may include local criminal records checks through local law enforcement agencies. (2) The security background investigations under this section must ensure that no persons subject to the provisions of this section have been found guilty of, regardless of adjudication, or entered a plea of nolo contendere or guilty to, any offense prohibited under any of the following provisions of the Florida Statutes or under any similar statute of another jurisdiction: (a) Section , relating to sexual misconduct with certain developmentally disabled clients and reporting of such sexual misconduct. (b) Section , relating to sexual misconduct with certain mental health patients and reporting of such sexual misconduct. (c) Section , relating to adult abuse, neglect, or exploitation of aged persons or disabled adults. (d) Section , relating to murder. (e) Section , relating to manslaughter, aggravated manslaughter of an elderly person or disabled adult, or aggravated manslaughter of a child. (f) Section , relating to vehicular homicide. Compiled & Formatted by Florida Health Care Association, 2006 Criminal History Screening Resource Guide, Page 40

41 SNFs & ALFs: 435, F.S. (g) Section , relating to killing of an unborn quick child by injury to the mother. (h) Section , relating to assault, if the victim of the offense was a minor. (i) Section , relating to aggravated assault. (j) Section , relating to battery, if the victim of the offense was a minor. (k) Section , relating to aggravated battery. (l) Section , relating to battery on a detention or commitment facility staff. (m) Section , relating to kidnapping. (n) Section , relating to false imprisonment. (o) Section (2), relating to taking, enticing, or removing a child beyond the state limits with criminal intent pending custody proceedings. (p) Section (3), relating to carrying a child beyond the state lines with criminal intent to avoid producing a child at a custody hearing or delivering the child to the designated person. (q) Section (1), relating to exhibiting firearms or weapons within 1,000 feet of a school. (r) Section (2)(b), relating to possessing an electric weapon or device, destructive device, or other weapon on school property. (s) Section , relating to sexual battery. (t) Former s , relating to prohibited acts of persons in familial or custodial authority. (u) Chapter 796, relating to prostitution. (v) Section , relating to lewd and lascivious behavior. (w) Chapter 800, relating to lewdness and indecent exposure. (x) Section , relating to arson. (y) Chapter 812, relating to theft, robbery, and related crimes, if the offense is a felony. (z) Section , relating to fraudulent sale of controlled substances, only if the offense was a felony. (aa) Section , relating to abuse, aggravated abuse, or neglect of an elderly person or disabled adult. Compiled & Formatted by Florida Health Care Association, 2006 Criminal History Screening Resource Guide, Page 41

42 SNFs & ALFs: 435, F.S. (bb) Section , relating to lewd or lascivious offenses committed upon or in the presence of an elderly person or disabled adult. (cc) Section , relating to exploitation of an elderly person or disabled adult, if the offense was a felony. (dd) Section , relating to incest. (ee) Section , relating to child abuse, aggravated child abuse, or neglect of a child. (ff) Section , relating to contributing to the delinquency or dependency of a child. (gg) Former s , relating to negligent treatment of children. (hh) Section , relating to sexual performance by a child. (ii) Section , relating to resisting arrest with violence. (jj) Section , relating to depriving a law enforcement, correctional, or correctional probation officer means of protection or communication. (kk) Section , relating to aiding in an escape. (ll) Section , relating to aiding in the escape of juvenile inmates in correctional institutions. (mm) Chapter 847, relating to obscene literature. (nn) Section (1), relating to encouraging or recruiting another to join a criminal gang. (oo) Chapter 893, relating to drug abuse prevention and control, only if the offense was a felony or if any other person involved in the offense was a minor. (pp) 1 Section , relating to sexual misconduct with certain forensic clients and reporting of such sexual misconduct. (qq) Section (3), relating to inflicting cruel or inhuman treatment on an inmate resulting in great bodily harm. (rr) Section , relating to harboring, concealing, or aiding an escaped prisoner. (ss) Section , relating to introduction of contraband into a correctional facility. (tt) Section , relating to sexual misconduct in juvenile justice programs. (uu) Section , relating to contraband introduced into detention facilities. Compiled & Formatted by Florida Health Care Association, 2006 Criminal History Screening Resource Guide, Page 42

43 SNFs & ALFs: 435, F.S. (3) The security background investigations conducted under this section for employees of the Department of Juvenile Justice must ensure that no persons subject to the provisions of this section have been found guilty of, regardless of adjudication, or entered a plea of nolo contendere or guilty to, any offense prohibited under any of the following provisions of the Florida Statutes or under any similar statute of another jurisdiction: (a) Section , relating to assault or battery of law enforcement officers, firefighters, emergency medical care providers, public transit employees or agents, or other specified officers. (b) Section , relating to burglary, if the offense is a felony. (c) Section , relating to escape. The Department of Juvenile Justice may not remove a disqualification from employment or grant an exemption to any person who is disqualified under this section for any offense disposed of during the most recent 7-year period. (4) Standards must also ensure that the person: (a) For employees or employers licensed or registered pursuant to chapter 400 or chapter 429, does not have a confirmed report of abuse, neglect, or exploitation as defined in 2 s (6), which has been uncontested or upheld under s (b) Has not committed an act that constitutes domestic violence as defined in s (5) Under penalty of perjury, all employees in such positions of trust or responsibility shall attest to meeting the requirements for qualifying for employment and agreeing to inform the employer immediately if convicted of any of the disqualifying offenses while employed by the employer. Each employer of employees in such positions of trust or responsibilities which is licensed or registered by a state agency shall submit to the licensing agency annually, under penalty of perjury, an affidavit of compliance with the provisions of this section. History.--s. 47, ch ; s. 16, ch ; s. 22, ch ; s. 4, ch ; s. 5, ch ; s. 88, ch ; s. 7, ch ; s. 5, ch ; s. 4, ch ; s. 111, ch ; s. 90, ch Note.--The cited section does not exist; s relates to prohibition of sexual misconduct with forensic clients. 2 Note.--Repealed by s. 26, ch Requirements for covered employees.--except as otherwise provided by law, the following requirements shall apply to covered employees: (1)(a) Every person employed in a position for which employment screening is required must, within 5 working days after starting to work, submit to the employer a complete set of information necessary to conduct a screening under this section. Compiled & Formatted by Florida Health Care Association, 2006 Criminal History Screening Resource Guide, Page 43

44 SNFs & ALFs: 435, F.S. (b) For level 1 screening, the employer must submit the information necessary for screening to the Florida Department of Law Enforcement within 5 working days after receiving it. The Florida Department of Law Enforcement will conduct a search of its records and will respond to the employer agency. The employer will inform the employee whether screening has revealed any disqualifying information. (c) For level 2 screening, the employer or licensing agency must submit the information necessary for screening to the Florida Department of Law Enforcement within 5 working days after receiving it. The Florida Department of Law Enforcement will conduct a search of its criminal and juvenile records and will request that the Federal Bureau of Investigation conduct a search of its records for each employee for whom the request is made. The Florida Department of Law Enforcement will respond to the employer or licensing agency, and the employer or licensing agency will inform the employee whether screening has revealed disqualifying information. (d) The person whose background is being checked must supply any missing criminal or other necessary information to the employer within 30 days after the employer makes a request for the information or be subject to automatic disqualification. (2) Unless otherwise prohibited by state or federal law, new employees may be placed on probationary status pending a determination of compliance with minimum standards set forth in this chapter. (3) Each employer required to conduct level 2 background screening must sign an affidavit annually, under penalty of perjury, stating that all covered employees have been screened or are newly hired and are awaiting the results of the required screening checks. History.--s. 47, ch ; s. 208, ch. 99-8; s. 46, ch ; s. 63, ch ; s. 21, ch Exclusion from employment.-- (1) When an employer or licensing agency has reasonable cause to believe that grounds exist for the denial or termination of employment of any employee as a result of background screening, it shall notify the employee in writing, stating the specific record which indicates noncompliance with the standards in this section. It shall be the responsibility of the affected employee to contest his or her disqualification or to request exemption from disqualification. The only basis for contesting the disqualification shall be proof of mistaken identity. (2) The employer must either terminate the employment of any of its personnel found to be in noncompliance with the minimum standards for good moral character contained in this section or place the employee in a position for which background screening is not required unless the employee is granted an exemption from disqualification pursuant to s (3) Any person who is required to undergo employment screening and who refuses to cooperate in such screening or refuses to submit the information necessary to complete the screening, Compiled & Formatted by Florida Health Care Association, 2006 Criminal History Screening Resource Guide, Page 44

45 SNFs & ALFs: 435, F.S. including fingerprints when required, shall be disqualified for employment in such position or, if employed, shall be dismissed. History.--s. 47, ch Exemptions from disqualification.--unless otherwise provided by law, the provisions of this section shall apply to exemptions from disqualification. (1) The appropriate licensing agency may grant to any employee otherwise disqualified from employment an exemption from disqualification for: (a) Felonies committed more than 3 years prior to the date of disqualification; (b) Misdemeanors prohibited under any of the Florida Statutes cited in this chapter or under similar statutes of other jurisdictions; (c) Offenses that were felonies when committed but are now misdemeanors; (d) Findings of delinquency; or (e) Commissions of acts of domestic violence as defined in s For the purposes of this subsection, the term "felonies" means both felonies prohibited under any of the Florida Statutes cited in this chapter or under similar statutes of other jurisdictions. (2) Persons employed by treatment providers who treat adolescents 13 years of age and older who are disqualified from employment solely because of crimes under s , s , or s may be exempted from disqualification from employment pursuant to this section without the 3-year waiting period. (3) In order for a licensing department to grant an exemption to any employee, the employee must demonstrate by clear and convincing evidence that the employee should not be disqualified from employment. Employees seeking an exemption have the burden of setting forth sufficient evidence of rehabilitation, including, but not limited to, the circumstances surrounding the criminal incident for which an exemption is sought, the time period that has elapsed since the incident, the nature of the harm caused to the victim, and the history of the employee since the incident, or any other evidence or circumstances indicating that the employee will not present a danger if continued employment is allowed. The decision of the licensing department regarding an exemption may be contested through the hearing procedures set forth in chapter 120. (4) Disqualification from employment under subsection (1) may not be removed from, nor may an exemption be granted to, any personnel who is found guilty of, regardless of adjudication, or who has entered a plea of nolo contendere or guilty to, any felony covered by s solely by reason of any pardon, executive clemency, or restoration of civil rights. Compiled & Formatted by Florida Health Care Association, 2006 Criminal History Screening Resource Guide, Page 45

46 SNFs & ALFs: 435, F.S. (5) Exemptions granted by one licensing agency shall be considered by subsequent licensing agencies, but are not binding on the subsequent licensing agency. History.--s. 47, ch ; s. 47, ch ; s. 64, ch ; s. 29, ch ; s. 9, ch Payment for processing of fingerprints and state criminal records checks.--either the employer or the employee is responsible for paying the costs of screening. Payment shall be submitted to the Florida Department of Law Enforcement with the request for screening. History.--s. 47, ch ; s. 209, ch. 99-8; s. 48, ch Confidentiality of personnel background check information.--no criminal or juvenile information obtained under this section may be used for any purpose other than determining whether persons meet the minimum standards for employment or for an owner or director of a covered service provider. The criminal records and juvenile records obtained by the department or by an employer are exempt from s (1). History.--s. 47, ch ; s. 282, ch ; s. 49, ch Sharing of personnel information among employers.--every employer of employees covered by this chapter shall furnish copies of personnel records for employees or former employees to any other employer requesting this information pursuant to this section. Information contained in the records may include, but is not limited to, disciplinary matters and any reason for termination. Any employer releasing such records pursuant to this chapter shall be considered to be acting in good faith and may not be held liable for information contained in such records, absent a showing that the employer maliciously falsified such records. History.--s. 47, ch Penalties.-- (1) It is a misdemeanor of the first degree, punishable as provided in s or s , for any person willfully, knowingly, or intentionally to: (a) Fail, by false statement, misrepresentation, impersonation, or other fraudulent means, to disclose in any application for voluntary or paid employment a material fact used in making a determination as to such person's qualifications for a position of special trust. (b) Use records information for purposes other than screening for employment or release records information to other persons for purposes other than screening for employment. (2) It is a felony of the third degree, punishable as provided in s , s , or s , for any person willfully, knowingly, or intentionally to use juvenile records information for any purposes other than specified in this section or to release such information to other persons for purposes other than specified in this section. Compiled & Formatted by Florida Health Care Association, 2006 Criminal History Screening Resource Guide, Page 46

47 SNFs & ALFs: Attestations & Affidavits Attestations & Affidavits Affidavits - Assisted Living Facilities An affidavit of current compliance with the background screening requirements is necessary for a new hire if the employer does not wish to rescreen someone who has already been screened as a requirement for the new hire s professional license. The employer will also need to maintain a copy of the individual s license. An affidavit form is available in Appendix A (p. 37). Attestations - Nursing Homes A general attestation is required for nursing home employees in two scenarios: 1. An attestation would be necessary if a nursing home employer did not wish to rescreen a new hire who had already been screened by the state. Persons who have been screened and qualified and who have not been unemployed for more than 180 days thereafter shall not be required to be rescreened when they come to a facility for new employment, s (5), F.S. However, the facility must have written verification of qualifying screening results directly from the previous employer, or from the Agency for Health Care Administration s Background Screening website (see select Health Facilities; then Background Screening, then Logon). Additionally, the new hire must sign some form of attestation that they have not been convicted of a disqualifying offense since the completiom of their last background screening, s (5) F.S. The Agency no longer provides a particular form for the nursing home employees, but the Agency s Assisted Living Unit does provide an affidavit form (Appendix A, p. 37) that may be useful for helping a nursing home employer design their own attestation form. 2. Employees hired before October 1, 1998, who had not maintained continuous residency within the state of Florida for the five (5) years immediately preceding the date of request for their Level 1 background screening, would not have to complete a Level 2 screening. However, such employees would also need to attest that they have not been convicted of a disqualifying offense in another state or jurisdiction. Attestation of Residency - Nursing Homes All new nursing home hires must complete an Attestation of Residency in order to document whether or not they have maintained continuous residency within the state of Florida for the 5 years immediately preceding the date of request for background screening, (2) (b), F.S. If a new hire has not maintained continuous residency in Florida for the past 5 years, a Level 2 screening must be initiated. The Agency has provided an Attestation of Residency on their website and a copy may also be found in Appendix A (p. 37). 2006, Florida Health Care Association Criminal History Screening Resource Guide, Page 47

48 2006, Florida Health Care Association Criminal History Screening Resource Guide, Page 48

49 Appendix A Appendix A Agency for Health Care Administration Forms Compiled & Formatted by Florida Health Care Association, 2006 Criminal History Screening Resource Guide, Page 49

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51 Appendix A Level 1 Criminal History Request Any individual required by law to undergo background screening in accordance with Chapter 435, Florida Statutes, that is employed, seeking employment or otherwise associated with a provider currently licensed or seeking licensure through the Agency for Health Care Administration (Agency), may complete this form for the purpose of requesting such screening through the Agency. Health Care Provider (Required Information): Name: AHCA License #: Mailing Address: ( ) City State Zip Phone Number Type of Provider: Home Health Agency Nursing Home Facility Laboratory Homemaker, Companion Sitter Agency Adult Day Care Center Hospital Assisted Living Facility Adult Family Care Home Nurse Registry Health Care Services Pool Home Medical Equipment Hospice Health Care Clinic Other (please specify type): Type of Applicant: Administrator Exemption Application RN/LPN/CNA Financial Officer Employee/Staff Person Relief Person Owner or Operator w/ 5% interest or more Identifying Information: Please print legibly or type information. The Florida Department of Law Enforcement requires specific identifying information upon submission of a criminal history request, including the social security number if available (section 11C-6.003(1), Florida Administrative Code). Disclosure of your social security number is mandatory. The Agency for Health Care Administration shall use such information for purposes of internal identification. Name: Last First Middle Maiden Current Mailing Address: City State Zip Social Security No.: or Individual Taxpayer Identification Number (ITIN) DOB: Race: W B I A U Sex: Male Female W=WHITE B=BLACK I=AMER. INDIAN OR ALASKAN A=ASIAN OR PACIFIC ISLANDER U=UNKNOWN (INDICATE HISPANIC AS BLACK OR WHITE BASED ON SKIN COLOR) AHCA Form July 05 AHCA, 2727 Mahan Drive, MS #40, Tallahassee, FL 32308, (850) Form Available at: ahca.myflorida.com/mchq/long_term_care/background_screening/index.shtml

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53 Proper submission of a fingerprint card Appendix A The following must be filled out in order for a card to be processed: NAM - Print or type the Last Name, First Name, and Middle Name. Signature of Person Fingerprinted The person being printed must sign his or her legal name in this block. The card should be signed prior to taking prints to avoid the possibility of smearing. Aliases List any aliases (ex.: Duke, Dingo, Ace). Female applicants using a married name should enter their maiden name in this block. Date of Birth (DOB) date of birth must be entered as month, day and year. If the birthdate is unknown, enter the age of the applicant or the year of birth. Residence of Person Fingerprinted list the street address, city and state of the fingerprinted person. Social Security Number enter the social security number of the person to be screened. Citizenship enter the country of which the applicant is a citizen. Sex Use M for male and F for female. Race Use the following letters: W - White (includes Mexicans and Latins) B - Black I - American Indian or Alaskan Native A - Asian or Pacific Islander (includes Asian Indians, Eskimos, Filipinos, Indonesians, Koreans, Polynesians & other non-whites) U Unknown HGT (Height) enter height in feet and inches as such 5 11 = 511. Do not use fractions. WGT (Weight) enter weight in pounds such as 180lbs = 180. Place of Birth Enter the state, territorial possession, province or country of birth. Employer and Address list the name and address of the employer/facility requesting the screening.

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55 Appendix A ATTESTATION OF RESIDENCY The following information is provided to identify the individual attesting to the residency requirement for background screening pursuant to s F.S. NAME ADDRESS CITY STATE ZIP SOCIAL SECURITY NUMBER DATE OF BIRTH SEX RACE I,, do hereby attest under penalty of perjury that I have physically resided in the state of Florida for the previous 5 years and do hereby meet the residency requirement set forth as a condition of background screening pursuant to s , F.S. Signature of Affiant Date --OR-- I,, do hereby attest under penalty of perjury that I have not physically resided in the state of Florida for the previous 5 years and therefore, do not meet the residency requirement set forth as a condition of background screening and may be subject to Level II screening requirements. Signature of Affiant Date

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57 Dear Applicant: Appendix A Florida law requires assisted living facility (ALF) owners (if individuals), administrators, and financial officers be screened by the: Federal Bureau of Investigation (FBI), and Florida Department of Law Enforcement (FDLE) These background checks are addressed in Chapter 435, Florida Statutes, as level 2 screenings. Florida law also requires ALF owners or administrators to screen all employees hired on or after October 1, 1998 who provide personal services to residents through: FDLE This background check is addressed in Chapter 435, Florida Statutes, as a level 1 screening. Level 2 Screening Level 2 Screening must be completed on: Owner(s) of an ALF, if the owner(s) is an individual(s) (as opposed to a corporation, partnership, etc.); and ALF administrators; and a facility s financial officer Screening Compliance: The applicant must go to the local sheriff s office, police station, or nearest available FDLE fingerprinting location to obtain a set of fingerprints on each individual owner, administrator, and financial officer. your request for fingerprint cards to Use the attached instructions to correctly complete the card(s). Cards not completed correctly will be rejected by the FBI, redone and resubmitted, and can delay the processing of your application. Each completed fingerprint card must be submitted to the Agency for Health Care Administration, Assisted Living Unit, with the ALF application package. The Agency will submit the fingerprint cards to the appropriate screening authority. Fingerprint cards submitted for change of administrator, financial officer, and/or individual owner must be submitted within 10 days of employment. Screening Compliance: If an owner, administrator, or financial officer has already been screened by the Agency and are currently in compliance with background screening, they may simply complete the Assisted Living Facility (ALF) Background Screening Affidavit of Compliance (Attachment B). 5/4/04 1

58 Appendix A Level 2 Background Screening Fees: In addition to the ALF application fee, you must include the correct screening fee in a check made payable to the State of Florida. One check can be submitted with your ALF application for both the level 2 screening and the application license fee. The level 2 background screening fee is $47 for each person screened. Level 1 Screening Employee screening results must be maintained in the facility s employee file. Do not submit employee screening results with your ALF application package. Level 1 Screening must be completed on: All employees hired on or after October 1, 1998, who provide personal services to residents. The FDLE Criminal History Screening form must be completed and submitted for each employee requiring a level 1 screening. You may obtain the FDLE Criminal History Screening form on-line at ahca.myflorida.com by clicking on Background Screening. When submitting the FDLE Criminal History Screening form to the Agency, you must include the correct screening fee in a separate check made payable to the State of Florida. The FDLE background screening fee is $23. Please submit Level 1 screening requests to: The Agency for Health Care Administration Background Screening Unit 2727 Mahan Drive Tallahassee, Florida Screening Compliance: If an employee has already been screened and is currently in compliance with background screening, they may simply complete the Assisted Living Facility (ALF) Background Screening Affidavit of Compliance (Attachment B). The affidavit must be retained in the employee s file. License Renewal Assisted Living Facility (ALF) License Renewal Application Background Screening Affidavit of Compliance (Attachment C) must be completed and submitted with each ALF license renewal application confirming that all required employees have completed the level 1 or level 2 background screening requirements. 5/4/04 2

59 INSTRUCTIONS FOR BACKGROUND SCREENING Appendix A All forms must be thoroughly and accurately completed before the background screening process can proceed. Incomplete forms will be returned for completion which may cause a delay in the licensing process. Information and instructions provided below are to assist you in understanding what the forms are for and how to complete them. Please read this information carefully before completing the forms. I. FDLE Criminal History Screening form (Required for level 1): Complete each item on the form. You should make additional copies of the form as necessary. The fee for the FDLE Criminal History background screening is $23 per applicant. Level 1 background screening only requires completion of FDLE screening. The form and fee should be submitted to the address listed under level 1 screening in the cover letter. II. Applicant Fingerprint Card (FD-258) (Required for level 2): The fingerprint card will be used to obtain both the Florida Department of Law Enforcement (FDLE) and Federal Bureau of Investigation (FBI) checks. A separate fingerprint card (FD-258) must be completed by each owner, administrator, and financial officer. The information should be typed or printed clearly so it can be read. The fee for the FDLE and FBI screenings is $47 per applicant. If a fingerprint card is rejected the applicant must be fingerprinted again and the card resubmitted to FDLE. Several items that will cause a rejection of a fingerprint card include: Use of a highlighter in the entry blocks Poor penmanship Text not within boundary of the entry block Labels applied to Leave Blank areas Submission on nonstandard fingerprint card Use of pencil or ink other than black Descriptive data not complete (e.g., incomplete name, date of birth, no signature) There is no additional fee for the second set of fingerprints. A fee will be charged for the third or subsequent sets. The following instructions should assist you in completing the fingerprint card: 1. NAM Print or type the Last Name, First Name, Middle Name, Suffix (Jr., II etc., Example: Doe, John Wayne) A comma should separate the Last Name and first Name. If the person has no middle name or initial, indicate this as NMN. If the person has an initial only for their first and/or middle names indicate this as IO, place the "I" under first name and "O" under the middle name. If both letters are the first name place IO under first name and NMN in the space for middle name. 5/4/04 1

60 2. Signature of Person Fingerprinted The person being printed must sign his or her legal name in this block. The card should be signed prior to taking the prints to avoid the possibility of smearing the prints on the card. 3. Aliases (AKA) List the Last Name, First Name, Middle Name, and Suffix as indicated in item number 1. If the alias is one or two-words or a nickname such as (Example: Duke, Little Man, Ace, etc.) separate each by a comma and a space. Women applicants using a married name in the "NAM" block should enter the maiden name in the "Aliases" block. 4. Date of Birth (DOB) The applicant must enter the complete date of birth, the month, day, and year. If the applicant s date of birth is unknown enter the age of the applicant. When the month and day are unknown, enter two zeros (00) in the month and two zeros (00) in the day and enter the year of birth. 5. Residence of Person Fingerprinted Give the present street address, city and state of the person required to be fingerprinted. 6. Citizenship Enter in this space the country of which the applicant is a citizen. 7. Sex Use the following letters to indicate: Appendix A M F Male Female 8. Race Use the following letters to indicate: W B I A U White (includes, Mexicans and Latins) Black American Indian or Alaskan Native Asian or Pacific Islander ( includes, Asian Indians, Eskimos, Filipinos, Indonesians, Koreans, Polynesians and other non-whites) Unknown 9. HGT (Height) Enter height in feet and inches. Example: Height Enter on Card As 5'11" 511 6'0" 600 (Do not use fractions of an inch.) 5/4/04 2

61 10. WGT (Weight) Enter weight in pounds. Example: Weight Enter on Card As 94lbs lbs. 186 (Do not use a fraction of a pound.) Appendix A 11. Eyes and Hair Color of eyes and hair are to be entered on fingerprint card as follows: Color Enter on Card As Bald* BAL (Hair only) Black BLK Blond or Strawberry BLN Blue BLU Brown BRO Gray or Partially Gray GRY Green GRN (Eye only) Hazel HZL (Eye only) Maroon MAR (Eye only) Pink PNK (Eye only) Red or Auburn RED (Hair only Sandy SDY (Hair only) White WHI (Hair only) Unknown XXX (Eyes and Hair *Bald (BAL) is to be used when the applicant has lost most of the hair on the top of their head. 12. Place of Birth Enter the state, territorial possession, province or country of birth. 13. Signature of Official taking Fingerprints and Date The official taking the fingerprints (local sheriff's office, police station or FDLE fingerprinting location) should sign his or her name in this block and the date the card. 14. Employer and Address List your current employer or the facility to be employed by and their complete address in this block. 15. FBI No. (FBI) Leave this space blank. 16. Social Security Number (SOC) Enter the social security number of the person to be screened in this block 5/4/04 3

62 17. Reason Fingerprinted Do Not Complete Appendix A 18. Miscellaneous No. (MNU)/Armed Forces No. (MNU) Record the Miscellaneous number in this block as follows: AF-Air Force Serial Number AR-Alien Registration Number AS-Army Serial Number, National Guard Serial Number or Air National guard Number (regardless of state) CG-U.S. Coast Guard Serial Number MD-Mariner's Document or Identification Number MC-Marine Corps Serial Number MP-Royal Canadian Mounted Police Identification Number (FPS Number) NS-Navy Serial Number PP-Passport Number PS-Port Security Card Number SS-Selective Service Number VA-Veteran's Administration Claim Number *Omit any alpha character(s) prefixed to Army, National Guard, and Air National Guard serial numbers. Enter the serial number only. For Example: Serial Number Army serial number RA National Guard serial number NG Should Be Written As AS AS The appropriate two-letter identifying code from the list above must precede the number and is separated from the miscellaneous number by a hyphen(-). Any alpha character(s) that are part of the miscellaneous number area to be included. III. Volunteer Board Member Statement (Attachment A): Board members of a not for profit corporation or organization are not required to undergo background screening if the individual serves in a voluntary capacity, does not take part in the day to day operational decisions, receives no compensation or financial benefit, has no financial interest in the corporation or organization, and has no family members with a financial interest in the corporation or organization. The board member must complete, sign and date the Volunteer Board Member Statement affirming the board member's relationship to the facility if the above criteria is met. IV. ALF Background Screening Affidavit of Compliance (Attachment B): This form is completed when documenting an individual s level 1 or level 2 screening compliance in conjunction with their current professional or facility license. Refer to level 1 and level 2 screening compliance in this package. Please ensure the document is notarized. 5/4/04 4

63 Appendix A V. ALF License Renewal Application Background Screening Affidavit of Compliance (Attachment C): At each ALF license renewal, the facility owner or administrator must document current compliance with level 1 and level 2 background screening requirements pursuant to section , Florida Statutes. This document is completed by the facility s owner or administrator and submitted with the ALF license renewal application. VI. VII. Refer to section , Florida Statutes, Level 2 Screening Standards Refer to section , Florida Statutes, Level 1 Screening Standards 5/4/04 5

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65 Appendix A Attachment A VOLUNTEER BOARD MEMBER STATEMENT A member of the Board of Directors is not required to undergo background screening if the individual of a not-for-profit corporation or organization serves solely in a voluntary capacity, and submits a statement affirming that the directors relationship to the corporation or organization meets the terms on this form. Name of Agency or Facility: Name of member of Board of Directors: I affirm that I: -Serve in a voluntary capacity -Do not take part in day to day operational decisions -Receive no compensation or financial benefit -Have no financial interest in the corporation/organization -Have no family members with a financial interest in the corporation/organization Signature: Date:

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67 Appendix A Attachment B ASSISTED LIVING FACILITY (ALF) BACKGROUND SCREENING AFFIDAVIT OF COMPLIANCE SECTION , FLORIDA STATUTES Under penalty of perjury, I, do hereby (Print Name) certify that I currently comply with the background screening requirements of Chapter 435, Florida Statutes, for (please check the appropriate box): [ ] Level 1 Screening [ ] Level 2 Screening (Signature) (Date) STATE OF FLORIDA COUNTY OF BEFORE ME, the undersigned authority, personally appeared, and after first being duly sworn in, did depose and say that he/she did execute the foregoing Assisted Living Facility Background Screening Affidavit of Compliance and that the same is true, accurate and correct to the best of his/her knowledge, information and belief. SWORN TO AND SUBSCRIBED before me this day of, 200. NOTARY PUBLIC My commission expires: Personally known or Produced identification Type of identification produced

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69 Appendix A Attachment C ASSISTED LIVING FACILITY (ALF) LICENSE RENEWAL APPLICATION BACKGROUND SCREENING AFFIDAVIT OF COMPLIANCE SECTION , FLORIDA STATUTES Under penalty of perjury, I, as owner (Owner or Administrator Name) and/or administrator of do hereby certify (Facility Name) that all persons for whom background screening is required pursuant to section , Florida Statutes, are in compliance, and have no disqualifying offenses. (Signature) (Date) STATE OF FLORIDA COUNTY OF BEFORE ME, the undersigned authority, personally appeared, and after first being duly sworn in, did depose and say that he/she did execute the foregoing Assisted Living Facility Background Screening Affidavit of Compliance and that the same is true, accurate and correct to the best of his/her knowledge, information and belief. SWORN TO AND SUBSCRIBED before me this day of, 200. NOTARY PUBLIC My commission expires: Personally known or Produced identification Type of identification produced

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71 STATE OF FLORIDA Appendix A JEB BUSH, GOVERNOR AGENCY FOR HEALTH CARE ADMINIST RAT ION DR. RHONDA MEDOWS, SECRETARY Dear Exemption Applicant: The attached "Request for Exemption" application is being sent to you in response to your request for an exemption hearing. At this time the Agency for Health Care Administration has limited authority to provide exemption hearings. This state agency handles exemption requests only for individuals that have been terminated or denied employment in a non-licensed, non-certified occupation within health care facilities licensed under Chapter 400, Florida Statutes. In order to determine if this office has the necessary jurisdiction to review your request, we require that you complete this application. If this office does not have jurisdiction to review your request, we will forward it to the appropriate department. The "Request for Exemption" application must be completed and returned to the Agency for Health Care Administration along with the information listed on the attached checklist. Failure to supply all requested information will delay the review of your request. Failure to respond will result in your continued disqualification from employment and delay the review of your request Pursuant to (3), Florida Statutes, the employee must demonstrate by clear and convincing evidence that the employee should not be disqualified from employment. Employees seeking an exemption have the burden of setting forth sufficient evidence of rehabilitation, including, but not limited to, the circumstances surrounding the criminal incident for which an exemption is sought, the time period that has elapsed since the incident, the nature of the harm caused to the victim, and the history of the employee since the incident, or any other evidence or circumstances indicating that the employee will not present a danger if continued employment is allowed If you have any questions or need additional information, please contact the Background Screening Unit at 850/ Mahan Drive Tallahassee, Florida 32308

72 Agency for Health Care Administration s Appendix A Exemption Hearing Request Checklist IT IS IMPORTANT THAT YOU PROVIDE ALL OF THE INFORMATION BELOW AND CHECK OFF EACH ITEM AS YOU OBTAIN IT... Complete and return the Request for Exemption Application. Please print legibly and complete all information. Your application must include the following items. Criminal history screening report conducted by the Florida Department of Law Enforcement (FDLE). Your current or last place of employment may be able to provide you with this report. If not, please complete the enclosed form; attach the $23 fee and the Agency for Health Care Administration will obtain this report for you. You must identify the medical facility that you were employed or applying for employment with on this form. A copy of the court s disposition for each criminal offense is required. Court documents may be obtained from the Clerk of the Court in the county in which the offense occurred. The disposition is the court document that states what you were actually sentenced for and the conditions of your sentence. A copy of the arrest report for each criminal offense is required. You may obtain a copy of this report from the arresting agency (the Police or Sheriff agency that arrested you). The arrest report is the report the arresting officer wrote that states what events resulted in your arrest. If you were given probation or parole, you will need a letter from the probation department with the following information is required: The date you started probation or parole; the date you are scheduled to terminate probation or parole; are you eligible for early termination of probation or parole; have you violated probation or parole; and if you have violated your probation or parole, how you violated it. Provide 3-5 letters of recommendation or letters of reference that will attest to your good moral character. These may be from anyone that is familiar with your past and present character. At least one of the letters must be from an employer. Individuals providing a letter of recommendation should include their name, address and telephone number for verification or possible interview. Provide us with proof of your rehabilitation. This proof of rehabilitation may take the form of letters from employer s, records of successful participation in a rehabilitation program, further education or training, special awards or recognition, or information which indicates that you are not a danger to the safety or well being of others. If you did not receive court ordered rehabilitation or did not seek any voluntarily, please indicate so. Please complete the employment history record. Identify the name and address of employer, supervisor s name and telephone number, and your job responsibilities for the last 5 years. Please explain any breaks in employment that exceeded 3 months. Attach additional sheets if necessary. Please complete the residency affidavit identifying whether or not you have been a continuous resident of the State of Florida for the past 5 years. FAILURE TO PROVIDE ALL RELEVANT DOCUMENTATION WILL RESULT IN THE DELAY OF REVIEW OF THE EXEMPTION REQUEST AND CONTINUED DISQUALIFICATION FROM EMPLOYMENT

73 STATE OF FLORIDA Appendix A JEB BUSH, GOVERNOR AGENCY FOR HEALTH CARE ADMINIST RAT ION DR. RHONDA MEDOWS, SECRETARY Application for REQUEST FOR EXEMPTION Please print legibly or type. All questions must be answered. 1. Name: Last First Middle Maiden Please List all Prior Names, AKAs, or Aliases: Last First Middle Last First Middle Last First Middle 2. Mailing Address: 3. Social Security Number: Date of Birth: / / Sex Race 5. Telephone Number: Home:( ) - Work:( ) - 6. Professional License or Certificate # Type: (i.e., C.N.A., LPN, RN, Administrator or other medically related licensure) Date Issued: Date Expired: 7. Have you ever worked for a health care facility or agency or applied or work at a health care facility or agency? [ ] Yes [ ] No 8. Last or Most Recent Employer Medical Facility s Name Medical Facility s Address City ( ) - Area Code Phone Number Supervisor 2727 Mahan Drive Tallahassee, Florida 32308

74 Appendix A Type of facility: [ ] Nursing Home [ ] Home Health Agency [ ] Nurse Registry [ ] Homemaker-Companion-Sitter Agency [ ] Assisted Living Facility [ ] Health Care Services Pool [ ] Other: (Please specify) If you were employed at the above listed facility, what were your dates of employment? Employment Dates: From To Your position/title while employed at the above facility: If you only applied for work at the listed medical facility and you were not hired, when did you apply? Application Date: Position Applied For: 8. Have you lived in Florida continuously for the last 5 years? [ ] Yes [ ] No If you checked NO, list the dates and places you have lived during the last 10 years. You may be required to submit to a Level 2 criminal history screening. If you checked YES, list the dates and the Florida Counties you have lived in during the last 10 years. In addition to completing this application, you will need to provide a copy of the Florida Department of Law Enforcement (FDLE) criminal history report and /or a Federal Bureau of Investigation criminal history report. You will also need to provide the arrest report and court disposition for any disqualifying violations appearing on the FDLE criminal history report. A checklist of items needed to perform the initial review is attached.

75 Appendix A Request For Exemption Hearing I am formally requesting that the Agency for Health Care in accordance with the provisions of Chapter 435 and Chapter 400, Florida Statutes, provide me with an exemption hearing. I understand that I must provide clear and convincing evidence to support a reasonable belief that I am of good moral character and that I pose no danger to the health or safety of patients or their property. I also understand that the decision of the Agency for Health Care regarding this exemption may be contested through a hearing under the provisions of Chapter 120, F.S. Signature / / date

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77 Appendix A STATE OF FLORIDA JEB BUSH, GOVERNOR AGENCY FOR HEALTH CARE ADMINIST RAT ION DR. RHONDA MEDOWS, SECRETARY Addendum to Application for Request for Exemption Name Social Security Number Street Address Apt # City State Zip At this time the Agency for Health Care Administration has limited authority to provide exemption hearings. In order to determine if this office has the necessary jurisdiction to review your request, please provide the following information. 1. Have you ever worked for a health care facility? [ ] Yes [ ] No Your Position or Title at the Facility Your Supervisor s Name Date Hired Date Terminated ( ) -- Name of Health Care Facility Facility Address City State Facility Phone # 2. Have you ever been terminated or denied employment in a health care facility due to a criminal background screening? [ ] Yes [ ] No Type of facility: [ ] Nursing Home [ ] Home Health Agency [ ] Nurse Registry [ ] Homemaker-Companion-Sitter Agency [ ] Assisted Living Facility [ ] Health Care Services Pool [ ] Other: (Please specify) 3. If you were denied employment in a health care facility, please provide the following information. ( ) - Name of Medical Facility Facility Address City State Facility Telephone # Position you applied for: Date of Application:

78 Appendix A 4. Do you hold certification or professional licensure in a health-related occupation? [ ] Yes [ ] No License Type (i.e., C.N.A., LPN, RN, MD etc) License # Date Issued 5. Are you enrolled in or have you recently completed a training program to obtain certification or professional licensure in a health-related occupation? [ ] Yes [ ] No ( ) - Name of School or Facility Facility Address City State Facility Telephone # Type of Training Program:. i.e., Home Health Aide, Nursing Assistant, LPN, RN, Etc. Training Scheduled to Begin: Date Graduation Date: Date 6. Have you registered for examinations required to obtain certification or professional licensure in a health-related occupation? [ ] Yes [ ] No Date you applied: Date of Tests:

79 Employment History Record Identify the name and address of employer, supervisor s name and telephone number, and your job responsibilities for the last 5 years. Please explain any breaks in employment that exceeded 3 months. Attach additional sheets if necessary. Most Recent Employer Facility Name Facility Address City State ( ) - Supervisor Area Code Telephone Number Appendix A Dates Employed: From To Your Title or Occupation: Responsibilities: Next Employer Facility Name Facility Address City State ( ) - Supervisor Area Code Telephone Number Dates Employed: From To Your Title or Occupation: Responsibilities: Next Employer Facility Name Facility Address City State ( ) - Supervisor Area Code Telephone Number Dates Employed: From To Your Title or Occupation: Responsibilities:

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