United States Government Accountability Office

GAO

Report to Congressional Requesters

March 2006

LONG-TERM CARE
FACILITIES
Information on
Residents Who Are
Registered Sex
Offenders or Are
Paroled for Other
Crimes

GAO-06-326

March 2006

LONG-TERM CARE FACILITIES
Accountability Integrity Reliability

Highlights
Highlights of GAO-06-326, a report to
congressional requesters

Information on Residents Who Are
Registered Sex Offenders or Are Paroled
for Other Crimes

Why GAO Did This Study

What GAO Found

Approximately 23,000 nursing
homes and intermediate care
facilities for people with mental
retardation (ICF-MR) receive
federal Medicare and Medicaid
funding. Media reports have cited
examples of convicted sex
offenders residing in long-term care
facilities and, in some cases,
allegedly abusing other residents.
Given concerns about resident
safety, GAO was asked to assess
(1) the prevalence of sex offenders
and others on parole for non-sex
offenses living in long-term care
facilities and the extent of any
abuse they may have caused,
(2) the legal requirements for
notifying facilities and others when
offenders are residents, and (3) the
extent to which facilities have
different supervision and
separation requirements for
offenders. GAO analyzed a national
database for sex offenders and
analyzed state databases in a
sample of eight states for sex
offenders and parolees.

By analyzing the FBI’s NSOR, which is a compilation of sex offender
registries submitted by all states, GAO identified about 700 registered sex
offenders living in nursing homes or ICFs-MR during 2005. Most identified
sex offenders were male, under age 65, and living in nursing homes, and
represented 0.05 percent of the 1.5 million residents of nursing homes and
ICFs-MR. About 3 percent of nursing homes and 0.7 percent of ICFs-MR
housed at least 1 identified sex offender during 2005. However, these
estimates are understated due to data limitations. For example, because of a
lack of resources or an inability to comply with certain FBI reporting
requirements, states have had varying degrees of difficulty submitting their
full state registries to the NSOR. While the FBI does not track NSOR
submission rates, GAO compared sex offender registry data from seven of
the eight states reviewed to NSOR data and found that the NSOR data
included about 57 percent of sex offenders registered in these states, with
submission rates ranging from 1 percent to 83 percent. Because a national
data source on parolees that included address information was not available,
GAO also obtained parolee databases from the eight reviewed states and
identified 204 offenders on parole for non-sex offenses living in long-term
care facilities. GAO could not determine the overall risk that registered sex
offenders and parolees pose to other residents in long-term care facilities
because offender status is not tracked with abuse reporting. Facility
administrators expressed greater concern over the risk posed by cognitively
impaired or mentally ill residents.

What GAO Recommends
GAO recommends that the Federal
Bureau of Investigation (FBI)
assess the completeness of the
National Sex Offender Registry
(NSOR), including state submission
rates, and evaluate options to
increase its comprehensiveness.
The Department of Justice (DOJ)
commented that these
recommendations are unnecessary
because of efforts already in place.
GAO recognizes these efforts but
maintains that the
recommendations remain valid.
www.gao.gov/cgi-bin/getrpt?GAO-06-326.
To view the full product, including the scope
and methodology, click on the link above.
For more information, contact Kathryn G.
Allen at (202) 512-7118 or allenk@gao.gov.

Federal law requires state law enforcement agencies to release relevant
information about registered sex offenders when necessary to protect the
public, but GAO did not identify a similar federal law for the parolee
population. States have broad discretion in how to implement the
requirement for registered sex offender notification. Therefore, the extent to
which states’ community notification laws apply to all registered sex
offenders or explicitly include long-term care facilities varies. For example,
four of the eight states GAO reviewed—California, Illinois, Minnesota, and
Oklahoma—had laws that specified long-term care facilities as entities to be
notified for at least some registered sex offenders who entered them.
However, some facility administrators GAO contacted were uncertain as to
whether they could share information with staff and others about residents
who were known offenders in light of the Privacy Rule issued under the
Health Insurance Portability and Accountability Act of 1996 (HIPAA).
Long-term care facilities GAO contacted do not routinely impose different
supervision or separation requirements on residents who are offenders
based solely on their prior convictions. Instead, these facilities base such
decisions on the demonstrated behaviors of residents. Even if long-term care
facilities wanted to impose different supervision and separation
requirements on offenders, their ability to do so is limited because they are
not always aware of residents’ prior convictions.
United States Government Accountability Office

Contents

Letter

1
Results in Brief
Background
Identification of Offenders Living in Long-Term Care Facilities and
Assessment of the Risk They Pose Limited by Data
Shortcomings
States Required to Notify Community about Registered Sex
Offenders, but Extent of Notification Varies
Supervision and Separation of Long-Term Care Facility Residents
Largely Based on Behavior, Not Prior Convictions
Conclusions
Recommendations for Executive Action
Agency and State Comments and Our Evaluation

25
26
27
27

Appendix I

Scope and Methodology

31

Appendix II

Registered Sex Offenders Living in Nursing Homes
and ICFs-MR

34

Appendix III

Comments from the Department of Justice

36

Appendix IV

Comments from the Department of Health and
Human Services

41

GAO Contact and Staff Acknowledgments

43

Appendix V

3
6

11
18

Tables
Table 1: Estimated Submission Rates to NSOR, by States Reviewed,
2005
Table 2: Parolees Identified as Living in Long-term Care Facilities
in States Reviewed, 2005
Table 3: Validity of Offender Address Data by Data Source

Page i

14
16
32

GAO-06-326 Offenders in Long-Term Care Facilities

Table 4: Registered Sex Offenders Identified as Living in Nursing
Homes and ICFs-MR, by State, 2005

34

Abbreviations
CMS
FBI
HHS
HHS-OCR
HIPAA
ICF-MR
NNHS
NORS
NSOR
OSCAR

Centers for Medicare & Medicaid Services
Federal Bureau of Investigation
Department of Health and Human Services
Department of Health and Human Services Office for
Civil Rights
Health Insurance Portability and Accountability Act of 1996
intermediate care facility for people with mental
retardation
National Nursing Homes Survey
National Ombudsman Reporting System
National Sex Offender Registry
Online Survey, Certification and Reporting system

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GAO-06-326 Offenders in Long-Term Care Facilities

United States Government Accountability Office
Washington, DC 20548

March 31, 2006
The Honorable Charles E. Grassley
Chairman
Committee on Finance
United States Senate
The Honorable Henry A. Waxman
Ranking Minority Member
Committee on Government Reform
House of Representatives
The Honorable Betty McCollum
House of Representatives
Approximately 16,000 nursing homes and 6,600 intermediate care facilities
for people with mental retardation (ICF-MR) participate in Medicare,
Medicaid, or both, and receive federal funding to care for their residents.
Federal Medicare and Medicaid funds accounted for a significant portion
of total funding to these nursing homes and ICFs-MR—approximately
$43 billion of a total of over $110 billion in 2003, with about $37 billion
spent in nursing homes and $6 billion in ICFs-MR.1 Because of the large
amount of federal funding these long-term care facilities receive, there is a
strong interest in ensuring the safety and well-being of their vulnerable
residents.
Concerns about the quality of care provided to residents of long-term care
facilities are long-standing. Since 1998, a number of congressional hearings
have focused on ensuring the quality of care and protecting the safety and
rights of nursing home residents. Recently, news outlets and others have
reported accounts of convicted sex offenders residing in nursing homes
and, in some cases, allegedly abusing other residents. Often, nursing home
staff and residents’ families were not informed when convicted sex
offenders were residents. The admission to long-term care facilities of
individuals on parole for non-sex offenses2 raises similar concerns about

1

For this report, we refer to nursing homes and ICFs-MR together as long-term care
facilities.
2

For this report, we refer to registered sex offenders and other offenders on parole for nonsex offenses as offenders.

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GAO-06-326 Offenders in Long-Term Care Facilities

the potential for abuse. Because of your concerns about resident safety,
we are providing information on (1) the prevalence of offenders living in
nursing homes and ICFs-MR and the extent of abuse caused by such
offenders in these long-term care facilities; (2) whether federal and state
laws provide for notification of staff, residents’ families, and residents
when such offenders live in these long-term care facilities; and (3) the
extent to which these offenders are subject to supervision or separation
requirements that differ from those for other residents.
To determine the prevalence of registered sex offenders residing in these
long-term care facilities nationwide, we obtained the Federal Bureau of
Investigation’s (FBI) National Sex Offender Registry (NSOR), a national
database utilized by law enforcement that compiles information about
registered sex offenders submitted by all 50 states and the District of
Columbia, as of January 3, 2005. We used the NSOR to identify the home
addresses of registered sex offenders and matched them with the
addresses of nursing homes and ICFs-MR included in the Centers for
Medicare & Medicaid Services’ (CMS) Online Survey, Certification and
Reporting system (OSCAR) database, which compiles the results of state
nursing home surveys. To assess the completeness of the NSOR data, we
requested complete sex offender registries from eight states—California,
Florida, Illinois, Minnesota, Ohio, Oklahoma, New Jersey, and Utah—
which we selected on the basis of a number of criteria, including variation
in geographic location and in the number of registered sex offenders
identified as living in these states’ long-term care facilities based on our
preliminary analyses. Seven of the eight states provided their sex offender
registries, and we compared the total number of sex offenders on each of
the state registries with the total number for each state identified through
the NSOR.3 In the course of comparing the results of the NSOR and state
sex offender registries analyses, we became aware that the NSOR did not
include the full sex offender registries of these states. Since no national
database exists for parolees that includes address information, we also
obtained parolee databases from each of these eight states. We matched
parolee addresses with addresses for nursing homes and ICFs-MR from
OSCAR for the eight states; however, because of the limited number of
states reviewed, we could not generalize these results as representative of
all states. We obtained state registries and parolee databases from January
through September 2005.

3

California state officials did not provide us with the state’s sex offender registry in view of
their concerns with state privacy laws.

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GAO-06-326 Offenders in Long-Term Care Facilities

To gather information about the administration and content of state sex
offender registries, including their submission of records to the NSOR, we
interviewed state registry administrators from all eight states and
submitted a questionnaire via e-mail to all other states, receiving
responses from an additional 20 states. To assess the reliability of FBI and
state data, we discussed data quality control procedures, reviewed
relevant documentation with officials, and conducted electronic data
testing. We determined that while the NSOR does not include all registered
or convicted sex offenders, its records are regularly audited and are
sufficiently reliable for the purposes of this report. The lack of
comprehensiveness of the data was evaluated and taken into account in
our discussion of the results. We determined that the OSCAR database and
state parolee databases were sufficiently reliable for our purposes.
To obtain information about resident abuse perpetrated by sex offenders
and parolees residing in long-term care facilities, we reviewed existing
research and GAO reports and interviewed officials of industry
associations and long-term care ombudsmen. Within the eight states we
reviewed, we also interviewed state officials responsible for nursing home
and ICF-MR licensing, as well as administrators at 29 of 32 judgmentally
selected long-term care facilities—-4 from each state. We also relied on
these interviews, interviews with federal officials, and a review of federal
and state laws to determine whether federal and state laws provide for
notification of facility staff, residents, and residents’ families when
offenders live in these long-term care facilities and the extent to which
offenders are supervised and separated from other residents. In the eight
states we reviewed, we also examined states’ public sex offender Web site
registries to determine what information on registered sex offenders is
available to the public. We conducted our work from September 2004
through February 2006 in accordance with generally accepted government
auditing standards. (For additional information on our scope and
methodology, see app. I.)

Results in Brief

Using the FBI’s NSOR, we identified about 700 registered sex offenders
living in long-term care facilities during 2005, representing 0.05 percent of
the 1.5 million residents of these facilities. About 3 percent of nursing
homes and 0.7 percent of ICFs-MR housed a registered sex offender during
2005. Almost 90 percent of registered sex offenders we identified lived in
nursing homes and were considerably younger than the general nursing
home population, with 57 percent under age 65 compared to about
10 percent of all nursing home residents. However, our count is
understated because of limitations in data availability. For example, while

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the NSOR is a national database that compiles information about
registered sex offenders submitted by all 50 states and the District of
Columbia, it does not include convicted sex offenders who are not on state
registries, including those who were convicted or released from prison
before registration requirements went into effect and those who are
required by law to register but do not comply. While noncompliance is
difficult to track, four of the eight states we reviewed estimated
noncompliance rates that ranged from 4.5 percent to 25 percent of all sex
offenders required to register. In addition, because of a lack of resources
or an inability to comply with certain FBI reporting requirements, states
have had varying degrees of difficulty submitting their full state registries
to the NSOR. While the FBI does not track NSOR submission rates, our
analyses of the registries obtained from seven of the eight states we
reviewed indicated NSOR submission rates averaging about 57 percent,
ranging from 1 percent to 83 percent, while the 20 other states that
responded to our e-mail questionnaire reported NSOR submission rates
ranging from 46 percent to 100 percent. Because there is no national data
source on parolees that includes address information, we obtained parolee
databases from all eight states we reviewed and identified 204 offenders
on parole for non-sex offenses living in long-term care facilities. We could
not estimate the overall risk these registered sex offenders and parolees
pose to other residents in long-term care facilities because data are not
available in the reviewed states on abuse perpetrated specifically by
residents who have prior convictions. Facility administrators we
interviewed more frequently expressed concern over the potential for
abuse by residents with cognitive impairments or mental illness than those
with prior convictions.
Federal law requires state law enforcement agencies to release relevant
information about registered sex offenders when necessary to protect the
public, but we did not identify a similar federal law for the parolee
population. States have broad discretion on how to implement this
requirement for registered sex offenders and often do so through a
process known as community notification. Consequently, the extent to
which states’ community notification laws apply to all registered sex
offenders or explicitly include long-term care facilities varies, and this
variation was evident in the eight states we reviewed. For example, while
two states we reviewed apply uniform community notification
requirements to all registered sex offenders, the six remaining states vary
these notification requirements depending on the crime committed by the
registered sex offender or risk to re-offend. Similarly, only half of the
states we reviewed specify that long-term care facilities be notified when
at least some registered sex offenders are residents. Long-term care

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facilities in the remaining four states, or in states where community
notification of these facilities is not required for all registered sex
offenders, may not be aware of residents who are offenders or must rely
on other methods, such as publicly available state Web site registries, to
identify such individuals. While we identified no federal law that requires
community notification for parolees when they enter long-term care
facilities, three of the eight states we reviewed require community
notification for all or a subset of parolees. When long-term care facility
residents are known offenders, opinions differ among state and long-term
care officials we interviewed as to whether sharing information with other
residents and staff about such offenders’ prior convictions violates the
Privacy Rule issued under the Health Insurance Portability and
Accountability Act of 1996 (HIPAA). For example, while some state agency
officials indicated that the HIPAA Privacy Rule only applied to individuals’
health information and not their prior convictions, some long-term care
facility officials thought the HIPAA Privacy Rule prohibited the sharing of
any such information in most cases. Despite concerns that they may
violate the HIPAA Privacy Rule by disclosing information about the prior
convictions of certain residents, some long-term care facility officials said
that they would still notify staff if they became aware of such residents.
We brought the issue of long-term care facilities’ uncertainty regarding the
applicability of the HIPAA Privacy Rule to the attention of the Department
of Health and Human Services (HHS) in the event that this issue gains
more prominence in the future.
Having a prior conviction typically is not sufficient to subject offenders to
supervision or separation requirements that differ from those for other
residents, according to long-term care facility officials we interviewed.
Instead, these facilities generally base supervision and separation
requirements for residents on behavioral issues as they arise. Several longterm care ombudsmen, industry association officials, and facility officials
in the states we reviewed indicated that the residents they are most
concerned about in terms of behavioral problems are those with mental
illness, particularly dementia, for which behaviors are apt to change as the
disease progresses. Officials at only 2 of the 29 long-term care facilities we
contacted said they have a specific policy to separate offenders from other
residents based solely on their prior convictions. Even if long-term care
facility officials wanted to impose different separation and supervision
requirements on offenders, their ability to do so may be limited. Not only
are long-term care facilities not always notified when individuals with
prior convictions enter them, the assessment tools they use to determine
the health care needs of residents typically do not gather information
about prior convictions. In addition, in the event that a facility obtained

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such information, federal and state laws that we reviewed generally do not
provide for specific supervision or separation requirements for facility
residents with prior convictions.
While it was not part of our original objectives to fully evaluate the NSOR,
in the course of our work using the NSOR to identify registered sex
offenders residing in long-term care facilities, we became aware that the
database was incomplete for the seven states we reviewed for this
purpose. Therefore, to ensure that NSOR fulfills its potential as a national
database on registered sex offenders, we recommend that the Attorney
General direct the FBI to assess the completeness of the NSOR, including
state submission rates, and to evaluate options for making it a more
comprehensive national database of registered sex offenders.
In commenting on a draft of this report, the Department of Justice (DOJ)
said it believes the recommendations are unnecessary because the FBI
already performs assessments of the NSOR and explores options for
improvement. While we acknowledge the states’ and FBI’s efforts and
progress to date, we maintain that the intent of the recommendations
remains valid based on our analysis of a sample of states that indicates
some states are not submitting a significant percentage of registered sex
offender records to the NSOR. However, to be more specific regarding the
need to assess the completeness of NSOR, we revised the
recommendations to clarify that the FBI should assess state submission
rates. HHS commented that the report will help to resolve much of the
uncertainty about the application of the HIPAA Privacy Rule to the
disclosure of conviction information by a facility, including clarifying that
information could be used for activities necessary for the safe operation of
the facility or disclosures that are required by state laws.

Background

Nursing homes provide a residential setting and a range of health care
services for individuals who can no longer care for themselves because of
physical or mental limitations. According to the most recent National
Nursing Homes Survey (NNHS), approximately 90 percent of nursing
home residents were age 65 and older and more than two-thirds were
female.4 ICFs-MR are intended to provide a residential setting for
treatment, rehabilitation, and supervision of people who have mental

4

The NNHS is conducted by the Centers for Disease Control and Prevention’s National
Center for Health Statistics.

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retardation or other disabilities, such as seizure disorders or behavior
problems. In 2005, approximately 85 percent of ICF-MR residents were
from 22 to 65; only 7 percent of the total resident population was over
65 years of age. In addition, unlike the nursing home population, the
majority of ICF-MR residents were male.
Approximately 1.5 million individuals lived in Medicaid- and Medicarecertified nursing homes and ICFs-MR in 2005.5 Federal Medicaid and
Medicare funds accounted for approximately 33 percent of total spending
on nursing homes, and the remaining funds were from a combination of
state, local, and private sources in 2003. In the same year, ICFs-MR, which
are funded almost exclusively by Medicaid, received about 58 percent of
their total funding from federal Medicaid funds and the remainder from
state Medicaid dollars. Medicaid, a joint federal-state program that
finances health care coverage for certain categories of low-income
individuals, is the primary payment source for long-term care services for
older people with low incomes and limited assets. Medicaid pays for an
array of long-term care services, including services to assist people with
activities of daily living like eating, dressing, bathing, and using the
bathroom. In contrast, Medicare, which covers a variety of health care
services and items for individuals who are 65 or older, have end-stage
renal disease, or are disabled, does not pay for most long-term care
services. Medicare covers short-term skilled nursing care following a
hospital stay.
To qualify for Medicare or Medicaid funding, these long-term care facilities
must meet certain federal requirements. For example, they are required to
conduct resident assessments that examine areas such as demographic
information, cognition, mood and behavior, psychosocial well-being,
health conditions, and physical functioning. For example, the
Preadmission Screening and Resident Review, which is required by federal
law to determine whether the potential resident needs nursing home care,
includes an assessment of mental capacity. Although federal regulations
require that a resident assessment be conducted prior to admission to
ICFs-MR, there is no standardized assessment tool and admission can be
based on a prior assessment by an outside source. Individuals being
admitted to an ICF-MR generally meet certain criteria, including having an
intellectual functioning level below 70 to 75 and significant limitations in

5

Of the 1.5 million individuals living in these long-term care facilities in 2005, about 100,000
lived in ICFs-MR.

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two or more adaptive skill areas.6 In addition, at a minimum, resident
assessments are conducted annually by nursing home and ICF-MR facility
staff after admission in order to continually address a resident’s needs. For
each resident for whom they receive Medicare or Medicaid funding, these
long-term care facilities are also required to develop a plan of care that
addresses the resident’s medical, social, and other needs, as determined by
the resident assessment. Long-term care facilities are also required to
protect residents’ rights and privacy.7 In addition, the Privacy Rule issued
under HIPAA provides individuals with protections regarding the
confidentiality of their health information and restricts the use and
disclosure of individuals’ health information by health care providers,
including nursing homes and ICFs-MR.8
As a condition of Medicare or Medicaid participation, long-term care
facilities must report incidents of abuse according to state requirements.
CMS defines abuse as the willful infliction of injury, unreasonable
confinement, intimidation, or punishment with resulting physical harm,
pain, or mental anguish. Physical abuse generally includes hitting,
slapping, pushing, and sexual abuse, which is nonconsensual sexual
contact or nonconsensual sexual involvement of any kind. Although the
commission of a sexual offense may result in an incident of abuse, a
uniform definition of sexual offense does not exist, and states define
sexual offenses in their respective criminal codes. Some examples of
sexual offenses include rape, sexual assault, and incest.9 In some states,
related sexual offenses include child pornography and willful indecent
exposure in public.

6

Adaptive skills include communication, self-care, home living, and social skills. The
criteria specify that these conditions need to have been identified at or before the age of 18.

7

CMS sets conditions of participation for facilities that receive federal funding. Part of the
conditions of participation requires that residents have certain rights to personal privacy
and the confidentiality of personal records.

8

45 C.F.R. pts. 160 and 164 (2005).

9

Rape is defined as forced sexual intercourse with a male or female victim. Sexual assault
is defined as a variety of victimizations that involve unwanted sexual contact. Incest is
defined as nonforcible sexual intercourse between persons who are related to each other
to a degree where marriage is prohibited by law. Department of Justice, Bureau of Justice
Statistics, An Analysis of Data on Rape and Sexual Assault: Sex Offenses and Offenders
(Washington, D.C.: February 1997).

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Federal statute established the Jacob Wetterling Crimes Against Children
and Sex Offender Registration Program in 1994.10 The statute required
every state to have a program to register sex offenders by September 1997,
and required the Attorney General to provide states with guidelines for
developing their programs.11 At a minimum, an individual convicted of a
criminal offense against a minor or of a sexually violent offense must
register a current address for 10 years following his/her release from
prison or placement on parole, supervised release, or probation. In
addition, an individual who has one or more prior sexual offense
convictions, has been convicted of an aggravated offense, or is determined
to be a sexually violent predator must register a current address for life.12
States may impose more stringent registration requirements on a broader
class of offenders than required by federal law. The law also mandates that
registered sex offenders verify their addresses at least annually and that
registered offenders classified as sexually violent predators verify their
addresses quarterly. Registered sex offenders must notify local law
enforcement officials within their state of address changes, and those who
move to a different state must comply with registration requirements in
the new state. States that do not comply with the Wetterling Program
requirements are subject to a 10 percent reduction in their Byrne Formula
Grant law enforcement funding.13
The statute establishing the Wetterling Program was amended twice in
1996. The first amendment, Megan’s Law, required states to release
information about registered sex offenders when necessary to protect the

10

For this report, we refer to the Jacob Wetterling Crimes Against Children and Sex
Offender Registration Program as the Wetterling Program.
11

Violent Crime and Law Enforcement Act of 1994, Pub. L. No. 103-322, § 170101, 108 Stat.
1796, 2038 (1994) (codified at 42 U.S.C. § 14071).
12
Criminal offenses against minors include criminal sexual conduct toward a minor and
solicitation of a minor to engage in sexual conduct. “Sexually violent offenses” include
offenses that consist of aggravated sexual abuse or sexual abuse. A “sexually violent
predator” is defined as a person who has been convicted of a sexually violent offense and
who suffers from a mental abnormality or personality disorder that makes the person likely
to engage in predatory sexually violent offenses. 42 U.S.C. § 14071(a)(3).
13
Under the Byrne Formula Grants Program, the DOJ’s Bureau of Justice Assistance
provides federal financial assistance to grantees for the purpose of enforcing state and
local laws that establish offenses similar to offenses established under the Controlled
Substances Act and to improve the functioning of the criminal justice system with
emphasis on violent crime and serious offenders. In fiscal year 2004, all 50 states, the
District of Columbia, and the U.S. territories received financial assistance through Byrne
Grants.

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public, but this law did not specify how states must give notification.14 The
second amendment, the Pam Lychner Sexual Offender Tracking and
Identification Act of 1996,15 mandated the FBI’s creation of a national
database now known as the NSOR.16 According to the FBI, this national
database combines sex offender registries from all of the states to help law
enforcement officials track sex offenders on a national level.
Research on sex offender recidivism suggests that the majority of
individuals previously convicted of sex offenses do not commit additional
sex offenses, with one such study estimating that about 14 percent had a
new sex offense charge or conviction within 5 years of their release from
prison, increasing to 27 percent after 20 years. At the same time, however,
research also indicates that sex offenses are underreported. While it is
difficult to predict re-offense for any individual, certain factors such as
sexual deviancy, antisocial orientation, and an adverse family environment
may contribute to a higher likelihood of a re-offense. Those who have
strong social supports, such as a supportive family and a stable job, may
be less likely to re-offend. In addition, the likelihood of re-offending may
diminish as the sex offender ages.
Federal law requires that registered sex offenders be tracked on a national
and state level; however, parolees are generally monitored and supervised
by each state. Individuals released from prison prior to the completion of
their sentences may be subject to certain conditions and supervised as
parolees for a specified period. Typically the length of time states set for
parole is 1 to 3 years, although certain crimes and sentencing situations
may require more or less time. An individual can be convicted of a range of
crimes from fraud or forgery to murder and be eligible for parole. As of
December 2003, about 775,000 adults were on parole from federal and
state prisons nationwide.

14

Pub. L. No. 104-145, § 2, 110 stat. 1345 (1996) (codified at 42 U.S.C. § 14071).

15

For this report, we refer to the Pam Lychner Sexual Offender Tracking and Identification
Act of 1996 as the Lychner Act.
16
Pub. L. No. 104-236, § 2, 110 Stat. 3093 (1996) (codified at 42 U.S.C. § 14072). The NSOR is
a nationwide system that links the states’ sex offender registration and notification
programs. The system uses a person’s FBI number to connect the registration information
in the National Criminal Information Center with the registrant’s criminal history
information that includes his/her fingerprints. According to the DOJ the NSOR should be
used to enhance a state’s ability to locate offenders in its jurisdiction who may be violating
the law by not registering.

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Identification of
Offenders Living in
Long-Term Care
Facilities and
Assessment of the
Risk They Pose
Limited by Data
Shortcomings

Using the NSOR, we identified 683 registered sex offenders living in longterm care facilities during 2005. However, this understates the national
prevalence of convicted sex offenders residing in long-term care facilities
for a number of reasons. While the NSOR is a national database that
compiles information about registered sex offenders submitted by all
50 states and the District of Columbia, it does not include convicted sex
offenders who are not on state registries, including those sex offenders
who are required by law to register but choose not to comply. It also does
not include all registered sex offenders, as states have had varying degrees
of difficulty submitting their records to the NSOR because of technical
problems, lack of resources, or inability to provide the required FBI
number for certain offenders. Because there is no national data source on
parolees that includes address information, we also obtained parolee
databases from the eight states we reviewed and identified 204 offenders
on parole for non-sex offenses living in long-term care facilities. The risk
of abuse within nursing homes or ICFs-MR by residents with prior
convictions is unclear because states we reviewed do not report the prior
convictions of residents who commit abuse; however, facility
administrators we interviewed more frequently expressed concern about
the potential for abuse by residents with cognitive impairments or mental
illness than by residents with prior convictions.

Most Sex Offenders
Identified Were Male, Were
under Age 65, and Resided
in a Small Number of
Nursing Homes and ICFsMR

Using the NSOR, we identified 683 registered sex offenders living in longterm care facilities during 2005, representing about 0.05 percent of the
total 1.5 million residents of nursing homes and ICFs-MR. (See app. II.) Of
the approximately 16,000 nursing homes and 6,600 ICFs-MR that
participate in Medicare or Medicaid, we identified 3 percent of nursing
homes (470) and 0.7 percent of ICFs-MR (46) as housing at least 1
registered sex offender during 2005.
About 88 percent of the registered sex offenders we identified resided in
nursing homes, while the remaining 12 percent resided in ICFs-MR. Sex
offenders living in nursing homes were younger than the general nursing
home population, while those in ICFs-MR had a similar age distribution as
the general ICF-MR population. About 57 percent of registered sex
offenders we identified as living in nursing homes were under age 65,
compared to about 10 percent of the general nursing home population, and
30 percent were under age 50. Most sex offenders—95 percent—identified
as living in ICFs-MR were under age 65, which is similar to the age
distribution in the general population of these facilities. Similarly, nearly
all—99 percent—registered sex offenders we identified as residing in longterm care facilities were male, which is consistent with the gender of

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registered sex offenders overall. Among registered sex offenders for whom
we had information on the nature of their crimes, the majority of
convictions were for rape and sexual assault of adults and minors.

Number of Offenders
Identified as Living in
Long-term Care Facilities
Is Understated

The number of offenders that we identified as living in long-term care
facilities is understated because of shortcomings in the data. Specifically,
although national in scope, the NSOR does not include certain convicted
sex offenders who are not on state registries because the registries did not
exist at the time they were convicted or released from prison or because
their registration period has expired. The NSOR also does not include all
of the records of sex offenders who are registered in the states’ registries
because some states have had difficulty submitting their records to the
NSOR. NSOR records for convicted sex offenders who chose not to
comply with registration requirements may be incomplete or missing. In
addition, since no national data source for parolees exists that includes
parolee residence information, our data only include numbers of parolees
from the eight states we reviewed.

State Registries Do Not Include
All Convicted Sex Offenders

While some states already had sex offender registries in place, the
Wetterling Program statute mandated that all states implement a registry
by September 1997.17 Most state registries only include those sex offenders
convicted or released from prison after a specified date, generally after
1990.18 Consequently, those convicted or released before the specified date
were not required to register and therefore are not included in our
analysis. This limitation may help explain the age distribution of registered
sex offenders we identified as living in nursing homes. While the majority
of offenders identified in nursing homes were under the age of 65, this
could be a consequence of the limited period that sex offender registries
have existed rather than an accurate reflection of the age distribution of
convicted sex offenders living in nursing homes, since many elderly sex
offenders would not be registered if their convictions predated the
implementation of their state’s registry.

17
States could apply for a 2-year extension of the statutory deadline from the DOJ if they
had made good faith efforts to comply but were unable to meet the original deadline for
implementing a state sex offender registry.
18

Scott Matson and Roxanne Lieb, Sex Offender Registration: A Review of State Laws
(Olympia, Wash.: Washington State Institute for Public Policy, 1996). Department of
Justice, Bureau of Justice Statistics, Summary of State Sex Offender Registries, 2001
(Washington, D.C.: 2002).

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The nearly 700 registered sex offenders we identified through the NSOR
database as living in long-term care facilities also do not include convicted
sex offenders whose registration period expired or whose information was
missing because they did not comply with registration requirements. While
noncompliance is difficult to track, four of the reviewed states provided us
with estimated noncompliance rates ranging from 4.5 percent to
25 percent. Similarly, the advocacy organization, Parents for Megan’s Law,
released estimates in 2003 that 24 percent of sex offenders nationally fail
to comply with registration requirements. Sex offenders may fail to
comply for several reasons, including a lack of understanding about
registration requirements or to avoid the possible negative consequences
experienced by some registered sex offenders, such as the loss of a job,
harassment, social stigmatization, or physical assault.

State Submissions to the NSOR
Do Not Include All Registered
Sex Offenders

We found a range of submission rates by state registries to the NSOR,
which suggests that the NSOR may be missing a portion of sex offenders
who are registered in states. Registry administrators from the 20 states
that responded to our e-mail questionnaire estimated their submission
rates to be from 46 percent to 100 percent of the total number of records
in their state registries. Most reported that at least 80 percent of their
records were submitted, while 2 states reported that they were only able
to submit about half of their records. We also compared the total number
of sex offenders included in the state registries to the number included in
the NSOR for 7 of the 8 states we reviewed. (See table 1.) The NSOR
included about 57 percent of sex offenders registered in these states, with
submission rates ranging from 1 to 83 percent. For example, Utah had
submitted about 1 percent of its registry to the NSOR. While the state
intends to fully submit its registry to the NSOR in the future, it currently
lacks the resources to do so, according to a state official. However, the
FBI considers state participation in the national database to be in
compliance with federal requirements if a state has submitted at least one
record to the NSOR.19 A DOJ official confirmed that all states have been
determined to be in compliance with NSOR submission requirements,
based on FBI notifications regarding each state’s participation in the
NSOR, and was not aware of any state that had been penalized with the
loss of Byrne Formula Grant law enforcement funding solely on the basis
of the extent of state NSOR participation.

19

An FBI official explained that the submission of one record demonstrates that the state
has completed the reprogramming of its database to conform to NSOR standards.

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Table 1: Estimated Submission Rates to NSOR, by States Reviewed, 2005

State

Number of sex
Number of sex
offenders listed on
offenders listed on
state registry NSOR, January 3, 2005

State’s submission
rate to NSOR
(percentage)

Florida

34,810

25,494

73

Illinois

20,690

13,349

65

a

9,769

a

11,382

9,454

83

Minnesota
New Jersey
b

Ohio

16,864

2,409

14

Oklahoma

5,235

4,234

81

Utah

7,409

49

Average

1
57

Sources: GAO analysis of the FBI’s NSOR as of January 3, 2005; state sex offender registries as submitted by states to GAO from
January through August 2005.
a

Minnesota initially submitted to GAO only those offenders residing in Minnesota who could potentially
be identified as nursing home residents, which was the purpose of our request for the data, and
therefore excluded offenders who were listed as out of state, deported, homeless, civilly committed, in
the witness protection program, or address unknown. Consequently, we could not determine an
overall submission rate. As of February 2006, Minnesota reported that 73 percent of its active
registrants had been accepted by the NSOR.

b

As of January 3, 2005, Ohio had not submitted the majority of its sex offender registry because of
technical problems, but a state official reported that the state submitted registry data on computer
disk in August 2005.

Registry administrators from among the 8 states we reviewed and the 20
additional states that responded to our e-mail questionnaire reported that
several factors complicate their efforts to submit complete sex offender
registries to NSOR. For example, registry administrators frequently
responded that they were not able to submit records of registered sex
offenders who did not have FBI numbers. FBI numbers are required by the
FBI for all records submitted to the NSOR to ensure positive identification
of individuals for the purposes of employment background checks.20 States
may lack FBI numbers for several types of offenders, such as juvenile sex
offenders who do not receive FBI numbers or sex offenders from other
states. If a sex offender comes from out of state, his/her FBI number can

20

Under the Lychner Act, NSOR information must also be disclosed for employment
background checks. To ensure that information released in background checks is accurate,
a person’s identification is verified using fingerprints. The FBI number provides the
necessary link between the sex offender registry record and an offender’s fingerprint
records to technically achieve the inclusion of an offender’s NSOR records in employment
background checks.

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be obtained from the state where the conviction occurred, but it can be
labor-intensive if the other state does not cooperate or never submitted
fingerprint information to establish the offender’s FBI number.21 Registry
administrators in two of the states we reviewed estimated that in recent
years about 30 percent of the records they submitted to the NSOR were
rejected as incomplete.22 In addition, states are required to verify
information, including home address, for each registered offender at least
annually and quarterly for registered offenders classified as sexually
violent predators, a process that can also be labor-intensive.23 If states are
unable to verify an offender’s address information, the offender should be
considered noncompliant, and the NSOR record will not be up-to-date nor
reflect current address information. Some states have also experienced
technical difficulties submitting their registry records to the NSOR. An FBI
official told us that states that had registries prior to the creation of the
NSOR had difficulty reprogramming their registry databases to conform to
the NSOR formats. One of the states we reviewed did not realize until 2005
that only a fraction of its records were being submitted to the NSOR
because of a technical problem, and it is currently submitting records on
computer disks while making plans to implement a system for automatic
electronic submission of its full sex offender registry to the NSOR.
Although the FBI does not track states’ submission rates to the NSOR, it
does periodically assess state participation in the NSOR and provides
assistance to help states improve the comprehensiveness and accuracy of
their registries. In addition to the requirement that states annually validate
registry records, we were informed that the FBI conducts triennial audits
of states’ participation in the NSOR. During fiscal year 2005, the FBI also
conducted a fiscal audit, assessed states’ level of participation in the NSOR
and requested information from states about what assistance they need to

21

States also have the option of searching for an offender’s FBI number by conducting
inquiries of the FBI’s Fingerprint Identification Record System using name and date of birth
or fingerprints.
22

According to NSOR data documentation provided by the FBI certain pieces of
information are mandatory for state registry records to be accepted into the NSOR,
including: offender’s name; physical characteristics, including gender, height, weight, eye,
and hair color; race; date of birth; registration beginning and ending dates; FBI number; and
conviction information. The NSOR also includes other information, such as vehicle license
plate numbers and home address, but will accept records even if this information is not
provided.

23

In addition to annual address verification, states are required to validate information in
the NSOR on an annual basis to ensure the accuracy and completeness of the information.

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improve their participation. DOJ provides grants to help states improve
their law enforcement information systems, which states have utilized for
enhancements to their sex offender registries such as enabling the
automatic transmission of records to the NSOR and for monitoring data
accuracy. DOJ informed us that it also provides training and technical
assistance to states, and that the FBI has an advisory group that is
reviewing issues such as state submission of data to the NSOR and the
process for the verification and validation of NSOR records.

Approximately 200 Parolees
Identified as Living in Longterm Care Facilities in Eight
States

Using data provided by each of the eight states we reviewed, we identified
204 parolees as residents of long-term care facilities. (See table 2.)
Because there is no national source of data on parolees that includes their
home address information, our numbers are limited to the eight states and
cannot be generalized as representative of all states. Among parolees for
whom we had information on the nature of their crimes, the convictions
were most commonly for burglary, assault, murder, or drug-related
offenses.
Table 2: Parolees Identified as Living in Long-term Care Facilities in States
Reviewed, 2005
Nursing homes

ICFs-MR

Totala

63

4

67

Florida

7

0

7

Illinois

70

4

74

2

0

2

State
California

Minnesota
New Jersey
Ohio
Oklahoma

2

1

3

42

1

43

6

0

6

Utah

2

0

2

Total

194

10

204

Sources: GAO analysis of parolee databases for eight reviewed states, January through September 2005; CMS’s OSCAR database,
2004.
a

Results do not include parolees who were also listed on state sex offender registries or the NSOR.

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Abuse by Offenders Who
Live in Long-term Care
Facilities Not Tracked, but
Risk May Not Be
Widespread

Long-term care facilities participating in Medicare or Medicaid are
required to report all allegations of abuse and neglect to officials in
accordance with applicable state law and, in the case of nursing homes,
this includes reporting to the state.24 This requirement would encompass
the reporting of abuse committed by staff or residents. In the eight states
we reviewed, long-term care facilities do stratify reported abuse into
categories, such as physical, sexual, financial, or resident-to-resident
abuse; however, they do not report information on whether residents
alleged to have caused abuse have prior convictions. The National
Ombudsman Reporting System (NORS) also collects nursing home abuse
data on a national level and includes various categories of abuse, such as
incidents that occur between residents and incidents perpetrated by
nursing home staff. Similar to the states we reviewed, NORS does not
track whether residents alleged to have abused other residents have prior
convictions.
Because data are not available nationally or in our reviewed states on
abuse perpetrated specifically by residents who have prior convictions,
the potential risk for abuse by offenders residing in long-term care
facilities cannot be accurately estimated. However, based on a number of
factors, including the small percentage of facilities identified as housing
offenders, the risk may not be widespread. For example, offenders
residing in nursing homes or ICFs-MR who have significant physical
limitations may be unable to commit abuse against other residents. In
addition, research on recidivism by sex offenders also suggests that most
do not re-offend and that the risk of re-offending may decline with age.
In our interviews with officials of long-term care facilities, state nursing
home associations, and state ombudsmen for long-term care, concern was
more frequently expressed about the behavior and potential for abuse by
cognitively impaired and mentally ill residents than about abuse by
residents with prior convictions. Several of those interviewed mentioned
they were concerned about the potential for abuse by residents with
Alzheimer’s disease or dementia, a disease for which their behavior may
change significantly after their admission and original assessment. The
administrator of a facility in Ohio that specializes in residents with
behavioral issues and that has housed multiple offenders said that he has
had fewer problems with his residents who are identified sex offenders
than with other residents who have behavioral problems. Several sources,

24

42 C.F.R. §§ 483.13(c)(2), 483.420(d)(2).

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including ombudsmen, a researcher, and a nursing home advocate,
suggested that a resident’s behavioral issues are sometimes not fully
disclosed to a nursing home upon admission or that some nursing homes
with low occupancy may be more likely than others to accept mentally ill
patients in order to increase their occupancy levels.
Long-term care facility officials we interviewed, some of whom knew they
have had offenders as residents and some of whom spoke hypothetically,
said they would use their judgment to determine whether a registered sex
offender or parolee could appropriately be cared for in their facilities.
Several long-term care facility administrators told us that if they
discovered a resident was an offender, they would evaluate the potential
risk posed by that individual on a case-by-case basis. For example, the
facility administrator may determine the degree of safety risk on the basis
of whether the offender’s health status is such that the individual cannot
move independently. If the administrator determines that the risk is
greater than the long-term care facility can manage, the facility may
choose not to admit the offender.

States Required to
Notify Community
about Registered Sex
Offenders, but Extent
of Notification Varies

Federal law requires state law enforcement agencies to release relevant
information about registered sex offenders when necessary to protect the
public, but we did not identify a similar federal requirement pertaining to
the parolee population. The federal requirement for registered sex
offender notification allows states to implement this requirement at their
discretion, within broad federal guidelines. Consequently, the extent to
which states’ community notification laws apply to all registered sex
offenders or explicitly include nursing homes and ICFs-MR varies. Absent
direct notification, these facilities may not know they house offenders or
may only become aware of offenders through other means. For example,
in the case of registered sex offenders, facilities may identify some
offenders by reviewing publicly available Web sites, while for parolees,
they may become aware of the person’s criminal background from a
parole officer. When facility residents are known offenders, differing
interpretations exist among states, industry, and long-term care facility
officials as to whether sharing information about their prior convictions
may violate the Privacy Rule issued by HHS under HIPAA.

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Federal Law Requires
States to Provide
Community Notification
for Registered Sex
Offenders, but Direct
Notification to Long-term
Care Facilities Varied

Megan’s Law, a 1996 amendment to the Wetterling Program statute,
required each state to release information about registered sex offenders
when necessary to protect the public. The law applied specifically to
registered sex offenders and not to convicted sex offenders who were not
obligated to register.25 Although Megan’s Law stipulated that information
about the victims of registered sex offenders was not to be released, it
otherwise did not specify the information to be disseminated about
registered sex offenders, did not mandate that community notification be
uniform for all registered sex offenders, and did not specify how states
were to release information.
Consequently, states’ community notification laws vary, particularly in
terms of the extent to which notification by law enforcement entities
applies to all registered sex offenders. Such variation was evident in the
notification laws of the eight states we reviewed. While two states we
reviewed—Illinois and Utah—apply community notification requirements
to all registered sex offenders uniformly in each state,26 the community
notification requirements in the remaining six states—California, Florida,
Minnesota, New Jersey, Ohio, and Oklahoma—vary depending on the
crime committed by the registered sex offender.27 For example, New
Jersey classifies its registered sex offenders into three categories based on
their assessed risk of re-offending. For sex offenders determined to be
lowest risk, state law requires notification of law enforcement agencies. In
contrast, for the highest risk sex offenders, the law requires notification of
additional entities, including schools, religious and youth organizations,
and those likely to encounter the offender. Similarly, Florida’s law
explicitly requires broad community notification when individuals
designated to be sexual predators reside in the community, but it does not
require broad notification for other sex offenders.
Variation also exists in the extent to which state community notification
laws explicitly require the notification of long-term care facilities. Four
states we reviewed—California, Illinois, Minnesota, and Oklahoma—

25
The federal law requires the registration of sex offenders convicted of criminal offenses
against minors or of sexually violent offenses or those designated as sexually violent
predators.
26

730 ILCS Stat. Ann. § 152/120 (West 2005); Utah Code Ann. § 77-27-21.5 (2003).

27

Cal. Penal Code § 290.45 (Dearing 2005); Fla. Stat. Ann. § 944.606 (West 2005); Minn. Stat.
Ann. § 244.052 (West 2003); N.J. Stat. Ann. § 2C: 7-8 (West 2005); Ohio Rev. Code Ann. §§
2950.081, 2950.11 (Anderson 2005); Okla. Stat. Ann. Tit. 57, § 584 (West 2005-2006).

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GAO-06-326 Offenders in Long-Term Care Facilities

passed laws in summer and fall 2005 that specified long-term care facilities
as entities to be notified for at least some registered sex offenders who
,
entered them.28 29 Notification in these states is conducted by individual
facility officials, state or law enforcement officials, or registered sex
offenders themselves. For example, Illinois’ law requires long-term care
facilities to determine whether each resident or potential resident is a
registered sex offender and to notify staff, residents or their legal
guardians, and facility visitors when offenders are residents.30 Similarly,
Oklahoma’s law requires notification of these facilities by several methods.
For example, the Department of Corrections must notify the Department
of Health when any person in its custody seeks placement in these
facilities, and the Department of Health must then notify the facility of the
potential for the placement of a registered sex offender. When residents
are determined to be registered sex offenders, information about them
must be displayed in the facility in an area that is accessible to staff,
visitors, and residents. The law in California also requires state officials to
notify long-term care facilities when registered sex offenders are released
to them from the Department of Corrections and Rehabilitation, the State
Department of Mental Health, or other state-operated places of
confinement. The law does not provide for such notification when sex
offenders enter long-term care facilities from the community. Unlike other
states we reviewed, Minnesota’s law requires registered sex offenders to
disclose their status if seeking admission to long-term care facilities. Upon
receiving such notification from certain registered sex offenders, longterm care facilities are responsible for sharing this information with other
residents or their legal guardians. Minnesota also requires law
enforcement officials to notify health care facilities if they become aware
that a registered sex offender has been admitted for care.

28

2005 Cal. Adv. Legis. Serv. c. 466 (Dearing); 2005 Ill. Legis. Serv. 94-163 (West); 2005 Minn.
Laws c. 243.166; 2005 Okla. Sess. Laws Serv. c. 465 (West).
29

Requirements in state community notification laws specifying that nursing homes and
ICFs-MR be notified about registered sex offenders who were residents appear to be a
recent trend. For example, a 2001 review of state community notification laws by the
Bureau of Justice Statistics found that states generally did not notify nursing homes or
ICFs-MR when offenders entered the facilities.
30
Emergency rules implementing this law require licensed long-term care facilities, such as
nursing homes and ICFs-MR, to check the background of potential residents through the
state sex offender database. 77 Ill. Reg. § 300.625 (as added for emergency rules published
on Sept. 2, 2005). These rules expired on December 7, 2005, and have not yet been replaced
by permanent rules.

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GAO-06-326 Offenders in Long-Term Care Facilities

The other four states we reviewed—Florida, New Jersey, Ohio, and Utah—
do not specifically require the notification of long-term care facilities when
registered sex offenders enter them. Long-term care facilities in these
states, or in states where community notification of such facilities is not
required for all registered sex offenders, may not be aware of residents
who are offenders or must rely on other methods to identify such
individuals. For instance, administrators we interviewed at 8 of the
29 long-term care facilities indicated that one or more registered sex
offenders had lived in their facilities for some period. Each of these 8 longterm care facilities was notified about the registered sex offenders,
although the method of notification varied. For example, while 4 facilities
were notified before the offenders entered them, either by offenders’
family members or the state department of corrections, the 4 remaining
facilities were notified after the registered sex offenders were admitted,
either by local law enforcement officials who were verifying sex offenders’
residential addresses or by an advocacy group conducting research on
registered sex offenders living in certain long-term care facilities.
Long-term care facilities may access states’ publicly available sex offender
registry Web sites to determine where registered sex offenders reside. A
2003 amendment to the Wetterling Program statute required states to
maintain a publicly available Web site with information about registered
sex offenders.31 The law did not provide instruction on how these Web
sites should be designed or what specific information should be included.32
Depending on the state, these Web sites provide varying amounts of
information to the public about registered sex offenders. For example, the
Web site registry in each of the eight states we reviewed included some
address information for all or a portion of the state’s adult registered sex
offenders. Five states we reviewed—Florida, Illinois, Ohio, Oklahoma, and
Utah—provided the full residential address of all the state’s adult
registered sex offenders, while three others—California, Minnesota, and
New Jersey—included certain registered sex offenders on their Web sites
and in some cases did not always list their full addresses. For example,
Minnesota separates offenders into three levels and includes Level 3
offenders—those deemed predatory or most likely to re-offend—on its
Web site. Approximately 6 percent of the registered sex offenders in this

31

The Prosecutorial Remedies and Other Tools to End the Exploitation of Children Today
Act of 2003, Pub. L. No. 108-21 § 604, 117 Stat. 650, 688.
32

DOJ has published proposed guidelines in the Federal Register with respect to state
Internet sites for sex offender information at 70 Fed. Reg. 12721 (2005).

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GAO-06-326 Offenders in Long-Term Care Facilities

state who are living in the community are assigned the highest risk level.
Similarly, New Jersey includes certain moderate and all high-risk
registered sex offenders on its Web site, which, according to a state
official, represents about 16 percent of all registered sex offenders in the
state. In California, a state official told us that its Web site registry
includes at least some address information for approximately 74 percent
of the state’s registered sex offenders, including full address information
for about 57 percent who committed crimes considered to be the most
serious. The remaining approximately 26 percent of the state’s registered
sex offenders are not posted on the Web site because they committed less
severe offenses or are excluded from the Web site for various reasons,
such as not being designated sexually violent predators. In addition, for
the registered sex offenders listed on the Web sites of the eight states we
reviewed, information is included about the crimes registered sex
offenders committed; their names, nicknames, or aliases, when applicable;
date of birth or age; and race or ethnicity.
While the NSOR database is not directly accessible by the general public,
long-term care facilities can access the recently developed National Sex
Offender Public Registry maintained by the DOJ.33 This Web site, which
was first launched in May 2005, seeks to compile public sex offender
registry information available through state Web sites, and as of January
2006, it included public registry data from all but two states. Although this
Web site provides the public with one-stop access to states’ online sex
offender registries, it may be of limited usefulness because states’ sex
offender registry Web sites, as described above, do not always include a
comprehensive list of registered sex offenders.

Although Community
Notification of Parolees
Not Uniformly Required,
Parolees in Long-term Care
Facilities Often Identified
by Law Enforcement

We did not identify a federal law specifying community notification
requirements for law enforcement when parolees enter the community
that was similar to the federal law for registered sex offenders. However,
three of the eight states we reviewed—Illinois, Minnesota, and
Oklahoma—passed laws in summer 2005 that require community
notification for offenders who have committed crimes other than sex
offenses, including some offenders who are parolees.34 Illinois’ law
requires the state Department of Corrections to give some information to

33

See http://www.nsopr.gov/.

34

2005 Ill. Legis. Serv. 94-163 (West); 2005 Minn. Laws c. 243.166; 2005 Okla. Sess. Laws
Serv. c. 465 (West).

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GAO-06-326 Offenders in Long-Term Care Facilities

certain long-term care facilities when parolees or certain other offenders
become residents. In addition, these long-term care facilities are required
to notify the other residents when parolees reside in their facilities. In
Minnesota and Oklahoma, long-term care facilities receive community
notification for some individuals convicted of non-sex offenses, including
some parolees, under the same requirements as those for registered sex
offenders. Minnesota’s law applies to individuals convicted of some
crimes, including murder or kidnapping. Oklahoma’s law requires
notification for individuals who are required to register under the Mary
Rippy Violent Crime Offenders Registration Act, which includes
individuals convicted of crimes such as murder or manslaughter in the
first degree.
Department of Corrections’ officials or other authorities in each of the
eight states we reviewed stated that as a matter of practice, they generally
notified long-term care facilities when individuals released from prison,
including parolees, are placed in such facilities. For example, according to
officials in Ohio’s Department of Rehabilitation and Corrections, when an
inmate who needs long-term care is paroled, a parole officer works with
the facility to ensure that medical records are transferred and that a plan
of care is established to meet the needs of the parolee.

Officials Uncertain about
Ability of Long-term Care
Facilities to Disclose
Offender Information
under the HIPAA Privacy
Rule

While the HIPAA Privacy Rule applies to individually identifiable health
information, differing interpretations exist among state, industry, and longterm care facility officials we interviewed in the eight states regarding the
applicability of the rule to facilities’ efforts to notify others about residents
who have prior convictions, such as those who are registered sex
offenders or parolees. These difficulties existed regardless of whether this
information was obtained from a medical record or in another way, such
as from a law enforcement official. For instance, long-term care agency
officials from three states we reviewed indicated that protection of health
information under the HIPAA Privacy Rule did not extend to information
on prior convictions. In addition, long-term care facility and other agency
officials from these and three other states we reviewed maintained that it
was permissible to disclose information about a resident’s prior
convictions to employees in a long-term care facility who needed to know
in order to provide care for the resident. Yet other officials in six of the
eight states we reviewed told us they were either unsure whether the
HIPAA Privacy Rule would be violated by sharing information about the
prior convictions of any offender living in a facility or that they believed
the HIPAA Privacy Rule did not apply to disclosing such information about
residents who are offenders. Officials at 11 of the 29 long-term care

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GAO-06-326 Offenders in Long-Term Care Facilities

facilities we interviewed in eight states said that they were concerned they
would violate the HIPAA Privacy Rule if they disclosed information about
the prior convictions of offenders living in their respective facilities, but
indicated that they would notify staff if they became aware of such
residents.
We brought the issue of long-term care facilities’ uncertainty regarding the
applicability of the HIPAA Privacy Rule to the attention of an official of the
Department of Health and Human Services Office for Civil Rights (HHSOCR), the federal entity responsible for implementing and enforcing the
HIPAA Privacy Rule. The official indicated that HHS-OCR has not
published regulations or other guidance specifically regarding the
applicability of the HIPAA Privacy Rule to the disclosure of information
related to prior convictions of long-term care facility residents. However,
the official stated that to the extent that such information is maintained by
long-term care facilities as protected health information under the HIPAA
Privacy Rule, such information could be used or disclosed for specifically
permitted purposes, such as when necessary to run the health care
operations of a facility or required by another federal or state law. In
addition, the HHS-OCR official indicated that affected entities, such as
long-term care facilities, would need to make the determination on a caseby-case basis as to whether the information is protected health
information, and if so, whether its intended use or disclosure is permitted
by the HIPAA Privacy Rule. The official added that long-term care facilities
should consult their legal counsel if they have questions in making this
determination. Although HHS-OCR does maintain a list of answers to
frequently asked questions about the HIPAA Privacy Rule on its Web site,
it does not cover this specific issue. In commenting on a draft of this
report, Department of Corrections officials from one state we reviewed
stated that it would be helpful for HHS-OCR to describe some situations in
which it believes HIPAA would not be applicable with regard to the
disclosure of information about offenders admitted to health care
facilities. They stated that HHS-OCR’s direction to approach each case
individually is not very helpful and that additional guidance would be very
useful.

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GAO-06-326 Offenders in Long-Term Care Facilities

Supervision and
Separation of LongTerm Care Facility
Residents Largely
Based on Behavior,
Not Prior Convictions

Residents’ prior convictions alone would not be sufficient in most cases to
subject them to supervision or separation requirements that differed from
other residents, according to facility officials we interviewed.
Administrators at only 2 of the 29 long-term care facilities we contacted
indicated that they have a specific policy to separate offenders from other
residents based solely on their prior convictions. Instead, long-term care
facilities in the eight states we reviewed typically base supervision and
separation decisions on behavioral issues that arise. For example, in the
states we reviewed, several long-term care ombudsmen, industry
association officials, and facility officials we interviewed indicated that the
residents they have particular concerns about, in terms of behavioral
problems, are those with mental illness, such as dementia, for which
behaviors are apt to change as the disease progresses.
Although most officials we spoke with at long-term care facilities in the
eight states we reviewed do not supervise or separate offenders based
solely on their prior convictions, some officials indicated the potential for
a future need for residential facilities separate from long-term care
facilities exclusively for certain offenders. For instance, Minnesota state
officials said that some long-term care facilities may be hesitant to accept
sex offenders as residents in the future, believing that certain sex
offenders pose a risk to the safety of other residents. Therefore, a state
commission has recommended the development of secure health care
settings that would serve people who have committed certain sex offenses
and who may not otherwise have access to services. In order to establish
this facility, state officials are working with federal officials to resolve
issues related to balancing resident rights with the safety interests of the
larger community.
Even if long-term care facility officials wanted to impose different
supervision and separation requirements on offenders, numerous factors
could affect their ability to do so. For example, as previously noted, longterm care facilities were not always notified when individuals with prior
convictions entered them. Federal laws we reviewed do not require longterm care facilities to obtain information about prior convictions, and
among the eight states we reviewed, only Illinois had such a requirement.35
In addition, assessment tools long-term care facilities in these eight states

35
77 Ill. Reg. §§ 300.615, 300.625 (as added by emergency rules published Sept. 2, 2005).
These rules expired on December 7, 2005, and have not yet been replaced by permanent
rules.

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GAO-06-326 Offenders in Long-Term Care Facilities

use to determine the health care needs of residents usually are not
designed to gather information about prior convictions. Even if facilities
obtained such information, federal and state laws that we reviewed
generally do not provide for specific supervision or separation practices
for facility residents with prior convictions.

Conclusions

Each incident of resident abuse committed by offenders living in nursing
homes—even if isolated or infrequent—is of concern. However, while
long-term care facilities may learn that certain of their residents are sex
offenders or parolees through required community notification or through
other means, our findings did not indicate that residents with prior
convictions are more likely than other residents to commit abuse within
these facilities. Absent such evidence, it may be more appropriate to focus
on residents’ behaviors versus their prior convictions when assessing the
potential for committing abuse. Facility officials we interviewed more
frequently expressed concerns about the behavior and potential for abuse
by cognitively impaired and mentally ill residents than by offenders who
may have no behavioral issues. Facilities already document problematic
behaviors and assess the risk of individuals through resident assessments
and care planning procedures, and when they accept residents with
behavioral issues or such issues arise after admission, they must
appropriately address those behaviors through the care planning for these
individuals or transfer them to facilities better equipped to handle such
residents. In addition, focusing on prior convictions alone can be
problematic in that some offenders, such as those with certain physical
impairments, likely do not pose a risk to other residents. Nonetheless, in
the interest of identifying potential risks and taking precautionary
measures, four states we reviewed—California, Illinois, Oklahoma, and
Minnesota—enacted measures in 2005 to require notification to long-term
care facilities when offenders are residents. Assessing their experiences as
they implement these measures over time, including any negative impact
on offenders’ access to long-term care, may be instructive for other states
with similar concerns.
While it was not part of our original objectives to fully evaluate the NSOR,
it was our primary data source for identifying registered sex offenders
residing in long-term care facilities. In the course of our analysis, we
became aware that the FBI’s NSOR, which links states’ sex offender
registration programs so that law enforcement agencies can identify sex
offenders regardless of which state maintains their registration, was
incomplete for the seven states we reviewed for this purpose. States face
various barriers to fully submitting their registry records to the NSOR,

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GAO-06-326 Offenders in Long-Term Care Facilities

including difficulties such as obtaining the required FBI number for each
offender and a lack of staff resources. While the FBI has been reviewing
issues related to states’ submission of records to the NSOR, it currently
does not track submission rates, so the proportion of state records missing
from the NSOR is not precisely known. Continued improvements in the
comprehensiveness of the NSOR can enhance the ability of local law
enforcement agencies to identify offenders and notify the community,
including long-term care facilities, where appropriate.

Recommendations for
Executive Action
•
•

Agency and State
Comments and Our
Evaluation

We recommend that the Attorney General direct the FBI to take the
following two actions:
assess the completeness of the NSOR, including state submission rates,
and
evaluate options for making it a more a comprehensive national database
of registered sex offenders.

We provided copies of a draft of this report for comment to DOJ; HHS; and
the eight states we reviewed: California, Florida, Illinois, Minnesota, New
Jersey, Ohio, Oklahoma, and Utah. We received written responses from
DOJ and HHS, which are included in this report as appendixes III and IV,
respectively. We also received comments from California, Florida, Illinois,
Minnesota, New Jersey, and Oklahoma. These agency and state comments
and our evaluation follow.
DOJ commented that the recommendations are unnecessary because the
FBI already performs assessments of the NSOR and explores options for
improvement. For example, DOJ said that the FBI conducts triennial
audits of states’ NSOR participation, provides training and technical
assistance to states, and seeks input from states about what assistance
they need to improve their level of participation in the NSOR. DOJ
characterized our evaluation as incomplete because we did not ask for
information about the entire NSOR program or include a more extensive
discussion in the draft report of their efforts to improve the NSOR. We
obtained information about these efforts over the course of our work
through interviews with FBI staff, documents available on their Web site,
and through state officials. Because a comprehensive evaluation of the
NSOR was not one of our reporting objectives, we did not include a
complete listing of the FBI’s assistance to states in our draft report. To
respond to DOJ’s comments, we revised the report to include additional
information about the FBI’s initiatives to assist states in data submission

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GAO-06-326 Offenders in Long-Term Care Facilities

and to assess the accuracy of NSOR records. Including this additional
information, however, does not alter our overall finding concerning the
discrepancy between state sex offender registries and states’ NSOR
submissions.
We acknowledge, as DOJ pointed out in its comments, that there may be
valid reasons for a certain amount of discrepancy between state registries
and their NSOR submissions, such as if a state chooses not to submit the
records of sex offenders still incarcerated since their whereabouts do not
need to be tracked by the NSOR until their release. We also acknowledge
the challenge states face in maintaining current and accurate information
about registered sex offenders. However, we continue to believe that the
intent of the recommendations remains valid because of the evidence we
analyzed for a sample of states that a significant percentage of registered
sex offender records are not being successfully submitted by some states
to the NSOR, despite the states’ and FBI’s efforts to date. We believe the
FBI needs to track state submission rates to the NSOR as a measure of
comprehensiveness that can quantify the remaining gap as well as
improvements over time. We therefore revised the first recommendation
to specify that we are recommending that the FBI assess state submission
rates as a means of assessing the completeness of NSOR.
DOJ commented on three additional issues:
•

•

The risk posed by offenders residing in long-term care facilities.
DOJ suggested that GAO discounted the risk posed by sex offenders
residing in long-term care facilities based on insufficient evidence. We
agree that the placement of a sex offender into a long-term care facility
requires careful evaluation, particularly as the often-frail condition of longterm care residents makes them vulnerable to victimization. Based on our
research and interviews with administrators of long-term care facilities, it
is our view that the risk posed by offenders should be considered on a
case-by-case basis. The presumption that offenders pose a threat to other
residents could lead facilities to unnecessarily deny admission to low-risk
offenders or unnecessarily seclude them from other residents. DOJ did not
provide any new evidence to support its assertion that sex offenders pose
a greater threat than the analysis we presented in the report.
The likelihood that convicted sex offenders will commit additional
sex offenses after their release from prison. DOJ objected to our
citation of sex offender recidivism rates of 14 percent because they were
based on only a 5-year post-incarceration period, saying the period was
too short to be the basis of inferences about the likelihood that a sex
offender will commit additional sex offenses, and because of evidence that

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GAO-06-326 Offenders in Long-Term Care Facilities

•

sex offenses are underreported. We revised the report to clarify that the
same research also cites 20-year sex offender recidivism rates of
27 percent.
The usefulness of the NSOR in assisting law enforcement to
identify sex offenders residing in long-term care facilities. DOJ
questioned GAO’s assertion that improvements in the comprehensiveness
of the NSOR would improve the ability of local law enforcement to
identify sex offenders residing in nursing homes, commenting that
offenders would either already be on the state registry and thus
identifiable or they would not be registered and therefore not included in
the NSOR. We believe that a more comprehensive NSOR would improve
the tracking of sex offenders who enter long-term care facilities in the
same way it improves the tracking of sex offenders generally. If offenders
are registered in one state but move to another state and fail to register,
their records could be in the NSOR from the original state but not on the
registry of the second state. A more comprehensive NSOR thus better
ensures the national tracking of sex offenders who may choose to cross
state lines.
HHS commented that this report brought to its attention the uncertainty
that some long-term care facility officials have about the application of the
HIPAA Privacy Rule to the disclosure of conviction information, as well as
the issue that future guidance may be needed. HHS commented that the
report will help to resolve the uncertainty about the HIPAA Privacy Rule,
including clarifying that disclosures could be allowed for activities
necessary for the safe operation of the facility or as required by state laws.
DOJ, HHS, and the states also provided technical comments, which we
incorporated as appropriate.

As arranged with your offices, unless you publicly announce the contents
of this report earlier, we plan no further distribution of it until 30 days
after its issue date. At that time, we will send copies to the Attorney
General, the Secretary of Health and Human Services, and other interested
parties. We will also make copies available to others upon request. This
report is also available at no charge on GAO’s Web site at
http://www.gao.gov.

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GAO-06-326 Offenders in Long-Term Care Facilities

If you or your staffs have any questions about this report, please contact
me at (202) 512-7118 or allenk@gao.gov. Contact points for our Offices of
Congressional Relations and Public Affairs may be found on the last page
of this report. GAO staff who made major contributions to this report are
listed in appendix V.

Kathryn G. Allen
Director, Health Care

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GAO-06-326 Offenders in Long-Term Care Facilities

Appendix I: Scope and Methodology

Appendix I: Scope and Methodology

To determine the prevalence of registered sex offenders residing in longterm care facilities nationwide, we matched the addresses of registered
sex offenders listed in the Federal Bureau of Investigation’s (FBI) National
Sex Offender Registry (NSOR) as of January 3, 2005, with the addresses of
nursing homes and intermediate care facilities for people with mental
retardation (ICF-MR) listed in the Centers for Medicare & Medicaid
Services’ (CMS) Online Survey, Certification and Reporting system
(OSCAR) database. After standardizing address spellings and
abbreviations, we used SAS, a statistical analysis program, to compare
registered sex offender and long-term care facility addresses. Using a SAS
function that quantifies the magnitude of difference between two text
variables, we identified exact matches as well as near matches where the
addresses differed slightly. We manually reviewed the addresses that
differed slightly to determine if they were the same address.
To evaluate the comprehensiveness of the NSOR, we requested the full
state sex offender registries from 8 states—California, Florida, Illinois,
Minnesota, Ohio, Oklahoma, New Jersey, and Utah—in order to compare
the number of records in each registry to the number of records in the
NSOR for that state. We chose these 8 states on the basis of a number of
criteria, including variation in geographic location and in the number of
registered sex offenders identified as living in long-term care facilities
based on our preliminary analyses. California state officials did not
provide us with the state’s sex offender registry in view of their concerns
with state privacy laws. We also interviewed FBI staff about the
management of the NSOR database. To obtain information about the
administration and content of state registries, including their submission
of records to the NSOR, we interviewed state registry administrators from
the 8 states we reviewed and submitted a questionnaire via e-mail to the
remaining 42 states, receiving responses from 20 of them.
Since no national data source on parolees that includes address
information exists, we obtained parolee databases from each of the eight
states we reviewed. We matched parolee addresses to nursing homes and
ICFs-MR in OSCAR using the same methods we used for our analysis of
NSOR and state sex offender registries.
We excluded some records from our analysis because there was no valid
domestic address for the offender. Table 3 shows the number of records
we analyzed from all data sources for both registered sex offenders and
parolees, and the number of records excluded from each source because
of missing, invalid, or otherwise unusable address information.

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GAO-06-326 Offenders in Long-Term Care Facilities

Appendix I: Scope and Methodology

Table 3: Validity of Offender Address Data by Data Source
Parolee data from eight
reviewed states

NSOR
Validity of offender
address data

Number of
records

Share of
total

Number of
records

Share of
total

State abbreviation
does not match one of
50 states or
Washington, D.C.

27,141

7%

-

-

Offender incarcerated
or deported

23,863

6%

529

0%

Offender transient,
homeless, or address
unknown

5,936

2%

1,653

1%

Address listed is invalid

8,775

2%

11,879

5%

City/state does not
match zip code

327

0%

12

0%

Valid address

304,489

82%

248,290

95%

All

370,531

100%

262,363

100%

Sources: GAO analysis of the NSOR, 2005; GAO analysis of parolee databases for eight reviewed states obtained March through
September 2005.

To obtain information about resident abuse perpetrated by registered sex
offenders and parolees, we reviewed existing research and prior GAO
reports. We also interviewed long-term care facility administrators in the
eight states we reviewed, including administrators at facilities with
registered sex offenders as residents, as well as state department of health
and industry association officials and ombudsmen. To identify facilities for
administrator interviews, we initially chose four long-term care facilities in
each of the eight states we reviewed. These facilities were chosen from
two groups of facilities based on our initial analysis of NSOR and OSCAR
data. One group comprised facilities with registered sex offender matches
and the other group did not have any such matches, and when possible, we
selected two facilities from each grouping. If a selected facility refused our
request for an interview, we selected another facility as a replacement
from the same group. If a state did not have enough facilities with or
without sex offenders to complete two interviews from each group of
facilities, we used facilities from the other group. In all, we interviewed
administrators at 29 long-term care facilities, 11 with registered sex
offender matches and 18 without matches. We achieved a 91 percent
response rate for the facility interviews.

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GAO-06-326 Offenders in Long-Term Care Facilities

Appendix I: Scope and Methodology

To determine whether federal laws provide for notification of facility staff,
residents, and residents’ families when sex offenders or parolees live in
long-term care facilities or for the supervision and separation of sex
offenders and parolees living in these facilities, we reviewed federal laws
and interviewed Department of Justice and CMS officials. We also
interviewed Department of Health and Human Services Office for Civil
Rights officials about the applicability of the Health Insurance Portability
and Accountability Act of 1996 Privacy Rule to the notification of facilities
about residents who are sex offenders or parolees.
To determine whether states we reviewed have laws or long-term care
facilities have practices that provide for notification of these individuals
and to determine the extent to which these individuals are subject to
supervision and separation requirements that differ from those for other
residents, we reviewed laws and interviewed state officials responsible for
long-term care facility licensing, industry officials, long-term care
ombudsmen, and the administrators at 29 long-term care facilities, which
were chosen based on the criteria discussed above. We also interviewed
Department of Corrections’ officials regarding their efforts to inform
facilities about their placement of parolees in them. To determine what
information on sex offenders is available to the public, we also reviewed
state sex offender Web site registries available in the states we reviewed.
The key sources used to identify registered sex offenders and parolees
living in long-term care facilities included CMS’s OSCAR database, the
NSOR, and parolee databases from selected states. To assess the reliability
of these data, we conducted electronic data testing, reviewed relevant
documentation, and interviewed knowledgeable agency officials about the
data quality control procedures. We determined that while the NSOR does
not include all registered or convicted sex offenders, its records are
regularly audited and are sufficiently reliable for the purposes of this
report. The lack of comprehensiveness of the data was evaluated and
taken into account in our discussion of the results. The OSCAR database
and state parolee databases were also found to be sufficiently reliable for
our purposes.
We conducted our work from September 2004 through February 2006 in
accordance with generally accepted government auditing standards.

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GAO-06-326 Offenders in Long-Term Care Facilities

Appendix II: Registered Sex Offenders Living
in Nursing Homes and ICFs-MR

Appendix II: Registered Sex Offenders Living
in Nursing Homes and ICFs-MR
To determine the prevalence of registered sex offenders residing in longterm care facilities nationwide, we matched the addresses of registered
sex offenders listed in the NSOR as of January 3, 2005, with the addresses
of nursing homes and ICFs-MR listed in CMS’s OSCAR database. Using this
methodology we identified 683 registered sex offenders living in long-term
care facilities. The number of registered sex offenders identified as
residing in long-term care facilities in each state varied considerably,
ranging from 0 to 144, as demonstrated in table 4.
Table 4: Registered Sex Offenders Identified as Living in Nursing Homes and ICFsMR, by State, 2005
State
Alabama

Nursing homes

ICFs-MR

Total

1

0

1

Alaska

3

0

3

Arizona

15

0

15

Arkansas

10

1

11

California

141

3

144

Colorado

9

6

15

Connecticut

9

2

11

Delaware

6

0

6

District of Columbia

0

0

0

Florida

31

4

35

Georgia

14

0

14

Hawaii

0

0

0

Idaho

5

7

12

Illinois

78

2

80

Indiana

3

1

4

Iowa

9

5

14

Kansas

9

1

10

Kentucky

5

0

5

Louisiana

11

2

13

Maine

3

0

3

Maryland

2

0

2

Massachusetts

0

0

0

Michigan

18

1

19

Minnesota

22

3

25

Mississippi

0

0

0

19

2

21

Missouri

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GAO-06-326 Offenders in Long-Term Care Facilities

Appendix II: Registered Sex Offenders Living
in Nursing Homes and ICFs-MR

State

Nursing homes

ICFs-MR

Total

Montana

1

0

1

Nebraska

0

0

0

Nevada

0

0

0

New Hampshire

4

0

4

New Jersey

12

0

12

New Mexico

13

2

15

New York

10

23

33

North Carolina

10

0

10

North Dakota

0

0

0

Ohio

3

0

3

10

1

11

6

0

6

Oklahoma
Oregon
Pennsylvania

0

0

0

Rhode Island

1

0

1

South Carolina

1

3

4

South Dakota

11

0

11

1

0

1

61

8

69

Utah

0

0

0

Vermont

0

0

0

Virginia

7

2

9

Washington

8

0

8

West Virginia

1

0

1

Wisconsin

20

1

21

Wyoming

0

0

0

603

80

683

Tennessee
Texas

Total

Sources: GAO analysis of the FBI’s NSOR as of January 3, 2005; CMS’s OSCAR database, 2004.

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GAO-06-326 Offenders in Long-Term Care Facilities

Appendix III: Comments from the
Department of Justice

Appendix III: Comments from the
Department of Justice

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GAO-06-326 Offenders in Long-Term Care Facilities

Appendix III: Comments from the
Department of Justice

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GAO-06-326 Offenders in Long-Term Care Facilities

Appendix III: Comments from the
Department of Justice

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GAO-06-326 Offenders in Long-Term Care Facilities

Appendix III: Comments from the
Department of Justice

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GAO-06-326 Offenders in Long-Term Care Facilities

Appendix III: Comments from the
Department of Justice

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GAO-06-326 Offenders in Long-Term Care Facilities

Appendix IV: Comments from the Department
of Health and Human Services

Appendix IV: Comments from the
Department of Health and Human Services

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GAO-06-326 Offenders in Long-Term Care Facilities

Appendix IV: Comments from the Department
of Health and Human Services

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GAO-06-326 Offenders in Long-Term Care Facilities

Appendix V: GAO Contact and
Staff Acknowledgments

Appendix V: GAO Contact and Staff
Acknowledgments
GAO Contact

Kathryn G. Allen, (202) 512-7118 or allenk@gao.gov

Acknowledgments

In addition to the contact named above, Susan T. Anthony, Assistant
Director; George Bogart; Katherine Crumley; Michaela M. Monaghan;
Elizabeth T. Morrison; Sari B. Shuman; and Kara Sokol made key
contributions to this report.

(290416)

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GAO-06-326 Offenders in Long-Term Care Facilities

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