Screening Candidates to Reduce the Risk of Abuse and Neglect

The interview process can seem – and in fact is – time consuming. But it is time well spent: with all this information, you should be able to select caring and capable people to work for your agency. Before making a job offer, however, you must attend to this important step: assessing whether this promising applicant will provide safe, attentive care.

Frail elders and dependent adults are at risk for neglect, physical, sexual and emotional abuse and exploitation in much the same ways that children are. Having more assets than children, they are at unparalleled risk for financial abuse, fraud, theft and identify theft. They may be more isolated than children who typically go to child care or school, places staffed by mandated reporters (people required by state law to report suspicions of neglect and abuse to the appropriate protective agency). At a minimum, children play outside and tend to be noticed by neighbors. Children cry and scream when hit, distressing sounds that are often overheard by neighbors.

Housebound elders, on the other hand, may be invisible and inaudible to their well-intentioned neighbors and may be isolated in general. Their human contact may consist of their in-home help and the occasional visit to the doctor and dentist. They might find it too humiliating and frightening to ask for protection from somebody caring for them. And they may believe they have no alternative.

You can reduce, but not remove, the risk of hiring somebody who might abuse or neglect a client through prudent screening of candidates.

A responsible screening protocol includes two key steps:

• Checking documents and
• Screening against registries that can provide additional information about candidates and validate or contradict the information they provide.

Which documents should I request?

You’ll want:

• A chronological resume
• A list of references
• A credit check
• A DMV clearance
• A fingerprint clearance
• A statement of knowledge of and agreement to comply with elder abuse reporting laws.

Resumes

Make sure that applicants list education, credentials and work experience in reverse chronological order. Ask about gaps. See if the applicant is trying to hide or disguise anything. The applicant is applying for a relatively low paying job. Short tenures are to be expected. What you’re looking for is the commitment to follow through with one caseload, not a commitment to stay with the agency for years. You want the applicant to have an appreciation of how hard changing helpers is on clients and to be able to give credible assurances about not leaving people in the lurch. You also want to explore gaps that may attempt to mask time in jail or prison. This is not to say that you should never hire somebody with a record, but that you should not do so unknowingly. Highlight gaps on your copy of the resume.

When you interview, let candidates walk through the resume to tell you about their history. Immediately after that, ask about every gap you have identified. Ask for detail. If they say “I was out for a year because I had my second child” ask, with interest, about the child. “How wonderful for you. It must have been nice to be able to stay home. What did you like best? Did you have a boy or a girl? What school does your child go to now? How old is he/she?” And so on. You are probing for any inconsistencies.

Checking References

References are of no value unless you call the phone numbers and ask questions about the candidates. Be aware, though, that references almost always say good things about candidates. People simply don’t volunteer the names of former employers likely to speak negatively about their performance, and former employers fear being sued if they provide more than dates of employment. Beyond that, people with problematic pasts use the skills they developed along their troubled way to fabricate references using relatives and cohorts, making reference checking difficult.

To help you get the most from reference checks, use the chronological resume of the candidate. This resume structure allows you to ask about specific jobs, responsibilities, and gaps of employment, gaps that could result from an illness, a new baby, or jail time.

If a reference is an agency, ask the agency contact what its clients have had to say about the candidate. Ask specifically what people most liked and disliked about this person and what the agency sees as his or her strengths and weaknesses. These pluses and minuses should help you assess how the candidate fits with your agency’s clientele and priorities.

Candidates should also provide the name and phone numbers of one or two clients and/or relatives of clients. These people can tell you what it feels like to receive care from the candidates and can describe strengths and weaknesses from their perspective.

Candidates should have let the references know to expect calls; they may also have told them what to say. So it’s important to ferret out actual information from the vague nice things people say and to consider references in concert with more objective indicators. Pin down the legitimacy of each reference by asking for specifics about when and where the person worked, the nature of the tasks, and the candidate’s strengths and weaknesses.
Remember that employers, wary of litigation, rarely do more than confirm dates of employment.

Getting the information: What to ask

• How long and in what capacity have you known the candidate?
• For what services would you employ the candidate again?
• What are the strengths and weaknesses of the candidate?
• What was one thing you wish the candidate did differently?
• What do you value most about the candidate?
• When the candidate wasn’t on time, what happened?
• If you were going to give the candidate some advice, what would it be?
• Which tasks should I offer this candidate and which should I offer to other workers? What should I be prepared to have backup for?
• Tell me how you and the candidate handled a difference of opinion.
• Working in somebody else’s home creates an immediate and sometimes awkward intimacy. Describe the candidate’s boundaries.

Be wary of vague positives or a lack of specificity, answers like “He tries hard,” “She cares.” “Well, I didn’t employ him in that capacity;” “It wasn’t a good fit.” Also be wary of conflicting information, an unwillingness to share specific stories, or curt answers. These are red flags.

Credit check

Ask the candidate to bring a credit check done within the past 30 days. It’s free once a year at www.annualcreditreport.com. Look for defaults, bad debts, outstanding judgments, accounts sent to collections and high unpaid balances. Be realistic—people earning $25,000 per year are likely to have some debts, and perhaps high balances on a couple of credit cards. But, they can still be financially responsible. Are payments made monthly? Is anything in arrears? Have any accounts been sent to collection agencies? Is the car loan about the same as the candidate’s annual income?

Remember you are sending relatively low paid people into homes that may seem to be abounding with riches, many of which the client no longer uses. Temptation is a given—you are looking for indicators of integrity, financial responsibility and good impulse control.

Are your agency and its employees insured and bonded? Despite your best efforts to screen and supervise, people can still behave badly. Protect yourself, your agency and your clients. By following the screening procedures below, you should be able to negotiate reasonable rates because you are reducing risk and exposure.

Screening

Screening allows you to check your candidate against various lists of problematic people. Helpful information can be gained through

• the DMV,
• sex offender registries,
• the child abuse and neglect index, and
• other criminal data bases.

These screens are vitally important because they allow you to intercept candidates who may be abusive financially or physically, who may have records as drug or alcohol abusers, who may have extensive driving violations, or who may have served jail or prison time for theft, fraud, or other criminal activities especially threatening to an older person alone in the house.

The activities of daily living your clients want assistance with put them at a different type of risk and you’ll want to know how your candidate fared as a parent or child care provider when similar needs arose. If your candidate was taken to juvenile court for beating a child who wet the bed, you wouldn’t want to ask this person to provide assistance with toileting, changing wet sheets or any other intimate matter. If a candidate has a conviction for domestic violence, you wouldn’t want him/her working in a home. Learning about this background requires sex offender, child abuse, and criminal database checks.

Unfortunately, few home health agencies do criminal background checks and almost none include the child abuse data base in their screening. Their reasons for limiting their screening are worrisome. Agencies usually give reasons like these for limiting screening:

• But everyone likes him!

Rationale:
Most adults are happy with the employees provided through the agency, even those staffers who would not meet the mandatory standards for work with children. As a result, agencies see no need for, and do not want, a governmental bureaucracy telling them whom they can hire.

Counter:
There is a difference between flying blind and making informed choices. You are sending strangers into the homes of vulnerable adults and giving them access to their bodies, property, financial data, charge cards, and everything else in their homes and wallets. How tempting—and easy—to pocket a little something now and then, especially when the employee works hard, feels underpaid and perhaps underappreciated. Because this proclivity can be identified through a credit check, this check is critical before sending an employee into somebody’s home.

• Do you know how expensive more screening would be and how much more we would have to charge clients?

Rationale:
Costs to fingerprint and screen are prohibitive. The candidate pays a nominal fee (usually about $15) to the DMV or police or sheriff’s department to be fingerprinted and the agency is charged about $85-100 for the state Department of Justice to run the prints against existing prints in their child abuse and criminal data bases. Agencies for seniors and dependent adults claim that the cost for fingerprinting is too high.

Counter:
In other fields where safety is of paramount concern, this argument does not fly. Child care providers and schools must submit fingerprints of all employees who have contact with children, and manage to pay for it somehow.

Child care agencies and schools do not allow unscreened employees to work with children. Take measures to assure that your employees are screened as thoroughly as those who work with children. Offer to reimburse the employee his/her $15 after a month of good work.

• No way, I’m not getting sued.

Rationale:
Many agency directors really believe their liability is reduced by limiting screening to reference checks and a DMV clearance. They think their liability would increase if their screening were more extensive and a more thoroughly screened employee abused, neglected, stole from, or defrauded a client.

Counter:
Limited screening increases risk – significantly – and therefore increases the agency’s liability.

Adults brought to juvenile court for neglecting, physically, sexually or emotionally abusing their (or their partner’s) children may be unknown to criminal and traffic courts. Thus, an applicant who abused a child for wetting the bed can apply for a job as an attendant for an incontinent elder and sail through the reference and DMV checks.

Further, a number of county jails and state prisons have pre-release programs that suggest that inmates become in-home care providers. Parole agents and probation officers often recommend in-home care jobs to their parolees and probationers because they know the background checks are cursory and the staffing shortages are chronic in this line of work. These guys are strong (all that working out in the yard) and can lift non-ambulatory patients on and off furniture and toilet seats, a vital skill, and something many aides cannot do. These ex-cons will sail through the DMV check because they don’t drive while incarcerated. This is not to say you should never hire an ex-con, but that you have the right to pertinent history about the person you are sending into homes of vulnerable clients.

Insist on measures comparable to those required for work with children in order to filter out people with records of financial, physical, sexual, emotional abuse and neglect: a safer situation both for your clients and your agency.

Then, ask your insurance and bonding companies to reduce your rates to offset your costs of screening. You are lowering your risk and their exposure.

• We’re already short staffed. We can’t find enough people to work in this field. If we screen more, we won’t have anyone to send clients who need help.

Rationale:
Agency heads say, “If I knew more about each applicant’s background, I’d hire fewer applicants and have an even harder time filling the staffing needs of my clients.”

Counter:
Consumers trust agencies to send safe people into their homes. This trust is misplaced and unfounded by today’s practices. Staffing shortages do not justify taking unnecessary risks with the lives of clients.

DMV Clearance

Transportation is a service your agency offers. A history of safe driving is necessary for this job. A record of safe driving also shows impulse control, tolerance for frustration and good judgment, qualities also needed for in-home work.

Requiring DMV clearances from candidates establishes your agency as one concerned about the welfare of its clients and taking reasonable steps to weed out unsuitable people. A candidate with a history of unsafe driving is unsuitable for any client needing help with transportation.


Ask candidates to obtain and bring with them a clearance from the local DMV office. Check for :

• dangerous driving,
•driving under the influence, and
•unpaid fines and tickets. Unpaid fines and tickets may be an indicator of financial problems; this concern should be cross checked with the credit check.

Fingerprint Clearance

Require the candidate to go through a fingerprint screen that is checked against child abuse as well as criminal and DMV data bases. If you do not know how to do this, check with the child care referral agency in your area. There is usually a backlog and the clearance may take weeks. Schools and child care programs do not let people begin work until their clearances have arrived. Good in-home care providers will not wait around for a couple of months while you wait for the clearance to come in mail. And, submitting fingerprints is a pretty good deterrent in and of itself. Require submission of fingerprints before work begins and a probationary period to last until the fingerprint clearance arrives.

A Signed Statement of Knowledge of and Compliance with Elder Abuse Reporting Laws.

Give each candidate a copy of your state’s elder abuse reporting form and review with each candidate the laws and procedures for reporting suspicions of abuse and neglect in your jurisdiction. Have the candidate read it, and ask him/her to sign a statement saying he or she has read it, understands it, and agrees to comply with state law.

Interviewing

Interviewing is a critical part of the hiring process and can elicit all kinds of information unavailable through references. The interview should include two steps: a preliminary phone interview and a face-to-face interview. The preliminary phone contact serves as an initial screen and is intended to gather basic information that helps you decide whether to take the time to do a face-to-face interview. The phone interview reduces the number of candidates suitable for a face-to-face interview, allowing time to talk to people you might wish to hire. For this reason, both the phone and face-to-face interviews are important. Do not skip either step.

The Preliminary Phone Contact

You will be introducing yourself and your agency to prospective employees with this first phone call. During this phone interview it is helpful to:

• ask how the candidate learned of your agency;

• ask which services the candidate offers;

• be clear and specific about how many hours and which hours of employment you can offer (mandatory night shifts, for example);

• state what duties the job requires;

• ask the candidate’s salary requirements and provide your pay scale;

• ask about job experience, qualifications, credentials;

• ask for three references, two professional and one personal. Call the promising candidates’ references right away (for questions to ask, go to Getting the information: What to ask).

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Tell the candidates you wish to meet to bring three documents to the interview: a chronological resume, a DMV clearance, and a credit check (let them know they can obtain one for free at www.annualcreditreport.com). Tell them you will also require, and will pay for, fingerprinting. This conversation alone will screen out candidates who can’t follow directions, aren’t organized enough to get everything together, or who know that the DMV clearance or fingerprinting will nix their chance of employment. Giving this information up front will spare you interviewing unsuitable people.

If the candidate has problems with any of the requirements or does not seem suitable during the conversation, say thanks and end the conversation. This candidate has not made the cut. Invite promising candidates for a face-to-face interview and schedule a date and time.

Give driving directions, instructions about parking, and any other information the candidate needs to get to the interview. Keep an eye out to see if these instructions are followed and how prompt the candidate is. Anybody can get lost going someplace for the first time, but candidates should also want to make a good impression. Lateness should be a red flag, a large one because it may result in clients being unattended without warning.

The Face-to-Face Interview

Interviews can be stressful, both for the interviewer and the interviewee. To minimize the stress, consider having a colleague join you for the interviews. Go over the checklists and screening protocols together and discuss how the two of you should participate in the conversation ahead of time.

These third parties can be helpful especially as another set of eyes and ears and a second opinion about issues relating to honesty, safety, and judgment. Their presence also indicates to the candidates that your agency takes its job very seriously.

Explain Agency Policies and Procedures:

In the face-to-face interview, give the candidate a copy of your policies and procedures and discuss them.

Explain and check that the candidate understands policies and procedures related to:

•Attendance: How are attendance and promptness monitored and what happens if there is a problem?

•Quality of service: How does the agency find out if the client is happy, and what happens if a problem arises?

•Payment: How often is payment made? How – is direct deposit available, required?

•Reviews and raises: How is performance reviewed? Are there regular, or any, raises? How do they happen – automatically, based on length of service, based on quality of service?

•Taxes: What is the status (independent contractor/employee) of the service providers? How are taxes withheld – by them, the agency, the client?

•Benefits: Are there any benefits available through the agency?

•Accepting money and gifts: Are gifts or extra money acceptable from clients? If so, what’s the limit? Do they have to be reported? To whom?

•Firing offenses: What offenses will result in immediate termination?

Be honest and straightforward in this presentation: it’s better that candidates know the landscape and what they are getting in to. If you fudge the information to attract a candidate, you are asking to run into trouble later.

When you have finished presenting the policies and procedures, have the candidate sign at the bottom of each page to indicate that he/she has received them, read them, had an explanation, and had any questions answered. Make a copy of the signed document. Give one to the candidate and keep one in the candidate’s personnel file.

Holding the interview – what to ask:

Good interview questions are among the most important tools available for figuring out whom to hire. It is impossible to find out everything about how candidates would behave and what they would do in every instance, but strong interview questions can help you discover key information.

To gain a feel for candidates’ maturity, judgment, appropriateness, and boundaries, get candidates talking freely about the work they have done and how they have behaved in circumstances similar to those they’d encounter working for your agency.

Because past behavior is the best predictor for future performance, learn as much as you can about candidates’ past experience. As much as possible, stay away from questions that require a “yes” or “no” answer. Focus on getting a feel for each candidate’s attitude, behavior, decision-making process and values. To do this, you will need to work your way through four sets of questions:

1. open ended questions,
2. temperament-based questions,
3. anecdotal questions, and
4. forced answer questions.

1. Open-ended Questions

• What did you like most about your last job?
• What did you like least about your last job?
• How do you show respect for clients’ dignity?
• How do you offer help?
• How do you handle emergencies?

Tell candidates a vignette involving judgment and values and consider the response. Choose something important, a client with a DNR who has a seizure, for example. This is a critical area – it’s possible to hire highly skilled helpers whose values prevent them from following your agency’s policies. To avoid this situation, ask follow-up questions:

•Have you been in this situation (one that goes against the candidate’s personal values) before? Tell me about it.
•What did you do? What did you opt not to do?
•Have you ever been in a situation in which you disagreed with your client’s health care wishes?
•What did you do?
•Have you ever been in a situation in which you disagreed with your agency’s policies or practices?
•What did you do?
•What support do you expect from the agency?

2. Temperament-based questions: Be sure to have the temperament checklist handy at the interview. For each item on the checklist, ask candidates about their preferences. Explain that you give prospective clients a similar checklist so that you can make harmonious matches. You are looking for candidates’ temperament traits and a sense of how well they tolerate extremes in other people.

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3. Anecdotal questions: This part of the interview is intended to get a feel for the candidate’s actual behavior in comparable situations and to learn more about the candidate’s judgment and attitude.

• Ask candidates to give an anecdote or two from recent jobs.
What do you think of the candidate’s tone? Was the anecdote appropriate to a get-acquainted conversation? Was the candidate respectful of the client and the client’s privacy, telling a story but not revealing personal information?

• Ask for an anecdote about a disagreement with a client and how it was resolved.
See whether the disagreement was about something important like safety or an unimportant personal preference that nonetheless ended up in a disagreement. Is there an issue of authority? Are your clients going to feel bossed around? Did the candidate tell a story showing the use of humor, patience, and tact to resolve a disagreement?

• Ask the candidates if they have children.
Say “tell me something about your children” and see what is volunteered. Ask how the candidate handled toilet training and toileting accidents, complaints about food, discipline, misbehavior, and other analogous topics. Does the candidate talk a lot about control, discipline, structure? What does the candidate say about normal frustrations? Or does the candidate share warm stories about enjoying the process of helping and teaching?

• Ask about similarities and differences in caring for children and elders.
See if the candidate mentions that the elder is in charge and makes the rules.

• Ask candidates how they show respect for a client’s dignity and privacy while assisting with activities of daily living. Ask candidates to share an experience balancing a client’s privacy and need for assistance. Does the candidate minimize the concern for privacy? Or does the candidate describe a true appreciation of the individual’s dignity?

• Ask candidates about bathing and grooming tasks. Ask candidates how they prefer to handle these responsibilities. Follow this general question with a request for a story about a specific instance. Finally, give an anecdote about a client’s preferences for bathing and grooming and ask how the candidate would handle this routine. Does the candidate indicate a true ability to help clients through their habitual routines without imposing a new one? Are the stories about the aide deciding how to handle things or about the aide finding ways to accommodate the client’s existing routine? How much flexibility is described in the stories?

That is not to say that trained aides don’t change wet clothes or dressings on sores as they deem appropriate, but that an older person who has always showered before bedtime should not be forced to shower in the middle of the afternoon because the aide prefers to do bathing at the beginning of the shift.

The larger question is whether aides assist or direct their clients. To some extent, this depends on each client’s needs. If the needs are only or primarily physical, the aide should assist and take direction from the client. If the client has some memory or cognitive problems, the aide must take a more directive role—while respecting preferences as much as possible—to make sure that bathing, brushing teeth and toileting take place at regular intervals. Since this is a progression, you are looking for aides who can assess ability accurately, and help without infantilizing people.

• Ask candidates about the normal challenges of in-home work. Tell candidates that you know in-home work can be isolating, tiring and frustrating at times. Ask about a situation that was particularly challenging and how the candidate handled it.

4. Forced choice questions: Forced choice questions ask people to rank items in order of preference. All items must fit somewhere so forced choice questions usually elicit honest information and show priorities, likes, and dislikes. Ask candidates to rank activities of daily living in order of preference (all candidates should know what activities of daily living are). Next, ask candidates to rank household chores and pet care in order of preference.

This information will enable you to pair what your employees most likes doing with clients’ needs. You’ll create good matches and reduce the risk of abuse and neglect.

For those candidates who seem suitable, discuss salary, agency policies and schedule next.

• Salary: Tell them how much you will pay, whether you will pay weekly, bi-weekly, or at some other interval, how often you will give bonuses, raises, paid sick leave, holidays and vacation time. Discuss overtime. Can you pay generously if an aide stays late to handle illness or an emergency?

• Status: Will the candidate be an employee of your agency? If so, you are responsible for withholding money to pay taxes and providing a W-2 form each January. What other benefits do you offer? Overtime? Overtime rates for weekends and holidays worked? Paid holidays off? Sick leave? Vacation? Health insurance? Will the candidate be an independent contractor? Do you offer overtime for extra hours? Weekends and holidays? And paid time off? Make sure the candidate is clear that you provide a 1099 form and the candidate is responsible for making estimated payments to the IRS quarterly.

• Schedule: Review the hours/shifts you are offering and ask the candidate to confirm hours he/she will work. Stress that you need dependability. Make clear whether 9:00 means 9:00 on the dot or a window of 10 minutes one way or the other. Agree on breaks. Ask when the candidate is available to start if hired. Also ask and if the candidate has anything planned that would require time off after that date. Discuss how you handle interruptions in schedule (illness, for example), and how you will handle holidays. Pull out a calendar and see which holidays are coming up in the next 3 months. Agree on days worked, days off, paid and unpaid holidays. Keep in mind that offering a few paid holidays generates a lot of good will.

If your agency doesn’t have a written contract, adapt the model agreement for your circumstances. Review it with the candidate, then prepare two copies that both of you will sign. Give one copy to the candidate and put the second in the candidate’s personnel file along with the credit report, DMV clearance, signed copy of the agency’s policies and procedures and signed statement agreeing to follow the elder abuse reporting laws. Add the fingerprint clearance when it arrives.

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