Jan 23 2025 | Reporting Facility Investigation Outcome – 5 Day Requirement

There is a portion of the federal requirements related to facility investigations of abuse, neglect, exploitation, or mistreatment that has historically received little attention. However, that will be changing. Following recent discussions with Residential Care Services (RCS) headquarters staff, 2025 will bring heightened attention on this portion of the requirements of participation that is often overlooked related to reporting outcomes of facility investigations.

Facilities are well aware that F609 and F610 require reporting and investigation of all allegations of abuse, neglect, exploitation, or mistreatment. However, a portion of the requirement that facilities can anticipate surveyors/complaint investigators exploring with heightened focus is that a facilty must also report the results of all investigations to the administrator or his/her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

This requirement is not new. This means that facilities have to report back to the department (RCS) via the Complaint Resolution Hotline the results/outcome of your investigation, as well as what actions the facility has taken to address the issue, protect resident, and/or prevent repeated incidents. The facility needs to maintain documentation that this has occurred, as well as document that the administrator (or designated representative) has also been informed of the results of investigations. If a designated representative is utilized, this needs to be part of the facility’s policy and individuals need to understand that role.

The Center for Medicare and Medicaid Services (CMS) states that as a result of a facility’s investigation, if an alleged violation is verified, the facility must take appropriate corrective action to protect residents. The facility should oversee the implementation of corrective action and evaluate whether it is effective. While some corrective actions may be limited in scope, facilities should determine whether more systemic actions may be necessary to prevent recurrence of the situation. In addition, the Quality Assessment & Assurance committee should monitor the reporting and investigation of the alleged violations, including assurances that residents are protected from further occurrences and that corrective actions are implemented, as necessary.

Each facility needs to have a systematic process to ensure that these actions are occurring with each and every facility investigation of abuse, neglect, exploitation, or mistreatment. These steps are not only necessary to meet the requirements, they are primarily to protect residents but also necessary for your facility to mitigate risk.

It is important to note that the Critical Element Pathways utilized by surveyors/complaint investigators specifically address these requirements through record review and interviews of facility staff. For example, the administrator can expect to be asked questions which are not limited to the following:

• When were you notified of the allegation and by whom?
• When was the initial report reported to required agencies and law enforcement if necessary?
• When were the results of the investigation reported to you and the required agencies?
• When and what actions were taken to protect the alleged victim and other residents from harm/further incident during and after the investigation was completed?

Surveyors/complaint investigators will also ask about the facility’s systems for prevention, reporting, and investigating abuse, neglect, exploitation, and mistreatment. CMS clearly directs the state to cite the facility if they did not report the results of all investigations within five working days to the administrator or his/her designated representative and to other officials in accordance with State law (including to the State survey and certification agency).

As mentioned, facilities can expect a heightened regulatory focus on this portion of this regulation in 2025. If you have questions, please contact Elena Madrid, Executive Vice President for Education and Regulatory Affairs.