Written Procedures

5310.1 - Written Procedures (Rev. 212; Issued; 02-10-23; Effective: 10-21-22; Implementation: 10-24-22) The State must develop and implement written procedures for the timely review and investigation of allegations of resident abuse and neglect, and misappropriation of resident property, including both complaints and facility-reported incidents. The State’s policies and procedures must be consistent with Federal requirements as well as with procedures in the State Operations Manual. Nursing homes send the following types of incidents to the State Survey Agency: • All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property; • The results of all facility investigations involving alleged violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property; and • Reasonable suspicions of crimes against nursing home residents. NOTE: If the SA receives information that a suspected crime may have occurred in a facility and there is indication that it has not been reported or the SA cannot verify that a report was made to law enforcement, then the SA forwards the information from the initial report immediately to law enforcement. The SA must follow applicable laws and regulations related to information disclosures, privacy and confidentiality, as it makes referrals. The SA may also contact the CMS Location office for more information. A. Initial Reporting of Facility-Reported Incidents The information collected during intake is critical in determining what may be occurring in a facility and the effect(s) that it may have on residents. While States have discretion in how they collect information from facilities (e.g., through electronic submission), at a minimum, the State Survey Agency must provide instructions to the facility and collect sufficient information to determine how the incident should be prioritized. See also Exhibit XX for sample instructions with examples of information and Appendix PP, Tag F609. If the facility has not provided sufficient information, the SA should take this into consideration as it triages the incident. 1. Facility Reported Incidents – Initial Report The facility must provide in its report sufficient information to describe the alleged violation and indicate how residents are being protected [See §483.12(c)(3)]. It is important that the facility provide as much information as possible, to the best of its knowledge at the time of submission of the report, so that state agencies can initiate action necessary to oversee the protection of nursing home residents. See Exhibit XX for a sample form for initial reporting with examples of information and see also Appendix PP, Tag F609. B. Reporting of Investigation Findings for Facility-Reported Incidents For alleged violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, the facility is required to submit a report of the results of the investigation within 5 working days to the State Survey Agency (See 42 C.F.R. §483.12(c)(4), Tag F609 of Appendix PP of the State Operations Manual). While States have discretion in how they collect information from facilities (e.g., through electronic submission), at a minimum, the State Survey Agency must provide instructions to the facility and collect sufficient information to determine how the incident should be prioritized. 5-Day Final Report of Suspected Allegation Within 5 working days of the incident, the facility must provide in its report sufficient information to describe the results of the investigation, and indicate any corrective actions taken, if the allegation was verified. It is important that the facility provide as much information as possible, to the best of its knowledge at the time of submission of the report, so that State agencies can initiate action necessary to oversee the protection of nursing home residents [see §483.12(c)(4)]. See Exhibit XX for a sample form for the investigation report with examples of information, and see also Appendix PP, Tag F609.