Jeannine LeCompte, Compliance Research Specialist
A long-term care facility that is the recipient of Medicare or Medicaid funding is legally obligated to ensure that there is no fraud, waste, and abuse in any of its systems or processes. This includes the nature and quality of any investigations into incidents involving fraud, waste, and abuse.
The Department of Health will cite facilities when there are failures in the investigation process. Failures can include investigations not completed in a timely manner, documentation which does not support the conclusion, lack of sufficient information for a conclusion to be drawn, incomplete or contrary information, and even the lack of an investigation.
Conducting investigations properly is an important component of adhering to Compliance and Ethics obligations.
F607 of the State Operations Manual Appendix PP – Guidance to Surveyors for Long Term Care Facilities states that all facilities must develop and implement written policies and procedures that establish policies and procedures to investigate all cases of abuse, neglect, and exploitation of residents and misappropriation of resident property. Furthermore, facilities are obligated to include training as required and establish coordination with their Quality Assurance and Performance Improvement (QAPI) programs.
The policies and procedures must include the following seven components: screening, training, prevention, identification, investigation, protection, and reporting/response.
F607 also states that the facility’s written procedures for investigations must include:
- Investigating different types of alleged violations;
- Identifying and interviewing all involved persons, including the resident/alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations;
- Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and
- Providing complete and thorough documentation of the investigation.
Element 1, Standards, Policies, and Procedures, of the OIG’s seven Elements, requires written policies for program activities, including oversight of qualify of care, protection of residents’ rights, and response to reports of concerns. Written protocols guiding the investigation process are an important component of a Compliance and Ethics Program.
