Department of Health and Human Services 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
N F  
URSING  ACILITIES  
 
C   W F
OMPLIANCE  ITH  EDERAL 
 
  R F
EGULATIONS  OR 
 
R   A  
EPORTING  LLEGATIONS 
A N  
OF  BUSE OR  EGLECT 
 
Daniel R. Levinson   
Inspector General  
 
August 2014 
OEI-07-13-00010   
   
EXECUTIVE SUMMARY:  NURSING FACILITIES COMPLIANCE WITH FEDERAL 
REGULATIONS FOR REPORTING ALLEGATIONS OF ABUSE OR NEGLECT  
OEI-07-13-00010 
 
WHY WE DID THIS STUDY 
 
To protect the well-being of residents, nursing facilities must develop and implement written 
policies related to reporting allegations of abuse, neglect, mistreatment, injuries of unknown 
source, and misappropriation of resident property (allegations of abuse or neglect).  Further, 
allegations of abuse or neglect must be reported to the facility administrator or designee and 
the State survey agency within 24 hours.  Results of investigations of these allegations must 
be reported to the same authorities within 5 working days.  Nursing facilities must also notify 
owners, operators, employees, managers, agents, or contractors of nursing facilities (covered 
individuals) annually of their obligation to report reasonable suspicions of crimes. 
 
HOW WE DID THIS STUDY  
 
This study included a: (1) review of sampled nursing facilities policies related to reporting 
allegations of abuse or neglect, (2) review of sampled nursing facilities policies related to 
reasonable suspicions of crimes, and (3) survey of administrators from those sampled 
facilities.  It also included an examination of a random sample of allegations of abuse or 
neglect identified from the sampled nursing facilities, and a review of documentation related 
to those sampled allegations. 
 
WHAT WE FOUND 
 
It is both required and expected that nursing facilities will report any and all allegations of 
abuse or neglect to ensure resident safety.  We found that 85 percent of nursing facilities 
reported at least one allegation of abuse or neglect to OIG in 2012.  Additionally, 76 percent 
of nursing facilities maintained policies that  address Federal regulations for reporting both 
allegations of abuse or neglect and investigation results.  Further, 61 percent of nursing 
facilities had documentation supporting the facilities compliance with both Federal 
regulations under Section 1150B of the Social Security Act. Lastly, 53 percent of allegations 
of abuse or neglect and the subsequent investigation results were reported, as Federally 
required. 
 
WHAT WE RECOMMEND  
 
We recommend that the Centers for Medicare & Medicaid Services (CMS) ensure that  
nursing facilities:  (1) maintain policies related to reporting allegations of abuse or neglect; 
(2) notify covered individuals of their obligation to report reasonable suspicions of crimes; 
and (3) report allegations of abuse or neglect and investigation results in a timely manner and 
to the appropriate individuals, as required.  CMS concurred with all three of our 
recommendations.  
   
   
TABLE OF CONTENTS 
 
Objectives ....................................................................................................1 

Background..................................................................................................1 

Methodology................................................................................................5 

Findings .......................................................................................................7 

Nursing facilities are required to report all allegations of abuse or 

neglect to ensure resident safety; 85 percent of nursing facilities 

reported at least one such allegation to OIG in 2012 ......................7 

Seventy-six percent of nursing facilities maintained policies  

that address Federal regulations for reporting allegations of abuse or 

neglect and subsequent investigation results ...................................9 

Sixty-one percent of nursing facilities had documentation supporting 

the facilities compliance with both Federal regulations under Section 

1150B of the SSA ..........................................................................10 

Fifty-three percent of allegations of abuse or neglect and the 

subsequent investigation results were reported,  

as Federally required .....................................................................12 

Conclusion and Recommendations ...........................................................14 

Agency Comments and Office of Inspector General 

Response........................................................................................16 

Appendixes ................................................................................................17 

A: Detailed Methodology .............................................................17 

B: Point Estimates, Sample Sizes, and Confidence Intervals .......22 

C: Means Testing Results for Specific Data Points ......................26 

D: Example of Letter Notifying Covered Individual of 

Obligation to Report Reasonable Suspicions of Crimes  ...............28 

E: Example of a Posted Notification Specifying Employees 

Rights to File a Complaint under Section 1150B of the SSA .......29 

F: Agency Comments  ...................................................................30 

Acknowledgments .....................................................................................33 

   
   
OBJECTIVES 
1. 	  To determine the extent to which nursing facilities: 
a. 	  reported allegations of abuse or neglect in 2012; 
b. 	  had written policies that address reporting allegations of abuse 
or neglect as required by Federal regulations; and 
c. 	  complied with Federal regulations related to reasonable 
suspicions of crimes under Section 1150B of the 
Social Security Act (SSA). 
2. 	  To determine the extent to which allegations of abuse or neglect were 
reported by nursing facilities in compliance with Federal regulations.  
BACKGROUND 
It is estimated that approximately 5 million, or 10 percent, of elderly 
adults are abused, neglected, or exploited annually.1 Between now and 
2050, the United States is projected to experience significant growth in its 
elderly population. In 2050, the number of Americans aged 65 and older 
is projected to be 88.5 million, more than double the population of 
40.2 million in 2010.2  Nursing facilities are likely to experience increases 
in their resident population; therefore, it is important to ensure that 
residents are protected from abuse and neglect. 
Types of Allegations  
Pursuant to Federal regulations, all nursing facility residents must not be 
subjected to abuse by anyone, including, but not limited to, facility staff.3   
Nursing facility residents also have the right to be free from 
mistreatment, neglect, and misappropriation of property.4  Further, all 
Medicare and/or Medicaid-certified nursing facilities must report alleged 
violations involving mistreatment, neglect, or abuse, including injuries of 
 
1Administration for Community Living, Release of the FY 2014  Budget Request to  
Congress, February 13, 2013.  Accessed  at 
http://acl.gov/About_ACL/Budget/docs/FY2014_ACL_CJ.pdf   on January 13, 2014. 
2 United States Census Bureau, The Next Four Decades, The Older Population in the  
United States:  2010 to 2050, May 2010.  Accessed at 
http://www.census.gov/prod/2010pubs/p25-1138.pdf   on  January 28, 2014.  
3 Centers for Medicare & Medicaid Services (CMS), State Operations Manual  
(Internet-Only  Manual), Pub. 100-07, Appendix  PP:   Guidance to Surveyors for Long  
Term Care Facilities, F223,   483.13(b), Abuse. 
4 Ibid, F224,   483.13(c), Staff Treatment of Residents.    
Nursing Facilities Compliance With Requirements for Reporting Allegations of Abuse or Neglect (OEI-07-13-00010)  1 
   
   
unknown source, and misappropriation of resident property....5,  6   Table 1 
includes CMS definitions of the terms abuse, injuries of unknown source, 
neglect, misappropriation of resident property, and mistreatment.  For the 
purposes of this study, we will use the general phrase allegations of abuse 
or neglect to refer to all types of allegations. 
Table 1: Definition of Each Type of Allegation  
Allegation  Definition  
The  willful  infliction  of  injury,  unreasonable  confinement,  intimidation,  or 
Abuse  7 
punishment with resulting physical harm, pain or mental anguish.  
An injury should be classified as an injury of unknown source  when both of  
the following conditions are met: 
1.  The source of the injury was not observed by any person or the  
source of the injury could not be explained by the resident; and 
Injuries of Unknown 
 
Source 
2.  The injury is suspicious because of the extent of the injury  or the 
location of the injury (e.g., the injury is located in an area not 
generally vulnerable to trauma) or the number of injuries observed at 
8 
one particular point in time or the incidence of injuries over time.  
Failure to provide goods and services necessary to avoid physical harm, 
Neglect  9 
mental anguish, or mental illness.  
The deliberate misplacement, exploitation, or wrongful, temporary or  
Misappropriation of 
permanent use of a residents belongings or money without the residents 
Resident Property   10 
consent.  
Mistreatment   Not defined as of March 2014.  
Source:  CMS, Memorandum to State Survey Agency Directors, S&C-05-09, Clarification of Nursing Home Reporting 
Requirements for Alleged Violations of  Mistreatment, Neglect, and Abuse, Including Injuries of Unknown Source, and 
Misappropriation of Resident Property, December 16, 2004. 
 
5 42 CFR   483.13(c)(2).  Pursuant to  42 CFR    483.5, a facility is defined as a skilled 
 
nursing  facility (SNF) that meets the requirements of sections  1819(a), (b), (c), and  (d) of  

the Act, or a nursing facility (NF) that meets the requirements of sections 1919(a), (b), 

(c), and (d) of the SSA.  For the purposes  of this report, we use the term nursing 
 
facility to refer to both Medicare skilled  nursing  facilities and Medicaid nursing 
 
facilities. 

6 All nursing  facilities participating in the Medicare and/or Medicaid programs  must be 
 
certified as meeting Federal nursing facility quality and safety requirements, including 
 
requirements regarding allegations of abuse  or neglect.  For the purposes  of this  study,  we 
 
did not  review deficiency  citations  or  actions taken for noncompliance by State survey 
 
agencies. 

7  42  CFR  488.301.  
 
8 CMS, Memorandum to State Survey Agency Directors, S&C-05-09, Clarification of 
 
Nursing Home Reporting Requirements for Alleged Violations of Mistreatment, Neglect, 
 
and Abuse, Including  Injuries of Unknown  Source, and Misappropriation of Resident  

Property, December 16, 2004. 

9 42 CFR   488.301.  

10 Ibid. 

Nursing Facilities Compliance With Requirements for Reporting Allegations of Abuse or Neglect (OEI-07-13-00010)  2 
   
   
Nursing Facilities Policies Related to Prohibiting  Abuse or 
Neglect 
Pursuant to Federal regulations, nursing facilities must develop and 
implement written policies that prohibit abuse or neglect.11 Nursing 
facilities policies prohibiting abuse or neglect must address the following 
seven components:  screening, training, prevention, identification, 
investigation, protection, and reporting/response.12 For the purposes of 
this study, we focused our review on written policies regarding reporting 
allegations of abuse or neglect. 
Reporting Allegations of Abuse or Neglect 
Nursing facilities must report all allegations of abuse or neglect13  
immediately to the nursing facility administrator or designee, State survey 
and certification agency (State survey agency), and to other officials in 
accordance with State law.14, 15   An allegation of abuse or neglect is 
required to be reported immediately; an investigation is subsequently 
conducted to determine and substantiate the allegation.  Not all allegations 
of abuse or neglect are substantiated. Nursing facilities are required to 
report the results of investigations of these allegations to the nursing 
facility administrator or designee, State survey agency, and to other 
officials in accordance with State law  within 5 working days of the 
incident.16 
In December 2004, CMS sent a memorandum to State survey agency 
directors clarifying the nursing facility reporting regulations at 
 
11 42 CFR   483.13(c).  See also CMS, State Operations Manual (Internet-Only  Manual), 

Pub.  100-07, Appendix  PP:  Guidance to Surveyors for Long Term Care Facilities, F226, 

 483.13(c), Staff Treatment  of  Residents. 
  
12 Ibid. 

13 Nursing facilities may become aware of allegations of abuse or neglect through many  

sources.  These sources may include:  residents, family members of residents, and nursing 

facility staff. 

14 42 CFR   483.13(c)(2).  State law may stipulate that nursing  facilities report 

allegations  of abuse to additional State officials beyond those specified in  Federal 
requirements. 
15 Generally, if a State survey agency determines that a nursing facility fails to comply 
with a specific requirement (e.g., failure to report an allegation of abuse or  neglect), the 
facility may receive a deficiency citation.  For the purposes of this study, we did not 
review deficiency citations  or actions taken for noncompliance by State survey agencies. 
16 42 CFR   483.13(c)(4).  State law may stipulate that nursing  facilities report 
investigative results to additional State officials beyond those specified in  Federal 
requirements.  No State law can override the obligation  of a Medicare and/or Medicaid 
certified  nursing  facility to fulfill the requirements at 42 CFR   483.13(c), including  
42 CFR  483.12(c)(2) and  (4).  Therefore,  States may not  establish longer timeframes 
for reporting than those mandated in the requirements at 42 CFR    483.13(c)(2) and (4).  
Nursing Facilities Compliance With Requirements for Reporting Allegations of Abuse or Neglect (OEI-07-13-00010)  3 
   
   
42 CFR  483.13(c)(2) and (4).17  The memorandum reiterated the 
reporting of allegations of abuse or neglect and the results of the 
investigations by nursing facilities to the State survey agency.  In this 
memorandum, CMS also clarified the requirement that nursing facilities 
report allegations of abuse or neglect immediately by defining the term  
immediately to mean as soon as possible, but ought not to exceed 
24 hours after discovery of the incident, in the absence of a shorter State 
timeframe requirement.18   
Reporting Reasonable Suspicions of Crimes 
Section 6703(b)(3) of the Elder Justice Act of 2009 amends the SSA by 
adding section 1150B.19  Section 1150B requires owners, operators, 
employees, managers, agents, or contractors of nursing facilities (covered 
individuals) in applicable nursing facilities to report any reasonable 
suspicion of crimes committed against a resident of that facility to the 
appropriate entities (e.g., law enforcement entities).20 The nursing 
facilitys responsibility to report all allegations of abuse or neglect is 
separate from a covered individuals responsibility outlined in 
Section 1150B. 
Section 1150B requires applicable nursing facilities  to annually notify 
covered individuals of their obligation to report to the appropriate entities  
any reasonable suspicions of a crime.21  Nursing facilities may not retaliate 
against covered individuals who lawfully report a reasonable suspicion of 
a crime.22  Further, nursing facilities are required to clearly post a notice 
for employees specifying employees rights to file a complaint under 
Section 1150B.23  
 
17 CMS, Memorandum to State Survey Agency Directors, S&C-05-09, Clarification of  
Nursing  Home Reporting Requirements for Alleged Violations of Mistreatment, Neglect, 
and Abuse,  Including Injuries  of Unknown  Source, and  Misappropriation of  Resident  
Property, December 16, 2004. 
18 Ibid. 
19 Elder Justice Act of 2009  (EJA), P.L. 111-148, title VI, subtitle H,  6703(b)(3), 
adding SSA  1150B,  42  U.S.C.   1320b-25.  The EJA was enacted as part of the Patient  
Protection and Affordable Care Act (PPACA).  The PPACA (P.L. 111-148, enacted on 
March  23, 2010) was amended  by the Health Care and Education Reconciliation  Act of 
2010  (P.L. 111-152, enacted on March  30, 2010).  Together, these laws are referred to as 
the Affordable Care Act (ACA).   
20  SSA  1150B.  Applicable nursing facilities include those facilities that receive at least 
$10,000 in  Federal funds under the SSA  during the preceding year.  Further, the law of  
the applicable political subdivision in which the long-term-care facility is located  defines 
the meaning of the phrase reasonable suspicion of a crime.   
21  SSA  1150B(a)(2). 
22  SSA  1150B(d).  
23  SSA  1150B(d)(3).  
Nursing Facilities Compliance With Requirements for Reporting Allegations of Abuse or Neglect (OEI-07-13-00010)  4 
   
   
In June 2011, CMS sent a memorandum to State survey agency directors 
that described the regulations related to reporting reasonable suspicions of 
crimes set forth in Section 1150B and provided answers to frequently 
asked questions.24  In this memorandum, CMS also indicated that nursing 
facilities policies should address the mechanism for documenting that all 
covered individuals have been notified annually of their reporting 
obligations.25   The memorandum further indicated that [e]xamples of 
such documentation may include a copy of a notice or letter sent to 
covered individuals or a completed training/orientation attendance sheet 
specifying reporting obligations. 
Related Reports 
In 2006, the Office of Inspector General (OIG) conducted an evaluation 
entitled Nursing Home Complaint Investigations (OEI-01-04-00340), 
which found that State agencies did not investigate some of the most 
serious nursing home complaints within required timeframes; States did 
not take full advantage of the available complaint reporting system; and, in 
a targeted review of five States, State agencies followed protocol for 
intake and triage but followup letters to complainants often lacked 
meaningful information.26  
METHODOLOGY 
We conducted this study in two parts.  The first part included a: 
(1) review of policies related to reporting allegations of abuse or neglect 
from a sample of 250 nursing facilities from two strata, as shown in 
Table 2, (2) review of the sampled nursing facilities policies and 
procedures related to reasonable suspicions of crimes, and (3) survey of 
administrators from the sampled nursing facilities.  All estimates for part 
one are projected to the population of nursing facilities.27  
   
 
24 CMS, Memorandum to State Survey Agency Directors, S&C: 11-30-NH, Reporting 
 
Reasonable Suspicion  of a Crime in a Long-Term Care Facility (LTC):  Section  1150B of 

the SSA,  June 17, 2011.  The memorandum  was revised on January 20, 2012, to include 

an updated questions-and-answers section and appendix. 
 
25 Ibid. 

26 OIG,  Nursing  Home Complaint Investigations (OEI-01-04-00340), July 2006. 

27  We  received information from 245 of the 250 nursing facilities in our sample resulting 

in a 98 percent response rate.  Therefore, the projected population  for  our sample is 

15,550 instead of 15,854. 
 
Nursing Facilities Compliance With Requirements for Reporting Allegations of Abuse or Neglect (OEI-07-13-00010)  5 
   
   
Table 2: Nursing Facility  Population and Sample Size 
Population  Sample 
Stratum Definition  
Size  Size 
Nursing Facilities That Have a Total Certified Size Greater  
6,347  125 
Than or Equal to 113 Beds  (Large Facilities)  
Nursing Facilities That Have a Total Certified Size Less Than 
9,507  125 
113 Beds (Small Facilities)  
Total  15,854   250 
 
Source:  OIG analysis of the Certification and Survey Provider Enhanced Reporting database as of  
March 26, 2013. 
The second part of this study included an examination of a sample of 
301 allegations of abuse or neglect (from the population of 
2,502 allegations) identified by the nursing facilities in the first part of the 
study.  The second part included a review of documentation related to 
sampled allegations of abuse or neglect (e.g., investigation records).  All 
estimates for part two are projected to the population of allegations of 
abuse or neglect reported by sampled nursing facilities from part one.  See 
Appendix A for a detailed description of our methodology. 
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General 
on Integrity and Efficiency. 
   
Nursing Facilities Compliance With Requirements for Reporting Allegations of Abuse or Neglect (OEI-07-13-00010)  6 
   
   
FINDINGS 
Nursing facilities are required to report all allegations 
of abuse or neglect to ensure resident safety; 
85 percent of nursing facilities reported at least one 
such allegation to OIG in 2012 
It is both required and expected that nursing facilities will report any and 
all allegations of abuse or neglect to ensure resident safety.  Eighty-five 
percent of nursing facilities reported at least one allegation of abuse or 
neglect to OIG in 2012.  An allegation of abuse or neglect is required to be 
reported immediately; an investigation is subsequently conducted to 
determine and substantiate the allegation.  Not all allegations of abuse or 
neglect are substantiated.28 Allegations of abuse or neglect include the 
following types: abuse, injuries of unknown source, misappropriation of 
resident property, neglect, or mistreatment.  A total of 149,313 allegations 
of abuse or neglect were reported by facilities to OIG in 2012.  Nursing 
facilities identified the type and nature of allegations that occurred.  
Abuse was the most common type of allegation, accounting for half of the 
allegations in 2012. See Table 3 for information regarding the types of 
allegations that nursing facilities reported to OIG in 2012.  Nursing 
facilities described the individuals involved in the alleged incidents by 
identifying the nature of the allegations (e.g., resident to resident).  
Nursing facilities identified 40 percent of allegations as employee to 
resident. See Table 4 for information regarding the nature of allegations of  
abuse or neglect that nursing facilities reported to OIG in 2012.  See 
Appendix B for all estimates and 95-percent confidence intervals for 
projections. 
   
 
28 For the purposes of this study, we did not  determine whether the allegations of abuse or  
neglect reported by  the sampled nursing facilities were substantiated.  
Nursing Facilities Compliance With Requirements for Reporting Allegations of Abuse or Neglect (OEI-07-13-00010)  7 
   
   
Table 3:  Types of Allegations of Abuse or Neglect That Nursing 
Facilities Reported in 2012  
Number of   Projected  
Allegations in  Number of   Percentage of  
Type of Allegation  
Sample  Allegations  Allegations 
(n=2,502)   (N=149,313) 
Abuse  1,265   75,658   50.7 
Injuries of unknown source   476  27,759   18.6 
Misappropriations of resident property   392  22,281   14.9 
Neglect  275  17,553   11.8 
Mistreatment 92  5,961   3.9 
Other 2  102  0.1 
     Total   2,502   149,314*   100 
Source:  OIG analysis of allegations of abuse or neglect reported by nursing facilities, 2014.  
 
* Numbers do not total precisely because of rounding.  
 
Table 4:  Nature of Allegations of Abuse or Neglect That Nursing 
Facilities Reported in 2012  
Number of   Projected  
Allegations in  Number of   Percentage of  
Nature of Allegation  
Sample  Allegations  Allegations 
(n=2,502)   (N=149,313) 
Employee  to resident  1,010   60,132   40.3 
Perpetrator unknown   659  39,099   26.2 
Resident to resident  600  36,078   24.2 
Resident self-neglect (e.g., resident self-inflicted injury)   89  5,733   3.8 
Family or other visitor to resident  59  3,476   2.3 
Nature not specified  46  2,538   1.7 
Resident to employee   25  1,320   0.9 
Outside medical professional to resident  14  938  0.6 
     Total   2,502   149,314*   100 
Source:  OIG analysis of allegations of abuse or neglect reported by nursing facilities, 2014.  
 
* Numbers do not total precisely because of rounding. 
Nursing Facilities Compliance With Requirements for Reporting Allegations of Abuse or Neglect (OEI-07-13-00010)  8 
   
   
When we reviewed facilities on the basis of size, we found that 87 percent  
of large nursing facilities had allegations of abuse or neglect in 2012, and 
84 percent of small nursing facilities had allegations of abuse or neglect.29,  30  
Seventy-six percent of nursing facilities maintained 
policies that address Federal regulations for reporting 
both allegations of abuse or neglect and subsequent 
investigation results 
Nursing facilities must have policies that prohibit abuse or neglect, which 
must include policies for reporting allegations of abuse or neglect and the 
subsequent investigation results to the appropriate individuals within the 
required timeframes.  In 2012, 76 percent of nursing facilities 
(11,744 facilities) maintained policies that address Federal regulations for 
reporting both allegations of abuse or neglect and subsequent investigation 
results. Ninety-five percent of nursing facilities had policies that reflected  
Federal regulations for reporting allegations of abuse or neglect.  
Seventy-six percent of nursing facilities had policies that reflected Federal 
regulations for reporting subsequent investigation results of allegations of 
abuse or neglect. See Table 5 for the number and percentage of nursing 
facilities that had policies that address Federal regulations for reporting 
allegations of abuse or neglect. 31  
   
 
29 Per our methodology in  Appendix A, we define large nursing facilities as facilities that 
have a total certified size greater than  or equal to 113  beds.  We  define small facilities as 
facilities that have a total  certified size less than 113 beds.  
30  We  did not identify a statistically significant difference (p=0.48) between these two 
types of  nursing homes.  See  Table C-1 in  Appendix C.  
31 The remaining 24  percent of  nursing  facilities maintained written  policies that prohibit 
abuse or neglect; however, these policies did not address the Federal requirements related 
to reporting allegations  of abuse or  neglect and/or the investigation results.  Further,  we 
did  not identify a statistically significant difference (p=0.52) between nursing facilities 
that maintained  policies and those facilities that did  not maintain  policies with  regard to  
reporting allegations of abuse or  neglect in part one of this  study.  See Table C-2 in  
Appendix C.  
Nursing Facilities Compliance With Requirements for Reporting Allegations of Abuse or Neglect (OEI-07-13-00010)  9 
   
   
Table 5: Nursing Facilities That Maintained Policies That Addressed 
Federal Regulations for Reporting Allegations of  Abuse or Neglect 
Percentage of  
Nursing 
Number of   Projected  
Facilities That 
Nursing  Number of  
Maintained 
Federal Regulations   Facilities  Nursing 
Policies That 
in sample  Facilities 
Addressed  
(n=245)   (N=15,550)  
Federal 
Regulations  
Allegations of abuse or neglect must be immediately  
reported to the nursing facility administrator or designee  232  14,738   94.8 
and the State survey agency 
Investigation results must be reported to the nursing  
facility administrator or designee and the State survey   185  11,871   76.3 
agency  within 5 working days of the incident 
     Total number of nursing facilities that had 
183  11,744   75.5* 
policies that addressed both Federal regulations  
Source:  OIG analysis of nursing facilities reporting policies, 2014. 
*The actual percentage of nursing facilities  that addressed  both Federal regulations  is  75.52 percent.  The actual number, 
75.52, rounds to 75.5.  As a whole number, this  percentage rounds to 76 percent. 
When we reviewed facilities on the basis of size, we found that 70 percent  
of large nursing facilities maintained policies that addressed both reporting 
allegations of abuse or neglect and reporting the investigation results.  
Seventy-nine percent of small nursing facilities maintained such policies.32  
Sixty-one percent of nursing facilities had 
documentation supporting the facilities compliance 
with both Federal regulations under Section 1150B of 
the SSA 
Under Section 1150B of the SSA, nursing facilities must annually notify 
covered individuals (i.e., owners, operators, employees, managers, agents, 
or contractors of nursing facilities) of their obligation to report to the 
appropriate entities any reasonable suspicion of a crime.  Further, nursing 
facilities must also clearly post a notice specifying employees rights to 
file a complaint under Section 1150B.  In 2012, 61 percent of nursing 
facilities (9,487 facilities) had documentation to support that both of these 
regulations were met.  See Table 6 for the number and percentage of 
nursing facilities that had documentation to support that Federal 
regulations related to reporting reasonable suspicions of crimes were met. 
   
 
32  We  did not identify a statistically significant difference (p=0.12) between these two 
types of  nursing homes.  See  Table C-3 in  Appendix C.  
Nursing Facilities Compliance With Requirements for Reporting Allegations of Abuse or Neglect (OEI-07-13-00010)  10 
   
   
Table 6: Nursing Facilities with Documentation to Support That Federal 
Regulations Related to Reasonable Suspicions of Crimes Were Met 
Percentage of  
Number of   Projected  
Nursing Facilities 
Nursing  Number of  
with Documentation  
Federal Regulations   Facilities in  Nursing 
to Support That  
Sample  Facilities 
Both Regulations 
(n=245)   (N=15,550)  
Were Met  
Nursing facility must annually notify covered 
individuals of their obligation to report to the 
162  10,400   66.8 
appropriate entities any reasonable suspicion 
of a crime 
Nursing facility must clearly post a notice for its 
employees specifying employees rights to file a  195  12,429   79.9 
complaint under Section 1150B of the SSA 
     Total number of nursing facilities with 
documentation to support that both  148  9,487   61.0 
regulations were met  
Source:  OIG analysis of nursing facilities submitted documentation regarding reasonable  suspicion of crimes, 2014. 
Nursing facilities provided various types of documentation to support that 
covered individuals were notified of their obligation to report reasonable 
suspicions of crimes.  Examples of documentation provided included 
letters to employees, employee training logs, Employee Bill of Rights, and 
employee-signed attestations.  See Appendix D for an example of a letter 
notifying a covered individual of his/her obligation to report reasonable 
suspicions of crimes. 
Nursing facilities also provided various types of documentation supporting 
compliance with the requirement to post notification specifying 
employees rights to file a complaint under Section 1150B of the SSA.  
Examples of documentation provided included copies of posters 
specifying rights, photographs of posted documentation in employee break 
rooms, and posted Employee Bill of Rights.  See Appendix E for an 
example of a posted notification specifying employees rights to file a 
complaint. 
When we reviewed facilities on the basis of size, we found that 57 percent  
of large nursing facilities had documentation to support that both Federal 
regulations related to reasonable suspicions of crimes were met.  Sixty-three 
percent of small nursing facilities had such documentation.33  
 
33  We  did not identify a statistically significant difference (p=0.32) between these two 
types of  nursing homes.  See  Table C-4 in  Appendix C.  
Nursing Facilities Compliance With Requirements for Reporting Allegations of Abuse or Neglect (OEI-07-13-00010)  11 
   
   
Fifty-three percent of allegations of abuse or neglect 
and the subsequent investigation results were 
reported, as Federally required 
In 2012, 53 percent of allegations of abuse or neglect and the subsequent 
investigation results (1,338 allegations) were reported, as Federally 
required. Sixty-three percent of allegations of abuse or neglect were 
immediately reported to the nursing facility administrator or designee and 
the State survey agency, as required. Further, the subsequent investigation 
results for 63 percent of allegations  of abuse or neglect were reported to 
the appropriate individuals within 5 working days, as required.  See 
Table 7 for the number and percentage of allegations of abuse or neglect 
that were reported in compliance with Federal regulations. 
Table 7: Allegations of Abuse or Neglect That Were Reported by Nursing 
Facilities in Compliance With Federal Regulations 
Number of   Projected  
Allegations  Number of   Percent of 
Federal Regulations  
in Sample  Allegations  Allegations 
(n=301)   (N=2,502)  
Allegations of abuse or neglect must be immediately  
reported to the nursing facility administrator or designee  189  1,571   62.8 
and the State survey agency 
Investigation results must be reported to the nursing facility  
administrator or designee and the State survey agency   191  1,588   63.4 
within 5 working days of the incident 
     Total number of allegations of abuse or neglect that 
were reported in compliance with both Federal   161  1,338   53.4 
regulations   
Source:  OIG analysis of documentation for allegations of  abuse or neglect provided by nursing facilities, 2014. 
When we reviewed facilities on the basis of size, we found that 57 percent 
of allegations of abuse or neglect were from large nursing facilities that 
provided documentation to support that allegations were reported in 
compliance with Federal regulations.  Forty-seven percent of small 
nursing facilities had such documentation.34  
Nursing facilities provided various types of documentation to support that 
allegations of abuse or neglect were reported in compliance with Federal 
regulations. Examples of documentation provided included copies of 
incident report forms signed and dated by the facility administrator, copies  
of facsimiles sent to the State survey agency, and copies of email 
 
34  We  did not identify a statistically significant difference (p=0.07) between these two 
types of  nursing homes.  See  Table C-5 in  Appendix C.  
Nursing Facilities Compliance With Requirements for Reporting Allegations of Abuse or Neglect (OEI-07-13-00010)  12 
   
   
confirmations from the State survey agency to the facility administrator  
regarding receipt of notification about the allegation of abuse. 
Nursing facilities also provided various types of documentation to support 
that investigation results of allegations of abuse or neglect were reported 
in compliance with Federal regulations.  Examples of documentation 
provided included copies of investigation report forms signed and dated by 
the facility administrator, copies of facsimiles sent to the State survey 
agency, and copies of screenshots from State reporting systems indicating 
that investigation results were reported to the State survey agency within 
the required timeframe. 
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CONCLUSION AND RECOMMENDATIONS 
It is both required and expected that nursing facilities will report any and 
all allegations of abuse or neglect to ensure resident safety.  Eighty-five 
percent of nursing facilities reported at least one allegation of abuse or 
neglect to OIG in 2012.  Seventy-six percent of nursing facilities 
maintained policies that address Federal regulations for both reporting 
allegations of abuse or neglect and subsequent investigation results.  
Further, 61 percent of nursing facilities had documentation supporting the 
facilities compliance with both Federal regulations under Section 1150B 
of the SSA.  Lastly, 53 percent of allegations of abuse or neglect and the 
subsequent investigation results were reported, as Federally required. 
Given the increasing elderly population in the United States and the 
growing number of individuals over age 65 receiving care in nursing 
facilities, elder abuse or neglect is likely to increase as well.  To ensure 
quality of care for this vulnerable population, we recommend that CMS: 
Ensure that nursing facilities maintain policies related to 
reporting allegations of abuse or neglect 
To ensure that CMS reaches all nursing facilities that may be out of 
compliance, CMS could update guidance that clearly describes the 
reporting regulations that should be established in facilities written 
policies for reporting allegations of abuse or neglect and the subsequent 
investigation results.  We will provide to CMS a list of the nursing 
facilities in our sample that did not address Federal regulations for 
reporting allegations of abuse or neglect and investigation results in their 
written policies.   CMS should take appropriate action to ensure these 
nursing facilities have the pertinent policies.  
Ensure that nursing facilities comply with their responsibilities 
under Section 1150B of the SSA  
To support nursing facilities implementation of Federal regulations, CMS  
could develop and share reporting templates.  For example, CMS could 
develop: (1) customizable templates of annual notification letters to 
covered individuals and (2) posters and materials describing employees  
rights to file a complaint under Section 1150B of the SSA.  Further, CMS  
could reissue guidance that recommends that nursing facilities maintain 
adequate documentation to support that they notified covered individuals.  
We will provide to CMS a list of the nursing facilities in our sample that 
did not have documentation to support that covered individuals were 
notified and notification was posted. 
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Ensure that nursing facilities report allegations of abuse or 
neglect and investigation results in a timely manner and to the 
appropriate individuals, as required 
To ensure that CMS reaches all nursing facilities that may be out of 
compliance, CMS could reissue guidance that clearly describes the 
timeframes and appropriate individuals for which allegations of abuse or 
neglect and the subsequent investigation results should be reported.  CMS  
should reiterate in this guidance that all allegations of abuse or neglect 
must be reported to the State survey agency, as required by Federal law.   
Further, the guidance could recommend that nursing facilities maintain 
adequate documentation to support that allegations of abuse or neglect are 
reported in compliance with these regulations.  We will provide to CMS a 
list of the nursing facilities in our sample that did not report allegations of 
abuse or neglect and investigation results in compliance with Federal 
regulations for appropriate action. 
   
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AGENCY COMMENTS AND OFFCIE OF INSPECTOR GENERAL  
RESPONSE 
CMS concurred with all three of our recommendations. 
In responding to our first recommendation, CMS stated that it previously 
distributed guidance related to the proper reporting of allegations of abuse 
or neglect via Survey and Certification memoranda provided to State 
agency directors and posted on the CMS Web site.  Additionally, CMS 
stated that it distributed a training toolkit to State survey directors 
regarding reporting regulations and guidance related to Section 1150B of 
the SSA. CMS further stated that it would advise State agencies and 
providers to use the various resources that it had made available, such as 
the State Operations Manuals and Survey and Certification memoranda.  
Lastly, CMS stated that it would explore additional opportunities to 
promote compliance with Section 1150B of the SSA. 
In responding to our second recommendation, CMS stated that it holds 
conference calls with stakeholders to discuss nursing facility issues and 
that it would use these calls to discuss and reinforce Section 1150B 
reporting regulations. CMS also stated that it provided guidance to State 
agency directors regarding the information that should be included in the 
posted notice about employees right to file a complaint under Section 
1150B of the SSA.  CMS stated that it would consider OIGs 
recommendation to draft such materials as:  (1) customizable templates of  
annual notification letters to covered individuals and (2) posters and 
materials describing employees rights to file a complaint under Section 
1150B of the SSA. 
In responding to our third recommendation, CMS stated that it would 
discuss OIGs report results with State agency directors and reiterate 
covered individuals reporting obligation timelines and regulations.  CMS 
also stated that it would update or reissue guidance on this issue, as 
necessary.  
We support CMSs efforts to address these issues and encourage continued 
progress, including taking appropriate action for those nursing facilities 
that did not comply with Federal regulations.   For the full text of CMSs 
comments, see Appendix F.  
   
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APPENDIX A 
Detailed Methodology 
Part One 
Nursing Facility Population and Sample Selection 
We selected a stratified random  sample from the population of 
15,854 nursing facilities listed in the Certification and Survey Provider 
Enhanced Reporting (CASPER) database as of March 26, 2013.35   To  
produce overall estimates of the number and percentage of nursing 
facilities that complied with Federal regulations related to reporting 
allegations of abuse or neglect, we selected a sample of 250 nursing 
facilities from 2 strata as shown in Table A-1.36    
Table A-1: Nursing Facility  Population and Sample Size 
Population  Sample 
Stratum Definition  
Size  Size 
Nursing facilities that have a total certified size 
6,347  125 
greater than or equal to 113 beds  
Nursing facilities that have a total certified size less  
9,507  125 
than 113 beds  
Total  15,854   250 
Source:  OIG analysis of CASPER  database as of March 26, 2013. 
We stratified our sample to determine whether the bed size of a nursing 
facility had any effect on whether it would have more or fewer allegations 
of abuse or neglect. Further, we wanted to determine whether the bed size 
of a nursing facility would affect whether the facility had policies related 
to allegations of abuse or neglect. 
Data Collection 
For each of the 250 sampled nursing facilities, we sent the nursing facility 
administrator a letter requesting (1) documentation of any policies related 
to allegations of abuse or neglect, (2) documentation supporting that all 
covered individuals were notified of their obligation to report reasonable 
suspicions of crimes, (3) documentation to support that the facility posted 
 
35 This population included  both Medicare- and Medicaid-certified nursing facilities as of  
March  26, 2013.  As such, the population  of nursing facilities from which  we selected our 
sample included  both Medicare skilled  nursing  facilities and  Medicaid  nursing facilities.  
Pursuant to 42  CFR   483.5, a facility is defined as a skilled nursing  facility that 
meets the requirements of sections 1819(a), (b), (c), and (d) of the SSA or a nursing  
facility that meets the requirements of sections  1919(a), (b), (c), and  (d) of the SSA.  For 
the purposes of this report, we use the term nursing  facility to  refer to both Medicare 
skilled nursing facilities and Medicaid nursing facilities. 
36  We established the two strata using a rule for forming strata boundaries developed by  
W.G. Cochran, founder of the Harvard Statistics Department. 
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notification specifying employees  rights to file a complaint under 
Section 1150B of the SSA, and (4) completion of a mail survey regarding  
allegations of abuse or neglect. We also requested that the nursing facility 
administrator identify the total number of allegations of abuse or neglect 
that occurred in the facility during 2012 and indicate the type of each 
allegation (e.g., abuse, neglect) and the nature of each allegation (e.g., the 
allegation involved a resident abusing another resident, the allegation 
involved an employee neglecting a resident).  We sent a second letter to 
nursing facility administrators who did not respond to our initial request.  
We sent a final letter with confirmation of receipt through the United 
Parcel Service to those nursing facilities that did not respond to the second 
request. In a last attempt to contact the nonresponsive nursing facilities, 
we contacted the administrators by telephone to verify that the facility was 
open and whether the administrator intended to respond to our request. 
We received responses from 245 of the 250 sampled nursing facilities 
from which we requested documentation, a response rate of 98 percent.  
For the other five sampled facilities,  four nursing facility administrators 
did not respond to our request.37, 38   The fifth nursing facility was closed in 
September 2012 by court order and the requested documentation was in 
the possession of the State in which the facility was located.39 Because of 
the nonresponse of 5 nursing facilities (2 percent of our sample), all 
estimates are projected to a population of 15,550 nursing facilities instead 
of the population of 15,854 facilities. 
Data Analysis  
We determined whether the sampled nursing facilities  policies regarding 
abuse or neglect addressed reporting allegations of abuse or neglect and 
the results of investigations to the appropriate authorities and within the 
specified timeframes.  We also determined whether the sampled nursing 
facilities had documentation supporting that (1) all covered individuals 
were notified of their obligation to report reasonable suspicions of crimes, 
 
37  We collected  data for part  one of the study from June 24, 2013, through 
August 31, 2013.  Because data collection for part two of the study was dependent on the  
total number of allegations of abuse or neglect identified in  part  one, those  nursing 
facilities that did not respond to our final request by August 31, 2013, were deemed  
nonresponders.  Two of the four nonresponders submitted the requested documentation  
approximately two weeks after data collection ended for part one of the study.   The  
information provided by these facilities was not included in  our data analysis for this 
study.  
38  We  referred the nursing facilities that did not respond to  our request to CMS for 
appropriate action. 

39 The court-appointed receiver for this nursing facility provided documentation 

supporting that the facility was closed  by the States superior court in  2012; as a result, 

all facility records were in the possession of the State.  We did not seek the 

documentation from the State. 

Nursing Facilities Compliance With Requirements for Reporting Allegations of Abuse or Neglect (OEI-07-13-00010)  18 
   
   
and (2) that the facility posted notification specifying employees rights to 
file a complaint under Section 1150B of the SSA.  Finally, we determined 
the total number of allegations of abuse or neglect for 2012 and the type 
and nature of each allegation.  
Determination of Whether Policies Address Reporting Regulations.   For 
each nursing facility that responded to our request, we reviewed 
documentation of its policies and procedures for reporting allegations of 
abuse or neglect and results of the investigation to the appropriate 
authorities and within the specified timeframes.  We considered nursing 
facilities policies to address reporting allegations of abuse or neglect if the 
policies indicated that (1) allegations  of abuse or neglect must be reported 
to the administrator or designee and the State survey agency, and (2) these 
allegations must be reported immediately (within 24 hours).  We  
considered nursing facilities policies to address reporting of results of the 
investigation if the policies indicated  that (1) results of the investigation 
must be reported to the administrator or designee and the State survey 
agency, and (2) these results must be reported within 5 working days of 
the incident.  
Determination of Whether All Covered Individuals Were Notified. For 
each nursing facility that responded to our request, we reviewed submitted 
documentation to determine whether it supported that the facility notified 
all covered individuals of their obligation to report reasonable suspicions 
of crimes.  Such documentation included copies of inservice training logs, 
copies of notices provided to the covered individuals indicating such 
obligations, and examples of signed acknowledgments of the obligation to 
report reasonable suspicions of crimes. 
Determination of Whether Nursing Facilities Posted Notification. For 
each nursing facility that responded to our request, we reviewed submitted 
documentation to determine whether it supported that the facility posted 
notification specifying employees  rights to file a complaint under 
Section 1150B of the SSA.   Such documentation included copies of 
posters specifying rights, photographs of posted documentation in 
employee break rooms, and posted Employee Bill of Rights. 
Identification of Allegations of Abuse or Neglect. We requested that each 
nursing facility administrator complete a survey identifying the total 
number of allegations of abuse or neglect in the facility during 2012.  The 
survey also asked the administrator to indicate the type of each allegation 
(e.g., abuse, neglect) and the nature of each allegation (e.g., the allegation 
involved a resident abusing another resident, the allegation involved an 
employee neglecting a resident).  We analyzed the responses of the 
245 nursing facility administrators who completed the survey and found 
Nursing Facilities Compliance With Requirements for Reporting Allegations of Abuse or Neglect (OEI-07-13-00010)  19 
   
   
that 209 of them indicated that at least one allegation of abuse or neglect 
occurred in their facilities in 2012.40  
Part Two 
Allegation Population and Sample Selection 
We constructed the total population of allegations of abuse or neglect that 
occurred in the 209 nursing facilities that reported at least one such 
allegation in 2012. The total population included 2,502 allegations of 
abuse or neglect. From this population, we selected a simple random  
sample of 301 such allegations from the two strata as shown in 
Table A-2.41   The 301 sampled allegations represent allegations of abuse or 
neglect reported by 121 nursing facilities. 
Table A-2: Population and Sample Size  
Population of   Number of  
Allegations 
Allegations  Nursing 
Stratum Definition   Sample 
Reported in Part   Facilities 
Size 
One   Represented  
Nursing facilities that have a total certified 
1,621  195  68 
size greater than or equal to 113 beds  
Nursing facilities that have a total certified 
881  106  53 
size less than 113 beds 
Total  2,502   301  121 
Source:  OIG analysis of allegations of abuse reported by nursing  facilities from part one of  this evaluation, 2014. 
Data Collection 
Nursing Facility Documentation. For each of the 121 nursing facilities 
that had a sampled allegation of abuse or neglect, we sent the 
administrator a letter requesting documentation related to the sampled 
allegation(s) (e.g., incident reports, witness statements, forms sent to the 
State survey agency, investigation results).  We sent a second letter to 
nursing facility administrators who did not respond to our initial request.  
After our second letter, we received responses from all 121 nursing 
facilities and received documentation for all 301 sampled allegations of 
abuse or neglect, a response rate of 100 percent. 
 
40  Thirty-four nursing facility administrators reported that no allegations of abuse or  
neglect occurred in their facilities in 2012.  Two nursing  facility administrators could  not 
identify the number of allegations of abuse or neglect that occurred in their facilities in  
2012 because they could not find the documentation. 
41 From each stratum, we selected a simple random sample of 12 percent of the 
population of allegations of abuse or neglect reported in  part one of the study.   This  
resulted in a sample of 301 allegations of abuse or neglect. 
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Data Analysis  
We reviewed the submitted documentation for the 301 sampled allegations 
of abuse or neglect to determine whether nursing facilities complied with 
Federal regulations. Figures derived from our analysis in part two are 
projected to the population of 2,502 allegations of abuse or neglect 
reported by nursing facilities in part one. 
Compliance with Federal Regulations for Reporting Allegations of Abuse 
or Neglect. We reviewed the submitted documentation to determine 
whether allegations of abuse or neglect were reported in accordance with 
Federal regulations. Specifically, we reviewed the documentation to 
determine whether it supported that nursing facilities reported all 
allegations of abuse or neglect within 24 hours to the administrator or 
designee and the State survey agency.42  Such documentation included 
incident report forms signed by the nursing facility administrator or 
designee, copies of facsimiles sent to the State survey agency, and printed 
screen shots of the State survey agencys online reporting form. 
Compliance with Federal Regulations for Reporting Investigation Results. 
We reviewed the submitted documentation to determine whether the 
results of investigations of allegations of abuse or neglect were reported in 
accordance with Federal regulations.  Specifically, we reviewed the 
documentation to determine whether nursing facilities reported the results 
of investigations of allegations of abuse or neglect to the nursing facility 
administrator or designee and State survey agency within 5 working days 
of the incident. Such documentation included investigation summaries 
signed by the nursing facility administrator or designee, copies of 
facsimiles sent to the State survey agency, and printed screen shots of the 
State survey agencys online reporting form. 
 
42 Nursing facilities are required to report allegations of abuse or neglect immediately, 
which has been  defined by CMS to mean as soon as possible, but ought  not exceed 
24 hours.  For the purposes of  our study, we considered  nursing facilities to  have  
complied with  this requirement if the allegation of abuse or neglect was reported within  
24 hours.   
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APPENDIX B 
Table B-1: Point Estimates, Sample Sizes, and Confidence Intervals 
Sample  Point  95-Percent 
Estimate Description  
Size  Estimate   Confidence Interval  
Finding 1:  Estimates of allegations of abuse or neglect that nursing facilities reported in 2012 
Percentage of nursing facilities that reported at least one allegation 
209  85.0%   80.4%89.6%  
of abuse or neglect in 2012 
Total number of allegations of abuse or neglect that nursing 
2,502  149,313   117,400181,226 
facilities reported in 2012 
Total abuse allegations that nursing facilities reported in 2012   1,265   75,658   60,80590,511  
Percentage of abuse allegations that nursing facilities reported in 
1,265  50.7%   43.1%58.2%  
2012  
Total injuries of unknown source allegations that nursing facilities 
476  27,759   9,07746,441  
reported in 2012  
Percentage of injuries of unknown source allegations that nursing 
476  18.6%   8.3%28.9%  
facilities reported in 2012 
Total misappropriation of resident property allegations that nursing 
392  22,281   11,57132,990  
facilities reported in 2012 
Percentage of misappropriation of  resident property allegations 
392  14.9%   8.7%21.1%  
that nursing facilities reported in 2012 
Total neglect allegations that nursing facilities reported in 2012   275  17,553   12,74522,361  
Percentage of neglect allegations that nursing facilities reported in 
275  11.8%   8.4%15.2%  
2012  
Total mistreatment allegations that nursing facilities reported in 
92  5,961   2,2169,706  
2012  
Percentage of mistreatment allegations that nursing facilities 
92  3.9%   1.5%6.5%  
reported in 2012  
Total other allegations that nursing facilities reported in 2012   2  102  0241  
Percentage of other allegations that nursing facilities reported in 
2  0.1%   0.0%0.2%  
2012  
Total employee-to-resident allegations  1,010   60,132   44,80575,459  
Percentage of employee-to-resident allegations  1,010   40.3%   32.2%48.4%  
Total perpetrator-unknown allegations  659  39,099   19,94058,258  
Percentage of perpetrator-unknown allegations  659  26.2%   16.7%35.7%  
Total resident-to-resident allegations  600  36,078   25,15846,997  
Percentage of resident-to-resident allegations  600  24.2%   17.6%30.7%  
Nursing Facilities Compliance With Requirements for Reporting Allegations of Abuse or Neglect (OEI-07-13-00010)  22 
   
   
ContinuedTable B-1: Point Estimates, Sample Sizes, and Confidence Intervals 
Sample  Point  95-Percent 
Estimate Description  
Size  Estimate   Confidence Interval  
Total resident-self-neglect allegations  89  5,733   2,5928,873  
Percentage of resident-self-neglect allegations  89  3.8%   1.7%6.0%  
Total family- or other visitor-to-resident allegations  59  3,476   2,1364,816  
Percentage of other visitor-to-resident allegations  59  2.3%   1.4%3.3%  
Total nature-not-specified allegations  46  2,538   6964,380  
Percentage of nature-not-specified allegations  46  1.7%   0.5%2.9%  
Total resident-to-employee allegations  25  1,320   02,760  
Percentage of resident-to-employee allegations  25  0.9%   0.0%1.9%  
Total outside medical professional-to-resident allegations  14  938  1991,677  
Percentage of outside medical professional-to-resident allegations  14  0.6%   0.2%1.1%  
Percentage of large nursing facilities that had at least one 
106  86.9%   80.9%92.9%  
allegation of abuse or neglect in their facility in 2012 
Percentage of small nursing facilities that had at least one 
103  83.7%   77.2%90.3%  
allegation of abuse or neglect in their facility in 2012 
Finding 2:  Estimates of nursing facilities written policies related to allegations of abuse or neglect  
Percentage of nursing facilities that had written policies that 
address both Federal regulations for reporting allegations of abuse  183  75.5%*   70.1%80.9%  
or neglect  
Total number of nursing facilities that had written policies that 
address both Federal regulations for reporting allegations of abuse  183  11,744   10,90212,586  
or neglect  
Total number of nursing facilities that had written policies that 
address reporting allegations of abuse or neglect immediately to 
232  14,738   14,29915,177  
the nursing facility administrator or designee and the State survey  
agency 
Percentage of nursing facilities that had written policies that 
address reporting allegations of abuse or neglect immediately to 
232  94.8%   91.9%97.6%  
the nursing facility administrator or designee and the State survey  
agency 
Total number nursing facilities that had written policies that 
address reporting investigation results to the nursing facility  
185  11,871   11,03912,703  
administrator or designee and the State survey agency  within 5 
working days of the incident 
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ContinuedTable B-1: Point Estimates, Sample Sizes, and Confidence Intervals 
Sample  Point  95-Percent 
Estimate Description  
Size  Estimate   Confidence Interval  
Percentage of nursing facilities that had written policies that 
address reporting investigation results to the nursing facility  
185  76.3%   71.0%81.7%  
administrator or designee and the State survey agency  within 5 
working days of the incident 
Percentage of large nursing facilities that had written policies that 
address both Federal regulations for reporting allegations of abuse  86  70.5%**   62.3%78.6%  
or neglect  
Percentage of small nursing facilities that had written policies that 
address both Federal regulations for reporting allegations of abuse  97  78.9%   71.6%86.1%  
or neglect  
Finding 3:  Estimates of nursing facilities that  had documentation to support that Federal regulations related 
to reasonable suspicions of crimes were met  
Percentage of nursing facilities that had documentation to support 
that both Federal regulations related to reasonable suspicions of  148  61.0%   54.8%67.2%  
crimes were met 
Total number of nursing facilities that had documentation to 
support that both Federal regulations related to reasonable  148  9,487   8,52110,452  
suspicions of crimes were met  
Total number of nursing facilities that had documentation to 
support that they annually notified covered individuals of their 
162  10,400   9,47211,328  
obligation to report to the appropriate entities any reasonable 
suspicions of a crime 
Percentage of nursing facilities that had documentation to support 
that they  annually notified covered individuals of their obligation to 
162  66.8%   60.9%72.8%  
report to the appropriate entities any reasonable suspicions of a 
crime 
Total number of nursing facilities that had documentation to 
support that they posted clearly a notice for its employees 
195  12,429   11,63813,220  
specifying  employees rights to file a complaint under Section 
1150B of the SSA 
Percentage of nursing facilities that had documentation  to support 
 
that they posted clearly a notice for its employees specifying  
195  79.9%   74.8%85.0%  
employees rights to file a complaint under Section 1150B of the 
SSA 
Percentage of large nursing facilities that had documentation to 
support that both Federal regulations related to reasonable  70  57.4%   48.6%66.2%  
suspicion of crimes were met  
 
Percentage of small nursing facilities that had documentation to 
support that both Federal regulations related to reasonable  78  63.4%   54.8%72.0%  
suspicion of crimes were met  
Nursing Facilities Compliance With Requirements for Reporting Allegations of Abuse or Neglect (OEI-07-13-00010)  24 
   
   
ContinuedTable B-1: Point Estimates, Sample Sizes, and Confidence Intervals 
Sample  Point  95-Percent 
Estimate Description  
Size  Estimate   Confidence Interval  
Finding 4:  Estimates of allegations of abuse or neglect that were reported by  nursing facilities in compliance  
with Federal regulations  
Percentage of allegations of abuse or neglect that were reported 
161  53.4%   48.2%58.8%  
by nursing facilities in compliance with both Federal regulations 
Total number of allegations of abuse or neglect that were reported 
161  1,338   1,2061,471  
by nursing facilities in compliance with both Federal regulations 
Total number of allegations of abuse or neglect that were reported 
immediately to the nursing facility administrator or designee and  189  1,571   1,4421,700  
the State survey  agency 
Percentage of allegations of abuse or neglect that were reported 
immediately to the nursing facility administrator or designee and  189  62.8%   57.6%67.9%  
the State survey  agency 
Total number of allegations of abuse or neglect that had 
investigation results reported to the nursing facility administrator or  
191  1,588   1,4611,715  
designee and the State survey agency  within 5 working days of the 
incident 
Percentage of allegations of abuse or neglect that had 
investigation results reported to the nursing facility administrator or  
191  63.4%   58.4%68.5%  
designee and the State survey agency  within 5 working days of the 
incident 
Percentage of large nursing facilities that reported allegations of 
111  56.9%   50.3%63.5%  
abuse or neglect in compliance with Federal regulations 
Percentage of small nursing facilities that reported allegations of 
50  47.2%   38.1%56.2%  
abuse or neglect in compliance with Federal regulations 
Source:  OIG analysis of policies, survey responses, and investigation documentation provided by nursing  facilities, 2014. 
*The actual percentage of nursing facilities that address both Fed eral regulations is 75.52 percent.  The actual number, 75.52,  rounds to  
75.5.  As a whole number, this percentage rounds to 76 percent. 
**The actual percentage of large nursing facilities  that  address both Federal  regulations is 70.49 percent.  The actual number, 70.49, 
rounds to 70.5.  However, as a whole number, this percentage rounds to 70  percent. 
Nursing Facilities Compliance With Requirements for Reporting Allegations of Abuse or Neglect (OEI-07-13-00010)  25 
   
   
APPENDIX C 
Means Testing Results for Specific Data Points  
Table C-1: Chi Square Analysis on Reported Allegations of Abuse or Neglect and 
Nursing Facility Type  
Nursing Facility Type Compared   Group A   Group B  Wald Chi-Square   F-Test Degrees of 
P-Value  
(Group A  vs. Group B)   Rate   Rate   Test Statistic   Freedom  
Large nursing facilities vs. small nursing  numerator = 1  
5,382  7,834   0.502   0.4793  
facilities  
denominator = 244 
Source:  OIG analysis of  survey responses provided by nursing facilities, 2014.  
 
Table C-2: Chi Square Analysis on Reporting Allegations of Abuse or Neglect in Part 
One of This Study and Nursing Facility Type 
Nursing Facility Type Compared   Group A   Group B  Wald Chi-Square   F-Test Degrees of 
P-Value  
(Group A  vs. Group B)   Rate   Rate   Test Statistic   Freedom  
Nursing facilities that maintained 
policies for reporting allegations of 
abuse or neglect vs. nursing facilities  numerator = 1  
12,480  736  0.418   0.5184  
that did not maintain policies for  denominator = 243 
reporting allegations of abuse or 
neglect 
Source:  OIG analysis of policies and survey responses provided by nursing facilities, 2014. 
 
Table C-3: Chi Square Analysis on Maintained Policies That Addressed Federal 
Regulations and Nursing Facility Type  
Nursing Facility Type Compared   Group A   Group B  Wald Chi-Square   F-Test Degrees of 
P-Value  
(Group A  vs. Group B)   Rate   Rate   Test Statistic   Freedom  
Large nursing facilities vs. small nursing  numerator = 1  
4,367  7,377   2.3705   0.1249  
facilities  
denominator = 244 
Source:  OIG analysis of policies provided by nursing facilities, 2014.  
 
   
Nursing Facilities Compliance With Requirements for Reporting Allegations of Abuse or Neglect (OEI-07-13-00010)  26 
   
   
Table C-4: Chi Square Analysis on Documentation Related to Reasonable Suspicions 
of Crimes and Nursing Facility Type  
Nursing Facility Type Compared   Group A   Group B  Wald Chi-Square   F-Test Degrees of 
P-Value  
(Group A  vs. Group B)   Rate   Rate   Test Statistic   Freedom  
Large nursing facilities vs. small nursing  numerator = 1  
3,554  5,932   0.9704   0.3256  
facilities  
denominator = 244 
Source:  OIG analysis of nursing facilities submitted documentation regarding reasonable  suspicion of crimes, 2014. 
 
Table C-5: Chi Square Analysis on Reporting Allegations of Abuse or Neglect in a 
Timely Manner and to the Appropriate Individuals by Nursing Facility Type  
Nursing Facility Type Compared   Group A   Group B  Wald Chi-Square   F-Test Degrees of 
P-Value  
(Group A  vs. Group B)   Rate   Rate   Test Statistic   Freedom  
Large nursing facilities vs. small nursing  numerator = 1  
923  415  3.22  0.0739  
facilities  
denominator = 300 
Source:  OIG analysis of documentation for allegations of  abuse or neglect provided by nursing facilities, 2014. 
Nursing Facilities Compliance With Requirements for Reporting Allegations of Abuse or Neglect (OEI-07-13-00010)  27 
   
   
APPENDIX D 
Example of Letter Notifying Covered Individual of Obligation to Report 
Reasonable Suspicion of Crimes43  
 
43 This example was provided  by one of the sampled nursing  facilities in part one of this 
evaluation.  The name of the nursing  facility has been  redacted. 
Nursing Facilities Compliance With Requirements for Reporting Allegations of Abuse or Neglect (OEI-07-13-00010)  28 
   
   
APPENDIX E 
Example of a Posted Notification Specifying Employees Rights to File a 
Complaint under Section 1150B of the SSA44  
 
   
 
44 This example was provided  by one of the sampled nursing  facilities in part one of this 
evaluation.  
Nursing Facilities Compliance With Requirements for Reporting Allegations of Abuse or Neglect (OEI-07-13-00010)  29 
  APPENDIX F 
Agency Comments 
DEPARTMENT OF HEALTH & HUMAN SERVICES  Centers tor t.M!dicaro & Medicaid Services 
------------ ------------
Administrator 
Washington, DC 20201 
DATE:  JUN 11 2014 
TO: 	 Daniel R. Levinson 
Inspector General 
FROM: 	 Nlal'il.vn T.!ivcmner 
Acting 1\dmin\<;trator 
SUBJECT: 	 Office oflnspcctor General (OK!) Draft Report: Nursing Facilities' Compliance with 
l'ederal Requirements for Reporting Allegations of Abuse or Neglect 
(OEI-07-13-000 I 0) 
Thank you for the opportunity to review and comment on the above subject OIG draft report 
which discusses the extent to which nursing facilities have met the requirements outlined in Section 
11508 ofthe Social Security Act (the Act) for notifying individuals oftheir responsibilities to report 
suspicions ofa crime including allegations ofabuse. neglect or misappropriation of resident proper1y. 
OIG's objectives for this report are to determine the extent to which-(I) Nursing facilities: 
(a)  Reported allegations of abuse or negkct in 2012. 
(b) Had WTitten policies that address reporting allegations ofabuse or neglect as required by 
federal requirements. 
(c) 	Complied with federal requirements related to reasonable suspicions ofcrimes under Section 
11508 of the Social Security Act (SSA); and 
(2)  Allegations of abuse or neglect were reported by nursing facilities in compliance with 
federal requirements. 
The CMS responses to OIG's recommendations are discussed below. 
OIG Recommendation 
The OIG recommends that CMS ensure that nursing facilities maintain policies related to 
reporting allegations ofabuse or neglect. 
Nursing Facilities' Compliance With Requirements for Reporting Allegations of Abuse or Neglect (OEI-07-13-0001 0)  30   
   
 
   
Nursing Facilities Compliance With Requirements for Reporting Allegations of Abuse or Neglect (OEI-07-13-00010)  31 
   
   
 
   
Nursing Facilities Compliance With Requirements for Reporting Allegations of Abuse or Neglect (OEI-07-13-00010)  32 
   
   
ACKNOWLEDGMENTS 
This report was prepared under the direction of Brian T.  Whitley, Regional 
Inspector General for Evaluation and Inspections, in the Kansas City 
regional office. 
Rae Hutchison served as team leader for this study.  Other Office of 
Evaluation and Inspections staff from the Kansas City regional office who 
conducted the study include Teresa Dailey, Conswelia McCourt, and 
Dennis Tharp.  Central office staff who provided support include 
Clarence Arnold and Heather Barton. 
Nursing Facilities Compliance With Requirements for Reporting Allegations of Abuse or Neglect (OEI-07-13-00010)  33 
   
   
Office of Inspector General
http://oig.hhs.gov  
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as  
amended, is  to protect the integrity of the Department of  Health and Human Services  
(HHS)  programs, as well as the health and welfare of beneficiaries  served by those 
programs.  This statutory mission  is  carried  out through  a nationwide network  of  audits, 
investigations, and inspections conducted by the  following operating components: 
Office of Audit Services 
The Office  of  Audit Services  (OAS) provides auditing services  for HHS, either by  conducting  
audits  with its own audit resources or by  overseeing  audit work done by others.  Audits  
examine the performance of HHS programs and/or its grantees and contractors in carrying  
out their respective responsibilities and are intended  to provide independent assessments of 
HHS programs and operations.  These assessments help reduce waste, abuse, and  
mismanagement and promote economy and efficiency  throughout  HHS. 
Office of Evaluation and Inspections 
The Office  of  Evaluation and Inspections (OEI)  conducts national evaluations to  provide 
HHS, Congress, and the public with timely, useful, and reliable information on significant 
issues.  These evaluations focus on preventing fraud,  waste, or abuse  and promoting  
economy, efficiency, and effectiveness of departmental programs.  To promote impact, OEI 
reports also present practical recommendations for improving program operations.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations  
of  fraud and misconduct  related to HHS programs, operations, and beneficiaries.  With 
investigators working in all 50 States and the District of Columbia, OI  utilizes its resources 
by actively  coordinating with the Department  of Justice  and other Federal, State, and local 
law enforcement authorities.  The investigative efforts of OI often lead to  criminal 
convictions, administrative sanctions,  and/or  civil monetary  penalties.  
Office of Counsel to the Inspector General 
The Office of Counsel to the  Inspector  General (OCIG) provides general legal services to 
OIG, rendering  advice and opinions on HHS programs and operations and  providing all  
legal support for OIGs  internal operations.  OCIG represents  OIG in all civil and 
administrative fraud and abuse cases involving HHS programs,  including False Claims Act, 
program exclusion, and civil monetary penalty cases.  In  connection with these cases, OCIG 
also negotiates and monitors corporate integrity agreements.  OCIG renders advisory 
opinions, issues compliance program  guidance, publishes fraud alerts, and provides other  
guidance  to  the health care industry concerning the anti-kickback statute and other  OIG  
enforcement authorities.