Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

NURSING FACILITIES’ 

COMPLIANCE WITH FEDERAL 

REGULATIONS FOR 

REPORTING ALLEGATIONS 

OF ABUSE OR NEGLECT 

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 

1

Administration 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. 

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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 

Abuse The willful infliction of injury, unreasonable confinement, intimidation, or 

punishment with resulting physical harm, pain or mental anguish.7 

Injuries of Unknown 

Source 

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 

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 

one particular point in time or the incidence of injuries over time.8 

Neglect Failure to provide goods and services necessary to avoid physical harm, 

mental anguish, or mental illness.9 

Misappropriation of 

Resident Property 

The deliberate misplacement, exploitation, or wrongful, temporary or 

permanent use of a resident’s belongings or money without the resident’s 

consent.10 

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’ 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 

facility’s responsibility to report all allegations of abuse or neglect is 

separate from a covered individual’s 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). 

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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.
 

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Table 2: Nursing Facility Population and Sample Size 

Stratum Definition Population 

Size 

Sample 

Size 

Nursing Facilities That Have a Total Certified Size Greater 

Than or Equal to 113 Beds (Large Facilities) 6,347 125 

Nursing Facilities That Have a Total Certified Size Less Than 

113 Beds (Small Facilities) 9,507 125 

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. 

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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 

Type of Allegation 

Number of 

Allegations in 

Sample 

(n=2,502) 

Projected 

Number of 

Allegations 

(N=149,313) 

Percentage of 

Allegations 

Abuse 

Injuries of unknown source 

Misappropriations of resident property 

Neglect 

Mistreatment

Other

1,265 

476 

392 

275 

92 

2 

75,658 

27,759 

22,281 

17,553 

5,961 

102 

50.7 

18.6 

14.9 

11.8 

3.9 

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 

Nature of Allegation 

Number of 

Allegations in 

Sample 

(n=2,502) 

Projected 

Number of 

Allegations 

(N=149,313) 

Percentage of 

Allegations 

Employee to resident 

Perpetrator unknown 

Resident to resident 

Resident self-neglect (e.g., resident self-inflicted injury) 

Family or other visitor to resident 

Nature not specified 

Resident to employee 

Outside medical professional to resident 

1,010 

659 

600 

89 

59 

46 

25 

14 

60,132 

39,099 

36,078 

5,733 

3,476 

2,538 

1,320 

938 

40.3 

26.2 

24.2 

3.8 

2.3 

1.7 

0.9 

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. 

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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. 

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Table 5: Nursing Facilities That Maintained Policies That Addressed 

Federal Regulations for Reporting Allegations of Abuse or Neglect 

Federal Regulations 

Number of 

Nursing 

Facilities 

in sample 

(n=245) 

Projected 

Number of 

Nursing 

Facilities 

(N=15,550) 

Percentage of 

Nursing 

Facilities That 

Maintained 

Policies That 

Addressed 

Federal 

Regulations 

Allegations of abuse or neglect must be immediately 

reported to the nursing facility administrator or designee 

and the State survey agency 

232 14,738 94.8 

Investigation results must be reported to the nursing 

facility administrator or designee and the State survey 

agency within 5 working days of the incident 

185 11,871 76.3 

Total number of nursing facilities that had 

policies that addressed both Federal regulations 183 11,744 75.5* 

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. 
 

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Table 6: Nursing Facilities with Documentation to Support That Federal 

Regulations Related to Reasonable Suspicions of Crimes Were Met 

Federal Regulations 

Number of 

Nursing 

Facilities in 

Sample 

(n=245) 

Projected 

Number of 

Nursing 

Facilities 

(N=15,550) 

Percentage of 

Nursing Facilities 

with Documentation 

to Support That 

Both Regulations 

Were Met 

Nursing facility must annually notify covered 

individuals of their obligation to report to the 

appropriate entities any reasonable suspicion 

of a crime 

162 10,400 66.8 

Nursing facility must clearly post a notice for its 

employees specifying employees’ rights to file a 

complaint under Section 1150B of the SSA 

195 12,429 79.9 

Total number of nursing facilities with 

documentation to support that both 

regulations were met 

148 9,487 61.0 

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. 
 

 

 

 

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 

Federal Regulations 

Number of 

Allegations 

in Sample 

(n=301) 

Projected 

Number of 

Allegations 

(N=2,502) 

Percent of 

Allegations 

Allegations of abuse or neglect must be immediately 

reported to the nursing facility administrator or designee 

and the State survey agency 

189 1,571 62.8 

Investigation results must be reported to the nursing facility 

administrator or designee and the State survey agency 

within 5 working days of the incident 

191 1,588 63.4 

Total number of allegations of abuse or neglect that 

were reported in compliance with both Federal 

regulations 

161 1,338 53.4 

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. 

Nursing Facilities’ Compliance With Requirements for Reporting Allegations of Abuse or Neglect (OEI-07-13-00010) 13 
 

 

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. 

Nursing Facilities’ Compliance With Requirements for Reporting Allegations of Abuse or Neglect (OEI-07-13-00010) 14 
 

 

 

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. 

Nursing Facilities’ Compliance With Requirements for Reporting Allegations of Abuse or Neglect (OEI-07-13-00010) 15 
 

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 OIG’s 

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 OIG’s 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 CMS’s 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 CMS’s 

comments, see Appendix F. 

Nursing Facilities’ Compliance With Requirements for Reporting Allegations of Abuse or Neglect (OEI-07-13-00010) 16 
 

 

 

 

 

 

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 

Stratum Definition Population 

Size 

Sample 

Size 

Nursing facilities that have a total certified size 

greater than or equal to 113 beds 6,347 125 

Nursing facilities that have a total certified size less 

than 113 beds 9,507 125 

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. 

Nursing Facilities’ Compliance With Requirements for Reporting Allegations of Abuse or Neglect (OEI-07-13-00010) 17 
 

 

 

 

 

 

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 State’s 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 

Stratum Definition 

Population of 

Allegations 

Reported in Part 

One 

Allegations 

Sample 

Size 

Number of 

Nursing 

Facilities 

Represented 

Nursing facilities that have a total certified 

size greater than or equal to 113 beds 1,621 195 68 

Nursing facilities that have a total certified 

size less than 113 beds 881 106 53 

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. 

Nursing Facilities’ Compliance With Requirements for Reporting Allegations of Abuse or Neglect (OEI-07-13-00010) 20 
 

Nursing Facilities’ Compliance With Requirements for Reporting Allegations of Abuse or Neglect (OEI-07-13-00010) 21 

 

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 agency’s 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 agency’s 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. 
 

APPENDIX B 

Table B-1: Point Estimates, Sample Sizes, and Confidence Intervals 

Estimate Description Sample 

Size 

Point 

Estimate 

95-Percent 

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 

of abuse or neglect in 2012 209 85.0% 80.4%–89.6% 

Total number of allegations of abuse or neglect that nursing 

facilities reported in 2012 2,502 149,313 117,400–181,226 

Total abuse allegations that nursing facilities reported in 2012 1,265 75,658 60,805–90,511 

Percentage of abuse allegations that nursing facilities reported in 

2012 1,265 50.7% 43.1%–58.2% 

Total injuries of unknown source allegations that nursing facilities 

reported in 2012 476 27,759 9,077–46,441 

Percentage of injuries of unknown source allegations that nursing 

facilities reported in 2012 476 18.6% 8.3%–28.9% 

Total misappropriation of resident property allegations that nursing 

facilities reported in 2012 392 22,281 11,571–32,990 

Percentage of misappropriation of resident property allegations 

that nursing facilities reported in 2012 392 14.9% 8.7%–21.1% 

Total neglect allegations that nursing facilities reported in 2012 275 17,553 12,745–22,361 

Percentage of neglect allegations that nursing facilities reported in 

2012 275 11.8% 8.4%–15.2% 

Total mistreatment allegations that nursing facilities reported in 

2012 92 5,961 2,216–9,706 

Percentage of mistreatment allegations that nursing facilities 

reported in 2012 92 3.9% 1.5%–6.5% 

Total “other” allegations that nursing facilities reported in 2012 2 102 0–241 

Percentage of “other” allegations that nursing facilities reported in 

2012 2 0.1% 0.0%–0.2% 

Total employee-to-resident allegations 1,010 60,132 44,805–75,459 

Percentage of employee-to-resident allegations 1,010 40.3% 32.2%–48.4% 

Total perpetrator-unknown allegations 659 39,099 19,940–58,258 

Percentage of perpetrator-unknown allegations 659 26.2% 16.7%–35.7% 

Total resident-to-resident allegations 600 36,078 25,158–46,997 

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 
 

 

 

Continued—Table B-1: Point Estimates, Sample Sizes, and Confidence Intervals 

Estimate Description Sample 

Size 

Point 

Estimate 

95-Percent 

Confidence Interval 

Total resident-self-neglect allegations 89 5,733 2,592–8,873 

Percentage of resident-self-neglect allegations 89 3.8% 1.7%–6.0% 

Total family- or other visitor-to-resident allegations 59 3,476 2,136–4,816 

Percentage of other visitor-to-resident allegations 59 2.3% 1.4%–3.3% 

Total nature-not-specified allegations 46 2,538 696–4,380 

Percentage of nature-not-specified allegations 46 1.7% 0.5%–2.9% 

Total resident-to-employee allegations 25 1,320 0–2,760 

Percentage of resident-to-employee allegations 25 0.9% 0.0%–1.9% 

Total outside medical professional-to-resident allegations 14 938 199–1,677 

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 

allegation of abuse or neglect in their facility in 2012 106 86.9% 80.9%–92.9% 

Percentage of small nursing facilities that had at least one 

allegation of abuse or neglect in their facility in 2012 103 83.7% 77.2%–90.3% 

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 

or neglect 

183 75.5%* 70.1%–80.9% 

Total number of nursing facilities that had written policies that 

address both Federal regulations for reporting allegations of abuse 

or neglect 

183 11,744 10,902–12,586 

Total number of nursing facilities that had written policies that 

address reporting allegations of abuse or neglect immediately to 

the nursing facility administrator or designee and the State survey 

agency 

232 14,738 14,299–15,177 

Percentage of nursing facilities that had written policies that 

address reporting allegations of abuse or neglect immediately to 

the nursing facility administrator or designee and the State survey 

agency 

232 94.8% 91.9%–97.6% 

Total number nursing facilities that had written policies that 

address reporting investigation results to the nursing facility 

administrator or designee and the State survey agency within 5 

working days of the incident 

185 11,871 11,039–12,703 

Nursing Facilities’ Compliance With Requirements for Reporting Allegations of Abuse or Neglect (OEI-07-13-00010) 23 
 

Continued—Table B-1: Point Estimates, Sample Sizes, and Confidence Intervals 

Estimate Description Sample 

Size 

Point 

Estimate 

95-Percent 

Confidence Interval 

Percentage of nursing facilities that had written policies that 

address reporting investigation results to the nursing facility 

administrator or designee and the State survey agency within 5 

working days of the incident 

185 76.3% 71.0%–81.7% 

Percentage of large nursing facilities that had written policies that 

address both Federal regulations for reporting allegations of abuse 

or neglect 

86 70.5%** 62.3%–78.6% 

Percentage of small nursing facilities that had written policies that 

address both Federal regulations for reporting allegations of abuse 

or neglect 

97 78.9% 71.6%–86.1% 

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 

crimes were met 

148 61.0% 54.8%–67.2% 

Total number of nursing facilities that had documentation to 

support that both Federal regulations related to reasonable 

suspicions of crimes were met 

148 9,487 8,521–10,452 

Total number of nursing facilities that had documentation to 

support that they annually notified covered individuals of their 

obligation to report to the appropriate entities any reasonable 

suspicions of a crime 

162 10,400 9,472–11,328 

Percentage of nursing facilities that had documentation to support 

that they annually notified covered individuals of their obligation to 

report to the appropriate entities any reasonable suspicions of a 

crime 

162 66.8% 60.9%–72.8% 

Total number of nursing facilities that had documentation to 

support that they posted clearly a notice for its employees 

specifying employees’ rights to file a complaint under Section 

1150B of the SSA 

195 12,429 11,638–13,220 

Percentage of nursing facilities that had documentation to support 

that they posted clearly a notice for its employees specifying 

employees’ rights to file a complaint under Section 1150B of the 

SSA 

195 79.9% 74.8%–85.0% 

Percentage of large nursing facilities that had documentation to 

support that both Federal regulations related to reasonable 

suspicion of crimes were met 

70 57.4% 48.6%–66.2% 

Percentage of small nursing facilities that had documentation to 

support that both Federal regulations related to reasonable 

suspicion of crimes were met 

78 63.4% 54.8%–72.0% 

Nursing Facilities’ Compliance With Requirements for Reporting Allegations of Abuse or Neglect (OEI-07-13-00010) 24 
 

 

Continued—Table B-1: Point Estimates, Sample Sizes, and Confidence Intervals 

Estimate Description Sample 

Size 

Point 

Estimate 

95-Percent 

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 

by nursing facilities in compliance with both Federal regulations 161 53.4% 48.2%–58.8% 

Total number of allegations of abuse or neglect that were reported 

by nursing facilities in compliance with both Federal regulations 161 1,338 1,206–1,471 

Total number of allegations of abuse or neglect that were reported 

immediately to the nursing facility administrator or designee and 

the State survey agency 

189 1,571 1,442–1,700 

Percentage of allegations of abuse or neglect that were reported 

immediately to the nursing facility administrator or designee and 

the State survey agency 

189 62.8% 57.6%–67.9% 

Total number of allegations of abuse or neglect that had 

investigation results reported to the nursing facility administrator or 

designee and the State survey agency within 5 working days of the 

incident 

191 1,588 1,461–1,715 

Percentage of allegations of abuse or neglect that had 

investigation results reported to the nursing facility administrator or 

designee and the State survey agency within 5 working days of the 

incident 

191 63.4% 58.4%–68.5% 

Percentage of large nursing facilities that reported allegations of 

abuse or neglect in compliance with Federal regulations 111 56.9% 50.3%–63.5% 

Percentage of small nursing facilities that reported allegations of 

abuse or neglect in compliance with Federal regulations 50 47.2% 38.1%–56.2% 

Source: OIG analysis of policies, survey responses, and investigation documentation provided by nursing facilities, 2014. 

*The actual percentage of nursing facilities that address 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. 

**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 vs. Group B) 

Group A 

Rate 

Group B 

Rate 

Wald Chi-Square 

Test Statistic 

F-Test Degrees of 

Freedom P-Value 

Large nursing facilities vs. small nursing 

facilities 5,382 7,834 0.502 

numerator = 1 

denominator = 244 

0.4793 

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 vs. Group B) 

Group A 

Rate 

Group B 

Rate 

Wald Chi-Square 

Test Statistic 

F-Test Degrees of 

Freedom P-Value 

Nursing facilities that maintained 

policies for reporting allegations of 

abuse or neglect vs. nursing facilities 

that did not maintain policies for 

reporting allegations of abuse or 

neglect 

12,480 736 0.418 

numerator = 1 

denominator = 243 

0.5184 

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 vs. Group B) 

Group A 

Rate 

Group B 

Rate 

Wald Chi-Square 

Test Statistic 

F-Test Degrees of 

Freedom P-Value 

Large nursing facilities vs. small nursing 

facilities 4,367 7,377 2.3705 

numerator = 1 

denominator = 244 

0.1249 

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 vs. Group B) 

Group A 

Rate 

Group B 

Rate 

Wald Chi-Square 

Test Statistic 

F-Test Degrees of 

Freedom P-Value 

Large nursing facilities vs. small nursing 

facilities 3,554 5,932 0.9704 

numerator = 1 

denominator = 244 

0.3256 

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 vs. Group B) 

Group A 

Rate 

Group B 

Rate 

Wald Chi-Square 

Test Statistic 

F-Test Degrees of 

Freedom P-Value 

Large nursing facilities vs. small nursing 

facilities 923 415 3.22 

numerator = 1 

denominator = 300 

0.0739 

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 
 

Nursing Facilities’ Compliance With Requirements for Reporting Allegations of Abuse or Neglect (OEI-07-13-00010) 28 

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. 
 

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 of a crime including allegations of abuse. 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 of abuse or neglect as required by 

federal requirements. 

(c) 	Complied with federal requirements related to reasonable suspicions of crimes 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 of abuse 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 OIG’s 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.