Reporting Reasonable Suspicion of a Crime

Angie Szumlinski
December 13, 2011

CMS recently issued a Bulletin to State Survey Agency Directors clarifying the requirements for reporting reasonable suspicion of a crime in a long term care facility.  Specifically, Section 1150B of the Social Security Act, as established by Section 6703(b)(3) of the Patient Protection Affordable Care Act of 2010 “requires specific individuals in applicable long term care facilities to report any reasonable suspicion of crimes committed against a resident of that facility.”[1]  State survey agencies have been instructed to focus on “(a) the events giving rise to reports made under this requirement; and (b) the facility’s responsibilities under existing CMS conditions of participation and requirements to report incidents, to prevent abuse or neglect, provide quality care and a safe environment, train staff, and similar duties of direct relevance to safety and quality care.”[2] 

Survey Guidance – Three Areas of Focus
Surveyors have been trained and given guidance regarding these requirements including:

1) Events giving rise to a suspected crime.  The State Agencies have been directed to intake and record all events giving rise to the reported suspicion and to investigate “when appropriate.” 

2) Allegations of a “Covered Individual’s” Failure to Report AND Allegations of a Facility’s Failure to Comply with Section 1150B.

a) Intake:  Survey Agencies have been directed to inquire as to the health and safety conditions of the LTC facility generally in an effort to determine if the facility may be in violation of a participation requirement (F-Tag).

b) Prioritize and Investigate:  Survey Agencies will investigate the alleged suspicion when it is deemed “appropriate.”

3) Potential Related Deficiencies.  LTC Facilities may be cited under several Tags, including, but not limited to:

a) 483.13 (c)-F226-Failure to develop and/or implement its policies and procedures; and/or

b) 483.75(d)-F493-Governing body-failure to establish/implement facility policies regarding the management and operation of the facility.

In accordance with the CMS memorandum, “covered individuals” must abide by all reporting requirements to both local law enforcement and state survey agencies.  Have you trained your staff on these requirements?  Have you developed a corporate compliance program to oversee facility activities and ensure these requirements are being met?  It may be time to review your current policies, update them as needed and provide training for your staff.  As always, if you need assistance, please feel free to contact HealthCap Risk Management.  

[1] CMS Memorandum, June 17, 2011, Reporting Reasonable Suspicion of a Crime in a long term care facility (LTC); Section 1150(b) of the Social Security Act.

[2] Department of Licensing and Regulatory Affairs, State of Michigan.

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