Investigations into allegations of fraud, waste, and abuse at Medicaid or Medicare funded facilities must fulfill the Centers for Medicare & Medicaid Services (CMS) guidelines. All investigations are to be thoroughly documented, with signed statements whenever possible. Accurate facts are most available at the time of an event. Reconstructing facts later is time consuming and may result in inaccuracies or missed details.
The first step is to secure the scene and make sure nothing relevant is disturbed. All physical evidence must be secured and documented. Next, generate a list of potential witnesses and conduct interviews to determine exactly what happened.
When interviewing a resident or an alleged victim, the investigator should ask:
- What happened, when, where, and how often?
- Can he/she can identify the instigator/alleged perpetrator? Any witnesses?
- What occurred prior to, during, and immediately following the event?
- Did he/she report the issue/allegation to anyone? If so, to whom, when and what was the response?
- Does he/she feel safe? Is he/she afraid of anyone or fearful of retaliation?
- Has he/she had past encounters with the instigator/alleged perpetrator?
When interviewing staff, the investigator should ask:
- Does he/she have knowledge of the event?
- What actions, if any, did he/she take in response?
- Are there any changes in the resident’s/alleged victim’s behavior as a result of the event?
- How are the instigator/alleged perpetrator and resident/alleged victim related to one another before and after the incident?
- Did the instigator/alleged perpetrator exhibit inappropriate behaviors toward the resident or other residents in the past, such as derogatory language, rough handling, or ignoring residents while giving care?
When the alleged perpetrator is known, it must be determined if this person is an outsider or a staff member. If the latter, a full work record must be obtained, and he or she interviewed about the full details of the event. Any other staff members who may have been witnesses or who noticed any behavioral changes should also be interviewed.
The resident’s full medical record should also be obtained to determine any relevant data, such as diagnoses, medications, physician orders, cognitive status, care plan, and any other interventions.
The conclusion of the investigation must be supported by documented facts, not assumptions or biases.
If the event does not meet the abuse definitions, document clearly the analysis leading to that conclusion, then follow the facility’s “Incident Review Policy,” to include evaluation of the event to determine cause, future preventative actions, and reporting to QAPI/QAA.
If there is reason to believe that abuse, neglect, mistreatment, or exploitation has occurred, immediately notify the administrator and the Department of Health through the Electronic Incident Reporting System. If it is obvious that a crime has been committed, the police must be informed.
Once all the evidence has been reviewed, it is important to ensure that all documentation and evidence are kept secure.
Finally, it is important to note what measures are being taken to protect residents from further occurrences.
In conclusion, the protection of residents from abuse, neglect, or exploitation is an important focus of the Office of Inspector General (OIG) for Compliance and Ethics Program efforts. Element 1, Standards, Policies, and Procedures, of the OIG’s seven Elements, requires written policies for program activities, including oversight of qualify of care, protection of residents’ rights, and response to reports of concerns. Protocols guiding the investigation process are an important component of a Compliance and Ethics Program.
