Provider Information

Posting Complaint Intake Contact Information

Residential mental health facilities, adult care homes and nursing homes need to display information for contacting Complaint Intake to be in compliance with various statutes/regulations. This poster (PDF, 435 KB) may be used to display the required contact information.

Long-term care facilities (nursing facilities, intermediate care facilities for individuals with intellectual disabilities and hospices that provide services in long-term care facilities) are required to conspicuously post, in an appropriate location, a notice for its employees specifying the employees' rights to file a complaint under Section 1150B of the Social Security Act. The notice must include a statement that an employee may file a complaint with the SA (Division of Health Service Regulation) against a long-term care facility that retaliates against an employee as specified above, as well as include information with respect to the manner of filing such a complaint. This poster (PDF, 475 KB) may be used to display the required contact information.

Verifying Registry Listings and Findings

Nurse Aide Registry
Federal regulations for long-term care facilities [skilled nursing and nursing facilities] require that before allowing an individual to serve as a nurse aide, a facility must receive registry verification that the individual has met competency evaluation requirements. Nursing home employers must also verify listing on the Health Care Personnel Registry prior to employing a nurse aide or other unlicensed assistant personnel who provide hands-on care. Nurse aides who have substantiated findings of resident abuse, resident neglect, or misappropriation of resident property in a nursing home listed against them on the North Carolina Nurse Aide Registry (or on any State's Nurse Aide Registry) are prohibited from working in a nursing facility [42 U.S.C. Section 1395i-3(g)(1)(C); 42 U.S.C. Section 1396r(g)(1)(C); 42 CFR 483.13 (c)(1)(ii)(B)]. (see Health Care Personnel Registry).

Medication Aide Registry
Effective July 1, 2006, state regulations for long-term care facilities [skilled nursing and nursing facilities] require that the facility must verify an individual is listed on the N.C. Medication Aide Registry before allowing an individual to work as a medication aide. An employer must keep a record of accessing the registry and must note each incidence of access in their business files. Nursing home employers must also verify listing on the Health Care Personnel Registry and Nurse Aide I Registry prior to employing a medication aide. A substantiated finding on the Health Care Personnel Registry disqualifies the medication aide from employment in a skilled nursing facility per G.S. 131E-270(C) (see Health Care Personnel Registry).

Health Care Personnel Registry
The Health Care Personnel Registry is a state-mandated registry (G.S. 131E-256; 10A NCAC 13O), that contains the names of health care personnel who have pending investigations of allegations or substantiated findings by the department of resident abuse, resident neglect, misappropriation of resident or facility property, fraud against a resident or facility, or diversion of drugs belonging to a resident or facility. The Health Care Personnel Registry includes all of the findings contained in the Nurse Aide I Registry (resident abuse, resident neglect, or misappropriation of the property of a resident in a nursing facility by a nurse aide) under G.S. 131E‑255.

Before hiring health care personnel into a health care facility or service, health care facility employers as defined in G.S. 131E‑256(b) must access the Health Care Personnel Registry and note each incident of access in their business files.

Note: Listing verification requirements and employment prohibitions unique to other health care employers may also apply. Health care employers needing guidance on verification requirements and prohibitions specific to them can contact their respective survey or licensure section within the Division of Health Service Regulation or other appropriate regulatory agency.

How to Verify
Verification of individuals listed on the N.C. Nurse Aide I Registry, N.C. Medication Aide Registry, or the N.C. Health Care Personnel Registry may be obtained from www.ncnar.org. The verification system provides date-specific confirmation numbers to validate each inquiry.

The information regarding substantiated findings or pending allegation investigations listed on the Health Care Personnel Registry is accessible to any inquirer 24-hours a day, seven days a week on the division's telephone voice response system at 919-715-0562, or via the online registry. Certain employers may have prohibitions from employing an individual with a finding listed on the Health Care Personnel Registry or the Nurse Aide I Registry. Please refer to the regulatory requirements applicable for the specific type of facility or service for any prohibitions from employment of individuals with substantiated findings.

Reporting Allegations/Investigations

Federal reporting requirements require nursing homes to report violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property to Health Care Personnel Investigations.

State statutes require health care facilities to report allegations involving any unlicensed staff that has direct access to residents, clients, or their property to Health Care Personnel Investigations. Direct access includes any facility unlicensed staff (including contracted staff) that during the course of employment has the opportunity for direct contact with an individual or an individual's property, when that individual is a resident or person to whom services are provided.

Allegations:

Procedures for Reporting to Health Care Personnel Investigations

Health care facilities must report allegations and facility investigations to Health Care Personnel Investigations in writing within 24-hours or upon becoming aware of the allegation [10A NCAC 13O .0102, PDF, 10 KB].

For certified nursing facilities and skilled nursing facilities, all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

For long term care (LTC) facilities (certified nursing facilities, skilled nursing facilities, hospices providing services in a LTC facility and intermediate care facilities for individuals with intellectual disability), reports of any reasonable suspicion of a crime against a resident of that facility must be submitted to at least one law enforcement agency of that jurisdiction and Health Care Personnel Investigations. If the events that cause the reasonable suspicion result in serious bodily injury to a resident, the suspicion shall be reported not later than two hours after forming the suspicion. If the events that cause the reasonable suspicion do not result in serious bodily injury to a resident, the suspicion shall be reported no later than 24 hours after forming the suspicion.

Although not required, an Allegation Report Form (PDF, 246 KB) is available for use. This form can be utilized for reporting all allegations within 2 hours or 24 hours and any suspicion of crimes.

The results of all facility investigations are required to be submitted to Health Care Personnel Investigations within 5-working days of the initial 24-hour report whether the allegation was substantiated or not. The report should include the documentation and results of a thorough investigation. Although not required, an Investigation Report Form (PDF, 314 KB) is available for use.

Reports may be faxed to 919-733-3207, or mailed to the Health Care Personnel Investigations, Division of Health Service Regulation, 2719 Mail Service Center, Raleigh, N.C. 27699-2719.

Procedures for Health Care Personnel Investigations

Allegation reports are reviewed and screened to determine if Health Care Personnel Investigations will conduct an investigation of the reported allegation. Additional information may be requested from the reporting health care facility.

A decision to investigate an allegation results in a "pending" (pending allegation investigation) listing entered on the Health Care Personnel Registry with the accused individual's name. A letter of notification is mailed to the reporting health care facility. The "pending" listing remains on the HCPR until the allegation is either unsubstantiated or a substantiated finding is listed on the Health Care Personnel Registry.

A decision not to investigate an allegation results in letters mailed to the reporting health care facility with notification of the decision. No pending allegation investigation is listed on the Health Care Personnel Registry, and no further action is planned.

During investigations of allegations, investigators gather evidence to determine whether an allegation is substantiated or unsubstantiated.  In some cases, a local law enforcement agency or the Medicaid Investigations Division of the Department of Justice may conduct an investigation as well.  Investigations may include on-site visits, records reviews, and interviews with victims, accused individuals, witnesses, and other individuals.

When an investigation is completed, the reporting health care facility is notified of the outcome by letter.

If the allegation is unsubstantiated, the "pending" listing is removed from the Health Care Personnel Registry.

If the allegation is substantiated after due process rights are completed, a finding is listed on the Health Care Personnel Registry. If the allegation was of abuse, neglect, or misappropriation of the property of a nursing home resident, the finding will also be entered on the Nurse Aide I Registry.

Reporting Deaths

Mental health facilities licensed under G.S. 122C, adult care homes licensed under G.S. 131D and in-patient psychiatric units of a hospital licensed under G.S. 131E are required to file a report with Complaint Intake of any death resulting from violence, accident, suicide or homicide and any death occurring within seven days of physical restraint or physical hold of the resident.

State operated facilities are required to report the death of any client, and, if known, the death of any former client of a facility who dies within 14 days of release from the facility, regardless of the manner of death to the medical examiner of the county in which the body of the deceased is found and to the State protection and advocacy agency (Disability Rights NC).  State policies also require state operated facilities to report all deaths to Complaint Intake.

Hospitals are required by federal regulations to report deaths associated with the use of seclusion or restraint to the Centers for Medicare and Medicaid Services.

Death Reporting Requirements

Forms