Reporting Allegations to N.C. Health Care Personnel Investigations Branch

Purpose: This procedure describes the requirements for health care providers to report allegations to the N.C. Health Care Personnel Registry (HCPR) and the general process followed during the HCPR Investigations Branch process once the reports are received. Citizens who want to report a complaint about the care and services provided to a patient/resident/consumer by health care providers licensed by the Division of Health Service Regulation may file a complaint with the Complaint Intake Unit.

The HCPR reporting requirements can be found in N.C. G.S. 131E-256. Rules in Title 10A of the North Carolina Administrative Code (10A NCAC 13O) apply. Additional reporting requirements for nursing facilities are contained in 42 CFR 483.13 (PDF, 46 KB). Reporting forms and additional information are available from the HCPR Investigations Branch.

The N.C. Health Care Personnel Registry is a comprehensive listing of unlicensed health care personnel who are under investigation for an allegation (pending allegation investigation) or have a substantiated allegation finding as defined in G.S. 131E-256(a). Information on the HCPR is available to health care employers about potential employees that have administrative actions listed including the nature of a finding or allegation and the status of an investigation (also see Verify Registry Listings). As required by federal law, 42 CFR 483.156(c)(iv) (PDF, 48 KB) and 42 U.S.C. 1819(g)(1)(C)(D), substantiated findings of resident abuse, resident neglect, and misappropriation of resident property committed by nurse aides against nursing home residents are also listed on the N.C. Nurse Aide I Registry.

Health care facilities are required to report the following allegations to the HCPR:

A "Health Care Facility" required to report allegations to the HCPR are all of the health care providers specified in G.S. 131E-256(b), including all of the following:

The statutory references for the types of health care providers required to report allegations to the HCPR Investigations Branch may be found in G.S.131E-256(b).

"Health Care Personnel" includes any unlicensed staff of a health care facility that has direct access to residents, clients, or their property [G.S. 131E-256(c)]. Direct access includes any health care 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 [G.S. 131E-256(c)].

Federal reporting requirements contained in 42 CFR 483.13 (PDF,46 KB) requires nursing home facilities to also report allegations made against any employee or contracted staff - licensed or unlicensed - providing services for nursing home residents.

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 forms and additional information are available from the HCPR Investigations Branch.

Contacts: For questions regarding any part of this process, please contact the Health Care Personnel Registry Section of the N.C. Division of Health Service Regulation.

Health Care Personnel Registry Section 919-855-3968
HCPR Investigations Branch 919-855-3968
24-Hour Automated Verification System 919-715-0562
Online Registry https://www.ncnar.org/verify_listings1.jsp

Procedure:

  1. Reporting to the Health Care Personnel Registry (HCPR) Investigations Branch
    1. Health care facilities must report allegations to the HCPR in writing. Reports may be faxed to 919-733-3207, or mailed to the Health Care Personnel Registry Investigations Branch, Division of Health Service Regulation, 2719 Mail Service Center, Raleigh, N.C. 27699-2719.
    2. 24-Hour Report - Health care facilities are required to report all allegations against health care personnel, and injuries of unknown source, to the HCPR Investigations Branch within 24-hours or becoming aware of the allegation [10A NCAC 13O .0102, PDF, 10 KB]. Nursing home facilities must report allegations made against any employee or contracted staff (licensed or unlicensed) providing services for nursing home residents. Although not required, a 24-hour report form (PDF, 44 KB) is available for use.
    3. 5-Working Day Report – The results of all investigations are required to be submitted 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, a 5-working day report (PDF, 49 KB) is available for use.
  2. Allegation report screening and pending allegation investigation listing
    1. The allegation report is reviewed and evaluated (screened) to determine if the HCPR Investigations Branch will conduct an investigation of the reported allegation. Additional information may be requested from the reporting health care facility.
    2. A decision to investigate an allegation results in a "pending" (pending allegation investigation) listing entered onto the Health Care Personnel Registry with the accused individual's name. A certified letter of notification is mailed to the accused individual (The letter includes notice of the investigation and due process rights available). A letter is also sent to the reporting health care facility. (The pending allegation investigation listing remains on the HCPR until the allegation is either unsubstantiated or a substantiated finding is listed onto the Health Care Personnel Registry.)
    3. A decision not to investigate an allegation results in letters mailed to the accused individual and the reporting health care facility notifying them of the decision. No pending allegation investigation is listed on the HCPR, and no further action is planned.
  3. Investigations of allegations
    1. HCPR investigations gather evidence to determine whether an allegation is substantiated or unsubstantiated. HCPR Investigators primarily conduct the investigations. (In some cases, a local law enforcement agency or the Medicaid Investigations Unit of the Department of Justice may conduct an investigation instead.) Investigations may include on-site visits, records reviews, and interviews with victims, accused individuals, witnesses, and other individuals.
    2. When an investigation is completed, the accused individual is notified of the outcome. If the allegation is substantiated, the accused is notified by certified letter of the intent to enter a finding onto the Health Care Personnel Registry. If the allegation was of abuse, neglect, or misappropriation of the property of a nursing home resident, the notification includes that the finding will also be entered onto the Nurse Aide I Registry. The notification contains information about the due process rights that are available to the individual. (The pending allegation investigation listing remains on the HCPR.)
    3. If the allegation is unsubstantiated, the "pending" allegation investigation listing is removed from the HCPR, and the accused and the reporting facility are notified of the outcome by letter.
  4. Listing Substantiated Findings
    1. Accused individuals with substantiated allegations have due process rights available to them. A substantiated finding is not listed until after the completion of a 30-days opportunity to file a petition for a contested case hearing with the Office of Administrative Hearings.
    2. If the accused individual does file a petition for a contested case hearing, the listing of the finding is postponed until after an Administrative Law Judge hears the case and the division director makes the final decision.
    3. If the accused individual does not exercise his/her due process rights by filing a petition for a contested case hearing with the Office of Administrative Hearings, the finding is listed. (The pending allegation listing is removed when the finding is listed.)
    4. After a finding is listed on the Health Care Personnel Registry (and, if applicable, the Nurse Aide I Registry), the specific allegation, the evidence summary, the date of the hearing (if the individual chose to have one) and the outcome are available to an inquirer. If the individual chooses to make a rebuttal statement, it is also included with the registry listing and provided to inquirers.