Interim Policy for Reporting Alleged Abuse, Mistreatment, Neglect, Misappropriation and Injuries of Unknown Source

CMS Reporting Requirements  42 CFR (c)(2) The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency).

 42 CFR (c)(4) The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

CMS Notice  Centers for Medicare & Medicaid Services issues S&C (12/16/04) Reiterates the reporting of alleged violations and the results of the investigation by nursing homes to the state survey and certification agency as mandated by 42 CFR (c)(2) and (4). Defines the terms “neglect”, “abuse”, “injury of unknown source” “misappropriation of resident property”, “immediately” and “in accordance with State law.”

Reactions  On January 13, 2005, the Bureau of Health Systems restates the CMS clarification and notifies providers of reporting and investigation requirements.  September 2005, Attorney General Cox charges two UP nursing home employees with patient abuse and failure to report injury and neglect.  October 1, 2005, second set of charges regarding failure to report.  October 19, 2005, third set of charges regarding failure to report.  February 27, 2006, fourth charge of failure to report.

Facility Reported Incidents FY FRIs – with harm referred to CIU 3049 FRIs – non harm referred to NHM Teams

Proposal  Alleged violations of abuse, mistreatment, neglect, misappropriation and injuries of unknown source are reported to the administrator of the facility.  Investigation commences immediately, while residents are safeguarded.

Incidents – Involving Harm  Alleged violations of abuse, mistreatment, neglect, misappropriation and injuries of unknown source that involve harm, are to be reported immediately to the Bureau of Health Systems (BHS). BHS OPS Hour Report completed.BHS OPS Hour Report completed. Recorded on BHS Facility Log.Recorded on BHS Facility Log. Investigation commences, while residents are safeguarded.Investigation commences, while residents are safeguarded.

Incidents – Involving Harm  Investigation results for alleged violations of abuse, mistreatment, neglect, misappropriation and injuries of unknown source, that involve harm: Report investigation results to BHS, complete the BHS OPS 363, 5 day Report form.Report investigation results to BHS, complete the BHS OPS 363, 5 day Report form. Record the investigation results on BHS Facility Log.Record the investigation results on BHS Facility Log. * Harm means some physical injury or damage, pain or mental anguish.

Incident – Without Harm  Alleged violations of abuse, mistreatment, neglect, misappropriation and injuries of unknown source that do not involve harm, are to be reported to the facility administrator. Recorded on BHS Facility Log.Recorded on BHS Facility Log. Investigation commences, while residents are safeguarded.Investigation commences, while residents are safeguarded. Investigation results reported to administrator.Investigation results reported to administrator. Facility takes corrective action, as needed.Facility takes corrective action, as needed.

BHS Facility Log

Facility Log Instructions Facilities are asked to make an initial determination about incidents and decide what is reportable and what is not, in accordance with CMS Regulations. If the facility has a question about whether or not an incident is reportable, they are advised to report. Incidents (and investigation findings) involving any level of harm should be reported to the Bureau’s Complaint Investigation Unit and summarized on the Facility Log. Incidents that do not involve harm should be summarized on the log, only. In all cases, facilities should assess the incident and implement corrective measures, as appropriate. Facilities are to submit logs minimally at the end of each quarter and may be requested to submit at any time. Facilities are advised to maintain this log as current. The Licensing Officer will review the log and may contact you with additional questions or for copies of investigational materials. Facilities should complete an internal investigation on each event. Information should include documentation that supports a summary statement of the event, conclusions reached and evidence of corrective action initiated, if appropriate. The Licensing Officer will determine what additional follow up or on-site surveyor investigation will be necessary. UpNorth Team Phone:(989) Fax: (989) UpNorth Team Phone:(989) Fax: (989) Metro West Team Phone:(313) Fax: (313) Metro West Team Phone:(313) Fax: (313) Metro East Team Phone:(313) Fax: (313) Metro East Team Phone:(313) Fax: (313) Mid-Mich Team Phone:(517) Fax: (517) Mid-Mich Team Phone:(517) Fax: (517) Southwest Team Phone:(517) Fax: (517) Southwest Team Phone:(517) Fax: (517)

BHS Facility Log -- Expectations  Facilities begin recording on 12/1/06.  Facilities send BHS Facility Log to Licensing Officer on/or about 1/15/07.  Licensing Officer or designee reviews BHS Facility Log upon receipt for timeliness of entries, completeness, understanding of harm.  Licensing Officer works with facilities, as appropriate, to get BHS Facility Log correct.

BHS Facility Log -- Expectations BHS Facility Logs are reviewed as part of off-site preparation for standard surveys to note: Patterns of injury.Patterns of injury. Patterns involving a resident victim.Patterns involving a resident victim. Patterns involving a resident/staff perpetrator.Patterns involving a resident/staff perpetrator. Possible inclusion in survey sample.Possible inclusion in survey sample.

BHS Facility Log -- Expectations Complaint Team surveyors will review the BHS Facility Logs completed since the last standard survey for entries relevant to the complaint/facility reported incident under investigation. Standard Survey Team will review on-site the log entries since the last quarterly report.

BHS Facility Log -- Expectations As part of discretionary review, (between standard surveys) Licensing Officers may: Require a plan of correction to address an incident. Require a plan of correction to address an incident. Request copies of reports or documents related to FRI. Request copies of reports or documents related to FRI. Request a voluntary in-service. Request a voluntary in-service. Initiate a State Monitoring visit. Initiate a State Monitoring visit. Require immediate reports and 5 day investigation reports for all alleged abuse, neglect, and mistreatment incidents. Require immediate reports and 5 day investigation reports for all alleged abuse, neglect, and mistreatment incidents.

This policy is intended to shift focus to serious facility reported incidents. This policy is intended to shift focus to serious facility reported incidents. Reduce the number of reports (incidents and investigations) sent to BHS, by requiring only transmittal of “Harm” reports. Reduce the number of reports (incidents and investigations) sent to BHS, by requiring only transmittal of “Harm” reports. Make FRI information referrals to Teams easier. Make FRI information referrals to Teams easier. Assist surveyors with off-site preparation involving FRIs. Assist surveyors with off-site preparation involving FRIs. Reduce unnecessary intakes. Reduce unnecessary intakes. Reduce paperwork burden for State and Providers. Reduce paperwork burden for State and Providers.

Summary Facilities continue to identify, investigate alleged violations of abuse, mistreatment, neglect, misappropriation and injuries of unknown source and take corrective action. Incidents that involve alleged violations of abuse, mistreatment, neglect, misappropriation and injuries of unknown source with harm are reported immediately after discovery and within 5 days of investigation. All incidents of abuse, mistreatment, neglect, misappropriation and injuries of unknown source with or without harm are logged. Logs are sent to BHS quarterly for review and action.

BHS Facility Log Policy This policy is effective for surveys starting after January 1, 2007 for which a BHS Facility Log is received.