Interim PolicyInterim Policy for for

Reporting Alleged Abuse, Reporting Alleged Abuse, Mistreatment, Neglect, Mistreatment, Neglect, Misappropriation and Misappropriation and Injuries of Unknown Injuries of Unknown

SourceSource

CMS Reporting RequirementsCMS Reporting Requirements

42 CFR 483.13(c)(2)42 CFR 483.13(c)(2)

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

42 CFR 483.13(c)(4)42 CFR 483.13(c)(4) The results of all investigations must be The results of all investigations must be

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

CMS NoticeCMS Notice

Centers for Medicare & Medicaid Services Centers for Medicare & Medicaid Services issues S&C-05-09 (12/16/04)issues S&C-05-09 (12/16/04)

Reiterates the reporting of alleged violations and Reiterates the reporting of alleged violations and the results of the investigation by nursing homes the results of the investigation by nursing homes to the state survey and certification agency as to the state survey and certification agency as mandated by 42 CFR 483.13(c)(2) and (4).mandated by 42 CFR 483.13(c)(2) and (4).

Defines the terms “neglect”, “abuse”, “injury of Defines the terms “neglect”, “abuse”, “injury of unknown source” “misappropriation of resident unknown source” “misappropriation of resident property”, “immediately” and “in accordance with property”, “immediately” and “in accordance with State law.”State law.”

ReactionsReactions

On January 13, 2005, the Bureau of Health Systems On January 13, 2005, the Bureau of Health Systems restates the CMS clarification and notifies providers of restates the CMS clarification and notifies providers of reporting and investigation requirements.reporting and investigation requirements.

September 2005, Attorney General Cox charges two UP September 2005, Attorney General Cox charges two UP nursing home employees with patient abuse and failure nursing home employees with patient abuse and failure to report injury and neglect.to report injury and neglect.

October 1, 2005, second set of charges regarding failure October 1, 2005, second set of charges regarding failure to report.to report.

October 19, 2005, third set of charges regarding failure October 19, 2005, third set of charges regarding failure to report.to report.

February 27, 2006, fourth charge of failure to report.February 27, 2006, fourth charge of failure to report.

Facility Reported IncidentsFacility Reported Incidents

210 801

4462

0

2000

4000

6000

FY04 FY05 FY06

FRIs Reported

5881

100

0

50

100

FY04 FY05 FY06

F223 Cited

20.5%32.6%

9.1%

0.0%

20.0%

40.0%

FY04 FY05 FY06

FRI Abuse Allegations Substantiated

FY06

1413 FRIs – with harm referred to CIU

3049 FRIs – non harm referred to NHM Teams

ProposalProposal

Alleged violations of abuse, mistreatment, Alleged violations of abuse, mistreatment, neglect, misappropriation and injuries of neglect, misappropriation and injuries of unknown source are reported to the unknown source are reported to the administrator of the facility. administrator of the facility.

Investigation commences immediately, Investigation commences immediately, while residents are safeguarded.while residents are safeguarded.

Incidents – Involving HarmIncidents – Involving Harm

Alleged violations of abuse, mistreatment, Alleged violations of abuse, mistreatment, neglect, misappropriation and injuries of neglect, misappropriation and injuries of unknown source that unknown source that involve harm, involve harm, are to are to be reported immediately to the Bureau of be reported immediately to the Bureau of Health Systems (BHS).Health Systems (BHS).• BHS OPS 362 24 Hour Report completed.BHS OPS 362 24 Hour Report completed.• Recorded on BHS Facility Log.Recorded on BHS Facility Log.• Investigation commences, while residents are Investigation commences, while residents are

safeguarded.safeguarded.

Incidents – Involving HarmIncidents – Involving Harm

Investigation resultsInvestigation results for alleged violations of for alleged violations of abuse, mistreatment, neglect, misappropriation abuse, mistreatment, neglect, misappropriation and injuries of unknown source, that involve and injuries of unknown source, that involve harm:harm:• Report investigation results to BHS, complete the Report investigation results to BHS, complete the

BHS OPS 363, 5 day Report form.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.* Harm means some physical injury or damage, pain or mental anguish.

Incident – Without HarmIncident – Without Harm

Alleged violations of abuse, mistreatment, Alleged violations of abuse, mistreatment, neglect, misappropriation and injuries of neglect, misappropriation and injuries of unknown source that do not involve harm, are to unknown source that do not involve harm, are to be reported to the facility administrator.be reported to the facility administrator.• Recorded on BHS Facility Log.Recorded on BHS Facility Log.• Investigation commences, while residents are Investigation commences, while residents are

safeguarded.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 LogBHS Facility LogLog For All Facility Incidents

Facility Name: Reporting Period__________ Year State ID Number: 10/1 thru 12/31 [ ] 1/1 thru 3/31 [ ] Provider ID Number: 23- 4/1 thru 6/30 [ ] 7/1 thru 9/30 [ ]

Person responsible for this report Title

● Please note that this form must be filed with your Licensing Officer quarterly (forwarded by 15th of the month following the end of the quarter) or

more frequently as directed. If there are no events to report on this log, write “NONE” and submit as required.

Gaylord Fax Number: (989)732-8958 Detroit Fax Number: (313)456-0348 Lansing Fax Number: (517)334-8473 For incidents that occur on or after December 1, 2006.

*CODE: A = Resident directly involved in accident or incident who may have suffered injury. B = Resident, staff person or other individual who may have been involved in accident or injury.

Resident Name and Code*

Room #

Diagnosis Date of Event

Describe Event/Incident and Outcome

Injury Y or N Describe injury

Date Facility Investigation Complete

Describe Intervention Implemented

Reported to State Y – N Date

Facility Log InstructionsFacility Log InstructionsFacilities are asked to make an initial determination about incidents and decide what is reportable 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 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) 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 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 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 log, only. In all cases, facilities should assess the incident and implement corrective measures, as appropriate.appropriate.

Facilities are to submit logs minimally at the end of each quarter and may be requested to submit 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.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 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 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. Information should include documentation that supports a summary statement of the event, conclusions reached and evidence of corrective action initiated, if appropriate. 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 Licensing Officer will determine what additional follow up or on-site surveyor investigation will be necessary.necessary.

UpNorth Team Phone:UpNorth Team Phone: (989) 732-8062(989) 732-8062 Fax: (989) 732-8958Fax: (989) 732-8958 Metro West Team Phone:Metro West Team Phone: (313) 456-0350(313) 456-0350 Fax: (313) 456-0348Fax: (313) 456-0348 Metro East Team Phone:Metro East Team Phone: (313) 456-0320(313) 456-0320 Fax: (313) 456-0348Fax: (313) 456-0348 Mid-Mich Team Phone:Mid-Mich Team Phone: (517) 334-8404(517) 334-8404 Fax: (517) 334-8473Fax: (517) 334-8473 Southwest Team Phone:Southwest Team Phone: (517) 334-8406(517) 334-8406 Fax: (517) 334-8473Fax: (517) 334-8473

BHS Facility Log -- ExpectationsBHS Facility Log -- Expectations

Facilities begin recording on 12/1/06.Facilities begin recording on 12/1/06. Facilities send BHS Facility Log to Licensing Facilities send BHS Facility Log to Licensing

Officer on/or about 1/15/07.Officer on/or about 1/15/07. Licensing Officer or designee reviews BHS Licensing Officer or designee reviews BHS

Facility Log upon receipt for timeliness of Facility Log upon receipt for timeliness of entries, completeness, understanding of harm.entries, completeness, understanding of harm.

Licensing Officer works with facilities , as Licensing Officer works with facilities , as appropriate, to get BHS Facility Log correct.appropriate, to get BHS Facility Log correct.

BHS Facility Log -- ExpectationsBHS Facility Log -- Expectations

BHS Facility Logs are reviewed as part of BHS Facility Logs are reviewed as part of off-site preparation for standard surveys to off-site preparation for standard surveys to note: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 -- ExpectationsBHS Facility Log -- Expectations

Complaint Team surveyors will review the Complaint Team surveyors will review the BHS Facility Logs completed since the last BHS Facility Logs completed since the last standard survey for entries relevant to the standard survey for entries relevant to the complaint/facility reported incident under complaint/facility reported incident under investigation.investigation.

Standard Survey Team will review on-site Standard Survey Team will review on-site the log entries since the last quarterly the log entries since the last quarterly report.report.

BHS Facility Log -- ExpectationsBHS Facility Log -- Expectations

As part of discretionary review, (between standard As part of discretionary review, (between standard surveys) Licensing Officers may:surveys) Licensing Officers may:

• Require a plan of correction to address an Require a plan of correction to address an incident.incident.

• Request copies of reports or documents related Request copies of reports or documents related to FRI.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 Require immediate reports and 5 day

investigation reports for investigation reports for allall alleged abuse, alleged abuse, neglect, and mistreatment incidents.neglect, and mistreatment incidents.

This policy is intended to shift focus to serious facility This policy is intended to shift focus to serious facility reported incidents. reported incidents.

Reduce the number of reports (incidents and Reduce the number of reports (incidents and investigations) sent to BHS, by requiring only transmittal investigations) sent to BHS, by requiring only transmittal of “Harm” reports.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.

SummarySummary

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

BHS Facility Log PolicyBHS Facility Log Policy

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