Seniors and People with Disabilities
Cathy Cooper
Authorized Signature
Policy
Transmittal
Number: SPD-PT-05-021
Issue Date: 08/08/2005
Topic: Protective Services
Transmitting (check the box that best applies):
New Policy
Policy Change
Policy Clarification
Administrative Rule
Manual Update
Other:
Applies to (check all that apply):
All DHS employees
Area Agencies on Aging
Children, Adults and Families
County DD Program Managers
Policy/Rule Title:
Policy/Rule Number(s):
Effective Date:
References:
Web Address:
Executive Letter
County Mental Health Directors
Health Services
Seniors and People with Disabilities
Other (please specify):
Revised Procedures for Referral of Certain Nursing Facility
Complaints to Client Care Monitoring Units for Complaint
Surveys
SPD-EL-02-001
Release No: N/A
10/01/2005
Expiration: N/A
ORS 441.630-441.680; OAR 411-089-0100; 42 CFR 483.13;
42 CFR 488.332(a).
http://www.dhs.state.or.us/admin/forms/ Form #0817
Discussion/Interpretation: ORS 441.630-441.680 and OAR 411-089-0100 require
Area Agencies on Aging (AAA), Seniors and People with Disabilities (SPD) or Law
Enforcement to cause an investigation of nursing facility complaints of abuse. 42 CFR
483.13 requires that nursing facility complaints be reported in accordance with State
law through established procedures, including to the State survey and certification
agency. 42 CFR 488.332 (a) requires the State survey agency to establish procedures
and maintain adequate staff to investigate nursing facility complaints that allege
violations of federal participation requirements. The Client Care Monitoring Units
(CCMU) of SPD are the State survey and certification offices.
EL-02-001, dated January 7, 2002, established procedures that became effective
March 1, 2002, for the referral of certain nursing facility complaints to the Client Care
DHS 0079 (02/04)
Monitoring Units for complaint surveys. An evaluation of the effectiveness of the 2002
referral procedures revealed inconsistent implementation of the procedures resulting in
a significant number of complaints meeting the referral criteria not referred to CCMU.
A collaborative effort between CCMU and Adult Protective Services (APS) was started
in January 2005 to evaluate the existing referral procedures and revise the procedures
to assure consistent implementation state-wide. Attachments to this transmittal
describe criteria for determining the types of allegations that must be referred from the
local APS to CCMU for investigation, the types of allegations that will be investigated
by APS and not referred to CCMU, the process to be used by APS to make a referral
to CCMU, monthly reports from CCMU to APS about the status/disposition of
complaints referred to CCMU, and situations that call for collaboration between APS
and CCMU.
Implementation/Transition Instructions: Area Agencies on Aging/SPD offices,
responsible for APS, must assure that staff who conduct the screenings of nursing
facility complaints understand the criteria for the types of complaints that must be
referred to CCMU, the process for referring nursing facility complaints to CCMU, and
the types of nursing facility complaints that will be investigated by the local protective
services agency and not referred to CCMU. Use the Licensed Facility Complaint
Intake Form, DHS Form # 0817, for all facility complaint intakes.
Training/Communication Plan: SPD Office of Licensing and Quality of Care will
provide regional trainings for local offices and nursing facility providers in September,
2005.
Local/Branch Action Required: Implement and follow procedures described in the
attachments.
Central Office Action Required: Provide regional trainings for providers and local
offices. Implement and follow procedures as outlined in the attachments.
Field/Stakeholder review:
Yes
No
If yes, reviewed by: Program Managers, Oregon Health Care Association,
Oregon Alliance of Senior and Health Services, Long-Term Care Ombudsman,
Centers for Medicare and Medicaid Services
Filing Instructions:
If you have any questions about this policy, contact:
Contact(s): Elaine Young
Phone: 503-945-6456
Fax: 503-378-8966
E-mail: Elaine.Young@state.or.us
DHS 0079 (02/04)
SUBJECT: Procedures for Referral of Certain Nursing Facility Complaints
to the Client Care Monitoring Units (CCMU) for Complaint Surveys
EFFECTIVE DATE: 10/01/2005. Replaces procedures established 2002
per SPD-EL-02-001.
OBJECTIVE: Maintain compliance with state and federal expectations for
the investigation of Nursing Facility complaints and self-reported incidents.
I.
Types of Protective Services Intakes, except as specified at
section II A of this document, to be referred to CCMU include all
complaints from any source and facility self-reported incidents that
allege any of the following outcomes to a resident:
• All falls, whether or not there is an injury;
• All bone fractures;
• All pressure ulcers on any part of the body. Pressure ulcers
are also known as bed sores, pressure sores, decubitus ulcers;
• All hospitalizations, emergency room visits, urgent care visits;
• All deaths;
• Any concern related to the use of a restraint or restraining
device, these include, but are not limited to, bed rails, lap
buddy, tray table, seat belt, reclining chair, geri-chair.
CCMU, not APS, will complete the screening, triage, assign a
response priority (in accordance with Oregon statute) and
complete the investigation as appropriate. CCMU, not APS, will
frame the allegation.
APS will not create an Initial Status Report (ISR); statute exempts
CCMU referrals from the ISR process.
For complaints involving multiple allegations, if one or more of the
allegations meets the referral criteria, all allegations of the
complaint will be referred to CCMU (including those that do not
meet the referral criteria).
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II.
Types of Protective Services Intakes to be investigated by the
local APS and not referred to CCMU:
A. Complaints from any source and facility self-reported incidents,
regardless of outcome, that allege any of the following:
•
•
•
•
Financial abuse
Verbal/Mental abuse
Sexual abuse
Involuntary Seclusion
B. Physical Abuse or Neglect of Care, including injuries of
unknown cause or resident to resident altercations, with outcomes
to a resident not listed in the six criteria for referral to CCMU.
If in the course of the local office investigation it is revealed that
the complaint did meet the referral criteria, the local office will
complete the investigation rather than stop and refer to CCMU.
III.
Local Office Process Before Referral to CCMU
• Use the state approved Licensed Facility Complaint Intake
Form, DHS Form # 0817, for all facility complaint intakes. This
form is available at http://www.dhs.state.or.us/admin.forms/;
• Public complaints: The complainant is to be told that the
concern is being referred to the state’s Client Care Monitoring
Unit. Describe that CCMU staff are healthcare professionals
trained specifically for investigations in nursing facilities. The
complainant should be told that they will receive a follow-up
phone call from CCMU. The complainant should be given the
toll-free phone number for CCMU, 1-877-280-4555.
• Facility Self-Reported Incidents: If the local office has received
a completed Nursing Facility Incident Self-Report Form that
reveals a resident outcome that meets any of the CCMU
referral criteria; that form will be immediately sent to CCMU with
no further action on the part of the local office. Do not inform
a nursing facility that the self-reported incident has been
referred to CCMU.
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IV.
Referral of Intake to CCMU
• Fax the completed Licensed Facility Complaint Intake Form,
DHS Form # 0817, and/or Nursing Facility Incident Self-Report
Form, DHS Form # 0819 to the Tualatin CCMU office at 1-800550-6788.
• Local office will maintain a log of faxed referrals to CCMU.
V.
Closing the loop between CCMU and APS
• CCMU will maintain a log of faxed referrals received from local
offices.
• CCMU will provide each local APS office with a monthly report
about the disposition or status of complaints referred to CCMU.
• CCMU management will attend the quarterly APS managers’
meetings to review data and discuss the referral process.
VI.
CCMU and APS Collaboration
• If CCMU prioritizes a referral as needing a same day onsite
presence to assure resident protection and CCMU, due to
travel distance, is unable make a timely response, the local unit
will be the first responder for the purpose of protection. If the
local unit is the first responder, CCMU will travel to the facility to
initiate and complete the investigation. The local unit does not
initiate a 723 investigation report.
• If, in the course of a CCMU investigation, it is determined that a
crime may have occurred, CCMU will contact the local APS
agency and request a referral to law enforcement. The local
APS agency will assign a staff person to liaison with law
enforcement and CCMU as necessary. CCMU will complete
the complaint investigation.
• If, in the course of a local APS investigation, it is determined
that the facility may have systemic problems in their delivery of
care such that there is a potential risk to more than an isolated
number of residents, the local office will contact the local CCMU
manager to discuss the need for a complaint survey referral.
Systemic problems include, but are not limited to infection
control, medication administration, food safety.
• CCMU will communicate ongoing issues, such as problematic
communication dynamics between the facility and family, to the
case manager or ombudsman.
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