PA Connecting Communities (PACC) 001.00
Title: Abuse, Incident Management, Rights Violations
Authority: Board of Directors
Issuing Officer: CEO
Background: Replace Previous Policy
Responsible Department: RM
Definition: None
Effective Date: March 1, 2014
Statement: PACC Policy
Supersedes: Current Abuse Policies
Responsibilities: All Departments
I. Purpose and Scope
PA Connecting Communities (PACC) Client Abuse Policy is written to conform to Federal
Department of Health and Human Services Regulation 42 CFR 483.420(d)(1).
II. Policy
42 CFR 483.420(d)(1) states in pertinent part: “The organization must develop and implement
written policies and procedures that prohibit mistreatment, neglect or abuse of the client. Staff of
the organization must not use physical, verbal, sexual, or psychological abuse or punishment”.
Wherever the words abuse, mistreatment, or neglect or implications relating to these words
appear within PACC's Client Abuse Policy, the intention of the use of these words shall be to
mean any direct or indirect abuse, mistreatment, or neglect or failure to prohibit (prevent) any
direct or indirect abuse, mistreatment, and/or neglect and shall be a violation of this policy and
federal regulation.
Failure to prohibit direct or indirect abuse, mistreatment, or neglect carries the same weight as
actually causing direct or indirect abuse, mistreatment, and/or neglect.
42 CFR 483.420(d)(1) cited above provides no distinction between failure to prevent abuse,
mistreatment, or neglect or actually committing abuse, mistreatment and/or neglect; and it is to
that definition that PACC’s Client Abuse Policy is written.
PACC’s policy is that abuse, mistreatment, or neglect of any individual will not be tolerated by
any person at any level to any extent. Individuals receiving services from PACC must not be
subjected to abuse by anyone including, but not limited to, all PACC staff, consultants,
volunteers, staff of other agencies serving the individual, family members or guardians, friends,
other individuals or themselves.
It is the responsibility of all staff at PACC to protect, respect, and uphold the basic human rights
of individuals who receive services from PACC. Among these rights are:
1. The right to be free from physical, verbal, sexual and or emotional abuse;
2. The right to be free from any punishment;
3. The right to be treated at all times with respect and dignity.
PACC will seek to ensure that all individuals are free from threats to their physical and
psychological health and safety.
Within the confines of this policy, an abusive act may be defined as an act or an omission which
causes or may reasonably be expected to cause physical or psychological pain to an individual or
which deprives an individual of rights defined by rules and regulations and/or which is
committed for the purpose of wrongfully controlling, punishing, or instilling fear.
Actions which fall under the definition of abusive acts include, but are not limited to, kicking,
slapping, punching, cursing, teasing, humiliating and degrading the individual.
Punishment or harsh and unusual treatment is defined as any act or practice which goes beyond
generally accepted professional practices and in so doing exposes the individual to the possibility
of physical or psychological harm. Examples of punishment include the application of aversive
or restrictive treatment methods in an inappropriate manner or without proper authorization.
Abuse -the infliction of injury, unreasonable confinement, intimidation, punishment, mental
anguish, sexual abuse or exploitation of a participant. Types of abuse include (but are not
necessarily limited to):
(a) Physical abuse (a physical act by an individual that may cause physical injury to a
participant);
(b) Psychological abuse (an act, other than verbal, that may inflict emotional harm, invoke fear
and/or humiliate, intimidate, degrade or demean a participant);
(c) Sexual abuse (an act or attempted act such as rape, incest, sexual molestation, sexual
exploitation or sexual harassment and/or inappropriate or unwanted touching of a participant).
(d) Verbal abuse (using words to threaten, coerce, intimidate, degrade, demean, harass or
humiliate a participant).
4) Neglect -the failure to provide an individual the reasonable care that he or she requires,
including but not limited to food, clothing, shelter, medical care, personal hygiene, and
protection from harm. Neglect also is defined as withholding regularly scheduled meals to an
individual.
5) Exploitation -an act of depriving, defrauding or otherwise obtaining the personal property of a
participant in an unjust or cruel manner, against one's will, or without one's consent or
knowledge for the benefit of self or others. An act or course of conduct by a caretaker or other
person against a client or a client’s resources, without the informed consent of the client or with
consent obtained through misrepresentation, coercion or threats of force that results in monetary,
personal or other benefit, gain or profit for the perpetrator or monetary or personal loss to the
client.
6) Service interruption --Any event that results in the participant's inability to receive services
that places his or her health or safety at risk. This includes involuntary termination by the
provider agency and failure of the participant's back up plan. In the occurrence of these events,
the provider agency must have a plan for temporary stabilization.
7) Medication errors that require medical interventions (i.e. hospitalization or emergency room
visits).
Additional Incident Definition:
A Preventable Incidents is a critical incident that could be avoided through appropriate training
of a staff member or participant following established policies and procedures or implementation
of other reasonable precautionary measures.PA Connecting Communities strives to prevent
incidents through thorough staff training and risk Management Committee reviews of
participant’s specific health and safety needs.
Incident Management:
In accordance with Chapter 51 Regulations (relating to incident management) and the
Department’s Certified Investigator Manual on the Department’s web site, a provider shall report
incidents to the Department and ensure that a certified investigation is conducted.
PACC shall take prompt action to protect the participant’s health, safety and rights when an
incident has been discovered or has occurred. PACC will establish participant rights by
Departmental guidelines. PACC shall report any of the following incidents in HCSIS within 24
hours of the discovery or occurrence of the incident:
1.
2.
3.
4.
5.
6.
7.
8.
Death.
Suicide attempt.
Hospitalization.
Psychiatric hospitalization.
Emergency room visit.
Abuse as follows:
Physical abuse.
Psychological abuse.
9. Sexual abuse.
10. Verbal abuse.
11. Improper or unauthorized use of restraint.
12. Individual to individual abuse.
13. Neglect.
14. Missing person.
15. Law enforcement.
16. Injury requiring treatment beyond first aid.
17. Disease reportable to the Department of Health.
18. Fire.
19. Misuse of funds.
20. Participant rights violation.
21. Emergency closure.
22. Crisis event.
23. Restraint
PACC shall report any of the following incidents in HCSIS within 72 hours of the discovery or
occurrence of an incident:
1. Medication administration error.
2. Restraint unless the restraint falls into the definition of ‘‘abuse’’ in § 51.3 (relating to
definitions).
PACC shall fax or scan an incident report to the Department if HCSIS is not available within 24
hours or 72 hours depending on the incident type as described under subsections When HCSIS
becomes available, the provider shall immediately enter the incident into HCSIS.
For incidents that are to be reported within 24 hours of the discovery or occurrence, a provider
shall finalize the incident report in HCSIS by including additional information about the incident,
results of a required investigation and corrective actions within 30 days of the discovery or
occurrence of the incident, unless the deadline is extended in HCSIS. PACC shall provide a
detailed description in HCSIS of the actions taken in response to an incident to include:
1.
2.
3.
4.
5.
6.
The prompt action to protect the health and welfare of the participant. 2.
The results of the incident investigation.
Corrective actions taken.
The staff that is responsible for implementing the actions.
The date the actions were implemented or are planned.
Specific information regarding disciplinary actions taken with staff to assure the health
and welfare of participants.
PACC shall review and analyze incidents at least quarterly or more frequently as required by the
Department. This quarterly review must contain information on the incident target.
PACC shall identify and implement actions to assure a participant is safeguarded from risk so the
number of preventable incidents is reduced.
PACC shall assure that its staff receive annual incident management training on preventing,
recognizing, reporting and responding to incidents and assuring a participant is safe as required
under § 51.23 (relating to provider training).
PACC shall provide additional training to the participant and staff as needed based on the
incident circumstances. PACC shall respond to actions designated by the Department or the
Department’s designee as a result of the management review of an incident.
Upon completion of a certified investigation, a Peer Review Committee will be established for
review of all reportable incidents and analysis of corrective actions. The Peer Review
Committee will include the Certified Investigator, Acting CEO, PACC Executive Management
Team, PACC Senior IT Analyst & Safety Committee Chair person, and other PACC employees
deemed necessary based on the circumstances of the investigation. The Peer Review Committee
will meet with-in two (2) business days from the completion of the investigation. The Certified
Investigator will present their investigative process, findings, and any supporting evidence
including witness statements, documentary evidence, physical evidence, and or demonstrative
evidence. The Peer Review Committee will discuss the investigative findings, develop corrective
actions regarding the health and safety of the individual/s and implement all corrective actions.
Based upon the outcome of the Peer Review Committee, the Acting CEO will determine
disciplinary actions (when applicable) up-to and including termination of employment for the
target of the investigation. The Peer Review Committee will complete and document their review
and findings accordingly in the PACC Final Investigative Report/ Last Section Peer Review
Committee. (Appendix A).
Client Rights/ Client Abuse
If you observe or suspect that one of the Individuals is being mistreated, abused or neglected,
Intervene and then Report It.
The steps to follow if you observe or suspect abuse:
Intervene
1. Stop the Abuse
2. Tell the employee to leave the area
3. Never leave the Individual unattended while you get help.
4. Remove the Individual from the area.
5. If necessary, take the Individual with you to call for assistance.
6. Stay with the Individual until appropriate management arrives.
If, in your honest judgment you feel that the Individual and you are in imminent danger, you are
to dial 911 and request for immediate emergency authority assistance.
1.
2.
3.
4.
Report what you heard and/or witnessed.
Report immediately to any available supervisor.
Document and answer all questions accurately.
Fill out an incident report.
5. Answer questions from investigative personnel – Certified Investigator.
6. Complete a written statement.
A. Failure to prohibit direct or indirect abuse, mistreatment or neglect carries the same
weight as actually causing director indirect abuse, mistreatment, and/or neglect.
B. It is the responsibility of all PA Connecting Communities (PACC), employees to protect,
respect and uphold the basic human right of Individuals PACC provides services to.
C. PACC will seek to ensure that all Individuals are free from threats to their physical and
psychological health and safety.
PACC Management/Supervisor will:
1. Immediately remove the person who allegedly violated the Individuals’ right.
2. Immediately notify the Risk Manager.
3. Secure any evidence.
Note: To ensure confidential treatment of all cases of violations of an individual’s right, only
personnel relevant to the above process or directly involved in the investigation will be informed
of the incident details.
Note: If you are involved in an incident concerning one of the Individuals receiving services
from PACC, the information you provide is to be kept confidential. Discussing the incident or
circumstances surrounding the incident with coworkers or people outside of PACC and those
involved in the incident, is prohibited and is cause for disciplinary action up to and including
termination of employment.
Subject: Procedure for Reporting Violations of Individual’s Rights
Policy
It is the policy of PA Connecting Communities that each individual’s rights are maintained and
that each individual is protected from any violation of those rights.
Procedure
Any person suspecting and/or witnessing a violation of the individuals’ rights is required to (1)
immediately make notification of the incident to their immediate supervisor or any available
supervisor, (2) the supervisor will immediately remove from the work area the individual who
allegedly violated the individual’s rights, (3) obtain a written statement of the incident, and (4)
assure that an incident report is completed. The supervisor will immediately contact the Risk
Manager. In the case of suspected or actual physical or sexual abuse, arrangements will be made
for physical examination of the individual by a medical professional as soon as possible. The
results of the examination will be documented and reported to the Risk Manager.
The Risk Manager will notify the Executive Director and the employee’s Department/Head
Manager. The Risk Manager will notify all appropriate persons/agencies of the alleged abuse, the
action(s) taken and the results of the investigation. The Risk Manager will begin the
investigation with 24 hours of the alleged abuse or assign a Certified Investigator to initiate the
investigation.
The Risk Manager or the assigned investigator will conduct the investigation by interviewing
witnesses, obtaining written statements, and securing physical evidence within the accordance to
the MR Bulletin practices for Certified Investigations.
The person(s) identified and under investigation for alleged violation(s) of the individual’s rights
will be subject to immediate initial suspension without pay pending further investigation.
Under completion of the investigation, a committee comprised of the Executive Director,
identified key management staff, the Risk Manager, and the employee’s Direct Supervisor will
review the investigation results and take appropriate action.
If the investigation yields that a violation of the individual’s rights did occur, disciplinary action
appropriate to the degree of misconduct, up to and including, termination of the employment will
be imposed.
The Risk Manager and or Certified Investigator will complete a final investigative report on the
incident.
To ensure confidential treatment in all cases of violation of an individual’s rights, only personnel
relevant to the above process or involved in the investigation of the report will be informed of
the incident. Records relating to violation of an individual’s rights will be maintained in a
confidential file.
Attached – Appendix A
Final Investigative Report Format
Client Name:
Investigator:
Date of Report:
Introduction
The date and time the incident allegedly occurred, if known.
The date and time the incident was reported to the point person.
The name of the person or persons reporting the incident.
The date and time the investigator was assigned the case.
The nature of the incident and/or information provided to the investigator at the time of
the assignment.
Investigative Procedure
General Information:
The dates and times the investigator visited the site of the incident.
The person(s) with whom the investigator spoke at the site (not witness
interviews).
Collecting Physical and Demonstrative Evidence:
The manner in which the scene of the incident, if any, was secured.
A list of each piece of physical evidence collected.
The manner in which the physical evidence was collected and logged.
The manner in which the physical evidence was kept after collection in order to
maintain the chain of custody.
A list of any pictures which were taken.
A list of any other demonstrative evidence available to the investigation -- e.g.
diagrams, maps, floor plans, x-rays.
Testimonial Evidence:
The way in which the investigator determined whom to interview.
A list of all persons interviewed in chronological order, including title, date and
time of each interview.
The person or persons, if any, identified as the target or targets of the
investigation.
The way in which the investigator afforded the person who is the target of the
investigation or other witnesses any right to representation, if such rights exist by
labor contract, law or regulation.
Documentary Evidence:
A list of any statements taken from individuals interviewed in the case. [This may
be noted, for convenience, on the list identified in above section.]
A list of any other documents collected in this case.
The manner in which any business records which were collected were secured
prior to and after their collection.
Summary of Evidence
The investigative question(s) which the investigator must answer.
A summary of all direct evidence available to answer each question.
A summary of all circumstantial evidence available to answer each question.
A summary of the target’s employment performance and records from the Department
Director or Manager.
Analysis and Findings
[Include an answer to each question identified in “Summary of Evidence” and the reasons
for your findings.]
Peer Review Committee
Peer Review Committee Meeting Date:________________________ Time:___________
Peer Review Committee Members in Attendance:
Peer Review Committee Members were presented with the following evidence:
Peer Review Committee Members Analysis and Findings:
Peer Review Recommendations for Corrective Actions:
Are Disciplinary Action/s recommended for the Target of the investigation based on the
results of the investigative outcome:
Have all Investigative Outcomes and Corrective Actions been reported to all parties
involved?
List parties notified and date notification was made:
Additional Comments:
Peer Review Committee Members Signature, Title, and Date:
1.________________________________________________
2.________________________________________________
3.________________________________________________
4.________________________________________________
5.________________________________________________