{"ref":"OH-HSP-ANE-01","title":"Recognizing and Reporting Abuse, Neglect and Exploitation of Adults","category":"Safeguarding","own":false,"summary":"Tells every staff member and volunteer how to recognize abuse, neglect (including self-neglect) and exploitation of adults, and how to make the immediate report to the county department of job and family services that Ohio's adult protective services law (ORC 5101.60 to 5101.63) requires of hospice staff serving adults aged 60 or older, together with the immediate internal report to the Administrator, the route for residents of nursing homes and residential care facilities, what to do for adults under 60, and the protections for people who report.","inShort":["Ohio law requires hospice staff who serve adults aged 60 or older to report suspected abuse, neglect or exploitation immediately.","Call adult protective services at 1-855-OHIO-APS (1-855-644-6277) at any time, or use the county Job and Family Services office or the online referral.","If someone is in immediate danger, call 911 first.","Also tell the Administrator right away; telling a supervisor does not replace your own report.","For patients in nursing homes or assisted living, report to the Ohio Department of Health or the long-term care ombudsman.","You are protected from retaliation for a good faith report, and failing to report is a crime."],"primaryCitation":"ORC 5101.63","citations":["ORC 5101.60","ORC 5101.61","ORC 5101.63","ORC 5101.99(B)","OAC 3701-19-09(C)","OAC 3701-19-06(C)(1)(b)"],"federalCitations":["42 CFR §418.52(b)(4)","42 CFR §418.52(c)(6)","42 CFR §418.112(c)(8)","45 CFR §164.512(c)"],"surveyorAsks":["If you thought a patient's son was taking her money, what would you do and how quickly?","Who in your agency is a mandatory reporter under Ohio law?","Where would you report suspected abuse of a patient who lives in a nursing home?","How do you make sure staff are not punished for making a report?","Show me the reports made in the last year and the dates they were made."],"version":"1.0","effectiveDate":"2026-10-01","reviewDate":"2027-10-01","approvedBy":"Pat Sample, Administrator","forms":[{"ref":"OH-HSP-ANE-01-A","title":"Internal Report of Suspected Abuse, Neglect or Exploitation"}],"sections":[{"heading":"Terms of Reference","body":["This section sets out the standing under which this policy is issued, who owns it, who is bound by it, and how it is kept current. It is not itself a procedure. The obligations begin at Section 1."],"table":{"caption":null,"headers":[["Item"],["Detail"]],"rows":[[["Issued by"],["The governing body of ",{"k":"field","name":"agency.name","text":"Sample Agency, LLC"}]],[["Document owner"],[{"k":"field","name":"people.administrator.name","text":"Pat Sample"},", ",{"k":"field","name":"people.administrator.title","text":"Administrator"}]],[["Authority"],["Adopted under Ohio Revised Code (ORC) 5101.60 to 5101.63 and 5101.99(B) (adult protective services), Ohio Administrative Code (OAC) 3701-19-09(C) (personnel do not abuse, exploit or neglect patients) and OAC 3701-19-06(C)(1)(b) (grievance and alleged violation policies). Federal: 42 CFR §418.52(b)(4) and (c)(6) and, for residents of nursing facilities, §418.112(c)(8)."]],[["Applies to"],["Every staff member, volunteer and contractor of the Agency, in every setting."]],[["Status"],["Mandatory. A report to adult protective services is never delayed to investigate first, to ask permission, or because someone else may report."]],[["Not covered here"],["The Agency's own investigation of alleged violations by anyone furnishing services on its behalf and the self-report to ODH (Policy OH-HSP-ANE-02). Children and young people with disabilities (Policy OH-HSP-ANE-03). Drug diversion (Policy OH-HSP-QA-02)."]],[["Review"],["Reviewed by the document owner at least every ",{"k":"field","name":"settings.reviewFrequencyMonths","text":"12"}," months, and within 30 days of any amendment to a rule cited in the References section. Each review is recorded in the Revision History."]],[["Amendment"],["Any change requires the approval of the governing body and the issue of a new version number. Superseded versions are retained for at least six years."]],[["Distribution"],["Master copy in the policy manual. Every staff member and volunteer carries the reporting card with ",{"k":"field","name":"fixed.abuseHotline","text":"1-855-OHIO-APS (1-855-644-6277)"}," and the Administrator's number."]],[["Questions"],["Direct to the document owner on ",{"k":"field","name":"agency.phone","text":"(614) 555-0100"}," or ",{"k":"field","name":"agency.email","text":"office@example.com"},"."]]]},"edited":false},{"heading":"1. Purpose","body":["This policy protects the patients of ",{"k":"field","name":"agency.name","text":"Sample Agency, LLC"}," (the \"Agency\") from abuse, neglect and exploitation by making sure that every person who works or volunteers for the Agency knows the signs, makes the reports Ohio law requires immediately and to the right place, and tells the Administrator so that the Agency can protect the patient."],"edited":false},{"heading":"2. Scope","body":["This policy covers suspected abuse, neglect (including self-neglect) and exploitation of any adult patient, and of any other adult staff meet in a patient's home, by anyone: family members, caregivers, other residents, visitors, strangers, Agency staff, volunteers or contractors, or the patient himself or herself."],"edited":false},{"heading":"3. Definitions","body":["The following terms have the meanings given below when used in this policy."],"table":{"caption":null,"headers":[["Term"],["Meaning"]],"rows":[[["Agency"],[{"k":"field","name":"agency.name","text":"Sample Agency, LLC"},", licensed by the Ohio Department of Health to provide a hospice care program under ORC Chapter 3712 and OAC 3701-19 (license ",{"k":"field","name":"agency.licenseNumber","text":"000000"},")."]],[["Patient"],["A hospice patient: a patient who has been diagnosed as terminally ill, has an anticipated life expectancy of six months or less, and has voluntarily requested and is receiving care from a licensed hospice care program (ORC 3712.01(B); OAC 3701-19-01). 42 CFR Part 418 also says \"patient\"; the two mean the same person here."]],[["Administrator"],["The qualified individual the governing body appoints under OAC 3701-19-06(C)(3): ",{"k":"field","name":"people.administrator.name","text":"Pat Sample"},", ",{"k":"field","name":"people.administrator.title","text":"Administrator"},". When the Administrator is absent, the individual designated to act in the Administrator's absence (",{"k":"field","name":"people.alternate.name","text":"Jo Sample"},", ",{"k":"field","name":"people.alternate.title","text":"Alternate Administrator"},") carries out the Administrator's duties in this policy."]],[["Adult (adult protective services)"],["\"any person sixty years of age or older within this state who is disabled by the infirmities of aging or who has a physical or mental impairment which prevents the person from providing for the person's own care or protection, and who resides in an independent living arrangement\" (ORC 5101.60(C)). Almost every hospice patient aged 60 or older who lives in his or her own home or a relative's home is such an adult."]],[["Independent living arrangement"],["\"a domicile of a person's own choosing, including, but not limited to, a private home, apartment, trailer, or rooming house.\" It includes a residential facility licensed under ORC 5119.22 that provides accommodations, supervision and personal care services for three to sixteen unrelated adults, \"but does not include any other institution or facility licensed by the state\" (ORC 5101.60(M)). Nursing homes and residential care facilities are therefore covered by Section 8, not by adult protective services."]],[["Abuse"],["\"the infliction upon an adult by self or others of injury, unreasonable confinement, intimidation, or cruel punishment with resulting physical harm, pain, or mental anguish\" (ORC 5101.60(B))."]],[["Neglect"],["\"(1) Failure of an adult to provide for self the goods or services necessary to avoid physical harm, mental anguish, or mental illness; (2) Failure of a caretaker to provide such goods or services; (3) Abandonment\" (ORC 5101.60(O)). Abandonment is \"desertion of an adult by a caretaker without having made provision for transfer of the adult's care\" (ORC 5101.60(A))."]],[["Exploitation"],["\"the unlawful or improper act of a person using, in one or more transactions, an adult or an adult's resources for monetary or personal benefit, profit, or gain\" when the person obtained or exerted control over the adult or the adult's resources without consent, beyond the scope of consent, or by deception, threat or intimidation (ORC 5101.60(J))."]],[["Caretaker"],["The person assuming the primary responsibility for the care of an adult voluntarily, by contract, through receipt of payment for care, as a result of a family relationship, or by court order (ORC 5101.60(E))."]],[["Senior service provider"],["\"a person who provides care or specialized services to an adult\" (ORC 5101.60(U)). Every Agency staff member who serves an adult patient is one."]],[["Reasonable cause to believe"],["Facts or observations that would lead a reasonable person in the same position to believe that abuse, neglect or exploitation is happening or has happened. Proof is not needed."]]]},"edited":false},{"heading":"4. Policy Statement (ORC 5101.63; OAC 3701-19-09(C); 42 CFR §418.52(b)(4))","body":["ORC 5101.63(A)(1) provides that \"No person listed in division (A)(2) of this section having reasonable cause to believe that an adult is being abused, neglected, or exploited, or is in a condition which is the result of abuse, neglect, or exploitation shall knowingly fail to immediately report such belief to the county department of job and family services.\" The persons listed include registered nurses and licensed practical nurses, physicians, psychologists, social workers, professional counselors and marriage and family therapists, pharmacists, members of the clergy, and \"Any other individual who is a senior service provider, other than a representative of the office of the state long-term care ombudsman program\" (ORC 5101.63(A)(2)(b), (e)-(h), (y), (ff)). Agency staff members who serve adult patients are senior service providers and therefore mandatory reporters, and the Agency requires every staff member and volunteer to report as Section 6 sets out. The Agency also ensures that all personnel treat each patient and each patient's property with respect, \"do not abuse, exploit, or neglect patients, and do not misappropriate a patient's property in accordance with section 3721.23 of the Revised Code\" (OAC 3701-19-09(C)), and that all alleged violations involving anyone furnishing services on behalf of the Agency are reported immediately to the Administrator (42 CFR §418.52(b)(4)(i))."],"edited":false},{"heading":"5. Signs to Watch For","body":["Hospice patients are frail and often depend on others. Signs can be subtle and must be weighed against the expected course of the illness, but staff report when they have reasonable cause to believe; they do not decide whether abuse occurred."],"table":{"caption":null,"headers":[["Type"],["Possible signs"]],"rows":[[["Physical abuse"],["Bruises, burns, fractures or injuries that do not match the explanation or are in different stages of healing; restraint marks; fear of a particular person; a caregiver who will not let staff see the patient alone."]],[["Emotional abuse and intimidation"],["Yelling, threats, humiliation or isolation of the patient; a patient who is withdrawn, fearful or agitated around a particular person."]],[["Sexual abuse"],["Injury, bleeding or infection in the genital area; new sexually transmitted infection; the patient reports it."]],[["Neglect by a caretaker"],["Untreated pressure injuries; soiled bedding; poor hygiene; dehydration or hunger not due to the dying process; medications not given or withheld; the patient left alone when unable to care for self; unsafe or unsanitary conditions; abandonment."]],[["Self-neglect"],["A patient living alone who cannot meet basic needs and refuses help, where the result is or is likely to be physical harm, mental anguish or mental illness."]],[["Exploitation"],["Missing money, checks or valuables; sudden changes to a will, deed, power of attorney or bank account; bills unpaid despite enough income; a new \"friend\" controlling finances; the patient's medicines or belongings taken."]]]},"edited":false},{"heading":"6. What Every Staff Member and Volunteer Does","body":[],"list":[["If the patient or anyone else is in immediate danger, call 911 first and stay with the patient if it is safe to do so."],["Report immediately to adult protective services. ",{"k":"field","name":"fixed.abuseReportRoute","text":"Adult Protective Services, a program of the Ohio Department of Job and Family Services: call 1-855-OHIO-APS (1-855-644-6277) at any time, contact the county Job and Family Services office, or use the Ohio Adult Protective Services Online Referral at https://aps.jfs.ohio.gov/. If someone is in immediate danger, call local law enforcement immediately."}," Make the call yourself. Reporting to your supervisor does not satisfy your own duty, and you do not need anyone's permission."],["Tell the Administrator (or, after hours, the on-call nurse, who tells the Administrator at once) immediately, and the same day at the latest (42 CFR §418.52(b)(4)(i))."],["Give the reporter the information you have. Written reports, when the county department asks for one, include \"(1) The name, address, and approximate age of the adult who is the subject of the report; (2) The name and address of the individual responsible for the adult's care, if any individual is, and if the individual is known; (3) The nature and extent of the alleged abuse, neglect, or exploitation of the adult; (4) The basis of the reporter's belief that the adult has been abused, neglected, or exploited\" (ORC 5101.63(C))."],["Write what you saw and heard, in the person's own words where possible, and the date and time of your report and the name of the person who took it, on Form OH-HSP-ANE-01-A, and a factual note in the clinical record. Do not write opinions about who is to blame."],["Do not investigate, confront the suspected person, or promise the patient that you will keep it secret."]],"ordered":true,"edited":false},{"heading":"6.1 Reports may be oral or written","body":["Reports \"shall be made orally or in writing except that oral reports shall be followed by a written report if a written report is requested by the department\" (ORC 5101.63(C)). The county department \"shall be available to receive the written or oral report provided for in this section twenty-four hours a day and seven days a week\" (ORC 5101.63(G)), so reports are not held until the next business day."],"edited":false},{"heading":"7. What the Administrator Does","body":[],"list":[["Confirms that the report to adult protective services was made and, if not, makes it at once."],["Makes sure the patient is safe now, with the IDT: an extra visit, a change in who gives care, respite or inpatient care, or a safety plan with the patient."],["If the person suspected is anyone furnishing services on behalf of the Agency (an employee, volunteer or contractor), starts the investigation and protective action in Policy OH-HSP-ANE-02 at once, including the self-report to ODH: ",{"k":"field","name":"fixed.hospiceIncidentRoute","text":"the Ohio Department of Health Hospice Self-Reported Incident Form (https://odh.ohio.gov/know-our-programs/hospice/resources/hospiceselfreportedincidentform), filed within five working days of becoming aware of an allegation of abuse, neglect, misappropriation, or injury of unknown source concerning a hospice patient"},"."],["If a crime may have been committed, makes sure law enforcement has been told."],["Cooperates with adult protective services and law enforcement, and gives them the information they are entitled to (45 CFR §164.512(c); Policy OH-HSP-PRV-01)."],["Records the matter on the safeguarding log and reports it to the QAPI program without names (Policy OH-HSP-QA-01)."]],"ordered":false,"edited":false},{"heading":"8. Residents of Nursing Homes and Other Facilities","body":["Nursing homes and residential care facilities licensed by the state are not an \"independent living arrangement\" (ORC 5101.60(M)), so their residents are not served by adult protective services. For a patient who lives in a nursing home, residential care facility (assisted living) or similar licensed facility:"],"list":[["Report as for any patient to the Administrator immediately."],[{"k":"field","name":"fixed.ltcFacilityAbuseRoute","text":"For abuse in a long-term care facility, contact the Ohio Department of Health complaint hotline online or at 1-800-342-0553, or the Office of the State Long-Term Care Ombudsman at 1-800-282-1206."}],["For a patient in a nursing facility or ICF/IID, the Agency reports all alleged violations involving mistreatment, neglect, or verbal, mental, sexual and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the Agency to the facility administrator within 24 hours of the Agency becoming aware of the alleged violation (42 CFR §418.112(c)(8); Policy OH-HSP-FAC-01). Agency staff tell the facility's nurse in charge at once and the Administrator makes sure the facility administrator is told."],["If the patient is in immediate danger, call 911."]],"ordered":false,"edited":false},{"heading":"9. Adults Under 60","body":["Ohio's adult protective services law covers adults aged 60 or older (ORC 5101.60(C)). For a patient aged 18 to 59 who may be abused, neglected or exploited, staff still report immediately to the Administrator. The Administrator reports to law enforcement where a crime may have been committed, follows Policy OH-HSP-ANE-02 where the person suspected furnishes services for the Agency, and, for a patient who receives developmental disabilities services, seeks advice from the county board of developmental disabilities on whether a report is required (Agency standard). A patient under 21 with a developmental disability or physical impairment is also covered by Policy OH-HSP-ANE-03."],"edited":false},{"heading":"10. Protection for People Who Report","body":[],"list":[["A person with reasonable cause to believe who makes a report, or who testifies in a proceeding arising from a report, is \"immune from civil or criminal liability on account of such investigation, report, or testimony, except liability for perjury, unless the person has acted in bad faith or with malicious purpose\" (ORC 5101.63(D))."],["The Agency will not \"(1) Discharge, demote, transfer, or prepare a negative work performance evaluation; (2) Reduce benefits, pay, or work privileges; (3) Take any other action detrimental to an employee or in any way retaliate against the employee\" because the employee filed a report (ORC 5101.63(E)). The same protection applies to volunteers and contractors (Agency standard)."],["Reports and the county's investigatory reports are confidential and are not public records (ORC 5101.63(F))."],["Failing to report: a person required to report who violates ORC 5101.63(A) \"is guilty of a misdemeanor of the fourth degree\" (ORC 5101.99(B)). Failing to report is also a breach of this policy and leads to discipline."]],"ordered":false,"edited":false},{"heading":"11. Supporting the Patient and Family","body":["A report does not end the Agency's care. The IDT continues to visit, respects the patient's right to make decisions where he or she has capacity, coordinates with adult protective services on the protective services plan, and offers the social worker and chaplain to the patient and family. Protective services provided by the county department may include case work, medical care, legal and guardianship services, homemaker services and placement (ORC 5101.60(S))."],"edited":false},{"heading":"12. Responsibilities","body":["Each role named below carries the duties shown."],"table":{"caption":null,"headers":[["Role"],["Responsibility"]],"rows":[[["Every staff member and volunteer"],["Reports immediately to adult protective services (or the facility route) and to the Administrator; documents facts; cooperates with investigations."]],[["Administrator"],["Confirms reports were made, protects the patient, starts Policy OH-HSP-ANE-02 when staff are involved, keeps the safeguarding log, protects reporters from retaliation."]],[["Social worker"],["Leads the IDT's safety planning and works with adult protective services and the family."]],[["Volunteer coordinator"],["Makes sure every volunteer knows how to report before the first assignment."]],[["Supervising nurse"],["Reviews visit notes for signs that should have led to a report and coaches staff."]]]},"edited":false},{"heading":"13. Records and Compliance Monitoring","body":["Form OH-HSP-ANE-01-A and the safeguarding log are kept in a confidential file, separate from the clinical record, for at least six years after the report (Agency standard). The clinical record contains factual observations and the fact and date of the report. Each quarter the Administrator reviews the log with the QAPI program for timeliness of reports and patterns."],"edited":false},{"heading":"14. Staff Training","body":["Every staff member and volunteer is trained before working with patients and every year on the signs of abuse, neglect and exploitation, the duty to report immediately, the reporting routes and the protections for reporters (Policies OH-HSP-HR-01 and OH-HSP-VOL-01)."],"edited":false},{"heading":"15. References","body":["This policy implements the following authorities."],"list":[["ORC 5101.60, definitions; ORC 5101.61, county departments of job and family services; ORC 5101.63, reports (effective April 4, 2023); ORC 5101.99(B), penalty"],["OAC 3701-19-09(C), respect for patients and property; OAC 3701-19-06(C)(1)(b), grievance and alleged violation policies"],["42 CFR §418.52(b)(4) and (c)(6), alleged violations and freedom from abuse; 42 CFR §418.112(c)(8), facility residents"],["45 CFR §164.512(c), disclosures about victims of abuse, neglect or domestic violence"],["Ohio Department of Aging, Ohio Elder Justice, \"How to Report\" (reporting route)"]],"ordered":false,"edited":false},{"heading":"16. Related Policies and Forms","body":["The following documents are read together with this policy."],"table":{"caption":null,"headers":[["Reference"],["Title"]],"rows":[[["Form OH-HSP-ANE-01-A"],["Internal Report of Suspected Abuse, Neglect or Exploitation"]],[["Policy OH-HSP-ANE-02"],["Investigating Alleged Violations and Self-Reported Incidents to the Ohio Department of Health"]],[["Policy OH-HSP-ANE-03"],["Recognizing and Reporting Child Abuse and Neglect"]],[["Policy OH-HSP-CMP-01"],["Patient Grievances and Complaints"]],[["Policy OH-HSP-PR-01"],["Patient and Family Rights and Responsibilities"]],[["Policy OH-HSP-FAC-01"],["Hospice Care for Residents of Nursing Facilities, ICF/IID and Residential Care Facilities"]],[["Policy OH-HSP-QA-02"],["Investigating and Reporting Suspected Drug Diversion"]],[["Policy OH-HSP-PRV-01"],["HIPAA Privacy and Ohio Confidentiality Laws"]],[["Policy OH-HSP-HR-01"],["Orientation, In-Service Training and Competency"]],[["Policy OH-HSP-VOL-01"],["Volunteer Program"]],[["Policy OH-HSP-SW-01"],["Medical Social Services"]],[["Policy OH-HSP-QA-01"],["Quality Assessment and Performance Improvement"]]]},"edited":false},{"heading":"17. Approval","body":["This policy is adopted by the governing body of ",{"k":"field","name":"agency.name","text":"Sample Agency, LLC"},". The effective date, the person who approved it, and the date of approval are shown in the header block and recorded in the signature lines below."],"edited":false},{"heading":"18. Revision History","body":["Every version of this policy, the date it took effect, a summary of what changed, and who approved it is recorded below. Where a rule cited in the References section is amended, the amendment is recorded in this table and a new version of this policy is issued."],"edited":false}],"missing":[],"editedCount":0,"pack":"oh-hospice","state":"Ohio","service":"Hospice","guides":[{"path":"/guides/abuse-neglect-exploitation-reporting/","h1":"Abuse, neglect and exploitation policies: what each state requires"},{"path":"/guides/hospice-policies/","h1":"What policies are required for hospice?"},{"path":"/guides/hospice-conditions-of-participation/","h1":"Hospice Conditions of Participation: which policies each one needs"}],"sample":true,"agency":{"name":"Sample Agency","legalName":"Sample Agency, LLC","logo":null}}